Hearing care for elders: a personal reflection on participatory action learning with primary care providers.

PURPOSE: This report is a reflective critical narrative of the authors' experience with an interdisciplinary collaboration of primary care providers (PCPs) and hearing health care providers (HHCPs) that followed the principles of participatory action research/learning. The goal for this report is to describe the 1st author's observed barriers to PCPs' willingness to learn about hearing health care and the subsequent facilitators to learning. METHOD: A team of PCPs and HHCPs created the "Communication: Hearing Loss in Elders" educational module. The module included (a) prereading developed from a combination of literature reviews and contextual factors and (b) a case study. RESULTS: The authors present the list of topics included in the module, and they reflect on why and how these topics were deemed important by the team. In particular, 2 topics were identified for motivating PCPs' behavior regarding hearing health care: (a) the overlap in symptoms and possible causation among depression, dementia, and hearing loss and (b) how hearing can affect efficiency of care regarding other health issues. CONCLUSIONS: This personal reflective narrative gives the authors' opinions about what can make for a successful collaboration and presents some hypotheses regarding information that may motivate behavior change with regard to hearing care.

A case-control study regarding relative factors for behavioural and psychological symptoms of dementia at a Canadian regional long-term extended care facility: a preliminary report.

BACKGROUND: Behavioural and psychological symptoms of dementia (BPSD) are prevalent and have an impact on the care of persons with dementia. Previous studies regarding predisposing factors have included pharmacotherapy, but other factors may not have been sufficiently studied. We hypothesized that psychotropic medications, past history, comorbid psychiatric disorders and other factors may be relevant factors related to BPSD. METHODS: Data were collected from patients' medical charts at an extended care facility over a 2-year period from 1 May 2008 to 30 April 2010. Information obtained included the presence of BPSD, gender, age, marital status, past history, comorbid psychiatric disorder and medication use. Patients were divided into two groups: a group with BPSD (n = 29) and a group without BPSD (n = 10). A binomial logistic regression analysis was performed for the above factors. RESULTS: Comorbid major depression was linked to BPSD (odds ratio = 12.57, 95% confidence interval: 1.31-120.74) as well as to the use of antidepressants (odds ratio = 6.49, 95% confidence interval: 1.02-41.25). There was a trend towards statistical significance in the relationship between greater use of antidepressants for the patients with comorbid major depression and the presence of BPSD. Past history of depression (Fisher's exact test; P = 0.03) and cerebral vascular accident (degrees of freedom = 1, χ(2) = 4.44, P = 0.04) were linked to the presence of BPSD and comorbid major depression. CONCLUSION: Accurate evaluation and treatment of comorbid major depression may affect BPSD. In order to reduce the burden of BPSD on patients and caregivers, there should be a careful and thoughtful diagnosis of comorbid major depression in patients with dementia.

Enhanced measurement sensitivity of hopeless ideation among older adults at risk of self-harm: Reliability and validity of Likert-type responses to the Beck Hopelessness Scale.

OBJECTIVE: Responses to the Beck Hopelessness Scale (BHS) have been identified as a significant predictor of suicide-related ideation and self-harm, of note, to a greater degree than severity of depressive symptoms. The BHS is the most widely used instrument to assess this construct, yet concern has been expressed about the traditional true/false response format of this instrument. For this study, we obtained responses from older adults to a revised four-point Likert-type BHS response format. METHOD: A national sample of 117 older Canadians at risk of self-harm was recruited from multiple sources for this study over a one-year period. Most participants were women (65%) with an average age of 68.47 years (SD = 9.02, range 50-92). RESULTS: Exploratory factor analysis suggests the existence of two factors labeled Powerlessness/Disappointment and Negative Future Expectancies. Concurrent validity of this two-factor model of BHS responses is provided vis-a-vis suicide-related ideation subsequent to statistical control for socio-demographic factors, physical health, and depressive symptomatology. Of note, the relative contribution to the measurement of BHS factors is proportionately equal and greater than all other independent variables. CONCLUSION: We contend that this revised BHS response format may be appropriate for use in clinical and research applications though replication with other samples and populations is warranted.

Developing a national consensus on the accessibility needs of older adults with concurrent and chronic, mental and physical health issues: a preliminary framework informing collaborative mental health care planning.

Canada faces a significant challenge in meeting the health care needs of older adults with complex mental and physical health issues. Studies have shown collaborative mental health services to effectively address the diverse health needs of this group. However, an often overlooked yet important aspect of service delivery planning for this population is to ensure that older adults are sufficiently able to access available best-practice services. The article reports on a national consensus-building exercise conducted by the Collaborative Mental Health Initiative-Seniors Working Group to develop a nationally informed framework on the accessibility needs of older adults as they relate to collaborative mental health care. The framework is intended to provide planners, administrators, and providers with an understanding of the unique accessibility needs of older adults across three priority pillars (personal, caregiver, systemic) and to enable them to embed strategies to address these issues within field-based collaborative mental health initiatives.

Assessing capacity within a context of abuse or neglect.

In 2000, with the implementation of Part III of the Adult Guardianship Act: Support and Assistance for Abused and Neglected Adults, British Columbia formally recognized the need to examine issues of decisional capacity of older adults within a context of abuse or neglect. Interestingly, however, although the test of capacity was clearly laid out under this piece of legislation, the potential influence that living in a situation of abuse or neglect may have on how the person makes decisions is not explicitly addressed. Similarly, this is a missing link throughout the literature discussing decisional capacity in older adults. This gap exists despite the fact that determining the "protection" needs of someone who is being abused and/or neglected often hinges directly on that person's decisional capacity. The purpose of this article is to examine the unique aspects associated with assessing and determining capacity for older adults who are living in a situation of abuse or neglect. The specific objectives are to: (a) examine how living in a situation of abuse or neglect may influence the determination of capacity and (b) explore the implications of conducting an assessment within a potentially abusive context. The legal notion of undue influence and the psychological concept of relational connection are introduced as potentially important for considering decision making within this context.

Disclosure of the diagnosis of dementia.

Most ethical guidelines strongly promote disclosure of a diagnosis of dementia to the affected individual, based on the principle of autonomy. Nevertheless, codes of medical ethics allow for various interpretations of this issue and surveys of clinical practice illustrate that such disclosure is by no means the rule. We argue that diagnostic disclosure for persons with dementia must be considered a process that begins when cognitive impairment is first suspected and that evolves over time as information is obtained. Whenever possible and appropriate, this process should involve not only the affected individual but also their family and/or other current or potential future care providers. Once a diagnosis is established it should be disclosed in a manner consistent with the expressed wishes of the patient, using an individualized patient-centered approach that maintains the individual's personal integrity. Diagnostic disclosure of dementia is a process that may require additional time as well as follow-up or referral to other specialists. We recommend that a progressive disclosure process be employed to address issues including: remaining diagnostic uncertainty, treatment options, future plans, financial planning, assigning power of attorney, wills and "living wills", driving privileges and the need for eventual driving cessation, available support services, and potential research participation. The potential for adverse psychological consequences to diagnostic disclosure must be assessed and these should be addressed through education and support of the patient and their family/caregivers throughout the diagnostic disclosure process. At present, few data are available regarding patients' perspectives on the diagnostic disclosure process and its consequences. This limitation and the apparent discrepancies in physician and caregiver opinions about the disclosure process, make it incumbent upon health care professionals to evaluate the diagnostic disclosure process within their practice.

Ethical considerations for decision making for treatment and research participation.

Here we review issues of patient decision-making and consent to treatment and research by persons with cognitive impairment and dementia. Clinicians and researchers must recognize their primary duty to care for the individual and must clearly distinguish their role as a clinician and/or researcher. Distinctions between standard care and research must be clearly understood by everyone, as must the clinician's role in each. Both actual and perceived conflicts of interest must be avoided. At present there is insufficient evidence to recommend specific methods for determining competency for decision-making, but a diagnosis of cognitive impairment or dementia does not preclude such competence. Competency is not a unitary or static construct and must be considered as the ability to make an informed decision about participation in the particular context of the specific treatment or study. Clinicians and researchers should consider consent as a process involving both the patient with cognitive impairment and his or her family/caregiver, particularly given the potential that competency for decision-making will change over time. As the availability of advance directives remains limited, clinicians and researchers must make efforts to ensure that decisions made by proxies are based on the prior attitudes and values of the patient.

Factors affecting the mental health of older adults in rural and urban communities: an exploration.

Stakeholders in rural and mid-size urban communities were asked to share their views concerning factors that affect the mental health of older adults, and indicate how, and how well, these factors were addressed in their community. The identified factors clustered into six categories: clinical, physical, organizational, educational, psychosocial, and spiritual. Additional factors impacting care providers and caregivers and their ability to support the mental health of older adults also emerged. Similarities and distinct differences between rural and urban communities were reported and call for innovative strategies to meet the needs of seniors, particularly those living in rural areas.