Older adults have a significantly greater risk of venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, than younger adults. The cause of this greater risk is thought ...to be multifactorial, including age‐related changes in hemostatic factors and greater comorbid conditions and hospitalizations, but is not completely understood. Moreover, VTE remains underrecognized in older adults and may present atypically. Thus, a low index of clinical suspicion is essential when evaluating older adults with possible VTE. Despite this underrecognition in older adults, the diagnostic approach remains similar for all age groups and includes estimation of pretest probability, measurement of the D‐dimer, and imaging. Antithrombotic agents are the mainstay of VTE treatment and, when used appropriately, substantially reduce VTE recurrence and complications. The approval of novel oral anticoagulants (NOACs), including dabigatran, rivaroxaban, apixaban, and edoxaban, provide clinicians with new therapeutic options. In some individuals, NOACs may offer advantages over warfarin, including fewer drug interactions, more‐predictable anticoagulation, and lower risk of bleeding. Nevertheless, anticoagulation of VTE in older adults should always be performed cautiously, because age is a risk factor for bleeding complications. Identifying modifiable bleeding risk factors and balancing the risks of VTE recurrence with hemorrhage are important considerations when using anticoagulants in older adults.
The Veterans Health Administration (VHA) has long recognized the need for age-friendly care. VHA leadership anticipated the impact of aging World War II veterans on VA healthcare systems and in 1975 ...developed Geriatric Research, Education, and Clinical Centers (GRECCs) to meet this need. GRECCs catalyzed a series of innovations in geriatric models of care that span the continuum of care, most of which endure. These innovative care models also contributed to the evidence base supporting the present-day Age-Friendly Health Systems movement, with which VHA is inherently aligned. As both a provider of and payor for care, VHA is strongly incentivized to promote coordination across the continuum of care, with resultant cost savings. VHA is also a major contributor to developing the workforce that is essential for the provision of age-friendly care. As VHA continues to develop and refine innovative geriatric models of care, policymakers and non-VHA health care systems should look to VHA programs as exemplars for the development and implementation of age-friendly care.
Aquifer Geriatrics, formerly web‐based Geriatrics Education Modules, was initially developed through Donald W. Reynolds Foundation funding, and is now the national curriculum of the American ...Geriatrics Society and the Association of Directors of Geriatric Academic Programs. Aquifer Geriatrics consists of 26 evidence‐based, peer‐reviewed, online case‐based modules based on the Association of American Medical Colleges/John A. Hartford Foundation Minimum Geriatrics Competencies for Medical Students and is available by subscription at www.aquifer.org/courses.
This curriculum aims to help address the national shortage of geriatrics educators, complement current teaching, bridge content gaps in geriatrics education, and standardize geriatrics‐focused educational content. This report will describe the development of Aquifer Geriatrics, highlight best practices to incorporate cases in a variety of teaching settings, describe teaching methods that utilize the curriculum to create a robust experience for learners, and address the cost of obtaining the curriculum. J Am Geriatr Soc 67:811–817, 2019.
See related editorial by van Zeuilen et al. in this issue.
BACKGROUND
Non-verbal communication is an important aspect of the diagnostic and therapeutic process, especially with older patients. It is unknown how non-verbal communication varies with physician ...and patient race.
OBJECTIVE
To examine the joint influence of physician race and patient race on non-verbal communication displayed by primary care physicians during medical interviews with patients 65 years or older.
DESIGN, SETTING, AND PARTICIPANTS
Video-recordings of visits of 209 patients 65 years old or older to 30 primary care physicians at three clinics located in the Midwest and Southwest.
MAIN MEASURES
Duration of physicians’ open body position, eye contact, smile, and non-task touch, coded using an adaption of the Nonverbal Communication in Doctor–Elderly Patient Transactions form.
KEY RESULTS
African American physicians with African American patients used more open body position, smile, and touch, compared to the average across other dyads (adjusted mean difference for open body position = 16.55, p < 0.001; smile = 2.35, p = 0.048; touch = 1.33, p < 0.001). African American physicians with white patients spent less time in open body position compared to the average across other dyads, but they also used more smile and eye gaze (adjusted mean difference for open body position = 27.25, p < 0.001; smile = 3.16, p = 0.005; eye gaze = 17.05, p < 0.001). There were no differences between white physicians’ behavior toward African American vs. white patients.
CONCLUSION
Race plays a role in physicians’ non-verbal communication with older patients. Its influence is best understood when physician race and patient race are considered jointly.
Previous evidence suggests that treatment with 3-hydroxy-3-methylglutaryl-coenzyme-A reductase inhibitors (statins) has a positive impact on dementia. We decided to investigate the association ...between the use of statins and the prevalence of dementia and statins' impact on the progression of cognitive impairment.
This is a case-control and a retrospective cohort study of a community-based ambulatory primary care geriatric practice. We included a convenience sample of all patients (N = 655, mean age 78.7 +/- 0.3 years, 85% Caucasian, 74% women) with hypercholesterolemia or dementia, or using statins. We compared those using statins with those who do not with respect to the clinical diagnosis of dementia and its subtypes and the progression of cognitive impairment.
At the initial visit, 35% had dementia, and 17% were using statins. After covariate adjustments, patients on statins were less likely to have dementia (odds ratio OR for dementia based on composite definition = 0.23; 95% confidence interval CI 0.1-0.56, p =.001, OR Alzheimer's disease = 0.37; 95% CI 0.19-0.74, p =.005, OR vascular dementia = 0.25; 95% CI 0.08-0.85, p =.027). At follow-up, patients on statins showed an improvement on their Mini-Mental Status Examination score by 0.7 +/- 0.4 compared to a decline by 0.5 +/- 0.3 in controls, p =.025 (OR for no change or improvement on statins = 2.81; 95% CI 1.02-8.43, p =.045) and scored higher on the Clock Drawing Test (difference of 1.5 +/- 0.1, p =.036).
The use of statins is associated with a lower prevalence of dementia and has a positive impact on the progression of cognitive impairment.
OBJECTIVES: The Program of All‐inclusive Care for the Elderly (PACE) is a long‐term care delivery and financing innovation. A major goal of PACE is prevention of unnecessary use of hospital and ...nursing home care.
SETTING: PACE serves enrollees in day centers and clinics, their homes, hospitals and nursing homes. Beginning at On Lok in San Francisco, the PACE model has been successfully replicated across the country. In 1995, PACE was fully operational in 11 cities in nine states.
PARTICIPANTS: To enroll in PACE, a person must be 55 years of age or older, be certified by the state as eligible for care in a nursing home and live in the program's defined geographical catchment area. PACE participants are ethnically diverse. In 1995, the average PACE enrollee was 80.0 years old and had an average of 7.8 medical conditions and 2.7 dependencies in Activities of Daily Living. A significant number have bladder incontinence (55%). Many enrollees (39%) live alone in the community, and 14% have no means of informal support.
INTERVENTION: Medicare and Medicaid waivers allow delivery of services beyond the usual Medicare and Medicaid benefits. The PACE service delivery system is comprehensive, uses an interdisciplinary team for care management, and integrates primary and specialty medical care. PACE receives monthly capitation payments from Medicare and Medicaid. Patients ineligible for Medicaid pay privately.
RESULTS: Outcomes of PACE programs have been positive. There has been steady census growth, good consumer satisfaction, reduction in use of institutional care, controlled utilization of medical services, and cost savings to public and private payers of care, including Medicare and Medicaid.
CONCLUSION: The growing number of older people in the United States challenges healthcare providers and policy makers alike to provide high quality care in an environment of shrinking resources. The PACE model's comprehensiveness of health and social services, its cost‐effective coordinated system of care delivery, and its method of integrated financing have wide applicability and appeal.
The aging of the United States population will offer unprecedented challenges and opportunities for the health care system at large, and particularly medical education. In this issue of Academic ...Medicine, three articles provide opportunities for medical educators and others to ponder anew how we can address this so-called "age wave" as the baby boomers become senior boomers. Leipzig and colleagues describe their process for identifying 26 recommended geriatrics competencies for medical students, Reuben and colleagues examine the results of the first cohort of Reynolds Foundation geriatrics education grants, and Bernard and colleagues discuss the benefits of committing to developing departments of geriatrics at academic health centers. In addition, the recent Institute of Medicine (IOM) report, Retooling for an Aging America: Building the Health Care Workforce, highlights many of these issues. In this commentary, the authors discuss implications of selected articles from this issue and the IOM report, in hopes of provoking discussion and consideration of solutions to address the challenges faced by medical educators and by those who make public policy.
Despite recent gains in establishing academic sections, divisions, and departments of geriatrics in medical schools, much remains to be done to meet the medical needs of an aging population. To ...better understand how medical schools are educating students in geriatric‐related topics, all U.S. allopathic and osteopathic medical schools were surveyed in two waves, in 1999 and 2000, using a questionnaire based on recommendations from the Education Committee of the American Geriatrics Society. Responding schools were more likely to address diseases and conditions of aging, psychosocial issues, and ethical issues and less likely to cover anatomic changes, nutrition, knowledge of healthcare financing, outcome measurement, and cultural aspects of aging. Although limited, the results indicate that medical schools have increased coverage of aging‐related material, although further expansion of geriatric content will be necessary to meet the needs of an aging society.
OBJECTIVES: To explore the presence of negative stereotypical attitudes among medical students and the extent to which attitudes changed over time.
DESIGN: Analysis of pre‐ and postexperience ...administration of attitude measures to four cohorts of medical students (two cohorts as quasi‐controls and two cohorts as curriculum “treatment” groups).
SETTING: The curriculum of a community‐based medical school in the United States.
PARTICIPANTS: Four sequential cohorts of medical students.
INTERVENTION: Experience in a required comprehensive vertically integrated curriculum.
MEASUREMENTS: The Aging Semantic Differential (ASD), using an 85‐year‐old woman as the cue image.
RESULTS: The reliability scores for all administrations were acceptable. The two control cohorts demonstrated no change in attitude scores, whereas the treatment cohorts reflected a slight shift toward more‐positive scores. However, all cohorts had scores for all sittings that were in the neutral range; on average students routinely scored 70% of the 32 items neither positively nor negatively.
CONCLUSION: These students seemed not to hold negative stereotypes as measured using the ASD. Although two of the 32 items prompted negative stereotyping, and six items elicited positive stereotyping, attitudes were neutral about older adults. Characteristics of the ASD itself or of the response set used in this study may have affected the results.
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