With global aging and scientific advances extending survival, the number of adults experiencing multiple chronic conditions has grown substantially and is projected to increase by another third between 2000 and 2030. Among the many challenges posed by multimorbidity, some of the most pressing include how to characterize and measure comorbid conditions, understand symptoms and illness burden, and provide person-centered care in the context of competing health care priorities and increasing complexity. In this white paper emanating from a National Institute on Aging supported conference to discuss research gaps at the geriatrics-palliative care interface, the authors review common definitions of multimorbidity; describe the association between multimorbidity and quality of life, functional status, quality of care, and health care utilization; note content and methodological gaps in multimorbidity evidence; and make recommendations regarding research priorities in this area of expanding public health impact.

Context

Age-related hearing loss can impair patient-provider communication about symptom management, goals of care, and end-of-life decision-making.

Objectives

To determine whether hospice and palliative care providers screen for or received training about hearing loss, believe it impacts patient care, and use strategies to optimize communication.

Methods

This was a national survey of hospice and palliative care providers conducted via email and social media. Survey questions were pilot tested with multidisciplinary providers in San Francisco.

Results

Of 510 responses (55% age 50+ years, 65% female, 64% in practice 5+ years, 57% practiced hospital-based palliative care, 45% hospice), 315 were physicians, 50 nurses, 48 nurse practitioners, 58 social workers, and 39 chaplains. Ninety-one percent reported that hearing loss has some or great impact on the quality of care for older adults. Eighty-eight percent recalled a situation where hearing loss created a communication problem with a patient and 56% a communication problem with a caregiver. Eighty-seven percent of physicians, nurses, and nurse practitioners reported not screening for hearing loss. Although 61% felt comfortable with their communication skills for patients with hearing loss, only 21% reported having received formal training in its management, 31% were unfamiliar with resources for patients with hearing loss, and 38% had never heard of a pocket talker amplification device.

Conclusion

Hospice and palliative medicine providers believe age-related hearing loss impacts care yet most do not screen. Although they feel they are managing well, few have formal training. Knowledge about management approaches and resources is suboptimal.

Delivery of serious illness communication (SIC) is necessary to ensure that all seriously ill patients receive goal-concordant care. However, the current SIC delivery process contains barriers that prevent the delivery of timely and effective SIC. In this paper, we describe the current bottlenecks of the traditional SIC workflow and explore how a hybrid artificial intelligence-human workflow may improve the efficiency and effectiveness of SIC delivery in busy practice settings.

Abstract

In the context of the opioid epidemic and the growing population of older adults living with chronic pain, clinicians are increasingly recommending nonpharmacologic approaches to patients as complements to or substitutes for pharmacologic treatments for pain. Currently, little is known about the factors that influence older adults' use of these approaches. We aimed to characterize the factors that hinder or support the use of nonpharmacologic approaches for pain management among older adults with multiple morbidities. We collected semistructured qualitative interview data from 25 older adults with multiple morbidities living with chronic pain for 6 months or more. Transcripts were coded to identify factors that hindered or supported participants' use of various nonpharmacologic approaches. We used the constant comparative method to develop a person-focused model of barriers and facilitators to participants' use of these approaches for chronic pain management. Participants described a wide range of factors that influenced their use of nonpharmacologic approaches. We grouped these factors into 3 person-focused domains: awareness of the nonpharmacologic approach as relevant to their chronic pain, appeal of the approach, and access to the approach. We propose and illustrate a conceptual model of barriers and facilitators to guide research and clinical care. This study identifies numerous factors that influence patients' use of nonpharmacologic approaches, some of which are not captured in existing research or routinely addressed in clinical practice. The person-centered model proposed may help to structure and support patient-clinician communication about nonpharmacologic approaches to chronic pain management.

Background and objectives

The opioid epidemic has led to substantive regulatory and policy changes. Little is known about how these changes have impacted older adults, especially those with chronic pain and multiple chronic conditions (MCC). We sought to understand the experiences of older adults with chronic pain and MCC in the context of the opioid epidemic and policy responses to it.

Research design and methods

Purposive sampling of older adults in a West Coast metropolitan area. Semistructured in-depth interviews lasting 45-120 min were digitally recorded and transcribed. Responses were analyzed using the constant comparative method. Participants were 25 adults aged 65 years and greater with three or more self-reported medical conditions and pain lasting for more than 6 months.

Results

Respondents' accounts revealed numerous unintended consequences of the opioid epidemic and its policy responses. We identified four main themes: changes to the patient-clinician relationship; lack of patient agency and access in pain management; patient ambivalence and anxiety about existing opioid treatment/use; and patient concerns about future use.

Discussion and implications

Older adults have high rates of chronic pain and MCC that may reduce their pain management options. The opioid epidemic and policies addressing it have the potential to negatively affect patient-clinician relationships and patients' pain self-management. Clinicians may be able to mitigate these unintended consequences by actively conveying respect to the patient, empowering patients in their pain self-management activities, and proactively addressing worries and fears patients may own related to their current and future pain management regimens.

Background

The unique needs of homebound adults receiving home-based medical care (HBMC) (ie, home-based primary care and home-based palliative care services) are ideally provided by interdisciplinary care teams (IDTs) that provide coordinated care. The composition of team members from an array of organizations and the unique dimension of providing care in the home present specific challenges to timely access and communication of patient care information. The objective of this work was to develop a conceptual framework and corresponding quality indicators (QIs) that assess how IDT members for HBMC practices access and communicate key patient information with each other.

Methods

A systematic review of peer-reviewed and gray literature was performed to inform a framework for care coordination in the home and the development of candidate QIs to assess processes by which all IDT members optimally access and use patient information. A technical expert panel (TEP) participated in a modified Delphi process to assess the validity and feasibility of each QI and to identify which would be most suitable for testing in the field.

Results

Thematic analysis of literature revealed 4 process themes for how HBMC practices might engage in high-quality care coordination: using electronic medical records, conducting interdisciplinary team meetings, sharing standardized patient assessments, and communicating via secure e-messaging. Based on these themes, 9 candidate QIs were developed to reflect these processes. Three candidate QIs were assessed by the TEP as valid and feasible to measure in an HBMC practice setting. These indicators focused on use of IDT meetings, standardized patient assessments, and secure e-messaging.

Conclusion

Translating the complex issue of care coordination into QIs will improve care delivered to vulnerable home-limited adults who receive HBMC. Guided by the literature, we developed a framework to reflect optimal care coordination in the home setting and identified 3 candidate QIs to field-test in HBMC practices.

Background

The number of older jail inmates in poor health is increasing rapidly. Among older adults, pain is common and leads to greater acute care use. In jail, pain management is complicated by concerns about misuse and diversion. A lack of data about the prevalence and management of pain in older jail inmates limits our ability to develop optimal palliative care strategies for this population.

Objective

To describe the prevalence of and factors associated with pain and analgesic use in a population of older jail inmates.

Design

Cross-sectional study. χ(2) tests assessed association between characteristics, pain, and analgesic use.

Setting/subjects

Two hundred ten jail inmates age 55 or older.

Measurements

"Severe frequent pain" defined as "severe or very severe" pain experienced "frequently or constantly" using the validated Memorial Symptom Assessment Scale. Medical conditions, substance use, and analgesic treatment determined through self-report and jail medical records.

Results

Participants' mean age was 59 years; 69% had multimorbidity; 75% reported any pain; 39% reported severe frequent pain. Report of severe frequent pain was associated with multimorbidity, functional impairment, and pre-jail acute care use (p<0.05), but not with substance use (57% versus 56%, p=0.89). Within a week of their interview, most participants with severe frequent pain had received an analgesic (87%) and many received an opioid (70%).

Conclusion

High rates of pain in a rapidly growing population of older jail inmates with multimorbidity and functional impairment suggest that jails are an important site for assessing symptom burden and developing appropriate palliative care interventions.

This cohort study evaluates the prevalence of homebound older adults in the US from 2011 to 2020 and assesses whether the COVID-19 pandemic was associated with a change in prevalence.