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.

Racial differences in the quality of care interactions among nursing home residents with dementia.

OBJECTIVE: The resident population in nursing homes is increasingly racially diverse. The purpose of this study was to assess racial differences in the quality of care interactions among nursing home residents with dementia. DESIGN: The study utilized baseline data from the Testing the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD), a randomized controlled pragmatic trial. The Quality of Interaction Scale (QuIS) was used to measure quality of staff-resident care interactions. The sample included 531 residents. An analysis of covariance was conducted to address the aim. RESULTS: The majority of interactions were positive social (42%) or positive care (37%). Black residents living with dementia had higher QuIS scores (M = 5.98, SD = 1.66) than White residents with dementia (M = 5.40, SD = 1.75), whereas higher QuIS scores indicating more positive interactions. However, the results of the analysis of covariance indicated that there was not a significant difference in QuIS scores between Black versus White residents living with dementia (p =.203). CONCLUSION: The findings suggest that care interactions in nursing homes are consistent between Black residents and White residents. Future research should evaluate the impact of staff race on the quality of care interaction among nursing home residents.

Examining pain, function, behavioral symptoms and associations with engagement in meaningful activity for residents with dementia in assisted living.

OBJECTIVES: The purpose of this study was to examine factors associated with engagement in meaningful activity among residents with dementia in assisted living. We hypothesized that greater functional independence, less pain, and lower behavioral and psychological symptom severity would be associated with higher engagement in meaningful activity after controlling for residents' age, gender, comorbidities, and cognition. Understanding factors associated with engagement in meaningful activity can help to inform strategies for optimizing engagement among residents with dementia in assisted living. METHOD: This descriptive study used baseline data from a randomized controlled trial, Meaningful Activity for Managing Behavioral Symptoms of Distress (MAC-4-BSD). Linear regression was used to examine factors associated with engagement in meaningful activity. RESULTS: A total of 71 residents from 5 assisted living settings were included in the sample. Most participants were female (n = 52, 73%), White (n = 62, 87%), and mean age was 85 years old (SD = 8.2). Controlling for age, gender, comorbidities, and cognition, pain was significantly associated with engagement in meaningful activity (b= -2.09, p < 0.05). There were no associations found between function and behavioral symptoms with engagement in meaningful activity. CONCLUSION: Findings from this study show that pain is a significant factor that is negatively associated with residents' engagement in meaningful activity. Ongoing research is needed to help improve pain management for residents with dementia in assisted living and support their engagement in meaningful activity.

Differential Gene Expression in Pain-Related Genes are not Affected by the Presence of Dementia.

BACKGROUND: Prior work has demonstrated differences in the transcriptome between those with and without chronic musculoskeletal pain. AIMS: The aim of this study was to explore whether pain-related gene expression is similar between individuals with and without dementia. DESIGN: This was a descriptive study using a one-time assessment. SETTINGS: PARTICIPANTS/SUBJECTS: A total of 20 older adults living in a continuing care retirement community, 50% of whom had dementia were inlcuded in this study. All were female and the mean age of participants was 89 (SD = 6). METHODS: Pain was evaluated based on the PROMIS Pain Intensity Short Form 3a. Whole blood was collected by venipuncture into Tempus vacutainer tubes (3 ml) and the RNA was extracted at the Translational Genomics Laboratory at the University of Maryland Baltimore. Analyses included a differential expression analysis, a weighted gene co-expression network analysis, and a pathway enrichment analysis. RESULTS: Eighty-three genes were differentially expressed between individuals with and without pain (p <.05). After normalizing gene counts and removing the low expressed genes, 18,028 genes were left in the final analysis. There was no clustering of the samples related to study variables of pain or dementia. CONCLUSION: The findings from this study provided some preliminary support that pain-related gene expression is similar between individuals with and without dementia.

Testing the feasibility and preliminary efficacy of Meaningful Activity for Managing Behavioral Symptoms of Distress (MAC-4-BSD) intervention for residents with dementia in assisted living: Protocol description.

The purpose of this manuscript is to describe the protocol for an Alzheimer's Association-funded cluster randomized trial that focuses on engaging assisted living residents with dementia in meaningful activity to help address their behavioral symptoms of distress using a theoretically based approach, Meaningful Activity for Managing Behavioral Symptoms of Distress (MAC-4-BSD). The development of MAC-4-BSD was based on the Social Ecological Model and Social Cognitive Theory. The MAC-4-BSD intervention includes the following four steps: (1) Assessment of the assisted living physical environment and policies to facilitate meaningful activity; (2) Education of staff about implementation of meaningful activity; (3) Assessment of resident preferences and goals for meaningful activity; (4) Mentoring and motivating staff and residents to facilitate engagement in meaningful activity. The overall aim of this study will be to determine the feasibility and preliminary efficacy of implementing the MAC-4-BSD intervention and test whether it will improve residents' engagement in meaningful activity, behavioral symptoms of distress, and quality of life as well as the environment and policies to promote meaningful activity in assisted living.

"I'll fill in the gaps": perspectives of HHAs on promoting aging in place for older adults with low incomes.

Older adults with low incomes experience disproportionate rates of cognitive and functional impairment and an elevated risk of nursing home admission. Home health aides (HHAs) may have insight into how to optimize aging in place for this population, yet little is known about HHAs' perspectives on this topic. We conducted 6 focus groups with 21 English-speaking and 10 Spanish-speaking HHAs in Pennsylvania and New Jersey. Transcripts were analyzed using qualitative thematic analysis, and three themes emerged. First, HHAs described the uniqueness of their role within multidisciplinary care teams. Second, HHAs shared concrete interventions they employ to help their clients improve their function at home. Third, HHAs discussed barriers they face when helping clients age in place. Our findings suggest that HHAs have important insights into improving aging in place for older adults with low incomes and that their perspectives should be incorporated into care planning and intervention delivery.

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.

Build It and They Will Come: Interdisciplinary Wellness Clinics in Low-Income Senior Housing.

PURPOSE: The purpose of this study was to describe the first 4 months of implementation of the University of Maryland Interdisciplinary Wellness Clinic (UM-IWC). The UM-IWC provided health care services that are difficult for older adults in low-income senior housing communities to access. DESIGN: This was a descriptive study including four low-income communities. METHODS: Measures included health information, participation, and services provided. FINDINGS: A total of 165 residents were seen (44%). The residents were mostly female (80%), Black (63%), and non-Hispanic (83%), with an average age of 77 years. We provided 253 patient visits with 98 residents seen once, 38 twice, 19 three times, and 10 four times. Visits included 165 intake assessments, 61 immunizations, 193 blood pressure checks, 28 foot care treatments, 12 cerumen removals, 12 completions of advance directives, 14 Annual Wellness Visits, and 3 home visits for acute medical problems. CONCLUSIONS: There was strong engagement of the residents, and we were able to provide a large number of services that were not easily accessible to these individuals. Future work will focus on increasing and maintaining the engagement of residents and sustainability of the clinics.

Pilot testing implementation of the pain management clinical practice guideline in nursing homes.

Pain is a common symptom for older adults living with dementia in nursing homes. Unfortunately, there are many challenges to pain assessment, diagnosis and management for these individuals. The purpose of this study was to pilot test the implementation of the newly published Pain Management Clinical Practice Guideline from AMDA: The Society of Post Acute and Long-Term Care using our theoretically based Pain-CPG-EIT approach. Implementation was provided by a research nurse facilitator and included four components: Component I: Establishing and working with a stakeholder team monthly; Component II: Education of the staff; Component III: Mentoring and motivating the staff; and Component IV: Ongoing monitoring of pain assessment, diagnosis and management for residents. Findings provide some preliminary support for the feasibility and effectiveness of our implementation approach.

The relationship between perceived engagement in meaningful activity and behavioral and psychological symptoms of dementia among assisted living residents.

The purpose of this study is to assess the relationship between engagement in meaningful activities and behavioral and psychological symptoms of dementia (BPSD), including agitation, apathy, irritability, and depression among 71 assisted living (AL) residents with moderate to severe dementia. This secondary analysis used baseline data from a randomized controlled trial, Meaningful Activity for Managing Behavioral Symptoms of Distress (MAC-4-BSD) in five AL communities. The Engagement in Meaningful Activities Scale and the Neuropsychiatric Inventory Questionnaire were completed. Logistic regression was used to compare those with and without each BPSD symptom of interest on engagement in meaningful activities while controlling for age, sex, and cognitive impairment. On average, participants were 85 years old, white, females. Perceived engagement in meaningful activities was significantly associated with decreased odds of having agitation (OR=0.94, 95 % CI [.88-0.99]) but not with apathy, depression, or irritability. Engagement in meaningful activities may help reduce agitation among AL residents.

Feasibility of aging in place clinics in low income senior housing.

The purpose of this study was to describe the feasibility of implementing interdisciplinary senior housing clinics. Feasibility was based on evidence of resident participation, services provided, improvement in clinical outcomes and sustaining clinics over time. Data were collected prospectively in four senior housing communities which included approximately 375 residents 60 years of age and older. Over the 12-month implementation period, 228 residents were seen, 61 % of all residents. We gave 131 immunizations, checked 576 blood pressures, completed 92 foot care treatments, 69 hearing evaluations and cerumen removal, completed 16 advance directives, 119 Annual Wellness Visits, and 13 assessments for acute medical problems. Overall, 87 individuals (38 %) had a decrease in their blood pressures, 121 (54 %) maintained their pressures and 19 (8 %) had increases in blood pressures. We reached over half of the residents living in these communities and estimated we could financially maintain the clinics with reimbursement based on billing.

Discovering "What Matters" to patients: A quality improvement project.

PURPOSE: Age-Friendly Health Systems were developed to provide an evidenced based framework to provide high-quality care to older adults. The purpose of this quality improvement initiative was to increase the completion of the "What Matters" section of the "Get to Know Me" boards. METHODS: Face-to-face training was provided to staff via individual sessions on "What Matters" to patients and how to complete the boards. Re-education continued weekly over a 15 week period. Board Completion rates were collected weekly. RESULTS: 60 nurses participated in this project. The "What Matters" completion rates increased from 27 % to 59 % over the intervention period on the SACU and 16 % to 32 % on the SIMC . CONCLUSIONS: The "Get to Know Me Boards" are a visible way to describe "What Matters" to patients. Education helped to increase the completion rate of the boards allowing for "What Matters" to be accessible to members of the healthcare team.

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.

Examining the association of physical activity and mortality among recently hospitalized older adults with dementia.

INTRODUCTION: This study aimed to examine the association between physical activity one month post discharge and mortality over the first-year post discharge among recently hospitalized older adults with dementia. METHODS: For this descriptive sub-study, among 42 participants, we obtained physical activity data via accelerometry at one month post discharge and death status via phone call at 6 months and 1 year post discharge. We performed logistic regression. RESULTS: We found that participants' amount of time spent in physical activity one month post hospital discharge was not statistically significantly associated with mortality within the first-year post hospital discharge (OR=.996, CI=.992,1.000; p=.053). However, we did observe a strong trend. CONCLUSIONS: Given the small sample of participants, this trend is salient and should be examined in a larger sample. The results highlight a specific patient profile, recently hospitalized older adults with dementia, that would greatly benefit from physical activity interventions.

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.

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.

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.