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•A multimodal education program works to train geriatric syndrome screeners.•Triage nurse screening identifies high risk older adults in the emergency department.•Screening high risk older adults leads to identification of geriatric syndromes.

This manuscript is the result of work supported by the use of resources and facilities at the Louis Stokes Cleveland Department of Veterans Affairs Medical Center, specifically, the Geriatric Research Education and Clinical Center (GRECC). Deficiency in 25-hydroxyvitamin D (25[OH]D) is common, especially in the elderly and African Americans (AA). While 25(OH) D deficiency is associated with multiple negative health outcomes, current recommendations for supplementation of this deficiency may be insufficient. To determine the prevalence of 25(OH)D deficiency, the extent of vitamin D supplementation, and the effect of supplementation on 25(OH) D levels in an elderly Veteran population. The study also focused specifically on the role of race in the risk for 25(OH)D deficiency and in the response to vitamin D supplementation. A retrospective chart review was conducted of information including 25(OH)D serum levels pre and post-supplementation, race, and vitamin D supplementation. Subjects were community-dwelling Veterans (≥60years) followed by a VA geriatric clinic. A total of 234 charts were reviewed (124 Caucasian, 78 AA, 32 other/unknown race). Information collected through the chart review was analyzed by comparing the means of 25(OH)D levels pre and post-supplementation across races and across times. At Baseline 206 subjects (88%) were 25(OH)D deficient (<32ng/ml). While 80.6% of them were supplemented, only 10.24% (17 of 166) achieved normal 25(OH)D serum levels. AAs (n=78) had significantly lower Baseline levels compared to Caucasians (n=124) and differences were consistent across time. Fewer AAs than Caucasians increased to normal (AA:6.3%; Caucasian:12.8%). Conservative oral vitamin D supplementation is largely ineffective at achieving therapeutic serum levels, especially for AAs. Future research is needed to focus on individualized supplementation strategies and targeted risk factors such as race.

Background: The impact of patients' perceptions of discrimination in healthcare on patient-provider interactions is unknown. Objective: To examine association of past perceived discrimination with subsequent patient-provider communication. Research Design: Observational cross-sectional study. Subjects: African-American (N = 100) and white (N = 253) patients treated for osteoarthritis by orthopedic surgeons (N = 63) in 2 Veterans Affairs facilities. Measures: Patients were surveyed about past experiences with racism and classism in healthcare settings before a clinic visit. Visits were audio-recorded and coded for instrumental and affective communication content (biomedical exchange, psychosocial exchange, rapport-building, and patient engagement/activation) and nonverbal affective tone. After the encounter, patients rated visit informativeness, provider warmth/respectfulness, and ease of communicating with the provider. Regression models stratified by patient race assessed the associations of racism and classism with communication outcomes. Results: Perceived racism and classism were reported by more African-American patients than by white patients (racism: 70% vs. 26% and classism: 73% vs. 53%). High levels of perceived racism among African-American patients was associated with less positive nonverbal affect among patients [β = -0.41, 95% confidence interval (CI) = -0.73 to -0.09] and providers (β = -0.34, 95% CI = -0.66 to -0.01) and with low patient ratings of provider warmth/respectfulness [odds ratio (OR) = 0.19, 95% CI = 0.05-0.72] and ease of communication (OR = 0.22, 95% CI = 0.07-0.67). Any perceived racism among white patients was associated with less psychosocial communication (β = -4.18, 95% CI = -7.68 to -0.68), and with low patient ratings of visit informativeness (OR = 0.40, 95% CI = 0.23-0.71) and ease of communication (OR = 0.43, 95% CI = 0.20-0.89). Perceived classism yielded similar results. Conclusions: Perceptions of past racism and classism in healthcare settings may negatively impact the affective tone of subsequent patient-provider communication.

There is heightened interest today in improving the outcomes in a variety of groups of patients. 1 – 3 Most recent efforts to improve patients' outcomes, however, have focused on specific diseases, 4 , 5 treatments, 6 – 8 or behavior of physicians. 9 , 10 We evaluated a clinical system of care designed to improve overall outcomes in a heterogeneous group of older adults who were hospitalized for acute illnesses. Patients 65 years of age or older account for 31 percent of acute care hospital admissions in the United States and 45 percent of hospital expenditures for adults. 11 These older patients are at high risk for loss . . .

Acute Care for Elders Units offer enhanced care for older adults in specially designed hospital units. The care is delivered by interdisciplinary teams, which can include geriatricians, advanced practice nurses, social workers, pharmacists, and physical therapists. In a randomized controlled trial of 1,632 elderly patients, length-of-stay was significantly shorter-6.7 days per patient versus 7.3 days per patient- among those receiving care in the Acute Care for Elders Unit compared to usual care. This difference produced lower total inpatient costs-$9,477 per patient versus $10,451 per patient-while maintaining patients' functional abilities and not increasing hospital readmission rates. The practices of Acute Care for Elders Units, and the principles they embody, can provide hospitals with effective strategies for lowering costs while preserving quality of care for hospitalized elders. [PUBLICATION ABSTRACT]

BACKGROUND The extent to which treatment recommendations in the orthopedic setting contribute to well-established racial disparities in the utilization of total joint replacement (TJR) in the treatment of advanced knee/hip osteoarthritis has not been explored. OBJECTIVE To examine whether orthopedic surgeons are less likely to recommend TJR to African-American patients compared to white patients with similar clinical indications, and whether there are racial differences in the receipt of TJR within six months of study enrollment. DESIGN Prospective, observational study. PARTICIPANTS African-American (AA; n = 120) and white (n = 337) patients seeking treatment for knee or hip osteoarthritis in Veterans Affairs orthopedic clinics. MAIN MEASURES Patients completed surveys that assessed socio-demographic and clinical variables that could influence osteoarthritis treatment. Orthopedic surgeons’ notes were reviewed to determine whether patients had been recommended for TJR and whether they underwent the procedure within 6 months of study enrollment. RESULTS Rate of TJR recommendation was 19.5%. Odds of receiving a TJR recommendation were lower for AA than white patients of similar age and disease severity (OR = 0.46, 95% CI = 0.26–0.83; P = 0.01). However, this difference was not significant after adjusting for patient preference for TJR (OR = 0.69, 95% CI = 0.36–1.31, P = 0.25). Overall, 10.3% of patients underwent TJR within 6 months. TJR was less likely for AA patients than for white patients of similar age and disease severity (OR = 0.41, 95% CI = 0.16–1.05, P = 0.06), but this difference was reduced after adjusting for whether patients had received a recommendation for the procedure at the index visit (OR = 0.57, 95% CI = 0.21–1.54, P = 0.27). CONCLUSIONS In this study, race differences in patient preferences for TJR appeared to underlie race differences in TJR recommendations, which led to race differences in utilization of the procedure. Our findings suggest that patient treatment preferences play an important role in racial disparities in TJR utilization in the orthopedic setting.

Abstract Older adults made over 21 million Emergency Room (ER) visits accounting for nearly 46% of all ER hospital admissions in 2015. The ER setting provides not only a unique opportunity to assess patients’ health, functional status and social issues, but also provide recommendations to help coordinate care. Geriatric ER assessments have been associated with reduced avoidable hospitalizations, functional decline, and institutionalization. However, few ER clinicians including physicians, nurses and technicians have received adequate training to perform geriatric screenings and implement timely referrals. In 2014 American College of Emergency physicians and American Geriatric Society published guidelines for care. Based on these guidelines A” Geri-Vet Bootcamp” Program was developed and piloted at the Northeast Ohio VAMC. This program included: simulation emphasizing standardized screenings, and the use of decision support aides for management and referrals for older adults seen in the ER. Following this multi-modal education program, 91% clinicians reported greater ability to apply knowledge learned, 82% clinicians were able to more accurately identify geriatric syndromes, and 86% were able to identify additional resources. Of the patients screened over one year, 73% of patients were identified as being at high risk for falls, 32% had high family caregiver burden, 15% had moderate to severe dementia, and 14% had positive delirium screens. Those veterans screened by Geri Vet trained Staff received significantly more referrals than usual care staff, home care 28.7% vs.15.6%, geriatric clinic 20.5% vs. 11.7% and caregiver support 5.0% vs. 1.3%. Data show hospital admissions have decreased 5-7%. Education and dissemination continues

Abstract Osteoarthritis (OA) is a leading cause of disability among older adults. By 2050, approximately 60 million will suffer from arthritis adding up to a total societal cost of $65 billion. Chronic illnesses resulting in pain, and functional decline have been associated with depression in previous studies. The primary goal of this study is to investigate whether OA severity, as measured by the Western Ontario McMasters Arthritis Composite (WOMAC), impacts reported levels of depression and to what degree clinical and sociodemographic variables play a part. A causal model was developed and tested examining the antecedents of OA disease severity and depression. Information on clinical, demographic, socioeconomic, and psychosocial variables was collected on 596 male Veterans with moderate to severe symptomatic OA of the knee\\hip. A Confirmatory Factor Analysis was conducted to determine the factor structure of the WOMAC. A 2nd order three factor solution (pain, stiffness, and function) fit the data well (TLI of .94, a CFI of .94 and a RMSEA of .058). The results of the Structural Equation Model reveal a final model that fit the data well (TLI of .95, a CFI of .97 and a RMSEA of .047). Depression was predicted by higher WOMAC scores (beta=.37 , p<.01); higher levels of comorbidity (beta= .11, p<.05); younger age (beta= -.29, p<.01); being white (beta=-.11, p<.05); lower levels of income (beta= -.12, p<.05); lower levels of religiosity (beta= 11, p<.05). Clinicians should be aware of the impact of disease severity when treating OA patients with depression.

Abstract Evidence continues to mount that sleep apnea (SA) occurs in 10-25% of Americans and is associated with significant morbidity and mortality (Schulman 2018). Among veterans, SA has been reported four times more often as compared to other non-veteran cohorts. (Wong 2015). The risk of developing dementia is increased in older individuals with OSA (Shastri, Bangar, & Holmes, 2015). The prevalence and characteristics of older adults with dementia and sleep apnea is not well known and long-term population-based studies on mortality have been lacking. Recent studies have reported overall mortality rates of 19%, in those individuals with SA, an increased rate of 1.5-3 times the mortality rate as compared to those individuals those without SA. Current recommendations support SA screening of high risk individuals including those with symptoms of snoring, fatigue, memory and concentration problems and mood changes. (Krist 2018). Despite a large number of older adults with suspected SA and comorbidities, the majority are not screened, referred, diagnosed and treated. In this VA pilot study of outpatient older male veterans with dementia and SA, N=195, mean age 75.83 years, SD=9.1, 51.3% were white, 37.5% were black. Frequently found comorbidities were: hypertension 88%, congestive heart failure 41%, Diabetes. 62% and, stroke 21%. Of note, among those who died, SA was significantly related to congested heart failure (r=.32, p<.001) and COPD (r=.40, p<.001). The overall mortality rate of 27% was higher than previous reports. Further investigation is needed to better understand the relationship between comorbidities, and SA, screening, treatment and mortality.

Objective: Although indwelling urinary catheterization is unpleasant and can cause complications, it is often performed without a specific medical indication. The objective of this study was to determine which patient characteristics were associated with indwelling urinary catheterization in hospitalized older patients without a specific medical indication. Methods: We studied 1586 medical patients aged 70 or older admitted to two teaching hospitals without a specific medical indication for urinary catheterization. Patients were interviewed on admission and medical records reviewed to determine demographic characteristics, reason for admission, co-morbidity, illness severity, cognitive impairment, dependence in activities of daily living, urinary incontinence, bedrest orders, and use of an indwelling urinary catheter. Results: Urinary catheters were used in 378 patients (24%) without a specific medical indication for catheterization. In bivariate and multivariate analyses, urinary catheterization without a specific medical indication was associated (P < 0.05) with several patient characteristics, including female sex, Charlson co-morbidity score >2, APACHE II scores ≥10, and four specific geriatric issues. Even among patients with low co-morbidity and APACHE II scores, 35% of those with three or more geriatric issues received urinary catheterization without a specific medical indication. Conclusions: Patients ≥70 years with co-morbidities and higher illness severity, and those with specific geriatric issues were at high risk for urinary catheterization without a specific medical indication, possibly increasing their risk for hospital-related adverse outcomes.