Center for Aging Research

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Communicating with Clinicians: The Experiences of Surrogate Decision‐Makers for Hospitalized Older Adults
(2012-08) Torke, Alexia M.; Petronio, Sandra; Purnell, Christianna E.; Sachs, Greg A.; Helft, Paul R.; Callahan, Christopher M.
OBJECTIVES: To describe communication experiences of surrogates who had recently made a major medical decision for a hospitalized older adult. DESIGN: Semistructured interviews about a recent hospitalization. SETTING: Two hospitals affiliated with one large medical school: an urban public hospital and a university-affiliated tertiary referral hospital. PARTICIPANTS: Surrogates were eligible if they had recently made a major medical decision for a hospitalized individual aged 65 and older and were available for an interview within 1 month (2-5 months if the patient died). MEASUREMENTS: Interviews were audio-recorded, transcribed, and analyzed using methods of grounded theory. RESULTS: Thirty-five surrogates were interviewed (80% female, 44% white, 56% African American). Three primary themes emerged. First, it was found that the nature of surrogate-clinician relationships was best characterized as a relationship with a "team" of clinicians rather than individual clinicians because of frequent staff changes and multiple clinicians. Second, surrogates reported their communication needs, including frequent communication, information, and emotional support. Surrogates valued communication from any member of the clinical team, including nurses, social workers, and physicians. Third, surrogates described trust and mistrust, which were formed largely through surrogates' communication experiences. CONCLUSION: In the hospital, surrogates form relationships with a "team" of clinicians rather than with individuals, yet effective communication and expressions of emotional support frequently occur, which surrogates value highly. Future interventions should focus on meeting surrogates' needs for frequent communication and high levels of information and emotional support.
Correlation Between Caregiver Reports of Physical Function and Performance-based Measures in a Cohort of Older Adults With Alzheimer Disease
(Ovid Technologies (Wolters Kluwer) - Lippincott Williams & Wilkins, 2016-04) Bernard, Brittany L.; Bracey, Lauren E.; Lane, Kathleen A.; Ferguson, Denisha Y.; LaMantia, Michael A.; Gao, Sujuan; Miller, Douglas K.; Callahan, Christopher M.; Medicine, School of Medicine
The objectives of this report are to determine the association between performance-based measures of physical function with caregiver reports of physical function in older adults with Alzheimer disease (AD) and to examine whether those associations vary by the level of patients' cognitive functioning. Subjects included 180 patient-caregiver dyads who are enrolled in a clinical trial testing the impact of an occupational therapy intervention plus guideline-level care to delay functional decline among older adults with AD. The primary caregiver-reported measure is the Alzheimer's Disease Cooperative Study Group Activities of Daily Living Inventory (ADCS-ADL). Performance-based measures include the Short Physical Performance Battery and the Short Portable Sarcopenia Measure. Analysis of covariance (ANCOVA) models were used to determine the associations of each physical performance measure with ADCS-ADL, adjusting for cognition function and other covariates. We found significant correlations between caregiver reports and observed performance-based measures across all levels of cognitive function, with patients in the lowest cognitive group showing the highest correlation. These findings support the use of proxy reports to assess physical function among older adults with AD.
Defining the Domain of Geriatric Medicine in an Urban Public Health System Affiliated with an Academic Medical Center
(Wiley, 2008-10) Callahan, Christopher M.; Weiner, Michael; Counsell, Steven R.; Department of Medicine, IU School of Medicine
The American Geriatrics Society has recommended a reexamination of the roles and deployment of providers with expertise in geriatric medicine. Healthcare systems use a variety of strategies to maximize their geriatric expertise. In general, these health systems tend to focus geriatric medicine resources on a group of older adults that are locally defined as the most in need. This article describes a model of care within an academic urban public health system and describes how local characteristics interact to define the domain of geriatric medicine. This domain is defined using 4 years of data from an electronic medical record combined with data collected from clinical trials. From January 2002 to December 2005, 31,443 adults aged 65 and older were seen at any clinical site within this healthcare system. The mean age was 75 (range 65–105); 61% were women; 35% African American, and 2% Hispanic. The payer mix was 80% Medicare and 17% Medicaid. The local geriatric medicine program includes sites of care in inpatient, ambulatory, nursing home, and home-based settings. By design, this geriatric medicine clinical practice complements the care provided to older adults by the primary care practice. Primary care physicians tend to cede care to geriatric medicine for older adults with advanced disability or geriatric syndromes. This is most apparent for older adults in nursing facilities or those requiring home-based care. There is a dynamic interplay between design features, reputation, and capacity that modulates volume, location, and type of patients seen by geriatrics.
Emergency Department Use Among Older Adults With Dementia
(Wolters Kluwer, 2016-01) LaMantia, Michael A.; Stump, Timothy E.; Messina, Frank C.; Miller, Douglas K.; Callahan, Christopher M.; Department of Medicine, IU School of Medicine
Although persons with dementia are frequently hospitalized, relatively little is known about the health profile, patterns of health care use, and mortality rates for patients with dementia who access care in the emergency department (ED). We linked data from our hospital system with Medicare and Medicaid claims, Minimum Data Set, and Outcome and Assessment Information Set data to evaluate 175,652 ED visits made by 10,354 individuals with dementia and 15,020 individuals without dementia over 11 years. Survival rates after ED visits and associated charges were examined. Patients with dementia visited the ED more frequently, were hospitalized more often than patients without dementia, and had an increased odds of returning to the ED within 30 days of an index ED visit compared with persons who never had a dementia diagnosis (odds ratio, 2.29; P<0.001). Survival rates differed significantly between patients by dementia status (P<0.001). Mean Medicare payments for ED services were significantly higher among patients with dementia. These results show that older adults with dementia are frequent ED visitors who have greater comorbidity, incur higher charges, are admitted to hospitals at higher rates, return to EDs at higher rates, and have higher mortality after an ED visit than patients without dementia.
Non-Traditional Surrogate Decision Makers for Hospitalized Older Adults
(Lippincott, Williams & Wilkins, 2018-04) Comer, Amber R.; Slaven, James E.; Montz, Annie; Burke, Emily; Inger, Lev; Torke, Alexia; Robert H. Mckinney School of Law
Background Without advanced preparation of legal documents, state law determines who may serve as a surrogate decision maker for patients in hospitals. Objectives To examine the relationship characteristics associated with traditional versus non-traditional healthcare surrogates who are making medical decisions for patients in hospitals. Research Design Secondary analysis of a baseline cross-sectional survey of a larger prospective observational study. Subjects 364 patient/ surrogate dyads consisting of patients age 65 years and older admitted to the medical or medical ICU services who lacked decision making capacity based on a physician assessment and also had a surrogate available. Results This study of surrogate decision makers for hospitalized older adults found that the relationships of non-traditional surrogates such as, nieces, nephews, and friends serving in the surrogate role is nearly identical to those of traditional, first degree relatives serving as a surrogate. Over two-thirds (71.2%) of non-traditional surrogates saw the patient in person at least weekly compared to 80.8% of legal surrogates (p-value .9023). Almost all traditional and non-traditional surrogates discussed the patient’s medical preferences with the patient (96.9% of legal surrogates and 89.2% of non-traditional surrogates; p=0.0510). Conclusion This study shows that both traditional and non-traditional surrogates, who are a patient’s primary care giver have similar relationships with patients. The findings of this study suggest that requiring family members such as grandchildren to take the extra step of formal appointment through a legal channel may not be necessary to protect patients. Therefore, broader state laws expanding the list of surrogates authorized by state statute to include more non-traditional surrogates may be necessary.
Older primary care patients' attitudes and willingness to screen for dementia
(Hindawi, 2015-04-20) Fowler, Nicole R.; Perkins, Anthony J.; Turchan, Hilary A.; Frame, Amie; Monahan, Patrick; Gao, Sujuan; Boustani, Malaz A.; Biostatistics, School of Public Health
OBJECTIVE: To understand older primary care patients' perceptions of the risks and benefits of dementia screening and to measure the association between attitudes and screening behaviors. METHODS: Eligible patients completed the Perceptions Regarding Investigational Screening for Memory in Primary Care (PRISM-PC) questionnaire and then were asked to undergo dementia screening by a telephone screening instrument. RESULTS: Higher scores on the PRISM-PC questionnaire items that measure attitudes about benefits of screening were associated with decreased odds of refusing screening. Participants who refused screening had significantly lower PRISM-PC questionnaire scores on the items that measure perceived benefits compared to those who agreed to screening. Participants who refused screening were less likely to agree on screening for other conditions, such as depression and cancer. Participants who know someone with Alzheimer's disease (AD) were less likely to refuse screening. DISCUSSION: Patients' attitudes about the benefits of dementia screening are associated with their acceptance of dementia screening.
Redesigning Systems of Care for Older Adults with Alzheimer' Disease
(The People-to-People Health Foundation, 2014-04) Callahan, Christopher M.; Sachs, Greg A.; LaMantia, Michael A.; Unroe, Kathleen T.; Arling, Greg A.; Boustani, Malaz A.; Department of Medicine, IU School of Medicine
Best-practice models of dementia care have evolved from strategies focused on family caregivers to guidelines predicated on supporting the patient-caregiver dyad along the care continuum. These models have grown in complexity to encompass medical and team-based care that is designed to coordinate dementia care across settings and providers for a defined population of patients. Although there is evidence that the models can improve outcomes, they have not been widely adopted. Barriers to the models' increased adoption include workforce limitations, the cost of necessary practice redesign, and limited evidence of their potential cost-effectiveness. We summarize the origins, evidence base, and common components of best-practice models of dementia care, and we discuss barriers to their implementation. We conclude by describing two current efforts to implement such models on a broad scale, supported by the Center for Medicare and Medicaid Innovation. Taken together, these models seek to demonstrate improved dementia care quality and outcomes, accompanied by cost savings, in both community-based and institutional care settings.
Religion and Spirituality in Surrogate Decision Making for Hospitalized Older Adults
(Springer, 2016-06) Geros-Willfond, Kristin N.; Ivy, Steven S.; Montz, Kianna; Bohan, Sara E.; Torke, Alexia M.; Department of Medicine, School of Medicine
We conducted semi-structured interviews with 46 surrogate decision makers for hospitalized older adults to characterize the role of spirituality and religion in decision making. Three themes emerged: (1) religion as a guide to decision making, (2) control, and (3) faith, death and dying. For religious surrogates, religion played a central role in end of life decisions. There was variability regarding whether God or humans were perceived to be in control; however, beliefs about control led to varying perspectives on acceptance of comfort-focused treatment. We conclude that clinicians should attend to religious considerations due to their impact on decision making.
Staff Care in the Midst of Traumatic Events
(Chaplaincy Innovation Lab, 2022-03-04) Varner-Perez, Shelley E; Nwokeogu, Patrick; Whitaker, Myra K.; Williams, Eric A.
Traumatic events bring upheaval and uncertainty. Yet not all difficult or jarring events are experienced as distressing, “traumatic,” or morally injurious by those present, the latter of which in military contexts involves an experience that violates one’s moral code or betrayal by once-trusted sources. Trauma has a certain subjective quality to it, as we learn from military personnel who may witness the same event and interpret or internalize it differently. Exposure to a potentially injurious event does not necessarily lead to post-traumatic stress or moral injury for all who witness the event. So, how do we define a traumatic event for the purposes of this eBook? Trauma overwhelms a person’s capacity to make meaning. Healthcare staff may experience traumatic events that tax their ability to respond, such as when a situation overwhelms their capabilities or when the details of an event intersect with current or past experiences, amplifying a common event to a traumatic level. The chaplain writers of this eBook chose a compilation of vignettes that incorporate multiple types of traumatic events. Some of these encounters are with individual staff members, while others occurred in staff groups. Some of these events are personal and individual, like a particularly jarring patient encounter, or intersection of personal story with professional experience; other events represent societal trauma such as experiences of racism, COVID-19, or attempts to disrupt activities of the federal government. Each traumatic event includes a particular chaplain’s approach to staff care, recognizing the contextual features of the encounter. Some vignettes are compilations, and details have been changed to protect privacy. A certified educator once described staff as the primary congregation the healthcare chaplain serves; in this metaphor, patients and families are visitors to the congregation. Though the specific words used for “staff” vary by setting (healthcare workers, team members, care partners, care receivers, professional caregivers, front line workers, employees, and so on), those who work and serve alongside chaplains are the metaphorical “regulars.” These co-laborers clean rooms, prep supplies, sterilize equipment, prepare food, compound medications, administer breathing treatments, process labs, perform surgeries, and manage conditions; each does their part to contribute to patients’ healing. With staff being integral to the flow and function of the setting, chaplains have a meaningful role in providing care to professional caregivers. Each vignette includes structural similarities: background about the encounter, the chaplain’s assessment (or, at times, the recipient’s self-assessment), chaplain-provided support or intervention, outcome or staff response, and the chaplain’s reflection or concluding thought. Recognizing a single setting has limitations and that no resource is exhaustive, the chaplain writers anticipate readers will adapt and modify these approaches to the benefit of other settings.
Timing of Do‐Not‐Resuscitate Orders for Hospitalized Older Adults Who Require a Surrogate Decision‐Maker
(2011-07) Torke, Alexia M.; Sachs, Greg A.; Helft, Paul R.; Petronio, Sandra; Purnell, Christianna E.; Hui, Siu; Callahan, Christopher M.
OBJECTIVES: To examine the frequency of surrogate decisions for in-hospital do-not-resuscitate (DNR) orders and the timing of DNR order entry for surrogate decisions. DESIGN: Retrospective cohort study. SETTING: Large, urban, public hospital. PARTICIPANTS: Hospitalized adults aged 65 and older over a 3-year period (1/1/2004–12/31/2006) with a DNR order during their hospital stay. MEASUREMENTS: Electronic chart review provided data on frequency of surrogate decisions, patient demographic and clinical characteristics, and timing of DNR orders.

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