Development of a Lived Experience Panel to inform the design of embedded pragmatic trials of dementia care interventions.

BACKGROUND: The National Institute on Aging (NIA) Imbedded Pragmatic Alzheimer's Disease and Alzheimer's Related Dementia Clinical Trials (IMPACT) Collaboratory convened a Lived Experience Panel (LEP) to inform the development of research priorities and provide input on conducting embedded pragmatic clinical trials (ePCTs) of dementia care interventions. Given the importance of people with lived experience to dementia research, and the unique considerations of engaging people with dementia, we report on our process for the recruitment, selection, and initial convening of the IMPACT LEP. METHODS: The IMPACT Engaging Partners Team, in partnership with the Alzheimer's Association, sought nominations of individuals with mild cognitive impairment or early-stage dementia, care partners of other people living with dementia (PLWD), and proxy representatives for individuals with mid-to-late stage dementia. The 11-member LEP was composed of individuals with diverse personal experiences in part due to their age, race, ethnicity, gender, sexual orientation, geography, disability, or type of dementia. In its first year, the LEP met with IMPACT's Patient and Caregiver Relevant Outcomes Core and Ethics and Regulation Core. RESULTS: LEP members provided valuable insights and nuanced discussion of issues relevant to ePCTs in dementia care from a broad range of personal experience. Panelists identified key research priorities and provided insight on outcomes often studied by researchers. The LEP also informed investigators' approaches to waivers and modifications of written informed consent and evaluation of minimal risk. Summary reports of the LEP meetings with each Core are available on the IMPACT website. At the end of the first year, changes were made to the composition of the LEP, and opportunities were identified for expanding panelist engagement with IMPACT investigators, as were priorities and scope for future input. CONCLUSIONS: The IMPACT LEP provides a model for engaging PLWD and care partners in the research process as collaborators.

The Other Dementia Breakthrough-Comprehensive Dementia Care.

This Viewpoint describes barriers to comprehensive dementia care and proposes strategies for overcoming them.

Polypharmacy Among Patients With Major Depressive Disorder and Co-occurring Substance Use Disorders in a Psychiatric Hospital Setting: Prevalence and Risk Factors.

BACKGROUND: Major depressive disorder (MDD) is common among patients admitted to a psychiatric hospital who frequently present with comorbid conditions such as substance use disorders (up to 50%). Polypharmacy (ie, being prescribed 3 or more medications) may be relatively common in dual-diagnosis patients. This study sought to examine prevalence and risk factors associated with psychotropic polypharmacy in hospitalized patients with MDD and co-occurring SUDs. METHODS: An electronic chart review was conducted with 1315 individuals admitted to a psychiatric hospital; 505 (38.4%) were identified as having co-occurring MDD + SUD. We examined psychotropic polypharmacy and clinical severity to explore risk for concerning drug interactions. RESULTS: Potentially problematic polypharmacy patterns were identified among those with MDD + SUD and were related to negative clinical outcomes, particularly in terms of increased sedation potential for individuals with an opioid use disorder (OUD). Groups at the highest risk for polypharmacy included patients who were female, older in age, lower in functioning, and presenting with a co-occurring OUD. Having an OUD was associated with particularly risky polypharmacy combinations, while having a cannabis use disorder was associated with the least polypharmacy. CONCLUSIONS: Results highlight a high prevalence of polypharmacy among a group that has an elevated risk for negative outcomes. There is a continued need to improve identification of complex patient presentations and adjust medications in a hospital setting to improve treatment outcomes and reduce future mortality.

Cost effectiveness of non-drug interventions that reduce nursing home admissions for people living with dementia.

INTRODUCTION: Six million Americans live with Alzheimer's disease and Alzheimer's disease and related dementias (AD/ADRD), a major health-care cost driver. We evaluated the cost effectiveness of non-pharmacologic interventions that reduce nursing home admissions for people living with AD/ADRD. METHODS: We used a person-level microsimulation to model the hazard ratios (HR) on nursing home admission for four evidence-based interventions compared to usual care: Maximizing Independence at Home (MIND), NYU Caregiver (NYU); Alzheimer's and Dementia Care (ADC); and Adult Day Service Plus (ADS Plus). We evaluated societal costs, quality-adjusted life years and incremental cost-effectiveness ratios. RESULTS: All four interventions cost less and are more effective (i.e., cost savings) than usual care from a societal perspective. Results did not materially change in 1-way, 2-way, structural, and probabilistic sensitivity analyses. CONCLUSION: Dementia-care interventions that reduce nursing home admissions save societal costs compared to usual care. Policies should incentivize providers and health systems to implement non-pharmacologic interventions.

Project MOVE: A randomized controlled trial of Interventions for initiating and maintaining physical activity in depressed individuals.

Objective: To test interventions for increasing aerobic exercise in depressed individuals. Methods: We conducted a 3-arm randomized controlled trial aimed at increasing minutes of moderate-to-vigorous physical activity (MVPA) in depressed adults (N = 242). Each successive arm included an added component that might serve to increase and maintain physical activity. Arms were: 1) Brief advice (BA) to aerobic exercise; 2) BA + supervised and home-based aerobic exercise (SHE) + health education (HE); and 3) BA + SHE +cognitive-behavioral sessions focused on increasing and maintaining aerobic exercise (CBEX). HE was intended to serve as a control for CBEX. Assessments were conducted at baseline, Month 1.5, end of intervention (Month 3), Month 6, and Month 9. The primary outcome of MVPA was assessed via accelerometry. Secondary outcomes included self-reported MVPA, depression severity, and other aspects of mood and affect. Results: At 3 months (the pre-designated primary outcome timepoint), the simple effect of treatment was statistically significant (F2, 569.0 = 4.17, p = .016), with BA+SHE+CBEX being superior to BA. We did not observe differences between BA+SHE+HE and either of the other arms. There were no statistically significant differences between treatment groups at 6- or 9-months. Treatment effects were not statistically significant for secondary outcomes. Conclusions: Supervised and home-based exercise, when combined with a cognitive-behavioral exercise intervention, is effective in increasing aerobic exercise in depressed adults in the short-term, although the impact diminishes post-intervention period.

Chronic disease management: why dementia care is different.

With the rise in the population of older adults, the number of individuals living with chronic diseases that need management will increase dramatically. Successful programs have been developed for chronic conditions (eg, heart failure, diabetes, asthma, chronic obstructive pulmonary disease) that use principles of self-management, monitoring, and care coordination. However, because of the effects of dementia on the mind including behavioral complications, the progressive loss of capacity for affected individuals to participate in care or decision-making, the devastating effects on care partners, and the scope of disease management beyond medical issues, the management of dementia is different and demands different approaches. The success of dementia management will depend upon how well the care provided is able to maximize the function, independence, and dignity of the individual living with dementia while minimizing care partner strain and burnout.

Comorbidity and Management of Concurrent Psychiatric and Medical Disorders.

Aging increases susceptibility to medical and psychiatric comorbidity via interrelated biological, psychological, and social mechanisms. Mental status changes or other psychiatric symptoms occurring in older adults with medical disorders most often result from delirium, depression, or the onset of Alzheimer's disease and related dementias (ADRD). Clinicians can use evidence-based tools to evaluate such symptoms including the 4A's Test for delirium, the Saint Louis University Mental Status Exam, and the Geriatric Depression Scale. Innovative models such as collaborative care can improve the outcome of care of older adults with medical disorders requiring treatment for depression or ADRD..

Dissemination of a successful dementia care program: Lessons to facilitate spread of innovations.

BACKGROUND: Despite the effectiveness of innovations to improve the care of persons with dementia, there has been limited diffusion of these into widespread clinical practice. We aimed to identify common barriers and address them directly in the initial phase of dissemination of a successful dementia care program. METHODS: Description of and early experience with a dissemination strategy of the UCLA Alzheimer's and Dementia Care Program to health care systems nationwide. We measured site-identified goals for the program and indicators of success, number of adopting sites, and participants in their programs. RESULTS: From January 2019 to December 2021, 80 sites expressed interest in adopting the program, 14 (18%) sites adopted it, and 10 of these sites have begun caring for patients. Another 4 sites have implemented the program as part of a randomized clinical trial. To date, over 1690 persons living with dementia and their caregivers have received Alzheimer's and Dementia Care (ADC) care at 14 adopting sites. Key lessons from the early dissemination efforts include the importance of identifying a strong product champion at the adopting site, creating a business case for adoption, training of clinical staff and adapting the model to fit local cultures and workflow, as well as recognizing the likely long length of time needed for the decision to adopt and implementation process. CONCLUSIONS: Despite many obstacles to dissemination, with local champions and technical assistance, successful innovations in dementia care can be implemented in diverse health systems. The ability to adopt sites to bring the program to full scale and achieve comparable outcomes to the original program remains to be determined.

Dissemination of a successful dementia care program: Lessons from early adopters.

BACKGROUND: Evidence-based models for providing effective and comprehensive care for Alzheimer's disease and related dementias exist but have yet to be successfully implemented at scale. The Alzheimer's and Dementia Care Program (ADC Program) is an effective comprehensive dementia care model that is being disseminated across the United States. This qualitative study examines barriers and facilitators to implementing the model among early adopting sites. METHODS: This study included semi-structured interviews with a total of 21 clinical site leaders and Dementia Care Specialists from a total of 11 sites across the US. Interviews were audio recorded, transcribed, and coded using Dedoose qualitative analysis software. Coding scheme development and data interpretation were informed by Rogers' Diffusion of Innovations framework. RESULTS: Key themes are organized in line with Rogers' framework. These include: the innovation-decision process, implementation and characteristics of the innovation, and sustainability. CONCLUSIONS: Across the three overarching themes presented in this manuscript, the importance of engagement from site leaders, the multifaceted nature of the dementia care specialist role, and the value of technical assistance from qualified experts are apparent. However, for this work to continue to be successful, there needs to be more appropriate payment to cover needed services and a mechanism for supporting comprehensive dementia care over time.

Differences in Burden Severity in Adult-Child Family Caregivers and Spousal Caregivers of Persons with Dementia.

Researchers are continuing to focus on the nature and sources of burden of family caregivers of persons living with dementia. Caregiving stress and burden are assessed and addressed by social workers, including at high-risk times such as hospitalization. This study tested whether adult-child family caregivers experience greater perceived burden than spousal caregivers, accounting for risks of acute stress which can accompany hospitalization for their care recipient, where social workers may be meeting with family caregivers for the first time. Family caregivers (N = 76; n = 42 adult-child; n = 34 spouse) were recruited during care-recipient clinical treatment. The settings of care included an outpatient memory care program and an inpatient geriatric psychiatry service. Results showed that adult-child caregivers reported greater burden as compared with spousal caregivers, but no differences regarding depressive symptoms, perceived stress, or grief. After controlling for demographics and location of care, being an adult-child caregiver remained a predictor of greater burden severity. Being an adult-child family caregiver may place an individual at increased risk for experiencing high burden. These findings suggest socials workers should consider how adult-child caregivers may benefit from strategies to address and reduce burden, beyond those typically offered to spousal caregivers.

The Role of Medical Comorbidity in the Rapid Psychiatric Readmission of Patients With Schizophrenia-spectrum Disorders.

OBJECTIVE: Inpatient admissions are common for individuals with schizophrenia-spectrum disorders, and difficulty transitioning from the hospital to the community results in these individuals being at high risk for hospital readmissions. Thus, psychotic disorders account for high rates of rapid readmission within 30 days of discharge. Increasing evidence highlights the role of comorbid medical conditions, such as circulatory and metabolic problems, in contributing to early readmission rates for these patients. This study examined the specific role of circulatory and metabolic problems in predicting psychiatric rehospitalizations while accounting for other medical conditions, psychiatric comorbidities, and preadmission medications. METHODS: The electronic medical records of 752 patients admitted to a psychiatric hospital were examined, with patients classified as having readmission within 30 days of their index hospitalization (n=79) or no readmission within 30 days (n=673). The 2 groups were compared on multiple variables in univariate and multivariate analyses. RESULTS: Male sex [odds ratio (OR)=2.02, P=0.019)], disability status (OR=1.96, P=0.027), and presence of a circulatory (but not a metabolic) condition (OR=3.43, P=0.003) were associated with significantly increased odds of being rehospitalized within 30 days, even when accounting for additional predictors, including age, substance use disorder, race, and other medical conditions. CONCLUSIONS: These findings highlight the importance of considering circulatory, in addition to metabolic disorders, during inpatient stays. This comorbidity pattern may signify a subset of individuals with schizophrenia-spectrum disorders requiring more comprehensive discharge planning and support after an inpatient hospitalization to prevent rapid rehospitalization.

Recommendations to Improve Payment Policies for Comprehensive Dementia Care.

Access to comprehensive dementia care is limited. Recent changes in billing for professional services, including new physician fee schedule codes, encourage clinicians to provide new services; however, current reimbursement does not cover costs for all needed elements of dementia care. The Payment Model for Comprehensive Dementia Care Conference convened more than 50 national experts from diverse perspectives to review promising strategies for payment reform including ways to accelerate their adoption. Recommendations for reform included payments for services to family caregivers; new research to determine success metrics; education for consumers, providers, and policymakers; and advancing a population health model approach to tier coverage based on risk and need within a health system.

Quality of Post-Acute Care in Skilled Nursing Facilities That Disproportionately Serve Hispanics With Dementia.

OBJECTIVES: As the number of Hispanics with dementia continues to increase, greater use of post-acute care in nursing home settings will be required. Little is known about the quality of skilled nursing facilities (SNFs) that disproportionately serve Hispanic patients with dementia and whether the quality of SNF care varies by the concentration of Medicare Advantage (MA) patients with dementia admitted to these SNFs. DESIGN: Cross-sectional study using 2016 data from Medicare certified providers. SETTING AND PARTICIPANTS: Our cohort included 177,396 beneficiaries with probable dementia from 8884 SNFs. METHODS: We examined facility-level quality of care among facilities with high and low proportions of Hispanic beneficiaries with probable dementia enrolled in MA and fee-for-service (FFS) using data from Medicare-certified providers. Three facility-level measures were used to assess quality of care: (1) 30-day rehospitalization rate; (2) successful discharge from the facility to the community; and (3) Medicare 5-star quality ratings. RESULTS: About 20% of residents were admitted to 1615 facilities with a resident population that was more than 15% Hispanic. Facilities with a higher share of Hispanic residents had a lower proportion of 4- or 5-star facilities by an average of 14% to 15% compared with facilities with little to no Hispanics. In addition, these facilities had a 1% higher readmission rate. There were also some differences in the quality of facilities with high (>26.5%) and low (<26.5%) proportions of MA beneficiaries. On average, SNFs with a high concentration of MA patients have lower readmission rates and higher successful discharge, but lower star ratings. CONCLUSIONS AND IMPLICATIONS: Achieving better quality of care for people with dementia may require efforts to improve the quality of care among facilities with a high concentration of Hispanic residents.

Engaging Stakeholders in the Design and Conduct of Embedded Pragmatic Clinical Trials for Alzheimer's Disease and Alzheimer's Disease-Related Dementias.

Embedded pragmatic clinical trials (ePCTs) of nondrug interventions for Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) are conducted in real-world clinical settings and designed to generate an evidence base to inform clinical and policy decisions about care for this vulnerable population. The ePCTs exist within a complex ecosystem of relationships between researchers, payors, policymakers, healthcare systems, direct care staff, advocacy groups, families, caregivers, and people living with dementia (PLWD). Because the rapid increase of the number of Americans with AD/ADRD outpaces curative treatments, there is an urgent need to mobilize the power of these relationships to improve dementia care and address a mounting public health crisis. Stakeholder engagement in ePCTs is essential to generate research questions, establish the relevancy of trials to the intended end users, and understand the factors that influence dissemination and implementation in real-world clinical settings. The process of including stakeholders in ePCTs for dementia is similar to stakeholder engagement in ePCTs for other diseases and conditions; however, the unique nature of embedded research, prevalence of caregiver and provider burden, and the progressive worsening of cognitive impairment in PLWD must be approached with additional strategies. This article presents key considerations of stakeholder engagement for ePCTs in AD/ADRD and main activities of the stakeholder engagement team in the National Institute on Aging IMPACT Collaboratory to move the field forward. J Am Geriatr Soc 68:S62-S67, 2020.

Combined intervention approaches for initiating and maintaining physical activity in depressed individuals: design and rationale of the Project MOVE randomized clinical trial.

INTRODUCTION: Regular engagement in physical activity decreases risks for many chronic conditions, and may also improve depression symptoms. However, rates of physical activity and adherence to exercise interventions remain low among depressed individuals relative to non-depressed individuals. METHODS: This is a study protocol for Project MOVE. This study is a theoretically-driven, 3-arm randomized controlled trial for increasing physical activity with depressed adults. Each successive arm includes an added component that may serve to increase and maintain physical activity. The arms are: 1) Brief advice (BA) to exercise alone (minimal treatment control condition); 2) BA + supervised and home-based exercise (SHE) + health education (HE; serves as contact control for CBEX); and 3) BA + SHE +cognitive-behavioral sessions focused on increasing and maintaining exercise (CBEX). The target sample size is 240. Assessments are conducted at baseline, Month 1.5, end of intervention (month 3), and at 6 and 9 months. The primary outcome is minutes of moderate-to-vigorous physical activity, assessed via an accelerometer. Secondary outcomes include cardiorespiratory fitness, body composition, and depression, and maintenance of moderate-vigorous physical activity through 6 and 9 month follow-ups. Mediators and moderators derived from behavior change theories, including the Health Behavior Model, Self-Determination Theory, and Social Ecological Theory, will be examined. CONCLUSION: Project MOVE is designed to test primarily whether both a structured exercise program (SHE) and a cognitive-behavioral group (CBEX) increase physical activity in depressed adults during both a 3-month intervention period, and during the 6-months that follow.

A Novel Experiential Quality Improvement Training Program During Residency Improves Quality Improvement Confidence and Knowledge: a Prospective Cohort Study.

OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) mandates resident quality improvement (QI) training to improve patient safety, cost control, and efficiency. Thus, understanding this topic is crucial for early career physicians. This manuscript describes an enhanced, experiential QI curriculum for psychiatry residents and its outcomes. METHODS: Two cohorts of 12 third-year residents completed the curriculum, which included didactics, external resources, and expert guidance through small group project design, implementation, and analysis/presentation. A survey on resident confidence in QI principles and the quality improvement knowledge assessment tool-revised (QIKAT-R) was used before and after curriculum participation. Data were analyzed using parametric descriptive tests and repeated measures general linear models with Benjamini-Hochberg correction for multiple comparisons. RESULTS: Resident confidence in performing seven of the ten steps of QI and QIKAT-R scores significantly improved for both cohorts (p = .011). Eighty-nine percent of residents felt that the curriculum met their goals. CONCLUSIONS: The QI curriculum effectively improved resident QI confidence and knowledge. Residents reported that experiential engagement in the design, implementation, and analysis/presentation of their project was crucial to these achievements. This experiential QI curriculum with resident-generated QI projects addressed ACGME training requirements while integrating QI training directly into the residents' clinical activities, making the QI efforts relevant and meaningful while also achieving ACGME goals.

Emerging Collaborative Care Models for Dementia Care in the Primary Care Setting: A Narrative Review.

The rapidly increasing population living with dementia presents a unique economic and public health challenge. However, primary care physicians, despite their position as first-line providers, often lack the time, support, and training to systematically screen for, diagnose, and treat dementia, as well as provide adequate psychosocial support to unpaid caregivers. Models of collaborative care, which have found success in reducing symptom severity and increasing quality of life for other chronic illnesses, have been studied for feasibility, efficacy, and cost effectiveness in treating individuals with dementia and supporting caregivers. A review of initial data from several models suggests that enrollment in a collaborative care program for dementia is associated with benefits such as reduction in behavioral symptoms of dementia, improved functioning and quality of life, less frequent utilization of acute medical services, and decrease in caregiver burden. These evidence-based models, if implemented widely, stand to facilitate delivery of highly effective dementia care while reducing associated total medical expense. In this narrative review, we examine the key components of collaborative care teams, summarize outcomes of prior studies and discuss barriers and opportunities for wider dissemination of collaborative care models that are partnered with and/or based within primary care settings.