Cathy S. Berkman

The Relationship among Income, other Socioeconomic Indicators, and Functional Level in Older Persons

Socioeconomic status (SES) is well established as a cause of morbidity and mortality, but relatively few studies have investigated the relationship between SES and functional level. Functional level is closely related to the use of long-term care services and is a more salient indicator of quality of life than specific diseases. We used data from 1,570 respondents in the Growing Older in New York City Study, a probability sample of people age 65 and older, to examine this relationship. The association between income and function was seen throughout the full gradient of income and remained significant when controlling for age, gender, race/ethnicity, household size, education, occupation, age of immigration, and locus of control. Education and residential environment, but not occupation, were independently associated with functional level. These findings support both the association between SES and functional limitation and the hypothesis that the SES and health association continues into old age.

Assessing medical students' training in end-of-life communication: a survey of interns at one urban teaching hospital.

Purpose Although interns are responsible for caring for dying patients, little is known about end-of-life education and training, including communication skills, in U.S. medical schools. This study of three consecutive cohorts of new interns assessed their perceptions of the amount and types of classroom and clinical instructional strategies used during medical school, their self-rated skill and comfort levels in different aspects of end-of-life communication, and the associations between these measures. Method A self-administered questionnaire was given to three consecutive cohorts (1996–1998) of incoming interns (n = 162). Measures were self-reported amount and type of education and clinical experience with four end-of-life communication domains (giving bad news, discussing advance directives, discussing prognosis with the patient, and discussing with the patients family) and self-perceived comfort and skill levels in relation to different types of end-of-life communication. Results A total of 157 interns completed the questionnaire. They reported very little classroom teaching, clinical observation, or clinical experience with end-of-life communication during medical school. They lacked comfort and skill in the end-of-life communication domains that were studied. More reported clinical observation and experience with caring for and communicating with dying patients was associated with greater perceived comfort and skill, while classroom teaching was not. Conclusions These interns, mostly U.S. medical school graduates (98.7%, n = 155) reported little training and low self-perceived comfort and skill with important elements of end-of-life communication that might contribute to a lack of preparedness to address these issues during their internship. Further research that confirms and explains the underlying reasons for these findings seems warranted.

Use of Alternative Treatments by People with Multiple Sclerosis

The prevalence, predictors, and description of alternative treatment use among peo ple with multiple sclerosis (MS) have not been well studied despite interest and con cern about such use among health care professionals and people with MS. The goal of this study was to describe the prevalence of the use of specific alternative treatments by people with MS, the sociodemographic and disease characteristics of those most likely to use alternative treatments, perceived benefits and harms from use of these treatments, and the reasons for their use. Almost three-fifths of the study sample of 240 people diagnosed with MS from two chapters of the National Multiple Sclerosis Society had used alternative treatments. Most (90 percent) of those who had used al ternative treatments did so in combination with traditional treatments. Only 7.1 per cent used any treatments considered to be high risk or dangerous. The primary reason for using alternative treatments was to obtain relief from physical and psychological symptoms. Implications of these findings for health care professionals are discussed. Key Words: Multiple sclerosis—Alternative therapies—Complementary therapies— Alternative medical practices—Unconventional medicine.

Methodologic Issues in Conducting Research on Hospitalized Older People

OBJECTIVE: To describe challenges in conducting research with hospitalized geriatric patients.

Preferences for disclosure of information about serious illness among older Korean American immigrants in New York City.

BACKGROUND The majority of persons of Western European background want to know their diagnosis and prognosis of serious illness, but minimal information is preferred by some ethnic groups, including Asians. Little is known about disclosure preferences of Korean Americans, the fourth largest East Asian immigrant group in the United States. OBJECTIVE The objective was to describe disclosure preferences about serious illness of Korean Americans in New York City and characteristics associated with disclosure preferences. METHODS A cross-sectional study of a volunteer sample of 26 Korean Americans, 65 years and older, was conducted. Interviews were conducted in Korean. Measures included comfort in talking about death and dying, disclosure preferences, disclosure to relatives, self-rated physical and mental health, and sociodemographic characteristics. RESULTS Most agreed doctors should tell patients (n = 23) and relatives (n = 25) if they have cancer, and should tell patients (n = 22) and relatives if they are likely to die from this disease. Less than half (n = 9) agreed doctors should not discuss death and dying with patients, yet 15 agreed it is best to avoid talking about serious illness and dying before they occur. Participants who agreed a doctor should tell patients their cancer diagnosis were younger and had lived in the United States longer than those who disagreed. Self-rated physical health and mental health were associated with disclosure preferences. CONCLUSIONS Health professionals are advised to determine the disclosure preferences about serious illness of older Korean Americans and avoid stereotypical assumptions that do not apply to many in this population.

Tube feeding in advanced dementia: an exploratory survey of physician knowledge.

The administration of artificial nutrition by means of a percutaneous endoscopic gastrostomy (PEG) tube in older persons in the advanced stages of dementia is commonplace, yet the treatment is associated with significant treatment burdens and unclear benefits in this population. In addition, there is wide and unexplained geographic variability in the use of PEG in advanced dementia, which may stem partly from physicians’ lack of understanding about its indications, risks, benefits, and effect on quality of life in advanced dementia. This study was a mail survey undertaken to assess physician knowledge regarding tube feeding in advanced dementia and explore whether certification in geriatrics or other physician characteristics are associated with physician knowledge. To assess knowledge about tube feeding, we asked participants to rate the importance of commonly cited, but non–evidence based, indications for tube feeding in advanced dementia, including recurrent aspiration pneumonia, abnormal swallowing evaluations, abnormal nutritional parameters, preventing an uncomfortable death, and others. Discrepancies between physician knowledge and current evidence regarding tube feeding in advanced dementia were found, indicating a need for improved education of primary care physicians in order to ultimately provide better end-of-life care for patients with advanced dementia.

What and When Korean American Older Adults Want to Know About Serious Illness

The aim of this exploratory study was to describe disclosure preferences about serious illness among Korean American older adults. Three focus groups (N = 6, 8, and 9) were conducted with Korean Americans age 65+ from two senior centers and a primary care practice in NYC. Six themes were identified: (1) Disclosure allows patients to make decisions and preparations, (2) Disclosure may cause emotional distress and hasten death, (3) Disclosure may be based on physician error or inability to know prognosis, (4) Disclosure should be based on severity of illness and the need to maintain hope, (5) Disclosure should be based on age, and (6) Disclosure practices of physicians vary by culture. Providing culturally competent care to East Asian older adults requires understanding the importance of family values and traditions, but not making assumptions about the degree to which the patient adheres to these beliefs.

Advance Directives Among Korean American Older Adults: Knowledge, Attitudes, and Behavior

The study objective was to explore knowledge, attitudes, and behavior about advance directives and how cultural values influence these beliefs. Three focus groups with 23 Korean American older adults were conducted. Advance directives were seen as helpful for ensuring that preferences for unwanted end-of-life treatment are honored and for relieving the decision-making burden on family members. However, some viewed completing advance directives as contrary to focusing on living. Culturally competent education about advance directives for Korean American older adults is necessary to help them make informed decisions about end-of-life care and informing family and health care providers of these preferences.

The Relationship Between Health Information Sources and Mental Models of Cancer: Findings from the 2005 Health Information National Trends Survey

This study used data from the 2005 Health Information National Trends Survey, a national sample of U.S. households (N = 5,586), to (1) explore the extent to which specific sources of health information are associated with certain beliefs about cancer; and (2) examine whether the relationship between health information sources and beliefs about cancer is moderated by psychological distress. Health information on the local news was associated with greater ambiguity about cancer prevention recommendations (OR 1.22, 95% CI 1.02–1.46, p < .05), while less ambiguity was associated with cancer-specific information (OR 0.81, 95% CI 0.69–0.94, p < .05), health information in the newspaper (OR 0.82, 95% CI 0.69–0.97, p < .05), and health information on the Internet (OR 0.71, 95% CI 0.61–0.84, p < .001). Health information on the local news was also associated with lower likelihood of higher perceived relative risk of cancer (OR 0.67, 95% CI 0.52–0.86, p < .01). No source of information was associated with the belief that cancer is primarily caused by behavior/lifestyle factors. Psychological distress greatly increased the optimistic bias of those who read health information in the news (OR 3.68, 95% CI 1.69–8.03, p < .001) but had no other moderating effect. Findings suggest that information seeking using active channels of health information decreases ambiguity and corrects for optimistic bias.

Integrating Housestaff into a Geriatric Inpatient Interdisciplinary Team

Abstract Medical housestaff are rarely members of interdisciplinary teams. In this study, housestaff participated in interdisciplinary team rounds during a month-long rotation on an Acute Care for Elders (ACE) unit and were then surveyed to determine their attitudes about the team and the unit. Twenty-nine residents responded, for a response rate of 85.3%. Over 90% found interdisciplinary rounds helpful for improving efficiency of patient management, the understanding of the patients hospital course, the roles of other health professionals, and the sensitivity to the needs of geriatric patients. Very few found rounds to be burdensome or a waste of time. ACE units may serve as viable experiential models for training in interdisciplinary teamwork as well as geriatric medicine.