Competing risk occurs when patients have >1 disease or condition that can affect an important outcome, such as mortality. In older adults who develop cancer, the presence of comorbid chronic diseases ...or functional impairments can change the likelihood that the cancer will lead to an adverse outcome. The recognition and incorporation of competing risk into oncology research started during the experimental development of chemotherapy. A related concept of considering performance status in clinical trials of cancer therapies also occurred in the context of treatment interventions using chemotherapy. Statistical methodologies for competing risk have advanced substantially over time, and a patient's performance measurements remain common in deciding how best to care for older patients with cancer. The historical development of these 2 uses of competing risk, statistical adjustment in research and patient performance measurement, is explained. Furthermore, this article discusses more recent advances in merging these 2 approaches. Particular attention is given to advances in calculating life expectancy that are specific to a patient's condition, status, or setting, and to describing how these estimates might be used to inform decisions about cancer care in older patients. Frameworks for moving beyond mortality as the only considered competing outcome to describe other outcomes, such as functional loss or the need for institutionalization, are also described. Finally, approaches that could more fully leverage the advanced methods for incorporating competing risks into clinical decision making are presented.
Abstract Since their inception in 1975, the Department of Veterans Affairs Geriatric Research, Education, and Clinical Centers (GRECCs) have served as incubators of innovation in geriatrics. Their ...contributions to the VA mission were last reviewed in 2012. Herein, we describe the continuing impact of GRECCs in research, clinical, and educational areas, focusing on the period between 2018 and 2022. GRECC research spans the continuum from bench to bedside, with a growing research portfolio notable for highly influential publications. GRECC education connects healthcare professions trainees and practicing clinicians, as well as Veterans and their caregivers, to engaging learning experiences. Clinical advancements, including age‐friendly care, span the continuum of care and leverage technology to link disparate geographical sites. GRECCs are uniquely positioned to serve older adults given their alignment with the largest integrated health system in the United States and their integration with academic health centers. As such, the GRECCs honor Veterans as they age by building VA capacity to care for the increasing number of aging Veterans seeking care from VA. GRECC advancements also benefit non‐VA healthcare systems, their academic affiliates, and non‐Veteran older adults. GRECCs make invaluable contributions to advancing geriatric and gerontological science, training healthcare professionals, and developing innovative models of geriatric care.
The Veterans Health Administration (VHA) has long recognized the need for age-friendly care. VHA leadership anticipated the impact of aging World War II veterans on VA healthcare systems and in 1975 ...developed Geriatric Research, Education, and Clinical Centers (GRECCs) to meet this need. GRECCs catalyzed a series of innovations in geriatric models of care that span the continuum of care, most of which endure. These innovative care models also contributed to the evidence base supporting the present-day Age-Friendly Health Systems movement, with which VHA is inherently aligned. As both a provider of and payor for care, VHA is strongly incentivized to promote coordination across the continuum of care, with resultant cost savings. VHA is also a major contributor to developing the workforce that is essential for the provision of age-friendly care. As VHA continues to develop and refine innovative geriatric models of care, policymakers and non-VHA health care systems should look to VHA programs as exemplars for the development and implementation of age-friendly care.
Abstract Although family caregivers are increasingly recognized for their essential role in helping vulnerable adults live in the community for as long as possible, their priorities and perspectives ...have not been well‐integrated into quality assessments of home‐ and community‐based services (HCBS). Our overall goal was to identify measurement gaps to guide monitoring and improve HCBS. Caregiver‐specific measurement priorities were identified during a multi‐level stakeholder engagement process that included 34 Veterans, 24 caregivers, and 39 facility leaders, clinicians, and staff across four VA healthcare systems. We mapped items from national quality measure sets for HCBS identified during an environmental scan onto the stakeholder‐identified measurement priorities. Only 5 of 11 non‐VA measure sets and three of four VA measure sets explicitly included caregiver‐specific items that were aligned with or relevant to stakeholders' measurement priorities. Six of 14 stakeholder‐identified priorities were not reflected in any measure sets, such as those that explicitly assess caregiver‐reported experience with services that directly or indirectly support their role as caregivers within HCBS. Although family caregivers fulfill a critical role in helping adults with complex medical needs live independently for as long as possible, their priorities and perspectives have not been well‐integrated into quality assessments of HCBS. Measures that acknowledge caregivers' roles and incorporate their priorities can help healthcare systems to better monitor and improve HCBS quality, thereby enabling Veterans to remain in the community as long as possible.
We sought to describe neuropsychiatric symptoms (NPS) among people living with dementia (PLWD) from diverse racial and ethnic groups receiving home health services while accounting for dementia ...severity, individual symptom prevalence, and neighborhood disadvantage.
A prospective study using cross-sectional data from n = 192 PLWD receiving skilled home healthcare in New Jersey enrolled in the Dementia Symptom Management at Home Program trial. We prospectively measured symptom prevalence with the Neuropsychiatric Inventory Questionnaire and dementia severity using the Quick Dementia Rating System. A one-way ANOVA determined NPS prevalence by dementia severity (mild, moderate, severe). Fisher's exact tests were used to assess the association of individual symptom prevalence with race and ethnicity and cross tabs to descriptively stratify individual symptom prevalence by dementia severity among groups. A Pearson correlation was performed to determine if a correlation existed among neighborhood disadvantages measured by the Area Deprivation Index (ADI) state decile scores and NPS prevalence and severity.
Participants identified as non-Hispanic White (50%), non-Hispanic Black (30%), or Hispanic (13%). NPS were prevalent in 97% of participants who experienced 5.4 ± 2.6 symptoms with increased severity (10.8 ± 6.6) and care partner distress (13.8 ± 10.8). NPS increased with dementia severity (p = 0.004) with the greatest difference seen between individuals with mild dementia (4.3 ± 2.3) versus severe dementia (5.9 ± 2.3; p = 0.002). Few differences were found in symptom prevalence by racial and ethnic sub-groups. Nighttime behaviors were higher in non-Hispanic Black (78%), compared with non-Hispanic Whites (46%) with moderate dementia, p = 0.042. State ADI scores were not correlated with the number of NPS reported, or severity.
NPS were prevalent and increased with dementia severity with commonalities among racial and ethnic groups with varying levels of neighborhood disadvantage. There is a need for effective methods for improving NPS identification, assessment, and management broadly for homebound PLWD.
Background
The increasing prevalence of dementia, including among rural veterans, highlights the improved outcomes possible for caregivers who receive effective support. However, providing these ...complex interventions in rural areas presents challenges. Internet‐based and telephone‐based caregiver support can potentially expand access to effective support.
Methods
We designed a multisite intervention for caregivers of veterans with dementia. Caregivers were stratified into 2 cohorts based on their use or nonuse of the Internet. Each cohort was then randomized to either a technology or telephone‐delivered support group within each cohort. All groups had a care manager who monitored the 4‐ to 6‐month multicomponent program of assessments, educational content, and skills training. Caregiver outcome measures included burden, anticipatory grief, depression, family conflict, and a desire to institutionalize the care recipient.
Results
The majority of comparative effectiveness outcomes were not different between caregivers receiving technology interventions versus those receiving telephone‐delivered support. This was true for the 68% of caregivers using home Internet and the 32% nonusers, as well as the 53% rural versus 47% urban caregivers. For experienced Internet users, a meaningful difference in the Marwit Grief Inventory was noted for caregivers receiving Internet versus telephone support, particularly for the Isolation Subscale.
Conclusion
This study demonstrates the feasibility and acceptability of using a variety of modalities to deliver caregiver support to a group of largely older, rural, spousal caregivers of veterans with dementia. The potential for reducing isolation for caregivers capable of receiving this intervention through the Internet is a promising finding.
Background
The transition to later-life caregiving roles, especially for couples caring for each other, can be rife with ambiguity. The incident discordance in spousal perceptions of one another’s ...role and its relationship to mental health outcomes have not been well-described.
Objectives
(1) To describe the range of daily agreement between older adult spouses’ perceptions of care given and care received; (2) to explore associations between caregiving agreement and daily caregiver depression, anxiety, and marital satisfaction; and (3) to evaluate differential effects for male and female caregivers.
Design
Cross-sectional, ecological assessment (daily diary).
Participants
Sample of 191 couples aged 60–64 (total 5196 daily surveys) drawn from the longitudinal Life and Family Legacies study.
Main Measures
During 2011–2012, spouses independently completed 14 consecutive daily surveys about their mood, marital interactions, and support exchanges. Caregiving agreement was defined as the daily ratio of spouse-reported care received to self-reported care given. Using generalized linear mixed effect modeling, we examined associations between spousal care agreement and outcomes of depression, anxiety, and marital satisfaction.
Key Results
Sample data demonstrated broad variability in spousal agreement, with couples exhibiting substantial disagreement on nearly one-third of couple days (780/2598 days). On days where care was exchanged, higher caregiving agreement was associated with lower caregiver depression (
p
< 0.01) and anxiety (
p
< 0.01) in male caregivers, and higher marital satisfaction (
p
= 0.03) in female caregivers. When care recipients reported receiving more support than their spouse reported giving, these associations did not persist.
Conclusions
Findings suggest that spousal agreement about the amount of care given and received varies broadly and is an important consideration for primary care providers who counsel these patients day-to-day. Furthermore, agreement appears to predict mental health and relationship outcomes and should be further evaluated in this growing population of mid-to-late life adults emerging into caregiving.
Abstract
Introduction
Caregiving has become an important world-wide concern due to the increasing number of people living to old age who need day to day functional support. Many caregivers report ...moderate to high levels of caregiver burden, which has been associated with increased morbidity and mortality for both the caregiver and care recipient. There are numerous research publications on people who are caregivers for military veterans. However, there is little information on military veterans who are themselves caregivers. This study proposed to determine if there are differences in health and health behaviors between veterans who are caregiving for others (VCOs) and veterans who are not caregiving for others (VNCOs).
Materials and Methods
Data were analyzed from a population-based observational cross-section involving persons who identified as veterans in the 2009 Center for Disease Control and Prevention’s (CDC) Behavioral Risk Factor Surveillance System (BRFSS) national telephone survey. Those identifying as veterans were then grouped by those who also identified as caregivers and those who did not identify as caregivers. Data were weighted using the CDC’s weighting equation. Group differences were analyzed using Chi-square and t-tests. We used multinomial logistic regression with a 95% confidence interval (1 = VCO; 0 = VNCO) to determine if caregiving status among veterans was independently correlated with clinically relevant and explanatory variables.
Results
Of 432,607 BRFSS participants, 12,629 were VCOs (23.4% of veterans; 10.7% of caregivers) and 44,356 were VNCOs (76.6% of veterans). Veterans who were caregivers reported similar proportions of hypertension, diabetes, coronary heart disease, history of stroke, and cancer compared with VNCOs, even though VCOs were younger than the VNCOs (57 vs. 59 yr, p < 0.01). Additionally, VCOs more often report current smoking (35% vs. 28%, p < 0.01), frequent insufficient sleep (29% vs. 21%, p < 0.01), and frequent mental distress (12% vs. 8%, p < 0.01).
Conclusion
Veterans who are caregiving for others (VCOs) despite being younger, have similar amounts of chronic health problems and more modifiable health factors (i.e., smoking) than veterans who are not caregiving for others (VNCOs). These characteristics have important implications for health management of veterans who are caregivers.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, ODKLJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Cancer is the leading cause of death in older adults aged 60 to 79 years. The biology of certain cancers and responsiveness to therapy changes with the patient's age. Advanced age alone should not ...preclude the use of effective treatment that could improve quality of life or extend meaningful survival. The challenge of managing older patients with cancer is to assess whether the expected benefits of treatment are superior to the risk in a population with decreased life expectancy and decreased tolerance to stress. These guidelines provide an approach to decision-making in older cancer patients based on comprehensive geriatric assessment and also include disease specific issues related to age in the management of some cancer types in older adults.
The Veterans Health Administration (VHA) is a leader in developing and implementing innovative healthcare technology. We review 19 exemplary peer-reviewed articles published between 2000 and 2009 of ...controlled, VHA-supported telemedicine intervention trials that focused on health outcomes. These trials underscore the role of telemedicine in large managed healthcare organizations in support of (1) chronic disease management, (2) mental health service delivery through in-home monitoring and treatment, and (3) interdisciplinary team functioning through electronic medical record information interchange. Telemedicine is advantageous when ongoing monitoring of patient symptoms is needed, as in chronic disease care (eg, for diabetes) or mental health treatment. Telemedicine appears to enhance patient access to healthcare professionals and provides quick access to patient medical information. The sustainability of telemedicine interventions for the broad spectrum of veteran patient issues and the ongoing technology training of patients and providers are challenges to telemedicine-delivered care.
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