Rainier P. Soriano

Dizziness and Syncope

Upon completion of the chapter, the student will be able to: 1. Describe the mechanisms that give rise to symptoms of dizziness and syncope among older adults. 2. Create a differential diagnosis for etiologies of dizziness and syncope in older adults utilizing key historical and physical examination data to create a differential diagnosis. 3. Identify and describe the prognosis and treatment of the common causes of dizziness and syncope in the elderly.

New 5-Factor Modified Frailty Index Using American College of Surgeons NSQIP Data

BACKGROUND The modified frailty index (mFI-11) is a NSQIP-based 11-factor index that has been proven to adequately reflect frailty and predict mortality and morbidity. These 11 factors, made of 16 variables, map to the original 70-item Canada Study of Health and Aging Frailty Index. In past years, certain NSQIP variables have been removed from the database; as of 2015, only 5 of the original 11 factors remained. The predictive power and usefulness of these 5 factors in an index (mFI-5) have not been proven in past literature. The goal of our study was to compare the mFI-5 to the mFI-11 in terms of value and predictive ability for mortality, postoperative infection, and unplanned 30-day readmission. STUDY DESIGN The mFI was calculated by dividing the number of factors present for a patient by the number of available factors for which there were no missing data. Spearmans rho was used to assess correlation between the mFI-5 and mFI-11. Predictive models, using both unadjusted and adjusted logistic regressions, were created for each outcome for 9 surgical sub-specialties using 2012 NSQIP data, the last year all mFI-11 variables existed. RESULTS Correlation between the mFI-5 and mFI-11 was above 0.9 across all surgical specialties except for cardiac and vascular surgery. Adjusted and unadjusted models showed similar c-statistics for mFI-5 and mFI-11, and strong predictive ability for mortality and postoperative complications. CONCLUSIONS The mFI-5 and the mFI-11 are equally effective predictors in all sub-specialties and the mFI-5 is a strong predictor of mortality and postoperative complications. It has credibility for future use to study frailty within the NSQIP database. It also has potential in other databases and for clinical use.

Longitudinal assessment of medical student attitudes toward older people

Abstract Delivering adequate care to older people requires an increasing number of physicians competent in the treatment of this expanding subpopulation. Attitudes toward older adults are important as predictors of the quality of care of older people and of medical trainee likelihood to enter the geriatrics field. This study assessed the attitudes of 404 US medical students (MS) from the start of medical school to graduation using the University of California, Los Angeles (UCLA) Geriatrics Attitude Scale. It is the first study to utilize a longitudinal design to assess attitudes among students in a medical school with a longitudinal geriatrics clinical experience in the first two years and a required geriatrics clerkship in the third year. Participants’ attitude scores toward older people were found to significantly decrease from 3.9 during the first two years to 3.7 during the final two. Significant differences existed between MS1 and MS3, MS1 and MS4, MS2 and MS3, and MS2 and MS4. Women and older students held significantly more positive attitudes than men and younger students. These results show that planned clinical exposures to older adults may not be sufficient to halt the decline in attitudes in medical school. A comprehensive empathy-building intervention embedded in the curriculum may better prevent this decline.

The Comprehensive Geriatric Assessment

Upon completion of the chapter, the student will be able to: 1. Explain the rationale behind the comprehensive geriatric assessment (CGA). 2. Enumerate the components of the CGA and the process of care. 3. Identify the members of the CGA team and understand their corresponding roles in the team. 4. Identify the various assessment instruments used to evaluate the different components or dimensions of the CGA.

Depression, Dementia, and Delirium

Upon completion of the chapter, the student will be able to: 1. State the epidemiology of depression, dementia, and delirium in older adults. 2. Describe the risk factors for the development of depression, dementia, and delirium. 3. Understand the diagnostic workup of depression, dementia, and delirium. 4. Develop a rational management plan for persons with depression, dementia, or delirium.

Overview of Palliative Care and Non-Pain Symptom Management

Upon completion of the chapter, the student will be able to: 1. Define palliative care and differentiate it from hospice care. 2. Enumerate and understand the general rules of good doctor-patient communication including communicating bad news and advance care planning. 3. Identify and treat nonpain symptoms including dyspnea, cough, nausea and vomiting, constipation, diarrhea, bowel obstruction, mouth symptoms, skin symptoms, odor, and spiritual distress. 4. Understand the Medicare hospice benefit.

Medication adherence and rejection rates in older vs younger adult liver transplant recipients

A growing number of older adults are undergoing liver transplantation (LT) in the United States. In some settings, it is thought that adherence declines with age. This retrospective study examined adherence and clinical outcomes in older vs younger adult LT recipients. Medical records of adult LT recipients from 2009 to 2012 from a single urban center were reviewed. The medication level variability index (MLVI) was the predefined primary outcome, with nonadherence defined as MLVI >2.5. The secondary outcome was incidence of rejection. Outcomes were evaluated starting 1 year post‐LT until 2015. A total of 42 of 248 patients were ≥65 at transplant. Older adults had significantly better adherence than younger ones (65%≥65 were adherent vs 42% younger adults; chi‐square two‐tailed P=.02). Survival analyses of rejection between age groups censored by time since transplant showed no difference among the four age groups (χ2=0.84, P=.84). Older age was not found to be a risk factor for reduced adherence or graft rejection in patients surviving at least 1 year post‐LT.

Approach to the Older Adult Patient

Upon completion of the chapter, the student will be able to: 1. Identify the different components of the history and physical examination and how these differ in older adults compared to younger adults. 2. Identify and understand the potential challenges in caring for older adults and ways to overcome them. 3. Enumerate the changes that occur with normal aging and contrast them with changes that occur secondary to disease.

That Was the Year That Was: An Evidence‐Based Clinical Geriatrics Update 2002–03

GINKGO, AT 120 MG/D, FOR 6 WEEKS, PROVIDES NO MEASURABLE BENEFIT IN COGNITIVE FUNCTION TO COGNITIVELY INTACT ELDERLY ADULTS (LEVEL OF EVIDENCE: 1b) Ginkgo biloba is the top-selling herbal dietary supplement in the United States, with retail sales of

Keeping Granny Safe on July 1: A Consensus on Minimum Geriatrics Competencies for Graduating Medical Students

46 million in 2001. Ginkoba packaging claims that 40mg three times a day (tid) for 4 weeks improves mental sharpness and focusing, and others claim that gingko improves memory. After 6 weeks of treatment with Ginkoba, this study found no improvement in cognitive performance of cognitively intact elders, but a recent meta-analysis suggests that gingko may provide some benefit in cognition, activities of daily living (ADLs), and mood for those who are cognitively impaired and demented.