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Over the course of a lifetime, the risk of experiencing multiple chronic conditions (multimorbidity) increases, necessitating complex healthcare regimens. Healthcare that manages these requirements in an integrated way has been shown to be more effective than services that address specific diseases individually. One such chronic condition that often accompanies ageing is hearing loss and related symptoms, such as tinnitus. Hearing loss is not only highly prevalent in older adults but is also a leading cause of disability. Accumulating evidence demonstrates an interplay between auditory function and other aspects of health. For example, poorer cardiometabolic health profiles have been shown to increase the risk of hearing loss, which has been attributed to microvascular disruptions and neural degeneration. Additionally, hearing loss itself is associated with significantly increased odds of falling and is a potentially modifiable risk factor for cognitive decline and dementia. Such evidence warrants consideration of new possibilities—a new horizon—for hearing care to develop a holistic, person-centred approach that promotes the overall health and wellbeing of the individual, as well as for audiology to be part of an interdisciplinary healthcare service. To achieve this holistic goal, audiologists and other hearing healthcare professionals should be aware of the range of conditions associated with hearing loss and be ready to make health promoting recommendations and referrals to the appropriate health practitioners. Likewise, healthcare professionals not trained in audiology should be mindful of their patients’ hearing status, screening for hearing loss or referring them to a hearing specialist as required.

Editor's note: This article is by 22 nursing gerontology experts who are all advocates of nursing home reform. They are listed at the end of this article.

Author(s): Joo, Yoonmee | Advisor(s): Wallhagen, Margaret | Abstract: Background: Age-related hearing loss effects negatively on an individual’s physical, psychosocial, and social status. Hearing loss may be accelerated in patients taking ototoxic medications. Given the high prevalence of hearing loss, drug-related ototoxicity among older adults may be a critical public health problem.Objectives: The aims of this dissertation were: 1) to identify risk factors of age-related hearing loss from a literature review; 2) to explore the prevalence of ototoxic medication use and the associated factors for ototoxic medication use; 3) to investigate the association of ototoxic medication use with incidence and progression of hearing loss.Methods: A search of the literature on risk factors for age-related hearing loss was performed using the electronic PubMed database. The research data were extracted from the Epidemiology of Hearing Loss Study datasets. The cohort was examined in 1993-1995 (n = 3753), 1998-2000 (n = 2800), and 2003-2005 (n = 2395) in Beaver Dam, Wisconsin. Medication use was obtained from the standardized questionnaire that was administered by the examiners. Hearing loss was defined as a pure tone average at 500, 1000, 2000, and 4000 Hz greater than 25 dB HL in either ear. Results: The Literature review revealed that the most consistently strong risk factors for age-related hearing loss across the studies were genetics, current smoking, diabetes, cardiovascular diseases, and obesity. The prevalence of any ototoxic medication use increased from 84% to 91% over the 10-year follow-up period. Non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and diuretics were common ototoxic medications taken by older adults. Hypertension, diabetes, cardiovascular diseases, and history of smoking were associated with ototoxic medication use. Participants who took loop diuretics had a high incidence of hearing loss for 10 years. Participants who took NSAIDs or a loop diuretic had worse progression of hearing loss over 10 years. Also, the use of concomitant ototoxic medications was associated with the incidence and severity of hearing loss.Conclusion: Ototoxicity may interact with aging leading to a more severe hearing loss than that associated with age alone. The findings suggest that ototoxic medications should be considered a potentially modifiable contributor to age-related hearing loss.

Context Discussions regarding values and goals of care are central to providing quality palliative care. An inability to hear during these sensitive discussions may significantly impair the quality of care provided, yet hearing loss (HL) is not formally addressed in these settings or in programs designed to assist practitioners gain advanced communication skills. Objective To gain an understanding of hospice and palliative care practitioners' experiences with HL and its impact on the care provided. Method SurveyMonkey questionnaire eliciting whether and how HL impacted care provided with an open-ended question asking for descriptions of a situation where HL created a problem in communication with an older patient. Responses were analyzed using constant comparative techniques. Results Of 510 respondents, 464 (91%) reported HL had some or great impact on the quality of care provided, 449 (88%) noted encountering a situation where HL impaired communication with an older adult, and 99 of these participants (22%) provided a specific example. The overarching theme was “Diagnostic and Treatment Uncertainty.” Nonmutually exclusive categories underpinning this theme included the following: unable to get needed information, misinterpreting level of understanding, patient misunderstanding of instructions, and goals-of-care errors. Conclusion HL impacts the quality of care provided to persons with serious illness by disrupting the identification, assessment, and treatment of the physical, psychosocial, and spiritual symptoms an individual is experiencing. HL should be formally addressed in programs designed to develop skills in conducting sensitive conversations. Practitioners should screen for HL, use practices that facilitate comprehension, and use assistive listening devices as needed.

This cohort study assesses the association between hearing impairment and decline in physical function in terms of balance and walking endurance in a group of community-dwelling older adults in the US., Key Points Question Is hearing impairment associated with poorer physical function, reduced walking endurance, and faster decline in physical function? Findings In this population-based cohort study of 2956 older adults in the US, participants with hearing impairment had significantly poorer physical function (particularly balance), worse walking endurance (over a 2-minute walk), and faster declines in physical function over time compared with those with normal hearing. Meaning This study’s findings suggest that because hearing impairment is a prevalent but treatable condition, it may be a target for interventions to slow the decline of physical function associated with aging., Importance Hearing impairment, a common treatable condition, may contribute to poorer physical function with aging. Objective To assess whether hearing impairment is associated with poorer physical function, reduced walking endurance, and faster decline in physical function. Design, Setting, and Participants In this cohort study, cross-sectional and longitudinal analyses were performed using data from the 2011 to 2019 period of the Atherosclerosis Risk in Communities study, a population-based study of community-dwelling adults at 4 sites in the US. Exposures Hearing thresholds (per 10 dB) assessed with pure tone audiometry and categorized as normal hearing or mild, moderate, or severe hearing impairment. Main Outcomes and Measures Physical function was assessed using the short physical performance battery (SPPB), with composite scores ranging from 0 to 12. A composite score of 6 or less and a score for each component (balance, gait speed, and chair stands) of 2 or less indicated poor performance. Walking endurance was assessed using a 2-minute fast-paced walk test. Tobit regression models adjusted for sociodemographic factors and medical history were used to calculate the mean differences in SPPB composite scores; logistic regression models, to estimate the odds ratios (ORs) of low SPPB composite and component scores; and linear mixed-effects models, to estimate the mean rate of change in SPPB composite scores over time. Results Of the 2956 participants (mean [SD] age, 79 [4.6] years) who attended study visit 6 between 2016 and 2017, 1722 (58.3%) were women, and 2356 (79.7%) were White. As determined by pure tone audiometry, 973 (33%) participants had normal hearing, 1170 (40%) had mild hearing impairment, 692 (23%) had moderate hearing impairment, and 121 (4%) had severe hearing impairment. In the Tobit regression model, severe hearing impairment was associated with a lower mean SPPB score (β, –0.82; 95% CI, –0.34 to –1.30) compared with normal hearing. In fully adjusted logistic regression models, hearing impairment was associated with higher odds of low physical performance scores (severe impairment vs normal hearing: OR for composite physical performance, 2.51 [95% CI, 1.47-4.27]; OR for balance, 2.58 [95% CI, 1.62-4.12]; OR for gait speed, 2.11 [95% CI, 1.03-4.33]). Over time (2 to 3 visits; maximum, 8.9 years), participants with hearing impairment had faster declines in SPPB compared with those with normal hearing (moderate hearing impairment × time interaction, –0.34 [–0.52 to –0.16]). In adjusted models for walking endurance, participants with moderate or severe hearing impairment walked a mean distance of –2.81 m (95% CI, –5.45 to –0.17 m) and –5.31 m (95% CI, –10.20 to –0.36 m) than those with normal hearing, respectively, during the 2-minute walk test. Conclusions and Relevance In this cohort study, hearing impairment was associated with poorer performance, faster decline in physical function, and reduced walking endurance. The results of the longitudinal analysis suggest that hearing impairment may be associated with poorer physical function with aging. Whether management of hearing impairment could delay decline in physical function requires further investigation.

Hearing loss is associated with multiple physical, cognitive, and psychosocial co-morbidities. Achievement of safe healthcare in the context of these complex co-morbidities necessitates accurate hearing and coordination across specialties. This paper discusses the potentials for and barriers to an interprofessional approach to integrating hearing screening and treatment across all healthcare settings.The paper reviews the relationship between hearing loss and other health care concerns to emphasise the need for an inclusive, coordinated, interprofessional approach; discusses interprofessional and patient/family centred coordinated care as essential to achieving quality care; and introduces the Age Friendly Health System initiative as a framework that could be leveraged to move towards comprehensive hearing healthcare.The literature highlights prior work identifying gaps in quality care and the need for new and innovative approaches to evolve interdisciplinary and interprofessional collaborations to achieve comprehensive healthcare. The literature also provides support for using the Age-Friendly initiative as a point of leverage.Bringing together thought leaders from the health care provider community, World Health Organisation, age-friendly cities movement, and field of architecture to coordinate the integration of hearing healthcare into Age Friendly Health Systems initiatives has potential to achieve comprehensive hearing healthcare across healthcare settings. (198).

Despite the need for leaders in health care improvement across health professions, there are no standards for the knowledge and skills that should be achieved through advanced interprofessional health care improvement training. Existing health care improvement training competencies focus on foundational knowledge expected of all trainees or for specific career pathways. Health care improvement leaders fill multiple roles within organizations and promote interprofessional improvement practice. The diverse skill set required of modern health care improvement leaders necessitates the development of training competencies specifically for fellowships in applied health care improvement.The authors describe the development of the revised national Veterans Affairs Quality Scholars (VAQS) Program competencies. The VAQS Program is an interprofessional, postdoctoral training program whose mission is to develop leaders and scholars to improve health care. An interprofessional committee of VAQS faculty reviewed and revised the competencies over 4 months beginning in fall 2018. The first draft was developed using 111 competencies submitted by eleven VAQS training sites and a review of published competencies. The final version included 22 competencies spanning 5 domains: interprofessional collaboration and teamwork; improvement and implementation science; organization and system leadership; methodological skills and analytic techniques for improvement and research; and teaching and coaching.Once attained, the VAQS competencies will guide the skill development that interprofessional health care improvement leaders need to participate in and lead health care improvement scholarship and implementation. These broad competencies are relevant to advanced training programs that develop health care improvement leaders and scholars and may be used by employers to understand the knowledge and skills expected of individuals who complete advanced fellowships in applied health care improvement.

With the continued loss of lives due to HIV/AIDS in sub-Saharan Africa, grandparents bear the stress of caring for children affected by the epidemic, often with very limited resources. Yet, despite the acknowledgement that these older adults serve as the backbone and safety net of the African family in this HIV/AIDS era, very limited research has focused on investigating the specific health outcomes of caregivers in this region and how these changes in health status impact the overall quality of life of caregivers. This study highlights the stress perceived by Ugandan grandparent-caregivers, its impact on their overall quality of life, and the coping strategies they use to manage their stress. Thirty-two grandparent-caregivers (age 50 years and older) were recruited from urban and rural areas in Uganda and individually interviewed in 2016. Using constructivist grounded theory as the qualitative methodology, the narratives generated from the semi-structured, one-on-one interviews were audio-recorded, transcribed, and analyzed using both open and axial coding as well as reflexive and analytic memoing. Descriptions of caregiver stress (physical, emotional, financial, and social) were reported. Additionally, study findings uniquely explore the impact of the perceived stress on the grandparents’ overall quality of life. Study findings provide a foundation upon which clinicians, researchers, and policy-makers can design and implement effective interventions to improve the health and quality of life of grandparent-caregivers in sub-Saharan Africa.

Hearing loss (HL) becomes increasingly common with age and can lead to multiple negative outcomes, including isolation, falls, depression, altered social relationships, and altered cognitive functioning. HL also can affect patient–provider communication and lead to misunderstandings. Despite the negative effects that HL has on multiple domains, less than 20% to 25% of individuals who might benefit from amplification devices and/or hearing aids own them. Barriers to use include stigma, cost, and access. Nurses can play a critical role in promoting appropriate care for individuals with HL and providing access for those who need hearing aids. The current article (a) briefly reviews how history and policies, especially Medicare and Medicaid, but also those defining the practice of audiology and dispensing of hearing aids, affect insurance coverage for hearing care; (b) reviews how a combination of forces brought the need for accessible and affordable hearing care to national attention and resulted in the Over-the-Counter (OTC) Hearing Aid Act; and (c) discusses the implications of the OTC Act for nurses and nursing practice. [ Journal of Gerontological Nursing, 44 (9), 9–14.]

CONTEXT:The most common adverse effects from neurotoxic chemotherapy are chemotherapy-induced neuropathy (CIPN), hearing loss, and tinnitus. Although associations between perceived stress and persistent pain, hearing loss, and tinnitus are documented, no studies have examined these associations in cancer survivors who received neurotoxic chemotherapy. OBJECTIVES:In this cross-sectional study, we evaluated for associations between perceived stress and the occurrence of CIPN, hearing loss, and tinnitus, in 623 adult cancer survivors who received platinum and/or taxane compounds. METHODS:Survivors completed self-report measures of hearing loss, tinnitus, and perceived stress (i.e., Impact of Events Scale-Revised [IES-R]). Separate logistic regression analyses were done for each neurotoxicity to evaluate whether each of the IES-R subscale (i.e., intrusion, avoidance, hyperarousal) and total scores made a significant independent contribution to neurotoxicity group membership. RESULTS:Of the 623 survivors in this study, 68.4% had CIPN, 34.5% reported hearing loss, and 31.0% reported tinnitus. Older age, higher body mass index, poorer functional status, being born prematurely, cancer diagnosis, and higher intrusion (P=0.013), hyperarousal (P=0.014), and total (P=0.047) IES-R scores were associated with CIPN. Older age, being male, poorer functional status, a worse comorbidity profile, and a higher IES-R hyperarousal (P=0.007) score were associated with hearing loss. Being male, having less education, a worse comorbidity profile, and a higher IES-R hyperarousal (P=0.029) score were associated with tinnitus. CONCLUSION:These findings suggest that increased levels of perceived stress are associated with the most common chemotherapy-induced neurotoxicities.

Objectives: To assess the experiences of people with hearing loss in healthcare environments to characterize miscommunication and unmet needs, and guide recommendations for improving outcomes and access. Methods: Anonymous survey developed by subject-matter experts was posted on a large national hearing-loss consumer and advocacy organization website and email listserv. Data were collected and managed via RedCAP. Results: Responses were received from 1581 individuals. Respondents reported moderate or significant difficulty communicating with all listed providers. Three communication situations emerged as often presenting communication difficulties: hearing one's name when called in the waiting room, hearing when the speaker's back was turned, and hearing when communicating by telephone. Despite 93% of respondents indicating they sometimes or often let providers know about their hearing loss, 29.3% of all respondents still reported that no arrangements were made to improve communication. Conclusions: This study clearly demonstrates the ongoing difficulties faced by individuals with hearing loss, particularly older adults, as they attempt to navigate both providers and situations associated with a typical primary care office visit. Clinical Implications: Inexpensive and efficient changes to improve communication include (1) Improving one-on-one provider communication by facing the individual with good lighting, clear speaking, and not obstructing one's mouth; (2) Environmental changes such as using visual or tactile alerting devices in waiting rooms and adding noise-dampening carpeting and curtains; and (3) Avoiding telephones and conveying health information in writing.

Pain is a significant problem for nursing home residents, yet its assessment is complex. Certified nursing assistants (CNAs) spend significant time with residents, but their role in understanding residents' pain is largely unexplored. The current qualitative grounded theory study analyzed interviews with 16 CNAs who described their experiences caring for residents in pain. Findings revealed how CNAs understood, recognized, interpreted, and responded to residents' pain. CNAs were found to differentiate between pain that they considered normal (everyday pain) and new pain judged significant enough to report to licensed nurses. CNAs exhibited a holistic understanding of pain, knowledge of strategies to identify and interpret pain, and actions to independently mitigate and report pain. Although additional confirmatory data are needed, the differentiation made between everyday and reportable pain may have important clinical implications suggesting that CNAs should always report to a licensed nurse when they perceive or suspect that residents have pain. [ Journal of Gerontological Nursing, 44 (4), 29–36.]

Context Older adults with advanced illness and associated symptoms may benefit from primary palliative care, but limited data exist to identify older adults in U.S. primary care to benefit from this care. Objectives To describe U.S. primary care visits among adults aged 65 years and older with advanced illness. Methods Cross-sectional analysis of the National Ambulatory and Hospital Ambulatory Medical Care Surveys (2009–2011) was conducted using Chi-squared tests to compare visits without and with advanced illness with U.S. primary care defined by National Committee for Quality Assurance Palliative and End-of-Life Care Physician Performance Measurement Set International Classification of Diseases, Ninth Revision (ICD-9) codes for end-stage illness. Results Among visits by older adults to primary care, 7.9% visits were related to advanced illness. A higher proportion of advanced illness visits was among men vs. women (8.9% vs. 7.2%; P = 0.03) and adults aged 75 years and older, non-Hispanic whites (8.3%) and blacks (8.2%) vs. Hispanic (6.7%) and non-Hispanic other (2.5%) ( P = 0.02), dually eligible for Medicare and Medicaid, and from patient ZIP Codes with lower median household incomes (below $32,793). A higher percentage of visits with advanced illness conditions to primary care was chronic obstructive pulmonary disease, congestive heart failure, dementia, and cancer, and symptoms reported with these visits were mostly pain, depression, anxiety, fatigue, and insomnia. Conclusion In the U.S., approximately 8% primary care visits among older adults was related to advanced illness conditions. Advanced illness visits were most common among those most likely to be socioeconomically vulnerable and highlight the need to focus efforts for high-quality palliative care for these populations.

The purpose of this study was to assess occupational injury characteristics and predictors among career firefighters. A total of 249 firefighters from central Texas and northern California participated in this Internet-based survey. Approximately 27% of firefighters had reported an occupational injury within the previous 12 months. The majority of injuries occurred on the scene of a non-fire call while performing an activity that required lifting, pushing, or pulling. Firefighters’ backs were most frequently injured. Of the reported injuries, approximately 18% returned to work on modified duty, but 46% were not allowed to work due to their occupational injuries. Firefighters who reported occupational injuries were more likely to be older and experiencing occupational stress compared with their coworkers who did not report occupational injuries. Injured firefighters were also more likely to report fewer job rewards (money/salary), overcommitment, less esteem (respect and support), and fewer promotional prospects. These injury factors should be incorporated into interventions to reduce or prevent workplace injuries.

PURPOSE:Limited information is available on the impact of chemotherapy (CTX)-induced neurotoxicity on adult survivors' symptom experience and quality of life (QOL). Purposes were to describe occurrence of hearing loss and tinnitus and evaluate for differences in phenotypic characteristics and measures of sensation, balance, perceived stress, symptom burden, and QOL between survivors who received neurotoxic CTX and did (i.e., neurotoxicity group) and did not (i.e., no neurotoxicity group) develop neurotoxicity. Neurotoxicity was defined as the presence of chemotherapy-induced neuropathy (CIN), hearing loss, and tinnitus. Survivors in the no neurotoxicity group had none of these conditions. METHODS:Survivors (n = 609) completed questionnaires that evaluated hearing loss, tinnitus, stress, symptoms, and QOL. Objective measures of sensation and balance were evaluated. RESULTS:Of the 609 survivors evaluated, 68.6% did and 31.4% did not have CIN. Of the survivors without CIN, 42.4% reported either hearing loss and/or tinnitus and 48.1% of the survivors with CIN reported some form of ototoxicity. Compared to the no neurotoxicity group (n = 110), survivors in the neurotoxicity group (n = 85) were older, were less likely to be employed, had a higher comorbidity burden, and a higher symptom burden, higher levels of perceived stress, and poorer QOL (all p

Hearing loss, common in older adults, is associated with negative health outcomes but screening rates in primary care clinics are low and individuals screened or referred often do not follow-through. To address these problems, we worked with 2 primary care clinics to design a simple screening and education protocol for integration into a standard office visit. To assess the effectiveness on the education brochure that was developed, we assessed its impact on individuals age 60 or older who screened positive for possible hearing loss. Ninety-four of 125 screened positive. Seventy-one agreed to participate and were given a brochure along with a brief review of the materials it contained. Of 67 completing follow-up, 23 (34%) sought further testing and 47 (70%) had used the information to enhance communication. A simple educational brochure accompanied by a brief review of its contents may enhance effective use of hearing healthcare services. (147).

Background To improve the effectiveness of community-based care programs, especially those targeting the oldest-old population (80+), data are needed that elucidate those factors associated with a successful response to the intervention. Two comparable nurse-led care programs have been evaluated in two large randomized controlled trials (RCTs), one in Switzerland and one in the Netherlands. Aims To identify common patient characteristics that are related to a successful response to proactive nurse-led care, we explored if and to what extent, identical factors were present in both study populations. Methods A secondary data analysis using trial data from the intervention group of both RCTs was conducted. The study sample consisted 461 older adults, 230 from the U-PROFIT trial (the Netherlands) and 231 from the HPC trial (Switzerland). The mean age of the total sample was 85.1 years (SD 3.7). The UPROFIT intervention, delivered by registered nurses, included a frailty assessment and a comprehensive geriatric assessment (CGA) at home followed by an individualized evidence-based care plan, care coordination, and follow-up. The HCP intervention was delivered by advanced practice nurses consisting of four home visits and three phone calls, and was guided by the principles of health promotion, empowerment, partnership, and family-centeredness. A successful response was defined as “stable” or “no decline” in daily functioning at follow-up. Daily functioning was measured with 13 items of activities of daily living and instrumental activities of daily living. Multivariate logistic regression models were applied to calculate the association between individual characteristics and a successful response. Results Almost half of the participants in the U-PROFIT trial (50.9%), and two-thirds (65.7%) of the participants in the HCP trial had a successful response at follow-up. Fewer comorbidities and a better self-rated health had the strongest predictive value for benefiting from the intervention (OR = 0.83 [95% CI 0.66–1.03], and OR = 1.5 [95% CI 0.92–2.45]), respectively. Linking Evidence to Action Two large RCTs demonstrated that a preventive nurse-led care program can preserve daily functioning in the oldest-old population. Older people with few comorbidities and higher self-rated health had a higher likelihood of a positive outcome. Unraveling the characteristics associated with a successful response provides important information for further refining and targeting an intervention to obtain maximum effectiveness. More effort is needed to modify interventions for the oldest-old with multiple morbidities and low levels of education.

AIMS AND OBJECTIVES The findings presented in this manuscript address two key research questions: (a) What factors contribute to the initiation and maintenance of the caregiving role as performed by the grandparent-caregivers; and (b) What are the perceived benefits of caregiving as reported by grandparent-caregivers? BACKGROUND Grandparents in sub-Saharan Africa have cared for their grandchildren for generations, yet little is known about this role in the context of the HIV epidemic. Although the impact of the epidemic is overwhelmingly negative, specifically in Uganda, knowledge of familial context and underlying motivations and rewards that incentivise grandparent-caregivers remains limited in the literature. METHODS Using a constructivist grounded theory approach, we explored the experiences of 32 Ugandan grandparents of grandchildren affected by HIV. Data were collected using a semi-structured and open-ended interview guide, participant observation and fieldnotes. Data analysis included open, focused and axial coding. FINDINGS The data revealed the influences of extended familial structures and of cultural and gender expectations on the decision-making processes and rewards of caregiving as perceived by the grandparent-caregivers. DISCUSSION AND RECOMMENDATION These findings provide a broad foundation for policy, practice, research and education interventions needed to support grandparents so they can enjoy the benefits of raising their grandchildren. IMPLICATIONS FOR PRACTICE Our findings can guide education programs and clinical practice for nurses, nursing students, and other health providers on cultural considerations for holistic care provided for older adults-especially older caregivers.

Objectives To explore how older adults in the community with a limited life expectancy make healthcare decisions and the processes used when they are not in an acute crisis. Design Grounded theory. Setting Medical programs and geriatrics clinics at the University of California, San Francisco, and the San Francisco Veterans Affairs Medical Center. Participants Community-dwelling adults aged 67 to 98 with a life expectancy of less than 1 year (N = 20). Measurements In-depth semistructured interviews in participants’ homes. Constant comparative analysis was used to develop codes and identify themes. Results Participants generally delegated decisions to others, expressing their wishes by describing desired end-of-life outcomes and highlighting meaningful aspects of their lives. They did this in the belief that the delegate would make appropriate decisions on their behalf. In this way, participants were able to achieve a sense of control without being in control of decisions. Four themes emerged from the analysis that reflect the various approaches participants used to articulate their goals and maintain a sense of control: direct communication, third-party analogies, adaptive denial, and engaged avoidance. Conclusion These findings challenge the prevailing view of personal autonomy. These older adults suggest a path to decision-making that focuses on priorities and goals, allowing them to take a more-passive approach to decision-making while still maintaining a sense of control.

Background Knowledge about expected recovery after hip fracture is essential to help patients and families set realistic expectations and plan for the future.

Hearing deficits are highly prevalent among older adults and are associated with declines in cognitive, physical, and mental health. However, hearing loss in the geriatric population often goes untreated and generally receives little clinical emphasis in primary care practice. This article reviews hearing health care for older adults, focusing on what is most relevant for family physicians. The objective of hearing loss treatment is to ensure that a patient can communicate effectively in all settings. We present the 5 major obstacles to obtaining effective hearing and rehabilitative care: awareness, access, treatment options, cost, and device effectiveness. Hearing technologies are discussed, along with recommendations on when it is appropriate to screen, refer, or counsel a patient. The purpose of this article is to provide pragmatic recommendations for the clinical management of the older adult with hearing loss that can be conducted in family medicine practices.

Community-based palliative care (CBPC) plays an integral role in addressing the complex care needs of older adults with serious chronic illnesses, but is premised on effective communication and collaboration between primary care providers (PCPs) and the providers of specialty palliative care (SPC). Optimal strategies to achieve the goal of coordinated care are ill-defined.The objective of this study was to understand the facilitators and barriers to optimal, coordinated interdisciplinary provision of CBPC.This was a qualitative study using a constructivist grounded theory approach. Thirty semistructured interviews were conducted with primary and palliative care interdisciplinary team members in academic and community settings.Major categories emerging from the data that positively or negatively influence optimal provision of coordinated care included feedback loops and interactions; clarity of roles; knowledge of palliative care, and workforce and structural constraints. Facilitators were frequent in-person, e-mail, or electronic medical record-based communication; defined role boundaries; and education of PCPs to distinguish elements of generalist palliative care (GPC) and more complex elements or situations requiring SPC. Barriers included inadequate communication that prevented a shared understanding of patients' needs and goals of care, limited time in primary care to provide GPC, and limited workforce in SPC.Our findings suggest that processes are needed that promote communication, including structured communication strategies between PCPs and SPC providers, clarification of role boundaries, enrichment of nonspecialty providers' competence in GPC, and enhanced access to CBPC.

PURPOSE:The purpose of this study was to evaluate for differences in demographic, clinical, and pain characteristics, as well as measures of sensation, balance, perceived stress, symptom burden, and quality of life (QOL) among survivors who received neurotoxic chemotherapy (CTX) and who reported only chemotherapy-induced neuropathy (CIN, n=217), CIN and hearing loss (CIN/HL, n=69), or CIN, hearing loss, and tinnitus (CIN/HL/TIN, n=85). We hypothesized that as the number of neurotoxicities increased, survivors would have worse outcomes. METHODS:Survivors were recruited from throughout the San Francisco Bay area. Survivors completed self-report questionnaires for pain and other symptoms, stress and QOL. Objective measures were assessed at an in person visit. RESULTS:Compared to survivors with only CIN, survivors with all three neurotoxicities were less likely to be female and less likely to report child care responsibilities. In addition, survivors with all three neurtoxicities had higher worst pain scores, greater loss of protective sensation, and worse timed get up and go scores. These survivors reported higher state anxiety and depression and poorer QOL. For some outcomes (e.g., longer duration of CIN, self-reported balance problems), significantly worse outcomes were found for the survivors with CIN/HL and CIN/HL/TIN compared to those with only CIN. CONCLUSIONS:Our findings suggest that compared to survivors with only CIN, survivors with CIN/HL/TIN are at increased risk for the most severe symptom burden, significant problems associated with sensory loss and changes in balance, as well as significant decrements in all aspects of QOL.

Background and purpose Drug-related ototoxicity may exacerbate presbycusis (age-related hearing loss); yet, few data are available on the prevalence of ototoxic medication use by older adults. The purposes of this study were to assess the impact of aging and ototoxicity on hearing loss, the prevalence of ototoxic medication use, and select characteristics associated with ototoxic medication use among older adults. Methods Cross-sectional analyses were conducted using select variables extracted from the baseline and 10-year follow-up assessments of the two population-based epidemiological studies to compare two points in time. Results Ninety-one percent of the sample was taking a medication reported to be ototoxic. Nonsteroidal anti-inflammatory drugs were the most commonly used (75.2%), followed by acetaminophen (39.9%) and diuretics (35.6%). Hypertension, diabetes, cardiovascular disease, and history of smoking were associated with ototoxic medication use. Participants with hearing loss were taking a significantly greater number of ototoxic medications than those without hearing loss. Conclusion Known ototoxic medications are widely used. Any subsequent ototoxicity may interact with age changes and a more severe hearing loss than that associated with only age. Implications for practice Nurse practitioners should inform older adults about the possibility of drug-related ototoxicity and monitor hearing acuity of all older adults taking known ototoxic medications.

Research focused on understanding that the nature of hospice decision making has both described the characteristics of those who do and do not utilize hospice and identified many factors related to choosing hospice. However, this literature has not explored the underlying decision-making processes, limiting our understanding. We examine the extant literature and propose a framework that views hospice decisions as an evolving process, identify key factors that bear directly on this process, and discuss the contextual environment, including the idea of a decision maker triad. We end with a discussion of how this framework can be used to support clinical practice and future research. Our goal is to provide a framework from which to understand the end-of-life needs of all patients, no matter where they receive care.

Objectives To compare hearing loss screening results of four simple tests with those of hand-held audiometry. Design Cross-sectional study of individuals screened during intake for physicals and other routine procedures. Setting Two primary care clinics in the San Francisco Bay area. Participants Older adults not wearing hearing aids (N = 125, mean age 72.9, 63% female). Measurements Direct question about hearing loss, indirect question, finger-rub test, whisper test, and audiometric results using a hand-held audiometer. Results Sensitivity was 91% for the finger-rub test compared with 89% for the direct question, 85% for the indirect question, and 79% for the whisper test. For specificity, the whisper test was highest, followed by the finger rub, indirect, and direct. Conclusion Simple screening procedures can be used to identify older adults with hearing loss in primary care and facilitate early referral for additional testing and treatment.

The purpose of this study was to seek understanding of the experiences of Ugandan grandparents (50-years and older) who provide primary care for their grandchildren. In Uganda, as in the rest of sub-Saharan Africa, the AIDS epidemic has placed a tremendous burden on elderly caregivers. However, limited research has been conducted to explore the impact of this caregiving experience on the physical and mental health of this elderly population. Using Grounded Theory qualitative method, interviews were conducted with grandparents recruited from general population impacted by the HIV/AIDS epidemic. Narratives revealed underlying factors that influenced grandparents’ caregiving experiences. These ranged from Micro (family structure and relationships; community) to Macro (Cultural, national and global). These findings could inform other researchers and clinicians who seek explanatory models upon which to design interventions and social services such as childcare and respite care for older adult caregivers to grandchildren.

Hearing loss (HL) is a common problem; approximately 538 million people older >5 have disabling hearing impairment globally. In the US, approximately 48 million individuals over the age of 12 experience HL which becomes increasingly common with age; approximately 68% of persons 70–79 and >80% of those >80 are affected. Although considered non-life threatening, HL is far from benign and is associated with depression, isolation, falls, and possibly cognitive impairment. Given this, the National Academies of Science released a report in 2016 emphasizing that HL is a significant public health issue needing far greater attention and remains undertreated with only about 20–30% of persons who could benefit from amplification using it, although rates increase with age and HL severity. There are multiple reasons for the low use of services. This brief presentation reviews the work I and colleagues are doing at UCSF addressing several of these factors.

To identify strategies to assist family caregivers of individuals with frontotemporal dementia (FTD) in dealing with their caregiving demands, nurses must understand these family members’ unique needs and how they currently deal with their demands. The purpose of this study was to examine the relationship between coping and caregiver physical and mental health among FTD family caregivers. Participants were primary caregivers of individuals with FTD (with behavioral symptoms) living at home ( N = 61). A small positive association was noted between problem-focused coping and caregiver physical health ( r = 0.29, p < 0.05), and a small but nonsignificant positive correlation was noted between emotion-focused coping and caregiver mental health ( r = 0.21, p = 0.10). However, multiple regression analysis showed that emotion-focused coping (β = 0.46, p < 0.05) made a statistically significant, unique contribution to caregiver mental health and explained approximately 14% of its variance. These findings support the potential value of emotion-focused coping strategies when dealing with behavioral symptoms manifested by individuals with FTD. [ Journal of Gerontological Nursing, 40 (1), 30–40.]

Clinically significant hoarding behaviors (HB) have been defined as acquisition of, and failure to discard, large numbers of items, which limits the use of one’s home and causes functional impairment or distress. HB disproportionally affect adults aged 55 and older, and although research on HB has accelerated in the past decade, few studies focus on older adults. This qualitative study, based on grounded theory methodology, utilized interview data from 22 older adults with HB to understand the dynamic interaction between HB and the aging process. Participants described the specific ways that their chronic HB were complicated by changes in their health status, social context, and home setting, resulting in greater functional impairment and distress. By identifying these changes that commonly occur with age and their synergistic relationship with HB, nurses and other health professionals can develop targeted interventions to improve home safety and support the independence of these older adults.

Understanding changes in decision making among older adults across time is important for health care providers. We examined how older adults with a limited prognosis used their perception of prognosis and health in their decision-making processes and related these findings to prospect theory. The theme of decision making in the context of ambiguity emerged, reflecting how participants used both prognosis and health to value choices, a behavior not fully captured by prospect theory. We propose an extension of the theory that can be used to better visualize decision making at this unique time of life among older adults.

The authors reflect on place-based public health interventions, urbanization, and longevity in relation to a call for American cities to enhance the quality of life for aging and disabled individuals as of 2016. The World Health Organization's Global Network of Age-Friendly Cities and the American Association of Retired Persons (AARP) Livable Communities programs are examined, along with Aging and Disability Friendly San Francisco organization and disability-friendly buildings and spaces.

Objectives To develop a prediction index for 1-year mortality after hip fracture in older adults that includes predictors from a wide range of domains. Design Retrospective cohort study. Settings Health and Retirement Study (HRS). Participants HRS participants who experienced hip fracture between 1992 and 2010 as identified according to Medicare claims data (N = 857). Measurements Outcome measure was death within 1 year of hip fracture. Predictor measures were participant demographic characteristics, socioeconomic status, social support, health, geriatric symptoms, and function. Variables independently associated with 1-year mortality were identified, and best-subsets regression was used to identify the final model. The selected variables were weighted to create a risk index. The index was internally validated using bootstrapping to estimate model optimism. Results Mean age at time of hip fracture was 84, and 76% of the participants were women. There were 235 deaths (27%) during the 1-year follow up. Five predictors of mortality were included in the final model: aged 90 and older (2 points), male sex (2 points), congestive heart failure (2 points), difficulty preparing meals (2 points), and not being able to drive (1 point). The point scores of the index were associated with 1-year mortality, with 0 points predicting 10% risk and 7 to 9 points predicting 66% risk. The c-statistic for the final model was 0.73, with an estimated optimism penalty of 0.01, indicating very little evidence of overfitting. Conclusion The prognostic index combines demographic, comorbidity, and function variables and can be used to differentiate between individuals at low and high risk of 1-year mortality after hip fracture.

The majority of individuals aged 80 and older live in communities, where they are responsible for managing their chronic conditions and any limitations that may complicate their daily lives. To avoid acute episodes or hospitalization, these older individuals require the knowledge and skills necessary to recognize symptoms of destabilization, negotiate support from social networks, create a safe environment, and decide when to use services that the healthcare system provides.1,2 These skills play a crucial role in maintaining health, quality of life, and independent living in the community. Programs aimed at promoting self-care and disease-management skills in persons with particular conditions, such as diabetes mellitus or cardiovascular diseases, have shown promising results in community and primary care settings.3–8 In addition, programs that focus on specific symptoms or problems such as individual falls are also effective in community-dwelling older persons,9,10 but programs that focus on a general population of older people living at home have produced controversial findings about the efficiency of these preventive home visits.11–14 Because frail older persons and persons with disabling health conditions are often excluded from preventive health program studies,15 the effects of such health conditions on functional impairment or healthcare utilization remain unclear in this heterogeneous population. It has been suggested that further research is needed that focuses not only on client groups that benefit most, but also on elderly populations in general, using outcomes of quality of life, mental health, social support, and caregiver burden.15,16 Many chronic illness management programs use advanced practice nurses (APNs) who, given their superior knowledge and skills, are well positioned to deliver and coordinate care that aims to improve the self-management abilities and health competencies of older persons and thus enhance their quality of life.7,8,17–22 With the international rise in the roles assumed by APNs,23,24 research is needed that tests the effectiveness of APN-led community-based programs that are complementary to, and done in collaboration with, the interprofessional healthcare team. The current study examined a new in-home health consultation program (HCP) implemented by APNs for a population of individuals age 80 and older living at home. The HCP comprises a standardized comprehensive geriatric assessment, evidence-based guidelines for prevalent health problems in elderly adults, four in-home consultations customized to individual needs, and three follow-up telephone calls over 9 months. To the knowledge of the authors, this is the first study investigating the use of APN health consultation to promote self-care ability and skills for a home-based population aged 80 and older. The main aim of this study was to evaluate the effectiveness of the HCP in terms quality of life, health indicators, and healthcare utilization. It was hypothesized that the HCP would increase quality of life, reduce adverse health outcomes (falls, acute events), and reduce healthcare utilization (hospitalization).

Background: Providing informal support to someone with frontotemporal dementia (FTD) could be very stressful. Clarifying the relationship between patient behavioral problems and caregiver health could spur future research on effective symptom management strategies. Methods: Sixty-one FTD family caregivers participated in a postal survey. Results: Patient symptom severity was negatively associated with caregiver mental health (r = –0.26, p < 0.05) but not significantly associated with caregiver physical health. In a regression analysis, caregiver emotional distress from patient behaviors made a statistically significant contribution to caregiver mental health, explaining approximately 10% of its variance. Conclusion: This study underscores the importance of focusing on FTD caregivers’ perceived emotional distress from patient behavioral problems and ensuring they are getting the appropriate support they need.

Judgment and problem solving are required when completing activities of everyday living such as writing checks, responding appropriately to strangers, and keeping track of appointments. Damage to the brain, including that caused by certain subtypes of dementia, is associated with the loss of function in judgment and problem solving (Auning, et al., 2011; Fellows and Farah, 2005; Fellows and Farah, 2007; Wallis and Rich, 2011). While the linkage between a decline judgment and problem solving and a decline in functional activities is intuitive, no studies have examined this relationship among individuals with one of the most serious neurodegenerative conditions in older adults, that of dementia. When health care professionals suspect that a decline in judgment and problem solving accompanies a decline in functional status in this population, a targeted specialized assessment of judgment and problem solving may not always be conducted due to time constraints, lack of resources or insufficient expertise. If an empirical relationship between functional status and judgment and problem solving can be documented, it may stimulate health care professionals to obtain a detailed assessment of judgment and problem solving in individuals when declining functional status is noted during a routine examination. Therefore, the purpose of this study was to determine if an empirical relationship exists between judgment and problem solving and functional status and the extent demographics (including dementia subtype) and cognition (mental status and executive function) may moderate that relationship in individuals with dementia.

Importance Nearly 38 million individuals in the United States have untreated hearing loss, which is associated with cognitive and functional decline. National initiatives to address hearing loss are currently under way. Objective To determine whether untreated hearing loss is associated with increased health care cost and utilization on the basis of data from a claims database. Design, Setting, and Participants Retrospective, propensity-matched cohort study of persons with and without untreated hearing loss based on claims for health services rendered between January 1, 1999, and December 31, 2016, from a large health insurance database. There were 154 414, 44 852, and 4728 participants at the 2-, 5-, and 10-year follow-up periods, respectively. The study was conceptualized and data were analyzed between September 2016 and November 2017. Exposures Untreated hearing loss (ie, hearing loss that has not been treated with hearing devices) was identified via claims measures. Main Outcomes and Measures Medical costs, inpatient hospitalizations, total days hospitalized, 30-day hospital readmission, emergency department visits, and days with at least 1 outpatient visit. Results Among 4728 matched adults (mean age at baseline, 61 years; 2280 women and 2448 men), untreated hearing loss was associated with $22 434 (95% CI, $18 219-$26 648) or 46% higher total health care costs over a 10-year period compared with costs for those without hearing loss. Persons with untreated hearing loss experienced more inpatient stays (incidence rate ratio, 1.47; 95% CI, 1.29-1.68) and were at greater risk for 30-day hospital readmission (relative risk, 1.44; 95% CI, 1.14-1.81) at 10 years postindex. Similar trends were observed at 2- and 5-year time points across measures. Conclusions and Relevance Older adults with untreated hearing loss experience higher health care costs and utilization patterns compared with adults without hearing loss. To further define this association, additional research on mediators, such as treatment adherence, and mitigation strategies is needed.

In this manuscript, we seek to highlight the consequences of caregiving and their impact on the health and overall quality of life of Ugandan grandparent-caregivers. Over the past two decades, the number of studies investigating grandparental caregiving provided to children affected by HIV/AIDS in sub-Saharan Africa has gradually increased. With the sustained loss of lives due to AIDS, older adults are continuing to bear the burden of caring for children affected by the epidemic, often with very limited resources. Despite the acknowledgement of the elderly as the backbone and safety net of the African family in this HIV/AIDS era, very limited research has been conducted to explore the impact of this burden on the caregivers’ mental health, physical wellbeing and overall quality of life. Thirty-two participants were recruited from urban and rural areas in Uganda and interviewed using a qualitative approach, specifically grounded theory methodology. The narratives generated from the semi-structured and one-on-one interviews were audio-recorded, transcribed and analyzed using both open and axial coding as well as reflexive and analytic memoing congruent with the methodology. Descriptions of physical, financial and emotional caregiver burden were reported. Additionally, our study findings uniquely explored the impact of the perceived burden on their health and overall quality of life; and provided an explanatory model of the caregiving experience. Therefore, the study findings provide a foundation upon which clinicians, researchers and policy makers can design and implement effective interventions needed to improve the health and quality of life of grandparent-caregivers.

Purpose To explore the relationship between the symptoms of schizophrenia experienced by older persons diagnosed with schizophrenia and type 2 diabetes mellitus and their response to a health promoting intervention. Methods Secondary data analysis of data obtained from a lifestyle intervention program that recruited participants over age 40 with schizophrenia or schizoaffective disorder and type 2 diabetes mellitus from board-and-care facilities and day treatment programs. Participants had been randomly assigned to a 24-week diabetes awareness and rehabilitation training (DART; n = 32) or a usual care plus information (UCI; n = 32) comparison group. Baseline and 6-month (intervention completion) assessments included a diabetes knowledge test (DKT), diabetes self-efficacy measured by the diabetes empowerment scale (DES), and symptomatology defined by the Positive and Negative Syndrome Scale (PANSS). Simple linear regression models in 3 steps were used to analyze the data. Results A significant condition by symptom interaction was found for DKT. The difference between change in knowledge for DART and UCI groups depended on the prevalence and severity of the total, negative, and general symptoms. There was no significant condition by positive symptom interaction for DKT. A significant main effect was found between total, negative, positive, and general symptoms in the total sample for improvement in DES scores. Higher prevalence and severity of symptoms was negatively associated with improvement in DES scores. Conclusion Researchers need to consider the impact of schizophrenia symptoms in response to health promoting interventions.

Aim. This paper is a report of a study of the extent to which demographic characteristics, medication-related factors, hypertension-related knowledge and medication adherence predict systolic and diastolic blood pressure. Background. Little is known about predictors of hypertension control in Chinese elders. Methods. A longitudinal study with a 3-month follow-up was conducted with 90 Chinese immigrants to the United States of America aged ‡65 years and recruited from 2006 to 2007. The independent variables were measured at baseline. Blood pressure was measured at 3 months. Multiple linear regression analysis was used to evaluate the independent effects of seven variables on change in blood pressure at 3 months. Results. Participants ranged in age from 66 to 92 years (Mean 76AE7, SD 6AE6). The overall regression model for systolic blood pressure was statistically significant (R 2 =0 AE32, F =4 AE37, P < 0AE01). A higher number of prescribed oral medications (sr 2 =0 AE06, t =2 AE42, P =0 AE02) and lower medication adherence (sr 2 =0 AE07, t = 2AE60, P =0 AE01) were statistically significant determinants of an increased systolic blood pressure. The overall regression model for diastolic blood pressure was statistically significant (R 2 =0 AE21, F =2 AE39, P =0 AE03). Male gender (sr 2 =0 AE06, t =2 AE26, P =0 AE03) and lower medication adherence (sr 2 =0 AE11, t = 3AE03, P < 0AE01) were statistically significant determinants of an increased diastolic blood pressure. Conclusion. A greater number of prescribed medications and lower adherence predicted higher level of systolic blood pressure. Male gender and lower adherence were significantly associated with higher level of diastolic blood pressure. These predictors should be considered when designing interventions to help Chinese elders achieve better hypertension management.

Sleep in older adults with Alzheimer's disease can often be extremely fragmented, thus disturbing normal sleep-wake rhythms. This poor-quality sleep is challenging for caregivers and frequently results in admitting older adults to long-term care institutions. Many variables, such as genes, medications, depression, and environmental factors, influence sleep in persons with Alzheimer's disease. Interventions, such as exposure to light, melatonin therapy, sleep hygiene, and physical activity, are commonly used to treat or to prevent sleep problems. Neuroscience nurses can play an important role in assessing sleep characteristics and related factors, educating caregivers and staff, providing family members with emotional support, and conducting research.

Background: Problems with cognitive function are common among older adults, yet there is little research assessing the extent to which the cognitive problems of older husbands and wives are related to those of their partners and whether any observed relationships are moderated by gender or marital quality. Objectives: Our purpose was to analyze longitudinal relationships between older spouses’ cognitive function and the cognitive function of their partners 5 years later, as well as to assess moderating roles of gender and marital quality. Methods: The subjects were 378 community-dwelling couples aged 46–89 years at baseline who were followed for 5 years. Cognitive function was measured with a scale assessing problems remembering names, finding the right word, misplacing things and paying attention. Marital quality was assessed by comparing those reporting marital problems often or sometimes with those reporting marital problems rarely or never. All data were collected by self-report. Statistical models adjusted for paired data where appropriate and included partner cognitive function, age, chronic conditions and financial hardship. Stratified models assessed moderating roles of gender and marital problems. Results: We found a negative relationship between husbands’ baseline lower cognitive function and wives’ subsequent cognitive function but only for the wives reporting marital problems. We found no comparable relationship between wives’ baseline lower cognitive function and their husbands’ subsequent cognitive function. Conclusions: Our gender-specific finding for wives is consistent with the gender differences noted in 2 previous studies. The limitation to wives with problems in their marriages is a new finding and might follow increased stress and depression responding to changes in their husbands’ cognitive functioning.

Older adults with schizophrenia experience a high prevalence of comorbid conditions. The perspective of older adults with schizophrenia about their physical health has not been considered as a contributing factor. This paper presents findings from a grounded theory study that explored this perspective among 28 older adults with schizophrenia. Analyses revealed that finding a sense of belonging supported feeling physically healthy. A sense of connection with others and a physical place were associated with supporting a sense of belonging. Awareness of the facilitators of and barriers to finding a place to belong is key to improving the physical health of this vulnerable population.