What Matters Most: The Documented Goals, Values and Motivators of Advanced Cancer Patients.

BACKGROUND: Goals of care conversations are essential to delivery of goal concordant care. Infrequent and inconsistent goals of care documentation potentially limit delivery of goal concordant care. METHODS: At Kaiser Permanente San Francisco Cancer Center, a standardized documentation template was designed and implemented to increase goals of care documentation by oncologists. The centralized, prompt-based template included value clarification of the goals and values of advanced cancer patients beyond treatment preferences. Documented conversations using the template during the initial pilot period were reviewed to characterization the clinical context in which conversations were recorded. Common goals and motivators were also identified. RESULTS: A total of 178 advanced cancer patients had at least 1 documented conversation by a medical oncologist using the goals of care template. Oncologists consistently documented within the template goals of therapy and motivating factors in decision making. The most frequently documented goals of care were "Avoiding Pain and Suffering," "Physical Independence," and "Living as Long as Possible." The least recorded goal was "Comfort Focused Treatment Only." CONCLUSIONS: Review of oncologist documented goals of care conversations using a prompt-based template allowed for characterization of the clinical context, therapy goals and motivators of advanced cancer patients. Communication of goals of care conversations by oncologists using a standardized prompt-based template within a centralized location has the potential to improve delivery of goal concordant care.

Feasibility of implementing a telephone-based frailty assessment.

BACKGROUND: Despite the growing literature on the importance of identifying and managing frailty, its assessment has been limited in clinical settings. With the goal of integrating frailty assessment into routine clinical practice, this quality improvement project aimed to determine the feasibility, acceptability, and utility of administering a telephone-based frailty assessment. METHODS: Between 9/2020 and 6/2021, we identified 169 established patients with serious illnesses in an academic primary care-geriatric clinic. Patients were contacted via telephone, and their current medical, functional, nutritional, cognitive, and mood statuses were assessed using validated screening tools. A deficit-accumulation frailty score was then calculated using an electronic medical record-based frailty index calculator and standardized documentation with recommendations was generated for providers. The primary outcome was feasibility, measured as the proportion of patients successfully assessed. Secondary outcomes included completion rates of each domain, administration time, providers' perception, and clinical utility of the assessment. RESULTS: A total of 139 (82.2%) patients, mean age of 82 years, 63.3% frail were successfully assessed. Of the 139 assessments, medical and functional domains were completed for all, while nutrition, mood, and cognition were completed by 88.5% (n = 123), 68.3% (n = 95), and 59.7% (n = 83) of the time, respectively. Conducting the full assessment took an average (standard deviation) time of 26.1 (7.3) minutes. Without the cognitive and mood domain, assessment took an average of 15.7 (7.5) minutes. Patients' providers found the information from the assessment helpful in evaluating and managing their patients. Care plans of 51.8% and 65.0% of patients who had mobility and mind issues, respectively, addressed these domains within 30 days after the assessment. CONCLUSION: Implementation of the telephone-based frailty assessment is feasible, acceptable, and has the potential to influence the care plans of older adults. This work demonstrated how frailty assessment can be integrated with the outpatient setting.

On the prevention and treatment of Alzheimer's disease: Control the promoters and look beyond the brain.

Alzheimer's disease (AD) is a progressive incurable neurodegenerative disease of the brain afflicting a third of the population aged 85 and older. Pathologic hallmarks include extracellular plaques of amyloid-beta (Aß), intraneuronal neurofibrillary tangles of hyperphosphorylated tau protein, synaptic destruction, neuronal death, and brain atrophy. Neuroinflammation, mediated by microglia, is a central component of the disease, and is intricately connected with peripheral inflammation. The clinical manifestations include progressive memory loss and eventual death. The present treatment of AD is largely ineffective. Nearly all AD is late-onset and presents age 65 or older, and the most common genetic risk factor is carriage of an apolipoprotein (APO) E4 allele, seen in about 25% of the general population. Individuals carrying an APOE4 allele produce more Aß and clear it less efficiently from the brain throughout life. There has been accumulating pathologic and clinical evidence that microbes, particularly the herpes simplex virus (HSV), is a causative factor for AD, most notable in carriers of the APOE4 allele. Eighty percent of the adult population harbors HSV and it resides in the trigeminal ganglion in latent state throughout life, but periodically reactivates, traveling antegrade resulting in herpes labialis and traveling retrograde into the brain leading to neuroinflammation. Functioning as an antimicrobial peptide, Aß inactivates HSV and the recurring process culminates in a buildup of Aß plaque and other hallmarks of AD over time. Periodontal disease exists in 20-50% of the adult population and is also a causative factor for AD. Accordingly, bacteria causing periodontal disease and their byproducts can enter the brain directly via the trigeminal nerve or indirectly through the bloodstream, resulting in AD pathology over time. There are many other promoters of AD, particularly inflammatory conditions outside of the brain, that can be mitigated. Small trials are finally in progress testing antimicrobial drugs for the prevention and treatment of AD. In the meantime, a more proactive approach to the prevention and treatment of AD is posited, with an emphasis on prevention, since the pathologic underpinnings of the disease start decades before the clinical manifestations. Individuals can be stratified in risk categories using family history, periodontal disease presence, APOE4 carriage, and HSV IgG positivity. Moderate- and high-risk individuals can be treated safely with various preventive measures and appropriate antimicrobial agents as discussed. Importantly, the proposed treatments are concordant with the accepted practice of medicine, and if utilized, could significantly decrease AD prevalence.

Randomized Controlled Trial of a Novel Device for Tinnitus Sound Therapy During Sleep.

PURPOSE: The aim of this study was to determine if a customized stimulus from the Otoharmonics Levo System reduces tinnitus perceptions and reactions for people with bothersome tinnitus. METHOD: Sixty participants were randomized to 1 of 3 groups that used sound therapy devices during sleep that differed in their acoustic stimulus: (a) tinnitus-matched (TM), (b) noise stimulus (NS), and (c) bedside sound generator (BSG). Outcome measures were the Tinnitus Functional Index (TFI), numeric rating scale of tinnitus loudness, and tinnitus loudness match. A Bayesian hierarchical model was fit to estimate the differences in treatment efficacy among groups. RESULTS: Average tinnitus reactions and perceptions improved across treatment groups. We are at least 87% certain that treatment with TM or NS reduces mean TFI compared to treatment with BSG, with an estimated relative efficacy of 4.5-5 points greater reduction. We are at least 95% certain that treatment with TM results in greater reduction in mean numeric rating scale (NRS) of tinnitus loudness compared to the other groups, with an estimated relative efficacy of about 0.75 points greater reduction. CONCLUSIONS: This study offers some support for greater average improvement in reactions to tinnitus with TM or NS devices compared to the BSG device. The TM group, compared to the BSG and NS groups, showed a greater reduction in ratings of tinnitus loudness on the NRS on average. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.5545759.

Experienced-Based Versus Scenario-Based Assessments of Shame and Guilt and Their Relationship to Alcohol Consumption and Problems.

BACKGROUND: Empirical studies of the relationships between shame, guilt, and drinking are sparse and sometimes appear contradictory. However, a more coherent picture emerges when researchers differentiate between measures of experienced of guilt and shame (i.e., questionnaires that ask how often people experience thoughts, feelings, and sensations associated with the emotion) versus proneness to guilt and shame (i.e., self-report of likely responses to imagined situations) is understood. OBJECTIVES: Assess the extent to which experiential versus proneness measures of shame and guilt are associated with alcohol consumption and alcohol-related problems. METHODS: Between 2012 and 2013, 89 community-dwelling non-abstaining adults were interviewed on a single occasion about their drinking and completed self-report measures of shame, guilt, and drinking-related behaviors. RESULTS: Overall, shame and guilt were most strongly related to alcohol-related problems and not drinking amount per se, and shame was more strongly related to alcohol-related problems than was guilt. A measure of experienced shame, the Internalized Shame Scale, was the strongest predictor of drinking-related problems and predicted problems above and beyond other measures of shame and guilt. While guilt proneness was related to less problematic drinking, guilt experienced at the time of the assessment was related to more problematic drinking. CONCLUSIONS: Shame appears to be more central to the experience of problematic drinking than guilt. Results also support the idea that guilt/shame proneness is distinct from experienced shame and guilt. Incorporating this distinction appears to account for the inconsistencies in the literature regarding how shame and guilt are related to drinking.