Training dementia care professionals to help caregivers improve the management of behavioral and psychological symptoms of dementia using the DICE Approach: A pilot study.

Most persons living with dementia (PLWD) exhibit behavioral or psychological symptoms of dementia (BPSD) over the course of the illness. The DICE Approach (DICE) is a framework that enables caregivers to identify, evaluate, and manage BPSD. This pilot pre-post test study examined the effects of DICE training on dementia care professionals' self-efficacy, knowledge, and attitudes regarding care of patients with BPSD. Participants underwent either in-person DICE training or, during the pandemic, online training. Case consultations were offered as additional learning opportunities in challenging situations. Of 134 participants in the trainings, 122 (91.0%) provided survey data for one or more instruments before and after training. Participants experienced significant improvement in knowledge and attitudes with respect to BPSD and improvement in self-efficacy with respect to helping caregivers respond to BPSD. Training dementia care professionals in DICE can improve their capacity to support caregivers in the management of BPSD.

Evaluation of Antipsychotic Reduction Efforts in Patients With Dementia in Veterans Health Administration Nursing Homes.

OBJECTIVE: The Veterans Health Administration (VHA) and the Centers for Medicare and Medicaid Services (CMS) each created initiatives to reduce off-label use of antipsychotics in patients with dementia in nursing homes. Although CMS has reported antipsychotic reductions, the impact on prescribing of antipsychotic and other CNS-active medications in the VHA remains unclear. The authors evaluated national trends in antipsychotic and other CNS-active medication prescribing for nursing home patients with dementia in the VHA. METHODS: The study sample was all veterans with dementia residing in VHA nursing homes for more than 30 days (N=35,742). Using an interrupted time-series design, the quarterly prevalences of antipsychotic, antidepressant, antiepileptic, anxiolytic, opioid, and memory medication prescribing were evaluated from FY2009 through FY2018. RESULTS: Antipsychotic prescribing in VHA nursing homes declined from FY2009 to FY2018 (from 33.7% to 27.5%), with similar declines in anxiolytic prescribing (from 33.5% to 27.1%). During this period, prescribing of antiepileptics, antidepressants, and opioids increased significantly (antiepileptics: from 26.8% to 43.3%; antidepressants: from 56.8% to 63.4%; opioids: from 32.6% to 41.2%). Gabapentin served as the main driver of antiepileptic increases (from 11.1% to 23.5%). Increases in antidepressant prescribing included sertraline, mirtazapine, and trazodone. From FY2009 to FY2018, the overall prescribing of non-antipsychotic psychotropic medications grew from 75.0% to 81.1%. CONCLUSIONS: Antipsychotic and anxiolytic prescribing for VHA nursing home residents with dementia declined, although overall prescribing of other psychotropic and opioid medications increased. Policies focused primarily on reducing antipsychotic use without considering use in the context of other medications may contribute to growth in alternative medication classes with even less evidence of benefit and similar risks.

Longitudinal associations between chronic condition discordance and perceived control among older couples.

Chronic health conditions among individuals and their partners may diminish perceived control, particularly when these conditions are highly complex. We considered how chronic condition discordance (i.e., the extent that two or more conditions have nonoverlapping self-management requirements) at the individual level and the couple level (i.e., between spouses) was linked to health-related control and personal mastery across an 8-year period, and whether these links varied by age. The U.S. sample included 879 wives (M = 53.81 years) and husbands (M = 57.19 years) from three waves (2006, 2010, and 2014) of the Health and Retirement Study. Dyadic growth curve models controlled for age, minority status, education, own and partner baseline negative marital quality, and own and partner time-varying depressive symptoms, and number of chronic health conditions. Overall, both individual-level and couple-level degrees of chronic condition discordance were associated with initial levels of and rates of change in perceived control. When wives had greater individual-level discordance, they reported lower initial personal mastery. When husbands had greater individual-level discordance, they reported lower initial health-related control and faster declines in health-related control and personal mastery, and their wives reported faster declines in personal mastery. When there was greater couple-level discordance, wives reported lower initial health-related control. Age moderated the associations between wives' individual-level discordance and their own initial level of health-related control and rate of change in personal mastery. Interventions to improve later-life well-being may be enhanced by targeting increases in perceived control among individuals and couples managing complex patterns of chronic conditions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Psychosis in Alzheimer disease - mechanisms, genetics and therapeutic opportunities.

Psychosis is a common and distressing symptom in people with Alzheimer disease, and few safe and effective treatments are available. However, new approaches to symptom assessment and treatment are beginning to drive the field forward. New nosological perspectives have been provided by incorporating the emergence of psychotic symptoms in older adults - even in advance of dementia - into epidemiological and neurobiological frameworks as well as into diagnostic and research criteria such as the International Psychogeriatric Association criteria for psychosis in neurocognitive disorders, the Alzheimer's Association International Society to Advance Alzheimer's Research and Treatment (ISTAART) research criteria for psychosis in neurodegenerative disease, and the ISTAART criteria for mild behavioural impairment. Here, we highlight the latest findings in genomics, neuroimaging and neurobiology that are informing approaches to drug discovery and repurposing. Current pharmacological and non-pharmacological treatment options are discussed, with a focus on safety and precision medicine. We also explore trial data for pimavanserin, a novel agent that shows promise for the treatment of psychosis in people with dementia, and discuss existing agents that might be useful but need further exploration such as escitalopram, lithium, cholinesterase inhibitors and vitamin D. Although the assessment and management of psychosis in people with dementia remain challenging, new opportunities are providing direction and hope to the field.

WeCareAdvisor, an Online Platform to Help Family Caregivers Manage Dementia-Related Behavioral Symptoms: an Efficacy Trial in the Time of COVID-19.

Dementia-related behavioral and psychology symptoms (BPSD) are undertreated and have negative consequences. However, families do not have access to disease information, tailored problem-solving  and effective management strategies, and with COVID-19, are more socially isolated and distressed. To address this dementia care gap, we describe a Phase III efficacy trial testing an online platform, WeCareAdvisor, and design modifications necessitated by COVID-19. WeCareAdvisor provides caregivers with disease information, daily tips, and a systematic approach for describing behaviors, investigating underlying causes, creating tailored strategies, and evaluating their effectiveness (DICE). The trial will enroll 326 caregivers nationwide, randomly assign them to immediately receive WeCareAdvisor (treatment), or a 3-month waitlist (control) and evaluate short (1- and 3-month) and long-term (6-month) outcomes for caregiver distress with and confidence managing BPSD, and BPSD occurrences. We will also evaluate utilization patterns with different prompting conditions: high-intensity (telephone and email reminders), low-intensity (email reminders), or no reminders to use WeCareAdvisor. COVID-19 necessitated design modifications resulting in greater inclusivity of caregivers from diverse races, ethnicities, and geographic areas. Key modifications include shifting from in-home, in-person interviewing to telephone; adjusting tool functionality from operating on a grant-funded iPad to caregivers' personal internet-capable devices; and expanding recruitment from one metropolitan area to nationwide. Study modifications necessitated by COVID-19 facilitate national outreach, easier tool adoption, and enable more diverse caregivers to participate. This study addresses a critical dementia care need, and design modifications may shorten timeline from efficacy testing to commercialization.

Using Geographic Information Systems (GIS) for Targeted National Recruitment of Community-Dwelling Caregivers Managing Dementia-Related Behavioral and Psychological Symptoms: A Recruitment Approach for a Randomized Clinical Trial.

Over 16 million caregivers of people living with dementia require support in a range of issues, including self-care, disease education, and guidance for how to manage behavioral and psychological symptoms of dementia (BPSD). Non-pharmacological interventions are needed to address these areas, and online applications have been shown to be safe and effective. To ensure the efficacy of such interventions, racially, ethnically, geographically, and socioeconomically diverse participants must be recruited to increase the generalizability of study outcomes. This protocol paper describes a recruitment plan using Geographic Information Systems (GIS) to reach a representative sample of caregivers across the United States for a national Phase III clinical study. Using publicly available census data from the American Community Survey (ACS), combined with location data for local aging resources such as Area Agencies on Aging (AAA), recruitment will be derived from data analysis conducted in ESRI ArcGIS v10.7.1. Datasets including age, gender, income, and education will be assessed nationally at the county and census tract spatial scale in a nine-step process to develop recruitment priority areas containing high concentrations of eligible participants living in the community. Overall, the current protocol will demonstrate the value of GIS in tailoring targeted outreach strategies to recruit community-dwelling populations through local resource institutions. This novel approach may have far-reaching implications in future recruitment initiatives and help to secure racially/ethnically diverse samples.

Social connectedness and dementia prevention: Pilot of the APPLE-Tree video-call intervention during the Covid-19 pandemic.

BACKGROUND AND OBJECTIVES: The Covid-19 pandemic reduced access to social activities and routine health care that are central to dementia prevention. We developed a group-based, video-call, cognitive well-being intervention; and investigated its acceptability and feasibility; exploring through participants' accounts how the intervention was experienced and used in the pandemic context. RESEARCH DESIGN AND METHOD: We recruited adults aged 60+ years with memory concerns (without dementia). Participants completed baseline assessments and qualitative interviews/focus groups before and after the 10-week intervention. Qualitative interview data and facilitator notes were integrated in a thematic analysis. RESULTS: 12/17 participants approached completed baseline assessments, attended 100/120 (83.3%) intervention sessions and met 140/170 (82.4%) of goals set. Most had not used video calling before. In the thematic analysis, our overarching theme was social connectedness. Three sub-themes were as follows: Retaining independence and social connectedness: social connectedness could not be at the expense of independence; Adapting social connectedness in the pandemic: participants strived to compensate for previous social connectedness as the pandemic reduced support networks; Managing social connections within and through the intervention: although there were tensions, for example, between sharing of achievements feeling supportive and competitive, participants engaged with various lifestyle changes; social connections supported group attendance and implementation of lifestyle changes. DISCUSSION AND IMPLICATIONS: Our intervention was acceptable and feasible to deliver by group video-call. We argue that dementia prevention is both an individual and societal concern. For more vulnerable populations, messages that lifestyle change can help memory should be communicated alongside supportive, relational approaches to enabling lifestyle changes.

Prevalence of Central Nervous System-Active Polypharmacy Among Older Adults With Dementia in the US.

Importance: Community-dwelling older adults with dementia have a high prevalence of psychotropic and opioid use. In these patients, central nervous system (CNS)-active polypharmacy may increase the risk for impaired cognition, fall-related injury, and death. Objective: To determine the extent of CNS-active polypharmacy among community-dwelling older adults with dementia in the US. Design, Setting, and Participants: Cross-sectional analysis of all community-dwelling older adults with dementia (identified by International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes; N = 1 159 968) and traditional Medicare coverage from 2015 to 2017. Medication exposure was estimated using prescription fills between October 1, 2017, and December 31, 2018. Exposures: Part D coverage during the observation year (January 1-December 31, 2018). Main Outcomes and Measures: The primary outcome was the prevalence of CNS-active polypharmacy in 2018, defined as exposure to 3 or more medications for longer than 30 days consecutively from the following classes: antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, and opioids. Among those who met the criterion for polypharmacy, duration of exposure, number of distinct medications and classes prescribed, common class combinations, and the most commonly used CNS-active medications also were determined. Results: The study included 1 159 968 older adults with dementia (median age, 83.0 years [interquartile range {IQR}, 77.0-88.6 years]; 65.2% were female), of whom 13.9% (n = 161 412) met the criterion for CNS-active polypharmacy (32 139 610 polypharmacy-days of exposure). Those with CNS-active polypharmacy had a median age of 79.4 years (IQR, 74.0-85.5 years) and 71.2% were female. Among those who met the criterion for CNS-active polypharmacy, the median number of polypharmacy-days was 193 (IQR, 88-315 polypharmacy-days). Of those with CNS-active polypharmacy, 57.8% were exposed for longer than 180 days and 6.8% for 365 days; 29.4% were exposed to 5 or more medications and 5.2% were exposed to 5 or more medication classes. Ninety-two percent of polypharmacy-days included an antidepressant, 47.1% included an antipsychotic, and 40.7% included a benzodiazepine. The most common medication class combination included an antidepressant, an antiepileptic, and an antipsychotic (12.9% of polypharmacy-days). Gabapentin was the most common medication and was associated with 33.0% of polypharmacy-days. Conclusions and Relevance: In this cross-sectional analysis of Medicare claims data, 13.9% of older adults with dementia in 2018 filled prescriptions consistent with CNS-active polypharmacy. The lack of information on prescribing indications limits judgments about clinical appropriateness of medication combinations for individual patients.

Prevalence of psychotropic and opioid prescribing among hospice beneficiaries in the United States, 2014-2016.

BACKGROUND/OBJECTIVES: Psychotropic and opioid medications are routinely prescribed for symptom management in hospice, but national estimates of prescribing are lacking. Changes in Medicare hospice payment in 2014 provide the first opportunity to examine psychotropic and opioid prescribing among hospice beneficiaries, and the factors associated with use of specific medication classes. DESIGN: Cross-sectional analysis of a 20% sample of traditional and managed Medicare with Part D enrolled in hospice, 2014-2016. SETTING: Beneficiaries enrolled in the Medicare hospice benefit. PARTICIPANTS: Medicare beneficiaries ≥65 newly enrolled in hospice between July 1, 2014 and December 31, 2016 (N = 554,022). MAIN OUTCOME: Prevalence of psychotropic and opioid medication prescribing by class and factors associated with prescribing. RESULTS: 70.3% of hospice beneficiaries were prescribed a psychotropic and 63.3% were prescribed an opioid. The most common psychotropic classes prescribed were: benzodiazepines (60.6%), antipsychotics (38.3%), antidepressants (18.4%), and antiepileptics (10.2%). Lorazepam (56.4%), morphine (52.8%), and haloperidol (28.6%) were received by the most beneficiaries. Prevalence of any psychotropic and opioid prescription was highest among beneficiaries who were female (76.7%), non-Hispanic white (76.6%), and those with cancer (78.9%). Compared to white beneficiaries, non-Hispanic black beneficiaries were less likely to receive nearly every class of medication, with significantly lower odds of receiving opioids (64.1% vs 57.9%; AOR 0.75, 95% CI 0.72-0.77) and benzodiazepines (61.6% vs 52.2%; AOR 0.66, 95% CI 0.64-0.68). Differences were seen across hospice diagnosis; those with cancer were more likely to receive opioids, benzodiazepines, and antipsychotics but less likely to receive antidepressants and antiepileptics. CONCLUSIONS: Psychotropic and opioid medications are frequently prescribed in hospice. Observed variations in prescribing across race and ethnicity may reflect disparities in prescribing as well as patient preferences for care. Further work is important to understand factors driving prescribing given limited studies surrounding medication prescribing in hospice.

Characterizing dementia caregiver style in managing care challenges: Cognitive and behavioral components.

BACKGROUND: Caring for a person living with dementia can take a physical and emotional toll, but understudied is the process by which family caregivers actually provide care. Caregiver management styles may vary and affect care decision-making, experiences, receptivity to and participation in interventions, and outcomes for the caregiver and person living with dementia. METHODS: Participants included 100 primary family caregivers for persons with dementia who were on average 64 years old and had been providing care for 55 months, 74% women, and 18% nonwhite. Participants were interviewed in Michigan and Ohio regarding their cognitive and behavioral management of a recent care challenge and values guiding their decision-making. The rigorous and accelerated data reduction technique was used to analyze qualitative data leading to the identification of caregiving styles. Styles were compared across sample characteristics using chi-square and ANOVA tests. FINDINGS: Five distinct styles emerged: "Externalizers" (superficial understanding, self-focused, and frequent expressions of anger or frustration), "Individualists" (provide care by going alone, emotionally removed, and lack management strategies), "Learners" (recognize need to change their approach but are stuck and emotionally turbulent), "Nurturers" (positive affect and empathy toward care and reflect natural mastery), and "Adapters" (arsenal of acquired management strategies and adapt to challenges). Style groups differed significantly in terms of age and use of formal care supports. DISCUSSION: We identified five distinct styles by which caregivers addressed care challenges using a robust qualitative methodology. Styles may be important to identify in order to better tailor interventions to needs and abilities.

Perceived Social Support and Interpersonal Functioning as Predictors of Treatment Response Among Depressed Older Adults.

OBJECTIVE: Social isolation is highly common in late life and is associated with devastating mental health and physical outcomes. This study investigated whether components of social isolation (marital status, perceived social support, and interpersonal problems) predict change in depression severity over the course of a brief adherence intervention delivered in a primary care setting. METHOD: A sample of 189 older adults with major depressive disorder were randomized to either an adherence intervention, "Treatment Initiation Program," or treatment as usual. Marital status, perceived social support and interpersonal problems were assessed at baseline. A mixed-effects regression was used to test whether these factors predicted the change trajectory in depression severity over 24 weeks. RESULTS: Being married (F(2,176) = 6.60; p = 0.001), reporting higher perceived social support (F(2,177) = 4.70; p = 0.01), and fewer interpersonal problems (F(2, 176) = 4.34; p = 0.01) predicted lower depression severity on average over the course of 24 weeks. CONCLUSION: Social variables such as living in partnership, perceiving others as supportive, and reporting few interpersonal problems may reduce older adults' vulnerability to depression and enhance their ability to benefit from treatment. These findings can guide development of interventions that will target these social factors early in treatment to increase efficacy.

Correction: Predictors and Consequences of Veterans Affairs Mental Health Provider Burnout: Protocol for a Mixed Methods Study.

[This corrects the article DOI: 10.2196/18345.].

Chronic condition discordance and physical activity among midlife and older couples.

OBJECTIVE: Chronic conditions in middle and later life are associated with lower physical activity. Yet little is known about chronic condition discordance (i.e., the extent to which conditions have nonoverlapping self-management requirements) within older individuals and couples and its implications for physical activity. We determined how the degrees of chronic condition discordance at the individual level and the couple level (i.e., between spouses) were linked to moderate physical activity across an 8-year period. METHOD: The U.S. sample included 1,621 couples from five waves of the Health and Retirement Study (2006-2014). Dyadic growth curve models estimated how individual-level and couple-level chronic condition discordance were linked to initial levels of and rates of change in moderate activity. Models controlled for age, minority status, education, and own and partner reports of baseline negative marital quality, time-varying depressive symptoms, and time-varying number of chronic conditions. RESULTS: A considerable proportion of wives (25.4%) and husbands (18.9%) reported moderate activity less than once a week. When individuals (wives: ß = -0.10; husbands: ß = -0.09) or their spouses (wives: ß = -0.04; husbands: ß = -0.05) had greater individual-level chronic condition discordance, lower initial moderate activity was reported. When husbands had greater individual-level discordance, both wives (ß = -0.16) and husbands (ß = -0.19) had a faster rate of decline in moderate activity over time. Couple-level chronic condition discordance was not significantly linked to moderate activity. CONCLUSIONS: These findings suggest the importance of promoting physical activity among individuals and couples managing complex chronic conditions. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Discordant Chronic Conditions and Depressive Symptoms: Longitudinal Associations Among Middle-Aged and Older Couples.

OBJECTIVES: Individuals often manage chronic conditions in middle and later life that may diminish well-being. Little is known, however, about discordant conditions (i.e., two or more conditions with competing self-management requirements) among older couples and their links to depressive symptoms. We considered discordant conditions at both the individual level and the couple level (i.e., between spouses), along with their long-term implications for depressive symptoms. METHODS: The U.S. sample included 1,116 middle-aged and older couples drawn from five waves (2006-2014) of the Health and Retirement Study. Longitudinal actor-partner interdependence models evaluated whether individual-level and couple-level discordant chronic health conditions were concurrently linked to depressive symptoms, and whether these associations became stronger over time. Models controlled for age, minority status, education, prior wave depressive symptoms, and each partner's baseline report of negative marital quality and number of chronic conditions in each wave. RESULTS: Wives and husbands reported significantly greater depressive symptoms when they had individual-level discordant conditions about 2 years after baseline, and these links intensified over time. Beyond this association, husbands had significantly greater depressive symptoms when there were couple-level discordant conditions. DISCUSSION: Individual-level and couple-level discordant conditions may have lasting implications for depressive symptoms during midlife and older adulthood.