Early clinical and quality impacts of the Age-Friendly Health System in a Veterans Affairs skilled nursing facility.

BACKGROUND: Skilled nursing facilities (SNFs) are an ideal setting to implement the Age-Friendly Health System (AFHS) approach, an initiative by the Institute for Healthcare Improvement (IHI) centered on the 4Ms: what matters, mobility, mentation, and medication. AFHS implementation has not been well studied in SNFs. METHODS: A 112-bed VA SNF implemented a facility-wide AFHS initiative including the following: (1) participating in a national IHI Age-Friendly Action Community; (2) establishing an AFHS workgroup centered on the 4Ms; (3) identifying meaningful clinical tools and frameworks for capturing each M; and (4) developing sustainment methods. Clinical (life-sustaining treatment, falls, disruptive behaviors, and medication deprescribing) and quality outcomes (rehospitalization, emergency department utilization, and discharge to the community) in addition to patient satisfaction were compared pre- and post-AFHS implementation (bed days of care [BDOC] 17413) to post-implementation (BDOC 20880). RESULTS: Clinical outcomes demonstrated improvements in the 4Ms, including: (1) what matters: 14% increase in life-sustaining treatment documentation (82%-96%; p < 0.01); (2) mobility: reduction in fall rate by 34% (8.15 falls/1000 BDOC to 5.41; p < 0.01); (3) mentation: decrease in disruptive behavior reporting system (DBRS) by 62% (5.11 DBRS/1000 BDOC to 1.96; p = 0.04); (4) medications: 53% increase in average potentially inappropriate medications (PIMs) deprescribing (0.38-0.80 interventions/patient; p < 0.01). Quality outcomes improved including rehospitalization (25.6%-17.9%) and emergency department utilization (5.3%-2.8%) within 30 days of admission. Patient satisfaction scores improved from a mean of 77.2 (n = 31, scale 1-100) to 81.3 (n = 42). CONCLUSIONS: Implementation of the AFHS initiative in a SNF was associated with improved clinical and quality outcomes and patient satisfaction. We describe here a sustainable, interprofessional approach to implementing the AFHS in a SNF.

Top Ten Tips Palliative Care Clinicians Should Know About Providing Care for People With Disabilities.

Palliative care (PC) clinicians are well poised to help people with disabilities (PWD) live well in the context of serious illness. PC prioritizes person-centered care with a focus on function, autonomy, and quality of life. This approach aligns with principles of high-quality care for PWD. An understanding of the unique experiences and needs of PWD can advance the delivery of comprehensive, equitable PC for this population. In this article, we provide 10 tips to help PC clinicians develop an informed disability lens in their approach to care.

Pharmacologic Pain Management: What Radiation Oncologists Should Know.

Individuals with cancer experience a host of symptoms, especially when the malignancy is advanced. Pain occurs from the cancer itself or related treatments. Undertreated pain contributes to patient suffering and lack of engagement in cancer-directed therapies. Adequate pain management includes thorough assessment; treatment by radiotherapists or anesthesia pain specialists; anti-inflammatory medications, oral or intravenous opioid analgesics, and topical agents; and attention to the emotional and functional effects of pain, which may involve social workers, psychologists, speech therapists, nutritionists, physiatrists and palliative medicine providers. This review discusses typical pain syndromes arising in cancer patients undergoing radiotherapy and provides concrete recommendations for pain assessment and pharmacologic treatment.

Lived Experience: A Case-Based Review of Trauma-Informed Hospice and Palliative Care at a Veterans Affairs Medical Center.

Many individuals who present for hospice or palliative care might have experienced trauma during their lives, with some progressing to post-traumatic stress disorder. As these individuals face life-limiting illness, trauma might resurface. Consequently, physical and emotional health might suffer due to exacerbation of trauma-related symptoms, such as anxiety, irritability, or flashbacks. Providing trauma-informed care can help mitigate the effects of trauma for those facing life-limiting illness who might not be able to tolerate formal trauma treatment due to limited prognosis, fatigue, or lack of willingness to engage in treatment. The goal of this narrative review is to describe how aging and the end-of-life experience can lead to a re-engagement with previous traumatic experiences and, using case-based examples, provide recommendations for all members of the interprofessional hospice or palliative care team on how to elicit and respond to a history of trauma to minimize the potential negative impact of trauma at end-of-life.

Help Me Understand: Providing Palliative Care to Individuals With Serious Mental Illness.

Individuals with serious mental illness (SMI) have shortened life expectancy with increased risk of developing comorbid medical illnesses. They might have difficulty accessing care and can be lost to follow-up due to complex socioeconomic factors, placing them at greater risk of dying from chronic or undiagnosed conditions. This, in combination with stigma associated with SMI, can result in lower quality end-of-life care. Interdisciplinary palliative care teams are in a unique position to lend assistance to those with SMI given their expertise in serious illness communication, values-based care, and psychosocial support. However, palliative care teams might be unfamiliar with the hallmark features of the various SMI diagnoses. Consequently, recognizing and managing exacerbations of SMI while delivering concurrent palliative or end-of-life care can feel challenging. The goal of this narrative review is to describe the benefits of providing palliative care to individuals with SMI with concrete suggestions for communication and use of recovery-oriented language in the treatment of individuals with SMI. The salient features of 3 SMI diagnoses-Bipolar Disorders, Major Depressive Disorder, and Schizophrenia-are outlined through case examples. Recommendations for working with individuals who have SMI and other life-limiting illness are provided, including strategies to effectively manage SMI exacerbations.

Complexities of Corona Virus Disease-19: The Role of Palliative Care at a Veterans Affairs Hospital.

The Corona Virus Disease-19 (COVID-19) pandemic accentuated the need for delivery of quality palliative care. We share the experience of our acute care hospital palliative care team in caring for veteran patients who died from COVID-19 and provide recommendations for palliative care teams caring for older adult populations. We conducted a retrospective chart review on 33 patients to gather characteristics data and delineate palliative care team involvement in their clinical courses. Our palliative care team participated in the care of 87.9% of patients who died from COVID-19. They were medically and psychosocially complex with 75.8% carrying at least four medical comorbidities, 87.8% presenting from an institutional facility, and 39.4% diagnosed with at least one psychiatric condition. Our results emphasize the impact of this pandemic on vulnerable populations and highlight the benefits of palliative care for support of patients, their loved ones, and the clinical teams caring for them.

ACT Now: The Intersection of Acceptance and Commitment Therapy with Palliative Care in a Veteran with Chronic Suicidal Ideation.

Suicide rates are increasing in the United States and groups at elevated risk include older adults, veterans, and those with life-limiting illnesses. However, the treatment of suicidality at end-of-life has been little studied. There is emerging evidence that palliative care itself may be protective against suicide and there is some support for the use of Acceptance and Commitment Therapy (ACT) at end-of-life. The overlapping mechanisms of palliative care and ACT are especially well-suited for individuals struggling with suicidality in the context of life-limiting illness.A case from a Veterans Affairs Home-Based Primary Care (HBPC) team is used to illustrate the challenges and opportunities when providing end-of-life care to an older veteran with chronic suicidal ideation. Prior mental health treatment had limited impact on his suicidality. However, with an integrated ACT and palliative care approach, the HBPC team was better able to focus on the veteran's goals. This approach was helpful in reducing suicidal ideation and engaging him in end-of-life decision-making discussions. This case highlights the valuable role of palliative care in suicide prevention and how the addition of ACT can aid in the effective treatment of chronic suicidal ideation at the end-of-life.

Rally the Troops: Interdisciplinary Response to a Veteran Who Attempted Suicide on a Veterans Affairs Hospice Unit.

Requests for hastened death and suicidal ideation may be more prevalent in populations approaching the end of life. Often these wishes and thoughts occur in the context of concurrent psychiatric disorders and emotional suffering. We discuss the case of a veteran with terminal lung cancer and comorbid psychiatric illness who attempted suicide while under the care of an inpatient interdisciplinary hospice team and describe our team's response to this suicide attempt. We review risk factors for suicidality at end of life, challenges of distinguishing desire for hastened death from suicidality, and the ethics of resuscitation of a dying patient after a suicide attempt.

Preferential association of serum amyloid P component with fibrillar deposits in familial British and Danish dementias: similarities with Alzheimer's disease.

Two hereditary forms of cerebrovascular amyloidosis, familial British and Danish dementias (FBD and FDD), share striking similarities with Alzheimer's disease (AD) despite structural differences among their amyloid subunits (ABri in FBD, ADan in FDD, and Abeta in AD). Neuropathological lesions in these disorders include neurofibrillary tangles, parenchymal amyloid and pre-amyloid deposits and overwhelming cerebral amyloid angiopathy co-localizing with reactive microglia and multiple amyloid associated proteins including activation products of the complement cascade. Immunohistochemical analysis of FBD and FDD brain lesions unveiled the presence of serum amyloid P-component (SAP) primarily associated with thioflavin positive amyloid deposits in spite of the significant pre-amyloid burden existing in both disorders. Using affinity chromatography and ELISA binding assays we demonstrated specific, calcium-dependent, saturable, high affinity binding interactions between SAP and ABri/ADan peptides, with dissociation constant values in the sub-nanomolar range and within the same order of magnitude as those resulting from the interaction of SAP with Alzheimer's Abeta1-40 and Abeta1-42. The preferential association of SAP with fibrillar amyloid lesions and not with non-fibrillar pre-amyloid deposits is puzzling, suggesting that SAP modulates the assembly and stability of the final fibril rather than participating in the early steps of protein misfolding and oligomerization.

Inhibition of glycogen synthase kinase-3 by lithium correlates with reduced tauopathy and degeneration in vivo.

Neurofibrillary tangles composed of hyperphosphorylated, aggregated tau are a common pathological feature of tauopathies, including Alzheimer's disease. Abnormal phosphorylation of tau by kinases or phosphatases has been proposed as a pathogenic mechanism in tangle formation. To investigate whether kinase inhibition can reduce tauopathy and the degeneration associated with it in vivo, transgenic mice overexpressing mutant human tau were treated with the glycogen synthase kinase-3 (GSK-3) inhibitor lithium chloride. Treatment resulted in significant inhibition of GSK-3 activity. Lithium administration also resulted in significantly lower levels of phosphorylation at several epitopes of tau known to be hyperphosphorylated in Alzheimer's disease and significantly reduced levels of aggregated, insoluble tau. Administration of a second GSK-3 inhibitor also correlated with reduced insoluble tau levels, supporting the idea that lithium exerts its effect through GSK-3 inhibition. Levels of aggregated tau correlated strongly with degree of axonal degeneration, and lithium-chloride-treated mice showed less degeneration if administration was started during early stages of tangle development. These results support the idea that kinases are involved in tauopathy progression and that kinase inhibitors may be effective therapeutically.

Cdk5 is a key factor in tau aggregation and tangle formation in vivo.

Tau aggregation is a common feature of neurodegenerative diseases such as Alzheimer's disease, and hyperphosphorylation of tau has been implicated as a fundamental pathogenic mechanism in this process. To examine the impact of cdk5 in tau aggregation and tangle formation, we crossed transgenic mice overexpressing the cdk5 activator p25, with transgenic mice overexpressing mutant (P301L) human tau. Tau was hyperphosphorylated at several sites in the double transgenics, and there was a highly significant accumulation of aggregated tau in brainstem and cortex. This was accompanied by increased numbers of silver-stained neurofibrillary tangles (NFTs). Insoluble tau was also associated with active GSK. Thus, cdk5 can initiate a major impact on tau pathology progression that probably involves several kinases. Kinase inhibitors may thus be beneficial therapeutically.