Frequently asked questions about mobility devices among older adults.

PURPOSE: To assess frequently asked questions (FAQs) about mobility devices among older adults. MATERIALS AND METHODS: We searched multiple terms on Google to find FAQs. Rothwell's classification, JAMA benchmark criteria, and Brief DISCERN were used to categorize and assess each entry. RESULTS: Our search yielded 224 unique combinations of questions and linked answer sources. Viewing questions alone resulted in 214 unique FAQs, with the majority seeking factual information (130/214, 60.7%). Viewing website sources alone resulted in 175 unique answer sources, most of which were retail commercial sites (68/175, 38.9%) followed by non-retail commercial sites (65/175, 37.1%). Statistical analysis showed a significant difference between the JAMA benchmark scores by source type (p < 0.00010) and Brief DISCERN scores by source type (p = 0.0001). DISCUSSION: Our findings suggest government, academic, and possibly non-retail commercial sources may provide better quality information about the use of mobility devices. We recommend medical providers be prepared to promote and provide quality resources on the risks, benefits, and proper techniques for using mobility devices.

Frequency and Predictors of Polypharmacy in US Medicare Patients: A Cross-Sectional Analysis at the Patient and Physician Levels.

BACKGROUND: Polypharmacy in older patients increases the risk of medication-related adverse events and can be a marker of unnecessary care. OBJECTIVES: The aim of this study was to describe the frequency of polypharmacy among patients 65 years of age or older and identify factors associated with the occurrence of patient-level and physician-level polypharmacy. METHODS: We performed a cross-sectional analysis of 100% Medicare claims data from January 1, 2016 to December 31, 2016. All patients with continuous Medicare coverage (Parts A, B, and D) throughout 2016 who were 65 years of age or older and who were prescribed at least one medication for at least 30 days were included in the analysis. Each patient was attributed to the primary care physician who prescribed them the most medications. Physicians treating fewer than ten patients were excluded. We defined polypharmacy based on the highest number of concurrent medications at any point during the year. We used hierarchical linear regression to study patient- and physician-level characteristics associated with high prescribing rates. RESULTS: We identified 25,747,560 patients attributed to 147,879 primary care physicians. The patient-level mean [standard deviation (SD)] concurrent medication rate was 5.6 (3.3), and the physician-level mean (SD) was 5.6 (1.1). A total of 6108 physicians (4.1% of sample) had a mean concurrent number of medications greater than two SDs above the physician-level mean. At the patient level in the adjusted model, a history of HIV/AIDS, diabetes mellitus, solid organ transplant, and systolic heart failure were the comorbidities most strongly associated with polypharmacy. The relative difference in number of medications associated with these comorbidities were 1.89, 1.39, 1.32, and 1.06, respectively. At the physician level, increased time since medical school graduation and smaller practice size were associated with lower rates of polypharmacy. CONCLUSIONS: Patterns of high prescribing to older patients is common and measurable at the physician level. Addressing high outlier prescribers may represent an opportunity to reduce avoidable harm and excessive costs.

A Qualitative Pilot Study of the Perceptions in Older Adults with End-Stage Kidney Disease on Hemodialysis.

BACKGROUND: Little is known about the perceptions of older adults with end-stage kidney disease (ESKD) on chronic hemodialysis (HD) even though this could potentially influence how treatment is received. This study explores the perceptions of older adults with ESKD on HD, specifically their decision to initiate HD, preconceptions and expectations of HD, perceived difficulties with HD, and coping strategies. DESIGN: Cross-sectional. SETTING: Outpatient chronic dialysis units. PARTICIPANTS: Older adults with ESKD on HD. INTERVENTION: Open-ended interviews were conducted with 15 participants. Inclusion criteria were age 60 years and older, HD duration of at least three months, and ability to consent and participate in the interview process. RESULTS: We report on four identified domains: decision to initiate HD; preconceptions and expectations of HD; drawback of HD; and coping strategies. All participants were reluctant to initiate HD, but made the decision on advice from their physicians for varying reasons. Trust in physicians' opinions also played a role for some. Some participants had positive preconceptions of HD, while a few had negative preconceptions or unrealistic expectations. Even though the majority of participants identified several difficulties with being on HD, they also had positive coping strategies, and the majority indicated that they would make the same decision to initiate HD. CONCLUSION: As clinicians are turning more to patient-centered medicine, understanding patients' perceptions of HD is of crucial importance. Our study highlights the importance of improving pre-hemodialysis education to ensure that patients' expectations are realistic, as well as identifying individualized coping strategies by patients.

Quality of Life, Perceptions, and Health Satisfaction of Older Adults with End-Stage Renal Disease: A Systematic Review.

OBJECTIVES: To explore the quality of life (QOL), perceptions, and health satisfaction of older adults with end-stage renal disease (ESRD) undergoing renal replacement therapy (RRT). DESIGN: Systematic review of literature. PARTICIPANTS: Individuals with ESRD undergoing RRT aged 65 and older. MEASUREMENTS: Articles identified from PubMed database search from January 1994 to December 2014. The methodological quality of each of the selected articles was assessed using eight standards adapted from well-established research quality review criteria. RESULTS: Of the initial 1,401 articles identified, 23 met the inclusion criteria. The age range of study participants examined was 65 to 90. Seventy-eight percent of the studies met six or more of the methodological standards; 47% found overall health-related and mental component summary QOL scores in elderly adults with ESRD to be similar to or higher than those of age-matched controls or younger individuals, although the physical component summary QOL scores tended to be lower in older adults. Only six studies addressed health satisfaction and perceptions of elderly adults with ESRD, with widely variable findings. CONCLUSION: Few studies specifically examine QOL in elderly adults with ESRD undergoing RRT and even fewer address issues of perceptions and health satisfaction. However, the limited data from the QOL studies looks promising with a significant proportion showing similar or higher overall health-related and mental component summary QOL scores in elderly adults with ESRD. The very limited data on perceptions and health satisfaction of elderly adults with ESRD undergoing RRT makes it difficult to make any generalizable conclusions. Overall, more research is needed to examine these factors in elderly adults with ESRD.

Delirium, a Symptom of UTI in the Elderly: Fact or Fable? A Systematic Review.

BACKGROUND: In geriatrics, delirium is widely viewed as a consequence of and, therefore, a reason to initiate workup for urinary tract infection (UTI). There is a possibility that this association is overestimated. To determine the evidence behind this clinical practice, we undertook a systematic review of the literature linking delirium with UTI. METHODS: A MEDLINE search was conducted from 1966 through 2012 using the MESH terms "urinary tract infection" and "delirium", limited to humans, age 65 and older. The search identified 111 studies. Of these, five met our inclusion criteria of being primary studies that addressed the association of UTI and delirium. The studies were four cross-sectional observational studies and one case series. No randomized control trials were identified. All studies were published between 1988 and 2011. Four collected data retrospectively and one prospectively, with study sizes ranging from 14 to 1,285. The methodological strength of the studies was evaluated using six standards adapted from a previous systematic review. RESULTS: Only two of the five studies adequately matched or statistically adjusted for differences in comparison groups. None of the studies evaluated subjects with equal intensity for the presence of delirium and UTI, nor did they have objective criteria for either diagnosis. In subjects with delirium, UTI rates ranged from 25.9% to 32% compared to 13% in those without delirium. In subjects with UTI, delirium rates ranged from 30% to 35%, compared to 7.7% to 8% in those without UTI. CONCLUSIONS: Few studies have examined the association between UTI and delirium. Though the studies examined conclude that there is an association between UTI and delirium, all of them had significant methodological flaws that likely led to biased results. Therefore, it is difficult to ascertain the degree to which urinary tract infections cause delirium. More research is needed to better define the role of UTI in delirium etiology.

Association of depression and antidepressant use with mortality in a large cohort of patients with nondialysis-dependent CKD.

BACKGROUND AND OBJECTIVES: Depression is common and is associated with higher mortality in patients with ESRD or CKD (stage 5). Less information is available on earlier stages of CKD. This study aimed to determine the prevalence of depression and any association with all-cause mortality in patients with varying severity of nondialysis-dependent CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This is a retrospective study of a national cohort of 598,153 US veterans with nondialysis-dependent CKD stages 1-5 followed for a median of 4.7 years in the US Department of Veterans Affairs Health System. Diagnosis of depression was established as a result of systematic screening and administration of antidepressants. Association of depression with all-cause mortality overall and stratified by CKD stages were examined with the Kaplan-Meier method and in Cox models. RESULTS: There were 179,441 patients (30%) with a diagnosis of depression. Over median follow-up of 4.7 years, depression was associated with significantly higher age-adjusted mortality overall (hazard ratio, 1.55; 95% confidence interval, 1.54-1.57; P<0.001). Sequential adjustments for sociodemographic characteristics and especially for comorbid conditions attenuated this association, which nevertheless remained significant (hazard ratio, 1.25; 95% confidence interval, 1.23-1.26). CONCLUSIONS: In this large cohort of predominantly elderly male patients with CKD, prevalence of depression and antidepressant use is high (30%) and is associated with significantly higher all-cause mortality independent of comorbid conditions.

Screening for depression in elderly hemodialysis patients.

BACKGROUND: Depression is common and associated with increased morbidity and mortality in elderly (≥65 years) hemodialysis patients. Beck's Depression Inventory (BDI) and the Geriatric Depression Scale (GDS) have been used in different cohorts to screen for depression. OBJECTIVES: We aimed to evaluate the 15-item GDS (GDS-15) as such a tool in elderly hemodialysis patients and compare it with BDI, a previously validated tool in younger hemodialysis patients. DESIGN: Cross-sectional study. SETTING: Four out-patient hemodialysis units; 1 based in a university hospital and 3 based in the community. PARTICIPANTS: Hemodialysis patients aged 65 years and older. INTERVENTION: Both tools were administered to all participants, and a geriatric psychiatrist blinded to the results evaluated them for depression by the gold standard psychiatric interview. MEASUREMENTS: The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for both tools were assessed against the psychiatric interview (n = 62). RESULTS: Patients who were depressed according to the psychiatric interview had significantly higher GDS-15 and BDI scores compared to those not depressed (p < 0.01 both). ROC curves showed high predictive accuracy of the GDS-15 and BDI (area under the curve: 0.808 and 0.729) versus the psychiatric interview. The GDS-15 cutoff with the best diagnostic accuracy was 5 with a sensitivity of 63%, specificity of 82%, PPV of 60% and NPV of 83%. The BDI cutoff with the best diagnostic accuracy was 10 with a sensitivity of 68%, specificity of 77%, PPV of 57% and NPV of 85%. CONCLUSION: These results provide evidence that the GDS-15 shows validity in comparison to a gold standard and can be used to screen for depression in the elderly hemodialysis population.

Tongue discoloration in an elderly kidney transplant recipient: Treatment-related adverse event?

BACKGROUND: With the increased occurrence of methicillin-resistant staphylococcus aureus infections, linezolid treatment might be administered more often. New rare adverse events are likely to follow. CASE SUMMARY: A 65-year-old man (weight, 91 kg; height, 185 cm) presented to the emergency department at the University of Virginia-affiliated Salem Veterans Affairs Medical Center, Salem, Virginia, after a recent (8 weeks) kidney transplantation with a 24-hour history of fatigue, chills, arthralgias, increased urinary frequency, and onset of tongue discoloration. Two days before admission, he completed a 14-day course of linezolid 600 mg PO BID for ampicillin-resistant enterococcal urinary tract infection. He was afebrile on admission and the dorsal aspect of his tongue was blackened centrally, browner peripherally, with normal pink mucosa on the periphery. Based on the Naranjo probability scale, the calculated score for tongue discoloration as a drug-related adverse event was 7 out of a maximum score of 13 points, designating it as a probable cause. The patient's tongue discoloration improved moderately during the hospital stay and resolved 6 months after the discontinuation of linezolid. CONCLUSIONS: We report a rare association of linezolid and tongue discoloration in an elderly kidney transplant recipient that improved with discontinuation. We present this case to increase clinicians' awareness of the potential adverse event.

The primary care physician's role in nursing facility care.

As more care is shifted from the acute care hospital and other sites to nursing facilities, and as the complexity of nursing facility care increases, more is expected of attending physicians. Physicians play an important role in helping patients and their families in this setting and in working with the facility staff in caring for these patients. Structuring visits to address patient and family needs and staff concerns; reviewing resident assessment instruments, care plans, and orders for care; and carefully documenting and coding those visits in such a way as to represent the purpose and complexity of the visit and the patient's clinical circumstances not only helps to improve the overall care provided to the patient but also helps others such as payors and regulators who are concerned about quality of care to have a better understanding of the patient's situation and future plans and expectations. Thus, as nursing facility care becomes more complex, the role of physicians in the nursing facility becomes even more essential.