Geriatric Program Research Articles

Academic Competencies at Post-Secondary Gerontology Programs

The paper explores how various demographic and health factors have contributed to aging in Iran with particular attention to Tehran City wherein larger number of elderly people live. Iran’s ageing increase was likely unexpected since the last 60 years when reforms and modernization gradually started especially in Tehran in terms of education, health, medication, sanitation, water improvements etc. Gerotologically speaking, all these variables affected aging in quantitative terms.

The geriatric certificate program: collaborative partnerships for building capacity for a competent workforce

ABSTRACT Many practicing health care providers find themselves ill-prepared to meet the complex care needs of older adults. The Geriatric Certificate Program (GCP) represents a collaborative partnership leveraging existing educational courses, with new courses developed to fill existing education gaps, aimed at improving quality of care for older adults. This paper describes the GCP and examines its impact on knowledge, skills, clinical practice, as well as confidence, comfort, and competence in providing geriatric care. Upon program completion, all graduates (N = 146; 100%) completed an online evaluation survey. The majority of graduates reported (5-point scale: 1 = much less now; 5 = much more now) being more confident (88%), comfortable (83%), and competent (89%) to provide optimal geriatric care than prior to the program. The GCP provides a significant opportunity for health care providers to build their capacity for the care of older adults. Key lessons learned in implementing the GCP and suggestions for further development are discussed.

AGS Report on Engagement Related to the NIH Inclusion Across the Lifespan Policy.

After passage of the 21st Century Cures Act, the National Institutes of Health held a workshop in 2017 to consider expanding its inclusion policy to encompass individuals of all ages. American Geriatrics Society (AGS) leaders and members participated in the workshop and formal feedback period. AGS advocacy clearly impacted the resulting workshop report and Inclusion Across the Lifespan policy that eliminates upper-age limits for research participation unless risk justified and changes the language used to describe older adults and other vulnerable groups. AGS recommendations that were not specifically stated in the updated policy were to encourage active recruitment of older adults, add standard measures of function and/or frailty, and change review criteria to ensure the health status of a study population mirrors typical clinical populations. The updated inclusion policy ultimately offers academic geriatrics programs the opportunities to expand knowledge about health in aging and to continue to provide leadership for research and advocacy efforts on behalf of older adults. J Am Geriatr Soc 67:211-217, 2019.

Development of a required longitudinal residency experience focused on deprescribing.

In this article we describe a novel required longitudinal experience focused on deprescribing designed for postgraduate year 2 (PGY2) geriatric pharmacy residents. This experience was embedded within a clinical pharmacist-driven deprescribing service. Insights on challenges faced and benefits gained during the first offering are also highlighted. Through collaboration with the University of Pittsburgh School of Pharmacy (UPMC) Palliative and Supportive Institute and the UPMC St. Margaret PGY2 geriatric pharmacy residency program, a year-long required deprescribing-focused experience was developed and executed. The experience was aligned with the American Society of Health-System Pharmacists' standard goals and objectives and was designed to focus and evaluate 3 skills necessary for all pharmacy practitioners: empathy, critical thinking, and communication. There is a need for proactive deprescribing initiatives to reduce the unnecessary burden and cost associated with potentially inappropriate medications for older patients. Focused deprescribing experiences can better equip pharmacist learners with the ability to lead these initiatives. A required longitudinal deprescribing-focused experience can provide PGY2 geriatric pharmacy residents with opportunities to practice empathy, critical thinking, and communication beyond those typically offered in a residency program.

Learning to Lead: Reflections from the Tideswell-AGS-ADGAP Emerging Leaders in Aging Program Scholars.

The Tideswell Emerging Leaders in Aging (ELIA) Program is a 1-year leadership training program focused on developing a sustainable pipeline of leaders in aging who are poised to lead initiatives that will optimize the health of older people. The Tideswell ELIA Program is jointly administered by the American Geriatrics Society, the Association of Directors of Geriatric Academic Programs, and Tideswell at University of California, San Francisco (UCSF), a program within the Division of Geriatrics at UCSF. The ELIA Program prepares early to midcareer healthcare professionals in aging (scholars) for their transition into key leadership roles that involve one or more areas of patient care, education, and research. The program emphasizes the understanding of one's own and others' inherent work strategies and communication styles as integral to leading programs. Approximately 15 ELIA scholars are selected annually to participate in this interactive leadership development program. We conducted a qualitative analysis of program evaluations from 2015 to 2018 scholars (n = 47) to determine effectiveness and impact. All scholars (100%) completed the end-of-training survey. Scholars' satisfaction with the program is high. Scholars reported heightened leadership development and improvements in leadership skills, including communication, team building, and self-awareness. Scholars also reported enhancement of personal leadership attributes that contributed to career advancement. The Tideswell ELIA Program accelerates scholars' personal career development, positively impacts their institutions, and ultimately benefits older people. Sustaining leadership programs such as the Tideswell ELIA Program is vital to ensure a continuous pipeline of leaders skilled in both advocating for and advancing the health of older Americans. J Am Geriatr Soc 67:434-436, 2019.

Comfort or Care: Why Do We Have to Choose? Implementing a Geriatric Trauma Palliative Care Program.

Comfort or Care: Why Do We Have to Choose? Implementing a Geriatric Trauma Palliative Care Program.

Aligning geriatric medicine fellowships with the Program of All-Inclusive Care for the Elderly (PACE)

ABSTRACT Geriatric medicine fellowship programs provide comprehensive training to one-year clinical fellows and must demonstrate successful progression of competence among fellows by reporting on 23 milestones to the Accreditation Council for Graduate Medical Education (ACGME). The Program of All-inclusive Care for the Elderly (PACE) is a model of care located throughout the United States and can serve as a training venue for fellows. We surveyed 113 fellowship program directors with a response rate of 42% (n = 48). The purpose of the survey was to assess: (1) familiarity and access to PACE and (2) perceived value of PACE to the fellowship program with regard to training and ability to achieve success in the 23 reporting milestones. Milestones involving communication and team management skills were most consistently identified as very valuable with a PACE clinical rotation. We then convened a focus group of four PACE medical directors who developed a fellowship curriculum for use in training fellows at PACE. We discuss the limitations of our design as well as the opportunities to build on the strengths of that model as a training site for fellows.

COMMUNITY-BASED COMPREHENSIVE GERIATRIC ASSESSMENT CLINICAL DECISION ALGORITHMS AND PRACTICE GUIDELINES

The Comprehensive Geriatric Assessment (CGA) has been suggested as the gold standard for the management of frailty in older people (British Geriatrics Society (BGS) 2014). It is a multi-dimensional process that requires expert clinical judgement and evidence-informed practices in order to gather, synthesize and interpret information of the client’s medical, social, psychological, physical and functional limitations to develop an integrated clinical profile and an individualized care plan (Kay, et al., 2017). Although the domains of the CGA are clearly documented, (Kay, et al., 2017), the intricacies of what to ask within the domains are not. The BGS practice guidelines for managing frailty suggest the need to develop local protocols and pathways of care to help guide assessment and treatment (BGS, 2014). The Regional Geriatric Program of Eastern Ontario’s Geriatric Assessment Outreach Team completed an evidence-based review to develop clinical decision algorithms for 15 domains within the CGA to support a practice that is effective and efficient. This poster will highlight the process and clinical outcomes of the 5-step evidence-based process that was used to develop a interview guide, decision algorithms and practice guidelines for 15 clinical topics for a CGA within a community context. These were developed to increase consistency amongst their interprofessional geriatric assessors and provide a practice framework that supported conscious competent clinical decision making. This poster will also highlight the challenges and opportunities of completing an evidence-based review with the provision of recommendations for other teams interested embarking on this type of clinical journey.

Vulnerable Elderly Surgical Patients: Is It the Time for Geriatric Emergency General Surgery Quality Improvement Program?

Vulnerable Elderly Surgical Patients: Is It the Time for Geriatric Emergency General Surgery Quality Improvement Program?

The teaching of gerontology: Seven years of course design, redesign, and assessment in a multigenerational classroom

ABSTRACT Intergenerational teaching using a multigenerational course design is certainly not a new pedagogical technique. However, the longitudinal assessment and redesign of three gerontology courses described here can offer educators and professionals insights into reflection as a requirement not only within the course but also about the course itself. Since 2009, the Gerontology Program at Nazareth College has collaborated with the St. John’s Senior Living Communities to offer college-level courses comprising both Nazareth students and elder residents. In these courses, the elders not only participate on an equal basis with the students but also, together with the students, engage in regular course assessments. This article offers a review of course designs, assignments linked to student-learning outcomes, service-learning projects, and the numerous opportunities created for both personal and professional growth. Utilizing three different courses, this comprehensive study of intergenerational and multigenerational learning provides examples of different forms of engagement between students and elders and serves as a model for course design.

Demand Survey for Development of Geriatric Depression Prevention Program

Demand Survey for Development of Geriatric Depression Prevention Program

Implementing geriatric programmes of excellence in Adelaide, Australia

Implementing geriatric programmes of excellence in Adelaide, Australia

Lessons Learned From a Multisite Evaluation of Geriatric and Extended Care Programs.

With the increased use of multisite evaluation and implementation studies in health care, our team of evaluators reflects on our evaluation of a large-scale multiyear geriatric and extended care program implementation. We share lessons from conducting multiple rounds of data collection, analyses, and reporting. We also identify some key factors that can facilitate or hinder multisite evaluation efforts involving programs with different models of implementation. This article strives to improve the quality of large-scale evaluations of health programs implementation. Knowledge gained from this complex evaluation will inform public health programs funders, implementers, and key program staff to better plan for, engage in, and benefit from effective complex evaluations to promote health in diverse settings.

The Power of a Toothbrush

The Power of a Toothbrush

Using an Evidence-Informed Framework and a Self-Assessment Tool to Drive Priority Setting and Action toward Senior-Friendly Care.

Since 2011, Ontario hospitals have been engaged in the Senior Friendly Hospital (SFH) Strategy led by the Regional Geriatric Program (RGP) of Toronto, in partnership with Ontario's Local Health Integration Networks (LHINs) and the RGPs of Ontario. Using the SFH Framework as a foundation, improvement in Ontario hospitals has been driven by the identification of common priorities, sharing of resources and best practices, and the development of quality indicators. We document this progress through a second environmental scan of hospitals conducted in 2014 that highlights significant advancement in all five domains of the SFH Framework. Key learnings will be shared on how this framework and its self-assessment tool helped drive practice change.

Growth Arrest Specific 6 in Regeneration after Skeletal Muscle Injury

Growth arrest‐specific 6 (Gas6) belongs to the family of vitamin K‐dependent proteins. Its functions in the cardiovascular, pulmonary and immune systems have been reported on in depth, but very little is known about its role in skeletal muscle. Because of its roles in the regulation of inflammation and cell proliferation in other tissues, our objective was to determine whether Gas6 plays an important role in skeletal muscle repair and/or regeneration after injury.Therefore, we unilaterally injured the tibialis anterior (TA) muscles of young adult (YA; 5 mo.) and old (O; 30 mo.) Fisher Brown‐Norway rats with barium chloride (n=5–8/group). At the time of injury we also implanted a subcutaneous osmotic pump that continuously infused Gas6 (4 mg/ml) or saline onto the TA muscle through silicone tubing. The contralateral muscles served as controls. One week after injury, blood and the TA muscles were collected and the rats were euthanized. Muscle sections were prepared and stained with hematoxylin and eosin. Muscle were homogenized and Gas6 concentration was measured by ELISA in both plasma and muscle homogenates.We found that muscle injury greatly increased Gas6 concentration in muscle, but not plasma. [Gas6] was greater in O vs. YA plasma, but age had no effect on Gas6 levels in skeletal muscle. Gas6 infusion increased regenerating muscle fiber size in YA rats, but not in O rats (n=3), despite a similar increase in Gas6 concentration with injury.These results suggest that Gas6 is likely an important player in the regeneration of skeletal muscle after injury, and that the impaired recovery of old skeletal muscle after injury may be due in part to Gas6 resistance.Support or Funding InformationResearch Support: BYU Gerontology Program GrantThis abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Inter-Rater Reliability of the Retrospectively Assigned Clinical Frailty Scale Score in a Geriatric Outreach Population.

BackgroundFrailty, a common clinical syndrome in older adults associated with increased risk of poor health outcomes, has been retrospectively calculated in previous publications; however, the reliability of retrospectively assigned frailty scores has not been established. The aim of this study was to see if frailty scores, based on chart review data, agreed with clinician-determined scores based on a comprehensive geriatric assessment.MethodsPer standard practice, all patients seen by one nurse clinician (JW) from the Southwestern Ontario Regional Geriatric Program, a tertiary care-based outreach service, between August 15, 2013 and December 31, 2015 received a comprehensive geriatric assessment which included the assignment of an interview-based Clinical Frailty Scale score (CFS-I). Subsequently, a medical student researcher (JD), blinded to the CFS-I, assigned each consenting patient a frailty score based on chart review data (CFS-C). The inter-rater reliability of the CFS-I and CFS-C was then determined.ResultsOf the 41 consented patients, 39 had both a CFS-I and CFSC score. The median CFS score was 6, indicating patients were moderately frail and required assistance for some basic activities of daily living. Cohen’s kappa coefficient was 0.64, indicating substantial agreement.ConclusionCFS scores can be reliably assigned retrospectively, thereby strengthening the utility of this measure.

Geriatric communication skills training: Shared decision making and care planning for the older cancer patient and the caregiver.

80 Background: Medical decision-making is the process of shared understanding of a patient’s personal values and subsequent negotiation to reach a treatment decision. Discussing options and engaging patients in decision-making remains a challenge for many clinicians. The challenge is greater when treating older patients, who may be cognitively impaired, and may have family members or caregivers playing significant roles in their care. The geriatric communication skills training (CST) guides clinicians in effectively communicating with older cancer patients and their caregivers around pivotal cancer care decisions. Methods: A multidisciplinary team from a Comprehensive Cancer Center collaborated on the development of a one-day training program, consisting of three geriatric specific CST modules: Geriatrics 101, Cognitive Syndromes and Shared Decision Making. Each module included a brief didactic (30 min) with exemplary videos, followed by experiential role play (90 min) with standardized patients (SP), co-led by multi-disciplinary facilitators. These sessions were video recorded to enable reflective learning, group discussion, and feedback. We examined preliminary efficacy of the intervention on multiple outcomes, including participant course evaluations, self-efficacy and coded SP assessments. Results: 28 clinicians, including mental health professionals, oncologists, family practitioners, physician assistants, nurse practitioners, and social workers participated in the training. All participants reported strong satisfaction results with the workshop. Self-efficacy ratings increased significantly across all three modules, t(21) = -4.58, p < .001 between pre-training (M = 3.39, SD = .66) and post-training (M = 4.13, SD = .59). In SP assessments, participants also demonstrated significant uptake of agenda setting skills and increased responsiveness to caregiver concerns from pre to post training. Conclusions: The geriatric CST program was well received and demonstrated improvements in knowledge. Interdisciplinary training groups present for excellent case discussion and modeling opportunities for a variety of communication challenges.

Abstract P4-10-14: Pilot data from the development of the Senior Women's Breast Cancer Clinic at Sunnybrook Odette Cancer Centre

Abstract Introduction: Women over 70 are a growing demographic of breast cancer patients with specific needs requiring individualized care plans. We developed the interdisciplinary Senior Women's Breast Cancer Clinic (SWBCC) to improve access to a comprehensive geriatric assessment (CGA) and allied health services such as social work, occupational therapy, and pharmacy assistance. After initiation of the SWBCC, we conducted a pilot study using the VES-13 (vulnerable elders survey-13) tool to screen all patients over 70 with the goal of focusing referrals for patients who may benefit most from a CGA. The VES-13 was developed for community-dwelling elders and is validated in oncology patients. The objective of this study is to examine the outcomes of VES-13 screening, determine the medical issues identified by the CGA, and describe the development of this clinic. Methods: A retrospective review of the clinic from May 2015 - May 2017 was performed using the electronic medical records and paper screening forms. We separately describe the impact of the VES-13 to manage CGA referrals. A score of 3 or greater is a positive screen, and indicates the patient is at risk for death or decline. Non-parametric descriptive statistics were used for statistical analyses. Results: A total of 25 patients have been seen in the SWBCC for CGA to date. Median age was 83, (range 67-97). A median of two (range 1-4) new medical issues were identified from the CGA for each patient. The most common new diagnoses or issues identified were cognitive impairment (15/25), falls (6/25), neuropathy (4/25), and pain (4/25). The geriatric day program and falls prevention program were common referrals. After the introduction of VES-13 screening, a total of 54 patients were screened. Median age in that group was 78.5 years (range 70-95). The median VES-13 score was 1 (range 0-10). Of the 21 patients screened positive on VES-13, 7 went on to have a CGA. Of the remaining screen-positive patients, 3/21 patients declined SWBCC referral, and the others were not referred at the discretion of the physician. None of the patients with negative VES-13 were referred for CGA. The SWBCC structure was developed to utilize breast cancer-specific resources, whereby geriatricians provide consultation within the oncology space, and the allied health providers were affiliated with the breast centre. Oncology and geriatric administrative staff organized bookings to better coordinate schedules between the two disciplines. The geriatricians supervised trainees for the CGA, and follow-ups took place at SWBCC or in the geriatric outpatient clinic. Clinic coordinators affixed the VES-13 tool to all new patient charts for those aged ≥70. Nursing resources were dedicated to assist patients with VES-13 if needed, and document scores in the electronic medical record. Conclusions: A dedicated clinic for seniors with breast cancer providing geriatric assessment can identify important undiagnosed medical issues that warrant intervention or monitoring during breast cancer treatment. The VES-13 screening tool provides useful information to help manage resources for geriatrics referral. A prospective trial examining the role of CGA in decision-making for adjuvant chemotherapy is underway in this clinic. Citation Format: Menjak IB, Trudeau ME, Mehta R, McCullock F, Bristow B, Wright F, Rice K, Gibson L, Pasetka M, Szumacher EF. Pilot data from the development of the Senior Women's Breast Cancer Clinic at Sunnybrook Odette Cancer Centre [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-14.

Implementing Models of Geriatric Care-Behind the Scenes.

Innovative geriatric clinical programs have proliferated in the 21st century, and many have been highlighted in the Journal of the American Geriatrics Society (JAGS). The Affordable Care Act has supported the accelerated innovation of publicized and unpublicized program development, adaptation, and implementation. Many JAGS articles report work conducted in programs with significant improvements in quality; high satisfaction for patients and providers; and for some, reductions in costs. Despite considerable detail, enabling implementers to attempt to adopt reported programs or adapt them to local environments, much less is typically conveyed about the subtleties of the implementation process that led to a successful outcome. Moreover, where we have been given a window into successful initiatives, far less is known about those that failed and even less about why some succeeded but others failed. With a focus on our shared needs as a geriatrics community, to foster the exchange of more-comprehensive models of successful and failed implementation, we propose publications that address implementation itself-a second layer of reporting about the "hidden" elements that may have been decisive factors in taking an efficacious test, treatment, or model and putting it into real-world practice. We propose a new platform for sharing a broader range of healthcare quality improvement initiatives-successes and failures. We include several salient characteristics that could be measured and described in support of dynamic, sustainable, evidence-based implementation of geriatrics programs.