Geriatric Expertise Research Articles

Integrating Non-pharmacological and Pharmacological Interventions in the Treatment of Behavioral and Psychological Symptoms of Dementia

Non-pharmacological interventions (NI) are accepted as the first line treatment to reduce the severity and frequency of behavioral symptoms of dementia (BPSD). However, there is a marked paucity of evidenced-based NI for BPSD, leading psychiatric providers to rely too heavily on the second-line treatment for BPSD; pharmacological interventions (PI). This clinically focused presentation will demonstrate a comprehensive approach for psychiatric providers to educate family and caregivers on NI aimed to reduce the severity and frequency of BPSD, as well as integrate this teaching material with PI psycho-education. Types of NI for BPSD include sensory stimulation interventions, cognitive/emotion-oriented interventions, behavior management techniques as well as exercise and pet therapy, with music therapy and behavioral management having the most evidence for reducing BPSD. There are multiple barriers to determining evidenced based NI, which has led to geriatric psychiatry expert consensus treatment guidelines for BPSD, namely the DICE approach. The evidenced based dementia care training program STAR (Staff Training in Assisted living Residences) has demonstrated significant reduction in BPSD in dementia patients residing in the assisted living setting. Key components of this behavior management approach can be applied by psychiatric providers to family and caregiver education in the clinic and long-term care setting. Published qualitative data on barriers to implementation of dementia psycho-education have been identified, and practical strategies can counter these, including teaching providers to quickly assess family/caregiver education needs, modeling communication skills, implementing pleasant event schedules for patients to reduce BPSD, and learning how to code/bill for time spent not involving face to face time with patients. These strategies can be integrated with already published treatment algorithms for PI for BPSD, though it requires psychiatric providers to effectively educate caregivers and family members on realistic expectations and safety risks associated with PI for BPSD. Psychiatric providers can then utilize this integrated approach in their consultative role with primary care and long-term care providers. Further investigation into the effectiveness of this integrated BPSD approach is needed as well as a concerted effort to systematize the delivery of psycho-education into dementia care.

Is There a Geriatric Mental Health Specialist in the House?

Is There a Geriatric Mental Health Specialist in the House?

Ageing and vision loss: looking to the future

Ageing and vision loss: looking to the future

Evidence for the 4Ms: Interactions and Outcomes across the Care Continuum.

Objectives: An expert panel reviewed and summarized the literature related to the evidence for the 4Ms—what matters, medication, mentation, and mobility—in supporting care for older adults. Methods: In 2017, geriatric experts and health system executives collaborated with the Institute for Healthcare Improvement (IHI) to develop the 4Ms framework. Through a strategic search of the IHI database and recent literature, evidence was compiled in support of the framework’s positive clinical outcomes. Results: Asking what matters from the outset of care planning improved both psychological and physiological health statuses. Using screening protocols such as the Beers’ criteria inhibited overprescribing. Mentation strategies aided in prevention and treatment. Fall risk and physical function assessment with early goals and safe environments allowed for safe mobility. Discussion: Through a framework that reduces cognitive load of providers and improves the reliability of evidence-based care for older adults, all clinicians and healthcare workers can engage in age-friendly care.

Focus on Depression in Parkinson's Disease: A Delphi Consensus of Experts in Psychiatry, Neurology, and Geriatrics.

Major and minor forms of depression are significant contributors to Parkinson's disease morbidity and caregiver burden, affecting up to 50% of these patients. Nonetheless, symptoms of depression are still underrecognized and undertreated in this context due to scarcity of evidence and, consequently, consistent clinical guideline recommendations. Here, we carried out a prospective, multicentre, 2-round modified Delphi survey with 49 questions about the aetiopathological mechanisms of depression in Parkinson's disease (10), clinical features and connections with motor and nonmotor symptoms (10), diagnostic criteria (5), and therapeutic options (24). Items were assessed by a panel of 37 experts (neurologists, psychiatrists, and a geriatrist), and consensus was achieved in 81.6% of them. Depressive symptoms, enhanced by multiple patient circumstances, were considered Parkinson's disease risk factors but not clinical indicators of motor symptom and disease progression. These patients should be systematically screened for depression while ruling out both anhedonia and apathy symptoms as they are not necessarily linked to it. Clinical scales (mainly the Geriatric Depression Scale GDS-15) can help establishing the diagnosis of depression, the symptoms of which will require treatment regardless of severity. Efficacious and well-tolerated pharmacological options for Parkinson's comorbid depression were selective serotonin reuptake inhibitors (especially sertraline), dual-action serotonin and norepinephrine reuptake inhibitors (venlafaxine, desvenlafaxine, and duloxetine), multimodal (vortioxetine, bupropion, mirtazapine, and tianeptine), and anti-Parkinsonian dopamine agonists (pramipexole, ropinirole, and rotigotine). Tricyclic antidepressants and combining type B monoamine oxidase inhibitors with serotonergic drugs have serious side effects in these patients and therefore should not be prescribed. Electroconvulsive therapy was indicated for severe and drug-refractory cases. Cognitive behavioural therapy was recommended in cases of mild depression. Results presented here are useful diagnostic and patient management guidance for other physicians and important considerations to improve future drug trial design.

Limits and Ethics of Mechanical Ventilation and Intensive Care Medicine in Old Age

Changing demography with more older people and more patients with chronic diseases as well as the progress of medicine leads to more geriatric patients treated in intensive care and requiring mechanical ventilation due to severe respiratory insufficiency.Frailty is associated with a more complicated intensive care stay, more difficult convalescence and with a higher mortality.In principle, geriatric expertise should be brought in as early as possible in the course of intensive care treatment for older patients in order to carry out adequate risk stratification and, depending on the extent of the impairment, to plan discharge or early rehabilitation.In older and frail patients preexisting chronic ventilatory insufficiency often leads to prolonged weaning. Patients with weaning failure should be referred to a specialized weaning center. Part of the assessment will be whether out-of-hospital invasive or non invasive ventilation is indicated and the wish of the patient.In intensive care the likelihood of a successful outcome and the patient's wishes must constantly be re-evaluated. This is particularly true in older patients. In addition it should be clarified with the patients and relatives what constitutes "success"; for example a patient may consider intensive care "worth it" if the ultimate goal is discharge to their own home but not if nursing home care and tracheostomy ventilation is the best that can be achieved. It may become apparent that a successful outcome is unlikely and then withdrawal of invasive ventilation is appropriate.

Geriatric Trauma Service: to Consult or Not to Consult?

This review focuses on the application of geriatric expertise to care for traumatically injured patients through the use of geriatrician consultation versus a surgeon-led geriatric trauma service (GTS). We offer guidance on elements needed to establish an effective geriatric trauma service. Geriatrics expertise, through consultation, can have a positive effect on several important outcomes in the elderly injured. Several groups have published on recent successes with surgeon-led geriatric trauma services. Surgeon-led geriatric trauma services have shown improvements in discharge disposition and hospital length of stay and trends toward improved mortality. Regardless of approach, geriatrics experience and expertise as well as focused and intentional deployment of important resources appears to improve outcomes in geriatric trauma. Care for the elderly injured can be significantly improved by incorporating expertise in geriatrics. This can be accomplished by consultation of a geriatrician; however, consolidation of these patients onto a dedicated surgeon-led geriatric trauma service with dedicated hospital resources may be more effective.

An ecological approach to the development of an active aging measurement in urban areas (AAMU)

BackgroundAn essential element in the process of “aging well” is the concept of Active Aging (AA). To propose an operational definition of Active Aging, the present study seeks to develop a new measurement tool through an ecological approach. The aim is to recognize significant indicators that play a role in assessing AA in urban areas.MethodsThis study was conducted through a two-phase process of consensus-building: 1) identifying a set of indicators that were likely candidates for inclusion based on literature review, and 2) a two-round modified Delphi survey using an international panel of academic experts in environmental sciences and gerontology to achieve consensus on the importance of the extracted indicators and validate the items. The panelists were asked to complete a researcher-developed questionnaire with an 11-point Likert scale based on the indicators derived in phase 1. Finally, the Delphi survey’s valid indicators and criteria were utilized to develop the measurement tool.ResultsAt the outset, a list of 111 indicators of AA was prepared through the desk study. A panel of 22 experts reviewed the extracted items and arrived at a consensus on 99 items in the first round and finalised in the second round. Thematic analysis of the panelists’ open-ended responses revealed new concepts that would be explicitly considered by the consensus group. This developed measurement scale consists of five domains, i.e., individual, spatial, socio-economic, governance, and health-related, which contain 15 criteria and 99 indicators.ConclusionsThe present researchers have developed the active aging measure for urban settlements (AAMU), which can be used both by policy-makers and as an informal self-reported statement among the elderly. AAM’s results in the elderly’s residential environmental communities can improve policy-making to address urban design to sustain an active, healthy life among older people in urban environments.

Early Results in Non-Displaced Femoral Neck Fractures Using the Femoral Neck System.

IntroductionFemoral neck fractures in the elderly are a major event and are rising in incidence over the last decade. Advancing age and numerous comorbidities largely account for high mortality rate and require geriatric expertise. Treatment options are total hip arthroplasty (THA), hemiarthroplasty (HA) or osteosynthesis. Literature suggests THA or HA for better outcomes, although no clear guidelines exist.Material and methodsA retrospective chart review was performed of 63 patients (80 ± 11 years; 32 women, 31 men) with Garden one femoral neck fractures treated between June 2018 and June 2020 with either HA or internal fixation with the Femoral Neck System (FNS). Primary outcome measures were surgical and non-surgical complication rates and best achievable mobilization during the hospital stay.ResultsThirty four patients were treated with HA, and 29 with the FNS. Mobilization was measured using the Charité Mobility Index (CHARMI). No difference between age, ASA, CCI or preoperative CHARMI was found. The CHARMI was significantly lower in the HA group. No difference in surgical complications was found. The HA cohort showed more non-surgical complications, a longer ICU stay and more blood transfusions. Hospitalization was significant longer in the HA than the FNS cohort (15.1 ± 5.1 vs 9.8 ± 3.8 days). Radiographic controls were performed after 6 and 12 weeks. The FNS group showed a mean shortening of 3.3 mm. 4 of 21 patient had shortening >5 mm. 20 of 21 patients showed radiographic signs of bone healing after 3 months.ConclusionEarly results with the FNS show faster recovery than patient with hemiarthroplasty. Internal fixation with the FNS may be an option in non-displaced femoral neck fractures. Further studies should be performed to better evaluate the FNS compared to traditional internal fixation methods and arthroplasty.

Supporting PhD Students to Become Faculty in Gerontological Social Work: AGESW’s Fellowship Program

In the United States, the field of social work faces a critical shortage of students and faculty with expertise in gerontology needed to meet the growing needs of an aging society. To help recruit, train, and retain aging-related social work practitioners, researchers, and educators, the Association for Gerontological Education in Social Work (AGESW) created the Pre-Dissertation Fellowship Program in 2010. AGESW provides leadership in the areas of gerontological social work education, research, and policy and its PDFP was designed to support doctoral students in their education and future careers. In this 10th anniversary year of the PDFP, this symposium presents multiple perspectives of PDFP program evaluation. The first paper uses qualitative data from eight years of PDFP evaluations to identify types of professional skills attained through the program and areas of professional development missing from PDFP fellows’ home doctoral programs. The second paper uses quantitative data from a retrospective survey administered to PDFP alumni to describe their perspectives on the effects of the program. The third paper uses data from a retrospective survey of three cohorts of PDFP alumni to demonstrate the use of social network analysis for program evaluation. The fourth and final paper uses an idiographic approach to explain benefits of the PDFP from the perspectives of early stage scholars who participated in the program. Overall, the symposium provides evidence that suggests the effectiveness of the PDFP in building professional networks, mentoring doctoral students, and teaching academic skills and discusses using the PDFP model in other gerontological fields.

Diagnosing Dyspneic Older Adult Emergency Department Patients: A Pilot Study.

Dyspnea is the second leading cause of US emergency department (ED) visits and an independent predictor of morbidity and mortality1 in older adult patients aged ≥65 years. Unfortunately, the diagnosis of the cause of dyspnea presents diagnostic challenges to emergency physicians2-4 that disproportionately affects older adults.5 One in 5 dyspneic older adults experience missed diagnosis in the ED2 and 21% are treated for ≥1 pneumonia, acute exacerbation of chronic obstructive pulmonary disease [COPD], and acute exacerbation of heart failure [HF].5 Importantly, some may have multiple causes of their dyspnea but accurate diagnosis remains critical.

Influence of Provider Characteristics on Geriatric Mental Health Workforce Training Needs

Approximately half of VA users are 65 years of age or older, with a substantial subset having complex and interacting medical, neurocognitive, and behavioral disorders. The goal of the present study was to assess knowledge and training gaps of VA mental health staff using a Web-based training needs assessment developed specifically for VA personnel. Provider characteristics, confidence in working with older adults with and without cognitive disorder, and geriatric training needs were assessed. VA psychologists, psychiatrists, social workers, nurses, and peer support specialists (N=3313) were invited to participate via email. Respondents were 489 mental health providers, a response rate of 13.8 percent. Respondents reported less confidence in treating and assessing older adults with cognitive disorders then older adults in general. This did not differ by any of the examined provider characteristics, including age, gender, or professional experience. Training need endorsement was high across most of the training categories; however, a few differences according to provider characteristics were noted. Providers under the age of 50 endorsed a greater need for training in psychotherapy with older adults with cognitive disorder (p = .02). Female providers endorsed a greater need for training on providing psychoeducation about cognitive disorder, such as dementia, to older adults and their families (p = .02). In sum, VA MH providers in general reported strong interest in a wide range of geriatric MH training topics, indicating a need for universal geriatric-related staff education. For some topics, endorsing geriatric expertise predicted stronger interest in training.

Evaluating a specialist education programme for nurses and allied health professionals working in older people care: A qualitative analysis of motivations and impact

BackgroundDeveloping clinical leaders is essential for high-quality, safe care for older people. Fundamental to achieving this is specialist continuing professional development for nurses and allied health professionals. ObjectivesTo investigate the motivations of nurses and allied health professionals to undertake a national specialist gerontological programme, the Older Persons Fellowship, and its impacts on their development and on older people care. DesignA qualitative descriptive design. MethodsParticipants were nurses and allied health professionals undertaking a national specialist gerontological programme in England. A purposive sample of 63 participants was recruited. Twelve focus groups and four individual interviews were conducted between February 2015 and February 2019. Data were analysed using thematic analysis. ResultsThree themes were identified: credible gerontological experts; challenging ageism and suboptimal services; and legitimising gerontological practice as a speciality. ConclusionsUnderstanding the motivations to undertake a specialist gerontological programme and the impacts on practitioners and older people care and services will help inform the continuing professional development agenda for nurses and allied health professionals working in this field of practice. Policy makers, commissioners, managers, and educators can use the findings to inform continuing professional development priorities and provision for the gerontological workforce.

Registered nurses in expanded roles improve care in nursing homes: Swiss perspective based on the modified Delphi method.

AimTo define both competencies and envisaged outcomes for registered nurses in expanded roles in Swiss nursing homes to be implemented and evaluated within a new model of care.BackgroundIn regions where Advanced Practice Nurses are rare or absent, registered nurses take up clinical leadership and expanded roles. To allow effective implementation, monitoring and evaluation of these nurses, stakeholders need a shared understanding of the competencies they require and what outcomes they should achieve.DesignRAND/UCLA Appropriateness Method – a modified Delphi method.MethodsA critical literature review and case studies were conducted to identify possible competencies and outcomes for registered nurses in expanded roles. In 2017, a two‐round rating process and an in‐person panel discussion was completed by a group of multi‐professional stakeholders.FindingsTwo rounds generated 190 competencies and 72 outcomes relevant to registered nurses in expanded roles.ConclusionThe relevant competencies and outcomes of registered nurses in expanded roles indicate their support for care teams and development of nursing care in nursing homes. Their geriatric expertise allows them to function as role models and innovators, reinforcing overall perceptions of nursing as a profession. These nurses are especially important in countries and settings where Advanced Practice Nurses are scarce or unavailable.ImpactThe identified competencies clarify the duties of expanded‐role registered nurses, thereby differentiating them from other care providers. Although conducted in the Swiss healthcare system, our methods and findings can be adapted to other healthcare settings. The results of this study will guide the development of an educational programme in a multi‐centre study to reduce avoidable hospitalizations, while the defined outcomes guide the evaluation of their impact.

Multidisciplinary consensus of experts in pain and geriatrics: Use of analgesics in the management of pain in the elderly (excluding anesthesia)

The aim of this study is to publish recommendations on the use of painkillers in the elderly, in sensitive, isolated or highly dependent patients. These recommendations have been prepared by a group of experts in the field of pain and geriatrics from several scientific societies: French Society for Research and Pain Treatment (SFETD), French Society of Geriatrics and Gerontology (SFGG), French Society for Palliative Support and Care (SFAP), French Society for Assistive Oncology (AFSOS).

A Better World in the Future

A Better World in the Future

Consensus on Components of Frailty Using the Delphi Method: Korean Frailty and Aging Cohort Study.

The concept of frailty has been suggested to comprise physical, mental, and social phenotypes. However, there is no general consensus about the appropriate components for assessing frailty. The purpose of this study was to reach consensus on components of frailty assessment using the Delphi process. To achieve consensus on the definition of frailty, a modified Delphi method was used. Geriatric and gerontologic experts were selected from various fields. The detailed components of frailty were composed of data from the Korean Frailty and Aging Cohort Study. Establishing consensus and collecting opinions from experts were conducted using a modified Delphi method. Overall, nine domains with 14 components of frailty assessment were accepted. There was consensus on the necessity of a broad phenotype including physical, mental, and social frailty. Consensus on the components of a frailty assessment in a clinical setting is achieved through the Delphi process to establish a new tool of frailty assessment.

Clinical Oral Disorders in Adults Screening Protocol (CODA-SP) from the 2019 Vancouver IADR Consensus Symposium.

The Clinical Oral Disorder in Elders (CODE) index was proposed in 1999 to assess the oral health status and treatment needs of older people who typically were edentate or had few natural teeth. Since then, more people are retaining natural teeth into old age and have oral disorders similar to younger adults. In addition, there has been further guidance on screening for disease that includes changes to the clinical indicators of several oral disorders and greater sensitivity to people's concerns about their oral health and care needs. Experts in dental geriatrics assembled at a satellite symposium of the International Association of Dental Research in June 2019 to revise the objectives and content of the CODE index. Before the symposium, 139 registrants were asked for comments on the CODE index, and 11 content experts summarised current evidence and assembled reference lists of relevant information on each indicator. The reference lists provided the base for a narrative review of relevant evidence supplemented by reference tracking and direct searches of selected literature for additional evidence. Analysis of the evidence by consensus of the experts produced the Clinical Oral Disorders in Adults Screening Protocol (CODA-SP). The CODA-SP encompasses multiple domains of physical and subjective indicators with weighted severity scores. Field tests are required now to validate its effectiveness and utility in oral healthcare services, outcomes and infrastructure.

150 Differences in Weekly Geriatric Emergency Department Visits and Specialty Consultations

To adequately prepare to serve the growing population of older adults, there have been increased efforts to build or implement geriatric-focused health care staff, settings and processes. Geriatric Emergency Nurse Initiative Experts (GENIEs) are those specialized in emergency geriatric care that provide thorough assessments of a patient’s well-being in the emergency department (ED). The objective of this study was to examine differences in the number of GENIE consults and number of patients admitted post-consult between to academic EDs in a single health system. We conducted a multi-center, retrospective study among older adult patients (>=65 years) presenting to two EDs (hospital A, an urban level 1 trauma center and Hospital B, a suburban academic hospital with combined annual census of ∼83,000). We compared differences in the weekly number of geriatric visits, number of GENIE consults and number of patients admitted post-GENIE-consult between October 2019 and May 2020 at two EDs. There were a total of 4,873 at hospital A and 5,724 geriatric visits hospital B in the study period. Overall, there were more weekly geriatric visits at hospital B (p=0.006), more weekly GENIE consults (p<0.001) and more GENIE consults admitted (p=0.019). For patients who received a GENIE consultation in the ED, 61.6% at hospital A compared to 38.6% at hospital B received at least one referral to a geriatric follow-up service. As the population of older adults continues to grow, it is important to evaluate the staff, services and processes implemented to address their needs. These evaluations will be important in assessing how to optimize workflows and staffing to best support older adults where and when they need care in the ED. Further studies are needed to understand the downstream effects of the implementation of the GENIE role on overall patient care and outcomes.

Fear of older adult falling questionnaire for caregivers (FOAFQ-CG): Evidence from content validity and item-response theory graded-response modelling.

(1) Determine the content validity of the Fear of Older Adult Falling Questionnaire-Caregivers using a panel of gerontological experts and a target sample of family caregivers (Stage 1) and (2) Examine the response patterns of the Fear of Older Adult Falling Questionnaire-Caregivers and compare it with older adult version of Fear of Falling Questionnaire Revised using graded-response modelling (Stage 2). Cross-sectional mixed-method design. Five content experts and 10 family caregivers were involved in the Stage 1 study and 53 family caregiver-older adult dyads (N=106) were included in the Stage 2 study. The content-validity index and graded-response modelling were used to analyse data. Among experts, the Fear of Older Adult Falling Questionnaire-Caregivers content-validity index for relevancy, importance, and clarity of individual items and total scale ranged from 0.60-1.00 and from 0.77-0.87, respectively. Among family caregivers, the ratings of the item and scale level content-validity index for relevancy, importance, and clarity ranged from 0.90-1.00 and from 0.95-0.97, respectively. Combining feedback from both groups, we revised one item. Subsequently, the graded-response modelling revealed that a 1-factor, 3-item version of the Fear of Older Adult Falling Questionnaire-Caregivers had acceptable psychometric properties. The brief 3-item version of the Fear of Older Adult Falling Questionnaire-Caregivers is promising for assessing caregivers' fear of their older adult care recipient falling. A significant concern for family caregivers is fearing that older adult care recipients will fall, but a lack of validated measures limits the study of this phenomena. A 3-item version of the Fear of Older Adult Falling Questionnaire-Caregivers has the potential to identify family caregivers with high fear of older adult falling so that fall risk can be appropriately assessed and addressed.