James S. Powers

ERYTHROPOIETIN RESPONSE TO ANEMIA AS A FUNCTION OF AGE

The erythropoietin (EPO) response to anemia was assessed for 244 subjects aged 1–64 years (mean 45.2 years) and 121 subjects aged 65–94 years (mean 68.3 years). Subjects included non‐anemic individuals as well as those with anemia of various etiologies, excluding renal disease and pregnancy. Significant inverse correlations between serum immunoreactive EPO and hematocrit were noted for both groups. Regression lines failed to show a significantly lower slope or y‐intercept for older compared to younger subjects. EPO levels were not significantly lower for older compared to younger subjects when controlled for hematocrit level. These results suggest that the EPO response to anemia in older subjects is similar to that of younger subjects.

Use of recombinant human erythropoietin to enhance autologous blood donation in a patient with multiple red cell allo-antibodies and the anemia of chronic disease

We treated a patient with alcohol-induced cirrhosis, intractable pain from a defective hip prosthesis, and multiple red cell allo-antibodies with recombinant human erythropoietin (EPO) in order to facilitate collection of blood for autologous transfusion during an elective total hip revision. This patient had experienced a delayed transfusion reaction 4 months earlier after receiving least incompatible packed red cells for gastrointestinal bleeding. His blood could not be crossmatched because of the development of multiple antibodies to homologous blood given during previous surgery and several episodes of gastrointestinal hemorrhage. Following initiation of EPO therapy, there was a prompt and persistent increase in the reticulocyte count from a baseline of 1.6% to a maximum of 8.6%. This was accompanied by maintenance of the hematocrit between 32% and 38.5% despite withdrawal of seven units of autologous blood over the 45-day treatment period. Poor venous access and availability of blood bank personnel, not hematocrit level, were the limiting factors that determined how frequently blood could be collected. We conclude that EPO stimulated erythropoiesis in this patient with underlying anemia of chronic disease and facilitated harvest of autologous blood for elective surgery.

Electronic surveillance and pharmacist intervention for vulnerable older inpatients on high-risk medication regimens.

To develop and evaluate an electronic tool to assist clinical pharmacists with reviewing potentially inappropriate medications (PIMs) in hospitalized elderly adults.

Rapid Measurement of Total Body Water to Facilitate Clinical Decision Making in Hospitalized Elderly Patients

BACKGROUND Bioelectrical impedance analysis (BIA) is a noninvasive rapid and simple bedside technique that can be used to predict total body water (TBW), extracellular water (ECW), and intracellular water (ICW) and identify altered fluid distribution following critical illness. METHODS An equivalence study of BIA in 32 hospitalized elderly patients was compared with reference standard dilutional measurements of deuterated water (TBW) and sodium bromide (ECW). The results were compared with anthropometric equations commonly used to predict TBW. RESULTS There was variability in TBW content among the participating hospitalized elderly patients. This variability was within (+/-5 L) and the percent difference between the standard and BIA was as follows: mean (range) -4.1% (-18.5 to 11.2). BIA reliably predicted TBW and ECW in individual participants, whereas standard prediction equations uniformly over- or underestimated TBW in individuals and whole group population. CONCLUSION TBW in hospitalized elderly patients can be estimated noninvasively by bedside BIA. Standardized anthropometric equations have to be used with caution in this population.

Direct assay of vitamins B1, B2, and B6 in hospitalized patients: relationship to level of intake.

High-performance liquid chromatography assays for vitamins B1 by erythrocyte thiamine pyrophosphate, B2 by plasma and urinary riboflavin, and B6 by plasma pyridoxal phosphate and urinary pyridoxic acid were used to evaluate the B vitamin status of hospitalized patients. Over an intake range of up to 3.4 mg of thiamine per day and up to 4.1 mg of riboflavin per day, erythrocyte thiamine pyrophosphate and urine and plasma riboflavin increased proportionately with intake. There was no relationship between B6 intake and blood levels. Rather, a constant blood level was maintained with an intake range of 0.5 to 4 mg/d, and urinary pyridoxic acid showed a linear increase proportionate to intake. There were extremely variable blood and urine concentrations of B vitamins noted in our patient population.

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

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.

Impaired arousal at initial presentation predicts 6-month mortality: an analysis of 1084 acutely ill older patients.

OBJECTIVES Impaired arousal signifies underlying brain dysfunction, but its clinical significance outside the intensive care unit remains unclear. We sought to determine if impaired arousal at initial presentation was associated with higher 6-month mortality and if this relationship existed in the absence of delirium. DESIGN Prospective cohort study. SETTING An emergency department located within an academic, tertiary care hospital. PARTICIPANTS A total of 1084 noncomatose patients who were aged 65 years or older. MEASUREMENTS The Richmond Agitation-Sedation Scale (RASS) is a 10-second arousal scale; a score of 0 indicates normal arousal. Cox proportional hazard regression was performed adjusting for patient characteristics, admission status, and psychoactive medication administration. To determine if impaired arousal in the absence of delirium was associated with 6-month mortality, Cox proportional hazard regression was performed in a subset of 406 patients who received a psychiatric assessment; the inverse weighted propensity score method was used to minimize residual confounding. Hazard ratios (HR) with their 95% confidence intervals (95% CI) were reported. RESULTS Patients with impaired arousal were 73% more likely to die within 6 months (HR: 1.73, 95% CI: 1.21-2.49). Even in the absence of delirium, patients with an abnormal RASS were more likely to die within 6 months (HR: 2.20, 95% CI: 1.10-4.41). CONCLUSION Impaired arousal at initial presentation is an independent predictor of death within 6 months in a diverse group of acutely ill older patients, even in the absence of delirium. Routine RASS assessment of arousal during clinical care may be warranted as it correlates with prognosis.

Impact of Clinical Pharmacy Specialists on the Design and Implementation of a Quality Improvement Initiative to Decrease Inappropriate Medications in a Veterans Affairs Emergency Department

BACKGROUND As the proportion of older adult patients who interface with the health care system grows, clinical pharmacy specialists (CPS) have a pivotal role in reducing potentially inappropriate medication (PIM) use in this population. OBJECTIVES To (a) describe CPS involvement in the design and implementation of a quality improvement (QI) initiative to decrease PIM prescribing in a Veterans Affairs (VA) emergency department (ED) and (b) report on changes in PIM prescribing before and after the initiative. METHODS Enhancing Quality of Prescribing Practices for Veterans Discharged from the Emergency Department (EQUiPPED) is an ongoing multisite QI project that aims to decrease ED PIM prescribing. We used a mixed-method approach that applied qualitative and quantitative measures in describing the CPS role and evaluating PIM rates. PIMs were defined using the 2012 Beers Criteria. We reported monthly PIM rates in patients aged 65 years and older who were discharged from the ED from January 2012 to November 2014. A piecewise, nonlinear regression model evaluated the pattern in PIM prescriptions over time. RESULTS At the Durham, North Carolina, VA Medical Center, a total of 4 CPS were involved with tailoring the design and implementation of the EQUiPPED intervention for local use. CPS input led to 3 key innovations: academic detailing performed by a physician-CPS pair, medication alert messages identifying medications as PIMs in the computerized patient record system, and automated reports describing the frequency and type of PIMs prescribed by each ED provider. Between February 2013 and November 2014, 73 ED providers received the academic detailing. The ED facility experienced a relative reduction of 47.5% in the rate of PIM prescribing over the observation period. CONCLUSIONS This QI project resulted in a meaningful decrease in PIM prescribing in older ED adults. CPS contributions to QI can extend beyond pharmacotherapy and provider education to also include information technology tools using formulary management expertise.

Care transitions: a leverage point for safe and effective medication use in older adults--a mini-review.

Older adults often face challenges as they transition out of the acute care hospital, especially with regard to adhering to their medications. In this narrative review, we discuss medication adherence in older adults across the continuum of care, describing reasons for nonadherence, methods to assess adherence and tools to improve adherence, with particular focus on emerging techniques and technologies. Taking steps at care transitions to assess medications and foster adherence to the medication regimen can increase the safety of older adults following hospitalization.

Common Presentations of Elder Abuse in Health Care Settings

Health care professionals encounter elder abuse in the community and in medical offices, emergency rooms, hospitals, and long-term care facilities. Keen awareness of risk factors for elder abuse and the variety of presentations in different health settings helps promote detection, treatment, and prevention of elder abuse.