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The role of early Do Not Resuscitate (DNR) in hospitalized older adults (OAs) with SARS-CoV-2 infection is unknown. The objective of the study was to identify characteristics and outcomes associated with early DNR in hospitalized OAs with SARS-CoV-2. We conducted a retrospective chart review of older adults (65+) hospitalized with COVID-19 in New York, USA, between March 1, 2020, and April 20, 2020. Patient characteristics and hospital outcomes were collected. Early DNR (within 24 hours of admission) was compared to non-early DNR (late DNR, after 24 hours of admission, or no DNR). Outcomes included hospital morbidity and mortality. Of 4961 patients, early DNR prevalence was 5.7% (n = 283). Compared to non-early DNR, the early DNR group was older (85.0 vs 76.8, P < .001), women (51.2% vs 43.6%, P = .012), with higher comorbidity index (3.88 vs 3.36, P < .001), facility-based (49.1% vs 19.1%, P < .001), with dementia (13.3% vs 4.6%, P < .001), and severely ill on presentation (57.9% vs 32.3%, P < .001). In multivariable analyses, the early DNR group had higher mortality risk (OR: 2.94, 95% CI: 2.10–4.11), less hospital delirium (OR: 0.55, 95% CI: 0.40–.77), lower use of invasive mechanical ventilation (IMV, OR: 0.37, 95% CI: .21–.67), and shorter length of stay (LOS, 4.8 vs 10.3 days, P < .001), compared to non-early DNR. Regarding early vs late DNR, while there was no difference in mortality (OR: 1.12, 95% CI: 0.85–1.62), the early DNR group experienced less delirium (OR: 0.55, 95% CI: .40–.75), IMV (OR: 0.53, 95% CI: 0.29–.96), and shorter LOS (4.82 vs 10.63 days, OR: 0.35, 95% CI: 0.30–.41). In conclusion, early DNR prevalence in hospitalized OAs with COVID-19 was low, and compared to non-early DNR is associated with higher mortality but lower morbidity.

Telehealth has emerged as an evolving care management strategy that is playing an increasingly vital role, particularly with the onset of the coronavirus disease 2019 pandemic. A meta-analysis of 20 randomized controlled trials was conducted to test the effectiveness of home telemonitoring (HTM) in patients with type 2 diabetes in reducing A1C, blood pressure, and BMI over a median 180-day study duration. HTM was associated with a significant reduction in A1C by 0.42% (P = 0.0084). Although we found statistically significant changes in both systolic and diastolic blood pressure (−0.10 mmHg [P = 0.0041] and −0.07 mmHg [P = 0.044], respectively), we regard this as clinically nonsignificant in the context of HTM. Comparisons across different methods of transmitting vital signs suggest that patients logging into systems with moderate interaction with the technology platform had significantly higher reductions in A1C than those using fully automatic transmission methods or fully manual uploading methods. A1C did not vary significantly by study duration (from 84 days to 5 years). HTM has the potential to provide patients and their providers with timely, up-to-date information while simultaneously improving A1C.

Purpose: Oropharyngeal dysphagia (OD) affects nearly 90% of hospitalized persons with dementia. Yet, little is known about the care partner experience. The purpose of our study was to describe the experience of care partners related to OD management in patients with dementia as they transition from the hospital to the community setting. Method: Using a mixed-methods approach, we conducted telephone interviews with care partners of recently hospitalized older adults with dementia and OD. Interviews consisted of quantitative/qualitative assessments: communication with health care team, perception about risks/benefits of dysphagia diet, and informational needs. Descriptive statistics were used for quantitative data. For the qualitative data, transcripts were independently coded by research team and categorized into themes. Results: Of the care partners interviewed ( N = 24), mean age was 63.5 ( SD = 14.9), 62.5% were female, and 66.7% were White. Nearly 60% of patients had severe dementia, and 66.7% required feeding assistance. Care partners ( n = 18) reported moderate burden of 14.11 ( SD = 10.03). Most care partners (83.3%) first learned about OD during hospitalization. Only 29.2% of care partners reported that they discussed OD with a physician. Care partner perception of dysphagia diet risks/benefits ranged widely: 33.3% thought dysphagia diets would promote a more enjoyable existence. Over half (54.2%) of care partners indicated no choice regarding dysphagia diets was presented to them. Two thirds ( n = 16) of care partners were nonadherent to diet recommendations; the top reason ( n = 13%) was diet refusal by patients. Although 83.3% of care partners wanted additional information regarding dysphagia management, only 20.8% sought any. Conclusions: Our findings highlight that care partners of persons with dementia face significant OD-related communication and informational gaps, which may lead to elevated burden. Future studies are needed to address unmet OD-related care partner needs.

This study aimed to determine whether a geriatrics-focused hospitalist trauma comanagement program improves quality of care. A pre-/post-implementation study compared older adult trauma patients who were comanaged by a hospitalist with those prior to comanagement at a level 1 trauma center. One-to-one propensity score matching was performed based on age, gender, Injury Severity Score, comorbidity index, and critical illness on admission. Outcomes included orders for geriatrics-focused quality indicators, as well as hospital mortality and length of stay. Wilcoxon rank-sum test (continuous variables) and chi-square or Fisher exact test (categorical variables) were used to assess differences. Propensity score matching resulted in 290 matched pairs. The intervention group had decreased use of restraints (P = 0.04) and acetaminophen (P = 0.01), and earlier physical therapy (P = 0.01). Three patients died in the intervention group compared with 14 in the control (P = 0.0068). This study highlights that a geriatrics-focused hospitalist trauma comanagement program improves quality of care.

Background Delirium is a common, devastating, and underrecognized syndrome in the intensive care unit (ICU). The study aimed to describe and evaluate a multicomponent education and training program utilizing a "Train-The-Trainer" (TTT) model, to improve delirium detection across a large health system. Methods Fourteen ICUs across nine hospitals participated in a multicomponent delirium program consisting of a 1-day workshop that included: (1) patient testimonials, (2) small group discussions, (3) didactics, and (4) role-playing. Additionally, four ICUs received direct observation/training via telehealth (tele-delirium training). The Kirkpatrick model was used for program evaluation in a pre/post-test design. Results A 1-day delirium workshop was held at two time points and included 73 ICU nurses. Of the 65 nurses completing the post-workshop satisfaction survey, most (46.2) had >10 years of clinical experience, and no or minimal delirium training (69.2%). All nurses (100%) identified lack of knowledge as a barrier to delirium detection, while time constraints and lack of importance accounted for only 25%. Overall, nurses rated the workshop positively (excellent 66.7%, and very good 23.3%), and likely to change practice (definitely 73.3% and very likely 15.0%). All validated Confusion Assessment Method for the ICU (CAM-ICU) cases demonstrated improvement in number of correct responses. Delirium detection across the health system improved from 9.1% at baseline to 21.2% in ICUs that participated in the workshop and 30.1% in those ICUs that also participated in the tele-delirium training (p = 0.005). Conclusion A multicomponent delirium education and training program using a TTT model was rated positively, improved CAM-ICU knowledge, and increased delirium detection.

The Centers for Disease Control and Prevention estimates that half of the antibiotic prescriptions for acute respiratory tract infections (ARTIs) in ambulatory care settings are unnecessary. To better understand the quality-of-care implications of prescription patterns for ARTIs, we conducted a retrospective chart review of outpatient ARTI visits, across a large integrated health system, and examined the association of patient characteristics with receiving antimicrobials, as well as the association between receiving antimicrobials and healthcare utilization (outpatient and emergency department visits). We found that 55.4% of all ARTI outpatients were treated with antimicrobials. There was no association between patient demographics and antimicrobial prescriptions on either the first (p < .0771) or follow-up (p < .6316) visits. A lower comorbidity score was significantly associated with receiving antimicrobials (p < .0022). Patients who received antimicrobials at the first visit had significantly higher number of follow-up visits (p < .005) and more follow-up antimicrobial prescriptions (p < .0066) as compared with patients who did not receive antimicrobials at the first visit. Our results highlight the potential for clinicians to improve quality of care in ARTI management.

Hospitalized persons living with dementia (PLWD) often experience behavioral symptoms that challenge medical care.This study aimed to identify clinical practices and outcomes associated with behavioral symptoms in hospitalized PLWD.A retrospective cross-sectional study.The study included PLWD (65+) admitted to one of severe health system hospitals in 2019.Behavioral symptoms were defined as the presence of (1) a psychoactive medication for behavioral symptoms; (2) an order for physical restraints or constant observation; and/or (3) physician documentation of delirium, encephalopathy, or behavioral symptoms.Associations between behavioral symptoms and patient characteristics and hospital practices (e.g., bladder catheter) were examined. Multivariable logistic/linear regression was used to evaluate the association between behavioral symptoms and clinical outcomes (e.g., mortality).Of hospitalized PLWD (N = 8637), the average age was 84.5 years (IQR = 79-90), 61.7% were female, 60.1% were white, and 9.4% (n = 833) were Hispanic. Behavioral symptoms were identified in 40.6% (N = 3606) of individuals. Behavioral symptoms were significantly associated with male gender (40.3% vs. 36.9%, p = .001), white race (62.7% vs. 58.3%, p .001), and residence in a facility prior to admission (26.6% vs. 23.7%, p .001). Regarding hospital practices, indwelling bladder catheters (11.2% vs. 6.0%, p .001) and dietary restriction (41.9% vs. 33.8%, p .001) were associated with behavioral symptoms. In multivariable models, behavioral symptoms were associated with increased hospital mortality (odds ratio [OR]: 1.90, CI95%: 1.57-2.29), length of stay (parameter estimate: 2.10, p .001), 30-day readmissions (OR: 1.14, CI95%: 1.014-1.289), and decreased discharge home (OR: 0.59, CI95%: 0.53-0.65, p .001).Given the association between behavioral symptoms and poor clinical outcomes, there is an urgent need to improve the provision of care for hospitalized PLWD.

Background Despite a growing cohort of intensive care unit (ICU) survivors, little is known about the early ICU aftercare period. Objective To identify gaps in early ICU aftercare and factors associated with poor hospital outcomes. Methods A multisite, retrospective study (January 1 to December 31, 2017) was conducted among randomly selected patients admitted to the medical ICU and subsequently transferred to acute medical care units. Records were reviewed for patient characteristics, ICU course, and early ICU aftercare practices and syndromes. Associations between practices and hospital outcomes were calculated with χ2 and Wilcoxon rank sum tests, followed by logistic regression. Results One hundred fifty-one patients met inclusion criteria (mean [SD] age, 64.2 [19.1] years; 51.7% male; 44.4% White). The most frequent diagnoses were sepsis (35.8%) and respiratory failure (33.8%). During early ICU aftercare, 46.4% had dietary restrictions, 25.8% had bed rest orders, 25.0% had a bladder catheter, 26.5% had advance directive documentation, 33.8% had dysphagia, 34.3% had functional decline, and 23.2% had delirium. Higher Charlson Comorbidity Index (odds ratio, 1.6) and midodrine use on medical units (odds ratio, 7.5) were associated with in-hospital mortality; mechanical ventilation in the ICU was associated with rapid response on medical unit (odds ratio, 12.9); and bladder catheters were associated with ICU readmission (odds ratio, 5.2). Conclusions Delirium, debility, and dysphagia are frequently encountered in early ICU aftercare, yet bed rest, dietary restriction, and lack of advance directive documentation are common. Future studies are urgently needed to characterize and address early ICU aftercare.

Objectives: This study examined differences in physical function, delirium, depressive symptoms, and behavioral and psychological symptoms of dementia (BPSD) in hospitalized African American and white older adults with dementia. Methods: This secondary data analysis using baseline data from an ongoing trial testing family-centered function-focused care included African American ( n = 159) and white persons ( n =135) with dementia. Results: A multivariate analysis of covariance showed that controlling for relevant demographic and health characteristics, African Americans with dementia had lower physical function, more delirium, and more depressive symptoms upon admission than white participants. There were no significant differences in BPSD between African American and white persons. Discussion: To our knowledge, this is the first study to examine racial differences in admission symptoms of hospitalized persons with dementia. While the findings are preliminary, they can be used to inform the design of future research, including identifying the causes of disparities.

The epidemiology of Behavioral and Psychological Symptoms of Dementia (BPSD) in hospitalized older adults with Alzheimer’s Disease (AD) and AD-related dementias (ADRD) has not been well-characterized. The purpose of this abstract is to examine the prevalence, patient-level factors and hospital outcomes associated with BPSD in hospitalized older adults with AD/ADRD. Data was extracted from the electronic health record (EHR) of older adults (aged 65+ years) with AD/ADRD, admitted to one of 7 hospitals in the greater New York metropolitan area during 2019. Three independent coders reviewed the EHR and recorded the presence or absence of the 11 domains of the Neuropsychiatric Inventory (NPI), a validated measure of BPSD. Of N = 1,865 hospitalized older adults with AD/ADRD, 1,564 had BPSD (prevalence = 83.9%). The most commonly reported BPSD were agitation (72.3%) and anxiety (17.7%). Older age (M = 84.6, SD = 7.6 versus M = 82.4, SD = 7.8, p = .000) and antipsychotic medication use prior to hospital admission (91% of the older adults who used home antipsychotics had BPSD, p = 000) was associated with BPSD. With regard to hospital outcomes, BPSD was associated with: increased mortality (of those who died, 90.6% had BPSD, p = .006), and increased likelihood of readmission to the hospital within 30 days of discharge (of those readmitted, 89.3% had BPSD, p = .007). Given its high prevalence and associated poor outcomes, recognizing and managing BPSD in hospitalized patients with AD/ADRD is critical to improving quality of care for this vulnerable population.

Antipsychotics are frequently used for managing both acute and chronic neuropsychiatric disorders. While antipsychotics are known to be associated with increased mortality due to cardiac arrhythmia, there is a lack of consensus on the timing and frequency of electrocardiogram (ECG) monitoring. The goal of this study was to examine current ECG monitoring practices for adults receiving antipsychotics, specifically during hospital admission.The study involved a multisite retrospective chart review of adults admitted across 8 hospitals between January 2010 and December 2015 who received antipsychotics during hospitalization. The primary outcome was the presence of an ECG after receiving an antipsychotic.During the study period, there were 26,353 hospitalizations during which adults received antipsychotic medication; the average age of the patients was 61.4 years, 50.1% were female, and 64.8% were white. The average comorbidity score was 1.4 with a median length of stay of 8.3 days. Of the 26,353 patients who were hospitalized, 60.6% (n=15,977) of patients in the sample had an ECG during their hospitalization, and 41.2% (n=10,865) had the ECG following antipsychotic administration. Patients who received a follow-up ECG had a longer length of stay (median: 11.3 d) compared with those who did not receive a follow-up ECG (median: 7.0 d). Follow-up ECGs were more likely among patients who had a history of heart failure [odds ratio (OR)=1.17, 95% confidence interval (CI): 1.06-1.30, P=0.002], who were receiving multiple antipsychotics (OR=1.3, 95% CI: 1.24-1.36, P0.001) or other QT-prolonging medications (OR=1.09, 95% CI: 1.07-1.1, P0.001), who were receiving risperidone (OR=1.12, 95% CI: 1.004-1.25, P=0.04), and who showed an increase in QTc duration (OR per 10 ms increase=1.02, 95% CI: 1.01-1.04, P=0.003). Follow-up ECGs were less likely to be administered to patients who were receiving antipsychotics before admission (OR=0.93, 95% CI: 0.87-0.997, P=0.04).This study demonstrated that, in a large health system, ECG monitoring is not routinely practiced for hospitalized patients receiving antipsychotics. Further studies are needed to identify patients who would most benefit from ECG monitoring in the acute care setting.

BACKGROUND/OBJECTIVES For older adults with acute hip fracture, use of preoperative noninvasive cardiac testing may lead to delays in surgery, thereby contributing to worse outcomes. Our study objective was to evaluate the preoperative use of pharmacologic stress testing and transthoracic echocardiogram (TTE) in older adults hospitalized with hip fracture. DESIGN Retrospective chart review. SETTING Seven hospitals (three tertiary, four community) within a large health system. PARTICIPANTS Patients, aged 65 years and older, hospitalized with hip fracture (n = 1,079; mean age = 84.2 years; 75% female; 82% white; 36% married). MEASUREMENTS Data were extracted from electronic medical records. The study evaluated associations between patient factors as well as clinical outcomes (time to surgery [TTS], length of stay [LOS], and in-hospital mortality) and the use of preoperative noninvasive cardiac testing (pharmacologic stress tests or TTE). Descriptive statistics were calculated. Cox regression was performed for both TTS and LOS (evaluated as time-dependent variable); logistic regression was used for in-hospital mortality. RESULTS Although 34.3% (n = 370) had a preoperative TTE, .7% (n = 8) underwent a nuclear stress test and none had a dobutamine stress echocardiogram. Median TTS was 1.1 days (IQR [interquartile range] = .8-1.8 days), median LOS was 5.3 days (IQR = 4.2-7.2 days), and in-hospital mortality was 3% (n = 32). Patients admitted to the medical service had 3.5 times greater odds of undergoing a TTE compared with those on the orthopedic service (P

Objectives Acute hip fracture is common and leads to significant morbidity and mortality. Co-management programs, such as American Geriatric Society (AGS) CoCare: Ortho®, that optimize perioperative care of older adults, have demonstrated improved outcomes. Yet there is substantial variation in hip fracture care nationally. Our objective was to describe the implementation of AGS CoCare: Ortho® across a large integrated health system. Design Program implementation of four phases. Setting Large integrated health system. Participants One tertiary and three community hospitals. Measurements The first two phases were communication and system-level planning. The communication phase consisted of getting health system leadership buy-in, creating an interdisciplinary steering committee, and building a business model. The planning phase consisted of choosing process and outcome measures, ensuring accurate and timely data collection, and creating standardized order sets and physician documentation. Results The second two phases were hospital-level planning and implementation. The planning phase consisted of identifying sites and developing the co-management structure. The implementation phase consisted of identifying and engaging frontline staff, rolling out the program, optimizing workflow, and educating providers. Conclusion The program was implemented at four diverse sites. Major lessons learned included the need for an engaged steering committee to oversee the program; the importance of standardizing order sets and documentation; the utilization of hospitalists as co-managers; the benefit of developing and actively using a data dashboard; the challenge of ensuring wide uptake of education modules; and the need to take proactive steps to improve multidisciplinary communication. J Am Geriatr Soc 68:1706-1713, 2020.

Background Delirium affects up to 80% of patients in the intensive care unit (ICU) but is missed in up to 75% of cases. Telehealth in the ICU (tele-ICU) has become the standard for providing timely, expert care to remotely located ICUs. Objectives This pilot study assessed the feasibility and acceptability of using tele-ICU to increase the accuracy of delirium screening and recognition by ICU nurses. Methods The pilot sites included 4 ICUs across 3 hospitals. A geriatrician with delirium expertise remotely observed 13 bedside ICU nurses administering the Confusion Assessment Method for the ICU (CAM-ICU) to patients in real time via the tele-ICU platform and subsequently provided training on CAM-ICU performance and delirium management. Training evaluation consisted of a validated spot check form, a 2-item satisfaction/change-of-practice survey, and a qualitative question on acceptability. Results Thirteen ICU nurses were observed performing 26 bedside delirium assessments. The top observed barriers to accurate delirium screening were CAM-ICU knowledge deficits, establishment of baseline cognition, and inappropriate use of the “unable to assess” designation. The mean percentage of correct observations improved from 40% (first observation) to 90% (second observation) (P < .001). All 13 nurses strongly agreed that the training was beneficial and practice changing. Conclusions The use of tele-ICU to improve the accuracy of delirium screening by ICU nurses appears to be feasible and efficient for leveraging delirium expertise across multiple ICUs. Future studies should evaluate the effects of tele-ICU delirium training on patient-centered outcomes.

OBJECTIVE. Currently, chest radiography is the first-line imaging test for identifying pneumonia; chest CT is considered the reference standard. The purpose of this study was to calculate the statistical measures of performance of chest radiography for identifying pneumonia when taking into account uncertain results of both chest radiography and CT examinations. MATERIALS AND METHODS. Statistical measures of performance of chest radiography, using CT as the reference standard, were calculated with 95% CIs by varying uncertain radiology report impressions of both chest radiography and CT to all negative or all positive. The resulting scenarios were as follows: scenario 1, uncertain chest radiography and CT impressions are considered positive for pneumonia; scenario 2, uncertain chest radiography impressions are positive but uncertain CT impressions are negative; scenario 3, uncertain chest radiography impressions are negative and uncertain CT impressions are positive; scenario 4, uncertain chest radiography and CT impressions are negative; and scenario 5, uncertain chest radiography and CT impressions are excluded. RESULTS. A retrospective analysis of 2411 patient visits revealed the prevalence of uncertain radiology report impressions to be 31.8% for chest radiography and 21.7% for CT. Scenario 1 yielded the following performance values: sensitivity, 51.9%; specificity, 71.3%; PPV, 59.4%; and NPV, 64.5%. Scenario 2 produced the following performance values: sensitivity, 59.6%; specificity, 67.1%; PPV, 59.6%; and NPV, 67.1%. Scenario 3 showed the following performance values: sensitivity, 13.4%; specificity, 97.7%; PPV, 82.6%; and NPV, 58.1%. Scenario 4 yielded the following performance values: sensitivity, 19.6%; specificity, 96.4%; PPV, 81.6%; and NPV, 59.5%. Scenario 5 produced the following performance values: sensitivity, 32.7%; specificity, 96.8%; PPV, 89.2%; and NPV, 63.8%. CONCLUSION. Uncertain chest radiography results for the evaluation of pneumonia are prevalent. A chest radiography impression using the strongest language in support of a pneumonia diagnosis is useful to rule in pneumonia radiographically, but a negative result performs poorly at ruling out disease.

BackgroundCOVID-19 has been associated with an increased risk of incident dementia (post-COVID dementia). Establishing additional risk markers may help identify at-risk individuals and guide clinical decision-making.MethodsWe investigated pre-COVID psychotropic medication use (exposure) and 1-year incidence of dementia (outcome) in 1,755 patients (≥65 years) hospitalized with COVID-19. Logistic regression models were used to examine the association, adjusting for demographic and clinical variables. For further confirmation, we applied the Least Absolute Shrinkage and Selection Operator (LASSO) regression and a machine learning (Random Forest) algorithm.ResultsOne-year incidence rate of post-COVID dementia was 12.7% (N = 223). Pre-COVID psychotropic medications (OR = 2.7, 95% CI: 1.8–4.0, P < 0.001) and delirium (OR = 3.0, 95% CI: 1.9–4.6, P < 0.001) were significantly associated with greater 1-year incidence of post-COVID dementia. The association between psychotropic medications and incident dementia remained robust when the analysis was restricted to the 423 patients with at least one documented neurological or psychiatric diagnosis at the time of COVID-19 admission (OR = 3.09, 95% CI: 1.5–6.6, P = 0.002). Across different drug classes, antipsychotics (OR = 2.8, 95% CI: 1.7–4.4, P < 0.001) and mood stabilizers/anticonvulsants (OR = 2.4, 95% CI: 1.39–4.02, P = 0.001) displayed the greatest association with post-COVID dementia. The association of psychotropic medication with dementia was further confirmed with Random Forest and LASSO analysis.ConclusionConfirming prior studies we observed a high dementia incidence in older patients after COVID-19 hospitalization. Pre-COVID psychotropic medications were associated with higher risk of incident dementia. Psychotropic medications may be risk markers that signify neuropsychiatric symptoms during prodromal dementia, and not mutually exclusive, contribute to post-COVID dementia.

Uncertain language in chest radiograph (CXR) reports for the diagnosis of pneumonia is prevalent. The purpose of this study is to validate an a priori stratification of CXR results for diagnosing pneumonia based on language of certainty.Retrospective chart review.CXR reports of 2,411 patient visits ≥ 18 years, admitted to medicine, who received a CXR and noncontrast chest CT within 48 hours of emergency department registration at two large academic hospitals (tertiary and quaternary care) were reviewed.The CXR and CT report impressions were categorized as negative, uncertain, or positive. Uncertain CXRs were further stratified into four categories based on language modifiers for the degree of pneumonia certainty. Comparison of CXR and CT results were determined using χCXR reports for the diagnosis of pneumonia revealed the following distribution: 61% negative, 32% uncertain, and 7% positive; CT reports were 55% negative, 22% uncertain, and 23% positive for the diagnosis of pneumonia. There were significant differences between CXR categories compared with CT categories for diagnosis of pneumonia (P.001). Negative CXR results were not significantly different than the uncertain category with the most uncertain language (P = .030) but were significantly different from all other uncertain categories and positive CXR results (each P.001). Positive CXR results were not significantly different than the least uncertain category (most certain language) (P = .130) but were significantly different from all other categories (each P.001).Language used in CXR reports to diagnose pneumonia exists in categories of varying certainty and should be considered when evaluating patients for pneumonia.

Background Age has been implicated as the main risk factor for COVID-19-related mortality. Our objective was to utilize administrative data to build an explanatory model accounting for geriatrics-focused indicators to predict mortality in hospitalized older adults with COVID-19. Methods Retrospective cohort study of adults age 65 and older (N = 4783) hospitalized with COVID-19 in the greater New York metropolitan area between 3/1/20-4/20/20. Data included patient demographics and clinical presentation. Stepwise logistic regression with Akaike Information Criterion minimization was used. Results The average age was 77.4 (SD = 8.4), 55.9% were male, 20.3% were African American, and 15.0% were Hispanic. In multivariable analysis, male sex (adjusted odds ration (adjOR) = 1.06, 95% CI:1.03-1.09); Asian race (adjOR = 1.08, CI:1.03-1.13); history of chronic kidney disease (adjOR = 1.05, CI:1.01-1.09) and interstitial lung disease (adjOR = 1.35, CI:1.28-1.42); low or normal body mass index (adjOR:1.03, CI:1.00-1.07); higher comorbidity index (adjOR = 1.01, CI:1.01-1.02); admission from a facility (adjOR = 1.14, CI:1.09-1.20); and mechanical ventilation (adjOR = 1.52, CI:1.43-1.62) were associated with mortality. While age was not an independent predictor of mortality, increasing age (centered at 65) interacted with hypertension (adjOR = 1.02, CI:0.98-1.07, reducing by a factor of 0.96 every 10 years); early Do-Not-Resuscitate (DNR, life-sustaining treatment preferences) (adjOR = 1.38, CI:1.22-1.57, reducing by a factor of 0.92 every 10 years); and severe illness on admission (at 65, adjOR = 1.47, CI:1.40-1.54, reducing by a factor of 0.96 every 10 years). Conclusion Our findings highlight that residence prior to admission, early DNR, and acute illness severity are important predictors of mortality in hospitalized older adults with COVID-19. Readily available administrative geriatrics-focused indicators that go beyond age can be utilized when considering prognosis.

OBJECTIVE To evaluate whether the implementation of a geriatrics-focused orthopedic and hospitalist comanagement program can improve perioperative outcomes and decrease resource utilization. DESIGN A retrospective chart review study was conducted before and after the implementation of a geriatrics-focused orthopedic and hospitalist comanagement program, based on the American Geriatrics Society (AGS) AGS CoCare:Ortho®. SETTING A large urban, academic tertiary center, located in the greater New York metropolitan area. PARTICIPANTS Patients 65 years and older hospitalized for operative hip fracture. Those with pathologic or periprosthetic fractures, and chronic substance use were excluded. MAIN OUTCOME MEASUREMENTS Outcome measures included: time to operating room (TtOR), length of stay (LOS), daily and total morphine milligram equivalents (MME), use of preoperative transthoracic echocardiogram (TTE) and blood transfusions, perioperative complications (e.g., urinary tract infections), and six-month mortality. RESULTS Our study included 290 patients hospitalized with hip fracture, before (N=128) and after (N=162) implementation. When compared to the pre-implementation group, the post-implementation comanagement group had a lower TtOR (36.2 vs 30.0 hrs, p=0.026) and hospital LOS; decreased use of indwelling bladder catheters pre and postoperatively (68.0 vs 46.9%, p

Context Few studies have described the characteristics and palliative care needs in hospitalized patients with coronavirus disease 2019 (COVID-19). Objectives Describing characteristics, consultation demands, patients’ needs, and outcomes of hospitalized patients with COVID-19 who received a palliative care evaluation. Methods Retrospective chart review of patients (aged 18+ years) with COVID-19 admitted to an academic quaternary center and seen by the geriatrics and palliative medicine team from March 1st to May 11th, 2020. Socio-demographics, operational metrics, severity of illness, goals of care-advanced care planning documentation, and outcomes were analyzed. Results Three hundred seventy-six (17.6%) out of 2138 COVID-19 admissions were seen by the consultation team. Compared with prepandemic situation (September 1st, 2019, to February 29th, 2020), overall new consults (205 vs. 371, P

Achieving therapeutic international normalized ratio (INRs) in warfarin naive older adults can be complicated due to sensitivity factors. While multiple tools exist for warfarin initiation in the outpatient setting, there is a dearth of guidance for inpatient initiation. This study aims to: (1) describe a large health system’s initiation warfarin quality metrics in older inpatients, defined by INR overshoots greater than or equal to 5.0; (2) identify intrinsic and extrinsic patient factors associated with overshoots; and (3) explore the association between inpatient overshoots and clinical outcomes. Data on inpatients ≥ 65 years initiated on warfarin 1/1/2014-6/30/2016 were extracted through retrospective chart review. The primary outcome was prevalence of overshoots (INR ≥ 5). Logistic regression modeling determined the risk factors for overshoots. Multivariate analysis was employed to associate overshoots with length of stay (LOS), bleeding, and mortality. Additional analysis of the impact of patient weight (kg) on overshoots was achieved through chi square analysis. Of 4556 inpatients initiated on warfarin, 8% experienced overshoots. Non-black race, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), mild liver disease, low weight, and no statin use were found to be predictive of overshoots. Compared to the group without overshoots, the group with overshoots experienced a significantly increased LOS (13 days vs. 8 days

Dysphagia is prevalent in older adults with dementia, particularly in the acute care setting. The objective of this study was to use an innovative approach to extract a more representative sample of patients with dysphagia from the electronic health record (EHR) to determine patient characteristics, hospital practices, and outcomes associated with dysphagia in hospitalized persons with dementia.A retrospective study of hospitalized adults (aged ≥65 years) with dementia was conducted in 7 hospitals across the greater New York metropolitan area.Data were obtained from the inpatient EHR with the following inclusion criteria: age ≥65 years; admitted to one of 7 health system hospitals between January 1, 2019, and December 31, 2019; and documented past medical diagnosis of dementia (based on International Classification of Diseases, Ninth Revision).A diagnosis of dysphagia was defined as nurse documentation of a positive bedside swallow screening, nurse documentation of "difficulty swallowing" as reason for not performing bedside swallow screening, and physician documentation of a dysphagia diagnosis.Of adults with dementia (N = 8637), the average age was 84.5 years, 61.6% were female, and 18.1% were Black and 9.3% Hispanic. Dysphagia was identified in 41.8% (n = 3610). In multivariable models, dysphagia was associated with invasive mechanical ventilation [odds ratio (OR) 4.53, 95% CI 3.55-5.78], delirium (OR 1.53, 95% CI 1.40-1.68), increased length of stay (B = 3.29, 95% CI 2.98-3.60), and mortality (OR 4.44, 95% CI 3.54-5.55).Given its high prevalence, underrecognition, and associated poor outcomes, improving large-scale dysphagia identification can impact clinical care and advance research in hospitalized persons with dementia.

Introduction: Our study aimed to determine 1) the association between time spent in the emergency department (ED) hallway and the development of delirium and 2) the hospital location of delirium development. Methods: This single-center, retrospective chart review included patients 18+ years old admitted to the hospital after presenting, without baseline cognitive impairment, to the ED in 2018. We identified the Delirium group by the following: key words describing delirium; orders for psychotropics, special observation, and restraints; or documented positive Confusion Assessment Method (CAM) screen. The Control group included patients not meeting delirium criteria. We used a multivariable logistic regression model, while adjusting for confounders, to assess the odds of delirium development associated with percentage of ED LOS spent in the hallway. Results: A total of 25,156 patients met inclusion criteria with 1920 (7.6%) meeting delirium criteria. Delirium group vs. Control group patients spent a greater percentage of time in the ED hallway (median 50.5% vs 10.8%, P

Background Literature indicates an atypical presentation of COVID-19 among older adults (OAs). Our purpose is to identify the frequency of atypical presentation and compare demographic and clinical factors, and short-term outcomes, between typical versus atypical presentations in OAs hospitalized with COVID-19 during the first surge of the pandemic. Methods Data from the inpatient electronic health record were extracted for patients aged 65 and older, admitted to our health systems’ hospitals with COVID-19 between March 1 and April 20, 2020. Presentation as reported by the OA or his/her representative is documented by the admitting professional and includes both symptoms and signs. Natural language processing was used to code the presence/absence of each symptom or sign. Typical presentation was defined as words indicating fever, cough, or shortness of breath; atypical presentation was defined as words indicating functional decline or altered mental status. Results Of 4 961 unique OAs, atypical presentation characterized by functional decline or altered mental status was present in 24.9% and 11.3%, respectively. Atypical presentation was associated with older age, female gender, Black race, non-Hispanic ethnicity, higher comorbidity index, and the presence of dementia and diabetes mellitus. Those who presented typically were 1.39 times more likely than those who presented atypically to receive intensive care unit–level care. Hospital outcomes of mortality, length of stay, and 30-day readmission were similar between OAs with typical versus atypical presentations. Conclusion Although atypical presentation in OAs is not associated with the same need for acute intervention as respiratory distress, it must not be dismissed.

Background: Given the increasing age and medical complexity of trauma patients, medical comanagement has been adopted as a strategy for high-risk patients. This study aimed to determine whether a geriatrics-focused hospitalist trauma comanagement program improves outcomes.Methods: A pre- and post-implementation study compared older adult trauma patients who were comanaged by a hospitalist with those prior to comanagement at a Level 1 trauma center. Criteria for comanagement included: age 65+, multiple comorbidities, and use of high-risk medications. Comanagement focused on geriatric trauma management guidelines. One-to-one propensity score matching (PSM) was performed based on age, gender, Injury Severity Score, Charlson comorbidity index, and initial admission to the intensive care unit (ICU). Outcomes included hospital mortality, length of stay (LOS), and orders for geriatrics-focused quality indicators. Differences were compared with the Wilcoxon Rank Sum test for continuous variables and chi- square or Fisher’s exact test for categorical variables.Results: From 792 control and 365 intervention patients, PSM resulted in 290 matched pairs. Three intervention group patients died compared to 14 in the control group (p=0.0068). Hospital LOS, 30-day readmission, ICU LOS, and ICU upgrades were not significantly different between groups. There was an overall trend toward improved geriatrics-focused quality indicators in the intervention group. Intervention group was less likely to be restrained (p=0.04), received earlier physical therapy (p=0.01), more doses of acetaminophen compared to control patients (pDiscussion: Our main findings highlight the higher medical complexity and increased risks in older adult trauma patients, as well as the mortality reduction and adherence increase to geriatrics-focused quality indicators. Limitations of our study included use of a single center, the possibility of selection bias in analyzing historical data, and a low sample size, all of which may limit generalizability. Conclusions: Our study demonstrates that a geriatrics-focused hospitalist trauma comanagement program improves survival and quality of care.

Background: Age has been implicated as the main risk factor for COVID-19-related mortality. Our objective was to determine patient factors associated with mortality in hospitalized older adults with COVID-19. Methods: Retrospective cohort study of adults age 65+ (N=4,949) hospitalized with COVID-19 in the greater New York metropolitan area between 3/1/20-4/20/20. Data included patient demographics and clinical presentation. Multivariate logistic regression was used to evaluate associations. Results: Average age 77.3 (SD=8.4), 56.0% male, 20.8% African American, 15.1% Hispanic. In a multivariate analysis, male gender (OR=1.47), higher comorbidity index (OR=1.10), admission from a facility (lower baseline function; OR=1.71), early DNR (declining life-sustaining treatments, OR=2.45), and higher illness severity (higher MEWS, OR=6.26, and higher oxygen requirements, OR=15.00) were associated with mortality, while age was not (p = 0.22). Conclusion: Our findings highlight the need to look beyond age in hospitalized older adults with COVID-19 when considering prognosis and treatment decisions.

Objectives To determine whether a multicomponent intervention improves care in hospitalized older adults with cognitive impairment. Design One‐year retrospective chart review with propensity score matching on critical demographic and clinical variables was used to compare individauls with cognitive impairmenet on intervention and nonintervention units. Setting Large tertiary medical center. Participants All hospitalized individuals age 65 and older with cognitive impairment admitted to medicine who required constant or enhanced observation for behavioral and psychological symptoms. Intervention Multicomponent intervention (geographic unit cohorting, multidisciplinary approach, patient engagement specialists (PES), staff education) or usual care. Measurements In‐hospital mortality, length of stay, readmission, management of behavioral disturbances. Results After propensity score matching, 476 of the 712 intervention visits were pair‐matched with 476 of the 558 usual care visits. Matching was successful in balancing baseline covariates between intervention and usual care units. Individuals admitted to the intervention unit had lower in‐hospital mortality (1.1% vs 2.9%, p=0.05) and shorter stays (5.0 vs 5.8 days, p=0.04). There was no difference in discharge home (p=0.90) or 30‐day readmission rates (p=0.44). Individuals on the intervention unit were less likely than those receivng usual care to have an order for constant (12.0% vs 45.8%, p

Medicare patients account for over 50% of hospital days at a cost of over $1 trillion per year. Yet, hospitalization of older adults often results in poor outcomes. We evaluated the role of geriatrician-hospitalists in the care of older adults. Materials and methods A retrospective cohort study was conducted in a 764-bed tertiary care hospital with patients 65 and older admitted to medicine. Geriatrician-hospitalists care was compared to usual care by non-geriatrician hospitalists (staff and non-staff). Outcome measures included length of stay (LOS) and 30-day readmissions. Process measures included geriatric-focused care practices, such as early mobilization, safety precautions, delirium management, use of potentially inappropriate medications and documentation of advanced directives as well as discharge disposition.Of the 10,529 patients, 2949 (28.0%) were cared for by staff hospitalists, 7181 (68.2%) by non-staff hospitalists and 399 (3.79%) by geriatrician-hospitalists. Patients cared for by geriatrician-hospitalists were significantly older with more comorbidities than those admitted to staff and non-staff hospitalists (average age: 86.3, 79.7, and 80.3, respectively, p 0.0001; Charlson Comorbidity Index: 7.46, 7.01, and 7.17, respectively, p = 0.0005). Multivariate analysis showed no difference in LOS, 30-day readmissions, and discharge disposition. In terms of care practices, significant differences were found for the following: time to PT (p 0.0001), duration of indwelling bladder catheters (p = 0.018), documentation of Do-Not-Resuscitate (p 0.0001), benzodiazepine use (p 0.0001) and anticholinergics (p = 0.0029), respectively.As the population continues to age at unprecedented rates and hospitals struggle to meet the demands and expectations, geriatrician-hospitalists may improve care practices important for older adult care management.

Objective To optimize the ability of hospitalized patients isolated because of coronavirus disease 2019 (COVID-19) to participate in physical therapy (PT). Design This was a prospective quality improvement trial of the feasibility and acceptability of a “hybrid” in-person and telerehabilitation platform to deliver PT to hospitalized adults. Setting Inpatient wards of a tertiary care, multispecialty academic medical center in the greater New York City metropolitan area. Participants A convenience sample of 39 COVID-19–positive adults (mean age, 57.3y; 69% male) all previously community dwelling agreed to participate in a combination of in-person and telerehabilitation sessions (N=39). Interventions Initial in-person evaluation by physical therapist followed by twice daily PT sessions, 1 in-person and 1 via a telehealth platform meeting Health Insurance Portability and Accountability Act confidentiality requirements. The communication platform was downloaded to each participant's personal smart device to establish audiovisual contact with the physical therapist. Main Outcome Measures We used the 6-clicks Activity Measure of Post-Acute Care (AM-PAC) to score self-reported functional status premorbidly and by the therapist at baseline and discharge. Results Functional status measured by AM-PAC 6-clicks demonstrated improvement from admission to discharge. Barriers to participation were identified and strategies were planned to facilitate use of the platform in the future. Conclusions A consistent and structured protocol for engaging patient participation in PT delivered via a telehealth platform was successfully developed. A process was put in place to allow for further development, recruitment, and testing in a randomized trial.

Objectives To evaluate physician knowledge and perceptions about the American Board of Internal Medicine/American Geriatrics Society (ABIM/AGS) Choosing Wisely recommendations regarding percutaneous endoscopic gastrostomy (PEG) in individuals with advanced dementia. Design Multicenter, mixed-mode, anonymous questionnaire. Setting Three tertiary and four community hospitals in New York. Participants Internal medicine physicians (N = 168). Measurements Physician knowledge and perceptions regarding PEG tubes in individuals with advanced dementia. Results Ninety-nine percent of physicians reported having cared for someone with advanced dementia; 95% had been involved in the PEG decision-making process; 38% were unsure whether the ABIM/AGSChoosing Wisely recommendations advise for or against PEG tubes in advanced dementia. Physicians who agreed that there is enough evidence to recommend against PEG placement for individuals with advanced dementia were more likely to know the ABIM/AGSChoosing Wisely recommendations (71% vs 28%, P

BACKGROUND Medicare patients account for approximately 50% of hospital days. Hospitalization in older adults often results in poor outcomes. OBJECTIVE To test the feasibility and impact of using Assessing Care of Vulnerable Elders (ACOVE) quality indicators (QIs) as a therapeutic intervention to improve care of hospitalized older adults. DESIGN >Post-test only prospective intervention with a nonequivalent retrospective control group. SETTING Large tertiary hospital in the greater New York Metropolitan area. PATIENTS Hospitalized patients, 75 years and over, admitted to medical units. INTERVENTION A checklist, comprised of four ACOVE QIs, administered during daily interdisciplinary rounds: venous thrombosis prophylaxis (VTE) (QI 1), indwelling bladder catheters (QI 2), mobilization (QI 3), and delirium evaluation (QI 4). MEASUREMENTS Variables were extracted from electronic medical records with QI compliance as primary outcome, and length of stay (LOS), discharge disposition, and readmissions as secondary outcomes. Generalized linear mixed models for binary clustered data were used to estimate compliance rates for each group (intervention group or control group) in the postintervention period, along with their corresponding 95% confidence intervals. RESULTS Of the 2,396 patients, 530 were on an intervention unit. In those patients not already compliant with VTE, compliance rate was 57% in intervention vs 39% in control (𝑃 < .0056). For indwelling catheters, mobilization, and delirium evaluation, overall compliance was significantly higher in the intervention group 72.2% vs 54.4% (𝑃 = .1061), 62.9% vs 48.2% (𝑃 < .0001), and 27.9% vs 21.7% (𝑃 = .0027), respectively. CONCLUSION The study demonstrates the feasibility and effectiveness of integrating ACOVE QIs to improve the quality of care in hospitalized older adults.

This study evaluates three warfarin dosing algorithms (Kimmel, Dawson, High Dose ≥ 2.5 mg) for hospitalized older adults. A random selection of 250 patients with overshoots (INR ≥ 5 after 48 h of hospitalization) and 250 patients without overshoots were accessed from a database of 12,107 inpatients ≥ 65 years treated with chronic warfarin during hospitalization between January 1, 2014 and June 30, 2016. Algorithms were retrospectively applied to patients 2 days prior to overshoots in the overshoot group, and 2 days prior to the maximum INR reached after 48 h of hospitalization in the non-overshoot group. Patients were categorized as overdosed or not overdosed and compared using descriptive statistics. Logistic regression modeling determined predictors for overshoots. There was no significant difference between overdose and non-overdose groups for progressing to overshoots by the Kimmel (51.0% vs. 48.7%, p = 0.67) or Dawson (48.5 vs. 57.9%, p = 0.19) algorithms. The Low Dose Group (≤ 2.5 mg) was significantly more likely to experience an overshoot than the High Dose Group (56.6% vs. 45.5%, p = 0.04). The Low Dose Group was more likely to be older (81.4% vs. 71.1%, p = 0.02), female (63.5% vs. 49.8%, p = 0.02), weigh less (71.3 ± 21.9 vs. 79 ± 23.1, p = 0.002), and be prescribed amiodarone (16.6% vs. 8.1%, p = 0.01). While none of the algorithms predicted overshoots in logistic regression modeling, weight over 70 kg and black race remained protective. The High Dose Algorithm revealed that providers appropriately gave lower doses to patients at highest risk for warfarin sensitivity. Future studies are needed to investigate tools for inpatient warfarin dosing in older adults.

This study examined the prognostic value of the Charlson Comorbidity Index (CCI) in predicting short-term clinical outcomes in hospitalized older adults. We conducted a retrospective cohort study of patients, older than 75 years, admitted to the medicine service at a large tertiary hospital (New York). We used the Enhanced International Classification of Disease, 9th Revision, Clinical Modification adaptation to abstract the CCI from electronic medical records. The CCI scores were compared, using the standard Deyo version and the Schneeweiss version. Outcome measures included in-hospital mortality, length of stay (LOS), and 30-day readmissions. When comparing Charlson/Deyo and Charlson/Deyo/Schneeweiss with and without age, we found similar significant association with regard to in-hospital mortality, with a moderate predictive ability (area under the curve [AUC]: 0.5906-0.6433). However, for 30-day readmissions and LOS, the predictive ability was poor (AUC: 0.5598-0.6106 and ρ: 0.11-0.12, respectively). The CCI is, at most, a moderate predictor of in-hospital mortality and a poor predictor of other important healthcare outcomes relevant to administrative healthcare practices.

Despite substantial staffing and cost implications, the use of constant observation (CO) has been poorly described in the acute care setting. The purpose of this cross-sectional, multicenter, survey study was to assess hospital provider practices regarding the use of CO. Of the 543 surveys distributed, 231 were completed across 5 sites. Most respondents worked on medical units (67.5%), as nurses (49.1%); 44.8% were white; and 75.6% were female. The majority (84.2%) reported at least 1 patient/wk requiring CO. Most frequent indication for CO was dementia with agitation (60.7%), in patients older than 70 (62.3%) and predominantly by nurse assistants (93.9%). Almost half (47.3%) stated they felt pressured to discontinue CO, despite a strong perceived benefit (76%). Enhanced observation (92.6%) was most frequently used to decrease CO. Finally, 77.9% perceived that those performing CO lacked training. Our study highlights the widespread use of CO for hospitalized older adults with dementia.

We conducted a meta-analysis of twenty-six randomized controlled trials that tested the effectiveness of home telemonitoring in patients with heart failure for reducing mortality and hospital use. We used the PICOT framework as a tool to address an important variable not previously studied: the timing or duration of monitoring. Specifically, we found that home telemonitoring decreased the odds of all-cause mortality and heart failure-related mortality at 180 days but not at 365 days. Home telemonitoring did not significantly affect the odds of all-cause hospitalization at 90 or 180 days, or of heart failure-related hospitalization at 180 days. At 180 days, home telemonitoring significantly increased the odds of all-cause emergency department visits. Home care provision did not moderate the effects of home telemonitoring on all-cause hospitalization. Recent regulatory changes that relaxed Medicare restrictions on telehealth reimbursement make it imperative that studies fully describe outcomes (for example, heart failure-related versus all-cause hospitalizations) and deliberately test all essential intervention elements, such as intervention duration.

Older adults are disproportionately affected by the coronavirus (COVID-19) pandemic. While age has been used to guide resource allocation based on studies implicating age as the main risk factor for COVID-19-related mortality, most did not account for critical factors such as baseline functional and cognitive status, or life-sustaining treatment preferences. The objective of this study was to determine whether age is independently associated with mortality in older adults hospitalized with COVID-19. We conducted a retrospective cohort study of adults age 65+ with confirmed COVID-19 hospitalized in the greater NY metropolitan area between 3/1/20-4/20/20. Primary outcome was in-hospital mortality, with age as the primary predictor. Multivariate logistic regression was used to evaluate association between age and in-hospital mortality after controlling for demographics, severity of acute illness, comorbidities, and baseline function, cognition, and life-sustaining treatment preferences. 4,969 patients were included, average age 77.3, 56.0% male, 46.8% White, 20.8% African American, 15.1% Hispanic. Common comorbidities included hypertension (61.1%), and diabetes (36.8%); average number of comorbidities was 3.4 (SD 2.8) and 13.0% had dementia. 20.8% arrived from a facility and 5.7% had early do-not-resuscitate orders. On arrival, the Modified Early Warning System score was 4.2 (SD 1.7) and 79.6% required oxygen therapy. 35.3% of patients expired. In multivariate analysis, age was not independently associated with mortality (p = .173). Functional status, multi-morbidity, life-sustaining treatment preferences, and illness severity, not age, were associated with mortality among older adults hospitalized with COVID-19, suggesting age should not be used as the main indicator to guide resource allocation.