Prevalence of the Use of Advance Directives among Residents of an Academic Long-Term Care Facility

Gayatri Gupta, MD, Assistant Professor of Medicine, Department of Medicine, Division of Geriatrics, New York Medical College, Valhalla, NY, USA.
Wilbert S. Aronow, MD, AGSF, FGSA, Clinical Professor of Medicine, Department of Medicine, Divisions of Geriatrics, Cardiology, and Pulmonary/Critical Care, New York Medical College, Valhalla, NY, USA.

Of 2,780 persons admitted to a long-term care (LTC) facility in the first half of 1993 and followed up in the facility through the end of 1994, 435 (16%) had advance directives and 805 (29%) had do not resuscitate orders either at admission to or subsequently while in the LTC facility. In contrast, 50 of 57 LTC residents (88%) in six Maryland community LTC facilities had either completed an advance directive or had another person complete one on their behalf. The physicians caring for the residents in an academic LTC facility affiliated with Westchester Medical Center/New York Medical College are members of the Geriatric faculty at New York Medical College and have been taught on numerous occasions to obtain advance directives for all residents admitted to the LTC facility. This article reports the prevalence of the use of advance directives among all residents currently residing in an academic LTC facility.
Key words: advance directives, long-term care facility, do not resuscitate orders, health care proxy, legal guardian.

A Study of Falls in Long-Term Care and the Role of Physicians in Multidisciplinary Evidence-Based Prevention

Victoria J. Scott, PhD, RN, Clinical Assistant Professor, School of Population and Public Health; Senior Advisor, Falls & Injury Prevention, BC Injury Research & Prevention Unit and Ministry of Healthy Living and Sport, Victoria, BC.
S. Johnson, PhD, Professor, Faculty of Kinesiology and Health Studies, University of Regina, SK.
J.F. Kozak, PhD, Assistant Professor, School of Population and Public Health, University of British Columbia; Director of Research Centre for Healthy Aging, Providence Health, Vancouver, BC.
Elaine M. Gallagher, PhD, RN, Professor, School of Nursing; Director, Centre on Aging,
University of Victoria, Victoria, BC.

Approximately one in two older adults living in long-term care (LTC) settings sustains a fall every year, resulting in significant human suffering and treatment costs. The complex set of factors that contribute to fall risk among this population demands a multidisciplinary approach to this problem, with physicians playing a pivotal role in risk assessment, prevention, and management. We describe a study where facility personnel from five LTC sites were trained in the use of a standardized surveillance tool to track falls, fall injuries, and contributing factors over 16-months. Using a pre-/post-test design, interventions included a multidisciplinary, evidence-based approach to fall risk assessment and monitoring, environmental modifications, exercise, and education strategies. Interventions by a multidisciplinary team, including physicians, were successful in reducing fall-related injuries and relatively successful in reducing the rate of falls among LTC residents. Further study is needed over a longer period of time, using a randomized control trial, to determine the effectiveness of specific interventions and to generalize findings to the larger population of LTC residents.
Key words: fall prevention, long-term care, multidisciplinary approach, older adults.

Critical Appraisal of Articles on Preventive Health Care

Christopher Patterson, MD, FRCPC, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON.
John W. Feightner, MD, MSc, FCFP, Chair, Canadian Task Force on Preventive Health Care; Department of Family Medicine, Faculty of Medicine, University of Western Ontario, London, ON.

The ultimate aim of critical appraisal is to decide whether the conclusions of an article are helpful in the prevention or management of illness in your patients. This requires the article to be relevant to your practice and to contain sufficient information to determine if the conclusions are supported by the evidence within it. We offer approaches to the appraisal of different types of publications addressing primary and secondary prevention.
Key words: prevention (primary, secondary), clinical research, critical appraisal, clinical practice guidelines.

Vaccines for Older Adults

Mazen S. Bader, MD, FRCPC, MPH, Department of Medicine, Division of Infectious Diseases, Memorial University of Newfoundland and Labrador, St. John’s, NL.
Daniel Hinthorn, MD, FACP, Department of Medicine, Division of Infectious Diseases, University of Kansas Medical Center, Kansas City, KS, USA.

Preventive health interventions are key to maintaining the health and good function of older adults. Despite being safe and a highly effective method of preventing certain infectious diseases, vaccination rates among older adults continue to lag behind national goals. Vaccines for older adults can be divided into three categories: those that are required for all older adults, those that may be required for special circumstances, and those that are required for travel. Physicians should be familiar with the indications, contraindications, and adverse effects of commonly used vaccines among older adults. This article will focus only on the vaccines required for all older adults.
Key words: vaccines, older adults, influenza, pneumococcal vaccine, herpes zoster, tetanus.

An Ounce of Prevention

Who could argue against prevention? It is clearly better not to become sick or disabled. In caring for older adults, there is still scope for preventive medicine, and the concept of delaying disease and/or disability in older adults is of great importance. In fact, modern medicine and public health advances have already resulted in a delay in the time of death: life expectancy has dramatically increased over the last 100 years. Perhaps of even more importance is the fact that age-related disability levels have also declined dramatically. Older adults are fitter and more capable at advanced ages than were prior cohorts of older people. However, as long as mortality remains with us, there is almost certainly going to be a period of decline and disability for some people. This concept of the ragged fringe is clearly articulated in Theodore Roszak’s book America the Wise: Longevity and the Culture of Compassion, published in 1998 by Houghton Mifflin Company. (Roszak, an historian, is perhaps better known for his earlier, youth-oriented, book The Making of a Counter Culture.) There will still be a need for caregivers for frail older adults for the foreseeable future.

Preventive services are usually provided on a large scale to many people; therefore, if the intervention is ineffective, there is the potential for great economic and even health-related harm. The article “Critical Appraisal of Articles on Preventive Health Care” by Dr. Christopher Patterson and Dr. John W. Feightner is particularly important so that we can uphold that important principle primum non nocere. One of the most cost-effective advances in medicine has been the use of vaccines. Our CME article this month is on the topic of “Vaccines for Older Adults” by Dr. Mazen Bader and Dr. Daniel Hinthorn. Even among frail institutionalized older adults, there is still scope for preventive services, as discussed in the article “A Study of Falls in Long-Term Care and the Role of Physicians in Multidisciplinary Evidence-Based Prevention” by Dr. Victoria Scott, Dr. Shanthi Johnson, Dr. J.F. Kozak, and Dr. Elaine Gallagher. Our cardiovascular column this month also has relevance to prevention. It is possible that improving environmental pollution can prevent or delay the symptoms of cardiac disease as discussed in the article “Smog Alert: Air Pollution and Heart Disease in Older Adults” by Dr. Bailus Walker Jr. and Dr. Charles Mouton.

As usual we have a collection of other articles on important geriatric topics. Dr. Michael Gordon and Kayi Li describe an innovative program in their article “POWER in Osteoporosis: Descriptive Review of a Multidisciplinary, Community-Based Prevention and Management Program.” As new dementia medications become available, it will become increasingly important for primary care physicians to diagnose dementia at an early stage. A new method to achieve this goal is reviewed in the article “Screening for Early Dementia in Primary Care” by Dr. Ellen Grober. Finally, I am thrilled to welcome an article by a new colleague of mine, Dr. M. Bachir Tazkarji, a family physician with a geriatric fellowship, whom we lured away from the United States. His article is titled “Abdominal Pain among Older Adults.”

Enjoy this month’s issue.
Barry Goldlist

Nutritional Guidelines in Canada and the US: Differences between Younger and Older Adults

Joan Pleuss, RD, MS, CDE, CD, Director, Bionutrion & Body Composition Units, Clinical & Translational Research Institute, Medical College of Wisconsin, Milwaukee, WI.

The requirement for some nutrients changes as adults age. The Dietary Reference Intakes, the 2007 Canada Food Guide, and the 2005 Dietary Guidelines for Americans (MyPyramid.gov) provide guidance for the consumer and the professional for nutritional needs throughout the life span. The Guidelines provide recommendations in user-friendly messages. MyPyramid.gov and the Food Guide allow the public to access information on the internet that is individualized for age, gender, and physical activity. The Dietary Reference Intakes provide the health professional with nutrition requirements for gender and specific age groupings through the entire lifespan. This article will address those nutrients whose requirements significantly change with adult aging.
Key words: Dietary Reference Intakes, Canada Food Guide, Dietary Guidelines of America, MyPyramid, aging, nutrition.

The Seniors Wellness Clinic: An Interprofessional Health Promotion and Disease Prevention Care Model

Lina Medeiros, MSW, Social Worker, University Health Network - Toronto Western Hospital, Toronto, ON.
Debbie Kwan, MSc, Assistant Professor, University of Toronto; Pharmacist, University Health Network - Toronto Western Hospital, Toronto, ON.
Carol Banez, MAN, Clinical Nurse Specialist, University Health Network - Toronto Western Hospital, Toronto, ON.
Beatrise Poroger-Edelstein, MHSc, Manager of Elder Care, North York General Hospital, Toronto, ON.
Kitty Mak, BHthSc, Nurse, University Health Network - Toronto Western Hospital, Toronto, ON.
Keegan K. Barker, MEd, PhD(c), University of Toronto, Toronto, ON.
Rory Agellon, BSc, Dietitian (Retired), University Health Network - Toronto Western Hospital, Toronto, ON.

In light of the aging population trend and the complex needs of the aging population, there is an increasing impetus to develop innovative service delivery models that focus on health promotion and disease prevention and management, are easily accessible for older adults of diverse ethnic backgrounds, are community-oriented, and incorporate an interprofessional team approach.
This article describes the development, implementation, and evaluation of the Seniors Wellness Clinic, an innovative health promotion model of care for older adults focusing on primary and secondary disease prevention and disease management.
Key words: health services for the aged, multidisciplinary care team, program development, health promotion.

Discussing End-of-Life Care with Older Patients: What Are You Waiting For?

Mary Anne Huggins, MD, CCFP, DABHPC, Palliative Care Services, Toronto General Hospital, University Health Network; Assistant Professor, Department of Family and Community Medicine, University of Toronto, Toronto, ON.
Laura Brooks, BScN, MScN, ACNP, Palliative Care Services, Toronto General Hospital, University Health Network, Toronto, ON.

Discussing end-of-life care with older patients is very important, as it ensures their preferences are known and they retain control over their care decisions even when they may no longer be actively involved in them. Unfortunately, these discussions do not always occur, and when they do occur, they are not always done well. There are patient and physician barriers to advanced care planning. Physicians may lack the skills necessary to accomplish the task of making decisions for future care. In this article we discuss advanced care planning, its importance as well as related challenges and barriers. We then outline a practical approach to advanced care planning for older adults.
Key words: end-of-life care, advance directives, advanced care planning, living wills, substitute decision-maker.

Aging in Africa

Irene Turpie, MB, ChB, MSc, FRCP(C), FRCP (Glas), Professor Emeritus, McMaster University, Hamilton, Ontario.
Leigh Hunsinger, BA, Medical Student, McMaster University, Hamilton, Ontario.

Africa, with its many countries and ethnic groups, has a population of 800 million people and the highest rate of growth of the older adult population in the world. Urbanization and the HIV/AIDS epidemic are changing the traditional role of older adults. The epidemiological transition from acute infections to chronic diseases is occurring more slowly in Africa than in other continents but it is occurring. Many older persons are malnourished and live in poverty. Hypertension, stroke, osteoarthritis, chronic respiratory and mood disorders are expected to increase in incidence and are increasingly being identified in a continent without the resources or infrastructure as yet to mount preventive campaigns and to treat chronic health conditions. What is known about many older Africans is that they have the capacity to age well through daily exercise and healthy diets low in processed sugar and saturated fats. Aging Africans are generally regarded with respect and dignity. There is much that needs to be done to prevent deleterious aging outcomes for older adults in that continent and there is much we can learn about healthy aging and lifestyle prevention.
Key words: aging, Africa, epidemiological transition, developing nations, HIV/AIDS.

Support for Caregivers of Older Adults with Chronic Conditions: A Canadian Perspective

Lili Liu, PhD, Associate Professor and Associate Chair, Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB.
Alison Barnfather, MSc, Co-Director, Social Support Research Program, University of Alberta, Edmonton, AB.
Miriam Stewart, PhD, Scientific Director, Institute of Gender and Health, Canadian Institutes of Health Research; Professor, Faculties of Nursing, Medicine and Dentistry, and School of Public Health; Principal Investigator, Social Support Research Program. University of Alberta, Edmonton, AB.

In Canada, older adults are the most likely of all age groups to experience chronic health conditions. Most Canadians living with disabilities or chronic conditions and most older adults are supported by family members or close friends. Caregivers frequently describe the emotional, physical, and financial burdens associated with the caregiver role. Accessible support programs can improve health outcomes for family/friend caregivers of older adults with chronic conditions. Practitioners can use the strategies presented to help caregivers access timely and accessible support resources.
Key words: family caregivers, caregiver support, older adults, home care, chronic conditions.