Drug Burden Index and Cognitive and Physical Function in Aged Care Residents: A Longitudinal Study

ObjectivesAnticholinergic/antimuscarinic and sedative medications (eg, benzodiazepines) have been found to be associated with poorer cognitive and physical function and mobility impairment in older age. However, previous studies were mostly conducted among community-dwelling older individuals and had often a cross-sectional design. Accordingly, our aim was to examine longitudinal associations between cumulative exposure to anticholinergic and sedative medications and cognitive and physical function among residents from aged care homes.DesignLongitudinal study.Setting and ParticipantsA total of 4624 residents of Dutch aged care homes of whom data were collected between June 2005 and April 2014.MethodsOutcome measures were collected with the Long-Term Care Facilities assessment from the international Residential Assessment Instrument (interRAI-LTCF) and included the Cognitive Performance Scale, the Activities of Daily Living (ADL) Hierarchy scale, a timed 4-meter walk test, distance walked, hours of physical activity, and days being outside. Cumulative exposure to anticholinergic and sedative medications was calculated with the Drug Burden Index (DBI), a linear additive pharmacological dose-response model. Associations were examined with linear mixed models to take the potential dependence of observations into account (ie, data were collected at repeated assessment occasions of residents who were clustered in aged care homes). Analyses were adjusted for sex, age, dementia, comorbidity (neurological, psychiatric, cardiovascular, oncological, and pulmonary), fractures, depressive symptoms, and medications excluded from the DBI.ResultsWe observed significant longitudinal associations between a higher DBI and poorer ADLs, fewer hours of physical activity, and fewer days being outside. We found no significant longitudinal association between a higher DBI and poorer cognitive function.Conclusions and ImplicationsOver time, cumulative exposure to anticholinergic and sedative medications is associated with poorer physical but not cognitive function in aged care residents. Careful monitoring of aged care residents with high cumulative anticholinergic and sedative medication exposure is needed.     

Interprofessional training: Geriatrics and palliative care principles for primary care teams in an ACO

ABSTRACT

There is a well-described need to increase the competence of the primary care workforce in the principles of geriatrics and palliative care, and as value-based payment models proliferate, there is increased incentive for the acquisition of these skills. Through a Geriatric Workforce Enhancement Program grant, we developed an adaptable curriculum around commonly encountered topics in palliative care and geriatrics that can be delivered to multidisciplinary clinicians in primary care settings. All participants in this training were part of an Accountable Care Organization (ACO) and were motivated to improve to care for complex older adults. A needs assessment was performed on each practice or group of learners and the curriculum was adapted accordingly. With the use of patient education and screening tools with strong validity evidence, the participants were trained in the principals of geriatrics and palliative care with a focus on advance care planning and assessing for frailty and functional decline. Comparison of pre- and post-test scores demonstrated increased confidence and knowledge in goals of care and basic geriatric assessment. Participants described feeling more able to address needs, have conversations around goals of care, and more able to recognize patients who would benefit from collaboration with geriatrics and palliative care.     

American Geriatrics Society Policy Brief: COVID-19 and Nursing Homes

This policy brief sets forth the American Geriatrics Society's (AGS's) recommendations to guide federal, state, and local governments when making decisions about care for patients with coronavirus disease 2019 (COVID-19) in nursing homes (NHs) and other long-term care facilities (LTCFs). The AGS continues to review guidance set forth in peer-reviewed articles and editorials, as well as ongoing and updated guidance from the Centers for Medicare and Medicaid Services, the Centers for Disease Control and Prevention, and other key agencies. This brief is based on the situation and any federal guidance/actions as of April 4, 2020. It is focused on NHs and other LTCFs, given their essential role in addressing the COVID-19 pandemic. J Am Geriatr Soc 68:908–911, 2020     

Perceived benefits of geriatric specialty telemedicine among rural patients and caregivers

Objective

Explore the perceived benefits of a Veterans Health Administration (VHA) geriatric specialty telemedicine service (GRECC Connect) among rural, older patients and caregivers to contribute to an assessment of its quality and value.

Data Sources

In Spring 2021, we interviewed a geographically diverse sample of rural, older patients and their caregivers who participated in GRECC Connect telemedicine visits.

Study Design

A cross-sectional qualitative study focused on patient and caregiver experiences with telemedicine, including perceived benefits and challenges.

Data Collection

We conducted 30 semi-structured qualitative interviews with rural, older (≥65) patients enrolled in the VHA and their caregivers via videoconference or phone. Interviews were recorded, transcribed, and analyzed using a rapid qualitative analysis approach.

Principal Findings

Participants described geriatric specialty telemedicine visits focused on cognitive assessments, tailored physical therapy, medication management, education on disease progression, support for managing multiple comorbidities, and suggestions to improve physical functioning. Participants reported that, in addition to prescribing medications and ordering tests, clinicians expedited referrals, coordinated care, and listened to and validated both patient and caregiver concerns. Perceived benefits included improved patient health; increased patient and caregiver understanding and confidence around symptom management; and greater feelings of empowerment, hopefulness, and support. Challenges included difficulty accessing some recommended programs and services, uncertainty related to instructions or follow-up, and not receiving as much information or treatment as desired. The content of visits was well aligned with the domains of the Age-Friendly Health Systems and Geriatric 5Ms frameworks (Medication, Mentation, Mobility, what Matters most, and Multi-complexity).

Conclusions

Alignment of patient and caregiver experiences with widely-used models of comprehensive geriatric care indicates that high-quality geriatric care can be provided through virtual modalities. Additional work is needed to develop strategies to address challenges and optimize and expand access to geriatric specialty telemedicine.     

Leveraging the Experiences of Informal Caregivers to Create Future Healthcare Workforce Options

The objective of this study was gather pilot data from informal caregivers regarding the potential for a training program to assist current or past caregivers in reentering the job market, and thus offering a pathway to economic resilience. In an effort that could foster a sustainable and competent caregiving market to help meet the needs of an aging America, whether training informal caregivers might help them transition into a paid caregiving or other health service role was explored. Caregivers (N = 55) of a chronically or terminally ill family member or friend in a suburban county near Chicago were interviewed. The interview guide addressed household economic effect of illness, emotional burden, and training program interest. Fifty‐six percent of caregivers were interested in training to work outside the home, caring for people in other households, 84% indicated a desire to learn more about health care, and 68% reported a desire to explore job possibilities in health care. Eighty‐two percent were experienced in working with an individual aged 50 and older. Informal caregivers' interest in a training program to bolster their qualifications for a role in the healthcare workforce, including the option of a formal caregiver position, supports the demand for such a program. Considering the need for healthcare workers to serve the growing elderly population and the desire of informal caregivers to find gainful employment, these informal caregivers could provide the impetus to invest in informal caregiver training.     

Comorbid Profile Rather than Age Determines Hip Fracture Mortality in a Nonagenarian Population

Background

In light of poor outcomes with nonoperative management of hip fractures, orthopedic surgeons are faced with difficult decisions about which patients are too ill or too old for surgical treatment.

Questions/Purposes

This study sought to investigate if patients over 90 years had different preoperative laboratory, clinical, and injury characteristics than younger patients with the same injury. We compared our cohort with previously published data. We wished to identify if there were pre-injury risk factors associated with 30-day mortality, which could be modified to enhance postoperative outcomes.

Methods

This is a retrospective review of 198 operatively managed hip fractures in patients 75 years or older. We collected data on demographics, select preoperative laboratory values, injury type, comorbidities, and 30-day mortality.

Results

Eleven (5.6%) of the cohort died within 30 days of surgery, 6.3% in the younger group, and 3.7% in the older group; the difference was not statistically significant. For baseline characteristics, there was no difference between the age groups for pre-injury comorbidities, hemoglobin, serum albumin, BUN, prevalence of UTI, or fracture type. A total of 67 (35.8%) patients had evidence of UTI on admission.

Conclusions

These findings reveal that in our dichotomized cohort, pre-injury characteristics were similar and age alone was not an independent predictor of mortality. These data may inform decision-making for orthopedic surgeons and the medical providers who consult to optimize these patients for surgery. We identified high rates of UTI in both age groups, a potentially remediable factor to optimize outcomes in hip fracture surgery in elderly patients.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-015-9435-y) contains supplementary material, which is available to authorized users.     

The correlation between fear of falling and upper extremity muscle strength

Objectives:To determine the relationship between fear of falling (FOF) and upper extremity muscle strength.Methods:This cross-sectional study included 112 hospitalized, mobile patients. Forty-seven (42%) were males and 65 (58%) were females, and the mean age was 72.3. The study was carried out between September 2018 and September 2019 at Balikli Rum Hospital Nursing Homes, Istanbul, Turkey. Patients were tested using geriatric tools (such as Mini-Mental State Examination) and physical tests such as handgrip, key pinch and 6-meter up and go tests.Results:The average annual falling number of elderly people with FOF was statistically significantly higher than that in those without FOF (p=0.001). Right handgrip, left handgrip, right key pinch, and left key-pinch mean values in elderly individuals with FOF were statistically significantly lower than those without FOF (p< 0.001, p< 0.001, p< 0.001, p< 0.001, respectively).Conclusion:The measurement of upper extremity strength could be a predicting parameter of FOF.