Patient and Caregiver Outcomes and Experiences With Team-Based Memory Care: A Mixed Methods Study.

Patients with dementia and their caregivers need ongoing educational and psychosocial support to manage their complex diagnosis. This mixed methods study evaluated the impact of a memory clinic with an embedded dementia navigator on the experiences and health outcomes of patients with dementia and their caregivers. At the 12-month follow-up, patients receiving memory clinic services (n = 238) had higher emergency department visits than a matched cohort with dementia (n = 938), although hospitalizations did not differ. Patient quality of life and caregiver burden scores also did not differ between baseline and 12-months. Interviews revealed that caregivers (n = 12) valued the educational and social support components of the memory clinic and perceived that the clinic had a positive impact on their experiences. Findings suggest that this embedded navigator model is useful for addressing caregiver needs and may have potential to stem increases in caregiver burden and patient quality of life that occur with disease progression.

Timing of Palliative Care Consultation and the Impact on Thirty-Day Readmissions and Inpatient Mortality.

BACKGROUND: Inpatient palliative care consultation (PCC) may reduce 30-day readmissions and inpatient mortality among seriously ill patients. OBJECTIVE: To evaluate the impact of timing of PCC on 30-day readmissions and inpatient mortality. DESIGN: Retrospective, observational study comparing risk-adjusted, observed-to-expected (O/E) 30-day readmissions and inpatient mortality among patients receiving inpatient PCC to all other inpatients. SETTING/SUBJECTS: Adult patients with hospital length of stay (LOS) <30 days, primary diagnoses of circulatory, infectious, respiratory, neoplasms, injury/poisoning, and digestive system were included from eight hospitals in a single health care system. RESULTS: Compared with non-PCC patients (n = 43,463), PCC patients (n = 6043) had a greater proportion of African Americans, Medicare, LOS ≥7 days, intensive care unit stays, discharges to skilled nursing facility and hospice, primary diagnoses of infections and neoplasms, comorbidities of congestive heart failure, cancer, and dementia, Charlson comorbidity score ≥8 (p < 0.001), and fewer males (p = 0.03). Adjusted readmission reduction attributed to PCC among 0-2-, 3-6-, and 7-30-day subgroups was 14.1%, 19.2%, and 16.4%, respectively (usual care O/E = 0.904 vs. subgroup O/Es = 0.764, 0.713, 0.741, respectively). Adjusted mortality reductions attributed to PCC among the 0-2- and 3-6-day subgroups were 19.4% and 19.1%, respectively. A 12% mortality increase was observed in the 7-30-day subgroup (usual care O/E = 0.738 vs. subgroup O/Es = 0.544, 0.547, 0.858, respectively). CONCLUSIONS: Inpatient PCC reduces 30-day readmissions and inpatient mortality with the greatest impact demonstrated within six days of hospital admission. Early PCC should be encouraged for eligible patients.

Healthy Aging: American Geriatrics Society White Paper Executive Summary.

In July 2015, the Journal of the American Geriatrics Society published a manuscript titled, "Failing to Focus on Healthy Aging: A Frailty of Our Discipline?" In response, the American Geriatrics Society (AGS) Clinical Practice and Models of Care Committee and Public Education Committee developed a white paper calling on the AGS and its members to play a more active role in promoting healthy aging. The executive summary presented here summarizes the recommendations from that white paper. The full version is published online at GeriatricsCareOnline.org. Life expectancy has increased dramatically over the last century. Longer life provides opportunity for personal fulfillment and contributions to community but is often associated with illness, discomfort, disability, and dependency at the end of life. Geriatrics has focused on optimizing function and quality of life as we age and reducing morbidity and frailty, but there is evidence of earlier onset of chronic disease that is likely to affect the health of future generations of older adults. The AGS is committed to promoting the health, independence, and engagement of all older adults as they age. Geriatrics as an interprofessional specialty is well positioned to promote healthy aging. We draw from decades of accumulated knowledge, skills, and experience in areas that are central to geriatric medicine, including expertise in complexity and the biopsychosocial model; attention to function and quality of life; the ability to provide culturally competent, person-centered care; the ability to assess people's preferences and values; and understanding the importance of systems in optimizing outcomes. J Am Geriatr Soc 67:17-20, 2019.

Geriatric emergency medicine service: a novel approach to an emerging trend.

Many studies have described benefits to patients from geriatric care in the emergency department (ED), yet few geriatric emergency departments exist nationally. As our nation ages and health care financing for these patients becomes more complex, it will be crucial for hospitals to develop ED services that address the needs of our sickest and frailest patients. In this article, we report on our experiences using advanced practice registered nurses (APRNs) embedded in an established ED. Our geriatric emergency medicine service (GEMS(SM)) model has improved patient satisfaction rates and decreased time spent in the ED. It has increased volume of geriatric patients in our hospital by 6%. Strong executive support for geriatric services has established our hospital as a local leader in geriatric emergency medicine. The program is fiscally neutral and serves a frail vulnerable population. We have improved healthcare for our seniors and believe this model of geriatric emergency care can easily be replicated nationally.

Local, regional and national responses for medical management of a radiological/nuclear incident.

Radiological and nuclear devices may be used by terrorists or may be the source of accidental exposure. A tiered approach has been recommended for response to a terrorist event wherein local, regional, state and federal assets become involved sequentially, as the magnitude in severity of the incident increases. State-wide hospital plans have been developed and published for Connecticut, New York and California. These plans address delineation of responsibilities of various categories of health professionals, protection of healthcare providers, identification and classification of individuals who might have been exposed to and/or contaminated by radiation and, in the case of Connecticut response plan, early management of victims. Regional response programs such as the New England Regional Health Compact (consisting of 6 member states) have been developed to manage consequences of radiation injury. The Department of Homeland Security is ultimately responsible for managing both health consequences and the crisis. Multiple US national response assets may be called upon for use in radiological incidents. These include agencies and programs that have been developed by the Department of Energy, the Environmental Protection Agency and the Department of Defense. Coordination of national, regional and state assets with local response efforts is necessary to provide a timely and efficient response.

Brain connectivity is not only lower but different in schizophrenia: a combined anatomical and functional approach.

BACKGROUND: Schizophrenia is hypothesized to involve disordered connectivity between brain regions. Currently, there are no direct measures of brain connectivity; functional and structural connectivity used separately provide only limited insight. Simultaneous measure of anatomical and functional connectivity and its interactions allow for better understanding of schizophrenia-related alternations in brain connectivity. METHODS: Twenty-seven schizophrenia patients and 27 healthy control subjects underwent magnetic resonance imaging with resting state functional magnetic resonance imaging and diffusion tensor imaging. Separate functional and anatomical connectivity maps were calculated and combined for each subject. Global, regional, and voxel measures and K-means network analysis were employed to identify group differences and correlation with clinical symptoms. RESULTS: A global connectivity analysis indicated that patients had lower anatomical connectivity and lower coherence between the two imaging modalities. In schizophrenia these group differences correlated with clinical symptom severity. Although anatomical connectivity nearly uniformly decreased, functional connectivity in schizophrenia was lower for some connections (e.g., middle temporal gyrus) and higher for others (e.g., cingulate and thalamus). Within the default mode network (DMN) two separate subsystems can be identified. Schizophrenia patients showed decoupling between structural and functional connectivity that can be localized to networks originating in posterior cingulate cortex as well as in the task-positive network and one of the DMN components. CONCLUSIONS: Combining two measures of brain connectivity provides more comprehensive descriptions of altered brain connectivity underlying schizophrenia. Patients show deficits in white matter anatomy, but functional connectivity alterations are more complex. Fusion of both methods allows identification of subsystems showing both increased and decreased functional connectivity.

Physician preferences for medical interventions in elderly patients.

PURPOSE: To identify factors influencing medical decision making in the elderly based on differences in age, cognition, and function. MEASUREMENTS: Physicians were given a clinical scenario and asked to select from three management options based on the patients' characteristics. RESULTS: Eighty-six percent would offer aggressive management to patients less than 85 years of age, whereas only 47.2% would offer similar care to those over 85 years of age (RR 0.5; 95% CI: 0.4-0.7). Physicians were less likely to offer aggressive management for patients with dementia (RR 0.2; 95% CI: 0.1-0.6), and for those requiring home assistance (RR: 0.2; 95% CI: 0.1-0.6) compared to those without dementia or functional limitations. CONCLUSION: Physicians are more likely to deny aggressive management to functionally active adults over 85 years of age, and to those with dementia or functional impairment irrespective of age.

Measuring brain connectivity: diffusion tensor imaging validates resting state temporal correlations.

Diffusion tensor imaging (DTI) and resting state temporal correlations (RSTC) are two leading techniques for investigating the connectivity of the human brain. They have been widely used to investigate the strength of anatomical and functional connections between distant brain regions in healthy subjects, and in clinical populations. Though they are both based on magnetic resonance imaging (MRI) they have not yet been compared directly. In this work both techniques were employed to create global connectivity matrices covering the whole brain gray matter. This allowed for direct comparisons between functional connectivity measured by RSTC with anatomical connectivity quantified using DTI tractography. We found that connectivity matrices obtained using both techniques showed significant agreement. Connectivity maps created for a priori defined anatomical regions showed significant correlation, and furthermore agreement was especially high in regions showing strong overall connectivity, such as those belonging to the default mode network. Direct comparison between functional RSTC and anatomical DTI connectivity, presented here for the first time, links two powerful approaches for investigating brain connectivity and shows their strong agreement. It provides a crucial multi-modal validation for resting state correlations as representing neuronal connectivity. The combination of both techniques presented here allows for further combining them to provide richer representation of brain connectivity both in the healthy brain and in clinical conditions.

Anemia prevalence in a home visit geriatric population.

OBJECTIVES: Ascertain anemia prevalence in the home visit geriatric population. DESIGN: Retrospective chart review. SETTING: A geriatric home visit program of a community-based teaching hospital. PARTICIPANTS: Non-institutionalized elderly patients referred to the geriatric home visit program from March 1, 2003, through October 1, 2006. MEASUREMENTS: Demographic, diagnostic, and hemoglobin data were abstracted. Anemia was defined using the WHO criteria of hemoglobin (Hb) less than 13 g/dL in men and less than 12 g/dL in women. RESULTS: The cohort consisted of 244 patients, predominantly white (88%), women (77%), and with a median age of 85 years. Anemia prevalence was 39.6% (95% CI: 32.6-46.9): 44.7% (95% CI: 30.2-59.9) in the men and 37.9% (95% CI: 30.0-46.4%) in the women. There was no statistically significant difference in anemia prevalence by race, known diagnosis of dementia, or by any other comorbidity. Majorities (86.8%) of the anemias were normocytic, 10.5% were microcytic, and 2.6% had macrocytosis. About 36.4% had nutrient deficiencies, 13.6% had anemia of chronic disease, 9.1% had myelodysplastic syndrome, and the etiology remained unknown for 40.9%. CONCLUSION: Anemia prevalence in the homebound geriatric population is high, about 4 times the National Health and Nutrition Examination Survey (NHANES III) estimate for the free-living, community-dwelling elderly. It mirrors the high prevalence in the nursing home population.