Adaptive Care Planning: A paradigm shift.

A key challenge of implementing advance care planning lies in the fact that decisions made in advance require patients and their family members to imagine what their clinical picture will look like rather than knowing or experiencing the clinical circumstances as they unfold. Even more important is the acknowledgment of the unpredictability of a given clinical course. This type of situation requires adaptiveness and flexibility in decision-making that frequently occurs in the moment(s) triggered by changes in health state(s). We describe an alternative frameshifting approach called "Adaptive Care Planning (AdaptCP)," which features an evolving communication between physicians and patients/families with ongoing incorporation of the patient's/family's perspective. This process continues iteratively until each decision can be reached in a way that is both harmonious with the patient's/family's perspective and is consistent with medical treatment options that are actionable for the healthcare team. We include a table of tools drawn from the literature that can help clinicians when implementing AdaptCP.

Fall Ascertainment and Development of a Risk Prediction Model Using Electronic Medical Records.

OBJECTIVES: To examine the use of electronic medical record (EMR) data to ascertain falls and develop a fall risk prediction model in an older population. DESIGN: Retrospective longitudinal study using 10 years of EMR data (2004-2014). A series of 3-year cohorts included members continuously enrolled for a minimum of 3 years, requiring 2 years pre-fall (no previous record of a fall) and a 1-year fall risk period. SETTING: Kaiser Permanente Hawaii, an ambulatory setting. PARTICIPANTS: A total of 57 678 adults, age 60 years and older. MEASUREMENTS: Initial EMR searches were guided by current literature and geriatricians to understand coding sources of falls as our outcome. Falls were captured by two coding sources: International Classification of Diseases, Ninth Revision (ICD-9) codes (E880-889) and/or a fall listed as a "primary reason for visit." A comprehensive list of EMR predictors of falls were included into prediction models enabling statistical subset selection from many variables and modeling by logistic regression. RESULTS: Although 72% of falls in the training data set were coded as "primary reason for visit," 22% of falls were coded as ICD-9 and 6% coded as both. About 80% were reported in face-to-face encounters (eg, emergency department). A total of 2164 individuals had a fall in the risk period. Using the 13 key predictors (age, comorbidities, female sex, other mental disorder, walking issues, Parkinson's disease, urinary incontinence, depression, polypharmacy, psychotropic and anticonvulsant medications, osteoarthritis, osteoporosis) identified through LASSO regression, the final model had a sensitivity of 67%, specificity of 69%, positive predictive value of 8%, negative predictive value of 98%, and area under the curve of .74. CONCLUSION: This study demonstrated how the EMR can be used to ascertain falls and develop a fall risk prediction model with moderate sensitivity/specificity. Concurrent work with clinical providers to enhance fall documentation will improve the ability of the EMR to capture falls and consequently may improve the model to predict fall risk.

Perceived social support and the risk of cardiovascular disease and all-cause mortality in the Women's Health Initiative Observational Study.

OBJECTIVE: Previous studies have shown social support to be inversely associated with cardiovascular disease (CVD) in men, whereas fewer studies have assessed the relationship in women. The purpose of this study was to evaluate the relationship between perceived social support and cardiovascular outcomes among postmenopausal women enrolled in the Women's Health Initiative Observational Study. METHODS: We examined the relationships between perceived social support and (1) incident coronary heart disease (CHD), (2) total CVD, and (3) all-cause mortality. Participants were Women's Health Initiative Observational Study women, ages 50 to 79 years, enrolled between 1993 and 1998 and followed for up to 10.8 years. Social support was ascertained at baseline via nine questions measuring the following functional support components: emotional/informational, tangible, positive social interaction, and affectionate support. RESULTS: Among women with prior CVD (n = 17,351) and no prior CVD (n = 73,421), unadjusted hazard ratios ranged from 0.83 to 0.93 per standard deviation increment of social support. Adjustment for potential confounders, such as smoking and physical activity levels, eliminated the statistical significance of the associations with CHD and CVD. However, for all-cause mortality and among women free of baseline CVD, the association was modest but remained statistically significant after this adjustment (hazard ratio = 0.95 [95% confidence interval, 0.91-0.98]). No statistically significant association was observed among women with a history of CVD. CONCLUSIONS: After controlling for potential confounding variables, higher perceived social support is not associated with incident CHD or CVD. However, among women free of CVD at baseline, perceived social support is associated with a slightly lower risk of all-cause mortality.

What's the Plan? Needing Assistance with Plan of Care Is Associated with In-Hospital Death for ICU Patients Referred for Palliative Care Consultation.

To inform earlier identification of intensive care unit (ICU) patients needing palliative care, we examined factors associated with in-hospital death among ICU patients (N=260) receiving palliative care consultations at a 542-bed tertiary care hospital (2005-2009). High pre-consultation length of stay (LOS, ≥7 days) (adjusted odds ratio (aOR)=5.0, 95% confidence interval (95% CI)=2.5-9.9, P<.01) and consultations for assistance with plan of care (aOR=11.6, 95% CI=5.6-23.9, P<.01) were independently associated with in-hospital death. Patients with both consultation for plan of care and high pre-consult LOS had the highest odds of in-hospital death (aOR=36.3, 95% CI=14.9-88.5, P<.001), followed by patients with consultation for plan of care and shorter pre-consult LOS (aOR=9.8, 95% CI=4.3-22.1, P<.001), and patients with long pre-consult LOS but no consultation for plan of care (aOR=4.7, 95% CI=1.8-12.4, P=.002). Our findings suggest that ICU patients who require assistance with plan of care need to be identified early to optimize end-of-life care and avoid in-hospital death.

The Impact of Multimorbidity and Coronary Disease Comorbidity on Physical Function in Women Aged 80 Years and Older: The Women's Health Initiative.

BACKGROUND: A better understanding of medically centered outcomes, such as physical function, for older women with multiple chronic conditions is a national public health priority. METHODS: The prevalence of multimorbidity (defined as having 2 chronic conditions from a list of 12) and comorbidity with coronary disease (CHD) were calculated for 33,386 women who were enrolled in the Women's Health Initiative since 1993-1998 and were ≥ 80 years old by mid-September 2012. Associations between multimorbidity and CHD comorbidity on RAND-36 physical function scores were estimated using linear regression models. RESULTS: The prevalence of multimorbidity in this sample was 59%. Women with 0-1 chronic condition had a mean physical function score of 74 (95% confidence interval [CI]: 73, 74). Relative decrements in physical function scores were -8 (95% CI: -8, -7), -13 (95% CI: -14, -12) and -19 (95% CI: -20, -18) in women with 2, 3, and ≥ 4 chronic conditions, respectively. Women with CHD in combination with hip fractures or cognitive impairment had the largest adjusted decreases in physical function scores compared to the scores for women with CHD only. The impact of select characteristics on physical function scores between multimorbid and non-multimorbid women were similar; however, overall mean physical functions scores were lower for women with multmorbidity. CONCLUSIONS: Multimorbidity profoundly impacted physical functioning in women aged more than 80 years. Modifiable risk factors, such as obesity and physical activity, were similar in older women regardless of multimorbidity status and provide targets for health interventions aimed at preventing loss of late-age physical functioning.

Correlates of Successful Aging in Racial and Ethnic Minority Women Age 80 Years and Older: Findings from the Women's Health Initiative.

BACKGROUND: Most research has focused on definitions and predictors of successful aging. However, racial/ethnic minorities are often under represented in this research. Given that the U.S. population is aging and becoming more racially diverse, we examined correlates of "successful aging," as defined by physical functioning and overall quality of life (QOL), among racial/ethnic minority women aged 80 years and older in the Women's Health Initiative. METHODS: Participants included 1,924 racial/ethnic minority women (African Americans, Asian/Pacific Islanders, Hispanic/Latinos, and American Indian/Alaskan Natives) 80 years of age and older who are enrolled in the Women's Health Initiative and have physical functioning data after turning 80 years of age. Analysis of covariance was used to examine between and within group differences in physical functioning and selfrated overall QOL for African Americans, Asian/Pacific Islanders, and Hispanic/Latinos. RESULTS: We found no significant differences in physical functioning between racial/ethnic minority groups in adjusted analyses. However, overall QOL was significantly different between racial/ethnic minority groups. Age, recreational physical activity, and overall selfrated health were independent correlates of physical functioning across racial/ethnic minority groups, whereas overall selfrated health was the only consistent correlate of overall QOL across the minority groups for the within minority group comparisons. CONCLUSIONS: Between racial/ethnic minority group differences in physical functioning are largely explained by demographic, psychosocial, behavioral, and health-related variables. We found statistically significant differences in selfrated overall QOL between racial/ethnic minority groups.

Global cognitive function before, surrounding, and after ischemic stroke: the role of risk and protective factors varies with time among ischemic stroke survivors.

An estimated 65% of individuals demonstrate multidomain cognitive impairment poststroke, although little is known about the varying role of cognitive risk and protective factors in preischemic, peri-ischemic, and postischemic stroke phases. Longitudinal changes in global cognitive function after ischemic stroke are not well characterized, especially in older adults over age 80. We examined global cognitive function trajectories in these three phases across a mean follow-up of 8.12 (2.30) years in 159 female stroke survivors aged 65-79 at baseline using linear mixed models with change points. In separate models controlling for demographic variables, we tested the interaction of baseline risk and protective factors with stroke phase on global cognitive function. None of the prestroke global cognitive function means or trajectories differed significantly. At the time of ischemic stroke, higher body mass index (BMI), the presence of hypertension (HTN), low optimism, and higher physical function were all associated with significantly greater mean decreases in global cognition (all p's <.0.0001), but were not significantly different from the contrasting level (all p's >0.05). Higher BMI, the presence of HTN, low optimism, and higher physical function were in turn protective of global cognitive decline postischemic stroke (all contrasting p values <.01). Baseline factors may play either a risk or a protective role in global cognitive function depending on the phase of ischemic stroke.

Factors Associated with Nursing Home Admission after Stroke in Older Women.

BACKGROUND: We examined the social and economic factors associated with nursing home (NH) admission in older women, overall and poststroke. METHODS: The Women's Health Initiative (WHI) included women aged 50-79 years at enrollment (1993-1998). In the WHI Extension Study (2005-2010), participants annually reported any NH admission in the preceding year. Separate multivariate logistic regression models analyzed social and economic factors associated with long-term NH admission, defined as an admission on 2 or more questionnaires, overall and poststroke. RESULTS: Of 103,237 participants, 8904 (8.6%) reported NH admission (2005-2010); 534 of 2225 (24.0%) women with incident stroke reported poststroke NH admission. Decreased likelihoods of NH admission overall were demonstrated for Asian, Black, and Hispanic women (versus whites, adjusted odds ratio [aOR] = .35-.44, P < .001) and women with higher income (aOR = .75, 95% confidence interval [CI] = .63-.90), whereas increased likelihoods of NH admission overall were seen for women with lower social support (aOR = 1.34, 95% CI = 1.16-1.54) and with incident stroke (aOR = 2.59, 95% CI = 2.15-3.12). Increased odds of NH admission after stroke were demonstrated for women with moderate disability after stroke (aOR = 2.76, 95% CI = 1.73-4.42). Further adjustment for stroke severity eliminated the association found for race/ethnicity, income, and social support. CONCLUSIONS: The level of care needed after a disabling stroke may overwhelm social and economic structures in place that might otherwise enable avoidance of NH admission. We need to identify ways to provide care consistent with patients' preferences, even after a disabling stroke.

Malnutrition in the nursing home.

PURPOSE OF REVIEW: Malnutrition in the nursing home is increasingly recognized as a major international research priority, given the expanding geriatric populations, serious consequences, and challenges conducting research in nursing homes. This review examines the recent literature and suggests implications for research and practice. RECENT FINDINGS: Across the recent studies, approximately 20% of nursing home residents had some form of malnutrition. However, malnutrition definitions were variable and prevalence ranged from 1.5 to 66.5%. Depression, cognitive impairment, functional impairment, and swallowing difficulty were consistently associated with malnutrition. Mortality was the major consequence of malnutrition among nursing home residents, whereas higher BMIs had lower risks of mortality. Beneficial interventions to reduce malnutrition in the nursing home included dietary supplements, greater resident role in food choice, and staff training programs. SUMMARY: To truly tackle the issue of malnutrition in the nursing home setting, a consistent definition is needed. We strongly recommend that an expert consensus panel identify a standard set of measures to more accurately compare the prevalence across countries. Given the mortality consequences of malnutrition and the paucity of intervention studies, research on interventions for malnutrition in the nursing home needs to be a higher priority for facilities, researchers, and funding agencies.

Factors associated with in-hospital death by site of consultation among elderly inpatients receiving pain and palliative care consultations.

BACKGROUND: Despite palliative care implementation, most deaths still occur in hospitals. OBJECTIVES: To identify factors associated with in-hospital death among elderly patients receiving palliative care, by site of consultation. DESIGN: Prospective observational study. SETTING/SUBJECTS: All inpatients aged 65 years and older receiving pain and palliative care consultations in a 533-bed acute tertiary care hospital in Honolulu, Hawaii, from January 2005 through December 2009. MEASUREMENTS: During consultation, demographics, diagnoses, consultation site (intensive care unit [ICU], non-ICU medical, non-ICU surgical, and rehabilitation floors), consultation indication (assistance with establishing goals of care versus pain and/or symptom management), Karnofsky scores, length of stay (LOS), discharge disposition, and in-hospital death were collected. Multiple logistic regression analyses examined factors associated with in-hospital death. RESULTS: Of 1630 elderly inpatients receiving palliative care, 305 (19%) died in-hospital. In-hospital death among non-ICU medical patients was associated with needing consultation to assist with plan of care (odds ratio [OR]=1.89, 95% confidence interval [CI]=1.27-2.80). Likelihood of in-hospital death increased 2% for each additional hospital day before consultation (OR=1.02, 95% CI=1.01-1.03). Among elderly ICU patients, likelihood of in-hospital death increased 8% for each additional hospital day before consultation (OR=1.08, 95% CI=1.01-1.16). CONCLUSION: Among elderly non-ICU medical patients receiving palliative care consultations, the need for a consultation to assist with plan of care was associated with in-hospital death, while length of stay prior to consultation was important among both elderly ICU and non-ICU medical patients. Elderly hospitalized patients may benefit from earlier identification and palliative care consultation for assistance with plan of care to avoid in-hospital death.

Combining quality improvement and geriatrics training: the nursing home polypharmacy outcomes project.

To examine sustained effects of an educational intervention, the authors repeated a successful quality improvement (QI) project on medication safety and cost effectiveness. In October 2007 and August 2008, the facility leadership and geriatrics faculty identified all patients receiving nine or more medications (polypharmacy cohort) in a 170-bed teaching nursing home. They then taught Geriatric Medicine fellows (n = 12 in 2007, 11 in 2008) to (a) systematically collect medication data; (b) generate medication recommendations (stop, taper, or continue) based on expert criteria (Beers criteria) or drug-drug interaction programs; (c) discuss recommendations with patients' attending physicians; and (d) implement approved recommendations. Over the two projects, the polypharmacy cohorts demonstrated decreased potentially inappropriate medications (odds ratio [OR] = .78, 95% confidence interval [95% CI] [0.69, 0.88], p < .001), contraindicated medications (OR = .63, 95% CI [0.47, 0.85], p = .002) and medication costs (OR = .97, 95% CI [0.96, 0.99], p < .001). Findings suggest that programs planning educational QI projects for trainees may benefit from a multiyear approach to maximize clinical and educational benefits.

Late-life factors associated with healthy aging in older men.

OBJECTIVES: To identify potentially modifiable late-life biological, lifestyle, and sociodemographic factors associated with overall and healthy survival to age 85. DESIGN: Prospective longitudinal cohort study with 21 years of follow-up (1991-2012). SETTING: Hawaii Lifespan Study. PARTICIPANTS: American men of Japanese ancestry (mean age 75.7, range 71-82) without baseline major clinical morbidity and functional impairments (N = 1,292). MEASUREMENTS: Overall survival and healthy survival (free from six major chronic diseases and without physical or cognitive impairment) to age 85. Factors were measured at late-life baseline examinations (1991-1993). RESULTS: Of 1,292 participants, 1,000 (77%) survived to 85 (34% healthy) and 309 (24%) to 95 (<1% healthy). Late-life factors associated with survival and healthy survival included biological (body mass index, ankle-brachial index, cognitive score, blood pressure, inflammatory markers), lifestyle (smoking, alcohol use, physical activity), and sociodemographic factors (education, marital status). Cumulative late-life baseline risk factor models demonstrated that age-standardized (at 70) probability of survival to 95 ranged from 27% (no factors) to 7% (≥ 5 factors); probability of survival to 100 ranged from 4% (no factors) to 0.1% (≥ 5 factors). Age-standardized (at 70) probability of healthy survival to 90 ranged from 4% (no factors) to 0.01% (≥ 5 factors). There were nine healthy survivors at 95 and one healthy survivor at 100. CONCLUSION: Several potentially modifiable risk factors in men in late life (mean age 75.7) were associated with markedly greater probability of subsequent healthy survival and longevity.

Low dietary vitamin D in mid-life predicts total mortality in men with hypertension: the Honolulu heart program.

BACKGROUND: Vitamin D deficiency was associated with total mortality in previous epidemiological studies. Little is known about the effects of dietary vitamin D intake on mortality. We examined the association between mid-life dietary vitamin D intake and 45-year total mortality. METHODS: The Honolulu Heart Program is a longitudinal cohort study of 8006 Japanese American men in Hawaii aged 45 to 68 at baseline (1965-1968). Mid-life dietary vitamin D intake was calculated from 24-hour dietary recall using Nutritionist IV v3 software. We divided subjects into quartiles of dietary vitamin D. Total mortality data were available over 45 years through 2010. RESULTS: Age-adjusted total mortality rates were higher in the lower quartiles of dietary vitamin D intake compared to the highest (p for trend = 0.011). Using Cox regression, low dietary vitamin D was significantly associated with total mortality; quartile (Q) 1 hazard ratio (HR) = 1.14, 95% confidence interval (95% CI) = 1.07-1.22, p < 0.001; Q2 HR = 1.11, 95% CI = 1.04-1.18, p = 0.002; and Q3 HR = 1.08, 95% CI = 1.01-1.15, p = 0.027; Q4 = reference. After adjusting for age, kilocalories, cardiovascular risk factors, and prevalent chronic diseases, only Q2 remained significant (HR = 1.08, 95% CI = 1.00-1.15, p = 0.037). Among hypertensive subjects only, those in the lower 2 quartiles had higher total mortality; Q1 HR = 1.12, 95% CI = 1.01-1.25, p = 0.039, and Q2 HR = 1.13, 95% CI = 1.02-1.26, p = 0.025, compared to Q4. There was no significant relationship in subjects without hypertension. CONCLUSIONS: Low dietary vitamin D intake in mid-life was a weak predictor of total mortality over 45 years of follow-up. We found a significant association between low dietary vitamin D intake and higher total mortality only among hypertensive subjects. Vitamin D may have cardioprotective effects.

Proteinuria in midlife and 39-year total mortality: the Honolulu Heart Program.

BACKGROUND: Previous population-based studies have shown that proteinuria is an independent predictor of total mortality. However, no studies have examined multiple proteinuria measurements or had a follow-up period longer than two decades. METHODS: Proteinuria was measured by urine dipstick on 6,815 Japanese-American men on two occasions, 6 years apart. Participants were classified into the "no proteinuria" group if both examinations were negative, "transient proteinuria" if either was positive, and "persistent proteinuria" if both were positive and followed for total mortality over 39 years. RESULTS: Prevalence of transient and persistent proteinuria was 6.4% and 1.3%, respectively. Age-adjusted total mortality rates were 41.9, 55.0, and 71.9 per 1000 person-years follow-up for no, transient, and persistent proteinuria groups, respectively (p for trend <.0001). Multivariate Cox proportional hazards models showed increased total mortality risk in a dose-response manner: HR, 1.40; P < .001 and HR, 2.26; P < .001 for transient and persistent proteinuria groups, respectively (using no proteinuria as reference). Stratified analyses showed stronger associations between proteinuria and mortality among those with prevalent cardiovascular diseases compared with those without. CONCLUSIONS: Proteinuria was independently associated with higher total mortality risk over 39 years. This risk was stronger among high-risk populations but also remained significant in low-risk populations. Simple urine dipstick can be a good risk assessment tool in the general population.

Prestroke weight loss is associated with poststroke mortality among men in the Honolulu-Asia Aging Study.

OBJECTIVE: To examine baseline prestroke weight loss and poststroke mortality among men. DESIGN: Longitudinal study of late-life prestroke body mass index (BMI), weight loss, and BMI change (midlife to late life) with up to 8-year incident stroke and mortality follow-up. SETTING: Community-based aging study data. PARTICIPANTS: Japanese-American men (N=3581; age range, 71-93y) who were stroke free at baseline. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Poststroke mortality: 30 days poststroke, analyzed with stepwise multivariable logistic regression; and long-term poststroke (up to 8y), analyzed with stepwise multivariable Cox regression. RESULTS: Weight loss (4.5kg decrements) was associated with increased 30-day poststroke mortality (adjusted odds ratio=1.48; 95% confidence interval [CI], 1.14-1.92), long-term mortality after incident stroke (all types, n=225; adjusted hazards ratio (aHR)=1.25; 95% CI, 1.09-1.44), and long-term mortality after incident thromboembolic stroke (n=153; aHR=1.19; 95% CI, 1.01 to 1.40). Men with overweight/obese late-life BMI (≥25kg/m(2), compared with healthy/underweight BMI) had increased long-term mortality after incident hemorrhagic stroke (n=54; aHR=2.27; 95% CI, 1.07-4.82). Neither desirable nor excessive BMI reductions (vs no change/increased BMI) were associated with poststroke mortality. In the overall sample (N=3581), nutrition factors associated with increased long-term mortality included the following: (1) weight loss (10lb decrements; aHR=1.15; 95% CI, 1.09-1.21), (2) underweight BMI (vs healthy BMI; aHR=1.76; 95% CI, 1.40-2.20), and (3) both desirable and excessive BMI reductions (vs no change or gain, separate model from weight loss and BMI; aHR range, 1.36-1.97; P<.001). CONCLUSIONS: Although obesity is a risk factor for stroke incidence, prestroke weight loss was associated with increased poststroke (all types and thromboembolic) mortality. Overweight/obese late-life BMI was associated with increased posthemorrhagic stroke mortality. Desirable and excessive BMI reductions were not associated with poststroke mortality. Weight loss, underweight late-life BMI, and any BMI reduction were all associated with increased long-term mortality in the overall sample.

Obesity and late-age survival without major disease or disability in older women.

IMPORTANCE: The effect of obesity on late-age survival in women without disease or disability is unknown. OBJECTIVE: To investigate whether higher baseline body mass index and waist circumference affect women's survival to 85 years of age without major chronic disease (coronary disease, stroke, cancer, diabetes mellitus, or hip fracture) and mobility disability. DESIGN, SETTING, AND PARTICIPANTS: Examination of 36,611 women from the Women's Health Initiative observational study and clinical trial programs who could have reached 85 years or older if they survived to the last outcomes evaluation on September 17, 2012. Recruitment was from 40 US clinical centers from October 1993 through December 1998. Multinomial logistic regression models were used to estimate odds ratios and 95% CIs for the association of baseline body mass index and waist circumference with the outcomes, adjusting for demographic, behavioral, and health characteristics. MAIN OUTCOMES AND MEASURES: Mutually exclusive classifications: (1) survived without major chronic disease and without mobility disability (healthy); (2) survived with 1 or more major chronic disease at baseline but without new disease or disability (prevalent diseased); (3) survived and developed 1 or more major chronic disease but not disability during study follow-up (incident diseased); (4) survived and developed mobility disability with or without disease (disabled); and (5) did not survive (died). RESULTS: Mean (SD) baseline age was 72.4 (3.0) years (range, 66-81 years). The distribution of women classified as healthy, prevalent diseased, incident diseased, disabled, and died was 19.0%, 14.7%, 23.2%, 18.3%, and 24.8%, respectively. Compared with healthy-weight women, underweight and obese women were more likely to die before 85 years of age. Overweight and obese women had higher risks of incident disease and mobility disability. Disability risks were striking. Relative to healthy-weight women, adjusted odds ratios (95% CIs) of mobility disability were 1.6 (1.5-1.8) for overweight women and 3.2 (2.9-3.6), 6.6 (5.4-8.1), and 6.7 (4.8-9.2) for class I, II, and III obesity, respectively. Waist circumference greater than 88 cm was also associated with higher risk of earlier death, incident disease, and mobility disability. CONCLUSIONS AND RELEVANCE: Overall and abdominal obesity were important and potentially modifiable factors associated with dying or developing mobility disability and major chronic disease before 85 years of age in older women.

"You're being paged!" outcomes of a nursing home on-call role-playing and longitudinal curriculum.

Effectively handling telephone calls about nursing home (NH) residents is an important skill for healthcare professionals, but little formal training is typically provided. The objective of the current study was to describe and evaluate the effectiveness of a novel structured role-playing didactic session followed by an on-call NH longitudinal clinical experience. The effectiveness of the structured role-playing didactic session was compared in different learners, including geriatric medicine fellows (n = 10), family medicine residents and faculty (n = 14), nurse practitioner students (n = 31), and other learners (n = 7). The curriculum focused on common problems encountered while caring for NH residents during on-call periods. Learners rated themselves using an 18-item pre/post questionnaire including five attitude and 13 skills questions, using a 1-to-5 Likert scale. T-tests were used to compare means before and after sessions. Significant improvements were found in overall mean attitudes and skills scores. For all learners, the greatest improvements were seen in "comfort in managing residents at the NH," "managing feeding or gastrostomy tube dislodgement," "identifying different availability of medications, laboratory studies, and procedures in NH," and "describing steps to send NH residents to the emergency department." Geriatric medicine fellows' attitudes and skills improved significantly after the longitudinal clinical experience. The faculty survey demonstrated improved documentation, communication, and fellows' management of on-call problems after curriculum implementation. This novel curriculum used role-playing to provide training for on-call management of NH residents. This curriculum has been successfully disseminated on a national geriatrics educational resource website (POGOe) and is applicable to geriatric medicine fellowships, internal medicine and family medicine residency programs, and other training programs.

Prestroke factors associated with poststroke mortality and recovery in older women in the Women's Health Initiative.

OBJECTIVES: To examine prestroke lifestyle factors associated with poststroke mortality and recovery in older women. DESIGN: Longitudinal prospective cohort study. SETTING: The Women's Health Initiative (WHI, clinical trials and observational study), 40 clinical centers in the United States. PARTICIPANTS: WHI participants, women aged 50 to 79, who were stroke-free at baseline (1993/98), with incident stroke before 2005. MEASUREMENTS: Participants were followed for mortality through 2010. Prestroke characteristics were from the last examination before the stroke event. Annual follow-up for clinical events ascertained hospitalization for stroke that was subsequently physician adjudicated with medical records. Multivariable regression models were used to analyze factors associated with poststroke mortality and poststroke recovery at hospital discharge (poststroke Glasgow score), adjusting for stroke type. RESULTS: Of 3,173 women with incident stroke, 1,111 (35%) died. Individuals who were overweight or obese before stroke had lower poststroke mortality than those who were normal weight (obese: hazard ratio (HR) = 0.69, 95% confidence interval (CI) = 0.53-0.88; overweight: HR = 0.72, 95% CI = 0.58-0.90); individuals who were underweight before stroke had nonsignificantly greater poststroke mortality (HR = 2.02, 95% CI = 0.98-4.16, P = .06). Other prestroke factors associated with poststroke mortality included diabetes mellitus (HR = 1.28, 95% CI = 1.01-1.64), current smoking (vs nonsmoker, HR = 2.13, 95% CI = 1.53-3.00), physical inactivity (vs >150 min of exercise per week, HR = 1.39, 95% CI = 1.09-1.78), and lowest physical function quartile (vs highest, HR = 1.54, 95% CI = 1.18-2.02). Prestroke diabetes mellitus was associated with lower odds of good recovery after stroke (odds ratio (OR) = 0.60, 95% CI = 0.44-0.82). Current hormone use before stroke was associated with greater odds of moderate than of severe disability after stroke (OR = 1.29, 95% CI = 1.00-1.66). CONCLUSION: Potentially modifiable factors before stroke, including smoking, diabetes mellitus, and being underweight, were associated with greater poststroke mortality in older women. Being overweight or obese and physical activity before stroke were associated with lower poststroke mortality in older women.

Aging and caregiving in the Republic of Palau.

Aging has been an important population trend of the twentieth century, with most elderly people living in developing countries. Little has been published on the healthcare needs of elderly in the Pacific Islands. The Pacific Islands Geriatric Education Center, at the University of Hawaii, has a mission to promote training in geriatric education in the Pacific Islands to improve healthcare to the elderly. The aim of this project was to develop and test a family caregiver training program for Palau and was achieved in two phases: (1) assessing needs by interviewing key informants and surveying elders and (2) evaluating the caregiver training program that was designed based on findings from the assessment. The Ecological Systems Theory provided the theoretical framework for this study. The needs assessment identified training and education of family caregivers as a top priority, with the Palauan culture of family caring for seniors presently threatened by caregiver burnout. Nearly all of the long-term care in Palau is provided by families, and elders have high prevalence of geriatric syndromes. A family caregiver train-the-trainer workshop was subsequently conducted in February 2011. Forty-four trainers, including 12 from other Pacific Islands, attended the workshop. To assess changes in knowledge and confidence to teach, we compared scores on pre- and post-questionnaires using paired t tests. The train-the-trainer workshop resulted in significantly improved self-assessed competence and confidence to teach in all geriatric syndromes, including dealing with difficult behaviors, gait and transfer training, caregiver stress relief, and resources for caregivers (p < 0.0001). This successful intervention identified geriatric care needs in Palau and successfully trained family caregivers to meet these needs, and may be used as a model for similar interventions in other Pacific Islands.