Delirium Severity and Physical Function in Hospitalized Persons Living With Dementia: Moderation by Age, Sex, and Race.

OBJECTIVE: This study investigated whether demographic characteristics (age, sex, and race) moderated delirium severity as a predictor of physical function in hospitalized persons living with dementia. METHODS: The sample consisted of 351 patients enrolled in a randomized controlled trial (Function Focused Care for Acute Care Using the Evidence Integration Triangle). Preliminary analysis was conducted to assess the main effect, and multiple linear regression was used to examine the moderating effect of demographic characteristics between delirium severity and physical function. RESULTS: Both age and sex were found to have significant moderating effects on the relationship between delirium severity and physical function (ß = 2.22; P = 0.02 and ß = 1.34; P = 0.04, respectively). Older adults aged 85 years or older with higher levels of delirium severity reported lower levels of physical function compared with older adults aged 65 to 84 years. Males with higher levels of delirium severity reported lower levels of physical function compared with females. Race did not significantly moderate the association between delirium severity and physical function (ß = 0.22; P = 0.90). CONCLUSIONS: Our findings suggest that age and sex may have differential effects on physical function across different levels of delirium severity in hospitalized persons living with dementia.

" I'm not a risk taker " : Risk Perceptions of Nursing Home Residents With Dementia.

BACKGROUND: Persons living with Alzheimer disease and related dementia (ADRD) in nursing homes (NH) are often excluded from conversations about their health/safety. These omissions impinge on personhood and the rights to have care preferences heard and honored. While persons with ADRD maintain the ability to communicate their preferences long after their decision-making abilities are affected, little is known about how persons with ADRD understand the risks associated with their preferences. METHODS: As part of a larger focused ethnography, in-depth interviews and an adapted risk propensity questionnaire explored the risk perceptions of NH residents with ADRD (N=7) associated with their preferences for care and activities of daily living. RESULTS: Residents generally self-identified as risk avoiders ( M =3.2±1.84) on the risk propensity scale and were able to rate risk associated with preferences described within 5 thematic categories: 1) participation in decision-making, 2) risk awareness, 3) paying attention to safety, 4) reliance on nursing home staff and family, and 5) impacts on quality of life and quality of care. DISCUSSION: Results suggest NH residents with ADRD can express risk surrounding their preferences and should be encouraged to participate in discussions about their health and safety.

Behavioral and psychological symptoms of dementia and adverse patient outcomes post-hospitalization.

OBJECTIVES: The occurrence of behavioral and psychological symptoms of dementia (BPSD) are associated with adverse outcomes but have largely been studied in populations outside of acute care. The current study examines (1) the prevalence of BPSD during acute hospitalization and (2) if BPSD are predictive of adverse patient outcomes. METHODS: A secondary analysis of Family-centered Function-focused Care (Fam-FFC) data including 461 patients with dementia/care partner dyads assessed at hospital admission, discharge, 2 months, and 6 months post-discharge, was conducted. Prevalence of BPSD (Neuropsychiatric Inventory-Questionnaire total and Frontal, Hyperactivity, Mood, and Psychosis sub-categories), associations with patient and care partner characteristics, and prediction of adverse events (falls, emergency room [ER] visits, hospitalizations, injury) were examined. RESULTS: BPSD were highly prevalent (93.9% admission, 86.7% discharge). The most common symptom cluster at admission was Hyperactivity (76.7%) followed by Mood (72.3%) and Psychosis (71.9%), and Frontal (25.9%). Higher admission Hyperactivity was associated with ER admissions at 2 months, higher discharge Hyperactivity was associated with ER admissions and hospitalizations at 2 months, and change in Psychosis was associated with ER admissions at 2 months. CONCLUSIONS: These findings highlight BPSD during hospitalization as potentially modifiable risk factors of adverse outcomes.

Mediating role of care partner burden among dementia care partners during post-hospital transition.

OBJECTIVES: This study examined the mediating role of care partner burden on the relationship between patient clinical factors (i.e. cognition, physical function, and behavioral and psychological symptoms of dementia [BPSD]) and care partner mental health (i.e. anxiety and depression) among dementia care partners at hospital discharge. METHOD: The sample consisted of 431 patient and care partner dyads enrolled in the Family centered Function-focused Care (Fam-FFC) study; ClinicalTrials.gov identifier NCT03046121. Mediation analyses were conducted to test the role of care partner burden on the associations between patient clinical factors, and care partner anxiety and depression. RESULTS: Mediation models demonstrated that care partner burden partially mediated the relationship between patient physical function and care partner anxiety and depression, as well as patient BPSD and care partner anxiety and depression. CONCLUSION: Findings highlight the need for clinicians and service providers to implement comprehensive strategies that address both patient clinical factors (i.e. physical function and BPSD) and care partner burden, to optimize care partner mental health outcomes during post-hospital transition.

A Descriptive Study Using Rasch Analysis and Hypothesis Testing to Evaluate the Psychometric Properties of the UMOVE Mobility Screen Tested With Hospitalized Older Adults.

The purpose of this study was to test the reliability and validity of the UMOVE Mobility Screen in older adults living with dementia using a Rasch analysis and hypothesis testing. The UMOVE Mobility Screen (UMOVE) focuses on nine activities: following commands, muscle strength, and basic functional mobility tasks. Trained evaluators completed assessments on 244 patients, the majority of whom were female (62%), and White (71%). Based on Rasch Analysis, there was evidence of good item and person reliability (indexes > 0.80), good INFIT statistics, and only one item fitting the model based on OUTFIT statistics. Validity was supported based on hypothesis testing. There was no evidence of Differential Item Functioning between races and genders. Item mapping raised concerns about the spread of the items across the full spectrum of mobility assessed in the UMOVE Mobility Screen. Future testing should consider adding some easier and some more difficult items.

The association between patient engagement and quality of care interactions among acute care patients with dementia.

Effective staff-patient communication is critical in acute care settings, particularly for patients with dementia. Limited work has examined the impact of quality of staff-patient care interactions on patient engagement. The purpose of this study was to determine whether the quality of staff-patient care interactions were associated with active patient engagement during the interaction after controlling for relevant covariates. The study was a secondary data analysis using baseline data from the Function Focused Care for Acute Care intervention study, with a total sample of 286 patients. Descriptive statistics and a generalized linear mixed model were used. The findings indicated that there was a significant relationship between the quality of care interactions and patient engagement such that receiving positive care interactions resulted in higher odds of active patient engagement. These findings can inform future interventions and training for acute care staff to improve quality of care interactions and patient engagement.

Gender, Pain, and Function Associated With Physical Activity After Hospitalization in Persons Living With Dementia.

BACKGROUND: The purpose of this study was to identify factors that are associated with physical activity after hospitalization in persons living with dementia. METHODS: Multiple linear regressions were conducted to test factors associated with objective activity levels (sedentary, low, moderate, and vigorous) among 244 patients living with dementia from a randomized controlled trial. RESULTS: Within 48 hours of hospital discharge, time in sedentary behavior was associated with increased pain (ß=0.164, P =0.015). Time in low activity was associated with less pain (ß=-0.130, P =0.049) and higher physical function (ß=0.300, P =<0.001). Time in moderate activity was associated with increased physical function (ß=0.190, P =0.008) and male gender (ß=0.155, P =0.016). No significant associations of potential factors were found with time in vigorous activity. CONCLUSIONS: Our findings suggest that managing or reducing pain, encouraging individual functional level, and gender could influence time spent in physical activity after acute hospitalization in persons living with dementia.

Delirium and Behavioral Symptoms in Persons With Dementia at Hospital Admission: Mediating Factors.

BACKGROUND: Hospitalized persons with dementia are at risk of delirium with behavioral symptoms, predisposing them to a higher rate of complications and caregiver distress. The purpose of this study was to examine the relationship between delirium severity in patients with dementia upon admission to the hospital and the manifestation of behavioral symptoms, and to evaluate the mediating effects of cognitive and physical function, pain, medications, and restraints. METHODS: This descriptive study used baseline data from 455 older adults with dementia enrolled in a cluster randomized clinical trial that tested the efficacy of family centered function-focused care. Mediation analyses were conducted to determine the indirect effect of cognitive and physical function, pain, medications (antipsychotics, anxiolytics, sedative/hypnotics, narcotics, and number of medications), and restraints on behavioral symptoms, controlling for age, sex, race, and educational level. RESULTS: The majority of the 455 participants were female (59.1%), had an average age of 81.5 (SD=8.4), were either white (63.7%) or black (36.3%), and demonstrated one or more behavioral symptoms (93%) and delirium (60%). Hypotheses were partially supported in that physical function, cognitive function, and antipsychotic medication partially mediated the relationship between delirium severity and behavioral symptoms. CONCLUSION: This study provides preliminary evidence identifying antipsychotic use, low physical function, and significant cognitive impairment as specific targets for clinical intervention and quality improvement in patients with delirium superimposed on dementia at hospital admission.

The association of physical activity and behavioral and psychological symptoms among a sample of hospitalized older adults living with dementia.

OBJECTIVES: The aims of this study were to: (1) describe the prevalence of behavioral and psychological symptoms of dementia in hospitalized older adults living with dementia and (2) examine the association of physical activity and behavioral and psychological symptoms of dementia among hospitalized older adults living with dementia, after controlling for covariates. METHODS: Physical activity was measured using the Physical Activity Survey and behavioral and psychological symptoms of dementia were measured using the Neuropsychiatric Inventory. Descriptive analysis and multiple linear regressions were run using baseline data on 294 older adults with dementia hospitalized on general medical units from an ongoing study entitled Function Focused Care for Acute Care Using the Evidence Integration Triangle. RESULTS: Participants performed an average of 7.92 (SD = 4.49) of 34 possible activities "in the last 24 h" prior to the Physical Activity Survey administration. A total of 132 participants (45.5%) had at least one behavioral and psychological symptom of dementia. We found that physical activity was not associated with behavioral and psychological symptoms of dementia (b = 0.01; p = 0.56), after controlling for covariates. CONCLUSIONS: Although this study found no evidence of an association between physical activity and behavioral and psychological symptoms of dementia, evidence of physical activity did not exacerbate these behaviors. Thus, given the benefits of physical activity, it is important to continue to encourage patients living with dementia to engage in activity.

Caregiver preparedness is associated with desire to seek long-term care admission of hospitalized persons with dementia.

INTRODUCTION: Hospitalized patients with dementia are more likely to be discharged to long-term care compared to persons without dementia. Little research has been conducted to examine the associations of caregiver preparedness and strain with desire to seek long-term care in hospitalized persons with dementia at discharge. The purpose of this study was to examine caregiver preparedness and strain as factors associated with desire to seek long-term care admission in caregivers of persons with dementia at hospital discharge. METHODS: Patient baseline and discharge data, and caregiver discharge data of 424 patient and caregiver dyads from a cluster randomized trial was used. Stepwise multiple linear regression was conducted to examine factors associated with caregiver desire to seek long-term care. RESULTS: After controlling for caregiver and patient characteristics, lower caregiver preparedness (ß = -0.069; p < 0.016) was significantly associated with increased desire to seek long-term care. DISCUSSION: Findings underscore the need for clinicians and service providers to provide further attention to caregiver preparedness throughout the course of hospitalization.

Comparative Implementation of a Brief App-Directed Protocol for Delirium Identification by Hospitalists, Nurses, and Nursing Assistants : A Cohort Study.

BACKGROUND: Systematic screening improves delirium identification among hospitalized older adults. Little data exist on how to implement such screening. OBJECTIVE: To test implementation of a brief app-directed protocol for delirium identification by physicians, nurses, and certified nursing assistants (CNAs) in real-world practice relative to a research reference standard delirium assessment (RSDA). DESIGN: Prospective cohort study. SETTING: Large urban academic medical center and small rural community hospital. PARTICIPANTS: 527 general medicine inpatients (mean age, 80 years; 35% with preexisting dementia) and 399 clinicians (53 hospitalists, 236 nurses, and 110 CNAs). MEASUREMENTS: On 2 study days, enrolled patients had an RSDA. Subsequently, CNAs performed an ultra-brief 2-item screen (UB-2) for delirium, whereas physicians and nurses performed a 2-step protocol consisting of the UB-2 followed in those with a positive screen result by the 3-Minute Diagnostic Assessment for the Confusion Assessment Method. RESULTS: Delirium was diagnosed in 154 of 924 RSDAs (17%) and in 114 of 527 patients (22%). The completion rate for clinician protocols exceeded 97%. The CNAs administered the UB-2 in a mean of 62 seconds (SD, 51). The 2-step protocols were administered in means of 104 seconds (SD, 99) by nurses and 106 seconds (SD, 105) by physicians. The UB-2 had sensitivities of 88% (95% CI, 72% to 96%), 87% (CI, 73% to 95%), and 82% (CI, 65% to 91%) when administered by CNAs, nurses, and physicians, respectively, with specificities of 64% to 70%. The 2-step protocol had overall accuracy of 89% (CI, 83% to 93%) and 87% (CI, 81% to 91%), with sensitivities of 65% (CI, 48% to 79%) and 63% (CI, 46% to 77%) and specificities of 93% (CI, 88% to 96%) and 91% (CI, 86% to 95%), for nurses and physicians, respectively. Two-step protocol sensitivity for moderate to severe delirium was 78% (CI, 54% to 91%). LIMITATION: Two sites; limited diversity. CONCLUSION: An app-directed protocol for delirium identification was feasible, brief, and accurate, and CNAs and nurses performed as well as hospitalists. PRIMARY FUNDING SOURCE: National Institute on Aging.

Pathway From Type 2 Diabetes Diagnosis to Action: How to Move People Forward.

Seven self-care behaviors-healthy coping, healthy eating, being active, taking medication, monitoring, reducing risk, and problem-solving-are recommended for individuals with diabetes to achieve optimal health and quality of life. People newly diagnosed with type 2 diabetes may find it challenging to learn and properly incorporate all of these self-care behaviors into their life. This qualitative study explored the experiences and perceived immediate self-management and psychosocial support needs in individuals newly diagnosed with type 2 diabetes. Data analysis revealed the significant challenges individuals encounter after a type 2 diabetes diagnosis. Five main themes were identified: 1) type 2 diabetes diagnosis competes with other complex life challenges, 2) difficulty in performing behavior modification actions, 3) lack of support, 4) emergence of emotional and psychological issues, and 5) need for planned individualized follow-up support after a type 2 diabetes diagnosis. This study revealed a gap in care after type 2 diabetes diagnosis. Individualized support is needed to assist people in moving successfully from diagnosis to being well equipped with the knowledge and skills necessary to properly manage the condition.

A Descriptive Study of Treatment of Pain in Acute Care for Patients Living With Dementia.

BACKGROUND: During the hospital stay pain is very common among patients living with dementia. METHODS: Descriptive data was obtained from chart review and included age, gender, race, comorbidities and admitting diagnosis. AIMS: The purpose of this study was to describe pain among patients living with dementia, the use of pharmacologic and nonpharmacologic treatment, and to compare treatments among those with and without pain. DESIGN: This was a descriptive study using baseline data from the first 233 participants from the study "Testing the Implementation of Function Focused Care for Acute Care Using the Evidence Integration Triangle (FFC-AC-EIT)". PARTICIPANTS/SUBJECTS: The mean age of participants was 83 (SD=5) and the majority was female (65%) and White (67%) with evidence of dementia (based on a mean Saint Louis University Mental Status Test = 7.23, SD=5.85). RESULTS: Overall 98 (42%) participants had pain and 135 (58%) no pain. Only 14 (6%) participants received no nonpharmacologic or pharmacologic interventions for pain and five of these individuals had pain. The most frequently used pharmacologic intervention among all participants was acetaminophen (n = 121, 52%), then tramadol (n = 19, 8%). Comfort measures and general nonpharmacologic approaches were the most frequently used non-pharmacologic approaches, then physical activity and therapeutic communication. From admission to discharge, there was a trend towards a decrease in pain. There was more use of opioids, physical activity, and therapeutic communication in the no pain group versus the pain group. CONCLUSIONS: The majority of hospitalized medical patients living with dementia were treated for pain, but an ongoing focus is needed to assure optimal pain management for all patients.

Remodeling Type 2 Diabetes Diagnosis: What Individuals Need for Success.

The diagnosis of type 2 diabetes initiates a new health-illness transition. However, little is known about the immediate support that people need to successfully cope with this diagnosis. This qualitative study explored the experiences and immediate support needed at the point of diagnosis among individuals with type 2 diabetes. The findings suggest the need for health care professionals to render immediate emotional support in the form of reassurance and partnership to manage the condition together. Pre- and post-counseling sessions can minimize the emotional and psychological strain associated with the new diagnosis. Individuals should be given information on available resources, as well as an immediate connection with a health care partner who can provide guidance and help with the transition.

Cognitive Exercise for Persons with Alzheimer's Disease and Related Dementia Using a Social Robot.

Reminiscence therapy (RT) can improve the mood and communication of persons living with Alzheimer's Disease and Alzheimer's Disease related dementias (PLWD). Traditional RT requires professionals' facilitation, limiting its accessibility to PLWD. Social robotics has the potential to facilitate RT, enabling accessible, home-based RT. However, studies are needed to investigate how PLWD would perceive a robot-mediated RT (RMRT) and how to develop RMRT for positive user experience and successful adoption. In this paper, we developed a prototype of RMRT using a humanoid social robot and tested it with 12 participants (7 PLWD, 2 with mild cognitive impairment, and 3 informal caregivers). The robot automatically displayed a memory trigger on its tablet and engaged participants in a relatable conversation during RMRT. A mixed-method approach was employed to assess its acceptability and usability. Our results showed that PLWD had an overall positive user experience with the RMRT. Participants laughed and sang along with the robot during RMRT and demonstrated intention to use it. We additionally discussed robot control method and several critical problems for RMRT. The RMRT can facilitate both verbal and nonverbal social interaction for PLWD and holds promise for engaging, personalized, and efficient home-based cognitive exercises for PLWD.

Factors Associated With Function-Focused Care Among Hospitalized Older Adults Living With Dementia.

This article reports a study that was designed to describe the incidence of pain among older hospitalized patients with dementia and to evaluate the factors that influence pain among these individuals. It was hypothesized that function, behavioral and psychological symptoms of dementia, delirium, pain treatment, and patient exposure to care interventions would be associated with pain. Patients who performed more functional activities had less delirium. They also experienced higher quality-of-care interactions and were less likely to have pain. The findings from this study support the relationship between function, delirium, and quality-of-care interactions and pain. It suggests that it may be useful to encourage patients with dementia to engage in functional and physical activity to prevent or manage pain. This study serves as a reminder to avoid neutral or negative care interactions among patients with dementia as a strategy to mediate delirium and pain.

Factors Associated With Physical Activity in Hospitalized Patients With Dementia.

Older adults continue to spend little time engaged in physical activity when hospitalized. The purpose of this study was to (a) describe activity among hospitalized older adults with dementia and (b) identify the association between specific factors (gender, ambulation independence, comorbidities, race, and hospital setting) and their physical activity. This descriptive study utilized baseline data on the first 79 participants from the Function Focused Care for Acute Care using the Evidence Integration Triangle. Multiple linear regression models were run using accelerometry data from the first full day of hospitalization. The participants spent an average of 83.7% of their time being sedentary. Male gender, ambulation independence, and hospital setting (the hospital in which the patient was admitted) were associated with greater activity. This study reports on the limited time spent in activity for older adults with dementia when hospitalized and highlights patient profiles that are particularly vulnerable to sedentary behavior in the hospital setting.

Caregiving for Persons Living With Dementia During the COVID-19 Pandemic: Perspectives of Family Care Partners.

Persons living with dementia (PLWD) are at increased risk for coronavirus disease 2019 (COVID-19) and poorer outcomes if they contract the disease. COVID-19 may also change and exacerbate usual stresses of family caregiving. The current qualitative descriptive study examined 14 family care partners' (FCPs) experiences and perspectives on how the COVID-19 pandemic impacted them, their care recipients, and their caregiving for their care recipients. Thematic analysis of interviews generated five themes: Cautious of COVID-19 Exposure, Challenges of Balancing COVID-19 Restrictions With Caregiving, Shared Loneliness, Functional Decline, and Communication Challenges With PLWD and Health Care Professionals (HCPs). FCPs are integral to the care of PLWD across care settings. The time is now to plan for changes in policy that will safely maintain FCPs' visitation with their care recipients with dementia and allow for partnering with HCPs to avoid the long-lasting negative effects on older adults' health and function. [Journal of Gerontological Nursing, 49(3), 27-33.].

Clinical factors associated with the quality of interactions between staff and hospitalized older patients with dementia.

This study examines the clinical factors associated with the quality of interactions between staff and hospitalized older patients with dementia. Following examination of bivariate associations, we conducted multiple linear regression in a sample of 140 hospitalized older patients with dementia who participated in the final cohort of an intervention study implementing Family-centered Function-focused Care (Fam-FFC). On average, the participants (male = 46.1%, female = 52.9%) were 81.43 years old (SD = 8.29) and had positive interactions with staff (mean QUIS score = 5.84, SD = 1.36). Accounting for 17.8% of variance in the model, non-pharmacological intervention use (b= 0.170; p<.001) and pain (b= -0.198; p<.01) were significantly associated with the quality of staff-patient interactions. To optimize care of hospitalized patients with dementia, staff should be encouraged to use non-pharmacological interventions. It is also important for staff to assess pain among the patients with dementia and prioritize pain management.

Gender differences in interactions and depressive symptoms among hospitalized older patients living with dementia.

Alzheimer's disease or a related dementia (ADRD) disproportionately affects women with two-thirds of individuals with ADRD comprised of women. This study examined gender-related differences in the quality of staff-patient interactions and depressive symptoms among hospitalized older patients living with dementia. This secondary analysis utilized baseline data of 140 hospitalized older patients with dementia who participated in the final cohort of a randomized controlled trial (ClinicalTrials.gov identifier: NCT03046121) implementing Family centered Function-focused Care (Fam-FFC). On average, the participants (male = 46.1%, female = 52.9%) were 81.43 years old (SD = 8.29), had positive interactions with staff and lower depressive symptoms based on Quality of Interaction Schedule (QUIS) scores and Cornell Scale for Depression in Dementia (CSDD) scores, respectively. Although males had more positive interactions (male = 6.06, SD = 1.13; female = 5.59, SD = 1.51) and lesser depressive symptoms (male = 7.52, SD = 4.77; female = 8.03, SD = 6.25) than females, no statistically significant gender differences were observed in linear models with appropriate covariates or multivariant analysis of covariant (MANCOVA). However, the multigroup regression conducted to further probe marginally significant moderation effect of gender and pain on staff-patient interactions demonstrated that greater pain was significantly related to lower quality or less positive staff-patient interactions for females compared to males (χ2diff (1) = 4.84, p = .03). Continued evaluation of gender differences is warranted to inform care delivery and interventions to improve care for hospitalized older patients with dementia.