We created a comprehensive, four-part, in-person, interactive community education series to teach informal, unpaid care partners of persons living with dementia (PLWD) how to support their PLWD, negotiate common day-to-day challenges, and navigate predictable situations that arise as the disease progresses over time. The purpose of this qualitative study was to explore the series impact on participant knowledge, care practices, and perceptions of caregiving. Inspired by the U.S. Medicare Cognitive Assessment and Care Plan Service visit and the 4Ms of the Age-Friendly Health Systems Framework, our curriculum focused on (1) expanding knowledge about the disease and disease progression, (2) developing skills to better connect and work with PLWD, (3) self-care for care partners, and (4) sharing resources to support future planning. The program was delivered in three communities in Central Pennsylvania (one rural, one small, and one medium metropolitan) and was attended by 146 individuals. Both session and final qualitative evaluation data were assessed using thematic analysis and five major categories emerged: lessons learned, activating new knowledge, impact and changes, assuming responsibility is challenging, and I need more help. Ongoing education, emotional support, and access to quality assistance for long-term planning are all needed and require sustained support.

The prevalence of type 1 diabetes mellitus (DMT1) in long-term care (LTC) settings is low compared to type 2 diabetes (∼18-30% of all LTC residents). Though people with DMT1 live longer now, many staff are not aware DMT1 requires a different approach than DMT2. Little guidance exists on how to best to manage DMT1 and navigate the challenges imposed by the LTC environment.

Abstract A mixed methods overall series evaluation was administered at session four in each location to assess preparedness, perceived increase in caregiver self-efficacy and wellness, development and implementation of skills, and overall program value. Fifty-five participants (73% response rate) completed the evaluation; 44 (80%) were care partners of a person living with dementia (PLWD). Twenty-four (44%) participants attended all four sessions, 9 (16%) attended three, 8 (15%) attended two, and 11 (20%) attended one. Those who attended all four sessions were more likely to strongly endorse that they felt better prepared (96% vs. 75%; X2 = 3.7, p = 0.05). On a 5-point scale (1 = Strongly disagree, 2 = Disagree, 3 = Neither agree/disagree, 4 = Agree, 5= Strongly agree), 38 (85%) reported agree or strongly agree to improved preparedness to meet the needs of their PLWD, and 41 (93%) reported improved confidence as a care-partner. The top 5 communication skills learned: Using fewer words (89%); Slowing down speech (89%); Focusing on the relationship (86%); Ending an encounter with thank you (86%); and Going with the flow (84%). Content analysis of qualitative data suggest care-partners’ new understanding and improved communication skills were having a positive influence on the pace and quality of daily life and reported less conflict and improved mood; challenges persisted with activities of daily living, such as showering and toileting. Programs like LWD that provide care partners education, skill development and support for self-care can improve daily life for care-dyads living with dementia.

Inspired by the Medicare Cognitive Assessment and Care Plan Services visit, we describe an Age-Friendly 4Ms curriculum developed to empower informal dementia-care-partners to understand dementia, develop skills to communicate and work with people living with dementia (PLWD), and plan for the future with dementia. Curriculum was developed by an interdisciplinary team and included the integration of evidence-based approaches to care, such as the Positive Approach® to Care model. Through 4 interactive workshops (Understanding Dementia-related Brain Changes, Understanding Behaviors as a Form of Communication, Resources for Dementia Caregivers, Planning for the Future with Dementia) we introduced and had care partners process and practice material to help them navigate everyday challenges faced by PLWD with the aim of assisting them to find opportunities to help improve quality of life with the disease for both themselves and their PLWD. We reached a total of 146 attendees in 3 rural and suburban communities in Central Pennsylvania. Fifty-nine (40.4%) people attended 1 session, 39 (26.7%) people attended 2 sessions, 22 (15.1%) people attended 3 sessions, and 26 (17.8%) people attended all 4 sessions. Across all four sessions, more than 80% of attendees reported knowledge and skill gains, and most attendees reported meeting session objectives. Final evaluation results suggest attendees wanted a way to stay informed, stay connected, and remain supported by the program.

Interprofessional, collaborative health care is the ideal standard in geriatrics. Students’ interprofessional practice skills are limited in typical siloed education. An experiential, team-based geriatrics course was designed to improve health professions (HP) students’ knowledge, skills, and attitudes about interprofessional practice. Students (n=209) from dentistry, medicine, nursing, nutrition, occupational therapy, pharmacy, physician assistant, social work, and speech-language pathology were assigned to interprofessional (IP) and medical-student only teams. The Interprofessional Collaborative Competency Attainment Survey-Revised (ICCAS-R) was administered pre- and post-course, along with program evaluations. Seventy percent of students completed both pre- and post-surveys. ICCAS-R scores were analyzed comparing the impact of training for medical students (n=78) on IP teams and remaining HP students (n=58). Students rated themselves as improved on all six ICCAS-R subscales (paired t-tests, p < 0.05). Sixty-nine percent rated themselves as better able to collaborate interprofessionally. A competitive team-based learning exercise using gamification was rated as the most authentic skill-building interprofessional activity. Experiential learning where students worked with the same team helped to build interprofessional and teamwork skills. Findings will be used to improve authenticity of the clinical and teamwork content, increase the use of gamification as a teaching technique, and refine students’ practice of IP teamwork competencies.

Objective. Pain management in persons with mild to moderate dementia poses unique challenges because of altered pain modulation and the tendency of some individuals to perseverate. We aimed to test the impact of an e-learning module about pain in communicative people with dementia on third-year medical students who had or had not completed an experiential geriatrics course. Design. Analysis of pre- to postlearning changes and comparison of the same across the student group. Setting. University of Pittsburgh School of Medicine and Saint Louis University School of Medicine. Subjects. One hundred four University of Pittsburgh and 57 Saint Louis University medical students. Methods. University of Pittsburgh students were randomized to view either the pain and dementia module or a control module on pain during a five-day geriatrics course. Saint Louis University students were asked to complete either of the two modules without the context of a geriatrics course. A 10-item multiple choice knowledge test and three-item attitudes and confidence questionnaires were administered before viewing the module and up to seven days later. Results. Knowledge increase was significantly greater among students who viewed the dementia module while participating in the geriatrics course than among students who viewed the module without engaging in the course (P < 0.001). The modules did not improve attitudes in any group, while student confidence improved in all groups. Conclusions. Medical students exposed to e-learning or experiential learning demonstrated improved confidence in evaluating and managing pain in patients with dementia. Those exposed to both educational methods also significantly improved their knowledge.

BACKGROUND Nursing homes (NHs) provide care to a complex patient population and face the ongoing challenge of meeting resident needs for specialty care. A NH telemedicine care model could improve access to remote specialty providers. INTRODUCTION Little is known about provider interest in telemedicine for specialty consults in the NH setting. The goal of this study was to survey a national sample of NH physicians and advanced practice providers to document their views on telemedicine for providing specialty consults in the NH. MATERIALS AND METHODS We surveyed physician and advanced practice providers who attended the 2016 AMDA-The Society for Post-Acute and Long-Term Care Medicine Annual Conference about their likelihood of referral to and perceptions of a telemedicine program for providing specialty consults in the NH. RESULTS We received surveys from 524 of the 1,274 conference attendees for a 41.1% response rate. Respondents expressed confidence in the ability of telemedicine to fill existing service gaps and provide appropriate, timelier care. Providers showed the highest level of interest in telemedicine for dermatology, geriatric psychiatry, and infectious disease. Only 13% of respondents indicated that telemedicine was available for use in one of their facilities. DISCUSSION There appears to be unmet demand for telemedicine in NHs for providing specialty consults to residents. CONCLUSIONS The responses of NH providers suggest support for the concept of telemedicine as a modality of care that can be used to offer specialty consults to NH residents.

Journal of Palliative MedicineVol. 21, No. 8 Fast Facts and ConceptsPain Management Considerations in Older Adults #356Jennifer Pruskowski, Rollin Wright, and Mamta BhatnagarJennifer PruskowskiAddress correspondence to:Jennifer Pruskowski, PharmDPalliative and Supportive InstituteUniversity of Pittsburgh Medical Center3600 Forbes Avenue at Meyran Avenue, Suite 308.15Pittsburgh, PA 15213E-mail Address: pruskowskija@upmc.eduSearch for more papers by this author, Rollin WrightSearch for more papers by this author, and Mamta BhatnagarSearch for more papers by this authorPublished Online:1 Aug 2018https://doi.org/10.1089/jpm.2018.0265AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Pain Management Considerations in Older Adults #356." Journal of Palliative Medicine, 21(8), pp. 1185–1186FiguresReferencesRelatedDetails Volume 21Issue 8Aug 2018 InformationCopyright 2018, Mary Ann Liebert, Inc.To cite this article:Jennifer Pruskowski, Rollin Wright, and Mamta Bhatnagar.Pain Management Considerations in Older Adults #356.Journal of Palliative Medicine.Aug 2018.1185-1186.http://doi.org/10.1089/jpm.2018.0265Published in Volume: 21 Issue 8: August 1, 2018PDF download

Health care providers receive little training about how to work with demented patients who have lost language and processing skills. We quantified the impact of a dementia communication skills curriculum on health professions students' attitudes and confidence about communicating with people living with dementia.

Health care providers receive little training about how to work with demented patients who have lost language and processing skills. We describe a curriculum to teach internal medicine residents how to work with families and patients living with dementia.

OBJECTIVE : To present the 11th in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of 12 important contributions to pain and disability in older adults with CLBP. This article focuses on dementia. METHODS A modified Delphi technique was used to develop an algorithm for an approach to treatment for older adults living with CLBP and dementia. A panel of content experts on pain and cognition in older adults developed the algorithm through an iterative process. Though developed using resources available within Veterans Health Administration (VHA) facilities, the algorithm is applicable across all health care settings. A case taken from the clinical practice of one of the contributors demonstrates application of the algorithm. RESULTS We present an evidence-based algorithm and biopsychosocial rationale to guide providers evaluating CLBP in older adults who may have dementia. The algorithm considers both subtle and overt signs of dementia, dementia screening tools to use in practice, referrals to appropriate providers for a complete a workup for dementia, and clinical considerations for persons with dementia who report pain and/or exhibit pain behaviors. A case of an older adult with CLBP and dementia is presented that highlights how an approach that considers the impact of dementia on verbal and nonverbal pain behaviors may lead to more appropriate and successful pain management. CONCLUSIONS Comprehensive pain evaluation for older adults in general and for those with CLBP in particular requires both a medical and a biopsychosocial approach that includes assessment of cognitive function. A positive screen for dementia may help explain why reported pain severity does not improve with usual or standard-of-care pain management interventions. Pain reporting in a person with dementia does not always necessitate pain treatment. Pain reporting in a person with dementia who also displays signs of pain-associated suffering requires concerted pain management efforts targeted to improving function while avoiding harm in these vulnerable patients.Key Words. Dementia; Chronic Pain; Low Back Pain; Lumbar; Primary Care.

Background: Appropriate medication prescribing for nursing home residents remains a challenge.Objective: The purpose of this study was to conduct a narrative review of the published literature describing randomized controlled trials that used interventions to improve suboptimal prescribing in nursing homes.Methods: The PubMed, International Pharmaceutical Abstracts, and EMBASE databases were searched for articles published in the English language between January 1975 and December 2009, using the terms drug utilization, pharmaceutical services, aged, long-term care, nursing homes, prescribing, geriatrics, and randomized controlled trial. A manual search of the reference lists of identified articles and the authors' files, book chapters, and recent review articles was also conducted. Abstracts and posters from meetings were not included in the search. Studies were included if they: (1) had a randomized controlled design; (2) had a process measure outcome for quality of prescribing or a distal outcome measure for medication-related adverse patient events; and (3) involved nursing home residents.Results: Eighteen studies met the inclusion criteria for this review. Seven of those studies described educational approaches using various interventions (eg, outreach visits) and measured suboptimal prescribing in different manners (eg, adherence to guidelines). Two studies described computerized decision-support systems to measure the intervention's impact on adverse drug events (ADEs) and appropriate drug orders. Five studies described clinical pharmacist activities, most commonly involving a medication review, and used various measures of suboptimal prescribing, including a measure of medication appropriateness and the total number of medications prescribed. Two studies each described multidisciplinary and multifaceted approaches that included heterogeneous interventions and measures of prescribing. Most (15/18; 83.3%) of these studies reported statistically significant improvements in >= 1 aspect of suboptimal prescribing. Only 3 of the studies reported significant improvements in distal health outcomes, and only 3 measured ADEs or adverse drug reactions.Conclusions: Mixed results were reported for a variety of approaches used to improve suboptimal prescribing. However, the heterogeneity of the study interventions and the various measures of suboptimal prescribing used in these studies does not allow for an authoritative conclusion based on the currently available literature. (Am J Geriatr Pharmacother. 2010;8:183-200) (C) 2010 Excerpta Medica Inc.

BACKGROUND Few studies have examined the risk of multiple or high doses of combined central nervous system (CNS) medication use for recurrent falls in the elderly. The study objective was to evaluate whether multiple- or high-dose CNS medication use in older adults was associated with a higher risk of recurrent (>or=2) falls. METHODS This longitudinal cohort study included 3,055 participants from the Health, Aging and Body Composition study who were well functioning at baseline. CNS medication use (benzodiazepine and opioid receptor agonists, antipsychotics, antidepressants) was determined annually (except Year 4) during in-person interviews. The number and summated standard daily doses (SDDs; low, medium, and high) of CNS medications were computed. Falls 1 year later were ascertained annually for 5 years. RESULTS For a period of 5 years, as many as 24.1% of CNS medication users took 2+ agents annually, whereas as no more than 18.9% of CNS medication users took high doses annually (3+ SDDs). Yearly, as many as 9.7% of participants reported recurrent falls. Multivariable Generalized Estimating Equation analyses showed that multiple CNS medication users compared with never users had an increased risk of sustaining 2+ falls (adjusted odds ratio [OR] 1.95; 95% confidence interval [CI] 1.35-2.81). Those taking high (3+) CNS SDDs also exhibited an increased risk of 2+ falls (adjusted OR 2.89; 95% CI 1.96-4.25). CONCLUSIONS Higher total daily doses of CNS medications were associated with recurrent falls. Further studies are needed to determine the impact of reducing the number of CNS medications and/or dosage on recurrent falls.

OBJECTIVES: To evaluate whether combined use of multiple central nervous system (CNS) medications over time is associated with cognitive change.DESIGN: Longitudinal cohort study.SETTING: Pittsburgh, Pennsylvania, and Memphis, Tennessee.PARTICIPANTS: Two thousand seven hundred thirty‐seven healthy adults (aged ≥65) enrolled in the Health, Aging and Body Composition study without baseline cognitive impairment (modified Mini‐Mental State Examination (3MS) score ≥80).MEASUREMENTS: CNS medication (benzodiazepine‐ and opioid‐receptor agonists, antipsychotics, antidepressants) use, duration, and dose were determined at baseline (Year 1) and Years 3 and 5. Cognitive function was measured using the 3MS at baseline and Years 3 and 5. The outcome variables were incident cognitive impairment (3MS score <80) and cognitive decline (≥5‐point decline on 3MS). Multivariable interval‐censored survival analyses were conducted.RESULTS: By Year 5, 7.7% of subjects had incident cognitive impairment; 25.2% demonstrated cognitive decline. CNS medication use increased from 13.9% at baseline to 15.3% and 17.1% at Years 3 and 5, respectively. It was not associated with incident cognitive impairment (adjusted hazard ratio (adj HR)=1.11, 95% confidence interval (CI)=0.73–1.69) but was associated with cognitive decline (adj HR 1.37, 95% CI=1.11–1.70). Longer duration (adj HR=1.39, CI=1.08–1.79) and higher doses (>3 standardized daily doses) (adj HR=1.87, 95% CI=1.25–2.79) of CNS medications suggested greater risk of cognitive decline than with nonuse.CONCLUSION: Combined use of CNS medications, especially at higher doses, appears to be associated with cognitive decline in older adults. Future studies must explore the effect of combined CNS medication use on vulnerable older adults.

Purpose To evaluate whether CNS medication use in older adults was associated with a higher risk of future incident mobility limitation.Methods This 5-year longitudinal cohort study included 3055 participants from the health, aging and body composition (Health ABC) study who were well-functioning at baseline. CNS medication use (benzodiazepine and opioid receptor agonists, antipsychotics, and antidepressants) was determined yearly (except year 4) during in-home or in-clinic interviews. Summated standardized daily doses (low, medium, and high) and duration of CNS drug use were computed. Incident mobility limitation was operationalized as two consecutive self-reports of having any difficulty walking 1/4 mile or climbing 10 steps without resting every 6 months after baseline. Multivariable Cox proportional hazard analyses were conducted adjusting for demographics, health behaviors, health status, and common indications for CNS medications.Results Each year at least 13.9% of participants used a CNS medication. By year 6, overall 49% had developed incident mobility limitation. In multivariable models, CNS medication users compared to never users showed a higher risk for incident mobility limitation (adjusted hazard ratio (Adj. HR) 1.28; 95% confidence interval (CI) 1.12-1.47). Similar findings of increased risk were seen in analyses examining dose- and duration-response relationships.Conclusions CNS medication use is independently associated with an increased risk of future incident mobility limitation in community dwelling elderly. Further studies are needed to determine the impact of reducing CNS medication exposure on mobility problems. Copyright (C) 2009 John Wiley & Sons, Ltd.

BACKGROUND:Medication underutilization, or the omission of a potentially beneficial medication indicated for disease management, is common among older adults but poorly understood. OBJECTIVES:The aims of this work were to assess the prevalence of medication underuse and to determine whether polypharmacy or comorbidity was associated with medication underuse among physically frail older veterans transitioning from the hospital to the community. METHODS:This was a cross-sectional analysis of patients who were discharged from 11 US veterans' hospitals to outpatient care, based on data from the Geriatric Evaluation and Management Drug Study, a substudy of the Veterans Affairs Cooperative Study of geriatric evaluation and management. Patients were enrolled between August 31, 1995, and January 31, 1999. To qualify for the study, patients had to be aged > or =65 years, hospitalized in a medical or surgical ward for >48 hours, and meet > or =2 of the following criteria: moderate functional disability; recent cerebrovascular accident with residual neurological deficit; history of > or =1 fall in the previous 3 months; documented difficulty with walking (ie, requiring personal assistance or equipment), not including preadmission use of a wheelchair with ability to transfer to and from chair independently; malnutrition (admission serum albumin of 3.5 g/dL, <80% of ideal body weight, or recent > or =15-lb weight loss reported in admission history); dementia; depression; documented diagnosis of new fracture or revision needed of older fracture; unplanned admission within 3 months of previous admission; and prolonged bed rest. Clinical pharmacist/physician pairs reviewed medical records and medication lists and independently applied the Assessment of Underutilization (AOU) index to determine omissions of indicated medications. Discordances in index ratings were resolved during clinical consensus conferences. The primary outcome measure was the percentage of patients with > or =1 medication omission detected by the AOU. Multivariable logistic regression analyses identified factors associated with underuse. RESULTS:A total of 384 patients were included in the study. The majority (53.6%) were between the ages of 65 and 74 years, and the mean (SD) Charlson comorbidity index was 2.44 (1.93). Overall, 374 patients (97.4%) were men and 274 (71.4%) were white. Medication undertreatment occurred in 238 participants (62.0%). Diseases of the Accepted for publication October 26, 2009. circulatory, endocrine/nutritional, musculoskeletal, and respiratory systems were the most commonly undertreated conditions. The indicated medications most likely to be omitted were nitrates for those with a history of myocardial infarction, multivitamins in those with malnutrition, and inhaled anticholinergics for chronic obstructive airways disease. Statistically significant factors associated with medication underuse included limitations in activities of daily living (adjusted odds ratio [AOR], 2.17 [95% CI, 1.27-3.71]; P = 0.01), being white (AOR, 1.70 [95% CI, 1.06-2.71]; P = 0.03), and Charlson comorbidity index (AOR, 1.13 for each 1-point increase [95% CI, 1.00-1.27]; P = 0.04). Discharge from a general medicine service as opposed to a surgical service was associated with lower risk of medication underuse (AOR, 0.61 [95% CI, 0.38-0.98]; P = 0.04). CONCLUSIONS:Medication underuse was relatively common in this study. Patients with greater comorbidity, but not polypharmacy, had increased odds of undertreatment.

Introduction: Epidemiologic studies demonstrated that 70% to 85% of nursing home residents have osteoporosis. Few studies report comprehensive information about treatment of osteoporosis in nursing facilities.Objective: To determine the prevalence of osteoporosis treatment and identify resident characteristics associated with the use of antiresorptive medications or supplements indicated to treat osteoporosis in nursing homes.Methods: The study design was cross-sectional. The Systematic Assessment of Geriatric Drug Use via Epidemiology database provided the data. From this database, 186,221 residents were identified as newly admitted to nursing facilities in Kansas, Maine, Missouri, Ohio, and South Dakota between 1998 and 2000. The outcome measure was the use of antiresorptive medications (alendronate, risedronate, calcitonin, estrogen, raloxifene) or supplements (calcium with vitamin D) indicated for treatment of osteoporosis. The independent variables included demographic, health status, and fracture risk factors.Results: Of the overall sample, 9.1% received antiresorptive medications and/or supplements indicated for osteoporosis treatment. The most commonly used treatment was the combination of calcium and vitamin D (5.0%). Calcitonin (2.5%) use exceeded that of any other antiresorptive. Multivariable logistic regression analyses revealed that a diagnosis of osteoporosis and female gender were strongly associated with being more likely to receive an osteoporosis treatment (OR 6.34 with 95% CI 6.11-6.64 and OR 2.67 with 95% CI 2.53-2.83 respectively). The number of medications residents received was also strongly associated with receiving osteoporosis treatment. Being black and having 4 or more active diagnoses were strongly associated with lower odds of receiving treatment (OR 0.63 with 95% CI 0.57-0.68 and OR 0.71 with 95% CI 0.68-0.74 for 4 to 6 diagnoses).Discussion: Newly admitted nursing facility residents infrequently received an indicated osteoporosis treatment, including calcium with vitamin D, despite the expected high prevalence of osteoporosis in this setting. Few demographic, health status, and fracture risk factors were strongly associated with receiving indicated treatment.