Michelle I. Rossi

Body mass index and mortality in nonsmoking older adults: the Cardiovascular Health Study.

OBJECTIVES This study assesses the relationship of body mass index to 5-year mortality in a cohort of 4317 nonsmoking men and women aged 65 to 100 years. METHODS Logistic regression analyses were conducted to predict mortality as a function of baseline body mass index, adjusting for demographic, clinical, and laboratory covariates. RESULTS There was an inverse relationship between body mass index and mortality; death rates were higher for those who weighed the least. Inclusion of covariates had trivial effects on these results. People who had lost 10% or more of their body weight since age 50 had a relatively high death rate. When that group was excluded, there was no remaining relationship between body mass index and mortality. CONCLUSIONS The association between higher body mass index and mortality often found in middle-aged populations was not observed in this large cohort of older adults. Over-weight does not seem to be a risk factor for 5-year mortality in this age group. Rather, the risks associated with significant weight loss should be the primary concern.

Consensus Guidelines for Oral Dosing of Primarily Renally Cleared Medications in Older Adults

OBJECTIVES: To establish consensus oral dosing guidelines for primarily renally cleared medications prescribed for older adults.

Deconstructing Chronic Low Back Pain in the Older Adult: Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part IV: Depression.

OBJECTIVE To present the fourth 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 twelve important contributors to pain and disability in older adults with CLBP. This article focuses on depression. METHODS The evaluation and treatment algorithm, a table articulating the rationale for the individual algorithm components, and stepped-care drug recommendations were developed using a modified Delphi approach. The Principal Investigator, a three-member content expert panel, and a nine-member primary care panel were involved in the iterative development of these materials. The algorithm was developed keeping in mind medications and other resources available within Veterans Health Administration (VHA) facilities. As panelists were not exclusive to the VHA, the materials can be applied in both VHA and civilian settings. The illustrative clinical case was taken from one of the contributors clinical practice. RESULTS We present an algorithm and supportive materials to help guide the care of older adults with depression, an important contributor to CLBP. The case illustrates an example of a complex clinical presentation in which depression was an important contributor to symptoms and disability in an older adult with CLBP. CONCLUSIONS Depression is common and should be evaluated routinely in the older adult with CLBP so that appropriately targeted treatments can be planned and implemented.

Deconstructing chronic low back pain in the older adult--step by step evidence and expert-based recommendations for evaluation and treatment: part I: Hip osteoarthritis.

OBJECTIVE To present the first 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 twelve important contributors to pain and disability in older adults with CLBP. This article focuses on hip osteoarthritis (OA). METHODS The evaluation and treatment algorithm, a table articulating the rationale for the individual algorithm components, and stepped-care drug recommendations were developed using a modified Delphi approach. The Principal Investigator, a five-member content expert panel and a nine-member primary care panel were involved in the iterative development of these materials. The algorithm was developed keeping in mind medications and other resources available within Veterans Health Administration (VHA) facilities. As panelists were not exclusive to the VHA, the materials can be applied in both VHA and civilian settings. The illustrative clinical case was taken from one of the contributors clinical practice. RESULTS We present an algorithm and supportive materials to help guide the care of older adults with hip OA, an important contributor to CLBP. The case illustrates an example of complex hip-spine syndrome, in which hip OA was an important contributor to disability in an older adult with CLBP. CONCLUSIONS Hip OA is common and should be evaluated routinely in the older adult with CLBP so that appropriately targeted treatment can be designed.

Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part II: Myofascial Pain.

OBJECTIVE To present an algorithm of sequential treatment options for managing myofascial pain (MP) in older adults, along with a representative clinical case. METHODS A modified Delphi process was used to synthesize evidence-based recommendations. A multidisciplinary expert panel developed the algorithm, which was subsequently refined through an iterative process of input from a primary care physician panel. RESULTS We present an algorithm and supportive materials to help guide the care of older adults with MP, an important contributor to chronic low back pain (CLBP). Addressing any perpetuating factors should be the first step of managing MP. Patients should be educated on self-care approaches, home exercise, and the use of safe analgesics when indicated. Trigger point deactivation can be accomplished by manual therapy, injection therapy, dry needling, and/or acupuncture. CONCLUSIONS The algorithm presented gives a structured approach to guide primary care providers in planning treatment for patients with MP as a contributor to CLBP.

Deconstructing Chronic Low Back Pain in the Older Adult – Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part III: Fibromyalgia Syndrome

OBJECTIVE To present the third 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 contributors to pain and disability in older adults with CLBP. This article focuses on fibromyalgia syndrome (FMS). METHODS A modified Delphi approach was used to create the evaluation and treatment algorithm, the table discussing the rationale behind each of the algorithm components, and the stepped-care drug recommendations. The team involved in the creation of these materials consisted of a principal investigator, a 5-member content expert panel, and a 9-member primary care panel. The evaluation and treatment recommendations were based on availability of medications and other resources within the Veterans Health Administration (VHA) facilities. However, non-VHA panelists were also involved in the development of these materials, which can be applied to both VA and civilian settings. The illustrative clinical case was taken from the clinical practice of the principal investigator. RESULTS Following expert consultations and a review of the literature, we developed an evaluation and treatment algorithm with supporting materials to aid in the care of older adults with CLBP who have concomitant FMS. A case is presented that demonstrates the complexity of pain evaluation and management in older patients with CLBP and concomitant FMS. CONCLUSIONS Recognition of FMS as a common contributor to CLBP in older adults and initiating treatment targeting both FMS and CLBP may lead to improved outcomes in pain and disability.

Deconstructing Chronic Low Back Pain in the Older Adult—Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part VII: Insomnia

OBJECTIVE : To present the seventh in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. This article focuses on insomnia and presents a treatment algorithm for managing insomnia in older adults, along with a representative clinical case. METHODS : A modified Delphi process was used to develop the algorithm and supportive materials. A multidisciplinary expert panel representing expertise in health psychology and sleep medicine developed the algorithm and supporting documents that were subsequently refined through an iterative process of input from a primary care provider panel. RESULTS : We present an illustrative clinical case and an algorithm to help guide the care of older adults with insomnia, an important contributor to CLBP and disability. Multicomponent cognitive behavioral therapy for insomnia (CBTI) and similar treatments (e.g., brief behavioral treatment for insomnia [BBTI]) are the recommended first-line treatment. Medications should be considered only if BBTI/CBTI is suboptimal or not effective and should be prescribed at the lowest effective dose for short periods of time (< 90 days). CONCLUSIONS : Insomnia is commonly comorbid with CLBP in older adults and should be routinely evaluated and treated because it is an important contributor to pain and disability. The algorithm presented was structured to assist primary care providers in planning treatment for older adults with CLBP and insomnia.

A Multisite Geriatric Education Program for Rural Providers in the Veteran Health Care System (GRECC-Connect)

Older patients who live in rural areas often have limited access to specialty geriatric care, which can help in identifying and managing geriatric conditions associated with functional decline. Implementation of geriatric-focused practices among rural primary care providers has been limited, because rural providers often lack access to training in geriatrics and to geriatricians for consultation. To bridge this gap, four Geriatric Research, Education, and Clinical Centers, which are centers of excellence across the nation for geriatric care within the Veteran health system, have developed a program utilizing telemedicine to connect with rural providers to improve access to specialized geriatric interdisciplinary care. In addition, case-based education via teleconferencing using cases brought by rural providers was developed to complement the clinical implementation efforts. In this article, the authors review these educational approaches in the implementation of the clinical interventions and discuss the potential advantages in improving implementation efforts.

Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment. Part VI: Lumbar Spinal Stenosis.

OBJECTIVE . To present the sixth in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. This article focuses on the evaluation and management of lumbar spinal stenosis (LSS), the most common condition for which older adults undergo spinal surgery. METHODS . The evaluation and treatment algorithm, a table articulating the rationale for the individual algorithm components, and stepped-care drug recommendations were developed using a modified Delphi approach. The Principal Investigator, a five-member content expert panel and a nine-member primary care panel were involved in the iterative development of these materials. The illustrative clinical case was taken from the clinical practice of a contributors colleague (SR). RESULTS . We present an algorithm and supportive materials to help guide the care of older adults with LSS, a condition that occurs not uncommonly in those with CLBP. The case illustrates the importance of function-focused management and a rational approach to conservative care. CONCLUSIONS . Lumbar spinal stenosis exists not uncommonly in older adults with CLBP and management often can be accomplished without surgery. Treatment should address all conditions in addition to LSS contributing to pain and disability.

Creation of an Interprofessional Teledementia Clinic for Rural Veterans: Preliminary Data

The teledementia clinic is a new model of care that expands the reach of specialized geriatric and dementia care using clinical video telehealth (CVT) to rural veterans, who frequently lack access to specialty care. The clinic is a Veterans Affairs (VA) Geriatric Research, Education, and Clinical Center clinical demonstration project. It is located in the Pittsburgh VA Healthcare System tertiary referral hospital and serves veterans in affiliated rural community‐based outpatient clinics (CBOCs). Rural CBOC primary care providers refer clinic patients, or referral is according to previous cognitive impairment diagnosis in a VAPHS geriatric clinic. Patients undergo interprofessional dementia assessment by a geriatrician, geropsychologist, geriatric psychiatrist or neurologist, and social worker using CVT technology. Metrics for clinic evaluation included rural patients served and savings in travel time, distance, and costs. Assessments collected depended upon individual presentation and included cognitive tests, geriatric depression scales, functional assessment, and the Zarit Burden Interview. A patient satisfaction survey was created and administered. In the first year, 95 individuals were served in 156 clinic visits and 251 interprofessional provider encounters. Of patients served, 61 lived in rural ZIP codes, 72 were diagnosed with dementia, 19 were diagnosed with mild cognitive impairment, and four were found to have primarily psychiatric diagnoses rather than cognitive impairment. The average Functional Assessment Staging of Alzheimers Disease Scale score was 4.3 ± 1.3. This clinic model demonstrates that CVT technology is a feasible means of providing interprofessional dementia evaluations and follow‐up to rural presidents.