Faculty Bibliography

The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate-to-high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.

Falls are common events that threaten the independence and health of older adults. Studies have found a wide range of fall statistics in different ethnic and racial groups throughout the world. These studies suggest that fall rates may differ between different racial and ethnic groups. Studies also suggest that the location of falls, circumstances of falls, and particular behaviors may also be different by population. Also migration to new locations may alter an individual's fall risk. However, there are few studies that directly compare ethnic and racial differences in falls statistics or examine how known fall risk factors change based on race and ethnicity. This paper reviews the existing literature on how falls may differ between different racial and ethnic groups, highlights gaps in the literature, and explores directions for future research. The focus of this paper is community dwelling older adults and immigrant populations in the United States.

OBJECTIVES: To determine whether greater burden of geriatric conditions would have contrasting effects on quality of care (QOC) than nongeriatric, general medical conditions. DESIGN: Cross-sectional observation over 1 year of ambulatory care. SETTING: The Assessing Care of Vulnerable Elders-2 study. PARTICIPANTS: Older adults prospectively screened for falls, incontinence, and dementia (N = 644). MEASUREMENTS: Participant-level QOC in absolute percentage points calculated using 65 ambulatory care care-process quality indicators (QIs) for 13 general medical and geriatric conditions (#QIs provided/#QIs eligible). Secondary outcomes were geriatric QOC (a subset of 38 geriatric care QIs) and medical QOC (the 27 remaining nongeriatric QIs). Exposure variables were number of six medical conditions (medical comorbidity) and six geriatric conditions (geriatric comorbidity), controlling for age, sex, number of primary care visits, and site. RESULTS: Medical and geriatric comorbidity were unrelated to each other (correlation coefficient = 0.04, P = .27) yet had opposite effects on QOC. Each additional medical condition was associated with a 3.2-percentage point (95% confidence interval (CI) = 2.3-4.2 percentage point) increment in QOC, and each additional geriatric condition was associated with 4.9-percentage point (95% CI = 3.5-6.5 percentage point) decrement in QOC. Participants with greater geriatric comorbidity received poorer medical and geriatric QOC. CONCLUSION: Greater burden of geriatric conditions, or geriatric multimorbidity, is associated with poorer QOC. Geriatric multimorbidity should be targeted for better care using a comprehensive approach.

Falling is expected to increase among older adults due to demographic shifts. We investigated the epidemiology of falling in the U.S. from 1998 to 2010, hypothesizing that any increase would be due to changes in the population's age-structure. We used data from 7 waves (1998-2010) of the Health and Retirement Study, a nationally-representative longitudinal health survey. The sample included adults >65 years (n>10,590 for each wave). We defined falling as >1 self-reported falls in the prior 2 years. Covariates included: sociodemographic characteristics, 6 diseases, 4 geriatric conditions, body mass index, and participation in prior waves. Cross-sectional and longitudinal analyses used age-stratified logistic models to investigate fall prevalence across waves. Fall prevalence increased from 28.2% (1998) to 36.3% (2010). Fall injury showed no change in prevalence. Stratifying by age (1 year age cohorts), fall prevalence increased from 1998 to 2010 for adults age 65 to 82 years (Figure). Using fully adjusted age-stratified logistic models across waves, linear time predicted increased fall prevalence for all but 3 age strata (p<.05). Increased fall prevalence was not associated with respondents' participation in prior interview waves (either immediate preceding wave or total number of waves). Contrary to our hypothesis, the increase in fall prevalence (1998-2010) is not largely due to demographic changes. Rather, more older adults (at each year of age from 65 to 82) reported falling. A next step is to examine whether this increase in self-report is due to an increase in fall prevalence or an increase in falls awareness. (Figure presented)

40% of Medicare beneficiaries with diabetes (DM) are >76 years. This group is not included in clinical trials, so we have poor understanding of DM's natural history in this population and limited evidence to guide its treatment. We hypothesized that 1) clinical databases can provide valuable information about this group and 2) compared to other ages, DM patients >76 years have differing trajectories for hemoglobin A1c (A1c), LDL cholesterol, and systolic/ diastolic blood pressures (SBP/