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Background: Evaluating infection in home‐based primary care is challenging, and these challenges may impact antibiotic prescribing. A refined understanding of antibiotic decision‐making in this setting can inform strategies to promote antibiotic stewardship. This study investigated antibiotic decision‐making by exploring the perspectives of clinicians in home‐based primary care. Methods: Clinicians from the Department of Veterans Affairs Home‐Based Primary Care Program were recruited. Semi‐structured interviews were conducted from June 2022 through September 2022 using a discussion guide. Transcripts were analyzed using grounded theory. The constant comparative method was used to develop a coding structure and to identify themes. Results: Theoretical saturation was reached after 22 clinicians (physicians, n = 7; physician assistants, n = 2, advanced practice registered nurses, n = 13) from 19 programs were interviewed. Mean age was 48.5 ± 9.3 years, 91% were female, and 59% had ≥6 years of experience in home‐based primary care. Participants reported uncertainty about the diagnosis of infection due to the characteristics of homebound patients (atypical presentations of disease, presence of multiple chronic conditions, presence of cognitive impairment) and the challenges of delivering medical care in the home (limited access to diagnostic testing, suboptimal quality of microbiological specimens, barriers to establishing remote access to the electronic health record). When faced with diagnostic uncertainty about infection, participants described many factors that influenced the decision to prescribe antibiotics, including those that promoted prescribing (desire to avoid hospitalization, pressure from caregivers, unreliable plans for follow‐up) and those that inhibited prescribing (perceptions of antibiotic‐associated harms, willingness to trial non‐pharmacological interventions first, presence of caregivers who were trusted by clinicians to monitor symptoms). Conclusions: Clinicians face the difficult task of balancing diagnostic uncertainty with many competing considerations during the treatment of infection in home‐based primary care. Recognizing these issues provides insight into strategies to promote antibiotic stewardship in home care settings. [ABSTRACT FROM AUTHOR]

Background: Interventions with the potential for broad reach in ambulatory settings are necessary to achieve a life course approach to advance care planning.Objective: To examine the effect of a computer-tailored, behavioral health model-based intervention on the engagement of adults in advance care planning recruited from ambulatory care settings.Design: Cluster randomized controlled trial with participant-level analysis. (ClinicalTrials.gov: NCT03137459).Setting: 10 pairs of primary and selected specialty care practices matched on patient sociodemographic information.Participants: English-speaking adults aged 55 years or older; 454 adults at practices randomly assigned to usual care and 455 at practices randomly assigned to intervention.Intervention: Brief telephone or web-based assessment generating a mailed, individually tailored feedback report with a stage-matched brochure at baseline, 2 months, and 4 months.Measurements: The primary outcome was completion of the following 4 advance care planning activities at 6 months: identifying and communicating with a trusted person about views on quality versus quantity of life, assignment of a health care agent, completion of a living will, and ensuring that the documents are in the medical record-assessed by a blinded interviewer. Secondary outcomes were completion of individual advance care planning activities.Results: Participants were 64% women and 76% White. The mean age was 68.3 years (SD, 8.3). The predicted probability of completing all advance care planning activities in usual care sites was 8.2% (95% CI, 4.9% to 11.4%) versus 14.1% (CI, 11.0% to 17.2%) in intervention sites (adjusted risk difference, 5.2 percentage points [CI, 1.6 to 8.8 percentage points]). Prespecified subgroup analysis found no statistically significant interactions between the intervention and age, education, or race.Limitations: The study was done in a single region and excluded non-English speaking participants. No information was collected about nonparticipants.Conclusion: A brief, easily delivered, tailored print intervention increased participation in advance care planning in ambulatory care settings.Primary Funding Source: National Institute of Nursing Research and National Institute of Aging. [ABSTRACT FROM AUTHOR]

This pilot study examined the feasibility and potential efficacy of a self-management program for seniors with chronic back pain and assessed for possible race/ ethnicity differences in program impact. Sixty-nine seniors (24 African Americans, 25 Hispanics, and 20 non-Hispanic Whites) enrolled in the 8-wk community-based program. Efficacy outcomes included pain-related disability as measured by the Roland Morris Disability Questionnaire (RMDQ), pain intensity, pain self-efficacy, depressive symptoms, social activity, and functional status. Eighty percent of enrollees completed the program. Clinically important decreases in RMDQ scores were found for non-Hispanic White (adjusted change score = -3.53), African American (-3.89), and Hispanic (-8.45) participants. Improvements in all other outcomes were observed, but only for Hispanic participants. Results confirm that implementation of the protocol in urban senior centers is feasible, and the program shows potential efficacy. The race/ethnicity differences observed in the current study merit further investigation. [ABSTRACT FROM AUTHOR]

Objectives To understand the perspectives of both patients and the person who would make medical decisions for them if they were unable (surrogates) on their participation in advance care planning ( ACP). Design Qualitative cross-sectional study. Setting Community. Participants Thirty-one veterans age 55 years and older and their surrogates. Measurements In interviews conducted with both the veteran and surrogate, they were asked to discuss their participation in four ACP activities: communication about life-sustaining treatment, communication about views on quality of life, completion of a living will, and appointment of a healthcare proxy. They were asked about barriers to and facilitators of ACP engagement. When they did not agree about engagement, they each provided their perspective on what they believed had or had not occurred. Results Many of the same barriers to and facilitators of engagement were discussed by both patients and surrogates. These included difficulty thinking about dying, differences in values, and experiences with others that demonstrated the ability of ACP to decrease burden or avoid conflict. Reasons for disagreements in perceptions about whether communication had occurred included surrogates' need for more detailed information, surrogates' lack of readiness to hear what the patient was saying, and surrogates' reliance on what they know about the patient. For some dyads, participation in the study prompted additional communication, resulting in a better shared understanding of ACP engagement. Conclusion Surrogates can both impede and facilitate engagement in ACP, and they can hold different perceptions from patients regarding this engagement. Efforts to promote ACP may be most successful if they assess and address both patients' and surrogates' attitudes and help to facilitate clear communication between them. [ABSTRACT FROM AUTHOR]

Objectives To evaluate age-related differences in sleep-wake symptoms. Design Cross-sectional. Setting Technologist-attended, laboratory-based polysomnography ( PSG). Participants Community-dwelling adults aged 20 to 89 (N = 201): 52 aged 18 to 39, 72 aged 40 to 59, and 77 aged 60 and older. Measurements Medical burden (Charlson Comorbidity Index, medications, health status), PSG-defined sleep disorders (sleep-disordered breathing ( SDB), sleep-associated hypoxemia, periodic limb movements in sleep ( PLMS)), sleep-wake symptoms (Epworth Sleepiness Scale ( ESS), Insomnia Severity Index ( ISI), fatigue (Facit-F Scale)). Results Medical burden increased significantly with age (Charlson Comorbidity Index and number of medications, P < .001; health status, P = .005). Severity of sleep disorders also increased significantly with age ( SDB and hypoxemia, P < .001; PLMS, P = .008). Conversely, sleep-wake symptoms decreased with age (daytime drowsiness ( ESS ≥ 10), P = .02; insomnia ( ISI ≥ 8), P = .04; fatigue, P < .001). In adjusted models, a 1-year increase in age was significantly associated with a 4% decrease in the odds of having daytime drowsiness (odds ratio ( OR) = 0.96, 95% confidence interval ( CI) = 0.93-0.98). Similarly, but only in those with mild SDB, a 1-year increase in age was significantly associated with a 5% decrease in the odds of having insomnia ( OR = 0.95, 95% CI = 0.92-0.99). Conclusion Older age was characterized by less-severe sleep-wake symptoms (daytime drowsiness, insomnia, fatigue), despite an age-related increase in disease severity (medical burden, sleep disorders). Because the increase in disease severity included well-established risk factors for having sleep-wake symptoms, the age-related decrease in sleep-wake symptoms may reflect a decrease in symptom awareness. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the associations between sleep disturbances and driving practices, including driving cessation and trajectories of daily driving mileage (change over time), in older drivers. Design Longitudinal. Setting New Haven, Connecticut. Participants Four hundred thirty older drivers, mean age 78.5, recruited from clinic and community sites. Measurements Baseline measures included medical history, daily driving mileage, Insomnia Severity Index ( ISI), Epworth Sleepiness Scale ( ESS), and Sleep Apnea Clinical Score ( SACS). Longitudinal outcomes included at least one episode of driving cessation and trajectories of miles driven per day, as recorded every 6 months over 2 years. Results At baseline, participants drove an average of 22.2 miles per day; 26.0% (112/430) had insomnia ( ISI ≥ 8), 19.3% (83/430) had daytime drowsiness ( ESS ≥ 10), and 19.9% (84/422) had high sleep apnea risk ( SACS > 15). The sleep-based predictors of insomnia (risk ratio ( RR) = 1.20, 95% confidence interval ( CI) = 0.65-2.20), daytime drowsiness ( RR = 0.94, 95% CI = 0.46-1.95), and high sleep apnea risk ( RR = 0.62, 95% CI = 0.27-1.42) did not confer a significantly greater risk of driving cessation. Insomnia was the only sleep-based predictor that conferred a significant change in driving mileage, yielding an average decrease of 4.5 miles per day over 2 years ( P = .01). In the insomnia model, covariates that were associated with less driving mileage were polypharmacy (≥4 medications) and each year of additional age, yielding an average decrease of 8.3 ( P = .01) and 0.4 miles per day ( P = .02), respectively, over 2 years. Conclusion In a cohort of older drivers, insomnia and the covariates of polypharmacy and advancing age were longitudinally associated with less daily driving mileage. Because reductions in driving mileage in older persons often occur in response to reductions in driving capacity, these results support a clinical approach that considers insomnia-based cognitive-behavioral therapy and reduced polypharmacy as strategies for improving driving capacity in older persons. [ABSTRACT FROM AUTHOR]

Objectives To design a tool for nonvalvular atrial fibrillation ( NVAF) to inform individuals of their individual stroke and bleeding risks, assist in clarifying priorities, and promote communication. Design Clustered randomized controlled trial. Setting Primary care clinics. Participants Individuals with NVAF (N = 135). Intervention Completion of tool before regularly scheduled visit. Measurements Primary outcomes included the 100-point informed and values clarity subscales of the decisional conflict scale (lower scores indicate individual is more informed and has greater clarity). Secondary outcomes included knowledge, patient-clinician communication, and change in treatment. Results Sixty-nine individuals were enrolled in the intervention group and 66 in the control group. After their visit, intervention participants had lower scores on the informed (mean difference = −11.9, 95% confidence interval ( CI) = −21.1 to −2.7) and values clarity subscales (mean difference = −14.6, 95% CI = −22.6 to −6.6). Greater proportions of intervention participants knew medications for reducing stroke risk (61% vs 31%, P < .001) and side effects (49% vs 37%, P = .07). Stroke (71% vs 12%) and bleeding risk (69% vs 20%) were discussed more frequently in the intervention than control group ( P < .001). Five intervention participants expressed a preference for medication that was not concordant with their current treatment plan. There was no change in treatment plan in either group. Conclusion The tool was effective in improving perceived and actual knowledge and values clarity and in increasing physician-patient communication but did not change treatment. [ABSTRACT FROM AUTHOR]

To examine agreement between older persons and their surrogates regarding participation in advance care planning (ACP). Observational cohort study. Community. Persons aged 65 and older and the individual they identified as most likely to make treatment decisions on their behalf. Older persons were asked about participation in four activities: completion of living will, completion of healthcare proxy, communication regarding views about life-sustaining treatment, and communication regarding views about quality versus quantity of life. Surrogates were asked whether they believed the older person had completed these activities. Of 216 pairs, 81% agreed about whether a living will had been completed (κ=0.61, 95% confidence interval (CI) 0.51-0.72). Only 68% of pairs agreed about whether a healthcare proxy had been completed (κ=0.39, 95% CI 0.29-0.50), 64% agreed about whether they had communicated regarding life-sustaining treatment (κ=0.22, 95% CI 0.09-0.35), and 62% agreed about whether they had communicated regarding quality versus quantity of life (κ=0.23, 95% CI 0.11-0.35). Although agreement between older persons and their surrogates regarding living will completion was good, agreement about participation in other aspects of ACP was fair to poor. Additional study is necessary to determine who is providing the most accurate report of objective ACP components and whether agreement regarding participation in ACP is associated with greater shared understanding of patient preferences. [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]