Which Patients Benefit the Most from a Geriatrician's Care? Consensus Among Directors of Geriatrics Academic Programs

The Landscape of Geriatric Fellow Scholarly Activity Participation: Findings From a National Survey of Program Directors

Introduction As the US population continues to age, there is a critical need for geriatricians to be trained and engaged in research to inform high-quality care for older adults. Our objective was to understand the extent, type, barriers, and facilitators of research training and the attitudes toward research training and scholarly activity among Accreditation Council for Graduate Medical Education (ACGME)-accredited US geriatric fellowship programs. Methods We conducted a cross-sectional survey of geriatric fellowship program directors from September to November 2022. Surveys assessing program characteristics, requirements for scholarly activity, director demographics, and director attitudes toward scholarly activity were distributed via email. We used descriptive statistics to assess fellowship scholarly activity requirements, facilitators, and perceived barriers. Results The survey response rate was 35.3% (41/116 programs). Most programs (82.9%) required participation in scholarly activity and provided protected time (73.2%). Definitions of scholarly activities greatly differed among programs. The most common scholarly activity requirements included participation in a scholarly project (70.7%) or local presentation (46.3%). The short duration of fellowship was the most common major barrier, reported by 70.7% of directors. Lastly, 34.1% of directors indicated satisfaction with the quality of research training provided, while 65.9% of directors reported satisfaction with the opportunities provided to participate in scholarly activities. Conclusions Overall, program requirements, facilitators, and perceived barriers to scholarly activity were heterogeneous among US geriatric program directors. Additionally, only about one-third of directors were satisfied with the research training provided. Our future work will compare the attitudes and reported barriers/facilitators of program director and fellow participants toward participation in scholarly activity.

[The role of private geriatricians in the health care system (2/2): comprehensive qualitative analysis using semi-structured interviews]

Private geriatricians report heterogeneous practices, while the specialty as a whole is questioning its model. We conducted semi-structured interviews to understand how private geriatricians viewed their role in the health care system. They report a certain homogeneity in their conception of their role, which corresponds to that of geriatricians as a whole: there seems to be a professional identity for geriatrics.

Exploring How Personal, Social, and Institutional Characteristics Contribute to Geriatric Medicine Subspecialty Decisions: A Qualitative Study of Trainees' Perceptions

PURPOSE

To explore internal medicine residents' and geriatrics fellows' perceptions of how personal, social, and institutional characteristics contribute to their professional identity and subspecialty decisions related to geriatric medicine.

METHOD

The authors conducted 23 in-depth, semistructured interviews with internal medicine residents, with and without an interest in geriatrics, and geriatrics fellows across 3 academic medical centers in the United States from October 2018 through June 2019. They then used a qualitative narrative approach to analyze the interview data.

RESULTS

Trainees related personal experiences, such as exposure to physicians and experiences with grandparents, to their interest in medicine. Trainees with an interest in geriatrics at 2 institutions did not feel supported, or understood, by peers and mentors in their respective institutions but maintained their interest in the field. The following variations between institutions that are supportive and those that are not were noted: the number of geriatricians, the proximity of the institution to geriatrics clinics, and the ways in which institutional leaders portrayed the prestige of geriatric medicine. Institutional characteristics influenced trainees' understanding of what it meant to be a doctor, what meaning they garnered from work as a physician, and their comfort with different types of complexity, such as those presented when providing care to older adults.

CONCLUSIONS

Institutional characteristics may be particularly important in shaping trainee interest in geriatric medicine. Institutions should encourage leadership training and opportunities for geriatricians so they can serve as role models and as hands-on mentors for trainees beginning in medical school. Increasing the number of geriatricians requires institutions to increase the value they place on geriatrics to generate a positive interest in this field among trainees. Institutions facilitating formation of professional identity and sense of purpose in work may consider engaging geriatricians in leadership and mentoring roles as well as curriculum development.

Complications in low-risk older adult trauma patients: A case-control study

BACKGROUND

Although some geriatric trauma patients may be at low risk of complications, poor outcomes are pronounced if complications do occur. Prevention in this group decreases the risk of excess morbidity and mortality.

METHODS

We performed a case-control study of trauma patients 65 years or older treated from January 2015 to August 2016 at a Level I trauma center with a Trauma Quality Improvement Program-predicted probability of complication of less than 20%. Cases had one of the following complications: unplanned admission to the intensive care unit (ICU), unplanned intubation, pneumonia, or unplanned return to the operating room. Two age-matched controls were randomly selected for each case. We collected information on comorbidities, home medications, and early medical care and calculated odds ratios using multivariable conditional logistic regression.

RESULTS

Ninety-four patients experienced unplanned admission to ICU (n = 51), unplanned intubation (n = 14), pneumonia (n = 21), and unplanned return to the operating room (n = 8). The 188 controls were more frequently intubated and had higher median ISS but were otherwise similar to cases. The adjusted odds of complication were higher for patients on a home β-blocker (adjusted odds ratio [aOR], 2.2; 95% confidence interval [CI], 1.2-4.0) and home anticoagulation (aOR, 2.2; 95% CI, 1.2-4.1). Patients with diabetes (aOR 2.0; 95% CI, 1.1-3.7) and dementia (aOR, 2.0; 95% CI, 1.0-4.3) also had higher odds of complication. The adjusted odds of complication for patients receiving geriatrics consultation was 0.4 (95% CI, 0.2-1.0; p = 0.05). Pain service consultation and indwelling pain catheter placement may be protective, but CIs included 1. There was no association between opiates, benzodiazepines, fluid administration, or blood products in the first 24 hours and odds of complication.

CONCLUSIONS

Geriatrics consultation was associated with lower odds of unplanned admission to the ICU, unplanned intubation, pneumonia, and unplanned return to the operating room in low-risk older adult trauma patients. Pathways that support expanding comanagement strategies with geriatricians are needed.

LEVEL OF EVIDENCE

Therapeutic/Care management, Level IV.

[Cross-speciality geriatrics: A health-care challenge for the 21st century]

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.

Inadequate Risk Adjustment Impacts Geriatricians' Performance on Medicare Cost and Quality Measures

OBJECTIVES

Medicare value-based payment programs evaluate physicians' performance on their patients' annual Medicare costs and clinical outcomes. However, little is known about how geriatricians, who disproportionately provide care for medically complex older adults, perform on these measures.

DESIGN

A retrospective study using multivariable regression methods to estimate the association of geriatric risk factors with annualized Medicare costs and preventable hospitalization rates and to compare geriatricians' performance on these outcomes to other primary care physicians (PCPs) under standard Medicare risk adjustment and after adding additional adjustment for geriatric risk factors.

SETTING

Eight years (2006-2013) of cohort data from the Medicare Current Beneficiary Survey.

PARTICIPANTS

Medicare beneficiaries, aged 65 years and older, with primary care services contributing 27 027 person-years of data.

MEASUREMENTS

Outcomes were costs and preventable hospitalization rates; geriatric risk factors were patient frailty, long-term institutionalization, dementia, and depression.

RESULTS

Geriatricians were more likely to care for patients with frailty (22.8% vs 14.1%), long-term institutionalization (12.0% vs 4.7%), dementia (21.6% vs 10.2%), and depression (23.6% vs 17.4%) than other PCPs (P < .001 for each). Under standard Medicare risk adjustment, geriatricians performed more poorly on costs compared to other PCPs (observed-expected [O-E] ratio = 1.24 vs 0.99) and preventable hospitalizations (O-E ratio = 1.16 vs 0.98). Adding frailty, institutionalization, dementia, and depression to risk adjustment improved geriatricians' performance on costs by 25% and on preventable hospitalization rates by 35%, relative to other PCPs. Concurrent-year risk prediction that removed the influence of unpredictable acute events further improved geriatricians' performance vs other PCPs (O-E ratio = 0.99 vs 1.00).

CONCLUSION

Medicare should consider risk adjusting for frailty, long-term institutionalization, dementia, and depression to avoid inappropriately penalizing geriatricians who care for vulnerable older adults. J Am Geriatr Soc 68:297-304, 2020.

Improving geriatric care and reducing hospitalisations in regional and remote areas: The benefits of telehealth

INTRODUCTION

The aim of this study was to compare the effectiveness of two geriatrician models of care, the telegeriatric service (TGS) and visiting geriatrician (VG), in regional and remote settings in terms of potential cost-savings to the health system and impact on health service use (HSU). Furthermore, to establish whether longer wait-times for clinic appointments led to increased HSU by study participants.

METHODS

Trends in patient emergency department presentations, hospitalisations and bed-days (HSU) were compared from 18 months before to 12 months after geriatrician appointment for the two services in the Western Australian Midwest region. The relationships between wait times, patient triage level and HSU were modelled. The costs of providing the services were offset against reductions in HSU after appointments.

RESULTS

The sample comprised consecutive patients using the TGS (n = 84) and VG service (n = 124). Patient characteristics were similar, although patients using the VG service had longer wait-times, were triaged as more urgent and demonstrated the highest levels of HSU. Both models were effective with similar rates of reduced HSU following appointments. Increased wait-times and higher patient triage urgency were associated with increased HSU.

DISCUSSION

Although TGS and VG showed similar reduced rates of HSU, TGS had the capacity to see a higher volume of patients, a broader geographical reach and improved waitlist management. Consequently, TGS was more effective at reducing avoidable hospitalisations and subsequent health deterioration due to shorter wait-times. Whilst face-to-face consultations are recognised as 'gold standard' a combination of the two models is most efficient.

Putting Complex Older Persons First: How the Centers for Medicare and Medicaid Services 2019 Payment Proposal Fails Older Americans

In July 2018, the Centers for Medicare and Medicaid Services (CMS) released its proposed Medicare Physician Fee Schedule rule for calendar year 2019 (MPFS2019). The proposal sets forth CMS-recommended updates to Medicare payment policies, payment rates, and quality provisions for services provided in the next calendar year. From year to year, the rule also can serve as a vehicle for soliciting input on new payment proposals and changes to existing policies. Among the payment and quality proposals in the MPFS2019 proposal, CMS proposed extensive changes to Current Procedural Terminology codes that are the framework for documentation and payment for office-based evaluation and management (E/M) services. The American Geriatrics Society (AGS) believes the proposed payment methodology changes for E/M services would have had a significant negative impact on care for older Americans. On September 10, 2018, the AGS submitted its comments on this proposal and other aspects of the rule, and the AGS also submitted a comment letter signed by 41 organizations from an AGS-led multispecialty coalition. The coalition also worked collaboratively on outreach to Congress, which included visits to Capitol Hill and a coalition letter stressing our collective support for reducing the burden of documentation for clinicians and our opposition to the proposed changes in payment methodology. In all letters, we noted that the AGS and members of our coalition hoped to work collaboratively with CMS and other stakeholders to develop a refined approach that would achieve the best possible outcomes for patients, particularly frail older Americans with multiple chronic conditions. In releasing their final MPFS2019, CMS postponed the E/M coding collapse for at least two years, a decision that speaks to the hard work of the AGS, its members, and the multi-specialty coalition, and which opens the door for further discussions about the future of payment for E/M services so critical to older people. J Am Geriatr Soc 67:145-150, 2019.

Raising enthusiasm for the medical care of elderly patients: a concept mapping study to find elements for an elderly friendly medical curriculum

BACKGROUND

To deliver high quality of care for the growing population of older patients more geriatricians are needed. However, the interest of medical students for a career in geriatrics is lagging behind due to a lack of exposure, the nature of the work, and the low status and financial rewards. So far, only isolated interventions aimed at enhancing interest and/or attitudes with regard to geriatrics have been studied, pointing to the need for a broader-based strategy. The goal of this research is to find elements for a curriculum framework that can raise medical students' enthusiasm for the medical care of elderly patients.

METHODS

We used the concept mapping method developed by Trochim. This computer-assisted procedure consists of five steps: brainstorming, prioritizing and clustering with several experts, followed by processing by the computer and analysis.

RESULTS

The views that were generated were grouped into the following clusters: a patient-centered medical curriculum, a curriculum representative of patient population, geriatrics presented as intellectually challenging and emotionally appealing, senior-friendly role models, a clear professional perspective. The results are presented in the form of a graphic chart.

CONCLUSIONS

An agenda to discuss the necessary actions for drastic curricular reforms in medical schools is set. This may give some guidance to this urgent, but highly complicated issue how to make medical student enthusiastic for the medical care for elderly patients.

Understanding functional and social risk characteristics of frail older adults: a cross-sectional survey study

Background

Frailty is a condition of increasing importance, given the aging adult population. With an anticipated shortage of geriatricians, primary care physicians will increasingly need to manage care for frail adults with complex functional risks and social-economic circumstances.

Methods

We used cross-sectional data from 4551 adults ages 65–90 who responded to the 2014/2015 cycle of the Kaiser Permanente Northern California Member Health Survey (MHS), a self-administered survey that covers multiple health and social characteristics, to create a deficits accumulation model frailty index, classify respondents as frail or non-frail, and then compare prevalence of functional health issues including Activities of Daily Living (ADL)/Instrumental Activities of Daily Living (IADL) and social determinants of health (SDOHs) by frailty status.

Results

The overall prevalence of frailty was 14.3%, higher for women than men, increased with age, and more common among those with low levels of education and income. Frail older adults were more likely than non-frail to have ≥ 3 chronic diseases (55.9% vs. 10.1%), obesity (32.7% vs. 22.8%), insomnia (36.4% vs. 8.8%), oral health problems (25.1% vs. 4.7%), balance or walking problems (54.2% vs. 4.9%), ≥ 1 fall (56.1% vs. 19.7%), to use ≥ 1 medication known to increase fall risk (56.7% vs. 26.0%), and to need help with ≥2 ADLs (15.8% vs. 0.8%) and ≥ 2 IADLs (38.4% vs. 0.8%). They were more likely to feel financial strain (26.9% vs. 12.6%) and to use less medication than prescribed (7.4% vs. 3.6%), less medical care than needed (8.3% vs 3.7%), and eat less produce (9.5% vs. 3.2%) due to cost. Nearly 20% of frail adults were unpaid caregivers for an adult with frailty, serious illness or disability.

Conclusions

This study examined the prevalence of frailty and identified modifiable and non-modifiable risk factors of health. The frail older adult population is heterogeneous and requires a patient-centered assessment of their circumstances by healthcare providers and caregivers to improve their quality of life, avoid adverse health events, and slow physical and mental decline. The characteristics identified in this study can be proactively used for the assessment of patient health, quality of life, and frailty prevention.

The Effect of an In-Hospital Comprehensive Geriatric Assessment on Short-Term Mortality During Orthogeriatric Hip Fracture Program-Which Patients Benefit the Most?

Aims

To examine the association of patient-related factors with the effect of an in-hospital comprehensive geriatric assessment (CGA) on hip fracture mortality.

Methods

Population-based, prospective data were collected on 1425 consecutive hip fracture patients aged ≥65 in a central hospital providing orthogeriatric service. Outcome was mortality at 1 month after hip fracture associated with receiving versus not receiving CGA.

Results

Of the patients receiving CGA compared to those who did not, 8.5% versus12.0% had died within 1 month of the hip fracture (P = .028). In the age- and sex-adjusted Cox proportional hazards model, CGA was associated with a decreased risk of 1-month mortality in patients aged 80 to 89 years (hazard ratio [HR] 0.46, 95% confidence interval [CI]: 0.29-0.73), females (HR: 0.57, 95% CI: 0.38-0.86), having American Society of Anesthesiologists (ASA) score 1 to 3 (HR: 0.60, 95% CI: 0.37-0.99), taking 4 to 10 daily medications (HR: 0.59, 95% CI: 0.38-0.91), with a diagnosis of memory disorder (HR: 0.50, 95% CI: 0.29-0.88), with an estimated glomerular filtration rate <30 mL/min/1.73m² (HR: 0.28, 95% CI: 0.10-0.76), or living in an assisted living accommodation (HR: 0.40, 95% CI: 0.21-0.76).

Conclusion

Several modifiable and patient-related factors were associated with decreased risk of 1-month mortality when CGA was performed during hospitalization for hip fracture. Between "younger and fitter" and "oldest and frailest," there is a large group of hip fracture patients whose survival can be improved by in-hospital CGA.

The Association of Geriatric Syndromes with Hospital Outcomes

BACKGROUND

Frailty, history of dementia (HoD), and acute confusional states (ACS) are common in older patients admitted to hospital.

OBJECTIVE

To study the association of frailty (≥6 points in the Clinical Frailty Scale [CFS]), HoD, and ACS with hospital outcomes, controlling for age, gender, acute illness severity (measured by a Modified Early Warning Score in the emergency department), comorbidity (Charlson Comorbidity Index), and discharging specialty (general medicine, geriatric medicine, surgery).

DESIGN

Retrospective observational study.

SETTING

Large university hospital in England.

PATIENTS

We analyzed 8202 first nonelective inpatient episodes of people aged 75 years and older between October 2014 and October 2015.

MEASUREMENTS

The outcomes studied were prolonged length of stay (LOS ≥10 days), inpatient mortality, delayed discharge, institutionalization, and 30-day readmission. Statistical analyses were based on multivariate regression models.

RESULTS

Independently of controlling variables, prolonged LOS was predicted by CFS ≥6: odds ratio (OR) =1.55; 95% confidence interval [CI], 1.36-1.77; P ⟨ 0.001; HoD: OR = 2.16; 95% CI, 1.79-2.61; P ⟨ 0.001; and ACS: OR = 3.31; 95% CI, 2.64-4.15; P ⟨ 0.001. Inpatient mortality was predicted by CFS ≥6: OR = 2.29; 95% CI, 1.79-2.94; P ⟨ 0.001. Delayed discharge was predicted by CFS ≥6: OR = 1.46; 95% CI, 1.27-1.67; P ⟨ 0.001; HoD: OR = 2.17; 95% CI, 1.80-2.62; P ⟨ 0.001; and ACS: OR = 2.29; 95% CI: 1.83-2.85; P ⟨ 0.001. Institutionalization was predicted by CFS ≥6: OR = 2.56; 95% CI, 2.09-3.14; P ⟨ 0.001; HoD: OR = 2.51; 95% CI, 2.00-3.14; P ⟨ 0.001; and ACS: OR 1.93; 95% CI, 1.46-2.56; P ⟨ 0.001. Readmission was predicted by ACS: OR = 1.36; 95% CI, 1.09-1.71; P = 0.006.

CONCLUSIONS

Routine screening for frailty, HoD, and ACS in hospitals may aid the development of acute care pathways for older adults. Journal of Hospital Medicine 2017;12:83-89.

European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome

This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization's classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.

European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome

This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization's classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.

Clinical frailty and functional trajectories in hospitalized older adults: A retrospective observational study

AIM

Frailty predicts inpatient mortality and length of stay, but its link to functional trajectories is under-researched. Addenbrooke's Hospital, Cambridge, UK, collects the Clinical Frailty Scale (CFS) within 72 h of admission for those aged ≥75 years. We studied whether the CFS links to functional trajectories in hospitalized older adults.

METHODS

This was a retrospective observational study in an English university hospital. We analyzed all first episodes of county residents aged ≥75 years admitted to the Department of Medicine for the Elderly wards between December 2014 and May 2015. Data were extracted from the hospital's information systems. Patients were classified as non-frail (CFS 1-4), moderately frail (CFS 5-6) and severely frail (CFS 7-8). Function was retrospectively measured with the modified Rankin Scale (mRS) at preadmission, admission and discharge.

RESULTS

Of 539 eligible patients, 46 died during admission (mortality rates: 2% in CFS 1-4, 5% in CFS 5-6, 19% in CFS 7-8). Among the 493 survivors, 121 were non-frail, 235 moderately and 137 severely frail. The mean mRS of the non-frail was 1.8 (95% CI 1.7-2.0) at baseline, 3.3 (95% CI 3.1-3.5) on admission and 2.2 (95% CI 2.0-2.3) on discharge (mean length of stay 9 days). The moderately frail had a mean mRS of 2.9 (95% CI 2.8-3.0) at baseline, 4.0 (95% CI 3.8-4.1) on admission and 3.2 (95% CI 3.1-3.3) on discharge (mean length of stay 15 days). The severely frail had mean mRS of 3.5 (95% CI 3.3-3.6) at baseline, 4.3 (95% CI 4.1-4.4) on admission and 3.7 (95% CI 3.6-3.9) on discharge, respectively (mean length of stay 17 days).

CONCLUSIONS

In older inpatients, frailty might be linked to lower and slower functional recovery. Prospective work is required to confirm these trajectories and understand how to influence them. Geriatr Gerontol Int 2017; 17: 1063-1068.

Failing to Focus on Healthy Aging: A Frailty of Our Discipline?

The academic geriatrics community has provided outstanding leadership in addressing frailty and complexity in older adults, but a minority of older adults are frail. Although resources to treat older adults are limited, and it is appropriate to focus clinical efforts on those with frailty and multimorbidity, there is also important expertise that can be brought to bear on the health of ALL older adults. A review of the literature suggests that attention to healthy or successful aging has failed to keep pace with the focus on frailty. By providing leadership to promote successful aging, the quality of life of older adults across the spectrum can be improved and transitions to frailty reduced. The template that leaders have established in understanding frailty-defining and operationalizing it, understanding outcomes, identifying pathophysiology-can be used as an approach to successful aging. Several community-based programs have been successful in promoting successful aging. These are potentially highly scalable and could have a substantial effect on the aging population, but their essential components need to be better understood. The geriatrics community is uniquely positioned to take on this role. This is a critical time to work together to make the lives of all older adults as healthy and fulfilling as possible.

[Geriatric post-graduate training: Current recommendations and opinion of the trainees]

OBJECTIVE

To evaluate the level of compliance with the official curriculum residence programme by geriatrics trainees, and to analyse their level of satisfaction.

MATERIAL AND METHODS

A questionnaire was developed including these sections: trainee filiation, and questions related to their clinical training, academic formation, research training, satisfaction, and other comments. The survey was performed in Survey Monkey and sent to a geriatric trainee per hospital in March 2014. The results were collected between March and April of 2014.

RESULTS

Responses were received from 41% of the trainees of 23 Geriatric Teaching Units. Rates of over 95% were observed as regards clinical rotations in the basic period, while in the specific period these percentages varied between 34% and 69%, probably because some of the trainees had not yet arrived at the period in which these rotations are programmed. An external rotation could be performed by 83% of the trainees, and 90% do the recommended number of shifts. The mean number of instruction sessions per week was 2.3, and the number of meetings with the tutor was 2.5 times per year. The median number of presentations in congresses was 3.7 per trainee, with 0.2 publications during training. Each trainee attended 1.2 national meetings, 0.3 European meetings, and 0.1 American. Most of the trainees (85%) were satisfied or very satisfied with their training.

CONCLUSIONS

Geriatrics curricula for trainees are followed in the basic aspects, but not so much in the specific ones. The average level satisfaction of the trainees is very high. The recommended training activities within the specific department (sessions, etc.) are not always fulfilled. The research activity, evaluated by publications and presentations at meetings, is low. Following these data, reflection and the establishment of improvements are required in Geriatrics training at post-graduate level.

Short-term outcomes of seniors aged 80 years and older with acute illness: hospitalist care by geriatricians and other internists compared

BACKGROUND

Although acute geriatric units have improved the outcomes of hospitalized seniors, it is uncertain as to whether hospitalist care by geriatricians outside of these units confers similar benefit.

OBJECTIVE

To determine whether hospitalist care by geriatricians reduces short-term mortality and readmission, and length of stay (LOS) for seniors aged 80 years and older with acute medical illnesses compared with care by other internists.

DESIGN

Retrospective cohort study using administrative and chart review data on demographic, admission-related, and clinical information of hospital episodes.

SETTING

General internal medicine department of an acute-care hospital in Singapore from 2005 to 2008.

PATIENTS

Seniors aged 80 years and older with specific focus on 2 subgroups with premorbid functional impairment and acute geriatric syndromes.

INTERVENTION

Hospitalist care by geriatricians compared with care by other internists.

MEASURES

Hospital mortality, 30-day mortality or readmission, and LOS.

RESULTS

For 1944 hospital episodes (intervention: 968, control: 976), there was a nonsignificant trend toward lower hospital mortality (15.5% vs 16.9%) but not 30-day mortality or readmission, or LOS for care by geriatricians compared with care by other internists. A marginally stronger trend toward lower hospital mortality for care by geriatricians among those with acute geriatric syndromes (20.2% vs 23.1%) was observed. Similar treatment effects were found after adjustment for demographic, admission-related, and clinical factors.

CONCLUSIONS

For seniors aged 80 years and over with acute medical illness, hospitalist care by geriatricians did not significantly reduce short-term mortality, readmission, or LOS, compared with care by other internists.

The Geriatrician and Geriatric Psychiatrist Workforce in Texas

Objectives: This study provides a current analysis of the size and characteristics of the board-certified geriatrician and geriatric psychiatrist workforce in Texas, and thereby its capacity to meet increasing health needs of elders. Method: Secondary data on Texas board-certified geriatricians and geriatric psychiatrists from American Board of Medical Specialties database were analyzed. Results: The study found 1 geriatrician per 5,132 elders, and 1 geriatric psychiatrist per 21,327 elders, in Texas. Over 62% of geriatricians had active certification, 30% were females and the average age was 55.2 years. Rural geriatricians were disproportionately scarce ( p < .001). Discussion: The study indicated a serious shortage of board-certified geriatricians and geriatric psychiatrists in Texas. This shortage is worse than that at the national level, and more marked along the Texas–Mexico border and counties lacking large health facilities. Addressing this workforce deficiency requires improvements in the geriatric training pipeline, reimbursements, and practice environments.

Is geriatric care associated with less emergency department use?

OBJECTIVES

To determine whether community-dwelling individuals and nursing home (NH) residents treated by a geriatrician were less likely to use the emergency department (ED) than individuals treated by other physicians.

DESIGN

Retrospective cohort study using data from a national sample of older adults with a history of cardiovascular disease.

SETTING

Ambulatory care or NH.

PARTICIPANTS

Fee-for-service Medicare beneficiaries aged 66 and older diagnosed with one or more geriatric conditions from 2004 to 2007 and followed for up to 3 years.

MEASUREMENTS

Emergency department use was measured in Medicare inpatient and outpatient claims; geriatric care was measured as geriatrician visits in ambulatory or NH settings coded in physician claims.

RESULTS

Multivariable analyses controlled for observed and unobserved subject characteristics that were constant during the study period. For community-dwelling participants, one or more nonhospital geriatrician visits in a 6-month period were associated with 11.3% lower ED use the following month (95% confidence interval (CI) = 7.5-15.0, N = 287,259). Participants who received primary care from geriatricians were less likely to have ED use than those who had traditional primary care. Results for participants who received consultative care from geriatricians were similar to those for participants who received primary care from geriatricians. Results for NH residents (N = 66,551) were similar to those for community-dwelling participants.

CONCLUSION

Geriatric care was associated with an estimated 108 fewer ED visits per 1,000 community-dwelling residents and 133 fewer ED visits per 1,000 NH residents per year. Geriatric consultative care in collaboration with primary care providers may be as effective in reducing ED use as geriatric primary care. Increased provision of collaborative care could allow the existing supply of geriatricians to reach a larger number of individuals.

[Which patients benefit the most from hospital geriatric care in the opinion of the geriatricians?]

OBJECTIVE

To assess the most appropriate criteria considered by geriatricians to select patients who might benefit the most from geriatric hospital care.

MATERIAL AND METHODS

We carried out a survey that consisted of various socio-demographic, clinical, functional and mental criteria included in the definition of the geriatric and frail elderly patient. The survey was sent to all specialists in geriatrics in the different hospitals of the Madrid Health Service. They were asked to answer to each criterion indicating whether they considered it as high priority, priority, low priority or no priority. The responses were clustered by type of hospital: acute hospitals with or without a post-graduate geriatric program for medical residents, and medium and long stay hospitals.

RESULTS

A total of 83 questionnaires were completed (70% of the study population): 42 teaching hospitals a post-graduate geriatric program (74% of possible), 20 of those with an emergency department but without a post-graduate geriatric program (56% of possible), and 21 medium and long stay hospitals (84% of potential). All proposed criteria were considered individually as priority or high-priority by more than 50% of respondents. An age 85 years and over, admission for hip fracture, the presence of severe cognitive or functional impairment, frailty, and unexplained deterioration of health status, were considered individually as criteria for selecting high-priority target population by more than 85% of respondents.

CONCLUSIONS

Certain criteria, such as advanced age, or the presence of geriatrics-specific conditions, such as hip fracture or severe functional or cognitive impairment, are identified by geriatricians as useful to select patients to receive geriatric specialist hospital care.

The development of academic geriatric medicine in the United States 2005 to 2010: an essential resource for improving the medical care of older adults

Academic geriatric medicine programs are critical for training the physician workforce to care effectively for aging Americans. This article updates the progress made by U.S. medical schools from 2005 to 2010 in developing these programs. Academic leaders in geriatrics in accredited allopathic and osteopathic medical schools were surveyed in the winter of 2010 (60% response rate), and results were compared with findings from a similar 2005 survey (68% response rate). Physician faculty in geriatrics increased from 9.6 (mean) full-time equivalents (FTEs) in 2005 to 11.2 by 2010. In 2010, faculty and staff effort was mostly devoted to clinical practice (mean = 37%) and education (mean = 33%), with only seven responding schools devoting more than 40% of faculty effort to research. Schools that have been designated as Centers of Excellence had a median 20 FTE physician faculty, compared with seven at the other schools (P < .001). In 2010, 27% of medical schools required a geriatrics clerkship, and 87% (n = 83) had an elective geriatric clerkship. In summary, more fellows and faculty were recruited and trained in 2010 than in 2005, and some academic programs have emerged with strong education, research, and clinical initiatives. Medical student exposure to geriatrics curriculum has increased, but few academic geriatricians are pursuing research careers, and the number of practicing geriatricians is declining. New approaches to training the entire physician workforce to care for older adults will be required to ensure adequate medical care for aging Americans.

When is it the right time to ask for a geriatrician?

Given an aging population coupled with a shortage of people to care for them, it is essential to understand the patient qualities for which geriatric expertise would be most beneficial. For the practicing physician attempting to understand the timing of geriatric-care provision, this article reviews the relevant literature, which suggests geriatric expertise should be considered for the patients who benefit most: any patient aged ≥ 85 years, or adults aged < 85 years with complex multimorbidity, frailty, or other geriatric conditions; disability or dementia; or need for palliative or end-of-life care.

The geriatric patient: use of acute geriatrics units in the emergency care of elderly patients in France

We studied the factors influencing the choice of admission to Geriatrics units, instead of other acute hospital units after an emergency visit. We report the results from a cohort of 1283 randomly selected patients aged >75 years hospitalized in emergency and representative of the French University hospital system. All patients underwent geriatric assessment. Baseline characteristics of patients admitted to Geriatrics and other units were compared. A center effect influencing the use of Geriatrics units during emergencies was also investigated. Admission to a Geriatrics unit during the acute care episode occurred in 499 cases (40.3%). By multivariate analysis, 4 factors were related to admission to a Geriatrics unit: cognitive disorder: odds ratio (OR)=1.79 (1.38-2.32) (95% confidence interval=95% CI); "failure to thrive" syndrome OR=1.54 (1.01-2.35), depression: OR=1.42 (1.12-1.83) or loss of Activities of Daily Living (ADL): OR=1.35 (1.04-1.75). The emergency volume of the hospital was inversely related to the use of Geriatrics units, with high variation that could be explained by other unstudied factors. In the French University Emergency Healthcare system, the "geriatrics patient" is defined by the existence of cognitive disorder, psychological symptoms or installed loss of autonomy. Nevertheless, considerable nation-wide variation was observed underlining the need to clarify and reinforce this discipline in the emergency healthcare system.

Workforce development in geriatric home care

With the rapidly aging population, it is anticipated that within two decades several million more individuals in the United States with functional impairment and serious ill health will need home health care. This article discusses workforce development, which is a critical issue for future planning, as recently highlighted by the Institute of Medicine (IOM). Key aspects of recruitment, training, and retention of home care workers are discussed, including those who provide basic support for activities of daily living as well as a variety of skilled professionals: therapists, nurses, pharmacists, and physicians. Although the geriatric workforce shortage affects all care settings, it is especially critical in home health care, in part because we are starting with far too few clinicians to meet the medical needs of homebound elderly. A combination of actions is needed, including educational programs, such as those developed by the American Academy of Home Care Physicians (AAHCP), changes in financial incentives, and changes in the culture and practice of health care, to make the home the primary focus of care for these vulnerable, underserved individuals rather than an afterthought.