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Aim: To examine how health system design and delivery can fail to support the needs of LGBT+ older adults., Background: LGBT+ older adults face barriers in access to care, impacting their ability to receive person-centred care in old age, which is central to the prevention and management of frailty, disability and disease., Evaluation: Using a conceptual framework of access to care, this commentary illustrates issues LGBT+ older adults may face in accessing health and social care services in Ireland, and provides examples of how access may be improved from the published international literature., Key Issue(s): Health policies, service design and delivery all impact on the ability of the health system to meet the needs of LGBT+ older adults across all levels and types of care., Conclusion: Heteronormativity and discrimination must be addressed across the whole health system to achieve the health policy goal of supporting all older adults to enjoy health and well-being., Implications for Nursing Management: We suggest nursing professionals use a systems perspective to address the multilevel issues relating to care for LGBT+ older adults. Researchers in gerontological nursing should include the experiences and outcomes of service utilization for LGBT+ older adults in their research agenda., (© 2020 The Authors. Journal of Nursing Management published by John Wiley & Sons Ltd.)

Background: End-of-life experience is a subject of significant policy interest. National longitudinal studies offer valuable opportunities to examine individual-level experiences. Ireland is an international leader in palliative and end-of-life care rankings. We aimed to describe the prevalence of modifiable problems (pain, falls, depression) in Ireland, and to evaluate associations with place of death, healthcare utilisation, and formal and informal costs in the last year of life., Methods: The Irish Longitudinal Study on Ageing (TILDA) is a nationally representative sample of over-50-year-olds, recruited in Wave 1 (2009-2010) and participating in biannual assessment. In the event of a participant's death, TILDA approaches a close relative or friend to complete a voluntary interview on end-of-life experience. We evaluated associations using multinomial logistic regression for place of death, ordinary least squares for utilisation, and generalised linear models for costs. We identified 14 independent variables for regressions from a rich set of potential predictors. Of 516 confirmed deaths between Waves 1 and 3, the analytic sample contained 375 (73%) decedents for whom proxies completed an interview., Results: There was high prevalence of modifiable problems pain (50%), depression (45%) and falls (41%). Those with a cancer diagnosis were more likely to die at home (relative risk ratio: 2.5; 95% CI: 1.3-4.8) or in an inpatient hospice (10.2; 2.7-39.2) than those without. Place of death and patterns of health care use were determined not only by clinical need, but other factors including age and household structure. Unpaid care accounted for 37% of all care received but access to this care, as well as place of death, may be adversely affected by living alone or in a rural area. Deficits in unpaid care are not balanced by higher formal care use., Conclusions: Despite Ireland's well-established palliative care services, clinical need is not the sole determinant of end-of-life experience. Cancer diagnosis and access to family supports were additional key determinants. Future policy reforms should revisit persistent inequities by diagnosis, which may be mitigated through comprehensive geriatric assessment in hospitals. Further consideration of policies to support unpaid carers is also warranted.