Routine Care For Older Adults Research Articles

Barriers and facilitators to the uptake of electronic collection and use of patient-reported measures in routine care of older adults: a systematic review with qualitative evidence synthesis.

The aims of this systematic review were to (1) synthesize the available qualitative evidence on the barriers and facilitators influencing implementation of the electronic collection and use of patient-reported measures (PRMs) in older adults' care from various stakeholder perspectives and (2) map these factors to the digital technology implementation framework Non-adoption, Abandonment, challenges to the Scale-up, Spread, Sustainability (NASSS) and behavior change framework Capability, Opportunity, Motivation, Behaviour (COM-B). A search of MEDLINE, CINAHL Plus, and Web of Science databases from 1 January 2001 to 27 October 2021 was conducted and included English language qualitative studies exploring stakeholder perspectives on the electronic collection and use of PRMs in older adults' care. Two authors independently screened studies, conducted data extraction, quality appraisal using the Critical Appraisal Skills Programme (CASP), data coding, assessed confidence in review findings using Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative Research (GRADE CERQual), and mapped the findings to NASSS and COM-B. An inductive approach was used to synthesize findings describing the stakeholder perspectives of barriers and facilitators. Twenty-two studies were included from the 3368 records identified. Studies explored older adult, caregiver, healthcare professional, and administrative staff perspectives. Twenty nine of 34 review findings (85%) were graded as having high or moderate confidence. Key factors salient to older adults related to clinical conditions and socio-cultural factors, digital literacy, access to digital technology, and user interface. Factors salient to healthcare professionals related to resource availability to collect and use PRMs, and value of PRMs collection and use. Future efforts to implement electronic collection and use of PRMs in older adults' care should consider addressing the barriers, facilitators, and key theoretical domains identified in this review. Older adults are more likely to adopt electronic completion of PRMs when barriers associated with digital technology access, digital literacy, and user interface are addressed. Future research should explore the perspectives of other stakeholders, including those of organizational leaders, digital technology developers and implementation specialists, in various healthcare settings and explore factors influencing implementation of PREMs. CRD42022295894.

The effectiveness of emotion-oriented approaches on psychological outcomes and cognitive function in older adults: A meta-analysis of randomised controlled trials.

Emotion-oriented approaches have demonstrated effectiveness in the care of the elderly. However, related studies have reported conflicting results. We aimed to explore the pooled effect of emotion-oriented approaches on the psychological outcomes and cognitive function of older adults through a meta-analysis of randomised controlled trials (RCTs). We searched eight databases - CINAHL, Cochrane, Embase, Ovid MEDLINE, PsycINFO, PubMed, Scopus, and Web of Science - for RCTs from inception to 11 January 2024. Participants aged 60 years or older who received emotion-oriented approaches as the intervention, and reported outcomes of interest in the studies were included. The primary outcome was psychological outcomes (depression, self-esteem, life satisfaction and loneliness), and the secondary outcome was global cognitive function. The pooled effect size was computed in comprehensive meta-analysis 3.0 software using Hedges' g (g) with random-effects model. Furthermore, heterogeneity was assessed through Cochrane's Q and I2 tests. The quality of the included studies was evaluated using the Cochrane Risk of Bias tool. To explore potential sources of heterogeneity, moderator analyses were conducted. We included 37 RCTs and found that emotion-oriented approaches improve depression (g = -0.82, 95% CI = -1.08, -0.56), self-esteem (g = 0.98, 95% CI = 0.31, 1.64), life satisfaction (g = 0.63, 95% CI = 0.37, 0.88), loneliness (g = -2.22, 95% CI = -3.80, -0.64) and global cognitive function (g = 0.34, 95% CI = 0.19, 0.49) in older adults. We also observed significant follow-up effects on depression (g = -1.40, 95% CI = -2.45, -0.34) and loneliness (g = -3.48, 95% CI = 6.02, -0.94). Emotion-oriented approaches are promising interventions in improving psychological outcomes and global cognitive function in older adults. Health care workers should receive training to promote and integrate emotion-oriented approaches into routine care of older adults emphasising the importance of collaborative efforts among health care professionals and caregivers to ensure holistic care delivery.

Feasibility of integrating geriatric oncology and palliative care assessment into the routine care of older adults in a community setting.

e24024 Background: Emerging data support the value of geriatric assessment (GA) and palliative care (PC) domains in determining treatment for older adults with cancer. Limited data exist on the ability to integrate GA and PC in a community oncology clinic. The objective of this study was to determine the feasibility of integrating GA and PC screening in the community. Methods: Patients ≥ 75 were eligible. The GA included a health care provider assessment of performance status, cognitive function, functional status, psychological state, social support, and nutritional status. PC assessment included ESAS questionnaire, patient goals and values, advance care plans, and caregiver distress. Results: From September 2021 to Jan 2023, 131 consecutive older adults were assessed in one community clinic in the State of New Jersey, a satellite of the University of Pennsylvania. The median age was 82 (range 75-97). Using the VES-13 survey, 11% of patients were fit, 60% vulnerable and 29% frail. Issues were noted in cognition (11%), psychological state (27%), social support (38%), and nutrition (26%). The majority of patients prioritized quality of life over time (73%) and maintenance of independence was often cited as the most important goal (62%). Fewer than half of patients had formal advance directives (42%). 32% of the time, the final plan deviated from standard of care to align with patient/caregiver values. Conclusions: Integration of GA and PC is feasible in the community oncology setting. Further study is planned to evaluate the impact on patient and caregiver outcomes, and to standardize assessment for routine care across all Penn Medicine clinics.

Apixaban Concentrations in Routine Clinical Care of Older Adults With Nonvalvular Atrial Fibrillation

BackgroundDirect-acting oral anticoagulants are first-line agents for prevention of stroke in patients with nonvalvular atrial fibrillation (NVAF), but data are limited for the oldest patients, and with reduced dosing. ObjectivesThe purpose of this study was to determine steady-state apixaban peak and trough concentrations during routine care of older adults with NVAF, compare concentrations to clinical trial concentrations, and explore factors associated with concentrations. MethodsA cross-sectional study of medically stable older adults with NVAF (age ≥75 years or ≥70 years if Black) receiving apixaban. Peak (2.0-4.4 hours post-dose) and trough (before next dose) concentrations were determined by anti-Xa activity calibrated chromogenic assay. Patient characteristics associated with concentrations were determined by multivariate modeling. ResultsThe median age of patients (n = 115) was 80 (interquartile range: 77-84) years. The cohort comprised 46 women and 69 men; of which 98 are White, 11 are Black, and 6 are Asian. With 5 mg twice daily per labelling (n = 88), peak concentrations were higher in women: 248 ± 105 vs 174 ± 67 ng/mL in men (P < 0.001) and exceeded expected 95% range in 6 of 30 vs 0 of 55 men (P = 0.002). With 2.5 mg twice daily per label (n = 11), concentrations were <5 mg twice daily (peak: 136 ± 87 vs 201 ± 90 ng/mL, P = 0.026; trough: 65 ± 28 vs 109 ± 56 ng/mL, P < 0.001), but not different than 2.5 mg twice daily without reduction criteria (n = 13; peak: 132 ± 88 ng/mL; trough: 65 ± 31 ng/mL). Covariates associated with concentrations included sex, number of daily medications, and creatinine clearance. ConclusionsOlder women had higher than expected peak apixaban concentrations, and 2.5 mg twice daily produced lower concentrations than standard dosing. Factors not currently included in dosing recommendations affected concentrations. The impact of apixaban concentrations on outcomes needs evaluation.

Barriers and Facilitators for the Implementation of Geriatric Oncology Principles in Mexico: A Mixed-Methods Study.

PURPOSEThere is limited information regarding the use of the geriatric assessment (GA) for older adults with cancer in developing countries. We aimed to describe geriatric oncology practice among Mexican oncology professionals and to identify barriers and facilitators for the implementation of GA into the routine care of older adults with cancer in Mexico.METHODSWe conducted an explanatory sequential mixed-methods study. We administered an online survey to cancer specialists in Mexico about the routine use of GA and barriers for its use. We then conducted online semistructured interviews with survey respondents selected by their use of GA, expanding on barriers and facilitators for performing GA. Descriptive statistical analyses were performed for quantitative data; qualitative data were analyzed inductively through thematic analysis. We developed joint displays to integrate quantitative/qualitative results.RESULTSWe obtained 196 survey responses: 37 physicians (18.9%) reported routinely performing a GA. Medical oncologists (P = .002) and physicians seeing ≤ 10 patients/day (P = .010) were more likely to use GA. The most frequent barriers for GA use were lack of qualified personnel (49%), limited knowledge (43.9%), and insufficient time (37.2%). In the interviews (n = 22), the limited availability of geriatricians was commonly mentioned. Respondents highlighted the lack of geriatric oncology knowledge among cancer specialists and geriatricians. Saturation of oncology services and a lack of effective referral pathways for GA were also common issues. Facilitators included availability of geriatricians, system/administrative facilitators, presence of a multidisciplinary team, and availability of geriatric oncology education.CONCLUSIONThe routine use of geriatric oncology principles in Mexico is limited by the availability of qualified personnel and by insufficient knowledge. An educational intervention could improve the implementation of GA in cancer care.

An overview of chemotherapy toxicity prediction tools in older adults with cancer: A young international society of geriatric oncology and nursing and allied health initiative

An overview of chemotherapy toxicity prediction tools in older adults with cancer: A young international society of geriatric oncology and nursing and allied health initiative

Integration of a Geriatric Assessment With Intervention in the Care of Older Adults With Hematologic Malignancies.

The incidence of hematologic malignancies (HMs) is highest in the seventh decade of life and coincides with increasing occult, age-related vulnerabilities. Identification of frailty is useful in prognostication and treatment decision-making for older adults with HMs. This real-world analysis describes 311 older adults with HMs evaluated in a multidisciplinary oncogeriatric clinic. The accumulation of geriatric conditions [1-unit increase, hazards ratio (HR) = 1.13, 95% CI 1.00–1.27, p = 0.04] and frailty assessed by the Rockwood Clinical Frailty Scale (CFS, mild/moderate/severe frailty vs. very fit/well, HR = 2.59, 95% CI 1.41–4.78, p = 0.002) were predictive of worse overall survival. In multivariate analysis, HM type [acute leukemia, HR = 3.84, 95% CI 1.60–9.22, p = 0.003; myelodysplastic syndrome (MDS)/myeloproliferative neoplasm (MPN)/bone marrow failure, HR = 2.65, 95% CI 1.10–6.35, p = 0.03], age (per 5-year increase, HR = 1.46, 95% CI 1.21–1.76, p < 0.001), hemoglobin (per 1 g/dl decrease, HR = 1.21, 95% CI 1.05–1.40, p = 0.009), deficit in activities of daily living (HR = 2.20, 95% CI 1.11–4.34, p = 0.02), and Mini Nutrition Assessment score (at-risk of malnutrition vs. normal, HR = 2.00, 95% CI 1.07–3.73, p = 0.03) were independently associated with risk of death. The most commonly prescribed geriatric interventions were in the domains of audiology (56%) and pharmacy (54%). The Rockwood CFS correlated with prescribed interventions in nutrition (p = 0.01) and physical function (p < 0.001) domains. Geriatric assessment with geriatric intervention can be practically integrated into the routine care of older adults with HMs.

Accountable Care Organizations during Covid-19: Routine care for older adults with multiple chronic conditions

The COVID-19 pandemic threatens the health and well-being of older adults with multiple chronic conditions. To date, limited information exists about how Accountable Care Organizations (ACOs) are adapting to manage these patients. We surveyed 78 Medicare ACOs about their concerns for these patients during the pandemic and strategies they are employing to address them. ACOs expressed major concerns about disruptions to necessary care for this population, including the accessibility of social services and long-term care services. While certain strategies like virtual primary and specialty care visits were being used by nearly all ACOs, other services such as virtual social services, home medication delivery, and remote lab monitoring were far less commonly accessible. ACOs expressed that support for telehealth services, investment in remote monitoring capabilities, and funding for new, targeted care innovation initiatives would help them better care for vulnerable patients during this pandemic.

Synchrony in Old Age: Playing the Mirror Game Improves Cognitive Performance

ABSTRACT Objective Studies have shown that synchronized motion between people positively affects a range of emotional and social functions. The mirror-game is a synchrony-based paradigm, common to theater, performance arts, and therapy, which includes dyadic synchronized motion, playfulness, and spontaneity. The goal of the current study is to examine the effects of the mirror-game on subjective and cognitive indices in late life. Method Thirty-four older adults (aged 71–98) participated in a within-group study design. Participants conducted two sessions of 9-minute movement activities: the mirror-game and the control condition – a physical exercise class. Several measures were taken before and after experimental sessions to assess socio-emotional and attentional functions. Results The mirror-game enhanced performance on the attention sub-scale and led to faster detections of spoken words in noise. Further, it enhanced perceived partner responsiveness and led to an increase in positive reported experience. Conclusions Our preliminary findings suggest that the mirror-game, rather than the exercise class, may have an immediate impact on mood and some attentional functions. Clinical implications The mirror-game is a novel intervention, with potential benefits of social-emotional and cognitive functioning, which can be easily implemented into the daily routine care of older adults. Future studies should explore the effect of the mirror-game on additional cognitive and socio-emotional aspects.

156-OR: Risk-Benefit of SGLT2 Inhibitors (SGLT2i) vs. GLP-1 Receptor Agonists (GLP-1RA) in Routine Care of Older Adults

Both SGLT2i and GLP-1 RA have shown cardiovascular (CV) benefits in RCTs among diabetic patients generally younger than 65 years with CV disease. Whether these agents are associated with differential effectiveness and safety in routine care of older adults remains unexplored. Using claims data from Medicare (4/2013-12/2016), we identified 44,179 pairs of 1:1 propensity score-matched (PSM) patients ≥65 years with type 2 diabetes initiating a SGLT2i or a GLP-1 RA. We assessed a composite CV outcome (MI, stroke, or all-cause mortality), and hospitalization for heart failure (HHF). Safety outcomes of interest were severe hypoglycemia, bone fractures, lower-limb amputations (LLA), and diabetic ketoacidosis (DKA). We estimated HRs and 95% CIs in the PSM population well-balanced across &amp;gt;140 baseline covariates. Compared to GLP-1 RA, SGLT2i were associated with a similar risk of the composite CV outcome [HR (95% CI) = 1.04 (0.93-1.15)], and its components, but with decreased risk of HHF [0.68 (0.56-0.83)], over a mean 8.4-month follow-up (Table). Results were consistent in patients with and without CV disease. SGLT2i initiators had similar risk of severe hypoglycemia and fractures, but increased risk of LLA [1.47 (1.07-2.04)] and DKA [1.63 (1.16-2.28)]. Overall in 1,000 person-years, SGLT2i initiation vs. GLP-1 RA was associated with about 2.2 fewer HHF events, but 0.9 more LLA and 1.0 more DKA events. Disclosure E. Patorno: Research Support; Self; National Institute on Aging. Other Relationship; Self; Boehringer Ingelheim International GmbH. D.H. Kim: None. A. Pawar: None. S. Schneeweiss: Consultant; Self; Aetion, WHISCON, LLC. R.J. Glynn: Research Support; Self; AstraZeneca, Kowa Pharmaceutical Europe Co. Ltd., Novartis Pharmaceuticals Corporation, Pfizer Inc. M. Munshi: Consultant; Self; Lilly Diabetes, Sanofi. L.G. Bessette: None. S.C. Kim: Research Support; Self; Bristol-Myers Squibb Company, Genentech, Inc., Pfizer Inc.

Integrating geriatric assessment into routine gastrointestinal (GI) consultation: The Cancer and Aging Resilience Evaluation (CARE)

BackgroundIntegrating Geriatric Assessment (GA) in the management of older adults with cancer is recommended, yet rarely practiced in routine oncologic care. Our objective was to assess the feasibility of integrating routine GA in the management of older adults with gastrointestinal (GI) malignancies and characterize impairments in this population. MethodsPatients ≥60yo referred for consultation to the GI Oncology clinic were asked to complete the Cancer and Aging Resilience Evaluation (CARE) on their first visit. CARE was adapted from the Cancer and Aging Research Group GA with modifications to create a completely patient-reported version of the GA. Feasibility was defined as completion of CARE by ≥80% of eligible patients during the initial consultation. ResultsOf the eligible 354 new patients seen in the GI Oncology Clinic, 323 (91.2%) completed the CARE survey. Most patients (83.1%) felt the length of time to complete was appropriate (median time of 10 min [IQR 10–15.7 min]). GA impairments were prevalent: 54.7% reported dependence in Instrumental Activities of Daily Living, 15.5% reported dependence in Activities of Daily Living, 20.9% reported ≥1 fall, 35.9% reported a performance status ≥2, 55.7% were limited in walking one block, 74.0% reported polypharmacy (≥4 medications), and 36.4% had ≥3 comorbidities. ConclusionsPerforming a GA in the routine care of older adults with GI malignancies is feasible, and GA impairments are common among this population. A fully patient-reported GA such as the CARE may facilitate broader incorporation of GA in the routine clinic work flow.

Integrating geriatric assessment into routine gastrointestinal (GI) consultation: The Cancer and Aging Resilience Evaluation (CARE).

667 Background: Integrating Geriatric Assessment (GA) in the management of older adults with cancer is recommended, yet rarely practiced in routine oncologic care. In this report, we describe the feasibility of integrating the routine incorporation of GA in the management of older adults with GI malignancies and characterize GA impairments. Methods: CARE was adapted from the Cancer and Aging Research Group GA with modifications to create a completely patient-reported version. The CARE assesses self-reported functional status, physical function, nutrition, social support, anxiety/depression, cognitive function, comorbidities, and social activities. Patients ≥ 60yo referred for consultation to the GI Oncology clinic were asked to complete the CARE (paper/pencil) on their first visit. The completed CARE was collected during nurse triage and submitted to the clinical team prior to the physician encounter. Feasibility was defined as completion of the CARE by ≥ 80% of eligible patients during the initial consultation. Results: Between September 2017 and August 2018, 199 eligible new patients attended the GI Oncology Clinic, 192 (96.5%) were approached, and 181 (90.4%) completed the CARE. Most patients (79.6%) felt the length of time to complete was appropriate (median time of 10 minutes [IQR 10-15 minutes]). The mean age was 70y (range 60-96), 54.3% were male, and 75.1% were non-Hispanic white. Common tumor types included colon (27.8%), pancreatic (21.2%), and rectal (10.2%) cancer; predominately advanced stage diseases (stage III: 26.9%; stage IV: 40.0%). GA impairments were prevalent: 48.6% reported dependence in Instrumental Activities of Daily Living, 18.0% reported dependence in Activities of Daily Living, 22.5% reported ≥ 1 fall, 29.4% reported a performance status ≥ 2, 51.3% were limited in walking one block, 75.7% reported polypharmacy (≥ 4 medications), and 84.3% had ≥ 1 comorbidity. Conclusions: Performing a GA in the routine care of older adults with GI malignancies is feasible, and GA impairments are common among older adults with GI malignancies. A fully patient-reported GA such as the CARE may facilitate broader incorporation of GA in the routine clinic work flow.

Primary care physicians' perceived barriers, facilitators and strategies to enhance conservative care for older adults with chronic kidney disease: a qualitative descriptive study.

Although primary care physicians (PCPs) are often responsible for the routine care of older adults with chronic kidney disease (CKD), there is a paucity of evidence regarding their perspectives and practice of conservative (non-dialysis) care. We undertook a qualitative study to describe barriers, facilitators and strategies to enhance conservative, non-dialysis, CKD care by PCPs in the community. Semi-structured telephone and face-to-face interviews were conducted with PCPs from Alberta, Canada. Participants were identified using a snowball sampling strategy and purposively sampled based on sex, age and rural/urban location of clinical practice. Eligible participants had managed at least one patient ≥75 years with Stage 5 CKD (estimated glomerular filtration rate <15 mL/min/1.73 m2, not on dialysis) in the prior year. Participant recruitment ceased when data saturation was reached. Transcripts were analyzed thematically using conventional content analysis. In total, 27 PCPs were interviewed. The majority were male (15/27), were aged 40-60 years (15/27) and had practiced in primary care for >20 years (14/27). Perceived barriers to conservative CKD care included: managing expectations of kidney failure for patients and their families; dealing with the complexity of medical management of patients requiring conservative care; and challenges associated with managing patients jointly with specialists. Factors that facilitated conservative CKD care included: establishing patient/family expectations early; preserving continuity of care; and utilizing a multidisciplinary team approach. Suggested strategies for improving conservative care included having: direct telephone access to clinicians familiar with conservative care; treatment decision aids for patients and their families; and a conservative care clinical pathway to guide management. PCPs identified important barriers and facilitators to conservative care for their older patients with Stage 5 CKD. Further investigation of potential strategies that address barriers and enable facilitators is required to improve the quality of conservative care for older adults in the community.