Quality of life of older persons in nursing homes after the implementation of a knowledge-based palliative care intervention

Diagnostic Accuracy of Self-Reported Tools for Frailty Assessment in Older Adults With Cancer: A Diagnostic Meta-Analysis

INTRODUCTION

Questionnaires are commonly used for rapid frailty assessment. However, which scale is most appropriate for the identification of frailty in older adults with cancer remains unclear.

OBJECTIVE

A diagnostic meta-analysis was conducted to examine the sensitivity and specificity of questionnaire-based assessment tools in detecting frailty among older adults with cancer.

METHODS

Five databases were searched for eligible studies from inception to January 26, 2025. Study quality was evaluated using the revised Quality Assessment of Diagnostic Accuracy Studies tool. The pooled sensitivity and specificity of the frailty assessment tools were assessed through a bivariate random-effects model. Factors influencing the heterogeneity of sensitivity and specificity values were assessed through moderator analysis, which comprised a subgroup analysis and metaregression.

RESULTS

Five questionnaire-based tools (i.e., the Edmonton Frailty Scale, FRAIL scale, Groningen Frailty Indikator [GFI], Tilburg Frailty Indikator, and Vulnerable Elders Survey-13 [VES-13]) for assessing frailty in older adults with cancer were identified in the literature; the most commonly used were the GFI and VES-13. The sensitivity and specificity of the GFI (67% and 81%, respectively) and VES-13 (65% and 81%) were calculated. Studies with a high proportion of male participants had poorer GFI sensitivity. Older patient samples were associated with lower VES-13 sensitivity, and a high prevalence of frailty or patients having stage III-IV cancer was associated with higher sensitivity.

CONCLUSION

The GFI and VES-13 demonstrated high specificity but low sensitivity for frailty assessment in older adults with cancer. Frequent assessment with the GFI or VES-13 is recommended to improve frailty detection.

IMPLICATIONS FOR PRACTICE

Health-care professionals, including oncology nurses, care managers, and oncologists, can incorporate the GFI and VES-13 into cancer care settings to improve early frailty detection and management. Pre-Registration: The study protocol was registered at PROSPERO (CRD42024505836).

Conceptualizing the learning organization in nursing homes: a scoping review

BACKGROUND

Maintaining high-quality care in nursing homes is challenging. An ageing population and labour market shortages have created an imbalance in the supply and demand of care, and the focus of care has transitioned from quality of care to quality of life. This study explores how the 'learning organization' (LO) concept could contribute to a new quality paradigm in nursing homes, by 1) examining its efficacy and operationalization for and 2) identifying the elements most relevant to the nursing home setting.

METHODS

We use Arksey and O'Malley's scoping framework to answer the research questions and address gaps in the literature, guided by theories on the learning organization from Senge (The fifth discipline: The art and practice of the learning organization, 1990) and Watkins and Marsick (Sculpting the learning organization: Lessons in the art and science of systemic change, 1993). Literature searches (in Scopus, Medline, Web of Science, Business Source Elite, and ERIC) were performed from inception through 19 August 2024, in collaboration with a medical information specialist. Eligibility was limited to studies on learning organizations or organizational learning (OL) in nursing homes. Study aims, definitions, descriptions, key terms, theories, and operationalizations were mapped descriptively.

RESULTS

From 2,292 abstracts, 14 articles were included. Ten studies reference Senge (The fifth discipline: The art and practice of the learning organization, 1990) and/or Watkins and Marsick (Sculpting the learning organization: Lessons in the art and science of systemic change, 1993) in defining and describing a learning organization and organizational learning. Together, the studies reveal six elements of learning organizations in nursing homes: individual and collective learning, individual and interpersonal abilities, an adaptive and responsive culture, transformational leadership, organizational knowledge development, and systems thinking. All studies highlight organizational performance improvement as the primary aim of a learning organization, with only a few operationalizations (n = 3) examining the concept's full scope; most examine only single aspects.

CONCLUSIONS

To help nursing homes effectively adapt, the learning organization could offer a promising concept. However, current research is limited. The included studies provide insight into key elements of learning organizations and their benefits for organizational performance and job satisfaction. Future research should develop a consistent method of operationalization based on the six key elements most relevant for nursing homes transitioning to learning organizations. This approach should consider the interconnected nature of these elements, with systems thinking as the foundation.

Physicians' Perceptions of the Quality of Palliative Care and of the Importance of Collaboration in Interdisciplinary Teams in Norwegian Nursing Homes

Purpose

The palliative phase of a patient's life is often characterized by disease complexity, increasing the need for holistic care, support for the patient's relatives, and the up-to-date knowledge of a multidisciplinary healthcare team. Physicians in nursing homes have the main responsibility for providing palliative care to vulnerable and fragile patients. There is limited research uncovering physicians' experience and perceptions of what is important in this phase of patients' lives. The aim of the study was thus to investigate physicians' perceptions of factors that influence the quality of palliative care in Norwegian nursing homes and their descriptions of the importance of the team's collaboration.

Materials and Methods

The study has a qualitative research design based on interviews with twelve nursing home physicians in Eastern Norway. Interviews were conducted between February 2023 to May 2023, analyzed using qualitative content analysis.

Results

Three themes describe the content of the findings: i) Comprehensive care plans enhance the quality of palliative care, ii) A collaborative team provides higher-quality care than the sum of its parts, iii) Systemic and environmental factors affect the ability to ensure continuity of care.

Conclusion

The physicians in this study expressed that the quality of palliative care in nursing homes depended on comprehensive care plans, including up-to-date knowledge of medical treatment options, partnership with the patient and relatives, and a consistent holistic approach to the patient. The quality also depended on the interdisciplinary team's collaboration in assessing the patient, observing symptoms, and planning further care and treatment in accordance with patients' and their relatives' preferences and wishes. Finally, systemic and environmental factors affected the ability to ensure continuity of care. Further work is needed to ensure that systemic factors enable physicians to deliver high-quality palliative care and that a comfortable physical environment is created in nursing homes.

Effectiveness of integrated person-centered interventions for older people's care: Review of Swedish experiences and experts' perspective

Older adults have multiple medical and social care needs, requiring a shift toward an integrated person-centered model of care. Our objective was to describe and summarize Swedish experiences of integrated person-centered care by reviewing studies published between 2000 and 2023, and to identify the main challenges and scientific gaps through expert discussions. Seventy-three publications were identified by searching MEDLINE and contacting experts. Interventions were categorized using two World Health Organization frameworks: (1) Integrated Care for Older People (ICOPE), and (2) Integrated People-Centered Health Services (IPCHS). The included 73 publications were derived from 31 unique and heterogeneous interventions pertaining mainly to the micro- and meso-levels. Among publications measuring mortality, 15% were effective. Subjective health outcomes showed improvement in 24% of publications, morbidity outcomes in 42%, disability outcomes in 48%, and service utilization outcomes in 58%. Workshop discussions in Stockholm (Sweden), March 2023, were recorded, transcribed, and summarized. Experts emphasized: (1) lack of rigorous evaluation methods, (2) need for participatory designs, (3) scarcity of macro-level interventions, and (4) importance of transitioning from person- to people-centered integrated care. These challenges could explain the unexpected weak beneficial effects of the interventions on health outcomes, whereas service utilization outcomes were more positively impacted. Finally, we derived a list of recommendations, including the need to engage care organizations in interventions from their inception and to leverage researchers' scientific expertise. Although this review provides a comprehensive snapshot of interventions in the context of Sweden, the findings offer transferable perspectives on the real-world challenges encountered in this field.

Promoting stress and anxiety recovery in older adults: assessing the therapeutic influence of biophilic green walls and outdoor view

Previous research has already provided evidence regarding the favorable impact of green walls and outdoor views on stress reduction and anxiety alleviation. However, there has been limited exploration into the combined effects of green walls and outdoor views on older adults. In this study, a between-subjects experiment was conducted using virtual reality (VR) technology with 23 participants. Following exposure to stressors, each participant underwent four randomized sessions, each lasting 5 min, in various virtual reality (VR) environments, encompassing non-biophilic and biophilic environments (including green walls, outdoor views, and their combination). Throughout the process, we measured physiological indicators of stress responses, including heart rate, heart rate variability, skin conductance levels, and blood pressure, using biometric sensors. Psychological changes in participants, including anxiety levels, were evaluated through the State-Trait Anxiety Inventory, recovery scales, and self-reported emotional assessments. In conclusion, in comparison to non-biophilic environments, older adults consistently exhibited lower stress levels, experienced superior anxiety relief, and demonstrated improved recovery in nature connectedness environments, with a notably faster recovery rate. These findings suggest that the incorporation of nature connectedness principles into the indoor environments of public activity spaces within older adults care facilities can significantly contribute to stress reduction and anxiety alleviation among older adults. Furthermore, these effects appear to be contingent on the specific types of nature connectedness environments. These results can provide substantial evidence to support the design of indoor common activity spaces within older adults care facilities.

Unlocking timely palliative care: assessing referral practices and barriers at a ghanaian teaching hospital

BACKGROUND

The need for primary care physicians to be heavily involved in the provision of palliative care is growing. International agencies and practice standards advocate for early palliative care and the use of specialized palliative care services for patients with life-threatening illnesses. This study was conducted to investigate physicians' referral practices and perceived barriers to timely referral at the Korle Bu Teaching Hospital.

METHODS

A cross-sectional study design was employed using a convenience sampling technique to recruit 153 physicians for the study. Data on socio-demography, referral practices, timing and perceived barriers were collected using a structured questionnaire. Binary Logistic regression using crude and adjusted odds was performed to determine the factors associated with late referral. Significance was set at p < 0.05.

RESULTS

The prevalence of late referral was reported to be 68.0%. There were poor referral practices among physicians to palliative care services, and the major barriers to late referral were attributed to the perception that referring to a palliative care specialist means that the physician has abandoned his patient and family members' decisions and physicians' personnel choices or opinions on palliative care.

CONCLUSION

The healthcare system needs tailored interventions targeted at improving physicians' knowledge and communication strategies, as well as tackling systemic deficiencies to facilitate early and appropriate palliative care referrals. It is recommended that educational programs be implemented, palliative care training be integrated into medical curricula and culturally sensitive approaches be developed to address misconceptions surrounding end-of-life care.

The experience of Australian aged care workers during a trial implementation of a palliative care outcomes programme

End of life care is an essential part of the role of Australian aged care homes (ACHs). However, there is no national framework to support aged care staff in systematically identifying residents with palliative care needs or to routinely assess, respond to, and measure end of life needs. The Palliative Care Outcomes Collaboration (PCOC) is a national outcomes and benchmarking programme which aims to systematically improve palliative care for people who are approaching the end of life, and for their families and carers. The PCOC Wicking Model for Residential Aged Care was developed and piloted in four Australian ACHs. This paper reports on the qualitative findings from semi-structured interviews and focus groups conducted with ACH staff (N = 37) to examine feasibility. Thematic analysis identified three overarching themes about the pilot: (i) processes to successfully prepare and support ACHs; (ii) appropriateness of PCOC tools for the ACH setting; and (iii) realised and potential benefits of the model for ACHs. The lessons presented valuable insights to refine the PCOC Wicking Model and enrich understanding of the potential challenges and solutions for implementing similar programs within ACHs in future. The results suggest that key to successfully preparing ACHs for implementation of the PCOC Wicking Model is an authentic and well-paced collaborative approach with ACHs to ensure the resources, structures and systems are in place and appropriate for the setting. The PCOC Wicking Model for Residential Aged Care is a promising prototype to support ACHs in improving palliative and end of life care outcomes for residents and their carers.

Uncovering Methods and Outcomes of Palliative Care for Geriatric Patients: A Scoping Review

Background

Palliative care is an integral part of care for patients with life-limited diseases that focuses on reducing symptoms and maintaining and increasing the quality of life (QoL) for patients and their families. Geriatric patients were more likely to receive palliative care and had unique needs compared to the general population. To improve the quality of palliative care, especially for geriatric patients, it is necessary to have a better understanding of methods and outcomes for geriatric patients when delivering palliative care.

Objective

This study aims to identify the methods and outcomes of palliative care in geriatric patients across the globe.

Methods

This scoping review was guided by Arksey and 'O Malley's framework and utilized the Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist for providing transparent reporting to the readers. EBSCO, PubMed, and Scopus databases were used to search the relevant articles with a publication range of 2013-2023. Thematic analysis was used to identify and summarize palliative care methods and outcomes for geriatric patients in this review.

Results

Twenty-one studies were included in this review, and it was found that there were many types of methods for delivering palliative care to geriatric patients. In both acute care settings and community settings, a wide range of methods for delivering palliative care to geriatric patients were identified. Outcomes of palliative care in geriatric patients in hospitals and community settings, were reduced pain, depressive symptoms and anxiety, edema, constipation, odds of in-hospital death, and increased spiritual well-being, QoL and well-being, being comfortable, patient readiness, place of death, sleep quality, and quality of dying.

Conclusion

Geriatric patients had a variety of methods and outcomes in palliative care. This study suggests that outcomes should be evaluated continuously after implementing methods for delivering palliative care to geriatric patients.

Quality of Life among Next of Kin of Frail Older People in Nursing Homes: An Interview Study after an Educational Intervention concerning Palliative Care

One cornerstone of palliative care is improving the family’s quality of life (QoL). The principles of palliative care have not been sufficiently applied in nursing homes. The aim of this study was to investigate the experiences of QoL of next of kin of frail older persons in nursing homes after an educational intervention concerning palliative care. This qualitative interview study with 37 next of kin used an abductive design with deductive and inductive content analysis. The deductive analysis confirmed the three themes of QoL from the study before the implementation: (1) orientation to the new life-situation, (2) challenges in the relationship, and (3) the significance of the quality of care in the nursing home. The inductive analysis resulted in the sub-theme “Unspoken palliative care”. Being the next of kin of an older person living in a nursing home can be distressing despite round-the-clock care, so staff need to apply a more explicitly palliative care perspective. Future research needs to evaluate the influence of meaning-focused coping on next of kin’s QoL and integrate this knowledge in psychosocial interventions. Clinical Trial Database for Clinical Research: KUPA project NCT02708498.

What long-term care interventions have been published between 2010 and 2020? Results of a WHO scoping review identifying long-term care interventions for older people around the world

OBJECTIVE

The global population is rapidly ageing. To tackle the increasing prevalence of older adults' chronic conditions, loss of intrinsic capacity and functional ability, long-term care interventions are required. The study aim was to identify long-term care interventions reported in scientific literature from 2010 to 2020 and categorise them in relation to WHO's public health framework of healthy ageing.

DESIGN

Scoping review conducted on PubMed, CINHAL, Cochrane and Google Advanced targeting studies reporting on long-term care interventions for older and frail adults. An internal validated Excel matrix was used for charting.Setting nursing homes, assisted care homes, long-term care facilities, home, residential houses for the elderly and at the community.

INCLUSION CRITERIA

Studies published in peer-reviewed journals between 1 January 2010 to 1 February 2020 on implemented interventions with outcome measures provided in the settings mentioned above for subjects older than 60 years old in English, Spanish, German, Portuguese or French.

RESULTS

305 studies were included. Fifty clustered interventions were identified and organised into four WHO Healthy Ageing domains and 20 subdomains. All interventions delved from high-income settings; no interventions from low-resource settings were identified. The most frequently reported interventions were multimodal exercise (n=68 reports, person-centred assessment and care plan development (n=22), case management for continuum care (n=16), multicomponent interventions (n=15), psychoeducational interventions for caregivers (n=13) and interventions mitigating cognitive decline (n=13).

CONCLUSION

The identified interventions are diverse overarching multiple settings and areas seeking to prevent, treat and improve loss of functional ability and intrinsic capacity. Interventions from low-resource settings were not identified.

Training Residents in Virtual Advance Care Planning: A New Twist in Telehealth

CONTEXT

Advance care planning (ACP) conversations represent an important physician skill, a need further highlighted by the COVID-19 pandemic. Most resident ACP training occurs in inpatient, settings, often featuring goals of care (GOC) conversations during a crisis. Outpatient clinics are valuable but underutilized settings to provide skills training for residents, yet little research has been done in these spaces.

OBJECTIVE

We sought to 1) create an ACP curriculum harnessing the principles of a community of practice in a virtual format, and 2) obtain residents' perspectives regarding their skills and confidence in having early GOC conversations in the outpatient setting.

METHODS

We interviewed 48 internal medicine residents using questionnaires, reflective narratives, and transcripts of debriefing conversations. We created a virtual curriculum during the ambulatory week which included didactics, virtual role plays, ACP phone conversations with five patients, and group debriefings. Quantitative data were analyzed for changes in resident confidence. Qualitative data were coded using thematic analysis, guided by instructor field notes.

RESULTS

Residents reported decreased confidence in navigating advance directive conversations following training [Z=2.24, P=0.03, r = 0.33]. Resident reflections indicated that they felt more practiced at inpatient late GOC conversation skills, and that these skills were not fully transferable to the outpatient early GOC setting. Residents also endorsed the ambulatory environment as the best space for ACP conversations.

CONCLUSION

This study illustrates the feasibility of a virtual format for ACP curriculum. The virtual community of practice created space for a metacognitive unmasking of prior resident unconscious incompetence. Also, inpatient, crisis-oriented late GOC conversation skills may translate poorly to the outpatient setting requiring early and ongoing GOC skills. Residents need more training to navigate ACP conversations in ambulatory environments.

Palliative and end-of-life educational interventions for staff working in long-term care facilities: An integrative review of the literature

BACKGROUND

Given the increase in the number of deaths within long-term care facilities (LTCFs), the need for palliative and end-of-life (EOL) care education among such facilities has been increasing. As such, a systematic synthesis of global palliative and EOL care educational approaches and evaluation can aid further educational development.

OBJECTIVE

To synthesise the current literature on palliative and EOL care educational interventions for staff working in LTCFs and identify barriers to, and facilitators of, intervention implementation.

METHODS

The study used an integrative review framework wherein indexed databases, namely, CINAHL, EMBASE, MEDLINE, PsycINFO, Web of Science, Cochrane Library and Japan Medical Abstract Society, were systematically searched for studies published in English and Japanese between 2007 and 2019. Search terms that are related to palliative care, LTCF, and education were combined to increase search sensitivity. The quality of the papers was assessed using Joanna Briggs Institute Critical Appraisal Tools and the Mixed-Methods Appraisal Tool.

RESULTS

A total of 52 studies were included in the review. Our results suggested that although studies in this area and setting have been evolving, suboptimal developmental research and educational practices, global variability and unstandardised approaches to education and lacking viewpoints from service users have remained. Barriers to intervention implementation were also reported due to the specific characteristics of LTCFs, which include high staff turnover and considerable variation in professional skills and experience.

CONCLUSIONS

Given the different LTCF types, systems and policies across each country or region, further research on standardised educational interventions with contextual considerations using large-scale studies with robust methodology is needed to meet the increasing demand for palliative and EOL care among the global ageing population.

IMPLICATIONS FOR PRACTICE

Palliative and EOL care educational intervention for LTCF staff need to include more consideration of context, organisational culture and the user involvement throughout the process of education and research to enhance the quality of care in this complex setting.

A pilot evaluation of the Strengthening a Palliative Approach in Long-Term Care (SPA-LTC) program

Background

Despite increased annual mortality in long-term care (LTC) homes, research has shown that care of dying residents and their families is currently suboptimal in these settings. The purpose of this study was to evaluate resident and family outcomes associated with the Strengthening a Palliative Approach in LTC (SPA-LTC) program, developed to help encourage meaningful end of life discussions and planning.

Methods

The study employs a mixed method design in four LTC homes across Southern Ontario. Data were collected from residents and families of the LTC homes through chart reviews, interviews, and focus groups. Interviews with family who attended a Palliative Care Conference included both closed-ended and open-ended questions.

Results

In total, 39 residents/families agreed to participate in the study. Positive intervention outcomes included a reduction in the proportion of emergency department use at end of life and hospital deaths for those participating in SPA-LTC, improved support for families, and increased family involvement in the care of residents. For families who attended a Palliative Care Conference, both quantitative and qualitative findings revealed that families benefited from attending them. Residents stated that they appreciated learning about a palliative approach to care and being informed about their current status.

Conclusions

The benefits of SPA-LTC for residents and families justify its continued use within LTC. Study results also suggest that certain enhancements of the program could further promote future integration of best practices within a palliative approach to care within the LTC context. However, the generalizability of these results across LTC homes in different regions and countries is limited given the small sample size.

Evaluating person-centredness for frail older persons in nursing homes before and after implementing a palliative care intervention

Aim

To evaluate person-centeredness in nursing homes from the perspective of frail older persons, before and after implementing an educational intervention about palliative care.

Design

A crossover design.

Methods

Forty-four older persons living in nursing homes were interviewed. A convergent mixed-method was used to analyse data.

Results

The older persons expressed feelings of unsafety related to shortcomings in staff. These shortcomings implied that the responsibilities of everyday activities and making the residents' existence more bearable were transferred to the next of kin. The dropout rate related to death and not enough energy was considerably high (51%) even though one of the inclusion criteria was to have enough energy to manage a 1-hr interview. This result supports previous research describing the difficulties in retaining older persons in research and indicated that the dose of the intervention was not sufficient to improve person-centred care.

Quality of life of older persons in nursing homes after the implementation of a knowledge-based palliative care intervention

BACKGROUND

The goals of palliative care are to relieve suffering and promote quality of life. Palliative care for older persons has been less prioritised than palliative care for younger people with cancer, which may lead to unnecessary suffering and decreased quality of life at the final stage of life.

AIM

To evaluate whether a palliative care intervention had any influence on the perceived quality of life of older persons (≥65 years).

METHODS

This study was conducted as a complex intervention performed with an experimental crossover design. The intervention was implemented in 20 nursing homes, with a six-month intervention period in each nursing home. Twenty-three older persons (≥65 years) in the intervention group and 29 in the control group were interviewed using the WHOQOL-BREF and WHOQOL-OLD questionnaires at both baseline and follow-up. The collected data were analysed using the Wilcoxon signed-rank test to compare paired data between baseline and follow-up.

RESULTS

In the intervention group, no statistically significant increases in quality of life were found. This result contrasted with the control group, which revealed statistically significant declines in quality of life at both the dimension and item levels. Accordingly, this study showed a trend of decreased health after nine months in both the intervention and control groups.

CONCLUSION

It is reasonable to believe that quality of life decreases with age as part of the natural course of the ageing process. However, it seems that the palliative care approach of the intervention prevented unnecessary quality of life decline by supporting sensory abilities, autonomy and social participation among older persons in nursing homes. From the ageing perspective, it may not be realistic to strive for an increased quality of life in older people living in nursing homes; maybe the goal should be to delay or prevent reduced quality of life. Based on this perspective, the intervention prevented decline in quality of life in nursing home residents.

IMPLICATIONS FOR PRACTICE

The high number of deaths shows the importance to identify palliative care needs in older persons at an early stage to prevent or delay deterioration of quality of life.