Tina Sadarangani

Abstract

Older adult immigrants are often socially isolated and vulnerable to poor health. Adult day service (ADS) centers could potentially facilitate social integration and address their long-term health care needs. The current review (a) identifies barriers to and facilitators of ADS use among immigrants, (b) explores how ADS programs impact older adult immigrants’ health and well-being, and (c) isolates the most effective culturally based components of ADS programs. An integrative review was conducted using Whittemore and Knafl’s methodology. Four databases were searched. Articles were critically appraised and data were organized within an ADS-specific framework. Functional impairment, race, gender, and degree of loneliness were all predictors of ADS use. ADS enhanced immigrants’ quality of life and provided fulfillment. Transportation, bilingual nurses, peer support, and cultural activities were deemed essential by participants. ADS can provide support to older adult immigrants by adding cultural elements to existing services and using nurses as cultural liaisons. More research is needed to assess the impact of ADS on disease outcomes, including dementia, and on immigrants in multi-ethnic settings.

Abstract

Geriatric syndromes are common in hospitalized elders with heart failure (HF), but association with clinical outcomes is not well characterized. The purpose of this study (N = 289) was to assess presence of geriatric syndromes using Joint Commission-mandated measures, the Braden Scale (BS) and Morse Fall Scale (MFS), and to explore prognostic utility in hospitalized HF patients. Data extracted from the electronic medical record included sociodemographics, medications, clinical data, comorbid conditions, and the BS and MFS. The primary outcome of mortality was assessed using Social Security Death Master File. Statistical analysis included Cox proportional hazards models to assess association between BS and MFS scores and allcause mortality with adjustment for known clinical prognostic factors. Higher risk BS and MFS scores were common in hospitalized HF patients, but were not independent predictors of survival. Further study of the clinical utility of these scores and other measures of geriatric syndromes in HF is warranted.

Abstract

Purpose: To explore correlates of meeting recommended physical activity (PA) goals among middle-aged and older Korean Americans at risk for diabetes mellitus (DM). Design and Methods: PA patterns and their correlates were assessed among 292 middle-aged and older Korean Americans at risk for DM living in New York City using cross-sectional design of baseline information from a diabetes prevention intervention. PA was assessed by self-report of moderate and vigorous activity, results were stratified by age group (45-64 and 65-75 years), and bivariate analyses compared individuals performing less than sufficient PA and individuals performing sufficient PA. Logistic regression was used to calculate adjusted odds ratios predicting sufficient PA. Findings: After adjusting for sex, age group, years lived in the United States, marital status, health insurance, and body mass index (BMI), sufficient PA was associated with male sex, older age, lower BMI, eating vegetables daily, and many PA-specific questions (lack of barriers, confidence, and engagement). When stratified by age group, male sex and eating vegetables daily was no longer significant among Koreans 65 to 75 years of age, and BMI was not significant for either age group. Conclusions: PA interventions targeting this population may be beneficial and should consider the roles of sex, age, physical and social environment, motivation, and self-efficacy. Clinical Relevance: Clinical providers should understand the unique motivations for PA among Korean Americans and recognize the importance of culturally driven strategies to enable lifestyle changes and support successful aging for diverse populations.

Abstract

Objectives: The purpose of this integrative review is to: (1) identify the characteristics of family caregivers of patients with frontotemporal dementia, (2) explore the impact of providing care on family caregivers' health and well-being, and (3) identify coping strategies used by family caregivers. Background: Frontotemporal dementia is thought to be the second most common form of dementia after Alzheimer's disease. Family caregivers of patients with frontotemporal dementia face unique challenges due to its early onset, behavioral symptoms, and slow progression of decline. However, there is a dearth of research evaluating the health and wellbeing of family caregivers of patients with frontotemporal dementia. Design and data sources: An integrative review was conducted using the Whittemore and Knafl methodology. An electronic search of the literature was conducted using four electronic databases: PubMed, Embase, CINAHL, and Web of Science. The Crowe Critical Appraisal tool was used to evaluate the quality of the selected articles. Results: Findings of 11 articles informed this integrative review. Family caregivers of patients with frontotemporal dementia identify behavioral disturbances as most troubling. Spouses and female caregivers experience greater caregiver burden, distress, increased rates of depression, as well as decreased sleep related to behavior disturbances. Though less explored, providing care to those with behavioral disturbances may also impact caregiver physical health. Additionally, female caregivers are most likely to employ coping strategies, most commonly, adaptation and reframing. Effective interventions to reduce family caregiver burden are poorly understood but family caregivers suggest education and internet-based support groups are most helpful. Conclusions: Family caregivers of patients with frontotemporal dementia experience significant distress, which impacts their health and wellbeing. It is important for healthcare providers who care for patients with frontotemporal dementia to recognize the unique needs of family caregivers. Future research should focus on examining interventions and strategies to reduce caregiver burden.

Abstract

Newcomer elderly immigrants, defined as adults older than the age of 65 who have arrived in the United States in the last 10 years, represent a growing sector of the American population. Newcomers who experience limited English proficiency, financial strain, and acculturative stress are at considerable risk of developing poor health outcomes. Nursing's focus on healthy aging and aging in place has largely ignored the experiences of these older adults, who are said to be “aging out of place.” This concept analysis uses Rodgers's evolutionary method to define “aging out of place” and illustrates why existing theories of elderly migration do not necessarily apply to this population. The challenge for nurses is incorporating the family, with whom conflict may arise, into the care of these elders. Community-based strategies that enable social integration and create a greater division of labor in the care of newcomer elders are called for.

Abstract

The number of older adults emigrating to the United States is expected to quadruple by 2050. The health of immigrant older adults is complicated by the limited options for low-cost health insurance available to this population. Welfare reform has limited new immigrants' access to public assistance programs, such as Medicaid; and low-cost private insurance options rarely exist for individuals older than 65, even with the passage of the Patient Protection and Aff ordable Care Act (PPACA). Uninsured immigrant older adults have been found to forgo preventive care due to cost and are among the leading users of emergency departments for preventable complications of chronic disease, primarily cardiovascular disease (CVD). A review of the literature found that insurance coverage has a signifi cant impact on CVD risk among immigrant older adults. The current article discusses the implications of welfare reform initiatives and the shortcomings of the PPACA in addressing the health care needs of immigrant older adults.

Abstract

Objective. To evaluate the usefulness of the Frailty Index (FI) as a prognostic indicator of adverse outcomes in geriatric trauma patients,. Design. Prospective cohort study. Setting and participants. Geriatric (aged 65 and over) trauma patients admitted to inpatient units at a Level 1 trauma center in Arizona were enrolled. Patients were excluded if they were intubated/nonresponsive with no family members present or transferred from another institution (eg, skilled nursing facility). The following categories of data were collected: (a) patient demographics, (b) type and mechanism of injury, (c) vital signs (eg, Glasgow coma scale score, systolic blood pressure, heart rate, body temperature), (d) need for operative intervention, (e) in-hospital complications, (f) hospital and intensive care unit (ICU) lengths of stay, and (g) discharge disposition. Patients or, in the case of nonresponsive patients, their closest relative, responded to the 50-item Frailty Index questionnaire, which includes questions regarding age, comorbid conditions, medications, activities of daily living (ADLs), social activities, mood, and nutrition. FI score ranges from 0 (non-frail) to 1 (frail), with an FI of 0.25 or more indicative of frailty based on established guidelines. Patients were categorized as frail or non-frail according to their FI scores and were followed during the course of their hospitalization. Main outcome measure. The primary outcome measure was in-hospital complications. In-hospital complications included myocardial infarction, cardiopulmonary arrest, pneumonia, pulmonary embolism, sepsis, urinary tract infection, deep venous thrombosis, disseminated intravascular coagulation, renal insufficiency, and reoperation. The secondary outcome measure was adverse discharge disposition, which was defined as death during the course of hospitalization or discharge to a skilled nursing facility. Main results. The sample consisted of 250 patients with a mean age of 77.9 years. Among these, 44.0% were considered frail. Patients with frailty were more likely to have a higher Injury Severity Score (P = 0.04) and a higher mean FI (P = 0.01) than those without frailty. There were no statistically significant differences with respect to age (P = 0.21), mechanism of injury (P = 0.09), systolic blood pressure (P = 0.30), or Glasgow Coma Scale score (P = 0.91) between the groups. Patients with frailty were more likely to develop in-hospital complications (37.3% vs 21.4%, P = 0.001) than those without frailty. Among these complications, pneumonia and urinary tract infection were the most common. There were no differences in the rate of reoperation (P = 0.54) between the 2 groups. An FI of 0.25 or higher was associated with the development of in-hospital complications (P = 0.001) even after adjusting for age, systolic blood pressure, heart rate, and Injury Severity Score. Frail patients had longer hospital length of stay (P = 0.01) and ICU length of stay (P = 0.01), and were more likely to have adverse discharge disposition (37.3% vs. 12.9%, P = 0.001). All patients who died during the course of hospitalization (n = 5) were considered frail. Frailty was also found to be a predictor of adverse discharge disposition (P = 0.001) after adjustment for age, male sex, Injury Severity Score, and mechanism of injury. Conclusion. The FI is effective in identifying geriatric trauma patients, who are vulnerable to poor health outcomes.

Abstract

Objective. To evaluate the effectiveness of a collaborative telecare intervention on chronic pain management. Design. Randomized clinical trial. Settings and participants. Participants were recruited over a 2-year period from 5 primary care clinics within a single Veterans Affairs medical center. Patients aged 18 to 65 years were eligible if they had chronic (≥3 months) musculoskeletal pain of at least moderate intensity (Brief Pain Inventory [BPI] score ≥5). Patients were excluded if they had a pending disability claim or a diagnosis of bipolar disorder, schizophrenia, moderately severe cognitive impairment, active suicidal ideation, current illicit drug use or a terminal illness or received primary care outside of the VA. Participants were randomized to either the telephone-delivered collaborative care management intervention group or usual care. Usual care was defined as continuing to receive care from their primary care provider for management of chronic, musculoskeletal pain. Intervention. The telecare intervention comprised automated symptom monitoring (ASM) and optimized analgesic management through an algorithm-guided stepped care approach delivered by a nurse case manager. ASM was delivered either by an interactive voice-recorded telephone call (51%) or by internet (49%), set according to patient preference. Intervention calls occurred at 1 and 3 months. Additional contact with participants from the intervention group was generated in response to ASM trend reports. Main outcome measures. The primary outcome was the BPI total score. The BPI scale ranges from 0 to 10, with higher scores indicating worsening pain. A 1-point change is considered clinically important. Secondary pain outcomes included BPI interference and severity, global pain improvement, treatment satisfaction, and use of opioids and other analgesics. Patients were interviewed at 1, 3, 6, and 12 months. Main results. A total of 250 participants were enrolled, 124 assigned to the intervention group and 126 assigned to usual care. The mean (SD) baseline BPI scores were 5.31 (1.81) for the intervention group and 5.12 (1.80) for usual care. Compared with usual care, the intervention group had a 1.02-point lower BPI score at 12 months (95% confidence interval [CI], -1.58 to -0.47) (P < 0.001). Patients in the intervention group were nearly twice as likely to report at least a 30% improvement in their pain score by 12 months (51.7% vs. 27.1%; relative risk [RR], 1.9 [95% CI, 1.4 to 2.7]), with a number needed to treat of 4.1 (95% CI, 3.0 to 6.4) for a 30% improvement. Patients in the intervention group were more likely to rate as good to excellent the medication prescribed for their pain (73.9% vs 50.9%; RR, 1.5 [95% CI, 1.2 to 1.8]). Patients in the usual care group were more likely to experience worsening of pain by 6 months compared with the intervention group. A greater number of analgesics were prescribed to patients in the intervention group; however, opioid use between groups did not differ at baseline or at any point during the trial period. For the secondary outcomes, the intervention group reported greater improvement in depression compared with the usual care group, and this difference was statistically significant (P < 0.001). They also reported fewer days of disability (P = 0.34). Conclusion. Telecare collaborative management was more effective in improving chronic pain outcomes than usual care. This was accomplished through the optimization of non-opioid analgesic therapy facilitated by a stepped care algorithm and automated symptom monitoring.

Abstract

Objective. To investigate the feasibility and effectiveness of administering diabetes self-management support (DSMS) via telephone or secure messaging. Design. Prospective, longitudinal quasi-experimental study. Setting and participants. Participants (n = 150) who had previously completed diabetes self-management education (DSME) received follow-up DSMS in 1 of 3 selfselected ways: a one-time in-person visit, 3 brief visits by telephone, or via secure messaging via the electronic health record. The (usual care) in-person group (n = 47) received 1 follow-up appointment at the patient's request with a certified diabetes educator (CDE) within 3 to 6 months of DSME completion. The telephone group (n = 44) was given follow-up phone appointments with a CDE, each lasting approximately 20 minutes, at 3, 6, and 9 months post-DSME. The secure message group (n = 59) received follow-up messages via the patient portal from a CDE at 3, 6, and 9 months post-DSME. At each interval, patients received 3 messages, an initial one followed by 2 structured replies. Motivational interviewing techniques were used in all 3 groups to identify barriers to achieving behavior goals and solutions. Main outcome measures. Behavior goal measures, feasibility measures, and physiologic measures at 9 months' post DSME. Behavior goal achievement was measured using a survey that asked patients to rate their achievement regarding the following AADE7 goals: healthy eating, being active, self-monitoring, taking medications, problem solving, reducing risks, and healthy coping. Goals are rated on a scale from 0 to 10, with a rating ≥ 7 considered successful completion. Feasibility to integrate this technology into a DSME platform was assessed by comparing the number of attempts to contact patients with the number of contacts achieved; also calculated was intervention completion, mean time spent with the CDE, and total cost of each visit. Physiologic measures included HbA1C and LDL levels collected through medical record review. Results. There were no statistically significant differences between groups with respect to any of the primary outcomes. Behavioral goals were achieved by 59% of the in-person group, 73% of the telephone group, and 77% of the secure message group . Mean goal achievement for all 3 groups combined improved from 6.2 ± 2.4 to 7.2 ± 1.8 (P < 0.05). Overall, 70.3% ± 0.46% achieved behavioral goals, with no difference among groups. In terms of feasibility, at 3 months the contact success rate was 39%, 46%, and 29% in the in-person, telephone, and secure message groups, respectively. At 6 months, the contact success rate was 47% in the phone group versus 32% in the secure message group. At 9 months, the contact success rate was 35% in the phone group versus 21% in the secure message group. Sixty-two participants (41%) completed the intervention per protocol: 51% of in-person patients, 47% of phone patients, and 28% of secure message patients (P < 0.02). Visits lasted and cost, on average, 60 minutes and $50.00, 45.3 minutes and $37.75, and 17.8 minutes (P < 0.05) and $14.83 for the in-person, telephone, and secure message groups, respectively. There was no difference in HbA1c among groups. Overall, HbA1c decreased by -0.88% ± 1.63 (P < 0.05) from baseline to 9 months. Change in LDL was not significant, and neither were there statistical differences among groups. Conclusion. Diabetes follow-up care delivered via telephone and secure messaging is feasible. Using either of these methods results in similar outcomes compared with the traditional in-person visit, while requiring less staff time.