Young People's Attitudes, Perceptions and Experiences of Social Distancing and Self-Isolation During the Second Wave of the COVID-19 Pandemic.

Objectives: Social distancing and self-isolation were key parts of the UK's strategy for reducing the spread of COVID-19. This study explored young people's attitudes, perceptions and experiences of social distancing and social isolation during the COVID-19 pandemic. Methods: Qualitative individual, family and paired-friendship interviews were conducted. All 26 participants lived or worked in East London and were aged between 20 and 39 years. Results: Qualitative analysis revealed three main themes: 1) trust and breaking of the social distancing and self-isolation rules-trust in their friends to be careful and say if they are unwell; 2) own rule making-making their own household rules which made them less guilty about breaking national rules as they were adhering to rules (albeit their own); and 3) lack of clarity around self isolation and the need for practical support-confusion around length of time needed to self isolate and what self-isolation really meant. Conclusion: Developing more effective and targeted communications and practical support mechanisms to encourage better adherence to social distancing and self-isolation rules among young people will be essential to prevent the spread of COVID-19.

Traumatic disclosures in the life stories of older Vietnam era veterans.

BACKGROUND: Eliciting life stories is an important component of person-centered care that may aid in understanding how an individual's unique background and narrative impacts their health. Such life stories, especially when gathered from older military Veterans, may include traumatic events, raising the urgency that clinicians be prepared to provide care that is trauma-informed and ensure Veteran's experiences are acknowledged and treated effectively. METHODS: We examined the prevalence and type of potentially traumatic and/or adverse life events spontaneously shared by 231 older Veterans participating in a life story intervention while receiving care within the U.S. Veterans Health Administration system. Veteran life stories were extracted from the electronic medical record and deductive qualitative content analysis was used to code potentially traumatic or adverse life experiences based on a codebook adapted from the Brief Trauma Questionnaire and Adverse Childhood Experience questionnaire. RESULTS: A majority (71.0%) of Veterans described at least one traumatic disclosure in their life story. Among narratives with a disclosure of any type, more than half (53.0%) included descriptions of combat trauma, 21.5% noted a history of life-threatening illness, and 9.5% reported having been in a serious accident. Fewer noted adverse childhood experiences (19.5%). CONCLUSIONS: Elicitation of life stories among older Veterans may advance person-centered care and life stories frequently include disclosure of potentially traumatic and/or adverse life events. These findings underscore the normative experience of traumatic events among older Veterans and highlight the importance of developing age-sensitive trauma-informed care competencies.

Enhancing Access to Yoga for Older Male Veterans After Cancer: Examining Beliefs About Yoga.

BACKGROUND: Yoga is an effective clinical intervention for cancer survivors. Most studies of the positive effects of yoga on cancer patients report on predominantly middle-aged women with breast cancer. Less is known about the use of yoga in older adults, veterans, and those from diverse racial or ethnic backgrounds. METHODS: We examined strategies to enhance access to yoga in older veterans after cancer, focusing on education (study 1) and intervention (study 2). Study 1 included 110 participants with a median (SD) age of 64.9 (9.4) years who were mostly male (99%) cancer survivors who were interviewed 12 months after their cancer diagnosis. Study 2 included 28 participants with a median (SD) age of 69.2 (10.9) years who were mostly male (96%) cancer survivors who participated in a yoga program within 3 years of their cancer diagnosis. Standardized interviews assessed interest in and barriers to yoga while self-reporting assessed health-related quality of life and beliefs about yoga. RESULTS: In study 1, interest in yoga increased from 5.5 to 31.8% (χ 2 = 22.25, P < .001) following education. In open-ended questions 4 themes related to negative beliefs or barriers emerged: lack of knowledge or skepticism, disinterest or dislike, physical health barriers, and logistical barriers. In study 2, beliefs were more positive following intervention for expected benefits (t = 4.44, P < .001), discomfort (t = 4.92, P < .001), and social norms (t = 4.38, P < .001) related to yoga. Physical function improved after participation in a yoga class, especially for those with higher beliefs in yoga prior to class. Age was not associated with beliefs about yoga in either sample. CONCLUSIONS: A portion of older veterans who are cancer survivors were interested in yoga but faced access barriers. Implications for practice and research include increasing knowledge about yoga benefits and addressing physical health and logistical barriers to enhance access to yoga for older veterans.

The Clock-in-the-Box, a brief cognitive screen, is associated with failure to return home in an elderly hospitalized sample.

PURPOSE: Cognitive screening upon hospital admission can provide important information about the patient's ability to process information during the inpatient stay. The Clock-in-the-Box (CIB) is a rapidly administered cognitive screening measure which has been previously validated with cognitive screening and neuropsychological assessments. The purpose of this study is to demonstrate the predictive validity of the CIB for discharge location among a sample of older medical inpatients. PATIENTS AND METHODS: Hospitalized Veterans (N=218), aged 55 years and older, were recruited on the day after admission after they gave their consent. These participants completed the CIB, the Montreal Cognitive Assessment, and self-report measures of daily functioning. Using logistic regression models, the bivariable and multivariable impact of the cognitive screening and functional assessments were examined for their ability to predict whether the participants did not return home after hospitalization (eg, admission to subacute rehabilitation facilities or nursing facilities). RESULTS: The participants were older (mean 71.5±9.5 years) and predominantly male (92.7%). The CIB score was independently associated with discharge to locations other than home (odds ratio =0.72, 95% confidence interval =0.60-0.87, P=0.001) and remained associated after adjusting for demographics, prehospitalization functional abilities, and Montreal Cognitive Assessment score (adjusted odds ratio =0.55, 95% confidence interval =0.36-0.83, P=0.004). CONCLUSION: The current evidence, combined with its brevity and ease of use, supports the use of the CIB as a cognitive screen for inpatient older adults, in order to help inform clinical treatment decisions and discharge planning.

Validation of a Delirium Risk Assessment Using Electronic Medical Record Information.

OBJECTIVE: Identifying patients at risk for delirium allows prompt application of prevention, diagnostic, and treatment strategies; but is rarely done. Once delirium develops, patients are more likely to need posthospitalization skilled care. This study developed an a priori electronic prediction rule using independent risk factors identified in a National Center of Clinical Excellence meta-analysis and validated the ability to predict delirium in 2 cohorts. DESIGN: Retrospective analysis followed by prospective validation. SETTING: Tertiary VA Hospital in New England. PARTICIPANTS: A total of 27,625 medical records of hospitalized patients and 246 prospectively enrolled patients admitted to the hospital. MEASUREMENTS: The electronic delirium risk prediction rule was created using data obtained from the patient electronic medical record (EMR). The primary outcome, delirium, was identified 2 ways: (1) from the EMR (retrospective cohort) and (2) clinical assessment on enrollment and daily thereafter (prospective participants). We assessed discrimination of the delirium prediction rule with the C-statistic. Secondary outcomes were length of stay and discharge to rehabilitation. RESULTS: Retrospectively, delirium was identified in 8% of medical records (n = 2343); prospectively, delirium during hospitalization was present in 26% of participants (n = 64). In the retrospective cohort, medical record delirium was identified in 2%, 3%, 11%, and 38% of the low, intermediate, high, and very high-risk groups, respectively (C-statistic = 0.81; 95% confidence interval 0.80-0.82). Prospectively, the electronic prediction rule identified delirium in 15%, 18%, 31%, and 55% of these groups (C-statistic = 0.69; 95% confidence interval 0.61-0.77). Compared with low-risk patients, those at high- or very high delirium risk had increased length of stay (5.7 ± 5.6 vs 3.7 ± 2.7 days; P = .001) and higher rates of discharge to rehabilitation (8.9% vs 20.8%; P = .02). CONCLUSIONS: Automatic calculation of delirium risk using an EMR algorithm identifies patients at risk for delirium, which creates a critical opportunity for gaining clinical efficiencies and improving delirium identification, including those needing skilled care.

Diagnosing and treating cannabinoid hyperemesis.

Cannabinoid hyperemesis is a newly emerging syndrome that manifests as intractable nausea and vomiting in people who regularly smoke cannabis. The signs and symptoms are relieved by bathing in hot water and by stopping smoking cannabis but are unresponsive to antiemetics. This article briefly examines the possible causes and clinical presentation of the condition and uses a case study to describe the management of patients.

The association between an ultrabrief cognitive screening in older adults and hospital outcomes.

BACKGROUND: Though often recommended, hospital cognitive assessment is infrequently completed due to clinical and time constraints. OBJECTIVE: This analysis aimed to evaluate the relationship between performance on ultrabrief cognitive screening instruments and hospital outcomes. DESIGN: This is a secondary data analysis of a quality improvement project. SETTING: Tertiary Veterans Administration hospital in New England. PATIENTS: Patients, ≥ 60 years old, admitted to the hospital. INTERVENTION: None. MEASUREMENTS: Upon admission, patients were administered 2 cognitive screening tools. The modified Richmond Agitation and Sedation Scale (mRASS) is a measure of arousal that can be completed in 15 seconds. The months of the year backward (MOYB) is a measure of attention that can be administered in ≤1 minute. In-hospital outcomes included restraints and mortality, whereas discharge outcomes included length of stay, discharge not home, and variable direct costs. Risk ratios were calculated for dichotomous outcomes and unadjusted Poisson regression for continuous outcomes. RESULTS: Patients (n = 3232) were screened. Altered arousal occurred in 15% of patients (n = 495); incorrect MOYB was recorded in 45% (n = 1457). Relative to those with normal arousal and attention, those with abnormal mRASS and incorrect MOYB had increased length of stay (incident rate ratio [IRR]: 1.23, 95% confidence interval [CI]: 1.17-1.30); restraint use (risk ratio [RR]: 5.05, 95% CI: 3.29-7.75), in-hospital mortality (RR: 3.46, 95% CI: 1.24-9.63), and decreased discharge home (RR: 2.97, 95% CI: 2.42-3.64). Hospital variable direct costs were slightly, but not significantly, higher (IRR: 1.02, 95% CI: 0.88-1.17). CONCLUSION: Impaired performance on ultrabrief cognitive assessments of arousal and attention provide valuable insights regarding hospital outcomes.

Impaired Arousal in Older Adults Is Associated With Prolonged Hospital Stay and Discharge to Skilled Nursing Facility.

BACKGROUND: Poor cognitive function is associated with negative consequences across settings of care, but research instruments are arduous for routine clinical implementation. This study examined the association between impaired arousal, as measured using an ultra-brief screen, and risk of 2 adverse clinical outcomes: hospital length of stay and discharge to a skilled nursing facility (SNF). DESIGN, SETTING, AND PARTICIPANTS: A secondary data analysis was conducted using 2 separate groups of medical ward patients: a Veterans Affairs medical center in the northeast (N = 1487, between 2010 and 2012) 60 years and older and a large tertiary care, university-based medical center (N = 669, between 2007 and 2013) 65 years and older in the southeastern United States. MEASUREMENTS: The impact of impaired arousal, defined by the Richmond Agitation Sedation Scale as anything other than "awake and alert," was determined using Cox Proportional Hazard Regression for time to hospital discharge and logistic regression for discharge to a SNF. Hazard ratios (HRs) and odds ratios (OR) with their 95% confidence intervals (CI) are reported, respectively. Both models were adjusted age, sex, and dementia. RESULTS: The 2156 total patients included in these groups had a mean age of 76 years, of whom 16.4% in group 1 and 28.5% in group 2 had impaired arousal. In the first group, patients with normal arousal spent an average of 5.9 days (standard deviation 6.2) in the hospital, while those with impaired arousal spent 8.5 days (9.2). On any given day, patients with impaired arousal had 27% lower chance of being discharged (adjusted HR 0.73 (95% CI 0.63-0.84). In the second group, individuals with normal arousal spent 3.8 (4.1) days in the hospital compared with 4.7 (4.6) for those with impaired arousal; indicating a 21% lower chance of being discharged [adjusted HR 0.79 (95% CI 0.66-0.95). With regard to risk of discharge to SNF, those with impaired arousal in group 1 had a 65% higher risk than those without impaired arousal [adjusted OR 1.65 (95% CI 1.21-2.25)], and those in group 2 had a nonsignificant 27% higher risk [adjusted OR 1.27 (0.80-2.03)]. Because of the quality improvement nature, this analysis did not control for comorbidities, which is a significant limitation. CONCLUSIONS: In this study of over 2000 older hospitalized patients, the simple observation of an abnormal arousal level may be an independent predictor of a longer hospital stay and discharge to SNF.

The Social Worker's Role in Delirium Care for Hospitalized Veterans.

Social workers can play an important role as part of the health care team in delirium risk identification, prevention, and care.

Delirium markers in older fallers: a case-control study.

BACKGROUND: When a hospitalized older patient falls or develops delirium, there are significant consequences for the patient and the health care system. Assessments of inattention and altered consciousness, markers for delirium, were analyzed to determine if they were also associated with falls. METHODS: This retrospective case-control study from a regional tertiary Veterans Affairs referral center identified falls and delirium risk factors from quality databases from 2010 to 2012. Older fallers with complete delirium risk assessments prior to falling were identified. As a control, non-fallers were matched at a 3:1 ratio. Admission risk factors that were compared in fallers and non-fallers included altered consciousness, cognitive performance, attention, sensory deficits, and dehydration. Odds ratio (OR) was reported (95% confidence interval [CI]). RESULTS: After identifying 67 fallers, the control population (n=201) was matched on age (74.4±9.8 years) and ward (83.6% medical; 16.4% intensive care unit). Inattention as assessed by the Months of the Year Backward test was more common in fallers (67.2% versus 50.8%, OR=2.0; 95% CI: 1.1-3.7). Fallers tended to have altered consciousness prior to falling (28.4% versus 12.4%, OR=2.8; 95% CI: 1.3-5.8). CONCLUSION: In this case-control study, alterations in consciousness and inattention, assessed prior to falling, were more common in patients who fell. Brief assessments of consciousness and attention should be considered for inclusion in fall prediction.

Implementing Yoga Therapy Adapted for Older Veterans Who Are Cancer Survivors.

OBJECTIVES: This goal of this paper is to describe the reach, application, and effectiveness of an 8-week yoga therapy protocol with older cancer survivors within a Veterans Health Administration setting. METHODS: To document the reach of this intervention, recruitment efforts, attendance, and practice rates were tracked. To explore the application of the protocol to this population, physical therapy pre-assessment and observations by the yoga therapist were recorded to ascertain necessary pose modifications. Effectiveness was measured through pre- and post-course structured interviews, tracking self-reported symptoms of combat-related posttraumatic stress disorder, depression, anxiety, fatigue, insomnia, and pain. RESULTS: Regarding reach, 15% of eligible veterans (n = 14) enrolled, participated in 3-16 classes (M±SD = 11.64±3.39), and practiced at home for 0-56 days (M±SD = 26.36±17.87). Participants were primarily Caucasian (n = 13), male (n = 13), ranged in age from 55 to 78 years (M±SD = 65.64±5.15), and had multiple medical problems. During application, substantial individualized modifications to the yoga therapy protocol were necessary. Effectiveness of the intervention was mixed. During post-course interviews, participants reported a variety of qualitative benefits. Notably, the majority of participants reported that breathing and relaxation techniques were the most useful to learn. Group comparisons of mean pre- and post-course scores on standardized measures showed no significant differences. CONCLUSIONS: A minority of older veterans express an interest in yoga, but those who do have high rates of class attendance and home practice. Careful physical pre-assessment and attentive therapists are required to undertake the adaptations required by participants with multiple comorbidities. The effectiveness of yoga in this setting requires additional study.

Implementing yoga therapy adapted for older veterans who are cancer survivors.

OBJECTIVES: This goal of this paper is to describe the reach, application, and effectiveness of an 8-week yoga therapy protocol with older cancer survivors within a Veterans Health Administration setting. METHODS: To document the reach of this intervention, recruitment efforts, attendance, and practice rates were tracked. To explore the application of the protocol to this population, physical therapy preassessment and observations by the yoga therapist were recorded to ascertain necessary pose modifications. Effectiveness was measured through pre- and post-course structured interviews, tracking self-reported symptoms of combat-related posttraumatic stress disorder, depression, anxiety, fatigue, insomnia, and pain. RESULTS: Regarding reach, 15% of eligible veterans (n = 14) enrolled, participated in 3-16 classes (M±SD = 11.64±3.39), and practiced at home for 0-56 days (M±SD = 26.36±17.87). Participants were primarily Caucasian (n = 13), male (n = 13), ranged in age from 55 to 78 years (M±SD = 65.64±5.15), and had multiple medical problems. During application, substantial individualized modifications to the yoga therapy protocol were necessary. Effectiveness of the intervention was mixed. During post-course interviews, participants reported a variety of qualitative benefits. Notably, the majority of participants reported that breathing and relaxation techniques were the most useful to learn. Group comparisons of mean pre- and post-course scores on standardized measures showed no significant differences. CONCLUSIONS: A minority of older veterans express an interest in yoga, but those who do have high rates of class attendance and home practice. Careful physical pre-assessment and attentive therapists are required to undertake the adaptations required by participants with multiple comorbidities. The effectiveness of yoga in this setting requires additional study.