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Background: The reasons for discordance between advance care planning (ACP) documentation and current preferences are not well understood. The POLST form offers a unique opportunity to learn about the reasons for discordance and concordance that has relevance for POLST as well as ACP generally., Design: Qualitative descriptive including constant comparative analysis within and across cases., Setting: Twenty-six nursing facilities in Indiana., Participants: Residents (n = 36) and surrogate decision-makers of residents without decisional capacity (n = 37)., Measurements: A semi-structured interview guide was used to explore the reasons for discordance or concordance between current preferences and existing POLST forms., Findings: Reasons for discordance include: (1) problematic nursing facility practices related to POLST completion; (2) missing key information about POLST treatment decisions; (3) deferring to others; and (4) changes over time. Some participants were unable to explain the discordance due to a lack of insight or inability to remember details of the original POLST conversation. Explanations for concordance include: (1) no change in the resident's medical condition and/or the resident is unlikely to improve; (2) use of the substituted judgment standard for surrogate decision-making; and (3) fixed opinion about what is "right" with little to no insight., Conclusion: Participant explanations for discordance between existing POLST orders and current preferences highlight the importance of adequate structures and processes to support high quality ACP in nursing facilities. Residents with stable or poor health may be more appropriate candidates for POLST than residents with a less clear prognosis, though preferences should be revisited periodically as well as when there is a change in condition to help ensure existing documentation is concordant with current treatment preferences., (© 2021 The American Geriatrics Society.)

Background: POLST is widely used to document the treatment preferences of nursing facility residents as orders, but it is unknown how well previously completed POLST orders reflect current preferences (concordance) and what factors are associated with concordance., Objectives: To describe POLST preference concordance and identify factors associated with concordance., Design: Chart reviews to document existing POLST orders and interviews to elicit current treatment preferences., Setting: POLST-using nursing facilities (n = 29) in Indiana., Participants: Nursing facility residents (n = 123) and surrogates of residents without decisional capacity (n = 152)., Measurements: Concordance was determined by comparing existing POLST orders for resuscitation, medical interventions, and artificial nutrition with current treatment preferences. Comfort-focused POLSTs contained orders for do not resuscitate, comfort measures, and no artificial nutrition., Results: Overall, 55.7% (123/221) of residents and 44.7% (152/340) of surrogates participated (total n = 275). POLST concordance was 44%, but concordance was higher for comfort-focused POLSTs (68%) than for non-comfort-focused POLSTs (27%) (p < 0.001). In the unadjusted analysis, increasing resident age (OR 1.04, 95% CI 1.01-1.07, p < 0.01), better cognitive functioning (OR 1.07, 95% CI 1.02-1.13, p < 0.01), surrogate as the decision-maker (OR 2.87, OR 1.73-4.75, p < 0.001), and comfort-focused POLSTs (OR 6.01, 95% CI 3.29-11.00, p < 0.01) were associated with concordance. In the adjusted multivariable model, only having an existing comfort-focused POLST was associated with higher odds of POLST concordance (OR 5.28, 95% CI 2.59-10.73, p < 0.01)., Conclusions: Less than half of all POLST forms were concordant with current preferences, but POLST was over five times as likely to be concordant when orders reflected preferences for comfort-focused care. Findings suggest a clear need to improve the quality of POLST use in nursing facilities and focus its use among residents with stable, comfort-focused preferences., (© 2021 The American Geriatrics Society.)

Objectives: To characterize pretransfer on-site nursing home (NH) management, transfer disposition, and hospital discharge diagnoses of long-stay residents transferred for behavioral concerns., Design: This was a secondary data analysis of the Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care project, in which clinical staff employed in the NH setting conducted medical, transitional, and palliative care quality improvement initiatives and gathered data related to resident transfers to the emergency department/hospital setting. R software and Microsoft Excel were used to characterize a subset of transfers prompted by behavioral concerns., Setting: NHs in central Indiana were utilized (N = 19)., Participants: This study included long-stay NH residents with behavioral concerns prompting transfer for acute emergency department/hospital evaluation (N = 355 transfers)., Measurements: The measures used in this study were symptoms prompting transfer, resident demographics and baseline characteristics (Minimum Data Set 3.0 variables including scores for the Cognitive Function Scale, ADL Functional Status, behavioral symptoms directed toward others, and preexisting psychiatric diagnoses), on-site management (e.g., medical evaluation in person or by phone, testing, and interventions), avoidability rating, transfer disposition (inpatient vs emergency department only), and hospital discharge diagnoses., Results: Over half of the transfers, 56%, had a medical evaluation before transfer, and diagnostic testing was conducted before 31% of transfers. After transfer, 80% were admitted. The most common hospital discharge diagnoses were dementia-related behaviors (27%) and altered mental status (27%), followed by a number of medical diagnoses., Conclusion: Most transfers for behavioral concerns merited hospital admission, and medical discharge diagnoses were common. There remain significant opportunities to improve pretransfer management of NH transfers for behavioral concerns., (© 2020 The American Geriatrics Society.)

What does it take to successfully lead a Division of Geriatrics? Is it the same skill set today as it was two or three decades ago? Is it the same for each chief, given the wide spectrum of geriatrics programs across our nation? Early leaders in our field showcased and role-modeled the career and job satisfaction that accompanies leadership of traditional geriatrics academic programs. This has been well articulated in past issues of the Journal of the American Geriatrics Society in articles by Dr William Hazzard and Dr Greg Sachs. How can we develop the next generation of geriatrics program leaders and ensure their success? Developed as a conversation between three generations of geriatrics division chiefs, this reflective article offers a shared perspective on what is required for success in advancing as a leader in our field and wholeheartedly enjoying the best job in the world., (© 2020 The American Geriatrics Society.)

Background/objectives: The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project is a successful, multicomponent demonstration project to reduce potentially avoidable hospitalizations of long-stay nursing facility residents. To continue to reduce hospital transfers, a more detailed understanding of these transfer events is needed. The purpose of this study was to describe differences in transfer events that result in treatment in the hospital versus emergency department (ED) only., Design: OPTIMISTIC project nurses collected data on residents who transferred. Transfer events that resulted in treatment in ED versus hospitalization were compared using t-tests and chi-square tests. A generalized estimating equations regression model was used to assess the associations between hospital admission and transfer characteristics., Participants: A total of 867 long-stay nursing facility residents enrolled in OPTIMISTIC, January 2015 to June 2016., Measurements: Resident and transfer characteristics from Minimum Data Set and project REDCap (Research Electronic Data Capture) database, including demographics, cognitive status, comorbidities, symptoms at time of transfer, and diagnoses., Results: The most common symptoms associated with treatment in the ED only were falls, trauma, or fracture (38% vs 10% admitted). Residents with cognitive impairment were more likely to be admitted to the hospital (odds ratio (OR) = 1.47; 95% confidence interval (CI) = 1.09-1.98; P = .011). Residents with respiratory complaints were more likely to be admitted (OR = 2.098; 95% CI = 1.198-3.675; P = .009); residents with hematological/bleeding (nongastrointestinal) (OR = 0.23; 95% CI = 0.107-0.494; P = .0002), pain (OR = 0.421; 95% CI = 0.254-0.698; P = .0008), or fall/trauma/fracture (OR = 0.181; 95% CI = 0.12-0.272; P < .001) were less likely to be admitted to the hospital., Conclusion: Some presenting symptoms and other characteristics are more associated with ED only treatment versus hospitalization. A knowledge of who is likely to receive ED only care could prompt adoption of targeted resources and protocols to further reduce these types of transfer events. Opportunity may exist in the ED as well to reduce hospitalizations and increase discharges back to the facility., (© 2020 The American Geriatrics Society.)

Background/objective: The benefits and harms of screening of Alzheimer disease and related dementias (ADRDs) are unknown. This study addressed the question of whether the benefits outweigh the harms of screening for ADRDs among older adults in primary care., Design, Setting, and Participants: Single-blinded, two-arm, randomized controlled trial (October 2012-September 2016) in urban, suburban, and rural primary care settings in Indiana. A total of 4005 primary care patients (aged ≥65 years) were randomized to ADRD screening (n = 2008) or control (n = 1997)., Intervention: Patients were screened using the Memory Impairment Screen or the Mini-Cog and referred for a voluntary follow-up diagnostic assessment if they screened positive on either or both screening tests., Measurements: Primary measures were health-related quality of life (HRQOL; Health Utilities Index) at 12 months, depressive symptoms (Patient Health Questionnaire-9), and anxiety symptoms (Generalized Anxiety Disorder seven-item scale) at 1 month., Results: The mean age was 74.2 years (SD = 6.9 years); 2257 (66%) were female and 2301 (67%) were white. At 12 months, we were unable to detect differences in HRQOL between the groups (effect size = 0.009 [95% confidence interval {CI} = -0.063 to 0.080]; P = .81). At 1 month, differences in mean depressive symptoms (mean difference = -0.23 [90% CI = -0.42 to -0.039]) and anxiety symptoms (mean difference = -0.087 [90% CI = -0.246 to 0.072]) were within prespecified equivalency range. Scores for depressive and anxiety symptoms were similar between the groups at all time points. No differences in healthcare utilization, advance care planning, and ADRD recognition by physicians were detected at 12 months., Conclusion: We were unable to detect a difference in HRQOL for screening for ADRD among older adults. We found no harm from screening measured by symptoms of depression or anxiety. Missing data, low rates of dementia detection, and high rate of refusal for follow-up diagnostic assessments after a positive screen may explain these findings. J Am Geriatr Soc 68:535-543, 2020., (© 2019 The American Geriatrics Society.)

Background/objectives: The Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project is a successful, multicomponent demonstration project to reduce potentially avoidable hospitalizations of long-stay nursing facility residents. Systematic advance care planning (ACP) is a core component of the intervention, based on research suggesting ACP is associated with decreased hospitalizations of nursing facility residents. The purpose of this study was to describe associations between ACP documentation resulting from the OPTIMISTIC intervention and hospitalizations., Design: Specially trained project nurses were embedded in 19 nursing facilities and systematically engaged in ACP as part of a larger demonstration project., Participants: Residents (n = 1482) enrolled in the demonstration project for a minimum of 30 days between January 1, 2015, and June 30, 2016., Measurements: ACP status: (1) Physician Orders for Scope of Treatment (POST) comfort measures or do not hospitalize (DNH) orders; (2) ACP orders with no hospitalization limit (eg, code status only); and (3) no ACP (potentially avoidable and all-cause hospitalizations per 1000 resident days)., Results: Residents with POST comfort measures/DNH orders (33.2% or n = 493) were less likely than residents with no ACP (14.7% or n = 218) to experience a potentially avoidable hospitalization (P = .001) or all-cause hospitalization (P = .001). These differences became statistically nonsignificant after adjusting for age, functional status, and cognitive functioning., Conclusion: In this successful multicomponent demonstration project to reduce potentially avoidable hospitalizations, ACP outcomes were not associated with hospitalization rates of nursing facility residents after adjusting for resident characteristics. These findings highlight the challenge of measuring the contributions of individual components of complex, multicomponent interventions. Associations between lower hospitalization rates and ACP completion may be influenced by contextual factors, such as clinical expertise and resources to manage acute conditions leading to hospitalization, in addition to interventions to increase ACP. J Am Geriatr Soc 67:1649-1655, 2019., (© 2019 The American Geriatrics Society.)

Objectives: To assess the use of the Indiana Physician Orders for Scope of Treatment (POST) form to record nursing home (NH) resident treatment preferences and associated practices., Design: Survey., Setting: Indiana NHs., Participants: Staff responsible for advance care planning in 535 NHs., Measurements: Survey about use of the Indiana POST, related policies, and educational activities., Methods: NHs were contacted by telephone or email. Nonresponders were sent a brief postcard survey., Results: Ninety-one percent (n=486) of Indiana NHs participated, and 79% had experience with POST. Of the 65% of NHs that complete POST with residents, 46% reported that half or more residents had a POST form. POST was most often completed at the time of admission (68%). Only 52% of participants were aware of an existing facility policy regarding use of POST; 80% reported general staff education on POST. In the 172 NHs not using POST, reasons for not using it included unfamiliarity with the tool (23%) and lack of facility policies (21%)., Conclusion: Almost 3 years after a grassroots campaign to introduce the voluntary Indiana POST program, a majority of NHs were using POST to support resident care. Areas for improvement include creating policies on POST for all NHs, training staff on POST conversations, and considering processes that may enhance the POST conversation, such as finding an optimal time to engage in conversations about treatment preferences other than a potentially rushed admission process., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Objectives: To describe the relationship between nursing facility resident risk conditions and signs and symptoms at time of acute transfer and diagnosis of conditions associated with potentially avoidable acute transfers (pneumonia, urinary tract infection, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) or asthma, dehydration, pressure sores)., Design: As part of a demonstration project to reduce potentially avoidable hospital transfers, Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project clinical staff collected data on residents who transferred to the emergency department (ED) or hospital. Cross-tabulations were used to identify associations between risk conditions or symptoms and hospital diagnoses or death. Mixed-effects logistic regression models were used to describe the significance of risk conditions, signs, or symptoms as predictors of potentially avoidable hospital diagnoses or death., Setting: Indiana nursing facilities (N=19)., Participants: Long-stay nursing facility residents (N=1,174), who experienced 1,931 acute transfers from November 2014 to July 2016., Measurements: Participant symptoms, transfers, risk factors, and hospital diagnoses., Results: We found that 44% of acute transfers were associated with 1 of 6 potentially avoidable diagnoses. Symptoms before transfer did not discriminate well among hospital diagnoses. Symptoms mapped into multiple diagnoses and most hospital diagnoses had multiple associated symptoms. For example, more than two-thirds of acute transfers of residents with a history of CHF and COPD were for reasons other than exacerbations of those two conditions., Conclusion: Although it is widely recognized that many transfers of nursing facility residents are potentially avoidable, determining "avoidability" at time of transfer is complex. Symptoms and risk conditions were only weakly predictive of hospital diagnoses., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Objectives: To describe processes and preliminary outcomes from the implementation of a systematic advance care planning (ACP) intervention in the nursing home setting., Design: Specially trained project nurses were embedded in 19 nursing homes and engaged in ACP as part of larger demonstration project to reduce potentially avoidable hospitalizations., Setting: Nursing homes., Participants: Residents enrolled in the demonstration project for a minimum of 30 days between August 2013 and December 2014 (n = 2,709) and residents currently enrolled in March 2015 (n = 1,591)., Measurements: ACP conversations were conducted with residents, families, and the legal representatives of incapacitated residents using a structured ACP interview guide with the goal of offering ACP to all residents. Project nurses reviewed their roster of currently enrolled residents in March 2015 to capture barriers to engaging in ACP., Results: During the initial implementation phase, 27% (731/2,709) of residents had participated in one or more ACP conversations with a project nurse, resulting in a change in documented treatment preferences for 69% (504/731). The most common change (87%) was the generation of a Physician Orders for Scope of Treatment form. The most frequently reported barrier to ACP was lack of time., Conclusion: The time- and resource-intensive nature of robust ACP must be anticipated when systematically implementing ACP in the nursing home setting. The fact that these conversations resulted in changes over 2/3 of the time reinforces the importance of deliberate, systematic ACP to ensure that current treatment preferences are known and documented so that these preferences can be honored., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives: To analyze the costs for long-stay (>90 days) nursing home (NH) decedents with and without hospice care., Design: Retrospective cohort study using a 1999-2009 data set of linked Medicare and Medicaid claims and minimum data set (MDS) assessments., Setting: Indiana NHs., Participants: Long-stay NH decedents (N = 2,510)., Measurements: Medicare costs were calculated for 2, 7, 14, 30, 90, and 180 days before death; Medicaid costs were calculated for dual-eligible beneficiaries. Total costs and costs for hospice, NH, and inpatient care are reported., Results: Of 2,510 long-stay NH decedents, 35% received hospice. Mean length of hospice was 103 days (median 34 days). Hospice users were more likely to have cancer (P < .001), a do-not-resuscitate order in place (P < .001), greater cognitive impairment (P < .001), and worse activity of daily living (ADL) function (P < .001) and less likely to have had a hospitalization in the year before death (P < .001). In propensity score analyses, hospice users had lower total Medicare costs for all time periods up to and including 90 days before death. For dually eligible beneficiaries, overall costs and Medicare costs were significantly lower for hospice users up to 30 days before death. Medicaid costs were not different between the groups except for the 2-day time period., Conclusion: In this analysis of costs to Medicare and Medicaid for long-stay NH decedents, use of hospice did not increase costs in the last 6 months of life. Evidence supporting cost savings is sensitive to analyses that vary the time period before death., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project aims to reduce avoidable hospitalizations of long-stay residents enrolled in 19 central Indiana nursing facilities. This clinical demonstration project, funded by the Centers for Medicare and Medicaid Services Innovations Center, places a registered nurse in each nursing facility to implement an evidence-based quality improvement program with clinical support from nurse practitioners. A description of the model is presented, and early implementation experiences during the first year of the project are reported. Important elements include better medical care through implementation of Interventions to Reduce Acute Care Transfers tools and chronic care management, enhanced transitional care, and better palliative care with a focus on systematic advance care planning. There were 4,035 long-stay residents in 19 facilities enrolled in OPTIMISTIC between February 2013 and January 2014. Root-cause analyses were performed for all 910 acute transfers of these long stay residents. Of these transfers, the project RN evaluated 29% as avoidable (57% were not avoidable and 15% were missing), and opportunities for quality improvement were identified in 54% of transfers. Lessons learned in early implementation included defining new clinical roles, integrating into nursing facility culture, managing competing facility priorities, communicating with multiple stakeholders, and developing a system for collecting and managing data. The success of the overall initiative will be measured primarily according to reduction in avoidable hospitalizations of long-stay nursing facility residents., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

Unbefriended, incapacitated individuals who lack surrogates to make medical decisions present a complex problem to the healthcare providers who treat them. Adults without surrogates are among the most vulnerable in the community and are often alone and estranged from family, neglected and abused, and at risk of receiving inappropriate medical treatment. This article describes the program model and outcomes for the first 2 years of the Wishard Volunteer Advocates Program (WVAP), a guardianship program using trained, supervised volunteers as surrogates for unbefriended, incapacitated individuals. Of the 50 individuals enrolled during the study period, 20 were female, and 39 were Caucasian and 11 African American. Their average age was 67. Nineteen were insured with Medicare as primary and Medicaid as supplementary insurance. Ninety-eight percent had four or more comorbid conditions at the time of the index hospitalization. Before program referral, many lived alone in unsafe conditions. Adult Protective Services was involved in almost half of the cases at the time of the index hospitalization. Approximately half of the participants required some type of property management. Healthcare usage data demonstrated that most were not receiving medical care before WVAP enrollment; the data indicated a decrease in emergency department visits and hospitalization after WVAP enrollment. The WVAP completed Medicaid applications for 12 participants, resulting in $297,481.62 in reimbursement for the index hospitalization and a payer source for subsequent hospitalization and long-term care. The volunteer advocate model provides an efficient and quality mechanism for providing unbefriended individuals with surrogates., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

Objectives: To describe the perspectives of family caregivers toward stopping cancer screening tests for their relatives with dementia and identify opportunities to reduce harmful or unnecessary screening., Design: Focus group study., Setting: Alzheimer's Association support groups for family members of individuals with dementia., Participants: Four focus groups including 32 caregivers (25 female; 24 white, 7 African American, one American/Indian; mean age 65.5, range 49-85)., Measurements: Focus group transcripts were transcribed and analyzed using methods of grounded theory., Results: Caregivers considered decisions to stop cancer screening in terms of quality of life and burden on the patient and caregiver. Many described having to intervene in the patient's care to stop unnecessary or harmful screening, and others met resistance when they advocated for stopping. Physicians varied widely in their knowledge of dementia care and willingness to consider cessation of screening., Conclusion: Many family caregivers wish to stop cancer screening tests as dementia progresses and are relieved when physicians bring it up. Caregivers are open to discussions of screening cessation that focus on quality of life, burdens, and benefits. Interventions are needed to increase caregiver and clinician discussion of screening cessation and to increase clinician awareness of the need to reconsider cancer screening in individuals with dementia., (© 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.)

Objectives: To describe communication experiences of surrogates who had recently made a major medical decision for a hospitalized older adult., Design: Semistructured interviews about a recent hospitalization., Setting: Two hospitals affiliated with one large medical school: an urban public hospital and a university-affiliated tertiary referral hospital., Participants: Surrogates were eligible if they had recently made a major medical decision for a hospitalized individual aged 65 and older and were available for an interview within 1 month (2-5 months if the patient died)., Measurements: Interviews were audio-recorded, transcribed, and analyzed using methods of grounded theory., Results: Thirty-five surrogates were interviewed (80% female, 44% white, 56% African American). Three primary themes emerged. First, it was found that the nature of surrogate-clinician relationships was best characterized as a relationship with a "team" of clinicians rather than individual clinicians because of frequent staff changes and multiple clinicians. Second, surrogates reported their communication needs, including frequent communication, information, and emotional support. Surrogates valued communication from any member of the clinical team, including nurses, social workers, and physicians. Third, surrogates described trust and mistrust, which were formed largely through surrogates' communication experiences., Conclusion: In the hospital, surrogates form relationships with a "team" of clinicians rather than with individuals, yet effective communication and expressions of emotional support frequently occur, which surrogates value highly. Future interventions should focus on meeting surrogates' needs for frequent communication and high levels of information and emotional support., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)

Objectives: To determine individuals' perceptions concerning dementia screening and to evaluate the possibility of an association between their perceptions and their willingness to undergo screening., Design: Cross-sectional study of primary care patients aged 65 and older., Setting: Urban primary care clinics in Indianapolis, Indiana, in 2008 to 2009., Participants: Five hundred fifty-four primary care patients without a documented diagnosis of dementia., Measurements: The Perceptions Regarding Investigational Screening for Memory in Primary Care Questionnaire (PRISM-PC) and agreement or refusal to undergo dementia screening., Results: Of the 554 study participants who completed the PRISM-PC, 65.5% were aged 70 and older, 70.0% were female, and 56.5% were African American; 57 (10.3%) refused screening for dementia. Of the 497 (89.7%) who agreed to screening, 63 (12.7%) screened positive. After adjusting for age, perception of depression screening, perception of colon cancer screening, and belief that no treatment is currently available for Alzheimer's disease, the odds of refusing screening were significantly lower in participants who had higher PRISM-PC domain scores for benefits of dementia screening (odds ratio (OR) = 0.85, 95% confidence interval (CI) = 0.75-0.97; P = .02). In the same regression model, the odds of refusing screening were significantly higher in participants aged 70 to 74 (OR = 5.65, 95% CI = 2.27-14.09; P < .001) and those aged 75 to 79 (OR = 3.63, 95% CI = 1.32-9.99; P = .01) than in the reference group of patients aged 65 to 69., Conclusion: Age and perceived benefit of screening are associated with acceptance of dementia screening in primary care., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)

Objectives: To examine the frequency of surrogate decisions for in-hospital do-not-resuscitate (DNR) orders and the timing of DNR order entry for surrogate decisions., Design: Retrospective cohort study., Setting: Large, urban, public hospital., Participants: Hospitalized adults aged 65 and older over a 3-year period (1/1/2004-12/31/2006) with a DNR order during their hospital stay., Measurements: Electronic chart review provided data on frequency of surrogate decisions, patient demographic and clinical characteristics, and timing of DNR orders., Results: Of 668 patients, the ordering physician indicated that the DNR decision was made with the patient in 191 cases (28.9%), the surrogate in 389 (58.2%), and both in 88 (13.2%). Patients who required a surrogate were more likely to be in the intensive care unit (62.2% vs 39.8%, P<.001) but did not differ according to demographic characteristics. By hospital Day 3, 77.6% of patient decisions, 61.9% of surrogate decisions, and 58.0% of shared decisions had been made. In multivariable models, the number of days from admission to DNR order was higher for surrogate (odds ratio (OR)=1.97, P<.001) and shared decisions (OR=1.48, P=.009) than for patient decisions. The adjusted hazard ratio for hospital death was higher for patients with surrogate than patient decisions (2.61, 95% confidence interval (CI)=1.56-4.36). Patients whose DNR orders were written on Day 6 or later were twice as likely to die in the hospital (OR=2.20, 95% CI=1.45-3.36) than patients with earlier DNR orders., Conclusion: For patients who have a DNR order entered during their hospital stay, order entry occurs later when a surrogate is involved. Surrogate decision-making may take longer because of the greater ethical, emotional, or communication complexity of making decisions with surrogates than with patients., (© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.)

Objectives: To compare attitudes toward dementia screening of older adults with and without an experience of dementia caregiving., Design: A cross-sectional study., Setting: Primary care clinics in Indianapolis, Indiana., Participants: Eighty-one participants with dementia caregiving experience (CG) and a random sample of 125 participants without dementia caregiving experience (NCG)., Measurements: Attitudes of dementia screening, including acceptance of dementia screening and its perceived harms and benefits, as determined according to the Perceptions Regarding Investigational Screening for Memory in Primary Care questionnaire., Results: After adjusting for age, race, sex, and education, CGs had a lower dementia screening acceptance mean score (53.9 vs 60.6; P=.03) and a higher perceived suffering score (61.6 vs 55.9, P=.04) than NCGs, but there were no differences in perceived benefits of dementia screening (72.8 vs 69.0; P=.50), perceived stigma (32.9 vs 37.5; P=.12), and perceived negative effect on independence (47.6 vs 54.0; P=.20). The top three barriers to screening identified by both groups were emotional suffering by the family (86% of CGs and 75% of NCGs), loss of driving privileges (75% of CGs and 78% of NCGs), and becoming depressed (64% of CGs and 43% of NCGs)., Conclusion: The experience of being a dementia caregiver may influence one's own attitude about accepting dementia screening for oneself., (© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.)

Objectives: To determine the extent to which hospice and nonhospice palliative care (PC) programs provide services to patients with dementia and to describe barriers and facilitators to providing nonhospice PC., Design: Telephone and Web-based surveys., Setting: U.S. hospice and PC programs from the National Hospice and Palliative Care Organization's program list., Participants: Executive directors of 240 hospice programs, 173 programs providing hospice and nonhospice PC, and 13 programs providing nonhospice PC., Measurements: A telephone survey of hospice and PC providers followed by an online survey of programs providing nonhospice PC., Results: Ninety-four percent of hospices and 72% of PC programs had served at least one patient with a primary diagnosis of dementia within the past year. Based on 80 responses to the online survey, the most highly rated barriers to providing PC were lack of awareness of PC by families and referring providers, need for respite services, and reimbursement policies. Highly rated needs were family information, assistance with caregiver burden, and behavioral symptoms. Strategies critical for success were an interdisciplinary team, collaboration with community organizations, and alternatives to aggressive end-of-life care., Conclusion: Almost all hospices and a majority of nonhospice PC programs serve patients with dementia. Education and policy efforts should focus on education for families and providers, support for caregivers, and reforming reimbursement structures to provide coverage for interdisciplinary PC earlier in the disease, when patients have high needs but are not hospice eligible., (© 2010, Copyright the Authors. Journal compilation © 2010, The American Geriatrics Society.)

Objectives: To describe the pattern and factors associated with daily medication use in nursing home (NH) residents with advanced dementia., Design: Prospective cohort study., Setting: Twenty-two Boston-area NHs., Participants: NH residents with advanced dementia (N=323)., Measurements: Data from residents' records were used to determine the number or daily medications, specific drugs prescribed, and use of drugs deemed "never appropriate" in patients with advanced dementia. Resident characteristics associated with the use of more daily medications and drugs deemed inappropriate were examined., Results: Residents were prescribed a mean of 5.9 +/- 3.0 daily medications, and 37.5% received at least one medication considered "never appropriate" in advanced dementia. Acetylcholinesterase inhibitors (15.8%) and lipid-lowering agents (12.1%) were the most common inappropriate drugs. Twenty-eight percent of residents took antipsychotics daily. Modest reductions in most daily medications occurred only during the last week of life. Factors independently associated with taking more daily medications included older age, male sex, non-white race, dementia not due to Alzheimer's disease, better cognition, cardiovascular disease, acute illness, and hospice referral. Factors independently associated with greater likelihood of taking inappropriate medications included being male, shorter NH stay, better functional status, and diabetes mellitus, whereas a do-not-hospitalize order was associated with a lower likelihood., Conclusion: Questionably beneficial medications are common in advanced dementia, even as death approaches. Several characteristics can help identify residents at risk for greater medication burden. Medication use in advanced dementia should be tailored to the goals of care.

Objectives: To compare assessments of the decisional capacity of cognitively impaired patients by research assistants (RAs) and by family caregiver/proxies and to determine whether either or both groups judge capacity differently depending on the specific (hypothetical) research enrollment decision being made., Design: Cross-sectional., Setting: Three clinics, one each in Ohio, Kentucky, and Illinois., Participants: One hundred forty-nine patients with established dementia diagnoses and their caregiver/proxies., Measurements: As part of a longer interview, patients were asked about future enrollment in five hypothetical research projects with varying risks and benefits. After patients reported each decision and reasons for that decision, RAs (using Applebaum and Grisso's four standards) indicated whether the patients were competent to make that decision on their own. In separate interviews, caregiver/proxies were asked for a similar appraisal based on life experience with the patient. RA and proxy judgments were compared., Results: Capacity judgments by RAs and by caregiver/proxies differed according to specific project for most patients. Agreement between RA and caregiver/proxy judgments varied according to project, but agreement was only fair when tested using kappa (range in data 0.21-0.39). Caregiver/proxies appraised 50 patients as competent for all decisions, and RAs assessed 47 as so. Of these, only 24 were the same patients., Conclusion: If capacity were assessed anew for each enrollment decision, more potential participants could maintain authority in making those decisions.

Objectives: To evaluate the feasibility of developing consensus recommendations for appropriate prescribing for patients with advanced dementia using a new conceptual framework and to determine the frequency of inappropriate medication use based on these recommendations in a small sample of patients with advanced dementia., Design: Medication data were obtained using chart review. Recommendations for appropriate prescribing were achieved using a modified Delphi consensus panel., Setting: Three long-term care facilities., Participants: Thirty-four patients with advanced dementia enrolled in the Palliative Excellence in Alzheimer Care Efforts Program were selected to evaluate medication use. Twelve geriatricians at the University of Chicago participated in the modified Delphi consensus panel., Measurements: Prescription and over-the-counter medications were recorded for the 34 patients. Following the modified Delphi process, medications were characterized into one of four categories for use in palliative care patients with advanced dementia: never appropriate, rarely appropriate, sometimes appropriate, or always appropriate., Results: Patients were taking an average of 6.5 medications at enrollment. Six patients were taking 10 or more medications daily. Consensus was reached ranking the appropriateness of 69 of 81 medication classes for patients with advanced dementia. Overall, 5% of the 221 medications prescribed at enrollment were considered to be never appropriate, and 10 of 34 patients (29%) had been taking a medication considered to be never appropriate., Conclusion: Based on these preliminary findings, consensus criteria for prescribing in advanced dementia are needed to decrease polypharmacy and reduce the use of medications that are of minimal benefit or high risk.

Objectives: To investigate the general awareness of cognitive impairment in persons with documented dementia, evaluate the subject's recall of a diagnostic disclosure from a physician and their recollection of the discussion, and determine whether this awareness of cognitive impairment or the recall of diagnostic disclosure is associated with poorer self-rated health scores., Design: Secondary data analysis., Setting: Three university-based clinical referral sites for dementia illnesses., Participants: Convenience sample of 149 patients with a diagnosis of dementia., Measurements: Bivariate and logistic regression models with the outcome variables of patient self-report of memory problems, patient report of being told about memory problems by a physician, and self-reported health scores., Results: Ninety-six of 149 (64.4%) subjects reported that they had memory problems, and this report was independently associated with younger age (P=.01) and higher Mini-Mental State Examination score (P=.02). Thirty-nine (26.2%) subjects reported being told by a physician about a diagnosis of dementia or memory problems. This recall was associated with younger age (P<.001), male sex (P=.04), and higher education level (P=.02). African Americans reported poorer self-rated health scores (odds ratio (OR)=2.4, 95% confidence interval (CI)=1.1-5.1). Persons who reported being told by a physician of a diagnosis of dementia were more likely to report poorer self-rated health (OR=2.5, 95% CI 1.1-5.5)., Conclusion: Further research is needed to elucidate the relationship between self-rated health and dementia specifically focusing on the potentially negative effects of diagnostic disclosure on self-rated health, further identification of factors that contribute to self-rated health in persons with dementia, and the prognostic value of self-rated health for persons with dementia.

Objectives: To assess the quality of care for hospitalized vulnerable elders using measures based on Assessing Care of Vulnerable Elders (ACOVE) quality indicators (QIs)., Design: Prospective cohort study., Setting: Single academic medical center., Participants: Subjects aged 65 and older hospitalized on the University of Chicago general medicine inpatient service who were defined as vulnerable using the Vulnerable Elder Survey-13 (VES-13), a validated tool based on age, self-reported health, and functional status., Measurements: Inpatient interview and chart review using ACOVE-based process-of-care measures referring to 16 QIs in general hospital care and geriatric-prevalent conditions (e.g., pressure ulcers, dementia, and delirium); adherence rates calculated for type of care process (screening, diagnosis, and treatment) and type of provider (doctor, nurse)., Results: Six hundred of 845 (71%) older patients participated. Of these, 349 (58%) were deemed vulnerable based on VES-13 score. Three hundred twenty-eight (94%) charts were available for review. QIs for general medical care were met at a significantly higher rate than for pressure ulcer care (81.5%, 95% confidence interval (CI)=79.3-83.7% vs 75.8%, 95% CI=70.5-81.1%, P=.04) and for delirium and dementia care (81.5%, 95% CI=79.3-83.7 vs 31.4% 95% CI=27.5-35.2%, P<.01). According to standard nursing assessment forms, nurses were responsible for high rates of adherence to certain screening indicators (pain, nutrition, functional status, pressure ulcer risk; P<.001 when compared with physicians), although in patients with functional limitations, nurse admission assessments of functional limitations often did not agree with reports of limitations by patients on admission., Conclusion: Adherence to geriatric-specific QIs is lower than adherence to general hospital care QIs. Hospital care QIs that focus on screening may overestimate performance by detecting standard nursing or protocol-driven care.

Objectives: To evaluate a research advance directive for persons with established dementia diagnoses and their family caregivers or proxies., Design: Prospective randomized, controlled trial., Setting: Three clinics, one each in Ohio, Kentucky, and Illinois., Participants: At the end of separate interviews about enrollment choices in five types of hypothetical research projects, 149 persons with established dementia diagnoses and their family proxies were randomized to jointly complete the Planning Ahead Together (PAT) document, a research advance directive (n=69) or to remain in the control group (n=80)., Intervention: The directive was assessed at two points: immediately after sample members received naturally occurring invitations to participate in other studies and again 2 years after initial enrollment., Measurements: Personal enrollment rates, reported ease of enrollment decision for patients and proxies, and proxy comfort were compared between the experimental and control groups., Results: Forty-one dyads were reinterviewed immediately after consent discussions for other trials. Forty-seven patients and 106 proxies were interviewed at 2-year follow-up. There was no evidence immediately after a trial enrollment opportunity or in the follow-up interview that the research advance directive (PAT) assisted patients or proxies. Enrollment rates, decision ease, and proxy comfort and certainty were similar in the PAT and control groups., Conclusion: Patient and proxy experience making hypothetical decisions in the interview may have affected enrollment decisions by the PAT and control groups. Although the low number of recruitment attempts and the natural attrition of the geriatric population limit conclusions about effectiveness that may be drawn from this unique data set, the feasibility of a research advance directive is clearly demonstrated.

Objectives: To explore the pharmacological treatment of noncancer pain in persons with dementia and identify predictors associated with insufficient analgesia., Design: Cross-sectional analysis of an observational cohort study., Setting: Academic outpatient geriatric clinic in Chicago, Illinois., Participants: A total of 115 dyads, mostly African American, consisting of community-dwelling persons with dementia and their caregivers., Measurements: Patient report of demographics, noncancer pain, function, cognition, and depression. Caregiver report of patient agitation and over-the-counter and prescription medications., Results: Sixty-two of 115 (54%) patients reported pain "on an average day." The caregivers of more than half of persons with dementia who reported pain "on an average day" did not report analgesic use. The majority of caregivers who reported analgesic use reported that patients took a World Health Organization Class I medication. No patients had been prescribed a Class III (strong opioid) drug. Fifty-three of 115 (46%) patients had potentially insufficient analgesia. In the logistic regression, insufficient analgesia was associated with greater age, Mini-Mental State Examination score of less than 10, and impairment in daily functioning. Insufficient analgesia was 1.07 times as likely (95% confidence interval (CI) = 1.01-1.14) for each additional year of age, 3.0 times as likely (95% CI = 1.05-9.10) if the subject had advanced dementia, and 2.5 times as likely (95% CI = 1.01-6.25) if the patient had any impairment in activities of daily living., Conclusion: In this convenience sample from a geriatric clinic, many persons with dementia and noncancer pain were not receiving pharmacological treatment. Those at greatest risk for insufficient analgesia were older, had moderate to severe dementia, and experienced impairments in activities of daily living.

Objectives: To assess whether geriatricians documented the bothersome symptoms of patients with advanced dementia, proxy reports of the most-bothersome symptoms affecting those patients (as elicited in research interviews) were compared with what geriatricians who had seen those patients in a proximate clinic visit documented in the medical record., Design: Retrospective chart review., Setting: Outpatient geriatrics clinic at the University of Chicago., Participants: Fifty-seven pairs of patients with dementia (Functional Assessment Staging Tool stage 6 or 7) and their proxies., Measurements: Clinic notes were reviewed for documentation of patients' bothersome symptoms that proxies reported during research interviews. Proxy reports had been recorded in the previously established Palliative Excellence in Alzheimer Care Efforts database., Results: The most-bothersome symptom was documented at least once in 84.2% (48/57) of clinic notes. The second-most-bothersome symptom was documented in 70.3% (26/37) of clinic notes. Most symptoms were documented in the Assessment and Plan section of the note., Conclusion: Geriatricians identified and documented the vast majority of bothersome symptoms, as reported by proxies, of patients with moderate to severe dementia.

Objectives: To assess interest of older adults in screening and treatment for mild cognitive impairment (MCI)., Design: Cross-sectional, in-person pilot survey with a convenience sample., Setting: Two university-based geriatrics clinic waiting rooms in Chicago., Participants: Healthy adults aged 35 and older without cognitive impairment (n = 149)., Measurements: Following a description of MCI extracted from the Alzheimer's Association Website "Fact Sheet," questions concerning willingness to be screened and treated for MCI., Results: Ninety-eight percent of respondents would be willing to be tested for MCI if a family member suggested they had memory problems, 99% were willing to take a medication if it would cut the risk of conversion from MCI to Alzheimer's disease (AD) in half, and 92% would take a medication to delay the conversion from MCI to AD by 1 year. If a family member suggested memory problems, African Americans were more willing than whites to be screened for MCI (75% vs 57%; P = .05)., Conclusion: Older adults expressed high interest in screening and treatment for MCI. Interest in screening is even stronger in African Americans than in whites. Such high interest is potentially troubling, given the current state of knowledge about MCI.

In July 2000, Dr. William Hazzard published an article in the Journal of the American Geriatrics Society entitled "So you think you want to lead an academic geriatric program?" My answer to that question the same month was "Yes," as I agreed to become the chief of the newly established Section of Geriatrics at the University of Chicago. With about 3.5 years on the job now, I offer a more complete reply to Dr. Hazzard's query. Although his paper covered many important and practical issues to consider in looking at becoming a chief, this article provides a perspective on the academic geriatric leadership position based on a new chief's observations. Topics covered include pressures for and against becoming a chief, changing perspectives on goals and rewards, good help, mentoring, money problems/issues, support for the chief, and communication and relationships. It is hoped that these observations will be of use to geriatricians considering leading an academic geriatrics program and to other newly appointed chiefs.

Persons with impaired decision-making capacity require special ethical protections during recruitment for and participation in research. To assess how fully basic protections for these persons were reported in the literature, the first structured review of a sample of reports of trials including Alzheimer's subjects was performed in 62 journals between January 1992 and December 1998. Neither institutional review board review nor informed consent was mentioned in 28% of the studies. In 48% of the studies, there was no mention of subject involvement in the consent process or that any potential subjects refused or withdrew. Protections may have been offered and simply not reported in the journal articles. The critical importance of these protections would be demonstrated if editors required that authors provide full documentation of ethical protections when submitting an article for review. These might be briefly reported in the articles but be made available electronically to interested readers. Authors could then specify in detail how they conducted their research involving persons with diminished decision-making capacity.

Objective: To assess the quality of reporting of research ethics in published clinical research that involves a particularly vulnerable population: nursing home residents., Design: A structured review of publications researched from 1992 to 1996 that involve nursing home residents. The review instrument assessed each publication's compliance with four common standards for research that involves nursing home residents or the cognitively impaired: justification of the use of nursing home residents, Institutional Review Board (IRB) review, nursing home committee review, and informed consent. For each publication, these results were summed into a quality score. The research ethics requirements contained in the journals' instructions for authors that corresponded with each publication were categorized in order to compare whether an association exists between the average quality score for each category and the detail of its research ethics instructions., Results: Forty-five publications were identified. The four quality measures of research ethics showed that (1) all 45 publications reported justification of use of nursing home residents, (2) 36 publications reported that informed consent was obtained or waived, (3) 18 publications reported IRB review, and (4) six publications reported nursing home committee review. Of the 35 publications reporting informed consent was obtained, 16 reported assessing subjects' decisional capacity, and 24 reported whether cognitively impaired subjects were included (19) or excluded (5). The research ethics requirements of each publication's instructions for authors ranked it in one of four categories: (A) None (9); (B) Less than "Uniform Requirements (UR) for Manuscripts Submitted to Biomedical Journals" (7); (C) UR (24); (D) UR plus Additional Instructions (5). A positive association exists between the detail of a research ethics instructions category and the average research ethics quality score for each category (Kruskal-Wallis chi2 = 11.2, P = .01). That is, the more detailed the instructions, the greater the quality score., Conclusion: In publications of research that involves nursing home residents, basic standards of research ethics are not typically reported. However, the positive association between research ethics instructions category and research ethics quality score suggests that a journal's instructions for authors or other features of peer review and editing can affect the quality of reporting research ethics.

Objectives: To describe differences in the characteristics, processes of care, and resource utilization of patients with heart failure cared for by geriatricians, general internists, cardiologists, and combinations of physicians., Design: A retrospective cohort study., Setting: An urban academic medical center., Participants: A total of 439 outpatients with a billing diagnosis of heart failure or cardiomyopathy who were treated by geriatricians, general internists, cardiologists, and combinations of physicians., Measurements: Demographic and clinical characteristics, medication use, diagnostic testing, hospitalizations, and inpatient and outpatient costs were measured., Results: Compared with patients of cardiologists, patients cared for by geriatricians were older, more likely to have hypertension, diastolic dysfunction, and high comorbidity, and less likely to undergo echocardiography, cardiac catheterization, and electrocardiography. Use of angiotensin-converting enzyme inhibitors was similar among patients with reduced systolic function. Patients cared for by geriatricians had the same costs, rates of hospitalization, and likelihood of being symptomatic as patients of cardiologists., Conclusions: The processes of care for patients with heart failure seen solely by geriatricians differ from those for patients seen by other physicians, but the case-mix also varies. Assessment of left ventricular function by geriatricians probably needs to be increased. However, although they were older and had more comorbidity, patients of geriatricians had total costs and symptomatology similar to those of patients of cardiologists. Future work is needed to identify those patients most likely to benefit from treatment by geriatricians and to determine how care can be optimally coordinated among different types of physicians and health providers.

Objectives: To demonstrate that the recent events in emergency research have broad implications for the conduct of human subjects research with the cognitively impaired. This essay illustrates the similarities between the two kinds of research and suggests how understanding these similarities might help to resolve issues in human subjects research on the cognitively impaired., Methods: A review of pertinent journal articles, books, regulations, and court cases., Results: The emergency research controversy resulted in large part because of conflicting interpretations of arguably inadequate research regulations. The proposed Food and Drug Administration (FDA) regulations include advance informed consent, a broad role for family in approving a subject's participation, replacement of a threshold of permissible risk, called minimal risk, with a more sensible balancing of risks and benefits, and a role for the community in research approval. The current state of research on the cognitively impaired suggests that many of the same problems exist now that existed in emergency research before the FDA issued its proposed regulations. The ongoing case of T.D. et al. vs N.Y. State Office of Mental Health suggest that unless steps are taken similar to those taken in emergency research, much of clinical research on the cognitively impaired could cease., Conclusion: Representatives of the government, medicine, and the public must recognize the unresolved issues and inadequate regulations relating to research on the cognitively impaired. The proposed FDA regulations for emergency research may provide guidance for a settlement of these issues.

Objective: The Health Care Surrogate Act (HCSA) in Illinois has been proposed as a model for state laws naming surrogate medical decision-makers for those without advance directives (ADs). Our objective was to determine if the HCSA identifies the same surrogate as older persons would choose for themselves. If not, is the discrepancy between legally identified surrogate and preferred surrogate troublesome to respondents? Because it is documented that black Americans have a variety of family structures, some of which may not be reflected in the HCSA list, we also wished to determine if discrepancies between surrogates named by the law and those desired by patients are associated with black or white race., Design, Setting and Participants: A convenience sample of 144 patients aged 65 and older, without cognitive impairment, was interviewed at the geriatrics clinic of an academic medical center., Main Outcome Measures: Respondents without ADs who had a different stated choice for surrogate medical decision-maker than the surrogate defined by the Illinois HCSA, based on their existing family., Results: Twenty-six percent of respondents without ADs chose a surrogate that differed from the surrogate defined by the HCSA. However, 67% of those with a different choice for surrogate than defined by law were not troubled by the discrepancy. The proportion of black subjects (25%) and white subjects (31%) who had surrogate discrepancies was not significantly different (P = .6)., Conclusion: Because the Illinois HCSA named surrogates who would be agreeable to the majority of our respondents, it appears that it may be a useful model for state surrogacy laws.

As nursing homes become increasingly important sites for biomedical and behavioral research, researchers must address the ethical problems of increased vulnerability and the high prevalence of mental and physical disorders in the nursing home population. Obtaining valid informed consent is but one of the many difficult issues that confronts the investigator in the nursing home. Efforts should be made to involve nursing home residents, as well as family and staff members, in the review of research. The benefits and burdens of research protocols should be equitably distributed, and potential conflicts of interest for staff members and physicians should be minimized or their potential adverse impact ameliorated. Appropriate attention to these ethical concerns may facilitate nursing home research while still safeguarding vulnerable residents. We offer proposed guidelines for the ethical conduct of research in nursing homes in an effort to stimulate discussion among investigators, nursing home staff and residents, residents' families, and ethicists.

Objective: To see if an educational intervention directed at older outpatients would lead to increased use or discussion of advance directives and to characterize patients' reasons for not obtaining advance directives., Design: Randomized, controlled trial of an educational intervention versus usual care., Setting: Outpatient geriatrics clinic of a university hospital., Patients: One hundred and thirty-one non-demented patients over the age of 65 who did not have an advance directive documented in their record at the start of the study. Forty-eight patients were in the trial arm and 83 in the control., Main Outcome Measures: All patients had their charts reexamined 6 months after enrollment to look for the presence of a living will, a durable power of attorney for health care, or a physician's note describing a discussion of advance directives. Trial patients were also re-interviewed to examine their reasons for not executing an advance directive., Main Results: Six months after the intervention, only seven of the 48 trial subjects (15%) had an advance directive or note describing discussion of advance directives in their charts compared to eight of the 83 controls (10%) (P greater than 0.05). When asked to give reasons for not obtaining an advance directive, many patients' responses pointed to procrastination as a significant barrier., Conclusions: Promoting advance directive use is a complicated task. Barriers other than information and access to documents appear to be involved and need to be addressed in future efforts.