A meta-synthesis on the older adults' perspective of advance care planning.

AIM: To synthesise the evidence regarding older adults' perception of advance care planning in preparation for end-of-life care. BACKGROUND: Advance care planning involves continuous communication of end-of-life care goals involving an individual's medical treatment preferences. However, its uptake among older adults remains low. DESIGN: The meta-synthesis was conducted according to the Enhancing Transparency in Reporting the Synthesis of Qualitative research (ENTREQ) guidelines and thematic synthesis was employed to synthesise the qualitative findings in an inductive manner. DATA SOURCE: A search was completed on six electronic databases (PubMed, EMBASE, CINAHL, PsycINFO, Web of Science, Scopus), for publications from 1 January 2000 to 4 December 2021. REVIEW METHOD: The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation and Confidence (GRADE-CERQual) in the Evidence from Reviews of Qualitative research. Two independent reviewers conducted this process, and disagreements were resolved through discussions. RESULTS: Fourteen studies were analysed. Four major themes and eleven subthemes emerged from the thematic synthesis: (1) psychosocial preparedness, (2) medical preparedness, (3) psychological barriers towards advance care planning and (4) extrinsic barriers towards advance care planning. DISCUSSION: These themes consolidated older adults' views of advance care planning and how engagement in this planning affected their end-of-life preparedness. CONCLUSION: This review suggested psychological and extrinsic factors were barriers to the uptake of advance care planning and provided directions for future research to achieve a holistic understanding of the impact of advance care planning on end-of-life preparedness. RELEVANCE TO CLINICAL PRACTICE: Healthcare professionals could maintain close communication with older adults and families periodically to evaluate their readiness to discuss advance care planning to improve their preparedness. Healthcare professionals could also provide psychological support during the discussion of clinical decision-making to enhance readiness and confidence among older adults and their families.

The impact of community nursing program on healthcare utilization: A program evaluation.

BACKGROUND: The role of nurses has evolved to meet the dynamic needs of an aging population. Community nursing has been established in Singapore with the aim to anchor population health and provide sustainable healthcare services beyond the hospital to the community. Community nurses provide health services to residents at the Community Nurse Posts (CNP) situated within the heartland residential estates. OBJECTIVE: To investigate the effect on healthcare utilization six months pre and post first community nurse visit in older adults, and if the effect is modified by the presence of two or more community nurse visits or absence of a polyclinic chronic disease diagnosis. DESIGN: A single-group pretest-posttest study SETTING(S): Fifty-one SingHealth CNPs at the southeast and east regions of Singapore PARTICIPANTS: Community-dwelling older adults aged ≥ 60 years, seen at any of the SingHealth CNPs between 1 April and 30 November 2019. METHODS: The number of emergency department (ED) visits, unplanned inpatient admissions, length of inpatient stay, specialist outpatient clinic (SOC) and polyclinic visits at SingHealth institutions six months from the first community nurse visit were compared to six months prior. Negative binomial generalized estimating equations were used to model healthcare utilization events, adjusting for baseline age, gender, and race. RESULTS: 1,600 community-dwelling participants were included, of whom 1,561 (median age of 71 years) survived the post-test period. There was a population-average 23% lower rate of ED visits (incidence rate ratio 0.77, 95% confidence interval 0.68 to 0.87, p<0.001) and 15% lower rate of unplanned inpatient admissions (0.85, 0.75 to 0.96, p=0.011). A trend towards a lower rate of inpatient length of stay and a higher rate of SOC and polyclinic visits was also observed. The reduction in acute care utilization may have been greater among adults with two or more community nurse visits. Participants with no recent polyclinic chronic disease diagnosis had a greater increase in SOC visits. CONCLUSIONS: Community nursing services are associated with reduced acute care utilization, especially for older adults with two or more community nurse visits. The trend of a higher rate of SOC visits could be attributed to the community nurses' referrals for undiagnosed/ new conditions and/or treatment of suboptimal health issues. There is a potential role for community nursing towards a sustainable healthcare system.

Online memory training intervention for early-stage dementia: A systematic review and meta-analysis.

OBJECTIVES: To evaluate the effectiveness of online memory training interventions in improving memory of patients diagnosed with early-stage dementia. The secondary outcomes comprised cognitive and psychological outcomes. DESIGN: This review was conducted for accordance to the Cochrane Handbook for Systematic Reviews of Interventions. DATA SOURCE: A comprehensive search from six electronic databases: PubMed, Embassy, The Cochrane Library, The Cumulative Index to Nursing and Allied Health Literature, Scopus and Web of Science was conducted (2000-2020). REVIEW METHODS: The populations included in this review comprised adults who had been clinically diagnosed with early-stage dementia and involved in online memory training interventions. Two reviewers appraised the risks of bias through the Cochrane Collaboration's tool and performed the meta-analysis, including the assessment of heterogeneity. RESULTS: Eleven randomized controlled trials retrieved from six databases demonstrated low to moderate levels of quality of evidence according to the GRADE approach. The meta-analysis revealed that online memory training interventions have demonstrated a moderate effect size in improving memory outcomes (d = 0.57; 95% confidence interval 0.28-0.85; p = 0.0001). Additionally, such interventions have shown improvements in secondary outcomes of cognition and psychological with small to medium effects. Duration of each online memory training session and its frequencies did not affect the memory outcome. As opposed to the conventional face-to-face interventions conducted for a group, it is more effective to be conducted for an individual setting. CONCLUSIONS: Online memory training intervention was effective in improving the memory for adults with dementia. IMPACT: Memory interventions have the prospect of reducing everyday problems caused by lapses in memory and improving well-being. With factors such as limited resources and restriction of social gathering due to pandemic, this review could offer relevant information for clinical decision-makers when planning online memory training interventions for adults with dementia.

Prevalence and predictors of medication non-adherence among older community-dwelling people with chronic disease in Singapore.

AIMS: To determine the prevalence and predictors of medication non-adherence among older community-dwelling people with at least one chronic disease in Singapore. DESIGN: A single-centre cross-sectional study. METHODS: The study was conducted in the largest tertiary public hospital in Singapore between May 2019 and December 2019. The community nurses of the hospital recruited a total of 400 community-dwelling older people aged ≥60 years old, who were diagnosed with at least one chronic disease and prescribed with at least one long-term medication. Medication non-adherence was assessed using the self-report 5-item Medication Adherence Report Scale, operationalized as a score of <25. A list of potential factors of medication non-adherence was structured based on the World Health Organization five-domain framework and collected using a self-report questionnaire. RESULTS: Sixty percent (n = 240) of our participants were non-adherent to their medication regime. Older people who smoked (OR 2.89, 95% CI 1.14-7.33), perceived their medication regime as being complicated (OR 2.54, 95% CI 1.26-5.13), felt dissatisfied with their regime (OR 2.50, 95% CI 1.17-5.31), did not know the purpose of all their medications (OR 2.56, 95% CI 1.42-4.63) and experienced side effects (OR 3.32, 95% CI 1.14-9.67) were found to be predictive of medication non-adherence. CONCLUSION: Medication adherence was found to be poor in community-dwelling older people in Singapore. The predictors identified in this study can help guide healthcare professionals in identifying older people who are at risk of medication non-adherence and inform the development of interventions to improve adherence. IMPACT: Medication non-adherence, especially in the older population with chronic diseases, constitutes a serious problem as it undermines the efforts to reduce morbidity and mortality associated with the underlying chronic diseases. To improve adherence, our findings propose the importance of assessing the older person's treatment satisfaction, which includes examining the aspects of side effects, effectiveness and convenience. Additionally, we highlight the need to address the older person's medication knowledge deficit.

Improving nutrition care and diet intake for hospitalised older people at risk of malnutrition through a nurse-driven mealtime assistance bundle.

BACKGROUND: Poor dietary intake is common in hospitalised older people. A targeted mealtime intervention is needed to improve nutrition care and dietary intake, especially for those at risk of malnutrition. OBJECTIVES: This quality improvement project designed, implemented and evaluated a mealtime assistance bundle consisting of care measures driven by the hospital nursing team. The aims were to improve the mealtime care process to promote dietary intake of the hospitalised older people and to improve nursing staff's knowledge, attitude and practice in malnutrition. METHODS: This project adopted a pre-post design, targeting older people aged 65 years and above, who were admitted to a general medical unit in a regional hospital in Singapore. A mealtime assistance bundle consisting of seven care measures, using the acronym CANFEED, was implemented for older adults at risk of malnutrition. Outcome measures on the amount of dietary intake during meals through chart reviews and surveys of nursing staff using Malnutrition Knowledge, Attitudes and perceived Practices (M-KAP) questionnaire were performed before and after implementation. RESULTS: There were fewer older adults with poor intake in the post-implementation group than the pre-implementation group. Among those at risk of malnutrition, older adults in the post-implementation group had higher average intake of all provided meals as well as the protein-dense main dish. Significant improvements were noted in the total scores rated by the nursing staff in both the Knowledge-Attitude subscale and Practice subscale of the M-KAP questionnaire. CONCLUSIONS: Integrating a nurse-driven mealtime assistance bundle into usual care may have positive outcomes on nutritional intake of hospitalised older people at risk of malnutrition, and on knowledge, attitude and practice of hospital nurses in nutrition care. IMPLICATIONS FOR PRACTICE: Nurses play a critical role in nutrition care for hospitalised older people. Continuing efforts to improve nutritional intake of hospitalised older people should focus on staff education, building a multidisciplinary food-promoting culture and patient, family and community empowerment. More efficient clinical processes incorporating information technology with the EMR to support better nutrition care of the hospitalised older people are needed.

Factors Influencing the Uptake of Seasonal Influenza Vaccination among Community-Dwelling Older Adults during COVID-19: A Mixed Methods Study.

Background: Despite making the influenza vaccine accessible and affordable, vaccination rates remained low among community-dwelling older adults. Therefore, this study aimed to explore the factors influencing vaccine uptake and the impact of COVID-19 on vaccine uptake among community-dwelling older adults in Singapore. Methods: A mixed methods study involving a survey and semi-structured interviews were conducted between September 2020 and July 2021. Community-dwelling older adults aged ≥ 65 years were recruited from 27 Community Nurse Posts. Data on participants' demographics, health condition(s), vaccination status, attitudes towards influenza infections and vaccinations, willingness to pay, intention for future vaccination and source of information were collected via the survey. Semi-structured interviews were conducted to understand vaccination experiences, key enablers and barriers, and the impact of COVID-19 on vaccine uptake. All interviews were analysed using Braun and Clarke's thematic analysis. Quantitative data were analysed using descriptive statistics, chi-square tests and multinomial logistic regressions. Results: A total of 235 participants completed the survey. Living arrangement was a statistically significant contributing factor for influenza vaccine uptake (ꭓ2= -0.139; p = 0.03). Participants who lived alone were 2.5 times more likely to be vaccinated than those living with others (OR = 2.504, 95% CI: 1.294-4.842, p = 0.006). Avoidance of getting infected (82.5%), avoidance of transmission to others (84.7%), and advice from healthcare professionals to receive vaccination (83.4%) were key enablers, while concerns about possible side effects (41.2%), the effectiveness of the vaccine (42.6%), and not having enough information (48.1%) were barriers. Twenty participants were interviewed. The findings were congruent with the survey results. Five themes were identified as follows: (1) Perceived importance of influenza vaccination, (2) Sphere of influence, (3) Healthcare schemes and medical subsidies, (4) Psychological impediments, and (5) Inconsistent emphases at various touch points. Conclusions: Greater public health efforts are needed to reach out to the larger population of older adults of different living arrangements and those concerned about the possible side effects and effectiveness of the influenza vaccine. Healthcare professionals need to provide more information to address these concerns, especially during COVID-19, to encourage vaccine uptake.

Evaluating the association of COVID-19 restrictions on discharge planning and post-discharge outcomes in the community hospital and Singapore regional health system.

Objectives: The COVID-19 is a global health issue with widespread impact around the world, and many countries initiated lockdowns as part of their preventive measures. We aim to quantify the duration of delay in discharge to community from Community Hospitals, as well as quantify adverse patient outcomes post discharge pre and during lockdown period. Design and methods: We conducted a before-after study comparing the length of stay in Community Hospitals, unscheduled readmissions or Emergency Department attendance, patients' quality of life using EQ5D-5l, number and severity of falls, in patients admitted and discharged before and during lockdown period. Results: The average length of stay in the lockdown group (27.77 days) were significantly longer than that of the pre-lockdown group (23.76 days), p = 0.003. There were similar proportions of patients with self-reported falls post discharge between both groups. Patients in the pre-lockdown group had slightly better EQ-5D-5l Index score at 0.55, compared to the lockdown study group at 0.49. Half of the patients in both groups were referred to Community Care Services on discharge. Conclusion: Our study would help in developing a future systematic preparedness guideline and contingency plans in times of disease outbreak and other similar public health emergencies.

Impact of COVID-19 Measures on Discharge Planning and Continuity of Integrated Care in the Community for Older Patients in Singapore.

Introduction: The COVID-19 pandemic affects the process of care transition for patients with underlying chronic conditions. This study aims to explore the impact of the pandemic measures on discharge planning and continuum of care for vulnerable older patients from multi-stakeholder perspectives. Methods: We conducted focus group discussions and individual interviews with healthcare workers, community partners, government officials and family caregivers in Singapore. All interviews were audio-recorded, transcribed verbatim and thematically analysed. Results: A total of 53 individuals participated in the study. Discharge planning and care continuity in the community were affected primarily by the limited step-down care options and remote assessment of discharge needs. Participants felt a need to revisit the decision of 'essential' community services through engagement of all stakeholders to enhance care community.To improve better care transition, participants suggested the need for clearer communication of guidelines, improved intersectoral collaboration, shared responsibility of patient care through community engagement and employment of novel models of care. Conclusion: The pandemic measures generated challenges of safe discharge of patients and care continuity in the community. Findings shed light on the need to proactively assess care pathways and catalyse novel models to improve care transition beyond the pandemic.

A systematic review of the effectiveness of bowel management strategies for constipation in adults with stroke.

OBJECTIVE: Constipation is one of the most common medical complications of acute stroke. Currently, management strategies to guide clinical practice are limited. This review aimed to examine the effectiveness of bowel management strategies for constipation in adults with stroke. DESIGN: A systematic review of randomised controlled trials or other quantitative research designs in the absence of randomised controlled trials was undertaken. DATA SOURCES: A comprehensive search of major electronic databases and all reference lists of relevant articles in the English language were performed from January 1990 up to March 2011. REVIEW METHODS: Data were extracted and assessed by two independent reviewers. Due to differences in the study designs, the findings are presented in narrative form. RESULTS: There were a total of three studies (two randomised controlled trials and one quasi-experimental study). One of the randomised controlled trials examined a single (once-only) structured nurse-led intervention and the other randomised controlled trial evaluated four bowel management programmes. Both studies yield improvements respectively in symptoms of bowel dysfunction and bowel training efficiency when the programme corresponded with the subjects' bowel patterns before the stroke onset. The quasi-experimental study compared the effectiveness of daily digital stimulation versus every other day and found higher bowel regularity with daily digital stimulation. CONCLUSION: Constipation management strategies are limited. This review suggests that structured bowel programmes and nurse-led intervention in bowel care have a significant effect in improving bowel evacuations.

Effectiveness of Non-Surgical Management Strategies for Constipation in Adults with Stroke: A Systematic Review.

BACKGROUND: Constipation is one of the most common medical complications of acute stroke. Identifying evidence-based management strategies are essential to ensure an optimum stroke rehabilitation outcome. Currently, there are limited management strategies of constipation in stroke. OBJECTIVE: The objective of this review was to determine the effectiveness of non-surgical management strategies for constipation in adults with stroke. SELECTION CRITERIA: This review included studies of people of 18 years of age or more with a clinical diagnosis of stroke and symptoms of constipation defined by Rome Foundation. This review included studies that evaluate any types of non-surgical management of constipation in an adult person with stroke. The following comparisons were made where possible: This review considered studies that included bowel evacuation as the outcome measure. TYPES OF STUDIES: All randomised controlled trials or other quantitative research designs were considered in the absence of RCTs. SEARCH STRATEGY: A comprehensive search of eight major databases and all reference lists of relevant articles in English was performed from January 1990 up to March 2011. DATA COLLECTION & ANALYSIS: Two reviewers independently assessed methodological quality using a standardised critical appraisal tool. Data was extracted from included studies using a standardised data extraction tool. There was heterogeneity in the types of intervention and outcome measures and statistical pooling of the findings was not appropriate. As such, the studies were grouped according to types of intervention where possible and the findings were presented in narrative form. MAIN FINDINGS: The review included two randomised controlled trials and one quasi-experimental study. All studies were small and most were of poor quality. A one-off structured nurse assessment and intervention can be effective in improving symptoms of bowel dysfunction in stroke subjects. Targeted educational approach with written materials can result in long term lifestyle changes such as modifying diet and fluid intake to control bowel (one trial). Daily bowel care with digital stimulation may assist in achieving regular bowel evacuation but not within a shorter time frame (one trial). Time-scheduled bowel evacuation which follows premorbid bowel habit is considered to contribute to the efficacy of a bowel management program. Morning bowel program schedules are more effective than evening schedules in establishing effective bowel movement pattern (one trial). CONCLUSION: The management strategies are limited due to insufficient evidence. The available evidence to support these treatments is only modest and not without methodological flaws. IMPLICATIONS FOR PRACTICE: It is recommended that bowel management programs should incorporate a nursing component (assessment and education interventions) to improve symptoms of bowel dysfunction. The recommended optimal time for bowel evacuation schedule is in the morning, after breakfast for those whose premorbid bowel habits are in the morning. IMPLICATIONS FOR RESEARCH: Future longitudinal and larger studies are needed to explore pharmacological and non-pharmacological aspects of care that could improve bowel dysfunction in patients with stroke. This review supports the integration of nursing intervention in the development of bowel care programs which merits further evaluation.