Planning and Decision Making for Care Transitions

Adaptation and Validation of the Preparation for Future Care Needs Scale for Chinese Older Adults in Hong Kong

Background and Objectives

Care planning can protect against or offset potential stressors in the caregiving stage and mitigate their detrimental effects. This study aimed to translate, adapt, and validate 2 short forms of the multidimensional, theory-guided scale measuring preparation for future care needs (PFCN) among Chinese older adults in Hong Kong.

Research Design and Methods

Data were derived from a cross-sectional survey of 862 community-dwelling individuals aged 60 years and older. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted to assess the structural validity of the scales. Criterion-related validity, known-groups validity, and internal consistency were also examined.

Results

EFA yielded a 14-item 4-factor (awareness, avoidance, decision making, and concrete planning) model, which was supported by CFA and explained 68.9% of the total variance. CFA also supported the structural validity of the 5-item scale. Criterion-related validity of the 2 scales was supported by their significant and positive correlations with domain-specific planning behaviors for retirement. Known-groups validity of the 2 scales was demonstrated by significant differences in scores between male and female older adults and scores between different educational levels and socioeconomic status. Cronbach’s alphas for the internal consistency of the 14-item and 5-item scales were 0.889 and 0.774, respectively.

Discussion and Implications

PFCN scales enable researchers and service practitioners to accurately understand and assess older adults’ processes and efforts in care planning, facilitate the identification of individuals at risk from inadequate planning, and inform the development of interventions to enhance care preparation in target domains.

Analysis of discharge documentation for older adults living with dementia: A cohort study

BACKGROUND

Older adults living with dementia frequently transition between healthcare settings. Care transitions increase vulnerability and risk of iatrogenic harm.

AIM AND OBJECTIVE

To examine the quality of transitional care arrangements within discharge documentation for older people living with dementia.

DESIGN

Secondary analysis of cohort study data.

METHOD

A secondary analysis of the IDEAL Study [ACTRN12612001164886] discharge documents, following the STROBE guidelines. Participants had a confirmed diagnosis of dementia and were discharged from hospital to a nursing home. An audit tool was used to extract the data. This was developed through a synthesis of existing tools and finalised by an expert panel. The analysis assessed the quality of discharge documentation, in the context of transitional care needs, and presented results using descriptive statistics. Functional ability; physical health; cognition and mental health; medications; and socio environmental factors were assessed.

RESULTS

Sixty participants were included in analyses, and half were male (52%), with a total participant mean age of 83 (SD 8.7) years. There was wide variability in the quality of core discharge information, ranging from excellent (37%), adequate (43%) to poor (20%). A sub-group of these core discharge documentation elements that detailed the participants transitional care needs were rated as follows: excellent (17%), adequate (46%) and poor (37%).

CONCLUSION

Discharge documentation fails to meet needs of people living with dementia. Improving the quality of discharge documentation for people living with dementia transitioning from hospital to nursing home is critical to provide safe and quality care.

RELEVANCE TO CLINICAL PRACTICE

There is a need for safe, timely, accurate and comprehensive discharge information to ensure the safety of people living with dementia and prevent adverse harm.

Perspectives on Aging-Related Preparation

When older adults face age-related life challenges, anticipating what to expect and how to access potential coping strategies can both prevent and provide the possibility of easier recovery from crises. Aging-Related Preparation (ARP) is defined as the continuum of thoughts and activities about how to age well, often beginning with the awareness of age-related changes, or the anticipation of retirement, and concluding with specifying end-of-life wishes. In the current paper, we introduce the concept of ARP and related formulations regarding plans for aging well, describe both predictors and outcomes of ARP for several the domains of ARP, and consider the elements of ARP within the context of existing social policy. We conclude that ARP is determined by a variety of influences both intrinsic to the older person (e.g., personality, cognitive ability, beliefs about planning, problem-solving skills), linked to social class and education, as well as dependent on family structures, access to and knowledge of options, services, and local community resources, and social policy. We further provide evidence that ARP has positive effects in the domain of pre-retirement planning (for retirement adjustment), of preparation for future care (for emotional well-being), and of ACP (for a good death). However, other domains of ARP, including planning for leisure, housing, and social planning are under-researched. Finally, we discuss policy implications of the existing research.

Care Values in Dementia: Patterns of Perception and Incongruence Among Family Care Dyads

BACKGROUND AND OBJECTIVES

Persons with dementia (PWDs) often place greater importance on their care values (i.e., maintaining autonomy and social relations, choosing caregivers, avoiding being a burden) than family caregivers (CGs) perceive, which can detract from dementia care planning (e.g., care arrangements or surrogate decisions). Notable variability has been found across family care dyads (PWD and CG) in their perceptions of care values, suggesting that there may be multiple patterns of perception. The purpose of this study was to characterize distinct patterns of perception of care values in family care dyads.

DESIGN AND METHODS

Using cross-sectional data from 228 community-dwelling family care dyads, we quantified dyads' average perceptions and incongruence in perceptions of the importance of everyday care values using multilevel modeling. These scores were then used in a latent class analysis to identify distinct patterns of perception, with the dyad as the unit of analysis.

RESULTS

Two distinct patterns of care value perception were identified. 25% of dyads were labeled as "CG underestimating" due to lower average estimations of the importance of PWDs' care values, and a significant amount of dyadic incongruence. Underestimating dyads were characterized by a confirmed diagnosis of dementia, lower cognitive function, and younger age in PWDs, and higher relationship strain in the dyad.

IMPLICATIONS

Care dyads that fall into an underestimating pattern may be at greater risk for inadequate dementia care planning. Interventions to improve care planning in this higher-risk group may include care values identification with the PWD, strategies for alleviating relationship strain, early-stage planning, and disease education.

Ageing in the right place - a prototype of a web-based housing counselling intervention for later life

Background: Despite a strong desire among most older adults to age in place, there are few widely available services to support planning and preparing for one's future housing needs.Objective: To develop a prototype of a web-based housing counselling intervention for use in later life, by employing a user-centred design.Material and Methods: As the first step in intervention development, we employed a development process based on research circle methodology. Nine older adults participated in three sessions. Findings from literature reviews, a meeting with a technology and design panel (n = 6) and interviews with representatives of nonprofit organizations, companies, and municipalities (n = 7) served as discussion points.Result: An on-paper prototype was derived, composed of the THINK, LEARN and ACT module reflecting different stages of the decision-making process. Each module addressed preferences, health, home and social and financial resources. Key design features and theoretical underpinnings were included.Conclusion and Significance: A user-centred design process can result in services that are aligned with older adults' preferences for obtaining housing information. Services for planning and preparing future housing needs have the potential to increase older adults´ well-being at home as well as reduce costs for care and housing provision by the municipalities.

Family Support and Preparation for Future Care Needs Among Urban Chinese Baby Boomers

Objectives

Little is reported about the family's role in preparation for future care (PFC) before the onset of care needs. The primary aim was to examine the relationships between PFC and different types of family support exchanged with generations both above and below.

Method

Path analysis was conducted on 516 Chinese baby boomers aged 45-65 to examine the associations between PFC (care expectation, awareness, information gathering, and decision making) and 4 types of family support (instrumental support, financial assistance, information and appraisal, and emotional support) when the covariates were controlled for.

Results

The current planning status and planning paths are consistent with those of the U.S. and European populations. Providing instrumental support to a parent was positively associated with awareness of care needs. Providing emotional support to a child was negatively associated with information gathering. In general, receiving support from a child facilitated PFC. Although those receiving emotional support from an adult child had less awareness of care needs, they displayed more information gathering.

Discussion

The role of family support in PFC is more subtle than simply increasing and decreasing resource volumes. Future research is needed to better understand this complexity.

Involvement of Hospitalized Persons With Dementia in Everyday Decisions: A Dyadic Study

Background and Objectives

To examine the involvement of persons with dementia (PWDs) in everyday decision making from the perspectives of hospitalized PWDs and their family caregivers, and to identify determinants thereof.

Research Design and Methods

Using multilevel modeling, we examined cross-sectional data collected prospectively from 42 family care dyads regarding the care values of the PWD.

Results

Both members of the dyad rated the PWD, on average, as being "somewhat involved". There was a significant amount of variability around the average perceptions of PWD involvement in decision making for both PWDs (χ2 = 351.02, p < .001) and family caregivers (χ2 = 327.01, p < .001). Both PWDs and family caregivers were significantly more likely to perceive greater PWD involvement in decision making when the family caregiver reported the PWD as valuing autonomy. Additionally, PWDs were significantly more likely to report greater involvement when they had greater cognitive function. Finally, family caregivers perceived significantly greater involvement of the patient in decision making when they reported less strain in the relationship. Together, autonomy, relationship strain, cognitive function, and care-related strain accounted for 38% and 46% of the variability in PWDs' and family caregivers' perceptions, respectively, of the PWD's decision-making involvement.

Discussion and Implications

Although research indicates that decision-making abilities decline with advancing dementia, these results imply that working with families to support PWDs in their value of autonomy and mitigate strain in the dyad's relationship may help prolong PWDs' decision-making involvement.

Incongruent perceptions of the care values of hospitalized persons with dementia: a pilot study of patient-family caregiver dyads

OBJECTIVE

Many difficult decisions are made in the inpatient hospital setting regarding the daily care of persons with dementia (PWDs). Incongruent perceptions of the PWD's care values limit the family caregiver's ability to make surrogate decisions. The objectives of this pilot study were to describe and identify determinants of incongruent perceptions in the hospital setting.

METHODS

Using multilevel modeling (MLM), we examined cross-sectional data collected from 42 PWD-family caregiver dyads.

RESULTS

There was a significant amount of incongruence, on average, for all four subscales representing the PWD's care values: autonomy = -0.33 (p < .001); burden = -.49 (p < .001); safety/quality of care = -.26 (p < .001); and social interactions = -.21 (p = .004). Family caregivers (CG) rated the importance of care values to the PWD as lower than the PWD rated the importance. Determinants of greater incongruence included higher relationship strain and fewer positive dyadic interactions.

CONCLUSION

Our findings reveal significant levels of incongruence in perceptions of the PWD's values among dementia care dyads in the hospital setting. Our analysis suggests a potential impact of relationship variables on incongruence. Further research is needed around this overlooked interpersonal context for supporting the dementia care dyad in the hospital setting.

Older Adults in Rural Appalachia: Preference and Expectations for Future Care

Little is known about how rural-dwelling older adults anticipate and plan for future care needs. Using a mixed-method explanatory design, structural equation modeling ( n = 535) revealed significant associations between concerns about using services on preference for type of help; preference was associated with likelihood of using future services. Content analysis of interview data from 19 older adults who needed but were not receiving help revealed how they conceptualize their need for assistance and anticipated future care arrangements. Nine older adults were not thinking about future care needs. While most older adults articulated preferences for informal help, they indicated some openness to formal assistance. Preferences did not always align with expectations for the future. Rather, concerns about burdening family and friends outweighed concerns about community services and influenced expectations of using formal services. Understanding rural older adults' expectations for future care arrangements is necessary for advancing policy and implementing successful services options.

Shared decision-making in dementia: A review of patient and family carer involvement

This paper reviews empirical findings concerning the decision-making process of persons with dementia and their family carers, with a particular focus on the extent and determinants of involvement of persons with dementia in the decision-making process. To be included in this review, studies needed to be published in peer-reviewed journals between 1999 and 2014, report empirical data from participants with dementia and/or their family carers, and pertain to the involvement of persons with dementia and their family carers in decisions about everyday care, medical care and treatment, or long-term care. A total of 36 studies were included. Results indicated that not all persons with dementia are excluded from participating in the decision-making process, but there is a broad spectrum of what constitutes shared decision-making in dementia. Studies concerning the determinants of shared decision-making mostly focused on non-modifiable factors. Future research is needed to better promote shared decision-making among persons with dementia and their family carers.

Older adults' evaluations of middle-aged children's attempts to initiate discussion of care needs

We explored how older adults evaluated the strategies used by an adult child to initiate discussion of future care needs, and subsequently, whether these judgments affected older adults' willingness to engage in discussions about eldercare if approached in a similar fashion by one of their own children. One hundred and thirty older adults were randomly assigned to read one of four scripts depicting efforts by a middle-aged daughter to raise the topic of future care needs with her mother by implementing a variety of facework behaviors. Scripts manipulated the degree to which the daughter conveyed respect for her mother's desires for autonomy (negative face) and connection (positive face). The daughter's facework significantly predicted older parents' evaluation of her as supportive, which in turn predicted their willingness to discuss future care needs with one of their own children if they were to approach the conversation in a similar way.

"Keep dignity intact": exploring desires for quality long-term care among midlife women

The purpose of this qualitative study was to provide in-depth descriptions of preferences for receipt of long-term care among a small sample of information-rich cases. The participants in this study, women in late midlife caring for a parent or parent-in-law, expressed where they would prefer to receive care, who they would want to provide care, and personal traits that would be important in a caregiver. A major theme centered personal characteristics these women would want in a caregiver, traits such as empathy, sensitivity, and knowledgeable about elder care. Implications for social work practice are discussed.