Characteristics and End-of-Life Care Pathways of Decedents From a National Cohort of Assisted Living Residents.

BACKGROUND: Assisted living (AL) is an increasingly common, place of care for dying persons. However, it remains unclear to what extent residents are able to age in place or if AL represents an additional transition before death. OBJECTIVES: Examine the sociodemographic characteristics, comorbidities, health care utilization, and end-of-life care pathways of AL residents before death. RESEARCH DESIGN: A national cohort study of fee-for-service Medicare beneficiaries residing in large AL communities (25+ beds) during the month of January 2017 with 3 years of follow-up, using administrative claims data. SUBJECTS: 268,812 AL residents. MEASURES: Sociodemographic characteristics, comorbidities, and health care utilization at the end of life. RESULTS: Between 2017 and 2019, 35.1% of the study cohort died. Decedents were more likely than the overall AL population to be 85 years old or older (76.5% vs. 59.5%), and diagnosed with Alzheimer's disease and related dementia (70.3% vs. 51.6%). Most decedents (96.2%) had some presence in AL during the last year of life, but over 1 in 5 left AL before the last month of life. Among those in AL on day 30 before death, nearly half (46.4%) died in place without any health care transition, while 13.2% had 3 or more transfers before dying. CONCLUSIONS: AL is an important place of care for dying persons, especially for those with dementia. These findings indicate a need to assess existing policies and processes guiding the care of the frail and vulnerable population of dying AL residents.

"There has to be more caring": patient and care partner experiences of the disclosure of amyloid-ß PET scan results.

OBJECTIVES: To explore patient and care partner experiences of receiving an amyloid scan result, with a focus on how clinician disclosure practices influenced patient and care partner emotional responses to the scan result and/or diagnosis. METHODS: Semi-structured interviews with 38 people with mild cognitive impairment or dementia and 62 care partners who experienced the disclosure of results from an amyloid PET scan as part of the CARE-IDEAS study. We used thematic analysis to analyze interview transcripts. RESULTS: We identified four aspects of the disclosure process that could influence patient and care partner emotional experiences of the scan result/diagnosis: (1) mode of delivery, (2) presence of a care partner, (3) clarity of the scan result explanation, and (4) discussion of post-scan treatment and support options. CONCLUSIONS: Emotional experiences of an amyloid scan result can vary depending on how results are communicated. These findings support previous efforts to develop standard disclosure protocols. Scan results should be delivered in person with the care partner present. Clinicians should give a clear explanation of the result and its implications in an empathetic manner. Options for treatment and support should be discussed for all patients.

Social class and the risk of dementia: A systematic review and meta-analysis of the prospective longitudinal studies.

BACKGROUND: The association between belonging to a disadvantaged socio-economic status or social class and health outcomes has been consistently documented during recent decades. However, a meta-analysis quantifying the association between belonging to a lower social class and the risk of dementia has yet to be performed. In the present work, we sought to summarise the results of prospective, longitudinal studies on this topic. METHODS: We conducted a systematic review and meta-analysis of prospective, longitudinal studies measuring the association between indicators of social class and the risk of all-cause/Alzheimer's dementia. The search was conducted in four databases (Medline, Embase, Web of Science and PsychInfo). Inclusion criteria for this systematic review and meta-analysis were: (a) longitudinal prospective study, (b) aged ⩾60 years at baseline, (c) issued from the general population, (d) no dementia at baseline and (e) mention of social class as exposure. Exclusion criteria were: (a) study of rare dementia types (e.g. frontotemporal dementia), (b) abstract-only papers and (c) articles without full text available. The Newcastle-Ottawa scale was used to assess the risk of bias in individual studies. We calculated the overall pooled relative risk of dementia for different social class indicators, both crude and adjusted for sex, age and the year of the cohort start. RESULTS: Out of 4548 screened abstracts, 15 were included in the final analysis (76,561 participants, mean follow-up 6.7 years (2.4-25 years), mean age at baseline 75.1 years (70.6-82.1 years), mean percentage of women 58%). Social class was operationalised as levels of education, occupational class, income level, neighbourhood disadvantage and wealth. Education (relative risk (RR)=2.48; confidence interval (CI) 1.71-3.59) and occupational class (RR=2.09; CI 1.18-3.69) but not income (RR=1.28; CI 0.81-2.04) were significantly associated with the risk of dementia in the adjusted model. Some of the limitations of this study are the inclusion of studies predominantly conducted in high-income countries and the exclusion of social mobility in our analysis. CONCLUSIONS: We conclude that there is a significant association between belonging to a social class and the risk of dementia, with education and occupation being the most relevant indicators of social class regarding this risk. Studying the relationship between belonging to a disadvantaged social class and dementia risk might be a fruitful path to diminishing the incidence of dementia over time. However, a narrow operationalisation of social class that only includes education, occupation and income may reduce the potential for such studies to inform social policies.

"I know that my role is going to change": a mixed-methods study of the relationship between amyloid-ß PET scan results and caregiver burden.

BACKGROUND: Caregiver burden consists of disease specific and perceived stressors, respectively referred to as objective and subjective indicators of burden, and is associated with negative outcomes. Previous research has found that care partners to persons living with cognitive impairment and elevated levels of amyloid-ß, as measured by a positron emission tomography (PET) scan, may experience caregiver burden. AIMS: To elucidate the relationship between amyloid scan results and subjective and objective indicators of burden. METHODS: A parallel mixed-methods design using survey data from 1338 care partners to persons with mild cognitive impairment (MCI) and dementia who received an amyloid scan from the CARE-IDEAS study; and semi-structured interviews with a subsample of 62 care partners. Logistic regression models were used to investigate objective factors associated with caregiver burden. A thematic analysis of semi-structured interviews was used to investigate subjective indicators by exploring care partners' perceptions of their role following an amyloid scan. RESULTS: Elevated amyloid was not associated with burden. However, the scan result influenced participants perceptions of their caregiving role and coping strategies. Care partners to persons with elevated amyloid expected increasing responsibility, whereas partners to persons without elevated amyloid and mild cognitive impairment did not anticipate changes to their role. Care partners to persons with elevated amyloid reported using knowledge gained from the scan to develop coping strategies. All care partners described needing practical and emotional support. CONCLUSIONS: Amyloid scans can influence subjective indicators of burden and present the opportunity to identify and address care partners' support needs.

The Potential of Social Policies in Preventing Dementia: An Ecological Study Using Systematic Review and Meta-Analysis.

Social policies determine the distribution of factors (e.g. education, cardiovascular health) protecting against the development of dementia in Alzheimer's disease (AD). However, the association between social policies and the likelihood of AD without dementia (ADw/oD) has yet to be evaluated. We estimated this association in an ecological study using systematic review and meta-analysis. Four reference databases were consulted; 18 studies were included in the final analysis. ADw/oD was defined as death without dementia in people with clinically significant AD brain pathology. The indicators of social policy were extracted from the Organisation for Economic Co-operation and Development database (OECD). The probability of ADw/oD with moderate AD brain pathology was inversely associated with the Gini index for disposable income, poverty rate, and certain public expenditures on healthcare. ADw/oD with advanced AD brain pathology was only associated with public expenditures for long-term care. Social policies may play a role in maintaining and sustaining cognitive health among older people with AD.

Interventions to Reduce Hospital and Emergency Department Utilization Among People With Alcohol and Substance Use Disorders: A Scoping Review.

BACKGROUND: Substance use disorders (SUDs), prevalent worldwide, are associated with significant morbidity and health care utilization. OBJECTIVES: To identify interventions addressing hospital and emergency department utilization among people with substance use, to summarize findings for those seeking to implement such interventions, and to articulate gaps that can be addressed by future research. RESEARCH DESIGN: A scoping review of the literature. We searched PubMed, PsycInfo, and Google Scholar for any articles published from January 2010 to June 2020. The main search terms included the target population of adults with substance use or SUDs, the outcomes of hospital and emergency department utilization, and interventions aimed at improving these outcomes in the target population. SUBJECTS: Adults with substance use or SUDs, including alcohol use. MEASURES: Hospital and emergency department utilization. RESULTS: Our initial search identified 1807 titles, from which 44 articles were included in the review. Most interventions were implemented in the United States (n=35). Half focused on people using any substance (n=22) and a quarter on opioids (n=12). The tested approaches varied and included postdischarge services, medications, legislation, and counseling, among others. The majority of study designs were retrospective cohort studies (n=31). CONCLUSIONS: Overall, we found few studies assessing interventions to reduce health care utilization among people with SUDs. The studies that we did identify differed across multiple domains and included few randomized trials. Study heterogeneity limits our ability to compare interventions or to recommend one specific approach to reducing health care utilization among this high-risk population.

Effect of advance care planning video on do-not-hospitalize orders for nursing home residents with advanced illness.

BACKGROUND: The purpose of the study is to evaluate the effect of an Advance Care Planning (ACP) Video Program on documented Do-Not-Hospitalize (DNH) orders among nursing home (NH) residents with advanced illness. METHODS: Secondary analysis on a subset of NHs enrolled in a cluster-randomized controlled trial (41 NHs in treatment arm implemented the ACP Video Program: 69 NHs in control arm employed usual ACP practices). Participants included long (> 100 days) and short (≤ 100 days) stay residents with advanced illness (advanced dementia or cardiopulmonary disease (chronic obstructive pulmonary disease or congestive heart failure)) in NHs from March 1, 2016 to May 31, 2018 without a documented Do-Not-Hospitalize (DNH) order at baseline. Logistic regression with covariate adjustments was used to estimate the impact of the resident being in a treatment versus control NH on: the proportion of residents with new DNH orders during follow-up; and the proportion of residents with any hospitalization during follow-up. Clustering at the facility-level was addressed using hierarchical models. RESULTS: The cohort included 6,117 residents with advanced illness (mean age (SD) = 82.8 (8.4) years, 65% female). Among long-stay residents (n = 3,902), 9.3% (SE, 2.2; 95% CI 5.0-13.6) and 4.2% (SE, 1.1; 95% CI 2.1-6.3) acquired a new DNH order in the treatment and control arms, respectively (average marginal effect, (AME) 5.0; SE, 2.4; 95% CI, 0.3-9.8). Among short-stay residents with advanced illness (n = 2,215), 8.0% (SE, 1.6; 95% CI 4.6-11.3) and 3.5% (SE 1.0; 95% CI 1.5-5.5) acquired a new DNH order in the treatment and control arms, respectively (AME 4.4; SE, 2.0; 95% CI, 0.5-8.3). Proportion of residents with any hospitalizations did not differ between arms in either cohort. CONCLUSIONS: Compared to usual care, an ACP Video Program intervention increased documented DNH orders among NH residents with advanced disease but did not significantly reduce hospitalizations. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02612688 .

Advance directives among cognitively impaired persons who had an amyloid PET scan and their care partners: a mixed-methods study.

BACKGROUND: Little research exists on the role of ß-amyloid PET scans as part of Alzheimer's diagnostic tests and documentation of end-of-life preferences for persons with cognitive impairment. The study objectives were to examine the association of amyloid PET scan results (elevated vs. not elevated amyloid levels) and diagnostic category (mild cognitive impairment vs. dementia) with the likelihood of having an advance directive (reported a median of 4.5 months post-scan); to explore perceptions of PET scan results and their influence on planning for the future among persons with cognitive impairment and their care partners. METHODS: Sequential, explanatory mixed-methods design using data from dyads in the CARE-IDEAS study: advance directives as a factor of diagnostic category and scan result using multivariable logistic regression models; thematic analysis of semi-structured interviews with persons with cognitive impairment and care partners to explore how scan results influenced documentation of future healthcare preferences. Participants included 1784 persons with cognitive impairment and care partners from the CARE-IDEAS study, and a subsample of 100 semi-structured telephone interviews. RESULTS: 81.6% of dyads reported an advance directive. Non-Hispanic, White participants had higher rates of advance directives. There was no significant association between having an advance directive and scan results. Qualitative analysis provided insight into perceived urgency to have advance directives, evolving healthcare preferences, and the context of completing advance directives. CONCLUSIONS: Although amyloid PET scans prompted persons with cognitive impairment and care partners to consider progressive cognitive impairment as part of evolving healthcare preferences, we found substantial variability in the perceived urgency of documentation.

Measurement Properties of the CAPACITY Instrument to Assess Perceived Communication With the Health Care Team Among Care Partners of Patients With Cognitive Impairment.

BACKGROUND: The CAregiver Perceptions About CommunIcaTion with Clinical Team members (CAPACITY) instrument measures how care partners perceive themselves to be supported by the patient's health care team and their experiences communicating with the team. OBJECTIVES: The objective of this study was to assess the measurement properties (ie, structural validity of the construct and internal consistency) of the CAPACITY instrument in care partners of patients with cognitive impairment, and to examine whether care partner health literacy and patient cognitive impairment are associated with a higher or lower CAPACITY score. RESEARCH DESIGN: This was a retrospective cohort study. SUBJECTS: A total of 1746 dyads of community-dwelling care partners and older adults in the United States with cognitive impairment who obtained an amyloid positron emission tomography scan. MEASURES: The CAPACITY instrument comprises 12 items that can be combined as a total score or examined as subdomain scores about communication with the team and care partner capacity-assessment by the team. The 2 covariates of primary interest in the regression model are health literacy and level of cognitive impairment of the patient (Modified Telephone Interview Cognitive Status). RESULTS: Confirmatory factor analysis showed the CAPACITY items fit the expected 2-factor structure (communication and capacity). Higher cognitive functioning of patients and higher health literacy among care partners was associated with lower communication domain scores, lower capacity domain scores, and lower overall CAPACITY scores. CONCLUSIONS: The strong psychometric validity of the CAPACITY measure indicates it could have utility in other family caregivers or care partner studies assessing the quality of interactions with clinical teams. Knowing that CAPACITY differs by care partner health literacy and patient impairment level may help health care teams employ tailored strategies to achieve high-quality care partner interactions.

Assessing the relationship between multimorbidity and depression in older men and women: the International Mobility in Aging Study (IMIAS).

Objectives: Our study aims to assess whether multimorbidity is an independent risk factor for the development of depression in older adults living in Canada, Brazil, Colombia, and Albania and examines differences in incidence of depression regarding social and psychosocial characteristics.Methods: The longitudinal International Mobility Aging Study (IMIAS) collected information from adults between 65-74 years old. Depression was defined by a 16 or higher score assessed by the Centre for Epidemiological Studies Depression (CES-D) Scale. Multimorbidity was defined as having two or more chronic conditions, which were self-reported by participants using a list of eight physical chronic conditions. Poisson regression was performed to estimate the relative risk of depression in older adults with multimorbidity compared to those living with 0-1 chronic conditions, adjusting for sex, age, education, number of doctor visits, degree of assistance needed, social support, and smoking status. The analysis was stratified by study region (Canada; Latin America; Albania).Results: Crude and adjusted models showed no statistically significant associations between multimorbidity and the incidence of depression in any of the study regions, confirmed by sensitivity analyses. However, the incidence of depression varied across study region, confirmed by the intra-class correlation coefficient which indicated that 13% of variations in depression incidence were due to geographic differences.Conclusion: Multimorbidity does not appear to increase the risk of developing depression in older adults between 65-74. Higher rates of depression in Latin America and Albania (compared to Canada) may be attributed to lifecourse exposures to social and economic adversity in these regions.

Is Fear of Falling the Missing Link to Explain Racial Disparities in Fall Risk? Data from the National Health and Aging Trends Study.

OBJECTIVES: Emerging research suggests Black older adults experience a 30% decreased risk for falls compared with their White U.S. counterparts, and this is mediated neither by physical performance nor activity. Fear of falling (FOF) is a significant risk factor for falls, yet we know little about how FOF varies by race/ethnicity. The purpose of this original research brief was to investigate the relationship between race/ethnicity and FOF among older adults. METHODS: 4,981 community-dwelling Medicare beneficiaries from the National Health and Aging Trends Study (NHATS) who had not self-reported a fall in the past 12 months were analyzed. Logistic regression analyses were conducted to examine the association between race/ethnicity and fear of falling, controlling for sex, age, total annual income, and mobility assistance. RESULTS: FOF differed significantly across racial groups. Black, non-Hispanic older adults were less likely to have FOF (OR = .87, 95% CI = .71,1.07) compared with their White, non-Hispanic counterparts. In the fully adjusted model, this difference persisted and became stronger (adjusted OR = .75, 95%CI = .61, .93). CONCLUSION: The decreased risk for falls in Black older adults could be explained by lower FOF in this group. CLINICAL IMPLICATIONS: These findings should inform public health fall prevention initiatives among community-dwelling older adults.

A Retrospective Study of Administrative Data to Identify High-Need Medicare Beneficiaries at Risk of Dying and Being Hospitalized.

BACKGROUND: Developing a definition of what constitutes high need among Medicare beneficiaries using administrative data is an important prerequisite to evaluating value-based payment reforms. While various definitions of high need exist, their predictive validity for different patient outcomes in the following year has not been systematically assessed for both fee-for-service (FFS) and Medicare Advantage (MA) beneficiaries. OBJECTIVE: To develop a definition of high need using administrative data in 2014 and to examine its predictive validity for patient outcomes in 2015 as compared to alternative definitions for both FFS and MA beneficiaries. DESIGN: Retrospective cohort study of national Medicare claims and post-acute assessment data. PARTICIPANTS: All Medicare beneficiaries in 2014 who survived until the end of the year (n = 54,717,039). MAIN MEASURES: Two or more complex conditions, 6 or more chronic conditions, acute or post-acute health services utilization, indicators of frailty, complete dependency in mobility or in any activities of daily living in post-acute care assessments, hospitalization, mortality, days in community, Medicare expenditures. KEY RESULTS: Based on our definition of high-need patients, 13.17% of FFS and 8.85% of MA beneficiaries were identified as high need in 2014. High-need FFS patients had mortality rates 7.1 times higher (16.23% vs. 2.27%) and hospitalization rates 3.4 times higher (40.69 vs. 12.03) in 2015 compared to other beneficiaries. Competing high-need definitions all had good specificity (≥ 0.88). Having 3 or more Hierarchical Chronic Conditions yielded a good positive predictive value for hospitalization, at 0.50, but only identified 19.71% of FFS beneficiaries hospitalized and 28.46% of FFS decedents that year as high need, as opposed to 33.92% and 51.98% for the new definition. Results were similar for MA beneficiaries. CONCLUSIONS: The proposed high-need definition has better sensitivity and yields a sample of almost 5 million FFS and 1.5 million MA beneficiaries, facilitating outcome performance comparisons across health systems.

Measurement validity of the Patient-Health Questionnaire-9 in US nursing home residents.

OBJECTIVES: The objective of this study was to assess the measurement properties of the self-reported Patient Health Questionnaire-9 (PHQ-9) and its 10-item observer version (PHQ-10OV) among nursing home residents. METHODS: We conducted a retrospective study of Minimum Data Set 3.0 assessments for national cohorts of Medicare Fee-for-Service beneficiaries who were newly admitted or incident long-stay residents in 2014-2015 at US nursing homes (NHs) certified by the Center for Medicare and Medicaid Services. Statistical analyses included examining internal reliability with McDonald's omega, structural validity with confirmatory factor analysis, and hypothesis testing for expected gender differences and criterion validity with descriptive statistics. The Chronic Condition Warehouse depression diagnoses were used as an administrative reference standard. RESULTS: Both the PHQ-9 and PHQ-10OV had good internal reliability with omega values above 0.85. The self-reported scale yielded good model fit for a one-factor solution, while the PHQ-10OV had slightly poorer fit and a lower standardized factor loading on the additional irritability item. Both scales appear sufficiently one-dimensional given that somatic items had higher factor loading on a general depression factor than on a somatic subfactor. We were unable to obtain expected gender differences on the PHQ-10OV scale. The PHQ-9 and PHQ-10OV were both highly specific but had poor sensitivity compared with an administrative reference standard. CONCLUSIONS: The PHQ-9 appears to be a valid and promising measurement instrument for research about depression among NH residents, while the validity of the PHQ-10OV should be examined further with a structured psychiatric interview as a stronger criterion standard.

Of dilemmas and tensions: a qualitative study of palliative care physicians' positions regarding voluntary active euthanasia in Quebec, Canada.

OBJECTIVES: In 2015, the Province of Quebec, Canada passed a law that allowed voluntary active euthanasia (VAE). Palliative care stakeholders in Canada have been largely opposed to euthanasia, yet there is little research about their views. The research question guiding this study was the following: How do palliative care physicians in Quebec position themselves regarding the practice of VAE in the context of the new provincial legislation? METHODS: We used interpretive description, an inductive methodology to answer research questions about clinical practice. A total of 18 palliative care physicians participated in semistructured interviews at two university-affiliated hospitals in Quebec. RESULTS: Participants positioned themselves in opposition to euthanasia. Their justifications were framed within their professional commitment to not hasten death, which sat in tension with the value of patients' autonomy to choose how to die. Participants described VAE as unacceptable if it impeded opportunities to evaluate and alleviate suffering. Further, they contested government rhetoric that positioned VAE as a way to improve end-of-life care. Participants felt that VAE would diminish the potential of palliative care to relieve suffering. Dilemmas were apparent in their narratives, about reconciling respect for patient autonomy with broader palliative care values, and the value of accompanying and not abandoning patients who make requests for VAE while being committed to neither prolonging nor hastening death. CONCLUSIONS: This study provides insight into nuanced positions of experienced palliative care physicians in Quebec and confirms expected tensions between an important stakeholder and the practice of VAE as guided by the new legislation.

Barriers and facilitators to implementing a pragmatic trial to improve advance care planning in the nursing home setting.

BACKGROUND: The PRagmatic trial Of Video Education in Nursing homes (PROVEN) aims to test the effectiveness of an advance care planning (ACP) video intervention. Relatively little is known about the challenges associated with implementing ACP interventions in the nursing home (NH) setting, especially within a pragmatic trial. To address this research gap, this report sought to identify facilitators of and barriers to implementing PROVEN from the perspective of the Champions charged with introducing the ACP video program delivery to patients and families. METHODS: In semi-structured telephone interviews at 4 and 15 months of the 18-month implementation period, ACP Champions at all PROVEN intervention facilities (N = 119) were asked about their perceptions of program implementation. Forty interviews were purposively sampled, transcribed, and analyzed using a hybrid deductive/inductive approach to thematic analysis incorporating the Consolidated Framework for Implementation Research's domains: Intervention Characteristics (IC), Inner Setting (IS), Characteristics of Individuals (CI), Outer Setting (OS), and Process (P). RESULTS: Implementation facilitators identified by Champions included: the intervention's adaptable mode of presentation and minimal time burden (IC) as well as the program's customizable delivery to patients and families and opportunity for group reflection on implementation among ACP Champions (P). Barriers included mandated protocol-driven aspects of the program (OS), limited time to deliver the intervention (IS), and lack of perceived relevance and emotional readiness for ACP amongst stakeholders (CI). CONCLUSIONS: Despite the promise of PROVEN's intervention for improving ACP in nursing homes, unchangeable setting and characteristics of Champions, patients, and family members presented implementation barriers. Researchers need to engage all program participants (i.e., facility staff, patients, and families), in addition to corporate-level stakeholders, in early pragmatic trial design to minimize such obstacles. Further, despite the facilitating nature of PROVEN's implementation processes, the study encountered tension between scientific rigor and real-world demands. Researchers need to optimize the real-world authenticity of pragmatic trial design while avoiding excessive implementation protocol deviations. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02612688. Registered 19 November 2015.

Community Preceptors' Motivations and Views about Their Relationships with Medical Students During a Longitudinal Family Medicine Experience: A Qualitative Case Study.

Phenomenon: Although current evidence emphasizes various benefits of community-oriented programs, little is still known about the nature of the relationships that students and family physicians develop in this educational setting. Our aim in this study was twofold: to identify family physicians' motivations to enroll as preceptors in a longitudinal undergraduate family medicine program and to explore the nature of the student-preceptor relationships built during the course. Approach: This was a qualitative exploratory case study. The case was the first edition of a longitudinal family medicine experience (LFME), a course that makes up part of the novel Medicinae Doctor et Chirurgiae Magister curriculum in place in a Canadian medical school since August 2013. All 173 family physician community preceptors of the academic year 2013-2014 were considered key informants in the investigation. Forty-three preceptors finally participated in one of six focus groups conducted in the spring of 2014. Several organizational documents relative to the LFME course were also gathered. Inductive semantic thematic analysis was performed on verbatim interview transcripts. Documents helped contextualize the major themes emerging from the focus groups discussions. Findings: Enjoying teaching, promoting family medicine, and improving medical education where salient motivations for family physicians to become LFME preceptors. The findings also pointed out the complexity of the student-preceptor exchanges that unfolded over the academic year, and the ambiguous and changing nature of the role that LFME preceptors adopted in their relationships with students: from simply being facilitators of students' clinical observership to behaving as their mentors. Insights: Family physicians were highly motivated to become LFME preceptors of 1st-year medical students. Whereas they consistently valued the relationships built during the academic year with the students assigned to them, they also considered that exchanges did not always happen without difficulties, and gauged the roles they played as complex, ambiguous, and necessarily evolving over time.

Low Socioeconomic Status but Resilient: Panacea or Double Trouble? John Henryism in the International IMIAS Study of Older Adults.

John Henry (JH) theory provides a framework for understanding the physiological toll exerted on low socioeconomic status (SES) individuals as they overcome psychosocial stressors imposed by their environments. This theory suggests that resilience, a seemingly positive social adaptation, may in fact be physically deleterious. JH theory has been well-described in low-SES rural male African Americans, however it is currently unclear whether validity of this theory extends to women, other races and outside the rural US. We assessed whether, in individuals with low income, there is an association between self-mastery/resilience and either blood pressure or depressive symptoms that is different from the association seen in individuals with higher income. Data were obtained from 1353 older men and women participants of the International Mobility in Aging Study (IMIAS). Across 3 countries and 4 sites, higher self-mastery/resilience was associated with lower depressive symptoms in both low and high income groups. In low income individuals from Saint-Hyacinthe, Québec, higher self-mastery/resilience was associated with both higher mean systolic blood pressure (n = 240, ß = 0.135, p ≤ 0.05) and higher mean diastolic blood pressure (n = 240, ß = 0.241, p ≤ 0.0001). In the high income group of Saint-Hyacinthe, no such associations were observed. The findings in the Saint-Hyacinthe cohort (but not the other settings), are consistent with the John Henry hypothesis, and demonstrates this effect extends beyond a rural African American population. This finding indicates that in certain populations, the positive psychological effects of resilience come with a cost to physical health.

Validation of a Social Networks and Support Measurement Tool for Use in International Aging Research: The International Mobility in Aging Study.

The purpose of this study was to develop and validate a new instrument to assess social networks and social support (IMIAS-SNSS) for different types of social ties in an international sample of older adults. The study sample included n = 1995 community dwelling older people aged between 65 and 74 years from the baseline of the longitudinal International Mobility in Aging Study (IMIAS). In order to measure social networks for each type of social tie, participants were asked about the number of contacts, the number of contacts they see at least once a month or have a very good relationship with, or speak with at least once a month. For social support, participants had to rate the level of social support provided by the four types of contacts for five Likert scale items. Confirmatory Factor Analysis was conducted to determine the goodness of fit of the measurement models. Satisfactory goodness-of-fit indices confirmed the satisfactory factorial structure of the IMIAS-SNSS instrument. Reliability coefficients were 0.80, 0.81, 0.85, and 0.88 for friends, children, family, and partner models, respectively. The models were confirmed by CFA for each type of social tie. Moreover, IMIAS-SNSS detected gender differences in the older adult populations of IMIAS. These results provide evidence supporting that IMIAS-SNSS is a psychometrically sound instrument and of its validity and reliability for international populations of older adults.

The psychosocial needs of students conducting research with patients and their families in advanced cancer and palliative care: A scoping review.

OBJECTIVE: The objective of this article was to explore the extent of the scientific literature and evidence base about the psychosocial needs of students conducting research in the fields of advanced cancer and palliative care. METHOD: A scoping review was conducted in major scientific databases. English-language articles on the topic of interest were retained if they were published in peer-reviewed journals between 1995 and 2013. RESULTS: A total of 3,161 references were screened, and 7 were retained for analysis. Only two articles were empirical studies involving the collection of primary empirical data. The remaining ones were commentaries and personal reflections. While there is a near absence of empirical research about the psychosocial needs of students, several commentaries suggest that students in this field have a high need for support. Three themes were identified in the limited literature retrieved: (1) the importance of proper training and supervision; (2) the availability of emotional support structures; and (3) the use of effective and deliberate self-care strategies. SIGNIFICANCE OF RESULTS: This scoping review demonstrates that little is known about the psychosocial needs of students conducting research in advanced cancer and palliative care. However, what is clear is that there is a large emotional impact on student researchers engaged in this type of work. Adequate training and support is needed to promote students' health and well-being, encourage retention of students, and foster high-quality studies. More empirical data are needed to better understand the experiences of students conducting this type of research and to ensure the sustainability of training and research in this field.

Accuracy and usefulness of the Palliative Prognostic Index in a community setting.

PURPOSE: In a community setting characterised by scarce inpatient palliative care resources, a precise prognosis could help determine which patients should be prioritised for end-of-life admission. AIM: The aim of this study was to assess the validity of the Palliative Prognostic Index (PPI) and to determine whether it is a helpful tool for nurses to administer as part of the admission protocol in the palliative care service of a community hospital. RESULTS: The PPI was a moderately accurate prognostic tool when assessing the frequency of 14-day overstay; 81% of patients died within 14 days of their expected prognosis. Based on sensitivity and specificity, the accuracy of the prognoses was acceptable for the 6-week prognosis group (80%), and poor for the 3-week prognostic group (53%). The tool was easy to administer by the admission nurse receiving referrals. CONCLUSION: A nurse-administered and minimally-invasive prognostic tool was helpful in this context.