Involvement Of Older Patients Research Articles

Randomised feasibility trial and embedded qualitative process evaluation of a new intervention to facilitate the involvement of older patients with multimorbidity in decision-making about their healthcare during general practice consultations: the VOLITION study protocol

BackgroundThe number of older people with multiple health problems is increasing worldwide. This creates a strain on clinicians and the health service when delivering clinical care to this patient group, who themselves carry a large treatment burden. Despite shared decision-making being acknowledged by healthcare organisations as a priority feature of clinical care, older patients with multimorbidity are less often involved in decision-making when compared with younger patients, with some evidence suggesting associated health inequalities. Interventions aimed at facilitating shared decision-making between doctors and patients are outdated in their assessments of today’s older patient population who need support in prioritising complex care needs in order to maximise quality of life and day-to-day function.AimsTo undertake feasibility testing of an intervention (‘VOLITION’) aimed at facilitating the involvement of older patients with more than one long-term health problem in shared decision-making about their healthcare during GP consultations.To inform the design of a fully powered trial to assess intervention effectiveness.MethodsThis study is a cluster randomised controlled feasibility trial with qualitative process evaluation interviews. Participants are patients, aged 65 years and above with more than one long-term health problem (multimorbidity), and the GPs that they consult with. This study aims to recruit 6 GP practices, 18 GPs and 180 patients. The intervention comprises two components: (i) a half-day training workshop for GPs in shared decision-making; and (ii) a leaflet for patients that facilitate their engagement with shared decision-making. Intervention implementation will take 2 weeks (to complete delivery of both patient and GP components), and follow-up duration will be 12 weeks (from index consultation and commencement of data collection to final case note review and process evaluation interview). The trial will run from 01/01/20 to 31/01/21; 1 year 31 days.DiscussionShared decision-making for older people with multimorbidity in general practice is under-researched. Emerging clinical guidelines advise a patient-centred approach, to reduce treatment burden and focus on quality of life alongside disease control. The systematic development, testing and evaluation of an intervention is warranted and timely. This study will test the feasibility of implementing a new intervention in UK general practice for future evaluation as a part of routine care.Trial registrationCLINICAL TRIALS.GOV registration number NCT03786315, registered 24/12/18

RDH5-Related Fundus Albipunctatus in a Large Japanese Cohort.

PurposeTo investigate clinical characteristics of RDH5-related fundus albipunctatus (FAP) in a Japanese cohort.MethodsTwenty-five patients from 22 pedigrees with RDH5-related FAP were studied. Ophthalmic medical records were reviewed. For genetic analysis, either Sanger sequencing of the RDH5 gene or whole-exome sequencing was performed.ResultsGenetic analysis identified eight different RDH5 variants, including seven known RDH5 variants (p.G35S, p.G107R, p.R167H, p.A240GfsX19, p.R278X, p.R280H, and p.L310delinsEV) and a novel variant: c.259C>T (p.Q87X). The most frequently observed variant was p.L310delinsEV (65.2%, 30/46 alleles). Of 50 eyes examined, 44 eyes (88.0%) showed logMAR best-corrected visual acuity (BCVA) of 0.10 or better. In optical coherence tomography, macular involvement was observed in 12 patients (24 eyes). Ten patients (83.3%) who had good BCVA (0.10 or better) exhibited diffuse disruption of the outer retina with foveal sparing, and two patients (16.7%) exhibited diffuse disruption throughout the macula and decreased BCVA. Among the 24 eyes, ring-or crescent-shaped hyperautofluorescence or irregular autofluorescence around the fovea was observed in 15 eyes (83.3%) of 18 eyes examined by fundus autofluorescence imaging. Full-field electroretinography showed extinguished or severely decreased rod responses in all 23 examined patients, whereas decreased cone responses were seen in 17 patients (73.9%).ConclusionsMultimodal imaging and electroretinography of RDH5-related FAP revealed high frequencies of macular involvement in older patients and decreased cone responses. Our findings suggest that progressive macular/cone dysfunction, as well as delayed rod function, may be key phenotypic features of RDH5-related FAP.

Visualization of Cardiac Implantable Electronic Device Data for Older Adults Using Participatory Design.

Patients with heart failure (HF) are commonly implanted with cardiac resynchronization therapy (CRT) devices as part of their treatment. Presently, they cannot directly access the remote monitoring (RM) data generated from these devices, representing a missed opportunity for increased knowledge and engagement in care. However, electronic health data sharing can create information overload issues for both clinicians and patients, and some older patients may not be comfortable using the technology (i.e., computers and smartphones) necessary to access this data. To mitigate these problems, patients can be directly involved in the creation of data visualization tailored to their preferences and needs, allowing them to successfully interpret and act upon their health data. We held a participatory design (PD) session with seven adult patients with HF and CRT device implants, who were presently undergoing RM, along with two informal caregivers. Working in three teams, participants used drawing supplies and design cards to design a prototype for a patient-facing dashboard with which they could engage with their device data. Information that patients rated as a high priority for the "Main Dashboard" screen included average percent pacing with alerts for abnormal pacing, other device information such as battery life and recorded events, and information about who to contact with for data-related questions. Preferences for inclusion in an "Additional Information" display included a daily pacing chart, health tips, aborted shocks, a symptom list, and a journal. These results informed the creation of an actual dashboard prototype which was later evaluated by both patients and clinicians. Additionally, important insights were gleaned regarding the involvement of older patients in PD for health technology.

PREVALENCE RATE AND IMPACT OF ADDICTIVE DISORDERS ON THE COURSE OF HIV-INFECTION IN IN-PATIENTS

Aim of the study. To make an analysis of the prevalence rate and the impact of addictive disorders on the course of HIV-infection and evaluate the efficacy of the antiretroviral therapy. Methods and Materials. The retrospective analysis of medical records of HIV-positive patients, examined by the narcologist in the S.P. Botkin Clinical Infectious Diseases Hospital during the period of from September to November in 2014 and 2016. Results. Half of the patients (576 out of 1164 patients, 49.5%) treated in HIV-infection hospital required consultation of narcologist. In 2014 and 2016 men were more prevalent among such patients (73% and 76% accordingly), with a trend toward the involvement of older patients. Most prevalent narcological pathology among HIV-positive patients was opioid dependence (48% and 45% accordingly). Despite an increase of absolute numbers of narcologist’s consultations in 2016 the only group in which the relative gain from 17% to 26% was observed there was a group of patients suffered both opioid dependency and chronic alcoholism simultaneously. According to our data odds ratio for starting antiretroviral therapy in the hospital were higher in women and in patients with remission of chronic alcoholism. Percentage of patients who started antiretroviral therapy was insufficient - 30% among patients discharged after the complete in-hospital stay. Conclusion. The pattern of HIV epidemic among patients with addictive disorders does not differ from the general HIV-positive population. The gain in percentage of patients with comorbidity such as opioid dependency with alcohol abuse was observed. Patients manifested the alcohol abuse at the time of admission have lower chances to begin to receive ARVT comparing to those who were in remission.

P-236: The involvement of older patients in medical student education from the University of Oxford

P-236: The involvement of older patients in medical student education from the University of Oxford

Spouses’ involvement in older patients’ fast‐track programmes during total hip replacement using case management intervention. A study protocol of the SICAM‐trial

To present the protocol of a two-group quasi-experimental study of spouses' involvement through case management (The SICAM-trial) in older patients' fast-track programmes during total hip replacement. Patients in fast-track programmes are required to take an active part in their treatment and rehabilitation. Spouses of older patients can often provide valued practical and emotional support, reducing stress, pain and length of stay - yet they are seldom invited to participate in a supporting role. A two-group quasi-experimental design with pre-test and repeated post-test measures (protocol approved in November 2012). A total of 120 patients aged 65years or older going through a fast-track programme for a total hip replacement and their spouses will be recruited from one Danish orthopaedic ward. We will initially include the control group for data collection and subsequently include the intervention group to avoid contamination of the control group. A case manager will be recruited to perform the case management intervention. Data will be collected from both groups at baseline, 2weeks and 3months after surgery. Outcome measures for patients include: functional status, nutrition, pain, depression and healthcare consumptions; and for spouses: caregiver satisfaction and difficulties and anxiety. The intervention will give further evidence on the need for relatives' participation in the patients' fast-track programmes and the results will contribute to education of the health professionals in their need to include relatives in fast-track programmes. The study was funded by the Novo Nordisk Foundation and the Regional Health Scientific Foundation of Sealand.

Age and Lymph Node Status in Breast Cancer: Not a Straightforward Relationship

Age and Lymph Node Status in Breast Cancer: Not a Straightforward Relationship

How do older patients and their GPs evaluate shared decision-making in healthcare?

BackgroundOlder persons represent a growing share of the population, yet very little is known about their specific healthcare needs, problems, and expectations. IMPROVE is an international research project that seeks to improve elderly persons' involvement in their healthcare. This paper analyzes perceptions of patient involvement by elderly patients and their GPs in family medicine in Slovenia.MethodsSemi-structured interviews with patients over 70 and their GPs were audio-taped and transcribed. The interviews were analyzed using qualitative content analysis.ResultsSpecific characteristics of old age must be taken into account in the involvement of older patients. It is important to know the patient's expectations and to communicate clearly with the patient. A trusting relationship between the GP and the patient is a prerequisite for involvement. GPs center involvement on the GP's side. Involvement of the elderly is linked to ethical dilemmas.ConclusionUnderstanding the involvement of the elderly focuses more on building a relationship than on making decisions. It is reasonable to educate GPs and GPs' coworkers about caring relationships. Ethical aspects have often been treated in a theoretical manner, whereas empirical practice may be entirely different from theoretical premises. GPs and older patients must learn more about how to address their ethical dilemmas.

Evaluation of an intervention designed to enhance involvement of older patients in their own care

Objective: To implement a programme for involvement of older patients aged 70+ in general practice, and to detect quality changes after its implementation. Methods: The study was performed in 11 European countries as an uncontrolled before-and-after study, in which a number of GPs and patients answered a questionnaire before and after receiving an intervention. The intervention was aimed at motivating, instructing and facilitating GPs and older patients to increase patient involvement during consultation by use of a specially designed consultation leaflet. Results: Valid data from seven countries exist. There was a total of 765 patients and 70 GPs in the pre-intervention phase, and 564 patients and 49 GPs in the post-intervention phase. In the post-intervention group, 43% of the patients thought that the consultation leaflet had improved the consultation and 62% of the GPs found it to be useful. There were no significant differences between pre- and post-intervention patient perceptions of the level of involvement, evaluations of consultations and perceptions of feeling enabled to deal with their health situation.Conclusion: Quality of consultations as measured by patient satisfaction and patient enablement did not improve as a result of the intervention, but nearly half of the patients and two thirds of the GPs found the intervention to be useful. Unselected use of this intervention on all patients cannot be advised without further studies on possible effects. Future studies should focus on the applicability and benefits of the methods for special patient groups.

Analysis of 388 cases of primary sclerosing cholangitis in Japan; Presence of a subgroup without pancreatic involvement in older patients.

We analyzed 388 cases of primary sclerosing cholangitis (PSC) in Japan, according to a questionnaire sent to gastroenterologists. There was male predominance (59%), and interestingly there were two peaks in the age distribution as seen in the previous study. Jaundice and itching, major symptoms in PSC patients included in the diagnostic criteria, were observed only 28 and 16%, respectively. Alkaline phosphatase level was less than twofold of the upper limit of the normal range in 35%. In this regard, the diagnostic criteria in 2003 from Mayo Clinic, including cholestatic symptoms and two to three-fold increases in serum alkaline phosphatase, should be modified in Japan. Inflammatory bowel diseases were complicated in 37%, and autoimmune pancreatitis (AIP) in 7.2%. PSC cases with inflammatory bowel diseases were younger than the average, creating the first peak in the age distribution, and have similar characteristics compared to patients with PSC in foreign countries. By contrast, those with AIP, who were more than 50 years old, responded well to corticosteroid therapy. In addition, even after the exclusion of cases of sclerosing cholangitis complicated with AIP, the second peak in the age distribution was clearly evident. Therefore, we conclude that PSC patients without apparent involvement of the pancreas are present in the older patients and seem to be specific in Japan.

Myasthenia gravis with ocular involvement in older patients

Background: There has been little previous study reporting the eye findings and presentation of elderly patients with myasthenia gravis. The purpose of this study was to review the findings and course of myasthenia gravis after the sixth decade of life.Methods: Retrospective observational case series. The authors reviewed the clinical records of 27 patients with onset of myasthenia gravis at age 60 years or more who were seen at a tertiary care academic ophthalmology centre in Houston between January 1992 and March 1999. The diagnosis of myasthenia gravis was based on conventional clinical and laboratory criteria.Results: Twenty patients (74%) were men. Of the 16 patients who underwent testing for anti-acetylcholine receptor antibodies, I I (69%) were seropositive. Concurrent thyroid disease was found in seven patients (26%), including five (71 %) of the seven women. No patient had thymoma. Sixteen patients (59%) manifested generalized symptoms during follow-up; 12 did so within I year of disease onset. Patients responded well to both anticholinesterase and corticosteroid therapy. At the most recent follow-up visit 18 patients (67%) were clinically improved, and no patient was clinically worse.Interpretation: Myasthenia gravis in this study was characterized by a male predominance, high rate of concurrent thyroid disease, high rate of progression to mild generalized symptoms, absence of thymoma, good response to medical therapy and minimal life-threatening complications. Clinicians should consider the diagnosis of myasthenia gravis in an older patient presenting with diplopia or ptosis.

Impact of lymph node metastasis in differentiated carcinoma of the thyroid: A matched‐pair analysis

Background Cervical lymph node metastasis in differentiated thyroid carcinoma has mostly been found to have little relationship to prognosis. However, some studies report nodal involvement to be an adverse factor, while others have found it to be favorable. We have undertaken a matched-pair analysis of previously untreated patients, with and without ipsilateral neck metastasis, to examine the significance of nodal spread in patients with otherwise equivalent prognostic factors for differentiated thyroid cancer. Method From a database of 931 patients, treated from 1930 to 1980, we used a computer to match patients with confirmed lateral neck metastasis (N1) to those who were stage NO, and had the following identical prognostic factors: no distant metastasis, age (within 4 years), and tumor size, histology, and intrathyroidal extent. When possible, matches were also made for gender, multifocality, and extent of thyroid surgery. Survival and treatment failures were analyzed, with and without stratification for age. Results We were able to select 100 N1 patients with corresponding NO patients, sharing the major prognostic risk factors as listed. Overall, there was no difference in survival, although N1 patients more often had recurrence. Mortality increased with age. Analysis at high-risk age (45 years and older) showed significantly more recurrences in N1 patients (p = .008). Twenty-year survival in N1 patients over the age of 45 was lower than that of NO patients. On the other hand, under the age of 45, N1 patients had better survival. These differences, however, did not reach statistical significance. Conclusion Nodal involvement in older patients with thyroid cancer increases the risk of recurrence, although no significant difference in survival is observed in relation to age. HEAD & NECK 1996;18:127–132 © 1996 John Wiley & Sons, Inc.

Impact of lymph node metastasis in differentiated carcinoma of the thyroid: a matched-pair analysis.

Cervical lymph node metastasis in differentiated thyroid carcinoma has mostly been found to have little relationship to prognosis. However, some studies report nodal involvement to be an adverse factor, while others have found it to be favorable. We have undertaken a matched-pair analysis of previously untreated patients, with and without ipsilateral neck metastasis, to examine the significance of nodal spread in patients with otherwise equivalent prognostic factors for differentiated thyroid cancer. From a database of 931 patients, treated from 1930 to 1980, we used a computer to match patients with confirmed lateral neck metastasis (N1) to those who were stage NO, and had the following identical prognostic factors: no distant metastasis, age (within 4 years), and tumor size, histology, and intrathyroidal extent. When possible, matches were also made for gender, multifocality, and extent of thyroid surgery. Survival and treatment failures were analyzed, with and without stratification for age. We were able to select 100 N1 patients with corresponding NO patients, sharing the major prognostic risk factors as listed. Overall, there was no difference in survival, although N1 patients more often had recurrence. Mortality increased with age. Analysis at high-risk age (45 years and older) showed significantly more recurrences in N1 patients (p = .008). Twenty-year survival in N1 patients over the age of 45 was lower than that of NO patients. On the other hand, under the age of 45, N1 patients had better survival. These differences, however, did not reach statistical significance. Nodal involvement in older patients with thyroid cancer increases the risk of recurrence, although no significant difference in survival is observed in relation to age.

顎関節症患者における顎関節部の骨変化について 特に臼歯欠損との関係について

Bone change in the temporomandibular joint (TMJ) in 540 patients with TMJ disorders was studied radiographically in relation to the loss of premolar and/or molar support.The incidence of bone change (erosion or deformity) which was observed in 49. 404 of the patients was higher in female patients and showed a tendency to increase in older pati-ents. The bone change was noted in the symptomatic side in 72.3%, in the asymptcmatic side in 13.5% and bilaterally in 14.2% with an increase of bilateral involvement in older patients. The joint pain and the limited range of motion of the mandible were seen significantly higher in patients with bone change at the initial examination. The bone change was observed in 56.4% of patients with loss of premohr and/or molar support which was significantly higher than 40.4% of the patients without loss. The number of patients with loss of premolar and/or molar support and the incidence of bone change seen in these patients increased with age.The results indicate that the loss of premolar and/or molar support is one of the factors leading to bone change in TMJ

Auto-sensitization in infectious eczematoid dermatitis.

Thirty cases of infectious eczematoid dermatitis were studied and form the basis of this report; 10 of the patients were in preadolescence, and 20 were beyond that stage of life. Involvement of practically every part of the skin was seen in the series, but the ears, nares and face were the predominant sites primarily involved in children, while the legs and feet were the commonest sites of primary involvement in older patients. The eruption was widespread with id formation in 19 cases (in nine of these cases there was a familial history of allergy) and localized in 11 cases (in only two of these cases was there a familial history of allergy.) Sixteen patients had had previous bouts of similar skin disease. All but three of the 30 patients had received local and/or systemic therapy for their current episode prior to seeking the aid of a dermatologist, often with