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Farrelly A, Daly L. Older persons' experiences of frailty: A systematic review. Int J Older People Nurs 2024; 19:e12611. [PMID: 38747586 DOI: 10.1111/opn.12611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 03/01/2024] [Accepted: 04/14/2024] [Indexed: 05/21/2024]
Abstract
OBJECTIVES The objective of this study was to synthesise the evidence of older persons' experiences of frailty. BACKGROUND The world's population is ageing with those aged over 60 years expected to total 2 billion by 2050. Although not exclusive to ageing, there is a higher prevalence of frailty in older adults, with corresponding demand for related healthcare. While definitions of frailty are debated, there is emerging consensus that sole reliance on biomedical conceptualisations is inadequate to capture the complex needs of older persons living with frailty. In addition, the voices of older persons have largely been excluded from frailty discourses. There is a consequent need for an expanded approach. METHODS A meta-synthesis was conducted of the literature on older persons' experiences of frailty. CINAHL, Medline, Embase and ASSIA databases were systematically searched up to January 2024. Reference lists of retrieved sources and grey literature were also searched. Studies were independently evaluated for inclusion by two reviewers using predetermined inclusion criteria. Included studies were quality appraised using a standardised tool, and extracted data were thematically analysed and synthesised. RESULTS Eight hundred and thirteen studies were identified as potentially relevant. Following title and abstract review, 52 studies were selected for full-text review. Thirty-four studies were subsequently excluded as they did not address the systematic review question, leaving 17 included in the final review. An additional two studies were identified via grey literature sources. Older persons' experiences of frailty were synthesised with reference to three themes: (i) living with frailty: a multidimensional experience; (ii) living with frailty: acceptability and associations; and (iii) living with frailty: resisting and adapting and losing control. CONCLUSIONS Older persons' experiences of frailty revealed a resistance to the biomedical use of the term generally used in clinical practice. Instead, a more nuanced and multidimensional understanding of frailty was identified in the experiences of older persons. IMPLICATIONS FOR PRACTICE Health and social care personnel should therefore consider an expanded approach in practice that incorporates the perspective of older people who strive to maintain independence and control when living with frailty. Doing so may enhance shared understanding and person-centred care planning between older persons and professionals.
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Affiliation(s)
- Alice Farrelly
- Midlands Regional Hospital, Tullamore, County Offaly, Republic of Ireland
| | - Louise Daly
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
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Su H, Hung HF, Hsu SP, Liu MH, Chao YC, Chiou AF. The Lived Experience of Frailty in Patients Aged 60 Years and Older with Heart Failure: A Qualitative Study. Asian Nurs Res (Korean Soc Nurs Sci) 2023; 17:191-199. [PMID: 37532098 DOI: 10.1016/j.anr.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/09/2023] [Accepted: 07/23/2023] [Indexed: 08/04/2023] Open
Abstract
PURPOSE The prevalence of frailty among patients with heart failure is about 45%. Frailty may result in patients' functional decline, falls, disability, and decreased quality of life. Qualitative studies can explore older patients' perceptions of frailty and help patients cope with it. However, a qualitative approach that explores the experience of frailty in older patients living with heart failure is lacking. This study aimed to explore the lived experience of frailty in older patients with heart failure. METHODS This qualitative study applies Giorgi's phenomenological method. Data were collected from October 2019 to August 2020. Thirteen older patients with heart failure aged at least 60 years were recruited using purposive sampling from a medical center in Taiwan. The participants participated in an in-depth interview using a semistructured interview guide. RESULTS Seven themes were identified: "being reborn at the end of the road but having difficulty recovering", "living with a disease with an ineffable feeling", "feeling like being drained: physical weakness and a dysfunctional body", "struggling with impaired physical mobility and facing unexpected events", "suffering from mental exhaustion", "receiving care from loved ones", and "turning over a new leaf". CONCLUSIONS Frailty in older patients with heart failure was obscure and difficult to describe. Frailty could be improved by medical intervention, self-management, and social support but was difficult to reverse. Patients with heart failure should be evaluated for frailty using multidimensional assessment tools at first diagnosis and provided frailty-related information so that patients have proper insight into their disease as early as possible.
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Affiliation(s)
- Hsuan Su
- Hsin Sheng Junior College of Medical Care and Management, Taoyuan, Taiwan, ROC
| | - Huei-Fong Hung
- Cardiology Department, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, ROC
| | - Shu-Pen Hsu
- Department of Nursing, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, ROC
| | - Min-Hui Liu
- Heart Failure Research Center, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan, ROC; Department of Nursing, Keelung Chang Gung Memorial Hospital, Taiwan, ROC; Department of Nursing, Ching Kuo Institute of Management and Health, Keelung, Taiwan, ROC
| | - Ying-Cheng Chao
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Ai-Fu Chiou
- College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC.
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Frechman E, Buck HG, Dietrich MS, Maxwell CA. Development of a Planning for Aging and Frailty Questionnaire. Res Gerontol Nurs 2022; 15:239-244. [PMID: 36113008 DOI: 10.3928/19404921-20220830-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
There is a gap in understanding adults' readiness to plan for adaptions across the aging trajectory. The purpose of the current psychometric project was to develop and test the Planning for Aging and Frailty Questionnaire. Clinical experience and extant literature formed the basis for creating items measuring planning for aging. Content validity was established with gerontology and health service research experts. Face validity testing was conducted through two cognitive interviewing and debriefing sessions at a senior center. All survey questions resulted in a content validity index ≥0.80 from experts. Face validity testing involved successful completion of the survey by 12 adults followed by cognitive interviewing/debriefing, resulting in minor changes. The 21-item Planning for Aging and Frailty Questionnaire demonstrates good initial validity and can be used to measure readiness in planning for aging and personal experiences and experiences with others. Further testing with additional usage is warranted. [Research in Gerontological Nursing, 15(5), 239-244.].
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Gobbens RJ, Vermeiren S, Van Hoof A, van der Ploeg T. Nurses' Opinions on Frailty. Healthcare (Basel) 2022; 10:1632. [PMID: 36141244 PMCID: PMC9498801 DOI: 10.3390/healthcare10091632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/17/2022] [Accepted: 08/23/2022] [Indexed: 11/26/2022] Open
Abstract
Nurses come into frequent contact with frail older people in all healthcare settings. However, few studies have specifically asked nurses about their views on frailty. The main aim of this study was to explore the opinions of nurses working with older people on the concept of frailty, regardless of the care setting. In addition, the associations between the background characteristics of nurses and their opinions about frailty were examined. In 2021, members of professional association of nurses and nursing assistants in the Netherlands (V&VN) received a digital questionnaire asking their opinions on frailty, and 251 individuals completed the questionnaire (response rate of 32.1%). The questionnaire contained seven topics: keywords of frailty, frailty domains, causes of frailty, consequences of frailty, reversing frailty, the prevention of frailty, and addressing frailty. Regarding frailty, nurses especially thought of physical deterioration and dementia. However, other domains of human functioning, such as the social and psychological domains, were often mentioned, pointing to a holistic approach to frailty. It also appears that nurses can identify many causes and consequences of frailty. They see opportunities to reverse frailty and an important role for themselves in this process.
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Affiliation(s)
- Robbert J. Gobbens
- Faculty of Health, Sports and Social Work, Inholland University of Applied Sciences, 1081 HV Amsterdam, The Netherlands
- Zonnehuisgroep Amstelland, 1186 AA Amstelveen, The Netherlands
- Department Family Medicine and Population Health, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium
| | - Sofie Vermeiren
- Department of Health and Science, AP University of Applied Sciences and Arts Antwerp, BE-2000 Antwerp, Belgium
| | - An Van Hoof
- Department of Health and Science, AP University of Applied Sciences and Arts Antwerp, BE-2000 Antwerp, Belgium
| | - Tjeerd van der Ploeg
- Faculty of Health, Sports and Social Work, Inholland University of Applied Sciences, 1081 HV Amsterdam, The Netherlands
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Joshanloo M. Positive and Negative Aging Perceptions as Predictors of the Longitudinal Trajectory of Perceived Stress. J Appl Gerontol 2021; 41:831-835. [PMID: 34284669 DOI: 10.1177/07334648211031047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study sought to examine whether positive and negative perceptions of aging (beliefs about the consequences of aging and levels of control over one's aging) are associated with perceived levels of stress over time. A sample of adults (N = 6,345, ≥50 years, Mage = 62.23) participating in the Irish Longitudinal Study on Ageing (TILDA) was used. Data were collected across four waves between 2009 and 2016. The results of latent growth curve modeling showed that, after controlling for age and gender, positive and negative perceptions of aging predicted initial levels of perceived stress. Therefore, aging perceptions have robust synchronous associations with the levels of perceived stress in adults and thus merit attention in aging-related research, practice, education, and policy making. However, these perceptions did not confidently predict longitudinal trajectories of perceived stress.
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Fotokian Z, Pourhabib A, Navabi N, Ghaffari F. Designing a structural equation model of marital satisfaction based on aging perception and demographic and clinical variables in Iranian elderly patients with coronary artery disease. ARYA ATHEROSCLEROSIS 2021; 16:161-169. [PMID: 33598036 PMCID: PMC7867309 DOI: 10.22122/arya.v16i4.2087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Marital satisfaction is an important variable in maintaining or promoting elderly health. Therefore, identifying the effective factors can increase life expectancy and quality of life. This study aimed to determine the relationship between aging perception and demographic and clinical characteristics with marital satisfaction in the elderly patients with coronary artery disease (CAD). METHODS This was a descriptive-correlational study. The sample size was 480 elderly patients with CAD who were referred to the heart clinics of hospitals in the west of Mazandaran Province, Iran, who were recruited by convenience sampling. Data were collected by a demographic checklist, ENRICH Marital Satisfaction Inventory, and Aging Perceptions Questionnaire (APQ). The data were analyzed by structural equation model (SEM) using Goodness of Fit Index (GFI and chi-square test. P-value less than 0.050 was considered as significant level. RESULTS The mean and standard deviation (SD) of marital satisfaction was 145.16 ± 12.12, and the mean and SD of aging perception was 113.39 ± 12.74. The results of the Pearson's correlation coefficient indicated that the highest correlation was between aging perception and marital satisfaction (r = 0.68, P < 0.001). The model fit indices of the hypothesized model met the criteria, with the GFI = 0.91, Comparative Fit Index (CFI) = 0.93, Normed Fit Index (NFI) = 0.94, and non-Normed Fit Index (NNFI) = 0.91. CONCLUSION Considering the psychological risk factors affecting marital satisfaction such as aging perception and suitable measurement can lead to marital health and improve treatment outcomes by increasing elderly motivation in self-care. Therefore, the elderly patients with CAD need more serious and long-term educational, counseling, and supportive interventions.
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Affiliation(s)
- Zahra Fotokian
- Assistant Professor, Nursing Care Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Ali Pourhabib
- PhD Candidate, School of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran
| | - Nasrin Navabi
- Lecturer, Nursing Care Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Fatemeh Ghaffari
- Associate Professor, Nursing Care Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
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"This Is Me!" Perceptions of Older Adult Simulated Participants in an Aging and Injury Simulation Experience. J Trauma Nurs 2021; 28:10-20. [PMID: 33417397 DOI: 10.1097/jtn.0000000000000552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Older adults played the role of frail and prefrail geriatric trauma patients in a frailty-focused communication workshop for nurses. Although subjects played a role (acting) as simulated participants (SPs) for simulation, workshop content and role-play also applied to them personally. We aimed to explore the effect that learning frailty-focused content, scripts, and portrayal of prefrail and frail older adults has on older adult SPs. METHODS Qualitative focus group. Participants included older adults older than 70 years (N = 6). PROCEDURE Focus group questions pertained to (1) the SP experience, (2) thoughts and emotions throughout the SP experience, and (3) applicability of workshop content and SP experience to personal life. The focus group lasted 90 min, was digitally recorded, and transcribed verbatim. Authors independently coded transcripts to identify categories and supporting quotations. Categories and subcategories were condensed and modified through iterative discussions. Descriptive content analysis was utilized for data analysis. RESULTS Six categories and 2 subcategories emerged, including (1) inevitability of aging: not playing a role (sub: inevitability of death), (2) shifting perceptions: how aging impacts thought and actions, (3) time as a factor: getting information sooner, (4) changing behavior/safety: mental recalibration, (5) attitude as a determining factor (sub: loss of independence), and (6) sharing information with others. CONCLUSION The study supports the use of frailty-focused communication with older adults to prompt contemplation of aging and frailty and eventual decline/death. Providing information earlier in the aging trajectory enables time for behavior change that can prevent and delay frailty and mitigate untoward outcomes (falls, hospitalizations).
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Maxwell CA, Rothman R, Wolever R, Simmons S, Dietrich MS, Miller R, Patel M, Karlekar MB, Ridner S. Development and testing of a frailty-focused communication (FCOM) aid for older adults. Geriatr Nurs 2020; 41:936-941. [PMID: 32709372 PMCID: PMC7738367 DOI: 10.1016/j.gerinurse.2020.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 07/03/2020] [Accepted: 07/07/2020] [Indexed: 01/16/2023]
Abstract
The concept of frailty as it pertains to aging, health and well-being is poorly understood by older adults and the public-at-large. We developed an aging and frailty education tool designed to improve layperson understanding of frailty and promote behavior change to prevent and/or delay frailty. We subsequently tested the education tool among adults who attended education sessions at 16 community sites. Specific aims were to: 1) determine acceptability (likeability, understandability) of content, and 2) assess the likelihood of behavior change after exposure to education tool content. Results: Over 90% of participants "liked" or "loved" the content and found it understandable. Eighty-five percent of participants indicated that the content triggered a desire to "probably" or "definitely" change behavior. The desire to change was particularly motivated by information about aging, frailty and energy production. Eight focus areas for proactive planning were rated as important or extremely important by over 90% of participants.
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Affiliation(s)
- Cathy A Maxwell
- Vanderbilt University School of Nursing (VUSN), 461 21st Ave. South, Godchaux Hall 420, Nashville 37240, TN, United States.
| | - Russell Rothman
- Vanderbilt University Medical Center (VUMC), Nashville, TN, United States.
| | - Ruth Wolever
- Vanderbilt University Medical Center (VUMC), Nashville, TN, United States.
| | - Sandra Simmons
- Vanderbilt University Medical Center (VUMC), Nashville, TN, United States.
| | - Mary S Dietrich
- Vanderbilt University School of Nursing (VUSN), 461 21st Ave. South, Godchaux Hall 420, Nashville 37240, TN, United States.
| | - Richard Miller
- Vanderbilt University Medical Center (VUMC), Nashville, TN, United States.
| | - Mayur Patel
- Vanderbilt University Medical Center (VUMC), Nashville, TN, United States.
| | - Mohana B Karlekar
- Vanderbilt University Medical Center (VUMC), Nashville, TN, United States.
| | - Sheila Ridner
- Vanderbilt University School of Nursing (VUSN), 461 21st Ave. South, Godchaux Hall 420, Nashville 37240, TN, United States.
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Ophey A, Roheger M, Folkerts AK, Skoetz N, Kalbe E. A Systematic Review on Predictors of Working Memory Training Responsiveness in Healthy Older Adults: Methodological Challenges and Future Directions. Front Aging Neurosci 2020; 12:575804. [PMID: 33173503 PMCID: PMC7591761 DOI: 10.3389/fnagi.2020.575804] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 08/26/2020] [Indexed: 12/15/2022] Open
Abstract
Background: Research on predictors of working memory training responsiveness, which could help tailor cognitive interventions individually, is a timely topic in healthy aging. However, the findings are highly heterogeneous, reporting partly conflicting results following a broad spectrum of methodological approaches to answer the question “who benefits most” from working memory training. Objective: The present systematic review aimed to systematically investigate prognostic factors and models for working memory training responsiveness in healthy older adults. Method: Four online databases were searched up to October 2019 (MEDLINE Ovid, Web of Science, CENTRAL, and PsycINFO). The inclusion criteria for full texts were publication in a peer-reviewed journal in English/German, inclusion of healthy older individuals aged ≥55 years without any neurological and/or psychiatric diseases including cognitive impairment, and the investigation of prognostic factors and/or models for training responsiveness after targeted working memory training in terms of direct training effects, near-transfer effects to verbal and visuospatial working memory as well as far-transfer effects to other cognitive domains and behavioral variables. The study design was not limited to randomized controlled trials. Results: A total of 16 studies including n = 675 healthy older individuals with a mean age of 63.0–86.8 years were included in this review. Within these studies, five prognostic model approaches and 18 factor finding approaches were reported. Risk of bias was assessed using the Quality in Prognosis Studies checklist, indicating that important information, especially regarding the domains study attrition, study confounding, and statistical analysis and reporting, was lacking throughout many of the investigated studies. Age, education, intelligence, and baseline performance in working memory or other cognitive domains were frequently investigated predictors across studies. Conclusions: Given the methodological shortcomings of the included studies, no clear conclusions can be drawn, and emerging patterns of prognostic effects will have to survive sound methodological replication in future attempts to promote precision medicine approaches in the context of working memory training. Methodological considerations are discussed, and our findings are embedded to the cognitive aging literature, considering, for example, the cognitive reserve framework and the compensation vs. magnification account. The need for personalized cognitive prevention and intervention methods to counteract cognitive decline in the aging population is high and the potential enormous. Registration: PROSPERO, ID CRD42019142750.
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Affiliation(s)
- Anja Ophey
- Department of Medical Psychology
- Neuropsychology & Gender Studies, Center for Neuropsychological Diagnostics and Intervention (CeNDI), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Mandy Roheger
- Department of Medical Psychology
- Neuropsychology & Gender Studies, Center for Neuropsychological Diagnostics and Intervention (CeNDI), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ann-Kristin Folkerts
- Department of Medical Psychology
- Neuropsychology & Gender Studies, Center for Neuropsychological Diagnostics and Intervention (CeNDI), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Nicole Skoetz
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Elke Kalbe
- Department of Medical Psychology
- Neuropsychology & Gender Studies, Center for Neuropsychological Diagnostics and Intervention (CeNDI), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Maxwell CA, Mixon AS, Conner E, Phillippi JC. Receptivity of Hospitalized Older Adults and Family Caregivers to Prognostic Information about Aging, Injury, and Frailty: A Qualitative Study. Int J Nurs Stud 2020; 109:103602. [PMID: 32534291 DOI: 10.1016/j.ijnurstu.2020.103602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 01/20/2020] [Accepted: 03/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Frailty is the leading prognosticator for poor outcomes and palliative care among older adults. Delivery of negative prognostic information entails potentially difficult conversations about decline and death. OBJECTIVE The study aims were to: 1) examine hospitalized older adults' and family caregivers' receptivity to general (vs. individualized) prognostic information about frailty, injury, and one-year outcomes; and 2) determine information needs based on prognostic information. DESIGN Provision of general prognostic information followed by semi-structured interview questions. We deductively analyzed qualitative data within the context of problematic integration theory. SETTING An academic medical center in the Southeast region of the U.S. PARTICIPANTS Purposive sampling was utilized to obtain a distribution of patients across the frailty continuum (non-frail [N=10], pre-frail [N=9], frail [9=6]). Twenty-five older adults (≥ age 65) hospitalized for a primary injury (e.g. fall) and 15 family caregivers of hospitalized patients were enrolled. METHODS Hospitalized older patients and family caregivers were shown prognostic information about one-year outcomes of injured older adults in the form of simple pictographs. Semi-structured interview questions were administered immediately afterwards. The interviews were audio-recorded, transcribed, and analyzed using qualitative content analysis. Demographic and medical information data were used to contextualize the responses during analysis. RESULTS Overall, participants (patients [56%], caregivers [73%]) were open to receiving prognostic information. A small number of family caregivers (N=3) expressed reservations about the frankness of the information and suggested delivery through a softer approach or not at all. Qualitative data was coded using categories and constructs of problematic integration theory. Four codes (personalizing the evidence, vivid understanding, downhill spiral, realities of aging) reflected probabilistic and evaluative orientation categories of problematic integration theory. One code (fatalism vs. hope) represented manifestations of ambivalence and ambiguity in the theory; and another code (exceptionalism) represented divergence and impossibility. Two codes (role of thought processes, importance of faith) reflected forms of resolutions as described in problematic integration theory. Information needs based on prognostic information revealed four additional codes: give it to me straight, what can I do? what can I expect? and how can I prevent decline? A consistently reported desire of both patients and caregivers was for honesty and hope from providers. CONCLUSION This study supports the use of general prognostic information in conversations about aging, injury, frailty and patient outcomes. Incorporating prognostic information into communication aids can facilitate shared decision making before end-of-life is imminent.
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Affiliation(s)
- Cathy A Maxwell
- Vanderbilt University School of Nursing, 461 21st Ave. South, Nashville, TN 37240.
| | - Amanda S Mixon
- Section of Hospital Medicine, Vanderbilt University Medical Center and Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System.
| | - Elizabeth Conner
- University of Tennessee Health Science Center, College of Medicine, 910 Madison Ave. Suite 1031, Memphis, TN 38163.
| | - Julia C Phillippi
- Vanderbilt University School of Nursing, 461 21st Ave. South, Nashville, TN 37240.
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