Milta O. Little

International Survey of Nursing Home Research Priorities

This article reports the findings of a policy survey designed to establish research priorities to inform future research strategy and advance nursing home practice. The survey was administered in 2 rounds during 2013, and involved a combination of open questions and ranking exercises to move toward consensus on the research priorities. A key finding was the prioritization of research to underpin the care of people with cognitive impairment/dementia and of the management of the behavioral and psychological symptoms of dementia within the nursing home. Other important areas were end-of-life care, nutrition, polypharmacy, and developing new approaches to putting evidence-based practices into routine practice in nursing homes. It explores possible innovative educational approaches, reasons why best practices are difficult to implement, and challenges faced in developing high-quality nursing home research.

Nursing home research: the first International Association of Gerontology and Geriatrics (IAGG) research conference.

The International Association of Gerontology and Geriatrics held its first conference on nursing home research in St Louis, MO, in November 2013. This article provides a summary of the presentations.

Hypertension: how does management change with aging?

Hypertension is a significant risk factor for cardiovascular morbidity and mortality in people older than 60 years. Isolated systolic hypertension and widened pulse pressure appear to be more important than diastolic hypertension. Very low blood pressure and orthostatic hypotension are associated with increased mortality, and should be checked for at every visit. Best evidence suggests that adjusting hypertension goals with age, and starting therapy when blood pressure is greater than 160/90 leads to improved outcomes. Therapy should start with a thiazide diuretic (best evidence) or an angiotensin-converting enzyme inhibitor.

The use of critical reflection in clinical practice and health profession education.

Rita Charon, MD, PhD, one of the founders of narrative medicine education, describes reflective practice as “the practice of medicine that is empathic, reflective, professional and trustworthy.”1 As she describes the way a patient narrates his or her story, she emphasizes the importance of gestures, posture, and silences, in addition to words, that are loaded with the subjective burdens of the patient. Through the study of narratives, we can understand fears, hopes, and expectations of the patient, giving us (the health care team) an opportunity to greatly improve the care we deliver to the person as a whole. In addition to being a tool for improving interpersonal communication, reflective practice can help us strengthen our intrapersonal relationship with the self. There are several types of narratives that are useful to the health care practitioner. The first is critical reflection. Critical reflection occurs “when we analyze and challenge the validity of our presuppositions and assess the appropriateness of our knowledge, understanding, and beliefs given our present contexts.”2 Examples of critical reflection written by health care practitioners can be found in many journals, such as the humanities section in JAMA, or popular books. The idea of creating a habit of critical reflection fits within the Ignatian pedagogy, which describes 5 key teaching elements: Context, Experience, Reflection, Action, and Evaluation.3 When undergoing a critical reflection exercise, either alone or as part of an educational initiative, it is helpful to answer the questions: “What?” (describe the situation and general reaction without attempting to uncover personal assumptions or beliefs about the situation); “So what?” (integrate meaningful reactions to the situation based on one’s own assumptions, beliefs, feelings, and alternative perspectives; this step requires some thoughtful introspection on how one’s experiences, beliefs, and reactions may differ from others, including patients, family members, or health care staff); and “Now what?” (uncover the root cause of our knowledge, assumptions, and beliefs with the goal of discovering new meaning and how this experience will impact and inform the future).4,5 The second type of narrative is reminiscence. Reminiscence provides a safe and conducive environment for people with like interests (for example, a local sports team) to reflect on their previous

Diagnostic Challenge of Bloodstream Infections in Long-Term Care

Management of infectious diseases continues to be a significant challenge for medical practitioners in long-term care (LTC) facilities. Lubart and colleagues present in this issue data on bacteremia from a multilevel geriatric hospital, which includes acute, rehabilitation, intermediate, and long-term care wards. Their study serves as a reminder of the unique characteristics of sepsis in this population. Episodes of sepsis have been estimated to occur at a rate of nearly 2500 cases per 100,000 persons aged 85 years or older each year in the United States. Few studies have examined the case rate of episodes outside the inpatient setting. Given that approximately 1.5 million elderly people reside in LTC facilities and bloodstream infections (BSIs) continue to be a significant source of morbidity and mortality in the elderly, more studies are needed to assess the prevalence and characteristics of septicemia in the LTC setting. The lack of evidence for treating BSIs in settings outside the acute inpatient ward has led to recommendations against blood culture accrual in LTC. A practice guideline by Bentley and others states that blood cultures should not be obtained solely ‘‘for the sake of completeness of evaluation or adherence to preconceived standards of practice.’’ The concluding recommendation is as follows:

Climbing Out of the Black Hole of Subacute Care

A black hole is an accumulation of mass so dense and compact that nothing, even light, can escape its gravitational force. The edge of the black hole is where space and time stop. Some theorize that wormholes exist in black holes, which make it possible to travel nonlinearly through time. What does the theory of black holes have to do with medicine? Unfortunately, subacute care facilities often become the informational black hole of medicine. Frail patients who are not well enough to discharge to their independent homes nor ill enough to remain in the hospital are transferred to a skilled nursing facility (SNF) and, to the rest of the health care community, disappear. At some point in the future, after a series of vague and confusing events, they reappear. Small chunks of information may precede or follow the patient’s discharge but most is lost in the black hole, leaving vulnerable patients at high risk of reentering the hospital. Recently, safety at transitions has come to the forefront as a topic of great interest, largely in part to the greater use of subacute care1 and the cost of recurrent hospital admissions. If not performed correctly, transitions between care settings can lead to adverse events.2e4 Unplanned rehospitalizations are a significant financial burden to Medicare.5,6 In addition to the financial burden, the hospital environment can be a significant cause of morbidity7,8 and errors tend to occur more frequently as patients shift between providers and/or care sites.9e11 Furthermore, long term care residents experiencing frequent transitions are often excluded from quality indicator measurements, which results in skewed epidemiologic data.12 Several health care provider societies have endorsed position papers calling for improved education, communication, policy, and clinical care at transitions.3,13e16 Medical education at both the undergraduate and graduate levels that includes formal teaching on hand-offs and care transitions17e21 is becoming more common, although there continues to be a significant gap.22 Inaddition, quality improvement initiativeshavebeendeveloped to reduce rehospitalizations, improve patient care outcomes, and increase patient and provider satisfaction.23e32 However, there is a significant lag in the health care system as awhole to adopt universal strategies to reduce the burden of rehospitalizations and enhance the care at transitions.33 Furthermore, historically, care transition interventions focused primarily on hospital-to-home transfers.18e21,24,27,31 Care transition programs and policies that are cost-effective, pragmatic, and universally applicable are desperately needed to enhance patient safety during these critical transfers between all sites of care.

Interventions Against Disability in Frail Older Adults: Lessons Learned from Clinical Trials

As the population ages, the number of older people with frailty is expected to increase worldwide with consequent rising of expenditures for healthcare and long-term care. Effective methods for preventing or delaying the onset of disability are urgently required. Frailty is a common and important geriatric condition characterized by age-associated declines in multiple physiological mechanisms, leading to increased vulnerability to stressors and higher risk for adverse health outcomes. Significant advancements have been made in the understanding of the frailty pathophysiological background. Given its multidimensional nature, reversing frailty requires a comprehensive approach. In this context, several studies testing the effects of pharmacological approach, physical activity, nutritional intervention, or cognitive training showed evidence of efficacy in frail older adults. Important innovations in ongoing trials include the development of multidomain interventions. Challenges include the use of trial designs, the development of standardized, sensitive outcome measures, and the need for interventions that can be implemented in resource-poor settings. In this viewpoint paper, based on recent literature, our aim was to identify relevant studies performed to reverse or delay disability in frail older adults.

End-of-life care in low-and middle-income countries

End-of-life care in lowand middle-income countries Dulce M Cruz-Oliver, Milta O Little, Jean Woo & John E Morley a Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, Saint Louis, MO, 63104, United States of America. b Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China. Correspondence to Dulce M Cruz-Oliver (email: dcruzoli@slu.edu). (Submitted: 14 September 2016 – Accepted: 6 October 2016 – Published online: 26 September 2017) Health-care providers are recognizing the importance of palliative and end-of-life care as a treatment option for seriously ill patients. Palliative care is an approach to improve the quality of life of patients and their families facing problems associated with life-threatening illness, through the prevention and relief of suffering, by means of early identification, assessment and treatment of pain and other distresses. 1 Palliative care begins at the start of a serious illness and is given alongside treatments designed to combat the disease. End-of-life care is a type of palliative care for people in the final months of life and is considered when the person’s condition deteriorates and active treatment does not control the disease. Palliative and end-of-life care helps those with advanced, progressive, incurable and serious illness to live as well as possible until they die. 2

Policy: Impact on Delivery and Access

Reducing health disparities and improving cultural competency requires complex collaborations between institutions of higher education, health profession societies, and political organizations. Support from federal and state legislation allows for improved collaboration and funding to provide culturally attuned education, perform effective research, and promote positive health outcomes for a heterogeneous group of aging adults. This chapter outlines key legislative efforts to improve ethnogeriatric care and aims to highlight the impact of systems-based policy changes that address the health disparities of the diverse aging population.

Utility of the Easy-Care Standard 2010 in the Comprehensive Geriatric Assessment of Adults Aging with Developmental Disabilities

Kaehr, E., Abele, P., & Little, M. (2016). Utility of the Easy-Care Standard 2010 in the Comprehensive Geriatric Assessment of Adults Aging with Developmental Disabilities. Journal of the American Medical Directors Association, 17(12), 1159–1160. https://doi.org/10.1016/j.jamda.2016.08.024 Utility of the Easy-Care Standard 2010 in the Comprehensive Geriatric Assessment of Adults Aging with Developmental Disabilities