Abstract
Perissinotto CM, Cenzer IS, Covinsky KE: Loneliness in older persons: A predictor of functional decline and death. Arch Intern Med 2012;172:1078–1083.
Loneliness is a common source of distress, suffering, and impaired quality of life in older persons. In this longitudinal cohort study, the authors examined the relationship between loneliness, functional decline, and death in 1604 adults older than 60 years in the United States. The participants were in the psychosocial module of the Health and Retirement Study, a nationally representative study of older persons. Baseline assessment was in 2002 and follow-up assessments occurred every two years until 2008.
Subjects were asked if they (1) felt left out, (2) felt isolated, or (3) lacked companionship. They were categorized as not lonely if they responded hardly ever to all three questions and lonely if they responded some of the time or often to any of the three questions. The primary outcomes were time to death over six years and functional decline over six years on the following four measures: difficulty in an increased number of activities of daily living (ADL), difficulty in an increased number of upper extremity tasks, decline in mobility, or increased difficulty in stair climbing. Multivariate analyses adjusted for demographic variables, socioeconomic status, living situation, depression, and various medical conditions. Results demonstrated that the mean age of subjects was 71 years. Fifty-nine percent were women; 81% were white, 11% black, and 6% Hispanic; and 18% lived alone. Among the participants, 43% reported feeling lonely. Loneliness was associated with all outcome measures. Lonely subjects were more likely to experience decline in ADL (24.8% versus 12.5%); develop difficulties with upper extremity tasks (41.5% versus 28.3%); experience decline in mobility (38.1% versus 29.4%); or experience difficulty in climbing (40.8% versus 27.9%). Loneliness was associated with an increased risk of death (22.8% versus 14.2%; adjusted HR, 1.45; 95% CI, 1.11–1.88). The authors conclude that among participants who were older than 60 years, loneliness was a predictor of functional decline and death.
Murad K, Kitzman DW: Frailty and multiple comorbidities in the elderly patient with heart failure: Implications for management. Heart Fail Rev 2012 (epub ahead of print, DOI 10.1007/s10741-011-9258-y).
Heart failure (HF) in the elderly is a major public health problem, and its prevalence is rising as the population continues an aging trajectory. Outcomes of HF in the elderly have not changed in the past two decades despite the introduction of novel HF therapies.
This may be due to the combined impact of multiple comorbidities and frailty, as the majority of elderly patients with HF are frail with multiple comorbidities. These comorbidities, along with frailty, contribute to the poor outcome of HF in the elderly and pose independent management challenges. More research is needed to better understand the interaction between frailty and multiple comorbidities and the mechanisms by which they impact HF and its management; to develop prognostic tools that incorporate frailty and multiple comorbidities; to provide more accurate prediction of outcomes; to test available treatments in typical elderly patients; and to develop and test novel interventions that directly address the adverse impact of multiple comorbidities and frailty. Topics discussed in this article include frailty and HF in the elderly, comorbidities and HF in the elderly, the relationship between frailty and comorbidity, and implications for management.
Durall A, Zurakowski D, Wolfe J: Barriers to conducting advance care discussions for children with life-threatening conditions. Pediatrics 2012 (epub ahead of print, DOI 10.1542/peds.2011-2695).
Advance care discussions (ACD) occur infrequently or are initiated late in the course of illness. Although data exist regarding barriers to ACD among the care of adult patients, few pediatric data exist. The goal of this study was to identify barriers to conducting ACD for children with life-threatening conditions. Physicians and nurses from practice settings where advance care planning typically takes place were surveyed to collect data regarding their attitudes and behaviors regarding ACD. A total of 266 providers responded to the survey, 107 physicians and 159 nurses (54% response rate). Results demonstrated that the top three barriers were (1) unrealistic parent expectations, (2) differences between clinician and patient/parent understanding of prognosis, and (3) lack of parent readiness to have the discussion. Nurses identified lack of importance to clinicians (P=.006) and ethical considerations (P<.001) as impediments more often than physicians. Conversely, physicians believed that not knowing the right thing to say (P=.006) was more often a barrier. There were also perceived differences among specialties. Cardiac ICU providers were more likely to report unrealistic clinician expectations (P<.001) and differences between clinician and patient/parent understanding of prognosis (P=.014) as common barriers to conducting ACD. Finally, 71% of all clinicians believed that ACDs happen too late in the patient's clinical course. The authors conclude that clinicians perceive parent prognostic understanding and attitudes as the most common barriers to conducting ACD. Educational interventions aimed at improving clinician knowledge, attitudes, and skills in addressing these barriers may help health care providers overcome perceived barriers.
Ranse K, Yates P, Coyer F: End-of-life care in the intensive care setting: A descriptive exploratory qualitative study of nurses' beliefs and practices. Australian Crit Care 2012;25:4–12.
End-of-life care is a significant component of work in intensive care; however, limited research has been undertaken on the provision of end-of-life care by nurses in the intensive care setting. The purpose of this descriptive exploratory study was to explore end-of-life-care beliefs and practices of intensive care nurses. Five intensive care nurses from one hospital participated in a semistructured interview. Interview transcripts were analyzed using an inductive coding approach. Results demonstrated that three major categories emerged from analysis of the interviews: beliefs about end-of-life care, end-of-life care in the intensive care context, and facilitating end-of-life care. The first two categories incorporated factors contributing to the end-of-life care experiences and practices of intensive care nurses. The third category captured the nurses' end-of-life care practices. The authors conclude that despite the uncertainty and ambiguity surrounding end-of-life care in this practice context, the intensive care setting presents unique opportunities for nurses to facilitate positive end-of-life experiences, and nurses valued their participation in the provision of end-of-life care. Care of the family was at the core of nurses' end-of-life care work, and nurses play a pivotal role in supporting the patient and his or her family to have positive and meaningful experiences at the end of life.
Neuhaus T, Ko YD, Stier S: Successful treatment of intractable hiccups by oral application of lidocaine. Support Care Cancer 2012 (epub ahead of print, DOI 10.1007/s00520-012-1533-5).
Persistent and intractable hiccups are a rather rare but a distressing gastrointestinal symptom found in palliative care patients that can significantly reduce quality of life. Although several recommendations for treatment are given, hiccups may persist. In this article the authors describe a new pharmacological approach for successfully treating hiccups in four cancer patients. In the first patient, chronic and intractable hiccups lasted for more than 18 months, but disappeared immediately after swallowing a viscous 2% lidocaine solution for treatment of mucositis. Based on this experience the authors successfully treated three further patients suffering from singultus using a lidocaine-containing gel. To the author's knowledge this is the first report about managing hiccups by oral application of a lidocaine solution.
Heiney SP, Underwood SM, Tavakoli A, et al.: Randomized trial of therapeutic group by teleconference: African American women with breast cancer. Cancer 2012;118:3822–3832.
The effects of a therapeutic group by teleconference for African American women with breast cancer have not been documented, although the benefits of therapeutic groups for European women are well established. African American women with breast cancer may experience social disconnection, a sense of being cut off from partners, family, and friends because of side effects of treatment and fatalistic beliefs about cancer. In this randomized study, the authors attempted to determine if a therapeutic group by teleconference could counteract these problems and improve social connection. Data was collected on 185 participants at baseline, at the end of the intervention, and 16 weeks from baseline. Repeated-measures, fixed-factor analyses of covariance were used for each outcome. The between-subject factors were group and replicate set, and the within-subject factor was time. Physical well being and educational level differed significantly between the two groups at baseline and were used as covariates. Results demonstrated that the mixed-model analysis of the outcome variables revealed significant changes over time for knowledge, with higher scores on knowledge observed for the control group. Group-by-time interactions were observed for fatalism, fear, and social connection as measured by the Social Well Being subscale from the Functional Assessment of Cancer Treatment–Breast Cancer Version. No group-by-time interaction was observed for social connection as measured by the Social Support Questionnaire. Social connection measured with the Social Well Being subscale improved significantly in the intervention group, whereas fatalism and fear significantly decreased. The authors conclude that in this study there were documented benefits of a therapeutic group by teleconference, a novel way to provide support for African American women with breast cancer. They also note that further research should include a behavioral outcome, such as treatment adherence.