Approach to Evaluating the Multimorbid Patient with Cardiovascular Disease Undergoing Noncardiac Surgery.

Older patients undergo more inpatient and outpatient procedures than do younger individuals, and their risk of suffering undesired outcomes is greater. The performance of a productive preoperative assessment entails more than the application of the sundry clinical practice guidelines relating to a patient's various medical diagnoses. A better approach involves adoption of a physiologically integrated, whole-person assessment that takes into account the patient's cognitive function, mood, physical function and mobility (including the possibility of frailty), social support, nutritional status, and medication use. This article outlines such an approach and highlights the many gaps in the current evidence base.

Optimal older adult emergency care: introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine.

In the United States and around the world, effective, efficient, and reliable strategies to provide emergency care to aging adults is challenging crowded emergency departments (EDs) and a strained health care system. In response, geriatric emergency medicine (EM) clinicians, educators, and researchers collaborated with the American College of Emergency Physicians (ACEP), American Geriatrics Society (AGS), Emergency Nurses Association (ENA), and the Society for Academic Emergency Medicine (SAEM) to develop guidelines intended to improve ED geriatric care by enhancing expertise, educational, and quality improvement expectations; equipment; policies; and protocols. These "Geriatric Emergency Department Guidelines" represent the first formal society-led attempt to characterize the essential attribute of the geriatric ED and received formal approval from the boards of directors for each of the four societies in 2013 and 2014. This article is intended to introduce EM and geriatric health care providers to the guidelines, while providing proposals for educational dissemination, refinement via formal effectiveness evaluations and cost-effectiveness studies, and institutional credentialing.

Optimal older adult emergency care: introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine.

In the United States and around the world, effective, efficient, and reliable strategies to provide emergency care to aging adults is challenging crowded emergency departments (EDs) and strained healthcare systems. In response, geriatric emergency medicine clinicians, educators, and researchers collaborated with the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine to develop guidelines intended to improve ED geriatric care by enhancing expertise, educational, and quality improvement expectations, equipment, policies, and protocols. These Geriatric Emergency Department Guidelines represent the first formal society-led attempt to characterize the essential attributes of the geriatric ED and received formal approval from the boards of directors of each of the four societies in 2013 and 2014. This article is intended to introduce emergency medicine and geriatric healthcare providers to the guidelines while providing recommendations for continued refinement of these proposals through educational dissemination, formal effectiveness evaluations, cost-effectiveness studies, and eventually institutional credentialing.

Preoperative assessment of the older patient: a narrative review.

IMPORTANCE: Surgery in older patients often poses risks of death, complications, and functional decline. Prior to surgery, evaluations of health-related priorities, realistic assessments of surgical risks, and individualized optimization strategies are essential. OBJECTIVE: To review surgical decision making for older adult patients by 2 measures: defining treatment goals for elderly patients and reviewing the evidence relating risk factors to adverse outcomes. Assessment and optimization strategies for older surgical patients are proposed. EVIDENCE ACQUISITION: A review of studies relating geriatric conditions such as functional and cognitive impairment, malnutrition, facility residence, and frailty to postoperative mortality and complications (including delirium, discharge to an institution, and functional decline). Medline, EMBASE, and Web of Science databases were searched for articles published between January 1, 2000, and December 31, 2013, that included patients older than 60 years. RESULTS: This review identified 54 studies of older patients; 28 that examined preoperative clinical features associated with mortality (n = 1,422,433 patients) and 26 that examined factors associated with surgical complications (n = 136,083 patients). There was substantial heterogeneity in study methods, measures, and outcomes. The absolute risk and risk ratios relating preoperative clinical conditions to mortality varied widely: 10% to 40% for cognitive impairment (adjusted hazard ratio [HR], 1.26 [95% CI, 1.06-1.49] to 5.77 [95% CI, 1.55-21.55]), 10% to 17% for malnutrition (adjusted odds ratio [OR], 0.88 [95% CI, 0.78-1.01] to 59.2 [95% CI, 3.6-982.9]), and 11% to 41% for institutionalization (adjusted OR, 1.5 [95% CI, 1.02-2.21] to 3.27 [95% CI, 2.81-3.81]).) Risk ratios for functional dependence relating to mortality ranged from an adjusted HR of 1.02 (95% CI, 0.99-1.04) to an adjusted OR of 18.7 (95% CI, 1.6-215.3) and for frailty relating to mortality, ranged from an adjusted HR of 1.10 (95% CI, 1.04-1.16) to an adjusted OR of 11.7 (95% CI not reported) (P < .001). Preoperative cognitive impairment (adjusted OR, 2.2; 95% CI, 1.4-2.7) was associated with postoperative delirium (adjusted OR, 17.0; 95% CI, 1.2-239.8; P < .05). Frailty was associated with a 3- to 13-fold increased risk of discharge to a facility (adjusted OR, 3.16 [95% CI, 1.0-9.99] to 13.02 [95% CI, 5.14-32.98]). CONCLUSIONS AND RELEVANCE: Geriatric conditions may be associated with adverse surgical outcomes. A comprehensive evaluation of treatment goals and communication of realistic risk estimates are essential to guide individualized decision making.

Assessing challenges in end-of-life conversations with elderly patients with multiple morbidities.

INTRODUCTION: This study reports on physicians' experiences in conducting end-of-life conversations with elderly patients who suffered from multiple co-morbidities (MCM). Our hypothesis was that both the lack of prognostic certainty and the lack of good communication tools contributed to physicians' discomfort with conducting EOL conversations with patients and families of patients with these conditions especially when compared with patients and families of patients who had a single, clear terminal diagnosis (e.g. pancreatic cancer). METHODS: Focus group questions were semi-structured and explored three general themes: (1) differences between having an end-of-life conversation with patients/families with MCM versus those with a single, terminal diagnosis; (2) timing of the end-of-life conversation; and (3) approaches to the end-of-life conversation. RESULTS: Three themes emerged: (1) It is more difficult for them to have EOL conversations with patients with MCM and their families, as opposed to conversations with families and patients who have a clear, terminal diagnosis. (2) In deciding when to raise the subject of EOL care, participants reported that they rely on a number of physical and/or social signs to prompt these discussions. Yet a major reason for the difficulty that providers face in initiating these discussions with MCM patients and families is that there is a lack of a clear threshold or prompting event. (3) Participants mentioned three types of approaches to initiating EOL conversations: (a) direct approach, (b) indirect approach, (c) collaborative approach. CONCLUSION: Prognostic indicies and communication scripts may better prepare physicians to facilitate end-of-life conversations with MCM patients/families.

Assessment of a chief complaint-based curriculum for resident education in geriatric emergency medicine.

INTRODUCTION: We hypothesized that a geriatric chief complaint-based didactic curriculum would improve resident documentation of elderly patient care in the emergency department (ED). METHODS: A geriatric chief complaint curriculum addressing the 3 most common chief complaints-abdominal pain, weakness, and falls-was developed and presented. A pre- and postcurriculum implementation chart review assessed resident documentation of the 5 components of geriatric ED care: 1) differential diagnosis/patient evaluation considering atypical presentations, 2) determination of baseline function, 3) chronic care facility/caregiver communication, 4) cognitive assessment, and 5) assessment of polypharmacy. A single reviewer assessed 5 pre- and 5 postimplementation charts for each of 18 residents included in the study. We calculated 95% confidence and determined that statistical significance was determined by a 2-tailed z test for 2 proportions, with statistical significance at 0.003 by Bonferroni correction. RESULTS: For falls, resident documentation improved significantly for 1 of 5 measures. For abdominal pain, 2 of 5 components improved. For weakness, 3 of 5 components improved. CONCLUSION: A geriatric chief complaint-based curriculum improved emergency medicine resident documentation for the care of elderly patients in the ED compared with a non-age-specific chief complaint-based curriculum.

Hospice care in nursing homes: does it contribute to higher quality pain management?

PURPOSE: The purpose of this study was to investigate pain management among 42 hospice and 65 non-hospice residents in two proprietary nursing homes. DESIGN AND METHODS: In this prospective, anthropological, quantitative, and qualitative study, we used participant observation, event analysis, and chart review to obtain data. The Medication Quantification Scale was used in order to account for the prescription and administration of all analgesic medications. RESULTS: Although 72% of residents experienced pain, we found no statistically significant differences in the proportion of hospice versus non-hospice residents (a) who had been prescribed opioids and co-analgesics, and (b) whose medication was administered around the clock or as needed. Limited physician availability, lack of pharmacologic knowledge, and limitations of nursing staff hindered pain management of both groups of residents. IMPLICATIONS: Although hospice care is of some benefit, pain management and high-quality end-of-life care is dependent upon the context in which it is provided. Given that between 1991 and 2001 Medicare expenditures for nursing home-based hospice care increased from dollar 8.6 million to dollar 21.8 million, the effectiveness of hospice-care programs in nursing homes warrants further study.

Delirium in postacute and long-term care.

Delirium is a classic geriatric syndrome that occurs commonly among the frail elders who make up many of the residents in postacute and long-term care facilities. The prevalence of the disorder in these settings may be increasing as a result of the pressure to reduce hospital length of stay. Clinicians often do not recognize when patients in their care are delirious, but simple and practical means exist to allow its diagnosis. Those who practice in long-term care must be knowledgeable about the risk factors for the disorder, as well as how to recognize, diagnose, prevent, and treat it.