Acute coronary syndrome in the older adults

Coronary heart disease remains the leading cause of death in the developed world. Advanced age is the single strongest risk factor for coronary artery disease (CAD) and independent predictor for poor outcomes following an acute coronary syndrome (ACS). ACS refers to a spectrum of conditions compatible with acute myocardial ischemia and/or infarction due to various degrees of reduction in coronary blood flow as a result of plaque rupture/erosion and thrombosis formation or supply and demand mismatch. Unstable angina and non-ST segment elevation myocardial infarction are often continuous and clinically indistinguishable, collectively referred as non-ST elevation ACS (NSTE-ACS). An abrupt total occlusion of a coronary artery causing transmural myocardial ischemia/necrosis and displaying ST segment elevation or new left bundle branch block on a12-lead ECG leads to the diagnosis of ST segment elevation myocardial infarction (STEMI). NSTE-ACS and STEMI require acute cardiac care. Professional societies have established guidelines for high quality contemporary care for ACS patients, i.e., American Heart Association/American College of Cardiology guidelines for STEMI and NSTE-ACS, European Society of Cardiology guidelines for STEMI and NSTE-ACS, and the United Kingdom National Institute for Health and Care Excellence guidelines for STEMI and NSTE-ACS.[1]–[6] Implementation of evidence-based therapies has significantly decreased mortality and morbidities of ACS.[3],[7],[8] However, these advancements in ACS management have not equally improved outcomes for older adults. Vulnerable older patients continue to be at high risk of poor outcomes, are less likely to receive evidence based care, and have high mortality rates regardless of treatments given.[9],[10] These disparities and challenges in caring for ACS in older adults are well recognized.[11]–[13] This review summarizes the increasing burden and persistent unfavorable outcome of ACS in older adults, and discusses the clinical presentation, diagnosis and strategies for medical and invasive therapy

Stable ischemic heart disease in the older adults

Ischemic heart disease is caused by atherosclerotic and/or thrombotic obstruction of coronary arteries. Clinical spectrum of ischemic heart disease expands from asymptomatic atherosclerosis of coronary arteries to acute coronary syndromes (ACS) including unstable angina, acute myocardial infarction (non-ST elevation myocardial infarction and ST elevation myocardial infarction). Stable ischemic heart disease (SIHD) refers to patients with known or suspected SIHD who have no recent or acute changes in their symptomatic status, suggesting no active thrombotic process is underway. These patients include those with (1) recent-onset or stable angina or ischemic equivalent symptoms, such as dyspnea or arm pain with exertion; (2) post-ACS stabilized after revascularization or medical therapy; and (3) asymptomatic SIHD diagnosed by abnormal stress tests or imaging studies. This review summarizes clinical features and management of SIHD in the older adult. ACS in older adults is not considered in this review

Association of Low Dietary Intake of Fiber and Liquids with Constipation: Evidence from the National Health and Nutrition Examination Survey (NHANES)

Epidemiological studies support an association of self-defined constipation with fiber and physical activity, but not liquid intake. The aims of this study were to assess the prevalence and associations of dietary fiber and liquid intake to constipation

An Effective Community–Academic Partnership to Extend the Reach of Screenings for Fall Risk

Older adults should be screened for fall risk annually. Community providers (people without formal medical training who work with older adults in senior centers or aging services) may be a viable group to expand the reach of screenings. Our community–academic partnership developed a program to increase and assess fall risk screenings by community providers. Community sites hosted training workshops and screening events. Community screenings were well attended and received by providers and older adults. With administrative support from the regional fall prevention coalition and technical support from academia, community providers screened 161 older adults from a broad geographic area. Twenty-one community providers completed the training. Knowledge and confidence surveys demonstrated improvements before and after training (P < .001). Skills assessments demonstrated mastery of most skills, but some providers required additional training. Provider feedback indicated screening procedures were complex. Future projects will examine this model using simplified screening procedures

The Prevalence of Neck and Shoulder Symptoms and Associations with Comorbidities and Disability: The Johnston County Osteoarthritis Project

Neck and shoulder pain are common but underreported by older people, raising important questions of frequency, medical comorbidities, gender and racial disparities and functional impact associated with neck and shoulder symptoms in elders, which we examined in this analysis

A Feasibility Study for An Integrated Approach to Fall Prevention in Community Care: Stay Up and Active in Orange County

Introduction: Falls amongst persons over 60 present significant risks for serious injury or debility. Falls place burdens on Emergency Medical Services (EMS), hospitals, and the adults themselves. Recognizing a need to provide interventions to minimize risk, Orange County Emergency Services (OCES), the Orange County Department on Aging (OCDoA), and the University of North Carolina at Chapel Hill (UNC) partnered to create the Stay Up and Active Program (SUAA). Methods: A streamlined workflow algorithm between the OCES and OCDoA was created and employed to provide falls risk assessment and necessary services. Qualitative techniques were used to assess the need for such a program and its potential impact. A subset of individuals were interviewed three months after the intervention to assess the impact of the intervention on their fall risk. Results: In the first seven months, 478 instances of individuals who called OCES screened positive for falls risk. Of the 478 positive screenings, 55 individuals were identified as having received more than one positive fall screen due to multiple calls. The maximum number of positive screenings by one individual was 14. More women (61.3%) than men screened positive for fall risk. Individuals 88 years of age (6.9%) represented the mode of the individuals with positive screens. Nineteen (4.0%) people who called OCES and received the intervention completed a three month follow up survey. Of the nineteen, 86% (n=16) reported no recurrent fall.Conclusion: The number of individuals who screened positive supports the need for early identification and intervention through EMS. This program identified several challenges connecting older adults with services already available to keep them independent which provided insight to all stakeholders regarding factors that inhibit the program’s success. The program evaluation should continue to provide suggestions for improvement and ensure sustainability

Educational Interventions to Improve Advance Care Planning Discussions, Documentation and Billing

Background/Objectives: To determine the impact of educational interventions, clinic workflow redesign, and quality improvement coaching on the frequency of advance care planning (ACP) activities for patients over the age of 65. Design: Nonrandomized before-and-after study. Setting: 13 ambulatory care clinics with 81 primary care providers in eastern and central North Carolina. Participants: Patients across 13 primary care clinics staffed by 66 physicians, 8 physician assistants and 7 family nurse practitioners. Interventions: Interprofessional, interactive ACP training for the entire interprofessional team and quality improvement project management with an emphasis on workflow redesign. Measurements: From July 2017 through June 2018—number of ACP discussions, number of written ACP documents incorporated into the electronic medical record (EMR), number of ACP encounters billed. Results: Following the interventions, healthcare providers were more than twice as likely to conduct ACP discussions with their patients. Patients were 1.4 times more likely to have an ACP document included in their electronic medical record. Providers were significantly (p < 0.05) more likely to bill for an ACP encounter in only one clinic. Conclusions: Implementing ACP education for all clinic staff, planning for workflow changes to involve the entire interprofessional team and supporting ACP activities with quality improvement coaching leads to statistically significant improvements in the frequency of ACP discussions, the number of ACP documents included in the electronic medical record and number of ACP encounters billed

Survey of Geriatricians on the Effect of Fecal Incontinence on Nursing Home Referral: FECAL INCONTINENCE AND NURSING HOME REFERRAL

Determine the impact of fecal incontinence (FI) in health care providers’ decisions to refer patients for nursing home (NH) placement

Likelihood of Nursing Home Referral for Fecally Incontinent Elderly Patients is Influenced by Physician Views on Nursing Home Care and Outpatient Management of Fecal Incontinence

(1) Characterize physicians’ management practices for fecal incontinence (FI) among elderly patients, (2) describe physician perceptions of the quality of care for FI provided in nursing homes (NH), and (3) identify physician views and attributes associated with referral of elderly patients with FI to a NH

Nursing Home Revenue Source and Information Availability During the Emergency Department Evaluation of Nursing Home Residents

Lack of access to medical information for nursing home residents during Emergency Department (ED) evaluation is a barrier to quality care. We hypothesized that the quantity of information available in the ED differs based on the funding source of the resident’s nursing home