'They never talked to me about... ': Perspectives on aged care resident transfer to emergency departments.

AIMS: To explore perspectives of three groups concerning transfers from aged care facilities to emergency departments. We sought to reveal factors influencing transfer decisions; how active each group was in making decisions; and to what extent groups ceded decision-making to others. METHODS: Semi-structured interviews of 11 residents, 14 relatives and 17 staff with content analysis of interview transcripts. RESULTS: The three groups substantially differed in their involvement with initiating, and attitudes towards, transfer. Residents were least likely to be involved in the decision, yet most likely to support transfer. Staff felt conflicted between their desire to provide optimal treatment for one ill resident, and their obligations to other residents under care. Staff perspectives were largely consistent with published data, but we describe new results for other informant groups. CONCLUSIONS: Group expectations and preferences differ substantially. Service delivery to meet all preferences presents a challenge for health service design.

Dementia Knowledge Assessment Tool Version Two: development of a tool to inform preparation for care planning and delivery in families and care staff.

Care for the person with dementia requires understanding of the person's perspective and preferences, integrated with knowledge of dementia's trajectory and appropriate care. Version One of the Dementia Knowledge Assessment Tool addressed such knowledge in care workers; Version Two is for families as well as staff. Content validity was established during development. Revisions addressed clarity, time for completion, and reliability. When 671 staff completed Version One before an education intervention, internal consistency reliability estimates exceeded 0.70. Validity was supported by higher scores in professional versus nonprofessional staff and following the education. Version Two was used with 34 family carers and 70 staff members. Internal consistency reliability (Cronbach's alpha coefficient) was promising (0.79, both groups). Completion was within 15 minutes. Median correct responses (from 21) were 14 for families (range 4-20) and 16 for the staff (range 3-21). Eighteen staff members (26%) and two family carers (6%) reported substantive dementia education. Inclusion of the person with dementia in care planning is often limited because of a late diagnosis and the progressive impacts of the condition. Establishing a shared staff-family understanding of the dementia trajectory and care strategies likely to be helpful is therefore critical to embarking upon the development and implementation of collaborative long term and end-of-life care plans. Version Two can help establish needs for, and outcomes of, education programs and informational resources in a way that is feasible, minimises burden, and facilitates comparisons across family and staff carer groups.

Multimorbidity in patients attending 2 Australian primary care practices.

PURPOSE: Multiple chronic conditions in a single patient can be a challenging health burden. We aimed to examine patterns and prevalence of multimorbidity among patients attending 2 large Australian primary care practices and to estimate disease severity burden using the Cumulative Illness Rating Scale (CIRS). METHODS: Using published CIRS guidelines and a disease severity index calculated for each individual, we extracted data from the medical records of all 7,247 patients (58.5% female) seen over 6 months in 2008 who were rated for chronic conditions across 14 anatomical domains. RESULTS: Fifty-two percent of patients had multimorbidity in 2 or more CIRS domains, ranging from 20.6% if younger than 25 years, 43.7% if aged 25 to 44 years, 75.5% if aged 45 to 64 years, 87.5% if aged 65 to 74 years, and 97.1% if aged 75 years and older. Using a cutoff of 3 or more CIRS domains, 34.5% had multimorbidity ranging from 4.8% if younger than 25 years, 22.3% if aged 25 to 44 years, 56.1% if aged 45 to 64 years, 74.6% if aged 65 to 74 years, and 92.0% if aged 75 years and older. Musculoskeletal, singularly or in combination with others, was the commonest morbidity domain. The moderate severity index category increased with increasing age. CONCLUSIONS: Multimorbidity is a significant problem in men and women across all age-groups, and the moderate severity index increases with age. The musculoskeletal domain was most commonly affected. Mild and moderate severity index categories may underrepresent disease burden. Severity burden assessment in the primary care setting needs to take into account the severity index, as well as levels of domain severity within the index categories.

Early re-presentation to hospital after discharge from an acute medical unit: perspectives of older patients, their family caregivers and health professionals.

AIMS AND OBJECTIVES: To explore the perceptions of older patients who re-presented to hospital within 28 days of discharge from an acute medical unit (AMU), their family caregivers and appropriately experienced health professionals. BACKGROUND: Hospitals are increasingly using AMUs to provide rapid assessment and treatment for medical patients. Evidence of efficacy is building, however in-depth exploration of the experiences of older patients who re-present to hospital soon after discharge from an AMU, and those who care for them, appears to be lacking. DESIGN: A qualitative, descriptive design was used. METHODS: In 2007, our team purposively sampled older patients who re-presented to hospital within 28 days of discharge from an AMU (n = 12), family caregivers (n = 15), and health professionals (n = 35). Data were collected using semi-structured interviews and subjected to thematic content analysis. RESULTS: Four themes emerged: the health trajectory, communication challenges, discharge readiness and the decision to return. Re-presentation to hospital was seen as part of a declining health trajectory. The AMU was viewed as treating acute illness well, however patients and family caregivers left hospital with limited understanding of underlying health problems and, therefore, ill-prepared for future health crises. CONCLUSION: There are clear benefits for older patients from AMUs, which expedite treatment for acute health crises. However, AMU discharge planning needs to consider patients' overall health status and likely future needs to optimise outcomes. Such a requirement is problematic in the context of acute time pressures. RELEVANCE TO CLINICAL PRACTICE: To ensure prompt and expert attention to key aspects of discharge planning for older people leaving AMUs, there is a role for in-depth clinical expertise in the care of older people facing deteriorating life-limiting conditions. Therefore, a leadership role for nurses with geriatric and palliative care expertise, alongside medical and allied health professionals, merits attention in this context.

Measuring symptom distress among frail elders capable of providing self reports.

This study aimed to develop a valid and reliable method of measuring symptom distress in frail elderly people capable of providing self reports. We tested a tool used in palliative care settings with 46 elders in residential aged care, refined the tool, and tested the new version with 48 additional elders. Items assessed the prevalence and severity of distress attributed to nausea; pain; insomnia; fatigue; and breathing, bowel and appetite problems in the first phase, and pain; insomnia; fatigue; and breathing, bowel, and bladder problems in the second phase. Participants rated symptom distress on a 10-point scale over 5 days. Internal consistency reliability coefficients for the revised tool ranged from 0.50 to 0.64. Concurrent validity with an established measure of well-being was demonstrated. Further research will assess stability. The tool provides a valid overview of symptom distress in frail aged people able to provide self reports.

Methadone-related deaths in Western Australia 1993-99.

OBJECTIVES: To describe methadone-related deaths in Western Australia from 1993 to 1999 and determine differences between deaths in methadone maintenance treatment (MMT) in the public and private sectors. METHOD: Review of coronial and clinical data for all cases identified by methadone detected from toxicological analysis of post-mortem samples between January 1993 and December 1999. RESULTS: Eighty-four methadone-related deaths were identified. The majority (64%) were accidental; 74% of these were caused by a combination of drug effects. Overall, benzodiazepines were present in 74% of all decedents. Thirty-six (43% of all decedents) were registered in MMT when they died. Twenty-two decedents were registered with Next Step, of whom two died in the first week of treatment. In contrast, 14 decedents were registered with the CBMP, of whom eight died in the first week of treatment. The mortality rate in MMT peaked in 1998 (7.7 per 1,000 clients treated), one year after expansion into the private sector. A range of co-existing health conditions were present among decedents including: blood-bome viruses (BBVs), chronic pain/injury, asthma, epilepsy, diabetes, obesity, kidney disease, cardiac disease, pancreatitis, gall stones, paraplegia, cerebral palsy, schizophrenia, depression, suicidal ideation and arthritis. CONCLUSIONS: Overall, methadone-related mortality did not increase significantly despite an increase in the population in MMT. Polydrug use, in particular the use of benzodiazepines in combination with methadone, was a major risk factor for premature mortality. IMPLICATIONS: More attention is needed to reduce the use of benzodiazepines in combination with methadone. Decentralisation of methadone services into general practice must be carefully monitored to minimise the risk of mortality.