6/19/2018 Disclosures Geriatrics Literature Updates • Eric Widera Kenneth Covinsky, MD @geri_doc • Associate Editor, Social Media Editor, for the Journal of Eric Widera, MD @ewidera the American Geriatrics Society (JAGS) • Ken Covinsky University of California San Francisco • Editorial Board for the Journal of the American Geriatrics San Francisco VA Society (JAGS); Associate Editor, JAMA Internal Medicine Methods • Search of leading journals • January 2017-December 2017 • JAGS, NEJM, JAMA, JAMA-IM, Annals, Health Affairs, Lancet, BMJ, Academic Medicine, JGIM, J Geron-Med Sci, JPM, JPSM, Annals of Family Medicine • Search of social media: • Twitter (i.e. @AGSJournal), Blogs, PC-FACS, podcasts, Health In Aging Research Summaries (healthinaging.org) • Selection Criteria • Impact and Interest JAMA Int Med. 2017 Aug; 177(8): 1102-1109 1
6/19/2018 Background Methods • Single blind parallel group comparative • Most older adults have not engaged in advance effectiveness RCT • Everyone got some form of advance care planning care planning (ACP) • Potential barriers: • Included • Clinicians’ lack of time, training, and resources • 414 Veterans >= 60 years (9% women, 43% non-white) • Advanced directives are difficult to understand receiving primary care at the SFVAMC • 2 chronic medical conditions • 3 out of 4 patients won’t be able to participate • 2 additional visits to the clinic, ED or hospital in some or all of their end-of-life decisions • Excluded: • Surrogates are often feel unprepared • Dementia or delirium • Blindness or deafness 2
6/19/2018 Primary Outcome at 9 months* Other Outcomes Advance PREPARE + • Greater increase in self-reported ACP PREPARE Directive Advance P engagement in Prepare + AD group Only Directive • No differences in ease-of-use scales or New ACP 25% 35% 0.04 Documentation in EMR satisfaction scales Legal Forms (i.e AD, 13% 20% 0.04 • No differences in depression or anxiety POLST, DPOA) Documented Discussions 20% 26% 0.13 * adjusted for prior ACP documentation and potential clustering by physician 3
6/19/2018 Limitations Bottom Line • Generalizability: 9% women, single site • Materials viewed in study offices not in homes It’s time we flip the PREPARE, a free, patient facing ACP tool classroom on advance care increases advance directive planning ! documentation. #AGS18 prepareforyourcare.org 4
6/19/2018 Falls In Assisted Living: Is ER For All Really Necessary? • Assisted Living: The Wild West of Geriatrics • Rapidly growing, largely unregulated • Falls extremely common (> 1/year) • Default protocol: Call EMS with ER transfer • Is this really good for residents? • Highly burdensome on patients and families • Significant risk of iatrogenic complications Williams et al. Ann Intern Med. 2017 The Protocol: Assessing Urgency Collaboration to Safely Reduce ER and Risk Visits • Collaboration between • Paramedic did directed history and physical to assign resident • 22 Assisted Living Facilities in Wake County, NC to one of three tiers • Large physician house call practice • Tier 1: OMG!!! This could be bad: Transfer to ER • Primary care provider for over 60% of residents • Hemorrhage, hypotension, altered mental status, hip • 24/7 availability pain + limited ROM • Same day appointments • Tier 3: Why worry?: No ER • Wake County Emergency Medical Services • No complaint, no hip pain, simple contusion or • Use of advanced practice paramedic with additional laceration training in decision making and patient navigation • Tier 2: Not sure: (Phone consultation with housecall • Assisted Living Residents physician) • Ground level fall, cared for by house calls practice • anticoagulation, baseline cognitive impairment, need • 359 residents with 840 falls (mean age 86, 73% for pain management, need for splinting, borderline women) vitals, injury worse than simple contusion 5
6/19/2018 Outcomes Outcome: Time Sensitive Condition • 553 (64%) of 840 falls recommended for no transport • Conditions developing within 72 hours which • 366 Tier 3 indicated need for prompt evaluation • 187 Tier 2 (70% of the 264 tier patients) • Wound requiring repair • 11 (2%) residents recommended for no transport had time • Fracture sensitive condition • 4 patients requested and received transport • ICU admission • 3 with minor injuries successfully treated by house call • Need for surgery or cardiac catheterization doctor on site • Death • 4 patients potentially inappropriate care • 3 fractures diagnosed and treated within one day (no adverse outcome) • 1 death 60 hours later unrelated to fall • Thus, no resident had adverse outcome due to non transport An Aspirational Endeavor? Bottom Line • High quality care that most assisted living facilities • Time to reject the status quo and advocate for not equipped to deliver better care in assisted living • Need for house calls medical practice • Better Care is Possible • 24/7 telephone consultation • Partnership between assisted living facilities, • Rapid follow-up EMS, Physicians to do what is best for the resident • Need for well trained and committed • A patient-centered model of care with paramedics implications for many conditions • Most EMS models pay for transport but not evaluation 6
6/19/2018 Khan et al. J Am Geriatr Soc 66:254–262, 2018 (epub 2017) Transcatheter aortic valve Replacement (TAVR) and the Brain • TAVR is associated with an increase risk of stokes and TIA • Subclinical brain injury may be substantially more frequent than stroke • New silent cerebral ischemic lesions detected by diffusion-weighted MRI in 98% of patients post TAVR 1 1. Haussig et al. JAMA. 2016;316(6):592-601 JAMA. 2016;316(6):592-601. doi:10.1001/jama.2016.10302 7
6/19/2018 Transcatheter aortic valve What did they do? Replacement (TAVR) and the Brain • TAVR is associated with an increase risk of stokes • Metaanalysis of individuals undergoing TAVR for and TIA severe aortic stenosis • Inclusion: studies with standardized neuropsychological • Subclinical brain injury may be substantially more measures before and after TAVR frequent than stroke • 18 studies, 1,065 individuals • New silent cerebral ischemic lesions detected by • Data were extracted for cognitive scores diffusion-weighted MRI in 98% of patients undergoing TAVR 1 • Before TAVR • Perioperatively (within 7 days after TAVR) • Concern that silent cerebral infarcts are associated • 1, 3, and 6 months after TAVR with subtle cognitive change and with an increased • 12 to 34 months after TAVR risk of subsequent dementia 1. Haussig et al. JAMA. 2016;316(6):592-601 Cognitive Performance Before and Limitations After TAVR • Not a whole lot of studies and individuals • Perioperatively (11 studies, n=598)) • No difference • Used a variety of neurocognitive tests • 1 month (7 studies, n=287) (MOCA, MMSE, global cognitive dimension battery, etc) • Improvement in cognition • Some may not be as sensitive • 3 and 6 months after TAVR (4 studies) • Limited to overall cognitive outcomes and • No difference not specific domains of cognition • 12 to 34 months after TAVR (3 studies, n=190) • Worsening cognition may be • No difference underrepresented because because of competing risks including death and debilitating strokes. 8
6/19/2018 Take Home • Overall cognition may be preserved after TAVR despite multiple ”silent” microembolization • Considerable individual variation in some individual studies 1 • Post-TAVR delirium may be associated with cognitive decline 1 Schoenenberger. Circ Cardiovasc Interv. 2016 Chia-Hui Chen et al. JAMA Surg. 2017;152(9):827-834. 9
6/19/2018 Background Methods • Cluster randomized clinical trial • Delirium affects 13% to 50% of patients undergoing • 2000-bed urban medical center in Taipei noncardiac surgery • 377 older patients undergoing gastrectomy, • Hospital Elder Life Program (HELP) has been shown pancreaticoduodenectomy, and colectomy to decrease incidence of delirium, LOS, and falls 1 • Primary indication for surgery was malignant tumor In 90% • Can a modified Hospital Elder Life Program (mHELP) • Inclusion: reduce delirium and hospital LOS in older patients • elective abdominal surgery undergoing abdominal surgery? • expected LOS longer than 6 days • Randomized by room to receive the mHELP or usual care. 1. Hshieh TT, JAMA Intern Med 2015 mHELP mHELP • 3 protocols administered daily in an inpatient ward • Median start time of mHELP: postoperative day 1 by a trained mHELP nurse • 61% starting by post-op day 1 • Orienting communication • 88% received by post-op day 3 • Oral and nutritional assistance • Intervention group participants received the mHELP • Early mobilization for a median of 7 days • Staff blinded except mHELP nurse (who did not • Mean time spent with each participant per session was 34 minutes assess outcomes) • Two outcome assessors specially trained for delirium assessment using CAM 10
6/19/2018 Limitations Outcomes Results P value • Single site • Small Study Usual Care mHELP (179 patients) (196 patients) • Single mHELP nurse Delirium 15% 7% .008 During Hospital Stay* Length of Stay 14 days 12 days 0.04 * NNT =12 Take Home A modified Hospital Elder Life Program (mHELP) significantly reduces delirium and length of stay in patients undergoing abdominal surgery. #AGS18 11
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