Exploring the Remote Administration of a Performance-Based Functional Assessment.

Performance-based assessments of instrumental activities of daily living (IADL) can detect subtle functional impairments better than self-reported questionnaires. While most performance-based IADL assessments were developed for in-person administration, remote administration could increase access to vulnerable older adults. This study compared in-person and remote administration of IADL tasks from the Performance Assessment of Self-Care Skills. Community-dwelling older adults completed tasks (shopping, checkbook balancing, and medication management) at baseline (in-person) and follow-up (either in-person or remote, with modifications) two years later. Scores between the two follow-up groups, change in scores from baseline to follow-up, and differential item functioning (DIF) between the two administration methods at follow-up were examined. There were no differences in scores between methods of administration, but remote tasks took longer, and one item had significant DIF (ps < .01). Clinicians found remote administration acceptable and feasible. With minor adaptations, remote administration of the three tasks was supported. Further validation research is needed.

Feasibility of adolescent musicians in delivering Project Unmute, a virtual, intergenerational active music-based intervention for older adults with Alzheimer's disease and dementia.

Background: Cases of dementia are increasing rapidly; music-based interventions have shown promise to support some of the negative outcomes. Methods: This research assesses the potential of adolescent musicians to deliver Project Unmute, a virtual, intergenerational music-based intervention for older adults with Alzheimer's disease and dementia. To assess the feasibility of the intervention, the research team calculated attendance of intervention sessions, assessed intervention preparation, and measured adherence during intervention delivery. Results: Eight adolescent musicians participated, ages 14-18. They attended 80/80 intervention sessions, were prepared for 32/32 mentorship sessions, and delivered 24/24 intervention ingredients. Conclusion: This research suggests that adolescent musicians have the potential to administer a well-defined music-based intervention with high adherence. There is potential for future research to explore the potential for the scalable population of adolescent musicians as successful facilitators of music-based interventions for older adults with Alzheimer's disease and dementia.

Sleep-wake behaviors associated with cognitive performance in middle-aged participants of the Hispanic Community Health Study/Study of Latinos.

OBJECTIVES: Many sleep-wake behaviors have been associated with cognition. We examined a panel of sleep-wake/activity characteristics to determine which are most robustly related to having low cognitive performance in midlife. Secondarily, we evaluate the predictive utility of sleep-wake measures to screen for low cognitive performance. METHODS: The outcome was low cognitive performance defined as being >1 standard deviation below average age/sex/education internally normalized composite cognitive performance levels assessed in the Hispanic Community Health Study/Study of Latinos. Analyses included 1006 individuals who had sufficient sleep-wake measurements about 2years later (mean age=54.9, standard deviation= 5.1; 68.82% female). We evaluated associations of 31 sleep-wake variables with low cognitive performance using separate logistic regressions. RESULTS: In individual models, the strongest sleep-wake correlates of low cognitive performance were measures of weaker and unstable 24-hour rhythms; greater 24-hour fragmentation; longer time-in-bed; and lower rhythm amplitude. One standard deviation worse on these sleep-wake factors was associated with ∼20%-30% greater odds of having low cognitive performance. In an internally cross-validated prediction model, the independent correlates of low cognitive performance were: lower Sleep Regularity Index scores; lower pseudo-F statistics (modellability of 24-hour rhythms); lower activity rhythm amplitude; and greater time in bed. Area under the curve was low/moderate (64%) indicating poor predictive utility. CONCLUSION: The strongest sleep-wake behavioral correlates of low cognitive performance were measures of longer time-in-bed and irregular/weak rhythms. These sleep-wake assessments were not useful to identify previous low cognitive performance. Given their potential modifiability, experimental trials could test if targeting midlife time-in-bed and/or irregular rhythms influences cognition.

Moderating Effects of Informal Care on the Relationship Between ADL Limitations and Adverse Outcomes in Stroke Survivors.

BACKGROUND: Stroke survivors with limitations in activities of daily living (ADL) have a greater risk of experiencing falls, hospitalizations, or physical function decline. We examined how informal caregiving received in hours per week by stroke survivors moderated the relationship between ADL limitations and adverse outcomes. METHODS: In this retrospective cohort, community-dwelling participants were extracted from the National Health and Aging Trends Study (2011-2020; n=277) and included if they had at least 1 formal or informal caregiver and reported an incident stroke in the prior year. Participants reported the amount of informal caregiving received in the month prior (low [<5.8], moderate [5.8-27.1], and high [27.2-350.4] hours per week) and their number of ADL limitations (ranging from 0 to 7). Participants were surveyed 1 year later to determine the number of adverse outcomes (ie, falls, hospitalizations, and physical function decline) experienced over the year. Poisson regression coefficients were converted to average marginal effects and estimated the moderating effects of informal caregiving hours per week on the relationship between ADL limitations and adverse outcomes. RESULTS: Stroke survivors were 69.7% White, 54.5% female, with an average age of 80.5 (SD, 7.6) years and 1.2 adverse outcomes at 2 years after the incident stroke. The relationships between informal caregiving hours and adverse outcomes and between ADL limitations and adverse outcomes were positive. The interaction between informal caregiving hours per week and ADL limitations indicated that those who received the lowest amount of informal caregiving had a rate of 0.12 more adverse outcomes per ADL (average marginal effect, 0.12 [95% CI, 0.005-0.23]; P=0.041) than those who received the highest amounts. CONCLUSIONS: Informal caregiving hours moderated the relationship between ADL limitations and adverse outcomes in this sample of community-based stroke survivors. Higher amounts relative to lower amounts of informal caregiving hours per week may be protective by decreasing the rate of adverse outcomes per ADL limitation.

Development of a Dyad-Focused Intervention for Stroke Survivors and Their Family Caregivers: A Feasibility Study.

IMPORTANCE: Transitioning from the hospital to the community poses significant challenges for stroke survivors and their caregivers. OBJECTIVE: To examine the feasibility and preliminary effects of a dyad-focused strategy training intervention. DESIGN: Single-arm trial with data collection at baseline, postintervention, and 3-mo follow-up. SETTING: Rehabilitation settings in Taiwan. PARTICIPANTS: Sixteen stroke survivor-caregiver dyads. INTERVENTIONS: Dyad-focused strategy training was provided to stroke survivor-caregiver dyads twice a week over 6 wk. The training included shared decision-making, goal setting, performance evaluation, strategy development and implementation, and therapeutic guided discovery. OUTCOMES AND MEASURES: Feasibility indicators were Goal Attainment Scaling, Dyadic Relationship Scale, Participation Measure-3 Domains, 4 Dimensions, Activity Measure for Post-Acute Care, Montreal Cognitive Assessment, Trail Making Test, Stroop Color and Word Test, Preparedness for Caregiving Scale, and Zarit Burden Interview. RESULTS: In total, 15 dyads completed all intervention sessions with full attendance. Both stroke survivors and their caregivers demonstrated high engagement and comprehension and reported moderate to high satisfaction with the intervention. From baseline to postintervention, the effects on goal attainment, frequency and perceived difficulty of community participation, executive function, mobility function, and caregiver preparedness were significant and positive. CONCLUSIONS AND RELEVANCE: Our study supports the feasibility and preliminary efficacy of dyad-focused strategy training for stroke survivor-caregiver dyads transitioning from the hospital to the community in Taiwan. Our preliminary evidence indicates that dyads who receive strategy training exhibit advancement toward their goals and experience considerable enhancements in their individual outcomes. Plain-Language Summary: This study addresses the scarcity of interventions catering to both stroke survivors and their caregivers. By demonstrating the feasibility of our dyad-focused intervention, the research offers preliminary evidence that supports the potential advantages of involving both stroke survivors and their caregivers in the intervention process.

Depressive Symptoms Associated With Social Participation in Older Adults Living With Mild Cognitive Impairment.

Mild Cognitive Impairment (MCI) affects 15% of adults 50 years old and over. Individuals living with MCI have shown decreased social participation, a critical activity as it may delay cognitive decline. Depression may be a key factor in limiting participation. This study is a secondary data analysis of 30 older adults living with MCI, looking for associations with participation. Participation was examined using the Patient Reported Outcomes Measurement Information System (PROMIS®) Satisfaction with Participation in Social Roles Computer Adaptive Test (CAT) form. Depressive symptoms were reported using the PROMIS Quality of Life in Neurological Disorders Depression CAT form and the Patient Health Questionnaire (PhQ-9) form. Results showed that demographics (age, sex) were not significantly associated with participation, but depressive symptoms were significantly associated. This suggests that adults living with MCI who have higher levels of depressive symptoms may be a uniquely vulnerable population who benefit from interventions that support participation.

The Role of Rehabilitation for Early-Stage Alzheimer's Disease and Related Dementias: Practice and Priorities.

The World Health Organization describes rehabilitation as interventions that focus on addressing disability through optimizing functional ability for individuals living with various health challenges in their unique daily life contexts. Rehabilitation services are typically seeking to enhance functional capacity and health, either in concert with, or in place of pharmacologic interventions. These services typically fall into 2 categories, restorative, where the client endeavors to return to a prior level of independent function, and compensatory, where s/he may not. In the latter case, clients might receive, and be trained to use, technology aids or other external supports to enable them to engage in a safe, healthy, and meaningful day-to-day life. For some populations, however, even enhanced functional capacity can present in the form of an insidious, albeit slower decline. So, what is, or should, rehabilitation's role be in progressive neurologic conditions? Specifically, what are the policy and practice implications of rehabilitation for (not in the presence of, but for) the care of persons living with neurodegenerative conditions such as Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD)?

Health system and patient-level factors associated with multidisciplinary care and patient education among hospitalized, older cancer survivors.

Objective: The purpose of this study was to examine system- and patient-level factors associated with the number of healthcare disciplines involved in delivery of patient education among hospitalized older cancer survivors. Methods: We used electronic health record (EHR) data from a single institution documenting patient education among hospitalized older patients (≥65 years) with a history of cancer between 9/1/2018 and 10/1/2019. We used parametric ordinal logistic regression to assess the number of healthcare disciplines involved in documented education activities. Results: The sample (n = 446) was predominantly male, White, and on average 74 years old. Adjusting for patient and system-level variables, men and larger department units had higher odds of receiving education from fewer healthcare disciplines. Patients with a history of breast or prostate cancer and longer lenths of stay had lower odds of receiving patient education from fewer healthcare disciplines. Conclusion: Hospital size, severity of illness, and cancer type are associated with delivery of multidisciplinary education in this sample. Innovation: EHR provides an opportunity to identify patterns in patient education among cancer survivors. Future research should investigate provider perspectives of the findings to inform provider- and system-level strategies to improve patient education.

Evaluation of Face Validity and Acceptability of the Care Partner Hospital Assessment Tool.

Background and Objectives: Care partners of hospitalized older adults report their caregiving needs are not being addressed. The Care Partner Hospital Assessment Tool (CHAT) is a feasible and appropriate tool for practitioners' use with care partners in the hospital setting. This article explores the face validity and acceptability of the CHAT among care partners of hospitalized older adults. Research Design and Methods: A qualitative descriptive study was used to identify common themes among care partners' responses from semistructured interviews. The CHAT was administered to care partners of older adults admitted to a medical-surgical unit in an academic medical center in Madison, WI, from October 2021 to January 2022. A semistructured, follow-up interview was completed by the same care partners after discharge. Interviews were transcribed and coded for themes to capture overall impressions of the CHAT. Care partners addressed the usefulness, comfort, content, and complexity of the CHAT. Results: Twelve care partners participated in the study. Care partners reported that the CHAT was easy to understand and complete, was judged to be useful to both the care partner and older adult, and helped identify care partner needs. Care partners suggested ways to improve the tool including administration, additional content areas to include, and modes of delivery. Discussion and Implications: The results establish the face validity of the CHAT and support the acceptability of the tool for use with care partners of hospitalized older adults.

The Relationship between Personal and Contextual Factors and Participation Restriction in Mid-Life Caregivers.

OBJECTIVES: Mid-life family caregivers (CGs) are at risk for participation restriction, which can worsen quality of care for care recipients (CR) and increase CG burden and poor health. We aimed to identify factors associated with participation restriction in mid-life CGs. METHODS: This was a cross-sectional study of CGs aged 40-64 years (n = 1100) from the 2015 cohort of the National Study of Caregiving (NSOC)/National Health and Aging Trends Study (NHATS). Multivariate logistic regression was used to evaluate personal and caregiving attributes associated with restricted participation. RESULTS: Individual items from the negative and Positive aspects of caregiving (PAC) scales were associated with participation restriction. Mid-life caregivers with "frequent changes to caregiving routine" and "no time for self" were more likely to report restricted participation and those feeling "closer to the CR" were less likely to report restricted participation. DISCUSSION: Interventions to optimize caregiving routines and improve dyadic relationships could decrease participation restriction in mid-life CGs.

Examining Real-World Therapy Practice of Cognitive Screening and Assessment in Post-Acute Care.

OBJECTIVES: Routine implementation of cognitive screening and assessment by therapy providers in post-acute settings may promote improved care coordination. This study examined the frequency of cognitive screening and assessment documentation across post-acute settings, as well as its relationship with contextual factors and outcomes. DESIGN: Cross-sectional observational study using Medicare claims and electronic health record data from 1 large health system. SETTING AND PARTICIPANTS: Older adults admitted to post-acute care after an acute hospitalization. METHODS: Descriptive analysis examined documentation of cognitive screening and assessment. Logistic and hierarchical linear regression evaluated the relationship among patient factors, cognitive screening and assessment, and patient outcomes. RESULTS: The most common admission diagnoses for the final sample (n=2535) were total hip or knee joint replacement (41.7%) and stroke (15.3%). Following acute hospitalization, patients were discharged to inpatient rehabilitation (22.6%), skilled nursing (9.3%), or home health (68.1%). During the post-acute care stay, 38% of patients had documentation of cognitive screening by any therapy discipline. Patterns of documentation varied across disciplines and post-acute settings. Documentation of standardized cognitive assessments was limited, occurring for less than 2% of patients. Admission for stroke was associated with significantly higher odds of cognitive screening or assessment [odds ratio (OR) 2.07, 95% CI 1.13, 3.82] compared to patients with other diagnoses. There was no significant relationship between documentation of cognitive screening or assessment and 30-day readmissions (OR 0.81, 95% CI 0.53, 1.28). CONCLUSION AND IMPLICATIONS: The key finding was inconsistent documentation of cognitive screening and assessment across disciplines and post-acute settings, which could be in part due to variation in electronic health record platforms. Future work can expand on these results to understand the degree to which contextual factors facilitate or inhibit routine delivery and documentation of cognitive screening and assessment. Findings can support implementation of standardized data elements to lead to improved care coordination and outcomes.

Developing a digital music program for older adults with changing cognition: A program development report.

This program development report describes the adaptation of a music program for older adults with memory loss from in-person to a digital format. The objective was to develop a music program that was both engaging for the older adults, acceptable for the music instructor, and clearly defined for future research and implementation. This report describes the content of the music program and the systematic process of its development.

Associations Between Implementation of the Caregiver Advise Record Enable (CARE) Act and Health Service Utilization for Older Adults with Diabetes: Retrospective Observational Study.

BACKGROUND: The Caregiver Advise Record Enable (CARE) Act is a state level law that requires hospitals to identify and educate caregivers ("family members or friends") upon discharge. OBJECTIVE: This study examined the association between the implementation of the CARE Act in a Pennsylvania health system and health service utilization (ie, reducing hospital readmission, emergency department [ED] visits, and mortality) for older adults with diabetes. METHODS: The key elements of the CARE Act were implemented and applied to the patients discharged to home. The data between May and October 2017 were pulled from inpatient electronic health records. Likelihood-ratio chi-square tests and multivariate logistic regression models were used for statistical analysis. RESULTS: The sample consisted of 2591 older inpatients with diabetes with a mean age of 74.6 (SD 7.1) years. Of the 2591 patients, 46.1% (n=1194) were female, 86.9% (n=2251) were White, 97.4% (n=2523) had type 2 diabetes, and 69.5% (n=1801) identified a caregiver. Of the 1801 caregivers identified, 399 (22.2%) received discharge education and training. We compared the differences in health service utilization between pre- and postimplementation of the CARE Act; however, no significance was found. No significant differences were detected from the bivariate analyses in any outcomes between individuals who identified a caregiver and those who declined to identify a caregiver. After adjusting for risk factors (multivariate analysis), those who identified a caregiver (12.2%, 219/1801) was associated with higher rates of 30-day hospital readmission than those who declined to identify a caregiver (9.9%, 78/790; odds ratio [OR] 1.38, 95% CI 1.04-1.87; P=.02). Significantly lower rates were detected in 7-day readmission (P=.02), as well as 7-day (P=.03) and 30-day (P=.01) ED visits, among patients with diabetes whose identified caregiver received education and training than those whose identified caregiver did not receive education and training in the bivariate analyses. However, after adjusting for risk factors, no significance was found in 7-day readmission (OR 0.53, 95% CI 0.27-1.05; P=.07), 7-day ED visit (OR 0.63, 95% CI 0.38-1.03; P=.07), and 30-day ED visit (OR 0.73, 95% CI 0.52-1.02; P=.07). No significant associations were found for other outcomes (ie, 30-day readmission and 7-day and 30-day mortality) in both the bivariate and multivariate analyses. CONCLUSIONS: Our study found that the implementation of the CARE Act was associated with certain health service utilization. The identification of caregivers was associated with higher rates of 30-day hospital readmission in the multivariate analysis, whereas having identified caregivers who received discharge education was associated with lower rates of readmission and ED visit in the bivariate analysis.

Chronic condition clusters and associated disability over time.

Objectives: Recent evidence shows that more complex clusters of chronic conditions are associated with poorer health outcomes. Less clear is the extent to which these clusters are associated with different types of disability (activities of daily living (ADL) and functional mobility (FM)) over time; the aim of this study was to investigate this relationship. Methods: This was a longitudinal analysis using the National Health and Aging Trends Study (NHATS) (n = 6179). Using latent class analysis (LCA), we determined the optimal clusters of chronic conditions, then assigned each person to a best-fit class. Next, we used mixed-effects models with repeated measures to examine the effects of group (best-fit class), time (years from baseline), and the group by time interaction on each of the outcomes in separate models over 4 years. Results: We identified six chronic condition clusters: Minimal Disease, Cognitive/Affective, Multiple Morbidity, Osteoporosis, Vascular, and Cancer. Chronic condition cluster was related to ADL and FM outcomes, indicating that groups experienced differential disability over time. At time point 4, all chronic condition groups had worse FM than Minimal Disease. Discussion: The clusters of conditions identified here are plausible when considered clinically and in the context of previous research. All groups with chronic conditions carry risk for disability in FM and ADL; increased screening for disability in primary care could identify early disability and prevent decline.

Project Unmute: A Digital Music Program Delivered by Adolescent Musicians to Older Adults with Cognitive Decline.

Effective intergenerational music programming has the power to positively influence the current lives of the millions of older adults who are experiencing Alzheimer's disease and dementia, as well as to support the confidence of the newest generation of young musicians. To explore this potential, we designed a digital, intergenerational music program delivered by adolescent musicians to older adults with cognitive decline. This program utilized songs preferred by the older adults and an interactive activity that engaged the two generations. We believe this type of easily scalable programming could support older adults and young musicians, as well as promote new intergenerational relationships.

Adaptation and Pilot Study of a Behavioral Intervention Targeting Morning Activation Deficits in Dementia Caregivers: Scheduling Activity and Monitoring Mornings (SAMM).

OBJECTIVES: Morning activation deficits (MADs) correlate with depression symptom persistence in older dementia caregivers. To clarify the potential of MADs as a target for depression interventions, we aimed to: 1) adapt an existing behavioral activation program, Engage therapy, to target mornings; and 2) evaluate effects on self-reported MADs and depression symptoms. METHODS: While trialing the 9-week Engage adaption (targeting mornings) in six older dementia caregivers, we incorporated feedback and finalized an adapted program called Scheduling Activity and Monitoring Mornings (SAMM). We delivered the SAMM protocol to 13 dementia caregivers (all female; mean age = 69, standard deviation = 7). We report modifications made/rationale, as well as changes in subjective MADs (relevant items from the Composite Scale of Morningness) and depression symptoms (Patient Health Questionnaire - 9). RESULTS: Using caregiver and expert input, we adapted the protocol to: include educational materials/content describing the potential relationship between morning inactivity and depression; target activity scheduling within 2 hours of awakening (preferably earlier); and focus only on the main components of morning activity scheduling, planning, and monitoring. This program was associated with decreases in subjective MADs averaging 29% at week 4, 52% at week 6, and 57% by week 9 (all p's <0.005). Initial depression symptoms were significantly reduced, by 62%, at week 9. CONCLUSIONS: These preliminary findings suggest that subjective MADs can be modified pragmatically, and that doing so may have antidepressant effects. A controlled trial with measures of the putative mechanism is needed to clarify whether, and if so how, targeting MAD with SAMM causally perturbs depression's mechanisms.

Exploration of patient and caregiver cancer education using electronic health records.

The objective of this short report was to describe types of education provided to older, hospitalized patients with cancer and their caregivers using electronic health record data. A total of 437 patients, representing 512 inpatient stays (admissions), met the inclusion criteria. The sample were predominately male (58%) and White (95%). The average patient age at first admission was 74 years (SD 6.21 years) and the average length of admission was 5 days (SD 3.41 days). Out of all admissions, 89% included at least one documented education session with a provider. Three important results emerged from this study 1) education on medications is commonly conveyed to cancer patients (77%), 2) nurses are primarily responsible for providing education (65%), and 3) caregivers are infrequently involved (41%) in patient education. Additional educational topics tailored to the long-term needs of older adults with cancer are warranted. These topics should be delivered by an array of interprofessional care providers with demonstrated competency. Lastly, patient education should ensure inclusion of caregivers as part of the interprofessional cancer care team to promote successful management of cancer-related concerns.

Multimorbidity groups based on numbers of chronic conditions are associated with daily activity.

OBJECTIVE: Instrumental activities of daily living (IADL) are important for managing multiple chronic conditions (MCC) and maintaining independence while aging. Using data from the National Health and Aging Trends Study (NHATS), we answered the question: are there differences in ability and performance of IADL among groups of older adults with 0-1 (no MCC), 2-4 (low MCC), and 5+ chronic conditions (multisystem morbidity: MM)? METHODS: Cross-sectional study using Poisson regression and incidence rate ratios. Participants were 6,019 community-dwelling older adults who regularly take medications. We derived composite variables for ability and performance of IADL; MCC groups were based on count of 11 chronic conditions. RESULTS: Older adults with MM had lower IADL count for ability (IRR = .81) and performance (IRR = .77), and MM group significantly predicted both ability and performance of IADL (p < .001); 'low MCC' group was not significantly different than 'no MCC' regarding disability. DISCUSSION: Having MM is statistically and clinically different than having low MCC or no MCC; 5+ chronic conditions may be a meaningful inclusion criterion for interventions to decrease disability and 2-4 chronic conditions may be better for trials to prevent disability. Researchers should measure both ability and performance of daily activity.

The Development and Content Validation of the Care Partner Hospital Assessment Tool.

BACKGROUND/OBJECTIVES: When aging adults are hospitalized due to a major health event, they often turn to care partners ('family members or friends') for support. Assessment of care partners' needs during hospital care may be important to inform and target information and skills training that will equip them to fulfill caregiving tasks for the aging adults. The objectives of this study were to develop and complete content validation of the Care Partner Hospital Assessment Tool (CHAT). METHODS: Based on standard instrumentation methodology and an assessment framework recommended by the National Center on Caregiving at the Family Caregiving Alliance, three steps were followed to develop and validate CHAT: (1) generation of a 24-item tool grouped into three content domains (background, plans and preferences, skills and supports), and a survey by a multidisciplinary team, (2) administration of an online survey of care partners and experts, and (3) assessment of item and scale-content validity indices (I-CVI and S-CVI). RESULTS: A total of four care partners that provide unpaid care to a family member or friend age 65 years or older with a chronic illness or disability either before or after a hospitalization, and 19 leading experts in gerontology, caregiving, and health services completed an online survey in English. Twenty-two items were accepted by having an I-CVI at or above the acceptable 78% cut point; the S-CVI for the tool was 85%. Most revisions to the tool were associated with modifying or clarifying language within each item. For example, participants shared the following open-ended suggestions for revising CHAT: (1) change the "do you prefer" sentence stem to "do you want" (n = 12), define "training" (n = 6), and (2) allow care partners to provide an unsure response (n = 5). CONCLUSION: CHAT may be a promising way to increase health care practitioner's understanding of care partners' backgrounds, preferences and plans, and potential information or training needs during a patient's hospital stay. Initial evaluation of CHAT reveals strong conceptual development and content validity.