Health Care Team Interventions to Reduce Distress Behaviors in Older Adults: A Systematic Review.

OBJECTIVES: This review examines health care team-focused interventions on managing persistent or recurrent distress behaviors among older adults in long-term residential or inpatient health care settings. METHODS: We searched interventions addressing health care worker (HCW) knowledge and skills related to distress behavior management using Ovid MEDLINE, Elsevier Embase, and Ovid PsycINFO from December 2002 through December 2022. RESULTS: We screened 6,582 articles; 29 randomized trials met inclusion criteria. Three studies on patient-facing HCW interactions (e.g. medication management, diagnosing distress) showed mixed results on agitation; one study found no effect on quality of life. Six HCW-focused studies suggested short-term reduction in distress behaviors. Quality-of-life improvement or decreased antipsychotic use was not evidenced. Among 17 interventions combining HCW-focused and patient-facing activities, 0 showed significant distress reduction, 8 showed significant antipsychotic reduction (OR = 0.79, 95%CI [0.69, 0.91]) and 9 showed quality of life improvements (SMD = 0.71, 95%CI [0.39, 1.04]). One study evaluating HCW, patient-, and environmental-focused intervention activities showed short-term improvement in agitation. CONCLUSIONS AND CLINICAL IMPLICATIONS: Novel health care models combining HCW training and patient management improve patient quality of life, reduce antipsychotic use, and may reduce distress behaviors. Evaluation of intervention's effects on staff burnout and utilization is needed.

The relationship between caregivers' behaviors and resistant behaviors of persons living with dementia during personal care in long-term care facilities: A lag sequential analysis.

Many older adults living with dementia exhibit resistant behaviors. Person-centered care is the gold standard of care; however, the sequential relationship between resistant and caregiving behaviors has not been identified. This study examined the sequential relationship between caregiving and care-resistant behaviors and analyzed 68 videos of personal care encounters of 21 residents living in four long-term care facilities. The videos were coded focusing on two sequences of behavior: residents' resistant behaviors and caregivers' behaviors. Lag sequential analysis was conducted using initial-response behavior pairs (resident-caregiver behavior or caregiver-resident behavior pairs). Person-centered care led to less resistant behavior (odds ratio 0.23; 95 % confidence interval 0.16, 0.33), whereas less person-centered care was followed by resistant behaviors (odds ratio 0.42; 95 % confidence interval 0.30, 0.59). A significant sequential association was found between task-centered behavior and resistant behavior. Hence, rigorous efforts are recommended to provide person-centered care through multilevel efforts.

Psychosocial stressors associated with frailty in community-dwelling older adults in the United States.

BACKGROUND: Frailty is multifactorial; however, psychosocial stressors contributing to frailty are poorly understood. This study aimed to examine whether gender, race/ ethnicity, and education are associated with differential exposure to psychosocial stressors, determine psychosocial stressors contributing to frailty, and explore the mediating psychosocial stressors pathway. METHODS: This cross-sectional study involved 7679 community-dwelling older adults (≥65) from the Health and Retirement Study (2006 and 2008 waves). Psychosocial stressors such as loneliness, low subjective social status, financial strain, poor neighborhood cohesion, everyday discrimination, and traumatic life events were measured. Frailty was defined by the Fried phenotype measure. Multivariable logistic regressions were used to examine the association of gender, race/ethnicity, and education with psychosocial stressors, psychosocial stressors associated with frailty, and the mediating psychosocial stressors pathway. RESULTS: Females experienced greater financial strain but lower discrimination (both p < 0.05). Older adults who identified as Hispanic, Black, and racially or ethnically minoritized experienced low subjective social status, high financial strain, low neighborhood cohesion, and high discrimination than their White counterparts (all p < 0.05). Those with lower education experienced high loneliness, low subjective social status, high financial strain, low neighborhood cohesion but lower traumatic life events (all p < 0.05). Psychosocial stressors: High loneliness, low subjective social status, high financial strain, and low neighborhood cohesion (all p < 0.05) independently increased the odds of frailty. The mediating pathway of psychosocial stressors was not significant.  CONCLUSION: Disparities exist in exposure to psychosocial stressors associated with frailty. Multilevel interventions are needed to reduce the influence of psychosocial stressors on frailty.

Comorbidity Patterns in Older Patients Undergoing Hip Fracture Surgery: A Comorbidity Network Analysis Study.

Comorbidity network analysis (CNA) is a technique in which mathematical graphs encode correlations (edges) among diseases (nodes) inferred from the disease co-occurrence data of a patient group. The present study applied this network-based approach to identifying comorbidity patterns in older patients undergoing hip fracture surgery. This was a retrospective observational cohort study using electronic health records (EHR). EHR data were extracted from the one University Health System in the southeast United States. The cohort included patients aged 65 and above who had a first-time low-energy traumatic hip fracture treated surgically between October 1, 2015 and December 31, 2018 (n = 1,171). Comorbidity includes 17 diagnoses classified by the Charlson Comorbidity Index. The CNA investigated the comorbid associations among 17 diagnoses. The association strength was quantified using the observed-to-expected ratio (OER). Several network centrality measures were used to examine the importance of nodes, namely degree, strength, closeness, and betweenness centrality. A cluster detection algorithm was employed to determine specific clusters of comorbidities. Twelve diseases were significantly interconnected in the network (OER > 1, p-value < .05). The most robust associations were between metastatic carcinoma and mild liver disease, myocardial infarction and congestive heart failure, and hemi/paraplegia and cerebrovascular disease (OER > 2.5). Cerebrovascular disease, congestive heart failure, and myocardial infarction were identified as the central diseases that co-occurred with numerous other diseases. Two distinct clusters were noted, and the largest cluster comprised 10 diseases, primarily encompassing cardiometabolic and cognitive disorders. The results highlight specific patient comorbidities that could be used to guide clinical assessment, management, and targeted interventions that improve hip fracture outcomes in this patient group.

Implementation Lessons Learned: Distress Behaviors in Dementia Intervention in Veterans Health Administration.

BACKGROUND AND OBJECTIVES: Evidence-based practices to manage distress behaviors in dementia (DBD) are not consistently implemented despite demonstrated effectiveness. The Veterans Health Administration (VA) trained teams to implement Staff Training in Assisted Living Residences (STAR)-VA, an intervention to manage DBD in VA nursing home settings, or Community Living Centers (CLCs). This paper summarizes multiyear formative evaluation results including challenges, adaptations, and lessons learned to support sustained integration into usual care across CLCs nationwide. RESEARCH DESIGN AND METHODS: STAR was selected as an evidence-based practice for DBD, adapted for and piloted in VA (STAR-VA), and implemented through a train-the-trainer program from 2013 to 2018. Training and consultation were provided to 92 CLC teams. Evaluation before and after training and consultation included descriptive statistics of measures of clinical impact and survey feedback from site teams regarding self-confidence, engagement, resource quality, and content analysis of implementation facilitators and challenges. RESULTS: STAR-VA training and consultation increased staff confidence and resulted in significant decreases in DBD, depression, anxiety, and agitation for Veterans engaged in the intervention. Implementation outcomes demonstrated feasibility and identified facilitators and barriers. Key findings were interpreted using implementation frameworks and informed subsequent modifications to sustain implementation. DISCUSSION AND IMPLICATIONS: STAR-VA successfully prepared teams to manage DBD and resulted in improved outcomes. Lessons learned include importance of behavioral health-nursing partnerships, continuous engagement, iterative feedback and adaptations, and sustainment planning. Evaluation of sustainment factors has informed selection of implementation strategies to address sustainment barriers. Lessons learned have implications for integrating team-based practices into system-level practice.

Structural determinants and cardiometabolic typologies related to frailty in community-dwelling older adults.

Frailty is a geriatric syndrome linked to adverse outcomes. Co-occurring cardiometabolic factors increase frailty risk; however, their distinct combinations (typologies) associated with frailty are unclear. We aimed to identify subgroups of older adults with distinct cardiometabolic typologies and characterize their relationship with structural determinants and frailty to inform tailored approaches to prevent and delay frailty. This study was cross-sectional design and included 7984 community-dwelling older adults (65+ years) enrolled in the Health and Retirement Study (2006 and 2008). Latent class analysis was performed using seven cardiometabolic indicators (abdominal obesity, obesity, low high-density lipoprotein; and elevated blood pressure, blood sugar, total cholesterol, C-reactive protein). Frailty was indicated by ≥3 features (weakness, slowness, fatigue, low physical activity, unintentional weight loss). Logistic regression was used to examine the relationship between structural determinants (gender, race/ethnicity, and education), cardiometabolic typologies, and frailty. Three cardiometabolic subgroups were identified: insulin-resistant (n = 3547), hypertensive dyslipidemia (n = 1246), and hypertensive (n = 3191). Insulin-resistant subgroup members were more likely to be female, non-Hispanic Black, and college non-graduates; hypertensive dyslipidemia subgroup members were more likely to be non-Hispanic Others and report high school education; and hypertensive subgroup members were more likely to be male and college educated (p≤.05). Frailty risk was higher for females, Hispanic or Non-Hispanic Black older adults, and those with lower education (p≤.001). Frailty risk was greater in the insulin-resistant compared to the other subgroups (both aOR=2.0, both p<.001). Findings highlight a need to design tailored interventions targeting cardiometabolic typologies to prevent and delay frailty.

Impact of Dementia on Incidence and Severity of Postoperative Pulmonary Complications Following Hip Fracture Surgery Among Older Patients.

Postoperative pulmonary complications (PPCs) are the leading cause of death following hip fracture surgery. Dementia has been identified as a PPC risk factor that complicates the clinical course. By leveraging electronic health records, this retrospective observational study evaluated the impact of dementia on the incidence and severity of PPCs, hospital length of stay, and postoperative 30-day mortality among 875 older patients (≥65 years) who underwent hip fracture surgery between October 1, 2015 and December 31, 2018 at a health system in the southeastern United States. Inverse probability of treatment weighting using propensity scores was utilized to balance confounders between patients with and without dementia to isolate the impact of dementia on PPCs. Regression analyses revealed that dementia did not have a statistically significant impact on the incidence and severity of PPCs or postoperative 30-day mortality. However, dementia significantly extended the hospital length of stay by an average of 1.37 days.

Nursing Home PRevention of Injury in DEmentia (NH PRIDE): A pilot study of a remote injury prevention service for NH residents.

BACKGROUND: Medication optimization, including prescription of osteoporosis medications and deprescribing medications associated with falls, may reduce injurious falls. Our objective was to describe a remote, injury prevention service (NH PRIDE) designed to optimize medication use in nursing homes (NHs), and to describe its implementation outcomes in a pilot study. METHODS: This was a non-randomized trial (pilot study) including NH staff and residents from five facilities. Long-stay residents at high-risk for injurious falls were identified using a validated risk calculator and staff referral. A remote team reviewed the electronic health record (EHR) and provided recommendations as Injury Prevention Plans (IPP). A research nurse served as a care coordinator focused on resident engagement and shared decision-making. Outcomes included implementation measures, as identified in the EHR, and surveys and interviews with staff. RESULTS: Across five facilities, 274 residents were screened for eligibility, and 46 residents (16.8%) were enrolled. Most residents were female (73.9%) and had dementia (63.0%). An IPP was completed for 45 residents (97.8%). The nurse made a total of 93 deprescribing recommendations in 36 residents (80% of residents had one or more deprescribing recommendation; mean 2.2 recommendations/resident). Twenty of 45 residents (44.4%) had a recommendation for osteoporosis treatment. Among residents with recommendations, 21/36 (58.3%) had one or more deprescribing orders written and 6/20 (30.0%) had an osteoporosis medication prescribed. At 4 months, most medication changes persisted. Adverse side effects were rare. Staff members identified several areas for program refinement, including aligning recommendations with provider workflow and engaging consultant psychiatrists. CONCLUSIONS: A remote injury prevention service is safe and feasible to enhance deprescribing and osteoporosis treatment in long-stay NH residents at risk for injury. Additional investigation is needed to determine if this model could reduce injurious falls when deployed across NH chains.

Does cumulative psychosocial stress explain frailty disparities in community-dwelling older adults?

OBJECTIVE: Frailty is a leading predictor of adverse outcomes in older adults. Although disparities in frailty are well-documented, it is unclear whether psychosocial stressors explain these disparities. This study aimed to examine the potential mediating role of psychosocial stress. METHODS: This cross-sectional study included 7,679 community-dwelling older adults (≥ 65) from Health and Retirement Study in the US (2006 and 2008). We used six dichotomized psychosocial stressors: a) loneliness, b) discrimination, c) financial strain, d) low subjective status, e) poor neighborhood cohesion, and f) traumatic life events to compute cumulative psychosocial stress. The Fried frailty phenotype defined frailty based on three features: slowness, poor strength, weight loss, fatigue, and low physical activity. Multivariable regressions were used to examine the structural determinants (gender, education, race, and ethnicity) frailty relationship and test whether cumulative psychosocial stress has a mediating role. RESULTS: The frailty prevalence was 22%. Females, Hispanics, Blacks, and those with less education had higher odds of frailty (p<.01). Race and ethnic minorities and non-college graduates experienced greater cumulative psychosocial stress relative to their White and college graduate counterparts (p<.05), respectively. Greater cumulative psychosocial stress was associated with increased odds of frailty (p < .001); however, it did not mediate the structural determinants and frailty relationship. CONCLUSION: Contrary to expectations, cumulative psychosocial stress did not mediate the relationship between structural determinants and frailty. Rather, high cumulative psychosocial stress was independently associated with frailty. Further research should examine other psychosocial mediators to inform interventions to prevent/delay frailty.

Perspectives on Deprescribing in long-term care: qualitative findings from nurses, aides, residents, and proxies.

BACKGROUND: Deprescribing initiatives in the long-term care (LTC) setting are often unsuccessful or not sustained. Prior research has considered how physicians and pharmacists feel about deprescribing, yet little is known about the perspectives of frontline nursing staff and residents. Our aim was to elicit perspectives from LTC nursing staff, patients, and proxies regarding their experiences and preferences for deprescribing in order to inform future deprescribing efforts in LTC. METHODS: This study was a qualitative analysis of interviews with nurses, nurse aides, a nurse practitioner, residents, and proxies (family member and/or responsible party) from three LTC facilities. The research team used semi-structured interviews. Guides were designed to inform an injury prevention intervention. Interviews were recorded and transcribed. A qualitative framework analysis was used to summarize themes related to deprescribing. The full study team reviewed the summary to identify actionable, clinical implications. RESULTS: Twenty-six interviews with 28 participants were completed, including 11 nurse aides, three residents, seven proxies, one nurse practitioner, and six nurses. Three themes emerged that were consistent across facilities: 1) build trust with team members, including residents and proxies; 2) identify motivating factors that lead to resident, proxy, nurse practitioner, and staff acceptance of deprescribing; 3) standardize supportive processes to encourage deprescribing. These themes suggest several actionable steps to improve deprescribing initiatives including: 1) tell stories about successful deprescribing, 2) provide deprescribing education to frontline staff, 3) align medication risk/benefit discussions with what matters most to the resident, 4) standardize deprescribing monitoring protocols, 5) standardize interprofessional team huddles and care plan meetings to include deprescribing conversations, and 6) strengthen non-pharmacologic treatment programs. CONCLUSIONS: By interviewing LTC stakeholders, we identified three important themes regarding successful deprescribing: Trust, Motivating Factors, and Supportive Processes. These themes may translate into actionable steps for clinicians and researchers to improve and sustain person-centered deprescribing initiatives. TRIAL REGISTRATION: NCT04242186.

The interagency care team: A new model to integrate social and medical care for older adults in primary care.

To integrate management of social drivers of health with complex clinical needs of older adults, we connected patients aged 60 and above from primary care practices with a nurse practitioner (NP) led Interagency Care Team (ICT) of geriatrics providers and community partners via electronic consult. The NP conducted a geriatric assessment via telephone, then the team met to determine recommendations. Thirteen primary care practices referred 123 patients (median age = 76) who had high rates of emergency department use and hospitalization (28.9% and 17.4% respectively). Issues commonly identified included medication management (84%), personal safety (72%), disease management (69%), food insecurity (63%), and cognitive decline (53%). Referring providers expressed heightened awareness of older adults' social needs and high satisfaction with the program. The ICT is a scalable model of care that connects older adults with complex care needs to geriatrics expertise and community services through partnerships with primary care providers.

Impact of Dementia on Long-Term Hip Fracture Surgery Outcomes: An Electronic Health Record Analysis.

OBJECTIVE: Older adults with dementia are at higher risk for sustaining hip fracture and their long-term health outcomes after surgery are usually worse than those without dementia. Widespread adoption of electronic health records (EHRs) may allow hospitals to better monitor long-term health outcomes in patients with dementia after hospitalization. This study aimed to (1) estimate how dementia influences discharge location, mortality, and readmission 180 days and 1 year after hip fracture surgery in older adults, and (2) demonstrate the feasibility of using selection-bias reduced EHR data for research and long-term health outcomes monitoring. DESIGN: Retrospective observational cohort study using EHRs. SETTING AND PARTICIPANTS: A cohort of 1171 patients over age 65 years who had an initial hip fracture surgery between October 2015 and December 2018 was extracted from EHRs of one health system; 376 of these patients had dementia. METHODS: Logistic regression was applied to estimate influences of dementia on discharge disposition and Cox proportional hazards model for mortality. The Fine and Gray regression model was used to analyze readmission, accounting for the competing risk of death. To reduce selection bias in EHRs, inverse probability of treatment weighting using propensity scores was implemented before modeling. RESULTS: Dementia had significant impacts on all outcomes: being discharged to facilities [odds ratio (OR) = 2.11, 95% confidence interval (CI) 1.19-3.74], 180-day mortality [hazard ratio (HR) = 1.69, 95% CI 1.20-2.38], 1-year mortality (HR = 1.78, 95% CI 1.33-2.38), 180-day readmission (HR = 1.62, 95% CI 1.39-1.89), and 1 year readmission (HR = 1.39, 95% CI 1.21-1.58). CONCLUSIONS AND IMPLICATIONS: Dementia was a significant risk factor for worse long-term outcomes. The inverse probability of treatment weighting approach can be used to reduce selection bias in EHR data for research and monitoring long-term health outcomes in the target population. Such monitoring could foster collaborations with post-acute and long-term health care services to improve recovery outcomes in patients with dementia after hip fracture surgery.

Veterans Health Administration Models of Community-Based Long-Term Care: State of the Science.

The complex care needs of older adults arising at the intersection of age-related illnesses, military service, and social barriers have presented challenges to the US Department of Veterans Affairs (VA) for decades. In response, the VA has invested in centers that integrate research, education, and clinical innovation, using approaches aligned with a learning health care system, to create, evaluate, and implement new care models. This article presents an integrative review of 6 community care models developed within the VA to manage multimorbidity, complex social needs, and avoid institutional care, examining how these models address complex care needs among older adults. The models reviewed include Home Based Primary Care, Medical Foster Home, the VA Caregiver Support Program, the Resources Enhancing Alzheimer's Caregiver Health (REACH)-VA program, the Caregivers of Older Adults Cared for at Home (COACH) program, and Veteran Directed Care. Core components and evaluation outcomes for each model are summarized, along with implications for more widespread implementation and research. Each model promotes coordinated care, integrates behavioral health, and leverages interprofessional expertise. All models are cost-neutral or incur only modest cost increases to improve outcomes. Broader implementation will require interprofessional workforce development, payment model realignment, and infrastructure to evaluate outcomes in new settings. The VA provides a blueprint for infrastructure that could be adapted to other domestic and international settings. Care models successfully implemented within the VA's single-payer system hold promise to address persistent dilemmas in long-term care, such as management of multimorbidity and social drivers of health, integration and support of family caregivers, and mental health integration. These models also demonstrate the value of incorporating care approaches that have been developed or tested outside the United States and argue for greater cross-fertilization of ideas from different health systems.

A Standardized Positive Physical Approach to Improve Oral Hygiene for Nursing Home Residents With Alzheimer's Disease and Related Dementias.

Residents with Alzheimer's disease and related dementias (ADRD) in nursing homes (NHs) rely on direct care workers (DCWs) to assist with activities of daily living, such as oral hygiene. The current quality improvement project was implemented to evaluate the effectiveness of teaching a standardized positive physical approach to oral hygiene completion for patients with ADRD residing in a NH. A pre-/postintervention evaluation incorporating a video presentation coupled with a hands-on simulation experience showed a statistically significant improvement in DCWs' overall Sense of Competency in Dementia score, as well as all subcategories of the Sense of Competence in Dementia Care Staff survey. In addition, residents' day shift oral hygiene care completion rates increased monthly pre- to postintervention. NHs should consider implementing training that includes hands-on experiences to equip DCWs with the knowledge and skill needed to improve oral hygiene among residents with ADRD. [Journal of Gerontological Nursing, 48(11), 15-20.].

Care rejection and aggression among veterans with dementia with and without posttraumatic stress disorder: A multi-group analysis.

BACKGROUND: In residential long-term care, military service veterans with co-occurring posttraumatic stress disorder (PTSD) and dementia encounter a range of physical and social stimuli that may serve as triggers of trauma-related distress that manifests as care rejection or aggression. Yet, PTSD rarely has been examined in research to understand behaviors of care rejection and aggression in veterans with dementia. OBJECTIVES: Guided by the need-driven dementia-compromised behavior model, we examined the moderation effect of PTSD on pathways from background factors and interpersonal triggers to rejection of care and aggression among veterans with dementia with and without co-occurring PTSD. DESIGN: Secondary data analysis of the Staff Training in Assisted Living Residences-Veterans Health Administration (STAR-VA) intervention evaluation by the U.S. Veterans Health Administration healthcare system. SETTING: 76 Veterans Health Administration-operated nursing homes. PARTICIPANTS: 315 veterans with dementia who participated in STAR-VA. METHODS: We converted text data on the occurrence of care rejection and aggression to binary variables, combined them with data on sociodemographic and PTSD status obtained using medical chart review, and measured anxiety, cognition, depression, and function using validated instruments. A multi-group structural equation modeling analysis was then conducted to test the moderating effect of PTSD on rejection of care and aggression. RESULTS: Although multi-group structural equation modeling did not support the hypothesis of overall moderation by PTSD, distinct patterns between the two groups were observed with respect to how background factors and interpersonal triggers related to care rejection and aggression. The magnitude of the direct effects of interpersonal triggers on rejection of care was greater in veterans with PTSD (ß = 0.42, p = .014 compared to those without ß = 0.29, p = .008). Depression had a statistically significant indirect effect on rejection of care via interpersonal triggers only in veterans with PTSD (ß = 0.09, p = .009). Functional status had a statistically significant direct effect on aggression only in the PTSD group (ß = 0.28, p = .044). CONCLUSIONS: Our study identified similar and distinct patterns of relationships among background factors, interpersonal triggers, and rejection of care and aggression between veterans with dementia with and without PTSD. The indirect effect of depression on care rejection via interpersonal triggers has implications for developing targeted interventions that focus on interpersonal triggers for veterans with dementia with PTSD who have greater depressive symptoms. This study underscores the importance of an enhanced focus on trauma-informed care for veterans with dementia and PTSD.

Examining Face Validity of Visual Stimuli Used in Preference Assessments for Older Adults With Communication Impairments.

PURPOSE: Preference assessment is integral to person-centered treatment planning for older adults with communication impairments. There is a need to validate photographs used in preference assessment for this population. Therefore, this study aimed to establish preliminary face validity of photographs selected to enhance comprehension of questions from the Preferences for Everyday Living Inventory-Nursing Home (PELI-NH) and describe themes in older adults' recommendations for revising photographic stimuli. METHOD: This qualitative, cognitive interviewing study included 21 participants with an average age of 75 years and no known cognitive or communication deficits. Photographic stimuli were randomized and evaluated across one to two interview sessions. Participants were asked to describe what the preference stimuli represented to them. Responses were scored to assess face validity. Participants were then shown the PELI-NH written prompt and asked to evaluate how well the photograph(s) represented the preference. A semideductive thematic analysis was conducted on interview transcripts to summarize themes in participant feedback. RESULTS: Forty-six (64%) stimuli achieved face validity criteria without revisions. Six (8%) stimuli achieved face validity after one partial revision. Twenty (28%) stimuli required multiple revisions and reached feedback saturation, requiring team review for finalization. Thematic analysis revealed challenges interpreting stimuli (e.g., multiple meanings) and participant preferences for improving photographs (e.g., aesthetics). CONCLUSIONS: Cognitive interviewing was useful for improving face validity of stimuli pertaining to personal care topics. Abstract and subjective preferences (e.g., cultural traditions) may be more challenging to represent. This study provides a framework for further testing with older adults with cognitive, communication, and hearing impairments.