Utilizing a Meals on Wheels Program to Teach Falls Risk Assessment to Medical Students

Falls are a critical public health issue for older adults, and falls risk assessment is an expected competency for medical students. The aim of this study was to design an innovative method to teach falls risk assessment using community-based resources and limited geriatrics faculty. The authors developed a Fall Prevention Program through a partnership with Meals-on-Wheels (MOW). A 3rd-year medical student accompanies a MOW client services associate to a client’s home and performs a falls risk assessment including history of falls, fear of falling, medication review, visual acuity, a Get Up and Go test, a Mini-Cog, and a home safety evaluation, reviewed in a small group session with a faculty member. During the 2010 academic year, 110 students completed the in-home falls risk assessment, rating it highly. One year later, 63 students voluntarily completed a retrospective pre/postsurvey, and the proportion of students reporting moderate to very high confidence in performing falls risk assessments increased from 30.6% to 87.3% (p < .001). Students also reported using most of the skills learned in subsequent clerkships. A single educational intervention in the MOW program effectively addressed geriatrics competencies with minimal faculty effort and could be adopted by many medical schools.     

Web‐Based Training in Geriatrics for Medical Residents: A Randomized Controlled Trial Using Standardized Patients to Assess Outcomes

Although Web‐based instruction offers an advantageous approach to medical education, few studies have addressed the use of Web‐based education to teach clinical content at the postgraduate level. Even fewer studies have addressed clinical outcomes after the Web‐based instruction, yet postgraduate training requirements now focus on outcomes of training. A randomized trial was conducted to compare knowledge of postgraduate year (PGY) 1 residents after Web‐based with that after paper‐based instruction and to compare residents' clinical application of their instruction using unannounced standardized patients (SPs) and unannounced activated standardized patients (ASPs). PGY 1 residents were assigned to a month‐long ambulatory rotation during which they were randomized as a block to Web‐ or paper‐based instruction covering the same four geriatric syndromes (dementia, depression, falls, and urinary incontinence). Outcome measures were mean change scores for before and after testing and scores from SP and ASP clinical encounter forms (checklist, chart abstraction, and electronic order entry). Residents who completed the Web‐based instruction showed significantly greater improvement on the knowledge tests than those who received paper‐based instruction. There were no significant differences in the scores from the SP and ASP clinical encounters except that the chart abstraction score was better for Web‐based group than the paper‐based group for dementia. Web‐based instruction is an educational tool that medical residents readily accept and can be used to improve knowledge of core geriatrics content as measured using immediate posttesting. More‐intensive educational interventions are needed to improve clinical performance by trainees in the care of older patients.     

Gait and Cognition: A Complementary Approach to Understanding Brain Function and the Risk of Falling

Until recently, clinicians and researchers have performed gait assessments and cognitive assessments separately when evaluating older adults, but increasing evidence from clinical practice, epidemiological studies, and clinical trials shows that gait and cognition are interrelated in older adults. Quantifiable alterations in gait in older adults are associated with falls, dementia, and disability. At the same time, emerging evidence indicates that early disturbances in cognitive processes such as attention, executive function, and working memory are associated with slower gait and gait instability during single‐ and dual‐task testing and that these cognitive disturbances assist in the prediction of future mobility loss, falls, and progression to dementia. This article reviews the importance of the interrelationship between gait and cognition in aging and presents evidence that gait assessments can provide a window into the understanding of cognitive function and dysfunction and fall risk in older people in clinical practice. To this end, the benefits of dual‐task gait assessments (e.g., walking while performing an attention‐demanding task) as a marker of fall risk are summarized. A potential complementary approach for reducing the risk of falls by improving certain aspects of cognition through nonpharmacological and pharmacological treatments is also presented. Untangling the relationship between early gait disturbances and early cognitive changes may be helpful in identifying older adults at risk of experiencing mobility decline, falls, and progression to dementia.     

A Patient Safety and Transitions of Care Curriculum for Third-Year Medical Students

The elderly are the most vulnerable to adverse events during and after hospitalization. This study sought to evaluate the effectiveness of a curriculum on patient safety and transitions of care for medical students during an Internal Medicine-Geriatrics Clerkship on students’ knowledge, skills, and attitudes. The curriculum included didactics on patient safety, health literacy, discharge planning and transitions of care, and postdischarge visits to patients. Analysis of pre- and postassessments showed afterwards students were significantly more comfortable assessing a patient’s health literacy and confident performing a medication reconciliation, providing education regarding medications, and identifying barriers during transitions. More students were able to identify the most common source of adverse events after discharge (86% vs. 62% before), risk factors for low health literacy (28% vs. 14%), and ways to assess a patient’s health literacy (14% vs. 2%). It was feasible to implement a postdischarge visit assignment in an urban tertiary care setting and only required on average of approximately an one and one half hours for students to complete.     

Systematic Review: Helping the Young to Understand the Old. Teaching Interventions in Geriatrics to Improve the Knowledge,Skills, and Attitudes of Undergraduate Medical Students

It is unclear whether geriatrics‐specific educational interventions lead to improvement in students' knowledge, skills, and attitudes and whether successful interventions possess any consistent features. This review examines the effect of educational interventions on undergraduate knowledge, skills, and attitudes in geriatric medicine and concludes that a wide range of innovative designs have the potential to improve each of these parameters, although evidence of interventions that improve student skills is lacking, and further research is necessary to confirm the efficacy of specific teaching strategies in geriatrics.     

Multisite Geriatrics Clerkship for Fourth-Year Medical Students: A Successful Model for Teaching the Association of American Medical Colleges' Core Competencies

As the population ages, it is important that graduating medical students be properly prepared to treat older adults, regardless of their chosen specialty. To this end, the Association of American Medical Colleges (AAMC) and the John A. Hartford Foundation convened a consensus conference to establish core competencies in geriatrics for all graduating medical students. An ambulatory geriatric clerkship for fourth-year medical students that successfully teaches 24 of the 26 AAMC core competencies using an interdisciplinary, team-based approach is reported here. Graduating students (N=158) reported that the clerkship was successful at teaching the core competencies, as evidenced by positive responses on the AAMC Graduation Questionnaire (GQ). More than three-quarters (80–93%) of students agreed or strongly agreed that they learned the seven geriatrics concepts asked about on the GQ, which cover 14 of the 26 core competencies. This successful model for a geriatrics clerkship can be used in many institutions to teach the core competencies and in any constellation of geriatric ambulatory care sites that are already available to the faculty.     

Integrating and Evaluating Geriatrics in Medical School: A Novel Approach for the Challenge

Brown Medical School developed a comprehensive curriculum in which enriched aging content increased from 22 to 80 hours in preclerkship courses and was also added for clerkships, residencies, and nongeriatrician physicians. Innovative evaluation strategies are also described. Highlights include “treasure hunts” in the anatomy laboratory, a Scholarly Concentration in Aging, Schwartz Communication Sessions, a Website of aging-related materials, and a monthly column in the state medical journal. Evaluation includes “tracking” to compute the “dose” of aging content, and “journaling” and focus groups to evaluate students' responses. Integrating geriatrics across a broad range of courses and clinical experiences is feasible.     

Self-Confidence in and Perceived Utility of the Physical Examination: A Comparison of Medical Students,Residents, and Faculty Internists

BACKGROUND AND OBJECTIVES Little is known about the differences in attitudes of medical students, Internal Medicine residents, and faculty Internists toward the physical examination. We sought to investigate these groups’ self-confidence in and perceived utility of physical examination skills. DESIGN AND PARTICIPANTS Cross-sectional survey of third- and fourth-year medical students, Internal Medicine residents, and faculty Internists at an academic teaching hospital. MEASUREMENTS Using a 5-point Likert-type scale, respondents indicated their self-confidence in overall physical examination skill, as well as their ability to perform 14 individual skills, and how useful they felt the overall physical examination, and each skill, to be for yielding clinically important information. RESULTS The response rate was 80% (302/376). The skills with overall mean self-confidence ratings less than “neutral” were interpreting a diastolic murmur (2.9), detecting a thyroid nodule (2.8), and the nondilated fundoscopic examination using an ophthalmoscope to assess retinal vasculature (2.5). No skills had a mean utility rating less than neutral. The skills with the greatest numerical differences between mean self-confidence and perceived utility were distinguishing between a mole and melanoma (1.5), detecting a thyroid nodule (1.4), and interpreting a diastolic murmur (1.3). Regarding overall self-confidence, third-year students’ ratings (3.3) were similar to those of first-year residents (3.4; p = .95) but less than those of fourth-year students (3.8; p = .002), upper-level residents (3.7; p = .01), and faculty Internists (3.9; p < .001). CONCLUSIONS Self-confidence in the physical exam does not necessarily increase at each stage of training. The differences found between self-confidence and perceived utility for a number of skills suggest important areas for educational interventions.     

The Strategies to Reduce Injuries and Develop Confidence in Elders Intervention: Falls Risk Factor Assessment and Management,Patient Engagement,and Nurse Co‐management

In response to the epidemic of falls and serious falls‐related injuries in older persons, in 2014, the Patient Centered Outcomes Research Institute (PCORI) and the National Institute on Aging funded a pragmatic trial, Strategies to Reduce Injuries and Develop confidence in Elders (STRIDE) to compare the effects of a multifactorial intervention with those of an enhanced usual care intervention. The STRIDE multifactorial intervention consists of five major components that registered nurses deliver in the role of falls care managers, co‐managing fall risk in partnership with patients and their primary care providers (PCPs). The components include a standardized assessment of eight modifiable risk factors (medications; postural hypotension; feet and footwear; vision; vitamin D; osteoporosis; home safety; strength, gait, and balance impairment) and the use of protocols and algorithms to generate recommended management of risk factors; explanation of assessment results to the patient (and caregiver when appropriate) using basic motivational interviewing techniques to elicit patient priorities, preferences, and readiness to participate in treatments; co‐creation of individualized falls care plans that patients’ PCPs review, modify, and approve; implementation of the falls care plan; and ongoing monitoring of response, regularly scheduled re‐assessments of fall risk, and revisions of the falls care plan. Custom‐designed falls care management software facilitates risk factor assessment, the identification of recommended interventions, clinic note generation, and longitudinal care management. The trial testing the effectiveness of the STRIDE intervention is in progress, with results expected in late 2019.     

A Novel Approach to Proactive Primary Care–Based Case Finding and Multidisciplinary Management of Falls,Syncope, and Dizziness in a One‐Stop Service: Preliminary Results

National and international evidence and guidelines on falls prevention and management in community‐dwelling elderly adults recommend that falls services should be multifactorial and their interventions multicomponent. The way that individuals are identified as having had or being at risk of falls in order to take advantage of such services is far less clear. A novel multidisciplinary, multifactorial falls, syncope, and dizziness service model was designed with enhanced case ascertainment through proactive, primary care–based screening (of individual case notes of individuals aged ≥60) for individual fall risk factors. The service model identified 4,039 individuals, of whom 2,232 had significant gait and balance abnormalities according to senior physiotherapist assessment. Significant numbers of individuals with new diagnoses ranging from cognitive impairment to Parkinson's disease to urgent indications for a pacemaker were discovered. More than 600 individuals were found who were at high risk of osteoporosis according to World Health Association Fracture Risk Assessment Tool score, 179 with benign positional paroxysmal vertigo and 50 with atrial fibrillation. Through such screening and this approach, Comprehensive Geriatric Assessment Plus (Plus falls, syncope and dizziness expertise), unmet need was targeted on a scale far outside the numbers seen in clinical trials. Further work is needed to determine whether this approach translates into fewer falls and decreases in syncope and dizziness.     

TeamCare: Development and Evaluation of an Evidence Based Model for Supporting Safer,Quality Care Delivery to Residents in Aged Care Facilities

This paper reports on the evaluation of a teamwork intervention designed to introduce four evidence-based teamwork protocols. The aim of the intervention was to standardize and improve team communication and team leadership in care delivered in a residential aged care facility. The evaluation framework examined changes in understanding and practice of the new teamwork protocols, as well as evolution of leadership from hierarchical, command-and-control style of traditional nursing, to a preferred distributed leadership. Of the four teams involved in training, only one successfully transitioned to working with the new protocols. This outcome is analyzed in terms of whole of organization factors impacting on practice change at the care delivery interface.     

Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction: A Report by the National Heart Attack Alert Program

An estimated 13 million people in the United States have coronary heart disease (CHD), peripheral vascular disease, or cerebrovascular disease. The risk for subsequent myocardial infarction (MI) and death in these patients is fivefold to sevenfold higher than for the general population. Many effective therapies are now available for patients with unstable angina, acute myocardial infarction (AMI), potentially fatal arrhythmias, and cardiogenic shock if they seek and receive care expeditiously. However, delays in accessing and receiving care are a continuing problem, threatening the effectiveness of available treatments. Patients with previously diagnosed CHD, including a previous MI, have the same or greater delay times as those without prior MI or CHD. Because of the high-risk status of these patients, combined with the problem of delay in seeking care, this Working Group of the National Heart Attack Alert Program Coordinating Committee advises physicians and other healthcare providers of their important role in reducing treatment delay in these patients. The Working Group recommends that primary care clinicians in the office and in inpatient settings provide these patients and their family members or significant others with contingency counseling about actions to take in response to symptoms of an AMI. The counseling should address the emotional aspects (e.g., fear and denial) that patients and those around them may experience, as well as barriers that may be associated with the healthcare delivery system. Assistance from other healthcare providers (e.g., nurses) should be solicited to initiate, reinforce, and supplement the counseling. A Patient Advisory Form is offered as an aid to providers in counseling their high-risk patients about these issues. Other materials and aids should be considered as well. Physicians offices and clinics should devise a system to triage patients rapidly when they call or walk in seeking advice for possible AMI symptoms. Further research is needed to learn more about effective counseling strategies; symptom manifestation in high-risk groups, including the elderly, women, and minorities; and healthcare delivery systems that enhance access to timely care for patients with prior CHD or other clinical atherosclerotic disease.     

A Randomized,Double-Blind,Placebo-Controlled Study of the Safety and Efficacy of Intravenous MCC-135 as an Adjunct to Primary Percutaneous Coronary Intervention in Patients with Acute Myocardial Infarction: Rationale and Design of the Evaluation of MCC-135 for Left Ventricular Salvage in Acute MI (EVOLVE) Study

Objectives: To examine the frequency of cerebrovascular complications among patients receiving abciximab (AB) undergoing PCI with prior intracranial hemorrhage (ICH) or recent (< 2 years) ischemic strokes.Background: AB improves clinical outcomes in high-risk patients undergoing percutaneous coronary intervention (PCI); however, the safety of AB in patients with prior stroke has not been adequately studied.Methods: A database review of 7,244 consecutive PCIs, from 7/97 to 10/01, identified 6,190 PCIs performed with AB among which 515 interventions were performed in patients with prior stroke history [ICH or recent ischemic stroke, (n = 101) and remote (> 2 years) ischemic stroke, (n = 414)].Results: The post-PCI stroke rate was significantly higher in patients with prior stroke (2.06% vs. 0.35%, p < 0.001 for all stroke; 0.38% vs. 0.03%, p = 0.023 for ICH). The incidence of ICH among the AB-treated group was 0.065%; a history of prior stroke did not increase the incidence of ICH in the AB-treated group (0.39% vs. 0.0%, p = ns). Moreover, the post-PCI stroke rate was similar between the prior ICH or recent ischemic stroke–group and remote ischemic stroke-group (2 vs. 1.9%; OR: 1.03; 95% CI: 0.21–4.90; p = ns for all strokes; 2% vs. 1.5%; OR: 1.4; 95% CI: 0.27–6.91; p = ns for ischemic stroke). Importantly, no ICH occurred in patients with recent ischemic or any prior ICH stroke.Conclusions: Abciximab, in addition to aspirin, heparin and ADP-inhibitors does not increase the risk of stroke in patients with prior stroke undergoing PCI.