How difficult is it for residents in your community to access appropriate ACP (Advance Care Planning) services?  In my experience, these conversations are often deferred until the time of a crisis, but we know these conversations are less beneficial then due to crisis related compromised cognition and emotional stress for patients, families, and providers.  Are there communities in our state where there are champions doing this good work electively in their community, particularly targeting members of their community who historically are less likely to have serious illness conversations and supported decision making?

A recent systematic review and meta-analysis article published in the July 2022 Journal of Neurology, Neurosurgery and Psychiatry suggests noradrenergic agents may be effective in early Alzheimer’s Disease to improve cognitive function. This original research included over 1800 patients showing a small significant positive effect on the global cognition measured on the Mini-Mental State Exam (MMSE) or on Alzheimer’s Disease Assessment Scale-Cognitive Subscale (ADAS-cog). 

As of July 27, 2022, over half of the 342 skilled nursing facilities (SNFs) in LA County are experiencing active COVID-19 outbreaks, which is the highest level of transmission since the surge last winter. All patients in SNFs are at high risk for progressing to severe COVID-19 if infected. Fortunately, there are now outpatient COVID-19 treatments such as oral antivirals that are easy to administer and can reduce the risk of poor outcomes, including hospitalization and death. Despite the wide availability of oral antivirals, they continue to be underutilized in the nursing home population. To close this crucial gap and significantly improve outcomes in this vulnerable population, Los Angeles County Department of Public Health issued an update on July 25, 2022 to the Order of the Health Officer for Control of COVID-19: Prevention of COVID-19 Transmission in Skilled Nursing Facilities requiring all SNF patients with a positive SARS-CoV-2 viral test to be immediately assessed by their healthcare provider for any symptoms of COVID-19. Oral COVID-19 antivirals should be initiated at the facility within 5 days of symptom onset if clinically appropriate, i.e., they have mild or moderate symptoms and there are no contraindications. Please do not transfer residents to hospitals solely for treatment of mild or moderate COVID-19. These residents should be treated at their SNF. Even if you are not practicing in Los Angeles County, CALTCM agrees that all PALTC medical directors, attending physicians and practitioners should evaluate every case of COVID for the potential ordering of therapeutics including Paxlovid.  Please work with SNFs where you provide care to help meet this recommendation and provide optimal care for your patients.

The 38th Annual UCLA Intensive Course in Geriatric Medicine and Board Review will take place September 14-17, 2022. This four-day virtual course is designed for health professionals interested in advancing their knowledge and enhancing their ability to care for older adults, as well as physicians preparing for certification or recertification examinations in Geriatric Medicine. The Intensive Course is CME and ACPE accredited and a nationally recognized premier course. 

How do our patients and their families define a good outcome from a surgical procedure, particularly if it is a high risk surgical procedure (defined as >1% 30-day mortality)?  What if the patient has dementia?  Have you had patients with advanced dementia with acute displaced hip fractures where the traditional best option offered has been surgical repair?  

I naively assumed when I began my journey in the field of Geriatric Medicine, that I would be followed over time by hordes of other physicians, given the impending increase in aging populations.  While the population of seniors has nearly doubled, the number of physicians with Geriatric Medicine training has diminished. Less than 5% of the current California healthcare workforce is certified in geriatrics.  Moreover, the California Census Bureau projects a rate of growth of the age 65 plus population that far exceeds the other age groups, particularly among the 85 plus group, and among the non-White populations. The percentage of filled first year geriatric fellow positions dropped from 91% in 1998 to 45% in 2017. Currently, the American Geriatric Society estimates that there are 3,590 full-time practicing geriatricians, out of a total pool of less than 7,000 board-certified geriatricians. A professional colleague recently commented that if things continue to progress as they are, American geriatricians will become a historical footnote. 

The moment you have all been waiting for!

One year ago, CALTCM members received an alert that the Alameda County Superior Court issued a modified judgment in the 2016 CANHR v. Angell case.  That order granted another 12-month extension for the requirement for nursing homes to include a non-facility-affiliated patient representative on the interdisciplinary teams (IDTs) that are making medical decisions that require informed consent for incapacitated unrepresented residents. The extension was due to expire this month.  

CMS had AHRQ (the Agency for Healthcare Research and Quality) develop validated patient-friendly surveys that could capture the patient’s experience of care in a particular facility.  This could provide a facility with important information about their care delivery, allow comparisons with other facilities (within their system and beyond) and spark collaborative learning.  In addition, this information could incentivize facilities to improve their survey results, if they were posted on the internet.  

On April 1, AMDA - The Society for Post-Acute and Long Term-Care Medicine, sent an email recommending this resource, Geriatric Notes, at a 20% discount.  This resource was first released in 2018 and targets advanced practice providers (APP) who care for elders in our settings of care.  In this offering through AMDA, you have access to the paperback book or the E-book version available via the internet and as the eReader2 app on smartphones.  This Ebook version has updates on health maintenance, diabetes management, and the Beers list (identifies potential inappropriate medications).  I have reviewed this textbook by Jamie W Smith and Bradley J Goad, and found it to be an easy to use resource for quick point of care decisions as well as for improving understanding of common diagnosis, topics, symptoms, and guidelines encountered in the care of an aging population. 

As CALTCM’s President, I am pleased to announce that our Board of Directors has appointed Dominic Lim as CALTCM’s Interim CEO. 

In recent years, seniors are voting with their feet.  We are living longer and becoming more disabled along the way.  These functional declines are often subtle in onset and progression, but eventually cause many to embrace some form of congregate living.  For many, the lower cost social model with more choices has been more attractive than the medical model of nursing homes.  Many ALFs (Assisted Living Facilities), RCFEs (Residential Care Facilities for the Elderly), and Memory Units now care for residents with similar medical complexity, polypharmacy, and functional decline as those living in SNFs. 

Since the California Court of Appeal ruled on the CANHR v. Smith case in late 2019, and since early 2020 when the state Ombudsman’s office prohibited their ombudsman from participating in IDTs where medical decisions would be made for incapacitated unrepresented nursing home residents, California’s skilled nursing facilities have been awaiting the implementation of a brand-new office to help with these decisions.  

“Baseline rates of burnout among physicians hovered around 50% even before the COVID-19 pandemic. Since COVID, rates have increased. Recent data show that 60% of healthcare workers reported that their mental health had suffered over the last year. And an astonishing 30% of physicians and residents and 54% of nurses reported moderate to high levels of burnout. “

As a physician licensed in California in 1976, I remember the strike by our state’s anesthesiologists and many other physicians protesting skyrocketing malpractice insurance costs.  This protest ended with the passage of MICRA (Medical Injury Compensation Reform Act) in September 1975, which capped awards for non-economic damages (pain and suffering) at $250,000.  This has subsequently resulted in more reasonable medical liability costs in California than in many states in our country.  At the same time, it has preserved access in our state to high risk specialty care.  As a primary care internist, my rates have remained reasonable especially at a time when costs of office based medicines dramatically increased in the late 80’s and 90’s.  These high costs drove me to close my part-time office in 2005 in favor of a full time SNF/CCRC/Teaching based practice.

State Alzheimer’s Disease Advocacy Day was on March 3, 2022. Following is the list of important bills that impact our patients living with Alzheimer’s and other dementias. They have been advocated by our Alzheimer’s Disease Society. I was fortunate to be part of it. This is the summary of these Bills.

Palliative sedation is the use of medical therapy to induce decreased awareness to relieve severe and refractory symptoms (1). A recent case I had involved the use of antipsychotics to the point of palliative sedation for refractory symptoms in a non terminally ill patient.

Recently, the California Partnership to Improve Dementia Care vetted its mission and vision statements that reflect our direction and commitment to the care processes that better support the quality of life of our residents living with dementia. We have broadened our focus from the SNF setting to include the home and community based (ALF, RCFE, CCRC, Senior Congregate living) settings. I have found the latter social care settings to be places where antipsychotics are commonly used as chemical restraints with informed consent seldom documented. In California, we have made some progress with reducing the inappropriate use of antipsychotics for our long stay nursing home residents. The National Partnership to Improve Dementia Care on 1/14/22 reported the Q2 2021 national, regional, and state percentage use of antipsychotics in long stay residents without an approved indication. Our CMS Region 9 located in San Francisco (represents Arizona, California, Hawaii, Nevada, and Pacific Territories) performed the 3rd best of the CMS Regions at 10.87%. CMS Region 10 located in Seattle (represents Alaska, Idaho, Oregon, and Washington) performed the best at 6.89%. California was ranked the 3rd best by states at 10.4% trailing only Hawaii and the District of Columbia. While most states including California have made < then 1% improvement in the past 3-4years, how is it that CMS Region 10 in Seattle, can achieve a 6.89% antipsychotic rate? What are they doing differently to achieve these impressive results?

CALTCM members may recall that for several years, Dr. Charlene Harrington and her team at University of California, San Francisco published a website, CalQualityCare that compared California nursing homes and other long-term care organizations on quality of care including information such as staffing, organizational characteristics, and deficiencies and fines.  In 2016 the website lost its funding and had to shut down. 

In October 2021, palliative medicine heavyweights Drs. Sean Morrison, Diane Meier, and Bob Arnold published a Viewpoint piece in JAMA Network with the provocative title, “What’s Wrong With Advance Care Planning?” https://jamanetwork.com/journals/jama/article-abstract/2785148  Dr. Morrison has published and presented in multiple venues on this topic for the past couple of years, repeatedly ACP-bashing and comparing advance care planning to your family’s “old Pinto,” that you keep pumping money into for repairs even when it’s clear the car is all washed up and beyond repair.  The motivation for these apparent attacks on ACP seems to stem mostly from frustration that millions of dollars of research funding have been spent on ACP research, despite the somewhat disappointing results of many of these studies.  No doubt some of our WAVE readers will remember this article, and I encourage those who haven’t read it to actually read the short article, and especially read the excellent comments several people have appended to the site.