Prevalence, country-specific prescribing patterns and determinants of benzodiazepine use in community-residing older adults in 7 European countries.

BACKGROUND: The use of benzodiazepines (BZDs) in older population is often accompanied by drug-related complications. Inappropriate BZD use significantly alters older adults' clinical and functional status. This study compares the prevalence, prescribing patterns and factors associated with BZD use in community-dwelling older patients in 7 European countries. METHODS: International, cross-sectional study was conducted in community-dwelling older adults (65 +) in the Czech Republic, Serbia, Estonia, Bulgaria, Croatia, Turkey, and Spain between Feb2019 and Mar2020. Structured and standardized questionnaire based on interRAI assessment scales was applied. Logistic regression was used to evaluate factors associated with BZD use. RESULTS: Out of 2,865 older patients (mean age 73.2 years ± 6.8, 61.2% women) 14.9% were BZD users. The highest prevalence of BZD use was identified in Croatia (35.5%), Spain (33.5%) and Serbia (31.3%). The most frequently prescribed BZDs were diazepam (27.9% of 426 BZD users), alprazolam (23.7%), bromazepam (22.8%) and lorazepam (16.7%). Independent factors associated with BZD use were female gender (OR 1.58, 95%CI 1.19-2.10), hyperpolypharmacy (OR 1.97, 95%CI 1.22-3.16), anxiety (OR 4.26, 95%CI 2.86-6.38), sleeping problems (OR 4.47, 95%CI 3.38-5.92), depression (OR 1.95, 95%CI 1.29-2.95), repetitive anxious complaints (OR 1.77, 95%CI 1.29-2.42), problems with syncope (OR 1.78, 95%CI 1.03-3.06), and loss of appetite (OR 0.60, 95%CI 0.38-0.94). In comparison to Croatia, residing in other countries was associated with lower odds of BZD use (ORs varied from 0.49 (95%CI 0.32-0.75) in Spain to 0.01 (95%CI 0.00-0.03) in Turkey), excluding Serbia (OR 1.11, 95%CI 0.79-1.56). CONCLUSIONS: Despite well-known negative effects, BZDs are still frequently prescribed in older outpatient population in European countries. Principles of safer geriatric prescribing and effective deprescribing strategies should be individually applied in older BZD users.

Unemployed, Immigrant, and Older Asian Workers in a U.S.-Based Job-Training Program: Their Experiences and Well-Being, and Strategies for Reaching This Important Population.

The Senior Community Service Employment Program (SCSEP) is a U.S.-based job-training program that serves unemployed workers aged 55 and older with incomes at or below 125% of the federal poverty level. While federal funds are set aside to serve Asian workers in SCSEP, little is known about their characteristics and experiences. In response, this pilot study aimed to document the health, well-being, and experiences of older Asian SCSEP participants in Massachusetts through the completion of a survey. Respondents (N = 39) ranged in age from 58 to 73 and identified as either Chinese (72%) or Vietnamese (28%). All were immigrants, and almost all spoke a language other than English at home. Most reported "good" health as well as financial difficulties. They also stated that their supervisors in their placements were supportive. On average, respondents noted moderate interest in searching for a paid job after exiting SCSEP, although more reported interest in searching for a volunteer role. Key to the success of this study was a robust collaboration with a local human services organization with strong ties to the Chinese and Vietnamese communities. The findings highlight the importance of this growing group of older workers.

Childhood trauma differentially impacts depression and stress associations with reintegration challenges among post-9/11 U.S. veterans.

BACKGROUND: Post-9/11 veterans exhibit high prevalence of deployment stress, psychological conditions, and traumatic brain injury (TBI) which impact reintegration, especially among those with a history of interpersonal early life trauma (I-ELT). The relative importance of each risk factor is unclear. PURPOSE: We examined major deployment and clinical exposures of reintegration challenges among veterans with and without I-ELT. METHOD: We analyzed cross-sectional data of 155 post-9/11 veterans from the Translational Research Center for TBI and Stress Disorders study. FINDINGS: Depression severity had the strongest association with reintegration challenges, followed by posttraumatic stress disorder (PTSD) severity, post-deployment stress, and deployment safety concerns. Deployment safety concerns had a stronger, significant association among veterans with I-ELT. In nearly every model, PTSD and depression severities were weaker for veterans with I-ELT, compared to those without. DISCUSSION: Clinicians should consider the relative risk of concurrent clinical conditions and trauma histories when considering veterans' reintegration needs.

Peer-to-peer support model to improve quality of life among highly vulnerable, low-income older adults in Cape Town, South Africa.

BACKGROUND: Developing countries are experiencing rapid population ageing. Many do not have the resources or formal structures available to support the health and wellbeing of people as they age. In other contexts, the use of peer support programmes have shown favourable outcomes in terms of reducing loneliness, increasing physical activity and managing chronic disease. Such programmes have not been previously developed or tested in African countries. We piloted a peer-to-peer support model among vulnerable community-dwelling adults in a developing country (South Africa) to examine the program's effect on wellbeing and social engagement. METHODS: A pre-post, pilot design was used to evaluate targeted outcomes, including wellbeing, social support, social interaction, mood, loneliness and physical activity. A total of 212 persons, aged 60+ years and living independently in a low-income area in Cape Town were recruited and screened for eligibility by trained assessors. Participants were assessed using the interRAI CheckUp, WHO-5 Wellbeing index, and the MOS-SS 8 instruments before and after the 5-month intervention, during which they received regular visits and phone calls from trained peer volunteers. During visits volunteers administered a wellness screening, made referrals to health and social services; built friendships with clients; encouraged social engagement; promoted healthy living; and provided emotional and informational support. RESULTS: Volunteer visits with clients significantly increased levels of self-reported wellbeing by 58%; improved emotional and informational support by 50%; decreased reports of reduced social interaction by 91%; reduced loneliness by 70%; improved mood scores represented as anxiety, depression, lack of interest or pleasure in activities, and withdrawal from activities of interest; and increased levels of physical activity from 49 to 66%. DISCUSSION: The intervention led to demonstrable improvement in client wellbeing. Policymakers should consider integrating peer-support models into existing health programs to better address the needs of the elderly population and promote healthy ageing in resource-poor community settings. Longer-term and more rigorous studies with a control group are needed to support these findings and to investigate the potential impact of such interventions on health outcomes longitudinally.

Physical Activity and Positive Psychological Well-Being Attributes Among U.S. Latino Older Adults.

Lack of physical activity is particularly problematic among U.S. Latino older adults. There is substantial evidence linking physical activity and well-being. However, associations between physical activity and positive psychological well-being among this population have never been studied or measured. Physical activity was compared to five positive psychological well-being measures based on the PERMA model. Secondary data analysis was completed on a sample of 68 Latino American individuals, age 60 and older, compared to 72 non-Hispanic White older adults. Overall, physical activity was positively associated with positive psychological well-being despite race. Pain, functional limitations, and physical restrictions did not moderate the relationship between physical activity and positive psychological well-being among Latino and non-Hispanic White older adults. Further research is needed to clarify whether physical activity and psychological well-being are perceived similarly or differently within various cultures. [Journal of Gerontological Nursing, 45(6), 44-56.].

Updating the Cognitive Performance Scale.

This study presents the first update of the Cognitive Performance Scale (CPS) in 20 years. Its goals are 3-fold: extend category options; characterize how the new scale variant tracks with the Mini-Mental State Examination; and present a series of associative findings. Secondary analysis of data from 3733 older adults from 8 countries was completed. Examination of scale dimensions using older and new items was completed using a forward-entry stepwise regression. The revised scale was validated by examining the scale's distribution with a self-reported dementia diagnosis, functional problems, living status, and distress measures. Cognitive Performance Scale 2 extends the measurement metric from a range of 0 to 6 for the original CPS, to 0 to 8. Relating CPS2 to other measures of function, living status, and distress showed that changes in these external measures correspond with increased challenges in cognitive performance. Cognitive Performance Scale 2 enables repeated assessments, sensitive to detect changes particularly in early levels of cognitive decline.

Development of the interRAI home care frailty scale.

BACKGROUND: The concept of frailty, a relative state of weakness reflecting multiple functional and health domains, continues to receive attention within the geriatrics field. It offers a summary of key personal characteristics, providing perspective on an individual's life course. There have been multiple attempts to measure frailty, some focusing on physiologic losses, others on specific diseases, disabilities or health deficits. Recently, multidimensional approaches to measuring frailty have included cognition, mood and social components. The purpose of this project was to develop and evaluate a Home Care Frailty Scale and provide a grounded basis for assessing a person's risk for decline that included functional and cognitive health, social deficits and troubling diagnostic and clinical conditions. METHODS: A secondary analysis design was used to develop the Home Care Frailty Scale. The data set consisted of client level home care data from service agencies around the world. The baseline sample included 967,865 assessments while the 6-month follow-up sample of persons still being served by the home care agencies consisted of 464,788 assessments. A pool of 70 candidate independent variables were screened for possible inclusion and 16 problem outcomes referencing accumulating declines and clinical complications served as the dependent variables. Multiple regression techniques were used to analyze the data. RESULTS: The resulting Home Care Frailty Scale consisted of a final set of 29 items. The items fall across 6 categories of function, movement, cognition and communication, social life, nutrition, and clinical symptoms. The prevalence of the items ranged from a high of 87% for persons requiring help with meal preparation to 3.7% for persons who have experienced a recent decline in the amount of food eaten. CONCLUSIONS: The interRAI Home Care Frailty Scale is based on a strong conceptual foundation and in our analysis, performed as expected. Given the use of the interRAI Home Care Assessment System in multiple, diverse countries, the Home Care Frailty Scale will have wide applicability to support program planning and policy decision-making impacting home care clients and their formal and informal caregivers throughout the world.

Strategies to reduce the risk of falling: Cohort study analysis with 1-year follow-up in community dwelling older adults.

BACKGROUND: According to the CDC, falls rank among the leading causes of accidental death in the United States, resulting in significant health care costs annually. In this paper we present information about everyday lifestyle decisions of the older adult that may help reduce the risk of falling. We pursued two lines of inquiry: first, we identify and then test known mutable fall risk factors and ask how the resolution of such problems correlates with changes in fall rates. Second, we identify a series of everyday lifestyle options that persons may follow and then ask, does such engagement (e.g., engagement in exercise programs) lessen the older adult's risk of falling and if it does, will the relationship hold as the count of risk factors increases? METHODS: Using a secondary analysis of lifestyle choices and risk changes that may explain fall rates over one year, we drew on a data set of 13,623 community residing elders in independent housing sites from 24 US states. All older adults were assessed at baseline, and a subset assessed one year later (n = 4,563) using two interRAI tools: the interRAI Community Health Assessment and interRAI Wellness Assessment. RESULTS: For the vast majority of risk measures, problem resolution is followed by lower rate of falls. This is true for physical measures such as doing housework, meal preparation, unsteady gait, transferring, and dressing the lower body. Similarly, this pattern is observed for clinical measures such as depression, memory, vision, dizziness, and fatigue. Among the older adults who had a falls risk at the baseline assessment, about 20 % improve, that is, they had a decreased falls rate when the problem risk improved. This outcome suggests that improvement of physical or clinical states potentially may result in a decreased falls rate. Additionally, physical exercise and cognitive activities are associated with a lower rate of falls. CONCLUSIONS: The resolution of risk problems and physical and cognitive lifestyle choices are related to lower fall rates in elders in the community. The results presented here point to specific areas, that when targeted, may reduce the risk of falls. In addition, when there is problem resolution for specific clinical conditions, a decreased risk for falls also may occur.

Predicting risk of hospital and emergency department use for home care elderly persons through a secondary analysis of cross-national data.

BACKGROUND: Older adults remain the highest utilization group with unplanned visits to emergency departments and hospital admissions. Many have considered what leads to this high utilization and the answers provided have depended upon the independent measures available in the datasets used. This project was designed to further understanding of the reasons for older adult ED visits and admissions to acute care hospitals. METHODS: A secondary analysis of data from a cross-national sample of community residing elderly, 60 years of age or older, and most of whom received services from a local home-care program was conducted. The assessment instrument used in this study is the interRAI HC (home care), designed for use in assessing elderly home care recipients. The model specification stage of the study identified the baseline independent variables that do and do not predict the follow-up measure of hospitalization and ED use. Stepwise logistic regression was used next to identify characteristics that best identified elders who subsequently entered a hospital or visited an ED. The items generated from the final multivariate logistic equation using the interRAI home care measures comprise the interRAI Hospital-ED Risk Index. RESULTS: Independent measures in three key domains of clinical complications, disease diagnoses and specialized treatments were related to subsequent hospitalization or ED use. Among the eighteen clinical complication measures with higher, meaningful odds ratios are pneumonia, urinary tract infection, fever, chest pain, diarrhea, unintended weight loss, a variety of skin conditions, and subject self-reported poor health. Disease diagnoses with a meaningful relationship with hospital/ED use include coronary artery disease, congestive heart failure, cancer, emphysema and renal failure. Specialized treatments with the highest odds ratios were blood transfusion, IV infusion, wound treatment, radiation and dialysis. Two measures, Alzheimer's disease and day care appear to have a protective effect for hospitalization/ED use with lower odds ratios. CONCLUSIONS: Examination into "preventable" hospitalizations and re-hospitalizations for older adults who have the highest rates of utilization are occurring beneath an umbrella of assuring the highest quality of care and controlling costs. The interRAI Hospitalization-ED Risk Index offers an effective approach to predicting hospitalization utilization among community dwelling older adults.

Application of the Rasch model to measure five dimensions of wellness in community-dwelling older adults.

BACKGROUND AND PURPOSE: Nurse researchers and practicing nurses need reliable and valid instruments to measure key clinical concepts. The purpose of this research was to develop an innovative method to measure dimensions of wellness among older adults. METHOD: A sample of 5,604 community-dwelling older adults was drawn from members of the COLLAGE consortium. The Wellness Assessment Tool (WEL) of the COLLAGE assessment system provided the data used to create the scores. Application of the Rasch analysis and Masters' partial credit method resulted in logit values for each item within the five dimensions of wellness as well as logit values for each person in the sample. RESULTS: The items fit the Rasch model, and the composite scores for each dimension demonstrated high reliability (1.00). The person reliability was low: social (.19), intellectual (.33), physical (.29), emotional (.20), and spiritual (.29). The small number of items within each dimension and the homogenous sample appear to have contributed to this low reliability. CONCLUSION: Ongoing research using multidimensional tools to measure dimensions of wellness among older adults is needed to advance wellness science and wellness promotion in nursing practice.

Scaling functional status within the interRAI suite of assessment instruments.

BACKGROUND: As one ages, physical, cognitive, and clinical problems accumulate and the pattern of loss follows a distinct progression. The first areas requiring outside support are the Instrumental Activities of Daily Living and over time there is a need for support in performing the Activities of Daily Living. Two new functional hierarchies are presented, an IADL hierarchical capacity scale and a combination scale integrating both IADL and ADL hierarchies. METHODS: A secondary analyses of data from a cross-national sample of community residing persons was conducted using 762,023 interRAI assessments. The development of the new IADL Hierarchy and a new IADL-ADL combined scale proceeded through a series of interrelated steps first examining individual IADL and ADL item scores among persons receiving home care and those living independently without services. A factor analysis demonstrated the overall continuity across the IADL-ADL continuum. Evidence of the validity of the scales was explored with associative analyses of factors such as a cross-country distributional analysis for persons in home care programs, a count of functional problems across the categories of the hierarchy, an assessment of the hours of informal and formal care received each week by persons in the different categories of the hierarchy, and finally, evaluation of the relationship between cognitive status and the hierarchical IADL-ADL assignments. RESULTS: Using items from interRAI's suite of assessment instruments, two new functional scales were developed, the interRAI IADL Hierarchy Scale and the interRAI IADL-ADL Functional Hierarchy Scale. The IADL Hierarchy Scale consisted of 5 items, meal preparation, housework, shopping, finances and medications. The interRAI IADL-ADL Functional Hierarchy Scale was created through an amalgamation of the ADL Hierarchy (developed previously) and IADL Hierarchy Scales. These scales cover the spectrum of IADL and ADL challenges faced by persons in the community. CONCLUSIONS: An integrated IADL and ADL functional assessment tool is valuable. The loss in these areas follows a general hierarchical pattern and with the interRAI IADL-ADL Functional Hierarchy Scale, this progression can be reliably and validly assessed. Used across settings within the health continuum, it allows for monitoring of individuals from relative independence through episodes of care.

Cognitive Change Among Nursing Home Residents: CogRisk-NH Scale Development to Predict Decline.

OBJECTIVES: Examine cognitive changes over time among nursing home residents and develop a risk model for identifying predictors of cognitive decline. DESIGN: Using secondary analysis design with Minimum Data Set data, cognitive status was based on the Cognitive Performance Scale (CPS). SETTING AND PARTICIPANTS: Baseline and 7 quarterly follow-up analyses of US and Canadian interRAI data (N = 1,257,832) were completed. METHODS: Logistic regression analyses identified predictors of decline to form the CogRisk-NH scale. RESULTS: At baseline, about 15% of residents were cognitively intact (CPS = 0), and 11.2% borderline intact (CPS = 1). The remaining more intact, with mild impairment (CPS = 2), included 15.0%. Approximately 59% residents fell into CPS categories 3 to 6 (moderate to severe impairment). Over time, increasing proportions of residents declined: 17.1% at 6 months, 21.6% at 9 months, and 34.0% at 21 months. Baseline CPS score was a strong predictor of decline. Categories 0 to 2 had 3-month decline rates in midteens, and categories 3 to 5 had an average decline rate about 9%. Consequently, a 2-submodel construction was employed-one for CPS categories 0 to 2 and the other for categories 3 to 5. Both models were integrated into a 6-category risk scale (CogRisk-NH). CogRisk-NH scale score distribution had 15.9% in category 1, 26.84% in category 2, and 36.7% in category 3. Three higher-risk categories (ie, 4-6) represented 20.6% of residents. Mean decline rates at the 3-month assessment ranged from 4.4% to 28.3%. Over time, differentiation among risk categories continued: 6.9% to 38.4.% at 6 months, 11.0% to 51.0% at 1 year, and 16.2% to 61.4% at 21 months, providing internal validation of the prediction model. CONCLUSIONS AND IMPLICATIONS: Cognitive decline rates were higher among residents in less-impaired CPS categories. CogRisk-NH scale differentiates those with low likelihood of decline from those with moderate likelihood and, finally, much higher likelihood of decline. Knowledge of resident risk for cognitive decline enables allocation of resources targeting amenable factors and potential interventions to mitigate continuing decline.

Optimising the care for older persons with complex chronic conditions in home care and nursing homes: design and protocol of I-CARE4OLD, an observational study using real-world data.

INTRODUCTION: In ageing societies, the number of older adults with complex chronic conditions (CCCs) is rapidly increasing. Care for older persons with CCCs is challenging, due to interactions between multiple conditions and their treatments. In home care and nursing homes, where most older persons with CCCs receive care, professionals often lack appropriate decision support suitable and sufficient to address the medical and functional complexity of persons with CCCs. This EU-funded project aims to develop decision support systems using high-quality, internationally standardised, routine care data to support better prognostication of health trajectories and treatment impact among older persons with CCCs. METHODS AND ANALYSIS: Real-world data from older persons aged ≥60 years in home care and nursing homes, based on routinely performed comprehensive geriatric assessments using interRAI systems collected in the past 20 years, will be linked with administrative repositories on mortality and care use. These include potentially up to 51 million care recipients from eight countries: Italy, the Netherlands, Finland, Belgium, Canada, USA, Hong Kong and New Zealand. Prognostic algorithms will be developed and validated to better predict various health outcomes. In addition, the modifying impact of pharmacological and non-pharmacological interventions will be examined. A variety of analytical methods will be used, including techniques from the field of artificial intelligence such as machine learning. Based on the results, decision support tools will be developed and pilot tested among health professionals working in home care and nursing homes. ETHICS AND DISSEMINATION: The study was approved by authorised medical ethical committees in each of the participating countries, and will comply with both local and EU legislation. Study findings will be shared with relevant stakeholders, including publications in peer-reviewed journals and presentations at national and international meetings.

Does the Person-Centered Care Model Support the Needs of Long-Term Care Residents With Serious Mental Illness and Intellectual and Developmental Disabilities?

Person-centered care approaches continue to evolve in long-term care (LTC). At the same time, these settings have faced increased challenges due to a more diverse and complex population, including persons with intellectual and developmental disabilities (IDD) and serious mental illness (SMI). This study examined the mental, social, and physical wellbeing of residents with different diagnoses, within a person-centered care model. It was hypothesized that individual wellbeing would be comparable among all residents, regardless of primary diagnosis. The study cohort was drawn from all admissions to long-term care facilities in the USA from 2011 to 2013. Data are based on admission, 3 and 6 month follow-up Minimum Data Set (MDS) 3.0 assessments. The groups examined included: schizophrenia, other psychotic disorders, IDD, dementia, and all others (i.e., none of the above diagnoses). The wellbeing outcomes were depression (mental), pain (physical), and behaviors (social). All residents experienced improvements in pain and depression, though the group without the examined diagnoses experienced the greatest gains. Behaviors were most prevalent among those with psychotic disorders; though marked improvements were noted over time. Improvement also was noted among persons with dementia. Behavior worsened over time for the three other groups. In particular, those with IDD experienced the highest level of worsening at 3-month follow-up, and continued to worsen. The results suggest person-centered care in US nursing homes provides the necessary foundation to promote mental and physical wellbeing in persons with complex needs, but less so for social wellbeing.

Evaluation of a Tool to Measure the Demands of Immigration.

BACKGROUND: The Demands of Immigration (DI) scale consists of six subscales and is designed to measure demands that negatively affect emotional health of immigrants. PURPOSE: The purpose of this review is to (a) examine the DI scale's language versions and translation procedures; and (b) evaluate reliability and validity of the DI scale based on studies subsequent to its initial development. METHODS: Published studies were identified through CINAHL Complete, MEDLINE, Social Sciences Premium Collection and PsycInfo. RESULTS: Seventeen quantitative studies reported the DI scale's reliability (internal consistency and test-retest) and/or validity (content and construct). Correlations among the DI subscales and key variables (e.g., job satisfaction, acculturation, depression, perceived support, and resilience) support its construct validity. CONCLUSION: The DI scale is a reliable and valid tool for measuring demands or challenges that immigrants face.

ArtontheBrain: Results of a Pilot Project Among Long-Term Care Residents.

For long-term care (LTC) residents, multiple barriers impede access to formal museum-based participa-tory art programming. Capitalizing on available technologies may circumvent common barriers and improve quality of life for those older adults even in the presence of dementia. Targets: A convenience sample of 31 older adults was recruited from the population of residents in one LTC facility. Intervention: ArtontheBrain, a web-based program, engages participants in activities centered on visual artwork, enabling users to learn about artists through activities, such as puzzles, storytelling, and group discussions. Mechanisms of Action: Researchers hypothesized that engagement with ArtontheBrain would benefit perceived quality of life in the domains of meaningful activity engagement and personal relationships and secondarily, improvements in functional performance, mood state, and cognitive performance may occur. Outcomes: Application of a quality of life survey pre and post ArtontheBrain intervention revealed significant improvements within the individual subsample for two activity options: engagement in enjoyable activities on weekends and evenings and explore new skills and interests. Total scores for the personal relationship scale had significant improvements post-intervention for the individual and group subsamples. The individual subsample demonstrated improvement in cognitive performance, which worsened for the group subsample. Mood and functional ability worsened for the entire sample.[Research in Gerontological Nursing, 14(5), 235-243.].

Machine-Learning Modeling to Predict Hospital Readmission Following Discharge to Post-Acute Care.

OBJECTIVES: Primary purpose was to generate a model to identify key factors relevant to acute care hospital readmission within 90 days from 3 types of post-acute care (PAC) sites: home with home care services (HC), skilled nursing facility (SNF), and inpatient rehabilitation facility (IRF). Specific aims were to (1) examine demographic characteristics of adults discharged to 3 types of PAC sites and (2) compare 90-day acute hospital readmission rate across PAC sites and risk levels. DESIGN: Retrospective, secondary analysis design was used to examine hospital readmissions within 90 days for persons discharged from hospital to SNF, IRF, or HC. SETTINGS AND PARTICIPANTS: Cohort sample was composed of 2015 assessment data from 3,592,995 Medicare beneficiaries, including 1,536,908 from SNFs, 306,878 from IRFs, and 1,749,209 patients receiving HC services. MEASURES: Initial level of analysis created multiple patient profiles based on predictive patient characteristics. Second level of analysis consisted of multiple logistic regressions within each profile to create predictive algorithms for likelihood of readmission within 90 days, based on risk profile and PAC site. RESULTS: Total sample 90-day hospital readmission rate was 27.48%. Patients discharged to IRF had the lowest readmission rate (23.34%); those receiving HC services had the highest rate (31.33%). Creation of model risk subgroups, however, revealed alternative outcomes. Patients seem to do best (i.e., lowest readmission rates) when discharged to SNF with one exception, those in the very high risk group. Among all patients in the low-, intermediate-, and high-risk groups, the lowest readmission rates occurred among SNF patients. CONCLUSIONS AND IMPLICATIONS: The proposed model has potential use to stratify patients' potential risk for readmission as well as optimal PAC destination. Machine-learning modeling with large data sets is a useful strategy to increase the precision accuracy in predicting outcomes among patients who have nonhome discharges from the hospital.

Assessing Older Adult Wellness: An Assessment of the Psychometric Properties of the Lifestyle Survey.

BACKGROUND AND PURPOSE: To measure wellness interventions, researchers need valid and reliable tools to measure the concept of wellness. The purpose of this study is to examine the validity and reliability of the Lifestyle Survey instrument. METHODS: Community-dwelling older adults were recruited and asked to evaluate the reliability by engaging in a test retest reliability. Observer agreement was measured by calculating a kappa score for each item. Content validity was evaluated with a focus group session. RESULTS: (n = 56) older adults completed the survey on time one and time two. Of 115 items, 77.39% demonstrated moderate or higher kappa agreement. Focus group respondents identified rewording a few items. CONCLUSION: With refinement, the Lifestyle Survey is a valid and reliable measure of wellness among community-dwelling older adults.

Toward a System Theory of Stress, Resilience, and Reintegration.

Military to civilian reintegration is a complex, multidimensional phenomenon warranting holistic perspectives. Complex phenomena require theory to understand and interpret relationships among concepts. Despite the need for theory-driven research, recent nursing reports often lack a theoretical structure. We extracted relevant concepts from the Neuman's Systems Model (stressors, environment, and person) and the Transactional Model of Stress and Coping (primary and secondary appraisal, coping, and adaptation) to form a Conceptual-Theoretical-Empirical model. Exemplar empirical instruments are presented, along with their conceptual and theoretical dimensions. An integrated System Theory of Stress, Resilience, and Reintegration is presented with its utility demonstrated through a research application.

Functional Recovery Within a Formal Home Care Program.

OBJECTIVE: To identify home care clients with substantial functional deficits who had capacity to improve and, thus, for whom recovery goals should be articulated. DESIGN: Retrospective longitudinal analysis of an international home care database. SETTING AND PARTICIPANTS: 523,907 persons receiving home care, having 2 assessments, on average, 8 months apart. MEASURES: Recovery algorithm variables included counts of dependencies of activities of daily living (ADL) and instrumental ADL (IADL) tasks, hospitalization in the last 30 days, functional decline in the last 90 days, and self-belief in one's capacity to improve. Primary dependent variable was improvement in the IADL-ADL Functional Hierarchy Scale. RESULTS: The Recovery Algorithm has 7 graded levels: the top 3 represent approximately 9% of home care clients, whereas the bottom level (where recovery is least likely to occur) includes 60% of home care clients (many with higher counts of extensive ADL or IADL dependencies). The improvement rates rise from 6.9% to 47.2% across the 7 levels of the algorithm. This relationship between change in IADL-ADL Functional Hierarchy Scale scores and Recovery Algorithm levels remained strong across age categories and cognitive performance levels. Higher rates of improvement occurred for persons who received physical therapy. CONCLUSIONS/IMPLICATIONS: The Recovery Algorithm is based on a mix of positive risk indicators and the person's challenged baseline functional status. For persons with higher scores on the algorithm, recovery is expected and should be considered in care plan goals. In addition, use of physical therapy increases the probability of recovery.