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Low VA Screening Rates for Elder Abuse
This study sought to evaluate VA healthcare sites nationally to describe the landscape of elder abuse (EA) screening practices – and to provide a foundation for future program development to improve EA detection in VA and other healthcare settings. Findings showed that very few sites specifically screened for elder abuse in older Veterans and even fewer used a previously published tool to do so. Further, of the five sites using a published tool, four different EA screening tools were used. These findings are consistent with low and inconsistent uptake of EA screening in non-VHA healthcare settings in the context of no national guidelines recommending screening. Overall, 130 sites (94%) responded to the survey. Of these sites, 5 (4%) reported EA screening using published tools; 6 (5%) reported EA screening using unpublished questions; 53 (41%) reported no screening; and 62 (48%) reported general abuse/neglect screening for all patients. This study represents an important first step towards understanding the landscape and variability in EA screening practices in a national integrated health system – and identifying opportunities to implement standardized EA screening approaches that can be studied and improved upon.
Date: January 8, 2024
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VA-GRACE Program Effectively Supports Aging Veterans and Caregivers But Does Not Reduce Readmissions
The Geriatric Resources for Assessment and Care of Elders (GRACE) program is a collaborative, multidisciplinary care model that provides home-based geriatric care management. This study evaluated VA-GRACE from its implementation (2010) to 2020 in terms of its effect on mortality and readmissions – and examined patient, caregiver, primary care provider, and VA-GRACE staff satisfaction. Findings showed that Veterans receiving VA-GRACE services had a much greater comorbidity burden than Veterans in usual care, indicating that the program is serving its target population: highest-risk, community-dwelling older Veterans. Veterans participating in VA-GRACE had higher 90-day and one-year hospital readmissions, but lower 90-day mortality rates than Veterans in usual care. Veterans, caregivers, and primary care providers reported very high satisfaction with the program. More specifically, Veterans and caregivers reported that VA-GRACE home visits reduced travel burden, and that the program linked them to needed resources. Primary care providers reported that the VA-GRACE team helped reduce their workload, improved medication management for their patients, and provided a view into patients’ daily living situation.
Date: August 29, 2022
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Intervention May Decrease Workplace Staff Injury Rates Due to Assaults in VA Community Living Centers
An interdisciplinary, person-centered, behavioral intervention for managing distress behaviors in dementia, called STAR-VA, has been implemented in VA Community Living Centers (CLCs). This study sought to describe the incidence of workplace disruptive behavior incidents and staff injury rates occurring in 120 CLCs (62 of which had completed STAR-VA training) from FY12-FY17 and to assess the association between STAR-VA implementation and workplace incidents. Findings showed that the implementation of STAR-VA was significantly associated with lower staff injury rates due to assault, particularly following the first year of training, but was not associated with other reported workplace disruptive behavior incident rates. Verbal incident rates increased over time. STAR-VA lowered agitation and target distress behavior frequency and severity among CLC residents with dementia.
Date: August 30, 2021
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Two Studies Show Positive Impact of COVID-19 Vaccinations on VA and Community Nursing Home Residents
U.S. nursing homes incurred more than one-third of COVID-19 fatalities in the United States and began vaccine clinics in mid-December. The first study describes the proportion of COVID-19 positive tests among 130 VA Community Living Centers (CLCs) before and after COVID-19 vaccination. Findings showed that the number of COVID-19 positive tests dropped among all CLC residents in the fourth week after vaccination, with an approximately 75% drop in the proportion of COVID-19 positive tests. The second study compared incident COVID-19 infection and 30-day hospitalization or death among residents with COVID-19 between non-VA nursing homes with earlier versus later vaccine clinics. Findings showed that one week after their initial vaccine clinics, nursing homes with earlier vaccination had 2.5 fewer new COVID-19 infections per 100 at-risk residents than expected relative to facilities with later vaccination. Cumulatively over 7 weeks, earlier vaccination facilities had 5.2 fewer infections per 100 at-risk residents and 5 fewer hospitalizations and/or deaths per 100 infected residents. These results suggest that COVID-19 vaccines accelerated the rate of decline of incident infections, morbidity, and mortality.
Date: April 16, 2021
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Inequities in Enhanced Pension Benefit for Veterans
This study examined sociodemographic, medical, and healthcare use characteristics associated with receipt of the Aid and Attendance (A&A) benefit among Veterans receiving pension. Findings identified potential inequities in Veterans’ receipt of the A&A enhanced pension. Among 89,845 Veterans who received a pension but not the A&A enhanced benefit in FY2016, 8,724 Veterans (10%) newly received the A&A enhanced pension in FY2017. Veteran pensioners who received A&A were significantly older and more likely to be white and married than those who did not receive A&A. Pensioners who were black, Hispanic, or other non-white race had a lower probability of receiving A&A than white Veterans after adjusting for indicators of need. Most indicators of need for assistance (e.g., home health use, dementia, stroke) were associated with significantly higher probabilities of receiving A&A, with notable exceptions: pensioners with PTSD or enrolled in Medicaid had lower probabilities of receiving A&A. Among Veterans receiving pension, receipt of A&A varied by medical center. While provider education and wider dissemination of information about A&A may help reduce observed inequities, action is required at the system level that will eliminate the possibility of bias in which some eligible pensioners are able to access this enhanced pension benefit and others are not.
Date: February 25, 2021
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Effectiveness of Deprescribing Interventions for Community-Dwelling Older Adults
This systematic review and meta-analysis evaluated the effectiveness, comparative effectiveness, and harms of deprescribing interventions in community-dwelling persons aged 65 or older. Findings showed that medication deprescribing interventions may provide small reductions in mortality and use of potentially inappropriate medications. Comprehensive medication review may have reduced all-cause mortality but probably had little to no effect on falls, health-related quality of life, or hospitalizations. Nine of thirteen trials reported fewer inappropriate medications in the intervention group. Among various educational initiatives, findings showed that they may reduce the use of inappropriate medications, but had uncertain effects on quality of life and rates of hospitalizations and falls. Among computer decision support interventions, two studies reported a significant reduction in inappropriate medications and two studies reported no effect. No studies assessed the comparative effectiveness of the different deprescribing approaches.
Date: August 20, 2020
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Repeated Temperature Readings with Patient Baseline Increases Sensitivity for COVID-19 Detection among Elderly Veterans
The purpose of this study was to compare temperature trends and identify maximum temperatures in Community Living Center (CLC) residents 14 days prior to and following systematic testing for COVID-19. Findings showed that a single temperature screening is unlikely to accurately detect COVID-19 in nursing home residents. Only 27% of residents who tested positive for the virus met the temperature threshold (38°C or 100.4°F) during the study period. While most nursing home residents (63%) with confirmed COVID-19 experienced two or more 0.5°C elevations above their baseline temperatures, there also was a group (20%) that was persistently cooler and had no temperature deviation from baseline. Temperatures in elderly Veterans with COVID-19 began rising 7 days prior to testing for the virus – and remained elevated during the 14-day follow-up. The average maximum temperature in COVID-19 positive patients was 37.66°C (99.8°F) compared to 37.11°C (98.8°F) in patients who were COVID-19 negative. Study findings suggest that the current fever threshold for COVID-19 screening should be reconsidered. Repeated temperature measurement with a patient-derived baseline could increase sensitivity for surveillance purposes when applied to a nursing home population.
Date: June 8, 2020
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Mobile Acute Care for Elders (MACE) Consultation Lowers Readmission and Mortality Rates
Underlying geriatric syndromes in hospitalized patients can lead to complications such as delirium, falls, and functional decline, which in turn may lead to increased morbidity, mortality, readmission, longer hospital stays, decreased quality of life, and increased costs. Mobile Acute Care for Elders (MACE) has emerged as a way to provide dedicated geriatric care designed to prevent these complications, without the need for a physical inpatient unit. This study examined records of Veterans admitted to the Indianapolis VA Medical Center who were age 65 and older and were screened within 48 hours of admission for geriatric syndromes. For positive screens, admitting staff was offered MACE consultation and ongoing collaboration with a geriatrician and gerontological nurse practitioner. Although no results were statistically significant, Veterans receiving MACE had lower odds of 30-day readmission than those not receiving MACE (12% vs.15%) and lower odds of 30-day mortality (6% vs.9%). The group of Veterans receiving MACE had lower median costs for 30-day readmission than the group not receiving MACE ($16,000 vs. $18,000). The MACE consultation model for older Veterans with geriatric syndromes leverages the limited supply of clinicians with geriatrics expertise. It has the potential to improve care of older Veterans while achieving cost savings to the health system.
Date: December 21, 2018
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Antihypertensive Deintensification Associated with Fewer Falls among Older VA Nursing Home Residents
This study sought to: 1) describe the frequency of antihypertensive de-intensification during scenarios suggesting over-aggressive treatment, 2) identify characteristics of residents associated with antihypertensive de-intensification, and 3) examine the association between antihypertensive de-intensification and subsequent falls. Findings showed that among Veterans with possibly over-aggressive antihypertensive treatment, just 11% underwent antihypertensive de-intensification. Among Veterans with low systolic blood pressure (SBP 80-100), antihypertensive de-intensification was associated with a lower risk of falling, but was not associated with risk of hospitalization or death. Among Veterans with possibly low SBP (101-120), antihypertensive de-intensification was associated with a higher risk of death, but not with risk of falling or hospitalization. In frail older adults, clinicians should repeatedly re-evaluate intensity of blood pressure management, taking into account the individual’s prognosis, goals of care, and an individualized estimate of the benefits and harms associated with the intensity of antihypertensive medication.
Date: December 1, 2018
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VA Geriatric Patient Aligned Care Teams Need Additional Mental Health Integration for Older Veterans
Geriatric Patient Aligned Care Teams (GeriPACT) provide healthcare for a subset of older Veterans with chronic disease, functional dependency, cognitive decline, and psychosocial challenges. This study examines mental healthcare integration within GeriPACT by describing the role of psychiatrists/psychologists to help inform geriatric mental health policy. Findings showed that mental health integration was less than 50% in the GeriPACT teams in this study: only 43% of GeriPACT teams had a mental health provider – either a psychiatrist (29%) and/or psychologist (24%). Teams with psychiatrist/psychologist providers were more likely to endorse management of psychosocial issues, dementia, and depression, indicating the potential benefit of including mental healthcare providers on teams.
Date: September 13, 2018
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Prior to Choice Act Elderly Medicare-Enrolled Veterans Increased Use of VA Healthcare versus Medicare
This study examined long-term trends in reliance on VA outpatient care at the system level among elderly Medicare-enrolled Veterans from FY2003 to FY2014. Findings showed that the number of elderly Veterans enrolled in VA and Fee-for-Service (FFS) Medicare was 1.7 million in 2003, decreasing to 1.5 million in 2014. Medicare-enrolled Veterans, who had a choice of using VA or Medicare providers, steadily increased their reliance on VA outpatient services (all categories) prior to the Choice Act. Elderly Medicare-enrolled Veterans received most of their mental healthcare from VA (75% in 2003 to 77% in 2014), while receiving most of their primary care (76% in 2003, 65% in 2014), specialty care (86% in 2003, 78% in 2014), and surgical care (85% in 2003, 78% in 2014) through Medicare. The increase in VA reliance was driven by a decrease in Medicare-only users, and an increase in VA-only users. Among users during the study period, the proportion of VA-only users increased in primary care (28% to 40%), mental health (80% to 88%), specialty care (18% to 26%), and surgical care (18% to 28%). Similar trends were seen in seven high-volume medical subspecialties. Despite the recent controversies of access to VA care, elderly Medicare-enrolled Veterans were increasingly reliant on VA outpatient care across a diverse range of services at the life stage of growing healthcare needs. This may reflect their greater satisfaction with VA care.
Date: August 27, 2018
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Easy-to-Use Advance Care Planning (ACP) Tools Increase Planning among Older Veterans
Study investigators created the PREPARE website, which has been shown to empower older adults to engage in advance care planning (ACP) through the use of a simple 5-step process and “how-to” videos. In addition, the team created an easy-to-read advance directive (AD) that has significantly increased patient documentation of ACP. The objective of this randomized clinical trial was to compare the efficacy of PREPARE plus the easy-to-read AD vs. the AD alone to increase ACP documentation and engagement. Findings showed that PREPARE plus an easy-to-read AD resulted in statistically significant higher advance care planning documentation (35%) compared with an easy-to-read AD alone (25%). Both tools were rated highly in terms of ease-of-use, satisfaction, helpfulness, and the likelihood Veterans would recommend the guide to others.
Date: August 1, 2017
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Initiative Decreases Inappropriate Prescribing to Older Veterans Discharged from VA Emergency Department Care
This study evaluated the effectiveness and sustainability of the Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED) program to reduce the use of potentially inappropriate medications (PIMs). Findings showed that EQUiPPED was associated with a sustained reduction in inappropriate medication prescribing at all four VAMCs in the study. Post-intervention, the proportion of PIMs at site one decreased from 12% to 5%; at site two it decreased from 8% to 5%, at site three from 9% to 6%, and at site four from 7% to 6%. The implementation timeline for the initiative ranged from 6 to 14 months depending on the site. While the implementation timelines varied across sites, all VAMCs achieved a monthly PIM proportion between 5% and 6%. The EQUiPPED intervention led to safer prescribing and was sustainable across multiple VA sites. Implementation is currently underway at six additional VA emergency department sites, as well as three non-VA ED sites to evaluate broader dissemination.
Date: April 7, 2017
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Comparing Food Insecurity between Veterans and non-Veterans
This study examined the prevalence of food insecurity in an older male population. Findings showed that there was a significantly lower prevalence of food insecurity among male Veterans compared to non-Veterans (6% vs. 12%, respectively). Nevertheless, several factors predisposed male Veterans to a higher risk for being food insecure. Younger Veterans (aged 50-64) were more likely to be food insecure and had nearly three times the prevalence of food insecurity compared to Veterans aged 65+ (12% vs. 4%, respectively). Overall, having a psychiatric diagnosis, self-reporting symptoms consistent with clinical depression, smoking, and experiencing any difficulty with activities of daily living (ADLs) were all significantly associated with increased odds of being food insecure, even after adjustment for demographics, medical comorbidities, and economic status. As Veterans aged 50-64 are not yet eligible for Social Security benefits, this group in particular should be screened for food insecurity.
Date: March 23, 2017
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Systematic Review Finds Treating Blood Pressure to Current Guidelines in Older Adults Improves Health Outcomes
This systematic review sought to compare the effects of more versus less intensive blood pressure control in older adults. Findings showed that treating blood pressure in adults over 60 to at least current guideline standards (<150/90 mmHg) substantially improves health outcomes in older adults, including reducing mortality, stroke, and cardiac events. The most consistent and largest effects were seen in studies of patients with higher baseline blood pressure (SBP >160mmHg) who achieved moderate blood pressure control (<150/90 mmHg). There is less consistent evidence, largely from one trial targeting SBP <120 mmHg, that lower blood pressure targets are beneficial for high cardiovascular risk patients. In patients with prior stroke or transient ischemic attack, treating to SBP < 140 mmHg reduces the risk of recurrent stroke. Lower blood pressure targets did not increase falls or cognitive decline, but were associated with hypotension, syncope, and greater medication burden.
Date: March 21, 2017
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Veterans with Dementia Using Both VA and Medicare More than Double their Odds of Exposure to Potentially Unsafe Medications
This study examined the prevalence and effect of dual use of VA and Medicare Part D prescription medications on prescribing safety among a national cohort of Veteran outpatients (aged >68 years) with a diagnosis of dementia prior to 2010, who were dually-eligible. Findings showed that the prevalence of exposure to potentially unsafe medications was high overall (44%), but was particularly high in dual users compared to VA-only users (59% versus 39%). Thus, compared to VA-only users, dual VA/Medicare users more than doubled the odds of exposure to potentially unsafe medications (PUM) overall –and to any “high-risk medications to avoid in older adults.” Dual-users had an adjusted average of 44 additional PUM-days of exposure compared to VA-only users. The odds of antipsychotic PUM exposure were 1.5 times greater for dual-users. Policymakers should consider implementing electronic health information exchanges and additional medication therapy management services across healthcare systems to keep pace with recent policies designed to expand Veterans’ access to non-VA care – and to protect vulnerable patients from risks associated with dual system use.
Date: December 6, 2016
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Prescription Opioids Associated with Lower Likelihood of Sustained Improvement in Pain among Older Veterans
This study sought to identify patient factors associated with improvements in pain intensity in a national cohort of Veterans 65 years or older with chronic pain. Findings showed that on average, Veterans prescribed an opioid were less likely to demonstrate sustained improvement in pain intensity scores compared to Veterans who were not prescribed opioids. Overall, average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds of Veterans met criteria for sustained improvement during follow-up. Findings call for further characterization of heterogeneity in pain outcomes in older adults, as well as further analysis of the relationships between prescription opioids and treatment outcomes.
Date: July 1, 2016
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Home-based Geriatric Care Management Decreases Rate of VA Healthcare Utilization for Older Veterans following Hospitalization
This practical clinical trial assessed Veterans aged 65 years and older with primary care providers (PCPs) from VAMCs in Indianapolis, IN, who were enrolled in the Geriatric Resources for Assessment and Care of Elders (GRACE) Team Care program following hospital discharge to home compared to Veterans who were not enrolled after hospital discharge. Findings showed that enrollment in GRACE was associated with a 7% reduction in emergency department visits, 15% fewer 30-day readmissions, a 38% reduction in hospital admissions, and 29% decreased total bed days of care. The 179 Veterans enrolled in GRACE avoided 15 hospital admissions and 53 readmissions in the year after program enrollment. This saved VA more than $200,000 in the first year – over and above GRACE program costs.
Date: July 1, 2016
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Antiviral Treatment Reduces Risk of Cirrhosis, Hepatocellular Cancer and Mortality among Veterans, Irrespective of Age
This study examined the association between age subgroups and risk of cirrhosis, hepatocellular cancer (HCC), or death among Veterans who tested positive for the hepatitis C virus (HCV), including those who received treatment in VA facilities. Findings showed that receipt of curative antiviral treatment was associated with a reduction in the risk of cirrhosis, HCC, and overall mortality, irrespective of age. Elderly Veterans were significantly less likely to receive antiviral treatment; however, among those who received treatment, sustained virological response was not different among the age groups, even after adjusting for other demographic and clinical factors, including comorbidities. Given the accelerated progression to advanced liver disease, elderly patients with chronic hepatitis C constitute a high-risk group that may need to be prioritized in the era of new antiviral treatments.
Date: April 3, 2016
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The Gerontologist Supplement Highlights VA Research on Health Issues Affecting Older Women Veterans
This Supplement includes 13 articles that highlight findings on a range of topics related to women Veterans and aging, such as, menopause, diabetes, cardiovascular disease, chronic pain, and substance use.
Date: February 1, 2016
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Study Assesses VA/Alzheimer’s Association Care Coordination Program for Informal Caregivers of Veterans with Dementia
A new initiative targeting caregivers of Veterans with dementia is “Partners in Dementia Care” (PDC) — a care-coordination program delivered via a partnership between VA and Alzheimer’s Association chapters. This study assessed the effectiveness of the PDC program. Findings showed that the PDC program is a promising model that improves linkages between VA healthcare services and community services for informal caregivers of Veterans with dementia. Compared to comparison caregivers, those who participated in the PDC program had significant improvement in outcomes representing unmet needs, all three types of caregiver strains, depression, and support resources. Most improvements were evident after six months, with more limited improvements from months 6 – 12. However, improvements after the first six months were maintained during the entire study. Some outcomes improved for all caregivers, while others improved for caregivers with more initial difficulties – or those who were caring for Veterans with more severe impairments.
Date: August 1, 2013
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Association between Several Common Antiepileptic Drugs and Suicide-Related Behavior in Older Veterans
This retrospective study examined the relationship between antiepileptic drugs (AEDs) and suicide-related behaviors among Veterans aged 65 years and older who received VA healthcare. Findings showed that, within the study sample of 2 million older Veterans, there were 332 cases of suicide-related behavior (SRB). Exposure to antiepileptic drugs was significantly associated with suicide-related behavior, even after controlling for psychiatric comorbidity and prior SRB. Individuals who received AEDs were significantly more likely to have prior diagnoses of suicide-related behavior, depression, anxiety, bipolar disorder, PTSD, schizophrenia, substance abuse/dependence, conditions associated with chronic pain, and dementia. Veterans who received prescriptions for several specific AEDs – valproate, gabapentin, lamotrigine, levetiracetam, phenytoin, and topiramate – were at greater risk of diagnosed suicide-related behavior than Veterans with no AED exposure. Findings indicated that suicide-related behavior may occur as early as one week following AED use.
Date: October 30, 2012
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Older Veterans Less Likely to Receive Treatment for Depression
In this study, 64% of Veterans with a new diagnosis of depression received some form of treatment within 12 months; however, one third (36%) of the Veterans in this study did not receive any treatment for their depression. Of those Veterans who did receive treatment, most received both antidepressants and psychotherapy (27%), followed by 21% who received antidepressants only, and 16% who received psychotherapy only. The odds of receiving any kind of treatment decreased notably with increasing age. Veterans ages 50 to 64 were more likely to receive antidepressants, psychotherapy, or both compared to those in the older age groups. Results also showed that depressed older adults with no medical comorbidities were more likely to receive both antidepressants and psychotherapy compared to no treatment. This study highlights the importance of continued outreach and intervention efforts for depressed older Veterans who are vulnerable to being under-treated.
Date: March 1, 2012
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Multi-Component Support Program Helps Lessen Burden for Caregivers of Aging Veterans with Disabilities
A multi-component support services program that allowed Veterans aging with a disability to remain in the home, while also addressing the unmet needs of caregivers, was implemented and evaluated in one VA facility in 2009. Caregivers experienced meaningful improvements in burden after support services were rendered. Although there were no changes in caregivers’ physical health status, the support services program had a positive impact on mental health that was reflected in significant improvements in caregiver scores on the mental health components of the SF-12 health status scale. Satisfaction with services increased from baseline to follow-up.
Date: February 1, 2012
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Diabetes Managed More Intensively in Older Veterans with Dementia and Cognitive Impairment
This study sought to examine and compare anti-glycemic medication use, glycemic control, and risk of hypoglycemia in older Veterans with and without dementia or cognitive impairment. Findings showed that diabetes was managed more intensively in older Veterans with dementia or cognitive impairment than in those with no impairment, with more patients on insulin (30% vs. 24%) among those with cognitive problems. These conditions were independently associated with a greater risk of hypoglycemia. Of all Veterans taking insulin, the incidence of hypoglycemia was higher among those with dementia (27%) or cognitive impairment (20%) than among those with neither condition (14%). Veterans with dementia or cognitive impairment also had a greater decline in HbA1c over the 2-year study period. These findings suggest that providers were less likely to pursue individualized glycemic goals, as recommended by VA-DoD clinical practice guidelines (updated in 2010), when patients had cognitive problems.
Date: December 8, 2011
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Adverse Drug Reactions Associated with Polypharmacy are Common Cause of Unplanned Hospitalizations among Older Veterans
This study sought to describe the prevalence of unplanned hospitalizations caused by adverse drug reactions (ADRs) among older Veterans. Findings showed that adverse drug reactions are a common cause of unplanned hospitalization among older Veterans, are frequently preventable, and are associated with polypharmacy (overall, 45% of Veterans took >9 outpatient medications and 35% took 5 to 8). The most common ADRs that occurred were bradycardia, hypoglycemia, falls, and mental status changes. Of the 678 unplanned hospitalizations that occurred during the study period, 70 ADRs involving 113 drugs occurred in 68 older Veterans, of which 37% were preventable. Extrapolating to a population of more than 2.4 million older Veterans receiving care during this time, 8,000 hospitalizations costing about $110 million (using FY04 dollars) may have been unnecessary. The most common reason for a preventable ADR was suboptimal prescribing (52%), followed by patient non-adherence (28%), and suboptimal monitoring (12%). In addition, 4 medication classes (cardiovascular, central nervous system, anti-thrombotic, and endocrine) accounted for almost 80% of all the drugs implicated in ADRs.
Date: December 8, 2011
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Quality Indicators may Lead to Unintended Harm in Elderly Patients with Complex Health Issues
This article highlights two ways that current quality indicators may lead to unintended harms for older patients with complex medical problems and proposes ways to improve quality indicators by minimizing or preventing those harms. For example, current quality indicators are unbalanced, with many encouraging more appropriate care but few indicators discouraging inappropriate care, such as mammography screening for patients with pre-existing advanced cancer or advanced dementia, who are unlikely to benefit. The authors suggest that quality indicators be refined and improved to drive real quality improvement for the entire patient population.
Date: October 5, 2011
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Potential Problems with the Use of Antidepressants among Older Veterans Residing in VA Nursing Homes
This study examined the prevalence and patient/site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants among Veterans aged 65 years and older that were admitted to any one of 133 VA Community Living Centers (CLC, previously called Nursing Home Care Units). Findings suggest potential problems with the use of antidepressants in older Veterans that reside in VA CLCs. Overall, only 18% of antidepressant use was optimal. Of the 877 Veterans with depression, 25% did not receive an antidepressant, suggesting potential underuse. Among depressed Veterans who received antidepressants, 43% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. In addition, of the 2,815 Veterans who did not have depression, 42% were prescribed one or more antidepressants; of these, only 4% had an FDA-approved labeled indication, suggesting potential overuse. Also, the co-prescribing of antipsychotics (in patients without schizophrenia) among those without depression was associated with an increased risk of antidepressant overuse.
Date: August 1, 2011
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Excessive Caution in Prescribing to Veterans with Geriatric Conditions May Be Unnecessary
This study evaluated whether common geriatric conditions were associated with risk of adverse drug events (ADEs). Findings show that over the one-year study period, 126 Veterans suffered a total of 167 ADEs, but there was no association between the presence of various geriatric conditions and ADEs. However, in exploratory analyses investigators found that the use of new medications (present at 12-month follow-up) was associated with a higher risk of ADEs. The authors suggest that while it is important to consider the unique circumstances of each patient, excessive caution in prescribing to elders with geriatric conditions may not be warranted.
Date: April 1, 2011
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Aggression May Be Linked to Psychosis in Elderly Persons with Dementia
This literature review examined the evidence on whether delusions or hallucinations contribute to the development of agitation or aggression in persons aged 65 and older with dementia. Most studies showed a statistically significant association between psychosis and aggression. Findings also showed that the use of antipsychotic medications in the setting of agitation/aggression and psychosis among patients with dementia is not uniformly supported. Authors note that given the multifactorial etiology of psychosis and aggression with other comorbid symptoms in dementia, it is important to understand the various contributing factors to facilitate more effective treatment interventions with least possible risk.
Date: June 1, 2010
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All Antipsychotics May Not Increase Short-Term Risk for Mortality among Veterans with Dementia
Commonly prescribed doses of haloperidol, olanzapine, and risperidone, but not quetiapine, were associated with short-term increases in mortality. During the first 30 days, there was a significant increase in mortality in subgroups prescribed a daily low dose of haloperidol, olanzapine, or risperidone, after adjusting for demographics, comorbidities, and medication history. However, increased mortality was not seen when quetiapine was prescribed. No antipsychotic was associated with increased mortality after the first 30 days. Therefore, the authors suggest that all antipsychotics might not pose the same degree of risk in all patient groups as implied by the general warnings that have been issued.
Date: May 7, 2010
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Assessment Tool for Elderly Adults’ Capacity to Live Independently
An interdisciplinary team of clinicians developed the Capacity Assessment and Intervention (CAI) model to evaluate vulnerable patients – and to assess their capacity for safe and independent living. Despite some challenges, the authors suggest that the CAI model provides a systematic approach to initiating, conducting, and following through an assessment of an older adult’s capacity to make and execute decisions regarding safe and independent living in the community.
Date: May 1, 2010
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More than One-Quarter of Elderly Individuals Require Surrogate Decision-Making Near the End of Life
Of the 3,746 elderly adults (non-Veterans) in this study, 26.8% required decision-making at the end of life and lacked decision-making capacity. Thus, surrogate decision-making was often required. Of those requiring surrogate decision-making, 67.6% had advance directives. Individuals who authored advance directives received care that was strongly associated with their preferences. And those who requested all care possible were far more likely to receive aggressive care compared to those who did not request it. Individuals with advance directives preferred limited and comfort care more than all care possible. Cognitive impairment, cerebrovascular disease, and nursing home status were associated with the need for decision-making and lost decision-making capacity before death; but these characteristics were so common (present in 65.3% of the study population) as to not be clinically useful risk factors.
Date: April 1, 2010
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Nursing Homes’ Disaster Response Activities Following Hurricanes Katrina and Rita
Hurricanes Katrina and Rita exposed significant flaws in the U.S. preparedness for catastrophic events – and in the nation’s capacity to respond to them. This article reviews VA’s response to these hurricanes, in regard to nursing home evacuation, and the literature on nursing home evacuation. Authors also propose a conceptual model to help guide decision-making for future evacuations.
Date: March 24, 2010
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Older Elderly Patients Experience Poorer Outcomes Following Collaborative Depression Care
This study examined the differences between young-old (age 60 to 74) and old-old (age 75 and older) patients who received collaborative depression care as part of the IMPACT (Improving Mood: Promoting Access to Collaborative Treatment) study, which include both VA and non-VA patients. Findings show that young-old and old-old patients who receive collaborative depression care have a similar initial clinical response, but old-old patients may have a lower rate of long-term treatment response and complete remission. For example, young-old and old-old patients randomized to the IMPACT intervention responded similarly to initial treatment at 3 months, but the old-old were less likely to respond to treatment at later follow-up intervals. Treatment response and remission rates peaked for both age groups at 6 months, although treatment response rates for the young-old were significantly higher than those for the old-old group (51% vs. 44%). Study findings also show that the process of care did not differ between young-old and old-old patients who received the IMPACT intervention.
Date: December 1, 2009
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Implementing a Successful Fall Prevention Program for Elderly Veterans
This article discusses the implementation of a Telecare fall prevention program at the VA Greater Los Angeles Healthcare System (VAGLAHS) that was designed to be sustainable. Findings show that leadership and workgroup meetings led to the development of a functional program. The Telecare fall prevention program screened its first Veteran in October 2008 and is ongoing. The program uses an existing telephone nurse advice line to: 1) place outgoing calls to Veterans at high risk of falling, 2) assess the Veterans’ risk factors, and 3) triage Veterans to the appropriate services. Because Telecare operates via the telephone, it can accept referrals from anywhere in VAGLAHS, thus reaching Veterans in geographically remote areas. The authors suggest that another potential advantage of the Telecare fall prevention program is the opportunity to unburden primary care providers of additional responsibilities by helping assess patients’ needs and arranging the appropriate services.
Date: November 16, 2009
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Barriers to Dementia Diagnosis
The goals of this study were to ascertain what is known about the prevalence of missed and delayed diagnosis of dementia in primary care, and to identify factors contributing to problems in diagnosis. While the findings did not definitively determine the prevalence of missed or delayed dementia diagnoses, estimates suggest that the number is substantial. Major barriers to diagnosing dementia included patient/provider communication (e.g., poor provider communication skills, language barriers), education deficits (e.g., belief that little or nothing can be done to treat dementia), and system resource constraints (e.g., time constraints for office visits). Attitude problems also were found; for example, among providers, a major barrier often noted was the attitude that diagnosis, particularly in the early stages of dementia, was more harmful than helpful, while patients often feared and/or denied cognitive problems.
Date: October 1, 2009
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Improving Acute Care for Elders at Risk for Poor Hospital Outcomes
For patients older than age 65, traditional hospital care frequently results in adverse outcomes that increase their risk of mortality, functional dependency, and institutionalization. There are several alternative models to traditional hospital care that have been shown to address these problems and improve outcomes for older patients. One such model is VA’s Geriatric Evaluation and Management (GEM) program, which was launched in 1976 to provide interdisciplinary, multi-dimensional evaluations for elderly Veterans in need of geriatric treatment, rehabilitation, health promotion, and social service interventions. However, alternative models are not widely disseminated. This Editorial challenges healthcare providers to think outside the traditional hospital box. They suggest broadening the implementation and availability of programs such as GEM and Hospital at Home (non-VA program providing hospital-level care of elders in their own homes) for those patients who would benefit from acute care outside a hospital setting.
Date: September 28, 2009
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Appropriate Prescription of Proton-Pump Inhibitors among Elderly Veterans Using NSAIDs
Using VA data, this observational study assessed VA provider awareness of NSAID gastro-protection and the therapeutic intent of proton-pump inhibitor (PPI) prescription among 1,491 elderly Veterans at one VAMC. In other words, investigators sought to better understand why VA physicians were prescribing these drugs. Findings show that among elderly Veterans who were prescribed a PPI, a therapeutic intent was documented in 71% of the cases, and of these prescriptions, 88.8% were considered appropriate. However, practitioner recognition of the need for gastro-protection in elderly patients was remarkably low (10%). Results also show that poor rates of appropriate therapeutic intent were noted when the PPI was initiated by the inpatient service, by certain sub-specialties (e.g., cardiology, otolaryngology), and for Veterans using the VA for medication refill only.
Date: September 15, 2009
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Ethnic Disparities in the Treatment of Veterans with Dementia
This study sought to determine if there were ethnic disparities in the evaluation and treatment of dementia among 410 Veterans treated at one VAMC between 4/05 and 6/05. Findings show that while laboratory and imaging workup (i.e., CT, MRI) did not differ between ethnic groups, there were significant differences in the treatment of dementia. For example, African American Veterans with dementia were 40% less likely than all other patients to receive acetylcholinesterase inhibitors. This treatment disparity did not appear to be due to differences in the evaluation of dementia, which was similar across groups, although significantly more Caucasian Veterans (43.8%) underwent neuropsychological testing compared to African American (24.8%) or Hispanic Veterans (32.4%).
Date: September 1, 2009
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Drugs-to-Avoid Criteria for the Elderly have Limited Value
Drugs-to-avoid criteria are lists of drugs considered to be potentially inappropriate for the elderly due to adverse effects, limited effectiveness, or both. For example, the Centers for Medicare and Medicaid Services use a version of the criteria of Beers et al. in nursing homes, and the National Committee for Quality Assurance uses the criteria of Zhan et al. to compare the quality of U.S. health plans. This study compared the Beers and Zhan criteria with individualized expert assessment of patients’ medications in 256 elderly Veterans from the Iowa City VAMC who were taking five or more medications. Findings show that the drugs-to-avoid criteria performed poorly when used as quality measures to assess the current state of a patient’s drug therapy. For example, half or more of the drugs flagged by the Beers and Zhan criteria were not considered problematic upon individualized expert review. In addition, the Beers and Zhan criteria identified only 8-15% of drugs that experts judged to be problematic. Therefore, authors suggest that while these criteria are useful as guides for initial prescribing decisions, they are insufficiently accurate to use as stand-alone measures for the quality of prescribing.
Date: July 27, 2009
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Panel Reaches Consensus on Oral Dosing for Primarily Renally Cleared Medications in Older Adults
Chronic kidney disease (CKD) is a growing public health problem that disproportionately affects older adults. Medications are the most frequently used therapy for the management of CKD-related problems in older adults, but they are often prescribed in inappropriate doses. This study sought to establish consensus dosing guidelines for primarily renally cleared oral medications commonly taken by older adults with renal insufficiency. An expert panel was able to reach consensus agreement on 18 oral medications that are primarily renally cleared, including anti-infectives and central nervous system medications.
Date: February 1, 2009
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Providing Better Care for Vulnerable Elders in the Primary Care Setting
Investigators identify three key processes of care needed to achieve better outcomes for vulnerable elder patients: communication, developing a personal care plan for each patient, and care coordination. They also describe two delivery models of primary care: co-management (e.g., primary care clinician shares patient responsibility with another clinician or care team with additional expertise in caring for vulnerable elders), and augmented primary care (e.g., enhanced decision support for clinicians, such as computerized clinical reminders).
Date: December 1, 2008
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Cancer Treatment Rates Low among Elderly Veterans
Cancer treatment was more common among younger elders (age 70-84) and the authors suggest that it is possible that an exaggerated level of trepidation regarding treatment ramifications among the elderly may be an obstacle to appropriate treatment in patients who could benefit from it.
Date: September 1, 2008
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More Daytime Sleeping Predicts Less Functional Recovery among Elderly Undergoing Inpatient Post-Acute Rehabilitation
More daytime sleep during the rehabilitation stay was associated with less functional recovery from admission to discharge, even after adjusting for other significant predictors (e.g., mental status, reason for admission, and hours of rehabilitation therapy). Further, more daytime sleep remained a predictor of less functional recovery at 3-month follow-up.
Date: September 1, 2008
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Fall Prevention and Management for Older Adults
This article describes fall prevention and management activities from a chronic care perspective that may help researchers, practitioners, and policymakers better understand existing programs and services. The authors propose a "no wrong door" approach to fall prevention and management, in which older adults at risk of falls are evaluated across three domains -- physical activity, medical risks, and home safety. Trained providers would then connect the patients and their caregivers to programs and services that address the identified risk in the most appropriate manner.
Date: August 1, 2008
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