Associations Between Cognitive Performance and Self-Efficacy for Pain Management in Older Adults With Chronic Pain.

BACKGROUND: Self-efficacy for pain management is the key to successful pain management, yet little is known about the effect of cognitive performance on self-efficacy for pain management. This study aimed to examine to what extent cognitive performance is related to self-efficacy for pain management in older adults with chronic pain. METHODS: The analyses utilized data from the baseline assessment of the MOBILIZE Boston Study. Five neuropsychological tests-the Clock in the Box Test, Letter Fluency Test, Trail-making Test, Hopkins Verbal Learning Test, and WORLD Test-were performed to measure the cognitive performance domains of 458 participants, aged 70 years and reporting chronic pain and self-efficacy for pain management. We measured self-efficacy for pain management using the Chronic Pain Self-Efficacy Scale. Statistical analyses were done using multiple linear regression analysis. RESULTS: After adjusting for sociodemographic factors, general cognitive performance, executive function, as measured by the Clock in the Box Test, and attention, as measured by the Trail-Making Test Part A, were significantly associated with self-efficacy for pain management in older adults with chronic pain. However, after controlling for sociodemographic factors, chronic conditions, pain interference, and physical performance, the associations between cognitive performance measures and self-efficacy for pain management weakened. CONCLUSION: Greater cognitive performance in attention and executive function might be associated with better self-efficacy for pain management. Future longitudinal research is required to investigate the long-term implications of cognitive performance changes on the progress of self-efficacy for pain management in community-dwelling older adults.

Social and Religious Networks with Respect to the Health Behaviors of African American Women: A Systematic Review.

The aim of this systematic mixed studies review was to examine how social networks influence physical activity and dietary patterns among African American women. We searched PUBMED, CINAHL, JSTOR, SocioIndex, Medline, Cochrane Library, sportDISCUS, and PsycINFO to review articles published between Jan 1, 2007, and July 1, 2021. Only 23 studies met the inclusion criteria. All studies were conducted in the US. Social support received from family members, friends, and churches was found to positively influence physical activity and/or dietary patterns among African American women. An inconsistent relationship was found between social network size, health behavior characteristics of social networks, and physical activity and/or dietary patterns among African American women. Future research should incorporate structural and functional social network strategies to promote physical activity and healthy eating behaviors effectively and sustainably among African American women.

Persistence of pain quality in community-dwelling older adults with chronic non-cancer pain.

Longitudinal assessment of chronic geriatric pain is complicated by an age-associated plateau in pain severity and increase in widespread pain, calling for innovative measures such as pain quality descriptors that characterize how pain may feel. We characterized persistence of pain quality and its relation to severity, activity interference and distribution of sites, in a population-based sample of adults aged≥70 years with chronic pain (n = 398). Persistent pain quality was defined as reporting descriptors within the same category: sensory, cognitive/affective, or neuropathic at baseline and 18 months. A count variable indicated number of persistent categories. Pain quality was highly persistent. Adjusted for baseline covariates, individuals endorsing 3 persistent categories were 2-2.5x more likely to experience more widespread pain at 18 months compared to fewer persistent categories. No associations were noted in changes in pain severity or interference. A comprehensive pain assessment that includes diverse pain quality descriptors may improve individualized pain management.

Clinical research nurses' perceptions of the unique needs of people of color for successful recruitment to cancer clinical trials.

BACKGROUND: Clinical trials (CTs) test new medical products for safety and effectiveness. Despite federal policy aimed at generating greater inclusivity of people of color (POC) in CTs, disparity in (CT) enrollment persists. Non-Hispanic White patients comprise the majority of CT participants while Black and Hispanic patient participation has declined over the past decade. The scope of Clinical Research Nurses (CRNs) includes recruitment of participants for CTs. The aim of this phenomenological study was to describe adult oncology CRNs' lived experiences of recruiting POC cancer patients to participate in CTs. The first paper for this study identified three major themes regarding how CRNs view their role in caring for POC considering or enrolling onto cancer clinical trials (CCTs): CRNs act as advocates, care coordinators and educators. This paper focuses on two additional major themes regarding how CRNs view the unique needs of POC in clinical research: establishing and maintaining trusting relationships and recruitment infrastructure. METHODS: Nineteen nurses participated in semi-structured one-to-one interviews and data analysis was based on Colaizzi's method. RESULTS: CRNs described a history of past research injustices, disparate access to care, inadequate cultural training, a physician-driven recruitment structure and provider-based implicit biases that hinder POC enrollment in CTs. CONCLUSION: Diversity in CCT enrollment requires CRNs to establish trust with POC, advocate for POC when implicit biases are observed and become competent practitioners of culturally sensitive care. Further, meaningful policy change at both federal and organizational levels must occur to ensure equitable access to novel cancer therapies.

Homelessness and Vulnerably-Housed Defined: A Synthesis of the Literature.

There is no single accepted definition used in policy or research for the concepts of homelessness and vulnerably housed. Neuman's systems model (NSM) was the framework for this mixed-studies review, with the client system defined as these social issues and categorized as environmental stressors. Eighteen unique definitions of the concepts were identified in 30 studies. Extrapersonal stressors included housing history, interpersonal stressors included dependence on others for housing, and intrapersonal stressors included self-identification. Each level of stressor should be considered when defining these populations for inclusion in future research. Proposed definitions were formulated from the analysis of the results.

The role of clinical research nurses in minority recruitment to cancer clinical trials.

Clinical trials (CTs) are the established research mechanism designed to examine how new medical therapies are tested for safety and effectiveness. Specifically, non-Hispanic White patients still account for most CT participants and Black patient participation has declined over the past decade. Clinical Research Nurses (CRNs) whose scope of practice includes the recruitment of participants for CTs, have the potential to significantly increase minority patients participation in cancer clinical trials (CCTs). The aim of this phenomenological study was to describe adult oncology CRNs' lived experiences of recruiting minority cancer patients to participate in CTs. A total of 19 nurses participated in semi-structured one-to-one interviews and data analysis was based on Colaizzi's method. The role of CRNs was described as advocates who coordinate care, establish trust, and provide education for CT patients within physician-driven recruitment structures. The CRN's role was also described as self-taught or learn on the go with no formalized recruitment training and lack of robust cultural training. To achieve diverse patient enrollment in CCTs, CRNs and study staff need to receive training on culturally competent clinical research care and the diversity of CRNs and study teams must be increased. Further, meaningful federal and hospital policy change must occur so that minority patients have equitable access to novel cancer therapies and the role of the CRN is delineated from other healthcare staff to optimize research patient care.

Is pain catastrophizing associated with poor mobility performance and falls in older adults?

BACKGROUND: Pain catastrophizing has been associated with pain intensity and mobility limitations in adults, and may be associated with mobility problems among older adults with chronic pain. This study examined the associations between pain catastrophizing and pain characteristics, and physical performance in older people. METHODS: The MOBILIZE Boston Study II (MBS) included 354 adults aged ≥70 years, living in the Boston area, originally enrolled in the MBS I from 2005-2008. Pain catastrophizing was measured using the 13-item Pain Catastrophizing Scale (PCS), with scores ranging from 13-65. Pain severity and pain interference were assessed by subscales of the Brief Pain Inventory. Pain distribution was classified as none, single site, and multisite. Mobility performance was assessed using the Short Physical Performance Battery (SPPB). Falls were assessed prospectively using monthly fall calendar postcards. RESULTS: One-fourth of all participants (24 %) had high scores on the PCS (score>30). PCS was inversely associated with age and was greater among those with osteoarthritis, depression, or anxiety (p-value<0.05). PCS score was associated with global measures of pain including pain severity (p-value = 0.01), pain interference (p-value = 0.004) and multisite pain compared to no pain (p-value = 0.006). After adjusting for confounders, PCS was not associated with mobility and fall in this older population. CONCLUSION: Although pain catastrophizing is prevalent in older adults with chronic pain, it was not associated with mobility or falls in older people. Further research is needed to determine possible long-term effects of pain catastrophizing on chronic pain and functioning in older adults.

Inter-facility communication barriers delay resolving medication discrepancies during transitions of care.

BACKGROUND: Medication discrepancies occurring during transitions of care between hospitals and nursing homes increase the risk of adverse events for patients. Resolving mismatched information between hospitals and nursing homes adds additional burden to nursing home staff. OBJECTIVE: The aim of this study was to characterize challenges facing nursing home staff in receiving and resolving medication discrepancies during resident intake. METHODS: This study used one focus group comprised of five nurses, one pharmacist and two administrators from four nursing homes to explore the staffs' experiences resolving medication discrepancies at resident intake. Thematic analysis was used to determine primary themes and categories arising from focus group transcripts. RESULTS: Three common challenges included 1) Nursing homes relying upon external providers for accurate information that is frequently delayed; 2) Prescribing data shared between hospitals and nursing facilities on incompatible formats with inconsistent content; 3) Following a specific communication workflow between facilities to resolve errors as efficiently as possible. CONCLUSIONS: Improving access to formularies and medical histories for providers across the continuum of care and improving information sharing across transitions would improve communication, decrease discrepancies and increase patient safety during post-acute care transitions.

Persistent Pain Quality as a Novel Approach to Assessing Risk for Disability in Community-Dwelling Elders With Chronic Pain.

BACKGROUND: This study aims to test whether persistent pain quality is associated with incident or worsening disability in four domains: mobility, activity of daily living (ADL) and instrumental activity of daily living (IADL) difficulty, and physical performance. METHODS: From the MOBILIZE Boston Study, a population-based cohort of adults aged ≥70 years, we studied participants with chronic pain who endorsed at least one pain quality descriptor (N = 398) and completed baseline and 18-month assessments. Pain quality was assessed using an adapted short-form McGill Pain Questionnaire with 20 pain quality descriptors in three categories: sensory, cognitive/affective, neuropathic. Persistence was defined as endorsing the same category at baseline and 18 months. Self-reported outcomes included mobility, ADL, and IADL difficulty. Physical performance was assessed using the short physical performance battery. RESULTS: After adjusting for baseline pain severity and other covariates, individuals with three persistent categories had a greater risk of developing new or worsening IADL difficulty relative to those with one persistent category (relative risk [RR] 2.69, 95% confidence interval [CI] 1.34, 7.79). Similar results were observed for ADL difficulty (RR 5.83, 95% CI 1.32, 25.85), but no differences were noted in risk for mobility difficulty. There was no significant linear trend in physical performance over 18 months according to number of persistent categories (p =.68). CONCLUSION: Elders with persistent pain quality experienced a higher risk of developing new or worsening IADL and ADL disability with each additional category but not mobility difficulty or poorer physical performance. Longitudinal assessment of pain quality could be useful in determining risk for global disability among elders with chronic pain.

Optimal Aging: A Neuman Systems Model Perspective.

The purpose of this paper is to describe aspects of optimal aging from the perspective of the Neuman systems model. An overview of the model is presented followed by a discussion of usual stressors encountered as people age and their common responses to these stressors. The position taken is that optimal aging for an individual is not necessarily equated with high-level wellness but rather is the best possible aging for that individual. A Neuman systems model practice methodology tool is used to illustrate how to apply the model to determine the optimal level of aging for individuals with and without chronic illnesses.

Pain quality descriptors in community-dwelling older adults with nonmalignant pain.

This study aimed to characterize the prevalence of various pain qualities in older adults with chronic nonmalignant pain and determine the association of pain quality to other pain characteristics namely: severity, interference, distribution, and pain-associated conditions. In the population-based MOBILIZE Boston Study, 560 participants aged ≥70 years reported chronic pain in the baseline assessment, which included a home interview and clinic exam. Pain quality was assessed using a modified version of the McGill Pain Questionnaire (MPQ) consisting of 20 descriptors from which 3 categories were derived: cognitive/affective, sensory, and neuropathic. Presence of ≥2 pain-associated conditions was significantly associated with 18 of the 20 pain quality descriptors. Sensory descriptors were endorsed by nearly all older adults with chronic pain (93%), followed by cognitive/affective (83.4%) and neuropathic descriptors (68.6%). Neuropathic descriptors were associated with the greatest number of pain-associated conditions including osteoarthritis of the hand and knee. More than half of participants (59%) endorsed descriptors in all 3 categories and had more severe pain and interference, and multisite or widespread pain than those endorsing 1 or 2 categories. Strong associations were observed between pain quality and measures of pain severity, interference, and distribution (P < 0.0001). Findings from this study indicate that older adults have multiple pain-associated conditions that likely reflect multiple physiological mechanisms for pain. Linking pain qualities with other associated pain characteristics serve to develop a multidimensional approach to geriatric pain assessment. Future research is needed to investigate the physiological mechanisms responsible for the variability in pain qualities endorsed by older adults.

Patient characteristics at hospital discharge and a comparison of home care referral decisions.

OBJECTIVES: Describe the characteristics of hospitalized older adults who were not referred for home care, compare the referral decisions of hospital clinicians with those of nurses with expertise in discharge planning and transitional care, and compare the characteristics of hospitalized older adults who did not receive a home care referral with patients who did receive a home care referral. DESIGN: Secondary analysis, descriptive, case series. SETTING: Subjects were discharged to home from one of two urban hospitals in Philadelphia, Pennsylvania. PARTICIPANTS: Ninety-nine patients for this study were drawn from the control group (n = 186) of a prior randomized clinical trial of advanced practice nurse hospital discharge planning and home follow-up. These 99 patients, or 56 of the control group, did not receive a home care referral even though they were screened into the original study as meeting at least one of the risk criteria associated with poor postdischarge outcomes. MEASUREMENTS: Case studies were generated from research records of the control group patients who did not receive a home care referral. They included patient sociodemographic and health characteristics. Nurses with expertise in discharge planning and transitional care, blinded to the actual decision, reviewed each case study and made a referral decision. RESULTS: Case studies revealed that control group patients, discharged without home follow-up, had many characteristics associated with the need for a home care referral, with the likelihood of receiving a referral, or with developing poor postdischarge outcomes. Overall, compared with control group patients who did not receive home care, those who did were older, had a longer hospital stay, more often rated their health as fair or poor, and had worse functional status. However, transitional care nurses judged that 96 of 99 of the control group patients discharged without home care had unmet discharge needs that may have benefited from a postdischarge referral. In addition, the transitional care nurses identified 49 of these 99 patients as having a high-priority need for home care. These patients had at least three of the characteristics associated with the need for a home care referral, the likelihood of receiving a referral, or of developing poor postdischarge outcomes. High-priority patients were significantly different in many sociodemographic and health characteristics and were rehospitalized significantly more often than other control group patients who were discharged without home care (P = .032). CONCLUSION: Study findings have demonstrated that the majority of older adults in this sample were discharged without postdischarge referrals despite the presence of several characteristics associated with the need for home care and risk of poor discharge outcomes. Findings suggest the need for improved methods to identify and synthesize patient characteristics associated with the need for postdischarge referral and to support clinical decision-making. Insurance or homebound status should also be explored as barriers to patients receiving the postdischarge care that they need.

Subtypes of potentially inappropriate medications in older Chinese-Americans during care transitions: cross sectional retrospective study.

BACKGROUND: The number of Chinese Americans is growing and nearly 20% of older Chinese-American home care patients have at least one potentially inappropriate medications (PIMs) prescribed at hospital discharge. Further examination of PIMs during care transition is warranted, especially among older Chinese-Americans. OBJECTIVES: To describe, during care transitions from hospital to home care: (i) the subtypes of PIMs, (ii) the difference of PIM prevalence prescribed at hospital discharge as compared to home care admission, (iii) the relationship between subtypes of PIMs, and (iv) issues affecting medication reconciliation among older Chinese-Americans. METHODS: This cross-sectional, retrospective study was conducted in a large urban home care agency from June 2010 to July 2011. From data collected by in-home survey and chart abstraction, PIMs were identified using 2002 diagnosis-independent Beers criteria. The difference of PIM prevalence at hospital discharge and at home care admission was analyzed by Wilcoxon Signed Ranks test. The relationship between subtypes of PIMs was evaluated using Phi coefficient. PARTICIPANTS: 82 older (age 65 years and above) Chinese-American home care patients following recent hospital discharge. RESULTS: 3.38% (22) and another 3.72% (28) of prescribed medications were identified as PIMs at hospital discharge and home care admission, respectively. There was no statistically significant difference in PIM prevalence identified at hospital discharge and at homecare admission (z=-1.732, p=.083). PIMs included: long-term use of stimulant laxatives and high-dosages of ferrous sulfate, and a significant relationship between these two PIMS (r=.224, p=.04). More than 80% (n=65) of study participants reported low education levels and limited English proficiency. CONCLUSIONS: Subtypes of PIMs were ordered during the post-hospital transfers, indicating the necessity to review the appropriateness of medications during this transition. Guidelines such as Beer's criteria regarding appropriateness of medications should be incorporated in medication reconciliation before adding new medications to treat the older adult's health problems. The medication management process needs to be both culturally sensitive and adapted to literacy level; validating the patients' full understanding of their medications is paramount.

Health-related quality of life: expanding a conceptual framework to include older adults who receive long-term services and supports.

For older adults receiving long-term services and supports (LTSS), health-related quality of life (HRQoL) has emerged as a critical construct to examine because of its focus on components of well-being, which are affected by progressive changes in health status, health care, and social support. HRQoL is a health-focused quality of life (QOL) concept that encompasses aspects of QOL that affect health such as function, physical, and emotional health. Examining existing theoretical constructs and indicators of HRQoL among LTSS recipients led us to posit a revised conceptual framework for studying HRQoL among LTSS recipients. We adapted the Wilson and Cleary HRQoL model by expanding function to specifically include cognition, adding behavior and LTSS environmental characteristics in order to create a more robust HRQoL conceptual framework for older adults receiving LTSS. This refined conceptual model allows for the measurement of a mix of structural, process, and outcome measures. Continued development of a multidimensional conceptual framework with specific HRQoL measures that account for the unique characteristics of older adults receiving LTSS will contribute significantly to LTSS research, policy, and planning efforts.

Automating the medication regimen complexity index.

OBJECTIVE: To adapt and automate the medication regimen complexity index (MRCI) within the structure of a commercial medication database in the post-acute home care setting. MATERIALS AND METHODS: In phase 1, medication data from 89 645 electronic health records were abstracted to line up with the components of the MRCI: dosage form, dosing frequency, and additional administrative directions. A committee reviewed output to assign index weights and determine necessary adaptations. In phase 2 we examined the face validity of the modified MRCI through analysis of automatic tabulations and descriptive statistics. RESULTS: The mean number of medications per patient record was 7.6 (SD 3.8); mean MRCI score was 16.1 (SD 9.0). The number of medications and MRCI were highly associated, but there was a wide range of MRCI scores for each number of medications. Most patients (55%) were taking only oral medications in tablet/capsule form, although 16% had regimens with three or more medications with different routes/forms. The biggest contributor to the MRCI score was dosing frequency (mean 11.9). Over 36% of patients needed to remember two or more special instructions (eg, take on alternate days, dissolve). DISCUSSION: Medication complexity can be tabulated through an automated process with some adaptation for local organizational systems. The MRCI provides a more nuanced way of measuring and assessing complexity than a simple medication count. CONCLUSIONS: An automated MRCI may help to identify patients who are at higher risk of adverse events, and could potentially be used in research and clinical decision support to improve medication management and patient outcomes.

Hospital to home health care transition: patient, caregiver, and clinician perspectives.

Increasing national attention is focused on improving posthospital transitions. Home health patients are in an opportune position to provide insight into this transition as they resume care for themselves with informal caregivers and home health professionals. This qualitative study describes the experiences of patients, informal caregivers, and home health clinicians during the posthospital transition. A total of 40 patients, 35 informal caregivers, and 15 clinicians participated in this study. Patients recalled receiving discharge instructions but with few details and limited information about follow-up actions if they had problems. Discharge instructions were a versatile means of communication. Home health clinicians used these instructions to guide discussions with patients and their caregivers. Both informal caregivers and home health care clinicians emphasized the inadequate preparation of caregivers during the discharge process. More attention is needed to proactively engage informal caregivers and involve home health clinicians who can facilitate the implementation of discharge plans to improve patient outcomes.

Medication problems occurring at hospital discharge among older adults with heart failure.

Medication reconciliation problems are common among older adults at hospital discharge and lead to adverse events. The purpose of this study was to examine the rates and types of medication reconciliation problems among older adults hospitalized for acute episodes of heart failure who were discharged home. This secondary analysis of data generated from a transitional care intervention included 198 hospital discharge medical records, representing 162 patients. A retrospective chart review comparing medication lists between hospital discharge summaries and patient discharge instructions was completed to identify medication reconciliation problems. Most hospital discharges (71.2%) had at least one type of reconciliation problem and frequently involved a high-risk medication (76.6%). Discrepancies were the most common problem (58.9%), followed by incomplete discharge summaries (52.5%) and partial patient discharge instructions (48.9%). More attention needs to be given to the quality of discharge instructions, and the problem of vague phrases (e.g., "take as directed") can be addressed by adding it to "do not use" lists to promote safer transitions in care.

Medication discrepancy and potentially inappropriate medication in older Chinese-American home-care patients after hospital discharge.

BACKGROUND: Studies of potential medication problems among older adults have focused on English-speaking populations in a single health care setting or a single potential medication problem. No previous studies investigated potential inappropriate medications (PIMs) and medication discrepancies (MDs) among older Chinese Americans during care transitions from hospital discharge to home care. OBJECTIVE: The aims of this study were to examine, in older Chinese Americans, the prevalence of both PIMs and MDs; the relationship between PIMs and MDs; and the patient and hospitalization characteristics associated with them during care transitions from hospital discharge to home care. METHODS: This cross-sectional study was conducted with a sample of older Chinese Americans from a large certified nonprofit home-care agency in New York City from June 2010 to July 2011. PIMs were identified by using 2002 diagnosis-independent Beers criteria. MDs were identified by comparing the differences between hospital discharge medication order and home-care admission medication order. Prevalence of PIMs and MDs and their relationship was determined. Logistic regression examined the relationship between hospitalization and patient characteristics with PIMs and MDs. RESULTS: The sample consisted of 82 older Chinese-American home-care patients. Twenty (24.3%) study participants were prescribed at least one PIM at hospital discharge. Fifty-one (67.1%) study participants experienced at least one MD. A positive correlation was found between the occurrence of PIMs and MDs (r = 0.22; P = 0.05). Number of medications was the only significant factor associated with both PIMs and MDs. In addition, older age and more hospitalization days were associated with PIMs. CONCLUSIONS: The evident prevalence of PIMs and MDs supports the practice of evaluating the appropriateness of medications while reconciling inconsistencies in medication regimens. The number of medications was the only factor associated with both PIMs and MDs, underscoring the need to address polypharmacy as a multifaceted threat to patient health.