November 2021

GERIATRICS

GERIATRIC KNOWLEDGE GAPS OF COMMUNITY-BASED PROVIDERS: A NATIONAL STUDY OF ASKED QUESTIONS

Featuring: ​Lee Ann Lindquist, MD, MPH, MBA, Alice Kerr, MD, Theresa Rowe, MD, MPH, Sara Bradley, MD​

INTRODUCTION
Primary care providers (PCP) - internists, family practitioners, physician assistants - play an integral role in the care of older adults, although many receive limited geriatrics education. Lee A Lindquist, MD, MPH, MBA, section chief of Geriatric Medicine in the Department of Medicine, George M. Eisenberg Research Professor of Geriatric Medicine and associate professor of General Internal Medicine and Geriatrics, Alice Kerr, MD, Health System Clinician of Medicine (General Internal Medicine and Geriatrics), Theresa Rowe, MD, MPH, assistant professor of Medicine (General Internal Medicine and Geriatrics), and Sara Bradley, MD, associate professor of Medicine (General Internal Medicine and Geriatrics) and Medical Education, sought to determine what the dissemination needs of primary care providers were towards these recommendations. 

METHODS
PCPs attended a live in-person 45 to 60-minute geriatrics-focused lecture as part of large clinical continuing medical education (CME) conferences across 12 states (FL, GA, CA, IL, NY, MA, DC, PA, AZ, TX, TN, WA) and entered questions into a mobile application. Lecture subjects included:
  1. Updates in Geriatrics
  2. Physical exam of older adults
  3. Falls
  4. Cognitive Impairment
  5. Polypharmacy
  6. Ask the Geriatric Expert (Q/A session)

All questions are anonymous and no identifiers are present. After a PCP attendee types in a question for the presenter, other PCP attendees can uptick the question, meaning that they have the same question and would like to prioritize it. Questions were then qualitatively analyzed using constant-comparison and tie-break methodology.

RESULTS
At all sites, 103 questions were asked with 158 upticks (PCPs could check off that they had similar question) with a range of 3-18 questions per lecture. PCPs asked questions on the following common themes: 
  1. Medication-related (e.g. discontinuing medicines in asymptomatic patients, optimizing pain relief)
  2. Dementia (e.g. prevention, nutraceuticals, agitation)
  3. Medicare Coding
  4. Falls
  5. Weight loss
  6. Insomnia 

There were a number of questions referencing incorrect practices (e.g. prescribing inappropriate medications such as benzodiazepines for sleep, placement of gastric tubes in late-stage dementia antibiotics to treat asympromatic bacteria).

Thematic Analysis of PCP Questions
The below features themes and example quotes associated with each.

Medication
  • "How comfortable are you in discontinuing medications when there are no complaints and lab data normal?"
  • "Why can't I use a specific benzodiazepine?"
  • "Research shows high level of pain releif using Tylenol and ibuprofen together - is the ibuprofen safe for seniors?"
  • "How about using methocarbomol muscle relaxant?"
  • "Is Baclofen just as bad as Flexeril?"

Dementia Agitation
  • "What do you recommend for sundowning behavior concerns associated with dementia?"

Coding for Wellness Visit
  • "Does physical exam get included for AMW?"

Falls
  • "What do I do when I get called for falls in nursing home patients?"

Urinary / UTI
  • "Do you consider incontinence a UTI symptom?"

Weight Loss
  • "What about percutaneous jejunal feed tube?"

Insomnia 
  • "What do you recommend to treat insomnia?"

​
DISCUSSION 
Community-based PCPs nationally experience gaps in geriatric knowledge and several utilize practices that could jeopardize older adult health. Several of the questions asked reflect issues with staying up to date with geriatrics guidelines. While attending CME-based lectures is one means of overcoming these gaps, some PCPs may not find time or realize geriatrics as an educational need. PCPs need to be better supported with opportunities to ask geriatric care-related questions in order to improve the care of older adults.

FINANCIAL DISCLOSURE
Dr. Lindquist receives funding through the NIA R01AG05877, NIA R01 AG06842, and the Claude D. Pepper Older Americans Independence Center (OAIC) at Northwestern University ​[NIA P30AG059988].
 Dr. Lee Ann Lindquist Headshot
Lee Ann Lindquist, MD, MPH, MBA, a Geriatrician and Chief of Geriatrics in the Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine. Her patient-centered research focuses on helping older adults age-in-place, when they develop Alzheimer’s disease, through home and community-based resources and supporting caregivers. She has extensive experience partnering in research with community organizations and community members for recruitment, study implementation, data collection, and dissemination. ​
Dr. Alice Kerr headshot
Alice Kerr, MD, Health System Clinician of Medicine (General Internal Medicine and Geriatrics).​
Dr.Theresa A Rowe headshot
Theresa Rowe, MD, MPH, assistant professor of Medicine (General Internal Medicine and Geriatrics).​
Dr. Sara Bradley headshot
Sara Bradley, MD, associate professor of Medicine (General Internal Medicine and Geriatrics) and Medical Education.​

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