Impact of a collaboration revolving around virtual capacity evaluations.

OBJECTIVE: To assess the impact of virtual capacity assessments on access to medical care, community supports, and transitions to higher levels of care. STUDY SETTING: Virtual capacity evaluations of homebound suspected elder abuse/neglect/financial exploitation victims identified via exclusion criteria and initiated by Cuyahoga County adult protective services (APS) and conducted with Cleveland Clinic Geriatric Medicine. STUDY DESIGN: A retrospective chart review was conducted in conjunction with APS using their database to determine the outcomes of individuals who underwent virtual capacity evaluation from May 2020 through September 2021. Variables collected included completion of a statement of expert evaluation, guardianship assignment, offering community services, transfer to a higher level of care, and establishment of primary care. DATA COLLECTION/EXTRACTION: Data were extracted from medical records and the APS database. Outcomes were measured as percentages. PRINCIPAL FINDINGS: Fifty-four individuals underwent evaluation. Statements of expert evaluation were completed in 38 cases (70%). Guardianship was assigned in 28 cases (52%). Community services were offered to 51 (89%). Thirty-one (57%) remained at home. At baseline, only 23 (43%) were receiving primary care. Post evaluation, 44 (81%) were connected or reconnected to their medical provider. CONCLUSION: Of individuals who underwent our virtual capacity evaluations, most were able to remain at home, offered community services for support, and linked to primary care.

How Telehealth Addresses the Needs of Vulnerable Elders.

BACKGROUND: One of the most vulnerable groups is older persons who seek medical care (patients), especially those who are cognitively impaired with limited access to technology or knowledge of its use. INTERVENTION: Cuyahoga County Adult Protective Services (APS) partnered with the geriatricians who work at Cleveland Clinic to arrange for clients to be seen virtually in their home environment. Once a patient was identified as having cognitive concerns or an unaddressed medical issue, an appointment was scheduled for a concurrent in-home nurse and virtual visit with a geriatrician.The APS nurse visited the patient's residence to perform an in-home assessment followed by the virtual portion of the visit concurrent with the geriatrician using a Health Insurance Portability and Accountability Act (HIPAA)-compliant electronic platform. OUTCOMES: Fifty-six patients were seen and evaluated in-home by a nurse and then simultaneously virtually by a geriatrician over a 12-month period. Among these patients, 53% had a guardian assigned, 55% were able to stay in their home, and 55% lacked regular health care before the visit, but afterward, 74% started primary medical care. CONCLUSION: Physicians working collaboratively with community agencies for in-home technology-enhanced visits led to positive outcomes for this vulnerable older population.

Assessing cognition in the era of COVID19: Do we need methods to assess cognitive function virtually?

BACKGROUND: With an aging population, cognitive impairment has become increasingly prevalent. Early symptoms are often missed in primary care and may progress to clinical dementia before being noticed. Screening for dementia has been a challenge. No clear guideline describes how to assess for cognition in primary care despite the robust data suggesting that early identification of dementia allows for mobilization of resources to support patients and caregivers, and there is no harm in proactive assessing cognition in older patients. In addition, most of the cognitive assessment methods requires in-person cognitive testing in primary care practices, this may be affected by situations where the in-person visitations to the physician offices are limited such as in the COVID 19 pandemic. Our study aims to access performance of in-person cognitive assessment in primary care during COVID 19 pandemic. METHODS: Cleveland Clinic implanted MiniCog as a cognitive screening tool in primary care at Cleveland Clinic Community Care (4C). Inclusion criteria are- Age 65+, Annual Wellness visit, no preexisting diagnosis of dementia, normal MiniCog in previous year. Data were registered from from January 2019 until November 2020. RESULTS: Figure 1 displays the number of MiniCog performed at 4C averaging 360 MiniCog every month. Total number of MiniCogs performed during the study period was 7126 out of which 6739 were normal (95%) and 387 were abnormal (5%). Figure 2 displays the impact of COVID 19 pandemic on in-person visits in 4C, resulting an impressive decline in cognitive assessment process leading to no cognitive testing in April and only two tests in May. CONCLUSION: Most of the cognitive assessment tools used in clinical practice requires in-person office based and are often needed to diagnose dementia. Telephonic cognitive interviews such as TICS and MoCA 5 minute protocol are available, but are difficult to administer in primary care. The substantial drop in the performance of in-person cognitive assessment during the COVID 19 pandemic raises the need of validated tools to virtually assess cognitive function and also highlights the negative impact of COVID 19 pandemic on already frail processes of assessing cognitive health of older adults in primary care.

Alzheimer dementia: Starting, stopping drug therapy.

Alzheimer disease is the most common type of dementia. Two classes of cognition-enhancing drugs are approved to treat the symptoms, and both have provided modest benefit in clinical trials. Psychotropic drugs are sometimes used off-label to treat behavioral symptoms of Alzheimer disease. All these medications should be continuously evaluated for clinical efficacy and, when appropriate, discontinued if the primary benefit--preservation of cognitive and functional status and a reduction in behaviors associated with dementia--is no longer being achieved.

Geriatrics update 2015: Vaccination, frailty, chronic disease guidelines, and cognition.

This paper discusses recent developments and recommendations for elderly patients concerning immunizations, heart failure, lipid therapy, blood pressure control, and dementia.

Don't forget non-Alzheimer dementias.

Dementia is commonly encountered in the elderly, with prevalence increasing with age. Although Alzheimer disease is the most recognized form of dementia, other types have distinct clinical features and are often overlooked. Proper identification aids patients, caregivers, and physicians in planning and management.

When to consider normal pressure hydrocephalus in the patient with gait disturbance.

Normal pressure hydrocephalus (NPH) is a chronic adult disorder of unknown cause. It is characterized by gradual onset of gait impairment, cognitive dysfunction, and urinary incontinence in the presence of enlarged ventricles. NPH is a relatively rare cause of these 3 common symptoms. Diagnosis is made based on suspicion of NPH symptoms, the additional finding of ventriculomegaly on imaging, and confirmatory testing with a trial of CSF drainage, which can predict improvement with CSF shunting. The differential diagnosis must consider common causes of each of the symptoms and include Alzheimer's disease (AD), Parkinson's disease (PD), vascular dementia, and spinal stenosis. Treatment involves CSF diversion, usually through implantation of a shunt from the ventricles to the peritoneal cavity. After surgery and in the absence of other contributing factors, the benefit of surgical intervention can be durable over years.

Does this patient have primary progressive aphasia?

Primary progressive aphasia (PPA) is a distinct clinical entity in which the patient develops language deficits while other cognitive domains remain relatively preserved until late in the course of the illness. The diagnosis can be relatively clear through an appropriate diagnostic approach based on the history and physical examination. There is no cure, but speech therapy is beneficial in this illness.

Normal pressure hydrocephalus: diagnosis and new approaches to treatment.

Impairment of gait occurs commonly in the elderly and has a profound impact on individual functional capacity and quality of life. Dementia and urinary incontinence are other common problems encountered in the elderly. In many circumstances, these problems are mutually exclusive, with treatments chosen to address each disease entity separately. When they appear over time in the same patient, however, these symptoms raise the possibility of normal pressure hydrocephalus.

When do common symptoms indicate normal pressure hydrocephalus?

The Adams triad (gait impairment, dementia, and urinary incontinence) of normal pressure hydrocephalus (NPH) is well known, but other illnesses present with similar symptoms. Accurate diagnosis of this rare disorder depends on careful evaluation. A ventriculoperitoneal shunt is the only effective therapy, and deciding whether the patient will benefit is the final challenge in the evaluation process.

If we were supposed to take vitamins, wouldn't they grow on trees?

Vitamin E supplementation may not be as innocuous as previously believed. A dose relationship between vitamin E and all-cause mortality may exist, beginning at 150 IU per day. Mortality risk was minimally but statistically higher for doses of Vitamin E 1000 IU/d or greater compared with placebo. Further controlled trials using both natural and synthetic forms of Vitamin E are warranted to determine the true effects.