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Riedel HB, Espejo T, Dreher-Hummel T, Bingisser R, Nickel CH. Screening for elder mistreatment in a Swiss emergency department: a prospective cohort study. Swiss Med Wkly 2024; 154:3775. [PMID: 38875501 DOI: 10.57187/s.3775] [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: 06/16/2024] Open
Abstract
AIM OF THE STUDY The mistreatment of older adults is a global and complex problem with varying prevalence. As there are no data on the prevalence of elder mistreatment in European emergency department populations, we aimed to translate and culturally adapt the Emergency Department Senior Abuse Identification (ED Senior AID) tool for German use, assess the positive screen rate for elder mistreatment with the German version, and compare characteristics of patients who screened positive and negative. METHODS To assess the prevalence of elder mistreatment, we created a German version of the ED Senior AID tool. This tool identifies intentional or negligent actions by a caregiver or trusted person that cause harm or risk to an older adult. Then, the German ED Senior AID tool was applied to all consecutively presenting patients aged ≥65 years at our academic emergency department in the Northwest of Switzerland from 25 April to 30 May 2022. Usability was defined as the percentage of patients with completed assessments using the German ED Senior AID tool. RESULTS We included 1010 patients aged ≥65 years, of whom 29 (2.9%) screened positive with the ED Senior AID tool. The patients who screened positive were older, more severely cognitively impaired, hospitalised more frequently, and presented with higher frailty scores than those who screened negative. Mortality up to 100 days after presentation was comparable in all patients (p = 0.861), regardless of their screening result. The tool showed good usability, with 73% of assessments completed. CONCLUSION This is the first prospective investigation on the prevalence of elder mistreatment in a European emergency department setting. Overall, 2.9% of patients screened positive using a validated screening tool translated into German. TRIAL REGISTRATION This study was registered with the National Institute of Health on ClinicalTrials.gov with the registration number NCT05400707.
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Affiliation(s)
- Henk B Riedel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tanguy Espejo
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thomas Dreher-Hummel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
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Molendijk-van Nieuwenhuyzen K, Belt-van Opstal R, Hakvoort L, Dikken J. Exploring geriatric trauma unit experiences through patients' eyes: a qualitative study. BMC Geriatr 2024; 24:476. [PMID: 38816688 PMCID: PMC11140891 DOI: 10.1186/s12877-024-05023-z] [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: 11/17/2023] [Accepted: 04/29/2024] [Indexed: 06/01/2024] Open
Abstract
INTRODUCTION The surgical management of older patients is complex due to age-related underlying comorbidities and decreased physiological reserves. Comanaged care models, such as the Geriatric Trauma Unit, are proven effective in treating the complex needs of patients with fall-related injuries. While patient-centered care is an important feature of these comanaged care models, there has been minimal research dedicated to investigating the patient experience within Geriatric Trauma Units. Therefore, it remains uncertain whether the Geriatric Trauma Unit's emphasis on a patient-centered approach truly manifests in these interactions. This study explores how patients with fall-related injuries admitted to a Geriatric Trauma Unit perceive and experience patient-centered care during hospitalization. METHODS This qualitative generic study was conducted in three teaching hospitals that integrated the principles of comanaged care in trauma care for older patients. Between January 2021 and May 2022, 21 patients were interviewed. RESULTS The findings highlight the formidable challenges that older patients encounter during their treatment for fall-related injuries, which often signify a loss of independence and personal autonomy. The findings revealed a gap in the consistent and continuous implementation of patient-centered care, with many healthcare professionals still viewing patients mainly through the lens of their injuries, rather than as individuals with distinct healthcare needs. Although focusing on fracture-specific care and physical rehabilitation aligns with some patient preferences, overlooking broader needs undermines the comprehensive approach to care in the Geriatric Trauma Unit. CONCLUSION Effective patient-centered care in Geriatric Trauma Units requires full adherence to its core elements: patient engagement, strong patient-provider relationships, and a patient-focused environment. This study shows that deviations from these principles can undermine care, emphasizing the need for a holistic approach that extends beyond treating immediate medical conditions.
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Affiliation(s)
| | | | | | - Jeroen Dikken
- De Haagse Hogeschool, Faculteit Gezondheid, Voeding & Sport, Johanna Westerdijkplein 75, 2521 EN, The Hague, The Netherlands
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Carpenter CR, Lee S, Kennedy M, Arendts G, Schnitker L, Eagles D, Mooijaart S, Fowler S, Doering M, LaMantia MA, Han JH, Liu SW. Delirium detection in the emergency department: A diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments. Acad Emerg Med 2024. [PMID: 38757369 DOI: 10.1111/acem.14935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/13/2024] [Accepted: 04/15/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test-treatment thresholds for ED delirium screening. METHODS We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta-analysis and estimated delirium screening thresholds. RESULTS Full-text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta-analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7-20.7) and rule out (pooled negative likelihood ratio [LR-] 0.18, 95% CI 0.09-0.34) delirium. We also conducted meta-analysis of two studies that quantified the accuracy of the Abbreviated Mental Test-4 (AMT-4) and found that the pooled LR+ (4.3, 95% CI 2.4-7.8) was lower than that observed for the 4AT, but the pooled LR- (0.22, 95% CI 0.05-1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%. CONCLUSIONS The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED-based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM-ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single-center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single-center study.
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Affiliation(s)
| | - Sangil Lee
- University of Iowa, Iowa City, Iowa, USA
| | - Maura Kennedy
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Glenn Arendts
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Linda Schnitker
- Bolton Clarke Research Institute, Bolton Clarke School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | | | - Simon Mooijaart
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, The Netherlands
| | - Susan Fowler
- University of Connecticut Health Sciences, Farmington, Connecticut, USA
| | - Michelle Doering
- Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | | | - Jin H Han
- Geriatric Research Education and Clinical Center (GRECC), Tennessee Valley Healthcare Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Espejo T, Riedel HB, Messingschlager S, Sonnleitner W, Kellett J, Brabrand M, Cooksley T, Bingisser R, Nickel CH. Predictive value and interrater reliability of mental status and mobility assessment in the emergency department. Clin Med (Lond) 2024; 24:100027. [PMID: 38369128 DOI: 10.1016/j.clinme.2024.100027] [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] [Indexed: 02/20/2024]
Abstract
AIM To investigate the predictive value of both mental status, assessed with the AVPUC (Alert, responds to Voice, responds to Pain, Unresponsive, and new Confusion) scale, and mobility assessments, and their interrater reliability (IRR) between triage clinicians and a research team. METHOD Prospective study of consecutive patients who presented to an ED. Mental status and mobility were assessed by triage clinicians and by a dedicated research team. RESULTS 4,191 patients were included. After adjustment for age and sex, patients with altered mental status have an odds ratio of 6.55 [4.09-10.24] to be admitted in the ICU and an odds ratio of 21.16 [12.06-37.01] to die within 30 days; patients with impaired mobility have an odds ratio of 7.08 [4.60-11.12] to be admitted in the ICU and an odds ratio of 12.87 [5.93-32.30] to die within 30 days. The kappa coefficient between triage clinicians and the research team for mental status assessment was 0.75, and 0.80 for mobility. CONCLUSION Assessment of mental status by the AVPUC scale, and mobility by a simple dichotomous scale are suitable for ED triage. Both altered mental status and impaired mobility are associated with adverse outcomes. Mental status and mobility assessment have good interrater reliability.
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Affiliation(s)
- Tanguy Espejo
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Henk B Riedel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Wolfram Sonnleitner
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - John Kellett
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Tim Cooksley
- Department of Acute Medicine, University Hospital of South Manchester, Manchester, UK
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland.
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Singh H, Benn N, Fung A, Kokorelias KM, Martyniuk J, Nelson MLA, Colquhoun H, Cameron JI, Munce S, Saragosa M, Godhwani K, Khan A, Yoo PY, Kuluski K. Co-design for stroke intervention development: Results of a scoping review. PLoS One 2024; 19:e0297162. [PMID: 38354160 PMCID: PMC10866508 DOI: 10.1371/journal.pone.0297162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/29/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Co-design methodology seeks to actively engage end-users in developing interventions. It is increasingly used to design stroke interventions; however, limited guidance exists, particularly with/for individuals with stroke who have diverse cognitive, physical and functional abilities. Thus, we describe 1) the extent of existing research that has used co-design for stroke intervention development and 2) how co-design has been used to develop stroke interventions among studies that explicitly used co-design, including the rationale, types of co-designed stroke interventions, participants involved, research methodologies/approaches, methods of incorporating end-users in the research, co-design limitations, challenges and potential strategies reported by researchers. MATERIALS AND METHODS A scoping review informed by Joanna Briggs Institute and Arksey & O'Malley methodology was conducted by searching nine databases on December 21, 2022, to locate English-language literature that used co-design to develop a stroke intervention. Additional data sources were identified through a hand search. Data sources were de-duplicated, and two research team members reviewed their titles, abstracts and full text to ensure they met the inclusion criteria. Data relating to the research objectives were extracted, analyzed, and reported numerically and descriptively. RESULTS Data sources used co-design for stroke intervention development with (n = 89) and without (n = 139) explicitly using the term 'co-design.' Among studies explicitly using co-design, it was commonly used to understand end-user needs and generate new ideas. Many co-designed interventions were technology-based (65%), and 48% were for physical rehabilitation or activity-based. Co-design was commonly conducted with multiple participants (82%; e.g., individuals with stroke, family members/caregivers and clinicians) and used various methods to engage end-users, including focus groups and workshops. Limitations, challenges and potential strategies for recruitment, participant-engagement, contextual and logistical and ethics of co-designed interventions were described. CONCLUSIONS Given the increasing popularity of co-design as a methodology for developing stroke interventions internationally, these findings can inform future co-designed studies.
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Affiliation(s)
- Hardeep Singh
- Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- The KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Natasha Benn
- The KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Agnes Fung
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Kristina M. Kokorelias
- Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- The KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Geriatrics Division, Sinai Health System, University Health Network, Toronto, Canada
| | - Julia Martyniuk
- Gerstein Science Information Centre, University of Toronto Libraries, University of Toronto, Toronto, Canada
| | - Michelle L. A. Nelson
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
| | - Heather Colquhoun
- Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Jill I. Cameron
- Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- The KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sarah Munce
- Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- The KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Marianne Saragosa
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
| | - Kian Godhwani
- Department of Psychology, University of Toronto Scarborough, Toronto, Canada
| | - Aleena Khan
- Biological Sciences, University of Toronto, Toronto, Canada
| | - Paul Yejong Yoo
- Division of Neurosciences and Mental Health, The Hospital for Sick Children Research Institute, Toronto, Canada
| | - Kerry Kuluski
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Institute for Better Health, Trillium Health Partners, Toronto, Canada
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6
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Albrecht R, Espejo T, Riedel HB, Nissen SK, Banerjee J, Conroy SP, Dreher-Hummel T, Brabrand M, Bingisser R, Nickel CH. Clinical Frailty Scale at presentation to the emergency department: interrater reliability and use of algorithm-assisted assessment. Eur Geriatr Med 2024; 15:105-113. [PMID: 37971677 PMCID: PMC10876739 DOI: 10.1007/s41999-023-00890-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/19/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE The Clinical Frailty Scale (CFS) allows health care providers to quickly stratify older patients, to support clinical decision-making. However, few studies have evaluated the CFS interrater reliability (IRR) in Emergency Departments (EDs), and the freely available smartphone application for CFS assessment was never tested for reliability. This study aimed to evaluate the interrater reliability of the Clinical Frailty Scale (CFS) ratings between experienced and unexperienced staff (ED clinicians and a study team (ST) of medical students supported by a smartphone application to assess the CFS), and to determine the feasibility of CFS assignment in patients aged 65 or older at triage. METHODS Cross-sectional study using consecutive sampling of ED patients aged 65 or older. We compared assessments by ED clinicians (Triage Clinicians (TC) and geriatric ED trained nurses (geriED-TN)) and a study team (ST) of medical students using a smartphone application for CFS scoring. The study is registered on Clinicaltrials.gov (NCT05400707). RESULTS We included 1349 patients aged 65 and older. Quadratic-weighted kappa values for ordinal CFS levels showed a good IRR between TC and ST (ϰ = 0.73, 95% CI 0.69-0.76), similarly to that between TC and geriED-TN (ϰ = 0.75, 95% CI 0.66-0.82) and between the ST and geriED-TN (ϰ = 0.74, 95% CI 0.63-0.81). A CFS rating was assigned to 972 (70.2%) patients at triage. CONCLUSION We found good IRR in the assessment of frailty with the CFS in different ED providers and a team using a smartphone application to support rating. A CFS assessment occurred in more than two-thirds (70.2%) of patients at triage.
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Affiliation(s)
- Rainer Albrecht
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland
| | - Tanguy Espejo
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland
| | - Henk B Riedel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland
| | - Søren K Nissen
- Research Unit for Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
| | - Jay Banerjee
- University Hospitals of Leicester NHS Trust, Leicester, UK
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Simon P Conroy
- St Pancras Hospital, Central and North West London NHS Foundation Trust, London, UK
- MRC Unit for Lifelong Health and Ageing, University College London, University College London Hospitals, London, UK
| | - Thomas Dreher-Hummel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland
| | - Mikkel Brabrand
- Research Unit for Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland.
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Rutten JJS, Smalbrugge M, van Buul LW, van Eijk J, Geerlings SE, Natsch S, Sloane PD, van der Wouden JC, Hertogh CMPM, Gerritsen DL. A Process Evaluation of an Antibiotic Stewardship Intervention for Urinary Tract Infections in Nursing Homes. J Am Med Dir Assoc 2024; 25:146-154.e9. [PMID: 38173264 DOI: 10.1016/j.jamda.2023.09.016] [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: 05/05/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES To assess the internal and external validity of a cluster randomized controlled trial (cRCT) evaluating a decision tool with supportive interventions for the empirical treatment of urinary tract infections (UTIs) in nursing homes (NHs), and to identify facilitators and barriers in implementing this antibiotic stewardship intervention. DESIGN Mixed-methods process evaluation study. SETTING AND PARTICIPANTS Physicians, nursing staff, client council members, and residents of Dutch NHs. METHODS We used cRCT data of the ANNA study (Antibiotic Prescribing and Non-prescribing in Nursing Home Residents With Signs and Symptoms Ascribed to Urinary Tract Infection). In addition, we sent out an online evaluation questionnaire, conducted semistructured interviews with physicians and nursing staff, and consulted client council members. RESULTS Internal validity was lowered: control group physicians participated in several non-study-related activities regarding UTI. External validity was good: almost all intervention components had a high fidelity (52%-74%) and were perceived as relevant (physicians: 7.2-8.6 of 10, nursing staff: 6.5-8.5 of 10) and feasible (physicians: 7.5 of 10, nursing staff 6.4 of 10), with feasibility for residents with dementia and urine incontinence needing attention. The most common reason for deviating from the advice generated by the decision tool was an unclear illness presentation. Identified facilitators to implementation were confidence in the intervention, repeated intervention encounter, and having "champions" in the NH. Barriers were limited involvement of nursing staff, unstable nursing teams, residents' and representatives' belief that antibiotics should be prescribed, and a low antibiotic prescribing threshold within the NH culture. CONCLUSIONS AND IMPLICATIONS Lowered internal validity may have reduced the study effect. Attention should be paid to the feasibility of the intervention in residents with dementia and urinary incontinence. Improvement opportunities for implementation were higher nursing staff involvement and repeated intervention offering.
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Affiliation(s)
- Jeanine J S Rutten
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands.
| | - Jorna van Eijk
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Suzanne E Geerlings
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Stephanie Natsch
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Philip D Sloane
- Department of Family Medicine, School of Medicine, and the Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Johannes C van der Wouden
- Department of General Practice, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Debby L Gerritsen
- Department of Primary and Community care, Radboudumc Alzheimer Center, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Sert ET, Kokulu K, Mutlu H, Yortanlı BC. Effects of Clinical Frailty Scale Score on Adverse Outcomes and Length of Emergency Department Stay Before Intensive Care Unit Admission. J Emerg Med 2024; 66:e10-e19. [PMID: 37919186 DOI: 10.1016/j.jemermed.2023.08.020] [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: 05/20/2023] [Revised: 08/18/2023] [Accepted: 08/31/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Older adults living with frailty who require treatment in hospitals are increasingly seen in emergency departments (EDs). OBJECTIVE This study investigated the effects of frailty severity according to the Clinical Frailty Scale (CFS) on adverse outcomes and length of stay in the ED before intensive care unit (ICU) admission. METHODS We conducted this prospective observational study with patients 65 years or older and admitted to the ICU from March 1, 2021 to December 31, 2022. We divided the patients into four groups according to their CFS scores. We determined the effects of frailty severity on length of ED stay and clinical outcomes using logistic regression analysis. RESULTS Of the 920 patients included in the study, 25.4% were nonfrail, 26.2% had mild frailty, 25.9% had moderate frailty, and 22.5% had severe frailty. In the regression analysis, compared with those who were nonfrail, the length of ED stay was significantly longer for those with moderate frailty (odds ratio [OR] 2.13; 95% confidence interval [CI] 1.63-2.90) or severe frailty (OR 3.32; 95% CI 1.92-3.87), but the result was not significant for those with mild frailty (OR 1.65; 95% CI 1.21-2.45). ICU mortality was significantly higher among patients with mild, moderate, or severe frailty than among those who were nonfrail. CONCLUSIONS We found CFS score to be a predictor of length of ED stay and adverse outcomes. Accordingly, CFS evaluation can provide an idea of the length of ED stay and the likelihood of adverse outcomes.
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Affiliation(s)
- Ekrem Taha Sert
- Department of Emergency Medicine, Aksaray University Medical School, Aksaray, Turkey
| | - Kamil Kokulu
- Department of Emergency Medicine, Aksaray University Medical School, Aksaray, Turkey
| | - Hüseyin Mutlu
- Department of Emergency Medicine, Aksaray University Medical School, Aksaray, Turkey
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Majmundar M, Patel KN, Doshi R, Mehta H, Vindhyal MR, Hance KA, Ali A, Gupta K. Prognostic Value of Hospital Frailty Risk Score and Clinical Outcomes in Patients Undergoing Revascularization for Critical Limb-Threatening Ischemia. J Am Heart Assoc 2023; 12:e030294. [PMID: 37642031 PMCID: PMC10547316 DOI: 10.1161/jaha.123.030294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/28/2023] [Indexed: 08/31/2023]
Abstract
Background The impact of medical record-based frailty assessment on clinical outcomes in patients undergoing revascularization for critical limb-threatening ischemia (CLTI) is unknown. Methods and Results This study included patients with CLTI aged ≥18 years from the nationwide readmissions database 2016 to 2018 who underwent endovascular revascularization (ER) or surgical revascularization (SR). The hospital frailty risk score, a previously validated International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) claims-based score, was used to categorize patients into low- (<5), intermediate- (5-15), and high-risk (>15) frailty categories. Primary outcomes were in-hospital mortality and major amputation at 6 months. A total of 64 338 patients were identified who underwent ER (82.3%) or SR (17.7%) for CLTI. The mean (SD) age of the cohort was 69.3 (11.8) years, and 63% of patients were male. This study found a nonlinear association between hospital frailty risk score and in-hospital mortality and 6-month major amputation. In both ER and SR cohorts, the intermediate- and high-risk groups were associated with a significantly higher risk of in-hospital mortality (high-risk group: ER: odds ratio [OR], 7.2 [95% CI, 4.4-11.6], P<0.001; SR: OR, 28.6 [95% CI, 3.4-237.6], P=0.002) and major amputation at 6 months (high-risk group: ER: hazard ratio [HR], 1.6 [95% CI, 1.5-1.7], P<0.001; SR: HR, 1.7 [95% CI, 1.4-2.2], P<0.001) compared with the low-risk group. Conclusions The hospital frailty risk score, generated from the medical record, can identify frailty and predict in-hospital mortality and 6-month major amputation in patients undergoing ER or SR for CLTI. Further studies are needed to assess if this score can be incorporated into clinical decision-making in patients undergoing revascularization for CLTI.
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Affiliation(s)
- Monil Majmundar
- Department of Cardiovascular MedicineUniversity of Kansas Medical CenterKansas CityKSUSA
| | - Kunal N. Patel
- Department of Cardiovascular MedicineWest Virginia UniversityMorgantownWVUSA
| | - Rajkumar Doshi
- Department of CardiologySt. Joseph’s University Medical CenterPatersonNJUSA
| | - Harsh Mehta
- Department of Cardiovascular MedicineUniversity of Kansas Medical CenterKansas CityKSUSA
| | - Mohinder R. Vindhyal
- Department of Cardiovascular MedicineUniversity of Kansas Medical CenterKansas CityKSUSA
| | - Kirk A Hance
- Department of Surgery, Division of Vascular SurgeryUniversity of Kansas Medical CenterKSKansas CityUSA
| | - Adam Ali
- Department of RadiologyUniversity of Kansas Medical CenterKansas CityKSUSA
| | - Kamal Gupta
- Department of Cardiovascular MedicineUniversity of Kansas Medical CenterKansas CityKSUSA
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Groot B, Hendrikx A, Bendien E, Woelders S, de Kock L, Abma T. In search of epistemic justice. Dialogical reflection of researchers on situated ethics in studies with people living with language and/or cognitive impairment. J Aging Stud 2023; 66:101154. [PMID: 37704272 DOI: 10.1016/j.jaging.2023.101154] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Academics aim to understand the experiences of people living with cognitive and/or language impairment in their search for epistemic justice. Methods that do not rely solely on verbal information (e.g., interviews, focus groups) but also employ an attunement to the non-verbal - such as participant observation and creative methods, are seen as a suitable way to do justice to people's non-verbal interactions. However, in practice, researchers still experience ethical issues in everyday encounters with participants with cognitive and/or language impairment even when trying to address epistemic issues while employing such methods. This article aims to demonstrate 1) the importance of attending to the non-verbal in order to prevent epistemic injustice in research and 2) how a case-study approach and discussing ethical dilemmas with peers may help to unpack some of the ethical tensions that the researchers experience. AIM AND METHODS This article focuses on ethical dilemmas the authors encountered during their research projects in the past. Three cases chosen by the authors illustrate these dilemmas. Dilemmas are presented as auto-ethnographical written accounts, which were discussed during ten retrospective dialogical sessions (60-90 min) organized by the research group consisting of six academic researchers. RESULTS Ethically sound research, in which older people living with cognitive and/or language impairment are engaged, entails much more than following procedures about informed consent, privacy, submitting a proposal to an ethics committee, and using suitable methods and techniques. Ethical issues in these studies relate to everyday situations in which researchers tried to do justice to the knowledge of people who have difficulties expressing themselves verbally, but were challenged by what they have initially experienced as 'having it wrong,' 'not knowing,' and 'losing something in translation' in their practice. Finally, we learned that the interactions the researchers encountered were complex. They had to constantly evaluate the appropriateness of their approach, balance rational and intuitive forms of interaction and interpretation, and consider ways of communicating the research findings. DISCUSSION AND CONCLUSION Approximating epistemic justice in research with people with cognitive and/or language impairment requires extra effort in daily research routines. Sharing everyday ethical issues via case stories and reflecting on these issues encourages moral learning and brings new knowledge about the craftsmanship of researchers. Especially the collaborative and dialogical reflection helped the researchers to dig deeper and find words for intangible processes that often remain unaddressed. However, sharing stories about ethical issues requires mutual trust and safety because sharing and reflecting may bring discomfort, messiness, and uncertainty.
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Affiliation(s)
- Barbara Groot
- Leiden University Medical Centre (LUMC), Leiden, the Netherlands; Leyden Academy on Vitality and Ageing, Leiden, the Netherlands; Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands.
| | | | - Elena Bendien
- Leiden University Medical Centre (LUMC), Leiden, the Netherlands; Leyden Academy on Vitality and Ageing, Leiden, the Netherlands
| | - Susan Woelders
- Susan Woelders - Onderzoek in Professionele Praktijken, Haarlem, the Netherlands
| | - Lieke de Kock
- Leiden University Medical Centre (LUMC), Leiden, the Netherlands; Leyden Academy on Vitality and Ageing, Leiden, the Netherlands
| | - Tineke Abma
- Leiden University Medical Centre (LUMC), Leiden, the Netherlands; Leyden Academy on Vitality and Ageing, Leiden, the Netherlands
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Salave S, Patel P, Desai N, Rana D, Benival D, Khunt D, Thanawuth K, Prajapati BG, Sriamornsak P. Recent advances in dosage form design for the elderly: a review. Expert Opin Drug Deliv 2023; 20:1553-1571. [PMID: 37978899 DOI: 10.1080/17425247.2023.2286368] [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: 09/17/2023] [Accepted: 11/17/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION With the increase in the elderly population and the prevalence of multiple medical conditions, medication adherence, and efficacy have become crucial for the effective management of their health. The aging population faces unique challenges that need to be addressed through advancements in drug delivery systems and formulation technologies. AREAS COVERED The current review highlights the recent advances in dosage form design for older individuals, with consideration of their specific physiological and cognitive changes. Various dosage forms, such as modified-release tablets/capsules, chewable tablets, and transdermal patches, can be tailored to meet the specific needs of elderly patients. Advancements in drug delivery systems, such as nanotherapeutics, additive manufacturing (three-dimensional printing), and drug-food combinations, improve drug delivery and efficacy and overcome challenges, such as dysphagia and medication adherence. EXPERT OPINION Regulatory guidelines and considerations are crucial in ensuring the safe utilization of medications among older adults. Important factors to consider include geriatric-specific guidelines, safety considerations, labeling requirements, clinical trial considerations, and adherence and accessibility considerations.
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Affiliation(s)
- Sagar Salave
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, India
| | - Pranav Patel
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, India
| | - Nimeet Desai
- Department of Biomedical Engineering, Indian Institute of Technology Hyderabad, Kandi, India
| | - Dhwani Rana
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, India
| | - Derajram Benival
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, India
| | - Dignesh Khunt
- Graduate School of Pharmacy, Gujarat Technological University, Gandhinagar, Gujarat, India
| | | | - Bhupendra G Prajapati
- Shree S. K. Patel College of Pharmaceutical Education and Research, Ganpat University, Mehsana, India
| | - Pornsak Sriamornsak
- Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, Thailand
- Academy of Science, The Royal Society of Thailand, Bangkok, Thailand
- Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
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12
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Mozersky J, Solomon ED, Baldwin K, Wroblewski M, Parsons M, Goodman M, DuBois JM. Barriers to Using Legally Authorized Representatives in Clinical Research with Older Adults. J Alzheimers Dis Rep 2023; 7:135-149. [PMID: 36891257 PMCID: PMC9986706 DOI: 10.3233/adr-220103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/09/2023] [Indexed: 02/10/2023] Open
Abstract
Background Older adults are at increased risk of cognitive impairments including Alzheimer's disease dementia. Legally authorized representatives (LARs) can provide informed consent when a participant is no longer able to, but little is known about barriers to incorporating them in research. Objective Explore reasons for not asking and documenting participant decisions to appoint LARs among researchers conducting clinical intervention trials studying older adults or individuals with cognitive impairments. Methods Mixed method design consisting of a survey (N = 1,284) and qualitative interviews (N = 40) regarding barriers to incorporating LARs. Participants were principal investigators and clinical research coordinators. Results 37% (N = 469) had not asked and documented participant decisions about appointing LARs in the prior year. They had significantly lower confidence in resources available to incorporate LARs and lower positive attitudes compared to their counterparts who had done so. The majority (83%) had no trials studying individuals with cognitive impairments and reported LARs were not applicable. A minority (17%) had at least one trial studying individuals with cognitive impairments and reported being unaware of LARs. Qualitative findings indicate discomfort broaching a sensitive topic especially with individuals who are not yet impaired. Conclusion Resources and education to increase awareness and knowledge of LARs are needed. Researchers studying older adults should, at minimum, have the knowledge and resources to incorporate LARs when necessary. Stigma and discomfort discussing LARs will need to be overcome, as early proactive discussions before a participant loses decisional capacity could enhance participant autonomy and facilitate recruitment and retention of older adults to research.
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Affiliation(s)
- Jessica Mozersky
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Erin D Solomon
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Kari Baldwin
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Matthew Wroblewski
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Meredith Parsons
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Melody Goodman
- School of Global Public Health, New York University, New York, NY, USA
| | - James M DuBois
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
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13
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A randomized implementation trial to increase adoption of evidence-informed consent practices. J Clin Transl Sci 2022; 7:e28. [PMID: 36721403 PMCID: PMC9884547 DOI: 10.1017/cts.2022.520] [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: 08/01/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Several evidence-informed consent practices (ECPs) have been shown to improve informed consent in clinical trials but are not routinely used. These include optimizing consent formatting, using plain language, using validated instruments to assess understanding, and involving legally authorized representatives when appropriate. We hypothesized that participants receiving an implementation science toolkit and a social media push would have increased adoption of ECPs and other outcomes. Methods We conducted a 1-year trial with clinical research professionals in the USA (n = 1284) who have trials open to older adults or focus on Alzheimer's disease. We randomized participants to receive information on ECPs via receiving a toolkit with a social media push (intervention) or receiving an online learning module (active control). Participants completed a baseline survey and a follow-up survey after 1 year. A subset of participants was interviewed (n = 43). Results Participants who engaged more with the toolkit were more likely to have tried to implement an ECP during the trial than participants less engaged with the toolkit or the active control group. However, there were no significant differences in the adoption of ECPs, intention to adopt, or positive attitudes. Participants reported the toolkit and social media push were satisfactory, and participating increased their awareness of ECPs. However, they reported lacking the time needed to engage with the toolkit more fully. Conclusions Using an implementation science approach to increase the use of ECPs was only modestly successful. Data suggest that having institutional review boards recommend or require ECPs may be an effective way to increase their use.
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Kabell Nissen S, Rueegg M, Carpenter CR, Kaeppeli T, Busch J, Fournaise A, Dreher‐Hummel T, Bingisser R, Brabrand M, Nickel CH. Prognosis for older people at presentation to emergency department based on frailty and aggregated vital signs. J Am Geriatr Soc 2022; 71:1250-1258. [PMID: 36511431 DOI: 10.1111/jgs.18170] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 11/07/2022] [Accepted: 11/19/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Risk stratification for older people based on aggregated vital signs lack the accuracy to predict mortality at presentation to the Emergency Department (ED). We aimed to develop and internally validate the Frailty adjusted Prognosis in ED tool (FaP-ED) for 30-day mortality combining frailty and aggregated vital signs. METHODS Single-center prospective cohort of undifferentiated ED patients aged 65 or older, consecutively sampled upon ED presentation from a tertiary Emergency Center. Vital signs were aggregated using the National Early Warning Score (NEWS) as a measure of illness or injury severity and frailty was assessed with the Clinical Frailty Scale (CFS). The FaP-ED was constructed by combining NEWS and CFS in multivariable logistic regression. The primary outcome was 30-day mortality. Measures of discrimination and calibration were assessed to evaluate predictive performance and internally validated using bootstrapping. RESULTS 2250 patients were included, 67 (1.8%) were omitted from analyses due to missing CFS, loss to follow-up, or terminal illness. Thirty-day mortality rate was 5.4% (N = 122, 95% CI = 4.5%-6.4%). Median NEWS was 1 (Inter-Quartile Range (IQR): 0-3) and median CFS was 4 (IQR: 3-5). The Area Under Receiver Operating Characteristic (AUROC) for FaP-ED was 0.86 (95% CI = 0.83-0.90). This was significantly higher than NEWS (0.81, 95% CI = 0.77-0.85, DeLong: Z = 3.5, p < 0.001) or CFS alone (0.82, 95% CI = 0.78-0.86, DeLong: Z = 4.4, p < 0.001). Bootstrapped estimates of FaP-ED AUROC, calibration slope, and intercept were 0.86, 0.95, and -0.09, respectively, suggesting internal validity. A decision-threshold of CFS 5 and NEWS 3 was proposed based on qualitative comparison of positive Likelihood Ratio at all relevant FaP-ED cutoffs. CONCLUSION Combining aggregated vital signs and frailty accurately predicted 30-day mortality at ED presentation and illustrated an important clinical interaction between frailty and illness severity. Pending external validation, the Fap-ED operationalizes the concept of such "geriatric urgency" for the ED setting.
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Affiliation(s)
- Søren Kabell Nissen
- Institute of Regional Health Research University of Southern Denmark Esbjerg Denmark
- Department of Emergency Medicine Hospital South West Jutland, University hospital of Southern Denmark Esbjerg Denmark
| | - Marco Rueegg
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
| | - Christopher R. Carpenter
- Department of Emergency Medicine Washington University in St. Louis School of Medicine, Emergency Care Research Core St. Louis Michigan USA
| | - Tobias Kaeppeli
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
| | - Jeanette‐Marie Busch
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
| | - Anders Fournaise
- Department of Cross‐sectoral Collaboration Region of Southern Denmark Vejle Denmark
- Epidemiology, Biostatistics and Biodemography, Department of Public Health University of Southern Denmark Odense Denmark
- Geriatric Research Unit, Department of Geriatric Medicine Odense University Hospital Odense Denmark
| | - Thomas Dreher‐Hummel
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
| | - Roland Bingisser
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
| | - Mikkel Brabrand
- Institute of Regional Health Research University of Southern Denmark Esbjerg Denmark
- Department of Emergency Medicine Odense University Hospital Odense Denmark
| | - Christian H. Nickel
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
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Carpenter CR, Southerland LT, Lucey BP, Prusaczyk B. Around the EQUATOR with clinician-scientists transdisciplinary aging research (Clin-STAR) principles: Implementation science challenges and opportunities. J Am Geriatr Soc 2022; 70:3620-3630. [PMID: 36005482 PMCID: PMC10538952 DOI: 10.1111/jgs.17993] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/25/2022] [Accepted: 07/04/2022] [Indexed: 12/24/2022]
Abstract
The Institute of Medicine and the National Institute on Aging increasingly understand that knowledge alone is necessary but insufficient to improve healthcare outcomes. Adapting the behaviors of clinicians, patients, and stakeholders to new standards of evidence-based clinical practice is often significantly delayed. In response, over the past twenty years, Implementation Science has developed as the study of methods and strategies that facilitate the uptake of evidence-based practice into regular use by practitioners and policymakers. One important advance in Implementation Science research was the development of Standards for Reporting Implementation Studies (StaRI), which provided a 27-item checklist for researchers to consistently report essential elements of the implementation and intervention strategies. Using StaRI as a framework, this review discusses specific Implementation Science challenges for research with older adults, provides solutions for those obstacles, and opportunities to improve the value of this evolving approach to reduce the knowledge translation losses that exist between published research and clinical practice.
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Affiliation(s)
- Christopher R Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Brendan P Lucey
- Department of Neurology, Washington University in St Louis School of Medicine, St. Louis, Missouri, USA
| | - Beth Prusaczyk
- Department of Medicine Institute for Informatics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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16
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Gettel CJ, Serina PT, Uzamere I, Hernandez‐Bigos K, Venkatesh AK, Cohen AB, Monin JK, Feder SL, Fried TR, Hwang U. Emergency department care transition barriers: A qualitative study of care partners of older adults with cognitive impairment. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2022; 8:e12355. [PMID: 36204349 PMCID: PMC9518973 DOI: 10.1002/trc2.12355] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION After emergency department (ED) discharge, persons living with cognitive impairment (PLWCI) and their care partners are particularly at risk for adverse outcomes. We sought to identify the barriers experienced by care partners of PLWCI during ED discharge care transitions. METHODS We conducted a qualitative study of 25 care partners of PLWCI discharged from four EDs. We used the validated 4AT and care partner-completed AD8 screening tools, respectively, to exclude care partners of older adults with concern for delirium and include care partners of older adults with cognitive impairment. We conducted recorded, semi-structured interviews using a standardized guide, and two team members coded and analyzed all professional transcriptions to identify emerging themes and representative quotations. RESULTS Care partners' mean age was 56.7 years, 80% were female, and 24% identified as African American. We identified four major barriers regarding ED discharge care transitions among care partners of PLWCI: (1) unique care considerations while in the ED setting impact the perceived success of the care transition, (2) poor communication and lack of care partner engagement was a commonplace during the ED discharge process, (3) care partners experienced challenges and additional responsibilities when aiding during acute illness and recovery phases, and (4) navigating the health care system after an ED encounter was perceived as difficult by care partners. DISCUSSION Our findings demonstrate critical barriers faced during ED discharge care transitions among care partners of PLWCI. Findings from this work may inform the development of novel care partner-reported outcome measures as well as ED discharge care transition interventions targeting care partners.
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Affiliation(s)
- Cameron J. Gettel
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
- Center for Outcomes Research and EvaluationYale School of MedicineNew HavenConnecticutUSA
| | - Peter T. Serina
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Ivie Uzamere
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Kizzy Hernandez‐Bigos
- Section of GeriatricsDepartment of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Arjun K. Venkatesh
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
- Center for Outcomes Research and EvaluationYale School of MedicineNew HavenConnecticutUSA
| | - Andrew B. Cohen
- Section of GeriatricsDepartment of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
| | - Joan K. Monin
- Social and Behavioral SciencesYale School of Public HealthNew HavenConnecticutUSA
| | - Shelli L. Feder
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
- Yale University School of NursingOrangeConnecticutUSA
| | - Terri R. Fried
- Section of GeriatricsDepartment of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
| | - Ula Hwang
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
- Geriatrics ResearchEducation and Clinical CenterJames J. Peters VA Medical CenterBronxNew YorkUSA
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Carpenter CR, Dresden SM, Shah MN, Hwang U. Adapting Emergency Care for Persons Living With Dementia: Results of the Geriatric Emergency Care Applied Research Network Scoping Review and Consensus Conference. J Am Med Dir Assoc 2022; 23:1286-1287. [PMID: 35940679 DOI: 10.1016/j.jamda.2022.05.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 05/14/2022] [Indexed: 12/16/2022]
Affiliation(s)
- Christopher R Carpenter
- Department of Emergency Medicine, Washington University in St Louis School of Medicine, Emergency Care Research Core, St Louis, MO, USA.
| | - Scott M Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
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Carpenter CR, Leggett J, Bellolio F, Betz M, Carnahan RM, Carr D, Doering M, Hansen JC, Isaacs ED, Jobe D, Kelly K, Morrow-Howell N, Prusaczyk B, Savage B, Suyama J, Vann AS, Rising KL, Hwang U, Shah MN. Emergency Department Communication in Persons Living With Dementia and Care Partners: A Scoping Review. J Am Med Dir Assoc 2022; 23:1313.e15-1313.e46. [PMID: 35940681 PMCID: PMC10802113 DOI: 10.1016/j.jamda.2022.02.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To synthesize published research exploring emergency department (ED) communication strategies and decision-making with persons living with dementia (PLWD) and their care partners as the basis for a multistakeholder consensus conference to prioritize future research. DESIGN Systematic scoping review. SETTINGS AND PARTICIPANTS PLWD and their care partners in the ED setting. METHODS Informed by 2 Patient-Intervention-Comparison-Outcome (PICO) questions, we conducted systematic electronic searches of medical research databases for relevant publications following standardized methodological guidelines. The results were presented to interdisciplinary stakeholders, including dementia researchers, clinicians, PLWD, care partners, and advocacy organizations. The PICO questions included: How does communication differ for PLWD compared with persons without dementia? Are there specific communication strategies that improve the outcomes of ED care? Future research areas were prioritized. RESULTS From 5451 studies identified for PICO-1, 21 were abstracted. From 2687 studies identified for PICO-2, 3 were abstracted. None of the included studies directly evaluated communication differences between PLWD and other populations, nor the effectiveness of specific communication strategies. General themes emerging from the scoping review included perceptions by PLWD/care partners of rushed ED communication, often exacerbated by inconsistent messages between providers. Care partners consistently reported limited engagement in medical decision-making. In order, the research priorities identified included: (1) Barriers/facilitators of effective communication; (2) valid outcome measures of effective communication; (3) best practices for care partner engagement; (4) defining how individual-, provider-, and system-level factors influence communication; and (5) understanding how each member of ED team can ensure high-quality communication. CONCLUSIONS AND IMPLICATIONS Research exploring ED communication with PLWD is sparse and does not directly evaluate specific communication strategies. Defining barriers and facilitators of effective communication was the highest-ranked research priority, followed by validating outcome measures associated with improved information exchange.
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Affiliation(s)
- Christopher R Carpenter
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, Emergency Care Research Core, St. Louis, MO, USA.
| | - Jesseca Leggett
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, Emergency Care Research Core, St. Louis, MO, USA
| | | | - Marian Betz
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO, USA
| | - Ryan M Carnahan
- Department of Epidemiology, The University of Iowa College of Public Health, Iowa City, IA, USA
| | - David Carr
- Department of Medicine and Neurology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Michelle Doering
- Becker Medical Library, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | | | - Eric D Isaacs
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Deborah Jobe
- Person Living with Dementia, 2021-2022 Alzheimer's Association National Early Stage Advisory Group, St. Louis MO, USA
| | | | - Nancy Morrow-Howell
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA
| | - Beth Prusaczyk
- Department of Medicine, Institute for Informatics, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Bob Savage
- Person Living with Dementia, LiveWell Alliance, Plantsville, CT, USA
| | - Joe Suyama
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Kristin L Rising
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale University, New Haven, CT, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
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Wang A, Ferro EG, Song Y, Xu J, Sun T, Yeh RW, Strom JB, Kramer DB. Frailty in patients undergoing percutaneous left atrial appendage closure. Heart Rhythm 2022; 19:814-821. [PMID: 35031495 PMCID: PMC9968991 DOI: 10.1016/j.hrthm.2022.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 01/01/2022] [Accepted: 01/06/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Frailty is associated with significant morbidity and mortality in older adults. Whether frailty predicts adverse outcomes after percutaneous left atrial appendage closure (LAAC) remains uncertain. OBJECTIVE The purpose of this study was to examine the association between frailty and clinical outcomes after percutaneous LAAC. METHODS We identified patients 65 years and older in Medicare fee-for-service claims who underwent LAAC between October 1, 2016, and December 31, 2019. Patients were identified as frail on the basis of the Hospital Frailty Risk Score (HFRS), a validated frailty measure centered on health resource utilization, with the cohort stratified into low (<5), intermediate (5-15), and high (>15) risk groups. RESULTS Of the 21,787 patients who underwent LAAC, 10,740 (49.3%) were considered frail (HFRS >5), including 3441 (15.8%) in the high-risk group. The mortality rate (up to 1095 days) were 16.1% in the low-risk group, 26.7% in the intermediate-risk group, and 41.1% in the high-risk group (P < .001). After adjusting for age, sex, and comorbidities, HFRS >15 (compared with HFRS <5) was associated with a higher risk of long hospital stay (odds ratio [OR] 8.29; 95% confidence interval [CI] 5.94-11.57), 30-day readmission (OR 1.80, 95% CI 1.58-2.05), 30-day mortality (OR 5.68, 95% CI 3.40-9.40), and 1-year mortality (OR 2.83, 95% CI 2.39-3.35). In restricted cubic spline models, the adjusted OR for all outcomes monotonically increased with increasing HFRS. CONCLUSION Frailty is common in patients undergoing LAAC and is associated with increased risks of long hospital stay, readmissions, and short-term mortality.
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Rueegg M, Nissen SK, Brabrand M, Kaeppeli T, Dreher T, Carpenter CR, Bingisser R, Nickel CH. The clinical frailty scale predicts 1-year mortality in emergency department patients aged 65 years and older. Acad Emerg Med 2022; 29:572-580. [PMID: 35138670 PMCID: PMC9320818 DOI: 10.1111/acem.14460] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/13/2021] [Accepted: 12/28/2021] [Indexed: 12/22/2022]
Abstract
Objective To validate the Clinical Frailty Scale (CFS) for prediction of 1‐year all‐cause mortality in the emergency department (ED) and compare its performance to the Emergency Severity Index (ESI). Methods Prospective cohort study at the ED of a tertiary care center in Northwestern Switzerland. All patients aged ≥65 years were included from March 18 to May 20, 2019, after informed consent. Frailty status was assessed using CFS, excluding level 9 (palliative). Acuity level was assessed using ESI. Both CFS and ESI were adjusted for age, sex and presenting condition in multivariable logistic regression. Prognostic performance was assessed for discrimination and calibration separately. Estimates were internally validated by Bootstrapping. Restricted mean survival time (RMST) was determined for all levels of CFS. Results In the final study population of 2191 patients, 1‐year all‐cause mortality was 17% (n = 372). RMST values ranged from 219 days for CFS 8 to 365 days for CFS 1. The adjusted CFS model had an area under receiver operating characteristic of 0.767 (95% confidence interval [CI]: 0.741–0.793), compared to 0.703 (95% CI: 0.673–0.732) for the adjusted ESI model. Conclusion The CFS predicts 1‐year all‐cause mortality for older ED patients and predicts survival time in a graded manner. The CFS is superior to the ESI when adjusted for age, sex, and presenting condition.
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Affiliation(s)
- Marco Rueegg
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
| | - Søren Kabell Nissen
- Institute of Regional Health Research, Centre South‐West Jutland University of Southern Denmark Odense Denmark
| | - Mikkel Brabrand
- Institute of Regional Health Research, Centre South‐West Jutland University of Southern Denmark Odense Denmark
- Department of Emergency Medicine Odense University Hospital, University of Southern Denmark Odense Denmark
| | - Tobias Kaeppeli
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
| | - Thomas Dreher
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
| | - Christopher R. Carpenter
- Department of Emergency MedicineWashington University in St. Louis School of Medicine, Emergency Care Research CoreSt. LouisMichiganUSA
| | - Roland Bingisser
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
| | - Christian H. Nickel
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
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21
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An exploration of financial toxicity among low-income patients with cancer in Central Texas: A mixed methods analysis. Palliat Support Care 2022; 21:411-421. [PMID: 35301963 DOI: 10.1017/s1478951522000256] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Financial toxicity is of increasing concern in the United States. The Comprehensive Score for Financial Toxicity (COST) is a validated measure; however, it has not been widely utilized among low-income patients and may not fully capture financial toxicity in this population. Furthermore, the relationships between financial toxicity, quality of life (QOL), and patient well-being are poorly understood. We describe the experience of financial toxicity among low-income adults receiving cancer care. We hypothesized that higher financial toxicity would be associated with less income and lower quality of life. Qualitative interviews focused on the financial impact of cancer treatment. METHOD This study was conducted at a cancer clinic in Central Texas. Quantitative and qualitative data were collected in Fall and Spring 2018, respectively. The quantitative sample (N = 115) was dichotomized by annual income (<$15,000 vs. >$15,000). Outcomes included financial toxicity (COST), quality of life (FACT-G), and patient well-being (PROMIS measures: Anxiety, Depression, Fatigue, Pain Interference, and Physical Function). Associations between quality of life, patient well-being, and financial toxicity were evaluated using linear regression. Sequential qualitative interviews were conducted with a subsample of 12 participants. RESULTS Patients with <$15k had significantly lower levels of QOL and patient well-being such as depression and anxiety compared to patients with >$15k across multiple measures. A multivariate linear regression found QOL (Β = 0.17, 95% CI = 0.05, 0.29, p = 0.008) and insurance status (Β = -3.79, 95% CI = -7.42, -0.16, p = 0.04), but not income, were significantly associated with financial toxicity. Three qualitative themes regarding patient's access to cancer care were identified: obtaining healthcare coverage, maintaining financial stability, and receiving social support. SIGNIFICANCE OF RESULTS Low-income patients with cancer face unique access barriers and are at risk for forgoing treatment or increased symptom burdens. Comprehensive assessment and financial navigation may improve access to care, symptom management, and reduce strain on social support systems.
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22
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Hunold KM, Goldberg EM, Caterino JM, Hwang U, Platts-Mills TF, Shah MN, Rosen T. Inclusion of older adults in emergency department clinical research: Strategies to achieve a critical goal. Acad Emerg Med 2022; 29:376-383. [PMID: 34582613 PMCID: PMC8958170 DOI: 10.1111/acem.14386] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 12/13/2022]
Abstract
Medical research across all fields has historically excluded older adults (aged 65 years and older). Because older adults have a higher burden of chronic illness, respond differently to treatment, and are more prone to medication side effects, the results of current research may not be applicable to this important population. To address this major research deficiency, the National Institutes of Health established the Inclusion Across the Lifespan policy, effective January 2019. We present important considerations and proven strategies for successful inclusion of older adults in emergency care research relating to study design, participant recruitment and retention, and sources of support for investigators.
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Affiliation(s)
| | | | | | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven CT,Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, NY
| | | | - Manish N. Shah
- BarbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Tony Rosen
- Department of Emergency Medicine, Division of Geriatric Emergency Medicine, New York-Presbyterian Hospital / Weill Cornell Medical Center, New York, NY
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23
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Solomon ED, Mozersky J, Wroblewski M, Baldwin K, Parsons M, Goodman M, DuBois JM. Understanding the Use of Optimal Formatting and Plain Language When Presenting Key Information in Clinical Trials. J Empir Res Hum Res Ethics 2022; 17:177-192. [PMID: 34410175 PMCID: PMC8712347 DOI: 10.1177/15562646211037546] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recent revisions to the Common Rule require that consent documents begin with a focused presentation of the study's key information that is organized to facilitate understanding. We surveyed 1,284 researchers working with older adults or individuals with Alzheimer's disease, supplemented with 60 qualitative interviews, to understand current use and barriers to using evidence-based formatting and plain language in key information. Researchers reported using formatting in 42% of their key information sections, and plain language in 63% of their key information sections. Perceived barriers included lack of knowledge, Institutional Review Board, other members of their team, and the burden associated with implementation. Education and training are required to increase adoption of the practices.
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Affiliation(s)
| | | | | | - Kari Baldwin
- Washington University School of Medicine in St. Louis (USA)
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24
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Daddato AE, Staton EW, Bettcher BM, Shanbhag P, Lum HD. Human-Centered Design of an Advance Care Planning Group Visit for Mild Cognitive Impairment. THE GERONTOLOGIST 2021; 62:1226-1237. [PMID: 34940855 PMCID: PMC9451012 DOI: 10.1093/geront/gnab181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVES While advance care planning (ACP) is critical for ensuring optimal end-of-life outcomes among individuals with mild cognitive impairment (MCI), many individuals who may benefit from ACP have not initiated this process. This article aims to describe the iterative design of an MCI group visit-based intervention and evaluate the feasibility and acceptability of the intervention. RESEARCH DESIGN AND METHODS We used human-centered design, rapid-cycle prototyping, and multiple methods to adapt an ENgaging in Advance Care planning Talks (ENACT) Group Visits intervention. We convened an advisory panel of persons with MCI and care partners (n = 6 dyads) to refine the intervention and conducted a single-arm pilot of 4 MCI ENACT intervention prototypes (n = 13 dyads). We used surveys and interviews to assess outcomes from multiple perspectives. RESULTS The advisory panel affirmed that ACP is a priority for individuals with MCI, described the need for ACP in a group setting, and suggested refinements to ACP resources for the MCI ENACT intervention. Feasibility of recruitment was limited. MCI ENACT intervention participants strongly agreed that group discussions provided useful information and recommended the intervention. Themes supporting acceptability included (a) feedback on acceptability of the intervention, (b) previous experiences with ACP, and (c) reasons for participation, including desire for discussions about MCI and how it relates to ACP. DISCUSSION AND IMPLICATIONS Despite stakeholders' positive ratings of acceptability of the MCI ENACT intervention, future work is needed to enhance the feasibility of recruitment to support implementation into clinical settings.
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Affiliation(s)
- Andrea E Daddato
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Elizabeth W Staton
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Brianne M Bettcher
- Alzheimer’s and Cognition Center, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Prajakta Shanbhag
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Hillary D Lum
- Address correspondence to: Hillary D. Lum, MD, PhD, Division of Geriatric Medicine, University of Colorado School of Medicine, 12631 E. 17th Ave., Mail Stop B179, Aurora, CO 80045, USA. E-mail: ; Twitter handle: @hdaylum
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25
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Perceived barriers to assessing understanding and appreciation of informed consent in clinical trials: A mixed-method study. J Clin Transl Sci 2021; 5:e164. [PMID: 34589234 PMCID: PMC8453455 DOI: 10.1017/cts.2021.807] [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: 04/06/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction: Participants and research professionals often overestimate how well participants understand and appreciate consent information for clinical trials, and experts often vary in their determinations of participant’s capacity to consent to research. Past research has developed and validated instruments designed to assess participant understanding and appreciation, but the frequency with which they are utilized is unknown. Methods: We administered a survey to clinical researchers working with older adults or those at risk of cognitive impairment (N = 1284), supplemented by qualitative interviews (N = 60). Results: We found that using a validated assessment of consent is relatively uncommon, being used by only 44% of researchers who had an opportunity. Factors that predicted adoption of validated assessments included not seeing the study sponsor as a barrier, positive attitudes toward assessments, and being confident that they had the resources needed to implement an assessment. The perceived barriers to adopting validated assessments of consent included lack of awareness, lack of knowledge, being unsure of how to administer such an assessment, and the burden associated with implementing this practice. Conclusions: Increasing the use of validated assessments of consent will require educating researchers on the practice and emphasizing very practical assessments, and may require Institutional Review Boards (IRBs) or study sponsors to champion the use of assessments.
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26
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Randell E, McNamara R, Busse M. Process evaluation in intellectual disability research: A case study and the need for adaptation of frameworks. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2021; 35:188-195. [PMID: 34553462 DOI: 10.1111/jar.12938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 04/01/2021] [Accepted: 08/22/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Involving adults with cognitive impairments, and specifically intellectual disability, in research is critical to developing appropriate and effective interventions but is highly challenging. Our aim was to examine where complexities lie in delivering research in underrepresented and hard to reach populations using an exemplar process evaluation conducted as part of a drug reduction trial. METHODS Quantitative methods were used to assess recruitment, adherence to the intervention and safety data. Qualitative interviews examined non-efficacy based barriers to drug reduction in clinical practice. RESULTS Feasibility of carrying out a drug reduction trial was limited by a lack of exploration of acceptability. Barriers to successful delivery included concerns around wider care team co-operation and consent procedures. CONCLUSIONS It is important to consider interventions involving adults with cognitive impairment, and particularly intellectual disability, as complex. Current process evaluation frameworks require further adaptation to guide research and innovation in these populations.
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Affiliation(s)
- Elizabeth Randell
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK
| | - Rachel McNamara
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK
| | - Monica Busse
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK
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27
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Paramasivam A, Jaiswal A, Minhas R, Wittich W, Spruyt-Rocks R. Informed Consent or Assent Strategies for Research With Individuals With Deafblindness or Dual Sensory Impairment: A Scoping Review. Arch Rehabil Res Clin Transl 2021; 3:100115. [PMID: 34179751 PMCID: PMC8212005 DOI: 10.1016/j.arrct.2021.100115] [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] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To synthesize evidence on existing informed consent/assent strategies and processes that enable the participation of individuazls with deafblindness or dual sensory impairment in research. DATA SOURCES Five scientific databases (PubMed, MEDLINE, Cumulative Index to Nursing and Allied Health, Web of Science, and PsycINFO) and other sources such as Google Scholar, Journal of Visual Impairment and Blindness, and British Journal of Visual Impairment were hand-searched from January 2015 until July 2020. STUDY SELECTION Studies were selected using a priori inclusion criteria of sensory and cognitive disabilities and focused on consent/assent strategies and processes in research within this population. Articles related to the medical or sexual consent processes were excluded. DATA EXTRACTION An Excel spreadsheet was used to extract data from the eligible sources. Discrepancies were resolved in discussion with team members. DATA SYNTHESIS A total of 2163 sources were screened, and 16 articles were included in the review. Seven sources only examined consent strategies, whereas the remaining 8 included a combination of consent/assent and dissent strategies. Using thematic analysis, 3 key themes emerged: consent/assent strategies, researcher capacity, and capacity to consent tools. Key identified strategies included the accessibility of the consent/assent process, building relationships with participants and caregivers, identifying behavioral cues, and communication training for researchers. CONCLUSIONS Despite the absence of literature on consent/assent strategies within the population with deafblindness, the review found promising strategies applied to individuals with other cognitive or sensory disabilities that researchers can adopt. Researchers are encouraged to use best practices in creating an inclusive research environment to include individuals with deafblindness.
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Affiliation(s)
| | - Atul Jaiswal
- School of Optometry, Université de Montréal, Montreal, Quebec, Canada
| | - Renu Minhas
- DeafBlind Ontario Services, Newmarket, Ontario, Canada
| | - Walter Wittich
- School of Optometry, Université de Montréal, Montreal, Quebec, Canada
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28
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Perni S, Hong K, Hong TS, Nipp RD. Toward a Science of Personalized Informed Consent in Cancer Clinical Trials. JCO Oncol Pract 2021; 17:655-661. [PMID: 33974444 DOI: 10.1200/op.20.00975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Subha Perni
- Harvard Radiation Oncology Program, Massachusetts General Hospital and Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA.,Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA
| | - Kessely Hong
- Harvard Kennedy School, Harvard University, Boston, MA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA
| | - Ryan D Nipp
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, MA
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29
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Amgarth-Duff I, Hosie A, Caplan GA, Agar M. Delirium researchers' perspectives of the challenges in delirium biomarker research: A qualitative study. PLoS One 2021; 16:e0243254. [PMID: 33826629 PMCID: PMC8026020 DOI: 10.1371/journal.pone.0243254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/17/2020] [Indexed: 12/02/2022] Open
Abstract
Background Despite the prevalence and impact of delirium, its pathophysiology remains unclear. In order to advance this field of research, robust scientific methodology is required, yet quality of reporting in this field of research has been highly inconsistent. Delirium biomarker research poses several challenges, none of which have been documented in the literature before. The aim of this study was to explore the perspectives of delirium researchers about key methodological issues in delirium biomarker research. Methods Following a Delphi study with delirium experts resulting in 60 recommendations for reporting delirium biomarker studies, semi-structured interviews with international delirium researchers were conducted. Interviews were audio-taped and transcribed verbatim, followed by thematic analysis of the qualitative data. Results Fifteen participants were interviewed between August and November 2019. Most were male (n = 12; 75%), clinician researchers (n = 13; 86%), and had more than ten years’ experience in conducting delirium research (n = 9; 60%). Analysis revealed two major themes and ten sub-themes, outlining key considerations to advance the field of delirium biomarker research. The major themes were: 1) Practical and scientific challenges of delirium biomarker research: stagnation versus driving improved methods and reporting; and 2) Valuing delirium research through investment and collaboration. Conclusion Findings identified a range of factors that contribute to the practical and ethical challenges of conducting delirium biomarker research, which have not previously been explicitly acknowledged or reported. A clear vision for collaborative efforts to enhance research quality for improved impact was also presented by the delirium researchers. This work complements the preceding Delphi and together these studies provide an in-depth understanding of what is needed in the field to inform and improve methods and reporting of delirium biomarker research.
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Affiliation(s)
- Ingrid Amgarth-Duff
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), University of Technology Sydney, Sydney, Australia
- * E-mail:
| | - Annmarie Hosie
- School of Nursing Sydney, The University of Notre Dame Australia, Sydney, Australia
- The Cunningham Centre for Palliative Care Research, St Vincent’s Health Network Sydney, Sydney, Australia
| | - Gideon A. Caplan
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, Australia
| | - Meera Agar
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), University of Technology Sydney, Sydney, Australia
- South West Sydney Clinical School, University of New South Wales, Liverpool, Sydney, Australia
- Ingham Institute of Applied Medical Research, Liverpool, Sydney, Australia
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30
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Wilcock D, Jicha G, Blacker D, Albert MS, D’Orazio LM, Elahi FM, Fornage M, Hinman JD, Knoefel J, Kramer J, Kryscio RJ, Lamar M, Moghekar A, Prestopnik J, Ringman JM, Rosenberg G, Sagare A, Satizabal CL, Schneider J, Seshadri S, Sur S, Tracy RP, Yasar S, Williams V, Singh H, Mazina L, Helmer KG, Corriveau RA, Schwab K, Kivisäkk P, Greenberg SM. MarkVCID cerebral small vessel consortium: I. Enrollment, clinical, fluid protocols. Alzheimers Dement 2021; 17:704-715. [PMID: 33480172 PMCID: PMC8122220 DOI: 10.1002/alz.12215] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/22/2020] [Indexed: 01/04/2023]
Abstract
The concept of vascular contributions to cognitive impairment and dementia (VCID) derives from more than two decades of research indicating that (1) most older individuals with cognitive impairment have post mortem evidence of multiple contributing pathologies and (2) along with the preeminent role of Alzheimer's disease (AD) pathology, cerebrovascular disease accounts for a substantial proportion of this contribution. Contributing cerebrovascular processes include both overt strokes caused by etiologies such as large vessel occlusion, cardioembolism, and embolic infarcts of unknown source, and frequently asymptomatic brain injuries caused by diseases of the small cerebral vessels. Cerebral small vessel diseases such as arteriolosclerosis and cerebral amyloid angiopathy, when present at moderate or greater pathologic severity, are independently associated with worse cognitive performance and greater likelihood of dementia, particularly in combination with AD and other neurodegenerative pathologies. Based on this evidence, the US National Alzheimer's Project Act explicitly authorized accelerated research in vascular and mixed dementia along with frontotemporal and Lewy body dementia and AD itself. Biomarker development has been consistently identified as a key step toward translating scientific advances in VCID into effective prevention and treatment strategies. Validated biomarkers can serve a range of purposes in trials of candidate interventions, including (1) identifying individuals at increased VCID risk, (2) diagnosing the presence of cerebral small vessel disease or specific small vessel pathologies, (3) stratifying study participants according to their prognosis for VCID progression or treatment response, (4) demonstrating an intervention's target engagement or pharmacodynamic mechanism of action, and (5) monitoring disease progression during treatment. Effective biomarkers allow academic and industry investigators to advance promising interventions at early stages of development and discard interventions with low success likelihood. The MarkVCID consortium was formed in 2016 with the goal of developing and validating fluid- and imaging-based biomarkers for the cerebral small vessel diseases associated with VCID. MarkVCID consists of seven project sites and a central coordinating center, working with the National Institute of Neurologic Diseases and Stroke and National Institute on Aging under cooperative agreements. Through an internal selection process, MarkVCID has identified a panel of 11 candidate biomarker "kits" (consisting of the biomarker measure and the clinical and cognitive data used to validate it) and established a range of harmonized procedures and protocols for participant enrollment, clinical and cognitive evaluation, collection and handling of fluid samples, acquisition of neuroimaging studies, and biomarker validation. The overarching goal of these protocols is to generate rigorous validating data that could be used by investigators throughout the research community in selecting and applying biomarkers to multi-site VCID trials. Key features of MarkVCID participant enrollment, clinical/cognitive testing, and fluid biomarker procedures are summarized here, with full details in the following text, tables, and supplemental material, and a description of the MarkVCID imaging biomarker procedures in a companion paper, "MarkVCID Cerebral small vessel consortium: II. Neuroimaging protocols." The procedures described here address a range of challenges in MarkVCID's design, notably: (1) acquiring all data under informed consent and enrollment procedures that allow unlimited sharing and open-ended analyses without compromising participant privacy rights; (2) acquiring the data in a sufficiently wide range of study participants to allow assessment of candidate biomarkers across the various patient groups who might ultimately be targeted in VCID clinical trials; (3) defining a common dataset of clinical and cognitive elements that contains all the key outcome markers and covariates for VCID studies and is realistically obtainable during a practical study visit; (4) instituting best fluid-handling practices for minimizing avoidable sources of variability; and (5) establishing rigorous procedures for testing the reliability of candidate fluid-based biomarkers across replicates, assay runs, sites, and time intervals (collectively defined as the biomarker's instrumental validity). Participant Enrollment Project sites enroll diverse study cohorts using site-specific inclusion and exclusion criteria so as to provide generalizable validation data across a range of cognitive statuses, risk factor profiles, small vessel disease severities, and racial/ethnic characteristics representative of the diverse patient groups that might be enrolled in a future VCID trial. MarkVCID project sites include both prospectively enrolling centers and centers providing extant data and samples from preexisting community- and population-based studies. With approval of local institutional review boards, all sites incorporate MarkVCID consensus language into their study documents and informed consent agreements. The consensus language asks prospectively enrolled participants to consent to unrestricted access to their data and samples for research analysis within and outside MarkVCID. The data are transferred and stored as a de-identified dataset as defined by the Health Insurance Portability and Accountability Act Privacy Rule. Similar human subject protection and informed consent language serve as the basis for MarkVCID Research Agreements that act as contracts and data/biospecimen sharing agreements across the consortium. Clinical and Cognitive Data Clinical and cognitive data are collected across prospectively enrolling project sites using common MarkVCID instruments. The clinical data elements are modified from study protocols already in use such as the Alzheimer's Disease Center program Uniform Data Set Version 3 (UDS3), with additional focus on VCID-related items such as prior stroke and cardiovascular disease, vascular risk factors, focal neurologic findings, and blood testing for vascular risk markers and kidney function including hemoglobin A1c, cholesterol subtypes, triglycerides, and creatinine. Cognitive assessments and rating instruments include the Clinical Dementia Rating Scale, Geriatric Depression Scale, and most of the UDS3 neuropsychological battery. The cognitive testing requires ≈60 to 90 minutes. Study staff at the prospectively recruiting sites undergo formalized training in all measures and review of their first three UDS3 administrations by the coordinating center. Collection and Handling of Fluid Samples Fluid sample types collected for MarkVCID biomarker kits are serum, ethylenediaminetetraacetic acid-plasma, platelet-poor plasma, and cerebrospinal fluid (CSF) with additional collection of packed cells to allow future DNA extraction and analyses. MarkVCID fluid guidelines to minimize variability include fasting morning fluid collections, rapid processing, standardized handling and storage, and avoidance of CSF contact with polystyrene. Instrumental Validation for Fluid-Based Biomarkers Instrumental validation of MarkVCID fluid-based biomarkers is operationally defined as determination of intra-plate and inter-plate repeatability, inter-site reproducibility, and test-retest repeatability. MarkVCID study participants both with and without advanced small vessel disease are selected for these determinations to assess instrumental validity across the full biomarker assay range. Intra- and inter-plate repeatability is determined by repeat assays of single split fluid samples performed at individual sites. Inter-site reproducibility is determined by assays of split samples distributed to multiple sites. Test-retest repeatability is determined by assay of three samples acquired from the same individual, collected at least 5 days apart over a 30-day period and assayed on a single plate. The MarkVCID protocols are designed to allow direct translation of the biomarker validation results to multicenter trials. They also provide a template for outside groups to perform analyses using identical methods and therefore allow direct comparison of results across studies and centers. All MarkVCID protocols are available to the biomedical community and intended to be shared. In addition to the instrumental validation procedures described here, each of the MarkVCID kits will undergo biological validation to determine whether the candidate biomarker measures important aspects of VCID such as cognitive function. Analytic methods and results of these validation studies for the 11 MarkVCID biomarker kits will be published separately. The results of this rigorous validation process will ultimately determine each kit's potential usefulness for multicenter interventional trials aimed at preventing or treating small vessel disease related VCID.
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Affiliation(s)
- Donna Wilcock
- Sanders-Brown Center on Aging, University of Kentucky College of Medicine, Lexington, KY 40504, USA
| | - Gregory Jicha
- Sanders-Brown Center on Aging, University of Kentucky College of Medicine, Lexington, KY 40504, USA
| | - Deborah Blacker
- Department of Epidemiology, Harvard T.H Chan School of Public Health and Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA
| | - Marilyn S. Albert
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Lina M. D’Orazio
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA
| | - Fanny M. Elahi
- Center for Memory and Aging, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA 94143, USA
| | - Myriam Fornage
- Brown Foundation Institute of Molecular Medicine, McGovern Medical School and Human Genetics Center, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Jason D. Hinman
- David Geffen School of Medicine, Department of Neurology, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Janice Knoefel
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Joel Kramer
- David Geffen School of Medicine, Department of Neurology, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Richard J. Kryscio
- Sanders-Brown Center on Aging, University of Kentucky College of Medicine, Lexington, KY 40504, USA
| | - Melissa Lamar
- Rush Alzheimer’s Disease Center, Rush University, Chicago, IL, USA
| | - Abhay Moghekar
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Jillian Prestopnik
- Center for Memory and Aging, University of New Mexico Health Sciences Center, Albuquerque, NM 87131, USA
| | - John M. Ringman
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA
| | - Gary Rosenberg
- Center for Memory and Aging, University of New Mexico Health Sciences Center, Albuquerque, NM 87131, USA
| | - Abhay Sagare
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Claudia L. Satizabal
- Glenn Biggs Institute for Alzheimer’s & Neurodegenerative Diseases, University of Texas Health San Antonio, San Antonio, TX 78229, USA
| | - Julie Schneider
- Rush Alzheimer’s Disease Center, Rush University, Chicago, IL, USA
| | - Sudha Seshadri
- Glenn Biggs Institute for Alzheimer’s & Neurodegenerative Diseases, University of Texas Health San Antonio, San Antonio, TX 78229, USA
| | - Sandeepa Sur
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Russell P. Tracy
- Department of Pathology and Laboratory Medicine, University of Vermont Larner College of Medicine, Burlington, VT 05405, USA
| | - Sevil Yasar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Victoria Williams
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA
| | - Herpreet Singh
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Lidiya Mazina
- Neurological Clinical Research Institute, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Karl G. Helmer
- Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | | | - Kristin Schwab
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Pia Kivisäkk
- Alzheimer’s Clinical and Translational Research Unit, Massachusetts General Hospital, Boston, MA 02129, USA
| | - Steven M. Greenberg
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
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Gooden MJ, Norato G, Martin SB, Nath A, Reoma L. Reducing Events of Noncompliance in Neurology Human Subjects Research: the Effect of Human Subjects Research Protection Training and Site Initiation Visits. Neurotherapeutics 2021; 18:859-865. [PMID: 33475954 PMCID: PMC8423976 DOI: 10.1007/s13311-020-01003-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2020] [Indexed: 11/29/2022] Open
Abstract
In an effort to minimize protocol noncompliance in neurological research studies that can potentially compromise patient safety, delay completion of the study, and result in premature termination and added costs, we determined the effect of investigator trainings and site initiation visits (SIVs) on the occurrence of noncompliance events. Results of protocol audits conducted at the National Institute of Neurological Disorders and Stroke from 2003 to 2019 on 97 research protocols were retrospectively analyzed. Based on the depth of auditing and provision of investigator research training, audit data were separated into four arms: 1) Early Period, 2003 to 2012; 2) Middle Period, 2013 to 2016; and Late Period, 2017 to 2019, further divided into 3) Late Period without SIVs; and 4) Late Period with SIVs. Events of noncompliance were classified by the type of protocol deviation, the category, and the cause. In total, 952 events occurred across 1080 participants. Protocols audited during the Middle Period, compared to the Early Period, showed a decrease in the percentage of protocols with at least 1 noncompliance event. Protocols with SIVs had a further decrease in major, minor, procedural, eligibility, and policy events. Additionally, protocols audited during the Early Period had on average 0.46 major deviations per participant, compared to 0.26 events in protocols audited during the Middle Period, and 0.08 events in protocols audited during the Late Period with SIVs. Protocol deviations and noncompliance events in neurological clinical trials can be reduced by targeted investigator trainings and SIVs. These measures have major impacts on the integrity, safety, and effectiveness of human subjects research in neurology.
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Affiliation(s)
- Matthew J Gooden
- Clinical Trials Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, Building 10, Room 2A23, Bethesda, MD, 20814, USA
| | - Gina Norato
- Clinical Trials Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, Building 10, Room 2A23, Bethesda, MD, 20814, USA
| | - Sandra B Martin
- Clinical Trials Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, Building 10, Room 2A23, Bethesda, MD, 20814, USA
| | - Avindra Nath
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, Building 10, Room 7C103, Bethesda, MD, 20814, USA
| | - Lauren Reoma
- Clinical Trials Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, Building 10, Room 2A23, Bethesda, MD, 20814, USA.
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, Building 10, Room 7C103, Bethesda, MD, 20814, USA.
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Shepherd V. How nurses can support the inclusion in research of older people who lack capacity to consent. Nurs Older People 2021; 33:26-31. [PMID: 33084258 DOI: 10.7748/nop.2020.e1267] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2020] [Indexed: 11/09/2022]
Abstract
Research is important because it underpins evidence-based care. However, people who lack capacity to consent are often excluded from research, due partly to ethical concerns and practical challenges, and partly to a lack of awareness among professionals of the legal framework that supports their inclusion. The COVID-19 pandemic, which has extensively affected care home residents, has reinforced the importance of including older people with cognitive impairment in research. Nurses who care for older people with impaired cognition have an important role in ensuring these people have the opportunity to contribute to and benefit from research. This article discusses some of the challenges associated with the inclusion in research of older people who lack capacity to consent, including the involvement of relatives and friends in decision-making. The article describes the findings of recent research and shares resources with the aim of supporting nurses to ensure that older people in their care who lack capacity can participate in research.
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Abstract
Geriatric emergency medicine has emerged as a subspecialty of emergency medicine over the past 25 years. This emergence has seen the development of increases in training opportunities, care delivery strategies, collaborative best practice guidelines, and formal geriatric emergency department accreditation. This multidisciplinary field remains ripe for continued development in the coming decades as the aging US population parallels a call from patients, health care providers, and health systems to improve the delivery of high-value care. This article educates emergency medicine practitioners and highlights high-value care practice trends to inform and prioritize decision-making for this unique patient population.
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Harper KJ, Arendts G, Barton AD, Celenza A. Providing fall prevention services in the emergency department: Is it effective? A systematic review and meta-analysis. Australas J Ageing 2021; 40:116-128. [PMID: 33605050 DOI: 10.1111/ajag.12914] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/21/2020] [Accepted: 12/15/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess the effects of fall prevention services initiated in the emergency department (ED) to support patients after discharge. METHODS A systematic review and meta-analysis were conducted. Analysis of pooled data used random-effects modelling with results presented as a risk ratio (RR). RESULTS Eleven studies were identified (n = 4,018). The proportion of older adults who fell did not differ between the intervention and control groups (RR 0.93; 95% CI, 0.82-1.06, I2 68%, P = 0.28). There was a significant (P = 0.01) reduction in the monthly rate of falling (RR 0.69; 95% CI, 0.52-0.91, I2 93%), fall-related injuries (RR 0.72; 95% CI, 0.59-0.88, I2 0%, P = 0.001), and hospital admissions (RR 0.76; 95% CI, 0.64-0.90, I2 0%, P = 0.002). CONCLUSIONS ED fall prevention services did not significantly reduce the proportion of older adults who had future falls. However, multifactorial intervention significantly reduced fall-related injuries and hospital admissions with low heterogeneity.
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Affiliation(s)
- Kristie J Harper
- Occupational Therapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Glenn Arendts
- Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Annette D Barton
- Occupational Therapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Antonio Celenza
- Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
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Holmes C, Brock K, Morgan P. Pain and its relationship with postural asymmetry in adults with cerebral palsy: A preliminary exploratory study. Disabil Health J 2021; 14:101063. [PMID: 33509734 DOI: 10.1016/j.dhjo.2021.101063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 01/11/2021] [Accepted: 01/14/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pain in adults with cerebral palsy (CP) is commonly reported, with muscular and skeletal dysfunction resulting in postural asymmetry as potential contributors to multifactorial causes of pain. The relationship between pain and postural asymmetry of the thoracic cage, pelvis and hips in non-ambulatory adults with CP however is unknown, particularly in those with cognitive and communication limitations. OBJECTIVE The primary aim of this study was to describe and quantify day and night pain in non-ambulatory adults with CP. Secondary aims were to investigate any relationship between pain and postural asymmetry and to describe current pain management strategies utilised. METHODS Pain was measured using the Non Communicating Adult Pain Checklist (NCAPC). Posture was measured using the Goldsmith Indices of Body Symmetry (GIofBS) and radiographs. Correlations between pain scores and posture (GIofBS and radiographs) were assessed using non-parametric analysis. Information regarding pain management strategies was gained from medical records and carer interviews. RESULTS Seventeen non-ambulatory adults with CP were recruited. High levels of day pain were experienced by ≥ 50% of participants with a high incidence of prescribed medications targeting pain. Strong positive correlations between day and night NCAPC scores, chest right left ratio and night pain, Cobb angle and day pain and between Cobb angle and night pain were evident. CONCLUSION The incidence and severity of pain in non-ambulatory adults with CP is high with postural asymmetry a potential contributor. Pain remains difficult to assess and manage in adults with significant cognitive and communication impairments and warrants further investigation.
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Affiliation(s)
- Carlee Holmes
- St. Vincent's Hospital, Melbourne, Australia; Physiotherapy Department, Monash University, Frankston, Australia.
| | - Kim Brock
- St. Vincent's Hospital, Melbourne, Australia.
| | - Prue Morgan
- Physiotherapy Department, Monash University, Frankston, Australia.
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Schnitker L, Nović A, Arendts G, Carpenter CR, LoGiudice D, Caplan GA, Fick DM, Beattie E. Prevention of Delirium in Older Adults With Dementia: A Systematic Literature Review. J Gerontol Nurs 2020; 46:43-54. [PMID: 32852044 DOI: 10.3928/00989134-20200820-02] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/08/2020] [Indexed: 11/20/2022]
Abstract
Although dementia is the largest independent risk factor for delirium and leads to poor health outcomes, we know little about how to prevent delirium in persons with dementia (PWD). The purpose of the current systematic literature review was to identify interventions designed to prevent delirium in older PWD. Seven studies meeting inclusion criteria were extracted. Five studies were in the acute care setting and two were community settings. One study used a randomized controlled trial design. Five of the seven interventions comprised multiple components addressing delirium risk factors, including education. Two studies addressed delirium by administration of medication or vitamin supplementation. Using the GRADE framework for the evaluation of study quality, we scored three studies as moderate and four studies as low. Thus, high-quality research studies to guide how best to prevent delirium in PWD are lacking. Although more research is required, the current review suggests that multicomponent approaches addressing delirium risk factors should be considered by health care professionals when supporting older PWD. [Journal of Gerontological Nursing, 46(10), 43-54.].
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Skinner HD. Mining the past to treat the present, ever mindful of the future: Low-dose radiotherapy and COVID-19 pneumonia. Cancer 2020; 126:5017-5021. [PMID: 32985700 PMCID: PMC7536983 DOI: 10.1002/cncr.33201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 12/15/2022]
Abstract
This editorial discusses an interim analysis of the clinical trial by Hess et al. The trial examines the use of low‐dose radiotherapy in the treatment of patients with coronavirus disease 2019 (COVID‐19) pneumonia.
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Affiliation(s)
- Heath D Skinner
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
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38
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Hosie A, Kochovska S, Ries N, Gilmore I, Parker D, Sinclair C, Sheehan C, Collier A, Caplan GA, Visser M, Xu X, Lobb E, Sheahan L, Brown L, Lee W, Sanderson CR, Amgarth-Duff I, Green A, Edwards L, Agar MR. Older Persons' and Their Caregivers' Perspectives and Experiences of Research Participation With Impaired Decision-Making Capacity: A Scoping Review. THE GERONTOLOGIST 2020; 62:e112-e122. [PMID: 32866239 DOI: 10.1093/geront/gnaa118] [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: 04/22/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Human research ethics statements support equitable inclusion of diverse groups. Yet older people are under-represented in clinical research, especially those with impaired decision-making capacity. The aim of this study was to identify perspectives and experiences of older persons and their caregivers of research participation with impaired decision-making capacity. RESEARCH DESIGN AND METHODS Scoping review of literature and online sources in January-February 2019 (updated June 2020) according to Joanna Briggs Institute methodology and PRISMA Extension for Scoping Reviews. English-language peer-reviewed research articles and Australian online narratives were included. Data were tabulated and narratively synthesized. RESULTS From 4171 database records and 93 online resources, 22 articles (2000-2019, 82% United States, 16 first authors) and one YouTube webinar (2018) were initially included; updated searches yielded an additional article (2020) and YouTube webinar (2020). Studies were heterogeneous in terminology, methods and foci, with hypothetical scenarios, quantitative analyses and examination of proxy consent predominating. Participants (n=7331) were older persons (71%), caregivers of older persons with dementia/cognitive impairment (23%) and older persons with dementia/cognitive impairment (6%). Synthesis identified two themes: willingness to participate and decision-making approaches. DISCUSSION AND IMPLICATIONS Research participation by older persons with dementia may be optimized through reducing risks and burdens and increasing benefits for participants, greater consumer input into study development, and shared and supported decision-making. Older persons' and caregivers' perspectives and experiences of research participation with impaired decision-making capacity require investigation in a greater range of countries and conditions other than dementia, and dissemination through more varied media.
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Affiliation(s)
- Annmarie Hosie
- School of Nursing Sydney, The University of Notre Dame Australia, Darlinghurst, New South Wales, Australia.,The Cunningham Centre for Palliative Care, St Vincent's Health Network Sydney, Darlinghurst, New South Wales, Australia
| | - Slavica Kochovska
- Faculty of Health, University of Technology Sydney, IMPACCT, Ultimo, New South Wales, Australia
| | - Nola Ries
- Faculty of Law, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Imelda Gilmore
- Faculty of Health, University of Technology Sydney, IMPACCT, Ultimo, New South Wales, Australia
| | - Deborah Parker
- Faculty of Health, University of Technology Sydney, IMPACCT, Ultimo, New South Wales, Australia
| | - Craig Sinclair
- ARC Centre of Excellence in Population Ageing Research, University of New South Wales, Kensington, New South Wales, Australia
| | - Caitlin Sheehan
- Palliative Care Department, Calvary Health Care Kogarah, Kogarah, New South Wales Australia
| | - Aileen Collier
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Gideon A Caplan
- Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia.,Department of Geriatric Medicine, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Mandy Visser
- Faculty of Health, University of Technology Sydney, IMPACCT, Ultimo, New South Wales, Australia.,Leiden University Medical Center, Leiden, South Holland, The Netherlands
| | - Xiaoyue Xu
- Faculty of Health, University of Technology Sydney, IMPACCT, Ultimo, New South Wales, Australia.,Faculty of Medicine, School of Population Health, University of New South Wales, Kensington, New South Wales, Australia
| | - Elizabeth Lobb
- Faculty of Health, University of Technology Sydney, IMPACCT, Ultimo, New South Wales, Australia.,Palliative Care Department, Calvary Health Care Kogarah, Kogarah, New South Wales Australia
| | - Linda Sheahan
- South Eastern Sydney Local Health District, Clinical Ethics Service, Randwick, New South Wales, Australia.,Sydney Health Ethics, University of Sydney, Camperdown, New South Wales, Australia
| | - Linda Brown
- Faculty of Health, University of Technology Sydney, IMPACCT, Ultimo, New South Wales, Australia
| | - Wei Lee
- The Cunningham Centre for Palliative Care, St Vincent's Health Network Sydney, Darlinghurst, New South Wales, Australia.,Faculty of Health, University of Technology Sydney, IMPACCT, Ultimo, New South Wales, Australia
| | - Christine R Sanderson
- Faculty of Health, University of Technology Sydney, IMPACCT, Ultimo, New South Wales, Australia
| | - Ingrid Amgarth-Duff
- Faculty of Health, University of Technology Sydney, IMPACCT, Ultimo, New South Wales, Australia
| | - Anna Green
- Faculty of Health, University of Technology Sydney, IMPACCT, Ultimo, New South Wales, Australia
| | - Layla Edwards
- Faculty of Health, University of Technology Sydney, IMPACCT, Ultimo, New South Wales, Australia
| | - Meera R Agar
- Faculty of Health, University of Technology Sydney, IMPACCT, Ultimo, New South Wales, Australia.,South West Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
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Richmond NL, Zimmerman S, Reeve BB, Dayaa JA, Davis ME, Bowen SB, Iasiello JA, Stemerman R, Shams RB, Haukoos JS, Sloane PD, Travers D, Mosqueda LA, McLean SA, Platts-Mills TF. Ability of Older Adults to Report Elder Abuse: An Emergency Department-Based Cross-Sectional Study. J Am Geriatr Soc 2020; 68:170-175. [PMID: 31917460 DOI: 10.1111/jgs.16211] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 08/30/2019] [Accepted: 09/07/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To characterize assessments of a patient's ability to report elder abuse within the context of an emergency department (ED)-based screen for elder abuse. DESIGN Cross-sectional study in which participants were screened for elder abuse and neglect. SETTING Academic ED in the United States. PARTICIPANTS Patients, aged 65 years and older, presenting to an ED for acute care were assessed by trained research assistants or nurses. MEASUREMENTS All patients completed the four-item Abbreviated Mental Test 4 (AMT4), then completed a safety interview (using the Emergency Department Senior Abuse Identification tool) designed to detect multiple domains of elder abuse and received a physical examination. Based on the cognitive assessment and safety interview, assessors ranked their confidence in the patient's ability to report abuse as absolutely confident, confident, somewhat confident, or not confident. To assess interrater reliability, two assessors independently rated confidence for a subset of patients. RESULTS Assessors suspected elder abuse in 18 of 276 patients (6.5%). Assessors were absolutely confident in the patient's ability to report abuse for 95.7% of patients, confident for 2.5%, somewhat confident for 1.5%, and not confident for 0.3%. Among patients with an AMT4 of 4 (n = 249), assessors were confident or absolutely confident in 100% of patients. Among patients with an AMT4 of less than 4 (n = 27), they were confident or absolutely confident in the patient's ability to report abuse for 81% of patients, including 11 of 12 patients with mild cognitive impairment and 7 of 11 patients with severe cognitive impairment. For patients receiving paired evaluations (n = 131), agreement between assessors regarding patient ability to report abuse was 97% (κ = 0.5). CONCLUSIONS In this sample of older adults receiving care in an ED, research assistants and nurses felt that the vast majority were able to report elder abuse, including many patients with cognitive impairment. J Am Geriatr Soc 68:170-175, 2019.
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Affiliation(s)
- Natalie L Richmond
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sheryl Zimmerman
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Bryce B Reeve
- Center for Health Measurement Department of Population Health Sciences and Pediatrics, Duke University, Durham, North Carolina
| | - Joseph A Dayaa
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mackenzie E Davis
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Samantha B Bowen
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - John A Iasiello
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Rachel Stemerman
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Rayad B Shams
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jason S Haukoos
- Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Philip D Sloane
- Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Debbie Travers
- University of North Carolina School of Nursing, Chapel Hill, North Carolina
| | - Laura A Mosqueda
- Family Medicine and Geriatrics, Keck School of Medicine, University of South California, Alhambra, California
| | - Samuel A McLean
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Timothy F Platts-Mills
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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O'Brien T, Russell CL, AlKahlout N, Rosenthal A, Meyer T, Tan A, Daloul R, Hathaway D. Recruitment of Older Kidney Transplant Recipients to a Longitudinal Study. Nurs Res 2020; 69:233-237. [PMID: 31688340 PMCID: PMC7313092 DOI: 10.1097/nnr.0000000000000406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Currently, limited information is available regarding selection of the most successful strategies for recruitment of older adult kidney transplant recipients as research participants. OBJECTIVE The aim of this study was to explore multiple modes of recruitment strategies to enroll older kidney transplant recipients in a 1-year longitudinal study. METHODS We used a feasibility design to explore the following recruitment methods: face-to-face contact in the transplant clinic, paper flyers placed in the transplant clinic, Facebook, an online transplant newsletter, and a university website listing of research studies. RESULTS Enrollment was open for 9 months, during which time websites and the Facebook portal were active, 142 newsletters were e-mailed, and 424 patients were approached in the transplant clinic. Among patients approached in the clinic, 12 did not own a smartphone required for the study. The sample consisted of 60 participants (39 men, 21 women), with a mean age of 64.5 ± 4.7 years. Of the participants who enrolled in the study, the largest number (75%, n = 45) was recruited using the face-to-face method in the transplant clinic. The online transplant newsletter was the second-best recruitment source (18%, n = 11). DISCUSSION Recruitment strategies using face-to-face contact and the online newsletter associated with the transplant clinic organization appeared to be more effective than strategies not associated with the transplant clinic (Facebook and university website). Findings suggest that using a familiar organization communication method to recruit older chronic disease population may be the most beneficial.
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Affiliation(s)
- Tara O'Brien
- Tara O'Brien, PhD, RN, CNE, is an Assistant Professor; Noor AlKahlout, BS, Anna Rosenthal, SN, and Tess Meyer SN, are Research Team Members; and Alai Tan, PhD, is a Research Associate Professor at The Ohio State University College of Nursing, Columbus. Cynthia Russell PhD, RN, FAAN, is a Professor at the School of Nursing and Health Studies, University of Missouri-Kansas City. Reem Daloul, MD, is an Assistant Professor at The Ohio State University College of Medicine, Columbus. Donna Hathaway PhD, RN, FAAN, is a Distinguished Professor at the University of Tennessee Health Science Center, Memphis
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Newmark J, Gebara MA, Aizenstein H, Karp JF. Engaging in Late-Life Mental Health Research: a Narrative Review of Challenges to Participation. ACTA ACUST UNITED AC 2020; 7:317-336. [PMID: 32837830 PMCID: PMC7242610 DOI: 10.1007/s40501-020-00217-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Purpose of review This narrative review seeks to ascertain the challenges older patients face with participation in mental health clinical research studies and suggests creative strategies to minimize these obstacles. Recent findings Challenges to older adults’ engagement in mental health research include practical, institutional, and collaboration-related barriers applicable to all clinical trials as well as more personal, cultural, and age-related patient barriers specific to geriatric mental health research. Universal research challenges include (1) institutional barriers of lack of funding and researchers, inter-researcher conflict, and sampling bias; (2) collaboration-related barriers involving miscommunication and clinician concerns; and (3) practical patient barriers such as scheduling issues, financial constraints, and transportation difficulties. Challenges unique to geriatric mental health research include (1) personal barriers such as no perceived need for treatment, prior negative experience, and mistrust of mental health research; (2) cultural barriers involving stigma and lack of bilingual or culturally matched staff; and (3) chronic medical issues and concerns about capacity. Summary Proposed solutions to these barriers include increased programmatic focus on and funding of geriatric psychiatry research grants, meeting with clinical staff to clarify study protocols and eligibility criteria, and offering transportation for participants. To minimize stigma and mistrust of psychiatric research, studies should devise community outreach efforts, employ culturally competent bilingual staff, and provide patient and family education about the study and general information about promoting mental health.
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Affiliation(s)
- Jordyn Newmark
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara St, Bellefield Towers 726, Pittsburgh, PA 15213 USA
| | - Marie Anne Gebara
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara St, Bellefield Towers 726, Pittsburgh, PA 15213 USA
| | - Howard Aizenstein
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara St, Bellefield Towers 726, Pittsburgh, PA 15213 USA
| | - Jordan F Karp
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara St, Bellefield Towers 726, Pittsburgh, PA 15213 USA.,Center for Interventions to Enhance Community Health, University of Pittsburgh, Pittsburgh, USA
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Kaeppeli T, Rueegg M, Dreher-Hummel T, Brabrand M, Kabell-Nissen S, Carpenter CR, Bingisser R, Nickel CH. Validation of the Clinical Frailty Scale for Prediction of Thirty-Day Mortality in the Emergency Department. Ann Emerg Med 2020; 76:291-300. [PMID: 32336486 DOI: 10.1016/j.annemergmed.2020.03.028] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/20/2020] [Accepted: 03/25/2020] [Indexed: 01/04/2023]
Abstract
STUDY OBJECTIVE We validate the Clinical Frailty Scale by examining its independent predictive validity for 30-day mortality, ICU admission, and hospitalization and by determining its reliability. We also determine frailty prevalence in our emergency department (ED) as measured with the Clinical Frailty Scale. METHODS This was a prospective observational study including consecutive ED patients aged 65 years or older, from a single tertiary care center during a 9-week period. To examine predictive validity, association with mortality was investigated through a Cox proportional hazards regression; hospitalization and ICU transfer were investigated through multivariable logistic regression. We assessed reliability by calculating Cohen's weighted κ for agreement of experts who independently assigned Clinical Frailty Scale levels, compared with trained study assistants. Frailty was defined as a Clinical Frailty Scale score of 5 and higher. RESULTS A total of 2,393 patients were analyzed in this study, of whom 128 died. Higher frailty levels were associated with higher hazards for death independent of age, sex, and condition (medical versus surgical). The area under the curve for 30-day mortality prediction was 0.81 (95% confidence interval [CI] 0.77 to 0.85), for hospitalization 0.72 (95% CI 0.70 to 0.74), and for ICU admission 0.69 (95% CI 0.66 to 0.73). Interrater reliability between the reference standard and the study team was good (weighted Cohen's κ was 0.74; 95% CI 0.64 to 0.85). Frailty prevalence was 36.8% (n=880). CONCLUSION The Clinical Frailty Scale appears to be a valid and reliable instrument to identify frailty in the ED. It might provide ED clinicians with useful information for decisionmaking in regard to triage, disposition, and treatment.
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Affiliation(s)
- Tobias Kaeppeli
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Marco Rueegg
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thomas Dreher-Hummel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Søren Kabell-Nissen
- Department of Emergency Medicine, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | | | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland.
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Ries NM, Mansfield E, Sanson-Fisher R. Ethical and legal aspects of research involving older people with cognitive impairment: A survey of dementia researchers in Australia. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2020; 68:101534. [PMID: 32033698 DOI: 10.1016/j.ijlp.2019.101534] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 12/03/2019] [Indexed: 06/10/2023]
Abstract
People with dementia are under-represented in clinical research, in part due to the ethical and legal complexities of involving people in studies who may lack capacity to consent. Excluding this population from research limits the evidence to inform care. The attitudes and practices of researchers are key to the inclusion of people with dementia in research, however, there are few empirical studies on researchers' perspectives in this area. A cross-sectional study involved researchers in Australia who had experience in the ethical aspects of conducting dementia-related studies with human participants (n = 70). Data were collected via an online survey from November 2017 to January 2018. Most respondents (97%) agreed with the importance of including people at all stages of dementia in research, yet around three-quarters of respondents perceived ethical and legal rules and processes as unduly restrictive or time-consuming. Researchers reported variable practices in assessing prospective participants' capacity to consent to their studies. Various tools are used for this purpose, ranging from tools designed for research (eg, MacArthur Competence Assessment Tool for Clinical Research) to more general cognitive function screens (eg, Mini Mental State Exam). Few respondents (14%) routinely exclude people from studies who are unable to give their own consent, but instead seek permission from proxy decision-makers, such as legally appointed guardians or family carers. Respondents reported positive and negative outcomes of ethics review processes. Positive outcomes included strengthening the protections for participants with cognitive impairment while negative outcomes included delays and inconsistent decisions from different ethics committees. The findings suggest a need for improved strategies in the research context to assess and enhance the decision-making capacity of people with dementia to support appropriate opportunities for inclusion. Education for ethics committees, proxy decision-makers and other gatekeepers is also needed to reduce barriers to participation in research.
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Affiliation(s)
- Nola M Ries
- Faculty of Law, University of Technology Sydney, PO Box 123, Broadway, NSW 2007, Australia.
| | - Elise Mansfield
- Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia.
| | - Rob Sanson-Fisher
- Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia.
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Special issues raised by evolving areas of clinical research. ETHICAL CONSIDERATIONS WHEN PREPARING A CLINICAL RESEARCH PROTOCOL 2020. [PMCID: PMC7329119 DOI: 10.1016/b978-0-12-386935-7.00014-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Each study presents its own set of ethical considerations. Certain kinds of ethical issues are inherent in particular areas of clinical research, regardless of specific ethical questions associated with a specific study. In this chapter, some of the most common special areas of clinical research are presented, highlighting the ethical issues most frequently associated with each.
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Mannheim I, Schwartz E, Xi W, Buttigieg SC, McDonnell-Naughton M, Wouters EJM, van Zaalen Y. Inclusion of Older Adults in the Research and Design of Digital Technology. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16193718. [PMID: 31581632 PMCID: PMC6801827 DOI: 10.3390/ijerph16193718] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 09/24/2019] [Accepted: 09/30/2019] [Indexed: 01/09/2023]
Abstract
Digital technology holds a promise to improve older adults' well-being and promote ageing in place. However, there seems to be a discrepancy between digital technologies that are developed and what older adults actually want and need. Ageing is stereotypically framed as a problem needed to be fixed, and older adults are considered to be frail and incompetent. Not surprisingly, many of the technologies developed for the use of older adults focus on care. The exclusion of older adults from the research and design of digital technology is often based on such negative stereotypes. In this opinion article, we argue that the inclusion rather than exclusion of older adults in the design process and research of digital technology is essential if technology is to fulfill the promise of improving well-being. We emphasize why this is important while also providing guidelines, evidence from the literature, and examples on how to do so. We unequivocally state that designers and researchers should make every effort to ensure the involvement of older adults in the design process and research of digital technology. Based on this paper, we suggest that ageism in the design process of digital technology might play a role as a possible barrier of adopting technology.
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Affiliation(s)
- Ittay Mannheim
- School of Allied Health Professions, Fontys University of Applied Science, Eindhoven 5631 BN, The Netherlands.
- Tranzo, School of Social and Behavioral Sciences, Tilburg University, Tilburg 5037 DB, The Netherlands.
| | - Ella Schwartz
- Louis and Gabi Weisfeld School of Social Work, Bar Ilan University, Ramat Gan 5290002, Israel.
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva 8410501, Israel.
| | - Wanyu Xi
- Louis and Gabi Weisfeld School of Social Work, Bar Ilan University, Ramat Gan 5290002, Israel.
| | - Sandra C Buttigieg
- Health Services Management, Faculty of Health Sciences, University of Malta, Msida MSD 2090, Malta.
- Health Services Management Centre, School of Social Policy, College of Social Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK.
| | - Mary McDonnell-Naughton
- Department of Nursing and Health Care Athlone Institute of Technology, Athlone N37 HD68, Ireland.
| | - Eveline J M Wouters
- School of Allied Health Professions, Fontys University of Applied Science, Eindhoven 5631 BN, The Netherlands.
- Tranzo, School of Social and Behavioral Sciences, Tilburg University, Tilburg 5037 DB, The Netherlands.
| | - Yvonne van Zaalen
- School of Allied Health Professions, Fontys University of Applied Science, Eindhoven 5631 BN, The Netherlands.
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Carpenter CR, McFarland F, Avidan M, Berger M, Inouye SK, Karlawish J, Lin FR, Marcantonio E, Morris J, Reuben D, Shah R, Whitson H, Asthana S, Verghese J. Impact of Cognitive Impairment Across Specialties: Summary of a Report From the U13 Conference Series. J Am Geriatr Soc 2019; 67:2011-2017. [PMID: 31436318 PMCID: PMC6800784 DOI: 10.1111/jgs.16093] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/27/2019] [Accepted: 06/30/2019] [Indexed: 11/28/2022]
Abstract
Although declines in cognitive capacity are assumed to be a characteristic of aging, increasing evidence shows that it is age-related disease, rather than age itself, that causes cognitive impairment. Even so, older age is a primary risk factor for cognitive decline, and with individuals living longer as a result of medical advances, cognitive impairment and dementia are increasing in prevalence. On March 26 to 27, 2018, the American Geriatrics Society convened a conference in Bethesda, MD, to explore cognitive impairment across the subspecialties. Bringing together representatives from several subspecialties, this was the third of three conferences, supported by a U13 grant from the National Institute on Aging, to aid recipients of Grants for Early Medical/Surgical Specialists' Transition to Aging Research (GEMSSTAR) in integrating geriatrics into their subspecialties. Scientific sessions focused on the impact of cognitive impairment, sensory contributors, comorbidities, links between delirium and dementia, and issues of informed consent in cognitively impaired populations. Discussions highlighted the complexity not only of cognitive health itself, but also of the bidirectional relationship between cognitive health and the health of other organ systems. Thus, conference participants noted the importance of multidisciplinary team science in future aging research. This article summarizes the full conference report, "The Impact of Cognitive Impairment Across Specialties," and notes areas where GEMSSTAR scholars can contribute to progress as they embark on their careers in aging research. J Am Geriatr Soc 67:2011-2017, 2019.
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Affiliation(s)
| | | | | | | | | | | | | | | | - John Morris
- Washington University School of Medicine, St. Louis, MO
| | | | - Raj Shah
- Rush University Medical Center, Chicago, IL
| | - Heather Whitson
- Duke University School of Medicine, Durham, NC and Geriatrics Research Education and Clinical Center, Durham VA, Durham, NC
| | - Sanjay Asthana
- University of Wisconsin, Madison, WI
- Albert Einstein College of Medicine, Bronx, NY
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Ries N, Mansfield E, Sanson-Fisher R. Planning Ahead for Dementia Research Participation: Insights from a Survey of Older Australians and Implications for Ethics, Law and Practice. JOURNAL OF BIOETHICAL INQUIRY 2019; 16:415-429. [PMID: 31297689 DOI: 10.1007/s11673-019-09929-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 07/04/2019] [Indexed: 06/10/2023]
Abstract
People with dementia have commonly been excluded from research. The adverse impacts of this exclusion are now being recognized and research literature, position statements, and ethics guidelines increasingly call for inclusion of people with dementia in research. However, few published studies investigate the views of potential participants on taking part in research should they experience dementia-related cognitive impairment. This cross-sectional survey examined the views of people aged sixty and older (n=174) attending hospital outpatient clinics about clinical research participation if they had dementia and impaired decision-making ability. Over 90 percent of respondents were agreeable to participating in a wide range of research activities, such as cognitive testing, physical measurements, imaging procedures, and blood draws. For drug studies, however, agreement dropped to 60 percent. Altruism was a strong motivator for research participation. In regard to who should be involved in decisions about their participation in research during periods of incapacity, respondents mostly preferred the person they appoint as their substitute decision-maker for healthcare matters (88%) or a doctor or health professional on the research team (78%). Over three-quarters (79%) expressed interest in making an advance research directive. The study findings are discussed in relation to law reforms in Australia that aim to strengthen respect and inclusion for people with impaired decision-making capacity, especially by providing frameworks for advance planning for research participation.
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Affiliation(s)
- Nola Ries
- Faculty of Law, University of Technology Sydney, PO Box 123, Broadway, Sydney, NSW, 2007, Australia.
| | - Elise Mansfield
- Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Rob Sanson-Fisher
- Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
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Lee JS, Tong T, Tierney MC, Kiss A, Chignell M. Predictive Ability of a Serious Game to Identify Emergency Patients With Unrecognized Delirium. J Am Geriatr Soc 2019; 67:2370-2375. [PMID: 31355442 DOI: 10.1111/jgs.16095] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 06/24/2019] [Accepted: 06/30/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Recognition of delirium in the emergency department (ED) is poor. Our objectives were to assess: (1) the diagnostic accuracy of the Predicting Emergency department Delirium with an Interactive Computer Tablet (PrEDICT) "serious game" to identify older ED patients with delirium compared to clinical recognition and (2) the feasibility of the PrEDICT application compared to existing tests of attention. DESIGN Prospective observational study. SETTING ED of a Canadian tertiary care center. PARTICIPANTS We included ED patients, aged 70 years and older, with a minimum 4-hour stay. We excluded anyone with critical illness, communication barriers, and visual impairment or those unable to use a computer tablet. None had prevalent delirium by ED clinicians' routine clinical assessment. MEASUREMENTS Participants were asked to tap targets on a tablet at four difficulty levels. Time and accuracy were automatically recorded. Other measures included the Confusion Assessment Method, the Delirium Severity Index, the Digit Vigilance Test (DVT), and the Choice Reaction Test (CRT). RESULTS We enrolled 203 patients. Their average age was 80.6 years, 49.8% were female, and their average ED length of stay was 15.9 hours. Sixteen subjects had clinically unrecognized delirium, and 14 of them completed the PrEDICT game (87.5%). We developed a threshold score with 100% sensitivity (95% confidence interval [CI] = 76.8%-100.0%) and 59.7% specificity (95% CI = 52.3%-66.6%) to identify patients with clinically unrecognized delirium. The area under the curve was 0.86 (95% CI = 0.77-0.94). Completion rates were 196/203 (96.6%) for the PrEDICT serious game compared to 128/203 (63.1%) for the CRT and 51/203 (25.1%) for the DVT. CONCLUSION Older ED patients were able to use our serious game, including 87.5% of those with clinically unrecognized delirium. The PrEDICT application has potential to act as a sensitive screening tool to identify older ED patients with clinically unrecognized delirium. J Am Geriatr Soc 67:2370-2375, 2019.
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Affiliation(s)
- Jacques S Lee
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Emergency Services, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Division of Emergency Services, Schwartz-Reisman Emergency Medicine Institute, Toronto, Ontario, Canada
| | - Tiffany Tong
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Mary C Tierney
- Division of Emergency Services, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Primary Care Research Unit, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Alex Kiss
- Division of Emergency Services, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Mark Chignell
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
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Courel-Ibáñez J, Pallarés JG. Effects of β-hydroxy-β-methylbutyrate (HMB) supplementation in addition to multicomponent exercise in adults older than 70 years living in nursing homes, a cluster randomized placebo-controlled trial: the HEAL study protocol. BMC Geriatr 2019; 19:188. [PMID: 31277595 PMCID: PMC6612176 DOI: 10.1186/s12877-019-1200-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 06/30/2019] [Indexed: 01/06/2023] Open
Abstract
Background Evidence supports the fact that multicomponent exercise and HMB supplementation are, separately, effective in improving older adult’s health and palliate functional metabolic diseases in older people. However, the true effect of HMB supplementation combined with a tailored exercise program in frail older adults is still unknown. Thus, the aim of the HEAL (HMB + Exercise = Adults Living longer) study is to assess the effects of the combination of a daily multicomponent exercise and resistance training (VIVIFRAIL program) intervention in addition to HMB supplementation on older adults’ health. Methods/design A 24-week cluster randomized, double-blind, placebo-controlled study will be conducted on 104 adults ≥70 years. Nursing homes will be randomized to either of four groups: Ex-HMB (exercise intervention with HMB), Ex-Plac (exercise intervention with placebo), NoEx-HMB (no exercise intervention with HMB), and Controls (No exercise and no HMB). Intervention groups which include exercise will complete the individualized multicomponent (strength, balance and cardiovascular exercises) training program VIVIFRAIL. Intervention groups which include HMB supplementation will receive a 3 g/daily dose of free acid HMB in powder form. The primary outcome measure is the functional capacity. Secondary outcome measures are muscle strength and power, frailty and fall risk, body composition, biochemical analyses and cardiometabolic risk factor, disability and comorbidity, cognitive function and depression. Discussion The findings of the HEAL study will help professionals from public health systems to identify cost-effective and innovative actions to improve older people’s health and quality of life, and endorse exercise practice in older adults and people living in nursing homes. Trial registration NCT03827499; Date of registration: 01/02/2019.
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Affiliation(s)
- Javier Courel-Ibáñez
- Human Performance and Sports Science Laboratory, Faculty of Sport Sciences, University of Murcia, Calle Argentina, 19, 30720, San Javier, Murcia, Spain.
| | - J G Pallarés
- Human Performance and Sports Science Laboratory, Faculty of Sport Sciences, University of Murcia, Calle Argentina, 19, 30720, San Javier, Murcia, Spain
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Dalpé G, Thorogood A, Knoppers BM. A Tale of Two Capacities: Including Children and Decisionally Vulnerable Adults in Biomedical Research. Front Genet 2019; 10:289. [PMID: 31024616 PMCID: PMC6459892 DOI: 10.3389/fgene.2019.00289] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 03/18/2019] [Indexed: 12/13/2022] Open
Abstract
The participation of individuals who lack decision-making capacity is essential for advancing genomics research and neuroscience, but raises ethical and legal challenges relating to vulnerability, consent, and exclusion. Capacity differences between populations and individuals, the dynamics of capacity over time, and evolving legal consent and capacity regimes all raise uncertainty for researchers, institutional review boards, and policy makers. We review international ethical and legal best practices for including children and decisionally vulnerable adults in health research. Research ethics norms and literature tend to split such groups into narrow silos, which results in inconsistency and conceptual confusion, or to lump them together, which fails to take into account morally relevant differences. Through a narrative review of international norms, we identify challenges common to both groups, while drawing out distinctions reflecting their opposite capacity trajectories. Our comparison between these two populations clarifies underlying ethical concepts and offers opportunities for critique. Children need protection to foster their long-term autonomy, while decisionally vulnerable adults need to be provided with support in order to exercise their autonomy. This leads to differences in how researchers determine who lacks capacity, who has authority to consent, and what criteria guide such decision-making. We also consider how capacity issues color contemporary research governance debates over broad consent, data protection compliance, data sharing, and the return of individual research results and incidental findings.
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Affiliation(s)
- Gratien Dalpé
- Centre of Genomics and Policy, McGill University, Montreal, QC, Canada
| | - Adrian Thorogood
- Centre of Genomics and Policy, McGill University, Montreal, QC, Canada
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