Geriatric Ambulatory Care Research Articles

A SADMAN With No Plan; Medication Management and Adherence To SADMAN Guidelines In Ambulatory Geriatric Care

Abstract Background Medication side effects are common causes of ill health, with ‘SADMAN’ medications identified as frequent offenders- sulphonylureas, angiotensin-converting enzyme inhibitors (ACEi), diuretics, metformin, angiotensin-receptor blockers, nonsteroidal anti-inflammatories and sodium/glucose cotransporter-2 inhibitors. Recent consensus recommendation published in the American Journal of Kidney Diseases is that patients on these should omit them if unwell1. We examined SADMAN usage within our Day Hospital, knowledge of this guidance and patients’ confidence in managing their medications. Methods All patients presenting for review in one week in our Day Hospital were included. Data collected included age, gender and number of medications including SADMAN. Patients were asked had they been advised to stop SADMAN medications if unwell, whether medications were blister packed and if they would be confident identifying and stopping a particular medication. Results 27 patients were included. 56% male, mean age 80 years old and mean number of medications 9 (range 0-22). 67% had medications blister-packed. 48% were prescribed one or more SADMAN medications and 15% more than one. Most commonly prescribed were ACEi (30%) and diuretics (19%). No patients had been advised to stop taking a SADMAN medication if they became unwell. Only 19% of patients (31% on SADMAN medications) were confident they could identify/stop a particular medication. Conclusion Despite clear guidelines to stop SADMAN medications if unwell, we found that no patients attending our Day Hospital were aware of this. Even if patients were appropriately educated, there was a lack of confidence in medication management. Polypharmacy and blister packing of medications pose significant barriers, leading us to question the feasibility of SADMAN guideline implementation in an Ambulatory Geriatric Care setting. Reference 1. Watson KE et al. Consensus Recommendations for Sick Day Medication Guidance for People With Diabetes, Kidney, or Cardiovascular Disease: A Modified Delphi Process. Am J Kidney Dis. 2023 May;81(5): 564-574.doi: 10.1053/j.ajkd.2022.10.012.

Building a Framework for Care of Older Patients in an Academic Setting: High Risk Geriatrics Ambulatory Care Program

BACKGROUND: Traditional models of geriatric medicine and health system reimbursement structure often force ambulatory care teams to function as high-volume delivery programs, thereby dis-servicing our most vulnerable and frail older patients. This “high cost and high needs” labeled demographic requires uniquely adapted plans from medical and social work providers. METHODS: To better examine opportunities for improved framework for geriatric ambulatory care, the Acute Life Interventions, Goals & Needs (ALIGN) Program has launched several inter-professional pilot programs, each with intention to explore components of health care service to older patients, and feasibility of implementation in other health care systems. Three current models include the ALIGN Program itself, a telemedicine community paramedicine program, and a geriatric surgery co-management program. RESULTS: Preliminary results are forthcoming, with initial promising findings. For the first 126 patients enrolled, mean emergency room (ED) visits 6 months prior to ALIGN enrollment were 1.7 visits per person, reduced to 0.7 ED visits/person 6 months post-graduation from the program, and 126 fewer ED visits. Mean hospitalization 6 months prior to enrollment was 0.32 per person, whereas 6 months post-graduation was 0.2 hospitalizations/person, totaling 40.32 hospitalizations saved. Mean length of stay in the hospital 6 months prior to ALIGN enrollment for the 22 patients admitted was 7.7 days, reduced to 7.3 days post-graduation, and 32 fewer hospital days in the small subset of patients requiring hospitalization despite program interventions. CONCLUSION: The ALIGN Program’s multi-professional and flexible modularity highlights promising innovative frameworks for ambulatory geriatrics care, warranting further exploration and collaboration.

Impact of Pharmacist Interventions in an Ambulatory Geriatric Care Clinic: The IMPACC Study.

To compare the impact of a pharmacist's presence for the detection of drug-related problems (DRP) in an interdisciplinary geriatric-ambulatory clinic with a control group without a pharmacist.<br/> DESIGN: Retrospective quasi-experimental study.<br/> SETTING: A geriatric ambulatory-care clinic of a 772-bed tertiary-care teaching hospital in Montreal, Canada.<br/> PARTICIPANTS: A total of 227 ambulatory patients 65 years of age and older presenting to their appointment at the geriatric ambulatory clinic between May 1, 2018, and April 30, 2019.<br/> MAIN OUTCOME MEASURE(S): DRP detected by the interdisciplinary team during the patient evaluation process. Data were collected from clinical notes written by the health care professionals in the electronic medical chart.<br/> RESULTS: The mean age was 80.8 years, and 60.8% of the population were female. Patients were prescribed a mean of 11.3 medications at home. Overall, 636 DRP were detected in the study population. In the adjusted analysis, the difference between the two groups was 2.7 (95% confidence interval 2.0-3.3) DRP detected favoring the group with a pharmacist.<br/> CONCLUSION: The inclusion of a pharmacist in an interdisciplinary team in an ambulatory geriatric-care clinic was associated to a positive impact on care by substantially increasing the number of DRP detected in older patients.

282 A Time to Wean: An Audit on Benzodiazepine and Z-drug Use Amongst Patients Attending a Geriatric Ambulatory Care Day Hospital

Abstract Background Benzodiazepine prescription is common among the Irish patient cohort. 23% of medical card holders have been prescribed a benzodiazepine or Z-drug, with a third of these being for a period longer than three months. This is despite these drugs being associated with addiction, falls, cognitive and psychomotor impairment, mood disorder, sleep automatism and drug interactions. We performed an audit looking at the repeat prescriptions of patients attending a geriatric day hospital. Methods The repeat prescriptions of all patients currently enrolled at a day hospital were analysed for benzodiazepines or Z-drugs. Medical records were then analysed to look for indication and whether these patients were currently attending psychiatric services. Subsequent to this, notices were placed in the patient consult room in direct line of sight of the registrar reminding them to consider weaning these drugs and detailing the negative side effects and guidelines for weaning from the Canadian National Pain Centre. Results 59 patients were enrolled at the day hospital when the audit was performed. 11 (19%) had either a benzodiazepine or Z-drug as part of their repeat prescription (benzodiazepine-5, Z-drug-5, both-1). The most common benzodiazepines prescribed were diazepam and clonazepam (2 patients on each). Of those prescribed a benzodiazepine, none were currently being weaned. Of those on benzodiazepines, 4 of 6 had a documented psychiatric diagnosis, and 1 of 6 had documented that they were currently attending psychiatric services. A re-audit three months later showed no change in those prescribed benzodiazepines (5/59), and a non-significant increase in those on Z-drugs (9/59, p=0.26). Conclusion This audit showed a significant number of patients attending our day hospital are being prescribed long term benzodiazepines or Z-drugs, and highlights that this setting is an opportune time and place to establish a supported program to wean people off these medications.

Geriatric Oncology Ambulatory Care Clinics

Cancer is a common comorbidity often associated with aging. Older patients can have specific needs such as caregiver concerns, transportation challenges, limited social support, and other problems ...

Symptom trajectory and symptom burden in older people with multimorbidity, secondary outcome from the RCT AGe-FIT study.

The aim of this study was to follow the symptom trajectory of community-dwelling older people with multimorbidity and to explore the effect on symptom burden from an ambulatory geriatric care unit, based on comprehensive geriatric assessment. Older community-dwelling people with multimorbidity suffer from a high symptom burden with a wide range of co-occurring symptoms often resulting to decreased health-related quality of life. There is a need to move from a single-disease model and address the complexity of older people living with multimorbidity. Secondary outcome data from the randomized controlled Ambulatory Geriatric Assessment Frailty Intervention Trial (AGe-FIT). Symptom trajectory of 31 symptoms was assessed with the Memorial Symptom Assessment Scale. Data from 247 participants were assessments at baseline, 12 and 24months, 2011-2013. Participants in the intervention group received care from an ambulatory geriatric care unit based on comprehensive geriatric assessment in addition to usual care. Symptom prevalence and symptom burden were high and stayed high over time. Pain was the symptom with the highest prevalence and burden. Over the 2-year period 68-81% of the participants reported pain. Other highly prevalent and persistent symptoms were dry mouth, lack of energy and numbness/tingling in the hands/feet, affecting 38-59% of participants. No differences were found between the intervention and control group regarding prevalence, burden or trajectory of symptoms. Older community-dwelling people with multimorbidity had a persistent high burden of symptoms. Receiving advanced interdisciplinary care at an ambulatory geriatric unit did not significantly reduce the prevalence or the burden of symptoms.

P048: Listening to care partners: a feasible method to screen for frailty in emergency medical services?

Introduction: Frailty is a state of vulnerability, and may go unrecognized in emergency medical services (EMS). Identifying frailty earlier may allow for services to be offered proactively to maintain function and prevent further health deterioration. The Clinical Frailty Scale (CFS) can be used to screen for frailty, but has only been validated when used by physicians. Our objective was to evaluate the feasibility and validity of a Care Partner-completed CFS, facilitated by a paramedic or nurse. Methods: A prospective sample of older adults (age ≥ 70 years) presenting in two settings (to EMS, following a 911 call, and to Geriatric Ambulatory Care) between February 2009 and March 2010 were included. Care partners completed a survey that included the nine-point CFS, which grades from 1 (very fit) to 9 (terminally ill). Demographic, clinical and outcome data were collected from the health care record, with one year follow-up. Based on clinical evaluations a frailty index was calculated for each patient. In each setting, descriptive statistics were used to compare fitter patients (CFS scores &lt;5) to frailer ones (CFS scores &gt;4). Results: The mean age was 82.2 ± 5.9 years (n=198) and most were women (n = 118, 62.1%). The Care Partner-CFS was incomplete for 3 surveys. The median CFS score in both the clinic and EMS groups was 5 (interquartile range = 4-6). The Care Partner-CFS correlated moderately with their independently assessed frailty index (0.64; p&lt;0.01; n=195). Most patients (n=125; 64%) had frailty scores &gt; 4. Frail patients were older and had worse health outcomes than the patients with score &lt;5. More EMS patients were severely frail or very severely frail compared to the geriatric clinic patients (n = 19, 19% vs. n =5, 5%). Conclusion: The Care Partner-CFS is a feasible and valid method for evaluating frailty in the EMS and medical clinic settings where frailty was common. It may be a useful EMS screening tool to identify those that could benefit from comprehensive assessment and follow-up after emergency care. Future research will evaluate this approach in multiple populations with community based follow-up intervention for those at higher risk.

Costs and Effects of an Ambulatory Geriatric Unit (the AGe-FIT Study): A Randomized Controlled Trial

ObjectivesTo examine costs and effects of care based on comprehensive geriatric assessment (CGA) provided by an ambulatory geriatric care unit (AGU) in addition to usual care. DesignAssessor-blinded, single-center randomized controlled trial. SettingAGU in an acute hospital in southeastern Sweden. ParticipantsCommunity-dwelling individuals aged 75 years or older who had received inpatient hospital care 3 or more times in the past 12 months and had 3 or more concomitant medical diagnoses were eligible for study inclusion and randomized to the intervention group (IG; n = 208) or control group (CG; n = 174). Mean age (SD) was 82.5 (4.9) years. InterventionParticipants in the IG received CGA-based care at the AGU in addition to usual care. Outcome measuresThe primary outcome was number of hospitalizations. Secondary outcomes were days in hospital and nursing home, mortality, cost of public health and social care, participant' sense of security in care, and health-related quality of life (HRQoL). ResultsBaseline characteristics did not differ between groups. The number of hospitalizations did not differ between the IG (2.1) and CG (2.4), but the number of inpatient days was lower in the IG (11.1 vs 15.2; P = .035). The IG showed trends of reduced mortality (hazard ratio 1.51; 95% confidence interval [CI] 0.988–2.310; P = .057) and an increased sense of security in care interaction. No difference in HRQoL was observed. Costs for the IG and CG were 33,371£ (39,947£) and 30,490£ (31,568£; P = .432). Conclusions and relevanceThis study of CGA-based care was performed in an ambulatory care setting, in contrast to the greater part of studies of the effects of CGA, which have been conducted in hospital settings. This study confirms the superiority of this type of care to elderly people in terms of days in hospital and sense of security in care interaction and that a shift to more accessible care for older people with multimorbidity is possible without increasing costs. This study can aid the planning of future interventions for older people. Trial Registrationclinicaltrials.gov identifier: NCT01446757.

Itch prevalence and characteristics in a Hispanic geriatric population: a comprehensive study using a standardized itch questionnaire.

A cross-sectional study of geriatric patients was performed to provide a comprehensive description of the prevalence and clinical characteristics of chronic itch affecting Hispanic geriatric subjects in Mexico. Participants were recruited from both nursing homes and geriatric ambulatory care centers. Patients without dementia were evaluated using an itch intensity and characteristic questionnaire and were assessed for itch-related dermatoses (n = 302). Data on medications and underlying systemic diseases were obtained from medical records. The prevalence of chronic itch was 25% in this population. Of those with chronic itch, 69% had xerosis, 28% had itch-related dermatoses, and 96% had documented comorbidities. The most common comorbidities were diabetes mellitus (OR = 2.3, 95% CI 1.3-3.9, p = 0.003) and chronic venous insufficiency (OR = 4.4, 95% CI 1.6-12.2, p = 0.002). The most common areas where patients experienced itch were legs (54%), back (45%), scalp (28%) and arms (27%). Patients experienced the greatest amount of itch in the winter (77%) and during the night (65%). Chronic itch is a common problem in the studied Hispanic geriatric population, and its presence significantly correlates with xerosis, diabetes, and venous insufficiency.

The validation of a care partner-derived frailty index based upon comprehensive geriatric assessment (CP-FI-CGA) in emergency medical services and geriatric ambulatory care.

The derivation of a frailty index (FI) based on deficit accumulation from a Comprehensive Geriatric Assessment (CGA) has been criticised as cumbersome. To improve feasibility, we developed a questionnaire based on a CGA that can be completed by care partners (CP-FI-CGA) and assessed its validity. We enrolled a convenience sample of patients aged 70 or older (n=203) presenting to emergency medical services (EMS) or geriatric ambulatory care (GAC). To test construct validity, we evaluated the shape of the CP-FI-CGA distribution, including its maximum value, relationship with age and gender. Criterion validity was evaluated by survival analysis and by the correlation between the CP-FI-CGA and specialist-completed FI-CGA. The mean age was 82.2±5.9 years. Most patients were women (62.1%), unmarried (widowed, divorced and single) (59.6%) and lived in their own home or apartment (78.3%). The mean CP-FI-CGA was 0.41±0.15 and was higher in the EMS group (0.45±0.15) than in GAC (0.37±0.14) (P<0.001). The CP-FI-CGA correlated well with the specialist-completed FI-CGA (0.7; P<0.05). People who died had a higher CP-FI-CGA than did survivors (0.48±0.13 versus 0.38±0.15). Each 0.01 increase in the FI was associated with a higher risk of death (HR 1.04; 95% CI 1.02-1.06). The CP-FI-CGA has properties that resemble other published FIs and may be useful in busy clinical practice for grading degrees of frailty. It efficiently integrates information from care partners so that it can help guide decision-making.

Ambulatory geriatrics in the Czech Republic: A survey of geriatricians’ opinions

According to the latest published data, the total of 33 outpatient geriatric facilities were registered in the Czech Republic at the end of 2011 employing (mostly on a part-time basis) 63 physicians. The aim of this paper was to analyze the reasons of this situation. An extensive survey of the opinions of Czech geriatricians performed in spring 2013 addressing all the 230 geriatricians registered in the Czech Medical Association of J. E. Purkyně was focused on the situation in ambulatory geriatric care, the experience with the demand for it, the approach of health insurance companies, and the cooperation with other physicians. The survey has identified that the major obstacle to the development of geriatrics is the persisting artificial separation of medical and social care. Its negative consequence is a breach of the complexity and consistency of care and the cooperation among specialists. A real threat to the development of ambulatory geriatric care is particularly the existing financing system of ambulatory geriatric services and the unofficial “stop state” of health insurance companies that prevent new contractual relationships. Another obstacle is the lack of readily available relevant information, so that the demand for specialist care remains on a low level. The phenomenon of the ageing population is still not perceived as a major challenge by the Czech society, and this situation is also reflected by the level of awareness and interest in these issues.

Development of an Ambulatory Geriatrics Knowledge Examination for Internal Medicine Residents

The number of older adults needing primary care exceeds the capacity of trained geriatricians to accommodate them. All physicians should have basic knowledge of optimal outpatient care of older adults to enhance the capacity of the system to serve this patient group. To date, there is no knowledge-assessment tool that focuses specifically on geriatric ambulatory care. We developed an examination to assess internal medicine residents' knowledge of ambulatory geriatrics. A consensus panel developed a 30-question examination based on topics in the American Board of Internal Medicine (ABIM) Certification Examination Blueprint, the ABIM in-training examinations, and the American Geriatrics Society Goals and Objectives. Questions were reviewed, edited, and then administered to medical students, internal medicine residents, primary care providers, and geriatricians. Ninety-eight individuals (20 fourth-year medical students, 57 internal medicine residents, 11 primary care faculty members, and 10 geriatrics fellowship-trained physicians) took the examination. Based on psychometric analysis of the results, 5 questions were deleted because of poor discriminatory power. The Cronbach α coefficient of the remaining 25 questions was 0.48; however, assessment of interitem consistency may not be an appropriate measure, given the variety of clinical topics on which questions were based. Scores increased with higher levels of training in geriatrics (P < .001). Our preliminary study suggests that the examination we developed is a reasonably valid method to assess knowledge of ambulatory geriatric care and may be useful in assessing residents.

Development and Validity and Reliability of Korean Comprehensive Assessment Tools for Geriatric Ambulatory Care

Department of Family Medicine, Seoul National University College of Medicine, Seoul, Functional Assessment Committee for the Elderly, Korean Geriatric Society, Seoul, Department of Internal Medicine, Inje University College of Medicine, Busan, Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea Institute of Health and Social Affairs, Seoul, Department of Family Medicine, Hallym University College of Medicine, Chuncheon, Department of Family Medicine, Kyung Hee University School of Medicine, Seoul, Department of Family Medicine, Hanyang University College of Medicine, Seoul, Department of Family Medicine, Incheon Eunhye Hospital, Incheon, Korea

Feasibility of Using Information Derived from a Care Partner to Develop a Frailty Index Based on Comprehensive Geriatric Assessment.

Frailty is a state of increasing vulnerability that places an individual at high risk for adverse health outcomes. The best approach for frailty measurement in clinical practice has not been resolved. Frailty can be measured by deficit accumulation and be derived from a comprehensive geriatric assessment (CGA). In busy clinical practice, it may not be feasible to gather this information entirely from patients, particularly from those with cognitive decline. We describe the feasibility of a frailty index based upon a care partner derived CGA (CP-CGA). In addition, we sought to establish the acceptability of the questionnaire and explore whether care partners felt that the provided information contribute to patient assessment. A cross-sectional data analysis of 99 community dwelling older adults attending geriatric ambulatory care clinics at a single tertiary care center. Care partners completed the CP-CGA and a Clinical Frailty Scale (CFS; Range 1 -Very fit- to 9 -Terminally ill). We evaluated the time to complete and item completeness. The mean age of patients was 81.3±5.7 years. Most were women (n=54), widowed, lived in their own home, with a median CFS of 5 (Mildly Frail). The care partner respondent was usually an offspring. Item completeness was 95% with a mean time to complete of 15.5±8.6 minutes. The CP-CGA seems feasible for gathering information that would be integral towards determining frailty by deficit accumulation. Future inquiries will evaluate its feasibility in other settings and validity as a form of frailty assessment.

Low-grade chronic inflammation and superoxide anion production by NADPH oxidase are the main determinants of physical frailty in older adults

Background. Physical performance measured by gait speed is being recognized as a major instrument for clinical evaluation in older adults, because it predicts physical frailty, loss of autonomy, hospitalization and decreased survival. Low-grade chronic inflammation and oxidative stress, mediated partly by the superoxide anion produced by NADPH oxidase, are closely linked and could be involved in age-related physical decline. Objective. To determine whether slow gait speed is associated with superoxide anion overproduction by NADPH oxidase and low-grade chronic inflammation. Design and setting. Observational study among the 280 elderly of an ambulatory geriatric care unit (191 women, 89 men, 79.9 ± 6.1 years old). Methods. Gait speed was evaluated by walking at self-chosen usual pace. Usual gait speed < 0.8 m/s was defined as slow gait speed. Superoxide anion production was evaluated using a lucigenin-based chemiluminescence method. Inflammation was evaluated by CRP, fibrinogen and leukocyte count. Results. Among the 280 participants, 179 (63.9%) walked with a gait speed < 0.8 m/s (slow walkers) and 101 (36.1%) with a gait speed ≥ 0.8 m/s. Superoxide production and inflammation markers, such as fibrinogen, were more important in slow walkers (p = 0.004 and p = 0.006, respectively). In multivariate analysis, superoxide anion overproduction and fibrinogen were independently associated with physical frailty assessed by slow gait speed (p = 0.028 and p = 0.007, respectively). Conclusion. Physical frailty in older people is associated with superoxide anion overproduction by NADPH oxidase and low-grade chronic inflammation.

Mount Sinai School of Medicine

Mount Sinai School of Medicine

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.

Assessment of Risk Associated with Medication‐Related Problems in Elderly Outpatients

ABSTRACTBackgroundThe Society of Hospital Pharmacists of Australia's (SHPA) Standards of Practice for Clinical Pharmacy provide a risk‐classification system for interventions made by pharmacists in hospital inpatients. These standards are based on Australian standards for risk management, where risk is based on an estimate of the likelihood and consequences of an adverse outcome from a medication‐related problem, if no intervention was made.AimTo adapt and validate the SHPA risk‐classification system for use in geriatric ambulatory care and to explore differences in classifications of risk made by pharmacists and geriatricians.MethodThe SHPA risk‐classification system was modified, piloted and reviewed by experts to assess face validity. 113 medication‐related problems identified by an outpatient clinical pharmacist in aged care were independently classified by a senior clinical pharmacist, a geriatrician and the outpatient clinical pharmacist. When there was disagreement, the case was discussed and consensus reached. A random sample of 30 medication‐related problems, stratified by consensus risk classification was classified by a second geriatrician.ResultsFace validity of the adapted risk‐classification system was established. Agreement between pharmacists on medication‐related problem risk was moderate and agreement between pharmacists and geriatricians was fair. Risk of adverse outcomes was rated lower by geriatricians than pharmacists. Consensus was easily reached through case discussion.ConclusionA system for classifying risk associated with pharmacist‐identified medication‐related problems in geriatric ambulatory care was developed. Differences were identified between pharmacists and geriatricians in the way medication‐related risks are perceived. Classification of pharmacist‐identified medication‐related problems/interventions may need to be based on consensus between at least one doctor and pharmacist.

Appropriate proton pump inhibitor use among older adults: A retrospective chart review

Background: Proton pump inhibitors (PPIs) are widely used, but not always with a clear indication. Nonindicated use is of particular concern among older adults, who may have multiple comorbidities and take more medications, increasing their risk for adverse drug reactions. Objective: This study examined the appropriateness of PPI use at an outpatient geriatric practice and the association between particular patient characteristics and appropriate use of these medications. Methods: This was a retrospective chart review of a group of randomly identified community-dwelling adults aged ≥65 years with a current prescription for a PPI (as of August 2006) from a geriatric ambulatory care practice within an urban academic medical center. The main outcome was appropriateness of PPI use, categorized as indicated, possibly indicated, or not indicated, based on US Food and Drug Administration-approved indications and national gastroenterology guidelines. Results: Out of ~2500 patients in the geriatric practice, 702 (~28%) were identified as having a current prescription for a PPI. From these, 110 charts were randomly selected for review, of which 10 were excluded based on predefined criteria. The sample was 79% female and 46% white, with a mean age of 82.8 years (range, 66–99 years). PPI use was indicated in 64% of these patients, possibly indicated in 7%, and not indicated in 29%. Compared with indicated PPI use, nonindicated use was significantly associated with use for <1 year (relative risk = 2.20; 95% CI, 1.00–4.86; P = 0.05). Nonindicated PPI use was not significantly associated with age, female sex, nonwhite race, or PPI initiation in the inpatient setting. Conclusion: Almost 30% of patients receiving a PPI in this academic geriatric practice had no documented indication for PPI use.

Reliability of the Hierarchical Assessment of Balance and Mobility in Frail Older Adults

To study the test-retest and interrater reliability of the Hierarchical Assessment of Balance and Mobility (HABAM) in frail older adults. Convenience sample of 167 frail older adults seen as part of routine care by an academic geriatrician at a tertiary care teaching hospital. Inpatient medical and geriatric wards, geriatric ambulatory care clinic, emergency department, home visits. The interrater reliability sample consisted of 98 inpatients and 69 outpatients. The test-retest reliability sample tracked 63 of the inpatients over the first 2 days of their hospital stay. Mobility and balance were assessed using the HABAM. Frailty was assessed using a frailty index based on a standardized Comprehensive Geriatric Assessment. Reliability was assessed using Pearson correlations and the intraclass correlation coefficients. The interrater reliability of the HABAM was 0.92 and ranged from 0.88 to 0.96 across settings for the various components (balance, transfers, mobility). Test-retest reliability was 0.91 (range 0.85-0.92). The HABAM appears to be a reliable means of assessing mobility and balance in frail older adults.