Advanced Geriatrics Evaluation Skills

BACKGROUND AND OBJECTIVES

Older adults are the fastest growing subset of the population and residency training in the basic concepts of care to the older adult is limited. We created a 1-day interactive training program, Advanced Geriatric Evaluation Skills (AGES), to upskill first-year primary care residents in the care of older adults.

METHODS

An interprofessional faculty team developed and taught the IRB-approved course to a convenience sample of family medicine and internal medicine interns in 2017, 2018, and 2019. Topics addressed common geriatric presentations seen in the outpatient setting. The faculty provided useful tips and hints for successful workup, diagnosis, and treatment.

RESULTS

Over the 3 years, 56 of the 135 (41%) first-year primary care residents participated. Residents reported that the course was well organized, relevant, and well taught, and they appreciated the dedicated time to focus on caring for older adults. During 2019, residents completed a pre- and posttest with 25 multiple-choice questions. The average score on the pretest was 76% and the average on the posttest was 88%. Ninety percent of the residents improved their score from the pre- to the posttest.

CONCLUSIONS

The development of an AGES program provided a structured geriatric didactic curriculum for primary care residents. The course was well received by the residents, was reported to be relevant and timely, and resulted in increased knowledge in the care of older adults in the outpatient setting.

C9orf72 ablation causes immune dysregulation characterized by leukocyte expansion, autoantibody production, and glomerulonephropathy in mice

The expansion of a hexanucleotide (GGGGCC) repeat in C9ORF72 is the most common cause of amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD). Both the function of C9ORF72 and the mechanism by which the repeat expansion drives neuropathology are unknown. To examine whether C9ORF72 haploinsufficiency induces neurological disease, we created a C9orf72-deficient mouse line. Null mice developed a robust immune phenotype characterized by myeloid expansion, T cell activation, and increased plasma cells. Mice also presented with elevated autoantibodies and evidence of immune-mediated glomerulonephropathy. Collectively, our data suggest that C9orf72 regulates immune homeostasis and an autoimmune response reminiscent of systemic lupus erythematosus (SLE) occurs in its absence. We further imply that haploinsufficiency is unlikely to be the causative factor in C9ALS/FTD pathology.

The MLK-related kinase (MRK) is a novel RhoC effector that mediates lysophosphatidic acid (LPA)-stimulated tumor cell invasion

The small GTPase RhoC is overexpressed in many invasive tumors and is essential for metastasis. Despite its high structural homology to RhoA, RhoC appears to perform functions that are different from those controlled by RhoA. The identity of the signaling components that are differentially regulated by these two GTPases is only beginning to emerge. Here, we show that the MAP3K protein MRK directly binds to the GTP-bound forms of both RhoA and RhoC in vitro. However, siRNA-mediated depletion of MRK in cells phenocopies depletion of RhoC, rather than that of RhoA. MRK depletion, like that of RhoC, inhibits LPA-stimulated cell invasion, while depletion of RhoA increases invasion. We also show that active MRK enhances LPA-stimulated invasion, further supporting a role for MRK in the regulation of invasion. Depletion of either RhoC or MRK causes sustained myosin light chain phosphorylation after LPA stimulation. In addition, activation of MRK causes a reduction in myosin light chain phosphorylation. In contrast, as expected, depletion of RhoA inhibits myosin light chain phosphorylation. We also present evidence that both RhoC and MRK are required for LPA-induced stimulation of the p38 and ERK MAP kinases. In conclusion, we have identified MRK as a novel RhoC effector that controls LPA-stimulated cell invasion at least in part by regulating myosin dynamics, ERK and p38.

Role of a DNA damage checkpoint pathway in ionizing radiation-induced glioblastoma cell migration and invasion

Ionizing radiation (IR) induces a DNA damage response that includes activation of cell cycle checkpoints, leading to cell cycle arrest. In addition, IR enhances cell invasiveness of glioblastoma cells, among other tumor cell types. Using RNA interference, we found that the protein kinase MRK, previously implicated in the DNA damage response to IR, also inhibits IR-induced cell migration and invasion of glioblastoma cells. We showed that MRK activation by IR requires the checkpoint protein Nbs1 and that Nbs1 is also required for IR-stimulated migration. In addition, we show that MRK acts upstream of Chk2 and that Chk2 is also required for IR-stimulated migration and invasion. Thus, we have identified Nbs1, MRK, and Chk2 as elements of a novel signaling pathway that mediates IR-stimulated cell migration and invasion. Interestingly, we found that inhibition of cell cycle progression, either with the CDK1/2 inhibitor CGP74514A or by downregulation of the CDC25A protein phosphatase, restores IR-induced migration and invasion in cells depleted of MRK or Chk2. These data indicate that cell cycle progression, at least in the context of IR, exerts a negative control on the invasive properties of glioblastoma cells and that checkpoint proteins mediate IR-induced invasive behavior by controlling cell cycle arrest.

The Donald W. Reynolds Consortium for Faculty Development to Advance Geriatrics Education (FD~AGE): a model for dissemination of subspecialty educational expertise

PURPOSE

Most U.S. medical schools and training programs lack sufficient faculty expertise in geriatrics to train future physicians to care for the growing population of older adults. Thus, to reach clinician-educators at institutions and programs that have limited resources for enhancing geriatrics curricula, the Donald W. Reynolds Foundation launched the Faculty Development to Advance Geriatrics Education (FD~AGE) program. This consortium of four medical schools disseminates expertise in geriatrics education through support and training of clinician-educators. The authors conducted this study to measure the effects of FD~AGE.

METHOD

Program leaders developed a three-pronged strategy to meet program goals: FD~AGE offers (1) advanced fellowships in clinical education for geriatricians who have completed clinical training, (2) mini-fellowships and intensive courses for faculty in geriatrics, teaching skills, and curriculum development, and (3) on-site consultations to assist institutions with reviewing and redesigning geriatrics education programs. FD~AGE evaluators tracked the number and type of participants and conducted interviews and follow-up surveys to gauge effects on learners and institutions.

RESULTS

Over six years (2004-2010), FD~AGE trained 82 fellows as clinician-educators, hosted 899 faculty scholars in mini-fellowships and intensive courses, and conducted 65 site visits. Participants taught thousands of students, developed innovative curricula, and assumed leadership roles. Participants cited as especially important to program success expanded knowledge, improved teaching skills, mentoring, and advocacy.

CONCLUSIONS

The FD~AGE program represents a unique model for extending concentrated expertise in geriatrics education to a broad group of faculty and institutions to accelerate progress in training future physicians.

Medicine in the 21st century: recommended essential geriatrics competencies for internal medicine and family medicine residents

BACKGROUND

Physician workforce projections by the Institute of Medicine require enhanced training in geriatrics for all primary care and subspecialty physicians. Defining essential geriatrics competencies for internal medicine and family medicine residents would improve training for primary care and subspecialty physicians. The objectives of this study were to (1) define essential geriatrics competencies common to internal medicine and family medicine residents that build on established national geriatrics competencies for medical students, are feasible within current residency programs, are assessable, and address the Accreditation Council for Graduate Medical Education competencies; and (2) involve key stakeholder organizations in their development and implementation.

METHODS

Initial candidate competencies were defined through small group meetings and a survey of more than 100 experts, followed by detailed item review by 26 program directors and residency clinical educators from key professional organizations. Throughout, an 8-member working group made revisions to maintain consistency and compatibility among the competencies. Support and participation by key stakeholder organizations were secured throughout the project.

RESULTS

The process identified 26 competencies in 7 domains: Medication Management; Cognitive, Affective, and Behavioral Health; Complex or Chronic Illness(es) in Older Adults; Palliative and End-of-Life Care; Hospital Patient Safety; Transitions of Care; and Ambulatory Care. The competencies map directly onto the medical student geriatric competencies and the 6 Accreditation Council for Graduate Medical Education Competencies.

CONCLUSIONS

Through a consensus-building process that included leadership and members of key stakeholder organizations, a concise set of essential geriatrics competencies for internal medicine and family medicine residencies has been developed. These competencies are well aligned with concerns for residency training raised in a recent Medicare Payment Advisory Commission report to Congress. Work is underway through stakeholder organizations to disseminate and assess the competencies among internal medicine and family medicine residency programs.

Functional regulatory T cells accumulate in aged hosts and promote chronic infectious disease reactivation

Declines in immune function are well described in the elderly and are considered to contribute significantly to the disease burden in this population. Regulatory T cells (T(regs)), a CD4(+) T cell subset usually characterized by high CD25 expression, control the intensity of immune responses both in rodents and humans. However, because CD25 expression does not define all T(regs), especially in aged hosts, we characterized T(regs) by the expression of FOXP3, a transcription factor crucial for T(reg) differentiation and function. The proportion of FOXP3(+)CD4(+) T(regs) increased in the blood of the elderly and the lymphoid tissues of aged mice. The expression of functional markers, such as CTLA-4 and GITR, was either preserved or increased on FOXP3(+) T(regs) from aged hosts, depending on the tissue analyzed. In vitro depletion of peripheral T(regs) from elderly humans improves effector T cell responses in most subjects. Importantly, T(regs) from old FoxP3-GFP knock-in mice were suppressive, exhibiting a higher level of suppression per cell than young T(regs). The increased proportion of T(regs) in aged mice was associated with the spontaneous reactivation of chronic Leishmania major infection in old mice, likely because old T(regs) efficiently suppressed the production of IFN-gamma by effector T cells. Finally, in vivo depletion of T(regs) in old mice attenuated disease severity. Accumulation of functional T(regs) in aged hosts could therefore play an important role in the frequent reactivation of chronic infections that occurs in aging. Manipulation of T(reg) numbers and/or activity may be envisioned to enhance the control of infectious diseases in this fragile population.

Caring for Older Americans: The Future of Geriatric Medicine

In response to the needs and demands of an aging population, geriatric medicine has grown rapidly during the past 3 decades. The discipline has defined its core values as well as the knowledge base and clinical skills needed to improve the health, functioning, and well-being of older persons and to provide appropriate palliative care. Geriatric medicine has developed new models of care, advanced the treatment of common geriatric conditions, and advocated for the health and health care of older persons. Nevertheless, at the beginning of the 21st century, the health care of older persons is at a crossroads. Despite the substantial progress that geriatric medicine has made, much more remains to be done to meet the healthcare needs of our aging population. The clinical, educational, and research approaches of the 20th century are unable to keep pace and require major revisions. Maintaining the status quo will mean falling further and further behind. The healthcare delivery and financing systems need fundamental redesign to improve quality and eliminate waste. The American Geriatrics Society (AGS) Task Force on the Future of Geriatric Medicine has identified five goals aimed at optimizing the health of older persons: To ensure that every older person receives high-quality, patient-centered health care; To expand the geriatrics knowledge base; To increase the number of healthcare professionals who employ the principles of geriatric medicine in caring for older persons; To recruit physicians and other healthcare professionals into careers in geriatric medicine; To unite professional and lay groups in the effort to influence public policy to continually improve the health and health care of seniors. Geriatric medicine cannot accomplish these goals alone. Accordingly, the Task Force has articulated a set of recommendations primarily aimed at the government, organizations, agencies, foundations, and other partners whose collaboration will be essential in accomplishing these goals. The vision described in this document and the accompanying recommendations are only the broad outline of an agenda for the future. Geriatric medicine, through its professional organizations and its partners, will need to mobilize resources to identify and implement the specific steps that will make the vision a reality. Doing so will require broad participation, consensus building, creativity, and perseverance. The consequences of inaction will be profound. The combination of a burgeoning number of older persons and an inadequately prepared, poorly organized physician workforce is a recipe for expensive, fragmented health care that does not meet the needs of our older population. By virtue of their unique skills and advocacy for the health of older persons, geriatricians can be key leaders of change to achieve the goals of geriatric medicine and optimize the health of our aging population. Nevertheless, the goals of geriatric medicine will be accomplished only if geriatricians and their partners work in a system that is designed to provide high-quality, efficient care and recognizes the value of geriatrics.

Building academic geriatric capacity: an evaluation of the John A. Hartford Foundation Centers of Excellence initiative

Almost 15 years ago, the John A. Hartford Foundation began its Centers of Excellence (CoE) program. In summer 2002, a quantitative and qualitative evaluation of the CoE program was conducted. The evaluation used previously collected quantitative data from surveys of program directors and graduates of fellowship programs, as well as interviews and surveys of currently funded CoEs. Since its inception, the CoE program has supported 163 geriatrics fellows, of whom 63% entered academic geriatrics. Almost half of these graduating fellows have gone to new academic institutions. CoEs have also supported 222 faculty, including some who were in disciplines other than geriatrics. The vast majority (82%) have remained in academics, and nearly two-thirds are currently in geriatrics. As the priorities and needs of the institutions and geriatrics programs changed, most centers shifted their CoE priorities. These changes predominantly took two forms: a refocus from one activity to another or an expansion of outreach or levels of support. Based upon this formal evaluation, the Hartford-supported CoE program has been successful in strengthening academic geriatrics, particularly in attracting, developing, and retaining geriatrics faculty.

The stress kinase MRK contributes to regulation of DNA damage checkpoints through a p38gamma-independent pathway

DNA damage induced by ionizing radiation (IR) activates a complex cellular response that includes checkpoints leading to cell cycle arrest. The stress-activated mitogen-activated protein kinase (MAPK) p38gamma has been implicated in the G(2) phase checkpoint induced by IR. We recently discovered MRK as a member of the MAPK kinase kinase family that activates p38gamma. Here we investigated the role of MRK in the checkpoint response to IR. We identified autophosphorylation sites on MRK that are important for its kinase activity. A phosphospecific antibody that recognizes these sites showed that MRK is activated upon IR in a rapid and sustained manner. MRK depletion by RNA interference resulted in defective S and G(2) checkpoints induced by IR that were accompanied by reduced Chk2 phosphorylation and delayed Cdc25A degradation. We also showed that Chk2 is a substrate for MRK in vitro and is phosphorylated at Thr(68) by active MRK in cells. MRK depletion also increased sensitivity to the killing effects of IR. In addition, MRK depletion reduced IR-induced activation of p38gamma but had no effect on p38alpha activation, indicating that MRK is a specific activator of p38gamma after IR. Inhibition of p38gamma by RNA interference, however, did not impair IR-induced checkpoints. Thus, in response to IR MRK controls two independent pathways: the Chk2-Cdc25A pathway leading to cell cycle arrest and the p38gamma MAPK pathway.

Using high-intensity care management to integrate acute and long-term care services: substitute for large scale system reform?

This study evaluates a demonstration that used high intensity care management to improve integration between the acute and long-term care service systems. The demonstration intervention included the use of clinical nurse care manager, supervised by a geriatrician, to supplement an existing in-home care management system. Chronically disabled home care clients age 60 and over were randomly assigned (N = 308) to receive enhanced clinical services plus traditional care management, or to the control group, to receive the normal care management services provided. Treatment group members were expected to experience lower use of hospitals and nursing homes and lower overall health and long-term care costs. Research subjects were followed for up to 18 months using Medicare records and mortality data. A subsample (N = 150) also received in-person interviews to cover a range of health and social outcomes anticipated as a result of the intervention. Although there was some variation in health use and cost across treatment and control groups over the 18 month time period, the overall conclusion is that there were no differences between groups on any of the outcome variables examined. Efforts to integrate the acute and long-term care systems have proven to be difficult. This intervention, which attempted to create integration through high intensity care managers, but without financial or regulatory incentives, was simply unable to create enough change in the care system to produce significant change for the clients served.

Geriatric medicine training for family practice residents in the 21st century: a report from the Residency Assistance Program/Harfford Geriatrics Initiative

Increasing the quality and quantity of geriatric medicine training for family practice residents is a particular challenge for community-based programs. With support from the John A. Hartford Foundation of New York City, the American Academy of Family Physicians (AAFP) implemented in 1995 a multi-part project to improve the amount and quality of geriatric medicine education received by family practice residents. This report summarizes the initial results of the regional geriatric medicine curriculum retreats for residency directors. The goals of the retreats were to build recognition among the residency directors of the skills that future family physicians will require to be successful providers of primary care to older adults and to allow the residency directors to identify and develop solutions to barriers to improving geriatric medicine training for residents. Forty-six program directors participated in the three retreats between February 2000 and February 2001. The participants represented 52 programs and rural tracks in all geographic regions, small and large programs, and urban and rural settings. The program directors developed a consensus on the geriatric medicine knowledge, skills, and attitudes that should be expected of all family practice residency graduates; developed a list of basic, required educational resources for each family practice residency program; and proposed solutions to common obstacles to successful curriculum development.

A national survey on the current status of family practice residency education in geriatric medicine

BACKGROUND AND OBJECTIVES

The dramatic increase in the elderly population expected over the next few decades will place a heavy strain on the current health care system. Family practice residents need to be prepared to take care of this geriatric population. In this study, we document the past, current, and future trends of geriatric education in family practice residency programs.

METHODS

A survey was mailed to all family practice residency directors in the United States (n = 471).

RESULTS

The response rate was 75%. Ninety-two percent of family practice residencies have a required geriatrics curriculum. Nursing homes, assisted living facilities, and home care are the predominant training sites for geriatrics. Training is most often offered in a longitudinal format. The mean number of physician faculty available to teach geriatrics is 2.6 per program (.83 full-time equivalent). Conflicting time demands with other curricula was ranked as the most significant barrier to geriatric education. Directors rated geriatrics as one of the three most important curriculum topics.

CONCLUSIONS

Faculty development to enhance the number of faculty who can teach geriatrics and broadening the exposure of residents to the elderly in a variety of settings will be important to ensure that future generations of family physicians are adequately equipped to care for the geriatric population.

Infections in nursing homes: assessing quality of care

BACKGROUND

Each year more than 25% of nursing home patients are taken to the hospital emergency room or hospitalized for the evaluation and treatment of infections. These transfers may have an adverse impact on the quality and the cost of patient care.

METHODS

Using both Medicare and Medicaid records from a sample of dually eligible elderly people in Ohio, we identified patients receiving antibiotic prescriptions in the nursing home and measured the frequency of nursing home physician visits and the hospital transfer rate.

RESULTS

Among the study sample (N = 1306), two thirds experienced a total of 3685 episodes of infections. Just under 5% of the sample were hospitalized as a result of the infection. In one third of the episodes, physicians saw the resident in person within 5 days (before or after) of the initiation of the medication. The hospital transfer rate was slightly higher (7% vs 3.5%) for those patients directly evaluated by a physician before receiving the prescription.

CONCLUSIONS

A majority of prescriptions were written without direct physician examination, raising key questions about practice patterns and the effect on patient care and costs.

Clues to early Alzheimer dementia in the outpatient setting

BACKGROUND

As the elderly population booms and the prevalence of dementia soars, it becomes imperative that primary care physicians recognize early dementia within their own practices. Early recognition and diagnosis of dementia will allow appropriate intervention and treatment to improve morbidity.

OBJECTIVE

To examine the most common symptoms associated with early Alzheimer disease (AD), as presented by patients and their families, and to compare these with the recommendations of the "7-Minute Screen" by Solomon et al for the identification of AD and the recommendations of the Agency for Health Care Policy and Research (AHCPR) for the early recognition of dementia.

METHODS

A retrospective medical record review was conducted in an outpatient referral population within 2 geriatric evaluation centers. Patient medical record selection was based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for AD, a Mini-Mental State Examination (MMSE) score of 23 or higher, a Geriatric Depression Scale score of less than 5, age above 60 years, and at least an eighth-grade level of education.

RESULTS

From 1025 medical records reviewed, 50 patients were chosen who fulfilled all inclusion criteria. Forty patients (80%) missed at least 2, if not all 3, recall items on the MMSE. Thirty patients (60%) had difficulty managing finances and/or balancing a checkbook; 16 (32%) frequently repeated stories and statements; 15 (30%) became lost while driving; 10 (20%) frequently forgot the names of relatives; and 10 (20%) had poor judgment. These results demonstrated a high correlation with recall as a diagnostic factor in diagnosing early AD as found in the 7-Minute Screen. Moreover, these "clues" correlated well with the AHCPR's symptoms that indicate dementia. The symptoms specifically overlapped in the areas of learning and retaining new information (repetition), handling complex tasks (calculation), reasoning ability (judgment), and spatial ability and orientation (driving).

CONCLUSIONS

There may be a constellation of symptoms associated with early AD. This constellation includes missing recall items on the MMSE, difficulty in calculation, repetition, getting lost while driving, forgetting the names of relatives, and having poor judgment. Recall is the symptom most consistent with the findings of the 7-Minute Screen in diagnosing AD. However, repetition, calculation, judgment, and driving highly correlate with the AHCPR's dementia symptom checklist. Therefore, if primary care physicians keep this constellation of symptoms in mind while evaluating their geriatric population, they will have greater ability to suspect, diagnose, and treat AD at an early stage. Arch Fam Med. 2000;9:1066-1070

Assessing physical status in Alzheimer disease research

In Alzheimer disease (AD), physical health problems can result from coexisting illness that is independent of the AD or can result directly from the consequences of the brain disease. Most of these physical health problems are not unique to AD, but they may have more functional impact in adults with AD. Coexistent or comorbid diseases may contribute directly to the outcomes of medical treatment. In future effectiveness studies in AD, in addition to measuring the severity of the AD, the presence and severity of coexisting illness should also be evaluated. In addition to accounting for comorbidity as part of AD effectiveness research, the reduction of comorbid physical illness may also be a legitimate independent outcome measure to target in the effectiveness of the clinical care provided to patients with AD. Examples of existing measures of comorbidity include the Charlson comorbidity index and the Greenfield index of coexistent disease. These existing measures of comorbid medical illness focus on system diseases and may not be applicable to the types of comorbid problems important to the AD patient. Further understanding of coexistent illness in AD may require the development of new measures of the cumulative occurrence of comorbid illness in this population.

Utility of clysis for hydration in nursing home residents

OBJECTIVES

To determine the utility of hypodermoclysis in the management of dehydration in nursing home residents and to review the recent literature on the use of clysis in older adults.

DESIGN

A retrospective chart review.

SETTING

Two continuing care retirement community nursing home units in Cincinnati.

PARTICIPANTS

Thirty-six nursing home residents with a mean age of 85 years.

MEASUREMENTS

A standard chart auditing form was used to collect demographic and clinical data from the patients' nursing home charts. Clinical outcomes were assessed at 1 week following the cessation of clysis.

RESULTS

The study subjects were functionally impaired, with 86% having significant cognitive impairment and 81% totally dependent with transfer. The most common indication for clysis was in association with an infection. Clysis was frequently initiated upon nursing observation of inadequate oral intake before obtaining laboratory results and discontinued upon resumption of adequate oral intake. The use of clysis was associated with the return to clinical/functional baseline in 71% of the cases. In the subset of subjects with pre- and post-clysis measurements of serum sodium and BUN/creatinine ratios, improvement in laboratory values was not significant. The use of clysis was not associated with significant complications, but in nine cases minor local skin reactions were documented.

CONCLUSIONS

Hypodermoclysis is a relatively safe and effective procedure in a nursing home. The use of clysis in the nursing home is an alternative to intravenous hydration. The use of clysis for short-term hydration has the potential to reduce cost and transfers to the hospital.

The physician decision-making process in transferring nursing home patients to the hospital

BACKGROUND

Each year more than 25% of nursing home patients are transferred to the emergency department or hospital for evaluation and treatment of infection. These transfers may have an adverse impact on the quality and cost of patient care. This study examined physician assessment and management of acute infections in the nursing home.

METHODS

A cross-sectional study was conducted of all acute urinary tract infections and lower respiratory tract infections occurring from February through June 1991 in eight randomly selected urban nursing homes. The numbers of transfers to the emergency department of hospital were recorded along with identification of the clinical, psychosocial, and institutional factors that influenced the physician's decision to transfer.

RESULTS

Three hundred fifty-nine patients had 258 urinary tract infections and 219 respiratory tract infections. Eighty-one (17%) of these events resulted in transfer to a hospital for evaluation (16/81) and/or admission (65/81). Less than one third (30.4%) of the events caused the patient to be examined in the nursing home by a physician before the decision to transfer to the hospital. The mean time between the staff notification of an acute event and physician response by telephone was 5.12 hours. Independent mobility (P < or = .05), a transfer to the hospital during the previous 6 months (P < or = .01), and fewer nursing home laboratory tests and treatments (P < or = .01) were all associated with hospital transfer.

CONCLUSIONS

In this sample of acutely ill nursing home patients, physicians collected limited clinical data before the decision to transfer. Although some transfers may be appropriate, a reduction in the transfer rate may reduce health care costs and limit the risk of iatrogenesis, thus improving the outcome of acute illnesses occurring in the nursing home.

The effectiveness of lumbar puncture in the evaluation of delirium and fever in the hospitalized elderly

OBJECTIVE

To determine the value of the cerebrospinal fluid examination in the evaluation of hospitalized; elderly patients with delirium and fever.

DESIGN

A retrospective case series of consecutive events during a 15-month period.

SETTING

Tertiary care center.

PARTICIPANTS

Elderly patients admitted to the University of Cincinnati (Ohio) Hospital between July 1, 1988, and October 1, 1989, who had a lumbar puncture and cerebrospinal fluid evaluation to evaluate fever and mental status changes.

MAIN OUTCOME MEASURES

Primary intracranial causes and the clinical characteristics of delirium and fever.

RESULTS

Eighty-one hospital admissions were reviewed. Fifty-seven (70%) of the lumbar punctures were performed as part of the admitting workup, and the remaining 24 (30%) were performed during the hospitalization. Eighty of the 81 cerebrospinal fluid cultures were negative for bacterial growth. The primary origins for fever and delirium included urinary tract infections (25%), pneumonia (22%), viral causes (17%), and metabolic causes/dehydration (14%). One case of bacterial meningitis was diagnosed in an alcoholic, 73-year-old man who was unresponsive in the emergency department. One case of presumed aseptic meningitis was diagnosed in a 65-year-old man who presented with fever and headaches and a blood pressure of 230/100 mm Hg.

CONCLUSIONS

Most hospitalized, older patients with fever and delirium have primary causes of the confusion outside the central nervous system and may not require a routine evaluation of their cerebrospinal fluid.

Free visits: a strategy to retain patients and improve continuity in a residency program

All family practice residencies attempt to offer continuity experience to residents and patients as part of their model practices. However, every year one third of the most experienced resident providers leave the practice to be replaced by new, inexperienced residents. This study reports a randomized controlled trial in which a sample of reassigned patients was offered a free visit with their new physician. The free visit was a scheduled appointment with the patient's newly assigned physician during a two-month period for the purpose of meeting the new physician. The offer of a free visit succeeded in helping patients make the initial office contact with their new physician. However, during six months of follow-up the free visit offer did not have an impact on visit frequency or primary provider continuity. In this study the reassignment of patients to new physician providers did not affect overall visit frequency, but did have a negative impact on primary provider continuity.