Advance Care Planning in the Outpatient Geriatric Medicine Setting.

This article describes how to perform advance care planning in the outpatient geriatric medicine setting. The article defines advance care planning and discusses components of advance care planning, such as advance directives, do-not-resuscitate orders, and Physician Orders for Life-Sustaining Treatment. The article describes how to document advance care planning discussions in the clinic and bill Medicare and ways for clinicians to improve their skill at leading these conversations.

Pressure ulcers in long-term care.

Pressure ulcers are common, costly, and debilitating chronic wounds, which occur preferentially in people with advanced age, physical or cognitive impairments, and multiple comorbidities. Residents with pressure ulcers have decreased quality of life and increased morbidity and mortality, and facilities with high rates of pressure ulcers have higher costs and risks of litigation. Health professionals who practice in this setting should be well versed in pressure ulcer management. This article reviews the significance, risk factors, pathophysiology, prevention, diagnosis, and management of pressure ulcers in long-term care.

Multifractal analysis of nonlinear complexity of sacral skin blood flow oscillations in older adults.

The objective of this study was to investigate the relationship between cutaneous vasodilatory function and nonlinear complexity of blood flow oscillations (BFO) in older people. A non-painful fast local heating protocol was applied to the sacral skin in 20 older subjects with various vasodilatory functions. Laser Doppler flowmetry was used to measure skin blood oscillations. The complexity of the characteristic frequencies (i.e., metabolic (0.0095-0.02 Hz), neurogenic (0.02-0.05 Hz), myogenic (0.05-0.15 Hz), respiratory (0.15-0.4 Hz), and cardiac (0.4-2 Hz)) of BFO was quantified using the multifractal detrended fluctuation analysis. Compared with the 65-75 years group, the complexity of metabolic BFO in the 75-85 years group was significantly lower at the baseline (P < 0.05) and the second peak (P < 0.001). Compared with baseline BFO, subjects in the 65-75 years group had a significant increase in the complexity of metabolic BFO (P < 0.01) in response to local heating; while subjects in the 75-85 years group did not. Our findings support the use of multifractal analysis to assess aging-related microvascular dysfunction.

Wavelet analysis of sacral skin blood flow oscillations to assess soft tissue viability in older adults.

The objective of this study was to investigate age-related changes of microvascular functions using wavelet analysis of blood flow oscillations (BFO), and to develop a new quantification method to present wavelet coefficients for studying the contribution of each blood flow control mechanism to the skin vasodilatory response. 20 older people between 65 and 85 years of age were recruited into the study. The heater temperature at the sacral skin was raised to 42 degrees C in 2 min and maintained at that temperature for the duration of the 50 minute heating period to induce a biphasic vasodilatory response: axon reflex mediated and nitric oxide mediated vasodilation. Wavelet-based spectrum analysis was used to calculate sacral skin blood flow and frequency bands including metabolic (0.008-0.02 Hz), neurogenic (0.02-0.05 Hz), myogenic (0.05-0.15 Hz), respiratory (0.15-0.4 Hz), and cardiac (0.4-2.0 Hz) frequencies. Biphasic Thermal Index is defined as ratios of first peak, nadir, and second peak to baseline blood flow. The results showed that older people have a biphasic blood flow response with lower vasodilatory function. Increased age is associated with an increase in baseline blood flow and a decrease of skin vasodilatory function (p<0.05). Biphasic Thermal Index is (5.5, 4.5, 10.1) for the 65-75 years group and is (3.7, 3.2, 6.7) for the 75-85 years group. During local heating, the metabolic frequency appears to become the most dominant frequency in power during the second peak, and the power of neurogenic frequency does not seem to significantly increase during the axon reflex mediated vasodilation. Wavelet coefficients averaged during the one-minute period are able to characterize time-series changes of frequencies. This study has shown the feasibility of using wavelet-based spectrum analysis of skin blood flow oscillations to assess skin microvascular function for detection of the specific conditions which constitute the highest risk factors for pressure ulcers among older people. Aging is associated with a decrease of skin blood flow function, which results in increased risk for ischemic damage and pressure ulcers.

Development and evaluation of a longitudinal Case Based Learning (CBL) experience for a geriatric medicine rotation.

The DWR Department of Geriatric Medicine at OUHSC and the OKC VA Medical Center began a mandatory third-year geriatric medicine clerkship in 2003. As part of the didactic sessions, the Department created a longitudinal Case-Based Learning (CBL) experience. The purpose of this paper is to describe the CBL experience, report student satisfaction with the CBL process, and discuss how students value CBL as a teaching method compared to other methods. The results indicate that CBL is highly valued among the students due to the interactive nature of the sessions and longitudinal nature of the cases.

Pressure ulcers and endothelial dysfunction: is there a link?

Pressure ulcers were first described in the medical literature in the mid-16th century. Today, in the 21st century, pressure ulcers continue to cause pain and suffering to patients and increase the cost of medical care. Researchers and clinicians have used significant time and money to develop prevention and treatment strategies for pressure ulcers. Accepted risk factors for pressure ulcer development include pressure, shear force, friction, moisture and malnutrition. Yet despite procedures to help minimize these risk factors, pressure ulcers are still problematic. Endothelial dysfunction, which is a well-documented cardiovascular risk factor, has been proposed as another risk factor for pressure ulcers. Yet little is known about how pressure ulcers and endothelial dysfunction are linked. In this article we explore the literature to build an argument that research into the role of endothelial function is a plausible line of translational investigation that would contribute greatly to the knowledge base that guides present-day practices in the prevention and treatment of pressure ulcers.

Health promotion in older adults. Prescribing exercise for the frail and home bound.

Some degree of physical activity is always preferable to a sedentary lifestyle. For home bound elderly, with limited mobility and strength, physical activity should be focused on "functional fitness," such as performing activities of daily living, transfers, and mobility. We examine the benefits of exercise for frail home bound elderly, potential barriers to exercise, and ways to initiate a physical activity program.

Effect of a mandatory geriatric medicine clerkship on third-year students.

A nationwide push has increased geriatric medicine instruction within medical school curricula. Some institutions have proceeded with an integrated 4-year curriculum while others have constructed discrete courses in the third or fourth year of medical school. This paper describes the impact of a new mandatory 4-week geriatric medicine clerkship on third-year students developed by the Donald W. Reynolds Department of Geriatric Medicine at the University of Oklahoma Health Sciences Center. In the first year of implementation, 135 students took the course on both the Oklahoma City and Tulsa campuses. Clinical sites included inpatient, VA extended care unit, outpatient clinics, dementia clinics, home care, long-term care settings, and hospice. Didactic instruction used formal lectures and problem-based learning. The impact of the clerkship on students was assessed in three areas: knowledge, skills, and attitude using a pre- and postknowledge test, student satisfaction survey, and written comments. This article discusses how the clerkship resulted in increased knowledge of geriatric medicine. Student self-report indicates that the clerkship enhanced clinical evaluation and patient assessment skills. Students indicated that the experience was positive and recognized the importance of geriatric medicine in their development as doctors.

Minimizing physical restraints in acute care.

The use of restraints to protect patients and insure continuation of care is an accepted fact in today's medical practice. However over the last 20 years a growing body of evidence supports the idea that restraints are harmful and should be used as the last resort. Since 1987, federal law requires long term care facilities to be restraint free. This article describes the use of restraints in the acute care setting, complications of using restraints and efforts to minimize restraint use in order to compliant with national policies.