Sleep movements and respiratory coupling as a biobehavioral metric for early Alzheimer's disease in independently dwelling adults.

INTRODUCTION: Sleep disorder is often the first symptom of age-related cognitive decline associated with Alzheimer's disease (AD) observed in primary care. The relationship between sleep and early AD was examined using a patented sleep mattress designed to record respiration and high frequency movement arousals. A machine learning algorithm was developed to classify sleep features associated with early AD. METHOD: Community-dwelling older adults (N = 95; 62-90 years) were recruited in a 3-h catchment area. Study participants were tested on the mattress device in the home bed for 2 days, wore a wrist actigraph for 7 days, and provided sleep diary and sleep disorder self-reports during the 1-week study period. Neurocognitive testing was completed in the home within 30-days of the sleep study. Participant performance on executive and memory tasks, health history and demographics were reviewed by a geriatric clinical team yielding Normal Cognition (n = 45) and amnestic MCI-Consensus (n = 33) groups. A diagnosed MCI group (n = 17) was recruited from a hospital memory clinic following diagnostic series of neuroimaging biomarker assessment and cognitive criteria for AD. RESULTS: In cohort analyses, sleep fragmentation and wake after sleep onset duration predicted poorer executive function, particularly memory performance. Group analyses showed increased sleep fragmentation and total sleep time in the diagnosed MCI group compared to the Normal Cognition group. Machine learning algorithm showed that the time latency between movement arousals and coupled respiratory upregulation could be used as a classifier of diagnosed MCI vs. Normal Cognition cases. ROC diagnostics identified MCI with 87% sensitivity; 89% specificity; and 88% positive predictive value. DISCUSSION: AD sleep phenotype was detected with a novel sleep biometric, time latency, associated with the tight gap between sleep movements and respiratory coupling, which is proposed as a corollary of sleep quality/loss that affects the autonomic regulation of respiration during sleep. Diagnosed MCI was associated with sleep fragmentation and arousal intrusion.

Measuring music engagement in older adults: the UNE music in aging wellness scale (MAWS).

OBJECTIVES: Engagement with music (i.e. listening, moving to the beat, joining in, performance) is documented to enhance cognition, mood, socialization, and a host of other wellness indicators in advancing age. A number of comprehensive scales measure this engagement, but a brief, accessible scale designed for general use with older adults is lacking. This project was undertaken to create and offer preliminary validation of the 7-item Music in Aging Wellness Scale (MAWS). METHOD: Seven items reflecting aspects of music engagement (ME) were developed by expert opinion (e.g. 'I always tap my foot or sway my body to good music') for completion on a 1-7, strongly disagree to strongly agree, Likert scale. These were subject to exploratory factor analysis (EFA) (n = 349 cases) along with a set of six experimental items on ageism. It was hypothesized these items would cluster by content, thus showing separation into distinct factors. RESULTS: This was achieved and the resulting measure showed sound internal consistency (0.82), split-half reliability (0.71), and one-year test-retest (0.83). The MAWS total score was found to correlate significantly in expected directions with common gerontological measures. High scorers reported less depression, more mastery, less loneliness, and larger social networks. No association was found for worry-based anxiety and self-reported cognitive decline. CONCLUSION: This preliminary reliability and validity study suggests that the MAWS may be an appropriate outcome and tracking measure for older adults involved in music-wellness interventions. Future research will further validate MAWS characteristics and associations with other established measures in this important field.

Telecollaboration in gerontology service learning: Addressing isolation & loneliness in a pandemic.

Social isolation and loneliness present significant challenges for the mental and physical health of older adults. Social distancing, mask wearing, and other precautions necessitated by the COVID-19 pandemic add to these challenges. This article details a telecollaborative service-learning project to engage older adults online and provide applied experiences for students. From March through October 2020, 54 students from Social Work (Master, Bachelor), the College of Osteopathic Medicine (COM; DO), and Occupational Therapy (Master) provided telephone support and Zoom™ based programming for older adults affiliated with the University of New England. Creative offerings were piloted weekly and debriefed on Friday afternoons in the spring, leading to more structured 8-week schedules in summer and fall. Peer-to-peer support took place between older adults with experience in video meetings and those willing to learn. Bidirectional and intergenerational benefits were noted as older adults and students navigated the exigencies of the pandemic and learned important lessons with and from each other to advance knowledge and improve quality of life.

Cross-Generational Understandings of Ageism and Its Perceived Impacts on Personal-Public Health.

In 2016, the World Health Organization (WHO) launched a global campaign to combat ageism, emphasizing its potential harm to personal and public health. This qualitative focus group study explored generational differences in understanding the WHO's definition and impact of ageism among baby boomers (ages 60-72; n = 17) and silent generation members (ages 78-85; n = 10). Verbatim transcripts were analyzed via a grounded theory approach, and representative themes and quotations were extracted by consensus. Members of both age groups initially downplayed personal impacts of ageism in favor of a broader discussion of age-related discrimination on a societal level. As each discussion progressed, however, participants acknowledged economic, social, and health impacts linked with ageism, but primarily for others. Both groups noted ageist actors in places of employment, healthcare settings, restaurants, retirement communities, and within family networks. Interestingly, each group rated risk of harm by ageism as greater for the other group. Our findings highlight challenges associated with the translation of a broad public health campaign to engage specific stakeholder subgroups. We discuss future research, education, and training initiatives across all ages to address the detrimental impacts of ageism.

Impairment for Medication Management in Older Adults: Validity of a Family Report Measure.

Objectives: Medication nonadherence can have significant consequences for the health of older adults. Difficulty managing medications is often a sign of cognitive impairment, and monitoring is an early caregiving task for family members. This study examined a screening tool for independence in medication management.Methods: Reliability and validity of the screening tool were assessed in a sample of 152 female care partners for a relative aged 65+years.Results: The tool showed sound test-retest reliability, convergent and discriminant validity, and test utility, such that medication assistance was not better predicted by a global rating of cognitive impairment.Conclusions: In context of cognitive impairment, detection of medication mismanagement could be improved in both primary care and specialty health encounters through adoption of this single-item screening tool.Clinical Implications: This single-item report can be used to quickly facilitate discussions of medication management and cognitive impairment screening in office visits. The item also shows promise for efficient measurement of impairment in medication management than typical IADL assessment language.

Predictors of Readiness for Mobility Transition in Older Drivers.

We administered the Assessment of Readiness for Mobility Transition (ARMT) to 301 older drivers and compared total scores with participant characteristics. Overall, 18% of participants were not attitudinally ready for mobility transition, while 19% were very ready. Notably, participants with hospitalizations in the past year were either very ready for mobility transition (20% vs 14% without hospitalizations) or not ready at all (30% vs 17%). Significant health events may polarize reactions towards mobility transition. Individualizing communication about driving cessation readiness could help address such differing views. To further consider its effectiveness, ARMT could be utilized in mobility transition counseling interventions.

Dementia spousal caregivers and past transgressions: Measuring and understanding forgiveness experiences.

The transition from "wife" to "caregiver" for a cognitively impaired husband can be an overwhelming experience. Communication patterns change and small conflicts can grow, at times bringing angry feelings and new burdens. Engagement with forgiveness processes may benefit wives by lowering resentment over past tensions, restoring trust, and enhancing the overall caregiving experience. This study examined the utility of the Enright Forgiveness Inventory (EFI) within a sample of caregiving wives. Our intent was to better understand this population's experience with forgiveness when other contextual factors were likely to influence this process. Forgiveness scores on the EFI were positively related to the cognitive status of the care recipient, a particularly important finding for clinical intervention, and inversely related to marital distress and state anxiety.

The instructional impact of the American Medical Association's Older Drivers Project online curriculum.

The Older Drivers Project (ODP) of the American Medical Association has provided evidence-based training for clinicians since 2003. More than 10,000 physicians and other professionals have been trained via an authoritative manual, the Physician's Guide to Assessing & Counseling Older Drivers, and an associated continuing medical education five-module curriculum offered formally by multidisciplinary teams from 12 U.S. States from 2003 to 2008. An hour-long, online version was piloted with medical residents and physicians (N = 259) from six academic and physician office sites from 2010 to 2011. Pre/postsurveys were completed. Most rated the curriculum of high quality and relevant to their practice. A majority (88%) reported learning a new technique or tool, and 89% stated an intention to incorporate new learning into their daily clinical practice. More than one half (62%) reported increased confidence in addressing driving. This transition from in-person to online instruction will allow the ODP to reach many more clinicians, at all levels of training, in the years to come.

Addressing individual differences in mobility transition counseling with older adults.

In the final phase of a 3-phase project, the Assessment of Readiness for Mobility Transition (ARMT) was clinically validated, emphasizing assessment/intervention. ARMT and coping, health/vision status, and social support measures were administered to 133 community-dwelling older adults. Concurrent validity is supported. Higher readiness to cope with mobility transition and self-confidence related to fall risk, higher self-rated health/vision, and fewer maladaptive behaviors, but not social support/adaptive coping, suggesting that those at risk can benefit from person-centered intervention to mobilize strengths for transportation/mobility planning. Older drivers may harbor unrealistic expectations regarding nonfamily mobility support. Implications for practice, education, research, and policy are presented.

Improving physician awareness of Alzheimer disease and enhancing recruitment: the Clinician Partners Program.

BACKGROUND: Primary care providers routinely evaluate older adults and are thus in a position to first detect symptoms and signs of Alzheimer disease. In urban areas, diagnostic or management difficulties may be referred to specialists; however, in rural areas, specialists may not be available. The Clinician Partners Program (CPP) was initiated to enhance rural health providers' ability in the diagnosis of dementia and care, and to increase research recruitment into dementia research studies of participants from rural communities. METHODS: The CPP is a 3-day "miniresidency" of didactic, observational, and skill-based teaching techniques. Participants completed pretests and posttests evaluating dementia knowledge, confidence in providing care, and practice behaviors. RESULTS: Between 2000 and 2009, 146 health care professionals with a mean age of 45.7±10.8 years attended the CPP; 79.2% were white, 58.2% were women, and 58% of participants had been in practice for more than 10 years. Posttests showed an improvement in knowledge and confidence for diagnosis and treatment and increased the use of dementia screening tools. Rural research participation in an urban Alzheimer Disease Research Center increased 52% over the pre-CPP period. CONCLUSIONS: The following primary goals were accomplished: increased knowledge and confidence, changed practice habits, and enhanced research recruitment. Educational programs such as the CPP may be beneficial for increasing access to accurate diagnoses and appropriate treatment for Alzheimer disease while also enhancing research participation.

Decoding the Miss Daisy Syndrome: an examination of subjective responses to mobility change.

The subjective responses associated with personal life space and mobility status were explored. Thirty individuals participated in focus groups based on self-rated disability status, current places visited, and availability. Qualitative analyses revealed that most participants equated personal mobility with driving a vehicle. Attitudes concerning mobility status and preparedness for change varied based on disability level and personal experience. Fear of dependence from future mobility loss was prominent in all groups. Few participants acknowledged significant planning for future retirement from driving or other mobility challenges. An understanding of common attitudes, perceptions and meanings can inform professionals who intervene and support older adults experiencing mobility changes.

The American Medical Association Older Driver Curriculum for health professionals: changes in trainee confidence, attitudes, and practice behavior.

Few gerontology and geriatrics professionals receive training in driver fitness evaluation, state reporting of unfit drivers, or transportation mobility planning yet are often asked to address these concerns in the provision of care to older adults. The American Medical Association (AMA) developed an evidence-based, multi-media Curriculum to promote basic competences. This study evaluated reported changes in practice behaviors 3 months posttraining in 693 professionals trained via the AMA approach. Eight Teaching Teams, designated and trained by AMA staff, offered 22 training sessions across the United States in 2006 to 2007. Trainees (67% female; mean age 46) completed a pretest questionnaire and a posttest administered by mail. Physicians were the largest professional group (32%). Although many trainees acknowledged having conversations with patients about driving at pretest, few endorsed utilizing specific techniques recommended by the AMA prior to this training. The posttest response rate was 34% (n = 235). Significant improvements in reported attitudes, confidence, and practices were found across measured items. In particular, posttest data indicated new adoption of in-office screening techniques, chart documentation of driver safety concerns, and transportation alternative planning strategies. Findings suggest that a well-designed, one-time continuing education intervention can enhance health professional confidence and clinical practice concerning driver fitness evaluation and mobility planning. Targeted dissemination of this Curriculum (in-person and online) will allow more to benefit in the future.

Predictors of physician referral for patient recruitment to Alzheimer disease clinical trials.

BACKGROUND: Inadequate recruitment into Alzheimer disease clinical trials is an important threat to the validity and generalizability of the studies. The majority of dementia patients are first evaluated by community-based physicians; however, physician perceptions of clinical research are largely unknown. METHODS: A survey was distributed to 3123 physicians in 3 states; 370 were returned. Survey items assessed attitudes, perceived benefits of and barriers to referral to clinical research, and physicians use of the internet for medical information. RESULTS: The mean age of the respondents was 50.6+/-10.8 years; 70% were male, 78% white, 61% were primary care providers; 63% used the internet > or =3 times/week. No demographic or medical specialty differences existed between those who were likely (n=193) and unlikely (n=162) to refer patients to clinical trials. Differences were discovered in perceived benefits reported by physicians who were more likely to refer, whereas differences in perceived barriers existed in primary care compared with specialists. Referral to clinical trials is predicted by close proximity to a research center [odds ratio (OR): 4.0; 95% confidence interval (CI), 1.1-15.6] and availability of internet information regarding diagnostic evaluation (OR: 2.3; 95% CI, 1.1-4.7). Primary barriers included concerns about exposure of patients to uncomfortable procedures (OR: 4.7; 95% CI, 1.2-18.7) and lack of time to discuss research participation (OR: 6.8; 95% CI, 1.4-32.3). CONCLUSIONS: Proximity to a research center and availability of diagnostic clinical tools are strong predictors of clinical trial referral. Concern over risks to patients and lack of time are strong barriers. These results suggest that dementia outreach education targeted to physicians should emphasize the importance of clinical trials with a focus on discussing research participation in a time-efficient manner and increasing awareness of risk reduction and the safety of research protocols. Providing easy access to up-to-date, user-friendly educational materials on dementia diagnosis and research via the internet are likely to improve referrals of patients to Alzheimer disease clinical trials from community physicians.

The "portable" CDR: translating the clinical dementia rating interview into a PDA format.

The Clinical Dementia Rating (CDR) is a common rating system used in clinical trials and longitudinal research projects to rate the presence and severity of cognitive problems in Alzheimer disease and related disorders. The interview process requires training and can be time-consuming. Here, we describe the validity, reliability, and discriminative ability of a computer-generated CDR using a personal digital assistant format. This project used clinical data from 138 archival and live evaluations (patient and informant interviews) collected for research purposes at Washington University to develop and test a software-based system for the administration and automatic scoring of the CDR. The system was programmed for use on a hand-held computer via the Palm Operating System. We developed domain-specific algorithms to quantify and translate clinical scoring decisions for the 3 cognitive (Memory, Orientation, Judgment and Problem Solving) and the 3 functional (Community Affairs, Home and Hobbies, Personal Care) domains of the CDR. An acceptable set of algorithms were developed using data from 104 research cases, reflecting a range of impairment levels (CDR 0 to 3) and expert scoring decisions. These algorithms were then tested for accuracy in a validation sample of 34 cases. The computer-generated CDR has excellent internal consistency (Cronbach's alpha ranging from 0.94 to 0.98) and interrater reliability (intraclass correlation coefficient ranging from 0.88 to 0.96). The computer-generated CDR showed excellent discrimination between demented and nondemented cases (Area under the curve=0.95; 95% confidence interval, 0.84-1.1). The computer-generated CDR using a Palm Operating System is easy to use, valid, and reliable. The level of agreement compares favorably to published interrater reliability data for the CDR. Software-based administration and automatic scoring of the CDR is a viable alternative to paper-based methods and may be useful in research and clinical settings, especially where electronic data management and reliability in scoring are critical.

Staff time requirements for postoperative pain management: Comparison of sufentanil sublingual tablet system and intravenous patient-controlled analgesia.

OBJECTIVE: Assessment and allocation of required staff time for postoperative pain management for two different pa-tient-controlled technologies, sufentanil sublingual tablet system (SSTS) and intravenous analgesia (PCiA). DESIGN: Activity-based evaluation. SETTING: The study was conducted at four German hospitals based on the availability of the two technologies studied and their respective bed capacity broadly reflecting the German hospital landscape. PATIENTS AND PARTICIPANTS: Staff activities were recorded for 162 SSTS and 154 PCiA procedures. Every hospital recorded around 40 procedures for each technology between December 2016 and July 2017. INTERVENTIONS: Staff time was recorded if a patient received one of the two considered postoperative pain management technologies and was under treatment of a trained nurse. No further criteria were defined. Documentation of resource utilization covered all staff activities concerning the two technologies by detailed activity recording forms. MAIN OUTCOME MEASURE(S): Staff time for five identified process areas (preparation of therapy option, provisioning at patients' bed, therapy, removal of therapy option, reprocessing, and storage) with significant impact on the entire process. RESULTS: The average staff time required for SSTS to manage the entire process was 36 minutes whereas for PCiA it was 49 minutes (p < 0.0001). In all process areas, SSTS showed significantly less staff time requirements. CONCLUSIONS: In comparison to PCiA, SSTS requires significantly less staff time to manage postoperative pain in the studied setting.

Transportation and Aging: An Updated Research Agenda to Advance Safe Mobility among Older Adults Transitioning From Driving to Non-driving.

Engagement in civic, social, and community life plays an important role in health, well-being, and quality of life, and requires individuals to be mobile in their environment. In this article, we review what is currently known about 2 areas relevant to safe mobility for older drivers and identify future research in these areas. Using a framework for transportation and safe mobility, 2 key areas were selected for review: the process of transitioning to non-driving and the maintenance of mobility after driving has ceased. This article serves as a companion to another article that used the same approach to explore safe mobility issues for older adults who are still driving. We found that although there has been progress in supporting transitioning process to non-driving and improving mobility options for older adults following driving cessation, many knowledge gaps still exist. We identified several research topics that would benefit from continued scientific inquiry. In addition, several themes emerged from the review, including the need for: multidisciplinary, community-wide solutions; large-scale, longitudinal studies; improved education and training for older adults and the variety of stakeholders involved in older adult transportation; and the need for programs and interventions that are flexible and responsive to individual needs and situational differences.

Driving and dementia in older adults: Implementation and evaluation of a continuing education project.

PURPOSE: We aimed to develop and evaluate a multimedia workshop curriculum to educate physicians and other health professionals about (a) driving-related assessment in older adults with dementia, and (b) strategies to encourage driving retirement for impaired individuals. DESIGN AND METHODS: A curriculum developed by the Older Drivers Project of the American Medical Association was expanded for presentation by a multidisciplinary team. One pilot and seven test workshops were offered. A program evaluation method-testing knowledge, confidence, attitudes, and practice behaviors-was employed at four points in time: T1 (Time 1; pretest focusing on the previous 12 months), T2 (Time 2; same-day post-test), T3 (Time 3; post-test at 3 months), and T4 (Time 4; post-test at 12 months). RESULTS: At T1, participants (N = 147) expressed high agreement that an assessment of driving ability is an important issue in clinical dementia care, but they reported low knowledge of assessment strategies, resources, and state reporting requirements. Modest gains in knowledge and confidence were demonstrated at both T3 (n = 93) and T4 (n = 63). In addition, the frequency of driving-related practice behaviors (i.e., incorporation of driving-related questions into clinical evaluation, chart documentation, reporting of impaired drivers) had increased significantly by T3 and T4. IMPLICATIONS: The results indicate that a focused workshop curriculum, with practical and immediate applications to care, can motivate measurable changes in clinical practice. Once they are informed, health professionals can address issues of driving ability in older patients with dementia and, with the support of available resources, encourage impaired individuals to retire from driving for the safety of everyone on the road.

Clinician Effectiveness in Assessing Fitness to Drive of Medically At-Risk Older Adults.

OBJECTIVES: To model the relative contributions of driver data and clinical judgments to clinical ratings of driver capability for a state licensing authority and to compare ratings with on-road test results. DESIGN: Retrospective, logistic regression. SETTING: Missouri Driver License Bureau. PARTICIPANTS: Adults aged 60 and older (N = 652; 52% male) evaluated by a physician of their choosing and a portion subsequently road tested (n = 286). MEASUREMENTS: Clinical data from an evidence-based physician statement (Form 1528). A three-level rating (likely capable, unclear, not capable) was collapsed into two outcomes (0 likely capable; 1 unclear, not capable) as the dependent variable. Independent variables (predictors) were age, sex, driving exposure, recent crash or police action, number of medical conditions, medication side effects, driver insight, and disease functional severity rating for driving. RESULTS: Three variables in the model (Nagelkerke coefficient of determination = 0.64; P < .001) were significant in the expected direction: disease functional severity for driving (odds ratio (OR = 6.65), insight (OR = 2.35), and age (OR = 1.06). Proportionately more drivers rated likely capable (73%) passed the road test than those rated unclear or not capable (62%). CONCLUSION: Judgments of disease severity, decrements in driver insight, and older age influenced clinician ratings of driving capability. Correspondence of physician ratings to on-road test outcomes was imperfect, highlighting the complexities in translation of clinical judgments to on-road performance. Both means of assessment have important and additive roles in driver licensing.