Shelley A. Sternberg

The Identification of Frailty: A Systematic Literature Review

An operational definition of frailty is important for clinical care, research, and policy planning. The literature on the clinical definitions, screening tools, and severity measures of frailty were systematically reviewed as part of the Canadian Initiative on Frailty and Aging. Searches of MEDLINE from 1997 to 2009 were conducted, and reference lists of retrieved articles were pearled, to identify articles published in English and French on the identification of frailty in community‐dwelling people aged 65 and older. Two independent reviewers extracted descriptive information on study populations, frailty criteria, and outcomes from the selected papers, and quality rankings were assigned. Of 4,334 articles retrieved from the searches and 70 articles retrieved from the pearling, 22 met study inclusion criteria. In the 22 articles, physical function, gait speed, and cognition were the most commonly used identifying components of frailty, and death, disability, and institutionalization were common outcomes. The prevalence of frailty ranged from 5% to 58%. Despite significant work over the past decade, a clear consensus definition of frailty does not emerge from the literature. The definition and outcomes that best suit the unique needs of the researchers, clinicians, or policy‐makers conducting the screening determine the choice of a screening tool for frailty. Important areas for further research include whether disability should be considered a component or an outcome of frailty. In addition, the role of cognitive and mood elements in the frailty construct requires further clarification.

Undetected Dementia in Community‐Dwelling Older People: The Canadian Study of Health and Aging

OBJECTIVE: To estimate the frequency and correlates of undetected dementia in community‐dwelling older people.

Alternative Therapy Use by Elderly African Americans Attending a Community Clinic

Objectives: To describe the use of orally ingested alternative therapies (OAT) by a community‐dwelling, primarily African‐American sample of elders.

Disparities in pneumococcal and influenza immunization among older adults in Israel: A cross-sectional analysis of socio-demographic barriers to vaccination☆

OBJECTIVE Vaccinations against influenza and pneumonia reduce morbidity and mortality among older adults. We examined vaccination rates among Israels diverse geriatric population to determine socio-demographic barriers to vaccination. METHODS This study is a quantitative data analysis with a cross-sectional design, comprising 136,944 patients aged 65 and older enrolled during 2008-2009 in the Maccabi Healthcare Services, one of Israels four sick funds (preferred provider organizations). We conducted multivariable logistic regression analyses to determine the association between vaccination status and socio-demographic characteristics, including age, gender, rural residency, socio-economic status, region of origin, immigrant status, and Holocaust survivorship. We controlled for potential confounders, including comorbidities, primary care visits and hospitalizations, as well as the physicians gender and region of origin. RESULTS Overall, vaccination rates were 72% for pneumonia and 59% for influenza. The strongest socio-demographic barriers to vaccination included female gender, rural residency, low socio-economic status, recent immigration, and being from or having a physician from the Former Soviet Union. CONCLUSION Efforts to further explore barriers to influenza and pneumococcal vaccination and interventions to reduce disparities in vaccination rates should focus on the sub-groups identified in this paper, with careful thought being given as to how to overcome these barriers.

THE VULNERABLE ELDERS SURVEY: A TOOL FOR IDENTIFYING VULNERABLE OLDER PEOPLE IN THE COMMUNITY

this time, a relapsing polychondritis was diagnosed according to standard criteria (Table 1), and the patient was started on corticosteroids (prednisone 50 mg/d). 3 Symptoms subsided and temperature normalized within 5 days, and the patient was discharged on methotrexate (7.5 mg/wk) and prednisone. Relapsing polychondritis should always be suspected in the presence of inflamed cartilage of the ears, nose, or throat. Cases characterized by the preferential involvement of noncartilaginous sites should be accurately distinguished from other rheumatological and immune-mediated diseases. In the presence of consistent clinical findings, older age should not be regarded as an exclusion criterion. Indeed, both the present case report and the largest available studies demonstrate that polychondritis can occur in older people and even in the old old. 3,6 Polychondritis should be suspected if no clear explanation or effective therapy for select common geriatric problems (for example arthritis, laryngotracheal symptoms, vertigo and ocular inflammation) is found. A careful ear, nose, and throat examination could help identify this commonly misdiagnosed condition.

The contribution of comprehensive geriatric assessment to primary care physicians

BackgroundTo provide quality care to the growing number of older patients, primary care physicians (PCPs) will require support from geriatric specialists. Multidisciplinary comprehensive geriatric assessment (CGA) has been found to improve outcomes in older people. This study explored the contribution of CGA to the management of older patients by their PCPs; PCP attitudes to CGA; and PCP satisfaction with CGA.MethodsTwo hundred PCPs in an Israeli Preferred Provider Organization were interviewed as part of an evaluative study of the contribution of a national outpatient CGA program to older patients, their families and physicians.ResultsThe main reasons for referral to CGA were cognitive impairment and rapid functional decline. Three domains described the contribution of CGA to PCPs: medical treatment, support in counseling patients, and treatment of cognitive impairment. About 69% of PCPs definitely agreed that CGA more fully addressed the physical, mental and social needs of patients than other consultative clinics. About half were very satisfied with the CGA staff’s attitudes to patients, their families and to the PCP.ConclusionsCGA contributed significantly to the care provided to older patients by PCPs. The expansion of CGA services deserves consideration.

Quality of Care of Older People Living with Advanced Dementia in the Community in Israel

To examine the quality of end‐of‐life (EOL) care of older people with advanced dementia (OPAD) living in the community.

The use of medications for cognitive enhancement.

OBJECTIVE To provide Canadian physicians and allied health care professionals with the evidence they need to help them make treatment decisions in the management of patients with Alzheimers disease or other dementias. OPTIONS The full range and quality of diagnostic and therapeutic modalities available to Canadian physicians for the management of dementia. OUTCOMES Improvement in the treatment of dementias, leading to reduced suffering, increased functional capacity and decreased economic burden. EVIDENCE AND VALUES: The creation of these evidence-based consensus statements involved literature reviews of the subject by the authors; comparison of alternative clinical pathways and description of the methods whereby published data were analyzed; definition of the level of evidence for data in each case; evaluation and revision in a conference setting (involving primary care physicians, neurologists, psychiatrists, geriatricians, psychologists, consumers and other interested parties); insertion of tables showing key variables and data from various studies and tables of data with recommendations; and reassessment by all authors. BENEFITS, HARMS, AND COSTS A rational plan for the therapy of dementias is likely to lead to substantial benefits in both human and economic terms. RECOMMENDATIONS Treatment decisions should be made taking into account the severity or stage of the disease, the availability of caregivers, the presence of disease affecting other bodily systems and the ability of the subject to pay the cost of the medications. Donepezil is considered to have positive effects upon certain tests of neuropsychological function and may produce some improvement in Alzheimers disease of mild to moderate severity as measured by rating scales. Its ability to improve quality of life remains uncertain. No other drug treatments (apart from symptomatic therapies) are at present approved for the treatment of Alzheimers disease*. VALIDATION These recommendations were created by a writing committee, evaluated and revised at a consensus conference and further reviewed and revised by the writing committee prior to publication.

TRAINING NURSES TO SCREEN FOR DEMENTIA IN OLDER PEOPLE WITH DIABETES

recognizing cognitive impairment and improved communication with PWD, 3) implementing Dementia Friendly environmental design features across the medical center, 4) identifying Dementia Friendly Champions among facility employees, 5) securing support frommanagement, and 6) collaboration between healthcare facility and the local community. The model is based in the theory of personhood and other inclusive, socially-based models. We describe process, facilitators and barriers to implementation of this model in a largeVeterans Affairs medical center, with 2000 employees serving 43,000 primarily older patients. Staff training has been well-received by clinical and non-clinical staff, and dementia knowledge increased following the training by almost 30%. Major way-finding improvements guided by research-based design principles have been completed, and Dementia Friendly environmental features are being incorporated in ongoing construction projects. This holistic model has promise for transforming healthcare culture and improving the care experience of PWD and their caregivers.

DEVELOPMENT OF AN ISRAELI NATIONAL DEMENTIA DATABASE

Background:The National Program to Address Alzheimer’s Disease and other Dementias in Israel has been led by theMinistry of Health, Division of Geriatrics and its partners, since 2013. Among these partners are the four health fundswhich providemedical services, as stipulated by law, to all citizens and permanent residents of Israel including medications, and primary and specialist care. In order to plan services, national data were needed on people with dementia including prevalence, demographic and health characteristics and service use. Methods: The Geriatric Division and the Israel Center for Disease Control collaborated with the four health funds to develop a national dementia survey using electronic medical record databases. Dementia case definition was based on a dementia diagnosis or the purchase of dementia medications. The population base was all people insured by the health funds aged 45 and over at the end of 2016. Results: The prevalence of dementia was 6.6% for people 65 and over (1.5% in 65-74, 8% in 75-84, 25% in 85+). The prevalence of dementia over age 60 standardized to the population of western Europe (6.8%) and the USA (5.7%) was lower in Israel at 4.9%. Of identified dementia cases, 36% were identified by diagnosis only, 19% by purchasing dementia medications, and 45% by both criteria, and 64% overall received dementia medications. Of identified dementia diagnoses, 57.2% were Alzheimer’s, 7.5% were vascular, 20.8% were non-specific and 14.6% were other. People with a lower socioeconomic status were underrepresented in the survey compared to the national average (8.3% vs 16%) and were less likely to purchase dementia medications. Conclusions:This national dementia survey, including all citizens and permanent residents of Israel, demonstrated a lower standardized prevalence of dementia than many otherWestern countries. Possible reasons might be underdiagnosis, lack of public and professional awareness, and diagnoses being made in the private rather than public system without information transfer. Future plans are to explore health services use by cross referencing encrypted personal identifiers with other national databases. This survey will provide the basis for a national dementia database that will help shape future policy for dementia.