Association between physical activity and risk of hospitalisation in bronchiectasis.

BACKGROUND: Patients with bronchiectasis have a less active lifestyle than healthy peers, but the association with hospital admission has not been explored. The aim of this study was to investigate the association between 1) any physical activity variable; and 2) sedentary time, with hospitalisation due to exacerbation in adults with bronchiectasis. METHODS: In this prospective observational study, baseline lung function, quality of life, exercise tolerance, severity of bronchiectasis and physical activity were recorded. Physical activity was objectively assessed over a week using a SenseWear armband and the results were expressed in steps·day-1 and sedentary time. Number of hospitalisations due to a bronchiectasis exacerbation and time to first event were recorded after 1-year follow-up. RESULTS: Sixty-four patients with bronchiectasis were analysed, of whom 15 (23%) were hospitalised during the follow-up. Hospitalised patients showed poor baseline clinical and severity outcomes, fewer steps walked per day and more sedentary behaviour than the non-hospitalised group. Patients who walked ≤6290 steps·day-1 or spent ≥7.8 h·day-1 in sedentary behaviour had an increased risk of hospital admission due to bronchiectasis exacerbation at 1-year follow-up. Specifically, ≥7.8 h·day-1 of sedentary behaviour was associated with a 5.9-fold higher risk of hospital admission in the following year. CONCLUSIONS: Low levels of physical activity and high sedentary time at baseline were associated with a higher risk of hospitalisation due to bronchiectasis exacerbation. If these findings are validated in future studies, it might be appropriate to include physical activity and sedentary behaviour as an item in severity scores.

Developing the Geriatric Injury Documentation Tool (Geri-IDT) to Improve Documentation of Physical Findings in Injured Older Adults.

BACKGROUND: Standardization in tools and documentation of child abuse and intimate partner violence have proven helpful in completely documenting injuries and suspected abuse among these populations. Similar tools do not yet exist for older adults and elder abuse. OBJECTIVE: To (1) use insights from experts to develop a tool to assist clinicians in appropriately and completely documenting physical findings in injured older adults for potential future forensic investigation of abuse or neglect and (2) to assess the feasibility of incorporating this tool into clinical practice. DESIGN: Two-phase, exploratory qualitative study. Phase 1: individual interviews with elder abuse experts from various specialties in medicine and criminal justice. Phase 2: focus groups with anticipated end users of the tool. PARTICIPANTS: Phase 1 telephone-based key informant interviews were conducted with 11 elder abuse experts (2 detectives, 3 prosecutors, 1 forensic pathologist, 2 geriatricians, and 3 emergency medicine physicians). Phase 2 focus groups were conducted among emergency medicine (n = 10) and primary care (n = 8) providers. APPROACH: Key informant interviews were conducted telephonically while the two focus groups were held in-person at an emergency medicine site in New York, NY, and a primary care site in Los Angeles, CA. KEY RESULTS: Experts agreed that medical providers' documentation of geriatric injuries is usually inadequate for investigating alleged elder abuse/neglect. They highlighted elements needed for forensic investigation: initial appearance before treatment is initiated, complete head-to-toe evaluation, documentation of all injuries (even minor ones), and documentation of pertinent negatives. Several noted the value of photographs to supplement written documentation. End users identified practical challenges to utilizing a tool, including the burden of additional or parallel documentation in a busy clinical setting, and how to integrate it into existing electronic medical records. CONCLUSION: A practical tool to improve medical documentation of geriatric injuries for potential forensic use would be valuable. Practical challenges to utilization must be overcome.

Developing an undue influence screening tool for Adult Protective Services.

The study purpose was to develop and pilot an undue influence screening tool for California's Adult Protective Services (APS) personnel based on the definition of undue influence enacted into California law January 1, 2014. Methods included four focus groups with APS providers (n = 33), piloting the preliminary tool by APS personnel (n = 15), and interviews with four elder abuse experts and two APS administrators. Social service literature-including existing undue influence models-was reviewed, as were existing screening and assessment tools. Using the information from these various sources, the California Undue Influence Screening Tool (CUIST) was developed. It can be applied to APS cases and potentially adapted for use by other professionals and for use in other states. Implementation of the tool into APS practice, policy, procedures, and training of personnel will depend on the initiative of APS management. Future work will need to address the reliability and validity of CUIST.

Protecting victims of elder financial exploitation: the role of an Elder Abuse Forensic Center in referring victims for conservatorship.

OBJECTIVES: The aim of this study was to examine the extent to which an Elder Abuse Forensic Center protects financial exploitation (FE) victims through referral to the Office of the Public Guardian (PG) for investigation and possible conservatorship (called 'guardianship' in many states). METHOD: Los Angeles County Elder Abuse Forensic Center cases involving adults aged 65 and older (April 2007-December 2009) were matched using one-to-one propensity-score matching to 33,650 usual care Adult Protective Services (APS) cases. The final analysis sample consisted of 472 FE cases. RESULTS: Compared to usual care, Forensic Center cases were more likely to be referred to the PG for investigation (30.6%, n = 72 vs. 5.9%, n = 14, p < .001). The strongest predictors of PG referral were suspected cognitive impairment, as identified by APS (odds ratio [OR] = 11.69, confidence intervals [CI]: 3.50-39.03), and Forensic Center review (OR = 7.85, CI: 3.86-15.95). Among referred cases, the court approved conservatorship at higher rates - though not statistically significant - for Forensic Center cases than usual care (52.9%, n = 36/68 vs. 41.7%, n = 5/12). CONCLUSION: Conservatorship may be a necessary last resort to improve safety for some FE victims, and the Forensic Center appears to provide a pathway to this service. These findings suggest modification to the Elder Abuse Forensic Center conceptual model and contribute to an emerging body of evidence on the role of the Forensic Center in addressing elder abuse.

Neuropsychological profiles of victims of financial elder exploitation at the los angeles county elder abuse forensic center.

The current article examines neuropsychological correlates of financial elder exploitation in a sample of older adults who have been documented victims of financial elder exploitation. The purpose of this exploratory study was twofold. First, a subsample of the referrals at the Los Angeles County Elder Abuse Forensic Center (LACEAFC) was compared to community dwelling adults in terms of the specific cognitive domains linked to financial capacity including memory, calculation, and executive functioning. Next, the correlation between presence of neuropsychological data and the likelihood of filing a case with the LA County's District Attorney office was examined. Twenty-seven LACEAFC cases and 32 controls were assessed. Overall, the forensic center group performed worse than a community-based age-matched control group on the MMSE, calculation, and executive functioning (ps < .01). The presence of neuropsychological data was significantly correlated to an increased likelihood of a case being filed.

Identifying risk of hospital readmission among Medicare aged patients: an approach using routinely collected data.

Readmission provisions in the Patient Protection and Affordable Care Act of March 2010 have created urgent fiscal accountability requirements for hospitals, dependent upon a better understanding of their specific populations, along with development of mechanisms to easily identify these at-risk patients. Readmissions are disruptive and costly to both patients and the health care system. Effectively addressing hospital readmissions among Medicare aged patients offers promising targets for resources aimed at improved quality of care for older patients. Routinely collected data, accessible via electronic medical records, were examined using logistic models of sociodemographic, clinical, and utilization factors to identify predictors among patients who required rehospitalization within 30 days. Specific comorbidities and discharge care orders in this urban, nonprofit hospital had significantly greater odds of predicting a Medicare aged patient's risk of readmission within 30 days.

Social Isolation and Nursing Leadership in Long-Term Care: Moving Forward After COVID-19.

Nursing leaders have a responsibility to promote and facilitate social engagement and connectedness to mitigate social isolation in long-term care (LTC). The COVID-19 pandemic has emphasized longstanding problems in LTC facilities, such as staff mix, workload, and support. The pandemic has shed light on the severe deleterious effect of social isolation and the critical importance of maintaining social engagement and connectedness, especially in times of crisis or major change. Staff education and ongoing support cannot be overemphasized. Critical nursing leadership and interdisciplinary collaboration engaging all team members are essential in operationalizing nonpharmacological approaches that foster the well-being of residents with dementia.

It's Time We Looked Under the Hood: An In-Depth Examination of Five Public California Area Agencies on Aging.

BACKGROUND AND OBJECTIVES: As the older adult population grows, it is important to understand the effectiveness of service delivery systems that support aging in place. Studying service delivery processes and organizational structures of Area Agencies on Aging (AAAs) is essential for future efforts to understand service delivery outcomes and innovations. RESEARCH DESIGN AND METHODS: We conducted site visits with 5 government-run California AAAs. We used a template and constant comparative analysis to analyze transcripts from site visits and focus groups with key informants. RESULTS: AAA representatives discussed how their organizational structure was related to (a) which services and programs they provided; (b) administrative cost savings and access to funding sources; (c) inter- and intra-agency coordination; and (d) visibility among clients and community partners. DISCUSSION AND IMPLICATIONS: These findings can be used to guide decisions surrounding how changes in AAA structure may affect funding, coordination, service delivery, and visibility, among other factors. Consolidating the AAA with other departments and programs facilitates coordination and shared administrative costs, yet consolidation may reduce standalone AAAs' visibility and ability to innovate. AAA structure should be tailored to fit community resources, local government organization, and the needs of older residents.

Prosecutors' Perspectives on Elder Justice Using an Elder Abuse Forensic Center.

Prosecution is a rare outcome in elder financial exploitation. Previous studies have shown that elder abuse forensic centers-multidisciplinary teams that help investigate and respond to elder mistreatment-increase prosecution rates by enhancing teamwork across agencies. Research is needed to identify what aspects of this intervention model lead to better elder justice outcomes. Six District Attorneys (DAs) were interviewed about their experiences working with other agencies at an elder abuse forensic center (the "Center") and how participating in case discussions influenced their professional perspectives on elder abuse. Transcripts were analyzed qualitatively revealing three themes: (1) "goal-driven" versus "mission-driven" professional orientations; (2) role blurring; and (3) value added from participating in the Center team. Important factors for increasing rates of prosecution were: (1) having key decision-makers present at the meeting; (2) the forensic expertise provided by the geriatrician and neuropsychologist; and (3) cross-discipline learning. Influenced by the other disciplines, DAs sought goals beyond prosecution as the default approach to resolving elder financial abuse and advocated for interventions that could best respond to the victim's needs, such as restitution or protection.

Inside the Black Box: The Case Review Process of an Elder Abuse Forensic Center.

OBJECTIVE: Preliminary evidence suggests that elder abuse forensic centers improve victim welfare by increasing necessary prosecutions and conservatorships and reducing the recurrence of protective service referrals. Center team members gather information and make decisions designed to protect clients and their assets, yet the collective process of how these case reviews are conducted remains unexamined. The purpose of this study is to present a model describing the interprofessional approach of investigation and response to financial exploitation (FE), a frequent and complex type of abuse of vulnerable adults. METHODS: To develop an understanding of the case review process at the Los Angeles County Elder Abuse Forensic Center (Center), a quasi-Delphi field study approach was used involving direct observations of meetings, surveying team members, and review from the Center's Advisory Council. The goal of this iterative analysis was to understand the case review process for suspected FE in Los Angeles County. RESULTS: A process map of key forensic center elements was developed that may be useful for replication in other settings. The process map includes: (a) multidisciplinary data collection, (b) key decisions for consideration, and (c) strategic actions utilized by an interprofessional team focused on elder justice. DISCUSSION: Elder justice relies on a complex system of providers. Elder abuse forensic centers provide a process designed to efficiently address client safety, client welfare, and protection of assets. Study findings provide a process map that may help other communities replicate an established multidisciplinary team, one experienced with justice system outcomes designed to protect FE victims.

Holding abusers accountable: an elder abuse forensic center increases criminal prosecution of financial exploitation.

PURPOSE: Despite growing awareness of elder abuse, cases are rarely prosecuted. The aim of this study was to examine the effectiveness of an elder abuse forensic center compared with usual care to increase prosecution of elder financial abuse. DESIGN AND METHODS: Using one-to-one propensity score matching, cases referred to the Los Angeles County Elder Abuse Forensic Center (the Forensic Center) between April 2007 and December 2009 for financial exploitation of adults aged 65 and older (n = 237) were matched to a population of 33,650 cases that received usual care from Adult Protective Services (APS). RESULTS: 1 Significantly, more Forensic Center cases were submitted to the District Attorney's office (DA) for review (22%, n = 51 vs. 3%, n = 7 usual care, p < .001). Among the cases submitted, charges were filed by the DA at similar rates, as was the proportion of resultant pleas and convictions. Using logistic regression, the strongest predictor of case review and ultimate filing and conviction was whether the case was presented at the Forensic Center, with 10 times greater odds of submission to the DA (Odds ratio = 11.00, confidence interval = 4.66-25.98). IMPLICATIONS: Previous studies have not demonstrated that elder abuse interventions impact outcomes; this study breaks new ground by showing that an elder abuse multidisciplinary team increases rates of prosecution for financial exploitation. The elder abuse forensic center model facilitates cooperation and group problem solving among key professionals, including APS, law enforcement, and the DA and provides additional resources such as neuropsychological testing, medical record review, and direct access to the Office of the Public Guardian.

Do we really need another meeting? Lessons from the Los Angeles County Elder Abuse Forensic Center.

PURPOSE: Elder abuse cases are often time consuming and complex, requiring interagency cooperation from a diverse array of professionals. Although multidisciplinary teams (MDTs) offer a potentially powerful approach to synergizing the efforts of different providers, there has been little research on elder abuse MDTs in general or elder abuse forensic centers in particular. This article draws on our experience with the development of an innovative elder abuse MDT model by describing the structure, process, and outcomes of the Los Angeles County Elder Abuse Forensic Center (the Center). DESIGN AND METHODS: We use a logic model to provide the framework for discussing the Center's components and de-identified client records to report key characteristics of the cases reviewed (n = 313). We summarize surveys of core team members' evaluations of team effectiveness (n = 37) and case presenters' assessments of the Center effectiveness (n = 108). RESULTS: During its first 3 years, the Center reviewed 2-4 cases per week and gained active and regular participation among core team members. Both team members' and presenters' evaluations were highly favorable. IMPLICATIONS: Process outcomes indicate that busy professionals found the model extremely valuable, with added consultation and services aiding elder abuse prevention, protection, and prosecution. The logic model offers structure, process, and outcomes with which to replicate and individualize the elder abuse forensic center model according to the needs and resources in each community.