IAGG/IAGG GARN International Survey of End-of-Life Care in Nursing Homes.

This article reports the findings of a survey on end-of-life (EOL) care in nursing homes of 18 long-term care experts across 15 countries. The experts were chosen as a convenience-based sample of known experts in each country. The survey was administered in 2016 and included both open-ended responses for defining hospice care, palliative care, and "end of life," and a series of questions related to the following areas-attitudes toward EOL care, current practice and EOL interventions, structure of care, and routine barriers. Overall experts strongly agreed that hospice and palliative care should be available in long-term care facilities and that both are defined by holistic, interdisciplinary approaches using measures of comfort across domains. However, it appears the experts felt that in most countries the reality fell short of what they believed would be ideal care. As a result, experts call for increased training, communication, and access to specialized EOL services within the nursing home.

PALLIATIVE CARE FOR OLDER ADULTS: STATE OF THE ART IN LEBANON.

Palliative care (PC) for older adults constitutes an important human rights challenge and a major public health care priority due to the aging of the population and the lack of health care services addressing the needs of the older people. In Lebanon, the surge in the number of older people with complex needs is unmatched by any increase in the services offered to them. PC in Lebanon is still under- developed and is subject to a number of challenges. These challenges are alarming and must be overcome through introducing health care providers to basic PC principles as recommended by the National Committee for Pain Relief and Palliative Care (NCPRPC).

Incorporating geriatrics into undergraduate medical education in Lebanon.

BACKGROUND: Although the proportion of older adults in Lebanon is expected to increase rapidly over the next few decades, the current healthcare workforce is unprepared to address the needs of this population. Currently, emphasis on geriatrics is lacking in medical education curricula of most universities in Lebanon, and there is a shortage of geriatricians in the country. METHODS: In this paper we present specific methods of integrating geriatrics into the undergraduate medical curriculum based on the experience of medical schools in the United States. RESULTS: Incorporating geriatrics into the medical curriculum requires support from deans and faculty members at medical schools, as well as training of non-geriatricians to teach geriatrics within their specialty. Geriatrics training can be gradually incorporated into existing courses throughout the four years of medical school, and should consist of a holistic approach that teaches students how to diagnose, treat, and interact with older adults and their caregivers while being mindful of their psychological, physical and social wellbeing. CONCLUSIONS: Increasing exposure to geriatric education during medical school promises to increase interest in geriatrics, and ultimately help address the shortage of geriatricians in the country.

International palliative care: Middle East experience as a model for global palliative care.

Care for elderly people with life-limiting illness cannot be delivered primarily by geriatricians or palliative care practitioners. The role of these clinicians is to help carers become adept in palliative care medicine. In a culture in which family ties run deep, the offer of palliative care from an outsider may be met with suspicion. The family bond in the Middle East is strong, but the emotional response to terminal illness may push families to request futile treatments, and physicians to comply. When palliative care is well developed and well understood, it provides a viable alternative to such extreme terminal measures.

An international definition for "nursing home".

There is much ambiguity regarding the term "nursing home" in the international literature. The definition of a nursing home and the type of assistance provided in a nursing home is quite varied by country. The International Association of Gerontology and Geriatrics and AMDA foundation developed a survey to assist with an international consensus on the definition of "nursing home."

Integration of complementary medicine in supportive cancer care: survey of health-care providers' perspectives from 16 countries in the Middle East.

INTRODUCTION: In this multinational Middle-Eastern study, we assessed health-care providers' (HCPs) perspectives on their patients' use of complementary and traditional medicine (CTM) and identified the leading barriers to CTM integration in supportive cancer care. METHODS: A 17-item questionnaire was developed and administered to HCPs attending palliative medicine workshops conducted across the Middle East by the Middle East Cancer Consortium. RESULTS: 339 HCPs from 16 countries across the Middle East completed the questionnaire (80.3 % response rate). Respondents perceived their patients' reasons for CTM use primarily in the context of cancer cure (63 %) and quality of life (QOL) improvement (57 %). Expectation regarding CTM's role in cancer cure/survival was more pronounced in Turkey, Jordan, the Palestinian Authority, and the Persian Gulf area. In contrast, the expectation that CTM would improve QOL was more emphasized in Israel. A mid-position between the cure/survival and QOL poles was observed in Cyprus, Lebanon, and the North African countries. Leading barriers to CTM integration in supportive cancer care included oncologists' skepticism and a gap between patients' expectations and HCP's objectives. Respondents' leading recommendation to HCPs was to communicate integrative care emphasizing well-being and improved functioning in accordance with their patients' health beliefs. CONCLUSION: CTM integration in supportive cancer care can be facilitated by implementing a platform for Middle Eastern clinical collaborations. HCPs' expectations and experiences with CTM have been positive in the oncology setting. These data need to be corroborated with information of patients' expectations on the provision of CTM over all phases of the oncology treatment.

Evaluating palliative care needs in Middle Eastern countries.

BACKGROUND: Cancer incidence in Middle Eastern countries, most categorized as low- and middle-income, is predicted to double in the next 10 years, greater than in any other part of the world. While progress has been made in cancer diagnosis/treatment, much remains to be done to improve palliative care for the majority of patients with cancer who present with advanced disease. OBJECTIVE: To determine knowledge, beliefs, barriers, and resources regarding palliative care services in Middle Eastern countries and use findings to inform future educational and training activities. DESIGN: Descriptive survey. SETTING/SUBJECTS: Fifteen Middle Eastern countries; convenience sample of 776 nurses (44.3%), physicians (38.3%) and psychosocial, academic, and other health care professionals (17.4%) employed in varied settings. MEASUREMENTS: Palliative care needs assessment. RESULTS: Improved pain management services are key facilitators. Top barriers include lack of designated palliative care beds/services, community awareness, staff training, access to hospice services, and personnel/time. The nonexistence of functioning home-based and hospice services leaves families/providers unable to honor patient wishes. Respondents were least satisfied with discussions around advance directives and wish to learn more about palliative care focusing on communication techniques. Populations requiring special consideration comprise: patients with ethnic diversity, language barriers, and low literacy; pediatric and young adults; and the elderly. CONCLUSIONS: The majority of Middle Eastern patients with cancer are treated in outlying regions; the community is pivotal and must be incorporated into future plans for developing palliative care services. Promoting palliative care education and certification for physicians and nurses is crucial; home-based and hospice services must be sustained.

Urinary incontinence in older adults.

Urinary incontinence is a common problem in the elderly which is under-reported and under-treated.It can have profound effects on the quality-of-life of affected persons and their companion or caregiver. Though common, incontinence is not an inevitable consequence of aging, but multiple anatomic and physiologic age-related changes increase the risk of UI with advancing age. Many treatment modalities are available for managing UI, some more effective than others. Patient education, and careful selection of treatment modalities can significantly improve urinary incontinence, and in some cases cure it, but treatment complications and side effects are common and must be closely monitored for successful long-term management. Surgical management of stress incontinence is a safe and effective intervention that is underutilized.

Sleep disturbance in palliative care.

Sleep disturbance in palliative medicine is a common and challenging condition that significantly adds to the burden of suffering experienced by patients with advanced stage diseases. Sleep disorders may be primary or, more commonly, a secondary symptom of the advancing disease process. The diverse nature of patients under palliative care makes management of sleep disorders particularly challenging and highly individualized. Multiple pharmacologic and nonpharmacologic interventions have been successfully used for the management of sleep disturbances in palliative medicine. Yet, despite these measures, many patients do not seek medical attention for sleep disturbances, and health care providers tend to under-diagnose this condition and under-treat it when diagnosed, thus missing an opportunity to improve the quality of life of patients already suffering from the burden of terminal disease.

Psychosocial impact of urinary incontinence in the elderly population.

The impact of urinary incontinence extends well beyond the evident physical and physiologic sequelae. Incontinence may leave affected persons in social, emotional, and mental disarray. Measuring the psychosocial impact of a disease, however, is difficult,and there is no single best tool to achieve such an assessment. Several incontinence-specific tools have been devised to document the impact of this condition and are described briefly in this review. Outcome measures have, until recently, focused on objective data; however, from the patient's viewpoint, subjective psychosocial measures may be a better reflection of the success ofa treatment intervention. For a variety of reasons, the majority of affected persons do not seek help. If the full benefit of treatment options is to be realized, the health care provider actively should seek a history of incontinence in patients who may be ashamed or embarrassed.

Cancer in the elderly: is it preventable?

It is the goal of the American Cancer Society to decrease the mortality from cancer by 50% and the incidence of cancer by 25% by the year 2015 in the United States. Achieving this goal requires intervention at the primary (incidence) and secondary (mortality) prevention stages, and will involve a concerted effort of the individual practitioner, governmental agencies, local, state, and national interest groups, and the population at large. Primary care practitioners must increase their level of enthusiasm for cancer prevention, and actively counsel patients about cancer risks and preventive measures. Practitioners should encourage inclined patients by providing support and specialty resources, such as dieticians, exercise therapists, and smoking and alcohol cessation programs. The greatest effort lies in the general population, who must adopt a healthier lifestyle, including appropriate diet, smoking cessation, control of obesity, and daily exercise. None of these lifestyle changes are easy to embrace, but once educated about lifestyle and risk of cancer, people have a powerful incentive to change. Continued public awareness campaigns and encouragement from health care providers are essential for the success of such programs. The success in smoking cessation shows that achieving societal lifestyle changes on a large scale is possible. The elderly are especially prone to benefit from primary and secondary prevention techniques, and it must not be assumed that only the young will realize the benefits of prevention and screening. The association of age and cancer risk will always be present, but need not be as consequential as it is now. Although cancer prevention may have a limited role in antiaging per se, the feasibility of cancer risk reduction has a definite role in aging successfully.

Osteoporosis for the home care physician. Part 1: etiology and current diagnostic strategies.

Osteoporosis affects over 20 million individuals in North America and is responsible for over 1.5 million fractures in the US. Although most cases of osteoporosis are primary, in 20% of older women and 40% of older men presenting with vertebral fractures, a secondary cause can be identified. The WHO based the diagnosis of postmenopausal osteoporosis on the presence of BMD T-score that is 2.5 standard deviations or greater below the mean for young women. The International Society of Clinical Densitometry defined male osteoporosis as BMD T-score of 2.5 or greater below the mean for young men. BMD assessment at the hip and spine by DXA is the standard procedure to assess bone density. Laboratory testing in patients with low BMD is performed to exclude other conditions that could cause low BMD such as multiple myeloma, endocrinopathies and osteomalacia. Bone turnover marker levels currently do not predict bone mass or fracture risk and are only weakly associated with changes in bone mass. Subsequently, they are of limited use in the clinical evaluation of bone density changes.

Sexuality in the nursing home, part 1: attitudes and barriers to sexual expression.

Sexuality is a basic human need that begins at birth and continues throughout life. The sexual needs of the elderly are similar to those of the young, but with variations in frequency, intensity, and mode of expression. Regardless of age, every individual has a need for love, intimacy, and companionship. Unfortunately, however, stereotypical thinking, ignorance, and prejudice dominate Western society's view on sexuality in the elderly. In a youth-oriented culture, sexuality is attributed to the young, healthy, and beautiful, and the myth that the elderly are asexual beings predominates. Consequently, the sexual needs of the elderly are frequently overlooked and ignored. Nowhere is this more emphatic than in the nursing home setting. This article explores barriers to sexual expression in the nursing home setting and discusses strategies to overcome them.

Sexuality in the nursing home, part 2: managing abnormal behavior--legal and ethical issues.

Everyone, regardless of age, needs love, touch, companionship, and intimacy. The 1.6 million elderly in the 20,000 U.S. nursing homes are not an exception. The literature indicates that nursing home residents continue to have an interest in sexual activity regardless of age. Sexuality, however, is frequently overlooked by physicians and staff working with nursing home residents. Many staff members have only a vague understanding of the sexual needs of the elderly. This results in a perception of residents' sexual interests as behavioral problems rather than expressions of need for love and intimacy. Inappropriate sexual behaviors in the nursing home can create an intense burden for nursing home staff. This article discusses ways to dealing with inappropriate sexual behaviors in long-term care settings and the ethical issues involved.

Sex and the nursing home.

Despite the known benefits of continued sexual activity on physical, mental, and emotional health, the nursing home resident continues to be sexually invisible. There are so few opportunities where the quality of life can be enhanced so greatly by so basic interventions. Sexuality in the nursing home is one of them. Failure of society to come to grips with the sexual needs of the elderly essentially robs them of a fundamental element of self-worth.