Eric Widera

Prognostic Indices for Older Adults: A Systematic Review

CONTEXT To better target services to those who may benefit, many guidelines recommend incorporating life expectancy into clinical decisions. OBJECTIVE To assess the quality and limitations of prognostic indices for mortality in older adults through systematic review. DATA SOURCES We searched MEDLINE, EMBASE, Cochrane, and Google Scholar from their inception through November 2011. STUDY SELECTION We included indices if they were validated and predicted absolute risk of mortality in patients whose average age was 60 years or older. We excluded indices that estimated intensive care unit, disease-specific, or in-hospital mortality. DATA EXTRACTION For each prognostic index, we extracted data on clinical setting, potential for bias, generalizability, and accuracy. RESULTS We reviewed 21,593 titles to identify 16 indices that predict risk of mortality from 6 months to 5 years for older adults in a variety of clinical settings: the community (6 indices), nursing home (2 indices), and hospital (8 indices). At least 1 measure of transportability (the index is accurate in more than 1 population) was tested for all but 3 indices. By our measures, no study was free from potential bias. Although 13 indices had C statistics of 0.70 or greater, none of the indices had C statistics of 0.90 or greater. Only 2 indices were independently validated by investigators who were not involved in the indexs development. CONCLUSION We identified several indices for predicting overall mortality in different patient groups; future studies need to independently test their accuracy in heterogeneous populations and their ability to improve clinical outcomes before their widespread use can be recommended.

Predicting 10-Year Mortality for Older Adults

TO THE EDITOR: Preventive interventions such as cancer screening exposes patients to immediate risks with delayed benefits, suggesting that risks outweigh the benefits in patients with limited life expectancy. Guidelines now recommend considering the likelihood of long-term survival when evaluating whether preventive interventions with long lagtimes-to-benefit (such as CRC screening and intensive glycemic control) are more likely to help or harm an individual patient.1, 2 However, most mortality indices have focused on short-term mortality risk (≤5 years).3, 4 To help clinicians identify patients who are at low risk for 10-year mortality and thus most likely to benefit from these preventive interventions, we examined whether our previously developed 4-year mortality index5 accurately predicted 10-year mortality.

Finances in the Older Patient With Cognitive Impairment: “He Didn't Want Me to Take Over”

Financial capacity can be defined as the ability to independently manage ones financial affairs in a manner consistent with personal self-interest. Financial capacity is essential for an individual to function independently in society; however, Alzheimer disease and other progressive dementias eventually lead to a complete loss of financial capacity. Many patients with cognitive impairment and their families seek guidance from their primary care clinician for help with financial impairment, yet most clinicians do not understand their role or know how to help. We review the prevalence and impact of diminished financial capacity in older adults with cognitive impairment. We also articulate the role of the primary care clinician, which includes (1) educating older adult patients and their families about the need for advance financial planning; (2) recognizing signs of possible impaired financial capacity; (3) assessing financial impairments in cognitively impaired adults; (4) recommending interventions to help patients maintain financial independence; and (5) knowing when and to whom to make medical and legal referrals. Clearly delineating the clinicians role regarding identification of financial impairment could establish for patients and families effective financial protections and limit the economic, psychological, and legal hardships of financial incapacity on patients with dementia and their families.

Approaching patients and family members who hope for a miracle.

A clinical problem may arise when caring for patients or their surrogates who prefer continued aggressive care based on the belief that a miracle will occur, despite a clinicians belief that further medical treatment is unlikely to have any meaningful benefit. An evidence-based approach is provided for the clinician by breaking this complex clinical problem into a series of more focused clinical questions and subsequently answering them through a critical appraisal of the existing medical literature. Belief in miracles is found to be common in the United States and is an important determinant of how decisions are made for those with advanced illness. There is a growing amount of evidence that suggests end-of-life outcomes improve with the provision of spiritual support from medical teams, as well as with a proactive approach to medical decision making that values statements given by patients and family members.

Hospitalization as an opportunity to integrate palliative care in heart failure management.

Purpose of reviewHospitalization for heart failure is a critical event associated with high rates of readmissions, morbidity, and mortality. This review examines the role of hospitalization for heart failure as an opportunity to assess comprehensive patient needs including palliative care needs. Recent findingsRecent evidence demonstrates that institution of a comprehensive care plan at discharge reduces the high rates of readmissions and death seen in patients with heart failure. The chronic progressive nature of heart failure, with its concomitant limitations in functioning, significant psychosocial distress, and risk of death at all stages of illness creates a need for palliative care services that span the disease trajectory. These services include symptom management, psychosocial care, advance care planning, assistance in defining goals of care, and family/caregiver support and should be provided simultaneously with optimal medical management. Hospice is also underutilized. SummaryHospitalization for heart failure should serve as an opportunity to assess, introduce, and provide comprehensive care that includes palliative care alongside optimal medical management. Palliative care services have the potential to positively impact the health and quality of life of patients with heart failure and should be integrated as an ongoing key component of their care.

AGS Position Statement: Making Medical Treatment Decisions for Unbefriended Older Adults

In this position statement, we define unbefriended older adults as patients who: (1) lack decisional capacity to provide informed consent to the medical treatment at hand; (2) have not executed an advance directive that addresses the medical treatment at hand and lack capacity to do so; and (3) lack family, friends or a legally authorized surrogate to assist in the medical decision‐making process. Given the vulnerable nature of this population, clinicians, health care teams, ethics committees and other stakeholders working with unbefriended older adults must be diligent when formulating treatment decisions on their behalf. The process of arriving at a treatment decision for an unbefriended older adult should be conducted according to standards of procedural fairness and include capacity assessment, a search for potentially unidentified surrogate decision makers (including non‐traditional surrogates) and a team‐based effort to ascertain the unbefriended older adults preferences by synthesizing all available evidence. A concerted national effort is needed to help reduce the significant state‐to‐state variability in legal approaches to unbefriended patients. Proactive efforts are also needed to identify older adults, including “adult orphans,” at risk for becoming unbefriended and to develop alternative approaches to medical decision making for unbefriended older adults. This document updates the 1996 AGS position statement on unbefriended older adults.

Usefulness and effect of online prognostic calculators.

Guidelines recommend incorporating mortality risk into clinical decision-making for older adults, such as cancer screening.1,2 We previously published a systematic review of prognostic indices to estimate mortality risk for older adults.1 To help clinicians, we converted the indices in our systematic review into an online repository of prognostic calculators (www.ePrognosis.org, launched in January 2012).This study aims to evaluate which online prognostic calculators are used in real world settings, if they impact clinical decision making or the perception of prognosis, and if they are rated as useful.

Teaching Geriatric Fellows How to Teach: A Needs Assessment Targeting Geriatrics Fellowship Program Directors

The entire healthcare workforce needs to be educated to better care for older adults. The purpose of this study was to determine whether fellows are being trained to teach, to assess the attitudes of fellowship directors toward training fellows to be teachers, and to understand how to facilitate this type of training for fellows. A nine‐question survey adapted from a 2001 survey issued to residency program directors inquiring about residents‐as‐teachers curricula was developed and administered. The survey was issued electronically and sent out three times over a 6‐week period. Of 144 ACGME‐accredited geriatric fellowship directors from geriatric, internal medicine, and family medicine departments who were e‐mailed the survey, 101 (70%) responded; 75% had an academic affiliation, 15% had a community affiliation, and 10% did not report. Academic and community programs required their fellows to teach, but just 55% of academic and 29% of community programs offered teaching skills instruction as part of their fellowship curriculum; 67% of academic programs and 79% of community programs felt that their fellows would benefit from more teaching skill instruction. Program directors listed fellow (39%) and faculty (46%) time constraints as obstacles to creation and implementation of a teaching curriculum. The majority of fellowship directors believe that it is important for geriatric fellows to become competent educators, but only approximately half of programs currently provide formal instruction in teaching skills. A reproducible, accessible curriculum on teaching to teach that includes a rigorous evaluation component should be created for geriatrics fellowship programs.

Nausea and Other Nonpain Symptoms in Long-Term Care

There is a need to improve the quality of end-of-life care in nursing homes by improving the timely assessment and management of various sources of suffering. Much of the research/discussion in this area has focused on the assessment and treatment of pain. This article reviews the frequency and management of nonpain symptoms in the long-term care setting, particularly focusing on patients at the end of life. Although the long-term care setting presents challenges to effective management, an approach for addressing these challenges is discussed and applied to 3 commonly encountered nonpain symptoms.

Fulfilling Our Obligation to the Caregiver: It's Time for Action: Comment on “Translation of a Dementia Caregiver Support Program in a Health Care System—REACH VA”

Family caregivers are relied upon by health care systems, yet, at the same time, neglected. They provide the bulk of care given to the more than 5 million persons diagnosed with Alzheimers disease in the United States. They are expected to take on increasing amounts of complex care in the home, a task that requires entire health care teams in institutional settings. Their work keeps people out of nursing homes while providing high quality care at minimal cost to public and private health care systems. In return, their efforts and their wellbeing too often go ignored. Family caregivers are often thrust into this position, with no training and little support, resulting in increased prevalence of adverse physical, social, and psychological outcomes. Caregivers are at greater risk for depression and anxiety. They are less likely to engage in preventative health measures, and there is some evidence suggesting increased risk of mortality. Although caring for those with dementia requires significant out-of-pocket costs, many family caregivers stop working in order to care for their loved ones. In real word settings, little has been done to decrease these risks to caregivers. What can public and private health care systems do to foster healthy caregiving? Providing family caregivers information, skills, and support systems to help care for dementia patients is one way to approach this problem. Several different caregiver interventions have now shown improvements in caregiver wellbeing in randomized control trials. One intervention took the form of a collaborative care approach led by advanced practice nurses who worked with caregivers and were integrated within primary care.1 Another was REACH II , an individualized multi-component home and telephone based intervention designed to enhance the caregivers coping skills and management of dementia related behaviors2. The REACH II intervention significantly improved caregiver quality of life in terms of burden, depression and emotional well-being, self-care and healthy behaviors, social support, and management of care recipient problem behaviors. It also resulted in an hour less per day that caregivers were required to provide direct care, giving much need respite in their busy day. A remaining question is whether these caregiver interventions can be implemented in real world health care settings outside the randomized controlled trial environment. In this issue of the Archives, Nichols and colleagues show with the REACH VA study that the answer is a resounding yes. Twenty-four Home Based Primary Care programs within the Veterans Health Administration (VHA) were able to put into practice a modified REACH II intervention. As in REACH II, the results improved caregiver outcomes including reductions in caregiver frustration, burden and depression. Some may argue that health care systems do not have a duty to provide caregiver support as their contractual obligation is with the patient and not the caregiver. However, if health systems are going to increasingly rely on family caregivers to deliver complex care, then they have the obligations to aid caregivers in this task and reduce the personal costs associated with it3. We now have compelling evidence that interventions focused on the caregivers are beneficial and can be practically implemented in existing health systems like the VHA. It is time that we fulfill our obligations to caregivers. The REACH II model should not suffer the same fate as many other proven geriatric models that were not disseminated widely, and there are hopeful indications that it may not. Congress has already passed a law providing supportive services such as training, education, and counseling assistance for caregivers of veterans (Public Law 111-163). The VHA should now take the next step by ensuring these services are universally available and based on proven multi-component caregiver interventions like REACH VA. Other health care systems should follow in its lead.