Palliative care for case managers: Building capacity to extend community-based palliative care to underserved older adults.

Palliative care has demonstrated effectiveness in alleviating the biological, emotional, social, and spiritual symptoms that accompany serious illness, and improving quality of life for seriously ill individuals and their family members. Despite increasing availability, there are significant disparities in access to and utilization of palliative care, particularly among diverse, low-income, and community-dwelling older adults with chronic illness. Training frontline service providers is a novel approach to expanding access to palliative care among underserved elders. This article presents a process and outcome evaluation of a palliative care curriculum that was developed and piloted for geriatric case managers in a large urban area. We describe the background, planning, design, implementation, and preliminary outcomes associated with a pilot implementation of the curriculum. We conclude with implications for replicating efforts to enhance frontline providers' knowledge, skills, and self-efficacy in extending palliative care to communities that lack access to critical supports for their burdensome symptoms.

Investigating associations between pain and complicated grief symptoms in bereaved Japanese older adults.

Objectives: About 10% of those who lose a loved one in hospice or palliative care settings will experience a mental health condition characterized by severe, prolonged grief responses. Criteria for this condition have evolved; we refer to this condition as Complicated Grief (CG) because it is one of the more common names. While there are some indications of associations between CG and poor physical health, explorations of the association between CG and pain is limited. The main objective of this study was to explore whether pain levels are higher in those with CG than those without, using a large population-based samples of Japanese older adults.Method: The study analyzed data from the Japan HOspice and Palliative care Evaluation (J-HOPE) study, a cross sectional study conducted in 2008 that examined the experiences and outcomes among adults throughout Japan who had lost a loved one within a palliative department or hospice setting, via self-report survey. We examined a subsample sample of 324 individuals aged 50 and above who completed a measure of CG.Results: Family members with high pain group had statistically significantly higher CG symptoms than those with low pain group (M = 66.95 vs. M = 52.05), an association which remained when controlling for demographic and loss-related factors.Conclusion: We found preliminary evidence of an association between CG symptoms and pain, which should be explored in additional samples. Should this finding be replicated, the mechanism of this association could be explored and treatment could potentially address both CG and pain.

"We Take Care of People; What Happens to Us Afterwards?": Home Health Aides and Bereavement Care in Hospice.

After a hospice patient dies, hospice providers can experience a variety of emotional responses. While work has been done on social workers' and nurses' reactions to patient death, home health aides (HHAs) have been overlooked. To address this gap, we conducted focus groups and individual qualitative interviews with 14 hospice HHAs. Questions covered HHAs' grief responses and how they coped with grief. We found a high burden of grief reactions; many HHAs often developed very close patient relationships. HHAs also noted that they often started working with new patients almost immediately after a death, leaving little time to process the loss. However, HHAs found support from other HHAs, their supervisors, as well as family, friends, and spiritual practices to be helpful in coping with their grief. Future work should enhance support to HHAs around patient loss; for example, grief support may be embedded into hospice team activities.

"Opening the door": developing and pilot testing an adult protective services worker engagement training in New York city.

About 10% of Americans over the age of 60 experience elder abuse (EA), but EA is frequently under detected. As the primary responders for alleged EA cases, Adult Protective Service (APS) caseworkers are ideally positioned to improve detection and intervention. The Opening the Door (OTD) training was developed in a multidisciplinary setting and designed in collaboration with APS workers to enhance their engagement skills in potential EA cases and thus maximize the possibility of disclosure. Rooted in a relational approach and utilizing adult learning theory, it is divided into three main topics: Preparing for Engagement, Engagement Practice, and Processing Engagement. The eight-hour training was piloted with three groups of urban APS caseworkers with a wide range of work experience. Pre- and post-tests and case reflections indicate a positive impact on caseworkers' sense of self-efficacy, while focus groups indicate the necessity for ongoing provision of trainings and development of additional supports for APS caseworkers. Future work could further explore the efficacy of the training and expand its reach.

Factors associated with depression detection in a New Hampshire mental health outreach program.

OBJECTIVES: For mental health outreach programs for older adults, accurately detecting depression is key to quality service provision. Multiple factors, including gender, cognitive impairment, or recent bereavement may affect depression detection, but this is under-studied. Therefore, we sought to both establish rates of depressive symptom detection and to examine factors associated with inaccuracies of detecting depression among participants in a mental health outreach program serving older adults. METHOD: We conducted a chart review of 1126 cases in an older adult-focused mental health outreach program in New Hampshire, the Referral Education Assistance & Prevention (REAP) program. Accuracy of depression detection was identified by comparing screen-positive scores for depressive symptoms on the 15-item Geriatric Depression Scale (GDS) to depression identification by counselors on a 'presenting concerns' list. RESULTS: Inaccurate depression detection (positive on the GDS but depression not identified by counselors) occurred in 27.6% of cases. Multivariate regression analyses indicated that anxiety, cognitive concerns, and rurality were all associated with detection innaccuracy. CONCLUSION: This study appears to be the first to examine factors influencing depression detection in a mental health outreach program. Future efforts should help ensure that all older mental health outreach clients have depression detected at optimal rates.

Professional quality of life of adult protective service workers.

Adult Protective Services (APS) workers are exposed to substantial occupational hazards and job stress, but these stressors are underdocumented. Therefore, we sought to describe APS workers' work environments and responses to occupational hazards and stressors, including compassion fatigue, burnout, and secondary traumatic stress. Survey data were gathered with closed-ended questionnaires administered to APS workers in an urban setting. Virtually all workers (97%) reported exposure to one or more environmental hazards in their work, and 80% reported hazard exposure in the past month. Workers also reported mixed responses to their work environment and to experiences with supervision. A sizable minority (22.7%) was at high risk for burnout, 24.6% were at risk for secondary traumatic stress, and 19.9% reported low compassion satisfaction. The results document multiple stressors in APS work. The APS partner is committed to ongoing efforts to better support its staff, and these findings can inform future efforts to enhance supervisor support and worker self-care, to minimize burnout and secondary traumatic stress.

Adult separation anxiety disorder in complicated grief: an exploratory study on frequency and correlates.

INTRODUCTION: Complicated grief (CG) has been the subject of increasing attention in the past decades but its relationship with separation anxiety disorder (SEPAD) is still controversial. The aim of the current study was to explore the prevalence and clinical significance of adult SEPAD in a sample of help-seeking individuals with CG. METHODS: 151 adults with CG, enrolled in a randomized controlled trial comparing the effectiveness of (CG) treatment to that of interpersonal therapy, were assessed by means of the Inventory of Complicated Grief (ICG), the Structured Clinical Interview for DSM-IV, the Hamilton Rating Scale for Depression (HAM-D), the Work and Social Adjustment Scale (WSAS), the Adult Separation Anxiety Questionnaire (ASA-27), the Grief Related Avoidance Questionnaire (GRAQ), the Peritraumatic Dissociative Experiences Questionnaire (PDEQ), and the Impact of Events Scale (IES). RESULTS: 104 (68.9%) individuals with CG were considered to have SEPAD (ASA-27 score ≥22). Individuals with SEPAD were more likely to have reported a CG related to the loss of another close relative or friend (than a parent, spouse/partner or a child) (p=.02), as well as greater scores on the ICG (p=<.001), PDEQ (p=.004), GRAQ (p<.001), intrusion (p<.001) and avoidance (p=<.001) IES subscales, HAM-D (p<.001) and WSAS (p=.006). ASA-27 total scores correlated with ICG (p<.0001), PDEQ (p<.001) GRAQ (p<.0001) scores and both the IES intrusion (p<.0001) and IES avoidance (p<.0001) subscale scores. People with SEPAD had higher rates of lifetime post-traumatic stress disorder (PTSD) (p=.04) and panic disorder (PD) (p=.01). CONCLUSIONS: SEPAD is highly prevalent among patients with CG and is associated with greater symptom severity and impairment and greater comorbidity with PTSD and PD. Further studies will help to confirm and generalize our results and to determine whether adult SEPAD responds to CG treatment and/or moderates CG treatment response.

THE STRUCTURED CLINICAL INTERVIEW FOR COMPLICATED GRIEF: RELIABILITY, VALIDITY, AND EXPLORATORY FACTOR ANALYSIS.

BACKGROUND: Complicated grief (CG) has been recently included in the DSM-5, under the term "persistent complex bereavement disorder," as a condition requiring further study. To our knowledge, no psychometric data on any structured clinical interview for CG (SCI-CG) is available to date. In this manuscript, we introduce the SCI-CG, a 31-item "SCID-like" clinician-administered instrument to assess the presence of CG symptoms. METHODS: Participants were 281 treatment-seeking adults with CG (77.9% [n = 219] women, mean age = 52.4, standard deviation [SD] = 17.8) who were assessed with the SCI-CG and measures of depression, posttraumatic stress, anxiety, functional impairment. RESULTS: The SCI-CG exhibited satisfactory internal consistency (α = .78), good test-retest reliability (interclass correlation [ICC] 0.68, 95% CI [0.60-0.75]), and excellent interrater reliability (ICC = 0.95, 95% CI [0.89-0.98]). Exploratory factor analyses revealed that a five-factor structure, explaining 50.3% of the total variance, was the best fit for the data. CONCLUSIONS: The clinician-rated SCI-CG demonstrates good internal consistency, reliability, and convergent validity in treatment-seeking individuals with CG and therefore can be a useful tool to assess CG. Although diagnostic criteria for CG have yet to be adequately validated, the SCI-CG may facilitate this process. The SCI-CG can now be used as a validated instrument in research and clinical practice.

The effect of recent bereavement on outcomes in a primary care depression intervention study.

OBJECTIVES: Although bereavement and depression are both common in older primary care patients, the effect of bereavement on depression intervention outcomes is unknown. We examined whether standard interventions for depression in primary care were as effective for bereaved as for non-bereaved depressed patients. DESIGN: Randomized controlled trial. SETTING: Twenty community-based primary care practices in New York City, greater Philadelphia, and Pittsburgh. Randomization to either intervention or usual care occurred by practice. PARTICIPANTS: Patients aged 60 years or older who met criteria for major depression or clinically significant minor depression (N = 599). Patients who did not complete the bereavement measure or who were missing 4-month data were excluded (final N = 417). INTERVENTION: Study-trained depression care managers offered guideline-concordant recommendations to primary care physicians at intervention sites and assisted patients with treatment adherence. Patients who did not wish to take antidepressants could receive interpersonal psychotherapy. MEASUREMENTS: Bereavement was captured using the Louisville Older Persons Events Schedule. Depression severity was assessed using the 24-item Hamilton Depression Rating Scale (HDRS). Outcomes at 4 months were remission (HDRS ≤7) and response (HDRS reduction ≥50% from baseline). RESULTS: Logistic regressions indicated that, for non-bereaved participants, response and remission were higher in intervention than usual care. However, recently bereaved older adults were less likely to achieve response or remission at 4 months if treated in the intervention condition. CONCLUSIONS: Standard depression care management appears to be ineffective among recently bereaved older primary care patients. Greater attention should be paid in primary care to emotional distress in the context of bereavement.

Suicide risk in primary care: identification and management in older adults.

The National Strategy for Suicide Prevention (2012) has set a goal to reduce suicides by 20% within 5 years. Suicide rates are higher in older adults compared to most other age groups, and the majority of suicide completers have visited their primary care physician in the year before suicide. Primary care is an ideal setting to identify suicide risk and initiate mental health care. We review risk factors for late-life suicide; methods to assess for different levels of suicidality; and recent research developments regarding both effective assessment and management of suicide risk among older primary care patients. We highlight that broader scale screening of suicide risk may be considered in light of findings that suicidality can occur even in the absence of major risk factors like depression. We also highlight collaborative care models targeting suicide risk, and recent innovative interventions that aim to prevent the development of suicidal ideation and suicidal behavior.

Primary care providers' bereavement care practices: recommendations for research directions.

OBJECTIVE: Bereaved patients are often seen in primary care settings. Although most do not require formal support, physicians may be called upon to provide support to some bereaved, particularly those with bereavement-related mental health disorders like complicated grief and bereavement-related depression. Research evidence on physician bereavement care is scant. We make recommendations for future research in this area. DESIGN: Literature review focuses on studies conducted between 1996 and 2013 in the United States. Searches of Medline and PsychInfo, along with hand searches of reference sections, were conducted. RESULTS: The limited existing research indicates substantial gaps in the research literature, especially in the areas of primary care physician skill and capacity, patient-level outcomes, and the quality of research methodology. No US studies have focused specifically on care for bereavement-related mental health disorders. We provide recommendations about how to improve research about primary care bereavement care. CONCLUSIONS: The primary care sector offers ample opportunities for research on bereavement care. With greater research efforts, there may be improvements to quality of bereavement care in primary care, in general, and also to the accurate detection and appropriate referral for bereavement-related mental health conditions.

Bereavement and complicated grief.

Bereavement is a common experience in adults aged 60 and older. Loss of a loved one usually leads to acute grief characterized by yearning and longing, decreased interest in ongoing activities, and frequent thoughts of the deceased. For most, acute grief naturally evolves into a state of integrated grief, where the bereaved is able to reengage with everyday activities and find interest or pleasure. About 7 % of bereaved older adults, however, will develop the mental health condition of Complicated Grief (CG). In CG, the movement from acute to integrated grief is derailed, and grief symptoms remain severe and impairing. This article reviews recent publications on the diagnosis of CG, risk factors for the condition and evidenced-based treatments for CG. Greater attention to CG detection and treatment in older adults is needed.

Complicated grief associated with hurricane Katrina.

BACKGROUND: Although losses are important consequences of disasters, few epidemiological studies of disasters have assessed complicated grief (CG) and none assessed CG associated with losses other than death of loved one. METHODS: Data come from the baseline survey of the Hurricane Katrina Community Advisory Group, a representative sample of 3,088 residents of the areas directly affected by Hurricane Katrina. A brief screen for CG was included containing four items consistent with the proposed DSM-V criteria for a diagnosis of bereavement-related adjustment disorder. RESULTS: Fifty-eight and half percent of respondents reported a significant hurricane-related loss: Most-severe losses were 29.0% tangible, 9.5% interpersonal, 8.1% intangible, 4.2% work/financial, and 3.7% death of loved one. Twenty-six point one percent respondents with significant loss had possible CG and 7.0% moderate-to-severe CG. Death of loved one was associated with the highest conditional probability of moderate-to-severe CG (18.5%, compared to 1.1-10.5% conditional probabilities for other losses), but accounted for only 16.5% of moderate-to-severe CG due to its comparatively low prevalence. Most moderate-to-severe CG was due to tangible (52.9%) or interpersonal (24.0%) losses. Significant predictors of CG were mostly unique to either bereavement (racial-ethnic minority status, social support) or other losses (prehurricane history of psychopathology, social competence.). CONCLUSIONS: Nonbereavement losses accounted for the vast majority of hurricane-related possible CG despite risk of CG being much higher in response to bereavement than to other losses. This result argues for expansion of research on CG beyond bereavement and alerts clinicians to the need to address postdisaster grief associated with a wide range of losses.

Complicated grief and related bereavement issues for DSM-5.

Bereavement is a severe stressor that typically incites painful and debilitating symptoms of acute grief that commonly progresses to restoration of a satisfactory, if changed, life. Normally, grief does not need clinical intervention. However, sometimes acute grief can gain a foothold and become a chronic debilitating condition called complicated grief. Moreover, the stress caused by bereavement, like other stressors, can increase the likelihood of onset or worsening of other physical or mental disorders. Hence, some bereaved people need to be diagnosed and treated. A clinician evaluating a bereaved person is at risk for both over-and under-diagnosis, either pathologizing a normal condition or neglecting to treat an impairing disorder. The authors of DSM IV focused primarily on the problem of over-diagnosis, and omitted complicated grief because of insufficient evidence. We revisit bereavement considerations in light of new research findings. This article focuses primarily on a discussion of possible inclusion of a new diagnosis and dimensional assessment of complicated grief. We also discuss modifications in the bereavement V code and refinement of bereavement exclusions in major depression and other disorders.

Risks for complicated grief in family caregivers.

Complicated grief (CG) is a recently recognized disorder experienced by the bereaved and characterized by intense distress that interferes with functioning. Estimates indicate that about 20 % of bereaved individuals may develop CG. Family caregivers of those who are chronically ill may face unique risks for CG, such as pre-death stressors associated with caregiving. In this article, existing literature on CG in family caregivers is reviewed to identify pre-bereavement risk factors for the disorder. Implications for practice are also discussed, including both preventive interventions that could be instituted before the ill person's death and therapeutic techniques for treating CG after the death.

Measures of Financial Capacity: A Review.

PURPOSE OF THE STUDY: Capacity to manage finances and make financial decisions can affect risk for financial exploitation and is often the basis for legal determinations of conservatorship/guardianship. Several structured assessments of financial capacity have been developed, but have not been compared regarding their focus, validity, or reliability. Therefore, we conducted a review of financial capacity measures to examine these factors. DESIGN AND METHODS: We searched electronic databases, reference lists in identified articles, conference proceedings and other grey literature for measures of financial capacity. We then extracted data on the length and domains of each measure, the population for which they were intended, and their validity and reliability. RESULTS: We identified 10 structured measures of financial capacity. Most measures could be completed in 25-30 min, and were designed to be administered to older adults with some level of cognitive impairment. Reliability and validity were high for most. IMPLICATIONS: Measurement of financial capacity is complex and multidimensional. When selecting a measure of financial capacity, consideration should be made of the population of focus and the domains of capacity to be assessed. More work is needed on the cultural sensitivity of financial capacity measures, their acceptability, and their use in clinical work. Better understanding of when, and to whom, to administer different financial capacity measures could enhance the ability to accurately detect those suffering from impaired financial capacity, and prevent related negative outcomes like financial exploitation.

Associations between psychological symptoms and treatment outcomes of a massage therapy intervention: Secondary analyses of a randomized controlled trial.

Massage therapy (MT) may be more effective for certain subgroups of advanced cancer patients, but this is not well-studied. Psychological symptoms are one potential moderator of MT outcomes, as they occur frequently in MT patients. Therefore, we conducted a secondary analysis of data from a multi-site study which compared MT to simple touch in 380 adults with advanced cancer. We examined whether the presence of depression or baseline psychological symptom frequency moderated outcomes of change in pain, interference of pain, quality of life, 60-second heart and respiratory rates, and physical distress. We found significant main effects of depression and baseline psychological symptom frequency on changes in pain, 60-second heart and respiratory rates, quality of life, and physical distress for both MT and simple touch, but did not find differential responses between groups in moderator analyses. Results imply that psychological interventions could be targeted to patients with cancer who are receiving any type of touch therapy to improve outcomes.

Hospice Bereavement Service Delivery to Family Members and Friends With Bereavement-Related Mental Health Symptoms.

OBJECTIVES:: A sizable minority of those who lose a loved one in hospice will experience symptoms of bereavement-related mental health disorders. Though hospices offer services to bereaved informal caregivers (family members or friends) of patients, little is known about services offered or interest in them. Therefore, we sought to assess services offered by hospice staff and interest expressed by bereaved informal caregivers with symptoms of depression, anxiety, or complicated grief (CG). METHODS:: De-identified electronic bereavement care charts of 3561 informal caregivers who lost someone in a large urban metropolitan hospice from October 1, 2015, to June 30, 2016, were reviewed. RESULTS:: Of bereaved informal caregivers in the sample, 9.4% (n = 333) were positive for symptoms of depression, anxiety, or CG. The symptom-positive family members/friends were more likely than other family members/friends to be offered mailings, one-to-one counseling, telephone calls, and reference material. However, interest in most services by symptom-positive caregivers was low, with only 6% interested in one-to-one counseling and 7% interested in outside referral. DISCUSSION:: The findings suggest that hospices offer a range of services to family members or friends with symptoms of anxiety, depression, and CG, but that there can be a gap between what is offered and in the interest levels of the bereaved. Engagement with symptomatic family members and friends could be enhanced in future work.

Assessing the palliative care needs and service use of diverse older adults in an urban medically-underserved community.

Although palliative care (PC) has become increasingly familiar, considerable gaps persist in access to and use of services. Community-based programs remain rare, and low-income, minority communities significantly under-utilize hospice and palliative services. We used community-based participatory research (CBPR) methods to conduct a mixed-methods community needs assessment of seriously-ill older adults (n=100) and providers from community-based programs and churches (n=41) in an urban medically-underserved community in the U.S. to explore: (I) the prevalence and severity of illness-related symptoms and psychosocial-spiritual concerns; (II) the scope and quality of community supports helping older adults manage their symptoms; and (III) the perceptions and utilization of palliative and supportive care services among older adults and community-based service providers. Participants reported high rates of chronic illness-related symptoms (i.e., pain, fatigue, sleeping difficulties, depression, and anxiety), and many described unmet needs around symptom management. Few had ever utilized PC or pain management services, and most relied primarily on family, friends, and faith communities to help them manage burdensome symptoms. Barriers included lack of familiarity with PC, limited access and financial concerns. Older adults were largely unfamiliar with PC, and many described unmet needs and desire for help with symptom burden. Findings support the need to further explore community-level and cultural barriers to PC among diverse, underserved older adults. Development of innovative community partnerships may help raise awareness of PC and address the physical and psychosocial-spiritual challenges facing chronically-ill minority older adults and their families.

Adolescents' and parents' agreement on posttraumatic stress disorder symptoms and functioning after adolescent injury.

Few investigations have simultaneously assessed concordance between youth and parent ratings of posttraumatic stress disorder (PTSD) symptoms and functioning. Randomly sampled adolescent injury survivors ages 12-18 and their parents were assessed on the inpatient ward and again at 2, 5, and 12-months postinjury (N = 99). Adolescent PTSD symptoms and functioning were rated by both adolescents and parents. Parent PTSD was also assessed; 27% of parents endorsed symptoms consistent with a diagnosis of PTSD over the course of the year after adolescent injury. The PTSD positive parents demonstrated significantly greater discordance in ratings of adolescent PTSD symptoms, family cohesion, and mental health functioning. These findings suggest caution in clinical and policy applications of parental ratings of adolescent symptomatic and functional outcomes after injury.