Geriatrics

More than 40 million surgeries are performed annually in the United States, of which > 18 million are orthopedic, including > 1 million emergency orthopedic surgeries and > 2 million joint replacements.^1-4 Notably, > 50% of patients undergoing orthopedic surgery are aged ≥ 65 years, a demographic shift driven by longer life expectancies and an increasing number of older adults remaining physically active for extended periods.⁵ Osteoarthritis, the most common joint disease, affects 10% of men and 18% of women aged > 60 years, often necessitating an orthopedic joint replacement.⁶ Perioperative morbidity and mortality are 2.9- to 6.7-times higher in older adults compared with younger adults.⁷ These risks include infection, venous thromboembolism (VTE), pressure ulcers, reduced mobility, and increased mortality. Due to the high incidence of these complications in older surgical patients, special perioperative protocols and considerations are needed when preparing an older patient for surgery. This review aims to establish concrete considerations and guidelines for perioperative management.

METHODOLOGY

A literature review of PubMed, Google Scholar, and IEEE Xplore identified research on perioperative challenges in geriatric orthopedic surgery. Keywords included geriatrics and orthopedic surgery, perioperative care in geriatric populations, and orthopedic perioperative care. Inclusion criteria were strictly defined to ensure relevance to the geriatric population, with studies focusing on patients aged ≥ 65 years. Exclusion criteria were applied to remove studies that did not involve geriatric populations or orthopedic surgeries or that lacked a clear perioperative focus. Studies were analyzed for design, interventions, and outcomes. Special attention was given to identifying common challenges and trends related to perioperative considerations. We developed a narrative report providing a comprehensive overview of the current understanding of perioperative care for geriatric orthopedic patients to offer practical recommendations for clinicians to use in their practice.

RESULTS

Consistent with the narrative review methodology described, the literature search yielded a broad range of publications addressing perioperative considerations in geriatric orthopedic patients. Articles were screened for relevance to patients aged ≥ 65 years undergoing orthopedic surgery and for applicability to perioperative optimization and postoperative outcomes. Given the heterogeneity in study design, population characteristics, and outcome reporting, findings are presented descriptively rather than being quantitatively pooled. Studies not focused on geriatric populations, orthopedic procedures, or perioperative management were excluded. Key themes included multimorbidity and comorbidity optimization, age-related physiologic changes, frailty assessment and fracture risk stratification, nutritional and bone health management, mechanism of injury considerations, prevention of postoperative complications, and the role of multidisciplinary perioperative care.

Unique Physiological Challenges

The aging process induces a range of physiological changes that can increase morbidity and mortality following surgery. One of the most essential elements to surgical recovery is wound healing, as impairments in this process can lead to adverse events, including infection, cosmetic deformity, and wound dehiscence. The general paradigm of aging involves cell senescence resulting in slower or disorganized functional capacity of these cells.⁸ While wound healing in older individuals was once thought to be defective, recent research has demonstrated that this process is not absent, but delayed.⁹

Wound healing is a tightly regulated and evolutionarily conserved process that proceeds through 3 main phases: inflammation, proliferation, and remodeling. Re-epithelialization begins with the migration of epithelial cells from hair follicles, sweat glands, or wound margins (depending on wound depth) and is influenced by oxygen levels, moisture, and growth factors.⁹ Several characteristics of aged skin contribute to the delayed healing process. Aged skin has fewer hair follicles and eccrine sweat glands, as well as decreased follicle thickness.¹⁰ This results in fewer proliferating cells for wound healing and lower amounts of sebum production for skin moisture.¹¹ Furthermore, aged fibroblasts are fewer in number and less effective in synthesizing extracellular matrices, resulting in slower and less tensile wound healing.¹² Additionally, microvascular changes associated with aging result in disorganized vasculature, which impairs oxygen delivery to the wound bed and diminishes the influx of proinflammatory cells necessary for effective healing.¹³ These senescent traits of aged skin contribute to the delayed wound healing process found in geriatric patients. 

Compounding these age-related factors is the prevalence of multimorbidity, or coexisting chronic diagnoses, in 55% to 98% of older patients.¹⁴ Common comorbidities include peripheral arterial disease, chronic venous insufficiency, type 1 and type 2 diabetes, neoplasms, atherosclerotic disease, and hypertension. Older patients are more likely to be prescribed corticosteroids and chemotherapeutic agents that impair the function of inflammatory cells necessary for wound healing.^15,16 Additionally, decreased mobility is more common in geriatric patients, which can increase the risk of wound formation, particularly pressure ulcers.¹⁷

Perioperative Considerations

All surgical patients undergo a formal or informal preoperative evaluation to assess their fitness for surgery, with the goal of minimizing both anesthesia-related risks and postoperative complications. A widely used tool in this assessment is the American Society of Anesthesiologists (ASA) physical status classification, which stratifies patients into 6 categories based on their medical history and overall health status.¹⁸ Classes range from healthy patients (Class I) to organ donors who are brain-dead (Class VI).

Cardiac optimization is an essential component of preoperative evaluation for older adults due to their higher risk of underlying cardiovascular disease.¹⁹ This process involves an in-depth review of the patient’s cardiac history, including the timing and nature of any prior interventions and the recurrence rate. Functional capacity is assessed through metabolic equivalents, where a threshold of > 4 metabolic equivalents (the ability to walk up a flight of stairs) is considered adequate for surgery. Risk is assessed based on the specific surgical procedure, and nonemergent orthopedic procedures are considered intermediate risk. If a patient is deemed high risk at any stage of this evaluation, further cardiac testing is indicated. 

Pulmonary optimization is typically necessary for geriatric patients, who are more likely to have conditions such as chronic obstructive pulmonary disease or interstitial lung disease.^14,20 In patients without severe systemic lung disease, pulmonary optimization involves assessing the functional expiratory volume and diffusing capacity for carbon monoxide. In addition, aggressive modification of risk factors, such as smoking cessation, is strongly recommended. 

Additional perioperative conditions are disease-specific and involve evaluation of comorbid illnesses and recognition of absolute contraindications to noncardiac surgery. For instance, an ejection fraction of < 35%, a history of myocardial infarction within 6 months, or active diabetic ketoacidosis are all absolute contraindications to elective surgery. For orthopedic procedures, additional contraindications include symptomatic bacteremia, active joint or local tissue infection, severe malnutrition, uncontrolled metabolic syndrome or chronic disease, untreated immunodeficiency, and active deep venous thrombosis (DVT) or pulmonary embolism.²¹

Bone Health and Nutrition

In the context of orthopedic surgery, the hallmark of clinically defined optimal bone health is a musculoskeletal system that provides the ability for pain-free functional and occupational tasks with an adequate capacity to withstand the mechanical forces imparted by everyday life. Back pain and arthritis are the fourth- and sixth-most common complaints in primary care, underscoring suboptimal bone health management in developed countries.²²

Optimizing bone health through proper nutrition is crucial in the perioperative management of geriatric orthopedic patients. The clinical diagnosis of malnutrition has well-studied associations with worse outcomes after orthopedic surgery, which include increased mortality, hospital length of stay, readmission rates, and health institution spending.^23-25 Some studies show that up to 60% of geriatric patients may be malnourished.²⁶ 

Regarding vitamin and mineral supplements, the general consensus before orthopedic surgery is that vitamins A, C, D, and E, and zinc are predictive in determining postoperative health.²⁷ However, Curtis et al state that therapy should be targeted at correcting relative deficiencies; supraphysiologic concentrations of these vitamins do not appear to be helpful.²⁷ This claim may merit serum studies to rule out deficiencies. Dietitians should be involved in the creation of a patient care plan in the spirit of multidisciplinary orthopedic surgery approaches, which have proven to result in superior patient outcomes.²⁸ Additionally, directive counseling should be provided when necessary. 

In patients with adequately managed nutrition, 7 to 10 days of diet optimization is typically sufficient, but patients with malnutrition may require sustained nutritional support for up to 6 weeks; a standardized time for adequate nutrition supplementation has not been identified.^25-27 Postoperative management is similar in older patients who are malnourished and those receiving adequate nutrition after orthopedic surgery, which typically involves 3 weeks of a high-protein diet.²⁶

Evaluating Mechanisms of Injury

Assessing the mechanism of injury (MOI) is essential to developing an appropriate and successful orthopedic treatment plan. MOI is typically categorized as low energy, which consists of ground-level falls and other minor trauma, or high energy, which can include motor vehicle crashes or falls from a height.²⁹ Unlike younger patients who typically experience trauma from high-energy MOIs, geriatric patients often sustain fractures from low-energy MOIs. The importance of assessing MOI for the geriatric population is magnified as it provides vital clues that not only help determine the nature of the injury, but also highlight underlying frailty, comorbidities, and potential complications. Weakness or deconditioning related to older age is often not discovered before trauma, which is why assessing the MOI can provide valuable information regarding overall patient health.³⁰

The MOI of trauma also is correlated with factors that influence postoperative recovery and overall prognosis (Figure). Falls comprise more than three-quarters of the MOI in geriatric patients with trauma, and > 90% of these falls are ground-level or other simple falls.³⁰ Falls secondary to an intrinsic disorder, rather than an extrinsic environmental hazard, are more common in geriatric patients.³¹ 

These events may be associated with an underlying medical condition, such as osteopenia, osteoporosis, or neuromuscular disorders, such as Parkinson disease.³² They may also be attributed to normal age-related changes, such as decreased visual acuity, reduced reaction time, or mild cognitive impairment.³⁰ An estimated 6% to 35% of geriatric patients who present to the emergency department have some degree of cognitive dysfunction.³³ Accordingly, a thorough understanding of the events leading up to injury is vital for the management of older patients. Knowing the specific circumstances of a fall can provide insight into the patient’s gait, balance, and need for further investigations such as cognitive screening or evaluation of home safety. This information can guide decisions regarding preoperative optimization of medications and postoperative rehabilitation interventions.

Frailty and Risk of Fracture

Frailty is a clinical syndrome defined by overall decreased capacity for the body’s adaptive changes to various stressors.³⁴ It is a common condition in geriatric populations due to cumulative degenerative changes and multisystem decline over a lifetime’s worth of disruptions to natural homeostasis.³⁴ In orthopedics, frailty typically refers to musculoskeletal durability and resilience in response to mechanical forces (ie, falls, trauma, and high-acceleration movements). Globally, > 200 million people have osteoporotic frailty, leading to 9 million hip fractures annually.³⁵ More than 30% of people aged ≥ 65 years fall ≥ 1 time per calendar year.³⁶

Assessing frailty in geriatric patients undergoing orthopedic surgery is vital, as it predisposes patients to higher rates of morbidity, mortality, and institutionalization, particularly from falls and resultant fragility fractures.^37-39 This is true for a wide range of orthopedic procedures, spanning elective to urgent surgeries and involving the axial and appendicular skeleton.^40,41 Given the high rates of fractures, subsequent patient morbidity, and financial burden on the health care system, effective frailty screening is essential. 

There are many strategies to assess frailty risk and subsequent fracture risk.⁴² Questionnaires or online medical calculators serve as easy-to-use tools for assessment of frailty or associated predictors of fragility fractures. Validated assessment tools are provided in Table 1. 

Dual-emission X-ray absorptiometry is a well-established way to determine bone density and establish fracture risk. The Fried Frailty Phenotype score and Short Performance Physical Battery test are clinically applicable methods of assessing frailty in older outpatient populations. Although these examinations focus on different aspects of the patient, they have moderate agreeability, are sensitive, and can be readily performed in the clinical setting as demonstrated by a > 90% patient participation rate for both methods.⁴² Finally, several serum studies can be predictive of frailty, the most readily modifiable of which are vitamin D3, ferritin, albumin, and calcium.⁴³ Although they are more invasive for the patient, serum studies can provide additional modifiable targets for perioperative optimization and contribute to risk stratification. 

Risk stratification should take place around 6 weeks before surgery, which should provide adequate time for rectification of preoperative barriers to elective surgical intervention—namely nutritional status. In cases of urgent or emergent procedures (ie, femoral neck fracture with concern for avascular necrosis of the femoral head), this may not be possible but should be conducted nonetheless for patient-specific postoperative rehabilitation and risk reduction.

Postoperative Complication Risks

Postoperative complications affect nearly 15% of geriatric orthopedic patients, highlighting the need for comprehensive preoperative evaluations to assess risk factors.⁴⁴ Age-related physiological changes, frailty, and comorbidities complicate recovery and management (Table 2).

Wound healing is impaired in older individuals due to suboptimal circulation and decreased oxygenation that is secondary to age-related changes, as well as the increased likelihood of comorbid conditions (eg, diabetes).⁷ Surgical site infections can be particularly malicious in geriatric patients, with a 4% incidence.^45,46 Hospitalization can be prolonged by a mean 2 weeks, which increases the risk of hospital-associated delirium and iatrogenic complications.⁴⁶ Both the mortality rate and costs associated with hospitalization are higher for older patients who develop surgical site infections compared with patients aged < 65 years, underscoring the importance of vigilant monitoring, early detection, and effective preoperative screening to identify and manage modifiable risk factors.⁴⁷ 

Postoperative delirium is another common complication of orthopedic surgery in the geriatric population, increasing morbidity and mortality. The incidence is reported to be as high as 53.3% in the trauma setting and 28.3% in the elective setting, indicating a need to assess patient risk preoperatively.^48,49 Several factors contribute to the high incidence of delirium, including advanced age, longer surgical durations, intraoperative hypotension and hypercapnia, pre-existing cognitive dysfunction, and postoperative sleep disorders.⁵⁰ 

VTE is another common cause of complications following orthopedic surgery. The development of DVT can lead to subsequent pulmonary embolism, which can be fatal. Orthopedic surgery patients are already at higher risk of DVT and VTE than other surgical patients, with an incidence as high as 40% to 60%, though it is frequently asymptomatic.^51,52 Geriatric patients may be more likely to have concurrent comorbidities that increase hypercoagulability.⁵³ Congestive heart failure, chronic kidney disease, and cardiovascular disease are all more common in older individuals and can increase the risk of VTE by 2-fold.⁵³ While anticoagulation is the standard of care to prevent VTE after orthopedic surgery, geriatric patients require more careful monitoring due to the higher incidence of bleeding complications. Additionally, early postoperative mobilization is critical to reduce the risk of DVT without significantly increasing pain or causing other adverse events.⁵⁴ 

Respiratory complications are common after orthopedic surgery, particularly atelectasis and bronchospasm, which can result from intraoperative mechanical ventilation.⁵⁵ While these conditions are typically self-limiting, more severe respiratory issues such as pneumonia are a significant concern because they may lead to the need for mechanical ventilation and admission to the intensive care unit (ICU). The more severe complications have an incidence of about 1% to 2% in orthopedic surgery patients.⁵⁶ Preventive strategies, such as respiratory physiotherapy and guided breathing exercises, are crucial to minimize perioperative pulmonary complications and promote optimal recovery. Addressing these challenges through early intervention is essential to improve outcomes.

Multidisciplinary Perioperative Care

Multidisciplinary care in orthopedic surgery involves collaborative management of patient care by general practitioners, surgeons, anesthesiologists, dietitians, physical and occupational therapists, inpatient health care practitioners (HCPs), and social services. The goal of this form of care is to provide a longitudinal sequence of health-optimization tactics that prepare a patient for surgery and give them the best chance of postoperative recovery.

Given that many aspects of geriatric health play a role in orthopedic postoperative outcomes, there are many preoperative factors to consider. As previously discussed, preoperative evaluation of geriatric patients should include nutritional and fragility screening to determine surgical candidacy and target modifiable risk factors for risk reduction. This screening can be conducted by primary care practitioners and orthopedic surgeons in an outpatient setting. A multidisciplinary approach benefits patients by decreasing time to surgery.³⁵ 

Several large studies have demonstrated the positive influence of a multidisciplinary approach on patient-oriented outcomes in orthopedic patients. Incorporation of this style of care in contrast to surgeon-led perioperative optimization leads to fewer floor and ICU admissions, shorter lengths of stay, and decreased mortality rates.^35,57 These findings are broadly applicable to a wide range of orthopedic surgeries and even surgeries outside of the musculoskeletal system.^58,59 In addition, this strategy has demonstrated reduced in-hospital health care costs due to shorter lengths of stay and fewer ICU admissions. Physical and occupational therapy also have irreplaceable roles in outcomes after orthopedic surgeries. They have independently been shown to decrease pain, increase range of motion, and increase functionality in daily life.⁶⁰ These aspects of recovery are essential for geriatric well-being.

Screening Tools

The World Health Organization FRAX fracture risk assessment tool (www.fraxplus.org/calculation-tool) was developed to identify patients at high risk of fracture and subsequent complications and to guide clinical decision-making regarding pharmacologic interventions.⁶¹ FRAX calculates the 10-year probability of fracture based on demographic factors, such as age and body mass index, clinical measures (eg, femoral neck bone mineral density), and risk factors (eg, prior fragility fractures, substance use history, and prolonged glucocorticoid use).⁶¹ The online tool is easy to use, making it a valuable resource for assessing fracture risk and determining appropriate treatment strategies.

The fatigue, resistance, ambulation, illnesses, loss of weight (FRAIL) scale assesses frailty in older adults. The scale classifies patients into 3 categories: robust, prefrail, and frail. The frail category is associated with an increased frequency of hip fracture and an elevated ASA class.⁶² Additionally, the FRAIL scale has demonstrated value in predicting hospital length of stay and the risk of postoperative complications.⁶² It also has shown utility in quantifying frailty status, which is traditionally challenging to assess systematically.⁶³

The Mini-Cog is commonly used in geriatric populations to screen for cognitive impairment. Preoperative Mini-Cog screening has been shown to predict the development of postoperative complications.⁶⁴ Geriatric patients who screened positive for cognitive impairment prior to orthopedic surgery were more likely to develop postoperative delirium, require alternative discharge disposition, and have a longer hospital length of stay.⁶⁴ Mini-Cog serves as an important preoperative tool for identifying patients who may benefit from closer postoperative monitoring and tailored care.

The Comprehensive Geriatric Assessment (CGA) is a multidimensional evaluation that has been validated for use in geriatric patients undergoing orthopedic surgery.⁶⁵ The CGA assesses functional status and the ability to perform activities of daily living (ADLs), such as eating, dressing, and ambulating. Poor ADLs are associated with increased risk of falls and cardiopulmonary complications. The CGA allows HCPs to identify patients at higher risk of complications and tailor interventions that optimize functional recovery during the perioperative period.

Nutritional screening is another component of preoperative evaluation in older adults undergoing orthopedic surgery. The Perioperative Nutrition Screen is a preoperative phone assessment of unintentional weight loss in the past 6 months.⁶⁶ Patients who screen positive are asked to come in for a preoperative visit with a registered dietitian who can further evaluate the nutritional status of the patient. 

The Mini Nutritional Assessment Short Form (MNA-SF), Malnutrition Universal Screening Tool, and Nutrition Risk Screening 2002 have all been validated for use in older patients undergoing orthopedic surgery. Among these, the MNA-SF has demonstrated superior utility in predicting hospital readmission and mortality.⁶⁷ Given the established links between malnutrition and poor surgical outcomes, routine nutritional screening is important for identifying geriatric patients who may require preoperative nutritional interventions.

CONCLUSIONS AND RECOMMENDATIONS

Perioperative management of geriatric patients undergoing orthopedic surgery requires an assessment and strategy focused on risk stratification, patient optimization, and mitigation of potential complications and mortality. Due to the complexity and comprehensive nature of an optimal perioperative plan, creating the plan early is essential to ensure adequate time for patient optimization and care coordination.

Nutrition plays a critical role in the success of surgical procedures, and orthopedics is no exception. Extra care should be taken to preoperatively optimize patient bone health before surgical intervention to enhance recovery and reduce the risk of complications. After an appropriate patient history and clinical picture are gathered, screening tools should be used on a case-by-case basis to further characterize comorbid conditions that may contribute to suboptimal outcomes. Additionally, given the proven association between frailty and fracture risk, frailty serves as a readily quantifiable predictor of patient-oriented outcomes. This should be assessed preoperatively with appropriate risk-stratification tools to determine appropriate postoperative measures to prevent morbidity and mortality. 

Orthopedic surgery is increasingly common in geriatric patients, who face higher perioperative risks due to age-related physiological changes, multimorbidity, and frailty. Optimizing preoperative assessment and adopting a multidisciplinary approach—integrating surgeons, anesthesiologists, physical therapists, and dietitians—can improve outcomes, reduce complications, and enhance recovery. The successful use of the tools and strategies outlined in this article by primary care should facilitate access to and recovery from orthopedic surgery in the geriatric population.

More than 40 million surgeries are performed annually in the United States, of which > 18 million are orthopedic, including > 1 million emergency orthopedic surgeries and > 2 million joint replacements.^1-4 Notably, > 50% of patients undergoing orthopedic surgery are aged ≥ 65 years, a demographic shift driven by longer life expectancies and an increasing number of older adults remaining physically active for extended periods.⁵ Osteoarthritis, the most common joint disease, affects 10% of men and 18% of women aged > 60 years, often necessitating an orthopedic joint replacement.⁶ Perioperative morbidity and mortality are 2.9- to 6.7-times higher in older adults compared with younger adults.⁷ These risks include infection, venous thromboembolism (VTE), pressure ulcers, reduced mobility, and increased mortality. Due to the high incidence of these complications in older surgical patients, special perioperative protocols and considerations are needed when preparing an older patient for surgery. This review aims to establish concrete considerations and guidelines for perioperative management.

METHODOLOGY

A literature review of PubMed, Google Scholar, and IEEE Xplore identified research on perioperative challenges in geriatric orthopedic surgery. Keywords included geriatrics and orthopedic surgery, perioperative care in geriatric populations, and orthopedic perioperative care. Inclusion criteria were strictly defined to ensure relevance to the geriatric population, with studies focusing on patients aged ≥ 65 years. Exclusion criteria were applied to remove studies that did not involve geriatric populations or orthopedic surgeries or that lacked a clear perioperative focus. Studies were analyzed for design, interventions, and outcomes. Special attention was given to identifying common challenges and trends related to perioperative considerations. We developed a narrative report providing a comprehensive overview of the current understanding of perioperative care for geriatric orthopedic patients to offer practical recommendations for clinicians to use in their practice.

RESULTS

Consistent with the narrative review methodology described, the literature search yielded a broad range of publications addressing perioperative considerations in geriatric orthopedic patients. Articles were screened for relevance to patients aged ≥ 65 years undergoing orthopedic surgery and for applicability to perioperative optimization and postoperative outcomes. Given the heterogeneity in study design, population characteristics, and outcome reporting, findings are presented descriptively rather than being quantitatively pooled. Studies not focused on geriatric populations, orthopedic procedures, or perioperative management were excluded. Key themes included multimorbidity and comorbidity optimization, age-related physiologic changes, frailty assessment and fracture risk stratification, nutritional and bone health management, mechanism of injury considerations, prevention of postoperative complications, and the role of multidisciplinary perioperative care.

Unique Physiological Challenges

The aging process induces a range of physiological changes that can increase morbidity and mortality following surgery. One of the most essential elements to surgical recovery is wound healing, as impairments in this process can lead to adverse events, including infection, cosmetic deformity, and wound dehiscence. The general paradigm of aging involves cell senescence resulting in slower or disorganized functional capacity of these cells.⁸ While wound healing in older individuals was once thought to be defective, recent research has demonstrated that this process is not absent, but delayed.⁹

Wound healing is a tightly regulated and evolutionarily conserved process that proceeds through 3 main phases: inflammation, proliferation, and remodeling. Re-epithelialization begins with the migration of epithelial cells from hair follicles, sweat glands, or wound margins (depending on wound depth) and is influenced by oxygen levels, moisture, and growth factors.⁹ Several characteristics of aged skin contribute to the delayed healing process. Aged skin has fewer hair follicles and eccrine sweat glands, as well as decreased follicle thickness.¹⁰ This results in fewer proliferating cells for wound healing and lower amounts of sebum production for skin moisture.¹¹ Furthermore, aged fibroblasts are fewer in number and less effective in synthesizing extracellular matrices, resulting in slower and less tensile wound healing.¹² Additionally, microvascular changes associated with aging result in disorganized vasculature, which impairs oxygen delivery to the wound bed and diminishes the influx of proinflammatory cells necessary for effective healing.¹³ These senescent traits of aged skin contribute to the delayed wound healing process found in geriatric patients. 

Compounding these age-related factors is the prevalence of multimorbidity, or coexisting chronic diagnoses, in 55% to 98% of older patients.¹⁴ Common comorbidities include peripheral arterial disease, chronic venous insufficiency, type 1 and type 2 diabetes, neoplasms, atherosclerotic disease, and hypertension. Older patients are more likely to be prescribed corticosteroids and chemotherapeutic agents that impair the function of inflammatory cells necessary for wound healing.^15,16 Additionally, decreased mobility is more common in geriatric patients, which can increase the risk of wound formation, particularly pressure ulcers.¹⁷

Perioperative Considerations

All surgical patients undergo a formal or informal preoperative evaluation to assess their fitness for surgery, with the goal of minimizing both anesthesia-related risks and postoperative complications. A widely used tool in this assessment is the American Society of Anesthesiologists (ASA) physical status classification, which stratifies patients into 6 categories based on their medical history and overall health status.¹⁸ Classes range from healthy patients (Class I) to organ donors who are brain-dead (Class VI).

Cardiac optimization is an essential component of preoperative evaluation for older adults due to their higher risk of underlying cardiovascular disease.¹⁹ This process involves an in-depth review of the patient’s cardiac history, including the timing and nature of any prior interventions and the recurrence rate. Functional capacity is assessed through metabolic equivalents, where a threshold of > 4 metabolic equivalents (the ability to walk up a flight of stairs) is considered adequate for surgery. Risk is assessed based on the specific surgical procedure, and nonemergent orthopedic procedures are considered intermediate risk. If a patient is deemed high risk at any stage of this evaluation, further cardiac testing is indicated. 

Pulmonary optimization is typically necessary for geriatric patients, who are more likely to have conditions such as chronic obstructive pulmonary disease or interstitial lung disease.^14,20 In patients without severe systemic lung disease, pulmonary optimization involves assessing the functional expiratory volume and diffusing capacity for carbon monoxide. In addition, aggressive modification of risk factors, such as smoking cessation, is strongly recommended. 

Additional perioperative conditions are disease-specific and involve evaluation of comorbid illnesses and recognition of absolute contraindications to noncardiac surgery. For instance, an ejection fraction of < 35%, a history of myocardial infarction within 6 months, or active diabetic ketoacidosis are all absolute contraindications to elective surgery. For orthopedic procedures, additional contraindications include symptomatic bacteremia, active joint or local tissue infection, severe malnutrition, uncontrolled metabolic syndrome or chronic disease, untreated immunodeficiency, and active deep venous thrombosis (DVT) or pulmonary embolism.²¹

Bone Health and Nutrition

In the context of orthopedic surgery, the hallmark of clinically defined optimal bone health is a musculoskeletal system that provides the ability for pain-free functional and occupational tasks with an adequate capacity to withstand the mechanical forces imparted by everyday life. Back pain and arthritis are the fourth- and sixth-most common complaints in primary care, underscoring suboptimal bone health management in developed countries.²²

Optimizing bone health through proper nutrition is crucial in the perioperative management of geriatric orthopedic patients. The clinical diagnosis of malnutrition has well-studied associations with worse outcomes after orthopedic surgery, which include increased mortality, hospital length of stay, readmission rates, and health institution spending.^23-25 Some studies show that up to 60% of geriatric patients may be malnourished.²⁶ 

Regarding vitamin and mineral supplements, the general consensus before orthopedic surgery is that vitamins A, C, D, and E, and zinc are predictive in determining postoperative health.²⁷ However, Curtis et al state that therapy should be targeted at correcting relative deficiencies; supraphysiologic concentrations of these vitamins do not appear to be helpful.²⁷ This claim may merit serum studies to rule out deficiencies. Dietitians should be involved in the creation of a patient care plan in the spirit of multidisciplinary orthopedic surgery approaches, which have proven to result in superior patient outcomes.²⁸ Additionally, directive counseling should be provided when necessary. 

In patients with adequately managed nutrition, 7 to 10 days of diet optimization is typically sufficient, but patients with malnutrition may require sustained nutritional support for up to 6 weeks; a standardized time for adequate nutrition supplementation has not been identified.^25-27 Postoperative management is similar in older patients who are malnourished and those receiving adequate nutrition after orthopedic surgery, which typically involves 3 weeks of a high-protein diet.²⁶

Evaluating Mechanisms of Injury

Assessing the mechanism of injury (MOI) is essential to developing an appropriate and successful orthopedic treatment plan. MOI is typically categorized as low energy, which consists of ground-level falls and other minor trauma, or high energy, which can include motor vehicle crashes or falls from a height.²⁹ Unlike younger patients who typically experience trauma from high-energy MOIs, geriatric patients often sustain fractures from low-energy MOIs. The importance of assessing MOI for the geriatric population is magnified as it provides vital clues that not only help determine the nature of the injury, but also highlight underlying frailty, comorbidities, and potential complications. Weakness or deconditioning related to older age is often not discovered before trauma, which is why assessing the MOI can provide valuable information regarding overall patient health.³⁰

The MOI of trauma also is correlated with factors that influence postoperative recovery and overall prognosis (Figure). Falls comprise more than three-quarters of the MOI in geriatric patients with trauma, and > 90% of these falls are ground-level or other simple falls.³⁰ Falls secondary to an intrinsic disorder, rather than an extrinsic environmental hazard, are more common in geriatric patients.³¹ 

These events may be associated with an underlying medical condition, such as osteopenia, osteoporosis, or neuromuscular disorders, such as Parkinson disease.³² They may also be attributed to normal age-related changes, such as decreased visual acuity, reduced reaction time, or mild cognitive impairment.³⁰ An estimated 6% to 35% of geriatric patients who present to the emergency department have some degree of cognitive dysfunction.³³ Accordingly, a thorough understanding of the events leading up to injury is vital for the management of older patients. Knowing the specific circumstances of a fall can provide insight into the patient’s gait, balance, and need for further investigations such as cognitive screening or evaluation of home safety. This information can guide decisions regarding preoperative optimization of medications and postoperative rehabilitation interventions.

Frailty and Risk of Fracture

Frailty is a clinical syndrome defined by overall decreased capacity for the body’s adaptive changes to various stressors.³⁴ It is a common condition in geriatric populations due to cumulative degenerative changes and multisystem decline over a lifetime’s worth of disruptions to natural homeostasis.³⁴ In orthopedics, frailty typically refers to musculoskeletal durability and resilience in response to mechanical forces (ie, falls, trauma, and high-acceleration movements). Globally, > 200 million people have osteoporotic frailty, leading to 9 million hip fractures annually.³⁵ More than 30% of people aged ≥ 65 years fall ≥ 1 time per calendar year.³⁶

Assessing frailty in geriatric patients undergoing orthopedic surgery is vital, as it predisposes patients to higher rates of morbidity, mortality, and institutionalization, particularly from falls and resultant fragility fractures.^37-39 This is true for a wide range of orthopedic procedures, spanning elective to urgent surgeries and involving the axial and appendicular skeleton.^40,41 Given the high rates of fractures, subsequent patient morbidity, and financial burden on the health care system, effective frailty screening is essential. 

There are many strategies to assess frailty risk and subsequent fracture risk.⁴² Questionnaires or online medical calculators serve as easy-to-use tools for assessment of frailty or associated predictors of fragility fractures. Validated assessment tools are provided in Table 1. 

Dual-emission X-ray absorptiometry is a well-established way to determine bone density and establish fracture risk. The Fried Frailty Phenotype score and Short Performance Physical Battery test are clinically applicable methods of assessing frailty in older outpatient populations. Although these examinations focus on different aspects of the patient, they have moderate agreeability, are sensitive, and can be readily performed in the clinical setting as demonstrated by a > 90% patient participation rate for both methods.⁴² Finally, several serum studies can be predictive of frailty, the most readily modifiable of which are vitamin D3, ferritin, albumin, and calcium.⁴³ Although they are more invasive for the patient, serum studies can provide additional modifiable targets for perioperative optimization and contribute to risk stratification. 

Risk stratification should take place around 6 weeks before surgery, which should provide adequate time for rectification of preoperative barriers to elective surgical intervention—namely nutritional status. In cases of urgent or emergent procedures (ie, femoral neck fracture with concern for avascular necrosis of the femoral head), this may not be possible but should be conducted nonetheless for patient-specific postoperative rehabilitation and risk reduction.

Postoperative Complication Risks

Postoperative complications affect nearly 15% of geriatric orthopedic patients, highlighting the need for comprehensive preoperative evaluations to assess risk factors.⁴⁴ Age-related physiological changes, frailty, and comorbidities complicate recovery and management (Table 2).

Wound healing is impaired in older individuals due to suboptimal circulation and decreased oxygenation that is secondary to age-related changes, as well as the increased likelihood of comorbid conditions (eg, diabetes).⁷ Surgical site infections can be particularly malicious in geriatric patients, with a 4% incidence.^45,46 Hospitalization can be prolonged by a mean 2 weeks, which increases the risk of hospital-associated delirium and iatrogenic complications.⁴⁶ Both the mortality rate and costs associated with hospitalization are higher for older patients who develop surgical site infections compared with patients aged < 65 years, underscoring the importance of vigilant monitoring, early detection, and effective preoperative screening to identify and manage modifiable risk factors.⁴⁷ 

Postoperative delirium is another common complication of orthopedic surgery in the geriatric population, increasing morbidity and mortality. The incidence is reported to be as high as 53.3% in the trauma setting and 28.3% in the elective setting, indicating a need to assess patient risk preoperatively.^48,49 Several factors contribute to the high incidence of delirium, including advanced age, longer surgical durations, intraoperative hypotension and hypercapnia, pre-existing cognitive dysfunction, and postoperative sleep disorders.⁵⁰ 

VTE is another common cause of complications following orthopedic surgery. The development of DVT can lead to subsequent pulmonary embolism, which can be fatal. Orthopedic surgery patients are already at higher risk of DVT and VTE than other surgical patients, with an incidence as high as 40% to 60%, though it is frequently asymptomatic.^51,52 Geriatric patients may be more likely to have concurrent comorbidities that increase hypercoagulability.⁵³ Congestive heart failure, chronic kidney disease, and cardiovascular disease are all more common in older individuals and can increase the risk of VTE by 2-fold.⁵³ While anticoagulation is the standard of care to prevent VTE after orthopedic surgery, geriatric patients require more careful monitoring due to the higher incidence of bleeding complications. Additionally, early postoperative mobilization is critical to reduce the risk of DVT without significantly increasing pain or causing other adverse events.⁵⁴ 

Respiratory complications are common after orthopedic surgery, particularly atelectasis and bronchospasm, which can result from intraoperative mechanical ventilation.⁵⁵ While these conditions are typically self-limiting, more severe respiratory issues such as pneumonia are a significant concern because they may lead to the need for mechanical ventilation and admission to the intensive care unit (ICU). The more severe complications have an incidence of about 1% to 2% in orthopedic surgery patients.⁵⁶ Preventive strategies, such as respiratory physiotherapy and guided breathing exercises, are crucial to minimize perioperative pulmonary complications and promote optimal recovery. Addressing these challenges through early intervention is essential to improve outcomes.

Multidisciplinary Perioperative Care

Multidisciplinary care in orthopedic surgery involves collaborative management of patient care by general practitioners, surgeons, anesthesiologists, dietitians, physical and occupational therapists, inpatient health care practitioners (HCPs), and social services. The goal of this form of care is to provide a longitudinal sequence of health-optimization tactics that prepare a patient for surgery and give them the best chance of postoperative recovery.

Given that many aspects of geriatric health play a role in orthopedic postoperative outcomes, there are many preoperative factors to consider. As previously discussed, preoperative evaluation of geriatric patients should include nutritional and fragility screening to determine surgical candidacy and target modifiable risk factors for risk reduction. This screening can be conducted by primary care practitioners and orthopedic surgeons in an outpatient setting. A multidisciplinary approach benefits patients by decreasing time to surgery.³⁵ 

Several large studies have demonstrated the positive influence of a multidisciplinary approach on patient-oriented outcomes in orthopedic patients. Incorporation of this style of care in contrast to surgeon-led perioperative optimization leads to fewer floor and ICU admissions, shorter lengths of stay, and decreased mortality rates.^35,57 These findings are broadly applicable to a wide range of orthopedic surgeries and even surgeries outside of the musculoskeletal system.^58,59 In addition, this strategy has demonstrated reduced in-hospital health care costs due to shorter lengths of stay and fewer ICU admissions. Physical and occupational therapy also have irreplaceable roles in outcomes after orthopedic surgeries. They have independently been shown to decrease pain, increase range of motion, and increase functionality in daily life.⁶⁰ These aspects of recovery are essential for geriatric well-being.

Screening Tools

The World Health Organization FRAX fracture risk assessment tool (www.fraxplus.org/calculation-tool) was developed to identify patients at high risk of fracture and subsequent complications and to guide clinical decision-making regarding pharmacologic interventions.⁶¹ FRAX calculates the 10-year probability of fracture based on demographic factors, such as age and body mass index, clinical measures (eg, femoral neck bone mineral density), and risk factors (eg, prior fragility fractures, substance use history, and prolonged glucocorticoid use).⁶¹ The online tool is easy to use, making it a valuable resource for assessing fracture risk and determining appropriate treatment strategies.

The fatigue, resistance, ambulation, illnesses, loss of weight (FRAIL) scale assesses frailty in older adults. The scale classifies patients into 3 categories: robust, prefrail, and frail. The frail category is associated with an increased frequency of hip fracture and an elevated ASA class.⁶² Additionally, the FRAIL scale has demonstrated value in predicting hospital length of stay and the risk of postoperative complications.⁶² It also has shown utility in quantifying frailty status, which is traditionally challenging to assess systematically.⁶³

The Mini-Cog is commonly used in geriatric populations to screen for cognitive impairment. Preoperative Mini-Cog screening has been shown to predict the development of postoperative complications.⁶⁴ Geriatric patients who screened positive for cognitive impairment prior to orthopedic surgery were more likely to develop postoperative delirium, require alternative discharge disposition, and have a longer hospital length of stay.⁶⁴ Mini-Cog serves as an important preoperative tool for identifying patients who may benefit from closer postoperative monitoring and tailored care.

The Comprehensive Geriatric Assessment (CGA) is a multidimensional evaluation that has been validated for use in geriatric patients undergoing orthopedic surgery.⁶⁵ The CGA assesses functional status and the ability to perform activities of daily living (ADLs), such as eating, dressing, and ambulating. Poor ADLs are associated with increased risk of falls and cardiopulmonary complications. The CGA allows HCPs to identify patients at higher risk of complications and tailor interventions that optimize functional recovery during the perioperative period.

Nutritional screening is another component of preoperative evaluation in older adults undergoing orthopedic surgery. The Perioperative Nutrition Screen is a preoperative phone assessment of unintentional weight loss in the past 6 months.⁶⁶ Patients who screen positive are asked to come in for a preoperative visit with a registered dietitian who can further evaluate the nutritional status of the patient. 

The Mini Nutritional Assessment Short Form (MNA-SF), Malnutrition Universal Screening Tool, and Nutrition Risk Screening 2002 have all been validated for use in older patients undergoing orthopedic surgery. Among these, the MNA-SF has demonstrated superior utility in predicting hospital readmission and mortality.⁶⁷ Given the established links between malnutrition and poor surgical outcomes, routine nutritional screening is important for identifying geriatric patients who may require preoperative nutritional interventions.

CONCLUSIONS AND RECOMMENDATIONS

Perioperative management of geriatric patients undergoing orthopedic surgery requires an assessment and strategy focused on risk stratification, patient optimization, and mitigation of potential complications and mortality. Due to the complexity and comprehensive nature of an optimal perioperative plan, creating the plan early is essential to ensure adequate time for patient optimization and care coordination.

Nutrition plays a critical role in the success of surgical procedures, and orthopedics is no exception. Extra care should be taken to preoperatively optimize patient bone health before surgical intervention to enhance recovery and reduce the risk of complications. After an appropriate patient history and clinical picture are gathered, screening tools should be used on a case-by-case basis to further characterize comorbid conditions that may contribute to suboptimal outcomes. Additionally, given the proven association between frailty and fracture risk, frailty serves as a readily quantifiable predictor of patient-oriented outcomes. This should be assessed preoperatively with appropriate risk-stratification tools to determine appropriate postoperative measures to prevent morbidity and mortality. 

Orthopedic surgery is increasingly common in geriatric patients, who face higher perioperative risks due to age-related physiological changes, multimorbidity, and frailty. Optimizing preoperative assessment and adopting a multidisciplinary approach—integrating surgeons, anesthesiologists, physical therapists, and dietitians—can improve outcomes, reduce complications, and enhance recovery. The successful use of the tools and strategies outlined in this article by primary care should facilitate access to and recovery from orthopedic surgery in the geriatric population.

More than 40 million surgeries are performed annually in the United States, of which > 18 million are orthopedic, including > 1 million emergency orthopedic surgeries and > 2 million joint replacements.^1-4 Notably, > 50% of patients undergoing orthopedic surgery are aged ≥ 65 years, a demographic shift driven by longer life expectancies and an increasing number of older adults remaining physically active for extended periods.⁵ Osteoarthritis, the most common joint disease, affects 10% of men and 18% of women aged > 60 years, often necessitating an orthopedic joint replacement.⁶ Perioperative morbidity and mortality are 2.9- to 6.7-times higher in older adults compared with younger adults.⁷ These risks include infection, venous thromboembolism (VTE), pressure ulcers, reduced mobility, and increased mortality. Due to the high incidence of these complications in older surgical patients, special perioperative protocols and considerations are needed when preparing an older patient for surgery. This review aims to establish concrete considerations and guidelines for perioperative management.

METHODOLOGY

A literature review of PubMed, Google Scholar, and IEEE Xplore identified research on perioperative challenges in geriatric orthopedic surgery. Keywords included geriatrics and orthopedic surgery, perioperative care in geriatric populations, and orthopedic perioperative care. Inclusion criteria were strictly defined to ensure relevance to the geriatric population, with studies focusing on patients aged ≥ 65 years. Exclusion criteria were applied to remove studies that did not involve geriatric populations or orthopedic surgeries or that lacked a clear perioperative focus. Studies were analyzed for design, interventions, and outcomes. Special attention was given to identifying common challenges and trends related to perioperative considerations. We developed a narrative report providing a comprehensive overview of the current understanding of perioperative care for geriatric orthopedic patients to offer practical recommendations for clinicians to use in their practice.

RESULTS

Consistent with the narrative review methodology described, the literature search yielded a broad range of publications addressing perioperative considerations in geriatric orthopedic patients. Articles were screened for relevance to patients aged ≥ 65 years undergoing orthopedic surgery and for applicability to perioperative optimization and postoperative outcomes. Given the heterogeneity in study design, population characteristics, and outcome reporting, findings are presented descriptively rather than being quantitatively pooled. Studies not focused on geriatric populations, orthopedic procedures, or perioperative management were excluded. Key themes included multimorbidity and comorbidity optimization, age-related physiologic changes, frailty assessment and fracture risk stratification, nutritional and bone health management, mechanism of injury considerations, prevention of postoperative complications, and the role of multidisciplinary perioperative care.

Unique Physiological Challenges

The aging process induces a range of physiological changes that can increase morbidity and mortality following surgery. One of the most essential elements to surgical recovery is wound healing, as impairments in this process can lead to adverse events, including infection, cosmetic deformity, and wound dehiscence. The general paradigm of aging involves cell senescence resulting in slower or disorganized functional capacity of these cells.⁸ While wound healing in older individuals was once thought to be defective, recent research has demonstrated that this process is not absent, but delayed.⁹

Wound healing is a tightly regulated and evolutionarily conserved process that proceeds through 3 main phases: inflammation, proliferation, and remodeling. Re-epithelialization begins with the migration of epithelial cells from hair follicles, sweat glands, or wound margins (depending on wound depth) and is influenced by oxygen levels, moisture, and growth factors.⁹ Several characteristics of aged skin contribute to the delayed healing process. Aged skin has fewer hair follicles and eccrine sweat glands, as well as decreased follicle thickness.¹⁰ This results in fewer proliferating cells for wound healing and lower amounts of sebum production for skin moisture.¹¹ Furthermore, aged fibroblasts are fewer in number and less effective in synthesizing extracellular matrices, resulting in slower and less tensile wound healing.¹² Additionally, microvascular changes associated with aging result in disorganized vasculature, which impairs oxygen delivery to the wound bed and diminishes the influx of proinflammatory cells necessary for effective healing.¹³ These senescent traits of aged skin contribute to the delayed wound healing process found in geriatric patients. 

Compounding these age-related factors is the prevalence of multimorbidity, or coexisting chronic diagnoses, in 55% to 98% of older patients.¹⁴ Common comorbidities include peripheral arterial disease, chronic venous insufficiency, type 1 and type 2 diabetes, neoplasms, atherosclerotic disease, and hypertension. Older patients are more likely to be prescribed corticosteroids and chemotherapeutic agents that impair the function of inflammatory cells necessary for wound healing.^15,16 Additionally, decreased mobility is more common in geriatric patients, which can increase the risk of wound formation, particularly pressure ulcers.¹⁷

Perioperative Considerations

All surgical patients undergo a formal or informal preoperative evaluation to assess their fitness for surgery, with the goal of minimizing both anesthesia-related risks and postoperative complications. A widely used tool in this assessment is the American Society of Anesthesiologists (ASA) physical status classification, which stratifies patients into 6 categories based on their medical history and overall health status.¹⁸ Classes range from healthy patients (Class I) to organ donors who are brain-dead (Class VI).

Cardiac optimization is an essential component of preoperative evaluation for older adults due to their higher risk of underlying cardiovascular disease.¹⁹ This process involves an in-depth review of the patient’s cardiac history, including the timing and nature of any prior interventions and the recurrence rate. Functional capacity is assessed through metabolic equivalents, where a threshold of > 4 metabolic equivalents (the ability to walk up a flight of stairs) is considered adequate for surgery. Risk is assessed based on the specific surgical procedure, and nonemergent orthopedic procedures are considered intermediate risk. If a patient is deemed high risk at any stage of this evaluation, further cardiac testing is indicated. 

Pulmonary optimization is typically necessary for geriatric patients, who are more likely to have conditions such as chronic obstructive pulmonary disease or interstitial lung disease.^14,20 In patients without severe systemic lung disease, pulmonary optimization involves assessing the functional expiratory volume and diffusing capacity for carbon monoxide. In addition, aggressive modification of risk factors, such as smoking cessation, is strongly recommended. 

Additional perioperative conditions are disease-specific and involve evaluation of comorbid illnesses and recognition of absolute contraindications to noncardiac surgery. For instance, an ejection fraction of < 35%, a history of myocardial infarction within 6 months, or active diabetic ketoacidosis are all absolute contraindications to elective surgery. For orthopedic procedures, additional contraindications include symptomatic bacteremia, active joint or local tissue infection, severe malnutrition, uncontrolled metabolic syndrome or chronic disease, untreated immunodeficiency, and active deep venous thrombosis (DVT) or pulmonary embolism.²¹

Bone Health and Nutrition

In the context of orthopedic surgery, the hallmark of clinically defined optimal bone health is a musculoskeletal system that provides the ability for pain-free functional and occupational tasks with an adequate capacity to withstand the mechanical forces imparted by everyday life. Back pain and arthritis are the fourth- and sixth-most common complaints in primary care, underscoring suboptimal bone health management in developed countries.²²

Optimizing bone health through proper nutrition is crucial in the perioperative management of geriatric orthopedic patients. The clinical diagnosis of malnutrition has well-studied associations with worse outcomes after orthopedic surgery, which include increased mortality, hospital length of stay, readmission rates, and health institution spending.^23-25 Some studies show that up to 60% of geriatric patients may be malnourished.²⁶ 

Regarding vitamin and mineral supplements, the general consensus before orthopedic surgery is that vitamins A, C, D, and E, and zinc are predictive in determining postoperative health.²⁷ However, Curtis et al state that therapy should be targeted at correcting relative deficiencies; supraphysiologic concentrations of these vitamins do not appear to be helpful.²⁷ This claim may merit serum studies to rule out deficiencies. Dietitians should be involved in the creation of a patient care plan in the spirit of multidisciplinary orthopedic surgery approaches, which have proven to result in superior patient outcomes.²⁸ Additionally, directive counseling should be provided when necessary. 

In patients with adequately managed nutrition, 7 to 10 days of diet optimization is typically sufficient, but patients with malnutrition may require sustained nutritional support for up to 6 weeks; a standardized time for adequate nutrition supplementation has not been identified.^25-27 Postoperative management is similar in older patients who are malnourished and those receiving adequate nutrition after orthopedic surgery, which typically involves 3 weeks of a high-protein diet.²⁶

Evaluating Mechanisms of Injury

Assessing the mechanism of injury (MOI) is essential to developing an appropriate and successful orthopedic treatment plan. MOI is typically categorized as low energy, which consists of ground-level falls and other minor trauma, or high energy, which can include motor vehicle crashes or falls from a height.²⁹ Unlike younger patients who typically experience trauma from high-energy MOIs, geriatric patients often sustain fractures from low-energy MOIs. The importance of assessing MOI for the geriatric population is magnified as it provides vital clues that not only help determine the nature of the injury, but also highlight underlying frailty, comorbidities, and potential complications. Weakness or deconditioning related to older age is often not discovered before trauma, which is why assessing the MOI can provide valuable information regarding overall patient health.³⁰

The MOI of trauma also is correlated with factors that influence postoperative recovery and overall prognosis (Figure). Falls comprise more than three-quarters of the MOI in geriatric patients with trauma, and > 90% of these falls are ground-level or other simple falls.³⁰ Falls secondary to an intrinsic disorder, rather than an extrinsic environmental hazard, are more common in geriatric patients.³¹ 

These events may be associated with an underlying medical condition, such as osteopenia, osteoporosis, or neuromuscular disorders, such as Parkinson disease.³² They may also be attributed to normal age-related changes, such as decreased visual acuity, reduced reaction time, or mild cognitive impairment.³⁰ An estimated 6% to 35% of geriatric patients who present to the emergency department have some degree of cognitive dysfunction.³³ Accordingly, a thorough understanding of the events leading up to injury is vital for the management of older patients. Knowing the specific circumstances of a fall can provide insight into the patient’s gait, balance, and need for further investigations such as cognitive screening or evaluation of home safety. This information can guide decisions regarding preoperative optimization of medications and postoperative rehabilitation interventions.

Frailty and Risk of Fracture

Frailty is a clinical syndrome defined by overall decreased capacity for the body’s adaptive changes to various stressors.³⁴ It is a common condition in geriatric populations due to cumulative degenerative changes and multisystem decline over a lifetime’s worth of disruptions to natural homeostasis.³⁴ In orthopedics, frailty typically refers to musculoskeletal durability and resilience in response to mechanical forces (ie, falls, trauma, and high-acceleration movements). Globally, > 200 million people have osteoporotic frailty, leading to 9 million hip fractures annually.³⁵ More than 30% of people aged ≥ 65 years fall ≥ 1 time per calendar year.³⁶

Assessing frailty in geriatric patients undergoing orthopedic surgery is vital, as it predisposes patients to higher rates of morbidity, mortality, and institutionalization, particularly from falls and resultant fragility fractures.^37-39 This is true for a wide range of orthopedic procedures, spanning elective to urgent surgeries and involving the axial and appendicular skeleton.^40,41 Given the high rates of fractures, subsequent patient morbidity, and financial burden on the health care system, effective frailty screening is essential. 

There are many strategies to assess frailty risk and subsequent fracture risk.⁴² Questionnaires or online medical calculators serve as easy-to-use tools for assessment of frailty or associated predictors of fragility fractures. Validated assessment tools are provided in Table 1. 

Dual-emission X-ray absorptiometry is a well-established way to determine bone density and establish fracture risk. The Fried Frailty Phenotype score and Short Performance Physical Battery test are clinically applicable methods of assessing frailty in older outpatient populations. Although these examinations focus on different aspects of the patient, they have moderate agreeability, are sensitive, and can be readily performed in the clinical setting as demonstrated by a > 90% patient participation rate for both methods.⁴² Finally, several serum studies can be predictive of frailty, the most readily modifiable of which are vitamin D3, ferritin, albumin, and calcium.⁴³ Although they are more invasive for the patient, serum studies can provide additional modifiable targets for perioperative optimization and contribute to risk stratification. 

Risk stratification should take place around 6 weeks before surgery, which should provide adequate time for rectification of preoperative barriers to elective surgical intervention—namely nutritional status. In cases of urgent or emergent procedures (ie, femoral neck fracture with concern for avascular necrosis of the femoral head), this may not be possible but should be conducted nonetheless for patient-specific postoperative rehabilitation and risk reduction.

Postoperative Complication Risks

Postoperative complications affect nearly 15% of geriatric orthopedic patients, highlighting the need for comprehensive preoperative evaluations to assess risk factors.⁴⁴ Age-related physiological changes, frailty, and comorbidities complicate recovery and management (Table 2).

Wound healing is impaired in older individuals due to suboptimal circulation and decreased oxygenation that is secondary to age-related changes, as well as the increased likelihood of comorbid conditions (eg, diabetes).⁷ Surgical site infections can be particularly malicious in geriatric patients, with a 4% incidence.^45,46 Hospitalization can be prolonged by a mean 2 weeks, which increases the risk of hospital-associated delirium and iatrogenic complications.⁴⁶ Both the mortality rate and costs associated with hospitalization are higher for older patients who develop surgical site infections compared with patients aged < 65 years, underscoring the importance of vigilant monitoring, early detection, and effective preoperative screening to identify and manage modifiable risk factors.⁴⁷ 

Postoperative delirium is another common complication of orthopedic surgery in the geriatric population, increasing morbidity and mortality. The incidence is reported to be as high as 53.3% in the trauma setting and 28.3% in the elective setting, indicating a need to assess patient risk preoperatively.^48,49 Several factors contribute to the high incidence of delirium, including advanced age, longer surgical durations, intraoperative hypotension and hypercapnia, pre-existing cognitive dysfunction, and postoperative sleep disorders.⁵⁰ 

VTE is another common cause of complications following orthopedic surgery. The development of DVT can lead to subsequent pulmonary embolism, which can be fatal. Orthopedic surgery patients are already at higher risk of DVT and VTE than other surgical patients, with an incidence as high as 40% to 60%, though it is frequently asymptomatic.^51,52 Geriatric patients may be more likely to have concurrent comorbidities that increase hypercoagulability.⁵³ Congestive heart failure, chronic kidney disease, and cardiovascular disease are all more common in older individuals and can increase the risk of VTE by 2-fold.⁵³ While anticoagulation is the standard of care to prevent VTE after orthopedic surgery, geriatric patients require more careful monitoring due to the higher incidence of bleeding complications. Additionally, early postoperative mobilization is critical to reduce the risk of DVT without significantly increasing pain or causing other adverse events.⁵⁴ 

Respiratory complications are common after orthopedic surgery, particularly atelectasis and bronchospasm, which can result from intraoperative mechanical ventilation.⁵⁵ While these conditions are typically self-limiting, more severe respiratory issues such as pneumonia are a significant concern because they may lead to the need for mechanical ventilation and admission to the intensive care unit (ICU). The more severe complications have an incidence of about 1% to 2% in orthopedic surgery patients.⁵⁶ Preventive strategies, such as respiratory physiotherapy and guided breathing exercises, are crucial to minimize perioperative pulmonary complications and promote optimal recovery. Addressing these challenges through early intervention is essential to improve outcomes.

Multidisciplinary Perioperative Care

Multidisciplinary care in orthopedic surgery involves collaborative management of patient care by general practitioners, surgeons, anesthesiologists, dietitians, physical and occupational therapists, inpatient health care practitioners (HCPs), and social services. The goal of this form of care is to provide a longitudinal sequence of health-optimization tactics that prepare a patient for surgery and give them the best chance of postoperative recovery.

Given that many aspects of geriatric health play a role in orthopedic postoperative outcomes, there are many preoperative factors to consider. As previously discussed, preoperative evaluation of geriatric patients should include nutritional and fragility screening to determine surgical candidacy and target modifiable risk factors for risk reduction. This screening can be conducted by primary care practitioners and orthopedic surgeons in an outpatient setting. A multidisciplinary approach benefits patients by decreasing time to surgery.³⁵ 

Several large studies have demonstrated the positive influence of a multidisciplinary approach on patient-oriented outcomes in orthopedic patients. Incorporation of this style of care in contrast to surgeon-led perioperative optimization leads to fewer floor and ICU admissions, shorter lengths of stay, and decreased mortality rates.^35,57 These findings are broadly applicable to a wide range of orthopedic surgeries and even surgeries outside of the musculoskeletal system.^58,59 In addition, this strategy has demonstrated reduced in-hospital health care costs due to shorter lengths of stay and fewer ICU admissions. Physical and occupational therapy also have irreplaceable roles in outcomes after orthopedic surgeries. They have independently been shown to decrease pain, increase range of motion, and increase functionality in daily life.⁶⁰ These aspects of recovery are essential for geriatric well-being.

Screening Tools

The World Health Organization FRAX fracture risk assessment tool (www.fraxplus.org/calculation-tool) was developed to identify patients at high risk of fracture and subsequent complications and to guide clinical decision-making regarding pharmacologic interventions.⁶¹ FRAX calculates the 10-year probability of fracture based on demographic factors, such as age and body mass index, clinical measures (eg, femoral neck bone mineral density), and risk factors (eg, prior fragility fractures, substance use history, and prolonged glucocorticoid use).⁶¹ The online tool is easy to use, making it a valuable resource for assessing fracture risk and determining appropriate treatment strategies.

The fatigue, resistance, ambulation, illnesses, loss of weight (FRAIL) scale assesses frailty in older adults. The scale classifies patients into 3 categories: robust, prefrail, and frail. The frail category is associated with an increased frequency of hip fracture and an elevated ASA class.⁶² Additionally, the FRAIL scale has demonstrated value in predicting hospital length of stay and the risk of postoperative complications.⁶² It also has shown utility in quantifying frailty status, which is traditionally challenging to assess systematically.⁶³

The Mini-Cog is commonly used in geriatric populations to screen for cognitive impairment. Preoperative Mini-Cog screening has been shown to predict the development of postoperative complications.⁶⁴ Geriatric patients who screened positive for cognitive impairment prior to orthopedic surgery were more likely to develop postoperative delirium, require alternative discharge disposition, and have a longer hospital length of stay.⁶⁴ Mini-Cog serves as an important preoperative tool for identifying patients who may benefit from closer postoperative monitoring and tailored care.

The Comprehensive Geriatric Assessment (CGA) is a multidimensional evaluation that has been validated for use in geriatric patients undergoing orthopedic surgery.⁶⁵ The CGA assesses functional status and the ability to perform activities of daily living (ADLs), such as eating, dressing, and ambulating. Poor ADLs are associated with increased risk of falls and cardiopulmonary complications. The CGA allows HCPs to identify patients at higher risk of complications and tailor interventions that optimize functional recovery during the perioperative period.

Nutritional screening is another component of preoperative evaluation in older adults undergoing orthopedic surgery. The Perioperative Nutrition Screen is a preoperative phone assessment of unintentional weight loss in the past 6 months.⁶⁶ Patients who screen positive are asked to come in for a preoperative visit with a registered dietitian who can further evaluate the nutritional status of the patient. 

The Mini Nutritional Assessment Short Form (MNA-SF), Malnutrition Universal Screening Tool, and Nutrition Risk Screening 2002 have all been validated for use in older patients undergoing orthopedic surgery. Among these, the MNA-SF has demonstrated superior utility in predicting hospital readmission and mortality.⁶⁷ Given the established links between malnutrition and poor surgical outcomes, routine nutritional screening is important for identifying geriatric patients who may require preoperative nutritional interventions.

CONCLUSIONS AND RECOMMENDATIONS

Perioperative management of geriatric patients undergoing orthopedic surgery requires an assessment and strategy focused on risk stratification, patient optimization, and mitigation of potential complications and mortality. Due to the complexity and comprehensive nature of an optimal perioperative plan, creating the plan early is essential to ensure adequate time for patient optimization and care coordination.

Nutrition plays a critical role in the success of surgical procedures, and orthopedics is no exception. Extra care should be taken to preoperatively optimize patient bone health before surgical intervention to enhance recovery and reduce the risk of complications. After an appropriate patient history and clinical picture are gathered, screening tools should be used on a case-by-case basis to further characterize comorbid conditions that may contribute to suboptimal outcomes. Additionally, given the proven association between frailty and fracture risk, frailty serves as a readily quantifiable predictor of patient-oriented outcomes. This should be assessed preoperatively with appropriate risk-stratification tools to determine appropriate postoperative measures to prevent morbidity and mortality. 

Orthopedic surgery is increasingly common in geriatric patients, who face higher perioperative risks due to age-related physiological changes, multimorbidity, and frailty. Optimizing preoperative assessment and adopting a multidisciplinary approach—integrating surgeons, anesthesiologists, physical therapists, and dietitians—can improve outcomes, reduce complications, and enhance recovery. The successful use of the tools and strategies outlined in this article by primary care should facilitate access to and recovery from orthopedic surgery in the geriatric population.

T he US Census Bureau projects that the number of older adults (aged ≥ 65 years) will exceed 49 million by 2030, and an estimated 20% (nearly 10 million) of this population will experience cognitive or mental health disorders.^1,2 The mental health workforce is not equipped to address the specialized mental health care needs of many older adults.^2,3 For example, geriatric psychiatrists specialize in the diagnosis and treatment of mental illness and cognitive disorders in the later stages of life, but their numbers are few and declining. Only 33.5% of geriatric psychiatry fellowship training slots were filled from 2017 to 2021, and only 62 fellows trained during the 2021-2022 academic year.⁴ Board-certified geriatric psychiatrists also tend to be concentrated in larger, urban, academically-affiliated medical centers, often leaving rural areas and smaller facilities without access, including facilities in the Veterans Health Administration (VHA).⁵

The VHA has been optimizing access to specialty geriatric mental health services via regional and national virtual consultation services. Seven of 19 Veterans Integrated Service Network (VISN) Clinical Resource Hubs (CRHs) have geriatric mental health teams.⁶ These provide interdisciplinary geriatric mental telehealth services, including geriatric psychiatry, for older veterans with complex care needs.^7,8 Likewise, the VHA National Expert Consultation & Specialized Services-Mental Health (NEXCSS- MH, formerly known as the National Telemental Health Center) sponsors video teleconsultations with board-certified geriatric psychiatrists and an Ask the Expert email consultation program.

This article describes the Ask the Expert Geriatric Psychiatry email program (one of several similar programs at NEXCSS-MH), building upon a symposium presented at the American Association for Geriatric Psychiatry (AAGP) annual meeting in March 2022.⁹ The program was initiated in June 2021 as a result of discussions between the National Mental Health Director, Geriatric Mental Health in the VHA Office of Mental Health and Suicide Prevention (now known as the Office of Mental Health [OMH]), and National Telemental Health Center leadership. VHA board certified geriatric psychiatrists were recruited to serve as expert consultants and respond to email questions submitted by VHA clinicians regarding the psychiatric care of older adult veterans. The results of this program identify educational needs among clinical staff and may inform the development of program materials for a range of clinicians.

Program Description

The national geriatric mental health director recruited prospective experts and met with each to assess interest and qualifications, consulting with OMH psychiatrist leaders before making selections. Five experts were initially selected; 1 later stepped down and was replaced by another, who also stepped down. The experts were board certified in psychiatry and geriatric psychiatry and held a variety of local and national leadership positions, including geriatric psychiatry fellowship director, US Department of Veterans Affairs (VA) research and clinical leader, and various roles in the AAGP; some had received teaching awards.

Operations

The national geriatric mental health director announced the program in June 2021 to VHA mental health and geriatric program email groups with reminders sent every few months. The announcement included information about the types of questions appropriate to submit, including examples of general clinical management questions that did not share patient-specific protected health information, and clarified that experts would not be conducting chart reviews because the time required for detailed chart reviews was not feasible for volunteer experts to integrate into their otherwise full-time jobs at their respective VA medical centers. The announcement also included brief biographies of the experts.

The Figure describes the daily operations of the Ask the Expert Geriatric Psychiatry email consultation program. The NEXCSS- MH developed a Microsoft Outlook mailbox and group email address where clinicians from across the VHA could submit questions. The experts, as well as the national geriatric mental health director and NEXCSS-MH staff, had access to this mailbox to track and/or respond to questions. One expert volunteered to be the program’s primary mailbox coordinator. The coordinator checked the inbox daily and assigned each question to one of the experts on a rotating basis using the color-coding feature in Outlook. The other experts were advised to check the email account at least once weekly and reply to any assigned questions.

Responding to a question entailed first determining whether the question was appropriate for the service. For example, if a question requested a chart review, the expert replied that experts could not provide chart reviews and requested that the question be reframed. Next, the expert often needed to define a specific clinical question from the information provided, as email questions often touched upon several topics. The expert provided personalized advice on diagnostic testing, nonpharmacologic treatment strategies, and/or pharmacologic treatment options. Experts also often attached relevant guidelines or review articles. The goal was to provide a response within 7 business days.

All email responses included a disclaimer indicating that the program was not intended for urgent or immediate medical advice and that the information provided was for VHA clinician education purposes only. The disclaimer explained that email communication did not establish a doctor-patient relationship between the expert and a specific veteran and that, if desired, a request for a clinical consultation could be submitted on a specific case (ie, a video teleconsultation).

Methods for Reviewing Questions

Descriptive statistics, including frequencies, means, and minimum and maximum ranges, were used to capture the number of questions the program received, type of requester, and length of time prior to response for emailed questions.⁹ Conventional content analysis procedures were used between January and October 2024 to analyze clinicians’ questions.¹⁰ Four subject matter experts (3 geriatric psychiatrists and 1 geropsychologist) served as coders, assigned in groups of 2 to review questions. Each coder independently reviewed assigned questions and identified preliminary themes. Themes were reviewed and revised using an iterative process during regular team meetings with coders to clarify and confirm interpretations. Discrepancies were discussed within team meetings to achieve consensus.

Questions received. Between February 2022 and December 2023, the program received 101 email questions. Requesters included 39 physicians, 17 nurse practitioners or physician assistants, 15 social workers, 14 psychologists, 9 nurses, 5 pharmacists, 1 dietitian, and 1 who was undetermined. Experts responded to the questions an average of 6 days after receipt (range, < 1-19); 73 responses (72%) met the 7-day goal.

Iterative changes to coded themes were made during group discussions. Multiple clinical questions were often posed within the same email. Initially, some coders identified themes solely based on reported symptoms; others identified themes based on reported and/or potential diagnostic conditions attributed to the symptom(s) described within the email. For example, some coders selected a primary theme of behavioral and psychological symptoms of dementia (BPSD) only if a behavior contributing to distress in the veteran or others was described, while others selected this theme when any psychiatric symptom (eg, psychosis) was present in the context of dementia. The group identified 1 primary theme per question based on the main clinical symptom or main concern presented. Co-occurring diagnostic conditions highlighted in the email requests were included as secondary themes, and each question could have > 1 secondary theme.

The most frequent requests related to clinical symptoms included questions about agitated behaviors, sleep and/or nightmares, and depression symptoms (Table 1). Twenty-seven of 33 email requests on agitated behaviors were related to a dementia diagnosis, as were several questions about sleep/nightmares, depression, psychosis/mania, and anxiety. Many diagnostic conditions were described in the email requests (Table 2). The most frequent condition was dementia, followed by a medical condition, depressive disorder, posttraumatic stress disorder, and/or serious mental illness.

Request for Feedback. In February 2022, an email request was sent to the 64 clinicians who asked email questions from the start of the program in June 2021 through December 2021. A second request included 11 clinicians who asked questions from January through February 2022. These requests were sent as part of preparations for the symposium on the program presented at the AAGP annual meeting in March 2022.⁹ In May 2024, feedback was requested from 37 clinicians who submitted questions from May 1, 2023, through May 15, 2024.

Requests for feedback included 6 closed-ended and 1 open-ended question: (1) Did the answer you received help inform clinical practice? (2) Did you receive a timely response? (3) What type of information was useful to you in addressing your question (ie, direct/specific answer to a clinical scenario, guidelines, articles, VA resources)? (4) Do you have access to a geriatric psychiatrist at your facility? (5) Are you likely to use Ask the Expert Geriatric Psychiatry in the future? (6) Would you use a geriatric psychiatry teleconsultation service? (7) Share suggestions for improvement. Frequencies of response selection were obtained for each question. Text responses to the open-ended question asking for suggestions for improvement were reviewed and summarized.

Responses

Thirty users responded to the feedback request (27% response rate). Respondents considered the answers received extremely (n = 14; 47%) or very much (n = 12; 40%) helpful for their clinical practice. Twenty-three respondents (77%) felt an answer was provided promptly, 7 respondents (23%) felt the answer was not timely but still useful, and none felt that the answer was too late. Respondents reported that the most useful type of information in addressing their questions was a direct/specific answer to a clinical scenario (n = 27; 90%), followed by guidelines (n = 12; 40%), articles (n = 7; 23%), and VA resources (n = 4; 13%).

Sixteen respondents (53%) reported that they rarely had ready access to a geriatric psychiatrist at their facility, 3 (10%) had access sometimes, 4 (14%) had access usually, 3 (10%) had access regularly, and 3 (10%) never had access. Twenty-seven respondents (90%) indicated they would be very likely to use the service again. If geriatric psychiatry teleconsultation and/or e-consultation were offered, many respondents indicated they would be extremely (n = 10; 33%) or very (n = 12; 40%) likely to use teleconsultation and/or e-consultation.

Suggestions for improvement included supporting experts to perform chart reviews for email questions, developing a template or consult form, holding a biweekly drop-in meeting to present questions to and discuss cases with a panel of experts, and providing further help addressing complex decisional capacity issues, delirium, and care or placement for veterans with severe behavioral issues in a rural setting.

Discussion

Although many older adults experience cognitive and mental health disorders that may benefit from management by a geriatric psychiatrist, the number of trained geriatric psychiatrists available is insufficient to allow for direct care for each patient. The Ask the Expert Geriatric Psychiatry email consultation program is one aspect of a multicomponent strategy within the VHA to increase access to specialty geriatric mental health services for veterans. A key advantage of the program is that it is not resource intensive. Experts can participate voluntarily, providing timely feedback to clinicians around the country while continuing other duties at their respective VA medical centers. Email replies to the experts’ answers elicited positive feedback on the program, include: “I found this service to be extremely helpful and I have shared the information they sent me with several other coworkers!”, “It was great!”, and “I endorsed the service to our VISN Rehabilitation and Extended Care group.”

The coding of primary and secondary themes from 101 email questions that were retained revealed the range and relative frequencies of clinical and administrative topics with which clinicians needed help. The most common (33%) theme was agitated behaviors. Nearly half of the questions (48%) were related to underlying dementia, and 29% were related to a patient’s medical comorbidities. These findings suggest that the expertise of a geriatric psychiatrist is particularly relevant when caring for older patients experiencing BPSD or patients with complex, overlapping psychiatric and medical conditions.

Despite a 27% response rate, participant feedback has been helpful. The program reached its intended audience of clinicians in rural areas and at smaller facilities with 53% of requesters reporting they rarely had access to a geriatric psychiatrist. Suggestions for improvement indicated that some clinicians desired additional support, including chart reviews, meetings with experts, and a video teleconsultation service (available through NEXCSS-MH).

Many clinicians without training in specialty geriatric mental health may require help with complex clinical presentations. For example, 39 clinicians who submitted questions to the program were physicians. Accreditation Council for Graduate Medical Education program requirements for general psychiatry residency include 4 weeks of geriatric psychiatry.¹¹ The findings of this study suggest that this level of training may not be adequate to independently care for every patient who experiences dementia or multimorbidity. Several training and mentoring initiatives have been developed to address the professional development need for psychiatrists.^12-14

The need for geriatric workforce development is significant across health care, including other mental health professions.^15,16 The VHA Geriatric Scholars program trains rural primary care practitioners, psychologists, and psychiatrists.^17,18 Likewise, consultative geriatric specialty support for primary care practitioners in rural areas is provided via the Geriatric Research Education and Clinical Center Connect program.¹⁹ The Ask the Expert Geriatric Psychiatry email program is an additional economical model to support clinician educational development and provide rapid educational responses to inform patient care.

Ask the Expert received fewer email questions than anticipated. Enhanced optimization may require more frequent and widespread announcements about the program. Clinical staff may not be aware of the program due to an overload of email communications. Likewise, it may be challenging for busy clinicians to take the time to seek consultation or recognize a potential gap in their knowledge or skills. Had more questions been submitted, the 5 volunteer experts may have had more difficulty addressing the demand. Feedback from this project may inform development of a frequently asked questions document to share with VHA teams and a drop-in office hour to pose clinical questions of geriatric psychiatry experts, as recommended by a clinician who participated in the program.

Limitations

Not all requesters were sent a request for feedback, and the response rate for the request for feedback was only 27%. As the program has evolved, it began sending a request for feedback immediately after answering each question, which may increase the odds of response. The goal of experts answering questions within 7 business days was met 72% of the time, likely an artifact of experts integrating question answering with many other duties. The mailbox coordinator has since provided email prompts to experts immediately upon being assigned a question with the goal of improving timeliness. The program did not include chart reviews or patient consultations, as neither was feasible for volunteer experts. The email consultation service is a single component of virtual consultative specialty geriatric mental health services within the VHA, including video consultations via NEXCSS-MH and regional geriatric mental health teams.

Conclusions

The need for specialty geriatric mental health services is increasing in the VHA and across the US. However, there are too few board-certified geriatric psychiatrists to provide direct patient care to all older adults with cognitive and mental health disorders. The VHA has leveraged telehealth to improve access to geriatric mental health care. The VHA Ask the Expert Geriatric Psychiatry email consultation program is a low-resource service which provides rapid feedback to clinicians nationwide on challenging clinical scenarios, many of which are dementia-related. Most users of the service who responded to requests for feedback reported that answers to their questions were helpful and timely. The email consultation program should continue to be supplemented by more comprehensive geriatric telemental health services for particularly complex cases to meet the needs of older veterans.

T he US Census Bureau projects that the number of older adults (aged ≥ 65 years) will exceed 49 million by 2030, and an estimated 20% (nearly 10 million) of this population will experience cognitive or mental health disorders.^1,2 The mental health workforce is not equipped to address the specialized mental health care needs of many older adults.^2,3 For example, geriatric psychiatrists specialize in the diagnosis and treatment of mental illness and cognitive disorders in the later stages of life, but their numbers are few and declining. Only 33.5% of geriatric psychiatry fellowship training slots were filled from 2017 to 2021, and only 62 fellows trained during the 2021-2022 academic year.⁴ Board-certified geriatric psychiatrists also tend to be concentrated in larger, urban, academically-affiliated medical centers, often leaving rural areas and smaller facilities without access, including facilities in the Veterans Health Administration (VHA).⁵

The VHA has been optimizing access to specialty geriatric mental health services via regional and national virtual consultation services. Seven of 19 Veterans Integrated Service Network (VISN) Clinical Resource Hubs (CRHs) have geriatric mental health teams.⁶ These provide interdisciplinary geriatric mental telehealth services, including geriatric psychiatry, for older veterans with complex care needs.^7,8 Likewise, the VHA National Expert Consultation & Specialized Services-Mental Health (NEXCSS- MH, formerly known as the National Telemental Health Center) sponsors video teleconsultations with board-certified geriatric psychiatrists and an Ask the Expert email consultation program.

This article describes the Ask the Expert Geriatric Psychiatry email program (one of several similar programs at NEXCSS-MH), building upon a symposium presented at the American Association for Geriatric Psychiatry (AAGP) annual meeting in March 2022.⁹ The program was initiated in June 2021 as a result of discussions between the National Mental Health Director, Geriatric Mental Health in the VHA Office of Mental Health and Suicide Prevention (now known as the Office of Mental Health [OMH]), and National Telemental Health Center leadership. VHA board certified geriatric psychiatrists were recruited to serve as expert consultants and respond to email questions submitted by VHA clinicians regarding the psychiatric care of older adult veterans. The results of this program identify educational needs among clinical staff and may inform the development of program materials for a range of clinicians.

Program Description

The national geriatric mental health director recruited prospective experts and met with each to assess interest and qualifications, consulting with OMH psychiatrist leaders before making selections. Five experts were initially selected; 1 later stepped down and was replaced by another, who also stepped down. The experts were board certified in psychiatry and geriatric psychiatry and held a variety of local and national leadership positions, including geriatric psychiatry fellowship director, US Department of Veterans Affairs (VA) research and clinical leader, and various roles in the AAGP; some had received teaching awards.

Operations

The national geriatric mental health director announced the program in June 2021 to VHA mental health and geriatric program email groups with reminders sent every few months. The announcement included information about the types of questions appropriate to submit, including examples of general clinical management questions that did not share patient-specific protected health information, and clarified that experts would not be conducting chart reviews because the time required for detailed chart reviews was not feasible for volunteer experts to integrate into their otherwise full-time jobs at their respective VA medical centers. The announcement also included brief biographies of the experts.

The Figure describes the daily operations of the Ask the Expert Geriatric Psychiatry email consultation program. The NEXCSS- MH developed a Microsoft Outlook mailbox and group email address where clinicians from across the VHA could submit questions. The experts, as well as the national geriatric mental health director and NEXCSS-MH staff, had access to this mailbox to track and/or respond to questions. One expert volunteered to be the program’s primary mailbox coordinator. The coordinator checked the inbox daily and assigned each question to one of the experts on a rotating basis using the color-coding feature in Outlook. The other experts were advised to check the email account at least once weekly and reply to any assigned questions.

Responding to a question entailed first determining whether the question was appropriate for the service. For example, if a question requested a chart review, the expert replied that experts could not provide chart reviews and requested that the question be reframed. Next, the expert often needed to define a specific clinical question from the information provided, as email questions often touched upon several topics. The expert provided personalized advice on diagnostic testing, nonpharmacologic treatment strategies, and/or pharmacologic treatment options. Experts also often attached relevant guidelines or review articles. The goal was to provide a response within 7 business days.

All email responses included a disclaimer indicating that the program was not intended for urgent or immediate medical advice and that the information provided was for VHA clinician education purposes only. The disclaimer explained that email communication did not establish a doctor-patient relationship between the expert and a specific veteran and that, if desired, a request for a clinical consultation could be submitted on a specific case (ie, a video teleconsultation).

Methods for Reviewing Questions

Descriptive statistics, including frequencies, means, and minimum and maximum ranges, were used to capture the number of questions the program received, type of requester, and length of time prior to response for emailed questions.⁹ Conventional content analysis procedures were used between January and October 2024 to analyze clinicians’ questions.¹⁰ Four subject matter experts (3 geriatric psychiatrists and 1 geropsychologist) served as coders, assigned in groups of 2 to review questions. Each coder independently reviewed assigned questions and identified preliminary themes. Themes were reviewed and revised using an iterative process during regular team meetings with coders to clarify and confirm interpretations. Discrepancies were discussed within team meetings to achieve consensus.

Questions received. Between February 2022 and December 2023, the program received 101 email questions. Requesters included 39 physicians, 17 nurse practitioners or physician assistants, 15 social workers, 14 psychologists, 9 nurses, 5 pharmacists, 1 dietitian, and 1 who was undetermined. Experts responded to the questions an average of 6 days after receipt (range, < 1-19); 73 responses (72%) met the 7-day goal.

Iterative changes to coded themes were made during group discussions. Multiple clinical questions were often posed within the same email. Initially, some coders identified themes solely based on reported symptoms; others identified themes based on reported and/or potential diagnostic conditions attributed to the symptom(s) described within the email. For example, some coders selected a primary theme of behavioral and psychological symptoms of dementia (BPSD) only if a behavior contributing to distress in the veteran or others was described, while others selected this theme when any psychiatric symptom (eg, psychosis) was present in the context of dementia. The group identified 1 primary theme per question based on the main clinical symptom or main concern presented. Co-occurring diagnostic conditions highlighted in the email requests were included as secondary themes, and each question could have > 1 secondary theme.

The most frequent requests related to clinical symptoms included questions about agitated behaviors, sleep and/or nightmares, and depression symptoms (Table 1). Twenty-seven of 33 email requests on agitated behaviors were related to a dementia diagnosis, as were several questions about sleep/nightmares, depression, psychosis/mania, and anxiety. Many diagnostic conditions were described in the email requests (Table 2). The most frequent condition was dementia, followed by a medical condition, depressive disorder, posttraumatic stress disorder, and/or serious mental illness.

Request for Feedback. In February 2022, an email request was sent to the 64 clinicians who asked email questions from the start of the program in June 2021 through December 2021. A second request included 11 clinicians who asked questions from January through February 2022. These requests were sent as part of preparations for the symposium on the program presented at the AAGP annual meeting in March 2022.⁹ In May 2024, feedback was requested from 37 clinicians who submitted questions from May 1, 2023, through May 15, 2024.

Requests for feedback included 6 closed-ended and 1 open-ended question: (1) Did the answer you received help inform clinical practice? (2) Did you receive a timely response? (3) What type of information was useful to you in addressing your question (ie, direct/specific answer to a clinical scenario, guidelines, articles, VA resources)? (4) Do you have access to a geriatric psychiatrist at your facility? (5) Are you likely to use Ask the Expert Geriatric Psychiatry in the future? (6) Would you use a geriatric psychiatry teleconsultation service? (7) Share suggestions for improvement. Frequencies of response selection were obtained for each question. Text responses to the open-ended question asking for suggestions for improvement were reviewed and summarized.

Responses

Thirty users responded to the feedback request (27% response rate). Respondents considered the answers received extremely (n = 14; 47%) or very much (n = 12; 40%) helpful for their clinical practice. Twenty-three respondents (77%) felt an answer was provided promptly, 7 respondents (23%) felt the answer was not timely but still useful, and none felt that the answer was too late. Respondents reported that the most useful type of information in addressing their questions was a direct/specific answer to a clinical scenario (n = 27; 90%), followed by guidelines (n = 12; 40%), articles (n = 7; 23%), and VA resources (n = 4; 13%).

Sixteen respondents (53%) reported that they rarely had ready access to a geriatric psychiatrist at their facility, 3 (10%) had access sometimes, 4 (14%) had access usually, 3 (10%) had access regularly, and 3 (10%) never had access. Twenty-seven respondents (90%) indicated they would be very likely to use the service again. If geriatric psychiatry teleconsultation and/or e-consultation were offered, many respondents indicated they would be extremely (n = 10; 33%) or very (n = 12; 40%) likely to use teleconsultation and/or e-consultation.

Suggestions for improvement included supporting experts to perform chart reviews for email questions, developing a template or consult form, holding a biweekly drop-in meeting to present questions to and discuss cases with a panel of experts, and providing further help addressing complex decisional capacity issues, delirium, and care or placement for veterans with severe behavioral issues in a rural setting.

Discussion

Although many older adults experience cognitive and mental health disorders that may benefit from management by a geriatric psychiatrist, the number of trained geriatric psychiatrists available is insufficient to allow for direct care for each patient. The Ask the Expert Geriatric Psychiatry email consultation program is one aspect of a multicomponent strategy within the VHA to increase access to specialty geriatric mental health services for veterans. A key advantage of the program is that it is not resource intensive. Experts can participate voluntarily, providing timely feedback to clinicians around the country while continuing other duties at their respective VA medical centers. Email replies to the experts’ answers elicited positive feedback on the program, include: “I found this service to be extremely helpful and I have shared the information they sent me with several other coworkers!”, “It was great!”, and “I endorsed the service to our VISN Rehabilitation and Extended Care group.”

The coding of primary and secondary themes from 101 email questions that were retained revealed the range and relative frequencies of clinical and administrative topics with which clinicians needed help. The most common (33%) theme was agitated behaviors. Nearly half of the questions (48%) were related to underlying dementia, and 29% were related to a patient’s medical comorbidities. These findings suggest that the expertise of a geriatric psychiatrist is particularly relevant when caring for older patients experiencing BPSD or patients with complex, overlapping psychiatric and medical conditions.

Despite a 27% response rate, participant feedback has been helpful. The program reached its intended audience of clinicians in rural areas and at smaller facilities with 53% of requesters reporting they rarely had access to a geriatric psychiatrist. Suggestions for improvement indicated that some clinicians desired additional support, including chart reviews, meetings with experts, and a video teleconsultation service (available through NEXCSS-MH).

Many clinicians without training in specialty geriatric mental health may require help with complex clinical presentations. For example, 39 clinicians who submitted questions to the program were physicians. Accreditation Council for Graduate Medical Education program requirements for general psychiatry residency include 4 weeks of geriatric psychiatry.¹¹ The findings of this study suggest that this level of training may not be adequate to independently care for every patient who experiences dementia or multimorbidity. Several training and mentoring initiatives have been developed to address the professional development need for psychiatrists.^12-14

The need for geriatric workforce development is significant across health care, including other mental health professions.^15,16 The VHA Geriatric Scholars program trains rural primary care practitioners, psychologists, and psychiatrists.^17,18 Likewise, consultative geriatric specialty support for primary care practitioners in rural areas is provided via the Geriatric Research Education and Clinical Center Connect program.¹⁹ The Ask the Expert Geriatric Psychiatry email program is an additional economical model to support clinician educational development and provide rapid educational responses to inform patient care.

Ask the Expert received fewer email questions than anticipated. Enhanced optimization may require more frequent and widespread announcements about the program. Clinical staff may not be aware of the program due to an overload of email communications. Likewise, it may be challenging for busy clinicians to take the time to seek consultation or recognize a potential gap in their knowledge or skills. Had more questions been submitted, the 5 volunteer experts may have had more difficulty addressing the demand. Feedback from this project may inform development of a frequently asked questions document to share with VHA teams and a drop-in office hour to pose clinical questions of geriatric psychiatry experts, as recommended by a clinician who participated in the program.

Limitations

Not all requesters were sent a request for feedback, and the response rate for the request for feedback was only 27%. As the program has evolved, it began sending a request for feedback immediately after answering each question, which may increase the odds of response. The goal of experts answering questions within 7 business days was met 72% of the time, likely an artifact of experts integrating question answering with many other duties. The mailbox coordinator has since provided email prompts to experts immediately upon being assigned a question with the goal of improving timeliness. The program did not include chart reviews or patient consultations, as neither was feasible for volunteer experts. The email consultation service is a single component of virtual consultative specialty geriatric mental health services within the VHA, including video consultations via NEXCSS-MH and regional geriatric mental health teams.

Conclusions

The need for specialty geriatric mental health services is increasing in the VHA and across the US. However, there are too few board-certified geriatric psychiatrists to provide direct patient care to all older adults with cognitive and mental health disorders. The VHA has leveraged telehealth to improve access to geriatric mental health care. The VHA Ask the Expert Geriatric Psychiatry email consultation program is a low-resource service which provides rapid feedback to clinicians nationwide on challenging clinical scenarios, many of which are dementia-related. Most users of the service who responded to requests for feedback reported that answers to their questions were helpful and timely. The email consultation program should continue to be supplemented by more comprehensive geriatric telemental health services for particularly complex cases to meet the needs of older veterans.

T he US Census Bureau projects that the number of older adults (aged ≥ 65 years) will exceed 49 million by 2030, and an estimated 20% (nearly 10 million) of this population will experience cognitive or mental health disorders.^1,2 The mental health workforce is not equipped to address the specialized mental health care needs of many older adults.^2,3 For example, geriatric psychiatrists specialize in the diagnosis and treatment of mental illness and cognitive disorders in the later stages of life, but their numbers are few and declining. Only 33.5% of geriatric psychiatry fellowship training slots were filled from 2017 to 2021, and only 62 fellows trained during the 2021-2022 academic year.⁴ Board-certified geriatric psychiatrists also tend to be concentrated in larger, urban, academically-affiliated medical centers, often leaving rural areas and smaller facilities without access, including facilities in the Veterans Health Administration (VHA).⁵

The VHA has been optimizing access to specialty geriatric mental health services via regional and national virtual consultation services. Seven of 19 Veterans Integrated Service Network (VISN) Clinical Resource Hubs (CRHs) have geriatric mental health teams.⁶ These provide interdisciplinary geriatric mental telehealth services, including geriatric psychiatry, for older veterans with complex care needs.^7,8 Likewise, the VHA National Expert Consultation & Specialized Services-Mental Health (NEXCSS- MH, formerly known as the National Telemental Health Center) sponsors video teleconsultations with board-certified geriatric psychiatrists and an Ask the Expert email consultation program.

This article describes the Ask the Expert Geriatric Psychiatry email program (one of several similar programs at NEXCSS-MH), building upon a symposium presented at the American Association for Geriatric Psychiatry (AAGP) annual meeting in March 2022.⁹ The program was initiated in June 2021 as a result of discussions between the National Mental Health Director, Geriatric Mental Health in the VHA Office of Mental Health and Suicide Prevention (now known as the Office of Mental Health [OMH]), and National Telemental Health Center leadership. VHA board certified geriatric psychiatrists were recruited to serve as expert consultants and respond to email questions submitted by VHA clinicians regarding the psychiatric care of older adult veterans. The results of this program identify educational needs among clinical staff and may inform the development of program materials for a range of clinicians.

Program Description

The national geriatric mental health director recruited prospective experts and met with each to assess interest and qualifications, consulting with OMH psychiatrist leaders before making selections. Five experts were initially selected; 1 later stepped down and was replaced by another, who also stepped down. The experts were board certified in psychiatry and geriatric psychiatry and held a variety of local and national leadership positions, including geriatric psychiatry fellowship director, US Department of Veterans Affairs (VA) research and clinical leader, and various roles in the AAGP; some had received teaching awards.

Operations

The national geriatric mental health director announced the program in June 2021 to VHA mental health and geriatric program email groups with reminders sent every few months. The announcement included information about the types of questions appropriate to submit, including examples of general clinical management questions that did not share patient-specific protected health information, and clarified that experts would not be conducting chart reviews because the time required for detailed chart reviews was not feasible for volunteer experts to integrate into their otherwise full-time jobs at their respective VA medical centers. The announcement also included brief biographies of the experts.

The Figure describes the daily operations of the Ask the Expert Geriatric Psychiatry email consultation program. The NEXCSS- MH developed a Microsoft Outlook mailbox and group email address where clinicians from across the VHA could submit questions. The experts, as well as the national geriatric mental health director and NEXCSS-MH staff, had access to this mailbox to track and/or respond to questions. One expert volunteered to be the program’s primary mailbox coordinator. The coordinator checked the inbox daily and assigned each question to one of the experts on a rotating basis using the color-coding feature in Outlook. The other experts were advised to check the email account at least once weekly and reply to any assigned questions.

Responding to a question entailed first determining whether the question was appropriate for the service. For example, if a question requested a chart review, the expert replied that experts could not provide chart reviews and requested that the question be reframed. Next, the expert often needed to define a specific clinical question from the information provided, as email questions often touched upon several topics. The expert provided personalized advice on diagnostic testing, nonpharmacologic treatment strategies, and/or pharmacologic treatment options. Experts also often attached relevant guidelines or review articles. The goal was to provide a response within 7 business days.

All email responses included a disclaimer indicating that the program was not intended for urgent or immediate medical advice and that the information provided was for VHA clinician education purposes only. The disclaimer explained that email communication did not establish a doctor-patient relationship between the expert and a specific veteran and that, if desired, a request for a clinical consultation could be submitted on a specific case (ie, a video teleconsultation).

Methods for Reviewing Questions

Descriptive statistics, including frequencies, means, and minimum and maximum ranges, were used to capture the number of questions the program received, type of requester, and length of time prior to response for emailed questions.⁹ Conventional content analysis procedures were used between January and October 2024 to analyze clinicians’ questions.¹⁰ Four subject matter experts (3 geriatric psychiatrists and 1 geropsychologist) served as coders, assigned in groups of 2 to review questions. Each coder independently reviewed assigned questions and identified preliminary themes. Themes were reviewed and revised using an iterative process during regular team meetings with coders to clarify and confirm interpretations. Discrepancies were discussed within team meetings to achieve consensus.

Questions received. Between February 2022 and December 2023, the program received 101 email questions. Requesters included 39 physicians, 17 nurse practitioners or physician assistants, 15 social workers, 14 psychologists, 9 nurses, 5 pharmacists, 1 dietitian, and 1 who was undetermined. Experts responded to the questions an average of 6 days after receipt (range, < 1-19); 73 responses (72%) met the 7-day goal.

Iterative changes to coded themes were made during group discussions. Multiple clinical questions were often posed within the same email. Initially, some coders identified themes solely based on reported symptoms; others identified themes based on reported and/or potential diagnostic conditions attributed to the symptom(s) described within the email. For example, some coders selected a primary theme of behavioral and psychological symptoms of dementia (BPSD) only if a behavior contributing to distress in the veteran or others was described, while others selected this theme when any psychiatric symptom (eg, psychosis) was present in the context of dementia. The group identified 1 primary theme per question based on the main clinical symptom or main concern presented. Co-occurring diagnostic conditions highlighted in the email requests were included as secondary themes, and each question could have > 1 secondary theme.

The most frequent requests related to clinical symptoms included questions about agitated behaviors, sleep and/or nightmares, and depression symptoms (Table 1). Twenty-seven of 33 email requests on agitated behaviors were related to a dementia diagnosis, as were several questions about sleep/nightmares, depression, psychosis/mania, and anxiety. Many diagnostic conditions were described in the email requests (Table 2). The most frequent condition was dementia, followed by a medical condition, depressive disorder, posttraumatic stress disorder, and/or serious mental illness.

Request for Feedback. In February 2022, an email request was sent to the 64 clinicians who asked email questions from the start of the program in June 2021 through December 2021. A second request included 11 clinicians who asked questions from January through February 2022. These requests were sent as part of preparations for the symposium on the program presented at the AAGP annual meeting in March 2022.⁹ In May 2024, feedback was requested from 37 clinicians who submitted questions from May 1, 2023, through May 15, 2024.

Requests for feedback included 6 closed-ended and 1 open-ended question: (1) Did the answer you received help inform clinical practice? (2) Did you receive a timely response? (3) What type of information was useful to you in addressing your question (ie, direct/specific answer to a clinical scenario, guidelines, articles, VA resources)? (4) Do you have access to a geriatric psychiatrist at your facility? (5) Are you likely to use Ask the Expert Geriatric Psychiatry in the future? (6) Would you use a geriatric psychiatry teleconsultation service? (7) Share suggestions for improvement. Frequencies of response selection were obtained for each question. Text responses to the open-ended question asking for suggestions for improvement were reviewed and summarized.

Responses

Thirty users responded to the feedback request (27% response rate). Respondents considered the answers received extremely (n = 14; 47%) or very much (n = 12; 40%) helpful for their clinical practice. Twenty-three respondents (77%) felt an answer was provided promptly, 7 respondents (23%) felt the answer was not timely but still useful, and none felt that the answer was too late. Respondents reported that the most useful type of information in addressing their questions was a direct/specific answer to a clinical scenario (n = 27; 90%), followed by guidelines (n = 12; 40%), articles (n = 7; 23%), and VA resources (n = 4; 13%).

Sixteen respondents (53%) reported that they rarely had ready access to a geriatric psychiatrist at their facility, 3 (10%) had access sometimes, 4 (14%) had access usually, 3 (10%) had access regularly, and 3 (10%) never had access. Twenty-seven respondents (90%) indicated they would be very likely to use the service again. If geriatric psychiatry teleconsultation and/or e-consultation were offered, many respondents indicated they would be extremely (n = 10; 33%) or very (n = 12; 40%) likely to use teleconsultation and/or e-consultation.

Suggestions for improvement included supporting experts to perform chart reviews for email questions, developing a template or consult form, holding a biweekly drop-in meeting to present questions to and discuss cases with a panel of experts, and providing further help addressing complex decisional capacity issues, delirium, and care or placement for veterans with severe behavioral issues in a rural setting.

Discussion

Although many older adults experience cognitive and mental health disorders that may benefit from management by a geriatric psychiatrist, the number of trained geriatric psychiatrists available is insufficient to allow for direct care for each patient. The Ask the Expert Geriatric Psychiatry email consultation program is one aspect of a multicomponent strategy within the VHA to increase access to specialty geriatric mental health services for veterans. A key advantage of the program is that it is not resource intensive. Experts can participate voluntarily, providing timely feedback to clinicians around the country while continuing other duties at their respective VA medical centers. Email replies to the experts’ answers elicited positive feedback on the program, include: “I found this service to be extremely helpful and I have shared the information they sent me with several other coworkers!”, “It was great!”, and “I endorsed the service to our VISN Rehabilitation and Extended Care group.”

The coding of primary and secondary themes from 101 email questions that were retained revealed the range and relative frequencies of clinical and administrative topics with which clinicians needed help. The most common (33%) theme was agitated behaviors. Nearly half of the questions (48%) were related to underlying dementia, and 29% were related to a patient’s medical comorbidities. These findings suggest that the expertise of a geriatric psychiatrist is particularly relevant when caring for older patients experiencing BPSD or patients with complex, overlapping psychiatric and medical conditions.

Despite a 27% response rate, participant feedback has been helpful. The program reached its intended audience of clinicians in rural areas and at smaller facilities with 53% of requesters reporting they rarely had access to a geriatric psychiatrist. Suggestions for improvement indicated that some clinicians desired additional support, including chart reviews, meetings with experts, and a video teleconsultation service (available through NEXCSS-MH).

Many clinicians without training in specialty geriatric mental health may require help with complex clinical presentations. For example, 39 clinicians who submitted questions to the program were physicians. Accreditation Council for Graduate Medical Education program requirements for general psychiatry residency include 4 weeks of geriatric psychiatry.¹¹ The findings of this study suggest that this level of training may not be adequate to independently care for every patient who experiences dementia or multimorbidity. Several training and mentoring initiatives have been developed to address the professional development need for psychiatrists.^12-14

The need for geriatric workforce development is significant across health care, including other mental health professions.^15,16 The VHA Geriatric Scholars program trains rural primary care practitioners, psychologists, and psychiatrists.^17,18 Likewise, consultative geriatric specialty support for primary care practitioners in rural areas is provided via the Geriatric Research Education and Clinical Center Connect program.¹⁹ The Ask the Expert Geriatric Psychiatry email program is an additional economical model to support clinician educational development and provide rapid educational responses to inform patient care.

Ask the Expert received fewer email questions than anticipated. Enhanced optimization may require more frequent and widespread announcements about the program. Clinical staff may not be aware of the program due to an overload of email communications. Likewise, it may be challenging for busy clinicians to take the time to seek consultation or recognize a potential gap in their knowledge or skills. Had more questions been submitted, the 5 volunteer experts may have had more difficulty addressing the demand. Feedback from this project may inform development of a frequently asked questions document to share with VHA teams and a drop-in office hour to pose clinical questions of geriatric psychiatry experts, as recommended by a clinician who participated in the program.

Limitations

Not all requesters were sent a request for feedback, and the response rate for the request for feedback was only 27%. As the program has evolved, it began sending a request for feedback immediately after answering each question, which may increase the odds of response. The goal of experts answering questions within 7 business days was met 72% of the time, likely an artifact of experts integrating question answering with many other duties. The mailbox coordinator has since provided email prompts to experts immediately upon being assigned a question with the goal of improving timeliness. The program did not include chart reviews or patient consultations, as neither was feasible for volunteer experts. The email consultation service is a single component of virtual consultative specialty geriatric mental health services within the VHA, including video consultations via NEXCSS-MH and regional geriatric mental health teams.

Conclusions

The need for specialty geriatric mental health services is increasing in the VHA and across the US. However, there are too few board-certified geriatric psychiatrists to provide direct patient care to all older adults with cognitive and mental health disorders. The VHA has leveraged telehealth to improve access to geriatric mental health care. The VHA Ask the Expert Geriatric Psychiatry email consultation program is a low-resource service which provides rapid feedback to clinicians nationwide on challenging clinical scenarios, many of which are dementia-related. Most users of the service who responded to requests for feedback reported that answers to their questions were helpful and timely. The email consultation program should continue to be supplemented by more comprehensive geriatric telemental health services for particularly complex cases to meet the needs of older veterans.

Though end-of-life care for veterans with chronic obstructive pulmonary disease (COPD) in the US Department of Veterans Affairs (VA) has become more prevalent in recent years, a recent retrospective cohort study found that most patients do not receive palliative care or inpatient VA hospice over the past year of life, with rates lower than for other terminal illnesses. 

Among 332,770 decedents traced from 2010 through 2020, only 16.8% received either palliative or inpatient hospice care in the year before their death. The median time between their first palliative care appointment and death was 46 days, reported pulmonologist Natalia Smirnova, MD, assistant professor of medicine, Emory School of Medicine, Atlanta, et al in CHEST Pulmonary. 

A total of 15.9% of the decedents received inpatient hospice care from the VA. 

“These findings point to an opportunity to improve access to palliative care and hospice services for veterans with COPD, including earlier identification of need and stronger access pathways across care settings,” Smirnova told Federal Practitioner.

COPD Common Among Vets

An estimated 8%-19% of US veterans have COPD, higher than the estimated rate of 6% in adults from the general population. The condition is believed to be underdiagnosed in veterans. 

“Palliative care should be integrated early into routine care, when symptoms start,” Kathleen Lindell, PhD, RN, associate professor and chair, Palliative Care Health, School of Nursing, Medical University of South Carolina, Charleston, explained in a Federal Practitioner interview. “COPD is a serious respiratory illness, and patients experience progressively debilitating dyspnea or shortness of breath, frequent hospitalizations. And they frequently experience high rates of anxiety and depression,” 

Lindell is familiar with the study findings but didn’t take part in the research. 

“Early palliative care,” she said, “addresses symptom management and advance care planning to reduce suffering and ensure what matters most to the patient as the disease progresses.”

Smirnova noted that “hospice is a related but distinct service for veterans with a terminal condition, generally when life expectancy is < 6 months and the veteran is no longer seeking treatment other than palliative care.”

The study analyzed electronic health records and patterns of palliative and hospice care in the year before death. The 332,770 patients were mostly male (98.1%) and White (81.0%). Many had comorbidities such as congestive heart failure (30.0%), depression (26.0%), coronary artery disease (25.5%), anxiety (13.4%), and lung cancer (12.1%).

Researchers found that palliative care was mostly (61.6% of encounters) delivered in the inpatient setting, where it occurred a median 30 days before death. In the outpatient setting, it began a median of 71 days before death. 

From 2010 through 2020, the prevalence of palliative care increased from 10.4% to 16.0%, and the prevalence of VA inpatient hospice care increased from 15.0% to 18.0%. Some veterans may have received hospice services in other settings; in-home hospice is common.

Who is More Likely to Receive Palliative Care?

Black patients (adjusted odds ratio [AOR], 1.21), Latino/Hispanic ethnicity (AOR, 1.22), patients with housing instability (AOR, 1.38) and who were underweight (AOR, 1.75) were linked to more palliative care use. Black patients were especially likely to get inpatient palliative care, a fact that “may, in part, be driven by increased care intensity at the end of life, as has been demonstrated in prior studies,” the authors noted.

Marriage (AOR, 0.88) was linked to less palliative care use, while patients with lung cancer were especially likely to receive it (AOR, 2.48). There were similar differences in use of hospice care apart from higher use for Black patients. 

Smirnova said the study was not designed to determine the causes of patterns in palliative care use. However, important factors appear to include hospitalization, comorbidities, and access to care at health care sites. (Usage rates were lower at rural centers and higher at more complex centers.)

COPD vs Other Terminal Diseases

“The modest increases in utilization of palliative care and VA inpatient hospice from 2010 to 2020 align with previous work [research] in inpatients with COPD and heart failure,” the researchers wrote, “possibly reflecting the effect of international professional society guidelines, increased acceptance of palliative care, improvements related to VA end-of-life care and life-sustaining treatment decisions initiatives, and increases in the specialist palliative care workforce.”

Still, there appears to be a major discrepancy regarding the use of palliative care for COPD within the VA compared with other diseases. A study of data from 2014 through 2017 found that for patients with several comorbidities—including COPD, heart failure, cancer, and dementia—inpatient palliative care was introduced a median of 58 days before death and outpatient care 160 days before death. 

“This suggests that veterans with COPD receive palliative care later than those with other serious illnesses,” the authors argued. 

Don’t Wait for the ‘Right Time’

Sarah Miller, PhD, RN, associate professor, and assistant dean, PhD Nursing Science Program, School of Nursing, Medical University of South Carolina, Charleston, praised the study in an interview and noted that uncertainty about the “right time” to refer patients to palliative care could play a role in the findings. Miller is familiar with the study but did not participate in the research.

Lindell, the chair of Palliative Care Health, agreed.

“With COPD—a chronic, progressive disease—decline can be gradual, which makes it difficult to identify a clear transition point,” Lindell told Federal Practitioner. “This has contributed to many palliative referrals happening only when patients are clearly deteriorating or nearing the end of life. But palliative care should not be introduced reactively; it should be integrated early, alongside disease-directed treatment.”

For her part, Miller noted that “many veterans with COPD are navigating complex comorbidities and fragmented care across settings. Diseases like COPD don’t follow a predictable path, so referrals don’t always happen like they should.”

Moving forward, “if symptoms are present, early palliative care is appropriate,” Lindell said. These conversations should happen early and over time.

“The VA should prioritize early referral and access to palliative care for patients with COPD to provide the best care for these individuals.”

No study funding was reported. Smirnova discloses relationships with the CHEST Foundation and National Heart, Lung, and Blood Institute. Other authors disclose relationships with various grantors. 

Miller discloses a relationship with AstraZeneca. Lindell discloses relationships with Boehringer Ingelheim and Heart & Lung: The Journal of Acute and Critical Care. 

Though end-of-life care for veterans with chronic obstructive pulmonary disease (COPD) in the US Department of Veterans Affairs (VA) has become more prevalent in recent years, a recent retrospective cohort study found that most patients do not receive palliative care or inpatient VA hospice over the past year of life, with rates lower than for other terminal illnesses. 

Among 332,770 decedents traced from 2010 through 2020, only 16.8% received either palliative or inpatient hospice care in the year before their death. The median time between their first palliative care appointment and death was 46 days, reported pulmonologist Natalia Smirnova, MD, assistant professor of medicine, Emory School of Medicine, Atlanta, et al in CHEST Pulmonary. 

A total of 15.9% of the decedents received inpatient hospice care from the VA. 

“These findings point to an opportunity to improve access to palliative care and hospice services for veterans with COPD, including earlier identification of need and stronger access pathways across care settings,” Smirnova told Federal Practitioner.

COPD Common Among Vets

An estimated 8%-19% of US veterans have COPD, higher than the estimated rate of 6% in adults from the general population. The condition is believed to be underdiagnosed in veterans. 

“Palliative care should be integrated early into routine care, when symptoms start,” Kathleen Lindell, PhD, RN, associate professor and chair, Palliative Care Health, School of Nursing, Medical University of South Carolina, Charleston, explained in a Federal Practitioner interview. “COPD is a serious respiratory illness, and patients experience progressively debilitating dyspnea or shortness of breath, frequent hospitalizations. And they frequently experience high rates of anxiety and depression,” 

Lindell is familiar with the study findings but didn’t take part in the research. 

“Early palliative care,” she said, “addresses symptom management and advance care planning to reduce suffering and ensure what matters most to the patient as the disease progresses.”

Smirnova noted that “hospice is a related but distinct service for veterans with a terminal condition, generally when life expectancy is < 6 months and the veteran is no longer seeking treatment other than palliative care.”

The study analyzed electronic health records and patterns of palliative and hospice care in the year before death. The 332,770 patients were mostly male (98.1%) and White (81.0%). Many had comorbidities such as congestive heart failure (30.0%), depression (26.0%), coronary artery disease (25.5%), anxiety (13.4%), and lung cancer (12.1%).

Researchers found that palliative care was mostly (61.6% of encounters) delivered in the inpatient setting, where it occurred a median 30 days before death. In the outpatient setting, it began a median of 71 days before death. 

From 2010 through 2020, the prevalence of palliative care increased from 10.4% to 16.0%, and the prevalence of VA inpatient hospice care increased from 15.0% to 18.0%. Some veterans may have received hospice services in other settings; in-home hospice is common.

Who is More Likely to Receive Palliative Care?

Black patients (adjusted odds ratio [AOR], 1.21), Latino/Hispanic ethnicity (AOR, 1.22), patients with housing instability (AOR, 1.38) and who were underweight (AOR, 1.75) were linked to more palliative care use. Black patients were especially likely to get inpatient palliative care, a fact that “may, in part, be driven by increased care intensity at the end of life, as has been demonstrated in prior studies,” the authors noted.

Marriage (AOR, 0.88) was linked to less palliative care use, while patients with lung cancer were especially likely to receive it (AOR, 2.48). There were similar differences in use of hospice care apart from higher use for Black patients. 

Smirnova said the study was not designed to determine the causes of patterns in palliative care use. However, important factors appear to include hospitalization, comorbidities, and access to care at health care sites. (Usage rates were lower at rural centers and higher at more complex centers.)

COPD vs Other Terminal Diseases

“The modest increases in utilization of palliative care and VA inpatient hospice from 2010 to 2020 align with previous work [research] in inpatients with COPD and heart failure,” the researchers wrote, “possibly reflecting the effect of international professional society guidelines, increased acceptance of palliative care, improvements related to VA end-of-life care and life-sustaining treatment decisions initiatives, and increases in the specialist palliative care workforce.”

Still, there appears to be a major discrepancy regarding the use of palliative care for COPD within the VA compared with other diseases. A study of data from 2014 through 2017 found that for patients with several comorbidities—including COPD, heart failure, cancer, and dementia—inpatient palliative care was introduced a median of 58 days before death and outpatient care 160 days before death. 

“This suggests that veterans with COPD receive palliative care later than those with other serious illnesses,” the authors argued. 

Don’t Wait for the ‘Right Time’

Sarah Miller, PhD, RN, associate professor, and assistant dean, PhD Nursing Science Program, School of Nursing, Medical University of South Carolina, Charleston, praised the study in an interview and noted that uncertainty about the “right time” to refer patients to palliative care could play a role in the findings. Miller is familiar with the study but did not participate in the research.

Lindell, the chair of Palliative Care Health, agreed.

“With COPD—a chronic, progressive disease—decline can be gradual, which makes it difficult to identify a clear transition point,” Lindell told Federal Practitioner. “This has contributed to many palliative referrals happening only when patients are clearly deteriorating or nearing the end of life. But palliative care should not be introduced reactively; it should be integrated early, alongside disease-directed treatment.”

For her part, Miller noted that “many veterans with COPD are navigating complex comorbidities and fragmented care across settings. Diseases like COPD don’t follow a predictable path, so referrals don’t always happen like they should.”

Moving forward, “if symptoms are present, early palliative care is appropriate,” Lindell said. These conversations should happen early and over time.

“The VA should prioritize early referral and access to palliative care for patients with COPD to provide the best care for these individuals.”

No study funding was reported. Smirnova discloses relationships with the CHEST Foundation and National Heart, Lung, and Blood Institute. Other authors disclose relationships with various grantors. 

Miller discloses a relationship with AstraZeneca. Lindell discloses relationships with Boehringer Ingelheim and Heart & Lung: The Journal of Acute and Critical Care. 

Though end-of-life care for veterans with chronic obstructive pulmonary disease (COPD) in the US Department of Veterans Affairs (VA) has become more prevalent in recent years, a recent retrospective cohort study found that most patients do not receive palliative care or inpatient VA hospice over the past year of life, with rates lower than for other terminal illnesses. 

Among 332,770 decedents traced from 2010 through 2020, only 16.8% received either palliative or inpatient hospice care in the year before their death. The median time between their first palliative care appointment and death was 46 days, reported pulmonologist Natalia Smirnova, MD, assistant professor of medicine, Emory School of Medicine, Atlanta, et al in CHEST Pulmonary. 

A total of 15.9% of the decedents received inpatient hospice care from the VA. 

“These findings point to an opportunity to improve access to palliative care and hospice services for veterans with COPD, including earlier identification of need and stronger access pathways across care settings,” Smirnova told Federal Practitioner.

COPD Common Among Vets

An estimated 8%-19% of US veterans have COPD, higher than the estimated rate of 6% in adults from the general population. The condition is believed to be underdiagnosed in veterans. 

“Palliative care should be integrated early into routine care, when symptoms start,” Kathleen Lindell, PhD, RN, associate professor and chair, Palliative Care Health, School of Nursing, Medical University of South Carolina, Charleston, explained in a Federal Practitioner interview. “COPD is a serious respiratory illness, and patients experience progressively debilitating dyspnea or shortness of breath, frequent hospitalizations. And they frequently experience high rates of anxiety and depression,” 

Lindell is familiar with the study findings but didn’t take part in the research. 

“Early palliative care,” she said, “addresses symptom management and advance care planning to reduce suffering and ensure what matters most to the patient as the disease progresses.”

Smirnova noted that “hospice is a related but distinct service for veterans with a terminal condition, generally when life expectancy is < 6 months and the veteran is no longer seeking treatment other than palliative care.”

The study analyzed electronic health records and patterns of palliative and hospice care in the year before death. The 332,770 patients were mostly male (98.1%) and White (81.0%). Many had comorbidities such as congestive heart failure (30.0%), depression (26.0%), coronary artery disease (25.5%), anxiety (13.4%), and lung cancer (12.1%).

Researchers found that palliative care was mostly (61.6% of encounters) delivered in the inpatient setting, where it occurred a median 30 days before death. In the outpatient setting, it began a median of 71 days before death. 

From 2010 through 2020, the prevalence of palliative care increased from 10.4% to 16.0%, and the prevalence of VA inpatient hospice care increased from 15.0% to 18.0%. Some veterans may have received hospice services in other settings; in-home hospice is common.

Who is More Likely to Receive Palliative Care?

Black patients (adjusted odds ratio [AOR], 1.21), Latino/Hispanic ethnicity (AOR, 1.22), patients with housing instability (AOR, 1.38) and who were underweight (AOR, 1.75) were linked to more palliative care use. Black patients were especially likely to get inpatient palliative care, a fact that “may, in part, be driven by increased care intensity at the end of life, as has been demonstrated in prior studies,” the authors noted.

Marriage (AOR, 0.88) was linked to less palliative care use, while patients with lung cancer were especially likely to receive it (AOR, 2.48). There were similar differences in use of hospice care apart from higher use for Black patients. 

Smirnova said the study was not designed to determine the causes of patterns in palliative care use. However, important factors appear to include hospitalization, comorbidities, and access to care at health care sites. (Usage rates were lower at rural centers and higher at more complex centers.)

COPD vs Other Terminal Diseases

“The modest increases in utilization of palliative care and VA inpatient hospice from 2010 to 2020 align with previous work [research] in inpatients with COPD and heart failure,” the researchers wrote, “possibly reflecting the effect of international professional society guidelines, increased acceptance of palliative care, improvements related to VA end-of-life care and life-sustaining treatment decisions initiatives, and increases in the specialist palliative care workforce.”

Still, there appears to be a major discrepancy regarding the use of palliative care for COPD within the VA compared with other diseases. A study of data from 2014 through 2017 found that for patients with several comorbidities—including COPD, heart failure, cancer, and dementia—inpatient palliative care was introduced a median of 58 days before death and outpatient care 160 days before death. 

“This suggests that veterans with COPD receive palliative care later than those with other serious illnesses,” the authors argued. 

Don’t Wait for the ‘Right Time’

Sarah Miller, PhD, RN, associate professor, and assistant dean, PhD Nursing Science Program, School of Nursing, Medical University of South Carolina, Charleston, praised the study in an interview and noted that uncertainty about the “right time” to refer patients to palliative care could play a role in the findings. Miller is familiar with the study but did not participate in the research.

Lindell, the chair of Palliative Care Health, agreed.

“With COPD—a chronic, progressive disease—decline can be gradual, which makes it difficult to identify a clear transition point,” Lindell told Federal Practitioner. “This has contributed to many palliative referrals happening only when patients are clearly deteriorating or nearing the end of life. But palliative care should not be introduced reactively; it should be integrated early, alongside disease-directed treatment.”

For her part, Miller noted that “many veterans with COPD are navigating complex comorbidities and fragmented care across settings. Diseases like COPD don’t follow a predictable path, so referrals don’t always happen like they should.”

Moving forward, “if symptoms are present, early palliative care is appropriate,” Lindell said. These conversations should happen early and over time.

“The VA should prioritize early referral and access to palliative care for patients with COPD to provide the best care for these individuals.”

No study funding was reported. Smirnova discloses relationships with the CHEST Foundation and National Heart, Lung, and Blood Institute. Other authors disclose relationships with various grantors. 

Miller discloses a relationship with AstraZeneca. Lindell discloses relationships with Boehringer Ingelheim and Heart & Lung: The Journal of Acute and Critical Care. 

The Centenarian Program at the US Department of Veterans Affairs (VA) has expanded to begin honoring veterans for special occasions, such as birthdays, as well as veterans with very limited life expectancy. 

Initially launched in 2020 as a special initiative that awarded commemorative coins to American heroes aged 100 years, the program recognizes each individual’s service to the country. 

“This program symbolizes the commitment that we promise to our veterans,” said Center for Development and Civic Engagement (CDCE) Chief Dennis Montgomery in West Palm Beach, Florida. “They are never forgotten. No matter the years since time of service, the VA will always honor and remind them of the gratitude we proudly hold in our hearts for their bravery and sacrifice.”

Eligible veterans receive a personalized letter from the VA Secretary, a commemorative coin, and public recognition from their local VA facility, which often includes a celebration. To be eligible, veterans must be enrolled and receiving care through the VA health care systems. 

Coins are customized for each veteran with unique attributes, including the veteran’s name, branch of service, military occupational specialty, and years of service.

“I originally learned of the program in 2022, and I explored the possibilities to expand the reach of active engagement from the Center of Development and Civic Engagement and the VA Secretary’s office,” said Saraswathy Battar, MD, a geriatrician at the Thomas H. Corey VA Medical Center (VAMC) Community Living Center in West Palm Beach, who oversaw the program until her retirement in November 2025. The program is currently administered by the office of VA Secretary Douglas Collins.

Between August 2022 and October 15, 2025, 1182 centenarian veterans and 285 special recognition honorees received commemorative coins. 

“As our local veteran population grows within the centenarian coin eligibility criteria,” Montgomery said, “I know this program will continue to grow as well and gain more popularity to honor our veterans as they have earned and deserved.”  

The VA conducts outreach through local health care professionals to identify veterans eligible for the program. This allows for veterans admitted to the VA to be identified, leading to activation of the ceremony process. 

If veterans are in declining health, they become eligible to receive recognition at age 95, Montgomery said. 

The Centenarian Program at the US Department of Veterans Affairs (VA) has expanded to begin honoring veterans for special occasions, such as birthdays, as well as veterans with very limited life expectancy. 

Initially launched in 2020 as a special initiative that awarded commemorative coins to American heroes aged 100 years, the program recognizes each individual’s service to the country. 

“This program symbolizes the commitment that we promise to our veterans,” said Center for Development and Civic Engagement (CDCE) Chief Dennis Montgomery in West Palm Beach, Florida. “They are never forgotten. No matter the years since time of service, the VA will always honor and remind them of the gratitude we proudly hold in our hearts for their bravery and sacrifice.”

Eligible veterans receive a personalized letter from the VA Secretary, a commemorative coin, and public recognition from their local VA facility, which often includes a celebration. To be eligible, veterans must be enrolled and receiving care through the VA health care systems. 

Coins are customized for each veteran with unique attributes, including the veteran’s name, branch of service, military occupational specialty, and years of service.

“I originally learned of the program in 2022, and I explored the possibilities to expand the reach of active engagement from the Center of Development and Civic Engagement and the VA Secretary’s office,” said Saraswathy Battar, MD, a geriatrician at the Thomas H. Corey VA Medical Center (VAMC) Community Living Center in West Palm Beach, who oversaw the program until her retirement in November 2025. The program is currently administered by the office of VA Secretary Douglas Collins.

Between August 2022 and October 15, 2025, 1182 centenarian veterans and 285 special recognition honorees received commemorative coins. 

“As our local veteran population grows within the centenarian coin eligibility criteria,” Montgomery said, “I know this program will continue to grow as well and gain more popularity to honor our veterans as they have earned and deserved.”  

The VA conducts outreach through local health care professionals to identify veterans eligible for the program. This allows for veterans admitted to the VA to be identified, leading to activation of the ceremony process. 

If veterans are in declining health, they become eligible to receive recognition at age 95, Montgomery said. 

The Centenarian Program at the US Department of Veterans Affairs (VA) has expanded to begin honoring veterans for special occasions, such as birthdays, as well as veterans with very limited life expectancy. 

Initially launched in 2020 as a special initiative that awarded commemorative coins to American heroes aged 100 years, the program recognizes each individual’s service to the country. 

“This program symbolizes the commitment that we promise to our veterans,” said Center for Development and Civic Engagement (CDCE) Chief Dennis Montgomery in West Palm Beach, Florida. “They are never forgotten. No matter the years since time of service, the VA will always honor and remind them of the gratitude we proudly hold in our hearts for their bravery and sacrifice.”

Eligible veterans receive a personalized letter from the VA Secretary, a commemorative coin, and public recognition from their local VA facility, which often includes a celebration. To be eligible, veterans must be enrolled and receiving care through the VA health care systems. 

Coins are customized for each veteran with unique attributes, including the veteran’s name, branch of service, military occupational specialty, and years of service.

“I originally learned of the program in 2022, and I explored the possibilities to expand the reach of active engagement from the Center of Development and Civic Engagement and the VA Secretary’s office,” said Saraswathy Battar, MD, a geriatrician at the Thomas H. Corey VA Medical Center (VAMC) Community Living Center in West Palm Beach, who oversaw the program until her retirement in November 2025. The program is currently administered by the office of VA Secretary Douglas Collins.

Between August 2022 and October 15, 2025, 1182 centenarian veterans and 285 special recognition honorees received commemorative coins. 

“As our local veteran population grows within the centenarian coin eligibility criteria,” Montgomery said, “I know this program will continue to grow as well and gain more popularity to honor our veterans as they have earned and deserved.”  

The VA conducts outreach through local health care professionals to identify veterans eligible for the program. This allows for veterans admitted to the VA to be identified, leading to activation of the ceremony process. 

If veterans are in declining health, they become eligible to receive recognition at age 95, Montgomery said. 

Deconditioning among hospitalized older adults contributes to significant decline in posthospitalization functional ability, physical performance, and physical activity.^1-10 Previous hospital-to-home interventions have targeted improving function and physical activity, including recent programs leveraging home telehealth as a feasible and potentially effective mode of delivering in-home exercise and rehabilitation.^11-14 However, pilot interventions have shown mixed effectiveness.^11,12,14 This study expands on a previously published intervention describing a pilot home telehealth program for veterans posthospital discharge that demonstrated significant 6-month improvement in physical activity as well as trends in physical function improvement, including among those with cognitive impairment.¹⁵ Factors that contribute to improved outcomes are the focus of the present study.

Key factors underlying the complexity of hospital-to-home transitions include hospitalization elements (ie, reason for admission and length of stay), associated posthospital syndromes (ie, postdischarge falls, medication changes, cognitive impairment, and pain), and postdischarge health care application (ie, physical therapy and hospital readmission).^16-18 These factors may be associated with postdischarge functional ability, physical performance, and physical activity, but their direct influence on intervention outcomes is unclear (Figure 1).^5,7,9,16-20 The objective of this study was to examine the influence of hospitalization, posthospital syndrome, and postdischarge health care application factors on outcomes of a US Department of Veterans Affairs (VA) Video Connect (VVC) intervention to enhance function and physical activity in older adults posthospital discharge.

Methods

The previous analysis reported on patient characteristics, program feasibility, and preliminary outcomes.^13,15 The current study reports on relationships between hospitalization, posthospital syndrome, and postdischarge health care application factors and change in key outcomes, namely postdischarge self-reported functional ability, physical performance, and physical activity from baseline to endpoint.

Participants provided written informed consent. The protocol and consent forms were approved by the VA Ann Arbor Healthcare System (VAAAHS) Research and Development Committee, and the project was registered on clinicaltrials.gov (NCT04045054).

Intervention

The pilot program targeted older adults following recent hospital discharge from VAAAHS. Participants were eligible if they were aged ≥ 50 years, had been discharged following an inpatient stay in the past 1 to 2 weeks, evaluated by physical therapy during hospitalization with stated rehabilitation goals on discharge, and followed by a VAAAHS primary care physician. Participants were either recruited during hospital admission or shortly after discharge.¹³

An experienced physical activity trainer (PAT) supported the progression of participants’ rehabilitation goals via a home exercise program and coached the patient and caregiver to optimize functional ability, physical performance, and physical activity. The PAT was a nonlicensed research assistant with extensive experience in applying standard physical activity enhancement protocols (eg, increased walking) to older adults with comorbidities. Participation in the program lasted about 6 months. Initiation of the PAT program was delayed if the patient was already receiving postdischarge home-based or outpatient physical therapy. The PAT contacted the patient weekly via VVC for the first 6 weeks, then monthly for a total of 6 months. Each contact included information on optimal walking form, injury prevention, program progression, and ways to incorporate sit-to-stand transitions, nonsitting behavior, and walking into daily routines. The initial VVC contact lasted about 60 minutes and subsequent sessions lasted about 30 minutes.¹³

Demographic characteristics were self-reported by participants and included age, sex, race, years of education, and marital status. Clinical characteristics were obtained from each participant’s electronic health record (EHR), including copay status, index hospitalization length of stay, admission diagnosis, and postsurgery status (postsurgery vs nonpostsurgery). Intervention adherence was tracked as the number of PAT sessions attended.

Posthospital Syndrome Factors

Participant falls (categorized as those who reported a fall vs those who did not) and medication changes (number of changes reported, including new medication, discontinued medication, dose changes, medication changes, or changes in medication schedule) were reported by participants or caregivers during each VVC contact. Participants completed the Montreal Cognitive Assessment (MoCA) at baseline, and were dichotomized into 2 groups: no cognitive impairment (MoCA score ≥ 26) and mild to moderate cognitive impairment (MoCA score 10-25).^13,21

Participants rated how much pain interfered with their normal daily activities since the previous VVC session on a 5-point Likert scale (1, not at all; to 5, extremely).²² Similar to prior research, participants were placed into 2 groups based on their mean pain interference score (individuals with scores from 1.0 to 2.0 in 1 group, and individuals with > 2.0 in another).^23-25 Participants were separated into a no or mild pain interference group and a moderate to severe pain interference group. Hospital readmissions (VA and non-VA) and postdischarge physical therapy outcomes were obtained from the participant’s EHR, including primary care visits.

Outcomes

Outcomes were collected at baseline (posthospital discharge) and 6 months postenrollment.

Self-Reported Functional Ability. This measure is provided by participants or caregivers and measured by the Katz Index of Independence in Activities of Daily Living (ADL), Lawton and Brody Instrumental ADL Scale (IADL), Nagi Disability Model, and Rosow-Breslau Scale. The Katz ADL assesses the ability to complete 6 self-care activities and awards 1 point for independence and 0 if the individual is dependent (total score range, 0-6).²⁶ The Lawton and Brody IADL measures an individual’s independence in 8 instrumental ADLs; it awards 1 point for independence and 0 if the individual is dependent (total score range, 0-8).²⁷ The Nagi Disability Model evaluates an individual’s difficulty performing 5 tasks (total score range, 0-5) and tallies the number of items with a response other than “no difficulty at all” (higher total score indicates greater difficulty). ²⁸ The Rosow-Breslau Scale is a 3-item measure of mobility disability; individual responses are 0 (no help) and 1 (requires help or unable); higher total score (range, 0-3) indicates greater disability.²⁹

Physical Performance. Measured using the Short Physical Performance Battery (SPPB), which evaluates standing balance, sit to stand, and walking performance. Scores range from 0 to 4 on the balance, gait speed, and chair stand tests, for a total composite score between 0 and 12 (higher score indicates better performance).³⁰

Physical Activity. Measured using actigraphy, namely a physical activity monitor adherent to the thigh (activ-PAL3TM, PAL Technologies Ltd., Glasgow, UK).³¹ Participants were instructed to wear the activPal for ≥ 1 week. Participants with a minimum of 5 days of wear were included in this analysis.

Data Analyses

Analyses were performed using SPSS software version 29.0.³² Continuous variables were summarized using mean (SD) or median and IQR using the weighted average method; categorical variables were summarized using frequencies and percentages. Baseline scores on outcome variables were compared by categorical hospitalization, posthospital syndrome, and postdischarge health care application factor variables using Mann-Whitney U tests. The differences between outcome variables from baseline to endpoint were then calculated to produce change scores. Relationships between the number of PAT sessions attended and baseline outcomes and outcome change scores were estimated using Spearman correlations. Relationships between categorical factors (hospitalization, posthospital syndrome, and postdischarge health care application) and outcome variable change scores (which were normally distributed) were examined using Mann-Whitney U tests. Relationships with continuous hospitalization (length of stay) and posthospital syndrome factors (medication changes) were estimated using Spearman correlations. Effect sizes (ES) were estimated with Cohen d; small (d = 0.2), medium (d = 0.5), or large (d ≥ 0.8). Missing data were handled using pairwise deletion.³³ Therefore, sample sizes were reported for each analysis. For all statistical tests, P < .05 was considered significant.

Results

Twenty-four individuals completed the pilot intervention.¹⁵ Mean (SD) age was 73.6 (8.1) years (range, 64-93 years) and participants were predominantly White males (Table 1). Eight participants had a high school education only and 13 had more than a high school education. Diagnoses at admission included 9 patients with orthopedic/musculoskeletal conditions (6 were for joint replacement), 6 patients with vascular/pulmonary conditions, and 4 with gastrointestinal/renal/urological conditions. Of the 11 postsurgery participants, 7 were orthopedic, 4 were gastrointestinal, and 1 was peripheral vascular.

Baseline outcome scores did not differ significantly between groups, except individuals with moderate to severe pain interference reported a significantly lower IADL score (median [IQR] 4 [2-7]) than individuals with mild or moderate pain interference (median [IQR] 8 [7-8]; P = .02) (Table 2). The mean (SD) number of PAT sessions attended was 9.3 (3.7) (range, 3-19). There were no significant relationships between number of sessions attended and any baseline outcome variables or outcome change scores.

Hospitalization Factors

Participants who were postsurgery tended to have greater improvement than individuals who were nonpostsurgery in ADLs (median [IQR] 0 [0-1.5]; ES, 0.6; P = .10) and SPPB (median [IQR] 2 [1.5-9]; ES, 0.9; P = .07), but the improvements were not statistically significant (Table 3). Mean (SD) length of stay of the index hospitalization was 6.7 (6.1) days. Longer length of stay was significantly correlated with an increase in Nagi score (ρ, 0.45; 95% CI, 0.01-0.75). There were no other significant or trending relationships between length of stay and outcome variables.

Posthospital Syndrome Factors

The 16 participants with mild to moderate cognitive impairment had less improvement in ADLs (median [IQR] 0 [0-1]) than the 8 participants with no impairment (median [IQR] 0 [-0.75 to 0]; ES, -1.1; P = .04). Change in outcome variables from baseline to endpoint did not significantly differ between the 8 patients who reported a fall compared with the 13 who did not, nor were any trends observed. Change in outcome variables from baseline to endpoint also did not significantly differ between the 8 participants who reported no or mild pain interference compared with the 10 patients with moderate to severe pain interference, nor were any trends observed. Mean (SD) number of medication changes was 2.5 (1.6). Higher number of medication changes was significantly correlated with a decrease in Rosow-Breslau score (ρ, -0.47; 95% CI, -0.76 to -0.02). There were no other significant or trending relationships between number of medication changes and outcome variables.

Postdischarge Health Care Application Factors

The 16 participants who attended posthospital physical therapy trended towards less improvement in IADLs (median [IQR] 0 [-0.5 to 1.5]; ES, -0.7; P = .11) and SPPB (median [IQR] 2 [-3.0 to 4.5]; ES, -0.5; P = .15) than the 8 patients with no postdischarge physical therapy. Eleven participants were readmitted, while 13 had no readmissions in their medical records between baseline and endpoint. Participants with ≥ 1 readmission experienced a greater increase in Rosow-Breslau score (median [IQR] 0 [-0.5 to 1.0]) than those not readmitted (median [IQR] 0 [-1.25 to 0.25]; ES, 1.0; P = .03). Borderline greater improvement in number of steps was found in those not readmitted (median [IQR] 3365.6 [274.4-7710.9]) compared with those readmitted (median [IQR] 319.9 [-136.1 to 774.5]; ES, -1.3; P = .05). Patients who were readmitted also tended to have lower and not statistically significant improvements in SPPB (median [IQR] 1 [-4.0 to 5.3]) compared with those not readmitted (median [IQR] 2 [0.3-3.8]; ES, -0.5; P = .17) (Table 3).

Discussion

This study examined the association between hospitalization, posthospital syndrome, and postdischarge health care use in patients undergoing a VVC-based intervention following hospital discharge. Participants who had no or mild cognitive impairment, no readmissions, higher medication changes, and a shorter hospital length of stay tended to experience lower disability, including in mobility and ADLs. This suggests individuals who are less clinically complex may be more likely to benefit from this type of virtual rehabilitation program. These findings are consistent with clinical experiences; home-based programs to improve physical activity posthospital discharge can be challenging for those who were medically ill (and did not undergo a specific surgical procedure), cognitively impaired, and become acutely ill and trigger hospital readmission. ¹⁵ For example, the sample in this study had higher rates of falls, pain, and readmissions compared to previous research.^2,3,34-39

The importance of posthospital syndrome in the context of recovery of function and health at home following hospitalization is well documented.^16-18 The potential impact of posthospital syndrome on physical activity-focused interventions is less understood. In our analysis, participants with mild or moderate cognitive impairment tended to become more dependent in their ADLs, while those with no cognitive impairment tended to become more independent in their ADLs. This functional decline over time is perhaps expected in persons with cognitive impairment, but the significant difference with a large ES warrants further consideration on how to tailor interventions to better promote functional recovery in these individuals.^40,41 While some cognitive decline may not be preventable, this finding supports the need to promote healthy cognitive aging, identify declines in cognition, and work to mitigate additional decline. Programs specifically designed to promote function and physical activity in older adults with cognitive impairment are needed, especially during care transitions.^41-43

While participants reported that falls and pain interference did not have a significant impact on change in outcomes between baseline and endpoint, these areas need further investigation. Falls and pain have been associated with function and physical activity in older adults.^42-46 Pain is common, yet underappreciated during older adult hospital-to-home transitions.^11,12,45,46 There is a need for more comprehensive assessment of pain (including pain intensity) and qualitative research.

Hospitalization and postdischarge health care application factors may have a significant impact on home-telehealth physical activity intervention success. Individuals who were postsurgery tended to have greater improvements in ADLs and physical performance. Most postsurgery participants had joint replacement surgery. Postsurgery status may not be modifiable, but it is important to note expected differences in recovery between medical and surgical admissions and the need to tailor care based on admission diagnosis. Those with a longer length of hospital stay may be considered at higher risk of suboptimal outcomes postdischarge, which indicates an opportunity for targeting resources and support, in addition to efforts of reducing length of stay where possible.⁴⁷

Readmissions were significantly related to a change in Rosow-Breslau mobility disability score. This may indicate the detrimental impact a readmission can have on increasing mobility and physical activity postdischarge, or the potential of this pilot program to impact readmissions by increasing mobility and physical activity, contrary to prior physical exercise interventions.^5,7,9,48 With 5% to 79% of readmissions considered preventable, continued efforts and program dissemination and implementation to address preventable readmissions are warranted.⁴⁹ Individuals with postdischarge physical therapy (prior to beginning the pilot program) tended to demonstrate less improvement in disability and physical performance. This relationship needs further investigation; the 2 groups did not appear to have significant differences at baseline, albeit with a small sample size. It is possible they experienced initial improvements with postdischarge physical therapy and plateaued or had little further reserve to improve upon entering the VVC program.

Strengths and Limitations

This pilot program provided evaluative data on the use of VVC to enhance function and physical activity in older adults posthospital discharge. It included individual (eg, fall, pain, cognitive impairment) and health service (eg, readmission, physical therapy) level factors as predictors of function and physical activity posthospitalization.^5,7,9,15-19

The results of this pilot project stem from a small sample lacking diversity in terms of race, ethnicity, and sex. There was some variation in baseline and endpoints between participants, and when hospitalization, posthospital syndrome, and postdischarge health care application factors were collected. The majority of participants were recruited within a month postdischarge, and the program lasted about 6 months. Data collection was attempted at regular PAT contacts, but there was some variation in when visits occurred based on participant availability and preference. Some participants had missing data, which was handled using pairwise deletion.³³ Larger studies are needed to confirm the findings of this study, particularly the trends that did not reach statistical significance. Home health services other than physical therapy (eg, nursing, occupational therapy) were not fully accounted for and should be considered in future research.

Conclusions

In patients undergoing a 6-month pilot VVC-based physical activity intervention posthospital discharge, improvements in mobility and disability were most likely in those who had no cognitive impairment and were not readmitted. Larger sample and qualitative investigations are necessary to optimize outcomes for patients who meet these clinical profiles.

Deconditioning among hospitalized older adults contributes to significant decline in posthospitalization functional ability, physical performance, and physical activity.^1-10 Previous hospital-to-home interventions have targeted improving function and physical activity, including recent programs leveraging home telehealth as a feasible and potentially effective mode of delivering in-home exercise and rehabilitation.^11-14 However, pilot interventions have shown mixed effectiveness.^11,12,14 This study expands on a previously published intervention describing a pilot home telehealth program for veterans posthospital discharge that demonstrated significant 6-month improvement in physical activity as well as trends in physical function improvement, including among those with cognitive impairment.¹⁵ Factors that contribute to improved outcomes are the focus of the present study.

Key factors underlying the complexity of hospital-to-home transitions include hospitalization elements (ie, reason for admission and length of stay), associated posthospital syndromes (ie, postdischarge falls, medication changes, cognitive impairment, and pain), and postdischarge health care application (ie, physical therapy and hospital readmission).^16-18 These factors may be associated with postdischarge functional ability, physical performance, and physical activity, but their direct influence on intervention outcomes is unclear (Figure 1).^5,7,9,16-20 The objective of this study was to examine the influence of hospitalization, posthospital syndrome, and postdischarge health care application factors on outcomes of a US Department of Veterans Affairs (VA) Video Connect (VVC) intervention to enhance function and physical activity in older adults posthospital discharge.

Methods

The previous analysis reported on patient characteristics, program feasibility, and preliminary outcomes.^13,15 The current study reports on relationships between hospitalization, posthospital syndrome, and postdischarge health care application factors and change in key outcomes, namely postdischarge self-reported functional ability, physical performance, and physical activity from baseline to endpoint.

Participants provided written informed consent. The protocol and consent forms were approved by the VA Ann Arbor Healthcare System (VAAAHS) Research and Development Committee, and the project was registered on clinicaltrials.gov (NCT04045054).

Intervention

The pilot program targeted older adults following recent hospital discharge from VAAAHS. Participants were eligible if they were aged ≥ 50 years, had been discharged following an inpatient stay in the past 1 to 2 weeks, evaluated by physical therapy during hospitalization with stated rehabilitation goals on discharge, and followed by a VAAAHS primary care physician. Participants were either recruited during hospital admission or shortly after discharge.¹³

An experienced physical activity trainer (PAT) supported the progression of participants’ rehabilitation goals via a home exercise program and coached the patient and caregiver to optimize functional ability, physical performance, and physical activity. The PAT was a nonlicensed research assistant with extensive experience in applying standard physical activity enhancement protocols (eg, increased walking) to older adults with comorbidities. Participation in the program lasted about 6 months. Initiation of the PAT program was delayed if the patient was already receiving postdischarge home-based or outpatient physical therapy. The PAT contacted the patient weekly via VVC for the first 6 weeks, then monthly for a total of 6 months. Each contact included information on optimal walking form, injury prevention, program progression, and ways to incorporate sit-to-stand transitions, nonsitting behavior, and walking into daily routines. The initial VVC contact lasted about 60 minutes and subsequent sessions lasted about 30 minutes.¹³

Demographic characteristics were self-reported by participants and included age, sex, race, years of education, and marital status. Clinical characteristics were obtained from each participant’s electronic health record (EHR), including copay status, index hospitalization length of stay, admission diagnosis, and postsurgery status (postsurgery vs nonpostsurgery). Intervention adherence was tracked as the number of PAT sessions attended.

Posthospital Syndrome Factors

Participant falls (categorized as those who reported a fall vs those who did not) and medication changes (number of changes reported, including new medication, discontinued medication, dose changes, medication changes, or changes in medication schedule) were reported by participants or caregivers during each VVC contact. Participants completed the Montreal Cognitive Assessment (MoCA) at baseline, and were dichotomized into 2 groups: no cognitive impairment (MoCA score ≥ 26) and mild to moderate cognitive impairment (MoCA score 10-25).^13,21

Participants rated how much pain interfered with their normal daily activities since the previous VVC session on a 5-point Likert scale (1, not at all; to 5, extremely).²² Similar to prior research, participants were placed into 2 groups based on their mean pain interference score (individuals with scores from 1.0 to 2.0 in 1 group, and individuals with > 2.0 in another).^23-25 Participants were separated into a no or mild pain interference group and a moderate to severe pain interference group. Hospital readmissions (VA and non-VA) and postdischarge physical therapy outcomes were obtained from the participant’s EHR, including primary care visits.

Outcomes

Outcomes were collected at baseline (posthospital discharge) and 6 months postenrollment.

Self-Reported Functional Ability. This measure is provided by participants or caregivers and measured by the Katz Index of Independence in Activities of Daily Living (ADL), Lawton and Brody Instrumental ADL Scale (IADL), Nagi Disability Model, and Rosow-Breslau Scale. The Katz ADL assesses the ability to complete 6 self-care activities and awards 1 point for independence and 0 if the individual is dependent (total score range, 0-6).²⁶ The Lawton and Brody IADL measures an individual’s independence in 8 instrumental ADLs; it awards 1 point for independence and 0 if the individual is dependent (total score range, 0-8).²⁷ The Nagi Disability Model evaluates an individual’s difficulty performing 5 tasks (total score range, 0-5) and tallies the number of items with a response other than “no difficulty at all” (higher total score indicates greater difficulty). ²⁸ The Rosow-Breslau Scale is a 3-item measure of mobility disability; individual responses are 0 (no help) and 1 (requires help or unable); higher total score (range, 0-3) indicates greater disability.²⁹

Physical Performance. Measured using the Short Physical Performance Battery (SPPB), which evaluates standing balance, sit to stand, and walking performance. Scores range from 0 to 4 on the balance, gait speed, and chair stand tests, for a total composite score between 0 and 12 (higher score indicates better performance).³⁰

Physical Activity. Measured using actigraphy, namely a physical activity monitor adherent to the thigh (activ-PAL3TM, PAL Technologies Ltd., Glasgow, UK).³¹ Participants were instructed to wear the activPal for ≥ 1 week. Participants with a minimum of 5 days of wear were included in this analysis.

Data Analyses

Analyses were performed using SPSS software version 29.0.³² Continuous variables were summarized using mean (SD) or median and IQR using the weighted average method; categorical variables were summarized using frequencies and percentages. Baseline scores on outcome variables were compared by categorical hospitalization, posthospital syndrome, and postdischarge health care application factor variables using Mann-Whitney U tests. The differences between outcome variables from baseline to endpoint were then calculated to produce change scores. Relationships between the number of PAT sessions attended and baseline outcomes and outcome change scores were estimated using Spearman correlations. Relationships between categorical factors (hospitalization, posthospital syndrome, and postdischarge health care application) and outcome variable change scores (which were normally distributed) were examined using Mann-Whitney U tests. Relationships with continuous hospitalization (length of stay) and posthospital syndrome factors (medication changes) were estimated using Spearman correlations. Effect sizes (ES) were estimated with Cohen d; small (d = 0.2), medium (d = 0.5), or large (d ≥ 0.8). Missing data were handled using pairwise deletion.³³ Therefore, sample sizes were reported for each analysis. For all statistical tests, P < .05 was considered significant.

Results

Twenty-four individuals completed the pilot intervention.¹⁵ Mean (SD) age was 73.6 (8.1) years (range, 64-93 years) and participants were predominantly White males (Table 1). Eight participants had a high school education only and 13 had more than a high school education. Diagnoses at admission included 9 patients with orthopedic/musculoskeletal conditions (6 were for joint replacement), 6 patients with vascular/pulmonary conditions, and 4 with gastrointestinal/renal/urological conditions. Of the 11 postsurgery participants, 7 were orthopedic, 4 were gastrointestinal, and 1 was peripheral vascular.

Baseline outcome scores did not differ significantly between groups, except individuals with moderate to severe pain interference reported a significantly lower IADL score (median [IQR] 4 [2-7]) than individuals with mild or moderate pain interference (median [IQR] 8 [7-8]; P = .02) (Table 2). The mean (SD) number of PAT sessions attended was 9.3 (3.7) (range, 3-19). There were no significant relationships between number of sessions attended and any baseline outcome variables or outcome change scores.

Hospitalization Factors

Participants who were postsurgery tended to have greater improvement than individuals who were nonpostsurgery in ADLs (median [IQR] 0 [0-1.5]; ES, 0.6; P = .10) and SPPB (median [IQR] 2 [1.5-9]; ES, 0.9; P = .07), but the improvements were not statistically significant (Table 3). Mean (SD) length of stay of the index hospitalization was 6.7 (6.1) days. Longer length of stay was significantly correlated with an increase in Nagi score (ρ, 0.45; 95% CI, 0.01-0.75). There were no other significant or trending relationships between length of stay and outcome variables.

Posthospital Syndrome Factors

The 16 participants with mild to moderate cognitive impairment had less improvement in ADLs (median [IQR] 0 [0-1]) than the 8 participants with no impairment (median [IQR] 0 [-0.75 to 0]; ES, -1.1; P = .04). Change in outcome variables from baseline to endpoint did not significantly differ between the 8 patients who reported a fall compared with the 13 who did not, nor were any trends observed. Change in outcome variables from baseline to endpoint also did not significantly differ between the 8 participants who reported no or mild pain interference compared with the 10 patients with moderate to severe pain interference, nor were any trends observed. Mean (SD) number of medication changes was 2.5 (1.6). Higher number of medication changes was significantly correlated with a decrease in Rosow-Breslau score (ρ, -0.47; 95% CI, -0.76 to -0.02). There were no other significant or trending relationships between number of medication changes and outcome variables.

Postdischarge Health Care Application Factors

The 16 participants who attended posthospital physical therapy trended towards less improvement in IADLs (median [IQR] 0 [-0.5 to 1.5]; ES, -0.7; P = .11) and SPPB (median [IQR] 2 [-3.0 to 4.5]; ES, -0.5; P = .15) than the 8 patients with no postdischarge physical therapy. Eleven participants were readmitted, while 13 had no readmissions in their medical records between baseline and endpoint. Participants with ≥ 1 readmission experienced a greater increase in Rosow-Breslau score (median [IQR] 0 [-0.5 to 1.0]) than those not readmitted (median [IQR] 0 [-1.25 to 0.25]; ES, 1.0; P = .03). Borderline greater improvement in number of steps was found in those not readmitted (median [IQR] 3365.6 [274.4-7710.9]) compared with those readmitted (median [IQR] 319.9 [-136.1 to 774.5]; ES, -1.3; P = .05). Patients who were readmitted also tended to have lower and not statistically significant improvements in SPPB (median [IQR] 1 [-4.0 to 5.3]) compared with those not readmitted (median [IQR] 2 [0.3-3.8]; ES, -0.5; P = .17) (Table 3).

Discussion

This study examined the association between hospitalization, posthospital syndrome, and postdischarge health care use in patients undergoing a VVC-based intervention following hospital discharge. Participants who had no or mild cognitive impairment, no readmissions, higher medication changes, and a shorter hospital length of stay tended to experience lower disability, including in mobility and ADLs. This suggests individuals who are less clinically complex may be more likely to benefit from this type of virtual rehabilitation program. These findings are consistent with clinical experiences; home-based programs to improve physical activity posthospital discharge can be challenging for those who were medically ill (and did not undergo a specific surgical procedure), cognitively impaired, and become acutely ill and trigger hospital readmission. ¹⁵ For example, the sample in this study had higher rates of falls, pain, and readmissions compared to previous research.^2,3,34-39

The importance of posthospital syndrome in the context of recovery of function and health at home following hospitalization is well documented.^16-18 The potential impact of posthospital syndrome on physical activity-focused interventions is less understood. In our analysis, participants with mild or moderate cognitive impairment tended to become more dependent in their ADLs, while those with no cognitive impairment tended to become more independent in their ADLs. This functional decline over time is perhaps expected in persons with cognitive impairment, but the significant difference with a large ES warrants further consideration on how to tailor interventions to better promote functional recovery in these individuals.^40,41 While some cognitive decline may not be preventable, this finding supports the need to promote healthy cognitive aging, identify declines in cognition, and work to mitigate additional decline. Programs specifically designed to promote function and physical activity in older adults with cognitive impairment are needed, especially during care transitions.^41-43

While participants reported that falls and pain interference did not have a significant impact on change in outcomes between baseline and endpoint, these areas need further investigation. Falls and pain have been associated with function and physical activity in older adults.^42-46 Pain is common, yet underappreciated during older adult hospital-to-home transitions.^11,12,45,46 There is a need for more comprehensive assessment of pain (including pain intensity) and qualitative research.

Hospitalization and postdischarge health care application factors may have a significant impact on home-telehealth physical activity intervention success. Individuals who were postsurgery tended to have greater improvements in ADLs and physical performance. Most postsurgery participants had joint replacement surgery. Postsurgery status may not be modifiable, but it is important to note expected differences in recovery between medical and surgical admissions and the need to tailor care based on admission diagnosis. Those with a longer length of hospital stay may be considered at higher risk of suboptimal outcomes postdischarge, which indicates an opportunity for targeting resources and support, in addition to efforts of reducing length of stay where possible.⁴⁷

Readmissions were significantly related to a change in Rosow-Breslau mobility disability score. This may indicate the detrimental impact a readmission can have on increasing mobility and physical activity postdischarge, or the potential of this pilot program to impact readmissions by increasing mobility and physical activity, contrary to prior physical exercise interventions.^5,7,9,48 With 5% to 79% of readmissions considered preventable, continued efforts and program dissemination and implementation to address preventable readmissions are warranted.⁴⁹ Individuals with postdischarge physical therapy (prior to beginning the pilot program) tended to demonstrate less improvement in disability and physical performance. This relationship needs further investigation; the 2 groups did not appear to have significant differences at baseline, albeit with a small sample size. It is possible they experienced initial improvements with postdischarge physical therapy and plateaued or had little further reserve to improve upon entering the VVC program.

Strengths and Limitations

This pilot program provided evaluative data on the use of VVC to enhance function and physical activity in older adults posthospital discharge. It included individual (eg, fall, pain, cognitive impairment) and health service (eg, readmission, physical therapy) level factors as predictors of function and physical activity posthospitalization.^5,7,9,15-19

The results of this pilot project stem from a small sample lacking diversity in terms of race, ethnicity, and sex. There was some variation in baseline and endpoints between participants, and when hospitalization, posthospital syndrome, and postdischarge health care application factors were collected. The majority of participants were recruited within a month postdischarge, and the program lasted about 6 months. Data collection was attempted at regular PAT contacts, but there was some variation in when visits occurred based on participant availability and preference. Some participants had missing data, which was handled using pairwise deletion.³³ Larger studies are needed to confirm the findings of this study, particularly the trends that did not reach statistical significance. Home health services other than physical therapy (eg, nursing, occupational therapy) were not fully accounted for and should be considered in future research.

Conclusions

In patients undergoing a 6-month pilot VVC-based physical activity intervention posthospital discharge, improvements in mobility and disability were most likely in those who had no cognitive impairment and were not readmitted. Larger sample and qualitative investigations are necessary to optimize outcomes for patients who meet these clinical profiles.

Deconditioning among hospitalized older adults contributes to significant decline in posthospitalization functional ability, physical performance, and physical activity.^1-10 Previous hospital-to-home interventions have targeted improving function and physical activity, including recent programs leveraging home telehealth as a feasible and potentially effective mode of delivering in-home exercise and rehabilitation.^11-14 However, pilot interventions have shown mixed effectiveness.^11,12,14 This study expands on a previously published intervention describing a pilot home telehealth program for veterans posthospital discharge that demonstrated significant 6-month improvement in physical activity as well as trends in physical function improvement, including among those with cognitive impairment.¹⁵ Factors that contribute to improved outcomes are the focus of the present study.

Key factors underlying the complexity of hospital-to-home transitions include hospitalization elements (ie, reason for admission and length of stay), associated posthospital syndromes (ie, postdischarge falls, medication changes, cognitive impairment, and pain), and postdischarge health care application (ie, physical therapy and hospital readmission).^16-18 These factors may be associated with postdischarge functional ability, physical performance, and physical activity, but their direct influence on intervention outcomes is unclear (Figure 1).^5,7,9,16-20 The objective of this study was to examine the influence of hospitalization, posthospital syndrome, and postdischarge health care application factors on outcomes of a US Department of Veterans Affairs (VA) Video Connect (VVC) intervention to enhance function and physical activity in older adults posthospital discharge.

Methods

The previous analysis reported on patient characteristics, program feasibility, and preliminary outcomes.^13,15 The current study reports on relationships between hospitalization, posthospital syndrome, and postdischarge health care application factors and change in key outcomes, namely postdischarge self-reported functional ability, physical performance, and physical activity from baseline to endpoint.

Participants provided written informed consent. The protocol and consent forms were approved by the VA Ann Arbor Healthcare System (VAAAHS) Research and Development Committee, and the project was registered on clinicaltrials.gov (NCT04045054).

Intervention

The pilot program targeted older adults following recent hospital discharge from VAAAHS. Participants were eligible if they were aged ≥ 50 years, had been discharged following an inpatient stay in the past 1 to 2 weeks, evaluated by physical therapy during hospitalization with stated rehabilitation goals on discharge, and followed by a VAAAHS primary care physician. Participants were either recruited during hospital admission or shortly after discharge.¹³

An experienced physical activity trainer (PAT) supported the progression of participants’ rehabilitation goals via a home exercise program and coached the patient and caregiver to optimize functional ability, physical performance, and physical activity. The PAT was a nonlicensed research assistant with extensive experience in applying standard physical activity enhancement protocols (eg, increased walking) to older adults with comorbidities. Participation in the program lasted about 6 months. Initiation of the PAT program was delayed if the patient was already receiving postdischarge home-based or outpatient physical therapy. The PAT contacted the patient weekly via VVC for the first 6 weeks, then monthly for a total of 6 months. Each contact included information on optimal walking form, injury prevention, program progression, and ways to incorporate sit-to-stand transitions, nonsitting behavior, and walking into daily routines. The initial VVC contact lasted about 60 minutes and subsequent sessions lasted about 30 minutes.¹³

Demographic characteristics were self-reported by participants and included age, sex, race, years of education, and marital status. Clinical characteristics were obtained from each participant’s electronic health record (EHR), including copay status, index hospitalization length of stay, admission diagnosis, and postsurgery status (postsurgery vs nonpostsurgery). Intervention adherence was tracked as the number of PAT sessions attended.

Posthospital Syndrome Factors

Participant falls (categorized as those who reported a fall vs those who did not) and medication changes (number of changes reported, including new medication, discontinued medication, dose changes, medication changes, or changes in medication schedule) were reported by participants or caregivers during each VVC contact. Participants completed the Montreal Cognitive Assessment (MoCA) at baseline, and were dichotomized into 2 groups: no cognitive impairment (MoCA score ≥ 26) and mild to moderate cognitive impairment (MoCA score 10-25).^13,21

Participants rated how much pain interfered with their normal daily activities since the previous VVC session on a 5-point Likert scale (1, not at all; to 5, extremely).²² Similar to prior research, participants were placed into 2 groups based on their mean pain interference score (individuals with scores from 1.0 to 2.0 in 1 group, and individuals with > 2.0 in another).^23-25 Participants were separated into a no or mild pain interference group and a moderate to severe pain interference group. Hospital readmissions (VA and non-VA) and postdischarge physical therapy outcomes were obtained from the participant’s EHR, including primary care visits.

Outcomes

Outcomes were collected at baseline (posthospital discharge) and 6 months postenrollment.

Self-Reported Functional Ability. This measure is provided by participants or caregivers and measured by the Katz Index of Independence in Activities of Daily Living (ADL), Lawton and Brody Instrumental ADL Scale (IADL), Nagi Disability Model, and Rosow-Breslau Scale. The Katz ADL assesses the ability to complete 6 self-care activities and awards 1 point for independence and 0 if the individual is dependent (total score range, 0-6).²⁶ The Lawton and Brody IADL measures an individual’s independence in 8 instrumental ADLs; it awards 1 point for independence and 0 if the individual is dependent (total score range, 0-8).²⁷ The Nagi Disability Model evaluates an individual’s difficulty performing 5 tasks (total score range, 0-5) and tallies the number of items with a response other than “no difficulty at all” (higher total score indicates greater difficulty). ²⁸ The Rosow-Breslau Scale is a 3-item measure of mobility disability; individual responses are 0 (no help) and 1 (requires help or unable); higher total score (range, 0-3) indicates greater disability.²⁹

Physical Performance. Measured using the Short Physical Performance Battery (SPPB), which evaluates standing balance, sit to stand, and walking performance. Scores range from 0 to 4 on the balance, gait speed, and chair stand tests, for a total composite score between 0 and 12 (higher score indicates better performance).³⁰

Physical Activity. Measured using actigraphy, namely a physical activity monitor adherent to the thigh (activ-PAL3TM, PAL Technologies Ltd., Glasgow, UK).³¹ Participants were instructed to wear the activPal for ≥ 1 week. Participants with a minimum of 5 days of wear were included in this analysis.

Data Analyses

Analyses were performed using SPSS software version 29.0.³² Continuous variables were summarized using mean (SD) or median and IQR using the weighted average method; categorical variables were summarized using frequencies and percentages. Baseline scores on outcome variables were compared by categorical hospitalization, posthospital syndrome, and postdischarge health care application factor variables using Mann-Whitney U tests. The differences between outcome variables from baseline to endpoint were then calculated to produce change scores. Relationships between the number of PAT sessions attended and baseline outcomes and outcome change scores were estimated using Spearman correlations. Relationships between categorical factors (hospitalization, posthospital syndrome, and postdischarge health care application) and outcome variable change scores (which were normally distributed) were examined using Mann-Whitney U tests. Relationships with continuous hospitalization (length of stay) and posthospital syndrome factors (medication changes) were estimated using Spearman correlations. Effect sizes (ES) were estimated with Cohen d; small (d = 0.2), medium (d = 0.5), or large (d ≥ 0.8). Missing data were handled using pairwise deletion.³³ Therefore, sample sizes were reported for each analysis. For all statistical tests, P < .05 was considered significant.

Results

Twenty-four individuals completed the pilot intervention.¹⁵ Mean (SD) age was 73.6 (8.1) years (range, 64-93 years) and participants were predominantly White males (Table 1). Eight participants had a high school education only and 13 had more than a high school education. Diagnoses at admission included 9 patients with orthopedic/musculoskeletal conditions (6 were for joint replacement), 6 patients with vascular/pulmonary conditions, and 4 with gastrointestinal/renal/urological conditions. Of the 11 postsurgery participants, 7 were orthopedic, 4 were gastrointestinal, and 1 was peripheral vascular.

Baseline outcome scores did not differ significantly between groups, except individuals with moderate to severe pain interference reported a significantly lower IADL score (median [IQR] 4 [2-7]) than individuals with mild or moderate pain interference (median [IQR] 8 [7-8]; P = .02) (Table 2). The mean (SD) number of PAT sessions attended was 9.3 (3.7) (range, 3-19). There were no significant relationships between number of sessions attended and any baseline outcome variables or outcome change scores.

Hospitalization Factors

Participants who were postsurgery tended to have greater improvement than individuals who were nonpostsurgery in ADLs (median [IQR] 0 [0-1.5]; ES, 0.6; P = .10) and SPPB (median [IQR] 2 [1.5-9]; ES, 0.9; P = .07), but the improvements were not statistically significant (Table 3). Mean (SD) length of stay of the index hospitalization was 6.7 (6.1) days. Longer length of stay was significantly correlated with an increase in Nagi score (ρ, 0.45; 95% CI, 0.01-0.75). There were no other significant or trending relationships between length of stay and outcome variables.

Posthospital Syndrome Factors

The 16 participants with mild to moderate cognitive impairment had less improvement in ADLs (median [IQR] 0 [0-1]) than the 8 participants with no impairment (median [IQR] 0 [-0.75 to 0]; ES, -1.1; P = .04). Change in outcome variables from baseline to endpoint did not significantly differ between the 8 patients who reported a fall compared with the 13 who did not, nor were any trends observed. Change in outcome variables from baseline to endpoint also did not significantly differ between the 8 participants who reported no or mild pain interference compared with the 10 patients with moderate to severe pain interference, nor were any trends observed. Mean (SD) number of medication changes was 2.5 (1.6). Higher number of medication changes was significantly correlated with a decrease in Rosow-Breslau score (ρ, -0.47; 95% CI, -0.76 to -0.02). There were no other significant or trending relationships between number of medication changes and outcome variables.

Postdischarge Health Care Application Factors

The 16 participants who attended posthospital physical therapy trended towards less improvement in IADLs (median [IQR] 0 [-0.5 to 1.5]; ES, -0.7; P = .11) and SPPB (median [IQR] 2 [-3.0 to 4.5]; ES, -0.5; P = .15) than the 8 patients with no postdischarge physical therapy. Eleven participants were readmitted, while 13 had no readmissions in their medical records between baseline and endpoint. Participants with ≥ 1 readmission experienced a greater increase in Rosow-Breslau score (median [IQR] 0 [-0.5 to 1.0]) than those not readmitted (median [IQR] 0 [-1.25 to 0.25]; ES, 1.0; P = .03). Borderline greater improvement in number of steps was found in those not readmitted (median [IQR] 3365.6 [274.4-7710.9]) compared with those readmitted (median [IQR] 319.9 [-136.1 to 774.5]; ES, -1.3; P = .05). Patients who were readmitted also tended to have lower and not statistically significant improvements in SPPB (median [IQR] 1 [-4.0 to 5.3]) compared with those not readmitted (median [IQR] 2 [0.3-3.8]; ES, -0.5; P = .17) (Table 3).

Discussion

This study examined the association between hospitalization, posthospital syndrome, and postdischarge health care use in patients undergoing a VVC-based intervention following hospital discharge. Participants who had no or mild cognitive impairment, no readmissions, higher medication changes, and a shorter hospital length of stay tended to experience lower disability, including in mobility and ADLs. This suggests individuals who are less clinically complex may be more likely to benefit from this type of virtual rehabilitation program. These findings are consistent with clinical experiences; home-based programs to improve physical activity posthospital discharge can be challenging for those who were medically ill (and did not undergo a specific surgical procedure), cognitively impaired, and become acutely ill and trigger hospital readmission. ¹⁵ For example, the sample in this study had higher rates of falls, pain, and readmissions compared to previous research.^2,3,34-39

The importance of posthospital syndrome in the context of recovery of function and health at home following hospitalization is well documented.^16-18 The potential impact of posthospital syndrome on physical activity-focused interventions is less understood. In our analysis, participants with mild or moderate cognitive impairment tended to become more dependent in their ADLs, while those with no cognitive impairment tended to become more independent in their ADLs. This functional decline over time is perhaps expected in persons with cognitive impairment, but the significant difference with a large ES warrants further consideration on how to tailor interventions to better promote functional recovery in these individuals.^40,41 While some cognitive decline may not be preventable, this finding supports the need to promote healthy cognitive aging, identify declines in cognition, and work to mitigate additional decline. Programs specifically designed to promote function and physical activity in older adults with cognitive impairment are needed, especially during care transitions.^41-43

While participants reported that falls and pain interference did not have a significant impact on change in outcomes between baseline and endpoint, these areas need further investigation. Falls and pain have been associated with function and physical activity in older adults.^42-46 Pain is common, yet underappreciated during older adult hospital-to-home transitions.^11,12,45,46 There is a need for more comprehensive assessment of pain (including pain intensity) and qualitative research.

Hospitalization and postdischarge health care application factors may have a significant impact on home-telehealth physical activity intervention success. Individuals who were postsurgery tended to have greater improvements in ADLs and physical performance. Most postsurgery participants had joint replacement surgery. Postsurgery status may not be modifiable, but it is important to note expected differences in recovery between medical and surgical admissions and the need to tailor care based on admission diagnosis. Those with a longer length of hospital stay may be considered at higher risk of suboptimal outcomes postdischarge, which indicates an opportunity for targeting resources and support, in addition to efforts of reducing length of stay where possible.⁴⁷

Readmissions were significantly related to a change in Rosow-Breslau mobility disability score. This may indicate the detrimental impact a readmission can have on increasing mobility and physical activity postdischarge, or the potential of this pilot program to impact readmissions by increasing mobility and physical activity, contrary to prior physical exercise interventions.^5,7,9,48 With 5% to 79% of readmissions considered preventable, continued efforts and program dissemination and implementation to address preventable readmissions are warranted.⁴⁹ Individuals with postdischarge physical therapy (prior to beginning the pilot program) tended to demonstrate less improvement in disability and physical performance. This relationship needs further investigation; the 2 groups did not appear to have significant differences at baseline, albeit with a small sample size. It is possible they experienced initial improvements with postdischarge physical therapy and plateaued or had little further reserve to improve upon entering the VVC program.

Strengths and Limitations

This pilot program provided evaluative data on the use of VVC to enhance function and physical activity in older adults posthospital discharge. It included individual (eg, fall, pain, cognitive impairment) and health service (eg, readmission, physical therapy) level factors as predictors of function and physical activity posthospitalization.^5,7,9,15-19

The results of this pilot project stem from a small sample lacking diversity in terms of race, ethnicity, and sex. There was some variation in baseline and endpoints between participants, and when hospitalization, posthospital syndrome, and postdischarge health care application factors were collected. The majority of participants were recruited within a month postdischarge, and the program lasted about 6 months. Data collection was attempted at regular PAT contacts, but there was some variation in when visits occurred based on participant availability and preference. Some participants had missing data, which was handled using pairwise deletion.³³ Larger studies are needed to confirm the findings of this study, particularly the trends that did not reach statistical significance. Home health services other than physical therapy (eg, nursing, occupational therapy) were not fully accounted for and should be considered in future research.

Conclusions

In patients undergoing a 6-month pilot VVC-based physical activity intervention posthospital discharge, improvements in mobility and disability were most likely in those who had no cognitive impairment and were not readmitted. Larger sample and qualitative investigations are necessary to optimize outcomes for patients who meet these clinical profiles.

Primary care practitioners (PCPs) in the US Department of Veterans Affairs (VA) provide care for patients with higher rates of many diseases—diabetes, heart disease, cancer, chronic obstructive pulmonary disease (COPD), and stroke—compared to the nonveteran population. ¹ Due to the medical complexities of these diseases, they are often misdiagnosed or not diagnosed at all.

COPD is hiding in plain sight, impacting quality of life and burdening US health care systems.² Research has yielded new treatments and evidence-based guidelines; however, COPD remains underdiagnosed. Only 13 million of the estimated 79 million US adults with COPD aged 20 to 79 years have been formally diagnosed.³ By the time patients are diagnosed, the disease is often advanced, and therapies are less effective. In 2 large studies of patients with COPD symptoms, later diagnosis was associated with worse outcomes.^4,5

Veterans have a higher prevalence of COPD (8%-19%) than nonveterans (6%), likely due to higher rates of smoking and service-related exposures, especially among veterans of post-9/11 conflicts.^6,7 Veterans do not always report symptoms and PCPs may not ask about symptoms, leading to underdiagnosis.⁸ The combination of high likelihood and underdetection of COPD presents a challenge and a target for VA quality improvement (QI).

The US Preventive Services Task Force (USPSTF) recommends against screening asymptomatic patients for COPD. However, both the USPSTF and the Global Initiative for Chronic Obstructive Lung Disease Report advocate for active case finding in primary care clinics to determine whether high-risk patients, such as smokers, experience COPD symptoms and warrant spirometry. ^9,10 To make early COPD diagnoses, clinicians may use questionnaires alone or in combination with handheld peak expiratory flow rate measurements.^11,12 Formal spirometry, considered the gold standard for COPD diagnosis, is ordered for patients who report COPD symptoms (ie, shortness of breath with exertion) or who have both COPD symptoms and reduced peak flow rates.

A systematic review and meta-analysis found that while the combination of questionnaires and peak flows was the more effective strategy overall, questionnaires alone were also valuable for identifying patients with possible COPD.¹³ Implementation of either screening method in primary care practices would be challenging. In a simulation study that applied chronic disease and preventive care guidelines to hypothetical patient panels, the time required for PCPs to provide guideline-recommended chronic and preventive care in addition to acute care far exceeded 8 hours per day, even in team-based settings.¹⁴ Overburdened PCPs are therefore unlikely to accept additional tasks like COPD case finding.

Why don’t patients report their pulmonary symptoms? Patients may not recognize the symptoms as evidence of COPD. Others may be afraid of a COPD diagnosis or the stigma that is associated with it.¹⁵ Perhaps they believe COPD treatment is ineffective because of lung damage from smoking. Some patients may not want to know if they have COPD, while others reduce activity levels to avoid symptoms.¹⁶

QUALITY IMPROVEMENT PROJECT

Given the high prevalence of COPD among veterans and the potential for underdiagnosis, VA Northeast Ohio Healthcare System (VANEOHS) internal medicine residents and faculty assessed the state of COPD diagnosis in its primary care clinic with a QI project in 2022. Patients in the clinic between August 1, 2015, and November 30, 2022, with an International Classification of Diseases-10 (ICD-10) COPD diagnosis code (J44) in the electronic health record were included. Of 157 included patients, 105 patients who had prior spirometry testing were excluded. Of the 52 patients with diagnosed COPD and no spirometry testing, 30 patients had computed tomography (CT) findings consistent with COPD (ie, airway thickening, emphysema, air trapping) that was performed for CT lung cancer screening (LCS).¹⁷ Twenty-three of these 30 patients were contacted by phone. All 23 were ever smokers and 13 reported COPD symptoms. The PCPs of the symptomatic patients were then contacted. Spirometry was ordered for all 13 patients and completed by 7. Three spirometry tests confirmed the COPD diagnosis. One PCP initiated inhaler therapy for a patient with newly diagnosed COPD.

All 11 PCPs of symptomatic patients were interviewed (many had > 1 symptomatic patient). They reported being unaware of patients’ COPD symptoms because the patients did not mention them, noting that screening for COPD was not a priority.

Role of Lung Cancer Screening

VA PCPs use electronic health record clinical reminders to track tests, consults, chronic disease education, cancer screenings, and routine health maintenance. A clinical reminder already exists (based on USPSTF recommendations) for LCS for patients aged 50 to 80 years who have a smoking history of 20 pack years. Patients who meet these criteria would also be considered high risk for COPD.

The VANEOHS QI project suggests that previously undiagnosed patients with findings of COPD on LCS may also have symptoms of COPD. Therefore, we wondered whether the LCS clinical reminder could serve a second purpose by prompting PCPs to ask veterans who meet LCS criteria about their COPD symptoms.

In 2022, about 13 million patients were eligible for LCS.¹⁸ Patients who qualify for LCS are at high risk for other cardiopulmonary disorders, such as COPD and coronary artery disease. Lung cancer is detected in only 1% of patients screened with CT at baseline. However, more often LCS yields evidence of additional cardiopulmonary disorders, such as emphysema or coronary artery calcifications. The International Early Lung Cancer Program (I-ELCAP) and the National Lung Cancer Screening Trial (NLST), which included > 79,000 patients, found evidence of emphysema on CT imaging in 24% and 31% of cases, respectively.^19,20 In both cohorts, > 80% of patients with emphysema on CT imaging had no prior history of COPD.

In a 2022 article summarizing the potential impact of CT LCS on COPD diagnosis, Mulshine et al suggest that detection of emphysema on CT LCS provides “earlier recognition for PCPs to identify patients who would benefit from detailed symptom screening to prompt spirometry for COPD detection” and additional motivation for tobacco cessation.²¹ The VANEOHS QI project was developed and implemented prior to I-ELCAP or NLST reporting results but reinforces the value of CT LCS for COPD diagnosis.

Early diagnosis of COPD remains challenging because PCPs do not ask, patients do not tell, and symptoms can easily be dismissed. However, earlier diagnosis of COPD in symptomatic patients improves outcomes.^3,4 To bridge this gap, VA PCPs and primary care patient aligned care teams (PACTs) need to commit to probing high-risk patients for COPD symptoms and ordering spirometry for those who are symptomatic. To accomplish this task, primary care teams need help.

The VANEOHS QI project confirmed that some patients with evidence of COPD on CT have symptoms of COPD that they did not share with their PCPs and suggests that LCS can be used as a dual action case finding method to screen both for lung cancer and COPD. We propose that patients who are eligible for LCS should also be probed for COPD symptoms at their clinic visits; for symptomatic patients, spirometry should be ordered, and COPD evidence-based management should be initiated when spirometry results are consistent with COPD. Annual probing for COPD symptoms could be considered in asymptomatic patients with ongoing tobacco use or emphysema on CT, since they may develop symptoms in the future. This new case-finding method bypasses the need for time-prohibitive questionnaires or peak flow measurements.

Future Opportunities

VA PCPs juggle many priorities and despite the simplicity of this new case finding COPD method, it may be unintentionally overlooked. PCPs often run out of time or may forget to ask patients about COPD symptoms when ordering LCS.

Future innovations to increase COPD diagnosis could include the creation of a yearly VA clinical reminder linked to the tobacco use reminder that has check boxes asking about symptoms of COPD in current and prior smokers. If patients have COPD symptoms, the reminder can prompt the ordering of spirometry. Similar reminders could be implemented to identify veterans with exposures to burn pits or other military environmental exposures who may have COPD symptoms. Another possible way to increase COPD diagnosis would be a partnership between primary care and the VA LCS program where patients receiving screening are asked about COPD symptoms during their LCS interviews and PACTs are alerted to order spirometry for symptomatic patients.

Elusive no longer! We can pull the veil back on COPD diagnosis and identify patients with possible COPD earlier in their course using their eligibility for LCS as a yearly reminder to probe them for symptoms. While not all patients who undergo LCS—even those with evidence of COPD on CT—will have COPD symptoms, symptoms may develop over time. LCS provides the possibility of 2 diagnoses from 1 test. This is an opportunity we cannot afford to miss.

Primary care practitioners (PCPs) in the US Department of Veterans Affairs (VA) provide care for patients with higher rates of many diseases—diabetes, heart disease, cancer, chronic obstructive pulmonary disease (COPD), and stroke—compared to the nonveteran population. ¹ Due to the medical complexities of these diseases, they are often misdiagnosed or not diagnosed at all.

COPD is hiding in plain sight, impacting quality of life and burdening US health care systems.² Research has yielded new treatments and evidence-based guidelines; however, COPD remains underdiagnosed. Only 13 million of the estimated 79 million US adults with COPD aged 20 to 79 years have been formally diagnosed.³ By the time patients are diagnosed, the disease is often advanced, and therapies are less effective. In 2 large studies of patients with COPD symptoms, later diagnosis was associated with worse outcomes.^4,5

Veterans have a higher prevalence of COPD (8%-19%) than nonveterans (6%), likely due to higher rates of smoking and service-related exposures, especially among veterans of post-9/11 conflicts.^6,7 Veterans do not always report symptoms and PCPs may not ask about symptoms, leading to underdiagnosis.⁸ The combination of high likelihood and underdetection of COPD presents a challenge and a target for VA quality improvement (QI).

The US Preventive Services Task Force (USPSTF) recommends against screening asymptomatic patients for COPD. However, both the USPSTF and the Global Initiative for Chronic Obstructive Lung Disease Report advocate for active case finding in primary care clinics to determine whether high-risk patients, such as smokers, experience COPD symptoms and warrant spirometry. ^9,10 To make early COPD diagnoses, clinicians may use questionnaires alone or in combination with handheld peak expiratory flow rate measurements.^11,12 Formal spirometry, considered the gold standard for COPD diagnosis, is ordered for patients who report COPD symptoms (ie, shortness of breath with exertion) or who have both COPD symptoms and reduced peak flow rates.

A systematic review and meta-analysis found that while the combination of questionnaires and peak flows was the more effective strategy overall, questionnaires alone were also valuable for identifying patients with possible COPD.¹³ Implementation of either screening method in primary care practices would be challenging. In a simulation study that applied chronic disease and preventive care guidelines to hypothetical patient panels, the time required for PCPs to provide guideline-recommended chronic and preventive care in addition to acute care far exceeded 8 hours per day, even in team-based settings.¹⁴ Overburdened PCPs are therefore unlikely to accept additional tasks like COPD case finding.

Why don’t patients report their pulmonary symptoms? Patients may not recognize the symptoms as evidence of COPD. Others may be afraid of a COPD diagnosis or the stigma that is associated with it.¹⁵ Perhaps they believe COPD treatment is ineffective because of lung damage from smoking. Some patients may not want to know if they have COPD, while others reduce activity levels to avoid symptoms.¹⁶

QUALITY IMPROVEMENT PROJECT

Given the high prevalence of COPD among veterans and the potential for underdiagnosis, VA Northeast Ohio Healthcare System (VANEOHS) internal medicine residents and faculty assessed the state of COPD diagnosis in its primary care clinic with a QI project in 2022. Patients in the clinic between August 1, 2015, and November 30, 2022, with an International Classification of Diseases-10 (ICD-10) COPD diagnosis code (J44) in the electronic health record were included. Of 157 included patients, 105 patients who had prior spirometry testing were excluded. Of the 52 patients with diagnosed COPD and no spirometry testing, 30 patients had computed tomography (CT) findings consistent with COPD (ie, airway thickening, emphysema, air trapping) that was performed for CT lung cancer screening (LCS).¹⁷ Twenty-three of these 30 patients were contacted by phone. All 23 were ever smokers and 13 reported COPD symptoms. The PCPs of the symptomatic patients were then contacted. Spirometry was ordered for all 13 patients and completed by 7. Three spirometry tests confirmed the COPD diagnosis. One PCP initiated inhaler therapy for a patient with newly diagnosed COPD.

All 11 PCPs of symptomatic patients were interviewed (many had > 1 symptomatic patient). They reported being unaware of patients’ COPD symptoms because the patients did not mention them, noting that screening for COPD was not a priority.

Role of Lung Cancer Screening

VA PCPs use electronic health record clinical reminders to track tests, consults, chronic disease education, cancer screenings, and routine health maintenance. A clinical reminder already exists (based on USPSTF recommendations) for LCS for patients aged 50 to 80 years who have a smoking history of 20 pack years. Patients who meet these criteria would also be considered high risk for COPD.

The VANEOHS QI project suggests that previously undiagnosed patients with findings of COPD on LCS may also have symptoms of COPD. Therefore, we wondered whether the LCS clinical reminder could serve a second purpose by prompting PCPs to ask veterans who meet LCS criteria about their COPD symptoms.

In 2022, about 13 million patients were eligible for LCS.¹⁸ Patients who qualify for LCS are at high risk for other cardiopulmonary disorders, such as COPD and coronary artery disease. Lung cancer is detected in only 1% of patients screened with CT at baseline. However, more often LCS yields evidence of additional cardiopulmonary disorders, such as emphysema or coronary artery calcifications. The International Early Lung Cancer Program (I-ELCAP) and the National Lung Cancer Screening Trial (NLST), which included > 79,000 patients, found evidence of emphysema on CT imaging in 24% and 31% of cases, respectively.^19,20 In both cohorts, > 80% of patients with emphysema on CT imaging had no prior history of COPD.

In a 2022 article summarizing the potential impact of CT LCS on COPD diagnosis, Mulshine et al suggest that detection of emphysema on CT LCS provides “earlier recognition for PCPs to identify patients who would benefit from detailed symptom screening to prompt spirometry for COPD detection” and additional motivation for tobacco cessation.²¹ The VANEOHS QI project was developed and implemented prior to I-ELCAP or NLST reporting results but reinforces the value of CT LCS for COPD diagnosis.

Early diagnosis of COPD remains challenging because PCPs do not ask, patients do not tell, and symptoms can easily be dismissed. However, earlier diagnosis of COPD in symptomatic patients improves outcomes.^3,4 To bridge this gap, VA PCPs and primary care patient aligned care teams (PACTs) need to commit to probing high-risk patients for COPD symptoms and ordering spirometry for those who are symptomatic. To accomplish this task, primary care teams need help.

The VANEOHS QI project confirmed that some patients with evidence of COPD on CT have symptoms of COPD that they did not share with their PCPs and suggests that LCS can be used as a dual action case finding method to screen both for lung cancer and COPD. We propose that patients who are eligible for LCS should also be probed for COPD symptoms at their clinic visits; for symptomatic patients, spirometry should be ordered, and COPD evidence-based management should be initiated when spirometry results are consistent with COPD. Annual probing for COPD symptoms could be considered in asymptomatic patients with ongoing tobacco use or emphysema on CT, since they may develop symptoms in the future. This new case-finding method bypasses the need for time-prohibitive questionnaires or peak flow measurements.

Future Opportunities

VA PCPs juggle many priorities and despite the simplicity of this new case finding COPD method, it may be unintentionally overlooked. PCPs often run out of time or may forget to ask patients about COPD symptoms when ordering LCS.

Future innovations to increase COPD diagnosis could include the creation of a yearly VA clinical reminder linked to the tobacco use reminder that has check boxes asking about symptoms of COPD in current and prior smokers. If patients have COPD symptoms, the reminder can prompt the ordering of spirometry. Similar reminders could be implemented to identify veterans with exposures to burn pits or other military environmental exposures who may have COPD symptoms. Another possible way to increase COPD diagnosis would be a partnership between primary care and the VA LCS program where patients receiving screening are asked about COPD symptoms during their LCS interviews and PACTs are alerted to order spirometry for symptomatic patients.

Elusive no longer! We can pull the veil back on COPD diagnosis and identify patients with possible COPD earlier in their course using their eligibility for LCS as a yearly reminder to probe them for symptoms. While not all patients who undergo LCS—even those with evidence of COPD on CT—will have COPD symptoms, symptoms may develop over time. LCS provides the possibility of 2 diagnoses from 1 test. This is an opportunity we cannot afford to miss.

Primary care practitioners (PCPs) in the US Department of Veterans Affairs (VA) provide care for patients with higher rates of many diseases—diabetes, heart disease, cancer, chronic obstructive pulmonary disease (COPD), and stroke—compared to the nonveteran population. ¹ Due to the medical complexities of these diseases, they are often misdiagnosed or not diagnosed at all.

COPD is hiding in plain sight, impacting quality of life and burdening US health care systems.² Research has yielded new treatments and evidence-based guidelines; however, COPD remains underdiagnosed. Only 13 million of the estimated 79 million US adults with COPD aged 20 to 79 years have been formally diagnosed.³ By the time patients are diagnosed, the disease is often advanced, and therapies are less effective. In 2 large studies of patients with COPD symptoms, later diagnosis was associated with worse outcomes.^4,5

Veterans have a higher prevalence of COPD (8%-19%) than nonveterans (6%), likely due to higher rates of smoking and service-related exposures, especially among veterans of post-9/11 conflicts.^6,7 Veterans do not always report symptoms and PCPs may not ask about symptoms, leading to underdiagnosis.⁸ The combination of high likelihood and underdetection of COPD presents a challenge and a target for VA quality improvement (QI).

The US Preventive Services Task Force (USPSTF) recommends against screening asymptomatic patients for COPD. However, both the USPSTF and the Global Initiative for Chronic Obstructive Lung Disease Report advocate for active case finding in primary care clinics to determine whether high-risk patients, such as smokers, experience COPD symptoms and warrant spirometry. ^9,10 To make early COPD diagnoses, clinicians may use questionnaires alone or in combination with handheld peak expiratory flow rate measurements.^11,12 Formal spirometry, considered the gold standard for COPD diagnosis, is ordered for patients who report COPD symptoms (ie, shortness of breath with exertion) or who have both COPD symptoms and reduced peak flow rates.

A systematic review and meta-analysis found that while the combination of questionnaires and peak flows was the more effective strategy overall, questionnaires alone were also valuable for identifying patients with possible COPD.¹³ Implementation of either screening method in primary care practices would be challenging. In a simulation study that applied chronic disease and preventive care guidelines to hypothetical patient panels, the time required for PCPs to provide guideline-recommended chronic and preventive care in addition to acute care far exceeded 8 hours per day, even in team-based settings.¹⁴ Overburdened PCPs are therefore unlikely to accept additional tasks like COPD case finding.

Why don’t patients report their pulmonary symptoms? Patients may not recognize the symptoms as evidence of COPD. Others may be afraid of a COPD diagnosis or the stigma that is associated with it.¹⁵ Perhaps they believe COPD treatment is ineffective because of lung damage from smoking. Some patients may not want to know if they have COPD, while others reduce activity levels to avoid symptoms.¹⁶

QUALITY IMPROVEMENT PROJECT

Given the high prevalence of COPD among veterans and the potential for underdiagnosis, VA Northeast Ohio Healthcare System (VANEOHS) internal medicine residents and faculty assessed the state of COPD diagnosis in its primary care clinic with a QI project in 2022. Patients in the clinic between August 1, 2015, and November 30, 2022, with an International Classification of Diseases-10 (ICD-10) COPD diagnosis code (J44) in the electronic health record were included. Of 157 included patients, 105 patients who had prior spirometry testing were excluded. Of the 52 patients with diagnosed COPD and no spirometry testing, 30 patients had computed tomography (CT) findings consistent with COPD (ie, airway thickening, emphysema, air trapping) that was performed for CT lung cancer screening (LCS).¹⁷ Twenty-three of these 30 patients were contacted by phone. All 23 were ever smokers and 13 reported COPD symptoms. The PCPs of the symptomatic patients were then contacted. Spirometry was ordered for all 13 patients and completed by 7. Three spirometry tests confirmed the COPD diagnosis. One PCP initiated inhaler therapy for a patient with newly diagnosed COPD.

All 11 PCPs of symptomatic patients were interviewed (many had > 1 symptomatic patient). They reported being unaware of patients’ COPD symptoms because the patients did not mention them, noting that screening for COPD was not a priority.

Role of Lung Cancer Screening

VA PCPs use electronic health record clinical reminders to track tests, consults, chronic disease education, cancer screenings, and routine health maintenance. A clinical reminder already exists (based on USPSTF recommendations) for LCS for patients aged 50 to 80 years who have a smoking history of 20 pack years. Patients who meet these criteria would also be considered high risk for COPD.

The VANEOHS QI project suggests that previously undiagnosed patients with findings of COPD on LCS may also have symptoms of COPD. Therefore, we wondered whether the LCS clinical reminder could serve a second purpose by prompting PCPs to ask veterans who meet LCS criteria about their COPD symptoms.

In 2022, about 13 million patients were eligible for LCS.¹⁸ Patients who qualify for LCS are at high risk for other cardiopulmonary disorders, such as COPD and coronary artery disease. Lung cancer is detected in only 1% of patients screened with CT at baseline. However, more often LCS yields evidence of additional cardiopulmonary disorders, such as emphysema or coronary artery calcifications. The International Early Lung Cancer Program (I-ELCAP) and the National Lung Cancer Screening Trial (NLST), which included > 79,000 patients, found evidence of emphysema on CT imaging in 24% and 31% of cases, respectively.^19,20 In both cohorts, > 80% of patients with emphysema on CT imaging had no prior history of COPD.

In a 2022 article summarizing the potential impact of CT LCS on COPD diagnosis, Mulshine et al suggest that detection of emphysema on CT LCS provides “earlier recognition for PCPs to identify patients who would benefit from detailed symptom screening to prompt spirometry for COPD detection” and additional motivation for tobacco cessation.²¹ The VANEOHS QI project was developed and implemented prior to I-ELCAP or NLST reporting results but reinforces the value of CT LCS for COPD diagnosis.

Early diagnosis of COPD remains challenging because PCPs do not ask, patients do not tell, and symptoms can easily be dismissed. However, earlier diagnosis of COPD in symptomatic patients improves outcomes.^3,4 To bridge this gap, VA PCPs and primary care patient aligned care teams (PACTs) need to commit to probing high-risk patients for COPD symptoms and ordering spirometry for those who are symptomatic. To accomplish this task, primary care teams need help.

The VANEOHS QI project confirmed that some patients with evidence of COPD on CT have symptoms of COPD that they did not share with their PCPs and suggests that LCS can be used as a dual action case finding method to screen both for lung cancer and COPD. We propose that patients who are eligible for LCS should also be probed for COPD symptoms at their clinic visits; for symptomatic patients, spirometry should be ordered, and COPD evidence-based management should be initiated when spirometry results are consistent with COPD. Annual probing for COPD symptoms could be considered in asymptomatic patients with ongoing tobacco use or emphysema on CT, since they may develop symptoms in the future. This new case-finding method bypasses the need for time-prohibitive questionnaires or peak flow measurements.

Future Opportunities

VA PCPs juggle many priorities and despite the simplicity of this new case finding COPD method, it may be unintentionally overlooked. PCPs often run out of time or may forget to ask patients about COPD symptoms when ordering LCS.

Future innovations to increase COPD diagnosis could include the creation of a yearly VA clinical reminder linked to the tobacco use reminder that has check boxes asking about symptoms of COPD in current and prior smokers. If patients have COPD symptoms, the reminder can prompt the ordering of spirometry. Similar reminders could be implemented to identify veterans with exposures to burn pits or other military environmental exposures who may have COPD symptoms. Another possible way to increase COPD diagnosis would be a partnership between primary care and the VA LCS program where patients receiving screening are asked about COPD symptoms during their LCS interviews and PACTs are alerted to order spirometry for symptomatic patients.

Elusive no longer! We can pull the veil back on COPD diagnosis and identify patients with possible COPD earlier in their course using their eligibility for LCS as a yearly reminder to probe them for symptoms. While not all patients who undergo LCS—even those with evidence of COPD on CT—will have COPD symptoms, symptoms may develop over time. LCS provides the possibility of 2 diagnoses from 1 test. This is an opportunity we cannot afford to miss.

About half of US adults aged ≥ 65 years report arthritis, and of those, 44% have an arthritis-attributable activity limitation.^1,2 Arthritis is a significant health issue for veterans, with veterans reporting higher rates of disability compared with the civilian population.³

Osteoarthritis (OA) is the most common type of arthritis.⁴ Among individuals aged ≥ 40 years, the incidence of OA is nearly twice as high among veterans compared with civilians and is a leading cause of separation from military service and disability.^5,6 OA pain and disability have been shown to be associated with increases in health care and medication use, including opioids, nonsteroidal anti-inflammatory medications, and muscle relaxants.^7,8 Because OA is chronic and has no cure, safe and effective management strategies—such as exercise— are critical to minimize pain and maintain physical function.⁹

Exercise can reduce pain and disability associated with OA and is a first-line recommendation in guidelines for the treatment of knee and hip OA.⁹ Given the limited exercise and high levels of physical inactivity among veterans with OA, there is a need to identify opportunities that support veterans with OA engaging in regular exercise.

Gerofit, an outpatient clinical exercise program available at 30 Veterans Health Administration (VHA) sites, may provide an opportunity for older veterans with arthritis to engage in exercise.¹⁰ Gerofit is specifically designed for veterans aged ≥ 65 years. It is not disease-specific and supports older veterans with multiple chronic conditions, including OA. Veterans aged ≥ 65 years with a referral from a VA clinician are eligible for Gerofit. Those who are unable to perform activities of daily living; unable to independently function without assistance; have a history of unstable angina, proliferative diabetic retinopathy, oxygen dependence, volatile behavioral issues, or are unable to work successfully in a group environment/setting; experience active substance abuse, homelessness, or uncontrolled incontinence; and have open wounds that cannot be appropriately dressed are excluded from Gerofit. Exercise sessions are held 3 times per week and last from 60 to 90 minutes. Sessions are supervised by Gerofit staff and include personalized exercise prescriptions based on functional assessments. Exercise prescriptions include aerobic, resistance, and balance/flexibility components and are modified by the Gerofit program staff as needed. Gerofit adopts a functional fitness approach and includes individual progression as appropriate according to evidence-based guidelines, using the Borg ratings of perceived exertion. ¹¹ Assessments are performed at baseline, 3 months, 6 months, and annually thereafter. Clinical staff conduct all assessments, including physical function testing, and record them in a database. Assessments are reviewed with the veteran to chart progress and identify future goals or needs. Veterans perform personalized self-paced exercises in the Gerofit group setting. Exercise prescriptions are continuously modified to meet individualized needs and goals. Veterans may participate continuously with no end date.

Participation in supervised exercise is associated with improved physical function and individuals with arthritis can improve function even though their baseline functional status is lower than individuals without arthritis. ¹² In this analysis, we examine the impact of exercise on the status and location of arthritis (upper body, lower body, or both). Lower body arthritis is more common than upper body arthritis and lower extremity function is associated with increased ability to perform activities of daily living, resulting in independence among older adults.^13,14 We also include upper body strength measures to capture important functional movements such as reaching and pulling.¹⁵ Among those who participate in Gerofit, the greatest gains in physical function occur during the initial 3 months, which tend to be sustained over 12 months.¹⁶ For this reason, this study focused on the initial 3 months of the program.

Older adults with arthritis may have pain and functional limitations that exceed those of the general older adult population. Exercise programs for older adults that do not specifically target arthritis but are able to improve physical function among those with arthritis could potentially increase access to exercise for older adults living with arthritis. Therefore, the purpose of this study was to determine whether change in physical function with participation in Gerofit for 3 months varies by arthritis status, including no arthritis, any arthritis, lower body arthritis, or both upper and lower body arthritis compared with no arthritis.

Methods

This is a secondary analysis of previously collected data from 10 VHA Gerofit sites (Ann Arbor, Baltimore, Greater Los Angeles, Canandaigua, Cincinnati, Miami, Honolulu, Denver, Durham, and Pittsburgh) from 2002 to 2019. Implementation data regarding the consistency of the program delivery at Gerofit expansion sites have been previously published.¹⁶ Although the delivery of Gerofit transitioned to telehealth due to COVID-19, data for this analysis were collected from in-person exercise sessions prior to the pandemic.¹⁷ Data were collected for clinical purposes. This project was part of the Gerofit quality improvement initiative and was reviewed and approved by the Durham Institutional Review Board as quality improvement.

Participants in Gerofit who completed baseline and 3-month assessments were included to analyze the effects of exercise on physical function. At each of the time points, physical functional assessments included: (1) usual gait speed (> 10 meters [m/s], or 10- meter walk test [10MWT]); (2) lower body strength (chair stands [number completed in 30 seconds]); (3) upper body strength (number of arm curls [5-lb for females/8-lb for males] completed in 30 seconds); and (4) 6-minute walk distance [6MWD] in meters to measure aerobic endurance). These measures have been validated in older adults.^18-21 Arm curls were added to the physical function assessments after the 10MWT, chair stands, and 6MWD; therefore, fewer participants had data for this measure. Participants self-reported at baseline on 45 common medical conditions, including arthritis or rheumatism (both upper body and lower body were offered as choices). Self-reporting has been shown to be an acceptable method of identifying arthritis in adults.²²

Descriptive statistics at baseline were calculated for all participants. One-way analysis of variance and X² tests were used to determine differences in baseline characteristics across arthritis status. The primary outcomes were changes in physical function measures from baseline to 3 months by arthritis status. Arthritis status was defined as: any arthritis, which includes individuals who reported upper body arthritis, lower body arthritis, or both; and arthritis status individuals reporting either upper body arthritis, lower body arthritis, or both. Categories of arthritis for arthritis status were mutually exclusive. Two separate linear models were constructed for each of the 4 physical function measures, with change from baseline to 3 months as the outcome (dependent variable) and arthritis status, age, and body mass index (BMI) as predictors (independent variables). The first model compared any arthritis with no arthritis and the second model compared arthritis status (both upper and lower body arthritis vs lower body arthritis) with no arthritis. These models were used to obtain mean changes and 95% CIs in physical function and to test for differences in the change in physical function measures by arthritis status. Statistical analyses were performed using R software, version 4.0.3.

Results

Baseline and 3-month data were available for 737 Gerofit participants and included in the analysis. The mean (SD) age was 73.5 (7.1) years. A total of 707 participants were male (95.9%) and 322 (43.6%) reported some arthritis, with arthritis in both the upper and lower body being reported by 168 participants (52.2%) (Table 1). There were no differences in age, sex, or race for those with any arthritis compared with those with no arthritis, but BMI was significantly higher in those reporting any arthritis compared with no arthritis. For the baseline functional measures, statistically significant differences were observed between those with no arthritis and those reporting any arthritis for the 10MWT (P = .001), chair stands (P = .046), and 6MWD (P = .001), but not for arm curls (P = .77), with those with no arthritis performing better.

All 4 arthritis status groups showed improvements in each of the physical function measures over 3 months. For the 10MWT the mean change (95% CI) in gait speed (m/s) was 0.06 (0.04-0.08) for patients with no arthritis, 0.07 (0.05- 0.08) for any arthritis, 0.07 (0.04-0.11) for lower body arthritis, and 0.07 (0.04- 0.09) for both lower and upper body arthritis. For the number of arm curls in 30 seconds the mean change (95% CI) was 2.3 (1.8-2.8) for patients with no arthritis, 2.1 (1.5-2.6) for any arthritis, 2.0 (1.1-3.0) for lower body arthritis, and 1.9 (1.1-2.7) for both lower and upper body arthritis. For the number of chair stands in 30 seconds the mean change (95% CI) was 2.1 (1.7-2.4) for patients with no arthritis, 2.2 (1.8-2.6) for any arthritis, 2.3 (1.6-2.9), for lower body arthritis, and 2.0 (1.5-2.5) for both lower and upper body arthritis. For the 6MWD distance in meters the mean change (95% CI) was 21.5 (15.5-27.4) for patients with no arthritis, 28.6 (21.9-35.3) for any arthritis, 30.4 (19.5-41.3) for lower body arthritis, and 28.6 (19.2-38.0) for both lower and upper body arthritis (Figure).

We used 2 models to measure the change from baseline to 3 months for each of the arthritis groups. Model 1 compared any arthritis vs no arthritis and model 2 compared lower body arthritis and both upper and lower body arthritis vs no arthritis for each physical function measure (Table 2). There were no statistically significant differences in 3-month change in physical function for any of the physical function measures between arthritis groups after adjusting for age and BMI.

Discussion

Participation in Gerofit was associated with functional gains among all participants over 3 months, regardless of arthritis status. Older veterans reporting any arthritis had significantly lower physical function scores upon enrollment into Gerofit compared with those veterans reporting no arthritis. However, compared with individuals who reported no arthritis, individuals who reported arthritis (any arthritis, lower body arthritis only, or both lower and upper body arthritis) experienced similar improvements (ie, no statistically significant differences in mean change from baseline to follow-up among those with and without arthritis). This study suggests that progressive, multicomponent exercise programs for older adults may be beneficial for those with arthritis.

Involvement of multiple sites of arthritis is associated with moderate to severe functional limitations as well as lower healthrelated quality of life.²³ While it has been found that individuals with arthritis can improve function with supervised exercise, even though their baseline functional status is lower than individuals without arthritis, it was not clear whether individuals with multiple joint involvement also would benefit.¹² The results of this study suggest that these individuals can improve across various domains of physical function despite variation in arthritis location and status. As incidence of arthritis increases with age, targeting older adults for exercise programs such as Gerofit may improve functional limitations and health-related quality of life associated with arthritis.²

We evaluated physical function using multiple measures to assess upper (arm curls) and lower (chair stands, 10MWT) extremity physical function and aerobic endurance (6MWD). Participants in this study reached clinically meaningful changes with 3 months of participation in Gerofit for most of the physical function measures. Gerofit participants had a mean gait speed improvement of 0.05 to 0.07 m/s compared with 0.10 to 0.30 m/s, which was reported previously. ^24,25 In this study, nearly all groups achieved the clinically important improvements in the chair stand in 30 seconds (2.0 to 2.6) and the 6MWD (21.8 to 59.1 m) that have been reported in the literature.^24-26

The Osteoarthritis Research Society International recommends the chair stand and 6MWD performance-based tests for individuals with hip and knee arthritis because they align with patient-reported outcomes and represent the types of activities relevant to this population.²⁷ The findings of this study suggest that improvement in these physical function measures with participation in exercise align with data from arthritis-specific exercise programs designed for wide implementation. Hughes and colleagues reported improvements in the 6MWD after the 8-week Fit and Strong exercise intervention, which included walking and lower body resistance training.²⁸ The Arthritis Foundation’s Walk With Ease program is a 6-week walking program that has shown improvements in chair stands and gait speed.²⁹ Another Arthritis Foundation program, People with Arthritis Can Exercise, is an 8-week course consisting of a variety of resistance, aerobic, and balance activities. This program has been associated with increases in chair stands but not gait speed or 6MWD.^30,31

This study found that participation in a VHA outpatient clinical supervised exercise program results in improvements in physical function that can be realized by older adults regardless of arthritis burden. Gerofit programs typically require 1.5 to 2.0 dedicated full-time equivalent employees to run the program effectively and additional administrative support, depending on size of the program.³² The cost savings generated by the program include reductions in hospitalization rates, emergency department visits, days in hospital, and medication use and provide a compelling argument for the program’s financial viability to health care systems through long-term savings and improved health outcomes for older adults.^33-36

While evidenced-based arthritis programs exist, this study illustrates that an exercise program without a focus on arthritis also improves physical function, potentially reducing the risk of disability related to arthritis. The clinical implication for these findings is that arthritis-specific exercise programs may not be needed to achieve functional improvements in individuals with arthritis. This is critical for under-resourced or exercise- limited health care systems or communities. Therefore, if exercise programming is limited, or arthritis-specific programs and interventions are not available, nonspecific exercise programs will also be beneficial to individuals with arthritis. Thus, individuals with arthritis should be encouraged to participate in any available exercise programming to achieve improvements in physical function. In addition, many older adults have multiple comorbidities, most of which improve with participation in exercise. ³⁷ Disease-specific exercise programs can offer tailored exercises and coaching related to common barriers in participation, such as joint pain for arthritis.³¹ It is unclear whether these additional programmatic components are associated with greater improvements in outcomes, such as physical function. More research is needed to explore the benefits of disease-specific tailored exercise programs compared with general exercise programs.

Strengths and Limitations

This study demonstrated the effect of participation in a clinical, supervised exercise program in a real-world setting. It suggests that even exercise programs not specifically targeted for arthritis populations can improve physical function among those with arthritis.

As a VHA clinical supervised exercise program, Gerofit may not be generalizable to all older adults or other exercise programs. In addition, this analysis only included a veteran population that was > 95% male and may not be generalizable to other populations. Arthritis status was defined by self-report and not verified in the health record. However, this approach has been shown to be acceptable in this setting and the most common type of arthritis in this population (OA) is a painful musculoskeletal condition associated with functional limitations.^4,22,38,39 Self-reported arthritis or rheumatism is associated with functional limitations.¹ Therefore, it is unlikely that the results would differ for physician-diagnosed or radiographically defined OA. Additionally, the study did not have data on the total number of joints with arthritis or arthritis severity but rather used upper body, lower body, and both upper and lower body arthritis as a proxy for arthritis status. While our models were adjusted for age and BMI, 2 known confounding factors for the association between arthritis and physical function, there are other potential confounding factors that were not included in the models. ^40,41 Finally, this study only included individuals with completed baseline and 3-month follow-up assessments, and the individuals who participated for longer or shorter periods may have had different physical function outcomes than individuals included in this study.

Conclusions

Participation in 3 months VHA Gerofit outpatient supervised exercise programs can improve physical function for all older adults, regardless of arthritis status. These programs may increase access to exercise programming that is beneficial for common conditions affecting older adults, such as arthritis.

About half of US adults aged ≥ 65 years report arthritis, and of those, 44% have an arthritis-attributable activity limitation.^1,2 Arthritis is a significant health issue for veterans, with veterans reporting higher rates of disability compared with the civilian population.³

Osteoarthritis (OA) is the most common type of arthritis.⁴ Among individuals aged ≥ 40 years, the incidence of OA is nearly twice as high among veterans compared with civilians and is a leading cause of separation from military service and disability.^5,6 OA pain and disability have been shown to be associated with increases in health care and medication use, including opioids, nonsteroidal anti-inflammatory medications, and muscle relaxants.^7,8 Because OA is chronic and has no cure, safe and effective management strategies—such as exercise— are critical to minimize pain and maintain physical function.⁹

Exercise can reduce pain and disability associated with OA and is a first-line recommendation in guidelines for the treatment of knee and hip OA.⁹ Given the limited exercise and high levels of physical inactivity among veterans with OA, there is a need to identify opportunities that support veterans with OA engaging in regular exercise.

Gerofit, an outpatient clinical exercise program available at 30 Veterans Health Administration (VHA) sites, may provide an opportunity for older veterans with arthritis to engage in exercise.¹⁰ Gerofit is specifically designed for veterans aged ≥ 65 years. It is not disease-specific and supports older veterans with multiple chronic conditions, including OA. Veterans aged ≥ 65 years with a referral from a VA clinician are eligible for Gerofit. Those who are unable to perform activities of daily living; unable to independently function without assistance; have a history of unstable angina, proliferative diabetic retinopathy, oxygen dependence, volatile behavioral issues, or are unable to work successfully in a group environment/setting; experience active substance abuse, homelessness, or uncontrolled incontinence; and have open wounds that cannot be appropriately dressed are excluded from Gerofit. Exercise sessions are held 3 times per week and last from 60 to 90 minutes. Sessions are supervised by Gerofit staff and include personalized exercise prescriptions based on functional assessments. Exercise prescriptions include aerobic, resistance, and balance/flexibility components and are modified by the Gerofit program staff as needed. Gerofit adopts a functional fitness approach and includes individual progression as appropriate according to evidence-based guidelines, using the Borg ratings of perceived exertion. ¹¹ Assessments are performed at baseline, 3 months, 6 months, and annually thereafter. Clinical staff conduct all assessments, including physical function testing, and record them in a database. Assessments are reviewed with the veteran to chart progress and identify future goals or needs. Veterans perform personalized self-paced exercises in the Gerofit group setting. Exercise prescriptions are continuously modified to meet individualized needs and goals. Veterans may participate continuously with no end date.

Participation in supervised exercise is associated with improved physical function and individuals with arthritis can improve function even though their baseline functional status is lower than individuals without arthritis. ¹² In this analysis, we examine the impact of exercise on the status and location of arthritis (upper body, lower body, or both). Lower body arthritis is more common than upper body arthritis and lower extremity function is associated with increased ability to perform activities of daily living, resulting in independence among older adults.^13,14 We also include upper body strength measures to capture important functional movements such as reaching and pulling.¹⁵ Among those who participate in Gerofit, the greatest gains in physical function occur during the initial 3 months, which tend to be sustained over 12 months.¹⁶ For this reason, this study focused on the initial 3 months of the program.

Older adults with arthritis may have pain and functional limitations that exceed those of the general older adult population. Exercise programs for older adults that do not specifically target arthritis but are able to improve physical function among those with arthritis could potentially increase access to exercise for older adults living with arthritis. Therefore, the purpose of this study was to determine whether change in physical function with participation in Gerofit for 3 months varies by arthritis status, including no arthritis, any arthritis, lower body arthritis, or both upper and lower body arthritis compared with no arthritis.

Methods

This is a secondary analysis of previously collected data from 10 VHA Gerofit sites (Ann Arbor, Baltimore, Greater Los Angeles, Canandaigua, Cincinnati, Miami, Honolulu, Denver, Durham, and Pittsburgh) from 2002 to 2019. Implementation data regarding the consistency of the program delivery at Gerofit expansion sites have been previously published.¹⁶ Although the delivery of Gerofit transitioned to telehealth due to COVID-19, data for this analysis were collected from in-person exercise sessions prior to the pandemic.¹⁷ Data were collected for clinical purposes. This project was part of the Gerofit quality improvement initiative and was reviewed and approved by the Durham Institutional Review Board as quality improvement.

Participants in Gerofit who completed baseline and 3-month assessments were included to analyze the effects of exercise on physical function. At each of the time points, physical functional assessments included: (1) usual gait speed (> 10 meters [m/s], or 10- meter walk test [10MWT]); (2) lower body strength (chair stands [number completed in 30 seconds]); (3) upper body strength (number of arm curls [5-lb for females/8-lb for males] completed in 30 seconds); and (4) 6-minute walk distance [6MWD] in meters to measure aerobic endurance). These measures have been validated in older adults.^18-21 Arm curls were added to the physical function assessments after the 10MWT, chair stands, and 6MWD; therefore, fewer participants had data for this measure. Participants self-reported at baseline on 45 common medical conditions, including arthritis or rheumatism (both upper body and lower body were offered as choices). Self-reporting has been shown to be an acceptable method of identifying arthritis in adults.²²

Descriptive statistics at baseline were calculated for all participants. One-way analysis of variance and X² tests were used to determine differences in baseline characteristics across arthritis status. The primary outcomes were changes in physical function measures from baseline to 3 months by arthritis status. Arthritis status was defined as: any arthritis, which includes individuals who reported upper body arthritis, lower body arthritis, or both; and arthritis status individuals reporting either upper body arthritis, lower body arthritis, or both. Categories of arthritis for arthritis status were mutually exclusive. Two separate linear models were constructed for each of the 4 physical function measures, with change from baseline to 3 months as the outcome (dependent variable) and arthritis status, age, and body mass index (BMI) as predictors (independent variables). The first model compared any arthritis with no arthritis and the second model compared arthritis status (both upper and lower body arthritis vs lower body arthritis) with no arthritis. These models were used to obtain mean changes and 95% CIs in physical function and to test for differences in the change in physical function measures by arthritis status. Statistical analyses were performed using R software, version 4.0.3.

Results

Baseline and 3-month data were available for 737 Gerofit participants and included in the analysis. The mean (SD) age was 73.5 (7.1) years. A total of 707 participants were male (95.9%) and 322 (43.6%) reported some arthritis, with arthritis in both the upper and lower body being reported by 168 participants (52.2%) (Table 1). There were no differences in age, sex, or race for those with any arthritis compared with those with no arthritis, but BMI was significantly higher in those reporting any arthritis compared with no arthritis. For the baseline functional measures, statistically significant differences were observed between those with no arthritis and those reporting any arthritis for the 10MWT (P = .001), chair stands (P = .046), and 6MWD (P = .001), but not for arm curls (P = .77), with those with no arthritis performing better.

All 4 arthritis status groups showed improvements in each of the physical function measures over 3 months. For the 10MWT the mean change (95% CI) in gait speed (m/s) was 0.06 (0.04-0.08) for patients with no arthritis, 0.07 (0.05- 0.08) for any arthritis, 0.07 (0.04-0.11) for lower body arthritis, and 0.07 (0.04- 0.09) for both lower and upper body arthritis. For the number of arm curls in 30 seconds the mean change (95% CI) was 2.3 (1.8-2.8) for patients with no arthritis, 2.1 (1.5-2.6) for any arthritis, 2.0 (1.1-3.0) for lower body arthritis, and 1.9 (1.1-2.7) for both lower and upper body arthritis. For the number of chair stands in 30 seconds the mean change (95% CI) was 2.1 (1.7-2.4) for patients with no arthritis, 2.2 (1.8-2.6) for any arthritis, 2.3 (1.6-2.9), for lower body arthritis, and 2.0 (1.5-2.5) for both lower and upper body arthritis. For the 6MWD distance in meters the mean change (95% CI) was 21.5 (15.5-27.4) for patients with no arthritis, 28.6 (21.9-35.3) for any arthritis, 30.4 (19.5-41.3) for lower body arthritis, and 28.6 (19.2-38.0) for both lower and upper body arthritis (Figure).

We used 2 models to measure the change from baseline to 3 months for each of the arthritis groups. Model 1 compared any arthritis vs no arthritis and model 2 compared lower body arthritis and both upper and lower body arthritis vs no arthritis for each physical function measure (Table 2). There were no statistically significant differences in 3-month change in physical function for any of the physical function measures between arthritis groups after adjusting for age and BMI.

Discussion

Participation in Gerofit was associated with functional gains among all participants over 3 months, regardless of arthritis status. Older veterans reporting any arthritis had significantly lower physical function scores upon enrollment into Gerofit compared with those veterans reporting no arthritis. However, compared with individuals who reported no arthritis, individuals who reported arthritis (any arthritis, lower body arthritis only, or both lower and upper body arthritis) experienced similar improvements (ie, no statistically significant differences in mean change from baseline to follow-up among those with and without arthritis). This study suggests that progressive, multicomponent exercise programs for older adults may be beneficial for those with arthritis.

Involvement of multiple sites of arthritis is associated with moderate to severe functional limitations as well as lower healthrelated quality of life.²³ While it has been found that individuals with arthritis can improve function with supervised exercise, even though their baseline functional status is lower than individuals without arthritis, it was not clear whether individuals with multiple joint involvement also would benefit.¹² The results of this study suggest that these individuals can improve across various domains of physical function despite variation in arthritis location and status. As incidence of arthritis increases with age, targeting older adults for exercise programs such as Gerofit may improve functional limitations and health-related quality of life associated with arthritis.²

We evaluated physical function using multiple measures to assess upper (arm curls) and lower (chair stands, 10MWT) extremity physical function and aerobic endurance (6MWD). Participants in this study reached clinically meaningful changes with 3 months of participation in Gerofit for most of the physical function measures. Gerofit participants had a mean gait speed improvement of 0.05 to 0.07 m/s compared with 0.10 to 0.30 m/s, which was reported previously. ^24,25 In this study, nearly all groups achieved the clinically important improvements in the chair stand in 30 seconds (2.0 to 2.6) and the 6MWD (21.8 to 59.1 m) that have been reported in the literature.^24-26

The Osteoarthritis Research Society International recommends the chair stand and 6MWD performance-based tests for individuals with hip and knee arthritis because they align with patient-reported outcomes and represent the types of activities relevant to this population.²⁷ The findings of this study suggest that improvement in these physical function measures with participation in exercise align with data from arthritis-specific exercise programs designed for wide implementation. Hughes and colleagues reported improvements in the 6MWD after the 8-week Fit and Strong exercise intervention, which included walking and lower body resistance training.²⁸ The Arthritis Foundation’s Walk With Ease program is a 6-week walking program that has shown improvements in chair stands and gait speed.²⁹ Another Arthritis Foundation program, People with Arthritis Can Exercise, is an 8-week course consisting of a variety of resistance, aerobic, and balance activities. This program has been associated with increases in chair stands but not gait speed or 6MWD.^30,31

This study found that participation in a VHA outpatient clinical supervised exercise program results in improvements in physical function that can be realized by older adults regardless of arthritis burden. Gerofit programs typically require 1.5 to 2.0 dedicated full-time equivalent employees to run the program effectively and additional administrative support, depending on size of the program.³² The cost savings generated by the program include reductions in hospitalization rates, emergency department visits, days in hospital, and medication use and provide a compelling argument for the program’s financial viability to health care systems through long-term savings and improved health outcomes for older adults.^33-36

While evidenced-based arthritis programs exist, this study illustrates that an exercise program without a focus on arthritis also improves physical function, potentially reducing the risk of disability related to arthritis. The clinical implication for these findings is that arthritis-specific exercise programs may not be needed to achieve functional improvements in individuals with arthritis. This is critical for under-resourced or exercise- limited health care systems or communities. Therefore, if exercise programming is limited, or arthritis-specific programs and interventions are not available, nonspecific exercise programs will also be beneficial to individuals with arthritis. Thus, individuals with arthritis should be encouraged to participate in any available exercise programming to achieve improvements in physical function. In addition, many older adults have multiple comorbidities, most of which improve with participation in exercise. ³⁷ Disease-specific exercise programs can offer tailored exercises and coaching related to common barriers in participation, such as joint pain for arthritis.³¹ It is unclear whether these additional programmatic components are associated with greater improvements in outcomes, such as physical function. More research is needed to explore the benefits of disease-specific tailored exercise programs compared with general exercise programs.

Strengths and Limitations

This study demonstrated the effect of participation in a clinical, supervised exercise program in a real-world setting. It suggests that even exercise programs not specifically targeted for arthritis populations can improve physical function among those with arthritis.

As a VHA clinical supervised exercise program, Gerofit may not be generalizable to all older adults or other exercise programs. In addition, this analysis only included a veteran population that was > 95% male and may not be generalizable to other populations. Arthritis status was defined by self-report and not verified in the health record. However, this approach has been shown to be acceptable in this setting and the most common type of arthritis in this population (OA) is a painful musculoskeletal condition associated with functional limitations.^4,22,38,39 Self-reported arthritis or rheumatism is associated with functional limitations.¹ Therefore, it is unlikely that the results would differ for physician-diagnosed or radiographically defined OA. Additionally, the study did not have data on the total number of joints with arthritis or arthritis severity but rather used upper body, lower body, and both upper and lower body arthritis as a proxy for arthritis status. While our models were adjusted for age and BMI, 2 known confounding factors for the association between arthritis and physical function, there are other potential confounding factors that were not included in the models. ^40,41 Finally, this study only included individuals with completed baseline and 3-month follow-up assessments, and the individuals who participated for longer or shorter periods may have had different physical function outcomes than individuals included in this study.

Conclusions

Participation in 3 months VHA Gerofit outpatient supervised exercise programs can improve physical function for all older adults, regardless of arthritis status. These programs may increase access to exercise programming that is beneficial for common conditions affecting older adults, such as arthritis.

About half of US adults aged ≥ 65 years report arthritis, and of those, 44% have an arthritis-attributable activity limitation.^1,2 Arthritis is a significant health issue for veterans, with veterans reporting higher rates of disability compared with the civilian population.³

Osteoarthritis (OA) is the most common type of arthritis.⁴ Among individuals aged ≥ 40 years, the incidence of OA is nearly twice as high among veterans compared with civilians and is a leading cause of separation from military service and disability.^5,6 OA pain and disability have been shown to be associated with increases in health care and medication use, including opioids, nonsteroidal anti-inflammatory medications, and muscle relaxants.^7,8 Because OA is chronic and has no cure, safe and effective management strategies—such as exercise— are critical to minimize pain and maintain physical function.⁹

Exercise can reduce pain and disability associated with OA and is a first-line recommendation in guidelines for the treatment of knee and hip OA.⁹ Given the limited exercise and high levels of physical inactivity among veterans with OA, there is a need to identify opportunities that support veterans with OA engaging in regular exercise.

Gerofit, an outpatient clinical exercise program available at 30 Veterans Health Administration (VHA) sites, may provide an opportunity for older veterans with arthritis to engage in exercise.¹⁰ Gerofit is specifically designed for veterans aged ≥ 65 years. It is not disease-specific and supports older veterans with multiple chronic conditions, including OA. Veterans aged ≥ 65 years with a referral from a VA clinician are eligible for Gerofit. Those who are unable to perform activities of daily living; unable to independently function without assistance; have a history of unstable angina, proliferative diabetic retinopathy, oxygen dependence, volatile behavioral issues, or are unable to work successfully in a group environment/setting; experience active substance abuse, homelessness, or uncontrolled incontinence; and have open wounds that cannot be appropriately dressed are excluded from Gerofit. Exercise sessions are held 3 times per week and last from 60 to 90 minutes. Sessions are supervised by Gerofit staff and include personalized exercise prescriptions based on functional assessments. Exercise prescriptions include aerobic, resistance, and balance/flexibility components and are modified by the Gerofit program staff as needed. Gerofit adopts a functional fitness approach and includes individual progression as appropriate according to evidence-based guidelines, using the Borg ratings of perceived exertion. ¹¹ Assessments are performed at baseline, 3 months, 6 months, and annually thereafter. Clinical staff conduct all assessments, including physical function testing, and record them in a database. Assessments are reviewed with the veteran to chart progress and identify future goals or needs. Veterans perform personalized self-paced exercises in the Gerofit group setting. Exercise prescriptions are continuously modified to meet individualized needs and goals. Veterans may participate continuously with no end date.

Participation in supervised exercise is associated with improved physical function and individuals with arthritis can improve function even though their baseline functional status is lower than individuals without arthritis. ¹² In this analysis, we examine the impact of exercise on the status and location of arthritis (upper body, lower body, or both). Lower body arthritis is more common than upper body arthritis and lower extremity function is associated with increased ability to perform activities of daily living, resulting in independence among older adults.^13,14 We also include upper body strength measures to capture important functional movements such as reaching and pulling.¹⁵ Among those who participate in Gerofit, the greatest gains in physical function occur during the initial 3 months, which tend to be sustained over 12 months.¹⁶ For this reason, this study focused on the initial 3 months of the program.

Older adults with arthritis may have pain and functional limitations that exceed those of the general older adult population. Exercise programs for older adults that do not specifically target arthritis but are able to improve physical function among those with arthritis could potentially increase access to exercise for older adults living with arthritis. Therefore, the purpose of this study was to determine whether change in physical function with participation in Gerofit for 3 months varies by arthritis status, including no arthritis, any arthritis, lower body arthritis, or both upper and lower body arthritis compared with no arthritis.

Methods

This is a secondary analysis of previously collected data from 10 VHA Gerofit sites (Ann Arbor, Baltimore, Greater Los Angeles, Canandaigua, Cincinnati, Miami, Honolulu, Denver, Durham, and Pittsburgh) from 2002 to 2019. Implementation data regarding the consistency of the program delivery at Gerofit expansion sites have been previously published.¹⁶ Although the delivery of Gerofit transitioned to telehealth due to COVID-19, data for this analysis were collected from in-person exercise sessions prior to the pandemic.¹⁷ Data were collected for clinical purposes. This project was part of the Gerofit quality improvement initiative and was reviewed and approved by the Durham Institutional Review Board as quality improvement.

Participants in Gerofit who completed baseline and 3-month assessments were included to analyze the effects of exercise on physical function. At each of the time points, physical functional assessments included: (1) usual gait speed (> 10 meters [m/s], or 10- meter walk test [10MWT]); (2) lower body strength (chair stands [number completed in 30 seconds]); (3) upper body strength (number of arm curls [5-lb for females/8-lb for males] completed in 30 seconds); and (4) 6-minute walk distance [6MWD] in meters to measure aerobic endurance). These measures have been validated in older adults.^18-21 Arm curls were added to the physical function assessments after the 10MWT, chair stands, and 6MWD; therefore, fewer participants had data for this measure. Participants self-reported at baseline on 45 common medical conditions, including arthritis or rheumatism (both upper body and lower body were offered as choices). Self-reporting has been shown to be an acceptable method of identifying arthritis in adults.²²

Descriptive statistics at baseline were calculated for all participants. One-way analysis of variance and X² tests were used to determine differences in baseline characteristics across arthritis status. The primary outcomes were changes in physical function measures from baseline to 3 months by arthritis status. Arthritis status was defined as: any arthritis, which includes individuals who reported upper body arthritis, lower body arthritis, or both; and arthritis status individuals reporting either upper body arthritis, lower body arthritis, or both. Categories of arthritis for arthritis status were mutually exclusive. Two separate linear models were constructed for each of the 4 physical function measures, with change from baseline to 3 months as the outcome (dependent variable) and arthritis status, age, and body mass index (BMI) as predictors (independent variables). The first model compared any arthritis with no arthritis and the second model compared arthritis status (both upper and lower body arthritis vs lower body arthritis) with no arthritis. These models were used to obtain mean changes and 95% CIs in physical function and to test for differences in the change in physical function measures by arthritis status. Statistical analyses were performed using R software, version 4.0.3.

Results

Baseline and 3-month data were available for 737 Gerofit participants and included in the analysis. The mean (SD) age was 73.5 (7.1) years. A total of 707 participants were male (95.9%) and 322 (43.6%) reported some arthritis, with arthritis in both the upper and lower body being reported by 168 participants (52.2%) (Table 1). There were no differences in age, sex, or race for those with any arthritis compared with those with no arthritis, but BMI was significantly higher in those reporting any arthritis compared with no arthritis. For the baseline functional measures, statistically significant differences were observed between those with no arthritis and those reporting any arthritis for the 10MWT (P = .001), chair stands (P = .046), and 6MWD (P = .001), but not for arm curls (P = .77), with those with no arthritis performing better.

All 4 arthritis status groups showed improvements in each of the physical function measures over 3 months. For the 10MWT the mean change (95% CI) in gait speed (m/s) was 0.06 (0.04-0.08) for patients with no arthritis, 0.07 (0.05- 0.08) for any arthritis, 0.07 (0.04-0.11) for lower body arthritis, and 0.07 (0.04- 0.09) for both lower and upper body arthritis. For the number of arm curls in 30 seconds the mean change (95% CI) was 2.3 (1.8-2.8) for patients with no arthritis, 2.1 (1.5-2.6) for any arthritis, 2.0 (1.1-3.0) for lower body arthritis, and 1.9 (1.1-2.7) for both lower and upper body arthritis. For the number of chair stands in 30 seconds the mean change (95% CI) was 2.1 (1.7-2.4) for patients with no arthritis, 2.2 (1.8-2.6) for any arthritis, 2.3 (1.6-2.9), for lower body arthritis, and 2.0 (1.5-2.5) for both lower and upper body arthritis. For the 6MWD distance in meters the mean change (95% CI) was 21.5 (15.5-27.4) for patients with no arthritis, 28.6 (21.9-35.3) for any arthritis, 30.4 (19.5-41.3) for lower body arthritis, and 28.6 (19.2-38.0) for both lower and upper body arthritis (Figure).

We used 2 models to measure the change from baseline to 3 months for each of the arthritis groups. Model 1 compared any arthritis vs no arthritis and model 2 compared lower body arthritis and both upper and lower body arthritis vs no arthritis for each physical function measure (Table 2). There were no statistically significant differences in 3-month change in physical function for any of the physical function measures between arthritis groups after adjusting for age and BMI.

Discussion

Participation in Gerofit was associated with functional gains among all participants over 3 months, regardless of arthritis status. Older veterans reporting any arthritis had significantly lower physical function scores upon enrollment into Gerofit compared with those veterans reporting no arthritis. However, compared with individuals who reported no arthritis, individuals who reported arthritis (any arthritis, lower body arthritis only, or both lower and upper body arthritis) experienced similar improvements (ie, no statistically significant differences in mean change from baseline to follow-up among those with and without arthritis). This study suggests that progressive, multicomponent exercise programs for older adults may be beneficial for those with arthritis.

Involvement of multiple sites of arthritis is associated with moderate to severe functional limitations as well as lower healthrelated quality of life.²³ While it has been found that individuals with arthritis can improve function with supervised exercise, even though their baseline functional status is lower than individuals without arthritis, it was not clear whether individuals with multiple joint involvement also would benefit.¹² The results of this study suggest that these individuals can improve across various domains of physical function despite variation in arthritis location and status. As incidence of arthritis increases with age, targeting older adults for exercise programs such as Gerofit may improve functional limitations and health-related quality of life associated with arthritis.²

We evaluated physical function using multiple measures to assess upper (arm curls) and lower (chair stands, 10MWT) extremity physical function and aerobic endurance (6MWD). Participants in this study reached clinically meaningful changes with 3 months of participation in Gerofit for most of the physical function measures. Gerofit participants had a mean gait speed improvement of 0.05 to 0.07 m/s compared with 0.10 to 0.30 m/s, which was reported previously. ^24,25 In this study, nearly all groups achieved the clinically important improvements in the chair stand in 30 seconds (2.0 to 2.6) and the 6MWD (21.8 to 59.1 m) that have been reported in the literature.^24-26

The Osteoarthritis Research Society International recommends the chair stand and 6MWD performance-based tests for individuals with hip and knee arthritis because they align with patient-reported outcomes and represent the types of activities relevant to this population.²⁷ The findings of this study suggest that improvement in these physical function measures with participation in exercise align with data from arthritis-specific exercise programs designed for wide implementation. Hughes and colleagues reported improvements in the 6MWD after the 8-week Fit and Strong exercise intervention, which included walking and lower body resistance training.²⁸ The Arthritis Foundation’s Walk With Ease program is a 6-week walking program that has shown improvements in chair stands and gait speed.²⁹ Another Arthritis Foundation program, People with Arthritis Can Exercise, is an 8-week course consisting of a variety of resistance, aerobic, and balance activities. This program has been associated with increases in chair stands but not gait speed or 6MWD.^30,31

This study found that participation in a VHA outpatient clinical supervised exercise program results in improvements in physical function that can be realized by older adults regardless of arthritis burden. Gerofit programs typically require 1.5 to 2.0 dedicated full-time equivalent employees to run the program effectively and additional administrative support, depending on size of the program.³² The cost savings generated by the program include reductions in hospitalization rates, emergency department visits, days in hospital, and medication use and provide a compelling argument for the program’s financial viability to health care systems through long-term savings and improved health outcomes for older adults.^33-36

While evidenced-based arthritis programs exist, this study illustrates that an exercise program without a focus on arthritis also improves physical function, potentially reducing the risk of disability related to arthritis. The clinical implication for these findings is that arthritis-specific exercise programs may not be needed to achieve functional improvements in individuals with arthritis. This is critical for under-resourced or exercise- limited health care systems or communities. Therefore, if exercise programming is limited, or arthritis-specific programs and interventions are not available, nonspecific exercise programs will also be beneficial to individuals with arthritis. Thus, individuals with arthritis should be encouraged to participate in any available exercise programming to achieve improvements in physical function. In addition, many older adults have multiple comorbidities, most of which improve with participation in exercise. ³⁷ Disease-specific exercise programs can offer tailored exercises and coaching related to common barriers in participation, such as joint pain for arthritis.³¹ It is unclear whether these additional programmatic components are associated with greater improvements in outcomes, such as physical function. More research is needed to explore the benefits of disease-specific tailored exercise programs compared with general exercise programs.

Strengths and Limitations

This study demonstrated the effect of participation in a clinical, supervised exercise program in a real-world setting. It suggests that even exercise programs not specifically targeted for arthritis populations can improve physical function among those with arthritis.

As a VHA clinical supervised exercise program, Gerofit may not be generalizable to all older adults or other exercise programs. In addition, this analysis only included a veteran population that was > 95% male and may not be generalizable to other populations. Arthritis status was defined by self-report and not verified in the health record. However, this approach has been shown to be acceptable in this setting and the most common type of arthritis in this population (OA) is a painful musculoskeletal condition associated with functional limitations.^4,22,38,39 Self-reported arthritis or rheumatism is associated with functional limitations.¹ Therefore, it is unlikely that the results would differ for physician-diagnosed or radiographically defined OA. Additionally, the study did not have data on the total number of joints with arthritis or arthritis severity but rather used upper body, lower body, and both upper and lower body arthritis as a proxy for arthritis status. While our models were adjusted for age and BMI, 2 known confounding factors for the association between arthritis and physical function, there are other potential confounding factors that were not included in the models. ^40,41 Finally, this study only included individuals with completed baseline and 3-month follow-up assessments, and the individuals who participated for longer or shorter periods may have had different physical function outcomes than individuals included in this study.

Conclusions

Participation in 3 months VHA Gerofit outpatient supervised exercise programs can improve physical function for all older adults, regardless of arthritis status. These programs may increase access to exercise programming that is beneficial for common conditions affecting older adults, such as arthritis.