Care For Vulnerable Older Adults Research Articles

A public health/hospital partnership to improve Emergency Department transitions of care for vulnerable older adults.

Community-dwelling older adults are at high risk for unmet social service needs. We describe a novel partnership embedding county services case managers in the Emergency Department (ED) to connect older adults to community services alongside their medical care. Setting: A medium-sized urban ED with 55,000 patient visits a year. Case managers from the Franklin County, Ohio Office on Aging (OA) were embedded within the ED. The OA team worked with the ED social work team to identify community-dwelling older patients, perform an in-person intake assessment, and initiate needed community services (including home-delivered meals, emergency response systems, house repairs, and transportation). Program logic model and development are reported in detail. From June to December 2023, there were 7284 ED visits for adults ≥60 years old. Referrals to the OA case manager ranged from 1 to 13 per day. The OA case managers performed 252 full intake assessments on unique patients. The population was 51% men. Only 11% (n = 28) were currently connected to OA services, and of those already connected 29% (n = 8) needed increased services. Of the remaining unconnected patients (n = 224), 8% (n = 20) were not county residents and the OA team connected them with other county OAs. Half 53% (n = 120) were accepting of services and had services from the OA or other community health programs initiated during the ED visit. The OA team made three new Adult Protective Services referrals and one referral to the long-term care ombudsman. The program did not increase ED length of stay or hospital admission rates. Embedding county service enrollment within a community ED is a cost neutral intervention that reached a population without previous services. Future plans include expansion of the program and evaluation of the program's ability to detect elder mistreatment and self-neglect.

A randomized phase II study of gemcitabine and nab-paclitaxel compared with 5-fluorouracil, leucovorin, and liposomal irinotecan in older patients with treatment-naïve metastatic pancreatic cancer (GIANT): ECOG-ACRIN EA2186.

4003 Background: Evidence-based data is lacking to guide the care of vulnerable older adults with newly diagnosed metastatic pancreatic ductal adenocarcinoma (mPDAC) resulting in extrapolation of the treatment approach utilizing data from younger patients. EA2186 is a phase II randomized controlled trial, and the first prospective study aiming to define the optimal treatment approach for vulnerable older adults with newly diagnosed mPDAC. Methods: EA2186 enrolled vulnerable patients ≥70 years of age with histologically confirmed mPDAC, ECOG PS 0-2 and adequate organ function. Vulnerability was defined by a screening geriatric assessment (GA) demonstrating mild abnormalities in functional status, comorbidities, cognition, or age ≥80 years. Patients were randomized to Arm A: Gemcitabine (1000mg/m2) and Nab-Paclitaxel (125mg/m2) every 14 days or Arm B: 5-Fluorouracil (2400mg/m2 over 46hr) Leucovorin (400mg/m2) and Liposomal Irinotecan (50mg/m2) every 14 days. A comprehensive GA and quality of life (QOL) evaluation were completed at baseline and 3 time points. Primary endpoint was overall survival (OS); secondary endpoints included progression free survival (PFS), response rate (RR), safety, and QOL. The study had 90% power to detect a difference in median OS of 7.7 vs. 10.7 months (HR of 0.72) using a one-sided log-rank test at the 0.10 significance level. Stratification factors included age 70-74 vs ≥75, and ECOG PS 0-1 vs 2. The study met the planned futility boundary for OS at its single interim analysis (60.6% information) and was closed early by the DSMC. Results: 176 patients were enrolled at 92 US sites between 6/2020 – 10/2023, 88 patients per arm. Median age of enrolled patients was 77 (range 70-90), 49% females, 24% ECOG-0, 64% ECOG-1 and 12% ECOG-2. Majority of patients were deemed vulnerable by cognition (46%), age (36%) or co-morbidities (31.4%), with some patients meeting vulnerability criteria in multiple domains. No significant difference was seen in median OS between the arms (4.7 vs. 4.4 months in Arms A and B respectively; p = 0.72). PFS, RR, and factors contributing to early treatment discontinuation and affecting the lower-than-expected survival will be presented at the meeting. At the time of data cut off rates of ≥grade 3 toxicity was 45.6% in Arm A and 58.7% in Arm B (p = 0.10); rates of ≥grade 4 toxicity were 7.6% in Arm A vs 14.7% in Arm B (p = 0.16). Most common ≥grade 3 toxicities included anemia, neutropenia, fatigue in both Arms, and diarrhea in Arm B. Conclusions: EA2186 did not demonstrate a significant difference in efficacy or overall toxicity between two attenuated regimens tested in vulnerable older adults with mPDAC. These results provide important data to guide treatment decisions and goals of care discussions in this vulnerable patient population. Clinical trial information: NCT04233866 .

Two variants of 'constrained participation' in the care of vulnerable adults: A proof-of-concept study.

There has been a radical turn towards ideals of patient autonomy and person-centred care, and away from historically entrenched forms of medical paternalism, in the last 50years of nursing practice. However, along the way, some shades of grey between the areas of ideal patient participation and of outright patient non-participation have been missed. The current article constitutes an exploratory proof-of-concept study of the real-world traction of a distinction-straddling concept of 'constrained participation' and its two sub-concepts of 'fought-for participation' and 'forced-to participation'. In order to concretise these additions to the conceptual terrain of person-centred participation and its anti-theses, we apply them to themes in the care of vulnerable older adults. In the final section, we close by eliciting some characterological, educational and clinical implications of adding these new tools also to the conceptual repertoire of nursing practice and education.

Delirium superimposed on dementia in post-acute care: Nurse documentation of symptoms and interventions

Delirium superimposed on dementia (DSD) is common in older adults being discharged to post-acute care settings (PAC). Nurse documentation remains poorly understood. Aims were to describe nurse documentation and to determine associations in a secondary data analysis of a large, single-blinded randomized controlled trial (Recreational Stimulation For Elders As A Vehicle To Resolve DSD (Reserve For DSD). Just under 75% of the sample had at least one symptom of delirium documented by the nursing staff, while 25.9% had none despite being CAM positive by expert adjudication. Only 32% had an intervention documented. Number of documented interventions were significantly associated with number of documented symptoms. There is a need for research and innovation related to nurse documentation and communication of DSD symptoms and interventions in an efficient and accurate manner to impact care for vulnerable older adults in these settings.

Frailty and emergency surgery: identification and evidence-based care for vulnerable older adults.

Frailty is a multidimensional state related to accumulation of age- and disease-related deficits across multiple domains. Older people represent the fastest growing segment of the peri-operative population, and 25-50% of older surgical patients live with frailty. When frailty is present before surgery, adjusted rates of morbidity and mortality increase at least two-fold; the odds of delirium and loss of independence are increased more than four- and five-fold, respectively. Care of the older person with frailty presenting for emergency surgery requires individualised and evidence-based care given the high-risk and complex nature of their presentations. Before surgery, frailty should be assessed using a multidimensional frailty instrument (most likely the Clinical Frailty Scale), and all members of the peri-operative team should be aware of each patient's frailty status. When frailty is present, pre-operative care should focus on documenting and communicating individualised risk, considering advanced care directives and engaging shared decision-making when feasible. Shared multidisciplinary care should be initiated. Peri-operatively, analgesia that avoids polypharmacy should be provided, along with delirium prevention strategies and consideration of postoperative care in a monitored environment. After the acute surgical episode, transition out of hospital requires that adequate support be in place, along with clear discharge instructions, and review of new and existing prescription medications. Advanced care directives should be reviewed or initiated in case of readmission. Overall, substantial knowledge gaps about the optimal peri-operative care of older people with frailty must be addressed through robust, patient-oriented research.

The concept of vulnerability in aged care: a systematic review of argument-based ethics literature

BackgroundVulnerability is a key concept in traditional and contemporary bioethics. In the philosophical literature, vulnerability is understood not only to be an ontological condition of humanity, but also to be a consequence of contingent factors. Within bioethics debates, vulnerable populations are defined in relation to compromised capacity to consent, increased susceptibility to harm, and/or exploitation. Although vulnerability has historically been associated with older adults, to date, no comprehensive or systematic work exists on the meaning of their vulnerability. To fill this gap, we analysed the literature on aged care for the meaning, foundations, and uses of vulnerability as an ethical concept.MethodsUsing PRISMA guidelines, we conducted a systematic review of argument-based ethics literature in four major databases: PubMed, Embase®, Web of Science™, and Philosopher’s Index. These covered biomedical, philosophy, bioethical, and anthropological literature. Titles, abstracts, and full texts of identified papers were screened for relevance. The snowball technique and citation tracking were used to identify relevant publications. Data analysis and synthesis followed the preparatory steps of the coding process detailed in the QUAGOL methodology.ResultsThirty-eight publications met our criteria and were included. Publication dates ranged from 1984 to 2020, with 17 publications appearing between 2015 and 2020. Publications originated from all five major continents, as indicated by the affiliation of the first author. Our analyses revealed that the concept of vulnerability could be distinguished in terms of basic human and situational vulnerability. Six dimensions of older adults’ vulnerability were identified: physical; psychological; relational/interpersonal; moral; sociocultural, political, and economic; and existential/spiritual. This analysis suggested three ways to relate to older adults’ vulnerability: understanding older adults’ vulnerability, taking care of vulnerable older adults, and intervening through socio-political-economic measures.ConclusionsThe way in which vulnerability was conceptualised in the included publications overlaps with distinctions used within contemporary bioethics literature. Dimensions of aged care vulnerability map onto defining features of humans, giving weight to the claim that vulnerability represents an inherent characteristic of humans. Vulnerability is mostly a value-laden concept, endowed with positive and negative connotations. Most publications focused on and promoted aged care, strengthening the idea that care is a defining practice of being human.

Incorporation of an Efficient Pharmacist Workflow During the Transition From In-Person to Telemedicine Geriatric Clinics in Response to the COVID-19 Pandemic

The COVID-19 pandemic created care continuity challenges for older adults in the ambulatory care setting. Similarly, maintaining the multidisciplinary team concept of geriatric care among healthcare practitioners working from home presented several logistical difficulties. It became apparent there was a need to address these problems to avoid care gaps in this vulnerable population. Realizing that in-person clinics could put vulnerable older adults at increased risk of contracting COVID-19, a workflow was proactively developed to convert a traditional in-person multidisciplinary geriatric clinic to a telemedicine-based model. A video patient encounter option within our electronic health record along with a secure on-line meeting platform was used to maintain a team-based approach to care. This resulted not only in a high level of efficiency in care delivery, but also ensured the safety of older adult patients served by the clinic. This model provides a template for the continued use of telemedicine as a strategy for the care of vulnerable older adults who experience challenges with attending in-person clinics.

Pioneering COVID-19 Pandemic Partnerships: Federally Qualified Health Centers and Geriatric Workforce Enhancement Programs Work Together to Care for Diverse Underserved Older Adults.

Background: The COVID-19 pandemic disproportionately affected populations served by Federally Qualified Health Centers (FQHCs), with high morbidity and mortality rates in ethnic minority older adults. In response to this pandemic, academic geriatric medicine teams through federally funded Geriatric Workforce Enhancement Program (GWEP) with FQHC partnership implemented new initiatives to improve the care for vulnerable older adults. Objectives: To describe how four FQHC/GWEP teams collaborated in caring for diverse communities of older adults during the pandemic. Methods: Four GWEPs have addressed pandemic response efforts with their respective FQHC partners. These collaborations to meet the increasing numbers of older adults seeking services, and the rising disparities exacerbated during the pandemic are delineated. Results: FQHC/GWEP partnerships enabled access to care, whether in-person or virtually to serve unmet needs of underserved older adults during the pandemic. Partnerships promoted COVID-19 education, testing, and vaccinations. Most FQHCs faced severe staffing shortages, and the digital divide challenged patients with barriers. GWEPs provided direct care, created educational materials, and developed telehealth programs. These partnerships addressed social determinants of health gaps caused by the pandemic. Conclusion: The findings demonstrate that strong partnerships between GWEPs and FQHCs mitigate health inequities for vulnerable ethnic minority and rural older adults during pandemic crises.

Virtual Geriatric Education Preferences of Rural Social Workers

Older adults in rural communities need access to comprehensive healthcare services provided by practitioners equipped with geriatric knowledge and skills. The Geriatric Rural Extension of Expertise through Telegeriatric Service (GREETS) project goal is to use telemedicine and telehealth to expand geriatric service options to underserved Michigan regions. GREETS educational programs train health practitioners to provide geriatric care for vulnerable older adults. To determine gaps in geriatric competencies, the team conducted an online survey of health professionals including behavioral health practitioners. Respondents identified educational topics and preferred virtual delivery methods. Demographic information included respondent’s professional position, practice setting, and county. The respondents were asked to indicate level of educational need using a scale ranging from a low, medium, or high need. Fifty (47%) of 106 total responses were from social workers. We compared the percent of social workers to other practitioners’ responses in our analysis. Four topics emerged for both groups as medium or high educational needs: 1) transitional care when changing residential settings or post-hospitalization; 2) assisting family caregivers cope with caregiving responsibilities; 3) incorporating community-based services into care plans; and 4) and managing frail older adults. Social workers noted higher need than the other respondents for: 1) managing chronic pain; 2) managing care of patients with multiple chronic conditions; 3) having serious illness conversations; 4) diagnosing dementia; and 5) discussing advance care planning. Both social worker and other respondents indicated interactive case-based webinars; published tools, toolkits, tip sheets; and didactic webinars as their top three learning formats.

Identifying Research Priorities in Adult Day Centers to Support Evidence-Based Care of Vulnerable Older Adults.

Adult day centers (ADCs) are essential community resources that allow frail older adults to remain in their communities. Research demonstrates that ADC staff have the capacity to leverage their culturally and socially congruent relationships with clients and caregivers, to deliver evidence-based interventions that improve health outcomes. Yet, they remain a largely overlooked neighborhood resource for older adults with complex health care needs. The National Adult Day Services Association (NADSA) created a multistakeholder work group to identify priority areas for research to enhance the quality of services offered in ADCs and the delivery of evidence-based practices to clients. This perspective piece, which presents the workgroup's findings in the form of key research priorities, is intended as practical guide for researchers seeking to align their research questions with the needs of ADCs and those they serve. In addition to identifying areas of further exploration, we discuss current studies being undertaken within the ADC setting.

Advocacy as an Academic and Nurse Practitioner

The first speaker is Dr. Lori Martin-Plank, an established academic at the University of Arizona, College of Nursing. Dr. Martin-Plank will provide her experiences in advocating for older adults in Pennsylvania and nationally through professional organizations, meeting with coalition partners to promote access to care for vulnerable older adults in rural areas by promoting full practice authority for nurse practitioners, and advocating for full home health authority for nurse practitioners. Dr. Martin-Plank will share how she is active in advocacy and policy at the local, state and federal levels, and how to build a presence and relationship with legislators on The Hill and State Capitol. Dr. Martin-Plank is a family, gerontological, and mental health nurse practitioner, practicing in Pennsylvania, New Jersey, and Arizona.

POLICY MODIFICATION, CLINICIAN TRAINING, AND ENROLLMENT OF COMMUNITY-DWELLING OLDER ADULTS TO ADOPT A MODEL OF CARE

Partnering with a Medicaid Home and Community Based waiver, we tests implementation strategies on adoption and sustainability of a model of care to support aging-in-place, intervening on individual capabilities and the home environment. Knowledge-to-Action model underpins the 2-arm (usual care + internal facilitation versus additive external facilitation) 3-year randomized (sites) trial statewide using an implementation strategy bundle (relationship/coalition/team building; education; interdisciplinary care/coordination; facilitation; and audit/feedback). Consolidated Framework for Implementation Research guides examining characteristics (site/RN-OT-SW/beneficiary), clinician attitude/self-efficacy, leadership/readiness to implement, and policy on adoption and sustainability; and intervention impact on beneficiary outcomes. Linear models will be used to analyze fidelity, Poisson and bootstrapping gage adoption, sustainability, fidelity, and level of facilitation. Champions (internal facilitators/supervisors; N=57) were engaged and 33.3% (n=19) completed online training (1.5 hours; 7.0 [SD 2.3] understood role; 6.8 [SD 1.8] would use training: 1-10 [lo-hi]); 100% (N=19) attended monthly coalition-building meetings. RN-OT-SWs were recruited (mail); 608 of 685 (88.8%) consented and completed online education (5.5 hours; Certified). Policymakers included quality incentives in contracts (10/1/2019) with sites for >95% certified RN-OT-SWs. Beneficiaries (N=12,000) were recruited (mail); 5% (n=608) did not participate (16.1% [n=98] poor cognition; 11.5% [n=70] nursing home/assisted living; 7.1% [n=43] no needs; 5.9% [n=36] too sick; 5.2% [n=32] many caregivers; 5.1% [n=31] inability to improve]; no English/hospitalized/other). Stages of Implementation Completion and fidelity data (September/October) will be reported. Adoption of models of care to support aging-in-place in Medicaid settings are a challenge, and this research harnesses a network (university/policymaker/supervisors/waiver sites-clinicians/beneficiaries) to improve care for vulnerable older adults.

IMPACT OF A NURSE-BASED INTERVENTION ON MEDICATION OUTCOMES IN OLDER ADULTS: THE CC-MAP STUDY

AbstractMedication-related problems are common in older adults with multiple chronic conditions. Holistic, patient-centered approaches may be particularly well-suited to addressing the complex and disease-crossing nature of these problems. In this presentation, we will present results of a cluster-controlled clinical trial that evaluated the impact of a nurse-based primary care intervention on medication outcomes in 1,218 high-risk older Israeli adults. Our primary outcome was the number of changes to patients’ medication regimens, a marker of attention to patient-centered prescribing. After 9 months of follow-up, intervention subjects had more changes to their medication regimen than control subjects (mean 4.04 vs. 3.62 medication changes; adjusted difference 0.55, P=0.001). Similarly, intervention subjects had more changes to their symptomatic medications (mean 1.38 vs. 1.26 changes, adjusted difference 0.20, P=0.003). We will discuss how our findings inform a broader understanding of the role of nurse-based interventions in improving pharmaceutical care for vulnerable older adults.

Poor care and the professional duty of the registered nurse.

Concerns have been raised in recent years about standards of care in the UK. Notable failures have been identified in the care of vulnerable older adults. This article identifies and discusses some logical steps which might be taken to minimise the risk of individual and systemic care failure in settings for older adults. These steps include frank discussion about ageism to promote empowerment and respect for older people; ensuring robust policies are in place that support and encourage the reporting of poor care; and ensuring that registered practitioners are aware of their accountability for their actions and also their omissions should they witness poor care. In addition to reducing the risk of poor care, these steps could contribute to having a more confident, competent and empowered workforce.

Frailty: a tale of two concepts.

Frailty is increasingly relevant for clinicians to improve care for vulnerable older adults. Prominent frailty measures include the frailty phenotype and the frailty index. The frailty phenotype is grounded in a theoretical construct hypothesized to have an underlying biological basis. The frailty index describes frailty as a nonspecific age-associated vulnerability, reflected in an accumulation of medical, social, and functional deficits. Building on this model, Minitski et al. describe the development of a biological index that proves to be a reasonable method to predict mortality when compared to other frailty measurements. Strengths include its ability to import clinical measures, interchangeable components, and its potential ability to identify latent risk factors. Obstacles include the lack of a unifying biological theory related to aging, inclusion of costly research measures, and its inability to provide specific clues to the etiology of frailty according to the frailty index definition. Refinement in measures focused on aging-related biological changes rather than using measures that result from chronic disease states could help provide important biological insights and aid in the development of future treatment and preventive modalities.Please see related article: http://www.biomedcentral.com/1741-7015/13/161.

Hip fracture: a trigger for palliative care in vulnerable older adults.

examined the survival and functional outcomes after hip fracture in 60 111 US long-term nursing home residents who were hospitalized with an acute hip fracture. Using a retrospective cohort study design and large national data sets (Medicare claims and Nursing Home Minimum Data Set), this study characterized patterns and risk factors of survival and new total dependence in locomotion after hip fracture in this uniquely vulnerable subset of patients with hip fractures. By 180 days after hip fracture, 36% of patients had died, including 46% of all male patients. Moreover, among patients who had some degree of functional independence in locomotion at baseline, 54% had either died or developed new total dependence in locomotion within 180 days of hip fracture. In these patients, risk factors most highly associated with decreased survival and new total dependence in locomotion after hip fracture were nonoperative fracture management, male sex, age over 90 years, advanced comorbidity, and severe cognitive impairment. The novel findings from the study by Neuman and colleagues 4 have tremendous implications on the clinical care of vulnerable older adults with hip fractures. The prognostication of survival and functional outcomes after hip fracture in long-term nursing home patients has historically been a challenge for practitioners because of limited evidence in the medical literature. Results from the current study strongly demonstrate that mortality and functional dependence, particularly among the very old and those with advanced comorbidity and cognitive impairment, are exceedingly common among nursing home residents after hip fracture. These extreme rates of mortality and functional disability place palliative care, front and center, in the clinical management of hip fracture in vulnerable older adults. Palliative care is a new interdisciplinary specialty that focuses on improving quality of life for patients and families by providing an added layer of support (pain and symptom management, goals of care discussions, care coordination) in the setting of serious illness. Palliative care is provided concurrently with all other disease-directed or curative treatments. Hospice, conversely, is care focused exclusively on comfort for patients with a prognosis of 6 months or less if the disease follows its usual course and who are willing to relinquish curative treatments. Orthopedic surgery and rehabilitation facilitate early mobilization and are the standard and mainstay of hip fracture treatment (Figure). More often than not, palliative and hospice care are only considered in instances when a patient with hip fracture deteriorates beyond the point of achieving meaningful recovery despite receiving this “old” model of care. Given the high rates of mortality and functional dependence after hip fracture in nursing home residents, we conceive a “new” model for hip fracture care in which palliative care is implemented at the onset of hip fracture and complements standard care in postfracture management. Furthermore, hospice care should be considered and administered early if appropriate, in the most vulnerable nursing home residents including the oldest-old and those with advanced comorbidity and cognitive impairment. Palliative care program for long-term nursing home residents who sustained hip fracture must provide patientcentered comprehensive interdisciplinary care for the residents and their families, with particular focus on effective communication, care planning and coordination, symptom management, psychosocial, spiritual and bereavement sup

HIP FRACTURE IN A DEVELOPING COUNTRY: A PICTURE IN NEED OF CHANGE

Objectives: To describe the clinical profile, patterns of care and mortality rates of aged patients who have undergone hip fracture surgical repair. Design: Retrospective patient record study. Setting: A public university hospital in Rio de Janeiro, Brazil. Participants: 352 patients aged 60 and older who underwent surgery for hip fracture between 1995-2000. Measurements: Sociodemographic data, type of fracture, cause of fracture, time from fracture to surgery, physical status, Charlson comorbidity index, type of surgery and anesthesia, access to in-hospital physiotherapy, use of antibiotic and thromboembolism prophylaxis, and mortality within one year after hospital admission. Results: Among 352 subjects, 74.4% were women. The mean age overall was 77.3 years. Very long delays from the time of fracture to hospital admission (mean 3 days) and from hospital admission to surgery (mean 13 days) were observed. Most femoral neck fractures (82.7%) were managed by hip arthroplasties, while 92.8% of the intertrochanteric fractures underwent internal fixation procedures. Less than 10% of patients received in-hospital physiotherapy. Mortality rates 30 days, 90 days and one year after hospital admission were 3.4%, 8.0% and 13.4%, respectively. Conclusion: Our study provides evidence within the context of a developing country of major gaps in the quality of care of vulnerable older adults who suffered a hip fracture. Our findings suggest that hip fracture has not been treated as an urgent condition or a priority within the Brazilian public healthcare system. Further research should address current patterns of care for hip fracture in Brazil and in other developing countries.

The Health of Geriatrics in Canada —More Than Meets the Eye

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Nurse Care Manager Contribution to Quality of Care in a Dual-Eligible Special Needs Plan

We evaluated the quality of care provided to older patients with complex needs in a dual-eligible, community-based Medicare Special Needs Plan that used a nurse care manager model. Care provided by physicians was substantially supplemented by nurse care managers, as measured by Assessing Care of Vulnerable Elders quality indicators. We describe selected nurse care manager activities for six geriatric conditions (falls, dementia, depression, nutrition, urinary incontinence, and end-of-life care) during provision of patient care coordination and management for patients in the highest decile of clinical complexity. We identify areas of high nurse performance (i.e., falls screening, functional assessment, behavioral interventions for dementia problems, advance care planning) and areas of potential missed opportunities (i.e., follow up for new memory problems, targeted dementia counseling, nutrition, and behavioral approaches to urinary incontinence). Increasing the collaborative interaction between nurses providing care in this model and physicians has the potential to enhance nurses' contributions to primary care for vulnerable older adults.

After the End of Free Fall: Geriatricizing Primary Care

After the End of Free Fall: Geriatricizing Primary Care