Melissa L. P. Mattison

Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society

Disclosure Information: Disclosures for the members of t Geriatrics Society Postoperative Delirium Panel are listed in Support: Supported by a grant from the John A Hartford Fou to the Geriatrics-for-Specialists Initiative of the American Geri (grant 2009-0079). This article is a supplement to the American Geriatrics Soci Practice Guidelines for Postoperative Delirium in Older Adu at the American College of Surgeons 100 Annual Clinic San Francisco, CA, October 2014.

American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults

The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate‐to‐high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.

Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system.

BACKGROUND Potentially inappropriate medication (PIM) use in hospitalized older patients is common. Our objective was to determine whether a computerized provider order entry (CPOE) drug warning system can decrease orders for PIMs in hospitalized older patients. METHODS We used a prospective before-and-after design among patients 65 years or older admitted to a large, urban academic medical center in Boston, Massachusetts, from June 1, 2004, through November 29, 2004 (for patients admitted before the warning system was added), and from March 17, 2005, through August 30, 2008 (patients admitted after the warning system was added). We instituted a medication-specific warning system within CPOE that alerted ordering providers at the point of care when ordering a PIM and that advised alternative medication or dose reduction. The main outcome measure was the rate of orders for PIMs before and after the warning system was deployed. RESULTS The mean (SE) rate of ordering medications that were not recommended dropped from 11.56 (0.36) to 9.94 (0.12) orders per day after the implementation of a CPOE warning system (difference, 1.62 [0.33]; P<.001), with no evidence that the effect waned over time. There were no appreciable changes in the rate of ordering medications for which only dose reduction was recommended or that were not targeted after CPOE implementation. These effects persisted in autoregressive models that accounted for secular trends and season (P<.001). CONCLUSION Specific alerts embedded into a CPOE system, used in patients 65 years or older, can decrease the number of orders of PIMs quickly and specifically.

ECHO-AGE: An Innovative Model of Geriatric Care for Long-Term Care Residents With Dementia and Behavioral Issues

OBJECTIVES To design, implement, and assess the pilot phase of an innovative, remote case-based video-consultation program called ECHO-AGE that links experts in the management of behavior disorders in patients with dementia to nursing home care providers. DESIGN Pilot study involving surveying of participating long-term care sites regarding utility of recommendations and resident outcomes. SETTING Eleven long-term care sites in Massachusetts and Maine. PARTICIPANTS An interprofessional specialty team at a tertiary care center and staff from 11 long-term care sites. INTERVENTION Long-term care sites presented challenging cases regarding residents with dementia and/or delirium related behavioral issues to specialists via video-conferencing. METHODS Baseline resident characteristics and follow-up data regarding compliance with ECHO-AGE recommendations, resident improvement, hospitalization, and mortality were collected from the long-term care sites. RESULTS Forty-seven residents, with a mean age of 82 years, were presented during the ECHO-AGE pilot period. Eighty-three percent of residents had a history of dementia and 44% were taking antipsychotic medications. The most common reasons for presentation were agitation, intrusiveness, and paranoia. Behavioral plans were recommended in 72.3% of patients. Suggestions for medication adjustments were also frequent. ECHO-AGE recommendations were completely or partially followed in 88.6% of residents. When recommendations were followed, sites were much more likely to report clinical improvement (74% vs 20%, P < .03). Hospitalization was also less common among residents for whom recommendations were followed. CONCLUSIONS The results suggest that a case-based video-consultation program can be successful in improving the care of elders with dementia and/or delirium related behavioral issues by linking specialists with long-term care providers.

Navigating the Challenges of In-flight Emergencies

S THE FLIGHT BEGINS ITS DESCENT, A CALL COMES over the intercom: “Is there a physician on board?” Three internists traveling together to a meeting respond. A woman has lost consciousness. She is incontinent and unresponsive, with a strong pulse and intermittent breathing. The physicians ultimately determine the patient has hypoglycemia and a seizure. It takes multiple requests before the flight attendants provide the physicians with the emergency medical kit. When the kit arrives, the flight attendants disappear, and the physicians search in vain for glucagon or intravenous dextrose. The physicians massage oral glucose gel into the patient’s buccal mucosa, and the seizure eventually stops. After landing, the cabin crew records the names and contact information of the physicians, with no discussion of the incident. Other reports have recounted physicians having chal

Road Map to a Patient-Centered Research Agenda at the Intersection of Hospital Medicine and Geriatric Medicine

ABSTRACTAs the United States ages, the patient population in acute care hospitals is increasingly older and more medically complex. Despite evidence of a high burden of disease, high costs, and often poor outcomes of care, there is limited understanding of the presentation, diagnostic strategies, and management of acute illness in older adults. In this paper, we present a strategy for the development of a research agenda at the intersection of hospital and geriatric medicine. This approach is informed by the Patient-Centered Outcomes Research Institute (PCORI) framework for identification and prioritization of research areas, emphasizing input from patients and caregivers. The framework’s four components are: 1) Topic generation, 2) Gap Analysis in Systematic Review, 3) Value of information (VOI) analysis, and 4) Peer Review. An inclusive process for topic generation requiring the systematic engagement of multiple stakeholders, especially patients, is emphasized. In subsequent steps, researchers and stakeholders prioritize research topics in order to identify areas that optimize patient-centeredness, population impact, impact on clinical decision making, ease of implementation, and durability. Finally, next steps for dissemination of the research agenda and evaluation of the impact of the patient-centered research prioritization process are described.

A standardized, bundled approach to providing geriatric-focused acute care.

To determine whether a bundled intervention can increase detection of delirium and facilitate safer use of high‐risk medications.

Extension for Community Healthcare Outcomes—Care Transitions: Enhancing Geriatric Care Transitions Through a Multidisciplinary Videoconference

To examine whether a novel videoconference that connects an interdisciplinary hospital‐based team with clinicians at postacute care sites improves interprofessional communication and reduces medication errors.

A patient‐centered research agenda for the care of the acutely Ill older patient

Hospitalists and others acute-care providers are limited by gaps in evidence addressing the needs of the acutely ill older adult population. The Society of Hospital Medicine sponsored the Acute Care of Older Patients Priority Setting Partnership to develop a research agenda focused on bridging this gap. Informed by the Patient-Centered Outcomes Research Institute framework for identification and prioritization of research areas, we adapted a methodology developed by the James Lind Alliance to engage diverse stakeholders in the research agenda setting process. The work of the Partnership proceeded through 4 steps: convening, consulting, collating, and prioritizing. First, the steering committee convened a partnership of 18 stakeholder organizations in May 2013. Next, stakeholder organizations surveyed members to identify important unanswered questions in the acute care of older persons, receiving 1299 responses from 580 individuals. Finally, an extensive and structured process of collation and prioritization resulted in a final list of 10 research questions in the following areas: advanced-care planning, care transitions, delirium, dementia, depression, medications, models of care, physical function, surgery, and training. With the changing demographics of the hospitalized population, a workforce with limited geriatrics training, and gaps in evidence to inform clinical decision making for acutely ill older patients, the identified research questions deserve the highest priority in directing future research efforts to improve care for the older hospitalized patient and enrich training.

Advancement of geriatrics education.

Mazotti et al. describe a train-the-trainer (TTT) program for hospitalists that enables hospitalists to teach geriatric medicine to house staff. We agree that it is important to ensure geriatric medicine proficiency for all hospitalists. Despite caring for many older patients, most hospitalists are inadequately trained in geriatrics. In 2006, we started a TTT program called the Advancement of Geriatrics Education Scholars Program (AGESP). Funded by the Reynolds Foundation, AGESP is a year-long program to teach geriatric medicine to hospitalists. In 2010, 23 Harvard Medical School hospitalists participated. When asked if AGESP improved their knowledge of geriatrics, the average response was 4.5 (1 1⁄4 not at all, 5 1⁄4 extremely; n 1⁄4 19). When asked if they felt more confident to teach geriatrics, the score was 4.2 (n 1⁄4 19). This year, 30 hospitalists from Eastern Massachusetts are enrolled. By July, 70 hospitalists will have completed the program. Our program and others like Dr. Mazotti’s merit support from hospitals, foundations, and the government to provide training to hospitalists. This training is crucial because the medical school and residency training received by current hospitalists incorporated minimal, if any, geriatrics.