Implementation and Effectiveness of Cognitive Behavioral Therapy for Insomnia in Geriatric Primary Care.

OBJECTIVES: We evaluated a plan for implementation and effectiveness of cognitive behavioral therapy for insomnia (CBT-I) in geriatric primary care by a geropsychologist. METHODS: The flow of referrals to a geropsychologist was tracked and, among those eligible and interested in participating, success in deprescribing sleep medications and the effectiveness of CBT-I were documented. RESULTS: Seventy patients were referred for evaluation of whom 62 were eligible for CBT-I; 34 began CBT-I and 29 completed a full course of treatment. Almost two-thirds of treatment completers were the "old old" (76-84 years) and "oldest old" (85-93 years) with multiple medical problems. Most treatment completers taking sleep medications had them deprescribed at the beginning of treatment and, one year after treatment, did not have them re-prescribed. After CBT-I, two-thirds of patients met the insomnia severity index criteria for response; and three-fifths for remission from insomnia. Further, most patients had sustained improvement in their target insomnia symptom(s) and sleep efficiency. CONCLUSIONS: CBT-I can be implemented in geriatric primary care with successful deprescribing of sleep medications and meaningful improvement in symptoms of insomnia in a group of older adults of advanced age with multiple medical problems. CLINICAL IMPLICATIONS: Clinical gerontologists can play an important role in improving late life insomnia.

Implementation of an evidence-based medicine curriculum in a fellowship program: Can it influence clinical practice?

While evidence-based medicine (EBM) curricula improves knowledge scores, correlation with physician behavior, and patient outcomes are not clear. We established an EBM curriculum for Geriatrics and Palliative Medicine fellows that included didactic teaching, opportunity for deliberate practice and presentation, and coaching and feedback from faculty experts, to determine the impact on self-assessed confidence in teaching EBM, Practice-Based Learning and Improvement (PBLI) competency rating and patient care decisions. Seventeen fellows at a New York City academic medical center participated during 2014-2015 academic year. We analyzed pre-/posttest surveys for self-assessed confidence in teaching EBM concepts, EBM worksheets for content of clinical questions and impact on patient care, and PBLI competency ratings for overall impact. Posttest survey indicated that fellows' self-assessed confidence in teaching EBM increased significantly. While most found Journal Club discussions and EBM case conferences valuable, only 36% of fellows found EBM worksheets completion to be good use of time (average completion time 89 minutes). EBM worksheets helped reinforce or change plan of care in 32 out of 50 cases. There was no impact on end-of-the-year PBLI ratings. This curriculum, integrating didactic, self-directed and peer learning with objective feedback, increased self-assessed confidence in teaching EBM, and influenced patient care plans.

Modifiable factors associated with postoperative delirium after hip fracture repair: An age-stratified retrospective cohort study.

BACKGROUND: Postoperative delirium in hip fracture patients is common and is associated with substantial morbidity and consumption of resources. OBJECTIVE: Using data from the USA, we aimed to examine the relationship between postoperative delirium and (modifiable) peri-operative factors mentioned in the American Geriatrics Society Best Practice Statement on Postoperative Delirium in Older Adults, stratified by 'young old' (<80 years) and 'old-old' (≥80 years) categories. DESIGN: Retrospective cohort study from 2006 to 2016. SETTING: Population-based claims data from the USA. PARTICIPANTS: Patients undergoing 505 152 hip fracture repairs between 2006 and 2016 as recorded in the Premier Healthcare Database. MAIN OUTCOMES AND MEASURES: The main outcome was postoperative delirium; modifiable factors of interest were peri-operative opioid use (high, medium or low; <25th, 25 to 75th or >75th percentile of oral morphine equivalents), anaesthesia type (general, neuraxial, both), use of benzodiazepines (long acting, short acting, both), pethidine, nonbenzodiazepine hypnotics, ketamine, corticosteroids and gabapentinoids. Multilevel models assessed associations between these factors and postoperative delirium, in the full cohort, and separately in those aged less than 80 and at least 80 years. Odds ratios (ORs) and Bonferroni-adjusted 95% confidence intervals (95% CIs) are reported. RESULTS: Overall, postoperative delirium incidence was 15.7% (n = 79 547). After adjustment for relevant covariates, the use of long-acting (OR 1.82, CI 1.74 to 1.89) and combined short and long-acting benzodiazepines (OR 1.56, CI 1.48 to 1.63) and ketamine (OR 1.09, CI 1.03 to 1.15), in particular, was associated with increased odds for postoperative delirium, while neuraxial anaesthesia (OR 0.91 CI 0.85 to 0.98) and opioid use (OR 0.95, CI 0.92 to 0.98 and OR 0.88, CI 0.84 to 0.92 for medium and high dose compared with low dose) were associated with lower odds; all P < 0.05. When analysing data separately by age group, effects of benzodiazepines persisted, while opioid use was only relevant in those aged less than 80 years. CONCLUSION: We identified modifiable factors associated with postoperative delirium incidence among patients undergoing hip fracture repair surgery.

Using Electronic Health Records to Enhance Predictions of Fall Risk in Inpatient Settings.

BACKGROUND: Falls are the most common adverse events of hospitalized adults. Traditional validated assessment tools have limited ability to accurately detect patients at high risk for falls. The researchers aim to develop an automated comprehensive risk score to enhance the identification of patients at high risk for falls and examine its effectiveness. METHODS: The enhanced fall algorithm (EFA) was developed from 171,515 hospitalizations and 2,659 falls, in an academic medical center, using hierarchical logistic regression. Routine nursing assessments, labs, medications, demographics, and patients' location during their hospitalization were gathered from the electronic health record (EHR). RESULTS: The fall rate was 2.8 per 1,000 patient-days. Morse fall score was the strongest predictor of falls (odds ratio = 7.16, 95% confidence interval = 6.48-7.91), with a model discrimination c-statistic of 0.687. By adding patient demographics, chronic conditions, lab values, and medications, and controlling for patient clustering within units, predication was enhanced and model discrimination increased to 0.805. By applying the enhanced model, we observed redistribution of patient by risk: low-risk group increased from 52.8% to 66.5%, and the high-risk group decreased from 28.0% to 16.2%, with an increase of fall detection from 3.1% to 5.1%. CONCLUSION: The EFA redistributes and identifies patients at high risk more accurately than the Morse score alone, decreasing the population of high-risk patients without increasing the rate of falls over time. The EFA requires no addition data collection and automatically updates the patient's fall risk based on new inputs in the EHR.

Introducing Aquifer Geriatrics, the American Geriatrics Society National Online Curriculum.

Aquifer Geriatrics, formerly web-based Geriatrics Education Modules, was initially developed through Donald W. Reynolds Foundation funding, and is now the national curriculum of the American Geriatrics Society and the Association of Directors of Geriatric Academic Programs. Aquifer Geriatrics consists of 26 evidence-based, peer-reviewed, online case-based modules based on the Association of American Medical Colleges/John A. Hartford Foundation Minimum Geriatrics Competencies for Medical Students and is available by subscription at www.aquifer.org/courses. This curriculum aims to help address the national shortage of geriatrics educators, complement current teaching, bridge content gaps in geriatrics education, and standardize geriatrics-focused educational content. This report will describe the development of Aquifer Geriatrics, highlight best practices to incorporate cases in a variety of teaching settings, describe teaching methods that utilize the curriculum to create a robust experience for learners, and address the cost of obtaining the curriculum. J Am Geriatr Soc 67:811-817, 2019.

The Strategies to Reduce Injuries and Develop Confidence in Elders Intervention: Falls Risk Factor Assessment and Management, Patient Engagement, and Nurse Co-management.

In response to the epidemic of falls and serious falls-related injuries in older persons, in 2014, the Patient Centered Outcomes Research Institute (PCORI) and the National Institute on Aging funded a pragmatic trial, Strategies to Reduce Injuries and Develop confidence in Elders (STRIDE) to compare the effects of a multifactorial intervention with those of an enhanced usual care intervention. The STRIDE multifactorial intervention consists of five major components that registered nurses deliver in the role of falls care managers, co-managing fall risk in partnership with patients and their primary care providers (PCPs). The components include a standardized assessment of eight modifiable risk factors (medications; postural hypotension; feet and footwear; vision; vitamin D; osteoporosis; home safety; strength, gait, and balance impairment) and the use of protocols and algorithms to generate recommended management of risk factors; explanation of assessment results to the patient (and caregiver when appropriate) using basic motivational interviewing techniques to elicit patient priorities, preferences, and readiness to participate in treatments; co-creation of individualized falls care plans that patients' PCPs review, modify, and approve; implementation of the falls care plan; and ongoing monitoring of response, regularly scheduled re-assessments of fall risk, and revisions of the falls care plan. Custom-designed falls care management software facilitates risk factor assessment, the identification of recommended interventions, clinic note generation, and longitudinal care management. The trial testing the effectiveness of the STRIDE intervention is in progress, with results expected in late 2019.

The 2025 Big "G" Geriatrician: Defining Job Roles to Guide Fellowship Training.

Changes in health care that are already in progress, including value- and population-based care, use of new technologies for care, big data and machine learning, and the patient as consumer and decision maker, will determine the job description for geriatricians practicing in 2025. Informed by these future certainties, 115 geriatrics educators attending the 2016 Donald W. Reynolds Foundation Annual meeting identified five 2025 geriatrician job roles: complexivist; consultant; health system leader and innovator; functional preventionist; and educator for big "G" and little "g" providers. By identifying these job roles, geriatrics fellowship training can be preemptively redesigned.

Big 'G' and Little 'g' Geriatrics Education for Physicians.

In the July 2016 issue of this journal, Dr. Mary Tinetti proposed that geriatric medicine abandon attempts to increase the numbers of board-certified geriatricians and change focus to the development of a "small elite workforce." What would be gained and what sacrificed by accepting this challenge? We agree that the best clinical use of a scarce resource, specialty trained geriatricians, is to care for frail, complex, severely ill elderly adults and to help design and study novel interventions in research, education, and care models to improve the care of all older adults, but for this to happen, all other providers must attain specific competency in the care of older adults. This article responds and discusses alternative pathways for teaching geriatrics care, training specialists, and geriatrics fellows.

A model for integrating the assessment and management of geriatric syndromes into internal medicine continuity practice: 5-year report.

A geriatric ambulatory curriculum was created to improve internal medicine residents' care of geriatric patients. Second-year residents met for a 3-hour session weekly for 4 consecutive weeks during a block rotation with faculty geriatricians for a curriculum focused on dementia, falls, and urinary incontinence. After a 1-hour case-based didactic session, residents applied learned content and concepts to patient consultations. Consultative encounters were precepted by faculty and shared with the team. After completing our curriculum, residents reported knowledge acquired and enhanced evaluation and management skills of these three syndromes and were more likely to use all recommended screening tests in future practice. This article describes the process and strategies guiding development of a successful ambulatory geriatric curriculum model that can be embedded into preexisting internal medicine clinics to help future internists to better manage these and other common geriatric syndromes.

High-Risk Medications in Hospitalized Elderly Adults: Are We Making It Easy to Do the Wrong Thing?

OBJECTIVES: To examine dosages of high-risk medications administered to elderly adults who fall in the hospital and to determine whether electronic default doses are appropriate for elderly adults. DESIGN: Retrospective. SETTING: Large urban academic hospital. PARTICIPANTS: Individuals aged 65 and older experiencing a fall. MEASUREMENTS: Prescribed daily dosages and use of high-risk medications (opiates, benzodiazepines, benzodiazepine-receptor agonists (BRAs), sleep medications, muscle relaxants, antipsychotics) administered within 24 hours before a fall were ascertained and compared with published recommended dosages for older adults and the hospital's electronic medical record (EMR) default doses for these drugs. RESULTS: Of 328 falls, 62% occurred in individuals administered at least one high-risk medication within the 24 hours before the fall, with 16% of the falls involving individuals receiving two, and another 16% in individuals receiving three or more. High-risk medications were often administered at higher-than-recommended geriatric daily doses, in particular benzodiazepines and BRAs, for which the dose was higher than recommended in 29 of 51 cases (57%). Hospital EMR default doses were higher than recommended for 41% (12/29) of medications examined. CONCLUSION: High-risk medications were administered to older fallers. Doses administered and EMR default doses were often higher than recommended. Decreasing EMR default doses for individuals aged 65 and older and warnings about the cumulative numbers of high-risk medications prescribed per person may be simple interventions that could decrease inpatient falls.

The portal of geriatrics online education: a 21st-century resource for teaching geriatrics.

The way students are taught and evaluated is changing, with greater emphasis on flexible, individualized, learner-centered education, including the use of technology. The goal of assessment is also shifting from what students know to how they perform in practice settings. Developing educational materials for teaching in these ways is time-consuming and can be expensive. The Portal of Geriatrics Online Education (POGOe) was developed to aid educators in meeting these needs and become quicker, better-prepared teachers of geriatrics. POGOe contains more than 950 geriatrics educational materials that faculty at 45% of allopathic and 7% of osteopathic U.S. medical schools and the Centers for Geriatric Nursing Excellence have created. These materials include various instructional and assessment methodologies, including virtual and standardized patients, games, tutorials, case-based teaching, self-directed learning, and traditional lectures. Materials with common goals and resource types are available as selected educational series. Learner assessments comprise approximately 10% of the educational materials. POGOe also includes libraries of videos, images, and questions extracted from its educational materials to encourage educators to repurpose content components to create new resources and to align their teaching better with their learners' needs. Web-Geriatric Education Modules, a peer-reviewed online modular curriculum for medical students, is a prime example of this repurposing. The existence of a robust compendium of instructional and assessment materials allows educators to concentrate more on improving learner performance in practice and not simply on knowledge acquisition. It also makes it easier for nongeriatricians to teach the care of older adults in their respective disciplines.