Substance Use Screening in Geriatric Primary Care: Cultural Issues and Alcohol Consumption in the Deep South.

OBJECTIVES: To investigate indicators of potentially hazardous alcohol use among older adults living in a region with high substance use stigma. METHODS: Patients at a university-affiliated geriatrics clinic in the Deep South of theUS completed behavioral health screenings including self-reported alcohol use, symptoms of depression or anxiety, and cognitive functioning between 2018 and 2022. RESULTS: Participants (N = 278) averaged 76.04 years of age (SD = 9.25), were predominantly female (70.9%), and non-Hispanic white (84.5%), with an averageof 6.08 comorbid diagnoses (SD = 2.86). Race/ethnicity, age, and symptoms of anxiety were associated with alcohol use and hazardous alcohol use, with non-Hispanic whites, younger individuals, and those with more anxiety symptoms reporting more alcohol use. Notably, alcohol use and hazardous alcohol use were associated with cognitive functioning in the dementia range. CONCLUSION: Self-reported alcohol use is low in geriatric primary care in the Deep South, US, differs by race/ethnicity, and is predictive of cognitive impairment when alcohol use is hazardous. Issues of trust and stigma may play a role in self-report ofstigmatized behaviors. CLINICAL IMPLICATIONS: Self-reported alcohol intake must be considered within the cultural context of regional stigma. Recommendations to address this are provided.

Psychological flexibility in older adulthood: a scoping review.

OBJECTIVES: Psychological flexibility/inflexibility (PF/PI) is a core component of the acceptance and commitment therapy (ACT) model, which is gaining more attention in the geropsychological literature. This scoping review examines the size and scope of the research on PF/PI in older adulthood related to age differences between older adult and younger samples, correlates relevant to psychological health, and changes with ACT. METHODS: A systematic literature search was conducted using PubMed, CINAHL, and PsycINFO. Peer-reviewed articles available in English were included that: had a mean age ≥65 and a minimum age ≥60; and reported self-report measures of PF/PI. We categorized PF/PI into three domains: open, aware, and engaged. RESULTS: Forty-six articles were included. Most studies measured open or aware domains; few measured the engaged domain. Older adults evidenced greater awareness compared to younger adults (9 of 13 analyses were significant). Openness and awareness consistently yielded medium to large correlations with anxiety and depression. PF/PI did not relate with positive affect and inconsistently correlated with quality of life measures. CONCLUSION: Despite emerging trends, variability and limitations were evident in the literature. Specifically, measurement issues, lack of conceptual clarity, and the omission of values and behavioral measures require future attention.

Biomarker Response to Mindfulness Intervention in Veterans Diagnosed with Post-traumatic Stress Disorder.

Objectives: This study evaluates the effects of treatment with mindfulness-based stress reduction (MBSR) compared to the active control, present-centered group therapy (PCGT), on morning plasma cortisol, interleukin-6 (IL-6), and C-reactive protein (CRP) in veterans diagnosed with post-traumatic stress disorder (PTSD). Methods: In a post hoc exploratory analysis, we pooled biomarkers and clinical outcomes of mindfulness, PTSD, and depression from two randomized controlled trials comparing MBSR (n = 104) to PCGT (n = 106) in U.S. military veterans diagnosed with PTSD. Linear mixed-effects modeling was used to evaluate associations between changes in biomarkers and clinical outcomes from baseline to 9-week primary endpoint and 16-week follow-up endpoint. Results: Cortisol levels were inversely related to self-reported PTSD symptoms at baseline (p = 0.02). Cortisol increased from baseline to 9-week endpoint for both groups, but significantly less so in the MBSR group compared to PCGT group (mean difference 1.69 ± 0.8 SE; p = 0.035). Changes in IL-6 and CRP did not differ between groups at either baseline or week 9. From baseline to week 9, increased mindfulness was significantly associated with increased cortisol (p = 0.02) and decreased PTSD and depression severity (p < 0.01). Increased IL-6 and CRP were significantly associated with decreased PTSD severity (p < 0.05), but not depression. Pooled analysis corroborated earlier findings that MBSR is significantly better than PCGT in improving clinical outcomes. Increased mindfulness was strongly associated with improved symptoms. Conclusions: Increased mindfulness is associated with a recalibration of cortisol levels which may be indicative of therapeutic response, especially in patients with lower baseline cortisol. Furthermore, mindfulness-based practices improve symptoms of PTSD and depression in a significant correlation with self-reported levels of mindfulness. Clinical Trial Registration clinicaltrialsgov: NCT01532999 and NCT01548742.

Healthcare Quality Improvement Competency: A Clinical and Training Imperative for Geropsychology.

Quality improvement (QI) work is increasingly necessary to ensure healthcare is delivered safely, efficiently, and equitably. As geropsychologists play an increasingly vital role in healthcare service delivery for older adults, it is imperative that they develop professional competence in QI, yet there is little formal QI training aimed at geropsychologists or to graduate students pursuing geropsychology. This article aims to elucidate the importance of QI education and training in geropsychology. In line with the Pikes Peak model for training in professional geropsychology, we outline QI knowledge and skills competencies for geropsychology training and suggest a rubric for integrating QI education into academic and clinical training from graduate school to professional practice. We provide recommended readings that geropsychology educators can read to become familiar with QI or use as part of a syllabus. Finally, we offer some recommendations for how current and future geropsychologists can be leaders in quality improvement work.

Improving Suicide Risk Detection and Clinical Follow-up after Discharge from Nursing Homes.

Objectives: Suicide Awareness for Veterans Exiting Community Living Centers (SAVE-CLC) is a brief intervention to standardize suicide-risk screening and clinical follow-up after VA nursing home discharge. This paper examines the outcomes of SAVE-CLC compared to care as usual.Methods: A quasi-experimental evaluation was conducted (N = 124) with SAVE-CLC patients (n = 62) matched 1:1 to a pre-implementation comparison group. Data were obtained through VA Corporate Data Warehouse resources and chart reviews. Outcomes examined (within 30/90 days of discharge) included mortality rates, frequency of outpatient mental health visits, emergency department visits, rehospitalizations, depression screens (PHQ-2), and the latency period for outpatient mental health care.Results: A greater portion of SAVE-CLC patients received a depression screen after discharge, n = 42, 67.7% versus n = 8, 12.9%, OR = 14.2 (5.7, 35.3), p < .001. The number of days between discharge and first mental health visit was also substantially shorter for SAVE-CLC patients, M = 8.9, SD = 8.2 versus M = 17.6, SD = 9.1; t = 2.47 (122), p = .02. Significant differences were not observed in emergency department visits, hospitalizations, or mortality.Conclusions: SAVE-CLC is a time-limited intervention for detecting risk and speeding engagement in mental health care in the immediate high-risk post-discharge period.Clinical Implications: Care transitions present an important opportunity for addressing older adults' suicide risk; brief telephone-based interventions like SAVE-CLC may provide needed support to individuals returning home.

What geropsychology trainees think geropsychologists do and what we actually do: A mixed-methods Study.

A shortage of individuals in academic geropsychology positions further perpetuates the shortage of clinicians trained to meet the needs of the aging population. Barriers to recruiting geropsychology trainees into academia and what attracts trainees into career paths within geropsychology are not understood. The current mixed-methods study examined 1) geropsychology trainees' (n = 28) knowledge and attitudes toward work in clinical or academic positions and 2) professional geropsychologists (n = 67) activities, career expectations, ideal activities, and work/life balance. We asked geropsychology trainees to estimate the amount of time their supervisors spent in clinical, research, education, and administrative activities, and professional geropsychologists reported how they currently spent their time in these same activities. We conducted qualitative interviews asking geropsychology trainees about experiences in academic or clinical settings and geropsychologists about career expectations, opportunities, and work/life balance. Geropsychology trainees had less accurate estimates of academic work time compared to clinically focused work time. Trainee interviews revealed negative perceptions of the university system, including bureaucracy, low salary, and perceived workload. Professional geropsychologists reported high agreement between actual and ideal work time with some individual differences. Each group discussed work-life balance, based on career stage or work setting. Interventions for recruiting more geropsychology trainees into academic jobs are discussed.

Capacity assessment training in geropsychology: Creating and evaluating an outpatient capacity clinic to fill a training gap.

Assessment of decision-making capacity of older adults is a growing area of practice but training opportunities are lacking. We present a needs assessment, program characteristics, pilot clinic process (n= 52 referrals) and outcome training (n= 4 interns) data for a capacity training clinic. Process data reveal that the training clinic provided consistent referrals (1 per week) across multiple capacity domains (independent living, treatment consent, and financial capacities), with 27% of referrals providing opportunities for training in protective services. Outcome data found three of the four interns reported proficient skills in capacity assessment, as well as improved skills in six areas related to capacity assessment: knowledge of limitations of assessment methods, person-environment interaction, identifying and applying ethical and legal standards, utilizing cognitive assessments, communicating results and recommendations, and assessing risk. The discussion shares lessons learned for the development of future training rotations and clinics in the capacity assessment.

SAVE-CLC: An Intervention to Reduce Suicide Risk in Older Veterans following Discharge from VA Nursing Facilities.

Objective: We describe the development and implementation of a telephonic intervention (SAVE-CLC) piloted at three VA sites for Veterans returning to the community from VA nursing facilities (Community Living Centers or "CLCs"). Care transitions present a known period of medical risk for older adults and may pose increased risk for suicide. Veterans discharging from CLCs are at elevated risk compared to age and gender matched controls.Methods: Using a quality improvement approach, input was gathered from key stakeholders to aid in the development of the intervention. Veterans were screened for depressive symptoms and need for additional support by phone.Results: Of the Veterans who received the SAVE-CLC intervention, 87.9% had at least one prior mental health diagnosis, though only 19.7% had an outpatient mental health appointment arranged at CLC discharge. Results suggest that the intervention is feasible across multiple outpatient settings and is generally well-received by Veterans and caregivers, with 97% of those contacted reporting that the telephone calls were helpful.Conclusion: This flexible, telephone-based intervention addresses the unmet need of integrating mental health care into discharge planning during care transitions.Clinical Implications: SAVE-CLC offers a feasible and acceptable solution to suicide risk in older Veterans exiting a CLC.

Safety Planning to Manage Suicide Risk with Older Adults: Case Examples and Recommendations.

Adults age 65 and older have high rates of suicide, despite recent efforts to reduce the suicide rate in this population. One suicide prevention strategy with burgeoning empirical support is safety planning; however, there is a lack of information and resources on safety planning for older adults to support uptake of this evidence-based practice in clinical settings where older adults are commonly seen. Safety plans can address risk factors for suicide in older adults, including social isolation, physical illness, functional limitations, and use of highly lethal means. Safety plans also promote relevant protective factors, including increasing use of coping strategies, social support, and help-seeking. Clinicians may encounter challenges and barriers to safety planning with older adults. This paper describes a collaborative, creative approach to safety planning that is relevant and useful for this vulnerable population. Using two case examples, we illustrate how to engage older adults in safety planning, including ways to minimize barriers associated with the aging process.

Masculinity and Military Culture in VA Hospice and Palliative Care: A Narrative Review With Clinical Recommendations.

This article examines the intersection between masculinity, military culture, and hospice and palliative care (HPC). The authors conducted a narrative literature review, supplemented with clinical annotations, to identify the impact of masculinity and military culture on the following topics salient to end-of-life care with older male veterans: pain management, mental health, coping, communication, autonomy and respect, and family roles. Findings suggest that traits associated with masculinity and military culture have an influence on the end-of-life process and HPC for older male veterans. Specifically, results suggest that older male veterans may deny or minimize physical pain, decline mental health treatment, utilize maladaptive coping strategies, avoid emotional conversations, struggle to manage perceived shifts in autonomy, and experience challenges negotiating changing family roles. The authors provide clinical recommendations for providers across various disciplines to address the aforementioned concerns with older male veterans in HPC. Overall, information presented in this article may be an important contribution to the literature for building cultural competencies with older male veterans and has the potential to improve the delivery of HPC for veterans and their families.

Person-Centered Care Practices in Long-Term Care in the Deep South: Consideration of Structural, Market, and Administrator Characteristics.

The purpose of this study was to identify structural, market, and administrator factors of nursing homes that are related to the implementation of person-centered care. Administrators of Medicare/Medicaid-certified nursing homes in the Deep South were invited to complete a standardized survey about their facility and their perceptions and attitudes regarding person-centered care practices (PCCPs). Nursing home structural and market factors were obtained from public websites, and these data were matched with administrator data. Consistent with the resource-based theory of competitive advantage, nursing homes with greater resources and more competition were more likely to implement PCCPs. Implementation of person-centered care was also higher in nursing homes with administrators who perceived culture change implementation to be feasible in their facilities. Given that there is a link between resource availability and adoption of person-centered care, future research should investigate the cost of such innovations.

Group-based Acceptance and Commitment Therapy (ACT) for Older Veterans: Findings from a Quality Improvement Project.

OBJECTIVES: The purpose of this project was to develop, implement, and evaluate a 12-session Acceptance and Commitment Therapy (ACT) for Older Veterans group protocol. METHODS: The Plan-Do-Study-Act (PDSA) quality improvement model was the foundational process for this project. Veterans age 55 years and older participated in an ACT for Older Veterans group in an outpatient geropsychology clinic at a Veterans Affairs Medical Center. Study methods included analysis of participant feedback gathered in a focus group, process measures (i.e., number of sessions attended and number of early terminations), and outcome measures (i.e., depressive symptoms, anxiety symptoms, and psychological flexibility). RESULTS: Seventeen participants completed an average of ten sessions. Less than 25% of participants terminated early. Depressive symptoms improved, though there were no statistically significant changes in anxiety symptoms and psychological flexibility. The focus group yielded several recommendations that were implemented in subsequent groups. CONCLUSIONS: The PDSA model helped in the development of a group therapy intervention that is both relevant and beneficial to older Veterans presenting with a variety of biopsychosocial issues. Results provide support for further research investigation of ACT for Older Veterans Group. CLINICAL IMPLICATIONS: ACT used in a group format is a feasible and acceptable psychotherapy for older Veterans.

Development of a New Tool for Systematic Observation of Nursing Home Resident and Staff Engagement and Relationship.

Purpose of Study: To develop a structured observational tool, the Resident-centered Assessment of Interactions with Staff and Engagement tool (RAISE), to measure 2 critical, multi-faceted, organizational-level aspects of person-centered care (PCC) in nursing homes: (a) resident engagement and (b) the quality and frequency of staff-resident interactions. Design and Methods: In this multi-method psychometric development study, we conducted (a) 120 hr of ethnographic observations in one nursing home and (b) a targeted literature review to enable construct development. Two constructs for which no current structured observation measures existed emerged from this phase: nursing home resident-staff engagement and interaction. We developed the preliminary RAISE to measure these constructs and used the tool in 8 nursing homes at an average of 16 times. We conducted 8 iterative psychometric testing and refinement cycles with multi-disciplinary research team members. Each cycle consisted of observations using the draft tool, results review, and tool modification. Results: The final RAISE included a set of coding rules and procedures enabling simultaneously efficient, non-reactive, and representative quantitative measurement of the interaction and engagement components of nursing home life for staff and residents. It comprised 8 observational variables, each represented by extensive numeric codes. Raters achieved adequate to high reliability with all variables. There is preliminary evidence of face and construct validity via expert panel review. Implications: The RAISE represents a valuable step forward in the measurement of PCC, providing objective, reliable data based on systematic observation.