Care For Vulnerable Older Adults Research Articles

Selecting process quality indicators for the integrated care of vulnerable older adults affected by cognitive impairment or dementia

BackgroundThis study aimed at evaluating face and content validity, feasibility and reliability of process quality indicators developed previously in the United States or other countries. The indicators can be used to evaluate care and services for vulnerable older adults affected by cognitive impairment or dementia within an integrated service system in Quebec, Canada.MethodsA total of 33 clinical experts from three major urban centres in Quebec formed a panel representing two medical specialties (family medicine, geriatrics) and seven health or social services specialties (nursing, occupational therapy, psychology, neuropsychology, pharmacy, nutrition, social work), from primary or secondary levels of care, including long-term care. A modified version of the RAND®/University of California at Los Angeles (UCLA) appropriateness method, a two-round Delphi panel, was used to assess face and content validity of process quality indicators. The appropriateness of indicators was evaluated according to a) agreement of the panel with three criteria, defined as a median rating of 7–9 on a nine-point rating scale, and b) agreement among panellists, judged by the statistical measure of the interpercentile range adjusted for symmetry. Feasibility of quality assessment and reliability of appropriate indicators were then evaluated within a pilot study on 29 patients affected by cognitive impairment or dementia. For measurable indicators the inter-observer reliability was calculated with the Kappa statistic.ResultsInitially, 82 indicators for care of vulnerable older adults with cognitive impairment or dementia were submitted to the panellists. Of those, 72 (88%) were accepted after two rounds. Among 29 patients for whom medical files of the preceding two years were evaluated, 63 (88%) of these indicators were considered applicable at least once, for at least one patient. Only 22 indicators were considered applicable at least once for ten or more out of 29 patients. Four indicators could be measured with the help of a validated questionnaire on patient satisfaction. Inter-observer reliability was moderate (Kappa = 0.57).ConclusionA multidisciplinary panel of experts judged a large majority of the initial indicators valid for use in integrated care systems for vulnerable older adults in Quebec, Canada. Most of these indicators can be measured using patient files or patient or caregiver interviews and reliability of assessment from patient-files is moderate.

Family Conflict at the End of Life: Lessons Learned in a Model Program for Vulnerable Older Adults

Purpose: This study examined the extent and nature of family conflict addressed by interdisciplinary team members caring for low-income older adults with advanced chronic disease in their last 6 months of life. Design and methods: The results are drawn from a larger longitudinal, multimethod case study designed to understand how end-of-life care is provided in an innovative, fully “integrated” community-based managed care program serving low-income, frail elders. Sources of data analyzed include quantitative and qualitative responses from survey data on 120 deceased elders, five focus groups with interdisciplinary team members, and two in-depth interviews with social workers. Results: Family conflict was present among 55% of the sample, and rated as somewhat to extremely important in 44% of the deaths. Team members felt that they were either very or extremely successful in addressing conflict in only 38% of the deaths. An explanatory matrix of family conflict at the end of life was developed depicting (1) the nature of end-of-life conflict, (2) family context, (3) conditions, (4) contributing factors, (4) intervening processes, and (5) consequences. Subcategories of each component of the theoretical model were identified and are illustrated by the narrative data. Implications: The “lessons learned” in this setting suggest program development and practice recommendations for addressing family conflict and improving end-of-life care for vulnerable older adults and their family members.

Tribute to David H. Solomon, MD, for his contributions to geriatrics and gerontology, on his 80th birthday.

Rarely in our lifetimes do we have the opportunity to meet an extraordinary individual who transcends what we expect, aspire to, do, or succeed in our daily lives. Such a person touches, influences, and changes us in different ways, under different circumstances, and at different times. But, always, that person somehow makes us better, helps us achieve greater heights, and teaches us how to be a nicer human being. Those of us who have been in the field of aging have had the good fortune of meeting, knowing, interacting, and learning from one such individual—David H. Solomon, MD. In this supplement issue of the Journal of the American Geriatrics Society, the editors give homage and pay tribute to Dr. Solomon for his enormous contributions to geriatrics and gerontology as part of the celebration of his 80th birthday. Dr. Solomon had an extraordinarily successful academic career as an endocrinologist—with his pioneering work in thyroid diseases—and as chairman of a department of internal medicine at one of the finest universities in the United States. After “retiring” from his chairmanship, Dr. Solomon returned to one of his original areas of academic endeavors—the field of aging. He immersed himself with his usual energy, enthusiasm, and commitment in a variety of areas in geriatrics and gerontology. Dr. Solomon's own interest in thyroid disease helped pave the way for his contributions toward understanding the clinical subtleties and nuances of hyper- and hypothyroidism in the elderly. After taking a sabbatical in the early 1980s at RAND in Santa Monica, California, Dr. Solomon focused on the issue of lack of sufficient geriatricians to care for the rapidly growing aging population in the United States. He later dedicated his efforts to assessing and developing new methods to measure the quality of care for vulnerable older adults. More recently, Dr. Solomon has provided the leadership on a major project supported by the American Geriatrics Society and the Hartford Foundation to increase geriatrics expertise in the surgical and related medical specialties. Despite this multitude of academic contributions and endeavors in geriatrics, Dr. Solomon still managed to find time to develop the Center on Aging at the University of California at Los Angeles campus, and become its first director. In addition, Dr. Solomon was editor-in-chief of the Journal of the American Geriatrics Society from 1988 to 1993. And all of these activities in geriatrics and gerontology began around the young age of 60! To recognize his extraordinary contributions to the field of aging during the past 20 years, the Journal is devoting this special supplement issue to honoring Dr. Solomon. The editors have invited noted authors to contribute an article in one of the five areas of contributions made by Dr. Solomon in the field of aging: geriatric endocrinology, geriatric manpower and training, quality of care of older adults, general surgery and aging, and geriatric urology. In addition, the editors have contributed a brief biography of Dr. Solomon. Finally, to recognize Dr. Solomon in a more personal manner, an 80th birthday celebration was held on March 8, 2003, (March 7 is his actual birthday) at the Loews Santa Monica Beach Hotel in Santa Monica, California. Dinner, special tributes, and gifts were part of a wonderful evening for a truly great person. Family, friends, and colleagues in geriatrics and gerontology honored and thanked Dr. Solomon for his contributions to aging and, equally important, for his positive influence on the lives of many who have been fortunate and privileged to know this fine and humble human being.