Acceptability of Telemedicine in a Geriatric Outpatient Practice During the COVID-19 Pandemic.

Background: Telemedicine utilization has increased dramatically during the COVID pandemic. Few studies have evaluated the use and acceptability of telemedicine in older populations. This study examined the use and acceptability of telemedicine with older adults in an urban, geriatric practice. Methods: An anonymous survey was sent to patients seen at an urban, geriatric practice using MyChart in EPIC in March 2021. This population of patients is 55 years and older, 50% Black, 40% white, 3% Latino, 3% Asian, and 4% other. This panel is comprised of 71% Medicare, 23% non-Medicare/non-Medicaid, and 6% Medicaid. The total panel of patients includes ∼1,400 patients. The percent of patients on MyChart at the time of the survey was 78%. Thus, about 1,092 patients received the survey. Results: Of the 1,092 patients who received the survey, 247 (22.6%) responded. Around 80.37% of respondents rated their overall experience with telemedicine as good or excellent. Theme areas emerged around the advantages and disadvantages of telemedicine. A majority (70.28%) of respondents rated themselves as Somewhat Confident to Very Confident in use of telemedicine without family/friend assistance. A majority (74.16%) of respondents stated they plan to use telemedicine again. Conclusions: This survey demonstrated the feasibility and acceptability of telemedicine in an urban, geriatric population. A limit to this study is that the survey was administered on-line, so that participants may be biased regarding use of online technology. However, this study showed that the vast majority of older adults were confident in using telemedicine as an alternative to in-person visits during the COVID pandemic and plan on using it again.

Tendinosis develops from age- and oxygen tension-dependent modulation of Rac1 activity.

Age-related tendon degeneration (tendinosis) is characterized by a phenotypic change in which tenocytes display characteristics of fibrochondrocytes and mineralized fibrochondrocytes. As tendon degeneration has been noted in vivo in areas of decreased tendon vascularity, we hypothesized that hypoxia is responsible for the development of the tendinosis phenotype, and that these effects are more pronounced in aged tenocytes. Hypoxic (1% O2 ) culture of aged, tendinotic, and young human tenocytes resulted in a mineralized fibrochondrocyte phenotype in aged tenocytes, and a fibrochondrocyte phenotype in young and tendinotic tenocytes. Investigation of the molecular mechanism responsible for this phenotype change revealed that the fibrochondrocyte phenotype in aged tenocytes occurs with decreased Rac1 activity in response to hypoxia. In young hypoxic tenocytes, however, the fibrochondrocyte phenotype occurs with concomitant decreased Rac1 activity coupled with increased RhoA activity. Using pharmacologic and adenoviral manipulation, we confirmed that these hypoxic effects on the tenocyte phenotype are linked directly to the activity of RhoA/Rac1 GTPase in in vitro human cell culture and tendon explants. These results demonstrate that hypoxia drives tenocyte phenotypic changes, and provide a molecular insight into the development of human tendinosis that occurs with aging.

American Geriatrics Society/Association of Directors of Geriatric Academic Programs curricular milestones for graduating geriatric fellows.

This article describes the curricular milestones for geriatric fellows and the process used to develop them. The curricular milestones were developed to determine what every graduating geriatric fellow should be able to demonstrate to ensure that they will be able to practice effectively and safely in all care settings and with different older adult populations. Three major domains were identified: Caring for the Elderly Patient, Systems-Based Care for Elder Patients, and Geriatric Syndromes. Six hundred thirty-five geriatricians each reviewed and commented on one domain. These geriatricians represented important stakeholder groups: geriatric fellowship program directors; Association of Directors of Geriatric Academic Programs (ADGAP) members, who are primarily geriatric program and fellowship directors; the American Geriatrics Society (AGS) and ADGAP Education Committee; the AGS Teacher's Section; Geriatric Academic Career Award awardees; and through the American Board of Internal Medicine and the American Board of Family Medicine, board-certified geriatricians who spend more than 50% of their time in clinical practice. The AGS and ADGAP boards approved the final set of 76 Geriatric Curricular Milestones, which were posted on the Portal of Geriatric Online Education in December 2012. These curricular milestones are intended to assist geriatric fellowship directors as they develop curricula and assessments to inform program director reporting to the Accreditation Council for Graduate Medical Education in the Next Accreditation System, which begins in July 2014.

Elders' preferences for life-prolonging treatment and their proxies' substituted judgment: influence of the elders' current health.

OBJECTIVE: People in poor health tend to view life-prolonging treatments (e.g., tube feeding) as more acceptable than do healthier people. Do proxies' substituted judgments reveal a similar tendency, showing greater acceptance when the elder is in worse health? METHOD: In a cross-sectional telephone-based survey of 202 elderly individuals and their proxies, preferences for 4 life-prolonging treatments in 7 health prospects were examined in relation to the elder's current health status, operationalized as number of deficits in activities of daily living. RESULTS: Stronger preferences for life-prolonging treatments in worse-health prospects were expressed by both elders and proxies when the elders' current health was relatively poor. The interaction effect was at least as pronounced for proxies' substituted judgment as for elders' own preferences. DISCUSSION: Findings provide important insight into proxy decision making and have particular implications for proxy decision making on behalf of elders with dementia or other causes of decisional incapacity.

The reluctance to burden others as a value in end-of-life decision making: a source of inaccuracy in substituted judgment.

Most patients are decisionally incapacitated at the end of life, leaving final treatment decisions to proxies, whose substituted judgment is often inaccurate. We investigated the reluctance to burden others (RBO), a commonly cited patient value, as a possible source of proxy inaccuracy. In a sample of 202 elders and their proxies, elders responded to three burden-related questions and the Life-prolonging Treatment Preferences Questionnaire. Proxies used substituted judgment to respond to the same questions. Although RBO predicted treatment preferences for both elders and proxies, elders rated RBO significantly more important than did proxies. In addition, larger elder-proxy differences in RBO were associated with more inaccurate substituted judgment.

Knowledge, attitudes, and practice behaviors of oncology advanced practice nurses regarding advanced care planning for patients with cancer.

PURPOSE/OBJECTIVES: To establish initial reliability and validity of a Web-based survey focused on oncology advanced practice nurses' (APNs') knowledge, attitudes, and practice behaviors regarding advanced care planning, and to obtain preliminary understanding of APNs' knowledge, attitudes, and practice behaviors and perceived barriers to advanced care planning. DESIGN: Descriptive, cross-sectional, pilot survey study. SETTING: The eastern United States. SAMPLE: 300 oncology APNs. METHODS: Guided by the Theory of Planned Behavior, a knowledge, attitudes, and practice behaviors survey was developed and reviewed for content validity. The survey was distributed to 300 APNs via e-mail and sent again to the 89 APNs who responded to the initial survey. Exploratory factor analysis was used to examine the construct validity and test-retest reliability of the survey's attitudinal and practice behavior portions. MAIN RESEARCH VARIABLES: Respondents' demographics, knowledge, attitudes, practice behaviors, and perceived barriers to advanced care planning practice. FINDINGS: Exploratory factor analysis yielded a five-factor solution from the survey's attitudes and practice behavior portions with internal consistency using Cronbach alpha. Respondents achieved an average of 67% correct answers in the 12-item knowledge section and scored positively in attitudes toward advanced care planning. Their practice behavior scores were marginally positive. The most common reported barriers were from patients' and families' as well as physicians' reluctance to discuss advanced care planning. CONCLUSIONS: The attitudinal and practice behaviors portions of the survey demonstrated preliminary construct validity and test-retest reliability. Regarding advanced care planning, respondents were moderately knowledgeable, but their advanced care planning practice was not routine. IMPLICATIONS FOR NURSING: Validly assessing oncology APNs' knowledge, attitudes, and practice behaviors regarding advanced care planning will enable more tailored approaches to improve end-of-life care outcomes.

Ask a different question, get a different answer: why living wills are poor guides to care preferences at the end of life.

CONTEXT: Living wills have a poor record of directing care at the end of life, as a copious literature attests. Some speculation centers on the questionable correspondence between the scenario described in living wills versus the real-life circumstances that typically arise at the end of life. OBJECTIVE: To assess the strength of association between responses to a standard living will question and preferences for treatments in six end-of-life scenarios. DESIGN: Cross-sectional. SETTING: Telephone interviews. PARTICIPANTS: Two hundred two community-dwelling men and women 70 years of age or older in the greater Philadelphia area. MAIN OUTCOME MEASURES: Strength of preferences for four life-sustaining treatments in each of six poor-health scenarios. RESULTS: Associations between responses to the standard living will question and preferences for treatment (means across the four) in six specific scenarios were statistically significant but modest in size, accounting for 23% of variance at most. The association for the worse-case scenario (severe stroke with coma) was significantly stronger than for any other association. CONCLUSIONS: The modest correspondence between living will responses and wishes for life-sustaining treatment in specific scenarios helps to elucidate the living will's poor performance. Presentation of more realistic end-of-life scenarios should improve the living will's ability to guide care, as well as preparing patients and families better for the end of life.

Multidisciplinary family meetings in the ICU facilitate end-of-life decision making.

OBJECTIVE: The aim of this study was to assess the feasibility of establishing a multi-disciplinary family meeting (MDFM) program and the impact of such a program on the end-of-life decision making in the setting of an ICU. METHODS: During the study period MDFMs were scheduled for patients requiring mechanical ventilation for 5 or more days. The meeting followed a structured format. The pertinent details of the meeting as well as the treatment goals were recorded. RESULTS: Twenty-nine patients were enrolled in this study. Thirty-five MDFM's were held on 24 patients. A meeting could not be arranged for four patients. All meetings addressed patient's diagnosis, prognosis and goals of care. Fifteen (52%) patients (9 of whom had metastatic malignancy) had life support withdrawal and died a mean of 4.8 + 4.2 days after the first family meeting. In the remaining 9 patients (3 with localized cancer and 6 with non-cancer diagnoses), the plan following the family meeting was to continue supportive care; all of these patients survived to hospital discharge. CONCLUSIONS: Proactive MDFM's improve communication and understanding between patients' family and the treating team and facilitates end-of-life decision making.

Intracerebral hemorrhage for the palliative care provider: what you need to know.

Intracerebral hemorrhage (ICH) makes up 10%-30% of all strokes. Palliative care providers are often asked to get involved with ICH cases to aid with development of short-term and long-term goals. Prognosis can be calculated using the ICH score (based on Glasgow Coma Score score, ICH volume, presence of intraventricular hemorrhage, age, and location of origin) or the Essen score (based on age, NIH Stroke Scale [NIHSS], and level of consciousness). Do-not-resuscitate (DNR) status is important to discuss with families. Expert consensus states DNR is appropriate if the patient has two of the following: severe stroke, life-threatening brain damage, or significant comorbidities. The process of withdrawing ventilatory support can differ greatly from that of a medical intensive care unit (ICU) patient. Most ICH patients die within 24 hours following extubation. Symptoms of dyspnea and pain warrant use of opioids before and after terminal extubation. In addition, treating death rattle and postextubation stridor are important interventions. Family meetings are a vital intervention to help explain prognosis, establish a plan of care, and to get all family members on the same page. Family meetings can have a rapid effect, with 66% of families opting for withdrawal of life support to decide within 24 hours of such a meeting.

The state of advance care planning: one decade after SUPPORT.

The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) was a landmark study regarding end-of-life decision making and advance care planning. Phase I of the study looked at the state of end of life in various hospitals, and phase II implemented a nurse-facilitated intervention designed to improve advance care planning, patient-physician communication, and the dying process. The observational phase found poor quality of care at the end of life and the intervention failed to improve the targeted outcomes. The negative findings brought public attention to the need to improve care for the dying and spawned a wealth of additional research on decision-making at the end of life. In the decade since SUPPORT, researchers have defined the attributes of a "good death," addressed the role of advance directives in advance care planning, and studied the use of surrogate decision-making at the end of life. This rekindled the discussion on advance care planning and challenged health care providers to design more flexible approaches to end of life care.

Self-injurious behavior in the elderly.

OBJECTIVE: To review the literature for self-injurious behavior (SIB) in the elderly and compare it with SIB in other populations. DATA SOURCES: Literature searches were conducted using MEDLINE/PubMed, Merck-Medicus, clinicaltrials.gov, OVID, and an Internet search for "self-injurious behavior, SIB, and self-mutilation." STUDY SELECTION: Sixteen studies were reviewed. Studies used provided data relative to SIB in general or treatment for the geriatric population. DATA SYNTHESIS: The data suggest that young children, adolescents, young adults, and developmentally disabled patients most commonly exhibit self-injurious behaviors. The elderly population, in particular those with certain psychiatric and neurodegenerative illnesses, also can exhibit these behaviors. There has been little published for this cohort in comparison with other populations. The authors reviewed the literature for papers on SIB and its management in the elderly. A general overview of SIB is provided, including specific factors for the elderly. Management strategies including pharmacological and behavioral interventions are also discussed. CONCLUSION: Although the prevalence of SIB appears to be relatively small, patients who do exhibit this behavior are of great concern to their families and caregivers. Risk factors such as dementia, depressive disorders, physical illness, and loss of a spouse, which are commonplace in the elderly, all may contribute to those who do exhibit SIB. The literature is devoid of specific drug therapies or treatments that demonstrate significant efficacy in patients with SIB, particularly the elderly. Additionally, while there is some understanding of why younger people engage in SIB, it is hypothesized that elderly SIB is different and is related to frustration, as well as to deficits in the ability to communicate effectively with others. Recognition of behavioral triggers, behavioral-care planning, and safety management are key.