Attitudes of terminally ill older adults toward complementary and alternative medicine therapies.

AIM: The aim of this study was to characterize the attitudes of older adults on an inpatient palliative care unit toward complementary and alternative medicine (CAM) therapies. METHODS: A consecutive sample of 33 inpatients (61 to 98 years old) completed a questionnaire that examined their attitudes toward CAM to determine the acceptability of these therapies. Corresponding questionnaires were gathered from 10 substitute decision makers (SDMs). Preferences for specific CAM modalities were identified. Correlational analyses were performed between interest in CAM therapies and demographic variables and clinical status, including physical and psychological distress. RESULTS: A total of 27 patients (82 percent) were interested in trying CAM therapies. The greatest interest was shown in music therapy (61 percent) and massage therapy (58 percent). All of the SDMs were interested in having CAM therapies available for their loved ones to try. DISCUSSION: Attitudes toward CAM therapies of terminally ill older inpatients and their SDMs are highly favourable. CAM treatments merit closer evaluation as a means of enhancing end-of-life care.

A Novel Approach to Measurement-Based Care: Integrating Palliative Care Tools Into Geriatric Mental Health.

Background: Older adults cared for in a geriatric mental health program often have medical co-morbidities causing physical symptoms which may be under-recognized. We explore the utility of palliative care tools in this patient population to identify the burden of symptoms and impact on patient dignity. Methods: Participants were recruited from a geriatric mental health inpatient unit and outpatient day hospital. Mood and somatic symptoms were tracked with self-report rating scales, including the Geriatric Depression Scale (GDS) and the Geriatric Anxiety Inventory (GAI) used in psychiatry, as well as the Edmonton Symptom Assessment Scale (ESAS) and Patient Dignity Inventory (PDI) used in palliative care. Demographic characteristics were collected from a retrospective chart review. Exploratory longitudinal models were developed for the GDS and GAI outcomes to assess change over time after adjusting for ESAS and PDI item scores. Results: Data were obtained for 33 English speaking patients (inpatients N = 17, outpatients N = 16) with a mean age of 76.5 (SD = 6.1). At baseline, several ESAS symptom burdens were rated as moderate and the PDI often captured physically distressing symptoms. GDS scores declined over time but at a slower rate for those reporting higher levels of pain on the ESAS (P = .04). GAI scores declined over time but at a slower rate for those identifying physically distressing symptoms on the PDI (P = .04). Conclusions: This study demonstrates how using the ESAS and PDI in a mental health population can be helpful in tracking symptoms and how these symptoms are related to psychiatric outcomes.

ECHO Care of the Elderly: Innovative Learning to Build Capacity in Long-term Care.

BACKGROUND: Older adults are entering long-term care (LTC) homes with more complex care needs than in previous decades, resulting in demands on point-of-care staff to provide additional and specialty services. This study evaluated whether Project ECHO® (Extension for Community Healthcare Outcomes) Care of the Elderly Long-Term Care (COE-LTC)-a case-based online education program-is an effective capacity-building program among interprofessional health-care teams caring for LTC residents. METHODS: A mixed-method, pre-and-post study comprised of satisfaction, knowledge, and self-efficacy surveys and exploration of experience via semi-structured interviews. Participants were interprofessional health-care providers from LTC homes across Ontario. RESULTS: From January-March 2019, 69 providers, nurses/nurse practitioners (42.0%), administrators (26.1%), physicians (24.6%), and allied health professionals (7.3%) participated in 10 weekly, 60-minute online sessions. Overall, weekly session and post-ECHO satisfaction were high across all domains. Both knowledge scores and self-efficacy ratings increased post-ECHO, 3.9% (p = .02) and 9.7 points (p < .001), respectively. Interview findings highlighted participants' appreciation of access to specialists, recognition of educational needs specific to LTC, and reduction of professional isolation. CONCLUSION: We demonstrated that ECHO COE-LTC can be a successful capacity-building educational model for interprofessional health-care providers in LTC, and may alleviate pressures on the health system in delivering care for residents.

Building Long-Term Care Staff Capacity During COVID-19 Through Just-in-Time Learning: Evaluation of a Modified ECHO Model.

OBJECTIVES: The onset of the COVID-19 pandemic significantly challenged the capacity of long-term care (LTC) homes in Canada, resulting in new, pressing priorities for leaders and health care providers (HCPs) in the care and safety of LTC residents. This study aimed to determine whether Project ECHO (Extension for Community Healthcare Outcomes) Care of the Elderly Long-Term Care (COE-LTC): COVID-19, a virtual education program, was effective at delivering just-in-time learning and best practices to support LTC teams and residents during the pandemic. DESIGN: Mixed methods evaluation. SETTING AND PARTICIPANTS: Interprofessional HCPs working in LTC homes or deployed to work in LTC homes primarily in Ontario, Canada, who participated in 12 weekly, 60-minute sessions. METHODS: Quantitative and qualitative surveys assessing reach, satisfaction, self-efficacy, practice change, impact on resident care, and knowledge sharing. RESULTS: Of the 252 registrants for ECHO COE-LTC: COVID-19, 160 (63.4%) attended at least 1 weekly session. Nurses and nurse practitioners represented the largest proportion of HCPs (43.8%). Overall, both confidence and comfort level working with residents who were at risk, confirmed, or suspected of having COVID-19 increased after participating in the ECHO sessions (effect sizes ≥ 0.7, Wilcoxon signed rank P < .001). Participants also reported impact on intent to change behavior, resident care, and knowledge sharing. CONCLUSIONS AND IMPLICATIONS: The results demonstrate that ECHO COE-LTC: COVID 19 effectively delivered time-sensitive information and best practices to support LTC teams and residents. It may be a critical platform during this pandemic and in future crises to deliver just-in-time learning during periods of constantly changing information.

Bereavement in cognitively impaired older adults: case series and clinical considerations.

The intersection of bereavement and cognitive impairment presents unique clinical challenges that have been overlooked in the literature. Cognitive impairment can interfere with normal ways of coping in the aftermath of loss. Elderly persons with cognitive impairment may have difficulty processing their loss and may even forget that their loved one has died, repeatedly asking other family members when the deceased is coming to visit. This can prove devastating for such individuals and their families, who are forced to keep reexperiencing their grief. This article examines the phenomenology of bereavement-related distress in older adults with cognitive impairment and dementia through a case series gathered from a large geriatric facility. The dilemmas in caring for bereaved elderly with cognitive difficulties and their families are highlighted, drawing attention to a vulnerable population. The purpose of this undertaking is to present a novel classification of a clinically relevant but overlooked issue as well as provide strategies for management and suggestions for future research.

The shifting landscape of psychotherapy in residency: stable framework of change.

This paper explores the impact of change on a psychiatry trainee's development through a case presentation. During training, psychiatry residents are exposed to constant transitions with frequent shifts in training sites and supervisors. Change is perhaps the most consistent characteristic of residency training. And yet, the maintenance of a changeless, stable frame is considered the gold standard for psychotherapy. The effect of a constantly shifting framework on the training therapist, the patient, and the therapy itself is considered. Reflecting on the multiple and varied themes elucidated by the case, it is evident that there are rich opportunities for growth for both the patient and the trainee who embark on a course of therapy together. Contrary to widely held beliefs, rather than diluting the psychotherapy and diminishing the learning experience, change can be a stimulating and enriching force.

Enhancing communication in end-of-life care: a clinical tool translating between the Clinical Frailty Scale and the Palliative Performance Scale.

OBJECTIVES: To create a clinical tool to translate between the Clinical Frailty Scale (CFS), which geriatrics teams use, and Palliative Performance Scale (PPS), which palliative care teams use, to create a common language and help improve communication between geriatric and palliative care teams. DESIGN: Cross-sectional. SETTINGS: Two academic health centers: inpatient palliative care and chronic care units, an outpatient geriatric clinic, and inpatient referrals to a palliative care consultation service. PARTICIPANTS: Older adults (≥65) aged 80.9±8.0, with malignant (51%) and nonmalignant (49%) terminal diagnoses (N=120). MEASUREMENTS: Each participant was assigned four scores: a CFS score each from a geriatric physician and nurse and a PPS score each from a palliative care physician and nurse. Interrater reliability of each measure was calculated using kappa coefficients. For each measure, the mean of physician and nurse scores was used to calculate every possible combination of CFS and PPS scores to determine the combination with maximum agreement. RESULTS: Interrater reliability of each measure was very high for the CFS (weighted κ=0.92) and PPS (weighted κ=0.80). The CFS-PPS score matching that achieved maximum agreement (weighted κ=0.71) was used to create a conversion chart between the two measures. CONCLUSION: This conversion chart is a reliable means of translating scores between the CFS and PPS and is useful for geriatric and palliative care teams collaborating in the care of elderly adults.