Publications

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.

INTRODUCTION

Elderly Veterans enrolled in VA Home Based Primary Care (HBPC) programs suffer from many diseases including malnutrition. Nutrition screening tools exist in the VA system but they are inconsistently utilized across ambulatory care programs and are neither research validated nor comparable with non-VA populations. The Mini-Nutritional Assessment short-form (MNA-SF) has been validated in international studies in a variety of settings. The primary aim of this study was to find the prevalence of malnutrition among Veterans enrolled in HBPC programs. The secondary objective was to determine the feasibility of adopting a validated nutrition screening tool (Mini-Nutritional Assessment short-form (MNA-SF)).

METHODS

2252 veterans age 65 and older from 18 HBPC programs from across the country participated in the study. The study period was between April and September 2012. WinPepi (version 11.25) was used for descriptive analysis.

RESULTS

We found that the prevalence of malnutrition was 15% (344/2252) and the prevalence of at risk for malnutrition was 40.3% (909/2252).

DISCUSSION

The MNA-SF is an efficient nutrition screening tool and it can be successfully used for the elderly veterans. The prevalence of malnutrition among veterans was high compared to the community dwelling U.S. civilian elderly population. By preventing and treating malnutrition, health care systems should be able to reduce overall health care costs.