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Background: Hospitalized patients with palliative care needs often have high levels of physical and psychological symptom distress. Virtual reality (VR) with a music therapy intervention may improve physical and psychological symptoms. Objectives: To assess symptom distress and quality of life (QOL) among hospitalized palliative care patients who participated in a virtual reality-based music therapy (VR-MT) intervention, and to explore VR-MT from the perspectives of health care professionals involved in their care. Design: Single-arm pilot study of a two-day VR-MT intervention. Setting/Participants: Patients seen by an inpatient palliative care consultation service at a U.S. hospital could participate in the VR-MT intervention. Participants created a customized soundtrack with a music therapist and then listened to it while experiencing a 360-degree VR nature-based environment of their choice. Measurements: Patients completed the Edmonton Symptom Assessment System, revised version (ESAS-r) and McGill Quality of Life, revised version (MQOL-R) before and after VR-MT. Members of the participants' health care teams were interviewed. Results: Seventeen patients completed VR-MT (range 20-79 years of age, 59% women). Moderate clinical improvements were observed for total ESAS-r score (Cohen's d effect size, 0.68), physical distress subscale (0.52), and psychological distress subscale (0.60); small improvements were observed in total MQOL-r score (0.26) and the existential subscale (0.27). Health care team members described the value of VR-MT as facilitating meaningful conversations. Conclusions: This pilot study of VR combined with a music therapy intervention for hospitalized patients with palliative care needs supports opportunities for future study of potential improvements in symptom distress and QOL.
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PURPOSE: Although interventions can increase advance care planning (ACP) engagement, it remains unclear which interventions to choose in primary care settings. This study compares a passive intervention (mailed materials) to an interactive intervention (group visits) on participant ACP engagement and experiences. METHODS: We used mixed methods to examine ACP engagement at baseline and six months following two ACP interventions. Eligible patients were randomized to receive mailed materials or participate in two ACP group visits. We administered the 4-item ACP Engagement survey (n = 110) and conducted interviews (n = 23). We compared mean scores and percent change in ACP engagement, analyzed interviews with directed content analysis to understand participants' ACP experiences, and integrated the findings based on mailed materials or group visits intervention. RESULTS: All participants demonstrated increased ACP engagement scores. At six months, group visit participants reported higher percent change in mean overall score compared with mailed materials participants (+8% vs +3%, P < .0001). Group visits participants reported that being prompted to think about end-of-life preferences, gaining knowledge about ACP, and understanding the value of completing ACP documentation influenced their ACP readiness. While both interventions encouraged patients to start considering and refining their end-of-life preferences, group visits made patients feel more knowledgeable about ACP, highlighted the importance of completing ACP documentation early, and sparked further ACP discussions with others. CONCLUSIONS: While primary care patients may benefit from mailed ACP materials, patients reported increased readiness after ACP group visits. Group visits emphasized the value of upstream preparation, ongoing conversations, and increased knowledge about ACP.
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Planificación Anticipada de Atención , Atención Primaria de Salud , Humanos , Planificación Anticipada de Atención/organización & administración , Masculino , Femenino , Anciano , Persona de Mediana Edad , Atención Primaria de Salud/organización & administración , Participación del Paciente , Encuestas y CuestionariosRESUMEN
To address the need for collaborative approaches to managing dementia in primary care, we implemented the Living with Dementia (LWD) program in a geriatric primary care clinic. This study evaluated the impact of short (≤6 months) and longer-term (7+ months) participation in LWD on care partner outcomes (i.e., self-efficacy, depression, and burden) using t-tests and examined dementia support topics discussed with care partners through the intervention using deductive content analysis. Across 20 months analyzed, 57 dyads participated in the LWD program. Short and longer-term LWD participation indicated a significant increase in self-efficacy with small effect sizes; no changes were observed in depression or burden. Dementia support topics most frequently discussed with care partners focused on care partner well-being, behavior management, and offering referrals. This early evaluation suggests a collaborative care program integrated into primary care can address needs related to caring for persons with dementia and may improve care partner self-efficacy.
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INTRODUCTION/OBJECTIVES: Due to the risks associated with sedative hypnotic medications in older adults, our study evaluated the impact of a multidisciplinary approach to deprescribing in geriatric primary care clinics. METHODS: The study was a retrospective review of older adults at 2 academic, geriatric primary care clinics who were prescribed sedative-hypnotic medications. Patients were mailed an education packet of information that included working with the clinical pharmacy team, behavioral health team, or both in order to deprescribe their sedative-hypnotic medication. The study assessed the rate of discontinuation of sedative-hypnotic medications between the different intervention groups. RESULTS: The study included 93 older adults with a mean age of 81.3 years and 39.8% discontinuation rate of their medication. The number of falls decreased in patients who discontinued use compared to when previously using a sedative hypnotic medication. CONCLUSION: Patients are more likely to discontinue their sedative hypnotic medication with a multidisciplinary approach, specifically with primary care provider support.
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Deprescripciones , Hipnóticos y Sedantes , Anciano , Anciano de 80 o más Años , Humanos , Hipnóticos y Sedantes/uso terapéutico , Atención Primaria de SaludRESUMEN
As adults age, they often require more assistance with personal care needs and other daily living activities. Along with requiring more assistance, access to affordable housing options is also a concern. Homesharing has emerged as a potential means of addressing these housing challenges for older adults. In this study, we surveyed 23 homeshare organizations and interviewed 16 survey respondents to understand characteristics of homeshare organizations, populations served, and the homeshare model. Findings suggest that homeshare organizations use a high-touch matching approach and that they experience challenges to sustainability. Individuals who enter a match are a small subset of those who apply due to organizational eligibility criteria and characteristics of applicants that impact their suitability for homesharing. While homesharing is a niche housing option that is not appropriate for many people, future research should explore whether homesharing fills gaps in housing options for older adults and the outcomes of homesharing.
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Actividades Cotidianas , Vivienda , Anciano , Humanos , Encuestas y CuestionariosRESUMEN
PURPOSE: The goal of this study was to determine the bone turnover marker (BTM) response to insufficient and subsequent recovery sleep, independent of changes in posture, body weight, and physical activity. METHODS: Healthy men (N = 12) who habitually slept 7-9 h/night were admitted to an inpatient sleep laboratory for a baseline 8 h/night sleep opportunity followed by six nights of insufficient sleep (5 h/night). Diet, physical activity, and posture were controlled. Serum markers of bone formation (osteocalcin, PINP) and resorption (ß-CTX) were obtained over 24 h at baseline and on the last night of sleep restriction, and on fasted samples obtained daily while inpatient and five times after discharge over 3 weeks. Maximum likelihood estimates in a repeated measures model were used to assess the effect of insufficient and subsequent recovery sleep on BTM levels. RESULTS: There was no statistically or clinically significant change in PINP (p = 0.53), osteocalcin (p = 0.66), or ß-CTX (p = 0.10) in response to six nights of insufficient sleep. There were no significant changes in BTMs from the inpatient stay through 3 weeks of recovery sleep (all p [Formula: see text] 0.63). On average, body weight was stable during the inpatient stay (Δweight = - 0.55 ± 0.91 kg, p = 0.06). CONCLUSION: No significant changes in serum BTMs were observed after six nights of insufficient or subsequent recovery sleep in young healthy men. Changes in weight and physical activity may be required to observe significant BTM change in response to sleep and circadian disruptions. Clinical Trials Registration Registered at ClinicalTrials.gov (NCT03733483) on November 7, 2018.
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Privación de Sueño , Sueño , Biomarcadores , Peso Corporal , Remodelación Ósea , Humanos , Masculino , Osteocalcina , Sueño/fisiologíaRESUMEN
BACKGROUND AND OBJECTIVES: While advance care planning (ACP) is critical for ensuring optimal end-of-life outcomes among individuals with mild cognitive impairment (MCI), many individuals who may benefit from ACP have not initiated this process. This article aims to describe the iterative design of an MCI group visit-based intervention and evaluate the feasibility and acceptability of the intervention. RESEARCH DESIGN AND METHODS: We used human-centered design, rapid-cycle prototyping, and multiple methods to adapt an ENgaging in Advance Care planning Talks (ENACT) Group Visits intervention. We convened an advisory panel of persons with MCI and care partners (n = 6 dyads) to refine the intervention and conducted a single-arm pilot of 4 MCI ENACT intervention prototypes (n = 13 dyads). We used surveys and interviews to assess outcomes from multiple perspectives. RESULTS: The advisory panel affirmed that ACP is a priority for individuals with MCI, described the need for ACP in a group setting, and suggested refinements to ACP resources for the MCI ENACT intervention. Feasibility of recruitment was limited. MCI ENACT intervention participants strongly agreed that group discussions provided useful information and recommended the intervention. Themes supporting acceptability included (a) feedback on acceptability of the intervention, (b) previous experiences with ACP, and (c) reasons for participation, including desire for discussions about MCI and how it relates to ACP. DISCUSSION AND IMPLICATIONS: Despite stakeholders' positive ratings of acceptability of the MCI ENACT intervention, future work is needed to enhance the feasibility of recruitment to support implementation into clinical settings.
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Planificación Anticipada de Atención , Disfunción Cognitiva , Disfunción Cognitiva/terapia , Humanos , Encuestas y CuestionariosRESUMEN
Background: Music therapy (MT) and virtual reality (VR) have shown favorable patient-reported outcomes during serious illness. Objectives: To evaluate implementation measures of feasibility, usability, and acceptability of a VR-based MT intervention. Design: A pilot implementation study of a two-day VR-MT intervention using mixed methods. Patients created a personalized soundtrack with a music therapist, and then paired the soundtrack with a 360° VR environment. Setting/Subjects: Hospitalized patients with palliative care needs. Results: Of 23 patients (ages 20-74 years, 52% women), 17 completed the intervention, including 39% during an intensive care unit stay. Participants scored usability above average. For satisfaction, 53% chose the highest rating. Most participants spoke favorably of VR-MT, describing pleasant emotional and physical responses. Participants provided feedback on length, frequency of use, VR options, and timing of delivery. Conclusion: This VR-MT intervention was feasible, usable, and acceptable for hospitalized palliative care patients. Further study will test VR-MT outcomes.
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Enfermería de Cuidados Paliativos al Final de la Vida , Musicoterapia , Música , Realidad Virtual , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cuidados Paliativos , Adulto JovenRESUMEN
BACKGROUND: Telephone and video telemedicine appointments have been a crucial service delivery method during the COVID-19 pandemic for maintaining access to health care without increasing the risk of exposure. Although studies conducted prior to the pandemic have suggested that telemedicine is an acceptable format for older adults, there is a paucity of data on the practical implementation of telemedicine visits. Due to prior lack of reimbursement for telemedicine visits involving nonrural patients, no studies have compared telephone visits to video visits in geriatric primary care. OBJECTIVE: This study aimed to determine (1) whether video visits had longer durations, more visit diagnoses, and more advance care planning discussions than telephone visits during the rapid implementation of telemedicine in the COVID-19 pandemic, and (2) whether disparities in visit type existed based on patient characteristics. METHODS: We conducted a retrospective, cross-sectional analysis of patients seen at two geriatric clinics from April 23 to May 22, 2020. Approximately 25% of patients who had telephone and video appointments during this time underwent chart review. We analyzed patient characteristics, visit characteristics, duration of visits, number of visit diagnoses, and the presence of advance care planning discussion in clinical documentation. RESULTS: Of the 190 appointments reviewed, 47.4% (n=90) were video visits. Compared to telephone appointments, videoconferencing was, on average, 7 minutes longer (mean 37.3 minutes, SD 10 minutes; P<.001) and had, on average, 1.2 more visit diagnoses (mean 5.7, SD 3; P=.001). Video and telephone visits had similar rates of advance care planning. Furthermore, hearing, vision, and cognitive impairment did not result in different rates of video or telephone appointments. Non-White patients, patients who needed interpreter services, and patients who received Medicaid were less likely to have video visits than White patients, patients who did not need an interpreter, and patients who did not receive Medicaid, respectively (P=.003, P=.01, P<.001, respectively). CONCLUSIONS: Although clinicians spent more time on video visits than telephone visits, more than half of this study's older patients did not use video visits, especially if they were from racial or ethnic minority backgrounds or Medicaid beneficiaries. This potential health care disparity merits greater attention.
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BACKGROUND: Advance care planning is the process of discussing health care treatment preferences based on patients' personal values, and it often involves the completion of advance directives. In the first months of 2020, a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), began circulating widely in the American state of Colorado, leading to widespread diagnosis of coronavirus disease (COVID-19), hospitalizations, and deaths. In this context, the importance of technology-based, non-face-to-face methods to conduct advance care planning via patient portals has increased. OBJECTIVE: The aim of this study was to determine the rates of use of a web-based advance care planning tool through a health system-based electronic patient portal both before and in the early months of the COVID-19 pandemic. METHODS: In 2017, we implemented web-based tools through the patient portal of UCHealth's electronic health record (EHR) for patients to learn about advance care planning and complete an electronically signed medical durable power of attorney (MDPOA) to legally appoint a medical decision maker. Patients accessing the portal can complete and submit a legally valid MDPOA, which becomes part of their medical record. We collected data on the patients' date of MDPOA completion, use of advance care planning messaging, age, sex, and geographic location during the early phase of the COVID-19 pandemic (December 29, 2019, to May 30, 2020). RESULTS: Over a 5-month period that includes the early phase of the COVID-19 pandemic in Colorado, total monthly use of the advance care planning portal tool increased from 418 users in January to 1037 users in April and then decreased slightly to 815 users in May. The number of MDPOA forms submitted per week increased 2.4-fold after the stay-at-home order was issued in Colorado on March 26, 2020 (P<.001). The mean age of the advance care planning portal users was 47.7 years (SD 16.1), and 2206/3292 (67.0%) were female. Women were more likely than men to complete an MDPOA, particularly in younger age groups (P<.001). The primary use of the advance care planning portal tools was the completion of an MDPOA (3138/3292, 95.3%), compared to sending an electronic message (148/3292, 4.5%). Over 50% of patients who completed an MDPOA did not have a prior agent in the EHR. CONCLUSIONS: Use of a web-based patient portal to complete an MDPOA increased substantially during the first months of the COVID-19 pandemic in Colorado. There was an increase in advance care planning that corresponded with state government shelter-in-place orders as well as public health reports of increased numbers of COVID-19 cases and deaths. Patient portals are an important tool for providing advance care planning resources and documenting medical decision makers during the pandemic to ensure that medical treatment aligns with patient goals and values.
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Betacoronavirus , Infecciones por Coronavirus , Pandemias , Neumonía Viral , Adulto , Planificación Anticipada de Atención , COVID-19 , Registros Electrónicos de Salud , Femenino , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Portales del Paciente , Estudios Retrospectivos , SARS-CoV-2RESUMEN
BACKGROUND: Group visits can support health behavior change and self-efficacy. In primary care, an advance care planning (ACP) group visit may leverage group dynamics and peer mentorship to facilitate education and personal goal setting that result in ACP engagement. OBJECTIVE: To determine whether the ENgaging in Advance Care Planning Talks (ENACT) group visits intervention improves ACP documentation and readiness in older adults. METHODS: This randomized clinical trial was conducted among geriatric primary care patients from the University of Colorado Hospital Seniors Clinic, Aurora, CO, from August 2017 to November 2019. Participants randomized to ENACT group visits (n = 55) participated in two 2-hour sessions with discussions of ACP topics and use of ACP tools (i.e., Conversation Starter Kit, Medical Durable Power of Attorney form, and PREPARE videos). Participants randomized to the control arm (n = 55) received the Conversation Starter Kit and a Medical Durable Power of Attorney form by mail. The primary outcomes included presence of ACP documents or medical decision-maker documentation in the electronic health record (EHR) at 6 months, and a secondary outcome was ACP readiness (validated four-item ACP Engagement Survey) at 6 months. RESULTS: Participants were a mean of 77 years old, 60% female, and 79% white. At 6 months, 71% of ENACT participants had an advance directive in the EHR (26% higher) compared with 45% of control arm participants (P < .001). Similarly, 93% of ENACT participants had decision-maker documentation in the EHR (29% higher) compared with 73% in the control arm (P < .001). ENACT participants trended toward higher readiness to engage in ACP compared with control (4.56 vs 4.13; P = .16) at 6 months. CONCLUSION: An ACP group visit increased ACP documentation and readiness to engage in ACP behavior change. Primary care teams can explore implementation and adaptation of ACP group visits into routine care, as well as longer-term impact on patient health outcomes. J Am Geriatr Soc 68:2382-2389, 2020.
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Planificación Anticipada de Atención , Procesos de Grupo , Participación del Paciente/métodos , Atención Primaria de Salud/métodos , Citas Médicas Compartidas , Anciano , Anciano de 80 o más Años , Documentación , Registros Electrónicos de Salud , Femenino , Implementación de Plan de Salud , Humanos , Masculino , Tutoría , Evaluación de Resultado en la Atención de Salud , Grupo ParitarioAsunto(s)
Cuidados para Prolongación de la Vida , Pacientes Ambulatorios , Anciano , Anciano de 80 o más Años , Humanos , Cuidados para Prolongación de la Vida/ética , Cuidados para Prolongación de la Vida/normas , Cuidados para Prolongación de la Vida/estadística & datos numéricos , Pacientes Ambulatorios/estadística & datos numéricos , Médicos , Órdenes de Resucitación/éticaRESUMEN
Despite the established benefit of advance care planning (ACP), achieving and sustaining high rates of ACP completion continue to be a challenge in many health care settings. A palliative care champions committee has targeted improving the ACP process through quality improvement initiatives at an academic medical center. To understand the impact of multiyear efforts to improve ACP, surveys of registered nurses, care coordinators, and medical assistants from inpatient and outpatient settings were conducted in 2013 and 2017 to explore comfort level with ACP, barriers preventing completion of ACP in daily practice, and suggestions for overcoming these barriers. The findings suggest strategies to further integrate ACP through interdisciplinary teams, including outpatient staff education, inpatient and outpatient quality improvement initiatives, and dedicated staff for ACP.
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Planificación Anticipada de Atención/estadística & datos numéricos , Documentación/normas , Mejoramiento de la Calidad/normas , Documentación/métodos , Documentación/estadística & datos numéricos , Humanos , Mejoramiento de la Calidad/estadística & datos numéricos , Encuestas y Cuestionarios/normasRESUMEN
OBJECTIVES: To understand patterns of marijuana use in community-dwelling older adults in Colorado. DESIGN: Anonymous survey. SETTING: Two academic geriatric primary care clinics. PARTICIPANTS: English-speaking individuals. MEASUREMENTS: We assessed self-reported characteristics and patterns of marijuana use and effect on targeted symptoms. Survey analysis focused on current users, defined as individuals who had used marijuana in the past 3 years. RESULTS: Three hundred forty-five individuals completed the survey (55% response rate); 113 (32%) had used marijuana in the past, of whom 55 (16%) had used since legalization. More than half of current users were aged 75 and older, and one-quarter were aged 85 and older. Most current users were white women. Of current users, 44% used marijuana products at least weekly for common conditions including chronic pain, depression, anxiety, and insomnia, and most found marijuana helpful for these conditions. Most respondents reported obtaining marijuana recreationally (67%) without a prescription. Nine respondents reported negative side effects attributable to marijuana use. CONCLUSION: To our knowledge, this is the first study to characterize marijuana use of older adults in a state in which it is legal for medical and recreational use. Marijuana was used for several common geriatric conditions, and respondents reported few side effects. The small number of survey respondents, the lack of generalizability in states where marijuana sales are illegal, and participation bias were the main study limitations. Further research is needed to better understand useful or harmful effects in this population. J Am Geriatr Soc 66:2167-2171, 2018.