Impact of Documented Fall-Risk, Self-Reported Health and Confidence to Prevent Falls on Concern About Falling Among Community-Dwelling Older Adults: Secondary Analysis of a Randomized Clinical Trial.

Purpose: Individuals identified as high fall risk are expected to have high concern about falling. However, perception and individual factors that influence concern about falling have yet to be thoroughly studied. We aimed to understand factors that influence concern about falling among older adults with increased risk for falling. Patients and Methods: This was a secondary analysis of a clinical trial among community-dwelling older adults (age ≥65 years old) at high risk for falls (n = 178). Descriptive and regression analyses were used. We analyzed the relationship between participants' baseline concern about falling - categorized into three groups: low (7-8), moderate (9-13), and high (≥14) - and factors that may impact their concern. Exploratory factors included age, sex, self-reported health status and confidence to address fall risks, fall risk scores, and physical performance measures. Results: Among these individuals, 15.2% reported low concern about falling. On average, individuals in higher concern about falling groups had higher fall risk scores (low [5.7], moderate [6.4], and high [8.0]; p < 0.001). Our regression model showed that the odds of being in a higher concern group increased by 21% for every one unit increase in fall risk score and increased by 67% for every one unit increase toward poorer health rating. Conversely, for every one unit increase in self-reported confidence, the odds of being in a higher concern group decreased by 27.5%. Conclusion: Knowledge of older adults' fall risk, health status, and concerns about falling can be used to assist in the personalization of fall prevention interventions for a more holistic approach.

How Are We Teaching Advocacy? A National Survey of Internal Medicine Residency Program Directors.

BACKGROUND: Although internal medicine (IM) physicians accept public advocacy as a professional responsibility, there is little evidence that IM training programs teach advocacy skills. The prevalence and characteristics of public advocacy curricula in US IM residency programs are unknown. OBJECTIVES: To describe the prevalence and characteristics of curricula in US IM residencies addressing public advocacy for communities and populations; to describe barriers to the provision of such curricula. DESIGN: Nationally representative, web-based, cross-sectional survey of IM residency program directors with membership in an academic professional association. PARTICIPANTS: A total of 276 IM residency program directors (61%) responded between August and December 2022. MAIN MEASUREMENTS: Percentage of US IM residency programs that teach advocacy curricula; characteristics of advocacy curricula; perceptions of barriers to teaching advocacy. KEY RESULTS: More than half of respondents reported that their programs offer no advocacy curricula (148/276, 53.6%). Ninety-five programs (95/276, 34.4%) reported required advocacy curricula; 33 programs (33/276, 12%) provided curricula as elective only. The content, structure, and teaching methods of advocacy curricula in IM programs were heterogeneous; experiential learning in required curricula was low (23/95, 24.2%) compared to that in elective curricula (51/65, 78.5%). The most highly reported barriers to implementing or improving upon advocacy curricula (multiple responses allowed) were lack of faculty expertise in advocacy (200/276, 72%), inadequate faculty time (190/276, 69%), and limited curricular flexibility (148/276, 54%). CONCLUSION: Over half of US IM residency programs offer no formal training in public advocacy skills and many reported lack of faculty expertise in public advocacy as a barrier. These findings suggest many IM residents are not taught how to advocate for communities and populations. Further, less than one-quarter of required curricula in public advocacy involves experiential learning.

Age-Friendly Research: A Pilot Exploration of Tools to Facilitate Inclusion of Older Adults in Research.

Older adults have a high burden of chronic diseases but are underrepresented in research. Researchers with geriatric or gerontology expertise have developed frameworks to recruit and retain older adults but these have not been widely adopted by the broader research community. We developed or adapted seven Age-Friendly research tools and invited research team members with no aging training to pilot test them. We consented 21 research team members and asked them to share strengths, limitations, and areas for improvement for each tool for up to 4 months via REDCap surveys. Sixteen participants (76%) completed at least one survey. The communication guide and Age-Friendly research checklist were the most utilized tools among participants. Key barriers to implementation were lack of time and lack of age-appropriate populations. Facilitators of tool implementation were accessibility and ease of use, webinar training, and supportive teams. Participants found the tools valuable to encourage Age-Friendly research studies. Adoption of Age-Friendly research tools could improve the experience for research team members and older adults alike.

Improving dose-related adverse drug events among hospitalized older adults using a geriatric prescribing context.

BACKGROUND: Adverse drug events (ADEs) during hospitalization are a serious, yet preventable concern for older adults. Our institution designed a Geriatric Prescribing Context (GPC) to adjust doses for the older adult population but its impact on ADEs was unknown. The goal of this study was to assess any differences in rates of ADEs before and after its implementation in July 2017. METHODS: We used relevant ICD-10 codes followed by confirmatory chart review to identify dose-related ADEs from 10 commonly used medications at our institution. We assessed differences in the number of admissions with an ADE before and after the GPC implementation using a test of binomial proportions. The pre-period was from July 2016 through June 2017 and the post-period was from August 2017 through July 2018. We compared the rate of ADEs per 1000 patient days between periods with a Poisson rate test and further examined any differences in harm categories using a Fisher's exact test. RESULTS: The proportion of admissions with any dose-related ADEs significantly decreased from 0.0082 to 0.0037 after the GPC (p = 0.04). The rate of dose-related ADEs also declined from 2.5 per 1000 patient days to 1.1 per 1000 patient days (p = 0.001). Harm categories did not change significantly between time points (p = 0.30). CONCLUSIONS: Based on our list of relevant ICD-10 codes, the GPC was associated with lower dose-related ADEs for our selected medications among hospitalized older adults.

A Quality Improvement Initiative to Increase Documentation of Preferences for Life-Sustaining Treatment in Hospitalized Adults.

BACKGROUND: Portable Orders for Life-Sustaining Treatment (POLST) forms allow patients to codify their preferences for life-sustaining treatments across inpatient and outpatient settings. In 2019 only 29.5% of our hospitalized internal medicine patients with an inpatient do-not-resuscitate (DNR) order and no DNR POLST at admission discharged with a DNR POLST. This presented an opportunity to improve POLST completion and avoid undesired or inappropriate care after discharge. METHODS: Using electronic health record (EHR) data, the authors identified hospitalized adults (age ≥ 50 years) admitted to an internal medicine service with a DNR order and discharged alive. Patient records were cross-referenced with the state's POLST registry for an active POLST form. Among patients with a missing or full-code POLST form at admission, the authors calculated the proportion with a DNR POLST form completed by discharge. These data were tracked over time with control charts to detect performance shifts following three Plan-Do-Study-Act (PDSA) cycles over 34 months, which included a single educational training on electronic POLST navigation, an EHR discharge navigator notification, and quarterly e-mailed individualized performance reports. RESULTS: The study population (N = 387) was 55.0% male and predominately non-Hispanic white (80.9%). Patients discharging to a skilled nursing facility or hospice were three times more likely to discharge with a DNR POLST compared to patients discharging home. Overall, the proportion of DNR POLST forms completed by discharge increased from 0.36 to 0.60 after three PDSA cycles (p < 0.001). CONCLUSION: This quality improvement initiative demonstrated improved POLST form completion rates in a target population of adults at elevated risk for readmission and death.

American Geriatrics Society response to the World Falls Guidelines.

Falls are a major cause of preventable death, injury, and reduced independence in adults aged 65 years and older. The American Geriatrics Society and British Geriatrics Society (AGS/BGS) published a guideline in 2001, revised in 2011, addressing common risk factors for falls and providing recommendations to reduce fall risk in community-dwelling older adults. In 2022, the World Falls Guidelines (WFG) Task Force created updated, globally oriented fall prevention risk stratification, assessment, management, and interventions for older adults. Our objective was to briefly summarize the new WFG, compare them to the AGS/BGS guideline, and offer suggestions for implementation in the United States. We reviewed 11 of the 12 WFG topics related to community-dwelling older adults and agree with several additions to the prior AGS/BGS guideline, including assessment and intervention for hearing impairment and concern for falling, assessment and individualized exercises for older adults with cognitive impairment, and performing a standardized assessment such as STOPPFall before prescribing a medication that could potentially increase fall risk. Notable areas of difference include: (1) AGS continues to recommend screening all patients aged 65+ annually for falls, rather than just those with a history of falls or through opportunistic case finding; (2) AGS recommends continued use of the Timed Up and Go as a gait assessment, rather than relying on gait speed; and (3) AGS recommends clinical judgment on whether or not to check an ECG for those at risk for falling. Our review and translation of the WFG for a US audience offers guidance for healthcare and other providers and teams to reduce fall risk in older adults.

Motivational Interviewing for Fall Prevention (MI-FP) pilot study: Older Adults' readiness to participate in fall prevention.

Older adults' readiness to participate in fall prevention behaviors is largely unknown. We evaluated the feasibility of recruitment for a fall prevention intervention and participants' readiness to participate in fall prevention activities. Patients ≥ 65 years at high fall risk were recruited. Feasibility of recruitment was assessed by reaching the goal sample size (200), and recruitment rate (50%). Surveys assessed participants' readiness to participate in fall prevention activities (confidence to manage fall risks [0-10 scale; 10 most confident] and adherence to fall prevention recommendations). We recruited 200 patients (46.3% of eligible patients), and 185 completed surveys. Participants reported high confidence (range 7.48 to 8.23) in addressing their risks. Their adherence to clinician recommendations was mixed (36.4% to 90.5%). We nearly met our recruitment goals, and found that older adults are confident to address their fall risks, but do not consistently engage in fall prevention recommendations.

Age-Friendly Research: promoting inclusion of older adults in clinical and translational research.

Introduction: Older adults have a high disease burden but are often underrepresented in research studies due to recruitment and retention obstacles, among others. Geriatric research specialists have identified solutions to these challenges and designed frameworks to help other researchers. Our team utilized three frameworks to create an interactive webinar series aimed to educate research team members on Age-Friendly practices. Methods: We recruited 40 non-aging-trained research team members to participate in a six-session, real-time webinar series from October to November 2022. Sessions were comprised of 20-30 minute didactics and 30-40 minute group discussions. Participants completed pre- and post-program surveys, commitment to change forms, and post-webinar session surveys. Responses were examined for strengths and areas for improvement. Wilcoxon signed-rank tests assessed differences in confidence scores. Results: Self-reported confidence scores improved after the webinar series. Most participants provided positive feedback and high likeliness to use what they learned and recommend the webinar to others. The strengths were practical tips, applicable tools, and real-world examples. The major area for improvement was information on industry-sponsored trials. The commitment to change responses varied from pledging to use more inclusive language to adapting materials to improve the consent process. Conclusion: This interactive Age-Friendly Research webinar series was feasible and well received by participants. We created an Age-Friendly Research community fostering commitment to change clinical and translational research to be more inclusive of older adults. Future work will include more information on industry-sponsored trials and expand to other research centers.

Resident-led research: a quality improvement project to improve serious illness conversations.

Skilled conversations regarding end-of-life (EOL) care reduce emotional suffering and increase goal-concordant care. The Ariadne Labs Serious Illness Conversation (SIC) framework is an effective tool for improving EOL communication, but research is lacking on use with resident physicians. This study led by internal medicine residents tested the feasibility and acceptability of training peers in SIC. In 2021, three resident project leaders recruited first and second year internal medicine residents at a single tertiary academic center to receive extracurricular training on the Ariadne Labs SIC Guide. Baseline and post-training surveys were conducted to determine attitudes, barriers, and confidence related to EOL discussions. Initial recruitment efforts were unsuccessful but participation increased from zero to seven after residency administrators approved protected time for SIC training. Six residents (85.7%) completed baseline and post-training surveys. Residents identified lack of time as the key barrier to initiating SIC. Self-reported comfort discussing EOL care and documenting the conversations improved after training. Both resident researchers and participants reported SIC training was valuable and successful. Institutional support with dedicated buy-in, strong faculty mentorship, and committed resident leaders all contribute to successfully implementing a resident-led project.