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Older Veterans with COVID-19 Have Increased Frailty Over 12 Months
In this study, researchers used the VA medical records of 91,338 Veterans infected with COVID-19 from March 1, 2020 to April 30, 2021 and an equal number of matched uninfected controls to investigate whether COVID-19 was associated with a change in frailty. Findings showed that older Veterans with COVID-19 experienced a greater increase in frailty, particularly functional impairment, compared to uninfected controls. An increase in frailty was associated with baseline frailty and COVID-19 infection severity, particularly hospitalization. After adjustment, those with COVID-19 accrued 1.5 times more deficits than those who were uninfected. The five most common new deficits were fatigue (10%), anemia (7%), muscle atrophy (7%), gait abnormality (6%), and arthritis (6%). The association of COVID-19 severity and hospitalization with accelerated frailty related to function and mobility suggests that clinicians caring for older adults with COVID-19 should seek to prevent hospitalization and help maintain and recover mobility during and after infection.
Date: November 9, 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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Early Temperature Trends May Identify COVID-19 Infection in Pre-Symptomatic Long-Term Care Residents
Pre-symptomatic COVID-19 transmission in nursing homes is common and older patients often have blunted febrile response to infection. As a result, current clinical screening for temperature above 38°C may not identify infected subclinical cases that risk transmission until later. This study sought to determine whether early temperature trends in the course of COVID-19 infection could identify pre-symptomatic Veterans in nursing homes. Findings showed that a change in temperature of 0.4°C from baseline identified 47% of VA nursing home residents who became COVID positive, earlier than standard testing by an average of 42 hours. Temperature variability of 0.5°C over three days, when paired with a 37.2°C temperature cutoff (instead of the VA standard of 38°C), identified 55% of VA nursing home residents who became COVID positive earlier than standard testing by an average of 44 hours. A change from baseline temperature of 0.4°C, when combined with temperature variability of 0.7°C over three days, identified 52% of VA nursing home residents who became COVID positive, earlier than standard testing by an average of 40 hours, and by more than 3 days in 22% of Veterans.
Date: August 4, 2022
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Receiving Hospice Services Improved Ratings of End-of-Life Care for Veterans in VA Home-Based Primary Care
This study sought to describe Veterans’ use of community-based hospice services while enrolled in home-based primary care (HBPC) and their associations with bereaved families’ perceptions of care. Findings showed that overall, 53% of family members reported that the care received by Veterans receiving HBPC in the last 30 days of life was excellent. Families of Veterans who received hospice services gave higher global ratings of end-of-life care quality than those who did not (56% vs. 47%). The highest scoring secondary Bereaved Family Survey (BFS) outcomes were related to providers always being kind, caring and respectful (87%) and managing PTSD symptoms among Veterans experiencing stress (85%). The lowest scoring items were related to receiving enough information about survivor (38%) and burial and memorial (43%) benefits following the Veteran’s death. On 12 of the 14 secondary BFS outcomes, Veterans who received hospice services scored higher than those that did not. Findings suggest that increased referrals to community hospice partners for qualifying Veterans may result in more favorable perceptions of the overall end of life care experience.
Date: September 29, 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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Majority of High-Risk Veterans Assigned to General Primary Care Rather than Specialized Primary Care
This study sought to characterize patterns of care for the top 5% highest-risk patients enrolled in VA healthcare nationally (based on Care Assessment Needs – CAN – score). Findings showed that most high-risk Veterans (88%) were cared for in general primary care rather than in specialized primary care; the remaining 12% were assigned to specialized primary care (i.e., women’s health, geriatrics, home-based primary care, homeless primary care). High-risk Veterans assigned to general primary care had more mental health and primary care visits than medical specialty care visits. Compared to low-risk patients, high-risk patients had 2.5 times the face-to-face, 4 times the telephone, and twice the number of secure messaging encounters in primary care during the year prior to being identified as being high risk for hospitalization. Approaches to support high-risk patients will likely need to be embedded within general primary care and mental healthcare if they are to improve outcomes for this population. This may be more beneficial than carve-out specialized or intensive primary care programs.
Date: June 29, 2020
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Veteran-Directed Care Adds to Options for Medically Complex Veterans Living in the Community – Without Raising Costs
One way in which VA facilitates independence and supports caregivers is through the Veteran-Directed Care (VDC) program, part of VA’s Office of Geriatrics and Extended Care Services. VDC enables enrollees to hire family members, friends, or neighbors as paid caregivers and also provides caregiver support, including caregiver training and burden monitoring. This study evaluated the incidence of VA hospital admissions, ambulatory care-sensitive admissions, and costs associated with inpatient care in the year after the initial receipt of a VDC service. Findings showed that Veterans enrolled in VDC had indicators of higher chronic disease burden and more functional limitations than Veterans enrolled in other purchased-care service programs, but experienced similar decreases in hospital use and costs from before to after enrollment in services. During the 6th month before receiving services, mean monthly hospital costs were $2,131 for VDC patients, $1,054 for comparison group patients at sites with an active VDC program, and $974 for comparison group patients at sites without an active VDC program. In the 6th month after receiving services, mean monthly costs were $1,569, $1,170, and $1,049, respectively. In the 12th month after receiving services, VDC patients still had higher mean monthly hospital costs ($1,331) than patients in the active or inactive comparison group ($1,007 and $1,027, respectively), but the difference between costs among VDC patients and comparison-group patients had decreased. Given VDC’s popularity among Veterans and caregivers, it is a valuable model for supporting medically complex patients who are living in the community.
Date: June 1, 2019
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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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Assessing Expansion of VA’s Home-Based Primary Care Program for American-Indian Veteran Patient Population
VA provides home-based primary care (HBPC) in rural communities with American Indian reservations, where prospective patients may qualify for healthcare from VA, Medicare (CMS), and/or the Indian Health Service (IHS). This multi-site study of the effectiveness of HBPC expansion to these rural areas also describes the characteristics of patients who meet the requirements for admission to rural HBPC. Findings showed that expansion of the HBPC program was effective in introducing non-institutional home-based primary medical care to populations residing in American Indian reservations and other rural communities. Among HBPC users, VA enrollment increased by 22%. Results suggest opportunities to identify new clients for services that support aging in rural settings.
Date: April 1, 2018
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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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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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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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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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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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Dementia More Prevalent among Older Veterans with PTSD
This study sought to determine the association between PTSD and dementia in older Veterans. Findings show that older Veterans with PTSD had twice the incidence and prevalence of dementia diagnoses, even after accounting for confounding illnesses, combat-related trauma (measured by receipt of a Purple Heart), and number of primary care visits. Rates of TBI were highest in the group with PTSD and a Purple Heart, while rates of stroke were slightly higher among all groups with PTSD (regardless of Purple Heart receipt). The prevalence of drug dependence and abuse and the rates of alcohol dependence and abuse were highest in the group with PTSD, but without a Purple Heart. The mechanism for the observed increased incidence and prevalence of dementia among Veterans with PTSD is unknown. Possibilities include a common risk factor underlying PTSD and dementia, or PTSD being a risk factor for dementia. Regardless, the authors suggest that veterans over 65 years of age with PTSD be considered for dementia screening.
Date: September 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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Use of Medicare and VA Healthcare among Veterans with Dementia
This study sought to characterize healthcare use among Veterans with dementia over a four-year period (1998-2001), and to determine predictors of whether a Veteran will be a VA-only, dual, or Medicare-only user. Findings show that during the four-year study period, Medicare-only use increased while VA-only use decreased. Results also show that an increased likelihood of some Medicare use was associated with being older, white, married, and having higher education, private insurance or Medicaid, and low VA priority level. Further, the number of functional limitations was associated with an increased likelihood of Medicare-only use and a decreased likelihood of VA-only use, while higher comorbidities were associated with a higher likelihood of dual use as opposed to any single system use. The authors suggest that these results imply that different aspects of Veterans’ needs have differential effects on where Veterans seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure patients receive high quality care, particularly among those with multiple comorbidities.
Date: October 1, 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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Physicians May Need More Education about Long-Term Care Options for Veterans
The purpose of this study was to obtain information about VA long-term care (LTC) referrals that could be used to develop interventions that increase the likelihood of referrals to home and community-based services (HCBS) instead of institutional care. Findings indicate that physicians are often seen as having limited familiarity with HCBS options and tend to refer Veterans with LTC needs to nursing homes. Training physicians about LTC referral options, with particular focus on how HCBS can be used to meet Veteran and caregiver needs, may help to increase those referrals.
Date: February 1, 2009
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