One Step at a Time: Improving Gait Speed Measurement in a Geriatric Medicine Clinic.

(1) Background: Mobility assessment is a key component of the assessment of an older adult as a part of the Age-Friendly Health System (AFHS) "geriatric 4Ms" framework. Several validated tools for assessing mobility and estimating fall risk in older adults are available. However, they are often under-utilized in daily practice even in specialty geriatric medicine care settings. We aimed to increase formal mobility assessment with brief gait speed measurement in a geriatric medicine outpatient clinic using phased change interventions. (2) Methods: This quality improvement (QI) initiative was conducted in a single outpatient geriatric medicine clinic. All clinic attendees who could complete a gait speed measurement were eligible for inclusion. The outcome measure was the completion of a 4 m gait speed. Several change interventions were implemented on a phased basis using the Model for Improvement methodology during the period from December 2018 to March 2020. Statistical process control charts were used to record gait speed measurements and detect non-random shifts. (3) Results: During this QI initiative, 80 patients were seen, accounting for 142 clinic visits. In response to change interventions, gait speed measurement at clinic visits increased from a median of 25% of visits to 67% by March 2020. (4) Conclusions: Adopting an AFHS care model is an urgent and challenging task to improve the quality of care for older adults. This initiative details how to effectively incorporate a brief, validated assessment of mobility using gait speed measurement into every geriatric medicine outpatient visit and progresses implementation of the AFHS "geriatric 4Ms". Mobility assessment can aid in identifying older adults at increased fall risk.

From the ground up: recognising risk of frailty syndromes and functional decline through foot examination.

Foot pathologies in older adults are associated with falls and complications such as amputations and ulcers. We report a case of an older man who presented to the geriatric medicine outpatient clinic. History taking revealed a fall, recent episode of delirium and decline in functional status with the patient reporting he was no longer able to cut his own toenails. Medical history included hypothyroidism, depression and hearing impairment. Physical examination detected very long, thickened toenails with bilateral bony deformities of the foot. Additionally, he had borderline slow gait speed and had difficulty completing a chair stand. Inability to maintain foot care suggested an early insight into a deterioration of overall function and emergence of frailty. An interprofessional team approach to the patient's care included a medication review, referrals to podiatry, orthotics, physiotherapy and occupational therapy. His toenails were debrided and orthopaedic shoes were prescribed with no further falls.

Taking prevention to the next step: implementation of a brief, sustainable frailty assessment in a cardiology clinic.

BACKGROUND: Frailty measurement is recommended when assessing older adults with cardiovascular disease to individualise prevention and treatment. We sought to address this by incorporating routine gait speed measurement by clinicians into an outpatient preventive cardiology clinic. METHODS: Quality improvement (QI) project initiated at VA Boston in January 2015 to measure usual gait speed in m/s over a 4 m distance for patients aged 70 and older. The primary outcome was completion and documentation of 4 m usual gait speed. Data were manually extracted from the electronic health record. Frequency distributions and descriptive statistics are presented. INTERVENTIONS: Several change interventions were implemented over a 5-year period (January 2015-December 2019) addressing (1) stakeholder engagement and project champions, (2) staff education, (3) assessment space, (4) electronic health record template update and (5) sustaining the initiative. Statistical process control charts were used to monitor proportion of gait speed measurement and to detect shifts resulting from 5 phase change interventions. RESULTS: During this QI project, 178 patients aged 70 and older attended the clinic, accounting for 1042 individual clinic visits. Gait speed was measured at least once for 157 patients; 21 were never assessed. At the end of the first month (January 2015), gait speed was measured during 40% of clinic visits and rose to a median measurement rate of 78% at clinic visits during the 2018-2019 study period. An unanticipated result was the spread of the initiative to other cardiology clinics. CONCLUSIONS: Gait speed measurement was successfully embedded into clinic assessments for older adults at a cardiology clinic following targeted interventions. This project highlights the feasibility of incorporating a brief frailty assessment such as gait speed, into non-geriatric medicine clinics.

Foot Examination for Older Adults.

The foot changes with age. Foot disorders in older adults are associated with falls, lower limb ulcers, and pain. Physical examination of the feet as part of the routine assessment of older adults is imperative to detect foot problems. Foot pain and pathologies are common in older adults. Regular foot care is important to prevent these issues. However, some older adults may find it difficult to complete foot care, including cutting toenails. Regular foot examination can detect common foot problems, functional decline, and is recommended for preventing falls. We describe a technique for performing a focused examination of the feet for older adults. This review addresses current podiatric issues in older patient populations and describes a method for foot examination to address the needs of older adults that can be incorporated into patient assessments in any clinical setting.

Omega-3 index and blood pressure responses to eating foods naturally enriched with omega-3 polyunsaturated fatty acids: a randomized controlled trial.

Diets low in seafood omega-3 polyunsaturated fatty acids (PUFAs) are very prevalent. Such diets have recently been ranked as the sixth most important dietary risk factor-1.5 million deaths and 33 million disability-adjusted life-years worldwide are attributable to this deficiency. Wild oily fish stocks are insufficient to feed the world's population, and levels of eicosapentaenoic acid and docosahexaenoic acid (DHA) in farmed fish have more than halved in the last 20 years. Here we report on a double-blinded, controlled trial, where 161 healthy normotensive adults were randomly allocated to eat at least three portions/week of omega-3-PUFA enriched (or control) chicken-meat, and to eat at least three omega-3-PUFA enriched (or control) eggs/week, for 6 months. We show that regular consumption of omega-3-PUFA enriched chicken-meat and eggs significantly increased the primary outcome, the red cell omega-3 index (mean difference [98.75% confidence interval] from the group that ate both control foods, 1.7% [0.7, 2.6]). Numbers of subjects with a very high-risk omega-3 index (index < 4%) were more than halved amongst the group that ate both enriched foods. Furthermore, eating the enriched foods resulted in clinically relevant reductions in diastolic blood pressure (- 3.1 mmHg [- 5.8, - 0.3]). We conclude that chicken-meat and eggs, naturally enriched with algae-sourced omega-3-PUFAs, may serve as alternative dietary sources of these essential micronutrients. Unlike many lifestyle interventions, long-term population health benefits do not depend on willingness of individuals to make long-lasting difficult dietary changes, but on the availability of a range of commonly eaten, relatively inexpensive, omega-3-PUFA enriched foods.

Deprescribing in multi-morbid older people with polypharmacy: agreement between STOPPFrail explicit criteria and gold standard deprescribing using 100 standardized clinical cases.

PURPOSE: Older people with advanced frailty are among the highest consumers of medications. When life expectancy is limited, some of these medications are likely to be inappropriate. The aim of this study was to compare STOPPFrail, a concise, easy-to-use, deprescribing tool based on explicit criteria, with gold standard, systematic geriatrician-led deprescribing. METHODS: One hundred standardized clinical cases involving 1024 medications were prepared. Clinical cases were based on anonymized hospitalized patients aged ≥ 65 years, with advanced frailty (Clinical Frailty Scale ≥ 6), receiving ≥ 5 regular medications, who were selected from a recent observational study. Level of agreement between deprescribing methods was measured by Cohen's kappa coefficient. Sensitivity and positive predictive value of STOPPFrail-guided deprescribing relative to gold standard deprescribing was also measured. RESULTS: Overall, 524 medications (51.2%) of medications prescribed to this frail, elderly cohort were potentially inappropriate by gold standard criteria. STOPPFrail-guided deprescribing led to the identification of 70.2% of the potentially inappropriate medications. Cohen's kappa was 0.60 (95% confidence interval 0.55-0.65; p < 0.001) indicating moderate agreement between STOPPFrail-guided and gold standard deprescribing. The positive predictive value of STOPPFrail was 89.3% indicating that the great majority of deprescribing decisions aligned with gold standard care. CONCLUSIONS: STOPPFrail removes an important barrier to deprescribing by explicitly highlighting circumstances where commonly used medications can be safely deprescribed in older people with advanced frailty. Our results suggest that in multi-morbid older patients with advanced frailty, the use of STOPPFrail criteria to address inappropriate polypharmacy may be reasonable alternative to specialist medication review.

Current approach to masked hypertension: From diagnosis to clinical management.

The term 'masked hypertension phenomenon' was first described by the late Professor Thomas Pickering and is commonly defined as having a normal clinic blood pressure (BP) but an elevated 'out of office' reading. In the main, these elevated readings have been provided through ambulatory BP monitoring (ABPM), but sometimes home BP monitoring is used. It is now largely accepted that ABPM gives a better classification of risk than clinic BP. Thus, the elevated ABPM levels should relate to higher cardiovascular risk, and it follows that these people may be regarded as being genuinely hypertensive and at higher cardiovascular risk. The problem for clinical practice is how to identify and manage these individuals. The phenomenon should be suspected in individuals who have had an elevated clinic BP at some time, in young individuals with normal or normal-high clinic BP who have early left ventricular hypertrophy, in individuals with a family history of hypertension in both parents, patients with multiple risks for cardiovascular disease and perhaps diabetic patients. Masked hypertension appears to be more prevalent in individuals of male gender, with younger age, higher heart rate, obesity or high cholesterol levels and in smokers. Those with masked hypertension are at higher risk of events such as stroke and have a higher prevalence of target organ damage, for example, nephropathy. In conclusion, most of the debate around this topic relates to its reliable identification. Given the higher ambulatory mean blood pressure values there is an increased cardiovascular risk making this diagnosis important.

Making ambulatory blood pressure monitoring accessible in pharmacies.

OBJECTIVES: Ambulatory blood pressure measurement (ABPM), although recommended for the diagnosis and management of hypertension, has limited availability. The objective of this study was to show that if the characteristics of patients attending pharmacies for ABPM are similar to those attending primary care, the technique can be made more widely available to patients through pharmacies. PATIENTS AND METHODS: A comparative study using a software program that allowed central collection, analysis and comparison of ABPM data from patients attending primary care and pharmacies for assessment of hypertension in Ireland. RESULTS: ABPM data from 46 978 patients attending primary care were compared with 1698 attending pharmacies between 2007 and 2013. The age, sex and blood pressure characteristics of patients attending primary care and pharmacies were similar. The mean pressures in all categories, except for systolic blood pressure recorded in primary care, were higher in men. The first ABPM measurements recorded in pharmacies were slightly higher than those in primary care (150.8 ± 19.5/88.7 ± 13.7 vs. 149.6 ± 20.7/88.0 ± 14.4 mmHg). More patients attending primary care were normotensive than those attending pharmacies (19.5 vs. 16.4%), whereas more patients attending pharmacies were hypertensive than those attending primary care (62.8 vs. 60.7%), particularly female patients (61.0 vs. 56.4%). White-coat hypertension was similar in patients attending primary care and pharmacies (19.8 vs. 20.8%), but it was more prevalent in men attending pharmacies (22.0 vs. 17.4%) and in women attending primary care (21.9 vs. 19.7%). There were more dippers in pharmacy then primary care ABPMs (84.7 vs. 79.4%). A preference for having ABPM on Fridays and Saturdays was evident in patients attending pharmacies (19.6 vs. 6.6%), whereas there was a preference for early morning recording in primary care (4.1 vs. 1.1%). CONCLUSION: This study, which is the first to report on ABPM data from the pharmacy setting, shows that the blood pressure characteristics of patients with ABPMs recorded in pharmacies are similar to those recorded in primary care practices. It is feasible, therefore, to perform ABPM in pharmacies, which can be utilized to make ABPM more accessible to the large number of patients in the population with hypertension.