Neuropsychiatric symptoms in people living with dementia receiving home health services.

BACKGROUND: We sought to describe neuropsychiatric symptoms (NPS) among people living with dementia (PLWD) from diverse racial and ethnic groups receiving home health services while accounting for dementia severity, individual symptom prevalence, and neighborhood disadvantage. METHODS: A prospective study using cross-sectional data from n = 192 PLWD receiving skilled home healthcare in New Jersey enrolled in the Dementia Symptom Management at Home Program trial. We prospectively measured symptom prevalence with the Neuropsychiatric Inventory Questionnaire and dementia severity using the Quick Dementia Rating System. A one-way ANOVA determined NPS prevalence by dementia severity (mild, moderate, severe). Fisher's exact tests were used to assess the association of individual symptom prevalence with race and ethnicity and cross tabs to descriptively stratify individual symptom prevalence by dementia severity among groups. A Pearson correlation was performed to determine if a correlation existed among neighborhood disadvantages measured by the Area Deprivation Index (ADI) state decile scores and NPS prevalence and severity. RESULTS: Participants identified as non-Hispanic White (50%), non-Hispanic Black (30%), or Hispanic (13%). NPS were prevalent in 97% of participants who experienced 5.4 ± 2.6 symptoms with increased severity (10.8 ± 6.6) and care partner distress (13.8 ± 10.8). NPS increased with dementia severity (p = 0.004) with the greatest difference seen between individuals with mild dementia (4.3 ± 2.3) versus severe dementia (5.9 ± 2.3; p = 0.002). Few differences were found in symptom prevalence by racial and ethnic sub-groups. Nighttime behaviors were higher in non-Hispanic Black (78%), compared with non-Hispanic Whites (46%) with moderate dementia, p = 0.042. State ADI scores were not correlated with the number of NPS reported, or severity. CONCLUSIONS: NPS were prevalent and increased with dementia severity with commonalities among racial and ethnic groups with varying levels of neighborhood disadvantage. There is a need for effective methods for improving NPS identification, assessment, and management broadly for homebound PLWD.

Understanding the travel challenges and gaps for older adults during the COVID-19 outbreak: Insights from the New York City area.

The COVID-19 pandemic has greatly impacted lifestyles and travel patterns, revealing existing societal and transportation gaps and introducing new challenges. In the context of an aging population, this study investigated how the travel behaviors of older adults (aged 60+) in New York City were affected by COVID-19, using an online survey and analyzing younger adult (aged 18-59) data for comparative analysis. The purpose of the study is to understand the pandemic's effects on older adults' travel purpose and frequency, challenges faced during essential trips, and to identify potential policies to enhance their mobility during future crises. Descriptive analysis and Wilcoxon signed-rank tests were used to summarize the changes in employment status, trip purposes, transportation mode usage, and attitude regarding transportation systems before and during the outbreak and after the travel restrictions were lifted. A Natural Language Processing model, Gibbs Sampling Dirichlet Multinomial Mixture, was adopted to open-ended questions due to its advantage in extracting information from short text. The findings show differences between older and younger adults in telework and increased essential-purpose trips (e.g., medical visits) for older adults. The pandemic increased older adults' concern about health, safety, comfort, prices when choosing travel mode, leading to reduced transit use and walking, increased driving, and limited bike use. To reduce travel burdens and maintain older adults' employment, targeted programs improving digital skills (telework, telehealth, telemedicine) are recommended. Additionally, safe, affordable, and accessible transportation alternatives are necessary to ensure mobility and essential trips for older adults, along with facilitation of walkable communities.

Implementation in action: developing implementation strategies for an evidence-based prevention program.

In this commentary, I introduce existing literature on implementation mapping and the development of implementation strategies. I argue that educational materials describing essential features of a prevention program are needed regardless of the program site and therefore may be a good starting point in the implementation process. I use the development of educational materials and resources for the Stroll Safe outdoor falls prevention program as an example to illustrate the process used.

In this paper, I begin by describing previous published journal articles on the process that can be used to ensure evidence-based prevention programs are applied in real-world settings. I argue that educational materials describing essential features of a prevention program are needed regardless of the community site where the program will be implemented and therefore may be a good starting point in this process. I use the development of educational materials for the Stroll Safe outdoor falls prevention program as an example to illustrate how I created materials and resources to facilitate the ability of other clinicians to lead the Stroll Safe program.

The Stroll Safe outdoor falls prevention program: Participant experiences in eight community sites.

BACKGROUND AND OBJECTIVES: Outdoor falls can negatively impact the quality of life of community-dwelling older adults. Although there are differences in risk factors for indoor and outdoor falls, none of the existing evidence-based fall prevention programs specifically targets outdoors falls. To fill this gap, the Stroll Safe program was developed. The purpose of this study was to explore participant's experiences in the Stroll Safe program RESEARCH DESIGN AND METHODS: In this qualitative study, we conducted focus groups at eight community program sites with Stroll Safe program participants. Thematic analysis, with both deductive and inductive coding were used. Researcher triangulation was employed to increase trustworthiness of the findings RESULTS: Four major themes emerged from the data, including (1) Precipitants of behavioral change, (2) Behavioral change, (3) Program design, and 4) Enjoyment of program experience. Several sub-themes were also uncovered DISCUSSION AND IMPLICATIONS: Although the qualitative findings are consistent with the quantitative findings from the efficacy trial, the results also reveal benefits that were not captured by the quantitative analysis. In addition, the findings related to the influence of the group leader and program design can be used to guide future implementation science studies.

Factors Associated With Participation in Physical Leisure Activities in Taiwanese Community-Dwelling Older Adults.

This study was to identify factors at the intrapersonal, interpersonal, and community levels that relate to physical leisure participation in Taiwanese community-dwelling older adults and to examine their relative importance. We used a cross-sectional study with purposive sampling (N = 160). Physical leisure participation was quantified as the variety, frequency, and duration of participation. Data were analyzed using a series of hierarchical multiple linear regressions. The results showed that higher variety, frequency, or duration of physical leisure participation was associated with older males and with those who reported having better health, fewer depressive symptoms, and greater social support. Intrapersonal- and interpersonal-level factors play a relatively more important role in predicting physical leisure participation than factors at the community level. Understanding factors that relate to these three levels of participation has the potential to inform interventions that are tailored to individual profiles.

Efficacy of the Stroll Safe Outdoor Fall Prevention Program: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Outdoor falls can negatively affect the independence and well-being of community-dwelling older adults. Although there is some overlap, there are also differences in risk factors for indoor and outdoor falls. There are no existing community-based fall prevention programs that specifically target outdoor fall prevention. To fill this gap, the Stroll Safe program was developed. RESEARCH DESIGN AND METHODS: A cluster-randomized controlled trial design was used with randomization at the site level. Participants (N = 86) were aged 60 and older, with a history of an outdoor fall or who had a fear of falling outdoors. Eight naturally occurring retirement community program sites were randomly assigned to the treatment or wait list control group. Outcome measures included the Outdoor Falls Questionnaire, the Falls Behavioral Scale for the Older Person, and the Falls Efficacy Scale-International to examine knowledge of risks, safe strategy use, protective behaviors, and fear of falling. An Analysis of Covariance (ANCOVA) was used to compare change scores between groups with covariates included for any initial differences between groups. A linear mixed model was also conducted to account for any clustering effects. RESULTS: Significant differences (ps < .05) were found between groups for knowledge of outdoor fall risks and safe strategy use. Effect sizes were large (Cohen's d = 1.2-1.9). Results were retained at 6-week follow-up. DISCUSSION AND IMPLICATIONS: Stroll Safe is effective in improving knowledge of outdoor fall risks and increasing safe strategy use for community mobility. Stroll Safe fills a gap in outdoor fall prevention programs. Clinical Trials Registration Number: NCT03624777.

Stimulating Research to Enhance Aging in Place.

Older adults may benefit from interventions to successfully age in place. Research has an opportunity to test interventions and implementation strategies to fulfill the needs of older adults through collective evidence building. The purpose of this article is to describe the proceedings of the American Occupational Therapy Foundation (AOTF) 2019 Planning Grant Collective and describe the areas of research that were identified as critical. The AOTF convened scientists with expertise in the area of aging in place to catalyze research on aging in place for older adults. Four priority areas in the aging in place literature were highlighted: (a) identification of factors that support aging in place, (b) classification of processes by which family members and care partners are included in aging in place efforts, (c) categorization of technology supporting older adults to age in place, and (d) development of science that clarifies implementation of evidence-based practice.

Out-of-Home Activities and Health in Older Adults: A Scoping Review.

Participating in out-of-home (OOH) activities has been shown to benefit health in older adults. This scoping review aimed to describe the nature of the literature on OOH activities and health in community dwelling older adults, and the operationalization of OOH activity and health-related variables. We followed the Joanna Briggs Institute guidelines. Four databases were searched; studies were selected through title/abstract and full-text screening; and data on study characteristics, sample, and OOH activity and health-related variables were extracted, and summarized descriptively. Sixty articles were identified. There was a considerable focus on leisure and social activities (78% and 75%, respectively) but no predominant health-related outcome was identified. Few studies analyzed sex/gender and/or racial differences (25% and 2%, respectively). Future studies may include systematic reviews focused on health outcomes associated with social and leisure OOH activities; as well as gender-based and/or race-based differences in OOH and health relationships.

Outdoor Falls Prevention Strategy Use and Neighborhood Walkability Among Naturally Occurring Retirement Community Residents.

BACKGROUND: Outdoor falls present a significant challenge to the health and well-being of older adults. Safe strategy use is an important component of falls prevention, yet little is known regarding use of outdoor falls prevention strategies. AIMS: To examine outdoor falls prevention strategy use among naturally occurring retirement community residents at risk for falls, and to examine associations with neighborhood walkability. METHODS: Descriptive analyses of pretest data from an intervention study (N = 97) were conducted to examine frequency of outdoor falls prevention strategy use. Walk Score® data were added to the dataset, and chi-square tests of independence were used to examine associations between walkability categories and outdoor falls prevention strategy use. RESULTS: Some strategies, such as visual scanning and holding rails on stairs, were used by 70% or more of participants while others, such as route planning, were infrequently or inconsistently used. With the exception of avoiding cell phone use while walking outdoors, no significant associations were found between walkability categories and outdoor falls prevention strategy use. CONCLUSION: Study findings serve as a needs assessment for health education and behavioral training.

Feasibility of the Stroll Safe Outdoor Fall Prevention Program.

OBJECTIVE: Although half of falls occur outdoors, existing prevention programs focus primarily on risk factors for indoor falls. The purpose of this study was to evaluate the feasibility of the Stroll Safe outdoor fall prevention program and to obtain feedback to refine the program and research methods to plan a larger scale study. METHOD: A quasi-experimental design (N = 24) was used. A fidelity checklist, attendance records, a focus group, and a reflective log were used to conduct a process, resource, and project management assessment. Preliminary outcomes were examined using fall calendars and standardized measures of fall prevention strategy use. RESULTS: Needed modifications were determined. Preliminary outcomes reveal increased use of fall prevention strategies and decreased stumbles, trips, slips, and falls outdoors among program participants. CONCLUSION: The Stroll Safe program is an innovative new program that is feasible to implement among community-dwelling older adults. Further study is warranted.

Falls Experiences and Prevention Preferences of Adults in Mid-life.

Falls prevention research and practice has focused primarily on older adults, yet healthy and productive aging does not begin at age 65. To help fill this gap in knowledge, the purpose of this study was to explore the falls experiences and prevention program preferences of adults in mid-life who had experienced falls or near falls. A qualitative study using content analysis was used. Multiple coders were employed to increase the reliability of the findings. Results revealed three major themes with regard to falls experiences including precursors to falls, physical implications, and functional implications. For prevention preferences, themes included a continuum of interest, convenience is key, money matters, people you trust prompt action, and preventing future injury. Study results reveal new insights regarding the falls experiences and prevention preferences of adults in mid-life and can serve as a starting point to inform prevention programs targeting this population.

Predicting Use of Outdoor Fall Prevention Strategies: Considerations for Prevention Practices.

PURPOSE: Outdoor falls are just as common as indoor falls, but have received less attention in research and practice. Behavioral strategies play an important role in outdoor fall prevention. The purpose of this study was to examine predictors of strategy use. METHOD: Backward stepwise regression was used to study factors associated with use of outdoor fall prevention strategies among a random sample ( N = 120) of community-dwelling seniors. RESULTS: Significant negative predictors of strategy use included higher education levels ( p < .01) and living in an urban versus a suburban environment ( p < .01). Concern about falls and number of identified risks were positive predictors ( ps < .05). Differences were found between outdoor fallers and nonfallers in the use of three different types of strategies ( ps < .05). CONCLUSION: There are some differences in the profiles of people who use and do not use outdoor fall prevention strategies. Further study of additional factors is warranted.

Leisure as an End, Not Just a Means, in Occupational Therapy Intervention.

Leisure is commonly treated as a means instead of an end goal of intervention. This approach, influenced by history and society's past values, does not reflect the fact that leisure is meaningful and unique to its participants and has a significant effect on their health. On the basis of the core values of the occupational therapy profession and its role in the health care system, in this article we advocate that occupational therapists should expand their focus to include leisure as a goal of intervention. Although adopting this proposed approach may not be easy, given that it involves challenges in reimbursement for services, potential competition with other health professions, and a twisting of the deep-rooted existing values of occupational therapists, we believe the proposed solutions address these concerns and shed light on how to make leisure a valued goal of intervention.

Characteristics and fall experiences of older adults with and without fear of falling outdoors.

OBJECTIVE: Using a theoretical model that combines an ecological perspective and Bandura's theory of self-efficacy as a guide, we sought to compare experiences and characteristics of community dwelling older adults with and without concern about falling outdoors. METHOD: A survey of randomly selected community dwelling older adults across NYC (N = 120) was conducted using the outdoor falls questionnaire. Descriptive quantitative analyses of participant characteristics were conducted for all participants and for those with and without concern about falling outside. Conventional content analysis using two coders was employed to examine outdoor fall experiences for each group. A mixed methods matrix was used to integrate qualitative and quantitative findings. RESULTS: Some participant characteristics were more common among those with a concern about falling outside such as decreased functional status, female gender, and number of prior outdoor falls. As per descriptions of outdoor fall experiences, participants with concern were more likely to report a fall while climbing stairs or stepping up a curb, describe an intrinsic factor as a cause of their fall, use an injury prevention strategy during the fall, sustain a moderate to severe injury, seek medical attention, have had an ambulance called, require help to get up, and describe implementation of a behavioral change after the fall. CONCLUSIONS: Differences exist in participant characteristics and outdoor fall experiences of those with and without concern about falling outside. The proposed model can be used to understand fear of falling outdoors and can help to inform the target population and content of intervention programs.

Pre-admission functional decline in hospitalized persons with dementia: The influence of family caregiver factors.

Older adults with dementia are more likely than those who do not have dementia to be hospitalized. Admission functional (ADL) performance is a salient factor predicting functional performance in older adults at discharge. The days preceding hospitalization are often associated with functional loss related to the acute illness. An understanding of functional changes during this transition will inform interventions to prevent functional decline. This secondary analysis examined data from a study that evaluated a family educational empowerment model and included 136 dyads (persons with dementia and their family caregiver). AMOS structural equation modeling examined the effects of family caregiver factors upon change in patient ADL performance (Barthel Index) from baseline (two week prior to hospitalization) to the time of admission, controlling for patient characteristics. Eighty-two percent of the patients had decline prior to admission. Baseline function, depression, and dementia severity, as well as Family caregiver strain, were significantly associated with change in pre-admission ADL performance and explained 40% of the variance. There was a good fit of the model to the data (Χ2=12.9, p=0.305, CFI=0.97, TLI=0.90, RMSEA=0.05). Findings suggest the need for a function-focused approach when admitting patients with dementia to the hospital. FCG strain prior to hospitalization may be a factor impacting trajectory of functional changes in older person with dementia, especially in those with advanced dementia. FCG strain is an important assessment parameter in the risk assessment for functional decline, to be considered when engaging the FCG in the plan for functional recovery.

Characteristics and consequences of falls among older adult trauma patients: Considerations for injury prevention programs.

BACKGROUND/AIM: Health promotion and prevention is an important component of occupational therapy practice. Falls are one of the most common causes of ER visits among older adults and injurious falls requiring trauma care can have a significant impact on the health and quality of life of elders. The aim of this study was to compare characteristics and consequences of falls among older adult trauma patients across different age groups with an eye towards informing injury prevention programs. METHODS: A retrospective study using the trauma database from a level one trauma centre in the U.S. (N = 711) was conducted. We compared patient and fall characteristics across age groups and then used logistic regression to estimate odds ratios for hospital length of stay >4 days, discharge disposition, and injury severity (ISS >15). RESULTS: Associations between age group and fall height, location and alcohol use at the time of the fall were statistically significant (P < 0.0001). As compared to the reference group (85 and older), younger age groups had lower odds ratios for discharge to a facility for rehabilitation. CONCLUSION: Results highlight differences among age groups of fallers admitted for trauma care and can help to inform injury prevention programs related to outdoor and indoor falls.

Knowledge, behavioral practices, and experiences of outdoor fallers: Implications for prevention programs.

OBJECTIVE: Although the epidemiology and prevention of falls has been well studied, the focus has been on indoor rather than outdoor falls. Older adults' knowledge of outdoor risk factors and their outdoor fall prevention practices have not been examined. To fill this gap, and to inform the development of a prevention program, we sought to explore the experiences and fall prevention knowledge and practices of older adults who had sustained an outdoor fall. METHODS: A cross-sectional study using random digit telephone dialing was used to survey community dwelling seniors (N=120) across the five boroughs of New York City. We used the Outdoor Falls Questionnaire (OFQ), a valid and reliable tool as the survey instrument. Perceived outdoor fall risks, strategies used for prevention, and outdoor fall experiences were examined. SPSS version 21 was used for descriptive analysis of participant characteristics and to determine frequencies of perceived outdoor fall risks and strategies used for prevention. Phenomenological analysis was used with the qualitative data. Qualitative and quantitative data were analyzed separately and a mixed methods matrix was used to interpret and integrate the findings. RESULTS: Analysis revealed diverse unmet education and training needs including the importance of using single vision glasses, understanding the fall risks associated with recreational areas and parking lots, safe outdoor walking strategies, safe carrying of items on level and uneven surfaces, as well as when walking up and down stairs, and safety in opening/closing doors. CONCLUSIONS: Study findings are informative for outdoor fall prevention programs as well as practice.

Factors associated with IADL independence: implications for OT practice.

BACKGROUND: Globally, the population is aging. Instrumental activities of daily living (IADL) are an important component of independent function and impact the ability of older adults to age in place. Therefore, factors associated with IADL independence warrant further study. OBJECTIVE: To explore the association of age, depressive symptoms and leisure participation with IADL independence, and the relative importance of these three factors in predicting IADL independence. METHODS: A cross-sectional design using an existing data set was employed. Older adults age 60 and older (n = 98) who resided in senior housing or their own home/apartment were included in the study. A hierarchical multiple regression analysis was employed. RESULTS: The second model predicting IADL independence using age, depressive symptoms and level of leisure participation was significant (F(3,96) = 15.57, p < 0.001) and explained 31.00% of the variance in IADL independence compared to the first regression model, which included age alone (R2 adjusted = 18.00%). Age was the strongest of the three predictors, accounting for 11.40% of the variance in IADL independence. Depressive symptoms and participation in leisure activities were also significant predictors, their unique contributions being 7.30 and 4.30%, respectively. CONCLUSION AND SIGNIFICANCE: Age, depressive symptoms and leisure participation are all significant predictors of IADL independence among older adults. Therefore, according to our preliminary findings, leisure participation and non-pharmacological interventions for depressive symptoms warrant attention in practice in relation to IADL independence.

Indoor and outdoor falls among older adult trauma patients: A comparison of patient characteristics, associated factors and outcomes.

AIM: The aim of the present study was to examine significant differences in patient characteristics, associated factors and outcomes for indoor versus outdoor falls among trauma patients. METHODS: A retrospective cross-sectional study using data from the trauma registry and electronic medical records at a level 1 trauma center in the USA was carried out. People aged 55 years or older, for whom fall location could be identified (n = 712), were included in the study. Demographic information, functional status before admission, comorbid conditions, activation level, Injury Severity Score, discharge disposition and injury type were included in the comparative analyses. Associated factors for falls and fractures in each location were also examined using logistic regression. RESULTS: Significant differences were found in patient characteristics between indoor and outdoor fallers. Significant differences in outcomes were found related to discharge disposition and injury type. Open wounds were more common among outdoor fallers (26.5%) as compared with indoor fallers (16.3%, P = 0.002). Although disorders of joints with difficulty walking were associated with fractures among both indoor (OR 7.20, CI 2.19-23.66) and outdoor fallers (OR 5.65, CI 1.27-25.06), sex was only associated with fractures among those who fell indoors (OR 1.69 CI 1.12-2.56). CONCLUSIONS: Significant differences exist in characteristics of indoor and outdoor fallers, and for discharge disposition and injury type for each fall location among patients admitted for trauma care. Factors associated with fractures differ between indoor and outdoor fallers. Results can help to inform targeted primary and secondary prevention initiatives. Geriatr Gerontol Int 2017; 17: 905-912.