Comorbidity profiles in older patients last seen by mental health prior to suicide attempt.

OBJECTIVES: Suicide in late life is a public health concern. Determining profiles of psychiatric/medical comorbidity in those who attempt while engaged in mental health services may assist with prevention. We identified comorbidity profiles and their association with utilization, means, and fatality in a national sample who attempted suicide. METHODS: Using latent class analysis, all patients aged ≥ 65 from the Department of Veterans Affairs (VA) healthcare services (2012-2018) last seen in mental health prior to suicide attempt were included. Diagnoses and attempt data were obtained from VA and Center for Medicare & Medicaid Services, VA Suicide Prevention Applications Network, and VA National Mortality Data Repository. RESULTS: 2,269 patients were clustered into three profiles, all with high probability of depression. Profiles included minimal comorbidity (50.4%), high medical comorbidity (28.6%), and high (psychiatric/medical) comorbidity (21.0%). Over half (61.7%) attempted suicide within one week of their visit. The class with highest comorbidity had lowest proportion of fatal attempts, while minimal comorbidity class had highest proportion. CONCLUSIONS: Older patients last seen in mental health prior to suicide attempt were characterized by depression and varying additional comorbidity and attempt-related factors. Findings have implications for risk assessment and intervention in mental health settings, beyond depression.

Problem-solving training for Veterans in home based primary care: an evaluation of intervention effectiveness.

BACKGROUND: Veterans enrolled in Veterans Health Administration (VHA) Home Based Primary Care (HBPC), a program providing in-home medical and mental health care by an interdisciplinary care team, often face substantial physical, cognitive, and mental health challenges. This program evaluation examined the impact of a brief problem-solving intervention on depressive symptoms, quality of life, and problem-solving abilities for Veterans enrolled in HBPC. DESIGN: Pre- and post-intervention outcomes for Veterans, and qualitative feedback from Veterans and clinicians regarding program satisfaction. PARTICIPANTS AND SETTING: A total of 230 HBPC patients (mean age in years = 72.1, SD = 11.6) within the U.S. national VHA health care system. INTERVENTION: Six-session, individual Problem-Solving Training (PST-HBPC). METHOD: Licensed psychologists and social workers (n = 115) completed training and administered the treatment with HBPC Veterans between 2014 and 2017. MEASUREMENTS AND RESULTS: From baseline to post-intervention, Veterans completing five or more PST-HBPC sessions (n = 199) reported significant reductions in depressive symptoms on the Patient Health Questionnaire 9-item (PHQ-9), in difficulty functioning due to depressive symptoms (PHQ-9 item 10), and in thoughts of death (PHQ-9 item 9). They also reported more effective problem-solving on the Social Problem-Solving Inventory - Revised: Short form (total score and subscales), and improved quality of life across life domains on the World Health Organization Quality of Life-BREF (WHOQOL-BREF) scale. Both clinicians and Veterans also reported satisfaction with the program. CONCLUSIONS: Preliminary findings support the continued dissemination and implementation of this brief PST intervention for HBPC Veterans, and its potential for use with non-VA home care populations with complex comorbidities.

Mental Health Needs of Aging Veterans: Recent Evidence and Clinical Recommendations.

Objectives: Large numbers of older Americans have a history of military service, which may be positively or negatively associated with mental health in late life. We reviewed literature with the aim of better understanding the mental health needs of older Veterans.Methods: Articles included those published in 2009-2018 and focused on prevalence/risk for mental illness and suicide among older Veterans; utilization of mental health services; effectiveness of evidence-based behavioral treatments; and pertinent care delivery models.Results: Older Veterans are generally resilient. A significant minority experience mental health concerns that are associated with poor outcomes including a substantial number of suicides. Most published research is based on the approximately one third of Veterans who use the Veterans Health Administration (VHA) for care. Older Veterans with mental health diagnoses are less likely to utilize mental health services compared to younger Veterans, but as likely to benefit once engaged. Integrated care models in primary and geriatric care settings are promising.Conclusions: Aging Veterans are a large subset of Americans whose mental health needs are complex and deserve attention.Clinical Implications: Clinicians should ask about history of military service (i.e., Veteran status) and utilize available resources when providing care for older Veterans.

A mixed methods study on the manifestations of behavioural symptoms of dementia among veterans with and without posttraumatic stress disorder.

AIMS: To explore how behavioural symptoms of dementia are manifested among veterans in residential long-term care settings, in the context of personal, interpersonal/social and environmental triggers and how the manifestations differ between veterans with and without posttraumatic stress disorder. DESIGN: Secondary analysis using a mixed methods approach. METHODS: We analysed text data from a stratified random sample of 66 cases derived from the programme evaluation dataset of the Staff Training in Assisted Living Residences-Veterans Health Administration (STAR-VA) intervention from 2013 to 2016, using framework analysis. The detailed behavioural assessment descriptions in this dataset are consistent with contemporary non-pharmacologic symptom management. Qualitative categories were converted to quantitative variables for two group comparisons. RESULTS: Four patterns emerged linking specific types of triggers and behavioural symptoms: (1) unmet physical needs or emotional distress triggers non-aggressive behaviours; (2) unsolicited direct care approach triggers care refusal, resistance or combativeness; (3) interpersonal interactions interfering with self-direction trigger aggressive behaviours; and (4) uncontrolled stimulation from environments trigger non-aggressive behaviours. The organisational culture of care influenced how staff conceptualised behavioural symptoms. Veterans with co-existing posttraumatic stress disorder and dementia tended to exhibit rejection of care with aggression compared to those with dementia alone. CONCLUSION: Contextualised accounts of behavioural symptoms of dementia revealed symptom heterogeneity, with different clusters of multi-level triggers arising from specific personal, interpersonal and environmental circumstances. Distinct patterns of symptom manifestations between veterans with and without posttraumatic stress disorder suggest a tailored approach is required to meet each veteran's unique biopsychosocial needs. IMPACT: Classifying behavioural symptoms with their triggers rather than solely by behaviours provides important new information for developing person-centred, non-pharmacological interventions to improve outcomes for veterans with dementia. Multi-level interventions should be considered to meet veteran's needs that account for their earlier life history and current life circumstances.

Impact of an interdisciplinary intervention for distress behaviors in dementia on psychotropic drug use in Veterans Health Administration Community Living Centers: STAR-VA impact on psychotropic drug utilization.

STAR-VA is an interdisciplinary behavioral approach for managing distress behaviors in residents with dementia, implemented at Veterans Health Administration nursing homes. This study evaluated the impact of STAR-VA implementation on psychotropic drug use. The study design is a retrospective, quasi-experimental cohort analysis of residents enrolled as STAR-VA training cases compared with eligible residents at untrained sites to evaluate treatment effects on psychotropic medication use. We matched 229 STAR-VA cases with 1,163 comparisons. STAR-VA cases experienced an average reduction of 0.92 "as-needed" doses per month (95% confidence interval [CI] -1.82, -0.02) compared with controls. No significant effect on non-STAR-VA cases in trained facilities was detected. STAR-VA programs are an important option for reducing potentially inappropriate psychotropic use.

Partnership to Enhance Resident Outcomes for Community Living Center Residents With Dementia: Description of the Protocol and Preliminary Findings.

The goal of this quality improvement project is to improve care planning around preferences for life-sustaining treatments (LST) and daily care to promote quality of life, autonomy, and safety for U.S. Department of Veterans Affairs (VA) Community Living Center (CLC) (i.e., nursing home) residents with dementia. The care planning process occurs through partnerships between staff and family surrogate decision makers. This process is separate from but supports implementation of the LST Decision Initiative-developed by the VA National Center for Ethics in Health Care-which seeks to increase the number, quality, and documentation of goals of care conversations (GOCC) with Veterans who have life-limiting illnesses. The current authors will engage four to six VA CLCs in the Mid-Atlantic states, provide teams with audit and feedback reports, and establish learning collaboratives to address implementation concerns and support action planning. The expected outcomes are an increase in CLC residents with dementia who have documented GOCC and LST plans. [Journal of Gerontological Nursing, 45(3), 21-30.].

Come, join, lead: Attracting students to careers in aging and promoting involvement in gerontological societies.

Geriatric educators face the challenge of attracting more clinicians, scientists, and educators into geriatrics and gerontology, and promoting involvement in gerontological societies. A survey of psychologists (N = 100) examined factors that attract students in clinical/counseling psychology to practice with older adults, as well as experiences in organizational service. For 58%, interest in aging began at the undergraduate level, but for others interest developed later. About one half cited academic exposure such as mentorship (51%), research (47%), or coursework (45%) as sparking interest, along with family (68%) or work experience (61%). Involvement in professional organizations lags (58%), in part owing to misperceptions about what those activities require. A continued targeted effort at the undergraduate and graduate level is essential to attract students to careers in aging. To preserve vital professional organizations, enhanced outreach may be useful to dispel myths about service and encourage engagement.

Development of a Bereavement Group in a Geriatric Mental Health Clinic for Veterans.

OBJECTIVES: This article describes the development and program evaluation of an 8-session outpatient geriatric mental health clinic bereavement group for United States military veterans who experienced the death of a loved one. METHODS: Group materials were developed based on a review of literature, with a focus on the dual process model of coping with bereavement and complicated grief treatment. Data are presented from 19 veterans who attended at least 4 of the 8 sessions across the five offerings of this group between 2013 and 2015. RESULTS: Self-report measures of complicated grief and depressive symptoms decreased significantly from the first to the final session. Veterans indicated that the group met their treatment goals and that they would recommend it to others. Adaptations made to the group over time based on feedback from members and facilitators are discussed. CONCLUSIONS: Preliminary evidence suggests that the group described in this manuscript is effective for bereaved older, male veterans. Future research would be helpful including larger samples and controlled studies. CLINICAL IMPLICATIONS: Most bereaved individuals do not require formal mental health treatment. However, for individuals with distressing symptoms, time-limited group therapy may be an effective treatment.

Managing Challenging Behaviors of Dementia in Veterans: Identifying and Changing Activators and Consequences Using STAR-VA.

One of the most challenging clinical issues for long-term care staff is the management of dementia-related behavioral symptoms. STAR-VA is an interdisciplinary intervention for managing challenging behaviors of Veterans with dementia in Community Living Centers (CLCs) within the U.S. Department of Veterans Affairs. The goals of the current article are to delineate categories of challenging behaviors found in CLCs, the context in which behaviors occurred, and the interventions used by CLC clinical teams when implementing STAR-VA. In 2013, 17 CLC teams completed STAR-VA training, enrolling 71 Veteran participants. Four independent raters identified common assessment and intervention themes for six behavior categories, coding activators, consequences, goal behaviors, and care plans for each category. Successful care plans included staff changes in communication approaches, incorporation of pleasant events into care, and individualized environmental modifications. Findings illustrate the range of interventions that CLC teams may apply as a result of systematic behavioral assessment informing an understanding of activators and consequences of dementia-related behaviors. [Journal of Gerontological Nursing, 43(2), 33-43.].

A Peer Mentorship Program for Mental Health Professionals in Veterans Health Administration Home-Based Primary Care.

OBJECTIVES: Mental health professionals working in integrated, interdisciplinary primary or geriatric care settings may have limited training for this growing model of care. Peer mentorship is one avenue of professional development support. We describe the development and evaluation of a peer mentorship program for mental health professionals working within Veterans Health Administration (VHA) Home Based Primary Care (HBPC) programs. METHODS: Electronic surveys were administered to 57 peer mentorship pairs matched for program participation. The survey examined program utilization characteristics, nature of peer contact, and benefits and challenges reported by participants. RESULTS: Overall, mentor and mentee respondents (N = 58) cited numerous benefits of engaging in the program. Mentees reported their peer mentorship relationships provided acceptance, support, encouragement and positive role modeling. CONCLUSIONS: Findings suggest peer mentoring can be an important professional resource to offer mental health professionals new to working in integrated, geriatric care settings. CLINICAL IMPLICATIONS: Mental health professionals new to working in geriatric and/or integrated care settings may have limited training to meet specialized needs of patients, families, and interdisciplinary care teams. Peer mentorship following formal academic training may be an important option for professional development, supporting enhanced competence and, ultimately, improved patient care and team functioning.

Valued life abilities among veteran cancer survivors.

BACKGROUND: When patients have multiple chronic illnesses, it is not feasible to provide disease-based care when treatments for one condition adversely affect another. Instead, health-care delivery requires a broader person-centred treatment plan based on collaborative, patient-oriented values and goals. OBJECTIVE: We examined the individual variability, thematic content, and sociodemographic correlates of valued life abilities and activities among multimorbid veterans diagnosed with life-altering cancer. SETTING AND PARTICIPANTS: Participants were 144 veterans in the 'Vet-Cares' study who completed a health-care values and goals scale 12 months after diagnosis of head and neck, gastro-oesophageal, or colorectal cancer. They had mean age of 65 years and one quarter identified as Hispanic and/or African American. DESIGN: At twelve months post-diagnosis, participants rated 16 life abilities/activities in their importance to quality of life on a 10-point Likert scale, during an in-person interview. Scale themes were validated via exploratory factor analysis and examining associations with sociodemographic variables. RESULTS: Participants rated most life abilities/activities as extremely important. Variability in responses was sufficient to identify three underlying values themes in exploratory factor analysis: self-sufficiency, enjoyment/comfort, and connection to family, friends and spirituality. Veterans with a spouse/partner rated self-sufficiency as less important. African American veterans rated connection as more important than did White veterans. CONCLUSIONS: It is feasible yet challenging to ask older, multimorbid patients to rate relative importance of values associated with life abilities/activities. Themes related to self-sufficiency, enjoyment/comfort in daily life and connection are salient and logically consistent with sociodemographic traits. Future studies should explore their role in goal-directed health care.

Improving Management of Behavioral and Psychological Symptoms of Dementia in Acute Care: Evidence and Lessons Learned From Across the Care Spectrum.

As the prevalence of Alzheimer disease and related dementias increases, dementia-related behavioral symptoms present growing threats to care quality and safety of older adults across care settings. Behavioral and psychological symptoms of dementia (BPSD) such as agitation, aggression, and resistance to care occur in nearly all individuals over the course of their illness. In inpatient care settings, if not appropriately treated, BPSD can result in care complications, increased length of stay, dissatisfaction with care, and caregiver stress and injury. Although evidence-based, nonpharmacological approaches to treating BPSD exist, their implementation into acute care has been thwarted by limited nursing staff expertise in behavioral health, and a lack of consistent approaches to integrate behavioral health expertise into medically focused inpatient care settings. This article describes the core components of one evidence-based approach to integrating behavioral health expertise into dementia care. This approach, called STAR-VA, was implemented in Veterans' Health Administration community living centers (nursing homes). It has demonstrated effectiveness in reducing the severity and frequency of BPSD, while improving staff knowledge and skills in caring for people with dementia. The potential for adapting this approach in acute care settings is discussed, along with key lessons learned regarding opportunities for nursing leadership to ensure consistent implementation and sustainability.

Training for Research and Teaching in Geropsychology: Preparing the Next Generation of Scholars and Educators.

For geropsychology to flourish in the years ahead, we need scientists to advance knowledge and teachers to draw new professionals into the field. In this project the authors surveyed 100 geropsychologists who completed a doctoral degree in clinical or counseling psychology about their experience with training for research and teaching. The majority were currently conducting some degree of research (38%) and some form of teaching (45%). The majority of ratings for components of research training were in the "very good to excellent" range, whereas elements of teacher training were rated in the "poor to good" range, though there was variability among persons and components. Qualitative comments revealed enthusiasm for research and teaching roles and a need to enhance our training of geropsychologists as educators. The authors provide several suggestions that could enhance research and teacher training for current and future students of professional geropsychology.

Neuropsychological performance within-person variability is associated with reduced treatment consent capacity.

OBJECTIVE: The capacity of older adults to make healthcare decisions is often impaired in dementia and has been linked to performance on specific neuropsychological tasks. Within-person across-test neuropsychological performance variability has been shown to predict future dementia. This study examined the relationship of within-person across-test neuropsychological performance variability to a current construct of treatment decision (consent) capacity. METHODS: Participants completed a neuropsychological test battery and a standardized capacity assessment. Standard scores were used to compute mean neuropsychological performance and within-person across-test variability. Assessments were performed in the participant's preferred location (e.g., outpatient clinic office, senior center, or home). Participants were recruited from the community with fliers and advertisements and consisted of men (N = 79) and women (N = 80) with (N = 83) or without (N = 76) significant cognitive impairment. Participants completed the MacArthur Competence Assessment Tool-Treatment and 11 neuropsychological tests commonly used in the cognitive assessment of older individuals. RESULTS: Neuropsychological performance and within-person variability were independently associated with continuous and dichotomous measures of capacity, and within-person neuropsychological variability was significantly associated with within-person decisional ability variability. Prevalence of incapacity was greater than expected in participants with and without significant cognitive impairment when decisional abilities were considered separately. CONCLUSION: These findings are consistent with an emerging construct of consent capacity in which discrete decisional abilities are differentially associated with cognitive processes and indicate that the sensitivity and accuracy of consent capacity assessments can be improved by evaluating decisional abilities separately.

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

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

Supporting Sustained STAR-VA Implementation: Evaluation of a Sustainment Coaching Program.

OBJECTIVES: The Veterans Health Administration (VA) STAR-VA program is a person-centered, interdisciplinary intervention for managing distress behaviors in dementia in VA nursing homes, called Community Living Centers (CLCs). Teams often struggle to sustain STAR-VA after site-lead partner turnover. The STAR-VA Sustainment Coaching Program was developed to support a new local STAR-VA behavioral coordinator and/or nurse champion (ie, site-leads) and engage the team to implement sustainment strategies. The aims of this evaluation were to document sustainment needs, barriers and facilitators, and effective strategies used during a sustainment intervention. DESIGN: We describe qualitative and quantitative findings of a program evaluation of the STAR-VA Sustainment Coaching pilot program. SETTING AND PARTICIPANTS: Eight CLC teams participated in the pilot program, 5 training a new nurse champion, 2 a new behavioral coordinator, and 1 both new site-leads. METHODS: CLC teams completed a needs assessment, developed sustainment goals and plans, tracked sustainment interventions implemented, and reported case outcomes. Outcome assessment and tracking reports were summarized and themes identified using a qualitative inductive approach. RESULTS: Common sustainment needs were to train a new nurse champion, promote staff understanding of dementia and distress behaviors, and promote a culture of person-centered dementia care. Most sites selected sustainment goals of implementing training procedures and behavioral rounds. Sustainment barriers included limited staff time, staff turnover, lack of supportive routines and tools, and limited awareness of STAR-VA. Facilitators included leadership support, staff interest, and training resources. Most sites reported successful implementation of STAR-VA behavior rounds, whereas strategies to achieve training-related goals had variable success. CONCLUSIONS AND IMPLICATIONS: The STAR-VA Sustainment Coaching Program helped CLC teams identify and implement strategies to support sustained STAR-VA implementation. The results of this project are informing ongoing efforts to integrate STAR-VA components into usual care processes for CLC residents with dementia.

Home-based primary care-mental health integration in the Veterans Health Administration: An updated evaluation of practice patterns.

Starting in 2008, the U.S. Veterans Health Administration required the integration of mental health providers (MH providers) in Home-Based Primary Care (HBPC) programs to promote access to and quality of mental health services for veterans enrolled in HBPC. Surveys were administered in both 2010 and 2019 to HBPC program directors and MH providers to evaluate the status of mental health practice in HBPC programs and inform the continued development of program resources. Findings reported here summarize responses to the 2019 survey and highlight changes compared to 2010 in key areas (e.g., mental health staffing and workload, services provided, training needs, and integration with and impact on the HBPC team). In 2019, approximately half of invited HBPC program directors (n = 66) and MH providers (n = 136) completed the voluntary, anonymous, and confidential surveys. Descriptive and bivariate analyses of quantitative data, and thematic analyses of open-text responses, were conducted. Comparisons of survey responses were made between the 2019 surveys and those collected in 2010 from MH providers (n = 132) and program directors (n = 112), and indicated similar patterns of variability in program staffing and practices across sites, with ongoing behavioral/mental health education and training needs reported for both MH providers and teams. The perceived degree and value of mental health integration in HBPC also remained high. Survey responses suggest integration of mental health services into HBPC continues to be feasible and improves access to key services. Findings may inform the expansion of home-based mental health services for meeting the needs of an aging population. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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

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

Impact of STAR-VA on Staff Injury and Disruptive Behavior Reports in VA Nursing Homes.

OBJECTIVES: Workplace disruptive behavior incidents can be costly for organizations, employees, and customers. Persons with dementia living in long-term care settings have a high risk of exhibiting distressed behaviors. We examined whether a resident-centered, behavioral intervention for residents with dementia led to a reduction in reported workplace disruptive behaviors and staff injury rate due to assault. Impactful interventions are important for quality of care. DESIGN: We examined whether a team-based behavioral program in community living centers (CLCs), where a nurse champion and behavioral coordinator were trained to work with the clinical team to understand and manage distressed behaviors commonly associated with dementia, was associated with reductions in behavior incidents. SETTING AND PARTICIPANTS: The setting was Veterans Health Administration CLCs. The sample consisted of 120 aggregated CLCs operating between 2012 and 2017 with 62 completing training. CLCs were distributed across the United States. METHODS: Outcomes included CLC-level rates of staff injury and number of workplace disruptive behavior incidents. Outcomes were regressed on measures of intervention completion, time since intervention, and several CLC characteristics. RESULTS: The intervention was significantly associated with lower incidence of assault with staff injury rates overall, particularly following the first year of training, but not with other reported workplace disruptive behavior incident rates. CONCLUSIONS AND IMPLICATIONS: A team-based behavioral intervention was associated with reduction of employee assaults, a critical repercussion of distressed behavior in dementia. Given rapid growth in patients with dementia in nursing homes, effective treatment practices, such as interdisciplinary behavioral management approaches may be impactful and valuable to implement.

Rejection of Care and Aggression among Older Veterans with Dementia: The Influence of Background Factors and Interpersonal Triggers.

OBJECTIVES: To test relationships among background factors, interpersonal triggers, rejection of care, and aggression among veterans living with dementia in residential long-term care settings, based on the need-driven dementia-compromised behavior model. DESIGN: A mixed methods secondary analysis of program evaluation data from the Staff Training in Assisted Living Residences-Veterans Health Administration intervention implemented by the US Department of Veterans Affairs healthcare system. SETTING AND PARTICIPANTS: In total, 315 older veterans who participated in the 2013‒2016 Staff Training in Assisted Living Residences-Veterans Health Administration program at 76 Community Living Centers (Veterans Affairs-operated nursing homes). METHODS: Text data that captured the interdisciplinary team observations of distressed behaviors of concern and their circumstances were coded into categorical variables and then combined with existing quantitative data to test hypothesized relationships using structural equation modeling. RESULTS: Rejection of care was directly affected by interpersonal triggers (ß = 0.32, P < .005) and background factors such as depression (ß = 0.29, P < .018), anxiety (ß = -0.18, P < .023), and cognitive status (ß = 0.10, P < .049). Depression also had an indirect effect on rejection of care through interpersonal triggers (α × ß = 0.13 × 0.32 = 0.04, P < .012). Aggression was directly affected by both interpersonal triggers (ß = 0.19, P < .009) and functional status (ß = 0.17, P < .011). Both function (α × ß = 0.12 × 0.19 = 0.02, P < .035) and depression (α × ß = 0.13 × 0.19 = 0.03, P < .005) had indirect effects on aggression through interpersonal triggers. CONCLUSIONS AND IMPLICATIONS: Interpersonal triggers influenced rejection of care and aggression in veterans with dementia. Background factors such as depression and severity of functional impairment increased the likelihood of these symptoms. Study findings emphasize the importance of developing and implementing interventions that improve interpersonal relationships and developing targeted interventions for those with depressive symptoms.