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.

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.

Use of a Humanoid Robot in Supporting Dementia Care: A Qualitative Analysis.

Introduction: Cognitive impairment significantly affects independence in persons with dementia, and consistent supervision is often needed. While interest has arisen in using humanoid robots, such as Pepper, to assist with daily caregiving activities, little is known about the perceptions of using Pepper to assist people with dementia. Objective: This study aimed to explore the perceptions of nonhealthcare workers, care partners, and healthcare workers on the use of a Pepper robot in dementia care. Methods: This was a secondary qualitative analysis. Data were collected from a pilot study conducted from November 2020 to March 2021 using an online survey. The survey consisted of quantitative and qualitative questions; this study only focused on the qualitative responses. The detailed procedures and the quantitative results were published elsewhere. Participants included nonhealthcare workers, care partners, and healthcare workers. Results: A total of 194 participants responded to the open-ended question. Participants described potential benefits of Pepper including assisting with daily activities, monitoring safety and medication use, initiating reminders, and promoting activities and social interactions. Participants had concerns about privacy, cost, poor acceptance/trust, Pepper making mistakes, limitations in environmental navigation and responding to emergencies, misuse of Pepper, and Pepper replacing humans. Participants suggested that Pepper should be tailored to each individual's background, preferences, and functions and recommended improving the logistics of using Pepper, offering more emotional support and responses, and using a more natural appearance and voice. Conclusion: Pepper may support dementia care; yet some concerns need to be addressed. Future research should consider incorporating these comments when designing robots for dementia care.

A Systematic Review of Barriers and Facilitators of Pain Management in Persons with Dementia.

Approximately 50% of persons living with dementia experience pain, yet it is frequently undetected and inadequately managed resulting in adverse consequences. This review aims to synthesize evidence on the barriers and facilitators of pain management in persons living with dementia. PubMed, CINAHL, PsycINFO, and Web of Science datasets were used for article searching. Inclusion criteria were peer-reviewed original articles written in English that examined the barriers and facilitators of pain management for persons living with dementia. The Mixed Methods Appraisal Tool was used to evaluate the quality of the studies. A total of 26 studies were selected, including 18 qualitative and 3 quantitative (all high quality), as well as 5 mixed methods studies (low-to-high quality). Results were categorized into intrapersonal, interpersonal, environmental, and policy categories. Factors that impact pain management in dementia include cognitive and functional impairment, healthcare workers' knowledge, collaboration and communication, healthcare workers' understanding of patients' baseline behaviors, observation of behaviors, pain assessment tool use, pain management consistency, staffing level, pain guideline/policy, and training. Overall, pain management is challenging in persons living with dementia. The results indicate that there is a need for multi-component interventions that involves multidisciplinary teams to improve pain management in persons living with dementia at the intrapersonal, interpersonal, environmental, and policy levels. PERSPECTIVE: This review systematically synthesized barriers and facilitators of providing pain management in persons living with dementia. Results were presented in intrapersonal, interpersonal, environmental, and policy categories and suggests that multicomponent interventions involving multidisciplinary teams are needed to systematically improve pain management in persons living with dementia.

Delirium superimposed on dementia in post-acute care: Nurse documentation of symptoms and interventions.

Delirium superimposed on dementia (DSD) is common in older adults being discharged to post-acute care settings (PAC). Nurse documentation remains poorly understood. Aims were to describe nurse documentation and to determine associations in a secondary data analysis of a large, single-blinded randomized controlled trial (Recreational Stimulation For Elders As A Vehicle To Resolve DSD (Reserve For DSD). Just under 75% of the sample had at least one symptom of delirium documented by the nursing staff, while 25.9% had none despite being CAM positive by expert adjudication. Only 32% had an intervention documented. Number of documented interventions were significantly associated with number of documented symptoms. There is a need for research and innovation related to nurse documentation and communication of DSD symptoms and interventions in an efficient and accurate manner to impact care for vulnerable older adults in these settings.

Collaborating toward equity in Pennsylvania: The Age-Friendly Care, PA project.

OBJECTIVE: To collaboratively implement the age-friendly health systems framework, known as the 4Ms: What Matters, Medication, Mentation, and Mobility, at The Primary Health Network (PHN), a federally qualified health center. DATA SOURCES: Data were collected from PHN electronic medical records (EMRs) for individuals over age 65 from December 30, 2019 to December 24, 2021 and from Project ECHO© attendance and evaluation surveys. STUDY DESIGN: The telementoring educational program, Project ECHO©, was used to engage PHN health care professionals working in rural areas of Pennsylvania to incorporate the 4Ms into their practice starting with the annual wellness visit (AWV). Project ECHO© was launched at three primary care sites. After 18 months, it was then disseminated to an additional 18 sites creating pilot and comparison groups. Outcomes included codesigned patient process metrics using EMR data and project ECHO© participant data. DATA COLLECTION METHODS: EMR data were generated by system reports created by PHN's quality assurance program manager. Project ECHO© data were collected and managed using REDCap electronic data capture tools. Outcomes were aggregated, analyzed for trends over time, and compared between groups. PRINCIPAL FINDINGS: All nine process outcomes increased from baseline to follow-up at the three initial sites, ranging from 4% to 43% g. At year two, the three initial sites had higher rates on AWVs (pilot 24%, comparison 12%; p < 0.0001), Advance Care Planning (New on file, pilot 8%, comparison 2%; Discussed with patient, pilot 18%, comparison 13%; Patient declined, pilot 0%, comparison 0%; p = 0.0001), Dementia Screening (pilot 24%, comparison 12%; p < 0.0001), Fall Risk Management (pilot 43%, comparison 10%; p < 0.0001), and Mobility Goal (pilot 19%, comparison 9%; p < 0.0001); and lower rates on High-Risk Medication Elimination (pilot 54%, comparison, 63%, p < 0.02). CONCLUSIONS: Access to high-quality geriatric care for rural older adults can be improved by increasing health care professionals' knowledge of the 4Ms, beginning with its incorporation into the AWV.

Prevalence and health outcomes in community-dwelling older adults with comorbid cancer and dementia: a longitudinal analysis.

OBJECTIVES: To examine health outcomes in community-dwelling older adults with: dementia only, cancer only, and comorbid cancer and dementia. METHODS: Longitudinal analysis was conducted using data from 2010 to 2016 waves of the Health and Retirement Study. Health outcomes included mortality, limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL), nursing home utilization, hospital stay, homecare use, self-rated health, and out-of-pocket medical expenditure. Panel regression was used for statistical analysis. RESULTS: The prevalence of comorbid cancer and dementia ranged from 2.56% to 2.97%. Individuals with comorbid cancer and dementia demonstrated a higher likelihood of nursing home utilization and poorer self-rated health but a lower likelihood of hospital stay, homecare use, and out-of-pocket expenditures, compared to the cancer only or dementia only groups. The differences in mortality and ADL and IADL limitations were not statistically significant. CONCLUSION: Comorbid cancer and dementia predicted longer nursing home utilization and poorer self-rated health. The results help guide care planning for individuals with comorbid cancer and dementia.

Effect of Ambient Bright Light on Behavioral and Psychological Symptoms in People With Dementia: A Systematic Review.

Background and Objectives: Behavioral and psychological symptoms of dementia (BPSD) commonly occur in persons living with dementia. Bright light (BL) interventions have shown some positive impact on BPSD. Ambient lighting is a more efficient approach to delivering BL with better compliance and less staff workload than individual-based lighting interventions. Yet, its effect has not been systematically reviewed. This review synthesized research evidence on the effect of ambient BL on BPSD. Research Design and Methods: This review searched literature from PubMed (Medline), CINAHL, Scopus, Web of Science, and Cochrane in February 2021. Original research testing the effect of ambient BL on BPSD in persons with dementia was included. Two reviewers independently screened, extracted data, and assessed the quality of each article. Results: Nine studies were reviewed with 1 randomized controlled trial and 8 quasi-experimental studies. The sample size ranged from 14 to 89 participants across care settings. While not all studies showed positive results, evidence from multiple studies revealed the positive effect of ambient BL on depressive symptoms and agitation in persons with dementia. The ambient BL that showed a positive effect targeted at approximately 350-750 lux, 4,500-9,325 K, and/or circadian stimulus = 0.375-0.4 for 10-12 hr a day for 4 weeks or longer. Evidence on other BPSD was mixed or too limited to draw conclusions. Discussion and Implications: A preponderance of evidence suggests that, when properly designed and implemented, ambient BL shows promise in reducing depressive symptoms and agitation. Future research, using more rigorous designs, is needed to further test the effect of ambient BL on BPSD with attention to lighting parameters, measurement approaches, and intervention fidelity.

Non-pharmacological interventions for pain in people with dementia: A systematic review.

CONTEXT: Pain commonly occurs in people living with dementia but is often undertreated. Non-pharmacological interventions are a safer first-line option for pain management, but evidence-based interventions for people living with dementia have not been established. An increasing number of studies have examined the effect of non-pharmacological interventions in pain management. However, the evidence that specifically focuses on people living with dementia has not been systematically reviewed. OBJECTIVES: This review aimed to systematically synthesize current evidence on non-pharmacological interventions to manage pain in people living with dementia. METHODS: A comprehensive search of the literature was conducted in PubMed, CINAHL, Scopus, and Web of Science databases. Studies were included if they were 1) peer-reviewed original quantitative research, 2) tested the effect of non-pharmacological interventions on pain in people with dementia, and 3) English language. Studies were excluded if they 1) included both pharmacological and non-pharmacological interventions and did not report separate results for the non-pharmacological interventions; 2) enrolled participants with and without dementia and did not have separate results reported for individuals with dementia; 3) tested dietary supplements as the intervention; and 4) were not original research, such as reviews, editorials, commentaries, or case studies. Title, abstract, and full text were screened. Quality assessment was conducted using the Cochrane Risk of Bias tool and Johns Hopkins Level of Evidence. Pain assessment tools, participant characteristics, study designs, intervention condition, and results were extracted. Results were synthesized through grouping the type of the interventions and weighting evidence based on quality and design of the studies. RESULTS: A total of 11 articles and 12 interventions were identified. A total of 486 participants were included. Interventions that have shown a positive impact on pain include ear acupressure, music therapy, reflexology, tailored pain intervention, painting and singing, personal assistive robot, cognitive-behavioral therapy, play activity, and person-centered environment program. Nevertheless, a majority of the interventions were only evaluated once. Moreover, most studies had similar sample characteristics and setting. CONCLUSION: Overall, the quality of included studies were mostly low to mixed quality and most participants only had mild to moderate baseline pain, which limits detection of the intervention's effect. Hence, these findings need to be duplicated in studies with a greater sample size, a more diverse population (race, gender, and settings), and a more rigorous design to validate the results.

The Implementation of the Sexual Assault Forensic Examination Telehealth Center: A Program Evaluation.

INTRODUCTION: Substantial disparities in the quality of post-sexual-assault (SA) care exist in the United States, particularly in rural areas. This study evaluates the implementation of the Sexual Assault Forensic Examination Telehealth Center, a program to improve SA care by increasing access to experienced sexual assault nurse examiners via telehealth, in three rural hospitals. MATERIALS AND METHODS: The Dynamic Sustainability Framework (DSF) guided the implementation of the intervention. Survey and implementation data were evaluated 1 year after implementation using a nonexperimental pre-post design. Outcomes include patient and nurse perceptions of telehealth, local site nurse (LSN) confidence, and hospital protocol/policy changes. RESULTS: Forty-one telehealth consultations were completed in the program's first year. An average of 34 system-level protocol changes were made per site. LSNs demonstrated statistically significant increases in confidence to provide SA care at 1 year. LSNs and telehealth sexual assault nurse examiners (expert consultants) reported that quality of SA care improved (87% and 83%, respectively). Patients highly rated the care they received (83%), reported telehealth improved care (78%), and reported feeling better after the examination (74%). DISCUSSION: Using the DSF for implementation supported a tailored approach and successful adoption and also allowed for program iteration based on lessons learned. CONCLUSIONS: The Sexual Assault Forensic Examination Telehealth model resulted in improved local nurse confidence in provision of SA care, nurse perception of improvement in care quality, and high patient care experience ratings. These findings and the use of the DSF have implications for SA specialty care implementation in rural communities.

Chronic conditions and depressive symptoms in older adults: the mediating role of functional limitations.

BACKGROUND: Depressive symptoms, chronic conditions, and functional limitations are common in older adults. Several studies have examined the relationship between chronic conditions or functional limitations and depressive symptoms separately. However, little is known about how much of the effect of chronic conditions on depressive symptoms is due to the functional limitations resulting from such conditions. METHODS: This paper examined the longitudinal association of chronic conditions and functional limitations with depressive symptoms in older adults aged 65 and over in the USA using the data from the 2012 wave and 2014 wave of the Health and Retirement Study (HRS). Mediation analysis was used to examine the mediation effects of 2012 functional limitations on the relationship between 2012 chronic conditions and 2014 depressive symptoms controlling for other measures including gender, age, race, education, marital status, and BMI. RESULTS: Results revealed that chronic conditions and functional limitations were significantly associated with depressive symptoms. There was a 13.7% mediation effect when 2012 functional limitations were added as a mediator on the relationship between 2012 chronic conditions and 2014 depressive symptoms. CONCLUSION: Functional limitations mediate the relationship between chronic conditions and depressive symptoms. Preventing or managing functional limitations may help reduce depressive symptoms in older adults with chronic conditions.

Prevalence and predictors of depressive symptoms in older adults with cancer.

INTRODUCTION: Older adults with cancer are at risk of developing depressive symptoms. However, little is known about the prevalence and predictors of depressive symptoms in older adults with cancer. MATERIALS AND METHODS: This study examined the prevalence and predictors of depressive symptoms among older adults with cancer in the United States using the data from the 2012 and 2014 wave of the Health and Retirement Study. This analysis included 1799 older adults aged 65 and over with a self-reported diagnosis of cancer. Multivariate regression analysis was used to examine the predictors of depressive symptoms. The main predictors included age, gender, race, education, marital status, chronic conditions, and functional limitations. RESULTS: Results revealed that the prevalence of depressive symptoms in older adults with cancer was 14.9%. Results of Poisson regression revealed that greater age, belonging to a race other than White or African American, not being married, presence of more chronic conditions, and higher levels of functional limitations were associated with higher levels of depressive symptoms. DISCUSSION: The prevalence of depressive symptoms is high in older adults with cancer and several factors predict depressive symptoms in this population. Individuals who are at high risk of developing depressive symptoms should be identified and appropriate timely interventions should be initiated to reduce the rates of depressive symptoms in older adults with cancer.

Linking Health And Social Services Through Area Agencies On Aging Is Associated With Lower Health Care Use And Spending.

Area Agencies on Aging are increasingly partnering with health care organizations to address the health-related social needs of older adults and contribute to multisector coalitions that promote community health. Using survey data for the period 2008-13, we examined the potential health impacts of establishing such partnerships. Partnerships with hospitals located in an agency's service county were associated with a reduction of $136 in average annual Medicare spending per beneficiary, while partnerships with mental health organizations in an agency's service county saw potentially avoidable nursing home use fall by 0.5 percentage points. When agencies were funded participants in livable community initiatives-multisector coalitions to promote the well-being and health of older adults-potentially avoidable nursing home use fell by nearly 1 percentage point. Our results suggest that investments in health and human services partnerships through Area Agencies on Aging can yield health returns among older adults, in the form of reduced health care use and spending.

It Is Not Your Parents' Long-Term Services System: Nursing Homes in a Changing World.

The long-term services system has changed substantially since the mid-1970s, when the landmark book Last Home for the Aged argued that the move to the nursing home was the last move an older person would make until death. Using detailed nursing home utilization data from the Minimum Data Set, this study tracks three cohorts of first-time nursing home admissions in Ohio from 1994 through 2014. Each cohort was followed for a 3-year period. Study results report dramatic reductions in nursing home length of stay between the 1994 and 2011 cohorts. Reduction in length of stay has important implications for nursing home practice and quality monitoring. The article argues that administrative and regulatory practices have not kept pace with the dramatic changes in how nursing homes are now being used in the long-term services system.

Scoring of Leisure Activities for Older Adults According to Cognitive, Physical, and Social Components.

Participation in leisure activities may be cognitively protective for older adults. However, there is no comprehensive scoring system for analyzing data related to the effectiveness of leisure activity engagement on cognitive decline risk. The authors developed a component scoring system to determine the typical amount of cognitive, physical, and social effort required for participation in common leisure activities. Fifty-nine leisure activities were scored on the three activity effort components in two rounds of expert panel review using a modified Delphi technique. Consensus on the component scores was esta blished. Interrater reliability (IRR) was acceptable across all three components (0.72). IRR was adequate for the cognitive component (0.75) and excellent for the physical (0.94) and social (0.95) components. Component scores can be used to examine how the level of cognitive, physical, or social effort required for engagement in specific leisure activities is associated with risk for cognitive decline and other poor outcomes. [Research in Gerontological Nursing, 13(1), 13-20.].

The Impact of Long-Term Care Ombudsman Presence on Nursing Home Survey Deficiencies.

OBJECTIVES: Each year states are required to survey nursing homes (NHs), including issuing deficiency citations when regulatory standards are not met. These deficiency citations can have substantial consequences for NHs. Because it is imperative that the survey process is conducted consistently across facilities, this study aims to determine whether deficiency outcomes vary with the presence of a long-term care ombudsman at the survey. DESIGN: A retrospective secondary data analysis of facility-level data using panel regression techniques was used to determine whether the presence of an ombudsman at a survey affected deficiency outcomes. Additional analysis assured the results were not due to ombudsmen being more likely to be present at poorer performing facilities. SETTING AND PARTICIPANTS: The data include freestanding NHs in the United States with at least 2 surveys between 2009 and 2015, resulting in 95,237 surveys from 14,996 unique NHs. MEASURES: The number and deficiency score were analyzed for 4 types of deficiencies: all deficiencies and the broad categories of quality of care, quality of life, and administration. The key explanatory variable is the presence of an ombudsman at survey. The regression model controlled for other important facility-level covariates. RESULTS: The presence of an ombudsman varied across states (range: 0.8%-82.0%; mean: 29.9%). Regression analysis found ombudsman presence was associated with a 0.2 increase in the number of deficiencies and 2.2-point increase in deficiency score. These correspond to a 3.9% and 5.9% increase, respectively. On a percentage basis, the largest effects were found for quality of life and administration deficiencies. CONCLUSIONS/IMPLICATIONS: By being present at surveys, ombudsmen may bring issues to the attention of state surveyors, resulting in worse deficiency outcomes during annual surveys. This can have consequences for NHs, and further work is needed to assure that ombudsmen are using their resources where they are most needed.

Is There a Woodwork Effect? Addressing a 200-Year Debate on the Impacts of Expanding Community-Based Services.

In U.S. social welfare history, many have suggested that if benefits were too attractive, consumers would come out of the woodwork to take advantage of the opportunity. Clinical trials have provided evidence of the woodwork effect's existence, suggesting caution when expanding home- and community-based services (HCBS). However, it is unclear whether these studies are best suited to assess whether a system-level effect occurs. Using state and federal data tracking Ohio's long-term services and support (LTSS) system from 1995 to 2015, this paper examines changes in the utilization rates and expenditures of Medicaid LTSS to explore whether a woodwork effect occurred as Ohio moved to improve its LTSS system balance (80% Nursing Home [NH], 20% HCBS) to (49% Nursing Home [NH], 51% HCBS). After accounting for population growth of individuals older than 60 and those with two or more impairments in activities of daily living, there was no change in utilization rates of older people with severe disability (1995: 491 per 1000 population, 2015: 495 per 1000 population) or overall LTSS expenditures (1997: $2.7 million [in 2013 dollars], 2013: $2.9 million). Our results suggest that states can make significant strides in HCBS expansion without increasing the overall long-term services utilization rate.

The Residential Long-Term Care Role in Health Care Transitions.

The objective of the current study is to describe the activities long-term care facilities are undertaking to reduce hospital admissions and readmissions by working to improve health care transitions. The data were collected via an online survey from 888 nursing facilities (NFs) and 527 residential care facilities (RCFs) that completed the care integration module of the Ohio Biennial Survey of Long-Term Care. Questions focused on partnerships, current work, type of care model, and perceived barriers to reducing hospital readmissions. More than nine in 10 (93.1%) of NFs and 63.6% of RCFs reported being engaged in a program to reduce hospital admissions/readmissions. Evidence-based care models were utilized by two thirds of NFs and one third of RCFs. Financial barriers were the most frequently cited challenges faced by facilities. Long-term care settings are increasingly becoming transitional care stops for short-term stay residents. Ensuring that facilities are well versed in current transition research and practice is critical to improve system outcomes.

Short-term variability in cognitive performance and the calibration of longitudinal change.

Recent studies have documented that normal adults exhibit considerable variability in cognitive performance from one occasion to another. We investigated this phenomenon in a study in which 143 adults ranging from 18 to 97 years of age performed different versions of 13 cognitive tests in three separate sessions. Substantial within-person variability was apparent across 13 different cognitive variables, and there were also large individual differences in the magnitude of within-person variability. Because people differ in the amount of short-term variability, we propose that this variability might provide a meaningful basis for calibrating change in longitudinal research. Correlations among the measures of within-person variability were very low, even after we adjusted for reliability, and there was little evidence that increased age was associated with a larger amount of within-person variability.