Carolyn Clevenger

Clinical Care of Persons with Dementia in the Emergency Department: A Review of the Literature and Agenda for Research

The segment of older adults who present to the emergency department (ED) with cognitive impairment ranges from 21% to 40%. Difficulties inherent in the chaotic ED setting combined with dementia may result in a number of unwanted clinical outcomes, but strategies to minimize these outcomes are lacking. A review of the literature was conducted to examine the practices undertaken in the care of persons with dementia (PWD) specific to the ED setting. PubMed and Cumulative Index to Nursing and Allied Health Literature were searched for published articles specific to the care of PWD provided in the ED. All English‐language articles were reviewed; editorials and reflective journals were excluded. Seven articles ultimately met inclusion criteria; all provided Level 7 evidence: narrative review or opinions from authorities. The articles recommended clinical practices that can be categorized into five themes: assessment of cognitive impairment, dementia communication strategies, avoidance of adverse events, alterations to the physical environment, and education of ED staff. Many recommendations are extrapolated from residential care settings. Review results indicate that there is minimal guidance for the care of PWD specific to the ED setting. There are no empirical studies of the care (assessment, interventions) of PWD in the ED. The existing (Level 7) recommendations lack a research base to support their effectiveness or adoption as evidence‐based practice. There is a significant opportunity for research to identify and test ways to meet the needs of PWD in the ED to ensure a safe visit, accurate diagnosis, and prudent transfer to the most appropriate level of care.

Contractures in Frail Nursing Home Residents

Contractures are a common but preventable consequence of prolonged physical immobility among nursing home residents. Significant for their associated costs in institutions rendering care to frail elder residents, contractures further reduce mobility and increase the risk of other outcomes of decreased mobility, such as pressure ulcers. This secondary analysis examines the prevalence of contractures in 273 residents who participated in an interventional study focusing on reducing restrictive siderails. Almost two thirds of the participants had at least 1 contracture, with the most common locations being the shoulder and knee. Presence of pain and being non-White were significant predictors of contracture presence. This study highlights the high prevalence of contractures, the underlying factors associated with them, and the need to prevent or minimize contracture formation, including the role restorative nursing care plays in this avoidable condition.

A Longitudinal Analysis of the Lifetime Cost of Dementia

OBJECTIVE Estimate the lifetime cost of dementia to Medicare and Medicaid. DATA SOURCE 1997-2005 Medicare Current Beneficiary Survey. STUDY DESIGN A multistage analysis was conducted to first predict the probability of developing dementia by age and then predict the annual Medicare/Medicaid expenditures conditional on dementia status. A cohort-based simulation was conducted to estimate the lifetime cost of dementia. PRINCIPAL FINDINGS The average lifetime cost of dementia per patient for Medicare is approximately

Contractures in Nursing Home Residents

12,000 (2005 dollars) and for Medicaid about

Teaching the teachers: faculty development in inter-professional education.

11,000. Dementia onset at older age leads to shorter duration and lower lifetime cost. Increased educational level leads to longer longevity, more dementia cases per cohort, but shorter duration, and lower lifetime cost per patient, which could offset the cost increase induced by more dementia cases. Increased body mass index leads to more dementia cases per cohort and higher lifetime cost per patient. CONCLUSION Net cost of dementia is lower than the estimates from cross-sectional studies. Promoting healthy lifestyle to reverse the obesity epidemic is a short-term priority to confront the epidemic of dementia in the near future. Promoting higher education among the younger generation is a long-term priority to mitigate the effect of population aging on the dementia epidemic in the distant future.

Enhancing the Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUiPPED): Preliminary Results from Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department, a Novel Multicomponent Interdisciplinary Quality Improvement Initiative

Contractures represent a common but preventable source of excess disability among nursing home residents. They result in many negative consequences such as pain, increased fall risk and decreased functional ability. Studies of prevalence vary in the definition of contracture and thus the exact enumeration, but consistently report the commonality in the nursing home setting. In this population, the clinician should focus on tertiary prevention and/or treatment. Methods such as those consistent with restorative care nursing have shown improvement in function and are a reasonable recommendation as a preventive measure for contractures. Assessment, prevention, and treatment approaches are discussed.

Enhancing care of older adults in the emergency department.

AIMS The purpose of this study is to evaluate changes in self-concept for the knowledge, skills and attitudes toward inter-professional teamwork of facilitators who participated in training and an inter-professional team training event. BACKGROUND Inter-professional education requires dedicated and educated faculty. METHODS A pretest posttest quasi-experimental design was used for the evaluation. Fifty-three facilitators were asked to complete pre-post questionnaires to measure inter-professional team self-concept (IPTSC), assessing self-concept for the knowledge, skills, and attitudes required for performing in an inter-professional team. RESULTS Post-session scores on inter-professional team knowledge, skills and attitudes were significantly higher (F(1, 31) = 5.59, p = .02). CONCLUSION A facilitator development course and participation in the teaching event had a positive impact on perceived knowledge, skills and attitudes toward inter-professional teamwork.

Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED)

Suboptimal medication prescribing for older adults has been described in a number of emergency department (ED) studies. Despite this, few studies have examined ED‐targeted interventions aimed at reducing the use of potentially inappropriate medications (PIMs). Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the ED (EQUiPPED) is an ongoing multicomponent, interdisciplinary quality improvement initiative in eight Department of Veterans Affairs EDs. The project aims to decrease the use of PIMs, as identified by the Beers criteria, prescribed to veterans aged 65 and older at the time of ED discharge. Interventions include provider education; informatics‐based clinical decision support with electronic medical record–embedded geriatric pharmacy order sets and links to online geriatric content; and individual provider education including academic detailing, audit and feedback, and peer benchmarking. Poisson regression was used to compare the number of PIMs that staff providers prescribed to veterans aged 65 and older discharged from the ED before and after the initiation of the EQUiPPED intervention. Initial data from the first implementation site show that the average monthly proportion of PIMs that staff providers prescribed was 9.4 ± 1.5% before the intervention and 4.6 ± 1.0% after the initiation of EQUiPPED (relative risk = 0.48, 95% confidence interval = 0.40–0.59, P < .001). Preliminary evaluation demonstrated a significant and sustained reduction of ED‐prescribed PIMs in older veterans after implementation of EQUiPPED. Longer follow‐up and replication at collaborating sites would allow for an assessment of the effect on health outcomes and costs.

Feasibility of a Low-Cost, Interactive Gaming System to Assess Balance in Older Women

The findings from a recent comprehensive systematic review, in combination with a case study, are used to illustrate the importance of translational research to inform advanced practice nursing. The review article discussed in this column is a comprehensive systematic review of age-friendly nursing interventions in the management of older persons in the emergency department (ED). Two themes were synthesized from the research and texts: (1) the ED can be a foreign and challenging environment for older patients, and (2) older ED patients need specialized care to meet their complex physical and psychosocial needs. At the same time, these authors acknowledged that much more high-quality research is needed in this field. Comments by a certified geriatric nurse practitioner elaborate on these findings and provide practical suggestions for the ED advanced practice registered nurse.

The Benefits of Being a Senior Mentor: Cultivating Resilience Through the Mentorship of Health Professions Students

EQUiPPED is a multicomponent quality improvement initiative combining education, electronic clinical decision support, and individual provider feedback to influence prescribing and improve medication safety for older adults. The objective here was to evaluate the effectiveness and sustainability of EQUiPPED to reduce the use of potentially inappropriate medications (PIMs), as defined by the American Geriatrics Society 2012 Beers Criteria, prescribed to older Veterans at the time of emergency department (ED) discharge. This evaluation represents a pre‐ and post‐intervention comparison of PIM prescriptions at 4 urban Veteran Affairs (VA) Medical Center EDs. Poisson regression was used to compare the number of PIMs prescribed to Veterans 65 years or older discharged from the ED for at least 6 months prior to the first EQUiPPED intervention at each site and for at least 12 months following the final EQUiPPED intervention. The implementation timeline varied by site depending on local resources. All 4 sites showed a significant and sustained reduction in use of PIMs. The proportion of PIMs at site one decreased from 11.9% (SD 1.8) pre‐EQUiPPED to 5.1% (SD 1.4) post‐EQUiPPED (P < .0001); site 2 from 8.2% (SD 0.8) pre to 4.5% (SD 1.0) post (P < .0001); site 3 from 8.9% (SD 1.9) pre to 6.1% (SD 1.7) post (P = .0007); and site 4 from 7.4% (SD 1.7) pre to 5.7% (SD 0.8) post (P = .04). These results suggest a multicomponent program to influence provider prescribing behavior leads to safer prescribing for older adults discharged from the ED and is sustainable across multiple VA ED sites.