Context To better target services to those who may benefit, many guidelines recommend incorporating life expectancy into clinical decisions. Objectives We conducted a systematic review to help physicians assess the quality and limitations of prognostic indices for mortality in older adults. Data Sources We searched MEDLINE, EMBASE, Cochrane, and Google Scholar through November 2011. Study Selection We included indices if they were validated and predicted absolute risk of mortality in patients whose average age was ≥ 60. We excluded indices that estimated ICU, disease-specific, or in-hospital mortality. Data Extraction For each prognostic index, we extracted data on clinical setting, potential for bias, generalizability, and accuracy. Results We reviewed 21,593 titles to identify 16 indices that predict risk of mortality from 6-months to 5 years for older adults in a variety of clinical settings: the community (six indices), the nursing home (two indices), and the hospital (eight indices). At least 1 measure of transportability was tested for all but 3 indices. By our measures, no study was free from potential bias. While 13 indices had c-statistics ≥ 0.70, none of the indices had c-statistics ≥ 0.90. Only two indices were independently validated by investigators who were not involved in the index’s development. Conclusion We identified several indices for predicting overall mortality in different patient groups; future studies need to independently test their accuracy in heterogeneous populations and their ability to improve clinical outcomes before their widespread use can be recommended.

"Presenteeism" occurs when an employee goes to work despite a medical illness that will prevent him or her from fully functioning at work. This problem has been well studied in the business and social science literature, and carries increased importance in the health care setting due to the risk of infectious disease transmission in vulnerable patient populations. In this manuscript, we discuss an outbreak of viral gastroenteritis in a long-term care facility and the role presenteeism played in disease transmission and extension of the outbreak. We use existing literature to point out the hazards of presenteeism in the health care sector. We will also discuss factors that may be involved in the decision to work while ill and propose policy changes that may reduce the incidence of presenteeism in health care organizations.

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word count: 324 ABSTRACT COVID-19 continues to impact older adults disproportionately, from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these needs have focused attention on how resources are ultimately allocated and used. Some strategies misguidedly use age as an arbitrary criterion, which inappropriately disfavors older adults.This statement represents the official policy position of the American Geriatrics Society (AGS). It is intended to inform stakeholders including hospitals, health systems, and policymakers about ethical considerations to consider when developing strategies for allocating scarce resources during an emergency involving older adults. Members of the AGS Ethics Committee collaborated with interprofessional experts in ethics, law, nursing, and medicine (including geriatrics, palliative care, emergency medicine, and pulmonology/critical care) to conduct a structured literature review and examine relevant reports. The resulting recommendations defend a particular view of distributive justice that maximizes relevant clinical factors and de-emphasizes or eliminates factors placing arbitrary, disproportionate weight on advanced age. The AGS positions include: (1) avoiding age per se as a means for excluding anyone from care; (2) assessing comorbidities and considering the disparate impact of social determinants of health; (3) encouraging decision makers to focus primarily on potential shortterm (not long-term) outcomes; (4) avoiding ancillary criteria such as -life-years saved‖ and -long-term predicted life expectancy‖ that might disadvantage older people; (5) forming and staffing triage committees tasked with allocating scarce resources; (6) developing institutional resource allocation strategies that are transparent and applied uniformly; and (7) facilitating appropriate advance care planning. The statement includes recommendations that should be Accepted Article 5 immediately implemented to address resource allocation strategies during COVID-19, aligning with AGS positions. The statement also includes recommendations for post-pandemic review.Such review would support revised strategies to ensure that governments and institutions have equitable emergency resource allocation strategies, avoid future discriminatory language and practice, and have appropriate guidance to develop national frameworks for emergent resource allocation decisions.consequences of severe illness, hospitalization and death. The extent to which this disproportionate impact is due to factors such as the disease itself, versus the response of health care systems to the disease, is unknown. Concerns about potential shortages of ventilators, ICU beds, and hospital bedsboth now and in the fall when resource shortages caused by any surge in COVID-19 will likely be intensified due to influenza -have focused attention on how decisions to allocate these scarce resources are being made. Many of the initially av...

Background The epidemiology of pain during the last years of life has not been well described. Objective To describe the prevalence and correlates of pain over the last two years of life. Design Observational study. We analyzed data from subjects who died while enrolled in the Health and Retirement Study. The survey interview closest to death was used. Each subject or proxy was interviewed once in the last 24 months of life and were classified into one of 24 cohorts based on the number of months between the interview and death. We modeled the relationship between time before death and pain adjusted for age, gender, race/ethnicity, education, net worth, income, terminal diagnosis category, arthritis, and proxy status. Setting The Health and Retirement Study, a nationally representative survey of community-living older adults (1994–2006). Participants Older adult decedents. Measurements Significant pain as indicated by a report that the subject was “often troubled” by pain of at least moderate severity. Results The sample included 4,703 decedents (mean age [SD] 75.7 [10.8], 83.1% white, 10.7% black, 4.7% Hispanic, 52.3% men). The adjusted prevalence of pain 24 months prior to death was 26% (95% CI, 23–30%). The prevalence remained flat until 4 months prior to death (28%, 25–32%), then increased, reaching 46% (38–55%) in the last month of life. The prevalence of pain in the last month of life was 60% among patients with arthritis vs. 26% among patients without arthritis (p<.001), and did not differ by terminal diagnosis category (cancer 45%, heart disease 48%, frailty 50%, sudden death 42%, other 47%, p=0.195). Limitations cross sectional data; 19% proxy responses; information about cause, location, and treatment of pain not available. Conclusions While the prevalence of pain increases in the last 4 months of life, pain is present in over a quarter of elders over the last 2 years of life. Arthritis is strongly associated with pain at the end of life. Primary Funding Source National Institute on Aging; National Center for Research Resources; National Institute on Musculoskeletal and Skin Diseases; National Palliative Care Research Center.

Financial capacity is the ability to manage money and financial assets in ways that meet a person’s needs and which are consistent with his/her values and self-interest. Financial capacity is essential for an individual to function independently in our society; however, dementia eventually leads to a complete loss of financial capacity. Many patients with cognitive impairment and their families turn to their primary care clinician for help with financial impairment, yet most clinicians do not understand their role or how to help. We review the prevalence and impact of financial incapacity in older adults with cognitive impairment. We also articulate the role of the primary clinician which includes: (1) educating older adult patients and families about the need for advance financial planning; (2) recognizing signs of possible impaired financial capacity; (3) assessing financial impairments in cognitively impaired adults; (4) recommending interventions to help patients maintain financial independence; and (5) knowing when and to whom to make medical and legal referrals. Clearly delineating the clinician’s role in financial impairment can lead to the establishment of effective financial protections and can limit the economic, psychological, and legal hardships of financial incapacity on patients with dementia and their families.

BACKGROUND: Graduate medical education programs assess trainees' performance to determine readiness for unsupervised practice. Entrustable professional activities (EPAs) are a novel approach for assessing performance of core professional tasks. AIM: To describe a pilot and feasibility evaluation of two EPAs for competency-based assessment in internal medicine (IM) residency. SETTING/PARTICIPANTS: Post-graduate year-1 interns (PGY-1s) and attendings at a large internal medicine (IM) residency program. PROGRAM DESCRIPTION: Two Entrustable professional activities (EPA) assessments (Discharge, Family Meeting) were piloted. PROGRAM FEASIBILITY EVALUATION: Twenty-eight out of 43 (65.1 %) PGY-1s and 32/43 (74.4 %) attendings completed surveys about the Discharge EPA experience. Most who completed the EPA assessment (10/ 12, 83.8 %, PGY-1s; 9/11, 83.3 %, attendings) agreed it facilitated useful feedback discussions. For the Family Meeting EPA, 16/26 (61.5 %) PGY-1s completed surveys, and most who participated (9/12 PGY1s, 75 %) reported it improved attention to family meeting education, although only half recommended continuing the EPA assessment. DISCUSSION: From piloting two EPA assessments in a large IM residency, we recognized our reminder systems and time dedicated for completing EPA requirements as inadequate. Collaboration around patient safety and palliative care with relevant clinical services has enhanced implementation and buy-in. We will evaluate how well EPA-based assessment serves the intended purpose of capturing trainees' trustworthiness to conduct activities unsupervised.