A Qualitative and Quantitative Analysis of the Geriatrics Update: Clinical Pearls Course

Background

The University of Calgary Cumming School of Medicine Annual Geriatrics Update: Clinical Pearls Course (Geriatrics Update) is a one-day, continuing medical education (CME) course designed to enhance geriatrics competency for family physicians (FPs), given increasing population age and complexity. We aimed to evaluate how the course meets FPs’ perceived learning needs and identify modifications that may better support FPs.

Methods

Descriptive data from 2018–2019 course evaluation surveys including demographic data, evaluations, and narrative feedback from participating FPs. Semi-structured phone and video-conferenced interviews with FPs were thematically analyzed each year.

Results

Evaluation surveys had high response rates of FPs (52 or 61% in 2018; 39 or 58% in 2019). Most FP respondents (84% in 2018 and 82% in 2019) intended to make practice changes. FPs were significantly (p=.001) more confident on course objectives after the course in both years. All interviewees (n=20) described fulfilled perceived and unperceived learning needs and planned to return. The Geriatrics Update course is the primary source of Geriatrics CME for 60% of interviewees.

Conclusions

Iterative evaluation of Geriatrics Update identified that the course is well received, and often FPs primary source of geriatric CME. Interviews provided additional context and descriptive feedback to improve course delivery and better meet FP learning needs.

Comparing frailty measures in their ability to predict adverse outcome among older residents of assisted living

BACKGROUND

Few studies have directly compared the competing approaches to identifying frailty in more vulnerable older populations. We examined the ability of two versions of a frailty index (43 vs. 83 items), the Cardiovascular Health Study (CHS) frailty criteria, and the CHESS scale to accurately predict the occurrence of three outcomes among Assisted Living (AL) residents followed over one year.

METHODS

The three frailty measures and the CHESS scale were derived from assessment items completed among 1,066 AL residents (aged 65+) participating in the Alberta Continuing Care Epidemiological Studies (ACCES). Adjusted risks of one-year mortality, hospitalization and long-term care placement were estimated for those categorized as frail or pre-frail compared with non-frail (or at high/intermediate vs. low risk on CHESS). The area under the ROC curve (AUC) was calculated for select models to assess the predictive accuracy of the different frailty measures and CHESS scale in relation to the three outcomes examined.

RESULTS

Frail subjects defined by the three approaches and those at high risk for decline on CHESS showed a statistically significant increased risk for death and long-term care placement compared with those categorized as either not frail or at low risk for decline. The risk estimates for hospitalization associated with the frailty measures and CHESS were generally weaker with one of the frailty indices (43 items) showing no significant association. For death and long-term care placement, the addition of frailty (however derived) or CHESS significantly improved on the AUC obtained with a model including only age, sex and co-morbidity, though the magnitude of improvement was sometimes small. The different frailty/risk models did not differ significantly from each other in predicting mortality or hospitalization; however, one of the frailty indices (83 items) showed significantly better performance over the other measures in predicting long-term care placement.

CONCLUSIONS

Using different approaches, varying degrees of frailty were detected within the AL population. The various approaches to defining frailty were generally more similar than dissimilar with regard to predictive accuracy with some exceptions. The clinical implications and opportunities of detecting frailty in more vulnerable older adults require further investigation.

Operationalizing frailty among older residents of assisted living facilities

BACKGROUND

Frailty in later life is viewed as a state of heightened vulnerability to poor outcomes. The utility of frailty as a measure of vulnerability in the assisted living (AL) population remains unexplored. We examined the feasibility and predictive accuracy of two different interpretations of the Cardiovascular Health Study (CHS) frailty criteria in a population-based sample of AL residents.

METHODS

CHS frailty criteria were operationalized using two different approaches in 928 AL residents from the Alberta Continuing Care Epidemiological Studies (ACCES). Risks of one-year mortality and hospitalization were estimated for those categorized as frail or pre-frail (compared with non-frail). The prognostic significance of individual criteria was explored, and the area under the ROC curve (AUC) was calculated for select models to assess the utility of frailty in predicting one-year outcomes.

RESULTS

Regarding feasibility, complete CHS criteria could not be assessed for 40% of the initial 1,067 residents. Consideration of supplementary items for select criteria reduced this to 12%. Using absolute (CHS-specified) cut-points, 48% of residents were categorized as frail and were at greater risk for death (adjusted risk ratio [RR] 1.75, 95% CI 1.08-2.83) and hospitalization (adjusted RR 1.54, 95% CI 1.20-1.96). Pre-frail residents defined by absolute cut-points (48.6%) showed no increased risk for mortality or hospitalization compared with non-frail residents. Using relative cut-points (derived from AL sample), 19% were defined as frail and 55% as pre-frail and the associated risks for mortality and hospitalization varied by sex. Frail (but not pre-frail) women were more likely to die (RR 1.58 95% CI 1.02-2.44) and be hospitalized (RR 1.53 95% CI 1.25-1.87). Frail and pre-frail men showed an increased mortality risk (RR 3.21 95% CI 1.71-6.00 and RR 2.61 95% CI 1.40-4.85, respectively) while only pre-frail men had an increased risk of hospitalization (RR 1.58 95% CI 1.15-2.17). Although incorporating either frailty measure improved the performance of predictive models, the best AUCs were 0.702 for mortality and 0.633 for hospitalization.

CONCLUSIONS

Application of the CHS criteria for frailty was problematic and only marginally improved the prediction of select adverse outcomes in AL residents. Development and validation of alternative approaches for detecting frailty in this population, including consideration of female/male differences, is warranted.

A pragmatic study exploring the prevention of delirium among hospitalized older hip fracture patients: Applying evidence to routine clinical practice using clinical decision support

Delirium occurs in up to 65% of older hip fracture patients. Developing delirium in hospital has been associated with a variety of adverse outcomes. Trials have shown that multi-component preventive interventions can lower delirium rates. The objective of this study was to implement and evaluate the effectiveness of an evidence-based electronic care pathway, which incorporates multi-component delirium strategies, among older hip fracture patients. We conducted a pragmatic study using an interrupted time series design in order to evaluate the use and impact of the intervention. The target population was all consenting patients aged 65 years or older admitted with an acute hip fracture to the orthopedic units at two Calgary, Alberta hospitals. The primary outcome was delirium rates. Secondary outcomes included length of hospital stay, in-hospital falls, in-hospital mortality, new discharges to long-term care, and readmissions. A Durbin Watson test was conducted to test for serial correlation and, because no correlation was found, Chi-square statistics, Wilcoxon test and logistic regression analyses were conducted as appropriate. At study completion, focus groups were conducted at each hospital to explore issues around the use of the order set. During the 40-week study period, 134 patients were enrolled. The intervention had no effect on the overall delirium rate (33% pre versus 31% post; p = 0.84). However, there was a significant interaction between study phase and hospital (p = 0.03). Although one hospital did not experience a decline in delirium rate, the delirium rate at the other hospital declined from 42% to 19% (p = 0.08). This difference by hospital was mirrored in focus group feedback. The hospital that experienced a decline in delirium rates was more supportive of the intervention. Overall, post-intervention there were no significant differences in mean length of stay (12 days post versus 14 days pre; p = 0.74), falls (6% post versus 10% pre; p = 0.43) or discharges to long-term care (6% post versus 13% pre; p = 0.20). Translation of evidence-based multi-component delirium prevention strategies into everyday clinical care, using the electronic medical record, was not found to be effective at decreasing delirium rates among hip facture patients.

Patient sex does not modify ejection fraction as a predictor of death in heart failure: insights from the APPROACH cohort

BACKGROUND

Normal and low ejection fraction (EF) heart failure patients appear to have similar outcomes.

OBJECTIVE

The object of this study was to determine whether sex modifies the effects of left ventricular EF on prevalent heart failure mortality.

DESIGN

Prospective cohort study.

PATIENTS

Patients (n = 6, 095) with a diagnosis of heart failure and a measure of EF undergoing cardiac catheterization in Alberta, Canada between April 1999 and December 2004; follow-up continued through October 2005.

MEASUREMENTS

All-cause mortality was assessed in analyses stratified by patient sex and EF (<or=50% vs. >50%).

MAIN RESULTS

Overall, female heart failure patients were older, had more hypertension, valvular disease, less systolic impairment and coronary artery disease. Baseline medication use was similar in the four sex-EF groups. Low EF heart failure mortality over 6.5 years was slightly higher but was not significantly modified by patient sex. This relationship remained unchanged after adjustment for differences in baseline characteristics and process of care (women normal EF, reference group; men normal EF adjusted HR 1.1, 95% CI 0.9-1.3; women low EF adjusted HR 1.5, 95% CI 1.1-2.0; men low EF adjusted HR 1.6, 95% CI 1.2-2.1).

CONCLUSIONS

Patient sex did not appear to modify the negative effects of low EF on long-term survival in this prospective study of prevalent heart failure. The small absolute difference in survival between low and normal EF heart failure highlights the need for further research into optimal therapy for the latter, a less well-understood condition.

Living alone, patient sex and mortality after acute myocardial infarction

BACKGROUND

Psychosocial factors, including social support, affect outcomes of cardiovascular disease, but can be difficult to measure. Whether these factors have different effects on mortality post-acute myocardial infarction (AMI) in men and women is not clear.

OBJECTIVE

To examine the association between living alone, a proxy for social support, and mortality postdischarge AMI and to explore whether this association is modified by patient sex.

DESIGN

Historical cohort study.

PARTICIPANTS/SETTING

All patients discharged with a primary diagnosis of AMI in a major urban center during the 1998-1999 fiscal year.

MEASUREMENTS

Patients' sociodemographic and clinical characteristics were obtained by standardized chart review and linked to vital statistics data through December 2001.

RESULTS

Of 880 patients, 164 (18.6%) were living alone at admission and they were significantly more likely to be older and female than those living with others. Living alone was independently associated with mortality [adjusted hazard ratio (HR) 1.6, 95% confidence interval (CI) 1.0-2.5], but interacted with patient sex. Men living alone had the highest mortality risk (adjusted HR 2.0, 95% CI 1.1-3.7), followed by women living alone (adjusted HR 1.2, 95% CI 0.7-2.2), men living with others (reference, HR 1.0), and women living with others (adjusted HR 0.9, 95% CI 0.5-1.5).

CONCLUSIONS

Living alone, an easily measured psychosocial factor, is associated with significantly increased longer-term mortality for men following AMI. Further prospective studies are needed to confirm the usefulness of living alone as a prognostic factor and to identify the potentially modifiable mechanisms underlying this increased risk.

Chronic cytomegalovirus infection and inflammation are associated with prevalent frailty in community-dwelling older women

OBJECTIVES

To evaluate the association between asymptomatic chronic cytomegalovirus (CMV) infection and the frailty syndrome and to assess whether inflammation modifies this association.

DESIGN

Cross-sectional analysis.

SETTING

Women's Health and Aging Study I & II, Baltimore, Maryland.

PARTICIPANTS

Seven hundred twenty-four community-dwelling women aged 70 to 79 with baseline measures of CMV, interleukin-6 (IL-6), and frailty status.

MEASUREMENTS

CMV serology and IL-6 concentrations were measured using enzyme-linked immunosorbent assay. Frailty status was based on previously validated criteria: unintentional weight loss, weak grip strength, exhaustion, slow walking speed, and low level of activity. Frail women had three or more of the five components, prefrail women had one or two components, and women who were not frail had none of the components. Multinomial logistic regression adjusted for potential confounders.

RESULTS

Eighty-seven percent of women were CMV seropositive, an indication of chronic infection. CMV was associated with prevalent frailty, adjusting for age, smoking history, elevated body mass index, diabetes mellitus, and congestive heart failure (CMV frail adjusted odds ratio (AOR)=3.2, P=.03; CMV prefrail AOR=1.5, P=.18). IL-6 interacted with CMV, significantly increasing the magnitude of this association (CMV positive and low IL-6 frail AOR=1.5, P=.53; CMV positive and high IL-6 frail AOR=20.3, P=.007; CMV positive and low IL-6 prefrail AOR=0.9, P=.73; CMV positive and high IL-6 prefrail AOR=5.5, P=.001).

CONCLUSION

Chronic CMV infection is associated with prevalent frailty, a state with increased morbidity and mortality in older adults; inflammation enhances this effect. Further prospective studies are needed to establish a causal relationship between CMV, inflammation, and frailty.