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Pain in older persons with cognitive impairment is often unrecognized and inadequately treated. A major problem associated with this undertreatment is the challenging nature of pain assessment and in particular the selection of accurate and useful assessment instruments. The purpose of this study was to review pain measurement instruments for acute and chronic pain suggested for use with cognitively impaired older persons and to summarize available evidence on their reliability and validity. A systematic search for pain instruments was conducted using several bibliographic databases, supplemented by a manual search of the bibliographies of retrieved articles and review chapters and by articles received from experts and clinicians in the field. Instruments were retained for review when the pain instrument was used or recommended for use with older persons with cognitive impairment. Thirty-nine instruments were reviewed; nine were excluded for various reasons. Of the remaining 30, 18 were self-report and 12 were staff administered. There were no instruments for which all major tests of reliability or validity were reported. Reliability and validity data were basic or unavailable for many instruments. One instrument had excellent validity but no reliability data. The remaining instruments had weak or adequate reliability and validity. The authors conclude that there is a need for further rigorous development and testing of pain instruments for use with cognitively impaired older persons. An adequate instrument would be one component of an effective program for assessment and management of pain in this population. [ABSTRACT FROM AUTHOR]

Objectives: To develop and validate a prognostic case finding tool that classifies the risk of emergency department (ED) use in an older home care population., Design: Population-based retrospective cohort study using routinely collected data from home care clinical assessments linked prospectively to ED records., Setting: Ontario and the Winnipeg Regional Health Authority, Canada., Participants: Older adults living at home and expected to receive in-home services for at least 60 days (N = 361,942)., Measurements: One or more ED visits within 6 months after an in-home clinical assessment was used as the main dependent measure. Ninety-five person-level risk measures from a clinical assessment instrument were selected as potential independent variables. The Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) Scale was derived using recursive partitioning analyses informed by a multinational clinical panel., Results: Overall, 41.2% had one or more ED visits within 6 months of their in-home assessment. Previous ED use and cardiorespiratory symptoms, cardiac conditions, and specific geriatric syndromes were predictors within the six-level DIVERT Scale. The scale provided adequate risk differentiation for case finding, with an area under the receiver operating characteristic curve of 0.62 (95% confidence interval = 0.61-0.62) and distinct risk gradients between risk scores. The multilevel validation demonstrated consistent performance across geographic and participant clusters., Conclusion: The DIVERT Scale is a valid case-finding tool for ED use in older home care clients. It may be suitable for preemptively and systematically risk-stratifying individuals or groups for additional assessment, case management, and preventative interventions. It may also be suitable for the stratification and adjustment of performance metrics., (© 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.)

In Canada, there is minimal training of geriatrics for physicians, a shortage of geriatricians, and extremely low numbers of students entering geriatrics. This study explored student interest in and barriers and enticements to geriatric medicine as a career choice. Medical students attending a university in Ontario, Canada, were surveyed in their first year (N=121), after a geriatric education session, and again in their second year (N=118) about their interest in a career in geriatrics. In the first year, less than 20% of students were interested in geriatrics; in the second year this decreased to 16%. In both years, female students were more interested than male students. Those students interested in geriatrics had higher hopes that their practice would involve primarily adults and seniors. Students not interested in geriatrics rated performing procedures and technical skills, not wanting to work with chronically ill patients, and caring for younger patients as important practice characteristics. Although the importance of prestige was low for all students, it was significantly higher for those not interested in geriatrics. Although changes to prestige, income, lifestyle, and length of residency training were identified as potential enticements to geriatrics, they were not major deterrents to a career in geriatrics. The findings suggest strategies that may affect student interest in geriatrics, such as increased and early student exposure to geriatrics with emphasis on fostering and nurturing student interest, consideration of various enticements to this specialty, and the development of health system-specific solutions to this problem. Knowledge of student and practice characteristics that increase the likelihood of selecting geriatrics as a specialty may allow for early identification and support of future geriatricians.

Pain in older persons with cognitive impairment is often unrecognized and inadequately treated. A major problem associated with this undertreatment is the challenging nature of pain assessment and in particular the selection of accurate and useful assessment instruments. The purpose of this study was to review pain measurement instruments for acute and chronic pain suggested for use with cognitively impaired older persons and to summarize available evidence on their reliability and validity. A systematic search for pain instruments was conducted using several bibliographic databases, supplemented by a manual search of the bibliographies of retrieved articles and review chapters and by articles received from experts and clinicians in the field. Instruments were retained for review when the pain instrument was used or recommended for use with older persons with cognitive impairment. Thirty-nine instruments were reviewed; nine were excluded for various reasons. Of the remaining 30, 18 were self-report and 12 were staff administered. There were no instruments for which all major tests of reliability or validity were reported. Reliability and validity data were basic or unavailable for many instruments. One instrument had excellent validity but no reliability data. The remaining instruments had weak or adequate reliability and validity. The authors conclude that there is a need for further rigorous development and testing of pain instruments for use with cognitively impaired older persons. An adequate instrument would be one component of an effective program for assessment and management of pain in this population.

Objectives: To describe a geriatric mental health outreach program based on a community development model and to review 4 years of experience with this program., Design: Program model and description of implementation experience., Settings: A geriatric mental health outreach program of a regional psychiatric hospital, serving a primarily non-urban area, with offices in the community it serves., Participants: The program targets community-dwelling or institutionalized older persons with late-onset mental health problems and/or behavioral disturbances, persons with long-standing psychiatric disorders with age-related changes, and their caregivers., Intervention: The program is a geriatric mental health outreach and consultation service that emphasizes community development and caregiver education. Program components include an interprofessional consultation team, a specialized information and resource service, educational service initiatives, and an ongoing role in planning and coordination activity in the local health care system., Measurements: Program monitoring, including a patient database and a description of program activities., Results: Cognitive impairment, behavioral disturbance, physical/medical problems and depression are the most common reasons for referral to the outreach program. Referred patients (mean age 78; 65% female) have usually (almost 90% of cases) been managed at a similar or lower level of care. Program activities have included focused educational initiatives in community and institutional settings and have emphasized the involvement and development of community caregivers and other local resources., Conclusion: The program is a multifaceted effort to make efficient use of scarce specialized resources in a manner that is sensitive and responsive to local circumstances and needs. Experience to date has shown evidence of the feasibility and potential benefits of a comprehensive approach to community development and outreach in geriatric mental health.