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BACKGROUND/OBJECTIVES: To determine the feasibility of conducting a cluster randomized controlled trial providing individualized feedback reports to increase advance care planning (ACP) engagement in the primary care setting. DESIGN: Pilot cluster randomized controlled trial. SETTING: Two primary care practices selected for geographic colocation. PARTICIPANTS: Adults aged 55 years and older. INTERVENTION: Brief assessment of readiness to engage in (stage of change for) three ACP behaviors (healthcare agent assignment, communication with agent about quality vs quantity of life, and living will completion) generating an individualized feedback report, plus a stage‐matched brochure. MEASURES: Patient recruitment and retention, intervention delivery, baseline characteristics, and stage of change movement. RESULTS: Recruitment rates differed by practice. Several baseline sociodemographic characteristics differed between the 38 intervention and 41 control participants, including employment status, education, and communication with healthcare agent. Feedback was successfully delivered to all intervention participants, and over 90% of participants completed a 2‐month follow‐up. More intervention participants demonstrated progression in readiness than did control participants, without testing for statistical significance. CONCLUSIONS: This pilot demonstrates opportunities and challenges of performing a clustered randomized controlled trial in primary care practices. Differences in the two practice populations highlight the challenges of matching sites. There was a signal for behavior change in the intervention group. J Am Geriatr Soc 67:1917–1921, 2019 [ABSTRACT FROM AUTHOR]

Objectives: To explore patient and caregiver experiences, preferences, and attitudes toward the provision and receipt of caregiving assistance with medical tasks. Design: Qualitative study consisting of in‐depth interviews with 20 patient–caregiver dyads. Setting: Community and academic‐affiliated primary care clinics. Participants: Individuals aged 65 or older with 2 or more health conditions and their family caregivers (n=20 patient–caregiver dyads). Measurements: Open‐ended questions were asked about the tasks that the patient and caregiver performed to manage the patient's health conditions; questions were designed to elicit participant reactions and attitudes toward the help they provided or received. Transcripts were analyzed using the constant comparative method. Results: Participant preferences and attitudes toward the receipt and provision of disease management tasks were highly personal. Participant responses clustered into 2 caregiving typologies: supportive caregiving relationships and conflicted caregiving relationships. Supportive relationships were characterized by patient–caregiver agreement about caregiver level of involvement, agreement about one another's competency to perform disease‐related tasks, mutual understanding, collaborative decision‐making and disease management, and use of family and formal caregiving. Conflicted relationships were characterized by disagreement about caregiver level of involvement, disagreement about one another's competency to perform disease management tasks, underappreciation of one another's experiences, disagreement over decision‐making and disease management, and use of formal caregiving. Conclusions: The views that patient–caregiver dyads expressed in this study illustrate the varied preferences and attitudes toward caregiving assistance with multiple health conditions. These findings support a dyadic approach to evaluating and addressing patient and caregiver needs and attitudes toward provision of assistance. [ABSTRACT FROM AUTHOR]

The article describes the case of clinicians' experience and perspective with therapeutic decision making for older patients with multiple conditions. The study reveals that clinicians treat older patients on the basis of the patients' ability to adapt to the complex medical treatment plan, difference in belief regarding the advantages and disadvantages of using guidelines, difference in weighing pros and cons of treatment, patient-involvement in decision-making and blocks to clinicians preference.

To develop stages-of-change measures for advance care planning (ACP), conceptualized as a group of interrelated but separate behaviors, and to use these measures to characterize older persons' engagement in and factors associated with readiness to participate in ACP. Observational cohort study. Community. Persons aged 65 and older recruited from physician offices and a senior center. Stages of change for six ACP behaviors: completion of a living will and healthcare proxy, communication with loved ones regarding use of life-sustaining treatments and quantity versus quality of life, and communication with physicians about these same issues. Readiness to participate in ACP varied widely across behaviors. Whereas between approximately 50% and 60% of participants were in the action or maintenance stage for communicating with loved ones about life-sustaining treatment and completing a living will, 40% were in the precontemplation stage for communicating with loved ones about quantity versus quality of life, and 70% and 75% were in the precontemplation stage for communicating with physicians. Participants were frequently in different stages for different behaviors. Few sociodemographic, health, or psychosocial factors were associated with stages of change for completing a living will, but a broader range of factors was associated with stages of change for communication with loved ones about quantity versus quality of life. Older persons show a range of readiness to engage in different aspects of ACP. Individualized assessment and interventions targeted to stage of behavior change for each component of ACP may be an effective strategy to increase participation in ACP. [ABSTRACT FROM AUTHOR]

Background: As the number of older drivers increases, concern has been raised about the potential safety implications. Flexibility, coordination, and speed of movement have been associated with older drivers' on road performance.Objective: To determine whether a multicomponent physical conditioning program targeted to axial and extremity flexibility, coordination, and speed of movement could improve driving performance among older drivers.Design: Randomized controlled trial with blinded assignment and end point assessment. Participants randomized to intervention underwent graduated exercises; controls received home, environment safety modules.Participants: Drivers, 178, age > or = 70 years with physical, but without substantial visual (acuity 20/40 or better) or cognitive (Mini Mental State Examination score > or =24) impairments were recruited from clinics and community sources.Measurements: On-road driving performance assessed by experienced evaluators in dual-brake equipped vehicle in urban, residential, and highway traffic. Performance rated three ways: (1) 36-item scale evaluating driving maneuvers and traffic situations; (2) evaluator's overall rating; and (3) critical errors committed. Driving performance reassessed at 3 months by evaluator blinded to treatment group.Results: Least squares mean change in road test scores at 3 months compared to baseline was 2.43 points higher in intervention than control participants (P = .03). Intervention drivers committed 37% fewer critical errors (P = .08); there were no significant differences in evaluator's overall ratings (P = .29). No injuries were reported, and complaints of pain were rare.Conclusions: This safe, well-tolerated intervention maintained driving performance, while controls declined during the study period. Having interventions that can maintain or enhance driving performance may allow clinician-patient discussions about driving to adopt a more positive tone, rather than focusing on driving limitation or cessation. [ABSTRACT FROM AUTHOR]