Informing Dementia Support Programs That Serve Low-Income, Multilingual Communities in a Safety Net Health System: Use of Focus Groups to Identify Specific Needs.

The Centers of Medicare and Medicaid Services recently announced a new voluntary nationwide model. This model aims to provide comprehensive, standard care for people living with dementia and their unpaid caregivers and to enhance health equity in dementia care. However, little is known about the needs of older adults with dementia and their caregivers in a multiethnic and multicultural patient population of a safety net health system. The aim of this study is to include their voices. We conducted four focus groups in English and Spanish to investigate the common needs and barriers unique to the care of patients within the Los Angeles County healthcare system. Using qualitative, iterative analyses of the transcripts, we identified four domains of concern from the dyads (persons with dementia and their caregivers): need for education for dyad-centered care, barriers to resources, dyad safety, and caregiver burden and insight. These domains are interconnected, and the way this patient population experiences these domains may differ compared to those in well-resourced or predominantly English-speaking healthcare settings. Therefore, the identified domains serve as potential building blocks for dementia support programs inclusive of underserved, multicultural populations.

Systematic Review of Dementia Support Programs with Multicultural and Multilingual Populations.

BACKGROUND: Dementia care programs have become more common due to a growing number of persons living with dementia and lack of substantial benefit from pharmacologic therapies. Cultural and language differences may present barriers to access and efficacy of these programs. In this article, we aimed to systematically review the current literature regarding outcomes of dementia care programs that included multicultural and non-English speaking populations. METHODS: A systematic review was conducted using four scientific search engines. All studies included in the review are English language, randomized control trials evaluating various care coordination models. The initial search strategy focusing on studies specifically targeting multicultural and non-English speaking populations resulted in too few articles. We expanded our search to articles that included these populations although these populations may not have been the focus of the study. RESULTS: Seven articles met inclusion criteria for final review. Measured outcomes included emergency room use, hospitalizations, provider visits, quality of life indicators, depression scores, and caregiver burden. CONCLUSIONS: Dementia care programs demonstrate significant ability to provide support and improve outcomes for those living with dementia and their caregivers. There is limited research in this field and thus opportunity for further study in underserved and safety net populations including more high-quality randomized controlled trials with larger sample sizes.

A randomized trial of a behavioral intervention to decrease hospital length of stay by decreasing bedrest.

BACKGROUND: Approximately half of hospitalized patients suffer functional decline due to spending the vast majority of their time in bed. Previous studies of early mobilization have demonstrated improvement in outcomes, but the interventions studied have been resource-intensive. We aimed to decrease the time hospital inpatients spend in bed through a pragmatic mobilization protocol. METHODS: This prospective, non-blinded, controlled clinical trial assigned inpatients to the study wards per routine clinical care in an urban teaching hospital. All subjects on intervention wards were provided with a behavioral intervention, consisting of educational handouts, by the nursing staff. Half of the intervention wards were supplied with recliner chairs in which subjects could sit. The primary outcome was hospital length of stay. The secondary outcome was the '6-Clicks' functional score. RESULTS: During a 6-month study period, 6082 patient encounters were included. The median length of stay was 84 hours (IQR 44-175 hours) in the control group, 80 hours (IQR 44-155 hours) in the group who received the behavioral intervention alone, and 88 hours (IQR 44-185 hours) in the group that received both the behavioral intervention and the recliner chair. In the multivariate analysis, neither the behavioral intervention nor the provision of a recliner chair was associated with a significant decrease in length of stay or increase in functional status as measured by the '6-Clicks' functional score. CONCLUSION: The program of educational handouts and provision of recliner chairs to discourage bed rest did not increase functional status or decrease length of stay for inpatients in a major urban academic center. Education and physical resources must be supplemented by other active interventions to reduce time spent in bed, functional decline, and length of stay. TRIAL REGISTRATION: ClinicalTrials.gov, HS-16-00804.

Geriatric Assessment in Multicultural Immigrant Populations.

While the traditional comprehensive geriatric assessment provides valuable information essential to caring for older adults, it often falls short in multicultural immigrant populations. The number of foreign-born older adults is growing, and in some regions of the United States of America (U.S.), they encompass a significant portion of the older adult population. To ensure we are caring for this culturally diverse population adequately, we need to develop a more culturally competent comprehensive geriatric assessment. In this review, we explore ways in which to do this, address areas unique to multicultural immigrant populations, and identify limitations of the current assessment tools when applied to these populations. In order to be more culturally sensitive, we should incorporate the concepts of ethnogeriatrics into a comprehensive geriatric assessment, by addressing topics like healthcare disparities, language barriers, health literacy, acculturation level, and culturally defined beliefs. Additionally, we must be sensitive to the limitations of our current assessment tools and consider how we can expand our assessment toolkit to address these limitations. We discuss the limitations in cognitive screening tests, delirium assessments, functional and mental health assessments, advance care planning, and elder abuse.

Low bone mineral density risk factors and testing patterns in institutionalized adults with intellectual and developmental disabilities.

BACKGROUND: Adults with intellectual or developmental disability (ID/DD) have multiple risks for low bone mineral density (BMD) without formal guidelines to guide testing. We sought to identify risk factors and patterns of BMD testing among institutionalized adults with ID/DD. METHODS: We evaluated risk factors for low BMD (Z-/T-score < -1) and patterns of BMD testing among adults with ID/DD receiving care at a state-run residential facility. Kruskal-Wallis, Fisher's exact and Pearson's chi-squared tests were used as appropriate. RESULTS: Of the 140 eligible patients, only 44% ever had BMD testing of which 89% had low BMD. Median age at diagnosis was 42 years old. Individuals with low BMD were more likely to be older, non-weight bearing, Caucasian and have severe cognitive delay. CONCLUSIONS: Adults with ID/DD in this facility had a high prevalence of low BMD. Further studies are needed to better characterize risk factors and inform screening within this high-risk population.

Mouse embryonic stem cells and preimplantation embryos require signaling through the phosphatidylinositol 3-kinase pathway to suppress apoptosis.

Whereas most mammalian cells require extracellular signals to suppress apoptosis, preimplantation embryos can survive and develop to the blastocyst stage in defined medium without added serum or growth factors. Since cells of these embryos are capable of undergoing apoptosis, it has been suggested that their lack of dependence upon exogenous growth factors results from the production of endogenous growth factors that suppress apoptosis by an autocrine signaling mechanism. In the present study, we have examined the growth factor requirements and intracellular signaling pathways that suppress apoptosis in both mouse preimplantation embryos and embryonic stem (ES) cells, which are derived from the blastocyst inner cell mass. Cultured ES cells, in contrast to intact embryos, required serum growth factors to prevent apoptosis. Suppression of ES cell apoptosis by serum growth factors required the phosphatidylinositol 3-kinase (PI 3-kinase) signaling pathway, since apoptosis was rapidly induced by inhibition of PI 3-kinase with LY294002. In contrast, inhibition of MEK/ERK signaling with U0126 or of mTOR with rapamycin had no detectable effect on ES cell survival. Thus, like most mammalian cells, the survival of ES cells is mediated by growth factor stimulation of PI 3-kinase signaling. Treatment with LY294002 (but not with U0126 or rapamycin) similarly induced apoptosis of mouse blastocysts in serum-free medium, indicating that intact preimplantation embryos are also dependent upon PI 3-kinase signaling for survival. These results demonstrate that PI 3-kinase signaling is required to suppress apoptosis of both ES cells and intact preimplantation embryos, consistent with the hypothesis that survival of preimplantation embryos is maintained by endogenous growth factors that stimulate the PI 3-kinase pathway.