Paula M. Podrazik

Using Assessing Care of Vulnerable Elders Quality Indicators to Measure Quality of Hospital Care for Vulnerable Elders

OBJECTIVES: To assess the quality of care for hospitalized vulnerable elders using measures based on Assessing Care of Vulnerable Elders (ACOVE) quality indicators (QIs).

Cardiopulmonary resuscitation requiring extracorporeal membrane oxygenation in the elderly: a review of the Extracorporeal Life Support Organization registry.

The role of extracorporeal membrane oxygenation (ECMO) as part of cardiopulmonary resuscitation (ECPR) among the elderly is not clearly defined. We sought to query the international Extracorporeal Life Support Organization (ELSO) registry database to investigate the use of ECMO support among the elderly. The objective of this study was to investigate survival to hospital discharge among the elderly supported on ECMO. The ELSO registry database was queried, identifying all elderly patients (>65 years of age) supported on ECMO for ECPR from 1998 to 2009. The primary outcome variable was survival to hospital discharge. Clinical characteristics between survivors and nonsurvivors were compared using univariate analysis. Ninety-nine elderly patients requiring ECPR were identified from the ELSO registry for the study period. The median age of the cohort was 70 years (range 65–86 years). The median admission to time on ECMO was 32 hours (range 1–998 hours), median time on ECMO was 69 hours (range 1–459 hours), and median time off to discharge for survivors was 587 hours (range 3–2,166 hours). Overall, survival at hospital discharge was 22.2% (22/99). No significant differences were noted between survivors and nonsurvivors for demographics, secondary diagnoses, pre-ECMO variables, complications on ECMO, as well as the type and duration of ECMO support. Among listed comorbidities, only the presence of pre-ECMO acute renal failure was significantly more frequent in nonsurvivors compared with survivors (14 vs. 0; p = 0.04). Survival to hospital discharge among the elderly supported on ECMO is lower than that for younger adult patients (28.7% vs. 40.0%). However, it is higher than that after conventional CPR (17%), suggesting that age should not be a bar against consideration for the use of ECMO in older patients but should be considered on a case-by-case basis.

Acute hospital care for the elderly patient: its impact on clinical and hospital systems of care.

A significant portion of hospital care involves elderly patients who have frequent and severe disease presentations, higher risk of iatrogenic injury during hospitalization, and greater baseline vulnerability. These risks frequently result in longer and more frequent hospitalizations. The frailty and complication rates of the elderly population underscore the importance of hospital-based programs of education and screening for cognitive and functional impairments to determine risk and needed additional care and services during hospitalization and at discharge. In addition, physicians are needed to take the lead in instituting programs of prevention and improving the systems of care. It is such a multi-tiered approach, with interventions in the areas of education, screening, prevention, and systems of care improvements, that is needed to improve the clinical care and outcomes of the hospitalized elderly patient.

Assisted living facilities: optimizing outcomes.

Seeing that the United States has nearly 36,400 assisted living facilities (ALFs) serving more than 900,000 residents, the American Geriatrics Society (AGS) recognizes that ALFs have become a critical component of long-term care (LTC). ALFs were established in response to consumer demand for an environment that was an alternative to home for older adults, particularly those with medical complexity or functional or cognitive decline, to live and age with grace and dignity. The challenge facing ALFs and the staff who provide their care is how to balance the goals of independence and maintaining a home-like environment in this medically, cognitively, and functionally diverse aging population. The ALFs need to recognize and address when the medical, functional, and safety needs of older people have outstripped their facilities’ capacity to provide safe; therefore quality care is the key. The tremendous variability that states have in definitions of level of care, philosophy regarding care, and licensing standards further complicated this challenge. However, it is clear that ALFs cater to a vulnerable and medically, functionally, and cognitively impaired population. A national study found that more than half of ALF residents were aged 85 and older, 25% had moderate or severe cognitive impairment, 33% experienced urinary incontinence, 51% received assistance with bathing, and 77% received assistance with medications. Of the residents who currently live in ALFs, 81% need help with one or more activities of daily living (ADLs) and 93% need help with instrumental activities of daily living (IADLs). The emphasis in caring for these residents is on maintaining independence and quality of life. There are a number of difficulties in developing standardized approaches to care provided for those living in ALFs. State and local governments regulate these facilities, and these regulations vary from state to state. Nevertheless, although this may account for some of the difficulties in developing standardized approaches in ALFs, there are sometimes conflicting views of the very definition and purpose of the ALF. The differing views of the ALF mission include the idea of the ALF as a facility that provides a distinct level of care versus a living site that provides a wide variety of supportive services to the senior. There is concern that ALFs will lose their role as a ‘‘home’’ if they are subjected to greater degrees of bureaucratic scrutiny with any further attempts to rigidly define and regulate these facilities and their market-driven need in the United States. The intent of this discussion is to balance the need for continued access to these facilities with the need to ensure high quality of care provided in them. This is accomplished by defining those aspects of care that are crucial to effective care of those living in ALFs.

Financial Exploitation of the Elderly: Review of the Epidemic—Its Victims, National Impact, and Legislative Solutions

Elder financial exploitation is the illegal or improper use of an older adult’s funds, property, or assets, and frequently occurs with other forms of abuse. This form of exploitation has emerged as one of the leading forms of elder abuse, having been described by some experts in the field as the epidemic of the twenty-first century. The societal repercussions are profound, affecting as many as seven million elderly Americans, with monies exploited estimated as

The Curriculum for the Hospitalized Aging Medical Patient program: A collaborative faculty development program for hospitalists, general internists, and geriatricians

2.9 billion annually. The many variables that contribute to financial exploitation of older persons in the United States include a cohort effect of unprecedented wealth, trust, and generosity in an unparalleled number of elderly aging into physically frailty and cognitive impairment, creating a concerning environment of vulnerability to abuse and financial exploitation. There are additional concerns that financial exploitation is on the rise, with an expanding list of perpetrators that include more than just family or caregivers. Scams and confidence schemes that involve total strangers and defrauded funds from Medicare and Medicaid have become emerging trends. Advances in research have better defined the victim, perpetrator, and risk factors for financial exploitation. Despite such advances, coordination in education, prevention at the local level, and support by state and federal governments continue to evolve.