A Comprehensive Digital Self-care Support System for Older Adults With Multiple Chronic Conditions: Development, Feasibility, and Usability Testing of myHESTIA.

The objective of this mixed methods study is to evaluate the need for a comprehensive digital self-care support system (CDSSS) for older adults with multiple chronic conditions (MCC) and to examine whether such a system can be developed to enable daily capture of self-care data. The 3-phase study involved Phase-1: user needs assessment and prototype development; Phase-2: preliminary user evaluation of the prototype; and Phase-3: 4-week small group usability and feasibility testing of the tracking component of the prototype. Results of Phase-1 show the need for a CDSSS. Phase-2 results demonstrate interest among older adults in using such a CDSSS and Phase-3 findings show that older adults found the tracking component of the system easy to use for capturing daily inputs. Overall, the findings show that it is feasible to design a CDSSS for older adults with MCC in a way that is usable and functional for them.

SARS-CoV-2 and Wisconsin Nursing Homes: Temporal Dynamics During the COVID-19 Pandemic.

OBJECTIVES: Evidence suggests that quality, location, and staffing levels may be associated with COVID-19 incidence in nursing homes. However, it is unknown if these relationships remain constant over time. We describe incidence rates of COVID-19 across Wisconsin nursing homes while examining factors associated with their trajectory during 5 months of the pandemic. DESIGN: Retrospective cohort study. SETTING/PARTICIPANTS: Wisconsin nursing homes. METHODS: Publicly available data from June 1, 2020, to October 31, 2020, were obtained. These included facility size, staffing, 5-star Medicare rating score, and components. Nursing home characteristics were compared using Pearson chi-square and Kruskal-Wallis tests. Multiple linear regressions were used to evaluate the effect of rurality on COVID-19. RESULTS: There were a total of 2459 COVID-19 cases across 246 Wisconsin nursing homes. Number of beds (P < .001), average count of residents per day (P < .001), and governmental ownership (P = .014) were associated with a higher number of COVID-19 cases. Temporal analysis showed that the highest incidence rates of COVID-19 were observed in October 2020 (30.33 cases per 10,000 nursing home occupied-bed days, respectively). Urban nursing homes experienced higher incidence rates until September 2020; then incidence rates among rural nursing homes surged. In the first half of the study period, nursing homes with lower-quality scores (1-3 stars) had higher COVID-19 incidence rates. However, since August 2020, incidence was highest among nursing homes with higher-quality scores (4 or 5 stars). Multivariate analysis indicated that over time rural location was associated with increased incidence of COVID-19 (ß = 0.05, P = .03). CONCLUSIONS AND IMPLICATIONS: Higher COVID-19 incidence rates were first observed in large, urban nursing homes with low-quality rating. By October 2020, the disease had spread to rural and smaller nursing homes and those with higher-quality ratings, suggesting that community transmission of SARS-CoV-2 may have propelled its spread.

What Can a Primary Care Physician Discuss With Older Patients to Improve Advance Directive Completion Rates? A Clin-IQ.

Advance directives (ADs) provide patients with the opportunity to indicate their preferences for medical care while they still maintain the capacity to express their wishes, thus retaining autonomy. ADs increase the likelihood that patients will receive the care they desire, as their family members and physicians will better understand the level of care desired. Despite this, the AD completion rate by elderly patients continues to be low, especially for patients not facing serious illnesses. Primary care physicians (PCPs) are uniquely positioned to engage patients in discussions about ADs before a health crisis arises yet often do not due to time constraints. Using assets associated with the PCP relationship to and longitudinal care for patients, findings reveal that PCPs who emphasize the importance of ADs and who normalize the discussion during office visits by asking questions to understand patients' health goals and holding short conversations over several visits can improve AD completion rates.

Geriatrics Education Team Model Results in Sustained Geriatrics Training in 15 Residency and Fellowship Programs and Scholarship.

Caring for the growing elderly population will require specialty and subspecialty physicians who have not completed geriatric medicine fellowship training to participate actively in patient care. To meet this workforce demand, a sustainable approach to integrating geriatrics into specialty and subspecialty graduate medical education training is needed. This article describes the use of a geriatrics education team (GET) model to develop, implement, and sustain specialty-specific geriatrics curricula using a systematic process of team formation and needs assessment through evaluation, with a unique focus on developing curricular interventions that are meaningful to each specialty and satisfy training, scholarship, and regulatory requirements. The GET model and associated results from 15 specialty residency and fellowship training programs over a 4-year period include 93% curriculum sustainability after initial implementation, more than half of the programs introducing additional geriatrics education, and more than 80% of specialty GETs fulfilling their scholarship requirements through their curriculum dissemination. Win-wins and barriers encountered in using the GET model, along with the model's efficacy in curriculum development, sustainability, and dissemination, are summarized.

Positioning medical students for the geriatric imperative: using geriatrics to effectively teach medicine.

Medical schools must consider innovative ways to ensure that graduates are prepared to care for the aging population. One way is to offer a geriatrics clerkship as an option for the fulfillment of a medical school's internal medicine rotation requirement. The authors' purpose was to evaluate the geriatrics clerkship's impact on internal medicine knowledge and medical student attitudes toward older adults. Mean National Board of Medical Examiners (NBME) internal medicine subject exam scores from geriatrics and internal medicine students who matriculated from 2005 to 2011 were compared using student's t-tests. Academic performance was controlled for using the United States Medical Licensing Exam Step 1 exam scores. Focus groups were conducted to explore student attitudes. Geriatrics students performed just as well on the NBME exam as their internal medicine colleagues, but reported greater comfort with elder care. Geriatrics students also reported more positive attitudes toward older adults. Completing an internal medicine requirement using a geriatrics clerkship is an innovation for medical school curriculum structure.

Gaming used as an informal instructional technique: effects on learner knowledge and satisfaction.

BACKGROUND: Jeopardy!, Concentration, quiz bowls, and other gaming formats have been incorporated into health sciences classroom and online education. However, there is limited information about the impact of these strategies on learner engagement and outcomes. To address this gap, we hypothesized that gaming would lead to a significant increase in retained short- and long-term medical knowledge with high learner session satisfaction. METHODS: Using the Jeopardy! game show model as a primary instructional technique to teach geriatrics, 8 PGY2 General Surgery residents were divided into 2 teams and competed to provide the "question" to each stated "answer" during 5 protected block curriculum units (1-h/U). A surgical faculty facilitator acted as the game host and provided feedback and brief elaboration of quiz answers/questions as necessary. Each quiz session contained two 25-question rounds. Paper-based pretests and posttests contained questions related to all core curriculum unit topics with 5 geriatric gaming questions per test. Residents completed the pretests 3 days before the session and a delayed posttest of geriatric topics on average 9.2 weeks (range, 5-12 weeks) after the instructional session. The cumulative average percent correct was compared between pretests and posttests using the Student t test. The residents completed session evaluation forms using Likert scale ratings after each gaming session and each protected curriculum block to assess educational value. RESULTS: A total of 25 identical geriatric preunit and delayed postunit questions were administered across the instructional sessions. The combined pretest average score across all 8 residents was 51.5% for geriatric topics compared with 59.5% (p = 0.12) for all other unit topics. Delayed posttest geriatric scores demonstrated a statistically significant increase in retained medical knowledge with an average of 82.6% (p = 0.02). The difference between delayed posttest geriatric scores and posttest scores of all other unit topics was not significant. Residents reported a high level of satisfaction with the gaming sessions: The average session content rating was 4.9 compared with the overall block content rating of 4.6 (scale, 1-5, 5 = Outstanding). CONCLUSIONS: The quiz type and competitive gaming sessions can be used as a primary instructional technique leading to significant improvements in delayed posttests of medical knowledge and high resident satisfaction of educational value. Knowledge gains seem to be sustained based on the intervals between the interventions and recorded gains.

The influence of age on the likelihood of receiving end-of-life care consistent with patient treatment preferences.

BACKGROUND: Age differences may help to explain discrepancies in medical care received by cancer patients near death. OBJECTIVES: Understanding age differences in advanced cancer patients' end-of-life experiences. DESIGN: NCI and NIMH funded multi-site prospective cohort study. PARTICIPANTS: 396 deceased cancer patients, mean age (58.6 +/- 12.5), in the Coping with Cancer study. MEASUREMENTS: Baseline interviews (Treatment Preference) and 1 week postmortem chart reviews (Treatment Received). RESULTS: 14.1% of patients were 20-44 years old, 54.0% were 45-64 years old, and 31.8% were > or = 65 years old. Compared to younger patients, middle-aged patients wanted less life-prolonging care (OR 0.32; CI 0.16-0.64). In the last week of life, older patients were less likely to undergo ventilation (OR 0.27; CI 0.07-1.00) than younger patients. Middle-aged patients who preferred life-prolonging care were less likely to receive it than younger patients (OR 0.21; CI 0.08-0.54), but were more likely to avoid unwanted life-prolonging care (OR 2.38; CI 1.20-4.75) than younger patients. Older patients were less likely to receive desired life-prolonging care than younger patients (OR 0.23; CI 0.08-0.68), however, they were not more likely to avoid unwanted life-prolonging care than younger patients (OR 1.74; CI 0.87-3.47). CONCLUSIONS: Likelihood of a patient's treatment preference being consistent with care differ by age and treatment preferences. Older patients preferring life-prolonging therapies are less likely to receive them than younger patients; middle-aged patients who want to avoid life-prolonging care are more likely to do so than younger patients. Both findings have implications for patients' quality-of-death, indicating a need for further research.

A Poisson-like model of sub-clinical signs from the examination of healthy aging subjects.

BACKGROUND AND AIMS: Our studies of the standard neurological examination on 66 middle-aged (50-64 yrs) and elderly subjects (65-84 yrs) demonstrate that healthy elders have neurological deficits (or "signs") that are not associated with specific known neurological disease. The purpose of the current study is to describe this loss of neurological function in healthy aging subjects as seen through accumulated subclinical neurological signs present. METHODS: Logistic regression is applied to the data on each of six signs. Parameters determined are used to describe the distribution of first occurrence times for each sign. The results are then used to construct a Poisson-like model that describes the accumulation in the number of signs present over time on average. This model is also used to simulate a longitudinal population to explore the variability in the number of signs present over time in an aging population. RESULTS: As the rate of arrival of the signs is heterogeneous, as determined through logistic regression, and the number of signs detected is finite, the resulting distributions of the number of signs over time have a different nature than Poisson. Our results suggest that we can expect to see on average one neurological deficit in healthy people by the age of 62, and that the expected number of deficits increases linearly at the rate of 1 additional sign every 12 years over a wide age range (age 70-90). The distribution of the number of deficits over time is also described. CONCLUSIONS: The linearity in the average rate at which signs appear in this population is somewhat of a surprise, in that an increasing (accelerating) rate might be anticipated. In addition to characterizing the neurological exam results in this group, we demonstrate a methodology that allows the comparison of groups and defines a rate of neurological aging.

Geriatrics for surgeons: infusing life into an aging subject.

PURPOSE: Geriatric patients have specific medical and social needs for which surgeons must become adept at caring. In an effort to improve the care of the elderly, we have committed to developing a geriatric component for our surgical curriculum that is part of our PGY2-protected block curriculum. Competencies covered by this curriculum plan include medical knowledge, systems-based practice, professionalism, patient care, practice-based learning, and communication skills. METHODS: The geriatrics curriculum is imbedded in our current protected block curriculum and includes 5 separate sessions during the PGY2 year. During the protected block curriculum, the residents (N = 7) are relieved of all clinical activity, including call. A needs assessment survey assessed the residents' perceptions of the residency program's current focus on geriatric principles. The geriatric portion of this curriculum uses small-group instructional methods consistent with adult learning principles that include practice-based learning, case-based learning, patient simulation using Objective Structured Video Examination (OSVE), and didactic sessions. Faculty instruction is a shared responsibility between geriatricians and general surgeons. The longitudinal geriatrics curriculum includes approximately 10 hours of learner activities over a single-year period. EVALUATION: The curriculum will be evaluated by assessing participant knowledge through the use of multiple-choice testing. Resident performance on OSVEs will likewise be assessed. This method will allow for assessment of higher decision making and clinical reasoning. Finally, a family meeting OSCE will be used to assess professionalism and communication skills further. Overall, all 6 competencies will be assessed using our specific assessment tools. The curriculum content and instructional delivery will be evaluated using longitudinal and session evaluation forms. RESULTS AND EXPERIENCE TO DATE: The geriatrics curriculum will be implemented fully over 2 years. Three sessions will be introduced during the 1st year, and 2 more will be implemented in the 2nd year. The needs assessment survey results demonstrated a lack of sufficient educational focus on geriatrics topics and a low comfort level in caring for the elderly patient. The 1st session of the curriculum has taken place with positive results. The 1st session was a case-based session that focused on critical care and end-of-life issues in the elderly. Although the medical knowledge data are limited thus far, the average pretest score was 57% compared with the 86% posttest score. The resident evaluations (N = 7) of the session demonstrated an average 4.7 (1-5 Likert scale) for content and a 3.9 (1-4 Likert scale) for instructional delivery. CONCLUSION AND NEXT STEPS: Elderly surgical patients have multiple challenges. Specific geriatric training for surgical trainees is lacking. Over the next 2 years, the curriculum will be developed and evaluated even more for its ability to provide adequate instruction in the specific care of the elderly surgical patient. The ultimate goal is to improve the care of the elderly surgical patient.

Objective Structured Video Examinations (OSVEs) for geriatrics education.

The Medical College of Wisconsin (MCW) and the Wisconsin Geriatric Education Center (WGEC) are committed to developing educational materials for primary care physicians in training. In response to the opportunity created by the Accreditation Council for Graduate Medical Education (ACGME) competency mandate, an MCW-led interdisciplinary working group has developed competency-linked video-based assessment tools for use in primary care residency training programs. Modeled after the Objective Structured Clinical Examinations (OSCE), used as part of the medical licensing examination process, we created geriatric-focused Objective Structured Video Examinations (OSVEs) as a strategy to infuse geriatrics into residency training. Each OSVE tool contains a 1-3 minute video trigger that is associated with a series of multiple choice and/or constructed response questions (e.g., fill in the blank). These questions assess residents' understanding of video-demonstrated ACGME competencies including professionalism, systems-based practice, communication, and practice-based learning. An instructor's guide and scoring key are provided for each tool. Response to the OSVEs has been overwhelmingly enthusiastic including greater than 90% commitment by statewide faculty to use the tools in residency training.

Palliative care education integrated into a geriatrics rotation for resident physicians.

The authors present the curricular elements of a palliative care experience for internal medicine residents at the Medical College of Wisconsin (MCW) and the Zablocki Veterans Affairs Medical Center (ZVAMC), Milwaukee, Wisconsin. To improve resident physicians' knowledge and skills in palliative care, a structured clinical/educational experience was integrated into an existing required geriatrics rotation for senior medicine residents. Each month, two residents rotate simultaneously in the palliative care and the geriatrics evaluation and management units at the ZVAMC. The curricular elements of palliative care include prognostication, assessment and management of pain and nonpain symptoms in end-of-life care. The geriatrics component emphasizes mechanisms of aging, pathophysiology of common geriatric diseases, clinical pharmacology and psychosocial aspects of geriatric care. Teaching methods include direct patient care, bedside teaching rounds, lectures, and multidisciplinary and family meetings. Rotation design avoided conflicting time demands on the residents. In a prerotation/postrotation knowledge self-assessment questionnaire, residents (n = 28) indicated significant knowledge improvement in all palliative care domains taught during the experience. The rotation was well integrated into the existing curricular elements in geriatrics and palliative medicine at MCW. This combined rotation can serve as a reference for educators interested in developing new or enhancing existing palliative care training programs.

Minor depression and rehabilitation outcome for older adults in subacute care.

During recent years, numerous studies have found an association between minor depressive symptoms and physical functioning for older adults recuperating from illness or injury Whereas earlier research has focused on the effects of minor depression during rehabilitation in acute or long-term settings, this study examined 209 patients receiving subacute physical therapy. The dependent measures were total score changes on the Functional Independence Measure (FIM) obtained at admission, discharge, and 3-month follow-up. The independent measure was minor depressive symptoms, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, obtained within 5 days of admission. A binary logistic regression analysis was conducted with dichotomized FIM scores and the presence/absence of minor depressive symnptoms. The results indicated a statistically significant relationship between FIM score change and minor depression from admission to discharge, but not from discharge to follow-up.

Primary care residents self assessment skills in dementia.

The ability to accurately self-assess is a critical component of professionalism and is included in the newly required Accreditation Council of Graduate Medical Education (ACGME) core competencies. To assess residents' ability to accurately self-assess their competencies related to a commonly presenting problem in geriatrics, a Standardized Patient, portraying an individual with early signs of dementia, was inserted into family medicine residents' clinic schedules. Immediately post the encounter, each resident self-assessed his/her performance using a four category (Communication, History of Present Illness, Social History, Functional Assessment), 17-item behavioral checklist. The items in each category highlighted items specific to a dementia-screening interview (e.g., HPI: Used a standardized exam which includes orientation, memory, recall and registration). Resident ratings were compared to ratings from two faculty assessors who independently viewed the videotape of each resident's SP interview. While statistically significant differences between the self-assessment and expert assessors appeared in only one of the four major checklist categories (functional assessment), item specific analysis revealed significant differences on discrete items within the dementia screening interview. Implications for teaching and assessment consistent with the ACGME required competency assessment category of professionalism are discussed.

The Medical College of Wisconsin's program to strengthen geriatrics education.

Medical care for geriatric patients requires physician training that promotes the acquisition of attitudes, knowledge and skills that will permit future practitioners to meet the health needs of increasing numbers of aged patients. MCW has strengthened its traditional curriculum by focusing on student attitudes in the early pre-clinical years through outreach and interest groups programs. Knowledge is integrated throughout the 4-year curriculum using our aging virtual patients. These patients are a teaching resource to the entire faculty. Attitudes, knowledge, and skills in geriatrics are further developed through an M3 geriatrics medicine option and the M4 Integrated Selective. Geriatric-specific skills are emphasized through the use of standardized patients and objective structured clinical examinations in the M4 Selective. It is anticipated that these students efforts will create interest in a novel residency experience (Med-Ger) that will ensure that upon successful completion of the program, residents are expert in geriatric medicine practice and meet criteria for board certification in geriatric medicine.

Role of hormones in the pathogenesis and management of sarcopenia.

There is growing evidence to indicate that age-related declines in growth hormone (GH), insulin-like growth factor (IGF)-1, and androgen and estrogen production play a role in the pathogenesis of sarcopenia (an age-related decline in muscle mass and quality). Although GH supplementation has been reported to increase lean body mass in elderly individuals, the high incidence of adverse effects combined with a very high cost has limited the applicability of this form of therapy. The assessment of an alternative approach to enhance the GH/IGF-1 axis in the elderly by using GH-releasing hormone and other secretagogues is currently under way and is showing some promise. Testosterone replacement therapy may increase muscle mass and strength and decrease body fat in hypogonadal elderly men. Long-term randomised, controlled trials are needed, however, to better define the risk-benefit ratio of this form of therapy before it can be recommended. Available data are currently insufficient to decide what role estrogen replacement therapy may play in the management of sarcopenia. Therefore, although the evidence linking age-related hormonal changes to the development of sarcopenia is rapidly growing, it is still too early to determine the clinical utility of hormonal supplementation in the management of sarcopenia.

Delirium severity and psychomotor types: their relationship with outcomes after hip fracture repair.

OBJECTIVES: To validate the Memorial Delirium Assessment Scale (MDAS) as a measure of delirium severity in a cohort of patients aged 65 and older; to examine the association between severity of delirium and patient outcomes; and to examine the association between psychomotor variants of delirium and each of those outcomes. DESIGN: Prospective assessment of sample. SETTING: Hospital. PARTICIPANTS: One hundred twenty-two older patients (mean age +/- standard deviation = 79 +/- 8) who had undergone acute hip fracture surgery. MEASUREMENTS: We used standardized instruments to assess prefracture activities of daily living (ADLs), ambulatory status, cognition, and living situation. Postoperatively, each patient was interviewed daily. Delirium was diagnosed using the Confusion Assessment Method (CAM), and delirium severity was measured using the MDAS. The MDAS was also used to categorize the psychomotor types of delirium into "purely hypoactive" or "any hyperactivity." Telephone or face-to-face interviews were conducted at 1 and 6 months to assess survival, ADL function, ambulatory status, and living situation. RESULTS: Of 122 patients, 40% developed CAM-defined delirium. Delirious patients had higher average MDAS scores than nondelirious patients (11.7 vs 2.4, P <.0001). We used the median of the average MDAS score to classify patients into mild or severe delirium. Severe delirium was generally associated with worse outcomes than was mild delirium, and the associations reached statistical significance for nursing home placement or death at 6 months (52% vs 17%, P =.009). Additionally, patients who did not meet full CAM criteria for delirium experienced worse outcomes if they had some symptoms of delirium than if they had no or few symptoms (nursing home placement or death at 6 months: 27% vs 0%, P =.001). Surprisingly, these patients with subsyndromal delirium who did not fulfill CAM criteria for delirium but demonstrated significant delirium symptoms, had outcomes similar to or worse than those with mild CAM-defined delirium. Pure hypoactive delirium accounted for 71% (34/48) of cases and was less severe than was delirium with any hyperactivity (average MDAS score 10.6 vs 14.8, P =.007). In our cohort, patients with pure hypoactive delirium had better outcomes than did those with any hyperactivity (nursing home placement or death at 1 month: 32% vs 79%, P =.003); this difference persisted after adjusting for severity. CONCLUSION: In this study of delirium in older hip fracture patients, the MDAS, a continuous severity measure, was a useful adjunct to the CAM, a dichotomous diagnostic measure. In patients with CAM-defined delirium, severe delirium was generally associated with worse outcomes than was mild delirium. In patients who did not fulfill CAM criteria, subsyndromal delirium was associated with worse outcomes than having few or no symptoms of delirium. Patients with subsyndromal delirium had outcomes similar to patients with mild delirium, suggesting that a dichotomous approach to diagnosis and management may be inappropriate. Pure hypoactive delirium was more common than delirium with any hyperactive features, tended to be milder, and was associated with better outcomes even after adjusting for severity. Future studies should confirm our preliminary associations and examine whether treatment to reduce the severity of delirium symptoms can improve outcomes after hip fracture repair.