Shifting Culture Toward Age-Friendly Care: Lessons From VHA Early Adopters.

Background: The need for a health care workforce with expanded skills in the care of older adults is increasingly evident as the US population ages. The evidence-based Age-Friendly Health Systems (AFHS) framework establishes a structure to reliably assess and deliver effective care of older adults with multiple chronic conditions: what matters, medication, mentation, and mobility (4Ms). Half of veterans receiving Veterans Health Administration (VHA) care are aged ≥ 65 years, driving its transformation into the largest AFHS in the US. In this article, we offer lessons on the challenges to AFHS delivery and suggest opportunities to sustaining age-friendly care. Observations: Within 3 months of implementation, 85% to 100% of patients received 4M care in all care settings at our VA facilities. Key lessons learned include the importance of identifying, preparing, and supporting a champion to lead this effort; garnering facility and system leadership support at the outset; and integration with the electronic health record (EHR) for reliable and efficient data capture, reporting, and feedback. Although the goal is to establish AFHS in all care settings, we believe that initially including a geriatrics-focused care setting helped early adoption of 4Ms care in the sites described here. Conclusions: Early adopters at 2 VHA health care systems demonstrated successful AFHS implementation spanning different VHA facilities and care settings. Successful growth and sustainability may require leveraging the EHR to reduce documentation burden, increase standardization in care, and automate feedback, tracking, and reporting. A coordinated effort is underway to integrate AFHS into VHA documentation, performance evaluation, and metrics in both the legacy and new Cerner EHRs.

Social Determinants of Health: Considerations for Care of Older Veterans.

Social determinants of health (SDOH), the environments and circumstances in which people are born, grow, live, work and age, are potent drivers of health, health disparities, and health outcomes over the lifespan. Military service affords unique experiences, exposures, and social and health vulnerabilities which impact the life course and may alter health equity and health outcomes for older veterans. Identifying and addressing SDOH, inclusive of the military experience, allows person-centered, more equitable care to this vulnerable population. Nurses and other health professionals should be familiar with how to identify and address health-related social needs and implement interdiciplinary, team-based approaches to connect patients with resources and benefits specifically available to veterans.

Outcomes using direct-acting antiviral hepatitis-C treatment in older versus younger Veterans.

BACKGROUND: Historically, older adults have been excluded from trials evaluating hepatitis C virus (HCV) treatment, in part, due to the adverse effects associated with previous regimens. Veterans are at high risk of HCV infection. Ledipasvir/sofosbuvir (LED/SOF) is a once daily antiviral regimen with demonstrated efficacy and tolerability among the younger population. We examined the tolerability and effectiveness of LED/SOF in Veterans age ≥65 years versus those <65 years who were treated at the Atlanta VA Health Care System (AVAHCS). METHODS: Using the VA Clinical Case Registry, all persons who filled a LED/SOF prescription at the AVAHCS from January 1, 2015, through March 31, 2016, were identified. The electronic medical records were reviewed to identify basic demographic information: comorbidities; polypharmacy; and outcomes. Sustained virologic response (SVR) was defined as an undetectable HCV RNA, at least 12 weeks after completing treatment. Descriptive statistics were employed using SAS v9.2. RESULTS: We identified 345 Veterans who filled LED/SOF during the study period; 94 were excluded due to exposure to ribavirin and IFN containing regimens; 97 (38.6%) were ≥65 years. Veterans were predominantly black (57%) and male (97%). Cancer was more prevalent among older Veterans (p = 0.047) as was polypharmacy (p = 0.001). Treatment completion rates between older and younger Veterans were not significantly different (99 vs. 95%, respectively; p = 0.16), but significantly more older Veterans achieved SVR (98 vs. 91%; p = 0.03). CONCLUSIONS: LED/SOF was a well-tolerated and effective regimen in an older Veteran population despite their multiple comorbidities and polypharmacy presence.

Academic Detailing to Reduce Sedative-Hypnotic Prescribing in Older Veterans.

BACKGROUND: Sedative-hypnotics, including benzodiazepines (BZDs) and benzodiazepine receptor agonists (BZD-RA), are considered potentially inappropriate medications (PIMs) in older adults. Academic detailing, an educational outreach delivered by trained clinicians to other clinicians to encourage evidence-based care, can promote deprescribing of PIMs. OBJECTIVE: To evaluate the impact of academic detailing on sedative-hypnotic prescribing to older veterans. METHODS: A retrospective analysis was performed to evaluate the impact of academic detailing on BZD and BZD-RA prescribing to veterans aged 75 years and older. Prescribing trends for primary care and mental health prescribers in the Veterans Health Administration (VA) Southeast Network were calculated for the 18 months before and after an initial academic detailing session for each prescriber. Pre-post interrupted time series analyses (ITSAs) were conducted, and period prevalence was calculated as the number of prescriptions per 1000 older veterans. RESULTS: A total of 155 prescribers were followed for 36 months. BZD prevalence declined by 23% (69.08-53.33 per 1000 population; P < .001) and by 15% for BZD-RA (18.07-15.38 per 1000 population; P < .001). New starts on BZD declined by 54% (2.36-1.09 per 1000 population; P < .001) and new starts on BZD-RA declined by 53% (1.02-0.48 per 1000 population; P < .001). Alternative medications for insomnia increased by 23% (39.98-49.27 per 1000 population; P < .001). Findings from the ITSA confirmed those of the pre-post analysis with sustained effects in the postintervention period. CONCLUSIONS: Academic detailing was associated with reduced sedative-hypnotic prescribing in the primary care and mental health setting.

Comorbidities, Age, and Polypharmacy Limit the Use by US Older Adults with Nocturia of the Only FDA-approved Drugs for the Symptom.

PURPOSE: The goal of this study was to determine if the US adult population with nocturia (waking from sleep at night to void) can easily take medications (desmopressin acetate) approved by the US Food and Drug Administration for nocturia. The study examined: (1) the prevalence of comorbid conditions, laboratory abnormalities, and concomitant medications that increase risk of desmopressin use; and (2) whether these factors are associated with age or nocturia frequency. METHODS: Using a cross-sectional analysis of four US National Health and Nutrition Examination Survey (NHANES) waves (2005-2012), a total of 4111 participants aged ≥50 years who reported ≥2 nightly episodes of nocturia were identified. The main outcome was frequency of contraindications and drug interactions as described in US Food and Drug Administration-approved prescribing information. These prescribing concerns were matched to examination findings, medical conditions, concomitant medications, and laboratory results of NHANES participants. The associations between prescribing concerns and nocturia severity and age groups were examined. FINDINGS: The mean participant age was 65.7 years (95% CI, 65.3-66.1), and 45.5% were male. Desmopressin prescribing concerns were present in 80.5% (95% CI, 78.0-82.9) of those ≥50 years of age with nocturia; 50.0% (95% CI, 47.0-53.0) had contraindications, and 41.6% (95% CI, 39.3-44.0) took a concomitant drug that could increase risk of low serum sodium. Desmopressin contraindications were higher with older age (P < 0.001) and present in 73.2% (95% CI, 69.3-77.1) of those ≥80 years of age. IMPLICATIONS: Using NHANES data, this study showed that older US adults with nocturia have a high prevalence of medical conditions, concomitant medications, and baseline laboratory abnormalities that likely increase the risk of potentially severe adverse side effects from desmopressin use. A medication designed and approved for a clinical symptom that is most common in older adults could not be taken by most of the older adults with the symptom.

Academic Detailing with Provider Audit and Feedback Improve Prescribing Quality for Older Veterans.

Suboptimal prescribing persists as a driver of poor quality care of older veterans and is associated with risk of hospitalization and emergency department visits. We adapted a successful medication management model, Integrated Management and Polypharmacy Review of Vulnerable Elders (IMPROVE), from an urban geriatric specialty clinic to rural community-based clinics that deliver primary care. The goals were to promote prescribing quality and safety for older adults, including reduced prescribing of potentially inappropriate medications (PIMs). We augmented the original model, which involved a pharmacist-led, one-on-one medication review with high-risk older veterans, to provide rural primary care providers (PCPs) and pharmacists with educational outreach through academic detailing and tools to support safe geriatric prescribing practices, as well as individual audit and feedback on prescribing practice and confidential peer benchmarking. Twenty PCPs and 4 pharmacists at 4 rural Georgia community-based outpatient clinics participated. More than 7,000 older veterans were seen in more than 20,000 PCP encounters during the 14-month intervention period. Implementation of the IMPROVE intervention reduced PIM prescribing incidence from 9.6 new medications per 100 encounters during baseline to 8.7 after the intervention (P = .009). IMPROVE reduced PIM prevalence (proportion of encounters involving veterans who were taking at least 1 PIM) from 22.6% to 16.7% (P < .001). These approaches were effective in reducing PIMs prescribed to older veterans in a rural setting and constitute a feasible model for disseminating geriatric best practices to the primary care setting.

Association of Nondisease-Specific Problems with Mortality, Long-Term Care, and Functional Impairment among Older Adults Who Require Skilled Nursing Care after Dialysis Initiation.

BACKGROUND AND OBJECTIVES: The majority of older adults who initiate dialysis do so during a hospitalization, and these patients may require post-acute skilled nursing facility (SNF) care. For these patients, a focus on nondisease-specific problems, including cognitive impairment, depressive symptoms, exhaustion, falls, impaired mobility, and polypharmacy, may be more relevant to outcomes than the traditional disease-oriented approach. However, the association of the burden of nondisease-specific problems with mortality, transition to long-term care (LTC), and functional impairment among older adults receiving SNF care after dialysis initiation has not been studied. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We identified 40,615 Medicare beneficiaries ≥65 years old who received SNF care after dialysis initiation between 2000 and 2006 by linking renal disease registry data with the Minimum Data Set. Nondisease-specific problems were ascertained from the Minimum Data Set. We defined LTC as ≥100 SNF days and functional impairment as dependence in all four essential activities of daily living at SNF discharge. Associations of the number of nondisease-specific problems (≤1, 2, 3, and 4-6) with 6-month mortality, LTC, and functional impairment were examined. RESULTS: Overall, 39.2% of patients who received SNF care after dialysis initiation died within 6 months. Compared with those with ≤1 nondisease-specific problems, multivariable adjusted hazard ratios (95% confidence interval) for mortality were 1.26 (1.19 to 1.32), 1.40 (1.33 to 1.48), and 1.66 (1.57 to 1.76) for 2, 3, and 4-6 nondisease-specific problems, respectively. Among those who survived, 37.1% required LTC; of those remaining who did not require LTC, 74.7% had functional impairment. A higher likelihood of transition to LTC (among those who survived 6 months) and functional impairment (among those who survived and did not require LTC) was seen with a higher number of problems. CONCLUSIONS: Identifying nondisease-specific problems may help patients and families anticipate LTC needs and functional impairment after dialysis initiation.

Polypharmacy Review of Vulnerable Elders: Can We IMPROVE Outcomes?

Medication management involving pharmacists and PCPs and empowering patients and caregivers resulted in higher satisfaction and cost savings.

Underreporting of nursing home utilization on the CMS-2728 in older incident dialysis patients and implications for assessing mortality risk.

BACKGROUND: The usage of nursing home (NH) services is a marker of frailty among older adults. Although the Centers for Medicare & Medicaid Services (CMS) revised the Medical Evidence Report Form CMS-2728 in 2005 to include data collection on NH institutionalization, the validity of this item has not been reported. METHODS: There were 27,913 patients ≥ 75 years of age with incident end-stage renal disease (ESRD) in 2006, which constituted our analysis cohort. We determined the accuracy of the CMS-2728 using a matched cohort that included the CMS Minimum Data Set (MDS) 2.0, often employed as a "gold standard" metric for identifying patients receiving NH care. We calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the CMS-2728 NH item. Next, we compared characteristics and mortality risk by CMS-2728 and MDS NH status agreement. RESULTS: The sensitivity, specificity, PPV and NPV of the CMS-2728 for NH status were 33%, 97%, 80% and 79%, respectively. Compared to those without the MDS or CMS-2728 NH indicator (No MDS/No 2728), multivariable adjusted hazard ratios (95% confidence interval) for mortality associated with NH status were 1.55 (1.46 - 1.64) for MDS/2728, 1.48 (1.42 - 1.54) for MDS/No 2728, and 1.38 (1.25 - 1.52) for No MDS/2728. NH utilization was more strongly associated with mortality than other CMS-2728 items in the model. CONCLUSIONS: The CMS-2728 underestimated NH utilization among older adults with incident ESRD. The potential for misclassification may have important ramifications for assessing prognosis, developing advanced care plans and providing coordinated care.