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Background: Patients receiving dialysis have unmet palliative care needs. Limited access to palliative care is a key barrier to its integration into routine dialysis care. Objective: To determine the feasibility and acceptability of telepalliative care in rural dialysis units. Methods: This was a single-arm pilot clinical trial. The target population was patients with kidney failure receiving outpatient dialysis in a rural U.S. state. Feasibility was measured by one-month completion rate. Acceptability was measured using an adapted telemedicine questionnaire. Results: We recruited 39 patients with mean age 71.2 years to undergo a telepalliative care consultation while receiving dialysis. Four specialty palliative care clinicians (three physicians and one nurse practitioner) conducted the visits. The recruitment rate was 40% (39/96), scheduling rate was 100% (39/39), and one-month completion rate was 77% (30/39). Thirty-six patient participants (14 women and 22 men) completed the baseline survey. Audiovisual aspects of the visit were rated highly. More than 80% reported the visit being at least as good as an in-person visit and 41% felt the teleconsult was better. Eighty-one percent of patients felt the appointment was relevant to them, 58% felt they learned new things about their condition, and 27% reported the appointment changed the way they think about dialysis. Discussion: Telepalliative care is acceptable to patients receiving dialysis and is a feasible approach to integrating palliative care in rural dialysis units. The study was registered with Clinicaltrials.gov (NCT03744117).

BACKGROUND/OBJECTIVES The number of older adults with complex health needs is growing, and this population experiences disproportionate morbidity and mortality. Interventions led by community health workers (CHWs) can improve clinical outcomes in the general adult population with multimorbidity, but few studies have investigated CHW-delivered interventions in older adults. DESIGN We systematically reviewed the impact of CHW interventions on health outcomes among older adults with complex health needs. We searched for English-language articles from database inception through April 2020 using seven databases. PROSPERO protocol registration CRD42019118761. SETTING Any U.S. or international setting, including clinical and community-based settings. PARTICIPANTS Adults aged 60 years or older with complex health needs, defined in this review as multimorbidity, frailty, disability, or high-utilization. INTERVENTIONS Interventions led by a CHW or similar role consistent with the American Public Health Association's definition of CHWs. MEASUREMENTS Pre-defined health outcomes (chronic disease measures, general health measures, treatment adherence, quality of life, or functional measures) as well as qualitative findings. RESULTS Of 5671 unique records, nine studies met eligibility criteria, including four randomized controlled trials, three quasi-experimental studies, and two qualitative studies. Target population and intervention characteristics were variable, and studies were generally of low-to-moderate methodological quality. Outcomes included mood, functional status and disability, social support, well-being and quality of life, medication knowledge, and certain health conditions (e.g., falls, cognition). Results were mixed with several studies demonstrating significant effects on mood and function, including one high-quality RCT, while others noted no significant intervention effects on outcomes. CONCLUSION CHW-led interventions may have benefit for older adults with complex health needs, but additional high-quality studies are needed to definitively determine the effectiveness of CHW interventions in this population. Integration of CHWs into geriatric clinical settings may be a strategy to deliver evidence-based interventions and improve clinical outcomes in complex older adults.

Agitation and aggression are common in older emergency department (ED) patients, can impede the expedient diagnosis of potentially life‐threatening conditions, and can adversely impact ED functioning and efficiency. Agitation and aggression in older adults may be due to multiple causes, but chief among them are primary psychiatric disorders, substance use, hyperactive delirium, and symptoms of dementia. Understanding the etiology of agitation in an older adult is critical to proper management. Effective non‐pharmacologic modalities are available for the management of mild to moderate agitation and aggression in patients with dementia. Pharmacologic management is indicated for agitation related to a psychiatric condition, severe agitation where a patient is at risk to harm self or others, and to facilitate time‐sensitive diagnostic imaging, procedures, and treatment. Emergency physicians have several pharmacologic agents at their disposal, including opioid and non‐opioid analgesics, antipsychotics, benzodiazepines, ketamine, and combination agents. Emergency physicians should be familiar with geriatric‐specific dosing, contraindications, and common adverse effects of these agents. This review article discusses the common causes and non‐pharmacologic and pharmacologic management of agitation in older adults, with a specific focus on dementia, delirium, and pain.

Rural communities need access to effective interventions that can prevent functional decline among a growing population of older adults. We describe the conceptual framework and rationale for a multicomponent intervention (“Mind, Mood, Mobility”) delivered by Area Agency on Aging staff for rural older adults at risk for functional decline due to early impairments in cognition, mood, or mobility. Our proposed model utilizes primary care to identify at-risk older adults, combines evidence-based interventions that address multiple risk factors simultaneously, and leverages a community-based aging services workforce for intervention delivery.

As the prevalence of persons with dementia increases, a larger, trained, and skilled healthcare workforce is needed. Attention has been given to models of person-centered care as a standard for dementia care. One promising role to deliver person-centered care is the care coordinator assistant. An inquiry about care coordinator assistant’s job satisfaction is reasonable to consider for retention and quality improvement purposes. We evaluated care coordinator assistants' job satisfaction quantitatively and qualitatively. This study was part of a Centers for Medicare & Medicaid Services Health Care Innovation Award to the Indiana University School of Medicine. Sixteen care coordinator assistants, predominately female, African American or Caucasian, college graduates with a mean age of 43.1 years participated. Care coordinator assistants wrote quarterly case reports to share stories, lessons learned, and/or the impact of their job and completed the revised Job Satisfaction Inventory and Job in General scales during the second year of the Centers for Medicare & Medicaid Services award. For the Job Descriptive Index subscales promotion, supervision, and coworkers and Job in General, care coordinator assistants scored similar to normative means. Care coordinator assistants reported significantly higher satisfaction on the work subscale and significantly lower satisfaction on the pay subscale compared to normative data. Care coordinator assistants completed 119 quarterly case reports. Job satisfaction and teamwork were recurring themes in case reports, referenced in 47.1% and 60.5% of case reports, respectively. To address the demands of increasing dementia diagnoses, care coordinator assistants can constitute a compassionate, competent, and satisfied workforce. Training care coordinator assistants to work together in a team to address the needs of persons with dementia and caregivers provides a viable model of workforce development necessary to meet the growing demands of this population.

Objectives: To measure older adults acceptability of dementia screening and assess screening test results of a racially diverse sample of older primary care patients in the United States. Design: Cross-sectional study of primary care patients aged 65 and older. Setting: Urban and suburban primary care clinics in Indianapolis, Indiana, in 2008 to 2009. Participants: Nine hundred fifty-four primary care patients without a documented diagnosis of dementia. Measurements: Community Screening Instrument for Dementia, the Mini-Mental State Examination, and the Telephone Instrument for Cognitive Screening. Results: Of the 954 study participants who consented to participate, 748 agreed to be screened for dementia and 206 refused screening. The overall response rate was 78.4%. The positive screen rate of the sample who agreed to screening was 10.2%. After adjusting for demographic differences the following characteristics were still associated with increased likelihood of screening positive for dementia: age, male sex, and lower education. Patients who believed that they had more memory problems than other people of their age were also more likely to screen positive for dementia. Conclusion: Age and perceived problems with memory are associated with screening positive for dementia in primary care.

Purpose of the study The study objective was to understand providers’ perceptions regarding identifying and treating older adults with delirium, a common complication of acute illness in persons with dementia, in the pre-hospital and emergency department environments. Design and methods The authors conducted structured focus group interviews with separate groups of emergency medical services staff, emergency nurses, and emergency physicians. Recordings of each session were transcribed, coded, and analyzed for themes with representative supporting quotations identified. Results Providers shared that the busy emergency department environment was the largest challenge to delirium recognition and treatment. When describing delirium, participants frequently detailed hyperactive features of delirium, rather than hypoactive features. Participants shared that they employed no clear diagnostic strategy for identifying the condition and that they used heterogeneous approaches to treat the condition. To improve care for older adults with delirium, emergency nurses identified the need for more training around the management of the condition. Emergency medical services providers identified the need for more support in managing agitated patients when in transport to the hospital and more guidance from emergency physicians on what information to collect from the patient’s home environment. Emergency physicians felt that delirium care would be improved if they could have baseline mental status data on their patients and if they had access to a simple, accurate diagnostic tool for the condition. Implications Emergency medical services providers, emergency nurses, and emergency physicians frequently encounter delirious patients, but do not employ clear diagnostic strategies for identifying the condition and have varying levels of comfort in managing the condition. Clear steps should be taken to improve delirium care in the emergency department including the development of mechanisms to communicate patients’ baseline mental status, the adoption of a systematized approach to recognizing delirium, and the institution of a standardized method to treat the condition when identified.

Objectives To describe emergency department (ED) utilization among long-stay nursing home residents with different levels of dementia severity. Design Retrospective cohort study. Setting Public Health System. Participants A total of 4491 older adults (age 65 years and older) who were long-stay nursing home residents. Measurements Patient demographics, dementia severity, comorbidities, ED visits, ED disposition decisions, and discharge diagnoses. Results Forty-seven percent of all long-stay nursing home residents experienced at least 1 transfer to the ED over the course of a year. At their first ED transfer, 36.4% of the participants were admitted to the hospital, whereas 63.1% of those who visited the ED were not. The median time to first ED visit for the participants with advanced stage dementia was 258 days, whereas it was 250 days for the participants with early to moderate stage dementia and 202 days for the participants with no dementia ( P = .0034). Multivariate proportional hazard modeling showed that age, race, number of comorbidities, number of hospitalizations in the year prior, and do not resuscitate status all significantly influenced participants' time to first ED visit ( P P = .66), years in nursing home before qualification ( P = .46), and gender ( P = .36) lost their significance. Conclusions This study confirms high rates of transfer of long-stay nursing home residents, with nearly one-half of the participants experiencing at least 1 ED visit over the course of a year. Although dementia severity is not a predictor of time to ED use in our analyses, other factors that influence ED use are readily identifiable. Nursing home providers should be aware of these factors when developing strategies that meet patient care goals and avoid transfer from the nursing home to the ED.

The objectives of this report are to determine the association between performance-based measures of physical function with caregiver reports of physical function in older adults with Alzheimer disease (AD) and to examine whether those associations vary by the level of patients' cognitive functioning. Subjects included 180 patient-caregiver dyads who are enrolled in a clinical trial testing the impact of an occupational therapy intervention plus guideline-level care to delay functional decline among older adults with AD. The primary caregiver-reported measure is the Alzheimer's Disease Cooperative Study Group Activities of Daily Living Inventory (ADCS-ADL). Performance-based measures include the Short Physical Performance Battery and the Short Portable Sarcopenia Measure. Analysis of covariance (ANCOVA) models were used to determine the associations of each physical performance measure with ADCS-ADL, adjusting for cognition function and other covariates. We found significant correlations between caregiver reports and observed performance-based measures across all levels of cognitive function, with patients in the lowest cognitive group showing the highest correlation. These findings support the use of proxy reports to assess physical function among older adults with AD.

Background: Dementia is underrecognized in older adult emergency department (ED) patients, which threatens operational efficiency, diagnostic accuracy, and patient satisfaction. The Society for Academic Emergency Medicine geriatric ED guidelines advocate dementia screening using validated instruments. Objectives: The objective was to perform a systematic review and meta-analysis of the diagnostic accuracy of sufficiently brief screening instruments for dementia in geriatric ED patients. A secondary objective was to define an evidence-based pretest probability of dementia based on published research and then estimate disease thresholds at which dementia screening is most appropriate. This systematic review was registered with PROSPERO (CRD42017074855). Methods: PubMed, EMBASE, CINAHL, CENTRAL, DARE, and SCOPUS were searched. Studies in which ED patients ages 65 years or older for dementia were included if sufficient details to reconstruct 2 × 2 tables were reported. QUADAS-2 was used to assess study quality with meta-analysis reported if more than one study evaluated the same instrument against the same reference standard. Outcomes were sensitivity, specificity, and positive and negative likelihood ratios (LR+ and LR–). To identify test and treatment thresholds, we employed the Pauker-Kassirer method. Results: A total of 1,616 publications were identified, of which 16 underwent full text-review; nine studies were included with a weighted average dementia prevalence of 31% (range, 12%–43%). Eight studies used the Mini Mental Status Examination (MMSE) as the reference standard and the other study used the MMSE in conjunction with a geriatrician's neurocognitive evaluation. Blinding to the index test and/or reference standard was inadequate in four studies. Eight instruments were evaluated in 2,423 patients across four countries in Europe and North America. The Abbreviated Mental Test (AMT-4) most accurately ruled in dementia (LR+ = 7.69 [95% confidence interval {CI} = 3.45–17.10]) while the Brief Alzheimer's Screen most accurately ruled out dementia (LR– = 0.10 [95% CI = 0.02–0.28]). Using estimates of diagnostic accuracy for AMT-4 from this meta-analysis as one trigger for more comprehensive geriatric vulnerability assessments, ED dementia screening benefits patients when the prescreening probability of dementia is between 14 and 36%. Conclusions: ED-based diagnostic research for dementia screening is limited to a few studies using an inadequate criterion standard with variable masking of interpreter's access to the index test and the criterion standard. Standardizing the geriatric ED cognitive assessment methods, measures, and nomenclature is necessary to reduce uncertainties about diagnostic accuracy, reliability, and relevance in this acute care setting. The AMT-4 is currently the most accurate ED screening instrument to increase the probability of dementia and the Brief Alzheimer's Screen is the most accurate to decrease the probability of dementia. Dementia screening as one marker of vulnerability to initiate comprehensive geriatric assessment is warranted based on test–treatment threshold calculations.

Describe the development of a competent workforce committed to providing patient-centered care to persons with dementia and/or depression and their caregivers; to report on qualitative analyses of our workforce's case reports about their experiences; and to present lessons learned about developing and implementing a collaborative care community-based model using our new workforce that we call care coordinator assistants (CCAs).Sixteen CCAs were recruited and trained in person-centered care, use of mobile office, electronic medical record system, community resources, and team member support. CCAs wrote case reports quarterly that were analyzed for patient-centered care themes.Qualitative analysis of 73 cases using NVivo software identified six patient-centered care themes: (1) patient familiarity/understanding; (2) patient interest/engagement encouraged; (3) flexibility and continuity of care; (4) caregiver support/engagement; (5) effective utilization/integration of training; and (6) teamwork. Most frequently reported themes were patient familiarity - 91.8% of case reports included reference to patient familiarity, 67.1% included references to teamwork and 61.6% of case reports included the theme flexibility/continuity of care. CCAs made a mean number of 15.7 (SD = 15.6) visits, with most visits for coordination of care services, followed by home visits and phone visits to over 1200 patients in 12 months.Person-centered care can be effectively implemented by well-trained CCAs in the community.

Objectives To describe transitions in care for older adults with dementia identified from a nationally representative cohort and to describe transition rates in those with more-severe levels of cognitive and functional impairment. Design Longitudinal cohort study. Setting Health and Retirement Study (HRS). Participants HRS respondents aged 65 and older whose survey data were linked with Medicare claims from 1999 to 2008 (N = 16,186). Measurements Transitions in care between home, home with formal services, hospital, and nursing facility care; cognitive function; activities of daily living; and mortality. Results The 3,447 (21.3%) HRS subjects who were ever diagnosed with dementia experienced frequent transitions. Of subjects transitioning from a hospital stay, 52.2% returned home without home care services, and 33.8% transitioned to a nursing facility. Of subjects transitioning from a nursing facility, 59.2% transitioned to the hospital, and 25.3% returned home without services. There were 2,139 transitions to death, and 58.7% of HRS subjects with dementia died at home. Even in persons with moderate to severe dementia, multiple transitions in care were documented, including transitions from the hospital to home and back to the hospital. Conclusion In this nationally representative sample of older adults, subjects diagnosed with dementia experience frequent transitions. Persons with dementia who are cared for at home and who transition back to home often have moderate to severe impairments in function and cognition.

Die angemessene Versorgung von alteren Menschen mit Demenz und/oder Depression verlangt nach innovativen Konzepten. Im vorliegenden Beitrag wird das US-amerikanische Aging Brain Care (ABC) Program beschrieben und eine mogliche Ubertragbarkeit auf den deutschen Versorgungskontext diskutiert. Das „ABC Medical Home Model“ in Indianapolis umfasst sowohl ein geriatrisch-spezialisiertes Versorgungszentrum, das an das Eskenazi Hospital angeschlossen ist, als auch ein Programm, in dem Mitarbeiter die betroffenen Menschen in ihrer Hauslichkeit aufsuchen. Im geriatrischen Zentrum werden die Diagnosen gestellt sowie Therapien und Versorgung geplant. Dies geschieht im multiprofessionellen Team, das die individuellen Hilfebedarfe der Patienten und ihrer Angehorigen ermittelt und diese in „family conferences“ bespricht, sowie in enger Abstimmung mit dem „Primary Care Center“ des Hospitals. Uber eine eigens fur das Programm entwickelte Software sowie uber festgelegte Ablaufe bzw. Handlungsanweisungen fur das Vorgehen im Versorgungszentrum und im Hausbesuchsprogramm werden die Betreuung, Diagnosestellung und Therapie gesteuert. Aus Sicht der Autoren scheinen insbesondere die Strukturierung der Versorgung aus einer Hand sowie die Qualifikation und die Qualifizierung der Beteiligten Kernelemente des ABC-Programms zu sein. Modelle wie das hier vorgestellte Programm sind vielversprechend, um den Herausforderungen einer alternden Bevolkerung begegnen zu konnen.

While fragmented care is a problem across the entire health care delivery system, it is especially problematic for vulnerable older adults with dementia and late-life depression. Most older adults have multiple chronic conditions. Cognitive impairment and mood disorders complicate the management of these comorbid conditions by interfering with the patient’s ability to monitor and report symptoms and comply with the care plan. To reduce fragmentation and promote integrated care, each medical provider must adopt a more holistic view of health care, recognizing the importance of communication and collaboration among all providers and the potential impact of any one action on the patient’s overall health. The Aging Brain Care (ABC) model provides a structure for integrating evidence-based interventions for dementia and depression into the primary care environment. By extending the delivery of care beyond the clinic, ABC offers patient-centered services aimed at coordinating care across multiple providers, settings, and community resources.

Background and objectives Persons living with dementia have complex care needs including memory loss that should be taken into account by providers and family caregivers involved with their care. The prevalence of comorbid conditions in people with dementia is high and, thus, how primary care, community providers and family caregivers provide best practice care, person-centered care is important. Research design and methods Care providers should understand the ongoing medical management needs of persons living with dementia in order to maximize their quality of life, proactively plan for their anticipated needs, and be as well prepared as possible for health crises that may occur. Results This article provides eight practice recommendations intended to promote understanding and support of the role of nonphysician care providers in educating family caregivers about ongoing medical management to improve the wellbeing of persons living with dementia. Discussion and implications Key among these are recommendations to use nonpharmacological interventions to manage behavioral and psychological symptoms of dementia as the first line of treatment and recommendations on how to best support the use and discontinuation of pharmacological interventions as necessary.

Best-practice models of dementia care have evolved from strategies focused on family caregivers to guidelines predicated on supporting the patient-caregiver dyad along the care continuum. These models have grown in complexity to encompass medical and team-based care that is designed to coordinate dementia care across settings and providers for a defined population of patients. Although there is evidence that the models can improve outcomes, they have not been widely adopted. Barriers to the models' increased adoption include workforce limitations, the cost of necessary practice redesign, and limited evidence of their potential cost-effectiveness. We summarize the origins, evidence base, and common components of best-practice models of dementia care, and we discuss barriers to their implementation. We conclude by describing two current efforts to implement such models on a broad scale, supported by the Center for Medicare and Medicaid Innovation. Taken together, these models seek to demonstrate improved dementia care quality and outcomes, accompanied by cost savings, in both community-based and institutional care settings.

Study Objectives To identify and summarize the pooled diagnostic test characteristics for dementia screening instruments in the emergency department (ED). Methods This was a systematic review and meta-analysis adherent to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis of Diagnostic Test Accuracy guidelines of prospective observational ED studies comparing appropriately brief dementia screening instruments against an acceptable criterion standard with sufficient detail to reconstruct 2x2 contingency tables. Two investigators independently assessed risk of bias using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2). When ≥1 study evaluated the same dementia screening instrument with the same criterion standard, pooled estimates of diagnostic accuracy were computed using a random-effects model and Meta-DiSc Version 1.4. Results From 1604 unique citations, 9 met inclusion criteria. QUADAS-2 assessment indicated moderate quality studies. The criterion standard for dementia was solely the Mini Mental Status Exam (MMSE) in 7 studies. The criterion standard for one of the other studies was a combination of the MMSE and a delirium screen, while the remaining study used a geriatrician’s assessment of Diagnostic Statistical Manual of Mental Disorders criteria as the gold standard. The weighted mean prevalence of dementia was 31% and ranged from 12% to 43% across studies. Eight instruments were described of which the Abbreviated Mental Test-4 (AMT-4) demonstrated the highest positive likelihood ratio [pooled LR+ 7.7, 95% CI 3.5-17.1] and the Brief Alzheimer’s Screen (BAS) demonstrated the lowest negative likelihood ratio [LR- = 0.10, 95% CI 0.02-0.28]. The Six Item Screener test time was reported as under 1 minute compared with 1.5 minutes for the Mini-Cog and 4.7 minutes for the AMT-4. Conclusions Existing research is limited by inadequate criterion standards juxtaposed with the reality that more widely acceptable comparators are impractical in ED settings. Acknowledging these limitations, the AMT-4 most accurately rules in dementia, while the BAS most accurately rules out dementia.

The increasing prevalence of cognitive impairment among the older adult population warrants attention to the identification of practices that may minimize the progression of early forms of cognitive impairment, including the transitional stage of mild cognitive impairment (MCI), to permanent stages of dementia. This article identifies both markers of disease progress and risk factors linked to the progression of MCI to dementia. Potentially modifiable risk factors may offer researchers a point of intervention to modify the effect of the risk factor and to minimize the future burden of dementia.

Background Alzheimer disease results in progressive functional decline, leading to loss of independence. Objective To determine whether collaborative care plus 2 years of home-based occupational therapy delays functional decline. Design Randomized, controlled clinical trial. (ClinicalTrials.gov: NCT01314950). Setting Urban public health system. Patients 180 community-dwelling participants with Alzheimer disease and their informal caregivers. Intervention All participants received collaborative care for dementia. Patients in the intervention group also received in-home occupational therapy delivered in 24 sessions over 2 years. Measurements The primary outcome measure was the Alzheimer's Disease Cooperative Study Group Activities of Daily Living Scale (ADCS ADL); performance-based measures included the Short Physical Performance Battery (SPPB) and Short Portable Sarcopenia Measure (SPSM). Results At baseline, clinical characteristics did not differ significantly between groups; the mean Mini-Mental State Examination score for both groups was 19 (SD, 7). The intervention group received a median of 18 home visits from the study occupational therapists. In both groups, ADCS ADL scores declined over 24 months. At the primary end point of 24 months, ADCS ADL scores did not differ between groups (mean difference, 2.34 [95% CI, -5.27 to 9.96]). We also could not definitively demonstrate between-group differences in mean SPPB or SPSM values. Limitation The results of this trial are indeterminate and do not rule out potential clinically important effects of the intervention. Conclusion The authors could not definitively demonstrate whether the addition of 2 years of in-home occupational therapy to a collaborative care management model slowed the rate of functional decline among persons with Alzheimer disease. This trial underscores the burden undertaken by caregivers as they provide care for family members with Alzheimer disease and the difficulty in slowing functional decline. Primary funding source National Institute on Aging.

Michael A LaMantia,1–4 Anthony J Perkins,5,6 Sujuan Gao,2,7 Mary G Austrom,8,9 Cathy A Alder,10 Dustin D French,11,12 Debra K Litzelman,2,3,13 Ann H Cottingham,3 Malaz A Boustani1–3,5 1Indiana University Center for Aging Research, 2Regenstrief Institute, Inc., 3Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, 4Department of Medicine, University of Vermont College of Medicine, Burlington, VT, 5Indiana University Center for Health Innovation and Implementation Science, 6Indiana Clinical and Translational Sciences Institute, 7Department of Biostatistics, Indiana University School of Medicine, 8Department of Psychiatry, Indiana University School of Medicine, 9Indiana University Alzheimer’s Disease Center, 10Eskenazi Health, Indianapolis, IN, 11Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, 12Veterans Affairs Health Services Research and Development Service, Chicago, IL, 13Indiana University Center for Health Services and Outcomes Research, Indianapolis, IN, USA Objective: To evaluate the effect of the Aging Brain Care (ABC) Medical Home program’s depression module on patients’ depression severity measurement over time.Design: Retrospective chart review.Setting: Public hospital system.Participants: Patients enrolled in the ABC Medical Home program between October 1, 2012 and March 31, 2014.Methods: The response of 773 enrolled patients who had multiple patient health questionnaire-9 (PHQ-9) scores recorded in the ABC Medical Home program’s depression care protocol was evaluated. Repeatedly measured PHQ-9 change scores were the dependent variables in the mixed effects models, and demographic and comorbid medical conditions were tested as potential independent variables while including random effects for time and intercept.Results: Among those patients with baseline PHQ-9 scores >10, there was a significant decrease in PHQ-9 scores over time (P50% decline from baseline) on the PHQ-9 at 6 months. Conclusion: These analyses demonstrate evidence for the sustained effectiveness of the ABC Medical Home program at inducing depression remission outcomes while employing clinical staff who required less formal training than earlier clinical trials. Keywords: geriatrics, care coordination, Medicare

Dementia in all its forms is complex and can be challenging to manage. Most patients will experience a gradual decline in both cognition and function, but the rate of decline and the range of symptoms vary widely from person to person, presenting challenges to detection, diagnosis and disease management (J Multidiscip Healthc 4: 125–147, 2011).

ACADEMIC EMERGENCY MEDICINE 2011; 18:S92–S96 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Despite an increasing number of elderly emergency department (ED) patients, emergency medicine (EM) residency training lacks geriatric-specific curricula. The objective was to determine if a 1-year geriatric curriculum, designed for residents, would affect residents’ attitudes, knowledge, and decision-making for older patients seen in the ED. Methods: The authors created a geriatric curriculum for EM residents composed of six lectures on the following topics: trauma, abdominal pain, transitions of care, medication management, iatrogenic injuries, and confusional states. A second component of the curriculum included seven high-fidelity simulation skills training sessions on aortic aneurysm, salicylate toxicity, drugs of abuse, infection from a posterior pressure ulcer, medication-induced elevated prothrombin time resulting in gastrointestinal bleeding, mesenteric ischemia, and myocardial infarction. Before and after completion of the curriculum, residents were assessed on attitudes toward caring for geriatric patients using a validated survey and knowledge of geriatric principals of care using a 35-question multiple choice test. To determine differences before and after the new curriculum was implemented, the paired t-test was performed on knowledge and attitude scores. ED records were also reviewed for frequency of chemical sedation and urinary catheter placement in patients aged 65 and over, both before and after the educational intervention, as a measure of appropriate decision-making. Appropriateness of urinary catheter placement was determined by two physician reviewers using criteria adapted from the Centers for Disease Control and Prevention indications for appropriate urinary catheter use. Reviewers met to adjudicate any disagreements about appropriateness. Fisher’s exact test was used to examine differences in frequency of chemical sedation and urinary catheter placement. Results: Twenty-nine EM residents underwent the training. There was no measured change in attitudes. Knowledge improved from the pre- to posttest with average scores of 58.5 and 68.0%, respectively (p

Transitions between healthcare settings are associated with errors in communication of information and treatment plans for frail older patients, but strategies to improve transitional care are lacking. A systematic review was conducted to identify and evaluate interventions to improve communication of accurate and appropriate medication lists and advance directives for elderly patients who transition between nursing homes and hospitals. MEDLINE, ISI Web, and EBSCO Host (from inception to June 2008) were searched for original, English-language research articles reporting interventions to improve communication of medication lists and advance directives. Five studies ultimately met all inclusion criteria. Two described interventions that enhanced transmission of advance directives, two described interventions that improved communication of medication lists, and one intervention addressed both goals. One study was a randomized controlled trial, whereas the remaining studies used historical or no controls. Study results indicate that a standardized patient transfer form may assist with the communication of advance directives and medication lists and that pharmacist-led review of medication lists may help identify omitted or indicated medications on transfer. Although preliminary evidence supports adoption of these methods to improve transitions between nursing home and hospital, further research is needed to define target populations and outcomes measures for high-quality transitional care.

Objectives: The study objective was to determine the sensitivity and specificity of the Emergency Severity Index (ESI) triage instrument for the identification of elder patients receiving an immediate life-saving intervention in the emergency department (ED). Methods: The authors reviewed medical records for consecutive patients 65 years or older who presented to a single academic ED serving a large community of elders during a 1-month period. ESI triage scores were compared to actual ED course with attention to the occurrence of an immediate life-saving intervention. The sensitivity and specificity of an ESI triage level of 1 for the identification of patients receiving an immediate intervention was calculated. For 50 cases, the triage nurse ESI designation was compared to the triage level determined by an expert triage nurse based on retrospective record review. Results: Of 782 consecutive patients 65 years or older who presented to the ED, 18 (2%) had an ESI level of 1, 176 (23%) had an ESI level of 2, 461 (60%) had an ESI level of 3, 100 (13%) had an ESI level of 4, and 18 (2%) had an ESI level of 5. Twenty-six patients received an immediate life-saving intervention. ESI triage scores for these 26 individuals were as follows: ESI 1, 11 patients; ESI 2, nine patients; and ESI 3, six patients. The sensitivity of ESI to identify patients receiving an immediate intervention was 42.3% (95% confidence interval [CI] = 23.3% to 61.3%); the specificity was 99.2% (95% CI = 98.0% to 99.7%). For 17 of 50 cases in which actual triage nurse and expert nurse ESI levels disagreed, undertriage by the triage nurses was more common than overtriage (13 vs. 4 patients). Conclusions: The ESI triage instrument identified fewer than half of elder patients receiving an immediate life-saving intervention. Failure to follow established ESI guidelines in the triage of elder patients may contribute to apparent undertriage. ACADEMIC EMERGENCY MEDICINE 2010; 17:238–243 © 2010 by the Society for Academic Emergency Medicine

Although persons with dementia are frequently hospitalized, relatively little is known about the health profile, patterns of health care use, and mortality rates for patients with dementia who access care in the emergency department (ED). We linked data from our hospital system with Medicare and Medicaid claims, Minimum Data Set, and Outcome and Assessment Information Set data to evaluate 175,652 ED visits made by 10,354 individuals with dementia and 15,020 individuals without dementia over 11 years. Survival rates after ED visits and associated charges were examined. Patients with dementia visited the ED more frequently, were hospitalized more often than patients without dementia, and had an increased odds of returning to the ED within 30 days of an index ED visit compared with persons who never had a dementia diagnosis (odds ratio, 2.29; P

The purpose of this study was to identify predictors of preference for hospice care and explore whether the effect of these predictors on preference for hospice care were moderated by race. Methods: An analysis of the North Carolina AARP End of Life Survey (N = 3035) was conducted using multinomial logistic modeling to identify predictors of preference for hospice care. Response options included yes, no, or don’t know. Results: Fewer black respondents reported a preference for hospice (63.8% vs 79.2% for white respondents, P < .001). While the proportion of black and white respondents expressing a clear preference against hospice was nearly equal (4.5% and 4.0%, respectively), black individuals were nearly twice as likely to report a preference of “don’t know” (31.5% vs 16.8%). Gender, race, age, income, knowledge of Medicare coverage of hospice, presence of an advance directive, end-of-life care concerns, and religiosity/spirituality predicted hospice care preference. Religiosity/spirituality however, was moderated by race. Race interacted with religiosity/spirituality in predicting hospice care preference such that religiosity/spirituality promoted hospice care preference among White respondents, but not black respondents. Conclusions: Uncertainties about hospice among African Americans may contribute to disparities in utilization. Efforts to improve access to hospice should consider pre-existing preferences for end-of-life care and account for the complex demographic, social, and cultural factors that help shape these preferences.

The Aging Brain Care (ABC) Medical Home aims to improve the care, health outcomes, and medical costs of Medicare beneficiaries with dementia or depression across central Indiana. This population health management program, funded by the Centers for Medicare and Medicaid Services Innovation Center, expanded an existing collaborative dementia and depression care program to serve 1,650 older adults in a local safety-net hospital system. During the first year, 20 full-time clinical staff were hired, trained, and deployed to deliver a collaborative care intervention. In the first 18 months, an average of 13 visits was provided per person. Thirty percent of the sample had a diagnosis of dementia, and 77% had a diagnosis of depression. Sixty-six percent of participants with high depression scores (Patient Health Questionnaire-9 score ≥14) had at least a 50% reduction in their depressive symptoms. Fifty-one percent of caregivers of individuals with dementia had at least a 50% reduction in caregiver stress symptoms (measured by the Healthy Aging Brain Care Monitor-Caregiver Version). After 18 months, the ABC Medical Home has demonstrated progress toward improving the health of older adults with dementia and depression. Scalable and practical models like this show initial promise for answering the challenges posed by the nation's rapidly aging population.

Over the last two decades, scientists from the Indiana Center for Aging Research (IUCAR) have led or participated in two randomized clinical trials testing comprehensive care models for older adults suffering from dementia and depression. Both studies were conducted in a primary care practice within Eskenazi Health (Eskenazi) [formerly Wishard Health Services], an urban safety net hospital system primarily serving a racially and ethnically diverse population of vulnerable adults. The findings from these two trials provided the justification and the foundation for the Indiana Aging Brain Care Project.

Purpose of the study Cognitive impairment (CI) is one of several factors known to influence hospitalization, hospital length of stay, and rehospitalization among older adults. Redesigning care delivery systems sensitive to the influence of CI may reduce acute care utilization while improving care quality. To develop a foundation of fundamental needs for health care redesign, we conducted focus groups with inpatient and outpatient providers to identify barriers, facilitators, and suggestions for improvements in care delivery for patients with CI. Design and methods Focus group sessions were conducted with providers to identify their approach to caring for cognitively impaired hospitalized adults; obstacles and facilitators to providing this care; and suggestions for improving the care process. Using a thematic analysis, two reviewers analyzed these transcripts to develop codes and themes. Results Seven themes emerged from the focus group transcripts. These were: (1) reflections on serving the cognitively impaired population; (2) descriptions of perceived barriers to care; (3) strategies that improve or facilitate caring for hospitalized older adults; (4) the importance of fostering a hospital friendly to the needs of older adults; (5) the need for educating staff, patients, and caregivers; (6) the central role of good communication; and (7) steps needed to provide more effective care. Implications Providing effective acute care services to older adults with CI is an important challenge in health care reform. An understanding derived from the perspective of multiple professional disciplines is an important first step. Future research will build on this preliminary study in developing new acute care models for patients with CI.

friendly space for both the employees and the public alike. The programme offered cohorts, grouped by age and stage of dementia, an adult learning course running nine weeks including regular public gallery engagement and creative artistic endeavours. Our aims were to enhance social capital, emotional recall, relationship building and the ability to relate to one’s own identity to a greater range of dementia stages. Participants tapped into shared historical memories and cultural reference points to create strong relationships with the museum, its staff members and volunteers which was enhanced by an ongoing sustainable alumni programme. To do this, we offered staff and volunteers training to meet the communication challenges present for these audiences and with opportunities to raise confidence in a range of person-centred engagements. For our evaluation, we created a rigorous and objective methodology by incorporating valid and reliable psychological measures to investigate inputs, outputs and outcomes while being sensitive to measurement burden and the risk of ’medicalising’ our participants. Reported results included improvements in mental health and wellbeing with positive outcomes for the Museum, its staff and volunteers. 56% of the course participants reported a development in their art skills through taking part, while 78% reported feeling more positive about themselves with a complementary 72% participants reporting an increase in levels of social inclusion and/or mental wellbeing.

Over the past two decades the collaborative care model within primary care has proved to be effective in improving care quality, efficiency, and outcomes for older adults suffering from dementia and depression. In collaboration with community partners, scientists from Indiana University have implemented this model at the Healthy Aging Brain Center (HABC), a memory care clinic that is part of Eskenazi Health, an integrated safety-net health care system in Indianapolis, Indiana. The HABC generates an annual net cost savings of up to $2,856 per patient, which adds up to millions of dollars for Eskenazi Health’s patients. This article demonstrates the financial sustainability of the care processes implemented in the HABC, as well as the possibility that payers and providers could share savings from the use of the HABC model. If it were implemented nationwide, annual cost savings could be in the billions of dollars.

Objectives To evaluate the effect of cognitive impairment on rehospitalization in older adults. Design One-year longitudinal study. Setting Medical service of an urban, 340-bed public hospital in Indianapolis between July 2006 and March 2008. Participants Individuals aged 65 and older admitted to the medical service (N = 976). Measurements Rehospitalization was defined as any hospital admission after the index admission. Participant demographics, discharge destination, Charlson Comorbidity Index, Acute Physiology Score, and prior hospitalizations were measured as the confounders. Participants were considered to have cognitive impairment if they had two or more errors on the Short Portable Mental Status Questionnaire. Results After adjusting for confounders, a significant interaction between cognitive impairment and discharge location was found to predict rehospitalization rate (P = .008) and time to 1-year rehospitalization (P = .03). Participants with cognitive impairment discharged to a facility had a longer time to rehospitalization (median 142 days) than participants with no cognitive impairment (median 98 days) (hazard ratio (HR) = 0.77, 95% confidence interval (CI) = 0.58–1.02, P = .07), whereas participants with cognitive impairment discharged to home had a slightly shorter time to rehospitalization (median 182 days) than those without cognitive impairment (median 224 days) (HR = 1.15, 95% CI = 0.92–1.43, P = .23). These two nonsignificant HRs in opposite directions were significantly different from each other (P = .03). Conclusion Discharge destination modifies the association between cognitive impairment and rehospitalization. Of participants discharged to a facility, those without cognitive impairment had higher rehospitalization rates, whereas the rates were similar between cognitively impaired and intact participants discharged to the community.

Objectives Older patients discharged from the emergency department (ED) have difficulty comprehending discharge plans and are at high risk of adverse outcomes. The authors investigated whether a postdischarge telephone call–mediated intervention by a nurse would improve discharge care plan adherence, specifically by expediting post–ED visit physician follow-up appointments and/or compliance with medication changes. The second objectives were to determine if this telephone call intervention would reduce return ED visits and/or hospitalizations within 35 days of the index ED visit and to determine potential cost savings of this intervention. Methods This was a 10-week randomized, controlled trial among patients aged 65 and older discharged to home from an academic ED. At 1 to 3 days after each patient's index ED visit, a trained nurse called intervention group patients to review discharge instructions and assist with discharge plan compliance; placebo call group patients received a patient satisfaction survey call, while the control group patients were not called. Data collection calls occurred at 5 to 8 days and 30 to 35 days after the index ED visits for all three groups. Chi-square or Fisher's exact tests were performed for categorical data and the Kruskal-Wallis test examined group differences in time to follow-up. Results A total of 120 patients completed the study. Patients were 60% female and 72% white, with a mean age of 75 years (standard deviation [SD] ± 7.58 years). Intervention patients were more likely to follow up with medical providers within 5 days of their ED visits than either the placebo or the control group patients (54, 20, and 37%, respectively; p = 0.04). All groups performed well in medication acquisition and comprehension of medication indications and dosage. There were no differences in return visits to the ED or hospital within 35 days of the index ED visit for intervention patients, compared to placebo or control group patients (22, 33, and 27%, respectively; p = 0.41). An economic analysis showed an estimated 70% chance that this intervention would reduce total costs. Conclusions Telephone call follow-up of older patients discharged from the ED resulted in expedited follow-up for patients with their primary care physicians. Further study is warranted to determine if these results translate into improved patient outcomes, decreased return ED visits or hospital admissions, and cost savings resulting from this intervention.

Objectives An estimated 14% to 25% of all scientific studies in peer-reviewed emergency medicine (EM) journals are medical records reviews. The majority of the chart reviews in these studies are performed manually, a process that is both time-consuming and error-prone. Computer-based text search engines have the potential to enhance chart reviews of electronic emergency department (ED) medical records. The authors compared the efficiency and accuracy of a computer-facilitated medical record review of ED clinical records of geriatric patients with a traditional manual review of the same data and describe the process by which this computer-facilitated review was completed. Methods Clinical data from consecutive ED patients age 65 years or older were collected retrospectively by manual and computer-facilitated medical record review. The frequency of three significant ED interventions in older adults was determined using each method. Performance characteristics of each search method, including sensitivity and positive predictive value, were determined, and the overall sensitivities of the two search methods were compared using McNemar's test. Results For 665 patient visits, there were 49 (7.4%) Foley catheters placed, 36 (5.4%) sedative medications administered, and 15 (2.3%) patients who received positive pressure ventilation. The computer-facilitated review identified more of the targeted procedures (99 of 100, 99%), compared to manual review (74 of 100 procedures, 74%; p

Older adults with dementia experience progressive functional decline, which contributes to caregiver burden and nursing home placement. The goal of this systematic review was to determine if any non-pharmacologic interventions have delayed functional decline among community-dwelling dementia patients.We completed a systematic literature review to identify controlled clinical trials reporting the impact of non-pharmacologic interventions on any measure of functional impairment or disability among community-dwelling dementia patients. We included studies that reported any proxy-respondent, self-reported, or performance-based standardized assessments.We identified 18 published clinical trials that met inclusion criteria and found that study interventions fell into three different groups: occupational therapy, exercise, and multi-faceted ("other") interventions. The three groups of studies tended to vary systematically regarding the conceptual framework for the disabling process, target of intervention, and type of outcome measure. Approximately half the studies were conducted in the United States with mean sample size of 99 (from 27 to 1131) and follow-up periods between three months and two years. Instruments used to measure functional impairment or disability varied widely with 55 instruments across 18 studies. Nine studies reported a statistically significant improvement in functional decline in the intervention group.The current literature provides clinical trial evidence that non-pharmacologic interventions can delay progression of functional impairment or disability among community-dwelling dementia patients. The clinical significance of this early evidence is uncertain. These early studies provide rationale for larger and longer-term studies to determine if these interventions are sufficiently potent to delay institutionalization.

Introduction: Health care systems in the United States are transitioning from volume-based purchasing models to value-based purchasing models that demand both delivery of personalized care for each patient and cost-effective population health management. The enhanced medical record for aging brain care (eMR-ABC) software is an electronic decision support system that facilitates the management of a high-risk population suffering from aging brain disorders such as dementia.Methods: Using the lenses of the Complex Adaptive System and the Reflective Adaptive Process, we assembled an interdisciplinary team of clinicians, health services researchers, and software developers who designed, implemented, evaluated, and continuously modified the eMR-ABC to meet the needs of care coordinators who manage the health of a targeted high-risk population.Results: The eMR-ABC captures and monitors the cognitive, functional, behavioral, and psychological symptoms of a registry of patients suffering from dementia or depression as well as the burden of patients’ family caregivers. It provides decision support to care coordinators to create a personalized care plan that includes evidence-based nonpharmacological protocols, self-management handouts, and alerts of medications with potentially adverse cognitive effects. The software’s built-in engine tracks patient visits and on-demand functionality to generate population reports for specified indicators.Discussion: Population health programs depend on data collection and information systems with the ability to provide valuable and timely feedback on an ongoing basis. Following these guidelines, the eMR-ABC was designed specifically to meet the management needs of a high-risk population./

Introduction: Triage of patients is critical to patient safety, yet no clear information exists as to the utility of initial vital signs in identifying critically ill older emergency department (ED) patients. The objective of this study is to evaluate a set of initial vital sign thresholds as predictors of severe illness and injury among older adults presenting to the ED. Methods: We reviewed all visits by patients aged 75 and older seen during 2007 at an academic ED serving a large community of older adults. Patients’ charts were abstracted for demographic and clinical information including vital signs, via automated electronic methods. We used bivariate analysis to investigate the relationship between vital sign abnormalities and severe illness or injury, defined as intensive care unit (ICU) admission or ED death. In addition, we calculated likelihood ratios for normal and abnormal vital signs in predicting severe illness or injury. Results: 4,873 visits by patients aged 75 and above were made to the ED during 2007, and of these 3,848 had a complete set of triage vital signs. For these elderly patients, the sensitivity and specificity of an abnormal vital sign taken at triage for predicting death or admission to an ICU were 73% (66,81) and 50% (48,52) respectively (positive likelihood ratio 1.47 (1.30,1.60); negative likelihood ratio 0.54 (0.30,0.60). Conclusion: Emergency provider assessment and triage scores that rely primarily on initial vital signs are likely to miss a substantial portion of critically ill older adults. [West J Emerg Med. 2013;14(5):453–460.]

We constructed a bidirectional Web-based system to transmit critical patient information in real time between referring nursing homes and a university hospital emergency department (ED) to facilitate the care of patients referred to our ED. Our model was inexpensive, improved measures of information transfer, and increased provider satisfaction.

Lack of access to medical information for nursing home residents during emergency department (ED) evaluation is a barrier to quality care. We hypothesized that the quantity of information available in the ED differs based on the funding source of the resident's nursing home.Cross-sectional observational study.Single academic ED.Participants were 128 skilled nursing facility (SNF) residents age 65 or older from 12 SNFs.Emergency physicians documented knowledge of 9 essential information items. SNFs were categorized as accepting or not accepting Medicaid.Questionnaires were completed for 128 patients, of whom 95 (74%) were from 1 of 8 Medicaid-funded SNFs and 33 (26%) were from 1 of 4 SNFs not accepting Medicaid. Patients from SNFs accepting Medicaid were younger (79 versus 87, P.001) and less frequently white (62% versus 97%, P.001). The mean number of 9 possible information items available was lower for patients from SNFs that accept Medicaid (7.13 versus 8.15, P.001). Emergency providers also reported lower satisfaction regarding access to information for residents from SNFs that accept Medicaid (P.05). The association between residence in an SNF that accepts Medicaid and lower ED information scores remained after linear regression with clustering by SNF controlling for age, gender, and race. The most common source of information for residents from both types of SNFs was transfer papers from the SNF.Less information is available to ED providers for patients from SNFs that accept Medicaid than for residents from SNFs that do not accept Medicaid. Further study is needed to examine this information gap.

Objectives: Methods to accurately identify elderly patients with a high likelihood of hospital admission or subsequent return to the emergency department (ED) might facilitate the development of interventions to expedite the admission process, improve patient care, and reduce overcrowding. This study sought to identify variables found among elderly ED patients that could predict either hospital admission or return to the ED. Methods: All visits by patients 75 years of age or older during 2007 at an academic ED serving a large community of elderly were reviewed. Clinical and demographic data were used to construct regression models to predict admission or ED return. These models were then validated in a second group of patients 75 and older who presented during two 1-month periods in 2008. Results: Of 4,873 visits, 3,188 resulted in admission (65.4%). Regression modeling identified five variables statistically related to the probability of admission: age, triage score, heart rate, diastolic blood pressure, and chief complaint. Upon validation, the c-statistic of the receiver operating characteristic (ROC) curve was 0.73, moderately predictive of admission. We were unable to produce models that predicted ED return for these elderly patients. Conclusions: A derived and validated triage-based model is presented that provides a moderately accurate probability of hospital admission of elderly patients. If validated experimentally, this model might expedite the admission process for elderly ED patients. Our models failed, as have others, to accurately predict ED return among elderly patients, underscoring the challenge of identifying those individuals at risk for early ED returns. ACADEMIC EMERGENCY MEDICINE 2010; 17:252–259 © 2010 by the Society for Academic Emergency Medicine