Anticoagulation Patterns Among Community-Dwelling Older Adults With Atrial Fibrillation.

OBJECTIVES: To assess clinicians' prescribing practices for anticoagulation in older adults with atrial fibrillation or atrial flutter (AF/F) and determine factors common among those without anticoagulation. METHODS: We performed a community-based retrospective cohort study of adults aged 65 years and older with a history of nonvalvular AF/F to determine the rate of oral anticoagulation utilization. We also assessed for associations between anticoagulation use and comorbid conditions and common geriatric syndromes. RESULTS: A total of 3832 patients with a diagnosis of nonvalvular AF/F were included (mean [SD] age, 79.9 [8.4] years), 2693 (70.3%) of whom were receiving anticoagulation (51.7%, a vitamin K antagonist; 48.1%, a direct-acting oral anticoagulant). Patients with higher Elderly Risk Assessment index (ERA) scores, a surrogate for health vulnerability, received anticoagulation less often than patients with lower scores. The percentage of patients with a history of falling was higher among those who did not receive anticoagulation than among those who did (44.4% vs 32.8%; P < .001). Similarly, a diagnosis of dementia was more common in the no-anticoagulation group than the anticoagulation group (18.5% vs 12.7%; P < .001). CONCLUSIONS: A substantial proportion of older adults with AF/F do not receive anticoagulation. Those without anticoagulation had higher risk of health deterioration based on higher ERA scores and had a higher incidence of dementia and fall history. This suggests that the presence of geriatric syndromes may influence the decision to withhold anticoagulation.

Risk of falls is associated with 30-day mortality among older adults in the emergency department.

OBJECTIVE: Falls in older adults correlate with heightened morbidity and mortality. Assessing fall risk in the emergency department (ED) not only aids in identifying candidates for prevention interventions but may also offer insights into overall mortality risk. We sought to examine the link between fall risk and 30-day mortality in older ED adults. METHODS: Observational cohort study of adults aged ≥ 75years who presented to an academic ED and who were assessed for fall risk using the Memorial Emergency Department Fall Risk Assessment Tool (MEDFRAT), a validated, ED-specific screening tool. The fall risk was classified as low (0-2 points), moderate (3-4 points), or high (≥5) risk. The primary outcome was 30-day mortality. Hazard ratios (HR) with 95% confidence intervals (CIs) were calculated. RESULTS: A total of 941 patients whose fall risk was assessed in the ED were included in the study. Median age was 83.7 years; 45.6% were male, 75.6% lived in private residences, and 62.7% were admitted. Mortality at 30 days among the high fall risk group was four times that of the low fall risk group (11.8% vs 3.1%; HR 4.00, 95% CI 2.18 to 7.34, p < 0.001). Moderate fall risk individuals had nearly double the mortality rate of the low-risk group (6.0% vs 3.1%), but the difference was not statistically significant (HR 1.98, 95% CI 0.91 to 4.32, p = 0.087). CONCLUSION: ED fall risk assessments are linked to 30-day mortality. Screening may facilitate the stratification of older adults at risk for health deterioration.

Improving Handoffs After Osteoporotic Fractures.

Osteoporotic fractures among long-term care residents have substantial economic and human costs. After a fracture, many older adults do not receive an osteoporosis diagnosis or evidence-based treatment, which leads to increased risk of recurrent fractures. Optimal processes are well defined for transitioning medical care after a hip or vertebral fracture for osteoporosis evaluation, but the handoff process from the specialist back to a primary care practitioner (PCP) or to a rehabilitative setting is not well defined. Our interdisciplinary quality improvement team developed and evaluated a program for transitioning care from a hospital-based fracture liaison clinic (FLC) to PCPs caring for older adults across the care continuum. To understand the current process of postfracture care transitions, we analyzed the postfracture patient experience. We surveyed PCPs to assess barriers to osteoporosis treatment, and retrospectively conducted a baseline analysis of 87 patients who had sustained an osteoporotic fracture in 2020. This preliminary work showed several opportunities for practice improvement and helped us develop a practical multicomponent intervention aimed at improving care transitions from the FLC to PCPs. The intervention (June-September 2021) comprised a standardized documentation template in the electronic health record (EHR) for FLC clinicians, a structured handoff process, and an engagement tool for patients outlining the roles and responsibilities of each care team member. We compared care transition measures before and after intervention. EHR documentation of an osteoporosis diagnosis increased from 56% (49 of 87 patients) before intervention to 92% (48 of 52) after intervention (P < .001). Additionally, increases were observed in documentation of treatment recommendations, associated risk factors, and PCP discussions with patients regarding osteoporosis and related treatment. This practical, commonsense intervention established clear roles for each care team member. The intervention addressed systemwide barriers in facilitating a safe transition from a subspecialty care team to PCPs providing care to older adults with osteoporosis.

Bridging the geroscience chasm between bench and bedside.

Geroscience-based therapeutics have the opportunity to transform the field of geriatric medicine, yet few training programs afford scholars with the necessary skills, knowledge, and experiences needed to successfully design and implement geroscience trials. We have developed a 2 year curriculum with two different training tracks for aging science scholars. The training tracks capitalize on the strengths and skillsets of eligible candidates. Both pathways afford scholars the opportunity to learn the fundamentals of aging research and the opportunity to apply this knowledge via a mentored translational research project. The two training pathways capitalize on existing clinical and research training infrastructures and include required and elective coursework, longitudinal clinical experiences, small group discussions, laboratory experience, and mentored translational research. This first of its kind geroscience training program is a potential feasible, scalable solution to the existing training gap. We believe that the Kogod Scholars Program at the Mayo Clinic can serve as a prototype for other academic aging centers.

Approach to the Older Adult With New Cognitive Symptoms.

Dementia affects nearly 50 million people worldwide, translating into one new case every 3 seconds. Dementia syndrome is one of the leading causes of disability among older adults, yet it remains vastly underdiagnosed. A timely diagnosis of dementia is essential to ensuring optimal care and support of individuals and their loved ones. Although there is no single test for dementia, health care providers can use a structured approach to the workup and management of new cognitive symptoms. Comprehensive MEDLINE and PubMed searches were performed to develop an unbiased, practical diagnostic approach to these symptoms. This review guides primary care providers in the workup, diagnosis, delivery, and initial management of patients presenting with new cognitive symptoms.

Assessing and Counseling the Older Driver: A Concise Review for the Generalist Clinician.

Older drivers are putting more miles on the road during their "golden years" than generations prior. Many older adults have safe driving habits, but unique age-related changes increase the risk for crash-related morbidity and mortality. Generalists are poised to assess and guide older adults' driving fitness. Although there is no uniformly accepted tool for driving fitness, assessment of 5 key domains (cognition, vision, physical function, medical comorbidities, and medications) using valid tools can help clinicians stratify older drivers into low, intermediate, and high risk for unsafe driving. Clinicians can then make recommendations about fitness to drive and appropriate referrals for rehabilitation or alternative transportation resources to optimize mobility, independence, and quality of life for older adults.

Utilization of Patient Electronic Messaging to Promote Advance Care Planning in the Primary Care Setting.

BACKGROUND: Advance care planning (ACP) is an instrumental mechanism aimed at preserving patient autonomy. Numerous interventions have been proposed to facilitate the implementation of ACP; however, rates of completed advance directives (ADs) are universally low. Patient electronic portal messaging is a newer tool in patient-provider communication which has not been studied as a method to promote ACP. In this study, we hypothesized that the use of ACP-specific patient electronic messages would increase rates of AD completion in patients aged 65 years and older in an academic primary care practice. METHODS: All primary care patients, aged 65+, who had previously enrolled in a patient electronic messaging system, within an academic primary care practice, were included for randomization. Two hundred patients were randomized to receive an electronic message. The primary outcome was the proportion of patients in each group who completed an AD, 3 months after intervention. Secondary outcomes included clinical utility of the completed ADs and proportion of patients who viewed their electronic messages. RESULTS: The intervention group completed an AD 5.5% of the time when compared to 2% in the control group (odds ratio 3.2 [1.6-6.3]). Up to 74.5% of patients opened their electronic messages. CONCLUSION: Among primary care patients aged 65 years and older, use of AD-specific electronic messaging statistically significantly increased the rate of AD completion, but the absolute number of completed AD remained relatively low. These data suggest that this valuable communication tool holds opportunities for further improvement. Older, frailer adults were more likely to complete an AD, and prompted directives were more likely to include a written expression of the individual's health-care values and preference.

Patient-reported geriatric symptoms as risk factors for hospitalization and emergency department visits.

There is an urgent need to identify predictors of adverse outcomes and increased health care utilization in the elderly. The Mayo Ambulatory Geriatric Evaluation (MAGE) is a symptom questionnaire that was completed by patients aged 65 years and older during office visits to Primary Care Internal Medicine at Mayo Clinic in Rochester, MN. It was introduced to improve screening for geriatric conditions. We conducted this study to explore the relationship between self-reported geriatric symptoms and hospitalization and emergency department (ED) visits within 1 year of completing the survey. This was a retrospective cohort study of patients who completed the MAGE from April 2008 to December 2010. The primary outcome was an ED visit or hospitalization within 1 year. Predictors included responses to individual questions in the MAGE. Data were obtained from the electronic medical record and administrative records. Logistic regression analyses were performed from significant univariate factors to determine predictors in a multivariable setting. A weighted scoring system was created based upon the odds ratios derived from a bootstrap process. The sensitivity, specificity, and AUC were calculated using this scoring system. The MAGE survey was completed by 7738 patients. The average age was 76.2 ± 7.68 years and 57% were women. Advanced age, a self-report of worse health, history of 2 or more falls, weight loss, and depressed mood were significantly associated with hospitalization or ED visits within 1 year. A score equal to or greater than 2 had a sensitivity of 0.74 and specificity of 0.45. The calculated AUC was 0.60. The MAGE questionnaire, which was completed by patients at an outpatient visit to screen for common geriatric issues, could also be used to assess risk for ED visits and hospitalization within 1 year.

From prednisone to pylori: a case of Helicobacter pylori-induced chronic immune thrombocytopenia.

A 54-year-old woman was seen by her primary care internist for a general health maintenance visit. Her major chronic illness was immune thrombocytopenic purpura (ITP) for which she had been treated with prednisone therapy for the past 15 years. Recent review of possible aetiologies of her chronic thrombocytopenia revealed infection with Helicobacter pylori. Successful eradication resulted in complete resolution of her thrombocytopenia within 2 months. She was weaned from steroid therapy and at 1-year follow-up, her platelet counts remained in the normal range. This case report summarises what is known about the association of H. pylori infection and ITP.

Improved resident physician confidence with advance care planning after an ambulatory clinic intervention.

Many primary care providers feel uncomfortable discussing end-of-life care. The aim of this intervention was to assess internal medicine residents' advance care planning (ACP) practices and improve residents' ACP confidence. Residents participated in a facilitated ACP quality improvement workshop, which included an interactive presentation and chart audit of their own patients. Pre- and postintervention surveys assessed resident ACP-related confidence. Only 24% of the audited patients had an advance directive (AD), and 28% of the ACP-documentation was of no clinical utility. Terminally ill patients (odds ratio 2.8, P < .001) were more likely to have an AD. Patients requiring an interpreter were less likely to have participated in ACP. Residents reported significantly improved confidence with ACP and identified important training gaps. Future studies examining the impact on ACP quality are needed.

Common curbsides and conundrums in geriatric medicine.

Within the next 15 years, the population of adults 65 years and older in the United States will double to approximately 70 million. Physicians must be well prepared to care for this rapidly growing population. Senior adults comprise a large proportion of most primary care practices in the United States, and the unique needs of this population cannot be overstated. Although traditional preventive screening modalities and disease-specific care models are of great utility, these processes may not be appropriate or consistent with the health goals of many older patients with multiple chronic conditions and reduced functional capacity. This Concise Review highlights commonly encountered clinical scenarios important to the care of these older patients. The topics include diagnosis and management of mild cognitive impairment, assessment of the cognitively impaired driver, cancer screening in the older patient, and sarcopenia.

Use of the elderly risk assessment (ERA) index to predict 2-year mortality and nursing home placement among community dwelling older adults.

The objective was to determine the relationship between a high score on the ERA index and 2-year mortality and nursing home placement. As of January 1, 2005, 12,650 community-dwelling patients over 60 years of age were impaneled with a primary care practice at the Mayo Clinic in Rochester, MN. This was a retrospective cohort study utilizing an administrative risk score, the ERA score. Primary outcomes were 2-year mortality and 2-year nursing home placement. The predictor variable was ERA score. Relative risk estimates were used to describe the association between the ERA index and mortality and nursing home placement. The relative risk of 2-year mortality was 51.4 (95% confidence interval=CI=28.0-94.4) in patients in the highest risk group compared to the lowest group. The relative risk of nursing home placement was 113.2 (95% CI=76.1-168.4). Patients with high ERA scores are at high risk for 2-year mortality and 2-year nursing home placement. These findings suggest that the utilization of an electronic risk score can help identify patients at risk for death or nursing home placement. Clinically, the identification of high risk individuals may be useful for utilization of clinical case management.

Advance care planning in the skilled nursing facility: what do we need for success?

INTRODUCTION: Despite the established benefits of advance care planning (ACP) in the geriatric population, documentation of ACP counseling in the skilled nursing facility (SNF) setting remains poor. The primary aim of this study was to identify key barriers to ACP completion among SNF providers. A secondary aim was to identify ACP practice-based differences between SNF physicians and midlevel providers. METHODS: As part of a divisional quality improvement project, 43 SNF providers from the area's 9 facilities were asked to complete an optional 14-item electronic survey. The survey was designed to explore and contrast SNF physicians' and midlevel providers' experiences with ACP counseling and documentation. RESULTS: We obtained a 91% completion rate. Systems-based factors, such as lack of a centralized document location, inconsistent documentation habits, dispersion of responsibility, lack of time, and under-recognition of team members' efforts, were cited as key barriers to ACP documentation. Perceived patient characteristics contributing to a low completion rate included cognitive impairment and lack of family involvement. Key differences between the 2 provider groups included the location of their ACP documentation (electronic medical record vs paper chart), frequency of documentation, and recognition of who is documenting the ACP. CONCLUSION: The survey demonstrated that systems-based barriers contribute to poor ACP documentation in the SNF setting. Key differences in attitudes about the impact of ACP on loved ones were identified between provider groups. Strategies aimed at mitigating practice-level barriers, such as standardizing a location for ACP documentation and formalizing workflow, are needed for increased ACP completion rates in SNFs.

Clinical decision support technology to increase advance care planning in the primary care setting.

Physicians are often unable to guide patients through the advance care planning (ACP) process due to cost and time constraints. We conducted a retrospective analysis in the primary care setting targeting older adults without an advance medical directive (AMD). An ACP educational packet was sent to intervention patients before their health maintenance examination (HME). Additionally, their physicians had access to a computerized clinical decision support system on AMD completion at the time of the HME. Control participants' physicians had access to the computerized decision support system and traditional resources only. All participants who received the packet were sent a follow-up survey. In all, 21.6% of intervention participants completed an AMD, compared with 4.1% of control participants. Combining clinical decision support systems and standardized processes enhances the ACP process.

Use of an electronic administrative database to identify older community dwelling adults at high-risk for hospitalization or emergency department visits: the elders risk assessment index.

BACKGROUND: The prevention of recurrent hospitalizations in the frail elderly requires the implementation of high-intensity interventions such as case management. In order to be practically and financially sustainable, these programs require a method of identifying those patients most at risk for hospitalization, and therefore most likely to benefit from an intervention. The goal of this study is to demonstrate the use of an electronic medical record to create an administrative index which is able to risk-stratify this heterogeneous population. METHODS: We conducted a retrospective cohort study at a single tertiary care facility in Rochester, Minnesota. Patients included all 12,650 community-dwelling adults age 60 and older assigned to a primary care internal medicine provider on January 1, 2005. Patient risk factors over the previous two years, including demographic characteristics, comorbid diseases, and hospitalizations, were evaluated for significance in a logistic regression model. The primary outcome was the total number of emergency room visits and hospitalizations in the subsequent two years. Risk factors were assigned a score based on their regression coefficient estimate and a total risk score created. This score was evaluated for sensitivity and specificity. RESULTS: The final model had an AUC of 0.678 for the primary outcome. Patients in the highest 10% of the risk group had a relative risk of 9.5 for either hospitalization or emergency room visits, and a relative risk of 13.3 for hospitalization in the subsequent two year period. CONCLUSIONS: It is possible to create a screening tool which identifies an elderly population at high risk for hospital and emergency room admission using clinical and administrative data readily available within an electronic medical record.

Advance care planning in the primary care setting: a comparison of attending staff and resident barriers.

Advance directive completion rates remain poor in the ambulatory setting. The purpose of this study was to explore and contrast staff provider and resident physicians' experiences with advance care planning (ACP) and to identify barriers to this process in the primary care setting. A 17-item survey was administered to staff primary care providers and categorical internal medicine residents. Staff providers were more likely to discuss ACP after prompting from patients' family members (P < .02) or after a change in health status (P < .02) and were more likely to believe that non-physician members of the care team should counsel patients about ACP. The majority of respondents cited system-based barriers as major obstacles to ACP. Strategies aimed at systematizing the ACP process for both patients and providers are needed.

Use of a geriatric home visit experience to teach medical students the functional status assessment.

INTRODUCTION: Functional status measures strongly predict hospital outcomes and mortality, yet teaching of these measures is often missing from medical schools' curricula. To address this deficiency, we developed a Geriatric Home-based Assessment (GHA) module for third-year medical students. The module was composed of a workshop and two to three home visits. OBJECTIVE: To determine whether the GHA module would improve students' knowledge and proficiency in the functional status assessment. PROGRAM EVALUATION: Students completed a validated questionnaire and evaluated a standardized patient in an Observed Structured Clinical Examination (OSCE). Scores from students completing the GHA were compared to the scores of students without this experience. RESULTS: Thirty-one students participated in the GHA module, and 19 students were in the control group. The mean score on the written assessment was 87% among GHA students vs. 46% in the control group (p < 0.001). The mean clinical examination score of the intervention group was also better than that of the control group (76% vs. 46%, p < 0.001). CONCLUSIONS: Our GHA module was effective in improving students' knowledge and proficiency in the functional status assessment. "Hands on" experiences like the GHA allow students to develop a solid foundation for assessing functional status and mobility.