Faculty Bibliography

Little is known about the association between cognitive dysfunction among informal caregivers and patients' plans and preferences for patients' end of life care. We report on the frequency of cognitive dysfunction among both patients and caregivers and examine associations between caregivers' cognitive screening scores and end of life plans and preferences of patients with advanced cancer. The current sample was derived from a National Cancer Institute- and National Institute of Mental Health-funded study of patients with distant metastasis who had disease progression on at least first-line chemotherapy, and their informal caregivers (n = 550 pairs). The Pfeiffer Short Portable Mental Status, a validated cognitive screen, was administered to patients and caregivers. Patients were interviewed about their end of life plans and preferences. Logistic regression models regressed patients' advance care planning and treatment preferences on caregivers' cognitive screen scores. Patients' cognitive screen scores were included as covariates. Most caregivers (55%) were spouses. Almost 30% of patients scored worse on the cognitive screen than their caregivers and 12% of caregivers scored worse than the patients. For each additional error that caregivers made on the cognitive screen, patients were more likely (AOR = 1.59, p = 0.002) to report that they preferred that everything possible be done to keep them alive and were less likely (AOR = 0.75, p = 0.04) to have a living will or a health care proxy/durable power of attorney. Worse caregiver cognitive screening scores were associated with higher likelihood of patients' reporting that they wanted everything done to save their lives and a lower likelihood of having a living will or other type of advanced care plan. Future studies should confirm these findings in other populations and determine the mechanisms that may underlie the identified relationships.

Antiretroviral therapy has enabled people to live long lives with human immunodeficiency virus (HIV). As a result, most HIV-infected adults in the United States are >50 years of age. In light of this changing epidemiology, HIV providers must recognize and manage multiple comorbidities and aging-related syndromes. Geriatric principles can help meet this new challenge, as preservation of function and optimization of social and psychological health are relevant to the care of aging HIV-infected adults, even those who are not yet old. Nonetheless, the field is still in its infancy. Although other subspecialties have started to explore the role of geriatricians, little is known about their role in HIV care, and few clinics have incorporated geriatricians. This article introduces basic geriatric nomenclature and principles, examines several geriatric consultation models from other subspecialties, and describes our HIV and Aging clinical program to encourage investigation of best practices for the care of this population.

People aging with HIV have medical and psychosocial needs that require more than the HIV services network can provide. HIV providers may lack experience managing multimorbidity or the functional consequences of aging. Social support services may be unable to provide necessary services for people living with HIV (PLWH) who are becoming increasingly frail or facing cognitive impairment. HIV providers will be caring for aging PLWH whose HIV management may seem simple compared with the significant burdens of stigma, mental health needs, social isolation, multimorbidity, and aging-related syndromes. Although practices can incorporate geriatric expertise and develop facility with the aging services network, a more comprehensive integration would adapt existing geriatric long-term care models for those aging with HIV. The diversity of aging PLWH and the tenuousness of the health safety net will necessitate innovative and flexible collaboration between content experts and social service agencies.

The World Health Organization, one of the leading authorities on pain management, stressed the need for further guidelines to help manage pain in patients with chronic disease. In light of the impact of pain on morbidity and quality of life, this article summarizes current knowledge about pain experienced by older adults in 3 advanced non-cancer-related chronic diseases (ie, congestive heart failure, end-stage renal disease, and stroke) in which pain is common but not typically a primary focus of disease management. This article examines the data on the prevalence of pain, co-occurring symptoms, and challenges in managing pain in these conditions.

Although 20% of adults 60 years and older receive community-based supports and services (CBSS), clinicians may have little more than a vague awareness of what is available and which services may benefit their patients. As health care shifts toward more creative and holistic models of care, there are opportunities for CBSS staff and primary care clinicians to collaborate toward the goal of maintaining patients' health and enabling them to remain safely in the community. This primer reviews the half-century history of these organizations in the United States, describes the most commonly used services, and explains how to access them.

Transcatheter aortic valve replacement offers patients with severe aortic stenosis an opportunity to live longer and better lives. Although this procedure allows clinicians to treat sicker and frailer patients who cannot undergo open heart surgery, age-related comorbidities, specifically cognitive impairment, must factor into the evaluation process.

BACKGROUND: Residents need to acquire an understanding of the biopsychosocial aspects of caring for older adults with chronic illness, along with effective use of interdisciplinary services inside and outside of the hospital. OBJECTIVE: We expanded the geriatric medicine experience for second-year internal medicine residents and present the results of the first year's experience. METHODS: We paired a mandatory rotation for postgraduate year-2 internal medicine residents (2 weeks of day and 1 week of night inpatient experience in the Acute Care for Elders Unit), and a 1-week outpatient systems-based practice experience with online modules and readings. Evaluation included a case presentation, an oral examination, a written questionnaire for all residents, and a global assessment of the residents' performance on the geriatrics portion of the 2012 In-Training Examination (ITE). RESULTS: All residents passed their oral examination; there was little difference between classes in systems-based practice knowledge. More than 90% (21 of 23) of the residents who took the rotation reported that it left a lasting impression on how they would care for their patients. Mean ITE scores in geriatrics for all residents increased from 53% (versus 61% overall) in 2010 to 87% (versus 81%) in 2012, although they dropped to 69% (versus 82%) in 2013. CONCLUSIONS: A rotation in geriatrics that is highly rated and covers both acute care and systems-based practice concepts is feasible for internal medicine residents. Residents did not learn detailed knowledge about specific programs for older adults, but clinical geriatrics knowledge improved.

BACKGROUND: Electronic communication between providers occurs daily in clinical practice but has not been well studied. PURPOSE: To assess the impact of provider-to-provider electronic communication tools on communication and healthcare outcomes through literature review. DATA SOURCES: Ovid MEDLINE, PubMed, Google Scholar, Cumulative Index to Nursing and Allied Health Literature, and Academic Search Premier. STUDY SELECTION: Publication in English-language peer-reviewed journals. Studies provided quantitative provider-to-provider communication data, provider satisfaction statistics, or electronic health record (EHR) communication data. DATA EXTRACTION: Literature review. DATA SYNTHESIS: Two reviewers conducted the title review to determine eligible studies from initial search results. Three reviewers independently reviewed titles, abstracts, and full text (where appropriate) against inclusion and exclusion criteria. LIMITATIONS: Small number of eligible studies; few described trial design (20%). Homogeneous provider type (physicians). English-only studies. CONCLUSIONS: Of 25 included studies, all focused on physicians; most were observational (68%). Most (60%) described electronic specialist referral tools. Although overall use has been measured, there were no studies of the effectiveness of intra-EHR messaging. Literature describing the effectiveness of provider-to-provider electronic communications is sparse and narrow in scope. Complex care, such as that envisioned for the Patient Centered Medical Home, necessitates further research.