Breast cancer screening motivation and behaviours of women aged over 75 years: a scoping review.

BACKGROUND: This scoping review aimed to identify and present the evidence describing key motivations for breast cancer screening among women aged ≥ 75 years. Few of the internationally available guidelines recommend continued biennial screening for this age group. Some suggest ongoing screening is unnecessary or should be determined on individual health status and life expectancy. Recent research has shown that despite recommendations regarding screening, older women continue to hold positive attitudes to breast screening and participate when the opportunity is available. METHODS: All original research articles that address motivation, intention and/or participation in screening for breast cancer among women aged ≥ 75 years were considered for inclusion. These included articles reporting on women who use public and private breast cancer screening services and those who do not use screening services (i.e., non-screeners). The Joanna Briggs Institute (JBI) methodology for scoping reviews was used to guide this review. A comprehensive search strategy was developed with the assistance of a specialist librarian to access selected databases including: the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Web of Science and PsychInfo. The review was restricted to original research studies published since 2009, available in English and focusing on high-income countries (as defined by the World Bank). Title and abstract screening, followed by an assessment of full-text studies against the inclusion criteria was completed by at least two reviewers. Data relating to key motivations, screening intention and behaviour were extracted, and a thematic analysis of study findings undertaken. RESULTS: A total of fourteen (14) studies were included in the review. Thematic analysis resulted in identification of three themes from included studies highlighting that decisions about screening were influenced by: knowledge of the benefits and harms of screening and their relationship to age; underlying attitudes to the importance of cancer screening in women's lives; and use of decision aids to improve knowledge and guide decision-making. CONCLUSION: The results of this review provide a comprehensive overview of current knowledge regarding the motivations and screening behaviour of older women about breast cancer screening which may inform policy development.

Age-friendly healthcare: integrating the 4Ms to enable age-friendly cancer care.

PURPOSE OF REVIEW: There is a growing movement towards person-centred, age-friendly healthcare in the care of older adults, including those with cancer. The Age-Friendly Health Systems (AFHS) initiative uses the 4Ms framework to enable this change. This review documents the utility and implications of 4Ms implementation across different settings, with a particular focus on cancer care. RECENT FINDINGS: The AFHS initiative 4Ms framework uses a set of core, evidence-based guidelines (focussing on What Matters, Medication, Mentation and Mobility) to improve person-centred care. The successful implementation of the 4Ms has been documented in many different healthcare settings including orthopaedics primary care, and cancer care. Implementation of the 4Ms framework into existing workflows complements the use of geriatric assessment to improve care of older adults with cancer. Models for implementation of the 4Ms within a cancer centre are described. Active engagement and education of healthcare providers is integral to success. Solutions to implementing the What Matters component are addressed. SUMMARY: Cancer centres can successfully implement the 4Ms framework into existing workflows through a complex change management process and development of infrastructure that engages healthcare providers, facilitating cultural change whilst employing quality improvement methodology to gradually adapt the status quo to age-friendly processes.

Breast cancer screening motivation and behaviours of women aged over 75 years.

OBJECTIVE: In Australia, breast screening is offered free every two years to women aged 50-74 years. Women aged ≥75 are eligible to receive a free mammogram but do not receive an invitation. This study aimed to explore the motivations and behaviours of women living in Australia aged ≥75 years regarding ongoing breast cancer screening given the public health guidance. METHODS: Sixty women aged ≥75 were recruited from metropolitan, regional, and rural areas across Australia to participate in a descriptive qualitative study. Semi-structured interviews were used to seek reflection on women's experience of screening, any advice they had received about screening beyond 75, their understanding of the value of screening and their intention to participate in the future. Thematic analysis of transcripts led to the development of themes. RESULTS: Themes resulting from the study included: reasons to continue and discontinue screening, importance of inclusivity in the health system and availability of information. Regular screeners overwhelmingly wished to continue screening and had strong beliefs in the benefits of screening. Women received limited information about the benefits or harms of screening beyond age 75 and very few had discussed screening with their Primary Healthcare Provider. No longer receiving an invitation to attend screening impacted many women's decision-making. CONCLUSION: More information via structured discussion with health professionals is required to inform women about the risks and benefits of ongoing screening. No longer being invited to attend screening left many women feeling confused and for some this led to feelings of discrimination.

Medications and cognitive risk in Aboriginal primary care: a cross-sectional study.

BACKGROUND: Aboriginal and Torres Strait Islander people are ageing with high rates of comorbidity, yet little is known about suboptimal prescribing in this population. AIM: The prevalence of potentially suboptimal prescribing and associated risk factors were investigated among older patients attending primary care through Aboriginal Community Controlled Health Services (ACCHSs). METHODS: Medical records of 420 systematically selected patients aged ≥50 years attending urban, rural and remote health services were audited. Polypharmacy (≥ 5 prescribed medications), potentially inappropriate medications (PIMs) as per Beers Criteria and anticholinergic burden (ACB) were estimated and associated risk factors were explored with logistic regression. RESULTS: The prevalence of polypharmacy, PIMs and ACB score ≥3 was 43%, 18% and 12% respectively. In multivariable logistic regression analyses, polypharmacy was less likely in rural (odds ratio (OR) = 0.43, 95% confidence interval (CI) = 0.24-0.77) compared to urban patients, and more likely in those with heart disease (OR = 2.62, 95% CI = 1.62-4.25), atrial fibrillation (OR = 4.25, 95% CI = 1.08-16.81), hypertension (OR = 2.14, 95% CI = 1.34-3.44), diabetes (OR = 2.72, 95% CI = 1.69-4.39) or depression (OR = 1.91, 95% CI = 1.19-3.06). PIMs were more frequent in females (OR = 1.88, 95% CI = 1.03-3.42) and less frequent in rural (OR = 0.41, 95% CI = 0.19-0.85) and remote (OR = 0.58, 95% CI = 0.29-1.18) patients. Factors associated with PIMs were kidney disease (OR = 2.60, 95% CI = 1.37-4.92), urinary incontinence (OR = 3.00, 95% CI = 1.02-8.83), depression (OR = 2.67, 95% CI = 1.50-4.77), heavy alcohol use (OR = 2.83, 95% CI = 1.39-5.75) and subjective cognitive concerns (OR = 2.69, 95% CI = 1.31-5.52). High ACB was less common in rural (OR = 0.10, 95% CI = 0.03-0.34) and remote (OR = 0.51, 95% CI = 0.25-1.04) patients and more common in those with kidney disease (OR = 3.07, 95% CI = 1.50-6.30) or depression (OR = 3.32, 95% CI = 1.70-6.47). CONCLUSION: Associations between potentially suboptimal prescribing and depression or cognitive concerns highlight the importance of considering medication review and deprescribing for these patients.

Geriatric Oncology in the Instagram Era: Feasibility and Acceptability Randomised Controlled Trial on Adopting PhotoVoice to Enable Empowerment, Patient-Centred Care, and Shared Decision Making-Study Protocol.

Geriatric assessment (GA) is fundamental to optimising cancer care in older adults, yet implementing comprehensive GA tools in real-world clinical settings remains a challenge. This study aims to assess the feasibility and acceptability of integrating information from patient-derived photographs (PhotoVoice) into enhanced supportive care (ESC) for older adults with cancer. A feasibility randomised controlled trial will be conducted at a regional cancer care centre in Australia. Participants aged 70 and above will be randomised into two groups: PhotoVoice plus ESC or usual care (ESC) alone. In the PhotoVoice group, participants will provide four photographs for deduction of representations of different aspects of their lives using photo-elicitation techniques. ESC will be conducted for both groups, incorporating PhotoVoice analysis in the intervention group. PhotoVoice may improve patient-centred care outcomes, including enhanced communication, shared decision making, and identification of patient priorities and barriers. Findings will provide insights into implementing PhotoVoice in geriatric assessment and guide future trials in cancer among older adults.

Evaluation of IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) a staff simulation training intervention to improve palliative care of people with advanced dementia living in nursing homes: a cluster randomised controlled trial.

BACKGROUND: People with dementia have unique palliative and end-of-life needs. However, access to quality palliative and end-of-life care for people with dementia living in nursing homes is often suboptimal. There is a recognised need for nursing home staff training in dementia-specific palliative care to equip them with knowledge and skills to deliver high quality care. OBJECTIVE: The primary aim was to evaluate the effectiveness of a simulation training intervention (IMPETUS-D) aimed at nursing home staff on reducing unplanned transfers to hospital and/or deaths in hospital among residents living with dementia. DESIGN: Cluster randomised controlled trial of nursing homes with process evaluation conducted alongside. SUBJECTS & SETTING: One thousand three hundred four people with dementia living in 24 nursing homes (12 intervention/12 control) in three Australian cities, their families and direct care staff. METHODS: Randomisation was conducted at the level of the nursing home (cluster). The allocation sequence was generated by an independent statistician using a computer-generated allocation sequence. Staff from intervention nursing homes had access to the IMPETUS-D training intervention, and staff from control nursing homes had access to usual training opportunities. The predicted primary outcome measure was a 20% reduction in the proportion of people with dementia who had an unplanned transfer to hospital and/or death in hospital at 6-months follow-up in the intervention nursing homes compared to the control nursing homes. RESULTS: At 6-months follow-up, 128 (21.1%) people with dementia from the intervention group had an unplanned transfer or death in hospital compared to 132 (19.0%) residents from the control group; odds ratio 1.14 (95% CI, 0.82-1.59). There were suboptimal levels of staff participation in the training intervention and several barriers to participation identified. CONCLUSION: This study of a dementia-specific palliative care staff training intervention found no difference in the proportion of residents with dementia who had an unplanned hospital transfer. Implementation of the intervention was challenging and likely did not achieve adequate staff coverage to improve staff practice or resident outcomes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618002012257 . Registered 14 December 2018.

Screening and diagnosis of chronic kidney disease in people with type 2 diabetes attending Australian general practice.

Australian guidelines recommend annual screening and monitoring of chronic kidney disease (CKD) in people with type 2 diabetes (T2D). A cross-sectional study utilising data from NPS MedicineWise MedicineInsight program from June 2015 to May 2016 was undertaken to explore: (1) the proportion of patients with T2D attending general practice who have had screening for, or ongoing monitoring of, CKD; (2) the proportion of patients without a documented diagnosis of CKD who have pathology consistent with CKD diagnosis; and (3) the patient factors associated with screening and the recording of a diagnosis of CKD. Of 90550 patients with T2D, 44394 (49.0%) were appropriately screened or monitored. There were 8030 (8.9%) patients with a recorded diagnosis of CKD, whereas 6597 (7.3%) patients had no recorded diagnosis of CKD despite pathology consistent with a diagnosis. Older age and diagnosis of hypertension or hyperlipidaemia were associated with increased odds of CKD diagnosis being recorded. Older patients, males, those with recorded diagnoses of hypertension or hyperlipidaemia and those who had their medical record opened more frequently were more likely to be screened appropriately. Screening and monitoring of CKD appears suboptimal. Research to explore barriers to screening, recording and monitoring of CKD, and strategies to address these, is required.

Identifying Risk for Diabetes in Adolescence (IRDA): A pilot study in general practice.

BACKGROUND: The prevalence of type 2 diabetes mellitus (T2DM) in adolescents is increasing, particularly among those in lower socioeconomic areas, and of Aboriginal and Torres Strait Islander, Pacific Islander and Asian ethnicities. OBJECTIVE: The aim of this article is to test the acceptability and feasibility of a brief screening program for T2DM risk factors in young adolescents in a general practice in a high-risk, low socioeconomic area. METHODS: Twenty-two adolescents participated in the program over three months. Anthropometric measures, glycated haemoglobin (HbA1c), lipids, diet and exercise data were collected. Parents completed a short survey. Data were summarised using descriptive statistics and frequency graphs, and brief qualitative data on acceptability were also collected. RESULTS: Nineteen out of the 22 adolescents had at least one risk factor for developing T2DM and 11 had three or more risk factors. Thirty-two per cent of the participants had a parent currently living with T2DM and five out of 22 had an HbA1c level >5.8%, suggesting increased risk for T2DM. DISCUSSION: Screening was feasible and acceptable in this setting. The findings suggest a need for extended screening in the future.

Process evaluation of a practice nurse-led smoking cessation trial in Australian general practice: views of general practitioners and practice nurses.

BACKGROUND: Support in primary care can assist smokers to quit successfully, but there are barriers to general practitioners (GPs) providing this support routinely. Practice nurses (PNs) may be able to effectively take on this role. OBJECTIVES: The aim of this study was to perform a process evaluation of a PN-led smoking cessation intervention being tested in a randomized controlled trial in Australian general practice. METHODS: Process evaluation was conducted by means of semi-structured telephone interviews with GPs and PNs allocated in the intervention arm (Quit with PN) of the Quit in General Practice trial. Interviews focussed on nurse training, content and implementation of the intervention. RESULTS: Twenty-two PNs and 15 GPs participated in the interviews. The Quit with PN intervention was viewed positively. Most PNs were satisfied with the training and the materials provided. Some challenges in managing patient data and follow-up were identified. CONCLUSION: The Quit with PN intervention was acceptable to participating PNs and GPs. Issues to be addressed in the planning and wider implementation of future trials of nurse-led intervention in general practice include providing ongoing mentoring support, integration into practice management systems and strategies to promote greater collaboration in GPs and PN teams in general practice. The ongoing feasibility of the intervention was impacted by the funding model supporting PN employment and the competing demands on the PNs time.

Quit in general practice: a cluster randomized trial of enhanced in-practice support for smoking cessation.

OBJECTIVES: To evaluate the uptake and effectiveness of tailored smoking cessation support, provided primarily by the practice nurse (PN), and compare this to other forms of cessation support. METHODS: Three arm cluster randomized controlled trial conducted in 101 general practices in Sydney and Melbourne involving 2390 smokers. The Quit with PN intervention was compared to Quitline referral and a usual care control group. Smoking cessation pharmacotherapy was recommended to all groups. Outcomes were assessed by self-report at 3- and 12-month follow-up. Uptake of the interventions is also reported. RESULTS: The three groups were similar at baseline. Follow-up at 12 months was 82%. The sustained and point prevalence abstinence rates, respectively, at 3 months by group were: PN intervention 13.1% and 16.3%; Quitline referral 10.8% and 14.2%; Usual GP care 11.4% and 15.0%. At 12 months, the rates were: PN intervention 5.4% and 17.1%; Quitline referral 4.4% and 18.8%; Usual GP care 2.9% and 16.4%. Only 43% of patients in the PN intervention group attended to see the nurse. Multilevel regression analysis showed no effect of the intervention overall, but patients who received partial or complete PN support were more likely to report sustained abstinence [partial support odds ratio (OR) 2.27; complete support OR 5.34]. CONCLUSION: The results show no difference by group on intention to treat analysis. Those patients who received more intensive PN intervention were more likely to quit. This may have been related to patient motivation or an effect of PN led cessation support.

Quit in general practice: a cluster randomised trial of enhanced in-practice support for smoking cessation.

BACKGROUND: This study will test the uptake and effectiveness of a flexible package of smoking cessation support provided primarily by the practice nurse (PN) and tailored to meet the needs of a diversity of patients. METHODS/DESIGN: This study is a cluster randomised trial, with practices allocated to one of three groups 1) Quit with Practice Nurse 2) Quitline referral 3) GP usual care. PNs from practices randomised to the intervention group will receive a training course in smoking cessation followed by access to mentoring. GPs from practices randomised to the Quitline referral group will receive information about the study and the process of written referral and GPs in the usual care group will receive information about the study. Eligible patients are those aged 18 and over presenting to their GP who are daily or weekly smokers and who are able to give informed consent. Patients on low incomes in all three groups will be able to access free nicotine patches.Primary outcomes are sustained abstinence and point prevalence abstinence at the three month and 12 month follow-up points; and incremental cost effectiveness ratios at 12 months. Process evaluation on the reach and acceptability of the intervention approached will be collected through Computer Assisted Telephone Interviews (CATI) with patients and semi-structured interviews with PNs and GPs.The primary analysis will be by intention to treat. Cessation outcomes will be compared between the three arms at three months and 12 month follow-up using multiple logistic regression. The incremental cost effectiveness ratios will be estimated for the 12 month quit rate for the intervention groups compared to usual care and to each other. Analysis of qualitative data on process outcomes will be based on thematic analysis. DISCUSSION: High quality evidence on effectiveness of practice nurse interventions is needed to inform health policy on development of practice nurse roles. If effective, flexible support from the PN in partnership with the GP and the Quitline could become the preferred model for providing smoking cessation advice in Australian general practice. TRIAL REGISTRATION: ACTRN12609001040257.

Development of the Falls Risk for Older People in the Community (FROP-Com) screening tool.

BACKGROUND: the aim of this study was to develop a brief screening tool for use in the emergency department (ED), to identify people who require further assessment and management. METHODS: this prospective study included 344 community-dwelling older people presenting to an ED after a fall. After direct discharge participants had a home-based assessment performed that included the Falls Risk for Older People in the Community (FROP-Com), a comprehensive, yet simple, multifactorial falls risk assessment tool. They were then monitored for falls for 12 months. The items from the FROP-Com assessment tool predictive of falls in a multifactorial logistic regression were used to develop the FROP-Com screen. RESULTS: the items significantly predictive of falls and combined to form the FROP-Com screen were: falls in the previous 12 months, observation of the person's balance and the need for assistance to perform domestic activities of daily living. At the cut-off with the highest Youden index sensitivity was 67.1% (95% CI 59.9-74.3) and specificity was 66.7% (95% CI 59.8-73.6). CONCLUSION: the FROP-Com screen has a relatively good capacity to predict falls. It can be used in time-limited situations to classify those at high risk of falls who require more detailed assessment and management.

Falls risk and functional decline in older fallers discharged directly from emergency departments.

BACKGROUND: There is currently no standard approach to falls risk assessment and management for older fallers presenting to the emergency department (ED) who are discharged directly home. Hence, this study was conducted to describe the prevalence of falls risk factors associated with older fallers presenting to the ED and to identify the factors associated with postdischarge decline in function in this group. METHODS: This cross-sectional study was performed with 300 community-dwelling individuals, aged 60 years or older, admitted to the ED following a fall, and discharged directly home. A home-based assessment after ED discharge was performed, which included the prevalence of falls risk factors, identification of functional decline, and objective measurements of balance, gait, depression, and falls efficacy. RESULTS: Fall-related injuries were sustained by 91% (95% confidence interval [CI], 87.2%-94.0%) of participants presenting to the ED. The most common falls risk factors identified in the home assessment were polypharmacy (79.0%, 95% CI, 73.9%-83.5%), home hazards (76.0%, 95% CI, 70.8%-80.7%), decreased balance (61.3%, 95% CI, 55.6%-66.9%), and arthritis (61.3%, 95% CI, 55.6%-66.9%). A decline in function was reported by 35% of participants (95% CI, 29.6%-40.7%). Sustaining a fracture, functional independence before the fall, being female, depression, and slower Timed Up and Go (TUG) scores were associated with a decline in function (p <.05). CONCLUSION: Older fallers discharged directly from the ED have a high prevalence of falls risk factors and are at risk of functional decline.

Does diet matter for survival in long-lived cultures?

In 1987, the International Union of Nutritional Sciences (IUNS) subcommittee on Nutrition and Ageing, in conjunction with the World Health Organization (WHO) global program for the elderly, embarked on the 'Food Habits in Later Life' (FHILL): a cross-cultural study to determine to what extent health, social and lifestyle variables, especially food intake, collectively predict survival amongst long-lived cultures. A total of 818 participants aged 70 years and over were recruited from five IUNS centres. Mortality data were collected after five to seven years. The cohorts included Swedes in Sweden (SWD), Greeks in Greece (GRS) and in Melbourne, Australia (GRM), Anglo-Celts in Australia (ACS) and Japanese in Japan (JPN). Information was obtained on health, lifestyle and diet at baseline. A Cox Proportional Hazard model containing ten potential predictors of survival, adjusted to age at enrollment and ethnicity/locality, was developed to analyse the survival data. Based on up to seven years survival data, it was found that being an elderly Greek in Australia conferred the lowest mortality risk and being an elderly Greek in Greece conferred the highest mortality risk. When the ten potential predictors of survival were entered into the Cox model, the memory score, the Mediterranean diet score, Activities of Daily Living (ADL) and general health status scores showed the greatest effects in significantly reducing mortality hazard ratios by 22%, 13%, 4% and 4%, respectively. For diet score, a one-unit change predicted a significant 13% difference in survival. Of the lifestyle (modifiable) variables entered in the multivariate model, exercise and social activity were not significant predictors of survival suggesting that diet is a more important predictor of survival than these variables. Another lifestyle variable, smoking, significantly increased mortality hazard ratios by 67%, making it a more important predictor of survival than diet. Being male (non-modifiable) also increased risk of death by 63%. Diet, particularly the Mediterranean Diet, operates irrespective and together with other factors as an appreciable contributor to survival, with a strength comparable to or greater than all other measured variables. The independence and strength of the predictiveness of food pattern for survival, and for this to be cross-cultural from Europe to Asia is a novel and important observation for food and health policy.

Legumes: the most important dietary predictor of survival in older people of different ethnicities.

To identify protective dietary predictors amongst long-lived elderly people (N= 785), the "Food Habits in Later Life "(FHILL) study was undertaken among five cohorts in Japan, Sweden, Greece and Australia. Between 1988 and 1991, baseline data on food intakes were collected. There were 785 participants aged 70 and over that were followed up to seven years. Based on an alternative Cox Proportional Hazard model adjusted to age at enrollment (in 5-year intervals), gender and smoking, the legume food group showed 7-8% reduction in mortality hazard ratio for every 20g increase in daily intake with or without controlling for ethnicity (RR 0.92; 95% CI 0.85-0.99 and RR 0.93; 95% CI 0.87-0.99, respectively). Other food groups were not found to be consistently significant in predicting survival amongst the FHILL cohorts.