Stéfanie Monod

Interventions Aiming at Balance Confidence Improvement in Older Adults: An Updated Review

Background: Loss of balance confidence is a frequent condition that affects 20–75% of community-dwelling older persons. Although a recent fall is a common trigger, loss of balance confidence also appears independent of previous experience with falls. Maintaining or improving balance confidence is important to avoid unnecessary, self-imposed restrictions of activity and subsequent disability. Holding another person’s hand or using an assistive device while walking are simple interventions that are used naturally to address poor balance confidence in daily life. However, more complex interventions have also been developed and tested to achieve more sustained improvement in balance confidence. Objectives: This review describes interventions that have been tested to improve balance confidence in older community-dwelling persons. Methods: Based on 2 recent systematic reviews, an additional search for literature was performed to update current information on interventions aiming at balance confidence improvement. Interventions were classified as those directly aimed at increasing balance confidence or not, and further stratified into those using monofactorial or multifactorial approaches. Results: A total of 46 randomized controlled trials were identified. Five of the 8 interventions that directly targeted balance confidence showed benefits. Among those, multicomponent behavioral group interventions provided the most robust evidence of benefits in improving balance confidence and in decreasing activity avoidance. Among interventions not directly aiming at balance confidence improvement (11/21 studies with benefits), exercise (including tai chi) appears as the most promising monofactorial intervention. Nine of the 17 multifactorial fall prevention programs showed an effect on balance confidence, exercise being a main component in 7 of these 9 studies. Interventions that targeted elderly persons reporting poor balance confidence and/or those at risk for falls seemed more likely to be beneficial. Conclusions: Positive and sometimes sustained improvement in balance confidence can be achieved by various interventions among community-dwelling elderly persons. The effect of these interventions on activity restriction associated with poor balance confidence have been less well studied, but some studies also suggest potential benefits.

The spiritual distress assessment tool: an instrument to assess spiritual distress in hospitalised elderly persons

BackgroundAlthough spirituality is usually considered a positive resource for coping with illness, spiritual distress may have a negative influence on health outcomes. Tools are needed to identify spiritual distress in clinical practice and subsequently address identified needs. This study describes the first steps in the development of a clinically acceptable instrument to assess spiritual distress in hospitalized elderly patients.MethodsA three-step process was used to develop the Spiritual Distress Assessment Tool (SDAT): 1) Conceptualisation by a multidisciplinary group of a model (Spiritual Needs Model) to define the different dimensions characterizing a patients spirituality and their corresponding needs; 2) Operationalisation of the Spiritual Needs Model within geriatric hospital care leading to a set of questions (SDAT) investigating needs related to each of the defined dimensions; 3) Qualitative assessment of the instruments acceptability and face validity in hospital chaplains.ResultsFour dimensions of spirituality (Meaning, Transcendence, Values, and Psychosocial Identity) and their corresponding needs were defined. A formalised assessment procedure to both identify and subsequently score unmet spiritual needs and spiritual distress was developed. Face validity and acceptability in clinical practice were confirmed by chaplains involved in the focus groups.ConclusionsThe SDAT appears to be a clinically acceptable instrument to assess spiritual distress in elderly hospitalised persons. Studies are ongoing to investigate the psychometric properties of the instrument and to assess its potential to serve as a basis for integrating the spiritual dimension in the patients plan of care.

Predictors of Functional Recovery in Patients Admitted to Geriatric Postacute Rehabilitation

OBJECTIVE To examine characteristics associated with functional recovery in older patients undergoing postacute rehabilitation. DESIGN Observational study. SETTING Postacute rehabilitation facility. PARTICIPANTS Patients (N=2754) aged ≥65 years admitted over a 4-year period. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Functional status was assessed at admission and again at discharge. Functional recovery was defined as achieving at least 30% improvement on the Barthel Index score from admission compared with the maximum possible room for improvement. RESULTS Patients who achieved functional recovery (70.3%) were younger and were more likely to be women, live alone, and be without any formal home care before admission, and they had fewer chronic diseases (all P<.01). They also had better cognitive status and a higher Barthel Index score both at admission (mean ± SD, 63.3±18.0 vs 59.6±24.7) and at discharge (mean ± SD, 86.8±10.4 vs 62.2±22.9) (all P<.001). In multivariate analysis, patients <75 years of age (adjusted odds ratio [OR]=1.51; 95% confidence interval [CI], 1.16-1.98; P=.003), women (adjusted OR=1.24; 95% CI, 1.01-1.52; P=.045), patients living alone (adjusted OR=1.61; 95% CI, 1.31-1.98; P<.001), and patients without in-home help prior to admission (adjusted OR=1.39; 95% CI, 1.15-1.69; P=.001) remained at increased odds of functional recovery. In addition, compared with those with moderate-to-severe cognitive impairment (Mini-Mental State Examination score <18), patients with mild-to-moderate impairment (Mini-Mental State Examination score 19-23) and those cognitively intact also had increased odds of functional recovery (adjusted OR=1.56; 95% CI, 1.13-2.15; P=.007; adjusted OR=2.21; 95% CI, 1.67-2.93; P<.001, respectively). CONCLUSIONS Apart from sociodemographic characteristics, cognition is the strongest factor that identifies older patients more likely to improve during postacute rehabilitation. Further study needs to determine how to best adapt rehabilitation processes to better meet the specific needs of this population and optimize their outcome.

Ethical issues in nutrition support of severely disabled elderly persons: a guide for health professionals.

Providing or withholding nutrition in severely disabled elderly persons is a challenging dilemma for families, health professionals, and institutions. Despite limited evidence that nutrition support improves functional status in vulnerable older persons, especially those suffering from dementia, the issue of nutrition support in this population is strongly debated. Nutrition might be considered a basic need that not only sustains life but provides comfort as well by patients and their families. Consequently, the decision to provide or withhold nutrition support during medical care is often complex and involves clinical, legal, and ethical considerations. This article proposes a guide for health professionals to appraise ethical issues related to nutrition support in severely disabled older persons. This guide is based on an 8-step process to identify the components of a situation, analyze conflicting values that result in the ethical dilemma, and eventually reach a consensus for the most relevant plan of care to implement in a specific clinical situation. A vignette is presented to illustrate the use of this guide when analyzing a clinical situation.

Development of a Comprehensive Approach for the Early Diagnosis of Geriatric Syndromes in General Practice.

According to demographic projections, a significant increase in the proportion of the elderly population is anticipated worldwide. This aging of the population will lead to an increase in the prevalence of chronic diseases and functional impairment. This expected increase will result in growing use of the health care system that societies are largely unprepared to address. General practitioners (GPs) are at the front line of this huge epidemiological challenge, but appropriate tools to diagnose and manage elderly patients in routine general practice are lacking. Indeed, while primary prevention and the management of common chronic diseases, such as hypertension, diabetes, or cardiac ischemic diseases, are routinely and mostly adequately performed in primary care, the management of geriatric syndromes is often incomplete. In order to address these shortcomings, this theoretical work aims to first develop, based on the best available evidence, a brief assessment tool (BAT) specifically designed for geriatric syndromes identification in general practice and, second, to propose a conceptual framework for the management of elderly patients in general practice that integrates the BAT instrument into the usual care of GPs. To avoid proposing unachievable goals for the care of elderly patients in general practice (for example, performing all the best screening tools for geriatric conditions identification and care), this work proposes an innovative way to combine geriatric assessment with the management of common chronic diseases.

Instruments to Assess Depressive Symptoms and Spiritual Distress Investigate Different Dimensions

ABSTARCT Objective: Although affective and spiritual states may share some common clinical features, the precise nature of the relationship between depression and spirituality is still unclear. We tested the hypothesis that two instruments that measure depressive symptoms and spiritual distress describe similar dimensions. Methods: Patients admitted to geriatric rehabilitation (N = 185; mean age 81.3 ± 6.9 years) had depressive symptoms assessed with the 15-item Geriatric Depression Scale (GDS-15) and spiritual distress evaluated with the Spiritual Distress Assessment Tool (SDAT). Results: A principal components analysis pooling GDS-15 and SDAT resulted in a 6-factor solution, with only one factor shared by both dimensions. Conclusions: Depressive symptoms and spiritual distress measured by the two instruments appeared only moderately correlated and corresponded to distinct dimensions.

Spiritual Assessment in Clinical Setting: The Need for Future Research

Dr. Garssen et al. are correct in their assertion that there is a risk of confounding the constructs of spiritual well-being and psychological well-being. Such criticism was previously made for spirituality constructs,1 and could also have been mentioned in our paper. However, the purpose of our review was to systematically identify instruments that have been previously used in clinical research to measure spirituality and to classify them in categories that could be easily understandable for researchers and clinicians interested in choosing an instrument. Our purpose was not to critically review the spirituality constructs that formed the basis for these instruments, nor was it to endorse one measure over another. Nevertheless, we agree that future work should address this confound between spiritual well-being and mental health outcomes. This should be done not only from a “well-being” perspective but also from a “distress” perspective. In particular, distinction between spiritual distress and depression should be further discussed.2 We also understand Dr. Garssen et al.’s comments about the number of religious items in these instruments with regard to their suitability for individuals who may be spiritual but not religious in a traditional sense. However, they are not clear as to what this threshold for religious items should be. This begs the question of how many religious items are too many to use in spiritual assessments. The overlap between spirituality and religion has received considerable attention in the literature, and there has been no clear consensus from either a conceptual or measurement perspective as to how to address this issue. In our review, we did exclude instruments that focused exclusively on religion/religiousness, but decided to include others even though they had high proportions of religious items. As noted by Pargament,3 for many individuals, spirituality is expressed in the context of religion. Thus, the inclusion items referencing religiousness in assessments of spirituality is certainly warranted for some individuals. For others, who consider themselves spiritual but not religious, those same assessments may not be appropriate. It is up to the clinician or the researcher to decide which measure would be the most appropriate in any given circumstance. In conclusion, we would like to thank again Dr. Garssen et al. for their emphasis about the need for future research in the field of spiritual assessment in clinical settings.

Differences in triage category, priority level and hospitalization rate between young-old and old-old patients visiting the emergency department

BackgroundEmergency Department (ED) are challenged by the increasing number of visits made by the heterogeneous population of elderly persons. This study aims to 1) compare chief complaints (triage categories) and level of priority; 2) to investigate their association with hospitalization after an ED visit; 3) to explore factors explaining the difference in hospitalization rates among community-dwelling older adults aged 65–84 vs 85+ years.MethodsAll ED visits of patients age 65 and over that occurred between 2005 and 2010 to the University of Lausanne Medical Center were analyzed. Associations of hospitalization with triage categories and level of priority using regressions were compared between the two age groups. Blinder-Oaxaca decomposition was performed to explore how much age-related differences in prevalence of priority level and triage categories contributed to predicted difference in hospitalization rates across the two age groups.ResultsAmong 39′178 ED visits, 8′812 (22.5%) occurred in 85+ patients. This group had fewer high priority and more low priority conditions than the younger group. Older patients were more frequently triaged in “Trauma” (20.9 vs 15.0%) and “Home care impossible” (10.1% vs 4.2%) categories, and were more frequently hospitalized after their ED visit (69.1% vs 58.5%). Differences in prevalence of triage categories between the two age groups explained a quarter (26%) of the total age-related difference in hospitalization rates, whereas priority level did not play a role.ConclusionsPrevalence of priority level and in triage categories differed across the two age groups but only triage categories contributed moderately to explaining the age-related difference in hospitalization rates after the ED visit. Indeed, most of this difference remained unexplained, suggesting that age itself, besides other unmeasured factors, may play a role in explaining the higher hospitalization rate in patients aged 85+ years.

Factors associated with quality of life in elderly hospitalised patients undergoing post-acute rehabilitation: a cross-sectional analytical study in Switzerland

Objectives We investigated whether biopsychosocial and spiritual factors and satisfaction with care were associated with patients’ perceived quality of life. Design This was a cross-sectional analytical study. Setting Data were collected from inpatients at a postacute geriatric rehabilitation centre in a university hospital in Switzerland. Participants Participants aged 65 years and over were consecutively recruited from October 2014 to January 2016. Exclusion criteria included significant cognitive disorder and terminal illness. Of 227 eligible participants, complete data were collected from 167. Main outcome measures Perceived quality of life was measured using WHO Quality of Life Questionnaire—version for older people. Predictive factors were age, sex, functional status at admission, comorbidities, cognitive status, depressive symptoms, living conditions and satisfaction with care. A secondary focus was the association between spiritual needs and quality of life. Results Patients undergoing geriatric rehabilitation experienced a good quality of life. Greater quality of life was significantly associated with higher functional status (rs=0.204, p=0.011), better cognitive status (rs=0.175, p=0.029) and greater satisfaction with care (rs=0.264, p=0.003). Poorer quality of life was significantly associated with comorbidities (rs=−.226, p=0.033), greater depressive symptoms (rs=−.379, p<0.001) and unmet spiritual needs (r s=−.211, p=0.049). Multivariate linear regression indicated that depressive symptoms (β=−0.961; 95% CIs −1.449 to 0.472; p<0.001) significantly predicted quality of life. Conclusions Patient perceptions of quality of life were significantly associated with depression. More research is needed to assess whether considering quality of life could improve care plan creation.

Geriatrie: Todeswunsch im Alter: eine Realität. Was wissen wir darüber?

Im Medizinstudium lernen wir, dass der Tod so lange wie möglich mit allen uns zur Verfügung stehenden therapeutischen Mitteln bekämpft werden soll. Auch wenn wir dem Tod in der Folge immer wieder begegnen, erscheint er uns oft als etwas eigentlich Unzulässiges und kann als Versagen erlebt werden. So reagieren Ärzte und Pflegende oft ratlos und wissen nicht, was antworten, wenn ein Patient den Wunsch ausdrückt, er «wolle nicht mehr weiterleben». Die Vorstellung, beim Suizid Hilfe leisten zu müssen, ist ein weitverbreitetes Schreckgespenst. Die Betreuenden empfinden dann einen starken Widerspruch zwischen der Respektierung des autonomen Patientenwillens und dem Prinzip, Gutes zu tun. Die Folge ist meist ein unbeholfener Aktivismus, der von den Patienten manchmal als Unverständnis der Medizin gegenüber ihren Wünschen erlebt wird, und es entsteht oft ein Gefühl des Versagens beim Patienten wie den Betreuenden. Der Todeswunsch bleibt ein grosses Tabu in unserer jüdisch-christlich geprägten Gesellschaft, auch wenn diese heute weitgehend säkularisiert ist. Trotzdem beschäftigt die Frage der Endlichkeit unseres Daseins wohl viele unserer (sehr) alten Patienten. Es ist daher wichtig, dass wir uns dieser Realität stellen und sie besser verstehen lernen, wenn wir diese schwierige Frage mit unseren Patienten sinnvoll besprechen und auch auf gesellschaftlicher Ebene ruhig diskutieren wollen.