Paid Caregiving in Dementia Care Over Time: Paid Caregiver, Family Caregiver, and Geriatrician Perspectives.

BACKGROUND AND OBJECTIVES: As long-term care increasingly moves from facilities to the community, paid caregivers (e.g., home health aides, other home care workers) will play an increasingly important role in the care of people with dementia. This study explores the paid caregiver role in home-based dementia care and how that role changes over time. RESEARCH DESIGN AND METHODS: We conducted individual, longitudinal interviews with the paid caregiver, family caregiver, and geriatrician of 9 people with moderate-to-severe dementia in the community; the 29 total participants were interviewed on average 3 times over 6 months, for a total of 75 interviews. Interviews were recorded, transcribed, and analyzed with structured case summaries and framework analysis. RESULTS: Paid caregivers took on distinct roles in the care of each client with dementia. Despite changes in care needs over the study period, roles remained consistent. Paid caregivers, family caregivers, and geriatricians described the central role of families in driving the paid caregiver role. Paid and family caregivers collaborated in the day-to-day care of people with dementia; paid caregivers described their emotional relationships with those they cared for. DISCUSSION AND IMPLICATIONS: Rather than simply providing functional support, paid caregivers provide nuanced care tailored to the needs and preferences of not only each person with dementia (i.e., person-centered care), but also their family caregivers (i.e., family-centered care). Deliberate cultivation of person-centered and family-centered home care may help maximize the positive impact of paid caregivers on people with dementia and their families.

Exploring How Personal, Social, and Institutional Characteristics Contribute to Geriatric Medicine Subspecialty Decisions: A Qualitative Study of Trainees' Perceptions.

PURPOSE: To explore internal medicine residents' and geriatrics fellows' perceptions of how personal, social, and institutional characteristics contribute to their professional identity and subspecialty decisions related to geriatric medicine. METHOD: The authors conducted 23 in-depth, semistructured interviews with internal medicine residents, with and without an interest in geriatrics, and geriatrics fellows across 3 academic medical centers in the United States from October 2018 through June 2019. They then used a qualitative narrative approach to analyze the interview data. RESULTS: Trainees related personal experiences, such as exposure to physicians and experiences with grandparents, to their interest in medicine. Trainees with an interest in geriatrics at 2 institutions did not feel supported, or understood, by peers and mentors in their respective institutions but maintained their interest in the field. The following variations between institutions that are supportive and those that are not were noted: the number of geriatricians, the proximity of the institution to geriatrics clinics, and the ways in which institutional leaders portrayed the prestige of geriatric medicine. Institutional characteristics influenced trainees' understanding of what it meant to be a doctor, what meaning they garnered from work as a physician, and their comfort with different types of complexity, such as those presented when providing care to older adults. CONCLUSIONS: Institutional characteristics may be particularly important in shaping trainee interest in geriatric medicine. Institutions should encourage leadership training and opportunities for geriatricians so they can serve as role models and as hands-on mentors for trainees beginning in medical school. Increasing the number of geriatricians requires institutions to increase the value they place on geriatrics to generate a positive interest in this field among trainees. Institutions facilitating formation of professional identity and sense of purpose in work may consider engaging geriatricians in leadership and mentoring roles as well as curriculum development.

Medication reviews in hospitalized patients: a qualitative study on perceptions of primary and secondary care providers on interprofessional collaboration.

BACKGROUND: In-hospital medication reviews are regularly performed. However, discontinuity in care could occur because secondary care providers lack insight into the outpatient history. Furthermore, for the implementation or follow-up of some medication review-based interventions, the help of primary care providers is essential. This requires interprofessional collaboration between secondary and primary care. Therefore, the aim of this qualitative study was to gain insight into the perceptions of primary and secondary care providers on interprofessional collaboration on medication reviews in hospitalised patients. METHODS: Ten face-to-face semi-structured interviews and three focus group discussions were conducted with 20 healthcare providers from three hospitals and community health services. The interviews were aimed at exploring general practitioners', community pharmacists', geriatricians', and hospital pharmacists' experiences, attitudes, and views of interprofessional collaboration. Focus groups consisted of representatives of all professional groups. Through group discussion, interprofessional collaboration was explored by addressing three main questions: 1) What are the benefits of in-hospital medication reviews? 2) What are the barriers to in-hospital medication reviews from an interprofessional collaboration perspective? 3) Given the barriers mentioned, how should this interprofessional collaboration between primary and secondary care be designed? Data were analysed using a thematic-content approach. RESULTS: The need for in-hospital medication reviews was underlined due to their many benefits, such as reducing potentially preventable re-admissions. Barriers regarding interprofessional collaboration between primary and secondary care can be subdivided into three main themes: 1) defining in-hospital medication reviews (e.g., lack of clear goals), 2) execution of medication reviews (e.g., hospital setting is dynamic), and 3) follow-up after discharge (e.g., unclear instructions). Care providers suggested solutions for each of the barriers mentioned, for example, by using supportive staff in order to overcome the gap between primary and secondary care providers and making clear agreements on proper means of communication. CONCLUSION: Primary and secondary care providers recognise the importance of in-hospital medication reviews and the need for interprofessional collaboration. To create satisfying interprofessional collaboration, conditions should be met on defining in-hospital medication reviews across settings and involving both primary and secondary care providers in implementing medication reviews and organising their follow-up.

[Adequacy of the pharmacological prescription during the admission in a geriatric hospital. Clinical experiencie with STOPP/START criteria]. / Adecuación de la prescripción farmacológica durante el ingreso en un centro sociosanitario: experiencia clínica con los criterios STOPP/START.

BACKGROUND AND OBJECTIVES: The elderly patient is particularly vulnerable to potentially inappropriate prescription (PIP) due to physiological reasons, comorbidity, polypharmacy or the different pharmacokinetics/pharmacodynamics of drugs. The aim of this study was to determine the prevalence of PIP according to the STOPP-START criteria in patients over 65 years admitted into a geriatric hospital, as well as to appraise its acceptance by geriatricians. MATERIAL AND METHODS: Retrospective observational study. Patients older than 65 years consecutively admitted to medium/long-stay units were included. The study information was obtained by reviewing the clinical record of the patients. The PIP according to the STOPP-START criteria were assessed by the geriatrician, who decided whether or not to modify the medication and recorded the reasons. RESULTS: 247 patients were included, mean age was 82.6 years (SD 7.3), 72.1% of patients were female and a median of 7 drugs (25-75 percentile: 4-9). 78.9% (95%CI: 73.3-83.9) of patients had at least one PIP STOPP-START at admission, 44.9% (95%CI: 38.6-51.4) PIP-STOPP and 59.5% (95%CI: 53.1-65.7) PIP-START. At hospital discharge, the prevalence of PIP-STOPP-START was 46.2% (95%CI: 39.8-52.6), 19.0% (95%CI: 14.3-24.5) of PIP-STOPP and 34.4% (95%CI: 28.5-40.7) PIP-START. CONCLUSIONS: The comprehensive geriatric assessment and the use of the STOPP-START criteria can significantly reduce the prevalence of PIP among patients admitted to a geriatric hospital. Nevertheless, issues such as frailty, multimorbidity and functional goals would be taken into account in the appropriateness of the prescription.

Physician Perspectives on Deprescribing Cardiovascular Medications for Older Adults.

BACKGROUND/OBJECTIVES: Guideline-based management of cardiovascular disease often involves prescribing multiple medications, which contributes to polypharmacy and risk for adverse drug events in older adults. Deprescribing is a potential strategy to mitigate these risks. We sought to characterize and compare clinician perspectives regarding deprescribing cardiovascular medications across three specialties. DESIGN: National cross-sectional survey. SETTING: Ambulatory. PARTICIPANTS: Random sample of geriatricians, general internists, and cardiologists from the American College of Physicians. MEASUREMENTS: Electronic survey assessing clinical practice of deprescribing cardiovascular medications, reasons and barriers to deprescribing, and choice of medications to deprescribe in hypothetical clinical cases. RESULTS: In each specialty, 750 physicians were surveyed, with a response rate of 26% for geriatricians, 26% for general internists, and 12% for cardiologists. Over 80% of respondents within each specialty reported that they had recently considered deprescribing a cardiovascular medication. Adverse drug reactions were the most common reason for deprescribing for all specialties. Geriatricians also commonly reported deprescribing in the setting of limited life expectancy. Barriers to deprescribing were shared across specialties and included concerns about interfering with other physicians' treatment plans and patient reluctance. In hypothetical cases, over 90% of physicians in each specialty chose to deprescribe when patients experienced adverse drug reactions. Geriatricians were most likely and cardiologists were least likely to consider deprescribing cardiovascular medications in cases of limited life expectancy (all P < .001), such as recurrent metastatic cancer (84% of geriatricians, 68% of general internists, and 45% of cardiologists), Alzheimer dementia (92% of geriatricians, 81% of general internists, and 59% of cardiologists), or significant functional impairment (83% of geriatricians, 68% of general internists, and 45% of cardiologists). CONCLUSIONS: While barriers to deprescribing cardiovascular medications are shared across specialties, reasons for deprescribing, especially in the setting of limited life expectancy, varied. Implementing deprescribing will require improved processes for both physician-physician and physician-patient communication. J Am Geriatr Soc 68:78-86, 2019.

Geriatricians' attitudes towards voluntary assisted dying: A survey of Australian and New Zealand Society for Geriatric Medicine members.

OBJECTIVE: To identify the attitudes of Australian and New Zealand geriatricians to legalisation of voluntary assisted dying. METHODS: An anonymous, voluntary, online survey of Australian and New Zealand Society for Geriatric Medicine (ANZSGM) members. RESULTS: A total of 226 members completed the survey equating to a 20% response rate. About 24% of respondents supported legalisation of voluntary assisted dying, whilst 53% opposed. If voluntary assisted dying was legalised, 12% would be willing to prescribe to an appropriate patient, and 61% would be willing to refer them onto a third party. Risk to vulnerable patients was the most important concern identified. CONCLUSIONS: Support for voluntary assisted dying among surveyed ANZSGM members is low, but varies according to patient circumstances. Key areas of concern highlighted were risk to vulnerable patients, estimating prognosis, and capacity assessments. Further training is required for doctors on discussing voluntary assisted dying options, estimating prognosis, and capacity assessments prior to implementation.

Engaging knowledge users in a systematic review on the comparative effectiveness of geriatrician-led models of care is possible: A cross-sectional survey using the Patient Engagement Evaluation Tool.

BACKGROUND: A systematic review (SR) was conducted to evaluate the comparative effectiveness of geriatrician-led models of care, and an integrated knowledge translation (iKT) approach facilitated SR relevance. Activities to engage knowledge users (KUs) in the SR were evaluated for perceived level of engagement. STUDY DESIGN AND SETTING: KUs included patients, caregivers, geriatricians, and policymakers from three Canadian provinces. Activities included 1) modified Delphi to select outcomes; 2) cross-sectional survey to select outcome measures, and 3) in-person meeting to discuss SR findings. KU engagement was assessed using the Patient Engagement Evaluation Tool (PEET) after the second and third activities. KUs rated the extent of successful engagement using a 7-point Likert scale ranging from "no extent" to "very large extent." RESULTS: In total, 15 KUs completed the PEET: eight geriatricians, four policymakers, two patients, and one caregiver. Median engagement scores across all activities (median range: 6.00-6.50) indicated that KUs felt engaged. Differences were observed for activity type; perceived engagement at in-person meeting resulted in higher meta-criteria scores for trust (P = 0.005), legitimacy (P = 0.003), fairness (P = 0.013), and competency (P = 0.035) compared with online activities. CONCLUSIONS: KUs can be engaged meaningfully in SR processes. Their perceived engagement was higher for in-person than for online activities.

A modified Delphi and cross-sectional survey to facilitate selection of optimal outcomes and measures for a systematic review on geriatrician-led care models.

OBJECTIVE: The objective of this study was to identify relevant outcomes and measures to inform a systematic review (SR) on the comparative effectiveness of geriatrician-led care models. STUDY DESIGN AND SETTING: In the modified Delphi to select outcomes for inclusion in the SR, knowledge users (KUs) from Ontario, Alberta, and Saskatchewan rated outcome importance using a Likert scale. A survey was then completed by geriatricians to determine optimal measures for selected outcomes. Findings were analyzed using frequencies, means, and standard deviations (SDs). RESULTS: Thirty-three KUs (patients, caregivers, policymakers and geriatricians) rated 27 outcomes in round 1 of the modified Delphi. Top-rated outcomes included function (mean 6.85 ± SD 0.36), cognition (6.47 ± SD 0.72), and quality of life (6.38 ± SD 0.91). Twenty-three KUs participated in round 2 and rated 24 outcomes. Top-rated outcomes in round 2 were function (6.87 ± SD 0.34), quality of life (6.45 ± SD 1.10), and cognition (6.43 ± SD 0.73). The survey was completed by 22 geriatricians and the highest ranked measures were Activities of Daily Living (function), Mini-Mental State Examination (cognition), and the Medical Outcomes Study SF-36 (quality of life). CONCLUSION: We identified the most relevant outcomes and measures for patients, caregivers, policymakers, and geriatricians, allowing us to tailor the SR to KU needs.

Could problem lists summarize comprehensive geriatric assessments? A nationwide cross-sectional survey on geriatricians' attitudes towards problem lists.

AIM: The use of problem lists is encouraged to overcome the inconsistency in reporting comprehensive geriatric assessment results. The present study aimed to identify the latent variables influencing the use of geriatrician problem lists. METHODS: Surveys were sent to all geriatricians registered with the Japan Geriatrics Society (n = 1439) as of November 2015, and responses (n = 204) were analyzed with univariate and exploratory factor analyses. To account for active, inactive and tentative items, the survey addressed "disease," "symptom" and "condition" separately. RESULTS: Most geriatricians (34.8%) composed problem lists for interdisciplinary information sharing. Nearly half of the respondents (46.6%) created problem lists for every patient. Information omissions were mainly due to the exclusion of information from other specialties (26% for omitted diseases and 12.3% for omitted symptoms), lack of time (25.5% for omitted diseases, 22.1% for omitted symptoms and 26.5% for omitted conditions), and lack of standardization of terminologies regarding observed diseases, symptoms and conditions (12.3% for omitted diseases, 19.6% for omitted symptoms and 16.7% for omitted conditions). An exploratory factor analysis, based on 20 predefined symptoms and conditions that are frequently omitted from problem lists, showed that considering the symptom "geriatric syndromes" and the condition "assistance needs in medication management" are crucial for improving problem list comprehensiveness. CONCLUSIONS: Geriatricians commonly use problem lists; however, there is considerable variation regarding the problems listed and their relationships. The listings of "geriatric syndrome" and "assistance needs in medication management" are crucial for improving problem list comprehensiveness. Geriatr Gerontol Int 2019; 19: 159-164.

What Can Thinking Like a Gerontologist Bring to Bioethics?

I am a social gerontologist, broadly defined as a social scientist who studies how later life is experienced, structured, and controlled in a society and in social settings. Although gerontology is often confused with geriatrics (a medical specialty), gerontologists are typically not clinicians but may study issues related to old age and health care such as the societal conditions that shape how medical care is provided and financed and how early exposure to education relates to later life health. In this essay, I argue that thinking like a gerontologist is important when considering what makes a good life in late life. To think like a gerontologist is to consider the cultural and societal values-past and present-that shape the experience of aging, to recognize people as complex beings whose individual lives do not follow predictable patterns or easily identified trajectories, and to recognize our own habits of regarding older persons as "other" and the consequences of "othering" for older persons and social systems. After a brief history of gerontology, highlighting a few core concepts that gerontologists share, I propose three important questions to consider regarding a good life in late life.

Early career reflections of three female gerontologists: Motivations, perceptions, and the life course.

As the number of individuals age 65 and older increases, so does the need for those prepared to work with this population. Doctoral-level preparation in the field of gerontology creates a uniquely prepared contingent who advocate, conduct research, instruct future generations, and serve the older adult population directly. Women are especially likely to pursue gerontology doctoral degrees, yet little is understood about the unique challenges and opportunities they face. The purpose of this reflection was to examine the experiences of three women who pursued doctoral-level gerontology education and faculty positions at different life stages to explore their challenges and opportunities through their educational process and early career experiences.

Challenges of modern medicine - geriatric otolaryngology or the advantages of cooperation between an otolaryngologist and a geriatrician.

Advanced age is often burdened with many deficits that are a consequence of the aging process, unfavorable lifestyle and multi-morbidity. They contribute to increased morbidity and disability of the older people. Laryngological problems often concern seniors, particularly progressing with age hearing impairment, dizziness, balance disorders, epistaxis, nasopharyngeal diseases, larynx, sinuses, and salivary glands disorders. They are not only a health threat, such as head and neck cancer, but they contribute to the deterioration of mobility, falls and injuries, depression, cognitive functions impairment and, consequently, functional disability, loss of independence and a sense of isolation. In this context, taking as an example the most common ailment, which is hearing impairment, laryngological procedures in the form of the use of hearing aids or cochlear implant improves cognitive functions, mood, self-esteem, opportunities for social interaction and everyday functioning, and the quality of life of older people. In turn, in view of the typical for older age polypathology and of significant reduction of the reserves of the organism, effective treatment aimed at improving health, preventing complications of diagnostics and therapy as well as disability with the desire to maintain independence and good quality of life requires the cooperation of different specialists. The knowledge and experience of geriatricians and the comprehensive geriatric assessment used as the diagnostic tool, aimed at identifying deficits typical of seniors' age may significantly contribute to a more adequate risk and benefit assessment, selection of optimal treatment for a given health situation and identification of high-risk individuals requiring during the treatment period special supervision to reduce the risk of complications and the risk of development of geriatric syndromes such as delirium, cognitive disorders, malnutrition, falls and injuries, functional disability.

Reasons for (not) discontinuing antipsychotics in dementia.

BACKGROUND: The gap between high antipsychotic prescription rates for patients with dementia and the guidelines' advice to prescribe cautiously indicates that barriers to discontinuation exist. This exploratory study used the theory of planned behaviour to give a first overview of the factors that influence physicians to discontinue antipsychotics in nursing home patients with dementia. METHODS: Forty-one physicians in the Netherlands completed an online survey based on the theory of planned behaviour. RESULTS: Half of the respondents agreed that antipsychotics have positive consequences for patients, such as calming effects. Physicians who indicated that they tend not to discontinue antipsychotics believe that antipsychotics are associated with positive consequences for nursing home staff. Physicians who tend to discontinue antipsychotics had a higher perceived behavioural control than those who indicated having a low intention. CONCLUSION: To enhance discontinuation of antipsychotics, interventions should focus on both patient-related factors and staff-related factors. Prescribing decisions are influenced by staff-related factors that need to be addressed as well.