Caring for Older Americans: The Future of Geriatric Medicine

Storylines of family medicine VII: family medicine across the lifespan

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VII: family medicine across the lifespan', authors address the following themes: 'Family medicine maternity care', 'Seeing children as patients brings joy to work', 'Family medicine and the care of adolescents', 'Reproductive healthcare across the lifespan', 'Men's health', 'Care of older adults', and 'Being with dying'. May readers appreciate the range of family medicine in these essays.

Perspectives and experiences of the first geriatricians trained in Canada

Many Canadian-trained geriatricians from the subspecialty's first decade of existence continue to practice today. The objective of this study was to examine the experiences and perspectives of the earliest cohort of geriatricians in Canada. Using qualitative description method, we conducted semi-structured interviews to explore participants' experiences in training and practice. We included geriatricians who trained in Canada between 1980-1989 and were in active clinical practice as of October 2021. Each transcript was coded independently by two investigators. Thematic analysis was used to develop key themes. Fourteen participants (43% female, mean years in practice 35.9) described their choice to enter geriatric medicine, their training process, the roles of a geriatrician, challenges facing the profession and advice for trainees. Two themes were developed from the data: (i) advocacy for the older adult and (ii) geriatrics as "the road less taken". Advocacy was described as the "core mission" of a geriatrician. Participants discussed the importance of advocacy in clinical practice, education, research and disseminating geriatric principles in the health system and society. "The road less taken" reflected the challenges participants faced during training, which led to relatively few geriatricians for the growing number of older adults in Canada. Despite these challenges, participants described rewarding careers and encouraged trainees to consider the profession.

Integrating CFIR-ERIC and e-Delphi Methods to Increase Telegeriatrics Uptake

BACKGROUND AND OBJECTIVES

Participatory implementation methods are needed in geriatric health care to improve care and services for a growing population of older adults. We describe an efficient participatory approach to improve uptake of Geriatric Research Education and Clinical Center (GRECC) Connect, a national geriatrics outpatient consultation service using telehealth technology to connect geriatric specialists to rural, older veterans though community-based clinics.

RESEARCH DESIGN AND METHODS

We designed a three-phase participatory method to identify high-priority implementation strategies to support the uptake of GRECC Connect. We used the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change (CFIR-ERIC) Strategy Matching Tool to derive expert-recommended implementation strategies informed by qualitative interviews with both GRECC Connect staff and clinicians at community-based clinics. We engaged expert panelists in a participatory two-step modified e-Delphi process using confidential surveys and discussion to prioritize strategies nationally.

RESULTS

Qualitative interviews revealed barriers, facilitators, and recommendations for program uptake. Many strategies recommended by CFIR-ERIC addressed multiple barriers but needed to be tailored to our specific context. In our two-step e-Delphi process, expert panelists shared previous experience with the strategies presented, views on the importance and feasibility of each, and arrived at a consensus about which strategies to prioritize nationally.

DISCUSSION AND IMPLICATIONS

We demonstrate the feasibility and benefits of engaging subject matter experts to identify strategies to be tested on a national level. Future considerations include weighting of survey responses, accounting for regional differences, and sensitivity of Likert scales used in the e-Delphi process.

What contributes most to the SPPB and its subscores in hospitalized geriatric patients: an ICF model-based approach

Background

Mobility deficits are highly prevalent among geriatric patients and have serious impact on quality of life, hospitalizations, and mortality. This study aims to capture predictors of mobility deficits in hospitalized geriatric patients using the International Classification of Functioning, Disability and Health (ICF) model as a framework.

Methods

Data were obtained from n = 397 patients (78 ± 7 years, 15 ± 7 ICD-11 diagnoses) on a geriatric ward at time of admission. Mobility was assessed using the Short Physical Performance Battery (SPPB) total score and gait, static balance and transfer subscores. Parameters from an extensive assessment including medical history, neuropsychological and motor examination, and questionnaires were assigned to the five components of the ICF model. Spearman’s Correlation and multiple linear regression analyses were calculated to identify predictors for the SPPB total score and subscores.

Results

Use of walking aid, fear of falling (FOF, but not occurrence of previous falls), participation in society, ADL and grip strength were strongly associated with the SPPB total score and all subscores (p < .001). FOF and grip strength were significant predictors for the SPPB total score as well as for gait and transfer subscores. FOF also showed a strong association with the static balance subscore. The clinical parameters of the ICF model could only partially explain the variance in the SPPB total score (24%) and subscores (12–23%), with no parameter from the activities and participation component being significantly predictive.

Conclusions

FOF and reduced grip strength are associated with mobility deficits in a hospitalized geriatric cohort. Further research should focus on interventions to reduce FOF and increase muscle strength in geriatric patients. Moreover, there is a need for ICF-based assessments instruments (especially in the activities and participation components) that allow a holistic view on mobility and further daily life-relevant health aspects in geriatric patients.

The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study

Background

The effectiveness of interventions to improve medication safety in older inpatients is unclear, given a paucity of properly designed intervention studies applying clinically relevant endpoints such as hospital-acquired preventable Adverse Drug Events (pADEs) and unrecognized Adverse Drug Events (uADEs). Therefore, we conducted a quality improvement study and used hospital-acquired pADEs and uADEs as main outcomes to assess the effect of an intervention aimed to improve medication safety in older inpatients.

Method

The study followed an interrupted time series design and consisted of three equally spaced sampling points during baseline and during intervention measurements. Each sampling point included between 80 to 90 patients. A total of 500 inpatients ≥65 years and admitted to internal medicine wards of three Dutch hospitals were included. An expert team retrospectively identified and assessed ADEs via a structured patient chart review. The findings from baseline measurement and meetings with the internal medicine and hospital pharmacy staff were used to design the intervention. The intervention consisted of a structured medication review by hospital pharmacists, followed by face-to-face feedback to prescribers, on average 3 days per week.

Results

The rate of hospital-acquired pADEs per 100 hospitalizations was reduced by 50.6% (difference 16.8, 95% confidence interval (CI): 9.0 to 24.6, P <  0.001), serious hospital-acquired pADEs by 62.7% (difference 12.8, 95% CI: 6.4 to 19.2, P <  0.001), and uADEs by 51.8% (difference 11.2, 95% CI: 4.4 to 18.0, P <  0.001). Additional analyses confirmed the robustness of the intervention effect, but residual bias cannot be excluded.

Conclusions

The intervention significantly decreased the overall and serious hospital-acquired pADE occurrence in older inpatients, and significantly improved overall ADE recognition by prescribers.

Trial registration

International Standard Randomized Controlled Trial Number Register, trial registration number: ISRCTN64974377, registration date (date assigned): 07/02/2011.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03118-z.

Comparing the scopes of practice of geriatric-focused physicians in Canada: a qualitative study of core competencies

BACKGROUND

Given long-standing deficits of medical expertise to care for a growing population of older adults, it is important to understand the geriatric medical workforce. We aimed to describe and compare the scopes of practice of the 3 geriatric-focused physician providers in Canada (i.e., family physicians with certification in Care of the Elderly [FM-COE], geriatricians and geriatric psychiatrists).

METHODS

We conducted a qualitative study to compare competencies across geriatric-focused physician provider types in Canada, using a directed content analysis approach. We identified and obtained relevant publicly available documents that described the competencies required for certification by searching the websites of The College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada between June 2 and July 31, 2020. An inductive content analysis was used to compare content within each CanMEDS Role according to the CanMEDS Framework.

RESULTS

We identified and obtained 4 relevant publicly available documents describing the competencies required for geriatric-focused certification for the 3 geriatric-focused physician provider types. We found substantial overlaps in the expected medical expertise of FM-COE and geriatricians. The few substantive differences across providers may result from different priorities about which competencies were made explicit for providers. The focused nature of mental health care is apparent in several competencies unique to geriatric psychiatry.

INTERPRETATION

This work highlights substantial overlaps in the scopes of practice for FM-COE and geriatricians. Our findings may encourage efforts to develop more robust delineations between the scopes of practice of these related professionals to facilitate inter-specialty collaboration to lead to more equitable and accessible medical care for older adults.

Efficacy of a patient decision aid for improving person-centered decision-making by older adults with obstructive sleep apnea

STUDY OBJECTIVES

Person-centered obstructive sleep apnea (OSA) care is a collaborative approach that is respectful of an individual's health priorities. Informed decision-making is essential to person-centered care, especially as patients age. In a feasibility study, we evaluated the effects of a new decision aid (Decide2Rest) on OSA treatment decision-making in older adults.

METHODS

Patients (aged ≥ 60 years) with newly diagnosed OSA were recruited from two health care systems and randomized either to Decide2Rest or to a control program. Postintervention outcomes included 1) Decisional Conflict Scale (0-100, where 0 = low and 100 = high conflict), which measures perceptions of uncertainty, whether decisions reflect what matters most to patients, and whether patients feel supported in decision-making; 2) Preparation for Decision-Making scale (0-100, where 0 = least and 100 most prepared); and 3) OSA knowledge (0-100, where 0 = poor and 100 = outstanding). Multivariable linear regression models examined relationships between Decide2Rest and outcomes (Decisional Conflict Scale, Preparation for Decision-Making, OSA knowledge).

RESULTS

Seventy-three patients were randomized to Decide2Rest (n = 36; mean age, 69 years; 72% male) vs control (n = 37; mean age, 69 years; 70% male). Results from the regressions, controlling for study site, indicate that the Decide2Rest program resulted in less decisional conflict (20.5 vs 32.7 on the Decisional Conflict Scale; P = .014), more preparedness for decision-making (87.8 vs 66.2 on the Preparation for Decision-Making scale; P < .001), and greater OSA knowledge (75.1 vs 65.3 OSA knowledge score; P = .04) scores than in the control group.

CONCLUSIONS

The Decide2Rest program promotes person-centered OSA decision-making for older patients with newly diagnosed OSA. Future studies are needed to optimize implementation of the program.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov, Name: Improving Older Adults' Decision-Making for OSAT (eDecide2Rest); URL: https://clinicaltrials.gov/ct2/show/NCT03138993; Identifier: NCT03138993.

Aligning geriatric medicine fellowships with the Program of All-Inclusive Care for the Elderly (PACE)

Geriatric medicine fellowship programs provide comprehensive training to one-year clinical fellows and must demonstrate successful progression of competence among fellows by reporting on 23 milestones to the Accreditation Council for Graduate Medical Education (ACGME). The Program of All-inclusive Care for the Elderly (PACE) is a model of care located throughout the United States and can serve as a training venue for fellows. We surveyed 113 fellowship program directors with a response rate of 42% (n = 48). The purpose of the survey was to assess: (1) familiarity and access to PACE and (2) perceived value of PACE to the fellowship program with regard to training and ability to achieve success in the 23 reporting milestones. Milestones involving communication and team management skills were most consistently identified as very valuable with a PACE clinical rotation. We then convened a focus group of four PACE medical directors who developed a fellowship curriculum for use in training fellows at PACE. We discuss the limitations of our design as well as the opportunities to build on the strengths of that model as a training site for fellows.

Validation of REAGERA-S: a new self-administered instrument to identify elder abuse and lifetime experiences of abuse in hospitalized older adults

This study aimed to develop and validate REAGERA-S, a self-administered instrument to identify elder abuse as well as lifetime experiences of abuse in older adults. REAGERA-S consists of nine questions concerning physical, emotional, sexual, financial abuse and neglect. Participants were recruited among patients (≥ 65 years) admitted to acute in-hospital care (n = 179). Exclusion criteria were insufficient physical, cognitive, or language capacity to complete the instrument. A semi-structured interview conducted by a physician was used as a gold standard against which to assess the REAGERA-S. The final version was answered by 95 older adults, of whom 71 were interviewed. Sensitivity for lifetime experiences of abuse was 71.9% and specificity 92.3%. For elder abuse, sensitivity was 87.5% and specificity was 92.3%. REAGERA-S performed well in validation and can be recommended for use in hospitals to identify elder abuse as well as life-time experience of abuse among older adults.

State of Science: Bridging the Science-Practice Gap in Aging, Dementia and Mental Health

The workforce available to care for older adults has not kept pace with the need. In response to workforce limitations and the growing complexity of healthcare, scientists have tested new models of care that redesign clinical practice. This article describes why new models of care in aging, dementia, and mental health diffuse inadequately into the healthcare systems and communities where they might benefit older adults. We review a general framework for the diffusion of innovations and highlight the importance of other features of innovations that deter or facilitate diffusion. Although scientists often focus on generating evidence-based innovations, end-users apply their own criteria to determine an innovation's value. In 1962, Rogers suggested six features of an innovation that facilitate or deter diffusion suggested: relative advantage, compatibility with the existing environment, ease or difficulty of implementation, trial-ability or ability to "test drive", adaptability, and observed effectiveness. We describe examples of models of care in aging, dementia and mental health that enjoy a modicum of diffusion into practice and place the features of these models in the context of deterrents and facilitators for diffusion. Developers of models of care in aging, dementia, and mental health typically fail to incorporate the complexities of health systems, the barriers to diffusion, and the role of emotion into design considerations of new models. We describe agile implementation as a strategy to facilitate the speed and scale of diffusion in the setting of complex adaptive systems, social networks, and dynamic macroenvironments.

Primary Care for the Elderly Bereaved: Recommendations for Medical Education

The aim of this study was to explore the current practices of primary care physicians (PCPs) in providing bereavement care to elderly patients, with implications for medical education. A total of 63 PCPs answered a brief online survey about their typical practices, barriers, comfort level with bereavement, and confidence in their ability to diagnose prolonged grief disorder (PGD). They were recruited through an online newsletter and contacts of one of the authors. The results found that two-thirds of the PCPs do not routinely screen their elderly patients for recent losses, nor do they refer to mental health clinicians when loss is identified. Barriers included not learning of the deaths in patients' lives and lack of time during clinic visits. Those PCPs who had experienced their own losses were significantly more comfortable in speaking to patients about recent losses and more confident in their ability to diagnose PGD. We recommend bereavement education be incorporated into the medical school curriculum from the outset, utilizing the psychological principle of graded exposure to bereaved individuals.

AGS Report on Engagement Related to the NIH Inclusion Across the Lifespan Policy

After passage of the 21st Century Cures Act, the National Institutes of Health held a workshop in 2017 to consider expanding its inclusion policy to encompass individuals of all ages. American Geriatrics Society (AGS) leaders and members participated in the workshop and formal feedback period. AGS advocacy clearly impacted the resulting workshop report and Inclusion Across the Lifespan policy that eliminates upper-age limits for research participation unless risk justified and changes the language used to describe older adults and other vulnerable groups. AGS recommendations that were not specifically stated in the updated policy were to encourage active recruitment of older adults, add standard measures of function and/or frailty, and change review criteria to ensure the health status of a study population mirrors typical clinical populations. The updated inclusion policy ultimately offers academic geriatrics programs the opportunities to expand knowledge about health in aging and to continue to provide leadership for research and advocacy efforts on behalf of older adults. J Am Geriatr Soc 67:211-217, 2019.

Frailty and geriatric conditions in older patients with idiopathic pulmonary fibrosis

BACKGROUND

Functional status, an important predictor of health outcomes in older patients, has not been studied in an IPF population. This study aimed to determine the prevalence of frailty and geriatric conditions in older patients with IPF.

METHODS

IPF patients age ≥65 years were identified prospectively at the University of Michigan. Frailty was assessed using the Fried frailty phenotype. Questionnaires addressing functional status, geriatric conditions and symptoms were administered. Quantitative measurement of pectoralis muscle area was performed. Patient variables were compared among different frailty groups.

RESULTS

Of the 50 participants, 48% were found to be frail and 40% had ≥2 geriatric conditions. Frailty was associated with increased age, lower lung function, shorter 6-min walk distance, higher symptom scores and a greater number of comorbidities, geriatric conditions and functional limitations (p < 0.05). Pectoralis muscle area was nearly significant (p = 0.08). Self-reported fatigue score (odds ratio [OR] = 2.13, confidence interval [CI] 95% 1.23-3.70, p = 0.0068) and diffusion capacity (OR = 0.54 CI 95% 0.35-0.85, p = 0.0071) were independent predictors of frailty.

CONCLUSIONS

Frailty and geriatric conditions are common in older patients with IPF. The presence of frailty was associated with objective (diffusion capacity) and subjective (self-reported fatigue score) data. Longitudinal evaluation is necessary to determine impact of frailty on disease-related outcomes in IPF.

Learning to Lead: Reflections from the Tideswell-AGS-ADGAP Emerging Leaders in Aging Program Scholars

The Tideswell Emerging Leaders in Aging (ELIA) Program is a 1-year leadership training program focused on developing a sustainable pipeline of leaders in aging who are poised to lead initiatives that will optimize the health of older people. The Tideswell ELIA Program is jointly administered by the American Geriatrics Society, the Association of Directors of Geriatric Academic Programs, and Tideswell at University of California, San Francisco (UCSF), a program within the Division of Geriatrics at UCSF. The ELIA Program prepares early to midcareer healthcare professionals in aging (scholars) for their transition into key leadership roles that involve one or more areas of patient care, education, and research. The program emphasizes the understanding of one's own and others' inherent work strategies and communication styles as integral to leading programs. Approximately 15 ELIA scholars are selected annually to participate in this interactive leadership development program. We conducted a qualitative analysis of program evaluations from 2015 to 2018 scholars (n = 47) to determine effectiveness and impact. All scholars (100%) completed the end-of-training survey. Scholars' satisfaction with the program is high. Scholars reported heightened leadership development and improvements in leadership skills, including communication, team building, and self-awareness. Scholars also reported enhancement of personal leadership attributes that contributed to career advancement. The Tideswell ELIA Program accelerates scholars' personal career development, positively impacts their institutions, and ultimately benefits older people. Sustaining leadership programs such as the Tideswell ELIA Program is vital to ensure a continuous pipeline of leaders skilled in both advocating for and advancing the health of older Americans. J Am Geriatr Soc 67:434-436, 2019.

Health care providers' roles and responsibilities in management of polypharmacy: Results of a modified Delphi

BACKGROUND

Little is known about the roles that allow interprofessional teams to effectively manage older patients experiencing polypharmacy.

OBJECTIVES

To identify and examine the consensus on salient interprofessional roles, responsibilities and competencies required in managing polypharmacy.

METHODS

Four focus groups with 35 team members practising in geriatrics were generated to inform survey development. The sessions generated 63 competencies, roles or responsibilities, which were categorized into 4 domains defined by the Canadian Interprofessional Health Collaborative. The resulting survey was administered nationally to geriatric health care professionals who were asked to rate the importance of each item in managing polypharmacy; we sought agreement within and across professions using a confirmatory 2-round Delphi method.

RESULTS

Round 1 was completed by 98 survey respondents and round 2 by 72. There was high intra-professional and interprofessional consensus regarding the importance of competencies among physicians, nurses and pharmacists; though pharmacists rated fewer competencies as important. Less consensus was observed among other health care professionals or they indicated the nonimportance of competencies despite focus group discussion to the contrary.

DISCUSSION

Although there is a strong consensus of polypharmacy management competencies across team members who have been more traditionally involved in medication management, there continue to be health care providers with differing understandings of competencies that may contribute to reduced reliance on medication. Lower importance ratings suggest pharmacists may not acknowledge or recognize their own potential roles in interprofessional polypharmacy management.

CONCLUSION

Further exploration to understand the underutilization of professional expertise in managing polypharmacy will contribute to refining role clarity and translating competencies in practical settings, as well as guiding educators regarding curricular content.

Origination, change, and modulation of geriatric disease-related gut microbiota during life

The age-related changes in the diversity and composition of the gut microbiota are well described in recent studies. These changes have been suggested to be influenced by age-associated weakening of the immune system and low-grade chronic inflammation, resulting in numerous age-associated pathological conditions. Gut microbiota homeostasis is important throughout the life of the host by providing vital functions to regulate various immunological functions and homeostasis. Based on published results, we summarize the relationship between the gut microbiota and aging-related diseases, especially Parkinson's disease, immunosenescence, rheumatoid arthritis, bone loss, and metabolic syndrome. The change in composition of the gut microbiota and gut ecosystem during life and its influence on the host immunologic and metabolic phenotype are also analyzed to determine factors that affect aging-related diseases. Approaches to maintain host health and prevent or cure geriatric diseases are also discussed.

Status of Geriatrics in 22 Countries

OBJECTIVES

The aim of this article is to describe the current status of geriatrics and position of geriatricians in 22 countries of three continents, and to portray their attitudes towards and resources allocated to geriatrics.

METHODS

An electronic survey was delivered to a convenience sample of 22 geriatricians in leading positions of their countries.

RESULTS

The time required in post graduation specialist training to become a geriatrician varied from one year (subspecialty in the USA) to six years (independent specialty in Belgium). The number in the population aged 80+ per geriatrician varied from 450 (Austria) to 25,000 (Turkey). Of respondents, 55% reported that geriatrics is not a popular specialty in their country. Acute geriatric wards, rehabilitation and outpatient clinics were the most common working places for geriatricians. Nearly half of the respondents had an opinion that older patients who were acutely ill, were receiving subacute rehabilitation or had dementia should be cared for by geriatricians whereas half of the respondents would place geriatricians also in charge of nursing home and orthogeriatric patients. The biggest problems affecting older people's clinical care in their countries were: lack of geriatric knowledge, lack of geriatricians, and attitudes towards older people. Half of respondents thought that older people's health promotion and comprehensive geriatric assessment were not well implemented in their countries, although a majority felt that they could promote good geriatric care in their present position as a geriatrician.

CONCLUSION

The position of geriatric, geriatricians' training and contents of work has wide international variety.

Medication adherence and rejection rates in older vs younger adult liver transplant recipients

A growing number of older adults are undergoing liver transplantation (LT) in the United States. In some settings, it is thought that adherence declines with age. This retrospective study examined adherence and clinical outcomes in older vs younger adult LT recipients. Medical records of adult LT recipients from 2009 to 2012 from a single urban center were reviewed. The medication level variability index (MLVI) was the predefined primary outcome, with nonadherence defined as MLVI >2.5. The secondary outcome was incidence of rejection. Outcomes were evaluated starting 1 year post-LT until 2015. A total of 42 of 248 patients were ≥65 at transplant. Older adults had significantly better adherence than younger ones (65%≥65 were adherent vs 42% younger adults; chi-square two-tailed P=.02). Survival analyses of rejection between age groups censored by time since transplant showed no difference among the four age groups (χ² =0.84, P=.84). Older age was not found to be a risk factor for reduced adherence or graft rejection in patients surviving at least 1 year post-LT.

How We Care for an Older Patient With Cancer

As the number of older patients with cancer is increasing, oncology disciplines are faced with the challenge of managing patients with multiple chronic conditions who have difficulty maintaining independence, who may have cognitive impairment, and who also may be more vulnerable to adverse outcomes. National and international societies have recommended that all older patients with cancer undergo geriatric assessment (GA) to detect unaddressed problems and introduce interventions to augment functional status to possibly improve patient survival. Several predictive models have been developed, and evidence has shown correlation between information obtained through GA and treatment-related complications. Comprehensive geriatric evaluations and effective interventions on the basis of GA may prove to be challenging for the oncologist because of the lack of the necessary skills, time constraints, and/or limited available resources. In this article, we describe how the Geriatrics Service at Memorial Sloan Kettering Cancer Center approaches an older patient with colon cancer from presentation to the end of life, show the importance of GA at the various stages of cancer treatment, and how predictive models are used to tailor the treatment. The patient's needs and preferences are at the core of the decision-making process. Development of a plan of care should always include the patient's preferences, but it is particularly important in the older patient with cancer because a disease-centered approach may neglect noncancer considerations. We will elaborate on the added value of co-management between the oncologist and a geriatric nurse practitioner and on the feasibility of adapting elements of this model into busy oncology practices.

Preferences for Shared Decision Making in Older Adult Patients With Orthopedic Hand Conditions

PURPOSE

The practice of medicine is shifting from a paternalistic doctor-patient relationship to a model in which the doctor and patient collaborate to decide optimal treatment. This study aims to determine whether the older orthopedic population desires a shared decision-making approach to care and to identify patient predictors for the preferred type of approach.

METHODS

This cross-sectional investigation enrolled 99 patients, minimum age 65 years, at a tertiary hand specialty practice between March and June 2015. All patients completed the Control Preferences Scale, a validated system that distinguishes among patient preferences for patient-directed, collaborative, or physician-directed decision making. Bivariate and logistic regression analyses assessed associations among demographic data; clinic encounter variables such as familiarity with provider, trauma, diagnosis, and treatment decision; and the primary outcome of Control Preferences Scale preferences.

RESULTS

A total of 81% of patients analyzed preferred a more patient-directed role in decision making; 46% of the total cohort cited a collaborative approach as their most preferred treatment approach. Sixty-seven percent cited the most physician-directed approach as their least preferred model of decision making. In addition, 49% reported that spending more time with their physician to address questions and explain the diagnosis would be most useful when making a health care decision and 73% preferred additional written informational material. Familiarity with the provider was associated with being more likely to prefer a collaborative approach.

CONCLUSIONS

Older adult patients with symptomatic upper-extremity conditions desire more patient-directed roles in treatment decision making. Given the limited amount of reliable information obtained independently outside the office visit, our data suggest that written decision aids offer an approach to shared decision making that is most consistent with the preferences of the older orthopedic patient.

CLINICAL RELEVANCE

This study quantifies older adults' desire to participate in decision making when choosing among treatments for hand conditions.

Behavioural activation written self-help to improve mood, wellbeing and quality of life in people with dementia supported by informal carers (PROMOTE): a study protocol for a single-arm feasibility study

BACKGROUND

Increases in life expectancy have resulted in a global rise in dementia prevalence. Dementia is associated with poor wellbeing, low quality of life and increased incidence of mental health difficulties such as low mood or depression. However, currently, there is limited access to evidence-based psychological interventions for people with dementia experiencing low mood and poor wellbeing. Behavioural activation-based self-help, supported by informal carers and guided by mental health professionals, may represent an effective and acceptable solution.

METHODS/DESIGN

The present study is a phase II (feasibility) single-arm trial informed by the Medical Research Council complex interventions research methods framework. Up to 50 dementia participant/informal carer dyads will be recruited from a variety of settings including primary care, dementia-specific health settings and community outreach. People living with dementia will receive behavioural activation-based self-help and be supported by their informal carer who has received training in the skills required to support the self-help approach. In turn, during the use of the intervention, the informal carer will be guided by mental health professionals to help them work through the materials and problem solve any difficulties. Consistent with the objectives of feasibility studies, outcomes relating to recruitment from different settings, employment of different recruitment methods, attrition, data collection procedures, clinical delivery and acceptability of the intervention will be examined. Clinical outcomes for people with dementia (symptoms of depression and quality of life) and informal carers (symptoms of depression and anxiety, carer burden and quality of life) will be measured pre-treatment and at 3 months post-treatment allocation.

DISCUSSION

This study will examine the feasibility and acceptability of a novel behavioural activation-based self-help intervention designed to promote wellbeing and improve low mood in people living with dementia, alongside methodological and procedural uncertainties associated with research-related procedures. As determined by pre-specified progression criteria, if research procedures and the new intervention demonstrate feasibility and acceptability, results will then be used to inform the design of a pilot randomised controlled trial (RCT) to specifically examine remaining methodological uncertainties associated with recruitment into a randomised controlled design.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN42017211.

The Psychosocial Challenges and Care of Older Adults with Diabetes: "Can't Do What I Used To Do; Can't Be Who I Once Was"

The prevalence of diabetes is increasing in older populations worldwide. Older adults with diabetes have unique psychosocial and medical challenges that impact self-care and glycemic control. These challenges may include psychological factors such as depression or anxiety, social factors such loss of independence and removal from home environment/placement in a facility, and medical factors such as multiple comorbidities and polypharmacy. Importantly, these challenges interact and complicate the everyday life of the older adult with diabetes. Thus, timely identification and interventions for psychosocial and medical challenges are a necessary component of diabetes care. This review summarizes the current literature, research findings, and clinical recommendations for psychosocial care in older adults with diabetes.

Vaccinations in prisons: A shot in the arm for community health

From the first day of imprisonment, prisoners are exposed to and expose other prisoners to various communicable diseases, many of which are vaccine-preventable. The risk of acquiring these diseases during the prison sentence exceeds that of the general population. This excess risk may be explained by various causes; some due to the structural and logistical problems of prisons and others to habitual or acquired behaviors during imprisonment. Prison is, for many inmates, an opportunity to access health care, and is therefore an ideal opportunity to update adult vaccination schedules. The traditional idea that prisons are intended to ensure public safety should be complemented by the contribution they can make in improving community health, providing a more comprehensive vision of safety that includes public health.

Meeting the Training Needs of Aging Network Nutrition Program Professionals: Past, Present, and Future

Aging network nutrition professionals must continuously adapt knowledge and skills in order to maintain the provision of high quality, appropriate, and targeted services able to address the evolving demographic, home- and health care-needs of the older Americans of today and tomorrow. This evolution must be supported by ready access to contemporary training and technical assistance. Since the passage of the Older Americans Act in 1972, the Administration on Aging has provided a diverse and contemporary array of supportive program development modalities for aging network nutrition professionals, ranging from the establishment of nutrition training centers and institutes, to the formation of action learning collaboratives. A sustainable and broad funding base is needed to support the training needs of aging network professionals and assure their continued acquisition of the skills, knowledge, and business acumen needed to integrate food and nutrition services into home and community-based social, health, and long-term care systems.

Teaching geriatric fellows how to teach: a needs assessment targeting geriatrics fellowship program directors

The entire healthcare workforce needs to be educated to better care for older adults. The purpose of this study was to determine whether fellows are being trained to teach, to assess the attitudes of fellowship directors toward training fellows to be teachers, and to understand how to facilitate this type of training for fellows. A nine-question survey adapted from a 2001 survey issued to residency program directors inquiring about residents-as-teachers curricula was developed and administered. The survey was issued electronically and sent out three times over a 6-week period. Of 144 ACGME-accredited geriatric fellowship directors from geriatric, internal medicine, and family medicine departments who were e-mailed the survey, 101 (70%) responded; 75% had an academic affiliation, 15% had a community affiliation, and 10% did not report. Academic and community programs required their fellows to teach, but just 55% of academic and 29% of community programs offered teaching skills instruction as part of their fellowship curriculum; 67% of academic programs and 79% of community programs felt that their fellows would benefit from more teaching skill instruction. Program directors listed fellow (39%) and faculty (46%) time constraints as obstacles to creation and implementation of a teaching curriculum. The majority of fellowship directors believe that it is important for geriatric fellows to become competent educators, but only approximately half of programs currently provide formal instruction in teaching skills. A reproducible, accessible curriculum on teaching to teach that includes a rigorous evaluation component should be created for geriatrics fellowship programs.

Addressing geriatric oral health concerns through national oral health policy in India

There is an escalating demand for geriatric oral healthcare in all developed and developing countries including India. Two-thirds of the world's elderly live in developing countries. This is a huge population that must receive attention from policy-makers who will be challenged by the changing demands for social and health services including oral health services. Resources are limited thus rather than being aspirational in wanting to provide all treatment needed for everybody, this critique presents a road map of how we might answer the present and future geriatric oral health concerns in a most efficient manner in a developing country. Viewing the recent Indian demographic profile and the trends in oral health, pertinent policy subjects have been discussed concerning the oral health needs of the elderly and also the associated challenges which include strategies to improve quality of life, strategies to train and educate the dental workforce and above all the role of healthcare systems towards realization of better aged society in India and other developing countries.

Long case or case vignettes: a comparison of two instructional methods in inpatient geriatrics for medical students

The varied, atypical manifestations of geriatric syndromes make knowledge transfer the ability to extend knowledge from one context to another a particularly relevant concept. The authors hypothesized that multiple, contrasting short cases, by facilitating knowledge transfer, would improve knowledge more than a single long case in geriatric medicine. The authors' objective was to assess the impact of two instructional methods (a single long case vs. contrasting short cases) on knowledge and knowledge retention among 3rd-year medical students on their Internal Medicine-Geriatrics Clerkship. They participated in the curriculum which consisted of four weekly mandatory sessions covering five content areas based on a systematic needs assessment. Instructional method alternated by month. Knowledge and knowledge retention were measured using an online multiple-choice question test administered before, immediately after, and one year following the curriculum. Students also completed a demographic survey prior to the curriculum and an evaluation of the curriculum following the curriculum. There was significant improvement in test scores from pre- to postcurriculum in both groups that persisted one year after the experience with no significant differences between the two groups. The two case-based instructional methods resulted in significant and enduring knowledge improvement, but one method was not better than the other.

Validation of 2 new measures of continuity of care based on year-to-year follow-up with known providers of health care

PURPOSE

In a primary care context favoring group practices, we assessed the validity of 2 new continuity measures (both versions of known provider continuity, KPC) that capture the concentration of care over time from multiple physicians (multiple provider continuity, KPC-MP) or from the physician seen most often (personal provider continuity, KPC-PP).

METHODS

Patients with diabetes or cardiovascular disease (N = 765) were approached in the waiting rooms of 28 primary care clinics in 3 regions of the province of Quebec, Canada; answered a survey questionnaire measuring relational continuity, interpersonal communication, coordination within the clinic, coordination with specialists, and overall coordination; and gave permission for their medical records to be reviewed and their medical services utilization data for the previous 2 years to be accessed to measure KPC. Using generalized linear mixed models, we assessed the association between KPC and the patients' responses.

RESULTS

Among the 5 different patient-reported measures or their combination, KPC-MP was significantly related with overall coordination of care: for high continuity, the odds ratio (OR) = 2.02 (95% CI, 1.33-3.07), and for moderate continuity, OR = 1.61 (95% CI, 1.06-2.46). KPC-MP was also related with the combined continuity score: for high continuity, OR = 1.52 (95% CI, 1.11-2.09), and for moderate continuity, OR = 1.48 (95% CI, 1.10-2.00). KPC-PP was not significantly associated with any of the survey measures.

CONCLUSIONS

The KPC-MP measure, based on readily available administrative data, is associated with patient-perceived overall coordination of care among multiple physicians. KPC measures are potentially a valuable and low-cost way to follow the effects of changes favoring group practice on continuity of care for entire populations. They are easy to replicate over time and across jurisdictions.

Identifying landmark articles for advancing the practice of geriatrics

Landmark articles from the peer-reviewed literature can be used to teach the fundamental principles of geriatric medicine. Three approaches were used in sequential combination to identify landmark articles as a resource for geriatricians and other healthcare practitioners. Candidate articles were identified first through a literature review and expert opinion survey of geriatric medicine faculty. Candidate articles in a winnowed list (n = 30) were then included in a bibliometric analysis that incorporated the journal impact factor and average monthly citation index. Finally, a consensus panel reviewed articles to assess each manuscript's clinical relevance. For each article, a final score was determined by averaging, with equal weight, the opinion survey, bibliometric analysis, and consensus panel review. This process ultimately resulted in the identification of 27 landmark articles. Overall, there was weak correlation between articles that the expert opinion survey and bibliometric analysis both rated highly. This process demonstrates a feasible method combining subjective and objective measures that can be used to identify landmark papers in geriatric medicine for the enhancement of geriatrics education and practice.

Geriatric education in undergraduate and graduate levels in Latin America

A recent dramatic increase in the elderly population has not been accompanied by a parallel increase in specialized health care professionals in Latin America. The main purpose of this work was to determine the stage of geriatrics teaching for undergraduate and graduate medical levels in Latin America. Using a questionnaire given in person and online, the authors surveyed geriatricians from 16 countries: eight from South America and eight from Central America. Among 308 medical schools, 35% taught undergraduate geriatrics, ranging from none in Uruguay, Venezuela, and Guatemala to 82% in Mexico. The authors identified 36 programs in 12 countries with graduate medical education in geriatrics, ranging from 2 to 5 years of training. The authors conclude that although the population is aging rapidly in Latin American countries, there has been a slow development of geriatrics teaching at undergraduate and postgraduate levels in the region.

Age, frailty, disability, institutionalization, multimorbidity or comorbidity. Which are the main targets in older adults?

OBJECTIVES

Age, frailty, disability, institutionalization, multimorbidity or comorbidity are main risk factors for serious health adverse outcomes in older adults. However, the adjusted relevance of each of them in order to determine which characteristics must be of importance for health policies in this population group, has not been established.

DESIGN

Concurrent population-based cohort study.

SETTING

Albacete city, Spain.

PARTICIPANTS

842 participants over age 70 from the FRADEA Study.

MEASUREMENTS

Age, gender, institutionalization, frailty (Fried's criteria), previous disability in basic activities of daily living (BADL) (Barthel index), comorbidity (Charlson index), and multimorbidity (≥ 2 from 14 selected diseases) were recorded in the basal visit. The combined event of mortality or incident disability in BADL was determined in the follow-up visit. The risk of presenting adverse events was determined by Kaplan-Meier analysis and logistic regression adjusted for age, sex, and institutionalization.

RESULTS

Mean follow-up 520 days. 63 participants died (7.5%). Among the remaining 779, 191 lost at least one BADL (24.5%). The combined event of mortality or disability was present in 254 participants (30.2%). Age (OR 1.10, 95%CI 1.06-1.14), frailty (OR 3.07, 95%CI 1.63-5.77), disability (OR 2.19, 95%CI 1.43-3.36) and institutionalization (OR 2.73, 95%CI 1.68-4.44) were independently associated with the combined adverse event, but not comorbidity or multimorbidity. In subjects younger than 80, only frailty, disability and institutionalization were risk factors, and in those aged ≥ 80, only age, disability and institutionalization were.

CONCLUSIONS

Health policies for older adults must take into account mainly frailty and disability in subjects younger than 80 and disability in those older than 80.

Decreasing trend of upper gastrointestinal bleeding mortality risk over three decades

BACKGROUND

Upper gastrointestinal bleeding (UGIB) causes over $1 billion in medical expenses annually.

AIMS

The purpose of this study was to examine changes of UGIB mortality risks and trends over the last three decades.

METHODS

We analyzed the National Hospital Discharge Sample from 1979 to 2009. Patients with primary ICD-9 code representing a diagnosis of UGIB were included. The UGIB mortality risks and trends in each decade by anatomical sites, bleeding causes, comorbidities, and other important variables were analyzed.

RESULTS

UGIB mortality risk decreased by 35.4 % from 4.8 % in the first decade to 3.1 % in the third decade (P < 0.001). Age and number of hospitalization days were significant risk factors in all decades. Most significant decreases were observed in patients over 65 years and during the first day of admission. Gastric (P < 0.001) and esophageal (P = 0.018) bleedings showed significant decreasing mortality risk trends. Duodenal bleeding mortality risk was stable in three decades. Mortality risk declined significantly among patients with renal failure (from 50.0 to 4.0 %) and heart failure (from 17.9 to 5.2 %; both P < 0.001) while changes in cases with ischemic heart disease, cancer, and liver failure were less significant.

CONCLUSION

UGIB morality risks, especially of the first hospital day and geriatric patients, significantly decreased over the last three decades, presumably from recent advances in emergency medical care. Mortality risk of gastric, but not duodenal, bleeding had the most significant reduction. Critical care improvements in patients with various comorbidities may explain significant UGIB mortality risk reductions. This study provides invaluable insight into the causes and trends of UGIB mortality risks for future studies.

Adverse drug events in older hospitalized patients: results and reliability of a comprehensive and structured identification strategy

BACKGROUND

Older patients are at high risk for experiencing Adverse Drug Events (ADEs) during hospitalization. To be able to reduce ADEs in these vulnerable patients, hospitals first need to measure the occurrence of ADEs, especially those that are preventable. However, data on preventable ADEs (pADEs) occurring during hospitalization in older patients are scarce, and no 'gold standard' for the identification of ADEs exists.

METHODOLOGY

The study was conducted in three hospitals in the Netherlands in 2007. ADEs were retrospectively identified by a team of experts using a comprehensive and structured patient chart review (PCR) combined with a trigger-tool as an aid. This ADE identification strategy was applied to a cohort of 250 older hospitalized patients. To estimate the intra- and inter-rater reliabilities, Cohen's kappa values were calculated.

PRINCIPAL FINDINGS

In total, 118 ADEs were detected which occurred in 62 patients. This ADE yield was 1.1 to 2.7 times higher in comparison to other ADE studies in older hospitalized patients. Of the 118 ADEs, 83 (70.3%) were pADEs; 51 pADEs (43.2% of all ADEs identified) caused serious patient harm. Patient harm caused by ADEs resulted in various events. The overall intra-rater agreement of the developed strategy was substantial (κ = 0.74); the overall inter-rater agreement was only fair (κ = 0.24).

CONCLUSIONS/SIGNIFICANCE

The ADE identification strategy provided a detailed insight into the scope of ADEs occurring in older hospitalized patients, and showed that the majority of (serious) ADEs can be prevented. Several strategy related aspects, as well as setting/study specific aspects, may have contributed to the results gained. These aspects should be considered whenever ADE measurements need to be conducted. The results regarding pADEs can be used to design tailored interventions to effectively reduce harm caused by medication errors. Improvement of the inter-rater reliability of a PCR remains challenging.

Geriatric workforce capacity: a pending crisis for nursing home residents

INTRODUCTION

The nursing home (NH) population in the US has grown to 1.6 million people and is expected to double by 2030. While 88.3% of NH residents are over 65, the elders aged 85 and more have become the principal group. This demographic change has increased the already high rates of chronic diseases and functional disabilities in NH residents.

METHODS

This study reviewed the supply of geriatricians in addressing the growing healthcare needs of NH residents.

RESULTS

English-written articles between 1989 and 2012 were reviewed. Trend data demonstrate that the geriatrician workforce has decreased from 10,270 in 2000 to 8,502 in 2010. Further, the pipeline analysis of physicians projected to receive board certification in geriatrics (and maintain this certification) indicates a worsening of the already insufficient supply of geriatricians for this vulnerable population.

CONCLUSION

Strategies to attract and maintain a geriatrician workforce are imperative to avert a mounting crisis in the geriatric care in NH and, by extension, other living settings.

What students experienced: a narrative analysis of essays written by first-year medical students participating in a geriatrics home visit

OBJECTIVES

To develop a house call experience for first-year medical students introducing them to challenges that homebound, chronically ill elderly adults face.

DESIGN

During the semester, two students were paired with a preceptor to see two to three patients.

SETTING

The house call practices of the Division of Geriatric Medicine at the University of Pennsylvania and the Philadelphia Veterans Affairs Hospital.

PARTICIPANTS

One hundred sixty-five first-year medical students.

MEASUREMENTS

Pairs of students worked together to write an essay after the visit. Essays addressed specific areas, as detailed in a provided checklist, including noting patients' functional limitations, identifying community supports available to patients, and writing about general surprises that the students discovered during their visit. These data were then measured using narrative analysis.

RESULTS

In all domains, students identified core goals and objectives. In the first domain (meeting challenges of functional limitations), students recognized the importance of family support. In the second domain (mentioning of functional limitation), high levels of compliance were seen. In the third domain (community support), students mentioned specific formal supports. In the fourth domain (surprises during the visit), students identified many important geriatrics concepts.

CONCLUSION

In writing their essays, students demonstrated a high level of recognition of functional impairment and noted the importance of family, social networks, and home environment in enabling homebound, chronically ill elderly adults to stay in their homes. Many students also demonstrated an awareness of the possibilities of independence and happiness despite significant illness and disability.

Meeting the geriatric workforce shortage for long-term care: opinions from the field

This article seeks to raise awareness of workforce issues among geriatricians in caring for the increasing number of older Americans with disabilities who will need long-term care. Using a snowball sampling technique, telephone or in-person interviews were conducted with 10 geriatricians to obtain providers' perspectives of the challenges of having an adequate supply of qualified physicians working in Texas nursing homes. Speaking from experience (these geriatricians had an average of 15 years of work experience in nursing homes), the geriatric experts reflected upon reasons for choosing (or not) geriatric medicine; reasons for choosing (or not) to work in nursing homes; and the status of geriatrics in the United States. To meet the increasing demand for nursing home services, the findings of this article suggest strengthening support for the geriatrician workforce. Specific recommendations for training the next generation of geriatricians are presented.

Impact of Geriatric Conditions Versus Medical Diagnoses on ADL Disability Among Nonagenarians and Centenarians

Objective: The authors investigated the relationship of activities of daily living (ADL) disability with medical diseases and geriatric conditions among nonagenarians and centenarians. Method: Cross-sectional, n = 870 Chinese (age range: 90-108 years). Self-reported medical diseases and geriatric-specific conditions were obtained by face-to-face interviews. Biomedical measurements included systolic/diastolic blood pressure, BMI (body mass index), albumin, fasting glucose, creatinine clearance, hemoglobin, and lipid panel. Results: In bivariate analyses, 4 of 7 geriatric conditions (hearing problems, falls, cognitive impairment, fracture), and 6 of 11 biomedical measurements (fasting glucose, cholesterol, LDL, creatinine clearance, hemoglobin, albumin), but none of 10 medical diseases and no degree of comorbidities, were associated with ADL disability. In four different multivariate logistic regression models, two geriatric conditions (impaired cognition, fracture) were significant in three models, respiratory disease in one model, and fasting glucose in two models. Discussion: This study emphasizes the importance of geriatric conditions and their association with ADL disability among the oldest-old adult population.

Medical student education program in Alzheimer's disease: the PAIRS Program

BACKGROUND

As life expectancy increases, dementia incidence will also increase, creating a greater need for physicians well-trained to provide integrated geriatric care. However, research suggests medical students have limited knowledge or interest in pursuing geriatric or dementia care. The purpose of this study is to evaluate the PAIRS Program and its effectiveness in enhancing medical education as a service-learning activity and replication model for the Buddy ProgramTM.

METHODS

Between 2007 and 2011, four consecutive classes of first year Boston University School of Medicine students (n = 45; 24 ± 3 years, 58% female, 53% White) participated in a year-long program in which they were paired with a patient with early-stage Alzheimer's disease (AD). Assessments included pre- and post-program dementia knowledge tests and a post-program reflective essay.

RESULTS

Program completion was 100% (n = 45). A paired-sample t-test revealed a modest improvement in dementia knowledge post-program (p < 0.001). Using qualitative coding methods, 12 overarching themes emerged from the students' reflective essays, such as observing care partner burden, reporting a human side to AD, reporting experiences from the program that will impact future clinical practice, and obtaining a greater understanding of AD.

CONCLUSIONS

Quantitative and qualitative findings suggest that the PAIRS Program can enhance the acquisition of knowledge, skills, and positive attitudes regarding geriatric healthcare in future generations of physicians, a skill set that is becoming increasingly relevant in light of the rapidly aging population. Furthermore, results suggest that The Buddy ProgramTM model can be successfully replicated.

A model for partnering first-year student pharmacists with community-based older adults

OBJECTIVES

To design, integrate, and assess the effectiveness of an introductory pharmacy practice experience intended to redefine first-year student pharmacists' views on aging and medication use through their work with a healthy, community-based older-adult population.

DESIGN

All students (N = 273) completed live skills training in an 8-hour boot camp provided during orientation week. Teams were assigned an independently living senior partner, completed 10 visits and reflections, and documented health-related information using an electronic portfolio (e-portfolio).

ASSESSMENT

As determined by pre- and post-experience survey instruments, students gained significant confidence in 7 skill areas related to communication, medication interviews, involving the partner in health care, and applying patient-care skills. Student reflections, in-class presentations, and e-portfolios documented that personal attitudes toward seniors changed over time. Senior partners enjoyed mentoring and interacting with students and many experienced health improvements as a result of the interaction.

CONCLUSIONS

The model for partnering first-year student pharmacists with community-based older adults improved students' skills and fostered their connections to pharmacist roles and growth as person-centered providers.

Environmental determinants of quality of life in nursing home residents with severe dementia

OBJECTIVES

To determine the relationship between quality of life (QOL) and environmental factors of temperature, noise, and lighting in nursing home residents with severe dementia.

DESIGN

Cross-sectional, observational, analytical.

SETTING

Eight public, long-term care nursing homes in the province of Girona, Spain.

PARTICIPANTS

Random sample of 160 nursing home residents with severe dementia.

MEASUREMENTS

Functional and cognitive impairment, pain, neuropsychiatric disturbances, and QOL were determined using standardized instruments. Temperature, noise, and lighting in bedrooms, dining rooms, and living rooms were measured in the morning and afternoon using a multifunction environment meter in a standardized manner.

RESULTS

Adjusted multivariate linear regression models demonstrated that environmental measures were independently associated with QOL and related factors. High temperature in the bedroom was associated with lower QOL (standardized β = 0.184), high noise levels in the living room were associated with low behavioral signs of social interactions (β = 0.196), and low lighting levels in the bedroom were associated with number of signs of negative affective mood (β = -0.135).

CONCLUSION

The QOL of nursing home residents with severe dementia was related to environmental factors such as temperature, noise, and lighting. The monitoring of these environmental factors may improve these individuals' QOL.

Prediction of risk of in-hospital geriatric complications in older patients with hip fracture

BACKGROUND AND AIMS

Hip fracture in older persons is a frequent reason for hospital admission and a substantial workload in orthopedic wards for geriatric liaison teams. However, robust patients who do not present in-hospital complications may not need geriatric liaison. For the sake of triage, we studied the ability of usual admission scores to identify patients who will not develop in-hospital complications, and who may therefore not be included in the overworked geriatric liaison teams.

METHODS

A retrospective cohort of consecutive community- living elderly patients (age ≥ 75 yrs), admitted for traumatic hip fracture in the orthopedic divisions of a teaching hospital over 18 months was examined. The predictive value of commonly used frailty scores (ISAR, VIP, KATZ) to rule out the incidence of three frequent and preventable in-hospital acute geriatric events (major behavioral problems, pressure sores, falls) was assessed by ROC curves and negative likelihood ratio (-LR).

RESULTS

Of 145 older persons with hip fracture (median age 84 years; 76% women; 57% living alone, 44% with pre-existing geriatric syndromes), 81 (56%) presented some acute geriatric events (AGE), i.e. major behavioral problems (46%), pressure sores (19%) and/or falls (5%). The three frailty admission scores showed low power for AGE prediction (area under the ROC curve: 53- 58%) and identification of patients who will not present in-hospital AGE (-LR>0.5 at the most sensitive cut-off).

CONCLUSIONS

None of the three scores helped in the triage of patients according to their risk of future in-hospital AGE. All older patients with hip fracture, irrespective of their admission frailty-robustness profile, should receive geriatric evaluation and intervention.

When is it the right time to ask for a geriatrician?

Given an aging population coupled with a shortage of people to care for them, it is essential to understand the patient qualities for which geriatric expertise would be most beneficial. For the practicing physician attempting to understand the timing of geriatric-care provision, this article reviews the relevant literature, which suggests geriatric expertise should be considered for the patients who benefit most: any patient aged ≥ 85 years, or adults aged < 85 years with complex multimorbidity, frailty, or other geriatric conditions; disability or dementia; or need for palliative or end-of-life care.