Development and pilot testing of the revised Patients' Attitudes Towards Deprescribing questionnaire for people with cognitive impairment.

OBJECTIVES: (i) To develop a version of the revised Patients' Attitude Towards Deprescribing (rPATD) questionnaire for people with mild cognitive impairment (MCI) and mild-to-moderate dementia (rPATDcog); and (ii) to capture the beliefs and attitudes of this population and their carers about deprescribing through a pilot study. METHODS: First, the rPATDcog was modified from the rPATD and tested in a small group of participants with MCI or mild dementia, and then, we conducted a pilot study of the rPATDcog and the carers' rPATD. RESULTS: Twenty-one participants with cognitive impairment and 11 carer participants (forming dyads) participated in this study. Eighty-one per cent (17/21) of participants said that they would stop one or more of their medications if their doctor said it was possible. There was an excellent agreement of corresponding questions between dyads. CONCLUSION: The rPATDcog was feasible to administer in this study. Further work is required to provide generalisable results and determine utility in practice.

Evidence of detraining after 12-week home-based exercise programs designed to reduce fall-risk factors in older people recently discharged from hospital.

OBJECTIVE: To measure the extent to which improved sensorimotor function and balance resulting from a 12-week exercise intervention were retained 12 weeks after exercise cessation in older adults recently discharged from hospital. DESIGN: Randomized controlled trial with reassessment 12 weeks after exercise cessation. SETTING: Home-based exercises. PARTICIPANTS: Adults (N=180) aged 65 years and older recently discharged from hospital (mean length of stay, 12.3±10.6d). INTERVENTIONS: Weight-bearing (WB) exercises (n=60), seated resistance (SR) exercises (n=60), or social visits (n=60). MAIN OUTCOME MEASURES: Physiological Profile Assessment (PPA), a composite sensorimotor fall-risk score, and 2 measures of controlled leaning balance assessed at baseline, immediately after the intervention (12wk, 95% assessed), and again 12 weeks later (24wk, 92% assessed). RESULTS: After the initial improvements in outcomes found at 12 weeks, both the SR and WB exercise groups showed detraining effects at 24 weeks. The PPA fall-risk scores for both SR and WB groups returned to close to baseline values, and there was no significant difference between groups at 24 weeks when controlling for baseline scores (P=.924). WB exercise participants lost up to half of the improvement in the maximal balance range and coordinated stability tests. There was no difference between groups for the maximal balance range test at 24 weeks when controlling for baseline scores (P=.207), but between-group differences were maintained for the coordinated stability test (P=.017). CONCLUSIONS: Balance improvements and fall-risk reductions associated with a 12-week home-based exercise program in older adults were partially to totally lost 12 weeks after the cessation of the intervention. These significant detraining effects suggest that sustained adherence to falls prevention exercise programs is required to reduce fall risk.

Which Aged Care inpatients are potentially suitable for community-based acute care?

AIM: To identify Aged Care inpatients potentially suitable for Acute/Post-Acute Care (APAC)-Aged Care, a new service offering community-based acute care as an alternative to hospital admission for frail older people. METHODS: Criteria were developed to identify suitable patients for APAC-Aged Care and applied to consecutive Aged Care inpatient admissions at Royal North Shore Hospital, Sydney, Australia, through retrospective chart review. RESULTS: Only 5/90 reviewed patients were potentially suitable for APAC-Aged Care. All five were from Residential Aged Care Facilities. The median age of the 90 patients was 86 years; 30% lived in Residential Aged Care Facilities; 53% of patients were medically stable on presentation; 70% required investigations beyond a standard baseline set; 27% had either no new functional decline on presentation or adequate community support to manage this; 91% had allied health input and 41% had medical/surgical consultation. CONCLUSION: APAC-Aged Care is a potentially suitable alternative to acute inpatient hospitalisation in a select minority of Aged Care patients.

Identifying the educational needs of parents at the completion of their child's cancer therapy.

For parents of children with cancer, the experience of completing treatment can be a time of celebration and hope as well as anxiety and fear. Previous research has identified the time immediately following completion of therapy as one of the most difficult and anxiety producing periods in parents' trajectory of cancer treatment. A gap in knowledge exists to guide nursing practice regarding parents' educational needs. The purpose of this study was to (a) determine the educational needs of parents as their children completed cancer treatment and (b) assess the feasibility of measuring parental educational needs, anxiety, and family management styles as treatment ends. The results support previous findings that parents are anxious at the end of therapy. Fear of relapse was their primary concern. Although parents desire education at the end of therapy, attention to parental readiness to learn and the individual needs of the patient and family must be considered. In the feasibility portion of this study, parents were able to complete the questionnaires with no negative feedback provided.

Fertility concerns for young males undergoing cancer therapy.

OBJECTIVES: To review the treatment factors that can affect male fertility, and the practices at a large metropolitan children's hospital that has successfully developed a sperm banking program. The role of the nurse in the education of families and facilitating the sperm banking process will be described. DATA SOURCES: Review of the literature and anecdotal information. CONCLUSION: Because of increased survival rates over the past three decades in children diagnosed with cancer, the importance of preserving fertility has become paramount in the minds of health care providers, families, and patients. IMPLICATIONS FOR NURSING PRACTICE: Early identification and prompt referral for sperm banking by nurses are key factors in helping young male adolescents with cancer.

Reducing risk of falling in older people discharged from hospital: a randomized controlled trial comparing seated exercises, weight-bearing exercises, and social visits.

OBJECTIVE: To compare the efficacy of seated exercises and weight-bearing (WB) exercises with social visits on fall risk factors in older people recently discharged from hospital. DESIGN: Twelve-week randomized, controlled trial. SETTING: Home-based exercises. PARTICIPANTS: Subjects (N=180) aged 65 and older, recently discharged from hospital. INTERVENTIONS: Seated exercises (n=60), WB exercises (n=60), and social visits (n=60). MAIN OUTCOME MEASURES: Primary outcome factors were Physiological Profile Assessment (PPA) fall risk score, and balance while standing (Coordinated Stability and Maximal Balance Range tests). Secondary outcomes included the component parts of the PPA and other physical and psychosocial measures. RESULTS: Subjects were tested at baseline and at completion of the intervention period. After 12 weeks of interventions, subjects in the WB exercise group had significantly better performance than the social visit group on the following: PPA score (P=.048), Coordinated Stability (P<.001), Maximal Balance Range (P=.019); body sway on floor with eyes closed (P=.017); and finger-press reaction time (P=.007) tests. The seated exercise group performed better than the social visit group in PPA score (P=.019) but for no other outcome factor. The seated exercise group had the highest rate of musculoskeletal soreness. CONCLUSIONS: In older people recently discharged from the hospital, both exercise programs reduced fall risk score in older people. The WB exercises led to additional beneficial impacts for controlled leaning, reaction time, and caused less musculoskeletal soreness than the seated exercises.

Balancing risk versus benefit: the elderly patient’s perspective on warfarin therapy / Sopesando riesgo y beneficio: perspectiva del paciente anciano a tratamiento con warfarina

Warfarin therapy is underused in the target at-risk elderly population. Clinicians perceive that older patients are reluctant to use this therapy, however the perspective of patients or their carers has yet to be explored. Objective: To explore in-depth the perspectives of elderly patients and/or their carers regarding the use of warfarin therapy. Method: A qualitative study, using semi-structured group interviews was undertaken. The audio-taped discussions were transcribed verbatim, then thematically analysed to identify emergent themes. Group discussions were conducted at a major Sydney teaching hospital, over a 2-month period. Individuals aged 65 years or older (and/or their carers) who were using long-term (6 months) warfarin therapy were recruited by voluntary response to study flyers. Results: 17 patients and carers (mean age 77.2 SD=7.5 years) participated in one of two focus groups. Five core themes emerged regarding warfarin therapy: inadequate knowledge and understanding about it, patients/carers variable experience of information provision, cycle of reactions to being on it, issues in its practical management, and the spectrum of experiences with it. Overall, participants were very accepting of the therapy, describing a high level of compliance, despite initial fears and anxieties, and a relative lack of knowledge. Patients felt somewhat abandoned in their management of warfarin due to the lack of ongoing support services in the community, and inadequate information provision. Conclusions: Elderly patients and their carers appear to be quite accepting of warfarin therapy, in contrast to the perceptions of health care professionals. More effort is needed, however, in terms of information provision, particularly in the form of community-based services, to assist patients in the long-term management of warfarin (AU)

El tratamiento con warfarina se sub-utiliza en los ancianos de alto riesgo. Los clínicos perciben que los ancianos son reacios a este tratamiento, sin embargo la perspectiva de los pacientes y de sus cuidadores aún no ha sido estudiada. Objetivo: Explorar en profundidad las perspectivas de los pacientes ancianos y/o sus cuidadores sobre el uso de tratamiento con warfarina. Método: Se realizó un estudio cualitativo, utilizando entrevista semi-estructurada en grupos. Las discusiones grabadas se transcribieron a papel, y se analizaron temáticamente para identificar los temas emergentes. Las discusiones en grupos se realizaron en un gran hospital universitario de Sydney durante un periodo de dos meses. Mediante respuesta voluntaria a folletos, se reclutó a individuos de 65 o más años (y/0 sus cuidadores) que estaban utilizando crónicamente (6 o más meses) tratamiento con warfarina. Resultados: 17 pacientes y cuidadores (edad media 77,2 DE=7,5 años) participaron en uno de los dos grupos focales. Emergieron 5 temas principales en relación al tratamiento con warfarina: conocimiento y entendimiento inadecuado, experiencia variable de pacientes/cuidadores de la información proporcionada, ciclo de reacciones de estar bajo esto, problemas de manejo práctico, y espectro de experiencias con el tratamiento. Generalmente los participantes aceptaban bien el tratamiento, describiendo altos niveles de cumplimiento, a pesar de sus miedos y ansiedades inicial, y la relativa falta de conocimiento. Los pacientes se sentían algo abandonados en su manejo del tratamiento con warfarina debido a la falta de servicios de apoyo continuo en la comunidad y de la inadecuada provisión de información. Conclusión: Los pacientes ancianos y sus cuidadores parecen estar tranquilos aceptando el tratamiento con warfarina, en contraste con la percepción de los profesionales de la salud. Sin embargo se necesita un mayor esfuerzo en relación a la provisión de información, especialmente en los servicios comunitarios, para ayudar a los pacientes en el manejo de la warfarina a largo plazo (AU)

Balancing risk versus benefit: the elderly patient's perspective on warfarin therapy.

UNLABELLED: Warfarin therapy is underused in the target at-risk elderly population. Clinicians perceive that older patients are reluctant to use this therapy, however the perspective of patients or their carers has yet to be explored. OBJECTIVE: To explore in-depth the perspectives of elderly patients and/or their carers regarding the use of warfarin therapy. METHOD: A qualitative study, using semi-structured group interviews was undertaken. The audio-taped discussions were transcribed verbatim, then thematically analysed to identify emergent themes. Group discussions were conducted at a major Sydney teaching hospital, over a 2-month period. Individuals aged 65 years or older (and/or their carers) who were using long-term (6 months) warfarin therapy were recruited by voluntary response to study flyers. RESULTS: 17 patients and carers (mean age 77.2 SD=7.5 years) participated in one of two focus groups. Five core themes emerged regarding warfarin therapy: inadequate knowledge and understanding about it, patients/carers variable experience of information provision, cycle of reactions to being on it, issues in its practical management, and the spectrum of experiences with it. Overall, participants were very accepting of the therapy, describing a high level of compliance, despite initial fears and anxieties, and a relative lack of knowledge. Patients felt somewhat abandoned in their management of warfarin due to the lack of ongoing support services in the community, and inadequate information provision. CONCLUSIONS: Elderly patients and their carers appear to be quite accepting of warfarin therapy, in contrast to the perceptions of health care professionals. More effort is needed, however, in terms of information provision, particularly in the form of community-based services, to assist patients in the long-term management of warfarin.

Sperm banking for adolescents with cancer.

Recent advances in diagnostic and therapeutic methods in pediatric oncology have led to greater survival rates in children with malignancies. However, major long-term complications can occur that limit the quality of survival, infertility being one of them. Chemotherapy, radiation treatment, surgery, and combinations of these treatments have been implicated in causing infertility, with males being especially sensitive to therapy. Cryopreservation of semen, or sperm banking, is an easy, widely available means to preserve fertility for adolescent and young adult males with cancer. In this article, the pertinent literature is reviewed, and a sperm-banking program is described. Recommendations are offered for institutions attempting to develop a successful program, and the nurse's role in education and facilitation is discussed.

Sperm banking for adolescent and young adult cancer patients: sperm quality, patient, and parent perspectives.

BACKGROUND: Infertility is often a complication for adolescent and young adult males who receive cancer therapy, a problem that might be averted through using cryopreserved sperm. We aim to evaluate feasibility of offering newly diagnosed patients the opportunity to bank sperm and, to determine the beliefs and decision-making processes of patients and their parents who considered sperm banking. PROCEDURE: Eligible patients and parents were approached and offered sperm cryopreservation. Semen samples from patients who sequentially attempted sperm banking were analyzed. Questionnaires were then administered to patients and parents who had been approached about sperm banking. RESULTS: Semen samples from 68 patients were analyzed. Nine patients were azoospermic; all had been pre-treated with chemotherapy. Fifty patients completed the questionnaire. Parent and patient made the decision together to bank 80% of the time. All sons who attempted to bank and their parents felt they had made the right decision, including those who attempted but failed. CONCLUSIONS: Viable sperm can be collected successfully from adolescent and young adults who are newly diagnosed with cancer. Semen quality was dramatically reduced by one course of gonadotoxic therapy. Parents and patients want information regarding sperm cryopreservation early. Parents appear to play an important role in the decision to sperm bank. We recommend sperm banking be offered to all eligible patients.

Management of warfarin in atrial fibrillation: views of health professionals, older patients and their carers.

OBJECTIVE: To identify the views of health professionals, patients and their carers on strategies to improve the use and management of warfarin in older patients with atrial fibrillation. DESIGN: Qualitative study based on analysis of group interviews. SETTING: A major metropolitan teaching hospital, from 1 March to 30 April 2003. PARTICIPANTS: 14 patients (>/= 65 years) with established atrial fibrillation and taking warfarin, three carers, 12 specialists, eight general practitioners, six community pharmacists, nine hospital pharmacists, and 11 nurses volunteered in response to flyers promoting the study. RESULTS: Suggested strategies to improve warfarin management targeted support services for GPs and patients. Hospital-based clinicians felt that dissemination of trial evidence to GPs to support treatment recommendations is required, and that GPs need to enlist allied health professionals in the management of patients taking warfarin. GPs preferred access to practical advice from expert colleagues on the day-to-day management. Patients requested more information about warfarin therapy, as access to information is inadequate, particularly from primary sources (GPs, community pharmacists). Verbal and written information are equally important, but a single counselling session or supply of a booklet was viewed as inadequate. Participants identified various interventions for all levels of warfarin management; from the collective input, a framework for management strategies was developed. CONCLUSIONS: Health professionals and patients require more customised information to support warfarin use and management.

Clinical application of family management styles to families of children with cancer.

The potential clinical application of family management styles for working with families who have children with cancer is discussed. Case studies are used to illustrate the usefulness and clinical application of the model.