"If You Don't Know, All of a Sudden, They're Gone": Caregiver Perspectives About Prognostic Communication for Disabled Elderly Adults.

OBJECTIVES: To describe preferences and experiences of caregivers of disabled older adults regarding being included in patient-clinician discussions about life expectancy. DESIGN: Qualitative interview study. SETTING: Caregivers were recruited from a Program of All-Inclusive Care for the Elderly (PACE), caregiver support groups and an advertisement on a nationwide caregiver advocacy group website. PARTICIPANTS: Active and bereaved caregivers whose primary language was either English or Cantonese who had provided care within the last 5 years to a disabled adult aged 65 and older (N = 42, 79% female, 60% white, average age 54). MEASUREMENTS: Semistructured telephone interviews were conducted with caregivers who were asked about experiences and preferences related to clinician communication about life expectancy, including preferences for and attitudes toward being included in discussions about life expectancy, how such information should be delivered, and how clinicians should address concerns about uncertainty and hope. Responses were analyzed qualitatively using constant comparison until thematic saturation was reached. RESULTS: Twenty-six percent of caregivers had been involved in a conversation with a clinician about life expectancy, even though 79% expressed a preference to have such a discussion. According to caregivers, clinician concerns about taking away hope or the uncertainty of prognostic information should not deter them from bringing up the topic of life expectancy. Thematic analysis suggested several approaches that may facilitate prognosis communication: establishing a relationship with the caregiver and care recipient; delivering the prognosis in clear, plain language; and responding to emotion with empathy. CONCLUSION: Caregivers reported a preference for being included in conversations about a care recipient's life expectancy.

"Everyone else gets ice cream here more often than I do--It burns me up"--Perspectives on Diabetes Care from Nursing Home Residents and their Doctors.

BACKGROUND: To explore the perspectives of nursing home (NH) residents with diabetes and their doctors regarding the burdens of living with diabetes and diabetes treatments. METHODS: Qualitative study of nursing home residents aged 65 and older with diabetes (n = 14) and nursing home physicians (n = 9) at a Department of Veterans Affairs nursing home (known as the Community Living Center). A semi-structured interview was used to elicit nursing home residents' and physicians' perspectives on the burden of diabetes and diabetes treatments. Transcripts were analyzed using constant comparative methods. RESULTS: The mean age of the nursing home residents was 74; Most (93%) were male and 50% self-identified themselves as white. The mean age of nursing home physicians was 39 and 55% were geriatricians. Dietary restrictions, loss of independence and fingersticks/insulin were noted to be the most burdensome aspects of diabetes. Nursing home residents with a more positive outlook were generally more engaged in their care, while nursing home residents with a more pessimistic outlook were less engaged, allowing their physicians to assume complete control of their care. While physicians noted the potential negative impact of dietary restrictions, nursing home residents' comments suggest that physicians underestimate the burden of dietary restrictions. CONCLUSIONS: Veterans Affairs nursing home residents were substantially burdened by their diabetes treatments, especially dietary restrictions and fingerstick monitoring. Since there is little evidence that dietary restrictions improve outcomes, fewer dietary restrictions may be appropriate and lead to lower treatment burdens for nursing home residents with diabetes.

Changing Patterns of Glucose-Lowering Medication Use in VA Nursing Home Residents With Diabetes, 2005 to 2011.

OBJECTIVE: Although nursing home (NH) residents make up a large and growing proportion of Americans with diabetes mellitus, little is known about how glucose-lowering medications are used in this population. We sought to examine glucose-lowering medication use in Veterans Affairs (VA) NH residents with diabetes between 2005 and 2011. RESEARCH DESIGN AND METHODS: Retrospective cohort study, using linked laboratory, pharmacy, administrative, and NH Minimum Dataset (MDS) 2.0 databases in 123 VA NHs. A total of 9431 long-stay (>90 days) VA NH residents older than 65 followed for 52,313 person-quarters. We identified receipt of glucose-lowering medications, including insulin, metformin, sulfonylureas, thiazolidinediones, and others (alpha-glucosidase inhibitors, meglitinides, glucagonlike peptide-1 analogs, dipeptidyl peptidase-4 inhibitors and amylin analogs) per quarter. RESULTS: The rates of sulfonylurea use in long-stay NH residents dropped dramatically from 24% in 2005 to 12% in 2011 (P < .001), driven in large part by the dramatic decrease in glyburide use (10% to 2%, P < .001). There was sharp drop in thiazolidinedione use in 2007 (4% to <1%, P < .001). Metformin use was stable, ranging between 7% and 9% (P = .24). Insulin use increased slightly from 30% to 32% (P < .001). Use of other classes of glucose-lowering medications was stable (P = .22) and low, remaining below 1.3%. CONCLUSIONS AND RELEVANCE: Between 2005 and 2011, there were dramatic declines in use of sulfonylureas and thiazolidinediones in VA NH residents, suggesting that prescribing practices can be quickly changed in this setting.