Describing providers' perspectives on the needs and challenges of family caregivers of African American people living with dementia

The primary purpose of this study was to explore the needs and challenges of African American family caregivers of People living with dementia (PLWD) from the perspective of service providers including healthcare and social service providers. The study conducted three online semi-structured focus group interviews with service providers (n = 15). Data were analyzed using Braun & Clarke's guide to thematic analysis approach. Five themes emerged from the analysis of the focus group data: (i) Inadequate information about resources; (ii) Dementia education; (iii) Burden of dementia on families; (iv) Limited financial support and funding; and (v) Suggestions for needed resources. Service providers expressed the lack of community-based dementia service and support programs in African American communities. Findings from the study indicated the need to provide culturally appropriate information on dementia caregiving. This study adds to the scope of knowledge by exploring the processes of seeking help and using services.

Creating a Nonprofit Spin-Off to Implement a Community Health Improvement Plan: A Case Study of a Midsize Health Department in the Midwest

A common problem faced by local health departments is engaging cross-sector stakeholders to achieve shared community goals. Community engagement is critical for effective Community Health Improvement Plan (CHIP) development and implementation, while also being a standard for health department accreditation. This case study describes one city-county health department's development of a nonprofit arm to act as a catalyst for connecting community leaders to identify and collaboratively address community health goals. First, we describe our process to develop a nonprofit entity and strategically recruit community members to comprise the founding board of directors. Then, we describe methods employed by the nonprofit to create a community action plan in response to identified community health needs and how we incentivized progress. We evaluated our process using a mixed-methods approach and conclude that a nonprofit arm of a health department can be a novel strategy for effectively engaging community stakeholders to advance community health.

Community Health Improvement Plans: An Analysis of Approaches Used by Local Health Departments

CONTEXT

The Public Health Accreditation Board requires accredited local health departments (LHDs) to complete community health improvement plans (CHIPs). Evidence suggests that participatory planning frameworks, cross-sector collaboration, social determinants of health (SDOHs), and steering organizations are integral to effective public health planning. However, little is known about the degree to which LHDs incorporate these aspects during the CHIP process.

OBJECTIVES

To describe the use of planning methods, SDOHs, cross-sector partnerships, and steering organizations during the CHIP development process among nationally accredited LHDs and to identify whether LHD jurisdictional size or region is associated with differences in use.

DESIGN

The most recent CHIPs from 93% of all nationally accredited LHDs (n = 195) were qualitatively reviewed and numerically coded for each of the planning components to calculate frequency and degree of use. Differences in use of each component by LHDs' jurisdictional size and region were tested using the chi-square test.

MAIN OUTCOME MEASURE

Use of CHIP planning frameworks, SDOH inclusion, cross-sector partnerships, and steering organizations.

RESULTS

One-half of LHDs (53%) reported use of Mobilizing for Action through Planning and Partnerships, but nearly one-fourth of LHDs did not use any planning framework. LHDs with a large jurisdictional size (>500 000) were significantly more likely to include SDOHs to a high degree than LHDs with mid- (100 000-499 999) to small- (<99 999) jurisdictional size (P < .01). Similarly, large LHDs were more likely to include cross-sector partners except for the category community members, which were rarely (10%) included. Mid-sized LHDs were more likely to lead the CHIP steering committee (61%) than small (29%) and large (9%) LHDs (P < .01). Differences in use of the 4 components by region were less significant.

CONCLUSIONS

Jurisdictional size, rather than region, was more strongly associated with LHD approaches to CHIP development. More studies are needed to determine how differences influence CHIP implementation and impact.

Cultural Unintelligibility and Marital Pressure: A Grounded Theory of Minority Stigma Against Women with Same-Sex Attraction in Mainland China

Minority stigma against sexual minority women and its contributions to these women's health disparities have been widely investigated in Western countries. By contrast, little has been known about minority stigma against women with same-sex attraction (WSSA) in mainland China. This study aimed at exploring the nature, genesis, and pathways of minority stigma among this rarely studied minority group in terms of China's unique social and cultural organization of gender and sexuality. A grounded theory approach was applied to 28 participants of Chinese WSSA through in-depth telephone interviews to elicit their views and perspectives anchored in their daily experiences with gender hierarchy and normative heterosexuality. Findings of this study identified marital pressure and cultural unintelligibility as two principal components of minority stigma against Chinese WSSA. A conceptual framework was developed to illustrate how minority stigma relies on the mutually reinforcing loop of martial pressure and culturally unintelligible status of female same-sex attraction to oppress Chinese WSSA within and across intrapersonal, interpersonal, and structural levels. The parent-daughter relationship, laden with the Confucian value of filial piety, was highlighted as the major pathway of minority stigma to force Chinese women with same-sex attraction into heterosexual marriage and make female same-sex attraction culturally unintelligible. These findings lay a foundation for conceptualizing and measuring minority stigma of Chinese WSSA caused by the stigmatization of their same-sex attraction. Moreover, these findings would contribute greatly to understanding how cultural particularities critically affect the local process of stigmatization through which power relations and social control are practiced.

A Snapshot of Oklahoma's CHR/CHW Workforce: Results from the Region 6 Training Needs Assessment Survey, 2019

BACKGROUND –

The Region 6 South Central Public Health Training Center conducts needs assessments to inform the development of online trainings tailored to the HRSA Region 6 health and public health workforce. The purpose of this study was to assess Oklahoma's Community Health Representative (CHR) / Community Health Worker (CHW) workforce characteristics, current trainings, and training needs to guide the development of online trainings.

METHODS –

This survey-based needs assessment for health and public health workforce training needs asked about alternative job titles, top three health issues addressed, roles played, skills used, current trainings, and training needs. Descriptive statistical analysis provided insights about CHRs/CHWs. The Fisher's exact test was used to compare frequency of responses between CHRs and CHWs, with p-values <0.05 considered significant. We analyzed qualitative data by using a modified content analysis.

RESULTS –

Fifty-one self-identified CHRs/CHWs in Oklahoma participated in the 2019 regional health and public health training needs assessment. Most CHRs/CHWs were female and identified as "frontline public health workers." Respondents reported a range of educational attainment and diverse job titles. CHRs worked at tribal health or public health organizations primarily in rural areas. Most CHWs worked in urban areas and were employed by state and local health departments or community-based organizations. CHRs/CHWs had a broad spectrum of roles and skills, with required trainings reflecting various organizational needs. CHRs/CHWs expressed strong interest in receiving additional trainings via multiple delivery formats.

DISCUSSION AND CONCLUSIONS –

Oklahoma's CHRs/CHWs would benefit from and utilize workforce development, including trainings on a broad spectrum of roles and skills in multiple delivery formats. Potential employers and funders across the state would benefit from education on CHRs/CHWs as a workforce, team-integration, and sustainable funding.

A population based caregivers profile and training needs assessment in Oklahoma

BACKGROUND AND OBJECTIVES

Studies indicate an expected population growth of almost fifty percent in Oklahomans aged 65 and older by 2030. According to the United Health Foundation, Oklahoma ranked 48th in overall senior health in 2017.

RESEARCH DESIGN AND METHODS

The Oklahoma Healthy Aging Initiative administered a Consumer Needs Assessment Survey by mail to a stratified random sample of the 475,518 registered voters aged 65 and older. The survey was anonymous and stratified by region. The survey contained six sections: introduction, health and health promotion, activities/recreation, information and assistance, caregiving and "about you."

RESULTS

Nearly one in three (32%) of respondents indicated that they directly or indirectly provide care to another, with another 9% responding they maybe provide care, and the remaining 59% responding no. Nearly 10% of people who say they are not caregivers reported that they participate at least one day a week in caring for a sick or invalid spouse, family member, or friend living with them, indicating current estimates of the number of caregivers is low.

DISCUSSION AND IMPLICATIONS

Those who report they are or are maybe caregivers tend to be more interested in community events and more interested in caregiver respite. In addition, maybe caregivers appear to be more interested in health improvement topics and classes, such as health and wellness, mental health, chronic disease, and computers when compared to both caregivers and non-caregivers. Our survey results indicate a need for caregivers to receive respite services as well as training courses in Oklahoma communities.

Results from the 2013 Senior's Health Services Survey: Rural and Urban Differences

PURPOSE

The purpose of this study was to compare and contrast health education needs of rural Oklahomans aged 65 and older compared to urban and sub-urban populations.

METHODS

Surveys were distributed to a list of registered voters age 65 and older in Oklahoma with a total of 1,248 surveys returned. Survey items asked about interests in services, classes and activities, plus current barriers to accessing and/or engaging in such programs.

FINDINGS

Survey respondents living in large rural towns (23.7%) and the urban core (21.5%) were significantly more likely than those in small rural towns (14.0%) or sub-urban areas (15.5%) to have attended a free health information event in the past year (P=0.0393). Older Oklahomans in small towns and isolated rural areas reported more frequently than those in the urban core that they would participate in congregate meals at a center (small town/isolated rural: 14.4%, urban core: 7.2%) (P=0.05). Lack of adequate facilities was more frequently reported by those residing in small town and isolated rural areas compared to urban core areas (16.4% vs. 7.8%, P=0.01). Finally, older Oklahomans in the large rural towns (0.6%) and small town and isolated rural locations (2.13%) less frequently reported use of senior information lines (Senior Infoline) than those in the urban core (6.0%) and in sub-urban areas (7.1%) (P=0.0009).

CONCLUSIONS

Results of this survey provide useful data on senior interests and current barriers to community programs/activities have some unique trends among both urban and rural populations.

Assessing Statewide Need for Older Adult Health Promotion Services: The Oklahoma Experience

The growing senior population and persistent poor health status of seniors in Oklahoma compels a fresh look at what health promotion services would be well received. Surveys were distributed to a list of registered voters age 65 and older in Oklahoma with a total of 1,248 surveys returned (19.8%). Survey items asked about interests in services, classes, and activities, plus current barriers to accessing and/or engaging in such programs. To account for survey weighting, Rao-Scott Chi-Square Tests were performed to determine differences by demographic characteristics. We identified services, classes, and activities that were (and were not) of interest to seniors in Oklahoma with legal assistance (52.1%), exercise classes (46.6%), internet classes (40.7%), and indoor exercise activities (45.5%) receiving the highest level of interest. Barriers to interest in participating in programs included not wanting to go and not knowing availability of such services. The results of this survey provide useful data on health promotion gaps for seniors, interests and barriers to engaging in such activities, and guidance for statewide program development. Future program development needs to be focused on areas of interest for older adults, including legal assistance, exercise classes, and internet classes.

Reduced Hospitalization Rates of Two Sets of Community-Residing Older Adults After Use of a Personal Response System

This study replicated, in a United States setting, an earlier study conducted in Canada to determine whether use of a 24-hour personal response system (PRS) affected selected hospital utilization rates among community-residing users. Utilization rates of 106 Canadian patients were reviewed for 1 year before and 1 year after enrollment in the PRS: These were compared with a similar set of 101 U.S. patients using the same PRS program. Self-paired analyses were conducted on number of emergency department (ED) visits and number of inpatient days. During the 1-year follow-up periods, both sets of subscribers using the Lifeline system experienced a statistically significant decrease (p < 0.05) in per person inpatient days (mean reduction = 6.5 days). No significant differences occurred in ED visits. When indicated, a PRS may be an appropriate environmental prescription.

Instructional Simulation Integrates Research, Education, and Practice

Instructional simulation is widely used in clinical education. Examples include the use of inanimate models meant to imitate humans, standardized patients who are actors portraying patients with certain conditions, and role-play where learners experience the disease through props and circumstances. These modalities are briefly described, and then case examples are provided of simulation curricula in use that integrate research findings and clinical practice expertise to guide development and implementation steps. The cases illustrate how formative and summative feedback from two legs of the "three-legged stool" can be potent integrating forces in development of simulation curricula. In these examples, the educational outputs benefit from purposeful inclusion of research and practice inputs. Costs are outlined for instructor and learner time commitments, space considerations, and expendables. The authors' data and experience suggest that instructional simulation that is supported by a solid scientific base and clinical expertise is appreciated by teachers and learners.

A controlled trial of Partners in Dementia Care: veteran outcomes after six and twelve months

Introduction

“Partners in Dementia Care” (PDC) tested the effectiveness of a care-coordination program integrating healthcare and community services and supporting veterans with dementia and their caregivers. Delivered via partnerships between Veterans Affairs medical centers and Alzheimer’s Association chapters, PDC targeted both patients and caregivers, distinguishing it from many non-pharmacological interventions. Hypotheses posited PDC would improve five veteran self-reported outcomes: 1) unmet need, 2) embarrassment about memory problems, 3) isolation, 4) relationship strain and 5) depression. Greater impact was expected for more impaired veterans. A unique feature was self-reported research data collected from veterans with dementia.

Methods and Findings

Five matched communities were study sites. Two randomly selected sites received PDC for 12 months; comparison sites received usual care. Three structured telephone interviews were completed every 6 months with veterans who could participate.

Results

Of 508 consenting veterans, 333 (65.6%) completed baseline interviews. Among those who completed baseline interviews, 263 (79.0%) completed 6-month follow-ups and 194 (58.3%) completed 12-month follow-ups. Regression analyses showed PDC veterans had significantly less adverse outcomes than those receiving usual care, particularly for more impaired veterans after 6 months, including reduced relationship strain (B = −0.09; p = 0.05), depression (B = −0.10; p = 0.03), and unmet need (B = −0.28; p = 0.02; and B = −0.52; p = 0.08). PDC veterans also had less embarrassment about memory problems (B = −0.24; p = 0.08). At 12 months, more impaired veterans had further reductions in unmet need (B = −0.96; p < 0.01) and embarrassment (B = −0.05; p = 0.02). Limitations included use of matched comparison sites rather than within-site randomization and lack of consideration for variation within the PDC group in amounts and types of assistance provided.

Conclusions

Partnerships between community and health organizations have the potential to meet the dementia-related needs and improve the psychosocial functioning of persons with dementia.

Trial Registry

NCT00291161

Attitude adjustment: shaping medical students' perceptions of older patients with a geriatrics curriculum

For more than half a century, scientific research has documented widespread avoidance and even denial of aging. Though nothing new, aversive reactions to the elderly are not only unfortunate but dangerous today, as increasing life expectancy and consequent demand for specialized geriatric medical care vastly outpace the supply of qualified clinicians equipped to provide it. This discrepancy has led to a crisis that is not easily resolved. At the same time, geriatrics reports the highest level of physician satisfaction among medical specialties. How can this apparent disconnect be explained, and what can be done about it? Citing evidence from medicine and other health care disciplines, the authors address these questions by emphasizing the role of aging-related attitudes, a complex but theoretically modifiable construct. Successful educational interventions are described, including the authors' experience at the helm of a monthlong geriatrics clerkship for fourth-year medical students. Novel suggestions are provided to combat the daunting challenges to achieving a workforce that is sufficient both in number and training to effectively meet the needs of the fastest-growing segment of the U.S. population. As patients continue to age across most medical specialties, the importance of geriatric curricula, particularly those sensitizing learners to the need for a systems-based, biopsychosocial (i.e., interdisciplinary) model of care, cannot be overemphasized. Such training, it is argued, should be a standard component of medical education, and future research should focus on identifying specific curricular content and teaching methods that most effectively achieve this end.

Employing external facilitation to implement cognitive behavioral therapy in VA clinics: a pilot study

Background

Although for more than a decade healthcare systems have attempted to provide evidence-based mental health treatments, the availability and use of psychotherapies remains low. A significant need exists to identify simple but effective implementation strategies to adopt complex practices within complex systems of care. Emerging evidence suggests that facilitation may be an effective integrative implementation strategy for adoption of complex practices. The current pilot examined the use of external facilitation for adoption of cognitive behavioral therapy (CBT) in 20 Department of Veteran Affairs (VA) clinics.

Methods

The 20 clinics were paired on facility characteristics, and 23 clinicians from these were trained in CBT. A clinic in each pair was randomly selected to receive external facilitation. Quantitative methods were used to examine the extent of CBT implementation in 10 clinics that received external facilitation compared with 10 clinics that did not, and to better understand the relationship between individual providers' characteristics and attitudes and their CBT use. Costs of external facilitation were assessed by tracking the time spent by the facilitator and therapists in activities related to implementing CBT. Qualitative methods were used to explore contextual and other factors thought to influence implementation.

Results

Examination of change scores showed that facilitated therapists averaged an increase of 19% [95% CI: (2, 36)] in self-reported CBT use from baseline, while control therapists averaged a 4% [95% CI: (-14, 21)] increase. Therapists in the facilitated condition who were not providing CBT at baseline showed the greatest increase (35%) compared to a control therapist who was not providing CBT at baseline (10%) or to therapists in either condition who were providing CBT at baseline (average 3%). Increased CBT use was unrelated to prior CBT training. Barriers to CBT implementation were therapists' lack of control over their clinic schedule and poor communication with clinical leaders.

Conclusions

These findings suggest that facilitation may help clinicians make complex practice changes such as implementing an evidence-based psychotherapy. Furthermore, the substantial increase in CBT usage among the facilitation group was achieved at a modest cost.

Development and evaluation of a longitudinal Case Based Learning (CBL) experience for a geriatric medicine rotation

The DWR Department of Geriatric Medicine at OUHSC and the OKC VA Medical Center began a mandatory third-year geriatric medicine clerkship in 2003. As part of the didactic sessions, the Department created a longitudinal Case-Based Learning (CBL) experience. The purpose of this paper is to describe the CBL experience, report student satisfaction with the CBL process, and discuss how students value CBL as a teaching method compared to other methods. The results indicate that CBL is highly valued among the students due to the interactive nature of the sessions and longitudinal nature of the cases.

Peer reviewing e-learning: opportunities, challenges, and solutions

Peer review is the foundation of academic publication and a necessary step in the scrutiny of any scholarly work. Simply defined, peer review is the attentive, unbiased assessment of any scholarly work that is submitted for formal scrutiny. Although medical school faculty increasingly use technology in clinical teaching, e-learning materials are often not subjected to a rigorous peer review process. The authors contrast peer review of e-learning materials with that of print materials, describe peer review issues regarding e-learning materials, propose approaches to address the challenges of peer review of e-learning materials, and outline directions for refinement of the e-learning peer review process. At its core, the peer review of e-learning materials should not differ substantially from that of traditional manuscripts. However, e-learning introduces new demands that impel reviewers to consider aspects that are unique to educational technology, including pedagogy, format, usability, navigation, interactivity, delivery, ease of updating, distribution, and access. Four approaches are offered to ease the burden and improve the quality of e-learning peer review: develop peer review training, embrace multidisciplinary peer review, develop guidelines, and provide incentives and compensation. The authors conclude with suggestions about peer review research.

The Consortium of E-Learning in Geriatrics Instruction

This paper describes the activities of the Consortium of E-Learning in Geriatrics Instruction (CELGI), a group dedicated to creating, using, and evaluating e-learning to enhance geriatrics education. E-learning provides a relatively new approach to addressing geriatrics educators' concerns, such as the shortage of professionals trained to care for older people, overcrowded medical curricula, the move to transfer teaching venues to community settings, and the switch to competency-based education models. However, this innovative education technology is facing a number of challenges as its use and influence grow, including proof of effectiveness and efficiency. CELGI was created in response to these challenges, with the goal of facilitating the development and portability of e-learning materials for geriatrics educators. Members represent medical and nursing schools, the Department of Veterans Affairs healthcare system, long-term care facilities, and other institutions that rely on continuing streams of quality health education. CELGI concentrates on providing a coordinated approach to formulating and adapting specifications, standards, and guidelines; developing education and training in e-learning competencies; developing e-learning products; evaluating the effect of e-learning materials; and disseminating these materials. The vision of consortium members is that e-learning for geriatric education will become the benchmark for valid and successful e-learning throughout medical education.

The use of the internet in geriatrics education: results of a national survey of medical geriatrics academic programs

In order to characterize use of the Internet in medical geriatrics education programs, 130 medical education programs in the U.S. that train medical students, interns, residents, fellows and practicing physicians were asked to complete a survey developed by the Consortium of E-Learning in Geriatrics Instruction (CELGI). Sixty-eight programs (52.3%) returned surveys. Fifty-four (79%) of those responding reported using the Internet specifically for geriatric medical education, and 38 (56%) reported they are developing Internet materials. Twentythree undergraduate, 31 graduate, and 26 continuing medical education programs reported at least 25% of their curriculum was Internet-based. Users and developers of medical geriatric Internet materials had more full-time faculty and nonclinical faculty. The results of our survey indicate that the Internet is being widely used in medical geriatric education.

Efficacy of a geriatric oral health CD as a learning tool

To better prepare professionals to meet the needs of older patients, a self-instructional computer module on geriatric oral health was previously developed. A follow-up study reported here tested the efficacy of this educational tool for improving student knowledge of geriatric oral care. A convenience sampling procedure was used. Sample size calculation revealed that fifty-six subjects were required to meet clinical and statistical criteria. Paired t-test addressed our hypothesis that use of the educational tool is associated with improvement in knowledge. Fifty-eight first-year dental students and nine third-year medical students completed the pre-intervention test and were given the CD-based educational tool. After seven days, all participants completed the post-intervention test. Knowledge of geriatric oral health improved among the sixty-seven students included in this study (p=0.019). When stratified on the basis of viewing the CD-ROM, the subgroup of thirty-eight students who reported not actually reviewing the CD-ROM had no change in their knowledge scores, while the subgroup of twenty-nine students who reported reviewing the CD had a significant improvement in test scores (p<0.001). Use of a self-instructional e-learning tool in geriatric oral health is effective among those students who choose to employ such tools.

Effect of a Mandatory Geriatric Medicine Clerkship on Third-Year Students

A nationwide push has increased geriatric medicine instruction within medical school curricula. Some institutions have proceeded with an integrated 4-year curriculum while others have constructed discrete courses in the third or fourth year of medical school. This paper describes the impact of a new mandatory 4-week geriatric medicine clerkship on third-year students developed by the Donald W. Reynolds Department of Geriatric Medicine at the University of Oklahoma Health Sciences Center. In the first year of implementation, 135 students took the course on both the Oklahoma City and Tulsa campuses. Clinical sites included inpatient, VA extended care unit, outpatient clinics, dementia clinics, home care, long-term care settings, and hospice. Didactic instruction used formal lectures and problem-based learning. The impact of the clerkship on students was assessed in three areas: knowledge, skills, and attitude using a pre- and postknowledge test, student satisfaction survey, and written comments. This article discusses how the clerkship resulted in increased knowledge of geriatric medicine. Student self-report indicates that the clerkship enhanced clinical evaluation and patient assessment skills. Students indicated that the experience was positive and recognized the importance of geriatric medicine in their development as doctors.

Prescribing physical activity for older adults

Physicians and other healthcare providers must disseminate the message promoting physical activity among all of their patients, especially frail older adults. Some degree of physical activity is always preferable to a sedentary life. The goals of physical activity counseling are to provide concrete information, clear and consistent recommendations, and to recognize barriers that older adults face in initiating and maintaining a program. Tailoring the message based on their patient's health and functional status is paramount and counseling should be ongoing and included at every visit. Focusing on what has been described as "functional fitness," such as walking, transferring (up and down from chair, in and out of car, up and down stairs) in order to more easily complete tasks of daily living, should also be stressed. Medical school curricula will need to address this deficiency of practicing physicians by enhancing this area of training for optimal disease prevention, chronic disease management and health promotion.

Attitudes toward neurosurgical procedures for Parkinson's disease and obsessive-compulsive disorder

Similar neurosurgical procedures exist for Parkinson's disease (PD) and obsessive-compulsive disorder (OCD). Because PD is seen as a brain disease and OCD as a disease of the mind, neurologists and psychiatrists may be more aware of and more optimistic toward neurosurgery for PD than for OCD. A questionnaire was sent to randomized American Psychiatric Association and American Academy of Neurology members, and 569 of 1,188 eligible members (47.9%) responded. Some 82.8% of the psychiatrists and 27.4% of the neurologists were aware of neurosurgical procedures for OCD, whereas 84.7% of psychiatrists and 99.4% of neurologists were aware of neurosurgery for PD (P < 0.001). Of psychiatrists, 74.1% would refer appropriate patients for OCD neurosurgery, 67.4% for PD neurosurgery (P = 0.15); of neurologists, 25.6% would refer for OCD, 94.3% for PD (P < 0.001). Specialty affected willingness to refer for OCD neurosurgery. Specialty and degree of contact with neurosurgeons affected willingness to refer for PD neurosurgery. There is poor physician awareness of neurosurgical options for OCD compared with PD, as well as a risk-benefit bias against OCD surgery by the neurologists surveyed.

Characteristics of patients receiving or foregoing resuscitation at the time of cardiopulmonary arrest

OBJECTIVE

To compare clinical, functional and social characteristics of DNR patients at the time of their cardiopulmonary arrest with characteristics of patients who receive cardiopulmonary resuscitation.

DESIGN

Retrospective chart review of all 261 patients who had a cardiopulmonary arrest during a 6-month period in an academic institution.

SETTING

Teaching Veterans Affairs Medical Center serving a large metropolitan area.

MEASUREMENTS

Demographic characteristics, medical diagnoses, and measures of functional status were collected when DNR orders were initiated and at the time of cardiopulmonary arrest.

RESULTS

The mean age of the studied group was 62 years. Ninety-nine percent were males, and the majority were non-Hispanic white men. One hundred ninety-eight (76%) patients/proxies elected for limiting treatment. Most (85%) elected a DNR order only. Patients were the most frequently documented participants in advance directive decisions in the DNR group. At the time of cardiopulmonary arrest, a higher proportion of the CPR group had coronary artery disease or chronic renal failure, and a higher proportion of the DNR group had cancer or AIDS. The functional status of the DNR group deteriorated from the time of DNR order to death. At the time of cardiopulmonary arrest, the majority of both groups were dependent in all functional domains, and 70% of the DNR group were stuporous or comatose compared with 47% of the CPR group (P = .05). DNR patients were hospitalized for an average of 13.7 +/- 29.5 days after a DNR order was initiated. Six of the 81 patients who received CPR (7.4%) were alive at discharge.

CONCLUSIONS

Patients and physicians deciding to implement a DNR order may be overly focused on medical diagnoses and less so on functional status. A significant proportion of patients with clinical characteristics associated with poor CPR outcome are electing for CPR.

Causes of death in geriatric patients: a cross-cultural study

BACKGROUND

The elderly are living longer and causes of death are shifting. At the same time, autopsy rate is at, or near, its lowest in history, compounded by an even lower interest in geriatric autopsies. Thus, the prevalent cause of death in this age group remains poorly studied.

METHODS

In a retrospective study, the autopsy protocols of 440 70-year-old or older patients from the Houston Veterans Affairs Hospital and 321 80-year-old or older patients from the II*Institute of Pathology in Prague (Czech Republic) were reviewed in order to establish a correct cause of death. The autopsy diagnosis was correlated with the prosectors' description of pathological findings in the protocol. In questionable cases or discrepancies, the patient's clinical chart and/or the histological autopsy slides were also reviewed.

RESULTS

The distribution of death by infections and cardiac disorders each accounted for one-third of all deaths. Congestive heart failure prevailed in the over 80-year-olds, and myocardial infarcts prevailed in the younger patients. The number of deaths due to malignancy dropped from 25% in those 70-79 years old to about 10% in the elder patients. Central nervous system disorders were frequent as an underlying disease, but were not common as a cause of death. The findings were similar in both series, thus supporting their accuracy.

CONCLUSION

Our findings bring into question the accuracy of reported causes of death in the elderly. With increasing age, differences appear in the levels of mortality and morbidity for various disease categories. This study underlines the need for more baseline data for older people which can be obtained only by more and well-performed autopsies.

Continuity of do-not resuscitate orders between hospital and nursing home settings

OBJECTIVE

To determine the relationship between interinstitutional communication and continuity of advance directives from hospital to nursing home (NH) settings.

DESIGN

Retrospective chart review of discharges to hospital affiliated or community NHs.

SETTING

Teaching Veterans Affairs Hospital and affiliated and community nursing homes.

MEASUREMENTS

Demographic characteristics, medical diagnoses, presence of advance directives, and documentation that relates to the topic.

RESULTS

A total of 83 patients were discharged to either setting. Before discharge to a NH, the prevalence of chronic obstructive pulmonary disease and cancer was higher among those who had a DNR order. Overall, subsequent discussions about advance directives were equally common in NHs. Having a hospital discussion about advance directives or having a hospital DNR order were associated with a higher rate of advance directive discussions in NHs. Hospital DNR orders were continued for 93% and 41% of patients admitted to the hospital-affiliated NH compared with community NHs, respectively (P < .001). Specific communication of hospital DNR status to the receiving NH was associated with better continuity of DNR orders (49% vs 9%, P = .001). Factors that predicted continuity of DNR orders in logistic regression analysis correctly included hospital DNR status, communication of advance directives to the receiving NH, and NH advance directive discussions.

CONCLUSIONS

There is higher continuation rate of DNR orders between the hospital under study and its affiliated NH than to community NHs despite a similar frequency of confirmation discussions. Completing advance directives before patients are discharged to NHs, communication of advance directives to the receiving NH, and follow-up discussions at the NH may improve the continuity of advance directives between hospitals and nursing homes.

Association of serum cholesterol and triglyceride levels with agitation and cognitive function in a geropsychiatry unit

Several studies have reported an association between aggression and cholesterol levels. The purpose of this study was to investigate the relationship of serum cholesterol and triglyceride levels with aggression and cognitive function in elderly inpatients. One hundred ten patients consecutively admitted to the Geriatric Psychiatry inpatient unit at Houston's Veterans Affairs Hospital received comprehensive evaluations by a multidisciplinary team. Fasting serum cholesterol and triglyceride levels were obtained within 3 days of admission. In addition, two geriatric psychiatrists administered the Mini-Mental State Examination (MMSE) and the Cohen-Mansfield Agitation Inventory (CMAI). Correlation coefficients were calculated between lipid levels, CMAI total and subscale scores, and MMSE scores. Multiple linear-regression analyses were done to further investigate the relation between lipid concentrations and various confounders. We found no significant correlation between serum triglyceride levels and MMSE, CMAI total, and CMAI factor scores. In addition, we found a significant positive correlation between serum cholesterol levels and physical nonaggressive behavior, and a significant negative correlation between serum cholesterol levels and MMSE scores. We found no relationship between aggressive behavior and serum cholesterol or triglyceride levels. However, an association between high cholesterol levels and agitation exists, which may be mediated by the association between high cholesterol levels and impaired cognition.

Limiting treatment in nursing homes: knowledge and attitudes of nursing home medical directors

OBJECTIVE

To determine nursing home medical directors' knowledge about cardiopulmonary resuscitation outcome and their support of treatment limitation requests and policies.

DESIGN

Mailed questionnaire, followed by telephone interview.

PARTICIPANTS

Forty-six medical directors of 70 community nursing homes in Harris County, Texas.

MEASUREMENTS

Medical directors were asked to estimate the CPR survival rate to discharge of all nursing home residents and that of two case scenarios. They were asked to indicate on a Likert scale their support for mandatory Do-Not-Resuscitate orders and for requests by nursing home patients to withhold other life support measures.

RESULTS

Responses were received from 33 directors. Overall CPR survival rate of older nursing home residents after cardiac arrest was thought to be 10.7%. The average CPR survival rate for healthy older people with witnessed arrests was believed to be 13.8%. The perceived rate for unwitnessed arrests in terminal patients was 4.6%, significantly lower than estimates for healthy older people (P = .003) and estimates of the overall survival rate (P = .02). Medical directors were split regarding mandatory Do-Not-Resuscitate orders for patients in vegetative states, with terminal illness, with an unwitnessed arrest, or in those older than 90 years of age. Mandatory use of Do-Not-Resuscitate orders for all nursing home residents was strongly opposed. Assuming a 2% survival rate did not significantly influence medical directors' opinions about mandatory DNR orders in these groups. Medical directors were more willing to support requests by stable nursing home residents to withhold resuscitation, mechanical ventilation, or hospitalization than requests to withhold antibiotics, intravenous fluids, or tube feedings (P < .005). The majority of medical directors were willing to withhold all such measures for terminal patients.

CONCLUSIONS

Health care professionals who are responsible for educating patients about the efficacy of cardiopulmonary resuscitation in nursing homes overestimate its benefit and may benefit from further education about its outcome. Although mandatory Do-Not-Resuscitate orders were favored for terminal or vegetative patients, medical directors are not supportive of such orders across the board. Medical directors are more willing to honor requests for treatment limitation by terminal patients than others.

Impact of a personal emergency response system on hospital utilization by community-residing elders

The purpose of this study was to determine whether use of a 24-hour personal emergency response system (PERS) might be associated with selected hospital utilization rates among community-residing users. Utilization rates of 106 patients were reviewed for 1 year before and 1 year after enrollment in the PERS. Self-paired analyses were conducted on number of visits to an emergency department (ED), number of hospital inpatient admissions, and number of inpatient days. During the 1-year follow-up period, those subscribers using the PERS had a statistically significant decrease in per person hospital admissions and inpatient days. No significant differences occurred in ED visits. When indicated, a PERS may be an appropriate environmental prescription.

Older nursing home residents have a cardiac arrest survival rate similar to that of older persons living in the community

OBJECTIVE

To determine the survival rates of older nursing home residents after cardiopulmonary resuscitation (CPR) and to compare it with that of older persons who experienced cardiac arrest in an outpatient setting. To identify patient characteristics, arrest characteristics, and effort characteristics that are associated with higher survival rates.

DESIGN

Retrospective review of emergency medical service charts and hospital medical records of a cohort of older nursing home residents (n = 114) after cardiopulmonary resuscitation and a matched cohort of community-residing older persons (n = 228) matched on age, gender, and year of cardiac arrest.

SETTING

A large metropolitan city served by a tiered emergency medical service.

MEASUREMENTS

Independent variables related to patient, cardiac arrest, and resuscitation effort characteristics. Dependent variables were defined as immediate survival after cardiopulmonary resuscitation and survival status at discharge.

RESULTS

The mean age of nursing home residents was 80.3 years; 62.3% were females. The majority of cardiac arrests for both groups were unwitnessed (67%) and had agonal rhythms (asystole and electromechanical dissociation). Emergency medical service efforts were similar for the two cohorts. Among nursing home residents, 26.3% had a return of blood pressure for more than 5 minutes, 70.2% were pronounced dead in the emergency room, and 10.5% were discharged from hospitals alive. In the matched community-residing subjects, 22.7% had a return of blood pressure, 78.1% were pronounced dead in the emergency room, and 9.2% were discharged alive. Between-group comparisons of these variables revealed no significant differences even though our sample size was adequate.

CONCLUSIONS

We conclude that survival after cardiac arrest of older persons residing in nursing homes is low; however, with an appropriate CPR/DNR selection process and an effective emergency medical system, survival of certain groups of nursing home residents following cardiac arrest could be comparable to that of community residing older persons. Despite the reasonably good survival rates for older persons seen above, our analyses indicated that patients who have unwitnessed arrests are not likely to survive to discharge and that patients with initial rhythms such as asystole or electromechanical dissociation rarely survive. These data suggest that patients who have an unwitnessed arrest in the nursing home should not receive resuscitation attempts, and in those patients for whom paramedics are called, resuscitation efforts should not proceed any further if their original rhythm is asystole or electromechanical dissociation. Thus, modification in nursing home policies regarding CPR efforts is needed.

Postoperative delirium. A review of 80 primary data-collection studies

We conducted an on-line search and manual searches for 1966 through 1992 to determine the incidence, diagnosis, risk factors, and treatment of postoperative delirium. Of the 374 citations found, 277 articles were excluded after criteria of relevance were applied. After methodologic criteria for validity were applied to the remaining 80 articles, 26 studies were retained for the final information synthesis. The incidence of postoperative delirium was 36.8% (range, 0% to 73.5%). Primary reasons for this disparity were insufficient sample size and inconsistent application of numerous diagnostic tools. One study provided statistically significant data that demonstrated that postoperative delirium is underdiagnosed by physicians and nurses. Four of the articles that met the established criteria provided risk factor data. Although age, preoperative cognitive impairment, and the use of anticholinergic drugs were significantly associated with postoperative delirium, gender, type and route of anesthesia, and sleep deprivation were not. Two studies demonstrated a decreased incidence of postoperative delirium when patients underwent preoperative psychiatric counseling or participated in a structured perioperative program. These findings indicate a need for (1) accurate incidence data with further definition of risk factors and (2) studies that address the diagnosis and treatment of this common postoperative problem.

Projecting patients' preferences from living wills: an invalid strategy for management of dementia with life-threatening illness

OBJECTIVE

To examine variation in elders' choices of therapies in different clinical scenarios and to assess the validity of extending preferences expressed in scenarios of usual health, terminal illness, and coma to preferences in a scenario of moderately advanced Alzheimer disease.

DESIGN

Questionnaire study of community-dwelling elders.

SETTING

Houston metropolitan area.

PARTICIPANTS

218 community-dwellers age 60 years and older.

MEASUREMENTS

Responses regarding choices of 10 interventions in 4 scenarios. Interventions were: cardiopulmonary resuscitation (CPR), ventilator, total parenteral nutrition (TPN), i.v. medication and hydration, any medication, enteral feeding, dialysis, ICU admission, hospitalization, and antibiotics. Interventions were selected "never", "always," or a "trial of intervention to assess efficacy." Independent variables were responses in scenarios of usual state of health with a life-threatening illness, irreversible coma, and terminal illness causing pain. Dependent variables were responses in a scenario of moderately advanced Alzheimer disease with a life-threatening illness. Frequencies of responses were calculated using "never," "trial," and "always." Subsequently "trial" and "always" were collapsed into a category of "accepting intervention" for dichotomous analysis with "refusing intervention" (the "never" category). Logistic regression was used to assess validity of predicting responses in one scenario from the others.

MAIN RESULTS

Preferences regarding medical therapies varied across scenarios (P < 0.01). In the Usual Health scenario, all interventions were accepted more frequently than refused. In Terminal Illness and Coma scenarios, CPR, ventilator, TPN, enteral feedings and dialysis were refused more frequently than accepted. In the Alzheimer scenario, medications, ICU admission, hospitalization, and antibiotics were accepted more often than rejected. Trial was preferred to always in 90% of all choices across all scenarios. Preferences expressed in Terminal Illness, Coma, and Usual Health scenarios predicted choices in the Alzheimer disease scenario poorly.

CONCLUSIONS

(1) Use of a scenario-based advance directive may be limited to the precise scenario described. (2) The common acceptance of interventions in the Alzheimer disease scenario differs from findings in earlier studies, possibly because of differences in populations surveyed or the stage of the disease described, highlighting the variability of preferences in this scenario. (3) Trial of intervention is attractive to many respondents, perhaps because it allows the advantage of potentially beneficial therapies without commitment to a course of therapy not leading to cure. (4) Results of this study should be interpreted in light of the study population, consisting largely of well educated, healthy Caucasians. Findings are likely not to be generalizable to other populations.

Estimation of severity of illness with APACHE II: age-related implications in cardiac arrest outcomes

The ability to predict outcomes of cardiac arrest before starting cardiopulmonary resuscitation (CPR) would be useful for discussions of resuscitation with elders and their families. We thought CPR outcome might be dependent on the severity of pre-existing illnesses. The APACHE II is a severity-of-illness (SOI) scale based, in part, on physiologic parameters whereby points are given for degree of deviation from normal. Additionally, up to six points are given for increased age. We hypothesized that (1) patients with the highest APACHE II would be least likely to survive, and (2) because of the blunted physiologic responsiveness, the APACHE II would underestimate the SOI of elderly patients who were sufficiently ill to have a cardiac arrest. A retrospective study of 172 arrests was carried out to evaluate these hypotheses. For the young cohort (n = 126; age, < 70; mean age, 59 +/- 8), mean admission APACHE II was 16.5 +/- 7.9 and pre-arrest APACHE II regression analysis.2+ carried out with both APACHE II scores and factors previously correlated with CPR outcome. Witnessed arrests and those requiring a low number of medications were most likely to result in immediate success (restoration of blood pressure) and in a live discharge. APACHE II score (24 h pre-arrest) was associated with live discharge in the regression analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Mapping personal, familial, and professional values in long-term care decisions

We mapped the values of elders, family members or friends, and professionals involved in a recently implemented long-term care decision, based on 60 in-depth retrospective interviews. The language used to express values by elders and family members was often quite expressive and particular, whereas professionals tended to employ a more abstract and formulaic language of values. Elders emphasized self-identity and environment, whereas for families and professionals health and well-being of the elder were important.

Use of morphometry as an aid in the differential diagnosis of large cell carcinoma of the lung

In a previous cytopathologic study a regression equation was generated that aided in the differential diagnosis of large cell carcinoma (LCC) of the lung from poorly differentiated adenocarcinoma (AC). This study was undertaken to validate and extend those findings. Cytopathologic and histopathologic specimens from 20 new patients were examined using computerized morphometry. There were 28 specimens from 10 cases of LCC and 25 specimens from 10 cases of AC (10-25 cells measured from each specimen). Histopathologic review by an expert (S.D.G.) provided the "gold standard" diagnosis. Morphometric parameters studied were (1) nucleolar/nuclear area ratio, (2) cell area, (3) cell form factor, and (4) nuclear form factor. Sensitivity analysis validated the diagnostic utility of our prior equation. A logistic regression with these parameters determined the probability that each sample was LCC. Relative operating characteristic curve analysis determined an optimum logistic cutoff point of 0.83. At this decision level the equation had a sensitivity of 72% for distinguishing LCC. Specificity was 46%, positive predictive value was 65%, negative predictive value was 55%, and classification efficiency was 61%. Morphometry of histopathologic material contributed no important additional information. Therefore, our logistic regression and sensitivity analysis supported the clinical utility of certain morphometric measurements in the cytopathologic, but not histopathologic, diagnosis of LCC.

Survival of elderly men with congestive heart failure

Congestive heart failure (CHF) is the most common discharge diagnosis for elderly patients. The survival of elderly (age greater than or equal to 75 years) patients with CHF has not recently been reported, especially with reference to left ventricular ejection fraction (LVEF). A patient database was searched for the diagnosis of CHF and then screened for age greater than or equal to 75, Framingham Criteria for CHF and an LVEF evaluation. Ninety-four men fitted all criteria, including a minimum potential follow-up of 3 years. Life-table analysis was employed to compare their survival experience to an expected survival based on a sex- and age-equivalent subset of the 1980 Census data. Causes of death were determined from autopsy, medical records or death certificates. Mean age at onset of CHF was 82.5. Forty-three per cent had an LVEF greater than or equal to 0.45. There was no difference in the prevalence of potential aetiologies between those with LVEF greater than or equal to 0.45 versus LVEF less than 0.45. Life-table analysis revealed that CHF patients had a worse survival than controls for the first 5 years after diagnosis, attributable primarily to a high first-year mortality (28%) for the CHF group. There was no difference in survival between the LVEF greater than or equal to 0.45 and LVEF less than 0.45 groups.

Educating the elderly: cardiopulmonary resuscitation decisions before and after intervention

Considering the limited success of cardiopulmonary resuscitation (CPR) in achieving survival to hospital discharge in older persons, it is appropriate to educate, discuss and determine patients' wishes at a time when they are able. Sixty-four ambulatory, non-depressed, non-demented veterans greater than 74 years of age were interviewed and educated. Knowledge of CPR at baseline was variable and most overestimated their survival chances. Most subjects desired routine CPR discussions with physicians. Only 17% had previously discussed their CPR preferences, and none had done so with physicians. Knowledge of CPR increased (P = 0.01) after educational intervention. There was no change in subjects' CPR decisions after education and presentation of current CPR outcome data. In considering five hypothetical scenarios, 9% never wanted CPR, and 17% always wanted CPR. Those who never wanted CPR were more realistic about their suspected survival chance (P = 0.003) and had higher educational levels (P = 0.03) Folstein (P = 0.03) and Geriatric Depression Scale (P = 0.04) scores. With the dependent variable being the number of hypothetical situations in which the patient desired CPR, a regression analysis (adjusted r2 = 0.72) limited significant variables to the patient's current CPR decision, Folstein score, religion, marital status, and previous ICU admissions. This study emphasizes that most elderly male veterans are willing and want to discuss their CPR attitude with physicians and that most have fixed CPR decisions which may be elicited under stable clinical conditions.

Estimation of survival time in terminal cancer patients: an impedance to hospice admissions?

Accurate estimation of survival time in terminal cancer patients is difficult yet may provide useful information. A historical prospective study on 172 patients admitted to a home based hospice service was performed to determine which variables were best correlated with survival time. Mean and median survival were 48 and 22 days, respectively, representing a highly skewed distribution of life span in this sample. As age increased, survival time decreased. All Activities of Daily Living (ADLs) recorded (Bathing, Continence, Dressing and Transfer) as well as other measures of performance (mobility and pulse) and nutrition (appetite and nourishment) were each strongly associated with survival. Multivariate analysis limited significant variables to dressing ability, pulse rate, level of appetite and transferring ability. Outliers (survival greater than 180 days) were differentiated from the remainder of the sample by significant differences in all ADLs recorded as well as the level of appetite. These findings establish the importance of assessing ADLs, a measure of functional status, and reinforce the importance of performance and nutrition measures when estimating length of survival in terminal cancer patients.

Morphometry of the aging heart

Myocardial structure was studied in seven geriatric patients (cases), aged 79 to 91, and ten younger adult patients (controls), aged 22 to 52. Myocardial sections of posterior left ventricle (PLV), anterior left ventricle (ALV), and ventricular septum (VS) were studied using computerized morphometry. Each section of heart (PLV, ALV, or VS region) was divided into three zones: subepicardial (epi), midmyocardial (myo), and subendocardial (endo). Interstitial collagen content and nuclear and cell diameters of myocytes were obtained. Large scars were excluded. Student's t-test was used to evaluate differences, which were considered significant at a level of P less than 0.001. No significant zonal or regional variation in collagen content was found in control hearts, where interstitial trichrome-positive tissue comprised 6.61% of the myocardium. By contrast, elderly hearts showed a distinct increase in interstitium in the PLV region (18.3%), as compared with ALV and VS, and as compared with control hearts (P less than 0.001). Relative myocyte hypertrophy with aging was most prominent in a zonal midmyocardial distribution (P less than 0.001). Myocyte nuclei showed shrinking with age in the subepicardial zone (P less than 0.001). These findings indicate there are specific age-related alterations in myocardium, which may relate to functional abnormalities seen in the elderly.

Cytomorphometry of large cell carcinoma of the lung

A computerized morphometry system was used to evaluate criteria for the cytologic diagnosis of large cell carcinoma (LCC) and poorly differentiated adenocarcinoma of the lung. There were 143 cells measured in six cases of LCC (five sputums and one bronchial washing) and 61 cells in four cases of adenocarcinoma (all sputum samples). Cellular and nuclear areas were significantly larger in adenocarcinoma whereas nucleolar area was greater in LCC, producing a higher nucleolar/nuclear area ratio in LCC. Cellular and nuclear form factors were smaller in LCC while the minor axis was longer in adenocarcinoma, resulting in a smaller axial ratio in adenocarcinoma. These data indicate that adenocarcinoma cells are larger and have a more rounded shape and less nucleolar material, as compared to the smaller, more ellipsoid and convoluted cells of LCC, which have more nucleolar area. A logistic regression identified cellular area, nucleolar/nuclear area ratio and cellular and nuclear form factors as significant contributors to the discrimination of LCC from adenocarcinoma, with a positive predictive value of 92%. Morphometry may therefore be helpful in the differential cytologic diagnosis of adenocarcinoma and LCC.