The Lived Experience of Already-Lonely Older Adults During COVID-19.

BACKGROUND AND OBJECTIVES: From the outset of the coronavirus disease 2019 (COVID-19) pandemic, analysts warned that older populations, due to their age, chronic illnesses, and lack of technological facility, would suffer disproportionately from loneliness as they sheltered in place indefinitely. Several studies have recently been published on the impact of COVID-19-related loneliness among older populations, but little has been written about the experiences of already-lonely older individuals; those who had lived with persistent loneliness before the advent of COVID-19. This qualitative study sought to understand how already-lonely older individuals navigated and endured the social isolation of the pandemic. RESEARCH DESIGN AND METHODS: Twelve semistructured interviews were conducted with individuals aged 65 or older who scored a 6 or above on the 3-item UCLA Loneliness Risk screening tool. Interviews were coded using the constant comparative method. Themes and understandings of loneliness that reoccurred within and across interviews were identified and collected. RESULTS: Already-isolated older interviewees did not necessarily experience the abject loneliness hypothesized by analysts. Most interviewees used longstanding arrangements, in place to mitigate loneliness and endure social isolation, to manage the social deprivation of COVID-19. As a result, their loneliness did not compound during long bouts of mandated social isolation. To the contrary, loneliness during the pandemic appeared to carry a new valence for interviewees, as COVID-19 imbued their isolation with new meaning, rendering their loneliness necessary and responsible. DISCUSSION AND IMPLICATIONS: Exploring individuals' subjective perceptions of loneliness can help provide a deeper understanding of what it means to be isolated and alone during COVID-19 and aid in designing strategies to mitigate loneliness.

Low-intensity frequent fires in coniferous forests transform soil organic matter in ways that may offset ecosystem carbon losses.

The impact of shifting disturbance regimes on soil carbon (C) storage is a key uncertainty in global change research. Wildfires in coniferous forests are becoming more frequent in many regions, potentially causing large C emissions. Repeated low-intensity prescribed fires can mitigate wildfire severity, but repeated combustion may decrease soil C unless compensatory responses stabilize soil organic matter. Here, we tested how 30 years of decadal prescribed burning affected C and nitrogen (N) in plants, detritus, and soils in coniferous forests in the Sierra Nevada mountains, USA. Tree basal area and litter stocks were resilient to fire, but fire reduced forest floor C by 77% (-36.4 Mg C/ha). In mineral soils, fire reduced C that was free from minerals by 41% (-4.4 Mg C/ha) but not C associated with minerals, and only in depths ≤ 5 cm. Fire also transformed the properties of remaining mineral soil organic matter by increasing the proportion of C in a pyrogenic form (from 3.2% to 7.5%) and associated with minerals (from 46% to 58%), suggesting the remaining soil C is more resistant to decomposition. Laboratory assays illustrated that fire reduced microbial CO2 respiration rates by 55% and the activity of eight extracellular enzymes that degrade cellulosic and aromatic compounds by 40-66%. Lower decomposition was correlated with lower inorganic N (-49%), especially ammonium, suggesting N availability is coupled with decomposition. The relative increase in forms of soil organic matter that are resistant to decay or stabilized onto mineral surfaces, and the associated decline in decomposition suggest that low-intensity fires may promote mineral soil C storage in pools with long mean residence times in coniferous forests.

Decadal changes in fire frequencies shift tree communities and functional traits.

Global change has resulted in chronic shifts in fire regimes. Variability in the sensitivity of tree communities to multi-decadal changes in fire regimes is critical to anticipating shifts in ecosystem structure and function, yet remains poorly understood. Here, we address the overall effects of fire on tree communities and the factors controlling their sensitivity in 29 sites that experienced multi-decadal alterations in fire frequencies in savanna and forest ecosystems across tropical and temperate regions. Fire had a strong overall effect on tree communities, with an average fire frequency (one fire every three years) reducing stem density by 48% and basal area by 53% after 50 years, relative to unburned plots. The largest changes occurred in savanna ecosystems and in sites with strong wet seasons or strong dry seasons, pointing to fire characteristics and species composition as important. Analyses of functional traits highlighted the impact of fire-driven changes in soil nutrients because frequent burning favoured trees with low biomass nitrogen and phosphorus content, and with more efficient nitrogen acquisition through ectomycorrhizal symbioses. Taken together, the response of trees to altered fire frequencies depends both on climatic and vegetation determinants of fire behaviour and tree growth, and the coupling between fire-driven nutrient losses and plant traits.

Development of a Content Valid and Reliable Prehospital Environmental Falls Risk Assessment Tool for Older Adults.

Introduction: The aging population reintroduces the need to establish early identification of falls risk as a means of primary and secondary prevention of falls. While there are several existing tools to assess environmental risk factors developed for consumers or home health providers, assessment of environmental falls risk by emergency medical services (EMS) providers represents a novel approach to primary and secondary prevention. The purpose of this study was to evaluate a content valid and reliable assessment of environmental fall risk to be performed in the prehospital setting. Methods: This was a mixed methods study, conducted from August, 2015 to September, 2017 in Mecklenburg County, NC, utilizing qualitative methodology to develop content valid items for an environmental falls risk assessment and quantitative methodology to assess those items for interrater reliability. Content validity was assessed using 2 expert panels. Expert Panel One was tasked with assessing validity of a construct to indicate an increased risk of an in-home fall for elderly individuals and expert Panel Two was responsible for assessing the likelihood of an EMS professional to identify a construct during their course of patient care. To assess reliability of the identified content valid items, 5 paramedics were recruited for interrater reliability (IRR) testing of the validated falls risk assessment tool. Each paramedic and their partner received education on documentation and deployment of the tool. Crews independently documented presence or absence of each item with pair agreement assessed using Cohen's kappa (κ). Results: A total of 87 items were identified for assessment through review of validated scales and relevant literature, with the content validation process reducing to 9 the number of items tested in the field for reliability. A total of 57 paired assessments were completed and included in analysis. One item returned almost perfect agreement (κ = 0.87), 5 items returned moderate agreement (κ = 0.41-0.54), with the remaining 3 items illustrating fair agreement (κ = 0.33-0.39). Conclusion: We developed a construct valid and reliable assessment of environmental falls risk to be performed in the prehospital setting. Further trials should be conducted using this tool to determine appropriate cut scores and deployment in the prehospital setting to help with primary and secondary fall prevention.

Results From a Survey of American Geriatrics Society Members' Views on Physician-Assisted Suicide.

BACKGROUND: Physician-assisted suicide (PAS) is a controversial practice, currently legal in nine states and the District of Columbia. No prior study explores the views of the American Geriatrics Society (AGS) membership on PAS. DESIGN: We surveyed 1488 randomly selected AGS members via email. PARTICIPANTS: A total of 369 AGS members completed the survey (24.8% response rate). ANALYSIS: We conducted bivariate correlation analyses of beliefs related to support for PAS. We also conducted qualitative analysis of open-ended responses. RESULTS: There was no consensus regarding the acceptability of PAS, with 47% supporting and 52% opposing this practice. PAS being legal in the respondent's state, belief that respect for autonomy alone is sufficient to justify PAS, and intent to prescribe or support requests for PAS if legal in state of practice all correlated with support for PAS. There was no consensus on whether the AGS should oppose, support, or adopt a neutral stance on PAS. Most respondents believed that PAS is more complex among patients with low health literacy, low English proficiency, disability, dependency, or frailty. Most respondents supported mandatory palliative care consultation and independent assessments from two physicians. Themes identified from qualitative analysis include role of the medical profession, uncertainty of the role of professional organizations, potential unintended consequences, autonomy, and ethical and moral considerations. CONCLUSION: There was no consensus among respondents regarding the acceptability of PAS. Respondents expressed concern about vulnerable older populations and the need for safeguards when responding to requests for PAS. Ethical, legal, and policy discussions regarding PAS should consider vulnerable populations. J Am Geriatr Soc 68:23-30, 2019.

Fundamental study of the ultrasonic induced degradation of the popular antihistamine, diphenhydramine (DPH).

Diphenhydramine (DPH) the active ingredient in Benadryl, has been detected in streams, rivers and other surface water sources. As a bioactive compound, DPH impacts human health even at low concentrations. Ultrasonic irradiation at 640 kHz leads to the rapid degradation of DPH in aqueous solution. Radical scavenging experiments and detailed product studies indicate the DPH degradation involves direct pyrolysis and degradation reactions mediated by the hydroxyl radicals produced during cavitation. The degradation can be modeled by pseudo-first order kinetics yielding rate constants k of 0.210, 0.130, 0.082, 0.050, 0.035, 0.023 min-1 at the initial concentrations of 2.8, 5.2, 13.9, 27.0, 61.0, 160.0 µmol L-1, respectively. The degradation process follows the Langmuir-Hinshelwood (heterogeneous) model with a partition coefficient, KL-H = 0.06 µmol·L-1and reactivity constant kr = 1.96 µmol min-1·L-1. A competition kinetic study conducted employing the hydroxyl radical trap, coumarin, illustrates that DPH was degraded primarily by hydroxyl radical mediated processes. Computational studies employing Gaussian 09 basis set provide fundamental insight into the partitioning of the reaction pathways and the degradation mechanisms. The study demonstrates the ultrasonic degradation of DPH is rapid, follows simple kinetic expressions and is accurately modeled using computational methods.

Chronic pain: challenges and opportunities for relieving suffering.

This issue of the NCMJ addresses the problem of chronic pain in North Carolina; its diagnosis and management in primary and specialty care; and the need to balance efficacy and safety when prescribing opioid medications, as these drugs are associated with significant potential for misuse and abuse. The commentaries in this issue not only address the use of opioids for the management of chronic pain but also explore various alternatives, including medical marijuana, epidural and other injections, surgery, acupuncture, and other integrative therapies. Articles in this issue also describe the management of chronic pain in palliative care, the ways in which mental health affects pain, and the unintended consequences of chronic pain management. Finally, this issue describes several initiatives across the state that are addressing the epidemic of prescription drug abuse; these initiatives are effecting systematic changes in clinical practice to more effectively manage chronic pain, protect patients, and minimize the negative impact of prescription drug abuse on communities.

Analgesic medication errors in North Carolina nursing homes.

The objective of this study was to characterize analgesic medication errors and to evaluate their association with patient harm. The authors conducted a cross-sectional analysis of individual medication error incidents reported by North Carolina nursing homes to the Medication Error Quality Initiative (MEQI) during fiscal years 2010-2011. Bivariate associations between analgesic medication errors with patient factors, error-related factors, and impact on patients were tested with chi-square tests. A multivariate logistic regression model explored the relationship between type of analgesic medication errors and patient harm, controlling for patient- and error-related factors. A total of 32,176 individual medication error incidents were reported over a 2-year period in North Carolina nursing homes, 12.3% (n = 3949) of which were analgesic medication errors. Of these analgesic medication errors, opioid and nonopioid analgesics were involved in 3105 and 844 errors, respectively. Opioid errors were more likely to be wrong drug errors, wrong dose errors, and administration errors compared with nonopioid errors (P < .0001 for all comparisons). In the multivariate model, opioid errors were found to have higher odds of patient harm compared with nonopioid errors (odds ratio [OR] = 3, 95% confodence interval [CI]: 1.1-7.8). The authors conclude that opioid analgesics represent the majority of analgesic error reports, and these error reports reflect an increased likelihood of patient harm compared with nonopioid analgesics.

Impact of a decision aid on surrogate decision-makers' perceptions of feeding options for patients with dementia.

OBJECTIVES: In advanced dementia, feeding problems are nearly universal, and families face difficult decisions about feeding options. Initial interviews for a randomized trial were used to describe surrogates' perceptions of feeding options, and to determine whether a decision aid on feeding options in advanced dementia would improve knowledge, reduce expectation of benefit from tube feeding, and reduce conflict over treatment choices for persons with advanced dementia. DESIGN: Semistructured interview with prestudy and poststudy design for surrogates in the intervention group. SETTING: Twenty-four skilled nursing facilities across North Carolina participating in a cluster randomized trial. PARTICIPANTS: Two hundred and fifty-five surrogate decision makers for nursing home residents with advanced dementia and feeding problems, in control (n = 129) and intervention (n = 126) groups. INTERVENTION: For intervention surrogates only, an audiovisual-print decision aid provided information on dementia, feeding problems in dementia, advantages and disadvantages of feeding tubes or assisted oral feeding options, and the role of surrogates in making these decisions. MEASUREMENTS: The interview included open-ended items asking surrogates to report advantages and disadvantages of tube feeding and assisted oral feeding. Knowledge of feeding options was measured with 19 true/false items and items measuring expectation of benefit from tube feeding. Surrogates reported which of these two feeding options they preferred for the person with dementia, and how confident they were in this choice; their level of conflict about the choice was measured using the decisional conflict scale. RESULTS: Before the decision aid, surrogates described advantages and disadvantages of assisted oral feeding and tube feeding in practical, ethical, and medical terms. After review of the decision aid, intervention surrogates had improved knowledge scores (15.5 vs 16.8; P < .001), decreased expectation of benefits from tube feeding (2.73 vs 2.32; P = .001), and reduced decisional conflict (2.24 vs 1.91; P < .001). Surrogates preferred assisted oral feeding initially and reported more certainty about this choice after the decision aid. CONCLUSIONS: A structured decision aid can be used to improve decision making about feeding options in dementia care.

Exploratory evaluation of medication classes most commonly involved in nursing home errors.

BACKGROUND: Medication errors may potentially pose significant risk of harmful outcomes in vulnerable nursing home residents. Current literature lacks data regarding the drug classes most frequently involved in errors in this population and their risk relative to underlying drug class utilization rates. OBJECTIVES: This study (1) describes the frequency and error characteristics for the drug classes most commonly involved in medication errors in nursing homes, and (2) examines the correlation between drug class utilization rates and their involvement in medication errors in nursing home residents. DESIGN: A cross-sectional analysis of individual medication error incidents reported by North Carolina nursing homes to the Medication Error Quality Initiative during fiscal years 2010 to 2011 was conducted. PARTICIPANTS: All nursing home residents in the state of North Carolina. MAIN MEASURES: The 10 drug classes most frequently involved in medication errors were identified. Characteristics and patient impact of these medication errors were further examined as frequencies and proportions within each drug class. Medication error data were combined with data from the 2004 National Nursing Home Survey to capture nationally representative estimates of medication use by drug class in nursing home patients. The correlation between medication utilization and error involvement was assessed. RESULTS: There were 32,176 individual medication errors reported to Medication Error Quality Initiative in years 2010-2011. The 10 drug classes most commonly involved in medication errors were analgesics (12.27%), anxiolytics/sedative/hypnotics (8.39%), antidiabetic agents (5.86%), anticoagulants (5.04%), anticonvulsants (4.05%), antidepressants (4.05%), laxatives (3.13%), ophthalmic preparations (2.77%), antipsychotics (2.47%), and diuretics (2.34%). The correlation between utilization and medication error involvement was not statistically significant (P value for spearman correlation coefficient = .88), suggesting certain drug classes are more likely to be involved in medication errors in nursing home patients regardless of the extent of their use. CONCLUSIONS: The drug classes frequently and disproportionately involved in errors in nursing homes include anxiolytics/sedatives/hypnotics, antidiabetic agents, anticoagulants, anticonvulsants, and ophthalmic preparations. Better understanding of the causes and prevention strategies to reduce these errors may improve nursing home patient safety.

Multisite qualitative study of primary care physicians' and midlevel providers' self-reported practices and perceptions about maintaining cognitive health.

INTRODUCTION: To facilitate national efforts to maintain cognitive health through public health practice, the Healthy Brain Initiative recommended examining diverse groups to identify stakeholder perspectives on cognitive health. In response, the Healthy Aging Research Network (HAN), funded by the Centers for Disease Control and Prevention (CDC), coordinated projects to document the perspectives of older adults, caregivers of people with dementia, and primary care providers (PCPs) on maintaining cognitive health. Our objective was to describe PCPs' perceptions and practices regarding cognitive health. METHODS: HAN researchers conducted 10 focus groups and 3 interviews with physicians (N = 28) and advanced practice providers (N = 21) in Colorado, Texas, and North Carolina from June 2007 to November 2008. Data were transcribed and coded axially. RESULTS: PCPs reported addressing cognitive health with patients only indirectly in the context of physical health or in response to observed functional changes and patient or family requests. Some providers felt evidence on the efficacy of preventive strategies for cognitive health was insufficient, but many reported suggesting activities such as games and social interaction when queried by patients. PCPs identified barriers to talking with patients about cognitive health such as lack of time and patient reactions to recommendations. CONCLUSION: Communicating new evidence on cognitive health and engaging older adults in making lasting lifestyle changes recommended by PCPs and others may be practical ways in which public health practitioners can partner with PCPs to address cognitive health in health care settings.

Measuring palliative care quality for seriously ill hospitalized patients.

OBJECTIVE: Hospice and palliative care providers need ways to measure and improve care processes. We tested feasibility, usability, reliability, and validity of Prepare, Embrace, Attend, Communicate, Empower (PEACE) quality measures for palliative care. METHODS: Trained research nurses abstracted data from medical records to generate quality measures for a random sample of 460 seriously ill patients without, and 102 patients with, specialty palliative care (SPC) services. RESULTS: Patient age ranged from 16 to 99 years, 50% were women, and 24% were African American. Of 34 PEACE quality measures, 17 were feasible for hospital palliative care. Inter-rater reliability was high (κ>0.80) for all but two quality measures. Face validity was endorsed by clinical service leaders, and construct validity was established by higher scores for patients receiving SPC. Comprehensive palliative care assessment was completed for only 10% of seriously ill hospitalized patients, compared with 56% of patients with SPC (p<0.001). Patients with moderate or severe pain were more likely to have a clinical assessment with SPC (67% versus 42%, p=0.002). Patients with SPC more often received attention for their emotional and spiritual needs (64% versus 40%, p<0.001) and documentation of preferences for life-sustaining treatments (91% versus 59%, p>0.001). Usability was endorsed by service leaders, who initiated two practice improvement projects. CONCLUSION: PEACE quality measures are feasible and reliable, and may be useful to examine and improve the quality of palliative care for seriously ill hospitalized patients as well as for patients in hospice. Research is needed to test measures for actionability and responsiveness to intervention.

Health care professionals' perceptions and use of the medical orders for scope of treatment (MOST) form in North Carolina nursing homes.

OBJECTIVES: To characterize the self-reported practices and opinions of nursing home (NH) health care professionals using the North Carolina Medical Orders for Scope of Treatment (MOST) form, an adaptation of the Physician Orders for Life-Sustaining Treatment (POLST) paradigm. DESIGN: A cross-sectional survey and semistructured interviews. PARTICIPANTS AND SETTING: Six physicians, 3 nurse practitioners, and 2 social workers from 2 NHs in North Carolina. MEASUREMENTS: Survey items covered timing and appropriateness of form completion, review criteria, barriers, and concerns about using the form. Interviews clarified survey responses and elicited descriptions of how subjects explain the scope of medical interventions to patients/families. RESULTS: NH admission and routine care plan meetings were considered the most important times to complete the MOST form. Treatment options on the form were often introduced in the context of patient preferences for hospitalization; however, there were considerable differences in how health care professionals explained and interpreted the scope of medical interventions. Nearly all health care professionals (10/11) believed that the form improves communication between physicians and patients/families. Only 3 of 11 respondents were aware of all of the MOST form's review requirements. Time was the most commonly cited barrier to use of the form. Respondents were concerned about forms getting lost or not being honored outside of the NH. CONCLUSION: Health care professionals generally viewed the MOST form as a useful tool for communicating patient treatment preferences in the NH. However, they may need specific strategies for explaining and interpreting the scope of medical interventions section and for meeting the form's review requirements.

Improving decision-making for feeding options in advanced dementia: a randomized, controlled trial.

OBJECTIVES: To test whether a decision aid improves quality of decision-making about feeding options in advanced dementia. DESIGN: Cluster randomized controlled trial. SETTING: Twenty-four nursing homes in North Carolina. PARTICIPANTS: Residents with advanced dementia and feeding problems and their surrogates. INTERVENTION: Intervention surrogates received an audio or print decision aid on feeding options in advanced dementia. Controls received usual care. MEASUREMENTS: Primary outcome was the Decisional Conflict Scale (range: 1-5) measured at 3 months; other main outcomes were surrogate knowledge, frequency of communication with providers, and feeding treatment use. RESULTS: Two hundred fifty-six residents and surrogate decision-makers were recruited. Residents' average age was 85; 67% were Caucasian, and 79% were women. Surrogates' average age was 59; 67% were Caucasian, and 70% were residents' children. The intervention improved knowledge scores (16.8 vs 15.1, P < .001). After 3 months, intervention surrogates had lower Decisional Conflict Scale scores than controls (1.65 vs 1.90, P < .001) and more often discussed feeding options with a healthcare provider (46% vs 33%, P = .04). Residents in the intervention group were more likely to receive a dysphagia diet (89% vs 76%, P = .04) and showed a trend toward greater staff eating assistance (20% vs 10%, P = .08). Tube feeding was rare in both groups even after 9 months (1 intervention vs 3 control, P = .34). CONCLUSION: A decision aid about feeding options in advanced dementia reduced decisional conflict for surrogates and increased their knowledge and communication about feeding options with providers.

Enhanced sorption of PAHs in natural-fire-impacted sediments from Oriole Lake, California.

Surface sediment cores from Oriole Lake (CA) were analyzed for organic carbon (OC), black carbon (BC), and their δ(13)C isotope ratios. Sediments displayed high OC (20-25%) and increasing BC concentrations from ∼0.40% (in 1800 C.E.) to ∼0.60% dry weight (in 2000 C.E.). Petrographic analysis confirmed the presence of fire-derived carbonaceous particles/BC at ∼2% of total OC. Natural fires were the most likely cause of both elevated polycyclic aromatic hydrocarbon (PAH) concentrations and enhanced sorption in Oriole Lake sediments prior to 1850, consistent with their tree-ring-based fire history. In contrast to other PAHs, retene and perylene displayed decreasing concentrations during periods with natural fires, questioning their use as fire tracers. The occurrence of natural fires, however, did not result in elevated concentrations of black carbon or chars in the sediments. Only the 1912-2007 sediment layer contained anthropogenic particles, such as soot BC. In this layer, combining OC absorption with adsorption to soot BC (using a Freundlich coefficient n = 0.7) explained the observed sorption well. In the older layers, n needed to be 0.3 and 0.5 to explain the enhanced sorption to the sediments, indicating the importance of natural chars/inertinites in sorbing PAHs. For phenanthrene, values of n differed significantly between sorption to natural chars (0.1-0.4) and sorption to anthropogenic black carbon (>0.5), suggesting it could serve as an in situ probe of sorbents.

Medical staff organization in nursing homes: scale development and validation.

PURPOSE: To construct a multidimensional self-report scale to measure nursing home (NH) medical staff organization (NHMSO) dimensions and then pilot the scale using a national survey of medical directors to provide data on its psychometric properties. DESIGN AND METHODS: Instrument development process consisting of the proceedings from the Nursing Home Physician Workforce Conference and focus groups followed by cognitive interviews, which culminated in a survey of a random sample of American Medical Directors Association (AMDA) affiliated medical directors. Analyses were conducted on surveys matched to Online Survey Certification and Reporting (OSCAR) data from freestanding nonpediatric nursing homes. A total of 202 surveys were available for analysis and comprised the final sample. RESULTS: Dimensions were identified that measured the extent of medical staff organization in nursing homes and included staff composition, appointment process, commitment (physiciancohesion; leadership turnover/capability), departmentalization (physician supervision, autonomy and interdisciplinary involvement), documentation, and informal dynamics. The items developed to measure each dimension were reliable (Cronbach's alpha ranged from 0.81 to 0.65).Intercorrelations among the scale dimensions provided preliminary evidence of the construct validity of the scale. IMPLICATIONS: This report, for the first time ever, defines and validates NH medical staff organization dimensions, a critical first step in determining the relationship between physician practice and the quality of care delivered in the NH.