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Open Access Publications from the University of California

Scholarly Works (24 results)

  • Article
  • Peer Reviewed
UC San Francisco Previously Published Works (2020)
Older adults use the Emergency Department (ED) more than any other age group besides infants. Despite high utilization, both the physical environment and care processes in the traditional ED are poorly suited to address the complex needs of older adults. As a result, older adults often experience poor outcomes in the ED. Geriatric nursing has been at the forefront of efforts to develop Geriatric Emergency Department Interventions (GEDI's) to try to address these deficits and improve care. As frontline providers with frequent patient contact, nursing brings critical viewpoints to these issues. This article provides some resources and other ideas for how frontline nurses can improve care for older adults in the ED. Ultimately, to have meaningful impacts on care of older adults in the ED, there is a dire need for greater financial investment specific to geriatric nursing education, training, and research in the ED.
    Cover page: Improving care for older adults in the Emergency Department warrants greater investment in geriatric nursing—Stat!
    • Thesis
    • Peer Reviewed
    UC San Francisco Electronic Theses and Dissertations (2018)

    Background and objectives: The National Plan to Address Alzheimer’s Disease has identified enhancing care quality and efficiency for older adults with dementia as a major priority. One way to achieve this goal is to reduce potentially avoidable Emergency Department (ED) visits. Although the majority of older adults with dementia live in the community---not nursing homes—there is limited research on the rates, reasons, and risk factors for ED use by community-dwelling older adults with dementia. Pain, which has been shown to increase risk of ED use in other groups, may be one risk factor. This dissertation examines ED use, pain, and the relationship between pain and ED use in community-dwelling older adults with dementia.

    Methods: This dissertation is comprised of three separate studies. The first study is an integrative review of the literature with a focus on rates, reasons, and risk factors for ED use in community-dwelling older adults with dementia. The second study is a cross-sectional analysis of prevalence of and risk factors for pain in community-dwelling older adults with dementia using data from the National Health and Aging Trends Study (NHATS). The third study leverages data from the NHATS mortality follow-back interview linked to Medicare claims data on healthcare use to investigate pain and ED use in the last month of life.

    Results: Results from the integrative review indicate that community-dwelling older adults with dementia have higher rates of ED visits compared to those without dementia (adjusted risk or odds ratios 1.3-1.8, p<0.05 in 12 of 13 studies), although differences were attenuated in the last year of life. Increased symptoms, disability, and poor care coordination were associated with increased ED use. More than six out of 10 community-dwelling older adults with dementia reported bothersome pain, and four out of 10 reported pain severe enough to limit activities. Risk factors for pain include arthritis, low energy and other physical symptoms, psychological symptoms, and other comorbidities such as heart and lung disease. The majority (56%) of decedents had an ED visit in the last month of life. Estimates suggest decedents with unmet need for pain management had ED visit rates that were 50% higher than those without unmet need for pain management (Adjusted Incident Rate Ration 1.51, 95% Confidence Interval 1.10-2.07).

    Discussion and Conclusion: Community-dwelling older adults with dementia are at high-risk of pain and frequent visits to the ED. Findings suggest that unmet need for pain management increases rates of ED use in the last month of life. Interventions to address pain may lower ED use in this vulnerable group.

      Cover page: Pain and Emergency Department Use in Community-Dwelling Older Adults with Dementia
      • Article
      • Peer Reviewed
      UC San Francisco Previously Published Works (2016)
      The quality of cancer care may be compromised in the near future because of work force issues. Several factors will impact the oncology health provider work force: an aging population, an increase in the number of cancer survivors, and expansion of health care coverage for the previously uninsured. Between October 2014 and March 2015, an electronic literature search of English language articles was conducted using PubMed(®) , the Cumulative Index to Nursing and Allied Health Sciences (CINAHL(®) ), Web of Science, Journal Storage (JSTOR(®) ), Google Scholar, and SCOPUS(®) . Using the scoping review criteria, the research question was identified "How much care in oncology is provided by nurse practitioners (NPs)?" Key search terms were kept broad and included: "NP" AND "oncology" AND "workforce". The literature was searched between 2005 and 2015, using the inclusion and exclusion criteria, 29 studies were identified, further review resulted in 10 relevant studies that met all criteria. Results demonstrated that NPs are utilized in both inpatient and outpatient settings, across all malignancy types and in a variety of roles. Academic institutions were strongly represented in all relevant studies, a finding that may reflect the Accreditation Council for Graduate Medical Education (ACGME) duty work hour limitations. There was no pattern associated with state scope of practice and NP representation in this scoping review. Many of the studies reviewed relied on subjective information, or represented a very small number of NPs. There is an obvious need for an objective analysis of the amount of care provided by oncology NPs.
        Cover page: A scoping review of the nurse practitioner workforce in oncology
        • Article
        • Peer Reviewed
        UC San Francisco Previously Published Works (2022)
        CONTEXT: Little is known about racial differences in place of death for persons with dementia (PWD), who may be especially vulnerable to receiving care at end of life that is not concordant with their goals or that places higher burden on caregivers. OBJECTIVES: To determine if there are racial and ethnic differences in place of death among PWD. METHODS: We analyzed data from the nationally representative National Health and Aging Trends study. Participants were included if they had probable dementia as defined by a previously validated algorithm and died between 2012 and 2020. Race and ethnicity were self-reported. Place of death was obtained from post-mortem interviews with bereaved caregivers. RESULTS: The sample included 993 decedents with dementia (81.4% white; 11.0% black, 7.6% hispanic). A higher percentage of black and hispanic decedents died in the hospital (30.3% and 32.8%, respectively) compared to white decedents (19.0%). A higher percentage of white decedents died in the nursing home (31.0%) than black (22.4%) or hispanic decedents (15.0%) In adjusted analyses, black decedents had a higher odds of hospital death (AOR 1.50; 95% CI 1.01, 2.24) compared to white decedents, with similar trends found for hispanic decedents. CONCLUSION: We found racial and ethnic differences in location of death for PWD, with black and hispanic PWD more likely to die in the hospital compared to white PWD. More research is needed to determine if the differences found represent goal concordant care or rather lack of access to high quality of care at the end of life.
          Cover page: The Association Between Race and Place of Death Among Persons With Dementia.
          • Article
          • Peer Reviewed
          UC San Francisco Previously Published Works (2023)
          BACKGROUND: The Medicare Hospice Benefit increasingly serves people dying with dementia. We sought to understand characteristics, hospice use patterns, and last-month-of-life care quality ratings among hospice enrollees with dementia coexisting with another terminal illness as compared to enrollees with a principal hospice diagnosis of dementia, and enrollees with no dementia. METHODS: We conducted a pooled cross-sectional study among decedent Medicare beneficiaries age 70+ using longitudinal data from the National Health and Aging Trends Study (NHATS) (last interview before death; after-death proxy interview) linked to Medicare hospice claims (2011-2017). We used unadjusted and adjusted regression analyses to compare characteristics of hospice enrollees with coexisting dementia to two groups: (1) enrollees with a principal dementia diagnosis, and (2) enrollees with no dementia. RESULTS: Among 1105 decedent hospice enrollees age 70+, 40% had coexisting dementia, 16% had a principal diagnosis of dementia, and 44% had no dementia. In adjusted analyses, enrollees with coexisting dementia had high rates of needing help with 3-6 activities of daily living, similar to enrollees with principal dementia (62% vs. 67%). Enrollees with coexisting dementia had high clinical needs, similar to those with no dementia, for example, 63% versus 61% had bothersome pain. Care quality was worse for enrollees with coexisting dementia versus principal dementia (e.g., 61% vs. 79% had anxiety/sadness managed) and similar to those with no dementia. Enrollees with coexisting dementia had similar hospice use patterns as those with principal diagnoses and higher rates of problematic use patterns compared to those with no dementia (e.g., 16% vs. 10% live disenrollment, p = 0.004). CONCLUSIONS: People with coexisting dementia have functional needs comparable to enrollees with principal diagnoses of dementia, and clinical needs comparable to enrollees with no dementia. Changes to hospice care models and policy may be needed to ensure appropriate dementia care.
            Cover page: Functional and clinical needs of older hospice enrollees with coexisting dementia.
            • Article
            • Peer Reviewed
            UC San Francisco Previously Published Works (2021)

            Introduction

            While the need for palliative care for people living with dementia has widely been recognised, they continue to be a disadvantaged group when it comes to timely initiation, and controversies remain regarding appropriate timing, or what elements constitute high quality palliative care early in the disease trajectory. To date, no literature review has summarised this debate or offered insights. The aim of this scoping review is to provide a general overview of research regarding palliative care in mild or moderate dementia, to identify existing controversies, and to examine what are key components of palliative care in dementia, specifically when initiated earlier in the disease trajectory.

            Methods and analysis

            Consistent with recent guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, we carried out a search for academic literature in PubMed, CINAHL, EMBASE, Cochrane Library, PsycINFO, Web of Science; on 5 November 2019 and an updated search on 2 February 2021. We will include studies with different study designs published in English over the last decade that focused on palliative care in early stages of dementia. We will include models targeting at least one outcome domain of palliative care (physical, psychological, social or spiritual) and advance care planning, and will exclude hospice models with limited prognosis similar to the requirements in the USA. We will report study characteristics and quality. We aim to apply narrative synthesis techniques to develop a theoretical model of how, for whom and why palliative care can be relevant in early stages of dementia, and what are facilitators and barriers. We anticipate to also describe if and how the concept of (early) palliative care in dementia changed across time and studies.

            Ethics and dissemination

            No ethical review required. Results will identify research gaps and lay out basic principles for conceptualising palliative care in early stages of dementia.
              • Article
              • Peer Reviewed
              UC San Francisco Previously Published Works (2021)

              Background/objective

              Guidelines recommend less intensive glycemic treatment and less frequent glucose monitoring for nursing home (NH) residents. However, little is known about the frequency of fingerstick (FS) glucose monitoring in this population. Our objective was to examine the frequency of FS glucose monitoring in Veterans Affairs (VA) NH residents with diabetes mellitus, type II (T2DM).

              Design and setting

              National retrospective cohort study in 140 VA NHs.

              Participants

              NH residents with T2DM and older than 65 years admitted to VA NHs between 2013 and 2015 following discharge from a VA hospital.

              Measurements

              NH residents were classified into five groups based on their highest hypoglycemia risk glucose-lowering medication (GLM) each day: no GLMs; metformin only; sulfonylureas; long-acting insulin; and any short-acting insulin. Our outcome was a daily count of FS measurements.

              Results

              Among 17,474 VA NH residents, mean age was 76 (standard deviation (SD) = 8) years and mean hemoglobin A1c was 7.6% (SD = 1.5%). On day 1 after NH admission, 49% of NH residents were on short-acting insulin, decreasing slightly to 43% at day 90. Overall, NH residents had an average of 1.9 (95% confidence interval (CI) = 1.8-1.9) FS measurements on NH day 1, decreasing to 1.4 (95% CI = 1.3-1.4) by day 90. NH residents on short-acting insulin had the most frequent FS measurements, with 3.0 measurements (95% CI = 2.9-3.0) on day 1, decreasing to 2.6 measurements (95% CI = 2.5-2.7) by day 90. Less frequent FS measurements were seen for NH residents receiving long-acting insulin (2.1 (95% CI = 2.0-2.2) on day 1) and sulfonylureas (1.7 (95% CI = 1.5-1.8) on day 1). Even NH residents on metformin monotherapy had 1.1 (95% CI = 1.1-1.2) measurements on day 1, decreasing to 0.5 (95% CI = 0.4-0.6) measurements on day 90.

              Conclusion

              Although guidelines recommend less frequent glucose monitoring for NH residents, we found that many VA NH residents receive frequent FS monitoring. Given the uncertain benefits and potential for substantial patient burdens and harms, our results suggest decreasing FS monitoring may be warranted for many low hypoglycemia risk NH residents.
                Cover page: Fingerstick Glucose Monitoring in Veterans Affairs Nursing Home Residents with Diabetes Mellitus
                • Article
                • Peer Reviewed
                UC San Francisco Previously Published Works (2020)

                Background

                Nearly 70% of nursing home residents are eligible for palliative care, yet few receive formal palliative care outside of hospice. Little is known about nursing home staff attitudes, knowledge, skills, and behaviors related to palliative care.

                Methods

                We administered a modified survey measuring attitudes toward death to 146 nursing home staff members, including both clinical and nonclinical staff, from 14 nursing homes.

                Results

                Nursing home staff generally reported feeling comfortable caring for the dying, but half believed the end of life is a time of great suffering. Pain control (63%), loneliness (52%), and depression (48%) were the most important issues identified with regard to these patients, and there was ambivalence about the use of strong pain medications and the utility of feeding tubes at the end of life. Top priorities identified for improving palliative care included greater family involvement (43%), education and training in pain control (50%) and in management of other symptoms (37%), and use of a palliative care team (35%) at their facility.

                Conclusions

                Findings show there is a need for more palliative care training and education, which should be built on current staff knowledge, skills, and attitudes toward palliative care.
                  Cover page: Original Research: Understanding Nursing Home Staff Attitudes Toward Death and Dying: A Survey.
                  • Article
                  • Peer Reviewed
                  UC San Francisco Previously Published Works (2021)

                  Background and objectives

                  Transitioning to a nursing home (NH) is a major life event for 1.4 million NH residents in the United States. Most post-acute NH admissions plan for rehabilitation and discharge home, but with nearly 70% of NH residents being palliative care (PC) eligible, many evolve into long-term placements secondary to poor health and associated decline in function and/or cognition. This article describes the perceptions of NH PC-eligible residents and families transitioning to life in a NH.

                  Methods

                  Residents at 3 NHs in Northern California (N = 228) were screened for PC eligibility. A convenience sample of PC-eligible residents and their family members (n = 28) participated in qualitative interviews that explored the experience of living as a NH resident with serious illness. Data were analyzed using grounded theory methodology.

                  Results

                  Our study provides insights into the experiences of transitioning to a NH from the perspectives of PC-eligible residents and their families. These data describe how PC-eligible residents and their families experienced disempowerment as they perceived being left out of decisions to go to a NH, loss of autonomy once at the NH, dealt with the realization that they would not be going home, and described perceived barriers to going home.

                  Discussion and implications

                  The inclusive and person-centered model of care that PC provides naturally empowers residents and family members. Adequate provision of PC services, together with changes in policy related to NH culture and benefit management, could improve the experience of transitioning to a nursing home.
                    Cover page: Transitioning to Life in a Nursing Home: The Potential Role of Palliative Care
                    • Article
                    • Peer Reviewed
                    UC San Francisco Previously Published Works (2022)
                    The Medicare hospice benefit was originally designed around a cancer disease paradigm but increasingly serves people living with dementia. At this time, almost half of all older adults receiving hospice care have dementia. Yet there is minimal evidence as to whether hospice benefits people living with dementia outside of nursing facilities. We asked whether and how the perceived quality of last-month-of-life care differed between people with and without dementia and whether hospice use among people living with dementia was associated with perceived quality of care compared with the quality of care for those who did not use hospice. We used nationally representative data from the National Health and Aging Trends Study and Medicare claims from the period 2011-17 to examine the impact of hospice enrollment on proxy perceptions of last-month-of-life care quality. Proxies of people living with dementia enrolled in hospice compared with proxies of those not enrolled more often reported care to be excellent (predicted probability: 52 percent versus 41 percent), more often reported having anxiety or sadness managed (67 percent versus 46 percent), and less often reported changes in care settings in the last three days of life (10 percent versus 25 percent). There were no differences in the impact of hospice on proxy ratings of care for people with and without dementia. Policy makers should consider these benefits when weighing changes to hospice policy and regulations that may affect people living with dementia.
                      Cover page: Hospice Improves Care Quality For Older Adults With Dementia In Their Last Month Of Life
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