Stages of change for the component behaviors of advance care planning

OBJECTIVES: To develop stages‐of‐change measures for advance care planning (ACP), conceptualized as a group of interrelated but separate behaviors, and to use these measures to characterize older persons' engagement in and factors associated with readiness to participate in ACP. DESIGN: Observational cohort study. SETTING: Community. PARTICIPANTS: Persons aged 65 and older recruited from physician offices and a senior center. MEASUREMENTS: Stages of change for six ACP behaviors: completion of a living will and healthcare proxy, communication with loved ones regarding use of life‐sustaining treatments and quantity versus quality of life, and communication with physicians about these same issues. RESULTS: Readiness to participate in ACP varied widely across behaviors. Whereas between approximately 50% and 60% of participants were in the action or maintenance stage for communicating with loved ones about life‐sustaining treatment and completing a living will, 40% were in the precontemplation stage for communicating with loved ones about quantity versus quality of life, and 70% and 75% were in the precontemplation stage for communicating with physicians. Participants were frequently in different stages for different behaviors. Few sociodemographic, health, or psychosocial factors were associated with stages of change for completing a living will, but a broader range of factors was associated with stages of change for communication with loved ones about quantity versus quality of life. CONCLUSION: Older persons show a range of readiness to engage in different aspects of ACP. Individualized assessment and interventions targeted to stage of behavior change for each component of ACP may be an effective strategy to increase participation in ACP.     

High rates of advance care planning in New York City's elderly population

BACKGROUND: Previous studies have demonstrated low rates of advance care planning (ACP), particularly among nonwhite populations, raising questions about the generalizability of this decision-making process. OBJECTIVE: To explore factors that may influence patients' willingness to engage in ACP. DESIGN: Survey. SETTING: Thirty-four randomly selected New York City senior centers. PARTICIPANTS: A total of 700 African American (n = 239), Hispanic (n = 237), and white (n = 224) adults 60 years and older. INTERVENTION: Participants were administered a 51-item survey that assessed attitudes, beliefs, and practices regarding ACP. MAIN OUTCOME MEASURES: Attitudes and beliefs about physicians' trustworthiness, fatalism, beliefs about surrogate decision making, and comfort discussing end-of-life medical care; factors associated with health care proxy completion; and health care proxy completion rates. RESULTS: More than one third of the participants had completed a health care proxy. There were no significant differences in completion rates across the 3 ethnic groups. Respondents who had a primary care physician (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.3-3.2), were more knowledgeable about advance directives (OR, 2.0; 95% CI, 1.4-2.9), or had seen a friend or family member use a mechanical ventilator (OR, 1.5; 95% CI, 1.02-2.1) were significantly more likely to have designated a health care proxy. Respondents who were only comfortable discussing ACP if the discussion was initiated by the physician (OR, 0.6; 95% CI, 0.0-0.8) were significantly less likely to have completed a health care proxy. CONCLUSIONS: African American, Hispanic, and white community-dwelling, older adults had similarly high rates of advance directive completion. The primary predictors of advance directive completion involved modifiable factors such as established primary care physicians, personal experience with mechanical ventilation, knowledge about the process of ACP, and physicians' willingness to effectively initiate such discussions. Some of the racial/ethnic differences in desire for collective family-based decision making that were observed in this study have implications for the evolution of ACP policy that respects and operationalizes these preferences.     

Opiniones: End‐of‐Life Care Preferences and Planning of Older Latinos

OBJECTIVES: To measure end‐of‐life (EOL) care preferences and advance care planning (ACP) in older Latinos and to examine the relationship between culture‐based attitudes and extent of ACP. DESIGN: Cross‐sectional interview. SETTING: Twenty‐two senior centers in greater Los Angeles. PARTICIPANTS: One hundred forty‐seven Latinos aged 60 and older. MEASUREMENTS: EOL care preferences, extent of ACP, attitudes regarding patient autonomy, family‐centered decision‐making, trust in healthcare providers, and health and sociodemographic characteristics. RESULTS: If seriously ill, 84% of participants would prefer medical care focused on comfort rather than care focused on extending life, yet 47% had never discussed such preferences with their family or doctor, and 77% had no advance directive. Most participants favored family‐centered decision making (64%) and limited patient autonomy (63%). Greater acculturation, education, and desire for autonomy were associated with having an advance directive (P‐values <.03). Controlling for sociodemographic characteristics, greater acculturation (adjusted odds ratio (AOR)=1.6, 95% confidence interval (CI)=1.1–2.4) and preferring greater autonomy (AOR=1.6, 95% CI=1.1–2.3) were independently associated with having an advance directive. CONCLUSIONS: The majority of older Latinos studied preferred less‐aggressive, comfort‐focused EOL care, yet few had documented or communicated this preference. This discrepancy places older Latinos at risk of receiving high‐intensity care inconsistent with their preferences.     

Experience in treating persons with HIV/AIDS and the legalization of assisted suicide: the views of Canadian physicians

The objective of this study is to determine the opinions of a random sample of Canadian family physicians and a population of non-specialist physicians known to provide care to persons with HIV/AIDS about the legalization of physician assisted suicide for persons with HIV disease. In addition, we have attempted to ascertain the physician characteristics that may be associated with a favourable or negative opinion. Self-administered, anonymous questionnaires were mailed to 2,890 family physicians across Canada. Logistic regression analysis was used to determine whether physician characteristics were predictive of agreement with the legalization of physician assisted suicide. Of the respondents who had an opinion, 60% agreed with the legalization of physician assisted suicide. Multivariate analyses indicated that physicians who were living in the provinces of British Columbia (BC), Ontario, or Québec (OR = 1.63, 95% CI: 1.10, 2.43) and who provided routine follow-up care (OR = 1.85, 95% CI: 1.30, 2.63) or palliative care (OR 1.66, 95% CI: 1.13, 2.44) to those with HIV disease were more likely to agree with legalization of physician assisted suicide. This analysis demonstrates a strong support for the legalization of physician assisted suicide for persons with HIV disease among physicians experienced in providing care to those affected.     

Communicating HIV Status in Sexual Interactions: Assessing Social Cognitive Constructs, Situational Factors, and Individual Characteristics Among South African MSM

This study assessed whether social cognitive constructs, situational factors, and individual characteristics were associated with communicating HIV status and whether communication was related to sexual risk behavior. A quota-sampling method stratified by age, race, and township was used to recruit 300 men who have sex with men to participate in a community-based survey in Pretoria in 2008. Participants reported characteristics of their last sexual encounter involving anal sex, including whether they or their partner had communicated their HIV status. Fifty-nine percent of participants reported that they or their partner had communicated their HIV status. HIV communication self-efficacy (aOR = 1.2, 95 % CI: 1.04–1.68), being with a steady partner (aOR = 0.36, 95 % CI: 0.19–0.67), and being Black (versus White; aOR = 0.08, 95 % CI: 0.03–0.27) were independently associated with communicating HIV status. Communicating HIV status was not associated with unprotected anal intercourse. HIV communication self-efficacy increases men’s likelihood of communicating HIV status. Being with a steady partner and being Black reduces that likelihood. Communication about HIV status did not lead to safer sex.     

Advance directives as acts of communication: a randomized controlled trial

BACKGROUND: Instructional advance directives are widely advocated as a means of preserving patient self-determination at the end of life based on the assumption that they improve surrogates' understanding of patients' life-sustaining treatment wishes. However, no research has examined whether instructional directives are effective in improving the accuracy of surrogate decisions. PARTICIPANTS AND METHODS: A total of 401 outpatients aged 65 years or older and their self-designated surrogate decision makers (62% spouses, 29% children) were randomized to 1 of 5 experimental conditions. In the control condition, surrogates predicted patients' preferences for 4 life-sustaining medical treatments in 9 illness scenarios without the benefit of a patient-completed advance directive. Accuracy in this condition was compared with that in 4 intervention conditions in which surrogates made predictions after reviewing either a scenario-based or a value-based directive completed by the patient and either discussing or not discussing the contents of the directive with the patient. Perceived benefits of advance directive completion were also measured. RESULTS: None of the interventions produced significant improvements in the accuracy of surrogate substituted judgment in any illness scenario or for any medical treatment. Discussion interventions improved perceived surrogate understanding and comfort for patient-surrogate pairs in which the patient had not completed an advance directive prior to study participation. CONCLUSIONS: Our results challenge current policy and law advocating instructional advance directives as a means of honoring specific patient wishes at the end of life. Future research should explore other methods of improving surrogate decision making and consider the value of other outcomes in evaluating the effectiveness of advance care planning.     

Advance Care Planning for Older Homeless‐Experienced Adults: Results from the Health Outcomes of People Experiencing Homelessness in Older Middle Age Study

Older homeless‐experienced adults have low engagement in advance care planning (ACP) despite high morbidity and mortality. We conducted a cross‐sectional analysis of a cohort of 350 homeless‐experienced adults aged 50 and older in Oakland, California. We assessed the prevalence of potential surrogate decision‐makers, ACP contemplation, discussions, and ACP documentation (surrogate designation, advance directives). We used multivariable logistic regression to examine factors associated with ACP discussions and documentation. The median age of the cohort was 59 (range 52–82), 75.2% were male, and 82.1% were black. Sixty‐one percent reported a potential surrogate, 21.5% had discussed ACP, and 19.0% reported ACP documentation. In multivariable models, having 1 to 5 confidants versus none (adjusted odds ratio (aOR)=5.8, 95% confidence interval (CI)=1.7–20.0), 3 or more chronic conditions versus none (aOR=2.3, 95% CI=0.9–5.6), and a recent primary care visit (aOR=2.1, 95% CI=1.0–4.4) were associated with higher odds of ACP discussions and each additional 5 years of homelessness (aOR=0.7, 95% CI=0.5—0.9) with lower odds. Having 1 to 5 confidants (aOR=5.0, 95% CI=1.4–17.5), being black (aOR=5.5, 95% CI=1.5–19.5), and having adequate versus limited literacy (aOR=7.0, 95% CI=1.5–32.4) were associated with higher odds of ACP documentation and illicit drug use (aOR=0.3, 95% CI=0.1–0.9) with lower odds. Although the majority of older homeless‐experienced adults have a potential surrogate, few have discussed or documented their ACP wishes; the odds of both were greater with larger social networks. Future interventions must be customized for individuals with limited social networks and address the instability of homelessness, health literacy, and the constraints of safety‐net healthcare settings.     

Painting pictures and playing musical instruments: Change in participation and relationship to health in older women

Aim: To explore how changed participation in painting pictures or playing a musical instrument is related to change in physical and mental health in older women. Method: Women enrolled in the 1921–1926 birth cohort of the Australian Longitudinal Study on Women's Health were surveyed in 2005 and 2008. Changed participation in painting pictures or playing a musical instrument was considered in relation to changes in social activity, social support, health status and health‐related quality of life. Results: Data were available for 5058 women. Improvements in instrumental activities of daily living (odds ratio (OR) 1.1, 95% confidence interval (CI) 1.0–1.2; P = 0.004) and role limitations due to emotional factors (OR 1.6, 95% CI 1.0–2.5; P = 0.002) were associated with starting participation. Decline in mental health‐related quality of life (OR 4.1, 95% CI 2.3–7.2; P < 0.0001) was associated with stopping. Conclusion: Changed participation was associated with change in functional capacity and tied to emotional well‐being.     

The feasibility of using a telephone-administered survey for determining nutritional service needs of noninstitutionalized older adults in rural areas: time and costs

PURPOSE: This study examined response, participation, time, and costs for a telephone-administered survey to obtain comprehensive information on general health, eating habits, living environment, and functional status from a sample of older persons in a rural North Carolina county. DESIGN AND METHODS: A probability sample of persons aged 60 years and older from the most recent electoral rolls were mailed a personalized letter, which was followed by telephone contact to recruit them into a contemporaneous survey that used a modified version of the Nutrition Screening Initiative's Level I and II screens. Time requirements and costs associated with the completion of surveys were calculated. RESULTS: Seventy-six percent of the persons contacted by telephone (residents of 96% of county precincts) completed the survey. Because minority elders were more likely to lack a working telephone, they were underrepresented in the sample. With 555 calling attempts (58% of surveys completed on first attempt), we estimated a cost of $10.65 per completed survey. IMPLICATIONS: Telephone-administered surveying of older adults may be considered as an appropriate component of an overall community-based service strategy. The estimation of the constituents of nutritional risk, by geographic area, economic status, or ethnicity, may aid in providing estimates of service needs and procuring and allocating resources. Additional methods of data collection are necessary in order to target older persons without telephone service.     

Valuing the outcomes of treatment: do patients and their caregivers agree?

BACKGROUND: Treatment outcomes are an important determinant of patients' treatment preferences. Although studies have examined how well surrogates agree with patients' preferences for specific treatment interventions, agreement regarding the valuation of health states as treatment outcomes is unknown. METHODS: Cross-sectional cohort study consisting of in-home interviews with 193 persons 60 years or older and seriously ill with cancer, congestive heart failure, or chronic obstructive pulmonary disease and their caregivers. Patients were asked whether, facing an exacerbation of illness, they would find a series of health states acceptable as a result of treatment (a rating of "unacceptable" meant they would prefer to die than to receive treatment). Caregivers were asked whether they would find these states acceptable for the patient. RESULTS: There was 80% or greater agreement for health states that were overall rated either acceptable (current health, mild memory impairment, mild pain, or other symptoms) or unacceptable (coma). There was 58% to 62% agreement (kappa = 0.10-0.25) about states with more severe physical or cognitive impairment. When disagreement occurred, caregivers were more likely to rate the state as acceptable. There was 61% to 65% agreement (kappa = 0.20-0.28) about states with severe pain or other symptoms. When disagreement occurred, caregivers and patients were equally likely to rate the state as acceptable. CONCLUSIONS: Patient-caregiver agreement about the acceptability of health states with functional or cognitive impairment, severe pain, or other symptoms was poor. Caregivers making surrogate decisions based on considerations of treatment outcomes may not effectively represent patients' preferences.     

Social participation and tooth loss,vision, and hearing impairments among older Brazilian adults

Background

Vision and hearing impairments can reduce participation in social activities. Given the prominent role of the mouth in face-to-face interactions, this study evaluated the associations of tooth loss, vision, and hearing impairments with social participation among older adults.

Methods

This analysis included 1947 participants, aged 60+ years, who participated in three waves (2006, 2010, and 2015) of the Health, Wellbeing and Aging Study (SABE) in Brazil. Social participation was measured by the number of formal and informal social activities (requiring face-to-face interaction) participants were regularly involved in. Teeth were counted during clinical examinations and categorized as 0, 1–19, and 20+ teeth. Reports on vision and hearing impairments were classified into three categories (good, regular, and poor). The associations of each impairment with the 9-year change in the social participation score were tested in negative binomial mixed-effects models adjusting for time-variant and time-invariant covariates.

Results

Each impairment was associated with the baseline social participation score and the annual rate of change in the social participation score. Participants with 1–19 (incidence rate ratio: 0.96, 95% CI: 0.91–1.01) and no teeth (0.92, 95% CI: 0.87–0.97), those with regular (0.98, 95% CI: 0.95–1.01) and poor vision (0.86, 95% CI: 0.81–0.90), and those with regular (0.94, 95% CI: 0.91–0.98) and poor hearing (0.91, 95% CI: 0.87–0.95) had lower baseline social participation scores than those with 20+ teeth, good vision, and good hearing, respectively. Furthermore, participants with 1–19 (0.996, 95% CI: 0.990–1.002) and no teeth (0.994, 95% CI: 0.987–0.999), those with regular (0.996, 95% CI: 0.992–0.999) and poor vision (0.997, 95% CI: 0.991–1.003), and those with regular (0.997, 95% CI: 0.992–1.001) and poor hearing (0.995, 95% CI: 0.990–0.999) had greater annual declines in the social participation score than those with 20+ teeth, good vision and good hearing, respectively.

Conclusion

This 9-year longitudinal study shows that tooth loss, vision, and hearing impairments are associated with reduced social participation among older adults.     

Sleep Duration and Mortality According to Health Status in Older Adults

OBJECTIVES: To examine the association between usual sleep duration and mortality according to physical and mental health status in older adults. DESIGN: Prospective study conducted from 2001 to 2008. SETTING: Community‐based study. PARTICIPANTS: Cohort study of 3,820 persons representative of the noninstitutionalized population aged 60 and older in Spain. MEASUREMENTS: Sleep duration was self‐reported at baseline. Analyses were performed using Cox regression and adjusted for the main confounders. The analyses were then stratified according to numerous indicators of health status. RESULTS: During follow‐up, 897 persons died. Mortality was higher in those who slept 8 hours (relative risk (RR)=1.34, 95% confidence interval (CI)=1.02–1.76), 9 hours (RR 1.48, 95% CI=1.12–1.96), 10 hours (RR 1.73, 95% CI=1.30–2.29) and 11 hours or more (RR 1.66, 95% CI=1.23–2.24) than in those who slept 7 hours (P for trend <.001). The association between long sleep duration (≥10 vs 7 hours) and mortality was observed even in persons with good health status: optimal perceived health, good cognitive function (Mini‐Mental State Examination score >27), no depression, quality of life better than the cohort median (Medical Outcomes Study 36‐item Short Form Survey Physical Component Summary score ≥46 and Mental Component Summary score ≥52), and without disability in instrumental activities of daily living. Sleeping 6 hours or less was not associated with higher mortality than sleeping 7 hours in persons with good health status. CONCLUSION: Self‐reported sleep duration was associated with 7‐year mortality in this cohort of older adults, even when adjusted for health status. Further research is needed to determine the mechanisms and clinical implications of these findings.     

Utilization of surgery in trimodality‐eligible patients with locally advanced esophageal adenocarcinoma in a nonprotocol setting

Trimodality therapy with neoadjuvant chemoradiation followed by surgery significantly improves the survival of locally advanced (clinical stage IIA–III) esophageal cancer patients compared to treatment with surgery alone. This has resulted in an increased use of neoadjuvant therapy in recent years, yet little is known regarding how this increase has impacted the utilization of surgery in the treatment of locally advanced disease. Although previous reports of experimental protocols suggest that 90–95% of patients complete trimodality therapy including a surgical resection, trimodality therapy completion among adenocarcinoma patients eligible for curative resection has not been evaluated in a nonprotocol setting. We sought to (i) assess the completion of trimodality therapy among locally advanced esophageal adenocarcinoma patients; (ii) characterize the reasons for avoiding surgery; and (iii) identify factors associated with failure to complete trimodality therapy. We identified 296 patients with locally advanced esophageal adenocarcinoma eligible for trimodality therapy at our institution. All patients were evaluated in a multidisciplinary setting and considered eligible for curative resection after initial staging and physiologic assessment. Multivariable logistic regression was used to identify factors associated with failure to complete trimodality therapy. Of 296 trimodality‐eligible patients, 33% (97/296) did not complete trimodality therapy. Reasons for not undergoing surgery included patient choice (27.8%, 27/97), distant progression of disease during chemoradiation (23.7%, 23/97), and physician preference for surveillance (23.7%, 23/97). In addition, 17.5% (17/97) of patients had physical deterioration in performance status, and treatment‐related deaths occurred in 7.2% (7/97) prior to surgery. In the total study population (n = 296), multivariable logistic regression identified older age (≥70 years: odds ratio [OR] = 6.611, 95% confidence interval [CI]: 2.900–15.071), pretreatment standard uptake value (6.8–10.1: OR = 2.393, 95% CI: 1.050–5.455; ≥15.8: OR = 3.623, 95% CI: 1.604–8.186), and a radiation dose of 50.4 Gy (OR = 5.312, 95% CI: 2.365–11.929) as being significantly associated with failure to complete trimodality therapy. Among the subgroup of patients that successfully completed chemoradiation (n = 266), older patients (≥70 years: OR = 9.606, 95% CI: 3.637–25.372), those with a comorbidity score of 2 or higher (OR = 4.059, 95% CI: 1.257–13.103), and those that received a radiation dose of 50.4 Gy (OR = 4.878, 95% CI: 1.974–12.054) were at a significantly higher risk of not completing trimodality therapy. Trimodality therapy completion among patients with locally advanced esophageal adenocarcinoma in a nonprotocol setting is considerably lower than what has previously been reported in clinical trials. Our findings suggest that a selective approach to surgery is commonly utilized in clinical practice. Trimodality‐eligible patients that are older and have a higher comorbidity score are at risk for not completing trimodality therapy.     

Depression and functional recovery after a disabling hospitalization in older persons

OBJECTIVES: To determine the association between depression and functional recovery in community‐living older persons who had a decline in function after an acute hospital admission. DESIGN: Prospective cohort study. SETTING: General community in greater New Haven, Connecticut, from March 1998 to December 2008. PARTICIPANTS: Seven hundred fifty‐four persons aged 70 and older. MEASUREMENTS: Hospitalization and disability in essential activities of daily living (ADLs) and mobility were assessed each month for up to 129 months, and depressive symptoms were assessed every 18 months using the Center for Epidemiologic Studies‐Depression Scale (CES‐D). Functional recovery was defined as returning to the community within 6 months at or above the prehospital level of ADL function and mobility. RESULTS: A decline in ADL function and mobility was observed after 42% and 41% of the hospitalizations, respectively. After controlling for several potential confounders, clinically significant depressive symptoms (CES‐D score ≥20) was associated with a lower likelihood of recovering mobility function (hazard ratio (HR)=0.79, 95% confidence interval (CI)=0.63–0.98) but not ADL function (HR=0.91, 95% CI=0.75–1.10) within 6 months of hospitalization. CONCLUSION: After a disabling hospitalization, community‐living older persons with preexisting depression may be less likely to recover their prehospitalization level of mobility function but not ADL function, although the reasons remain to be elucidated.     

Rates of hospitalisations and mortality of older adults admitted with burn injuries in Western Australian from 1983 to 2008

Aim: To estimate temporal trends in burn injury hospitalisations, mortality and hospital stay, for older adults with a burn‐related hospitalisation. Methods: De‐identified data of all incident burn hospitalisations for adults 60 years and older in Western Australia from 1983–2008 were analysed. Poisson regression analyses were used to estimate temporal trends in hospital admissions and mortality. Zero truncated negative binomial regression analysis was used to identify factors associated with hospital stay. Results: Between 1983 and 2008, hospitalisation rates increased for scalds (incident rate ratio (IRR) 1.01, 95% CI: 1.00–1.02) and contact burns (IRR 1.05, 95% CI: 1.03–1.07) while a significant reduction in flame hospitalisation rates (IRR 0.93, 95% CI: 0.92–0.94) was estimated. No significant changes in length of stay or burn‐related mortality were estimated. Conclusions: Burn safety and prevention strategies that include first aid education need to be developed that target older adults living in their homes, to decrease their risk of sustaining burn injuries.     

Depressive Symptoms in Middle Age and the Development of Later‐Life Functional Limitations: The Long‐Term Effect of Depressive Symptoms

OBJECTIVES: To determine whether middle‐aged persons with depressive symptoms are at higher risk for developing activity of daily living (ADL) and mobility limitations as they advance into older age than those without. DESIGN: Prospective cohort study. SETTING: The Health and Retirement Study (HRS), a nationally representative sample of people aged 50 to 61. PARTICIPANTS: Seven thousand two hundred seven community living participants in the 1992 wave of the HRS. MEASUREMENTS: Depressive symptoms were measured using the 11‐item Center for Epidemiologic Studies Depression Scale (CES‐D 11), with scores of 9 or more (out of 33) classified as significant depressive symptoms. Difficulty with five ADLs and basic mobility tasks (walking several blocks or up one flight of stairs) was measured every 2 years through 2006. The primary outcome was persistent difficulty with ADLs or mobility, defined as difficulty in two consecutive waves. RESULTS: Eight hundred eighty‐seven (12%) subjects scored 9 or higher on the CES‐D 11 and were classified as having significant depressive symptoms. Over 12 years of follow‐up, subjects with depressive symptoms were more likely to reach the primary outcome measure of persistent difficulty with mobility or difficulty with ADL function (45% vs 23%, Cox hazard ratio (HR)=2.33, 95% confidence interval (CI)=2.06–2.63). After adjusting for age, sex, measures of socioeconomic status, comorbid conditions, high body mass index, smoking, exercise, difficulty jogging 1 mile, and difficulty climbing several flights of stairs, the risk was attenuated but still statistically significant (Cox HR=1.44, 95% CI=1.25–1.66). CONCLUSION: Depressive symptoms independently predict the development of persistent limitations in ADLs and mobility as middle‐aged persons advance into later life. Middle‐aged persons with depressive symptoms may be at greater risk for losing their functional independence as they age.     

Advance Care Planning: Should we be Discussing it with our Patients?

Introduction : Advance care planning (ACP) is a term used for a variety of legal and informal options available to ensure that our wishes will be respected in the future, should we lose competence in decision making. Objectives : This research aimed to establish whether older people being treated at a regional rehabilitation service were aware of ACP options and whether discussion with a physician supplemented with written information increased their uptake of ACP options. Method : Forty people aged over 60 years and participating in inpatient or outpatient rehabilitation programs in Lismore, New South Wales (NSW) were interviewed and provided with verbal and written information about ACP options. They were then interviewed by telephone one month later to determine whether they had taken further action concerning ACP. Results : Overall 30 (78%) demonstrated a good level of knowledge of enduring power of attorney at baseline interview. Only 1 (2.5%) knew about enduring guardianship and 1 (2.5%) knew about advance directives. All those interviewed felt that ACP was an important issue, grading its' importance as 6 or greater on a 10 point scale. Thirty four (85%) patients were successfully followed up one month later. Of these 27 (77%) had taken further action in relation to their ACP‐ 13 (33%) had had discussions with family and important others and 14 (35%) had completed further documentation (10 enduring power of attorney, 3 enduring guardianship and 1 an advance directive). Conclusions : ACP is considered an important issue by older people undergoing rehabilitation. A short discussion with a physician along with written information increases the uptake of ACP. However the options of advance directives and enduring guardian are not readily taken up, with most people in this study preferring informal discussions with family and friends when considering advance care planning.     

Food Insecurity and Aging Outcomes in Older Adults Living with HIV

Little is known about food insecurity and its association with geriatric outcomes in older people living with HIV (PLWH). This was a cross-sectional study of 230 HIV-infected patients aged 50 and older recruited in December 2012 through June 2016. Poisson logistic regression models estimated the prevalence ratio (PR) and 95% confidence intervals (CI) for the association between food insecurity and the following geriatric outcomes: frailty, physical health and function, social support, mental health and cognition, and behavioral health. 157 (68%) participants were food secure, 35 (15%) had low food security, and 38 (17%) had very low food security. After adjusting the analyses for other significant covariates, at risk alcohol or drug use (PR = 3.14; 95% CI 1.75–5.64), being sedentary (PR = 3.30; 95% CI 1.09–10.00) depressive symptoms (PR = 1.77; 95% CI 1.13–2.76), and dependent instrumental activities of daily living (PR = 2.46; 95% CI 1.13–5.36) were significantly associated with very low food security. These results highlight a need for structural HIV interventions that incorporate targeted food assistance strategies for older PLWH.