Patient autonomy for the management of chronic conditions: a two-component re-conceptualization.

The clinical application of the concept of patient autonomy has centered on the ability to deliberate and make treatment decisions (decisional autonomy) to the virtual exclusion of the capacity to execute the treatment plan (executive autonomy). However, the one-component concept of autonomy is problematic in the context of multiple chronic conditions. Adherence to complex treatments commonly breaks down when patients have functional, educational, and cognitive barriers that impair their capacity to plan, sequence, and carry out tasks associated with chronic care.

Conceptual challenges and practical approaches to screening capacity for self-care and protection in vulnerable older adults.

Identifying impairments in the capacity to make and execute decisions is critical to the assessment and remediation of elder self-neglect. Few capacity assessment tools are available for use outside of healthcare settings, and none have been validated in the context of elder self-neglect. Health and social services professionals are in need of validated tools to assess capacity for self-care and self-protection (SC&P) during initial evaluations of older adults with suspected self-neglect syndrome.

Integrating diabetes self-management with the health goals of older adults: a qualitative exploration.

Objective: This study investigates the life and health goals of older adults with diabetes, and explores the factors that influence their diabetes self-management.

Methods: Qualitative in-depth interviews were conducted with 24 older adults with diabetes and other morbid conditions and/or their caregivers, when appropriate.

Results: Participants' provided a consistent set of responses when describing life and health goals.

Impairment in instrumental activities of daily living and the geriatric syndrome of self-neglect.

Purpose: We sought to characterize self-neglect definitively as a geriatric syndrome by identifying an association with functional impairment.

Design And Methods: We performed a cross-sectional home evaluation of 100 community-living older adults referred by Adult Protective Services for geriatric self-neglect and 100 matched adults from a community geriatrics clinic. We made our assessments by using two manual muscle tests, a timed-gait test, a modified Physical Performance Test (mPPT), and the Kohlman Evaluation of Living Skills (KELS).

Reducing diagnostic errors through effective communication: harnessing the power of information technology.

Diagnostic errors are poorly understood despite being a frequent cause of medical errors. Recent efforts have aimed to advance the "basic science" of diagnostic error prevention by tracing errors to their most basic origins. Although a refined theory of diagnostic error prevention will take years to formulate, we focus on communication breakdown, a major contributor to diagnostic errors and an increasingly recognized preventable factor in medical mishaps.

Improving hypertension control in diabetes mellitus: the effects of collaborative and proactive health communication.

Background: Communication between patients and clinicians using collaborative goals and treatment plans may overcome barriers to achieving hypertension control in routine diabetes mellitus care. We assessed the interrelation of patient-clinician communication factors to determine their independent associations with hypertension control in diabetes care.

Methods And Results: We identified 566 older adults with diabetes mellitus and hypertension at the DeBakey VA Medical Center in Houston, Tex.

Assessing capacity in suspected cases of self-neglect.

Self-neglect is a serious and burgeoning public health challenge representing the most common problem faced by Adult Protective Services agencies. Among older adults who are vulnerable to self-neglect, the capacity to make decisions may remain intact. However, the capacity to identify and extract oneself from harmful situations, circumstances, or relationships may be diminished.

Assessing capacity in the setting of self-neglect: development of a novel screening tool for decision-making capacity.

Compared with older adults with disabilities and those who autonomously choose to live in squalor, self-neglect syndrome arises from a predicate state of vulnerability in frail older adults. This state of vulnerability is characteristically associated with a decline in decision-making capacity regarding the ability to care for and protect oneself. We developed the COMP Screen to evaluate vulnerable older adults to identify potential gaps in decision-making capacity using a screening tool.

Is pain a significant factor in elder self-neglect?

Purpose: Pain is a worldwide health concern leading to cognitive impairments, depression, and decline in activities of daily living when poorly controlled. Self-neglect is also a serious public health issue being the most common allegation reported to Adult Protective Services (APS). The purpose of this analysis is to determine whether self-reported pain is associated with validated cases of self-neglect compared with matched controls.

Severe self-neglect: an epidemiological and historical perspective.

Older adults with severe self-neglect have multiple deficits in various social, functional and physical domains, and often live insqualor. These individuals often present with poor personal hygiene, domestic squalor and hoarding which results in a threat to their own health as well as personal and public safety. Severe self-neglect occurs along a continuum with older adults often having cognitive and affective disorders compared with younger individuals presenting with psychiatric illnesses.

Management of chronic hypertension in older men: an exploration of patient goal-setting.

Objective: Goal-setting is an approach to collaborative chronic care that involves clinicians and patients working together to set goals and to initiate and maintain specific self-care behaviors. Using patients' own perspectives, this study describes how goals for the self-management of hypertension are developed and whether or not they conform to the characteristics of effective goal-setting.

Methods: Qualitative methodology was used to explore the process of setting self-management goals for hypertensive patients.

Understanding the quality chasm for hypertension control in diabetes: a structured review of "co-maneuvers" used in clinical trials.

Background: Observational studies routinely describe a significant gap between rates of blood pressure control in routine diabetes care compared with those achieved in randomized controlled trials (RCTs).

Methods: We performed a systematic review of the literature to identify co-maneuvers used in RCTs, defined as ancillary activities or agents administered before, during, or immediately after the main agent under investigation (ie, principal maneuver), but not effectively translated to routine diabetes care. We searched multiple databases for RCTs evaluating the efficacy of treatments for hypertension control in adults with type 2 diabetes mellitus.

The utility of the Kohlman Evaluation of Living Skills test is associated with substantiated cases of elder self-neglect.

Purpose: Self-neglect is the most prevalent finding among cases reported to Adult Protective Services (APS) and is characterized by an inability to meet one's own basic needs. The Kohlman evaluation of living skills (KELS) has been validated in geriatric populations to assess performance with both instrumental and basic activities of daily living and as an assessment tool for the capacity to live independently; therefore, the purpose of this analysis was to compare the scores of the KELS between substantiated cases of self-neglect and matched community-dwelling elders.

Data Sources: This is a cross-sectional pilot study of 50 adults aged 65 years and older who were recruited from APS as documented cases of self-neglect and 50 control participants recruited from Harris County Hospital District outpatient clinics.

A quasi-experimental test of an intervention to increase the use of thiazide-based treatment regimens for people with hypertension.

Background: Despite recent high-quality evidence for their cost-effectiveness, thiazides are underused for controlling hypertension. The goal of this study was to design and test a practice-based intervention aimed at increasing the use of thiazide-based antihypertensive regimens.

Methods: This quasi-experimental study was carried out in general medicine ambulatory practices of a large, academically-affiliated Veterans Affairs hospital.

Goal setting as a shared decision making strategy among clinicians and their older patients.

Objective: Older adults are less likely than other age groups to participate in clinical decision-making. To enhance participation, we sought to understand how older adults consider and discuss their life and health goals during the clinical encounter.

Methods: We conducted six focus groups: four with community-dwelling older persons (n=42), one with geriatricians and internists (n=6), and one with rehabilitation nurses (n=5).

Underutilization of environmental adaptations for bathing in community-living older persons.

Objectives: To determine the prevalence and utilization of environmental adaptations (home modifications and assistive devices) for bathing in community-living older persons with and without bathing disability.

Design: Cross-sectional study.

Setting: General community of greater New Haven, Connecticut.

Will older persons and their clinicians use a shared decision-making instrument?

Objective: To examine experiences of older persons and their clinicians with shared decision making (SDM) and their willingness to use an SDM instrument.

Design: Qualitative focus group study.

Participants: Four focus groups of 41 older persons and 2 focus groups of 11 clinicians, purposively sampled to encompass a range of sociodemographic and clinical characteristics.

Bathing disability in community-living older persons: common, consequential, and complex.

Objectives: To identify the specific bathing subtasks that are affected in community-living-older persons with bathing disability and to determine the self-reported reasons for bathing disability.

Design: Cross-sectional study.

Setting: General community of greater New Haven, Connecticut.