Care of older people and people requiring palliative care with COVID-19: guidance from the Australian National COVID-19 Clinical Evidence Taskforce.

INTRODUCTION: Older people living with frailty and/or cognitive impairment who have coronavirus disease 2019 (COVID-19) experience higher rates of critical illness. There are also people who become critically ill with COVID-19 for whom a decision is made to take a palliative approach to their care. The need for clinical guidance in these two populations resulted in the formation of the Care of Older People and Palliative Care Panel of the National COVID-19 Clinical Evidence Taskforce in June 2020. This specialist panel consists of nursing, medical, pharmacy and allied health experts in geriatrics and palliative care from across Australia. MAIN RECOMMENDATIONS: The panel was tasked with developing two clinical flow charts for the management of people with COVID-19 who are i) older and living with frailty and/or cognitive impairment, and ii) receiving palliative care for COVID-19 or other underlying illnesses. The flow charts focus on goals of care, communication, medication management, escalation of care, active disease-directed care, and managing symptoms such as delirium, anxiety, agitation, breathlessness or cough. The Taskforce also developed living guideline recommendations for the care of adults with COVID-19, including a commentary to discuss special considerations when caring for older people and those requiring palliative care. CHANGES IN MANAGEMENT AS RESULT OF THE GUIDELINE: The practice points in the flow charts emphasise quality clinical care, with a focus on addressing the most important challenges when caring for older individuals and people with COVID-19 requiring palliative care. The adult recommendations contain additional considerations for the care of older people and those requiring palliative care.

A Clinical Evaluation of a Next Generation, Non-Invasive, Selective Radiofrequency, Hands-Free, Body-Shaping Device.

OBJECTIVE: The aim of this study was to compare clinical outcomes of a noninvasive selective radiofrequency (RF) eld device (BTL Vanquish METM, BTL Industries Inc., Boston MA) with its predecessor (VanquishTM, BTL Industries Inc., Boston MA). The BTL Vanquish METM system has been thoroughly redesigned for more efficient, predictable and homogenous energy delivery to the targeted tissue. MATERIALS AND METHODS: In this multi-center study, 36 subjects with BMIs under 30 were randomly assigned to be treated in Group A (BTL Vanquish METM) or Group B (VanquishTM) in order to obtain a side by side comparison of the devices' ef cacies. Each subject re- ceived 4 weekly 45-minute treatments with the device determined by their group assignments. Measurements of subject's abdominal fat were taken prior to the first treatment and again four weeks after finishing the final treatment. RESULTS: The primary outcome was abdominal fat thickness reduction as measured by ultrasound one month following each subject's final treatment. Thirty four subjects completed the study. Two patients did not complete their treatments due to the reasons unrelated to the study (one from each group). Subjects in Group A treated with BTL Vanquish METM had an abdominal fat thickness reduction of 4.17 mm, or 29.46%, while subjects in Group B treated with VanquishTM had an abdominal fat thickness reduction of only 2.72 mm, or 15.21%. The 4 weekly treatments with BTL Vanquish METM in Group A produced a 53% higher reduction (4.17 mm vs 2.72 mm) of abdominal fat layer thickness than those in Group B. The standard deviation of ultrasound measurements in Groups A and B were 1.42mm and 2.21mm, respectively. Assuming a homogenous response across the entire treatment area, the volume of fat reduced was calculated by multiplying the average measured reduction in fat layer by the surface area of the treatment applicator (2100 cm2; 325.5 square inches). It was calculated that Group A patients lost an average of 0.876 liter (0.23 liquid gallon) of fat, while Group B patients lost 0.571 liter (0.15 liquid gallon) of fat. DISCUSSIONS AND CONCLUSIONS: The mean difference between the tested groups was statistically significant proving better outcomes in the Vanquish METM than its predecessor. Furthermore, the reduction in standard deviation of fat reduction measurements in Group A vs Group B is evidence that the Vanquish METM provides more consistent performance. J Drugs Dermatol. 2016;15(12):1557-1561.

Medication management of type 2 diabetes in residential aged care

BACKGROUND: Medication management of type 2 diabetes mellitus (T2DM) in residential aged care facilities (RACFs) requires consideration of the residents' goals of care and susceptibility to adverse drug events (ADEs). OBJECTIVE: The aim of this article is to review best practice medication management for residents diagnosed with T2DM. DISCUSSION: Management of T2DM in RACFs is often focused on maintaining residents' quality of life rather than intensive glycaemic management to reduce chronic complications, because the risks of intensive glycaemic management typically outweigh the potential benefits. Australian RACF guidelines recommend individualised glycated haemoglobin targets of 7­8.5% (53­69 mmol/mol). Strategies to reduce the risk of preventable ADEs may include education for residents, carers and staff; assessment of hypoglycaemic risk and renal function; medication review and regimen simplification; de-intensification of glucose-lowering medications; and appropriate end-of-life medication management. Use of a resident-centred multidisciplinary approach and resources tailored to the RACF setting will support residents to achieve best possible health outcomes and quality of life.

Palliative care case conferences in long-term care: views of family members.

AIMS AND OBJECTIVES: This paper examines the use of structured Palliative Care Case Conferences in long-term care. The issues families bring to the Palliative Care Case Conference, their level of distress prior to the conference, the extent to which these issues are addressed by staff and family satisfaction with this process are described. BACKGROUND: In most developed countries, up to 30% of older people die in long-term care. A palliative approach generally refers to the resident and family as the 'unit of care'. Interventions, which include family in palliative care, are required in this setting. DESIGN: Descriptive and thematic results from the intervention arm of a pre-post, sequential mixed method study. METHODS: Examination of documents of 32 resident/family dyads participating in a Palliative Care Case Conference, and interviews with the residents' family postintervention. RESULTS: Main concerns raised by family members prior to a Palliative Care Case Conference were physical and medical needs, pain, end-of-life care planning and nutrition and hydration. Families rated a high level of concern, 7.5 on a 10-point rating scale, prior to the Palliative Care Case Conference. A formalised Palliative Care Case Conference process ensured issues relating to end-of-life care planning, pastoral care, pain and comfort and physical and medical needs were well documented by staff. Issues relating to care processes and the family role in care were less well documented. All families, interviewed postintervention, recommended Palliative Care Case Conferences; and over 90% of families felt their issues were addressed to their satisfaction. Families also reported an increased understanding of the resident's current and future care. CONCLUSIONS: The Palliative Care Case Conference in long-term care provides an important platform for family to voice concerns. Palliative Care Case Conference documentation indicates that staff are attending to these issues, although more reference to concerns relating to care processes and the family role could be made. IMPLICATIONS FOR PRACTICE: Increased communication between staff and family, in the form of a Palliative Care Case Conference, may reduce stress, anxiety and unwanted hospitalisations during the palliative phase.

The experience of fatigue for adults living with HIV.

AIMS: The aim of this study was to go beyond objective clinical assessment and explore the experience of fatigue and self-care strategies with adults who live with HIV. RATIONALE: This study responded to a perceived lack of available evidence to inform the practice of service providers about ways fatigue impacts on the lives of people with HIV. Prior understandings of fatigue are derived from survey or instrument-based tools or studies that do not consider the complexities of the personal experience that in-depth interviews can elicit. The focus remains generally on description, measurement or management from a biomedical perspective. METHODS: A qualitative study using participatory action research methods was conducted during 2003 with 15 adults diagnosed with HIV who perceived fatigue was a problem in their lives. Data were collected by individual interviews, researcher's notes and two participatory action research groups. RESULTS: Thematic analysis of data demonstrated that fatigue remains silent and invisible to participant's families, friends and employers. Fatigue experienced by people living with HIV generally also met with a lack of acknowledgement and understanding from health professionals. People developed self-care strategies over many years of trial and error. RELEVANCE TO CLINICAL PRACTICE: People living with a HIV seek to be acknowledged that fatigue is a legitimate concern, not only by health care professionals, but also people with whom they live. It is imperative that nurses who work with people living with HIV-related fatigue consider the wider social aspects of the person's life as well as physical symptoms. Most importantly, there then needs to be a process of engagement and active listening to the individual's account of their experience of fatigue. Advocating that fatigue is a legitimate complaint to the person living with HIV as well as the wider public and professional community is imperative.

Chronic illness self-management: locating the 'self'.

AIM: In this paper, we present the findings of a recent research project in which we explored self- management with older people who were diagnosed with asthma. BACKGROUND: Asthma self-management literature has focused on the need for the patient to 'adhere' to prescribed therapies, in particular the taking of medications, monitoring of respiratory function or recognizing and avoiding triggers. METHOD: Data were generated during a period of 9 months from three sources; in-depth interviews with 24 older participants, an open-ended questionnaire and two mixed-gender participatory action research groups. FINDINGS: Based on current literature, our previous research findings which have 'unpacked' what is 'self'-management, and data generated in this project, we propose that three asthma management models are in operation: Medical Model of Self-management, Collaborative Model of Self-management and Self-Agency Model of Self-management. Locating the 'self' in self-management means acknowledging that many people living with a chronic condition are already self-determining and their expertise should be acknowledged as such. CONCLUSION: Health care professionals can best facilitate people toward self-agency by embracing new understandings of self-management in long-term illness. This process is enhanced when the expertise a person brings to the management of their condition is given the respect it deserves. There needs to be a focus on providing people with the means to grow and learn in a participative relationship that cannot be fully realized with 'off the shelf' self-management solutions.