Not All Frailty Assessments Are Created Equal: Comparability of Electronic Health Data-Based Frailty Assessments in Assessing Older People in Residential Care

Objectives: To evaluate the comparability of frailty assessment tools - the electronic frailty index (eFI), retrospective electronic frailty index (reFI), and clinical frailty scale (CFS) - in older residents of care facilities. Methods: Data from 813 individuals aged 65 or older, with frailty and co-morbidities, collected between 2022 and 2023, were analysed using various statistical methods. Results: The results showed significant differences in frailty classification among the tools: 78.3% were identified as moderately to severely frail by eFI, 59.6% by reFI, and 92.1% by CFS. Statistical tests confirmed significant differences (p < .05) in their assessments, indicating variability in measurement methods. Discussion: This study advances the understanding of frailty assessment within aged-care settings, highlighting the differences in the efficacy of these assessment tools. It underscores the challenges in frailty assessments and emphasizes the need for continuous refinement of assessment methods to address the diverse facets of frailty in aged care.

Delivering Prognostic News to Older People with Chronic Disease: What Format Preference and Level of Involvement in Decision Making? A Hospital Survey

Shared decision making near end of life is a balancing act of communicating prognosis to patients and their surrogates/families and engaging them in considering value-concordant management choices. This cross-sectional survey aimed to determine the format in which older patients with chronic illnesses would prefer to receive prognostic information on their treatment options and disease progression, and their desired level of engagement in decision making. With a 60% participation rate, 139 inpatients in two hospitals and five surrogates were presented with six hypothetical scenarios with a randomly assigned sequence: verbal and written summary, graph, table, photo, video, and pamphlet. The majority (76%) of respondents chose the traditional verbal communication of prognosis by their doctor with a written summary as a reference and to share with family; the second choice was a condition-specific pamphlet (63%). Many found the graph and photo to be distressing (36% and 42%, respectively). Most (71%) wanted to know everything about their condition trajectory, and 63% chose shared decision making rather than completely autonomous or full delegation to clinicians or family. There were no gender differentials between wanting to know it all, supporting shared decision making or the preferred format for breaking news (p > 0.05). Older hospitalized patients with chronic conditions are willing to discuss end-of-life issues, learn about their prognosis, and be involved in shared decision making. Innovative formats such as graphs, videos, or photos were not welcome as part of the prognostic discussion.

General practitioners' perceptions on the feasibility and acceptability of implementing a risk prediction checklist to support their end-of-life discussions in routine care: a qualitative study

BACKGROUND

General practitioners' (GPs) play a central role in facilitating end-of-life discussions with older patients nearing the end-of-life. However, prognostic uncertainty of time to death is one important barrier to initiation of these discussions.

OBJECTIVE

To explore GPs' perceptions of the feasibility and acceptability of a risk prediction checklist to identify older patients in their last 12 months of life and describe perceived barriers and facilitators for implementing end-of-life planning.

METHODS

Qualitative, semi-structured interviews were conducted with 15 GPs practising in metropolitan locations in New South Wales and Queensland between May and June 2019. Data were analysed thematically.

RESULTS

Eight themes emerged: accessibility and implementation of the checklist, uncertainty around checklist's accuracy and usefulness, time of the checklist, checklist as a potential prompt for end-of-life conversations, end-of-life conversations not an easy topic, end-of-life conversation requires time and effort, uncertainty in identifying end-of-life patients and limited community literacy on end-of-life. Most participants welcomed a risk prediction checklist in routine practice if assured of its accuracy in identifying which patients were nearing end-of-life.

CONCLUSIONS

Most participating GPs saw the value in risk assessment and end-of-life planning. Many emphasized the need for appropriate support, tools and funding for prognostic screening and end-of-life planning for this to become routine in general practice. Well validated risk prediction tools are needed to increase clinician confidence in identifying risk of death to support end-of-life care planning.

Occupational engagement of people living with a life-limiting illness: Occupational therapists' perceptions

BACKGROUND/AIM

Occupational therapists working in palliative care aim to enable clients living with a life-limiting illness to continue participating in meaningful activities for as long as possible. However, little is published about the occupations people living with a life-limiting illness wish to engage in, and how occupational therapists can best enable occupational engagement. Therefore, this study aimed to gain an in-depth understanding of occupational therapists' perceptions on clients' occupational engagement post-diagnosis of a life-limiting condition.

METHODS

Occupational therapists working in Australia with people with a life-limiting illness were recruited to participate in a national online survey over the period of a month. Recruitment used a purposive, snowball sampling technique, resulting in 144 survey responses. Data were analysed using modified grounded theory methods.

RESULTS

Findings revealed two interrelated categories and four subcategories. The first category, focusing on life is concerned with therapists' perceptions of how clients continue to focus on living post diagnosis and encompasses two subcategories: (i) prioritised engagement and (ii) altered engagement. The second category, preparing for death, centres on therapists' perceptions of what clients do to practically prepare for death and find closure as their illness progresses, and is comprised of the two subcategories: (i) practical preparation for death and (ii) "facilitating closure".

CONCLUSION

Therapists perceived that meaningful occupational engagement changes over time as occupational performance levels decrease and clients prepare for death.

Exploring the impact of brain cancer on people and their participation

Introduction

Brain cancer diagnoses are rising, and the prognosis is commonly life-limiting. Brain cancer symptoms and the side effects of treatment are imposing and harmful. Little is known about the effect of these symptoms and treatments on occupational participation or about the role that occupational therapy can play for people with brain cancer.

Methods

Sixteen participants with brain cancer were purposively recruited from a single site. Data was collected using semi-structured interviews. Interviews were analysed thematically.

Results

Three overarching themes were identified: (a) ‘there’s a lot of things that I can’t do anymore’: adverse effects of tumour and treatments; (b) ‘you adjust with adversity’: accepting altered occupational participation levels; (c) occupational therapy: ‘why is she here?’

Conclusions

Findings highlight a connection between brain cancer symptoms, treatment side effects and occupational participation. A disconnect was found between occupational therapy services and occupational needs. Further research could explore whether realigning occupational therapy services to address the concerns identified in this study leads to enhanced occupational participation through the journey of brain cancer.

Occupational Therapy for People Living with a Life-Limiting Illness: A Thematic Review

Introduction:

Little is known about occupational therapy practice for people with a life-limiting illness. This paper aims to review the available occupational therapy literature in order to develop a greater understanding of the role and practice trends of occupational therapists working in this area.

Methods:

A systematic search of literature published from 1975–2013 was conducted. Three hundred and fifty-five pieces of literature were located and screened for inclusion using a three-stage process. All literature that met the inclusion criteria was then analysed thematically.

Findings:

An in-depth review of 52 articles, three position statements, two key occupational texts, and one clinical guideline identified three themes in the literature. These themes comprised: (i) reframing practice: defining a palliative approach in occupational therapy; (ii) continuing occupational engagement despite loss; and (iii) preparing for practice when your client is dying: educational requirements of occupational therapists.

Conclusion:

Occupational therapy has an important role to play in the care of people with a life-limiting illness. However, knowledge gaps remain concerning the scope of the role and how best to engage clients in meaningful occupations at the end of life. Further education is required at the undergraduate level and for clinicians working in this area.

The psychiatric-primary care nurse practitioner: a futuristic model for advanced practice psychiatric-mental health nursing

A new paradigm for delivering comprehensive mental and general health services has been born out of the necessity to integrate all aspects of health care. Because of issues of cost-effectiveness and capitation, fragmentation of services is no longer viable. Graduate programs in nursing will need to: (1) effectively prepare its practitioners to manage the complexity of both medical and psychiatric problems of clients, (2) promote health and prevent disease, and (3) counsel and refer clients. The psychiatric nurse practitioner is uniquely suited to provide comprehensive health care to both clients in psychiatric settings as well as primary care environments. An overview of the Psychiatric-Primary Care Nurse Practitioner program at the University of Pittsburgh is described.

Pharmacotherapy of impaired affect in recovering schizophrenic patients

BACKGROUND

Prominent and persistent anxiety, depression, and/or negative features characterize a substantial minority of recovered or residually psychotic schizophrenic outpatients and contribute to poor outcome. Because extrapyramidal side effects of typical neuroleptic medications often resemble such features, we first systematically studied the contribution of extrapyramidal side effects to these problems and their treatment. For patients who remained distressed, controlled trials of supplemental thymoleptics were undertaken.

METHODS

In trial 1, 92 distressed (depressed and/or anxious) patients and 36 patients in a defect state (patients with negative symptoms) participated in a double-blind, intramuscular challenge that compared centrally acting benztropine mesylate with peripherally acting glycopyrrolate. In trial 2, 57 distressed patients and 22 patients in a defect state were randomly assigned to a double-blind, neuroleptic medication dose-reduction group. In trial 3, 57 chronically distressed patients who were maintained on a low dose of fluphenazine decanoate were randomly assigned to a supplemental desipramine hydrochloride, lithium carbonate, or placebo group under double-blind conditions for 12 weeks.

RESULTS

For patients who were already maintained on antiparkinsonian medication, impaired affect was not resolved by additional benztropine. Only distressed patients with a family history of severe mental disorder (often affective) showed improvement with neuroleptic medication dose reduction. Patients in the defect-state group reported less dysphoria on a reduced neuroleptic medication dose, but negative symptoms persisted. Desipramine improved diverse aspects of mood and residual psychoticism, possibly as a prophylaxis against minor affective exacerbations. Depression improved in women only. Lithium positively affected multiple indexes of anxiety and anxious depression.

CONCLUSION

Most often, persistent affective impairments are neither resistant extrapyramidal side effects nor characterological traits. Thymoleptics improve the nonphasic, chronic types of anxiety and depression in contrast to the acute, episodic forms, for which little support can be found in the literature.

Hospitalized schizophrenic patient views about seclusion

Twenty-six of 100 consecutively admitted schizophrenic or schizoaffective patients required seclusion during their hospital stays. Seclusion episodes usually involved involuntarily committed, severely ill patients and occurred early in their hospitalizations. The recollections of the personal seclusion experiences of 17 patients were generally factually accurate, except for a tendency to play down disruptive aggressive behavior on their part. Patients described seclusion as a painful experience associated with feelings of helplessness, fear, sadness, and anger. However, patients also stated that seclusion rooms were necessary on inpatient psychiatric units and that the rooms were used for the control of disruptive aggressive patient behaviors. This study highlights not only the need for staff to clarify for patients what behavior has led to seclusion and what behavior will lead to release, but also the need for staff to acknowledge patients' distress at the experience.

Insight in schizophrenia. Its relationship to acute psychopathology

The relationship between insight and acute psychopathology was explored in a group of 52 acutely psychotic, schizophrenic patients. A measure of insight, reflecting patients' recognition of their illness and need for care, was validated against ratings from a semi-structured interview and against assessments of patients' compliance with medication. Contrary to expectations, degree of insight was not consistently related to the severity of acute psychopathology, as measured on two structured scales. Nor did changes in insight during hospitalization vary consistently with changes in acute psychopathology. These data suggest that very little of the deficiency in insight seen in schizophrenic patients is explainable on the basis of acute psychopathological features. The mechanism that accounts for impairment in insight in schizophrenia may be relatively resistant to treatment with neuroleptic medication.

1,25 dihydroxycholecalciferol effects in chronic dialysis. A double-blind controlled study

1,25 dihydroxycholecalciferol [1,25(OH)2D3] was studied in a double-blind controlled fashion in patients on chronic dialysis. Serum calcium was unchanged in 16 patients on vitamin D3 (D3) (400 to 1200 IU/day). In 15 patients on 1,25(OH)2D3 (0.5 to 1.5 microgram/day), serum calcium increased from 9.05 +/- .15 to 10.25 +/- .20 mg/dl (p less than 0.001), returning to 9.37 +/- .16 mg/dl (p less than 0.001) in the post control period. Patients on D3 showed no reversible decrease in immunoreactive parathyroid hormone levels, but patients on 1,25(OH)2D3 did, from a control of 1077 +/- 258 to 595 +/- 213 microliter equivalents/ml (p less than 0.01), and returned to 1165 +/- 271 microliter equivalents/ml (p less than 0.005). Nine of 12 patients on D3 who underwent serial iliac-crest biopsies showed histologic deterioration, and six of seven who received 1,25(OH)2D3 were improved or unchanged (p less than 0.025). Bone mineral and calcium decreased in patients on D3 (p less than 0.05) but not in those on 1,25(OH)2D3. Hypercalcemia occurred in five of 15 patients. We conclude that 1,25(OH)2D3 has a calcemic effect in chronic dialysis patients, decreases levels of immunoreactive parathyroid hormone, and is associated with histologic improvement in bone disease. Thus, 1,25(OH)2D3 is a valuable adjunct to the management of renal osteodystrophy but requires monitoring of serum calcium to avoid hypercalcemia.