The teledementia clinic is a new model of care that expands the reach of specialized geriatric and dementia care using clinical video telehealth (CVT) to rural veterans, who frequently lack access to specialty care. The clinic is a Veterans Affairs (VA) Geriatric Research, Education, and Clinical Center clinical demonstration project. It is located in the Pittsburgh VA Healthcare System tertiary referral hospital and serves veterans in affiliated rural community-based outpatient clinics (CBOCs). Rural CBOC primary care providers refer clinic patients, or referral is according to previous cognitive impairment diagnosis in a VAPHS geriatric clinic. Patients undergo interprofessional dementia assessment by a geriatrician, geropsychologist, geriatric psychiatrist or neurologist, and social worker using CVT technology. Metrics for clinic evaluation included rural patients served and savings in travel time, distance, and costs. Assessments collected depended upon individual presentation and included cognitive tests, geriatric depression scales, functional assessment, and the Zarit Burden Interview. A patient satisfaction survey was created and administered. In the first year, 95 individuals were served in 156 clinic visits and 251 interprofessional provider encounters. Of patients served, 61 lived in rural ZIP codes, 72 were diagnosed with dementia, 19 were diagnosed with mild cognitive impairment, and four were found to have primarily psychiatric diagnoses rather than cognitive impairment. The average Functional Assessment Staging of Alzheimer's Disease Scale score was 4.3 ± 1.3. This clinic model demonstrates that CVT technology is a feasible means of providing interprofessional dementia evaluations and follow-up to rural presidents.

Objectives To establish consensus oral dosing guidelines for primarily renally cleared medications prescribed for older adults. Design Two-round modified Delphi Survey. Participants Expert panel of 11 geriatric clinical pharmacists. Measurements After a comprehensive literature search and review by the investigative group of 6 physicians (2 from general internal medicine, 2 nephrologists, 2 geriatricians), 45 dosing recommendations for 30 medications at various levels of renal function were created. The expert panel rated their agreement with each of these 45 dosing recommendations using a 5-point Likert scale (1= strongly disagree to 5=strongly agree). Recommendation-specific means and 95% confidence intervals were estimated. Consensus was defined as a lower 95% confidence limit of >4.0 for the recommendation –specific mean score. Results The response rate was 81.8% (9/11) for the first round. All respondents that completed the first round also completed the second round. The expert panel reached consensus on 26 recommendations involving 18 (60%) medications. For 10 medications (chlorpropamide, colchicine, cotrimoxazole, glyburide, meperidine, nitrofurantoin, probenecid, propoxyphene, spironolactone, and triamterene), the consensus recommendation was not to use the medication in older adults below a specified level of renal function (e.g., creatinine clearance < 30 ml/min). For the remaining 8 medications (acyclovir, amantadine, ciprofloxacin, gabapentin, memantine, ranitidine, rimantadine, and valacyclovir), specific recommendations for dose reduction or interval extension were made. Conclusion An expert panel of geriatric clinical pharmacists was able to reach consensus agreement on a number of oral medications that are primarily renally cleared.