An examination of organisational policies for healthcare and lifestyle decision-making among Australian aged care providers.

OBJECTIVE: Examine policies of aged care organisations relating to healthcare and lifestyle decision-making. METHODS: Seven aged care organisations submitted policy documents. Policies were analysed using the Australian Law Reform Commission (ALRC) "Decision-Making Principles" as a framework. Senior staff (N = 9) with policy development roles participated in follow-up interviews. RESULTS: The structure and content of policy documents varied significantly between organisations. Most acknowledged the need to support the rights of care recipients in decision-making; however, the nature of this support was often unclear. Interview themes included factors relating to "organisational contexts" "policy development and implementation" and "ethical challenges." An overarching theme among high-performing organisations was "proactive response aimed at pre-empting decision-making dilemmas". We provide recommendations for policy development, including a self-assessment audit tool. CONCLUSION: Aged care provider organisations may need to review policies in the areas of healthcare and lifestyle decision-making to meet current best practice principles.

What you say and what I want: Priorities for public health campaigning and initiatives in relation to dementia.

OBJECTIVE: To examine the overlap between priorities expressed by representatives from national and local campaigning organisations and the views of key voices in relation to dementia. METHODS: Semi-structured, in-depth telephone interviews were conducted with 19 representatives from campaigning organisations, including nine countries and six local community initiatives in Australia. Responses were categorised into nine priorities. Views were compared to the voices of people with dementia (n = 19), carers (n = 28), and health-care (n = 21), social work (n = 23) and service professionals (n = 20). RESULTS: Local groups prioritised user-led decision-making and community normalising agendas. National groups were influenced by service frameworks and increasing public awareness. Professional and carer groups focused on increasing understanding and communication skills while people with dementia valued being a normal part of society. CONCLUSION: Future campaigning should use both national and local approaches to changing social relations, through interpersonal connections, advocacy and social mobilisation, to promote a normalising approach to attitude change.

Dementia care in Israel: top down and bottom up processes.

Dementia is one of the main causes of disability among older adults and is viewed as one of the most distressing and devastating of conditions. Dementia has a profound impact on those who suffer from the disease and on their family caregivers. In this article, we describe the added benefit of implementing top-down and bottom-up strategies in the process of influencing and developing healthcare services. We use Israel as an example to argue that breakthroughs in care implementation and development of services are more likely to occur when there is a convergence of top-down and bottom-up processes. In the first section of the article, we present the top-down plans, initiated to address the needs of people with dementia and their families. In the second section, we present examples of bottom-up projects that developed in Israel before and after the top-down plans were initiated. In the third section, we contend that it is the combination of these top-down and bottom-up strategies that led to a breakthrough and the expansion of services for people with dementia and their families, and we argue that the Israeli case study is applicable to other health systems.

The 5Ts: Preliminary Development of a Framework to Support Inclusion of Older Adults in Research.

BACKGROUND/OBJECTIVES: To address the underrepresentation of older adults in clinical research, the National Institutes of Health will require investigators to include individuals across the lifespan. As investigators from other fields endeavor to recruit participants who are more representative of the patient population, geriatricians may have the opportunity to influence a broad range of research studies in older adults. Our aims were to elicit challenges to inclusion of older adults in clinical research and to develop a preliminary framework for communicating these challenges to non-geriatrics-trained researchers. DESIGN: Communication framework development. SETTING: Academic hospital and Veterans Affairs Medical Center. PARTICIPANTS: Nongeriatrician researchers and staff, aging research experts. MEASUREMENTS: Interviews were used to elicit challenges nongeriatrician investigators and research staff experience when conducting research that includes older adults and then solicit experienced aging researchers' responses to these challenges. RESULTS: Challenges described by nongeriatrician investigators included lack of knowledge, rigid study structures, and a disease-focused approach. Responses from our geriatrics experts included communicating practical advice for avoiding common pitfalls. Our resulting framework is the 5Ts: Target Population, Team, Tools, Time, and Tips to Accommodate. This tool complements the 5Ms (Mind, Mobility, Medications, Multicomplexity, and Matters Most to Me) model for geriatric care and emphasizes representation of the Target Population, building research Teams that include aging expertise, incorporating appropriate Tools for function and patient-reported outcomes, anticipating Time for longer study visits, and accommodating common needs with practical Tips. Limitations include convenience sampling and lack of formal qualitative thematic analysis. CONCLUSION: Communicating with nongeriatrician researchers using the 5Ts may offer a practical approach to avoiding barriers to inclusion of older adults in research and complements an existing framework for communicating the value of geriatric medicine. Next steps in developing the 5Ts will be to include additional stakeholders (eg, national samples of nongeriatrician investigators, older adults and their families) and evaluating the impact of its implementation. J Am Geriatr Soc 67:342-346, 2019.

AGS Report on Engagement Related to the NIH Inclusion Across the Lifespan Policy.

After passage of the 21st Century Cures Act, the National Institutes of Health held a workshop in 2017 to consider expanding its inclusion policy to encompass individuals of all ages. American Geriatrics Society (AGS) leaders and members participated in the workshop and formal feedback period. AGS advocacy clearly impacted the resulting workshop report and Inclusion Across the Lifespan policy that eliminates upper-age limits for research participation unless risk justified and changes the language used to describe older adults and other vulnerable groups. AGS recommendations that were not specifically stated in the updated policy were to encourage active recruitment of older adults, add standard measures of function and/or frailty, and change review criteria to ensure the health status of a study population mirrors typical clinical populations. The updated inclusion policy ultimately offers academic geriatrics programs the opportunities to expand knowledge about health in aging and to continue to provide leadership for research and advocacy efforts on behalf of older adults. J Am Geriatr Soc 67:211-217, 2019.

Building Bridges between Gerontology and Elder Law.

BACKGROUND: Academics have long called for greater interaction between gerontologists and legal scholars. However, prior studies have suggested that disciplinary borders remain a barrier to such interaction, hampering gerontology's ability to function as a truly multi- or interdisciplinary field. OBJECTIVE: This study was designed to understand the nature of current interactions between legal scholars and gerontologists, and to identify opportunities to advance scientific dialogue and cooperation between the two. METHODS: Semi-structured, open-ended interviews with 27 participants (12 elder law scholars, 15 gerontologists) were conducted by phone, recorded, and analyzed by an interdisciplinary team. RESULTS: Both elder law scholars and gerontologists indicate that their field would benefit from research collaboration and cross-disciplinary teaching with the other field, but the fields remain distinct with little cross-disciplinary learning. Participants identified a series of opportunities, however, for increasing such learning and collaboration. CONCLUSIONS: The authors identify ways gerontologists can be encouraged to integrate elder law into their teaching and research, and suggest how this integration could enhance understanding of the aging experience.

Putting Complex Older Persons First: How the Centers for Medicare and Medicaid Services 2019 Payment Proposal Fails Older Americans.

In July 2018, the Centers for Medicare and Medicaid Services (CMS) released its proposed Medicare Physician Fee Schedule rule for calendar year 2019 (MPFS2019). The proposal sets forth CMS-recommended updates to Medicare payment policies, payment rates, and quality provisions for services provided in the next calendar year. From year to year, the rule also can serve as a vehicle for soliciting input on new payment proposals and changes to existing policies. Among the payment and quality proposals in the MPFS2019 proposal, CMS proposed extensive changes to Current Procedural Terminology codes that are the framework for documentation and payment for office-based evaluation and management (E/M) services. The American Geriatrics Society (AGS) believes the proposed payment methodology changes for E/M services would have had a significant negative impact on care for older Americans. On September 10, 2018, the AGS submitted its comments on this proposal and other aspects of the rule, and the AGS also submitted a comment letter signed by 41 organizations from an AGS-led multispecialty coalition. The coalition also worked collaboratively on outreach to Congress, which included visits to Capitol Hill and a coalition letter stressing our collective support for reducing the burden of documentation for clinicians and our opposition to the proposed changes in payment methodology. In all letters, we noted that the AGS and members of our coalition hoped to work collaboratively with CMS and other stakeholders to develop a refined approach that would achieve the best possible outcomes for patients, particularly frail older Americans with multiple chronic conditions. In releasing their final MPFS2019, CMS postponed the E/M coding collapse for at least two years, a decision that speaks to the hard work of the AGS, its members, and the multi-specialty coalition, and which opens the door for further discussions about the future of payment for E/M services so critical to older people. J Am Geriatr Soc 67:145-150, 2019.

Dental status, visits, and functional ability and dietary intake of elderly in Israel.

BACKGROUND: Epidemiological studies have shown deterioration in dental health accompanying the ageing process. Tooth loss increases with age. Chewing ability is closely correlated with number of natural teeth present: there is a threshold of 20-21 teeth, below which chewing ability declines. The government of Israel is currently considering adding dental treatment for elderly to the basket of services of the National Health Insurance Law. Information on the influence of elderly's dental health on nutrition and general health status can contribute to the decision making process. METHODS: Secondary analysis of data collected on a subsample (N = 1776) of the cross-sectional Mabat Zahav - National Health and Nutrition Survey of the Elderly was done. Intakes of energy, fiber, protein, fruits and vegetables, associations with dental visits, dentures presence and functional ability were analyzed. Linear regression adjusted for confounders was performed. RESULTS: Statistically significant differences in dietary intake of energy, fiber, protein and vegetables were found between elderly who visited a dentist in the last year and those who did not. Elderly who possessed dentures had lower dietary intakes than their dentate counterparts. Elderly with functional problems such as impaired chewing had worse dietary intakes than the others. This was so after controlling for education, degree of interest in the relationship between nutrition and health and reading the nutrition label. CONCLUSIONS: The findings in our study suggest that those who visited a dentist in the last year, had natural teeth and no denture/s and reported no chewing problems had better dietary intake. The results emphasize the importance of maintaining adequate dental health, preserving natural teeth and regular dental visits in the elderly to assure adequate nutrient status in this age group.

The Mental Capacity Act 2005 best interests test as applied to the elderly - is it fit for purpose?

The Mental Capacity Act 2005 ('MCA') sets out a regime which governs the making of decisions for people who lack mental capacity. Acts must be carried out, and decisions made, for such an incapacitated person, based on what is in her best interests (section 4 MCA). In this paper, I consider the body of post-MCA case law which applies the MCA best interests test to decision-making for elderly people, in various contexts. Is the best interests test 'fit for purpose' for the vulnerable elderly? The key aims of Parliament in introducing the test seem to have been empowerment, protection and support - and alertness to undue influence - as well as a balance between the objective and subjective viewpoints. Laudable attempts have been made by some judges, applying the MCA, to pay real heed to the patient's wishes and values, and to balance physical risk with welfare and happiness. However, it is not yet clear in my view that the new regime fully achieves Parliament's aims. Indeed, these aims themselves should be expanded; the law in this area should also promote the significance and value of advanced years and should recognise Aristotle's concept of 'human flourishing' in old age. Consideration should be given to amending the MCA, adding guidance specifically for the elderly and also to introducing a Convention of Human Rights for the older person and to creating a new statutory Older Persons' Commissioner and/or a cabinet-level Minister for Ageing and Older People.

Teaching legal competencies through an individualized elective in medicine and law.

Medical education, including education intended to prepare future physicians to care to older individuals, should include development and implementation of competencies relating to a physician's ability to understand and interact with the legal environment and legal actors who will affect the practice of medicine. The wisdom of integrating legal knowledge into the medical curriculum has been documented, and literature discusses the content and methods of teaching medical students and residents about law and the legal system. This article describes one unique but replicable, pedagogical approach to preparing future physicians to thrive in their inevitably interprofessional careers as they fulfill the fiduciary responsibilities that lie at the heart of their therapeutic and advocacy relationships with older patients.

Assessing and Meeting the Needs of LGBT Older Adults via the Older Americans Act.

SAGE and its partners have been focused on bridging the chasm between the greater need that LGBT older adults have for care, services, and supports, and the lower rate at which they access them, compared with their heterosexual and cisgender counterparts. The chasm is caused by discrimination, social isolation, disproportionate poverty and health disparities, and a lack of access to culturally competent providers. SAGE has used federal administrative and legislative advocacy to encourage the Aging Network to bridge this chasm by assessing and meeting the needs of LGBT older adults that can be addressed via the programs created under the Older Americans Act.