Cancer Caregivers’ Prognostic and End-of-Life Communication Needs and Experiences and their Impact

ContextFamily caregivers of patients with advanced cancer are integrally involved in communications regarding prognosis and end-of-life (EOL) planning and care. Yet little research has examined caregivers’ communication experiences or the impact of these experiences on patients and caregivers at EOL.ObjectivesInvestigate cancer caregivers’ communication experiences and potential impact on patient and caregiver outcomes.MethodsSemistructured interviews with bereaved family cancer caregivers (N=19) about their communication needs and experiences as their loved one approached EOL and died. Audiotaped interviews were transcribed and thematically analyzed for communication-related themes.ResultsCaregivers described fulfilling many important communication roles including information gathering and sharing, advocating, and facilitating—often coordinating communication with multiple partners (e.g., patient, family, oncology team, hospital team). Caregivers reported that, among the many topics they communicated about, prognosis and EOL were the most consequential and challenging. These challenges arose for several reasons including caregivers’ and patients' discordant communication needs, limited opportunity for caregivers to satisfy their personal communication needs, uncertainty regarding their communication needs and responsibilities, and feeling unacknowledged by the care team. These challenges negatively impacted caregivers’ abilities to satisfy their patient-related communication responsibilities, which shaped many outcomes including end-of-life decisions, care satisfaction, and bereavement.ConclusionCaregivers often facilitate essential communication for patients with advanced cancers yet face challenges successfully fulfilling their own and patients’ communication needs, particularly surrounding prognostic and end-of-life conversations. Future research and interventions should explore strategies to help caregivers navigate uncertainty, create space to ask sensitive questions, and facilitate patient-caregiver discussions about differing informational needs.     

Investigating Older Adults’ Expressed Needs Regarding Falls Prevention

Abstract

Aims: The purpose of this study was to explore perceptions regarding falls prevention programs for community-dwelling older adults offered in a specific geographic area. Method: The investigators conducted focus groups with 44 community-dwelling older adults in four locations. Focus group discussions were transcribed, coded, and analyzed by all investigators. Results: Themes included what people want, why people fall, what people do, impact of falls, and barriers to falls prevention participation. Older adults wanted falls prevention programs to include socialization among peers, various types of education, balance training, convenience in times and locations where falls prevention programs are offered, affordability, and independence and autonomy for decision-making. Participants believed they fell due to inattention and the aging process, and they made lifestyle changes and tried to recognize their own ability accordingly. Older adults believed the impact of falls on lifestyle was far-reaching and drastic. The main barrier to falls prevention participation was motivation, mitigated by other priorities. The Person-Environment-Occupation (PEO) Model provided a framework for considering occupational impact when addressing older adults’ concerns regarding falls. Conclusions: Occupational therapists can be key contributors to falls prevention programing by developing programs that focus on current perceptions and barriers in programing and the expressed wants and needs of community-dwelling older adults.     

Bereaved Families’ Experiences of End-of-Life Care at Home for Older Adults with Non-Cancer in South Korea

The aim of this study was to gain an understanding of the experiences of families who care for older adults with non-cancer diseases at the end of their lives. The data accrued through in-depth interviews, analyzed using Giorgi’s phenomenological method: caregiving burden; situational responsibility; consolation by support; and mourning for the deceased. In Korean culture, adult children had the responsibility of caring for their aged parents as a burden of caregiving and as a main motive for caregiving. Educational and psychological support programs for caregivers should aim to boost confidence, rather than merely focusing on their burden.     

Older Adults’ Experiences of Community Mobility in an Indian Metropolis: A Qualitative Study

Abstract

Aims: This study aimed to explore and understand how older adults experience community mobility within an urban Indian context, using a phenomenological approach. Methods: Ten older adults residing in Chennai city participated in this study. The investigator conducted individual, in-depth interviews of 60–75?minutes each. Results: Participants placed high value on community mobility, which contributed to their occupational participation and well-being. Participants identified numerous physical, social and attitudinal barriers to community mobility in their environment, leading to fear and restrictions in community mobility. Conclusion: The study findings underscore the need for the development of age-friendly communities within Indian society to promote occupational justice for older adults. Occupational therapists in India can intervene at the government, community, family and individual levels to enable older adults’ community mobility and occupational participation. Future research to investigate context-specific interventions to facilitate older adults’ community mobility is recommended.     

Are Children with Cerebral Palsy and Developmental Disability Living Longer?

A robust literature addresses life expectancy (LE) for children with cerebral palsy (CP) and developmental disability (DD). A Medline data search was completed using the terms CP, DD, LE, survival, as well as other pertinent terms. Further articles were gleaned from bibliographies of pertinent literature. Key disabilities accurately predict LE in children with CP and DD: (1) presence and severity of developmental disability, (2) inability to speak intelligible words, (3) inability to recognize voices, (4) inability to interact with peers, (4) severity of physical disability, (5) use of tube feeding, (6) incontinence, (7) cortical blindness, and (8) presence and severity of seizures. Children with CP and DD have a diminished LE, which can be accurately assessed based on simple clinical examination findings. Over the last 50 years there has been improvement in life expectancy based on comparison of newer and older studies. However in approximately the last 20 years, there has been only slight improvement in LE, and this has been found only in the most profoundly impaired children with CP and DD.     

Older Persons’ Lived Experiences of Depression and Self-Management

Mental ill-health, such as depression in the elderly, is a complex issue that is influenced by the life-world perspective of older persons. Their self-management ability should be strengthened based on an understanding of their situation, perspectives, and vulnerability. The aim of this study was to explore and increase understanding of old persons’ lived experiences of depression and self-management using an interpretative explorative design. Understanding was developed by means of hermeneutic interpretation. One theme, Relationships and Togetherness, and four subthemes, A Sense of Carrying a Shoulder Bag, Walking on Eggshells, Holding the Reins, and Estrangement—a Loss of Togetherness, emerged. A collaborative approach can be important for empowering older persons through self-development and management. Although the findings of the present study cannot be considered conclusive or definitive, they nevertheless contribute new knowledge of older persons’ lived experiences of depression in everyday life.     

Are the Leisure and Social Needs of Older Adults Residing in Assisted Living Facilities Being Met?

Abstract

Aims: This retrospective study explored if there was a change in participation in leisure activities among older adults after transitioning into an assisted living facility. Supports and barriers to leisure and social engagement were also investigated. Methods: The Activity Card Sort (modified) was administered to explore and compare the participants’ engagement in leisure and social activities prior to and after moving into an assisted living facility. Semi-structured interviews were conducted to examine the participants’ perspectives regarding the current supports and barriers to engagement in their individual and meaningful interests. Results: Quantitative data gathered from the Activity Card Sort (modified) revealed the participants engaged in only 34.13% of the activities they participated in prior to moving into an assisted living facility; results also revealed that only 42% of the participants engaged in a new leisure activity after moving into an assisted living facility. Qualitative data revealed four themes concerning supports and barriers to participation: physical abilities, social supports, available resources, and personal influences. Conclusion: Older adults in assisted living facilities face a decline in engagement in leisure participation and may be at risk for occupational deprivation. Occupational therapists are well-suited to address these concerns.     

Anxiety-Linked Differences in Older Adults’ Interpretation of Ambiguous Information

Cognitive models of anxiety propose that heightened anxiety vulnerability is characterized by a tendency to interpret ambiguous situations as threatening. The presence of such an interpretive bias has been confirmed in younger adults, using assessment measures that bypass the limitations of self-report and objectively assess interpretive processing. A recent pioneering study published in 2015 has sought to determine whether this anxiety-linked interpretive bias also is evident in older adults. However, their evidence supporting this hypothesis comes only from self-report measures and memory measures. The present study was designed to provide a stronger test of the hypothesis by objectively assessing interpretive process in high (n = 48) and low (n = 48) trait anxious older adults, using a text comprehension approach that circumvents reliance on self-report or memory measures. The findings were fully consistent with the hypothesis that older adults with higher levels of trait anxiety, compared to those with lower levels of trait anxiety, impose more threatening meanings on ambiguous information. These findings provide the first evidence, from an assessment approach that overcomes the limitations of self-report and memory measures, that elevated anxiety vulnerability in older adults is characterized by a negative interpretive bias.     

Executive Functioning in Children Aged 6–18 Years with Cerebral Palsy

Executive functioning (EF) is necessary for purposeful and goal-directed activity. Deficits in EF have been related to prematurity, low birth weight and early acquired brain lesions. Cerebral palsy (CP) is a condition where all these factors might be present and therefore suited to explore the relative contribution of each. The aim is to investigate factors that may contribute to variability in EF in children with CP. Participants were 68 children with CP, with various degrees of speech and motor impairment. Mean age 10;2 years (range 6;0 to 17;7 years), 38 were girls. EF was investigated with tests, Backward memory from Leiter-R and Wisconsin Card Sorting Test, which were adapted so that the children could respond regardless of their level of motor functioning. The mean standardized scores on tests of EF were within the normal range (89.5–105.9). The considerable individual variation (55–145) is explained by age and cognitive ability. Of the 68 participants, a measure of EF was available for 57 (83.8%). The 11 who did not complete the tests all had an intellectual disability. Variability in EF in children with CP was explained by age and cognitive ability, and not by prematurity, type of brain lesion or epilepsy. There was a developmental trend towards an increase in EF with age. However, the delay in EF may have consequences for overall cognitive and everyday functioning. The large variability in EF suggests that cognition should be assessed in all children with CP.     

Prevalence and Predictors of Ambulatory Care Physicians’ Documentation of Mobility Limitations in Older Adults

ObjectiveTo determine how often physicians document mobility limitations in visits with older adults, and which patient, physician, and practice characteristics associate with documented mobility limitations.DesignWe completed a cross-sectional analysis of National Ambulatory Medical Care Surveys, years 2012-2016. Multivariate analyses were conducted to identify patient, physician, and practice-level factors associated with mobility limitation documentation.SettingAmbulatory care visits.ParticipantsWe analyzed visits with adults 65 years and older. Final sample size represented 1.3 billion weighted visits.InterventionNot applicable.Main Outcome MeasureWe defined the presence/absence of a mobility limitation by whether any International Classification of Diseases (ICD)-9 or ICD-10 code related to mobility limitations, injury codes, or the patient's “reasons for visit” were documented in the visits.ResultsThe overall prevalence of mobility limitation documentation was 2.4%. The most common codes were falls-related. Patient-level factors more likely to be associated with mobility limitation documentation were visits by individuals over 85 years of age, relative to 65-69 years, (odds ratio 2.32, 95% confidence interval 1.76-3.07]; with a comorbid diagnosis of arthritis (odds ratio 1.35, 1.18-2.01); and with a comorbid diagnosis of cerebrovascular disease (odds ratio 1.60, 1.13-2.26). Patient-level factors less likely to be associated with mobility limitation documentation were visits by men (odds ratio 0.80, 0.64-0.99); individuals with a cancer diagnosis (odds ratio 0.76, 0.58-0.99); and by individuals seeking care for a chronic problem (relative to a new problem [odds ratio 0.36, 0.29-0.44]). Physician-level factors associated with an increased likelihood of mobility limitation documentation were visits to neurologists (odds ratios 4.48, 2.41-8.32) and orthopedists (odds ratio 2.67, 1.49-4.79) compared with primary care physicians. At the practice-level, mobility documentation varied based on the percentage of practice revenue from Medicare.ConclusionsMobility limitations are under-documented and may be primarily captured when changes in function are overt.     

Do EMS Providers Accurately Ascertain Anticoagulant and Antiplatelet Use in Older Adults with Head Trauma?

Objective: Prehospital provider assessment of the use of anticoagulant or antiplatelet medications in older adults with head trauma is important. These patients are at increased risk for traumatic intracranial hemorrhage and therefore field triage guidelines recommend transporting these patients to centers capable of rapid evaluation and treatment. Our objective was to evaluate EMS ascertainment of anticoagulant and antiplatelet medication use in older adults with head trauma. Methods: A retrospective study of older adults with head trauma was conducted throughout Sacramento County. All 5 transporting EMS agencies and all 11 hospitals in the county were included in the study, which ran from January 2012 to December 2012. Patients ≥55 years who were transported to a hospital by EMS after head trauma were included. We excluded patients transferred between two facilities, patients with penetrating head trauma, prisoners, and patients with unmatched hospital data. Anticoagulant and antiplatelet use were categorized as: warfarin, direct oral anticoagulants (DOAC; dabigatran, rivaroxaban, and apixaban), aspirin, and other antiplatelet agents (e.g., clopidogrel and ticagrelor). We calculated the percent agreement and kappa statistic for binary variables between EMS and emergency department (ED)/hospital providers. A kappa statistic ≥0.60 was considered acceptable agreement. Results: After excluding 174 (7.6%) patients, 2,110 patients were included for analysis; median age was 73 years (interquartile range 62–85 years) and 1,259 (60%) were male. Per ED/hospital providers, the use of any anticoagulant or antiplatelet agent was identified in 595 (28.2%) patients. Kappa statistics between EMS and ED/hospital providers for the specific agents were: 0.76 (95% CI 0.71–0.82) for warfarin, 0.45 (95% CI 0.19–0.71) for DOAC agents, 0.33 (95% CI 0.28–0.39) for aspirin, and 0.51 (95% CI 0.42–0.60) for other antiplatelet agents. Conclusions: The use of antiplatelet or anticoagulant medications in older adults who are transported by EMS for head trauma is common. EMS and ED/hospital providers have acceptable agreement with preinjury warfarin use but not with DOAC, aspirin, and other antiplatelet use.     

Usefulness of a Qualitative Ultrasound Evaluation of the Gastrocnemius–Soleus Complex with the Heckmatt Scale for Clinical Practice in Cerebral Palsy

Ultrasound is increasingly used for the evaluation of spastic muscles in cerebral palsy. Increased echo intensity is considered indicative of a muscle fibrous involution. The aim of this study was to highlight any correlation between increased echo intensity of the gastrocnemius–soleus complex and clinical tests for stiffness evaluation, age and functional level measured with the Gross Motor Function Classification System. We used the qualitative echo intensity grading system of the Heckmatt scale (HS) and tested its inter-rater reliability. The study group comprised 60 patients with cerebral palsy. We found a weak significant correlation between HS scores and clinical stiffness measures and between HS and age for all muscles studied, and between the HS and Gross Motor Function Classification System only for the soleus muscle. The study indicated moderate inter-rater reliability, with κ values between 0.60 and 0.73, for almost all muscles studied. Ultrasound provides a useful complementary survey of stiffness tests in cerebral palsy.     

Farmers’ Market Voucher Initiative to Improve Diabetes Control in Older Adults

This pilot study investigated reported fruit and vegetable consumption and diabetic control for older patients with a diagnoses of diabetes and food insecurity at a rural Midwestern Federally Qualified Health Center. Vouchers ($40 per month for 3 months) were provided for fruits and vegetables at a local farmers’ market during a 12-week program (June 2020-August 2020). Data revealed a statistically significant increase in reported green vegetable consumption and farmers’ market visits postintervention. There was not a significant change in hemoglobin A_1c, body mass index, or other reported produce consumption.     

Validity of Instrumented 360° Turn Test in Older Adults with Cognitive Impairment

Abstract

Aims: To examine concurrent and construct validity of inertial sensor 360° turn measures in relation with motion capture and mobility assessments in cognitively impaired older adults.

Methods: Data was collected in 31 participants, mean age 85.2 (SD 5.2), during clockwise (CW) and counter clockwise (CCW) 360° turns using (1) APDM body-worn inertial sensors and (2) Qualisys 8-camera laboratory-based motion capture.

Results: Absolute agreement between inertial sensor and motion capture measures was excellent for turn duration and turn peak velocity (ICC = 0.96–0.98). Strong to moderate correlations were present between inertial sensor turn measures and performance on the Timed Up and Go, Short Physical Performance Battery and 90-s Balance Test. ROC curve analysis of CCW 360° turn duration and turn peak velocity distinguished higher risk versus lower risk for mobility disability.

Conclusions: Inertial sensor 360° turn measures demonstrated concurrent and construct validity in relation to motion capture and mobility assessments.     

Quiet Time to Increase Breastfeeding Rates and Enhance Women’s Hospital Experiences in the Postpartum Period

ObjectiveTo facilitate optimal hospital experiences and breastfeeding clinical outcomes among women by reducing interruptions during their first 24 hours in the postpartum period.DesignEvidence-based practice change initiated by a registered nurse staff member.Setting/Local ProblemThere was concern that numerous visitor and staff interruptions to women during their early postpartum hours were interfering with establishing breastfeeding and maintaining a restful environment on our 21-bed postpartum unit within a 377-bed, Magnet-recognized, religiously affiliated hospital in suburban southern California.ParticipantsMedically stable women with uncomplicated childbirth during the previous 24 hours and women in the postpartum period whose responses were recorded in facility databases maintained by the departments of Lactation Services and Nursing Research.Intervention/MeasurementsA daily quiet time from 1:00 p.m. to 3:00 p.m. was instituted on the postpartum unit. Measurements before and after implementing quiet time included data on (a) interruptions, as the number of times someone opened or entered women’s room doors; (b) exclusive breastfeeding rates; and (c) women’s postdischarge reports of their hospital experiences.ResultsAfter quiet time was implemented, interruptions fell from an average of 74 to an average of 37 per day (n = 21, p = .02), and the percentage of women breastfeeding rose from 34% to 48% (n = 193, p = .39). Women’s ratings of unit quietness improved significantly (n = 169, p = .008) to above the benchmark, and their overall facility rating and willingness to recommend the facility remained above the benchmark on surveys from the Hospital Consumer Assessment of Healthcare Providers and Systems.ConclusionA daily afternoon quiet time for women hospitalized in the postpartum period may reduce interruptions to women and thereby potentially increase breastfeeding rates and improve women’s perceptions of their hospital experiences. Unsolicited reports from staff suggested that quiet time was well received by nurses providing postpartum care.