Objectives The study evaluated the feasibility of implementing Dementia Collaborative Coaching (DCC) into the routine workflow of speech-language pathologists (SLPs) working in nursing homes (NHs). DCC is an intervention delivered by SLPs to train nursing assistants (CNAs) in communication strategies to support people living with dementia (PLWD).
This chapter examines palliative care across residential care settings with a focus on nursing homes. It reviews the environment of nursing homes, describes the residents who live there, and provides details about the interdisciplinary team providers who care for the residents. It also discusses the challenges and opportunities for delivering palliative care services to nursing home residents with life-limiting illness. Quality end-of-life care in nursing homes is important because more than 1.4 million Americans live in nursing homes, and more than half of these residents require extensive assistance with bathing, dressing, toileting, and mobility. Of those nursing home residents over 65 years of age, 80% are 75 years or older. Despite the efforts to keep frail elders in the community, the nursing home population is expected to increase as the numbers of older persons in the United States and other developed countries increase. The chapter concludes with a description of models for delivering palliative care in nursing homes.
Empirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings.PERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations.The PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.
Abstract Discussing and documenting goals of care and life-sustaining treatment decisions with seriously ill patients is a widely endorsed practice by healthcare and professional organizations. In 2018, The Veterans Health Administration (VA) initiated a new national policy to standardize such practices, the Life Sustaining Treatment Decisions Initiative (LSTDI), which included a coordinated set of evidence-based strategies and practice standards for conducting, documenting, and supporting high-quality goals of care conversations (GoCCs); staff training to enhance skills in conducting, documenting, and supporting GoCCs; standardized, durable electronic health record tools for documenting patients’ goals and preferences; and monitoring and information technology tools to support implementation and improvement. In this symposium, we will describe the first 20 months of implementing the LSTDI across the VA, the largest integrated healthcare system in the US. The first paper will focus on the factors associated with documentation of a GoCC and treatment preferences. The second paper will present findings describing facilitators and barriers to implementing the LSTDI and identifying factors that promote high rates of LSTDI documentation. The third paper examines patient level outcomes associated with a documented goal of comfort care, specifically the odds of receipt of hospice/palliative care, hospitalization, or ICU admission. This symposium will provide attendees with important information regarding a wide range of individual and system strategies to enhance the care of seriously ill older adults by engaging patients with serious illness in GoCCs and documenting their preferences for treatment in durable, easily accessible notes and orders.
Abstract Loneliness in older adulthood is responsible for poor mental and physical health, cognitive decline, and early mortality. Older adults in the LGBTQIA+ community experience additional layers of vulnerability, such as discrimination, higher rates of childlessness, health inequity, and economic disparity that place them at high risk for loneliness. The purpose of this scoping review is to explore the existing literature on loneliness in LGBTQIA+ older adults and identify knowledge gaps to inform future research recommendations. Using the Arskey & O’Malley methodological framework, our team searched PubMed, Embase, CINAHL, PsychINFO, Scopus, and Google Scholar using keywords related to older adults, sexual and gender minorities, and loneliness. We identified 61 articles from 1980 to 2022. Most of the research in this literature reflected studies using descriptive and qualitative approaches. Intervention studies were the least reported. One opinion piece is included. Initial findings highlight associations between discrimination and loneliness, poor mental health and loneliness, the challenges of HIV in older adulthood and loneliness, and loneliness experienced in caregiving and end of life in LGBTQIA+ older adults. Importantly, many studies emphasized the protective nature of strong social support and community ties against loneliness. Equally, the literature suggests that limited social support is a significant risk factor for loneliness in this population. Older gender non-binary and LGBTQIA+ people of color were underrepresented in many studies. Future research should include intervention research that targets loneliness in this population as well as studies focused on understanding loneliness more comprehensively in underrepresented LGBTQIA+ older adults.
We conducted a two center, double-blind, placebo-controlled treatment trial with oral branched chain amino acids (BCAA) (L-leucine 12 g, L-isoleucine 8 g, and L-valine 6.4 g daily) or L-threonine (4 g daily) with pyridoxal phosphate (160 mg daily) for six months in patients with amyotrophic lateral sclerosis (ALS). The effect of treatment on disease progression was estimated every two months by recording clinical muscle strength, maximum isometric muscle torque in selected muscles, forced vital capacity (FVC), activities of daily living pertaining to the upper and lower limbs, and timed tasks. Ninety-five patients were randomized to receive BCAA (n = 31), L-threonine (n = 32), or placebo (n = 32), of whom 77 (81%) completed the trial. Mean weight loss in the placebo group was 1.1 kg and in the L-threonine group was 3.2 kg; the BCAA group gained 0.2 kg (p = 0.04). The estimated decline in FVC was about 2.5 times greater in the BCAA and L-threonine groups as compared to placebo (p = 0.03). Otherwise, no significant differences were found in the changes observed in clinical, functional, timed, or maximum torque measures among treatment groups. The amino acids were well tolerated. The results of our study failed to show a beneficial effect of BCAA or L-threonine treatment for six months on the disease course in ALS. The higher rate of loss of pulmonary function in patients treated with BCAA or L-threonine may have been due to chance, but an adverse effect of these amino acids cannot be ruled out. NEUROLOGY 1996;47: 1220-1226
