Interdisciplinary Protocol for Surgery in Older Persons: Development and Implementation.

As the population ages, more older adults will undergo surgical procedures, and common physiologic changes can raise the risk for surgical complications while increasing morbidity and mortality. In conjunction with the National Surgical Quality Improvement Program, we piloted a comprehensive and interdisciplinary assessment and intervention protocol for perioperative care for patients aged ≥75 years undergoing elective general, gynecology-oncologic, and orthopedic surgery. The intervention included screening tools for cognitive, functional, and nutritional deficits, a Geriatric Nurse Champion on each inpatient surgical unit, and an interdisciplinary Geriatric Surgery Quality Committee.

Pain Management in the Post-acute and Long-Term Care Setting: A Clinical Practice Guideline (CPG) from the Society for Post-acute and Long-Term Care Medicine (AMDA).

This comprehensive clinical guideline addresses pain issues that arise in care of patients commonly seen in post-acute and long-term care settings, including very old and frail individuals with multiple chronic medical and psychiatric conditions, short-stay patients needing posthospitalization care, and younger adults with chronic diseases and disabilities. Its sections proceed along the steps of the clinical process, and hence include pain definition, recognition, and assessment; diagnosis and cause-effect analysis; identification of care objectives; selection of interventions from the wide range or potential options, including a discussion of appropriate and rational use of opioids; and monitoring of the progress and outcomes of management decisions. The guideline emphasizes treating pain in the context of each patient's overall condition and not as a separate issue.

Policy Recommendations Regarding Skilled Nursing Facility Management of Coronavirus 19 (COVID-19): Lessons from New York State.

To provide policy recommendations for managing Coronavirus 19 (COVID-19) in skilled nursing facilities, a group of certified medical directors from several facilities in New York state with experience managing the disease used e-mail, phone, and video conferencing to develop consensus recommendations. The resulting document provides recommendations on screening, protection of staff, screening of residents, management of Coronavirus 19 positive and presumed positive cases, communication during an outbreak, management of admissions and readmissions, and providing emotional support for staff. These consensus guidelines have been endorsed by the Executive Board of the New York Medical Directors Association and the Board of the Metropolitan Area Geriatrics Society.

Medication Reconciliation: An Educational Module.

Introduction: Patients often transition between health care settings, such as office to hospital, hospital to nursing facility, or hospital to home. When a patient is admitted, it is imperative that clinicians review prior medication lists along with new orders to reconcile any discrepancies. This process should occur in a standardized manner to reduce medication errors leading to adverse events and patient harm.

The Looming Geriatrician Shortage: Ramifications and Solutions.

Geriatricians are skilled in the recognition of asymptomatic and atypical presentations that occur in the elderly and provide comprehensive medication management including recognizing adverse drug events, reducing polypharmacy, and de-prescribing. However, despite the increasing average age of the U.S.

Impact of Hospital-Wide Comprehensive Pain Management Initiatives.

This project aimed to improve pain management through clinician education, updated assessment tools, computer resources, and improved ordering and delivery systems. Clinicians were surveyed and results analyzed using Wilcoxon-Mann-Whitney testing and χ testing. Prescribing patterns were evaluated by comparing proportions of prescription orders and dose intervals.

Palliative Care in New York State Nursing Homes: A Descriptive Study.

Objective: To describe the current landscape of palliative care (PC) in nursing homes (NHs) in New York State (NYS).

Measurements: A statewide survey was completed by 149 respondents who named 61 different NHs as their workplace. Questions were related to presence, type, and composition of PC programs; perceptions of PC; barriers to implementing PC; and qualifying medical conditions.

Road Map for Opioid Management in the Inpatient Setting: A Structured Approach to Opioid Selection and Titration.

Introduction: Effective pain management is a major challenge of medicine as patients with acute and chronic pain conditions require careful evaluation and treatment. Despite required pain management education in postgraduate training, effective pain management is often not achieved in the hospital setting. For example, the Accreditation Council for Graduate Medical Education in 2007 required internal medicine residencies to include instruction on pain management.

Impact of computerized physician order entry alerts on prescribing in older patients.

Background: A computerized physician order entry (CPOE) system provides opportunity for real-time alerts to prescribers. Winthrop University Hospital began using CPOE in 2009.

Objective: We sought to improve prescribing among older hospitalized patients by adding alerts to the CPOE system for potentially inappropriate medications.

Medical Therapy of Malignant Bowel Obstruction With Octreotide, Dexamethasone, and Metoclopramide.

Background: Malignant bowel obstruction is a highly symptomatic, often recurrent, and sometimes refractory condition in patients with intra-abdominal tumor burden. Gastro-intestinal symptoms and function may improve with anti-inflammatory, anti-secretory, and prokinetic/anti-nausea combination medical therapy.

Objective: To describe the effect of octreotide, metoclopramide, and dexamethasone in combination on symptom burden and bowel function in patients with malignant bowel obstruction and dysfunction.

Evaluation of physician assistant student knowledge and perception of competence in palliative symptom management.

Purpose: To assess the impact of the current curriculum for physician assistant (PA) students in palliative medicine and end-of-life care.

Methods: PA students were invited to participate in an anonymous online survey evaluating seven domains of knowledge in palliative medicine coupled with a self-assessment in competence. Participants were also asked to identify current and desired educational formats in palliative medicine education.

Prevalence and Description of Palliative Care in US Nursing Homes: A Descriptive Study.

Objective: To describe rates and policies in U.S. Nursing Homes (NH) related to palliative care, comfort care, and hospice care based on a nationwide survey of directors of nursing.

The impact of an end-of-life communication skills intervention on physicians-in-training.

The palliative medicine literature consistently documents that physicians are poorly prepared to help patients experience a "good death" and are often unaware of their ill patients' preferences for end-of-life care. The present study, enrolling 150 physicians, sought to improve their communication skills for end-of-life care. We found significant attitudinal changes and a greater degree of self-rated competence in delivering end-of-life care for those in the intervention group.

Antipsychotic drug use since the FDA black box warning: survey of nursing home policies.

Objectives: To use a nationwide survey to assess changes in antipsychotic utilization patterns and usage policies in nursing homes (NHs) in the United States since the introduction of the black box warning by the FDA.

Design/setting/participants: A survey was distributed online and was completed by 250 directors of nursing of NH. The directors of nursing answered questions concerning policies about and use of antipsychotic medications.

Evaluation of housestaff knowledge and perception of competence in palliative symptom management.

Purpose: The Accreditation Council for Graduate Medical Education requires that internal medicine (IM) core curricula include end-of-life care and pain management concepts and that fellows in hematology/oncology, pulmonary/critical care, and geriatrics should receive formal instruction and clinical experience in palliative and end-of-life care. We aimed to assess the effectiveness of current teaching methods for housestaff in these fields.

Method: All of the IM residents, geriatric medicine fellows, hematology/oncology fellows, and pulmonary/critical care fellows from four regional graduate medical education sites were asked to participate in an online survey at the beginning and end of the 2008-2009 academic year.

Smoking rates in dementia patients in the outpatient setting.

The purpose of this study is to determine the prevalence of tobacco use in patients diagnosed with dementia or cognitive impairment in an outpatient setting as they may be unsafe smokers and present safety risks to themselves and others. We conducted a retrospective chart review of new patients between 1/06 and 8/07 who were diagnosed with dementia or cognitive impairment in a geriatric outpatient practice. The data collected included age, gender, tobacco use patterns and mini-mental state examination (MMSE) score.

Antipsychotic treatments for the elderly: efficacy and safety of aripiprazole.

Delusions, hallucinations and other psychotic symptoms can accompany a number of conditions in late life. As such, elderly patients are commonly prescribed antipsychotic medications for the treatment of psychosis in both acute and chronic conditions. Those conditions include schizophrenia, bipolar disorder, depression and dementia.

Nursing home procedures on transitions of care.

Objective: To identify nursing home standards through a nationwide survey of directors of nursing regarding transitions of care for residents transferred from acute care hospitals to skilled nursing facilities (SNFs).

Methods: A national survey was distributed online and was completed by 241 directors of nursing of SNFs. The directors of nursing were asked about communication methods, transfer of records, and staff involvement with admissions from acute care hospitals.

Nursing home policies on items brought in from the outside for facility residents.

Objective: To identify nursing home standards related to items brought in from the community for residents through a nationwide survey of directors of nursing. Specifically we examined the policies with regard to food, cigarettes, alcoholic beverages, and over-the-counter medications.

Methods: A national survey was distributed online and was completed by 299 directors of nursing of skilled nursing facilities.

Nursing home resident smoking policies.

Objective: To identify nursing home standards related to resident smoking through a nation wide survey of directors of nursing.

Methods: A national survey was distributed online and was completed by 248 directors of nursing. The directors of nurses answered questions concerning resident smoking including the criteria utilized to determine an unsafe resident smoker.

Do geriatricians practice what they preach?: geriatricians' personal establishment of advance directives.

Previous research has been conducted regarding preferences of physicians for life-sustaining treatments for themselves, but there is a dearth of data on personal use of advance directives (ADs) by geriatricians specifically. Using a phone survey, we contacted all graduates of the geriatric fellowship program to assess their personal use of advance directives and their personal preferences for life-sustaining treatment. Of the 124 living graduates of the Parker Jewish Institute for Health Care and Rehabilitation, 70 agreed to participate.

Falls in the nursing home setting: does time matter?

Objectives: Falls increase morbidity and mortality among nursing home residents and have varied causes and risk factors. The purpose of this study was to assess whether falls in nursing home residents were more prevalent at particular times of the day.

Design/participants: This study was a retrospective chart review for falls in a skilled nursing facility in New York from January to June, 2007.

Quetiapine-associated dysphagia.

We report a case of quetiapine-induced dysphagia in a geriatric patient which improved with discontinuation of the antipsychotic. The patient had developed dysphagia while being treated with antipsychotics for bipolar disorder. The patient's dysphagia showed significant improvement when she was taken off quetiapine.