Vaping cessation support recommendations from adolescents who vape: a qualitative study.

BACKGROUND: Youth vaping is a serious public health concern, being more prevalent than any other tobacco use. To inform cessation interventions, we explored what adolescents perceive as their reasons for quitting and strategies to help them quit. METHOD: Semi-structured interviews were conducted with a convenience sample of 11 adolescents reporting vaping in the past 90 days and recruited from a high school in Massachusetts. Interviews were transcribed and dual-coded. Inductive thematic analysis was employed, and thematic summaries were prepared. RESULTS: Reasons adolescents reported for quitting included cost, experiencing "nic-sick" from nicotine withdrawal or excess intake, negative impacts on mood, concentration, or health, and experiencing symptoms of nicotine dependence. Nearly all tried to quit multiple times. Barriers to quitting included exposure to vaping, access to vape products, stress, and "cool" new products or flavors. Quit strategies included avoiding others vaping, seeking social support to quit, addressing peer pressure to continue vaping, learning successful quit strategies from peers, and using distraction strategies or alternatives to vaping. CONCLUSION: Many adolescents who vape want to quit, and most have tried multiple times. Interventions need to engage adolescents with varying reasons to quit, barriers, and quit strategy preferences. CLINICAL TRIAL REGISTRATION: This study is registered through ClinicalTrials.gov. The trial registration number is NCT05140915. The trial registration date is 11/18/2021.

Vaping Cessation Support Recommendations from Adolescents Who Vape: A Qualitative Study.

Background: Youth vaping is an epidemic, being more prevalent than any other tobacco use. To inform cessation interventions, we explored what adolescents perceive to be their reasons for quitting and strategies to help in their quit efforts. Method: Semi-structured interviews were conducted with a convenience sample of 11 adolescents reporting vaping in the past 90 days and recruited from a high school in Massachusetts. Interviews were transcribed, and dual coded. Inductive thematic analysis was employed and thematic summaries were prepared. Results: Reasons adolescents reported for quitting included: cost; experiencing "nic-sick" from nicotine withdrawal or excess intake; negative impacts on mood, concentration, or health; and experiencing symptoms of nicotine dependence. Nearly all tried to quit multiple times. Barriers to quitting included: exposure to vaping; access to vape products; stress; and "cool" new products or flavors. Quit strategies included: avoiding others vaping; seeking social support to quit; addressing peer pressure to continue vaping; learning successful quit strategies from peers; and using distraction strategies or alternatives to vaping. Conclusion: Many adolescents who vape want to quit and most have tried multiple times. Interventions need to engage adolescents with varying reasons to quit, barriers, and quit strategy preferences. Clinical Trial Registration: This study is registered through ClinicalTrials.gov. The trial registration number is NCT05140915. The trial registration date is 11/18/2021.

Social engagement and cognitive impairment among nursing home residents: The role of sensory impairment.

BACKGROUND AND OBJECTIVES: Using US national nursing home data, this cross-sectional study sought to evaluate 1) the association between lack of social engagement and level of cognitive impairment; and 2) the extent to which this association differs by hearing and visual impairment. RESEARCH DESIGN AND METHODS: Our sample included 793,846 nursing home residents aged ≥ 50 years. The Index of Social Engagement was categorized as none/lower (0, 1, 2) or higher levels (3 through 6). Cognitive Performance Scale was grouped as intact/mild (0, 1, 2), moderate (3, 4), or severe (5, 6). Multinomial models provided adjusted odds ratio (aOR) and 95 % confidence intervals (CI) between none/lower social engagement and cognitive impairment. We estimated relative excess risk due to interaction (RERI) to quantify the joint effects of social engagement and sensory impairment types. RESULTS: Overall, 12.6 % had lower social engagement, 30.3 % had hearing impairment, and 40.3 % had visual impairment. Compared to residents with high social engagement, those with lower social engagement were more likely to have moderate/severe cognitive impairment (aORmoderate = 2.21, 95 % CI 2.17-2.26; aORsevere = 6.49, 95 % CI 6.24-6.74). The impact of low social engagement on cognitive impairment was more profound among residents with hearing impairment and/or visual impairment (RERIhearing = 3.89, 95 % CI 3.62-4.17; RERIvisual = 25.2, 95 % CI 23.9-26.6)). DISCUSSION AND IMPLICATIONS: Residents with lower social engagement had higher levels of cognitive impairment. Residents with sensory impairments are potentially more susceptible to the negative impact of lower levels of social engagement on level of cognitive impairment.

Eating Disorder Specialist Views on Gender Competency and Education for Treating Gender Minority Patients.

Studies exploring patient experience with eating disorder specialists have reported poor gender competency among clinicians, as revealed through patient-clinician interactions. Through interviews with eating disorder specialists, the authors sought to (1) clarify how and why current practice and clinical training may not meet the needs of transgender and gender-diverse patients, (2) assess where and how clinicians received education on gender identity, and (3) how changes can be made to meet educational and patient needs. Specialists were recruited, and semi-structured interviews were conducted. Narratives were coded by two independent coders, using thematic analysis. Four key themes emerged from 19 completed interviews: Training and education received, importance of receiving training or education, self-education, and improvements recommended by clinicians. Only ~ 16% (n = 3) of clinicians reported sufficient training both in graduate school and through their place of employment. Most with sufficient education received it at their clinic/practice. Despite lacking formal training, all clinicians engaged in some form of self-education on gender. These findings support the need for standardized and comprehensive graduate curricula, in-service training, and continuing education requirements. Advocacy is required to encourage accrediting organizations to mandate training on gender among mental health clinicians.

U.S. nursing home leadership experiences with COVID-19 and its impact on residents and staff: A qualitative analysis.

OBJECTIVES: To explore experiences of U.S. (United States) nursing home leadership during the COVID-19 pandemic in their efforts to address resident loneliness and social isolation and to elicit stories about personal and professional impacts on themselves and staff. DESIGN: Qualitative inquiry via three optional open-ended questions appended to a national self-administered survey of American nursing home leaders was employed. Textual data was analyzed using an iterative reflexive thematic approach. SETTING AND PARTICIPANTS: A stratified sample frame defined by facility size (beds: 30-99, 100+) and quality ratings (1, 2-4, 5) was employed. Web survey links and paper surveys were sent to 1,676 nursing home directors of nursing between February and May 2022. RESULTS: Open text responses were collected from 271 nursing homes. Broad themes included: 1) Addressing needs of residents & families; 2) Challenges; and 3) Personal experiences of nursing home leadership/staff. Respondents described trauma to residents, staff, and leadership. Resident loneliness was addressed using existing and newer technologies and innovative indoor and outdoor activities. Residents experienced fear, illness, loss, and sometimes death. Isolation from family and lack of touch were particularly difficult. Regulations were seen as punitive while ignoring emotional needs of residents. Staffing challenges and pressures to do more with less created additional stress. Leadership and staff made significant sacrifices resulting in physical, social, and emotional consequences. Beneficial outcomes included staff bonding, professional growth, and permanent implementation of new interventions. CONCLUSIONS AND IMPLICATIONS: New and creative interventions were successfully implemented to address social isolation and loneliness. Improved Wi-Fi and other nursing home infrastructure upgrades are needed to maintain them. Reimagining often conflicting overlapping federal, state, and local regulations, grounding them in good clinical judgement, and incentivizing performance improvement should be considered. Trauma experienced by staff needs to be addressed to deal with current and future workforce needs.

Health effects of social connectedness in older adults living in congregate long-term care settings: A systematic review of quantitative and qualitative evidence.

BACKGROUND: The overall impact of social connectedness on health outcomes in older adults living in nursing homes and assisted living settings is unknown. Given the unclear health impact of social connectedness for older adults in congregate long-term care settings worldwide, a comprehensive systematic review is required to evaluate the overall relationship between social connectedness and health outcomes for them. OBJECTIVES: The purpose of this article was to synthesize the literature regarding the health impact of social connectedness among older adults living in nursing homes or assisted living settings. METHODS: Using PRISMA guidelines, we identified eligible studies from Scopus, MEDLINE, PsycINFO, CINAHL and Cochrane databases (1990-2021). Bias and quality reporting assessment was performed using standardized criteria for cohort, cross sectional and qualitative studies. At each stage, ≥ 2 researchers conducted independent evaluations. RESULTS: Of the 7350 articles identified, 25 cohort (follow-up range: 1 month-11 years; with two also contributing to cross sectional), 86 cross sectional, eight qualitative and two mixed methods were eligible. Despite different instruments used, many residents living in nursing homes and assisted living settings had reduced social engagement. Quantitative evidence supports a link between higher social engagement and health outcomes most studied (e.g. depression, quality of life). Few studies evaluated important health outcomes (e.g. cognitive and functional decline). Most cohort studies showed that lack of social connectedness accelerated time to death. CONCLUSIONS: Social connectedness may be an important modifiable risk factor for adverse health outcomes for older adults living in nursing homes and assisted living facilities. Most studies were cross sectional and focused on quality of life and mental health outcomes. Longitudinal studies suggest that higher social engagement delays time to death. Evidence regarding other health outcomes important to older adults was scant and requires further longitudinal studies.

Adolescents Who Vape Nicotine and Their Experiences Vaping: A Qualitative Study.

Introduction: Understanding adolescent perceptions of vaping and roles it plays in their lives is needed to design effective interventions to help adolescents quit. We explored vaping experiences of 11 adolescents from initiation through quit attempts. Methods: A convenience sample of students who vaped in the last 90 days was recruited from one suburban high school in Massachusetts. Qualitative interviews were transcribed and coded. An inductive thematic analysis approach was employed. Areas of agreement and range of responses in code reports were summarized. Results: Eleven open-ended semi-structured interviews were conducted (mean = 32.5 minutes each). Vaping initiation often occurred when socializing with friends who also supplied vaping devices. Vaping was "something to do" and new flavors engaged adolescents further. Solitary activities coupled with vaping included video gaming, getting ready for school, talking on the phone, or studying. Peak hours for vaping included morning, before and after school, before parents returned from work, and after parents went to bed. Several vaped to address anxiety/stress. For some, anxiety control was a main reason for vaping. Participants were concerned about health effects and nicotine dependence. Cost and health effects were drivers of quitting. Quit strategies relied on willpower and distraction. Conclusions: Peers have powerful influences on the initiation and maintenance of adolescent vaping. Vaping habits can become routinized into adolescent lives. Addiction is a concern although nicotine's anxiolytic effects were valued by many. Social connection was enhanced by communal vaping, sharing, and common vernacular, secrecy and rule-breaking. We describe the context in which adolescents vape nicotine, their reasons for vaping, and reasons to quit. This information can inform the development of interventions to better address adolescents' triggers to vape, and social and psychosocial barriers to quitting. Our findings suggest a desire to quit vaping but a limited awareness of quitting strategies.

Rising to the Occasion: A National Nursing Home Study Documenting Attempts to Address Social Isolation During the COVID-19 Pandemic.

OBJECTIVES: COVID-19-related policies introduced extraordinary social disruption in nursing homes. In response, nursing facilities implemented strategies to alleviate their residents' loneliness. This study sought to describe interventions nursing homes used, document the perceived effectiveness of efforts, and determine barriers to implementing strategies to mitigate social isolation and loneliness. DESIGN: National survey of nursing homes sampled in strata defined by facility size (beds: 30-99, 100+) and quality ratings (1, 2-4, 5). SETTINGS AND PARTICIPANTS: US Nursing Home Directors of Nursing/Administrators (n = 1676). METHODS: The survey was conducted between February and May 2022 (response rate: 30%; n = 504, weighted n = 14,506). Weighted analyses provided nationally representative results. RESULTS: One-third were extremely concerned about their home's ability to meet residents' medical and social needs during COVID-19 before vaccines were available and 13% after vaccines. Nearly all reported trying to mitigate residents' social isolation during the pandemic. Efforts tried, and perceived as most useful, included using technology (tablets, phones, emails), assigning staff as a family contact, and more staff time with residents. Most frequently cited barriers to implementation were related to staffing issues. CONCLUSIONS AND IMPLICATIONS: Despite multiple challenges, nearly all nursing homes tried to implement many different approaches to address residents' social needs, with some (eg, having an assigned family contact, use of tablets and phones) perceived as more useful than others. Staffing issues presented barriers for addressing the social needs of nursing home residents. Many strategies for addressing social isolation placed more demands on a workforce already stretched to the limit. While concerns about resident social isolation reduced after vaccine availability, administrators remained extremely concerned about staff burnout and mental health.

Provider perceptions of barriers and facilitators to care in eating disorder treatment for transgender and gender diverse patients: a qualitative study.

BACKGROUND: The prevalence of eating disorders is higher in transgender and non-binary compared to cisgender people. Gender diverse people who seek eating disorder treatment often report struggling to find affirming and inclusive treatment from healthcare clinicians. We sought to understand eating disorder care clinicians' perceptions of facilitators of and barriers to effective eating disorder treatment for transgender and gender diverse patients. METHODS: In 2022, nineteen US-based licensed mental health clinicians who specialized in eating disorder treatment participated in semi-structured interviews. We used inductive thematic analysis to identify themes around perceptions and knowledge of facilitators and barriers to care for transgender and gender diverse patients diagnosed with eating disorders. RESULTS: Two broad themes were identified: (1) factors affecting access to care; and (2) factors affecting care while in treatment. Within the first theme, the following subthemes were found: stigmatization, family support, financial factors, gendered clinics, scarcity of gender-competent care, and religious communities. Within the second theme, prominent subthemes included discrimination and microaggressions, provider lived experience and education, other patients and parents, institutions of higher education, family-centered care, gendered-centered care, and traditional therapeutic techniques. CONCLUSION: Many barriers and facilitators have potential to be improved upon, especially those caused by clinicians' lack of knowledge or attitudes towards gender minority patients in treatment. Future research is needed to identify how provider-driven barriers manifest and how they can be improved upon to better patient care experiences.

Eating disorders are more common among transgender and non-binary compared to cisgender people. Despite this, gender diverse people who seek eating disorder treatment often report struggling to find affirming and inclusive care. We interviewed nineteen US-based licensed mental health clinicians who specialized in eating disorder treatment to learn perceptions and knowledge of facilitators and barriers to care for transgender and gender diverse patients diagnosed with eating disorders. Factors affecting access to care included stigmatization, family support, financial factors, gendered clinics, scarcity of gender-competent care, and religious communities. Factors affecting care while in treatment included discrimination and microaggressions, provider lived experience and education, other patients and parents, institutions of higher education, family-centered care, gendered-centered care, and traditional therapeutic techniques. This research identified barriers and facilitators with the potential for improvement, especially those caused by clinician's lack of knowledge or attitudes towards gender minority patients in treatment.

Social Connectedness among Long-Stay Nursing Home Residents with Alzheimer's and Dementia: Exploring Individual and Facility-Level Variation.

INTRODUCTION: This study sought to explore individual and facility-level variation in social connectedness among long-stay nursing home residents with Alzheimer's or other dementias (ADRD). METHODS: We identified 721,074 long-stay residents with ADRD using 2016 Minimum Data Set 3.0 data. Social connectedness was defined using the social connectedness index (SCI) (high: SCI = 5, lower: 0 < SCI ≤ 4). Adjusted odds ratios (aOR) provided estimates of the associations between resident-level and facility-level characteristics, and high SCI was derived from logistic models. RESULTS: The SCI Cronbach's alpha was 0.69; 78.6% had high SCI scores. Men were less likely than women to have higher SCI scores (aOR = 0.97; 95% CI: 0.97-0.98). Increasing age was associated with higher SCI scores (e.g., aOR [85-94 vs. 40-64 years]: 1.07; 95% CI: 1.06-1.07). Those with moderate cognitive impairment (aOR: 0.87) and severe cognitive impairment (aOR: 0.85) had reduced odds of SCI = 5 relative to those with mild/intact cognitive function. Residents living in homes with special care dementia units and with higher percentage of residents with dementia had decreased odds of high social connectedness. DISCUSSION/CONCLUSION: Understanding resident- and nursing home-level variation in social connectedness may be important for targeting interventions that reduce isolation among residents with ADRD.

Health effects of loneliness and social isolation in older adults living in congregate long term care settings: A systematic review of quantitative and qualitative evidence.

BACKGROUND: Mounting evidence of loneliness and negative health impacts has placed loneliness among the "geriatric giants" in need of intervention by the healthcare system. OBJECTIVE: To evaluate the literature regarding the health impact of loneliness among older adults living in congregate living settings (i.e., assisted living, nursing homes). MATERIALS AND METHODS: Five databases were searched for quantitative and qualitative studies from January 1990 through August 2021. Methodological quality was assessed using modified criteria specific to quantitative and qualitative studies. Dual review assured the quality of the systematic review conduct. RESULTS: Five qualitative, 3 mixed method, 19 cross-sectional, and 4 cohort articles were eligible. Despite different tools used to measure loneliness, loneliness appeared common among older residents in congregate living situations. In most studies, loneliness was associated with depression (regardless of scale used), albeit all but one came from cross-sectional studies. Few studies noted the association between loneliness and suicidal ideation and frailty. The three cohort studies that evaluated loneliness and mortality had mixed results. Resilience and activities appeared to mediate the association between loneliness and negative health outcomes and social support appeared to moderate associations. CONCLUSIONS: For older adults living in congregate long term care settings, loneliness is a common phenomenon, with cross-sectional studies suggesting links to depression, suicidal ideation, and frailty. Additional longitudinal studies to understand the impact of loneliness on health outcomes in older adults living in congregate settings are needed, as are rigorous evidence-based interventions to address loneliness and mitigate its harmful effects during life's final chapter.

Personal Experiences with Diagnostic Delay Among Axial Spondyloarthritis Patients: A Qualitative Study.

INTRODUCTION: On average, patients with axial spondyloarthritis (axSpA) suffer from symptoms up to 13 or more years before diagnosis, contributing to psychological distress and healthcare burden METHODS: We conducted six semi-structured focus groups with 26 axSpA patients (from 3 rheumatology practices located in the states of Massachusetts, Colorado, and Pensylvania, USA) exploring early disease and diagnostic experiences. Verbatim transcripts were coded using a start list with emerging thematic codes added. A qualitative thematic analysis was performed RESULTS: Many participants described meandering and frustrating diagnostic journeys. Participants reported that intermittent axSpA symptoms and idiopathic pain contributed to physician confusion and delay in patients seeking care. Participants were sometimes perceived as somaticizing, drug-seeking, or "crazy." Diagnostic delay led to frustration and mental suffering. Doctors "giving up" was considered profoundly negative. Stories of symptoms fell into five areas: (1) pain; (2) stiffness; (3) impact on sleep; (4) impact on daily activities; and (5) changes with weather. Self-advocacy and family advocacy were considered essential. Participants suggested wider use of HLA-B27 testing and development of a definitive diagnostic test CONCLUSION: Most participants described significant suffering prior to axSpA diagnosis which could have been avoided with earlier intervention. Further research on the early disease experiences of axSpA patients is needed.

The relationship between restless sleep and symptoms of the knee: data from the Osteoarthritis Initiative.

OBJECTIVE: To examine the associations between restless sleep and knee symptoms among individuals with radiographically confirmed KOA. METHODS: Cross-sectional and longitudinal associations were examined using Osteoarthritis Initiative (OAI) data. Participants with radiographic KOA (n = 2517) were asked how often sleep was restless in the past week over the 4 years, and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) was used to measure knee symptoms. Adjusted ß coefficients (aß) and 95% confidence intervals (CI) were derived from generalized estimating equations (GEEs) models stratified by sex. RESULTS: One in 7 participants reported ≥ 3 nights with restless sleep. Cross-sectional analyses indicated that restless sleep 5-7 nights was associated with worse symptoms (Women: pain: aß 1.93, 95% CI 1.12-2.74, stiffness: aß 0.57, 95% CI 0.19-0.94, physical function: aß 5.68, 95% CI 3.09-8.27; Men: pain: aß = 1.85, 95% CI 0.85-2.86; stiffness: aß 0.63, 95% CI 0.15-1.12; physical function: aß 5.89, 95% CI 2.68-9.09) compared with < 1 night. Longitudinal analyses confirmed that more nights with restless sleep were associated with worse pain (P trend = 0.01) and function (P trend = 0.04) in women and physical function in men (P trend = 0.04), although estimates did not meet thresholds for minimal clinically meaningful differences. CONCLUSION: While the analysis of cross-sectional data supported the association between restless sleep and KOA symptoms, such relationships were not confirmed in more robust longitudinal analysis. Further research examining whether sleep quality, duration, or disorders is associated with worsening symptoms in persons with KOA is warranted. Key Points • The prevalence of frequent restless sleep among persons with knee OA is not uncommon. • There were linear trends between frequency of restless sleep and self-reported symptoms of the knee in cross-sectional analyses. • In the more robust longitudinal analysis, despite the statistically significant linear trends observed between frequency of restless sleep and symptoms (women: pain and physical function; men: function), none appeared to reach the a priori selected ranges for minimally clinically relevant differences.

Rigor and reproducibility training for first year medical students in research pathways.

In the Spring of 2020, we launched a rigor and reproducibility curriculum for medical students in research training programs. This required class consisted of eight, 2-h sessions, which transitioned to remote learning in response to the coronavirus disease 2019 (COVID-19) epidemic. The class was graded as pass/fail. Flipped classroom techniques, with multiple hands-on exercises, were developed for first-year medical students (MD/PhD [n = 9], Clinical and Translational Research Pathway (CTRP) students [n = 9]). Four focus groups (n = 13 students) and individual interviews with the two instructors were conducted in May 2020. From individual interviews with instructors and focus groups with medical students, the course and its components were favorably reviewed. Students thought the course was novel, important, relevant, and practical-and teaching strategies were effective (e.g., short lectures, interactive small group exercises, and projects). Most students expressed concerns about lack of time for course preparation. Sharper focus and streamlining of preparation work may be required. Pre- and post-student self-assessments of rigor and reproducibility competencies showed average post-scores ranging from high/moderate to strong understanding (n = 11). We conclude that rigor and reproducibility can be taught to first-year medical students in research pathways programs in a highly interactive and remote format. Study Highlights WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC? The rigor and reproducibility crisis calls for robust training of scientists in best practices for enhancing the research rigor. WHAT QUESTION DID THIS STUDY ADDRESS? We evaluated a curriculum to develop physician-scientists skilled at documenting research workflow from idea generation to publication with reproducibility in mind. WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE? Highly interactive exercises, coupled with a hands-on replication group project provide a pathway for students to gain competencies important to the improvement of rigor and reproducibility in scientific research. Rigor and reproducibility can be taught in a highly interactive format and using a remote format. HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE? Formal training is needed to raise awareness of the reproducibility crisis and improve the rigor of research conducted. If techniques taught are used, the transparency and reproducibility of clinical and translational science will be improved.

Physical Activity and Attitudes Toward Exercise in People With Axial and Peripheral Spondyloarthritis.

OBJECTIVE: To evaluate physical activity and attitudes toward exercise among people with axial (ax-) and peripheral (p-) spondyloarthritis (SpA). METHODS: Using baseline information from an ongoing, longitudinal, prospective SpA cohort study (n = 264), self-reported attitudes and beliefs toward exercise were assessed using questionnaires. Total metabolic equivalent (MET) hours of self-reported physical activity per week, time spent in activities, and activity levels were calculated from the Nurses' Health Study Physical Activity Questionnaire II (NHSPAQ II). Adjusted multivariable linear models estimated the relationship between physical activity and disease status (axial vs peripheral). RESULTS: Regardless of predominant anatomic distribution of disease, most participants were well-educated, non-Hispanic White men. Approximately 40% met the US Department of Health and Human Services physical activity recommendations. Positive attitudes, beliefs, and perceived benefits toward exercise were similar by anatomic distribution of disease. Despite similar MET h/week, participants with axial disease had greater concerns regarding discomfort and joint injuries than those with peripheral disease. Compared to those with pSpA (n = 201), participants with axSpA (n = 63) spent less time engaging in light and moderate activities (adjusted ß in light activity: -1.94 min/week, 95% CI -2.96 to -0.93; adjusted ß in moderate activity: -1.05 min/week, 95% CI -2.12 to 0.02). CONCLUSION: Participants with axSpA had greater concerns regarding discomfort and injuries from exercise than those with pSpA. Although no differences in time spent in vigorous activities were observed, participants with axSpA spent less time than those with pSpA in light to moderate activities.

Prevalence of Pain on Admission by Level of Cognitive Impairment in Nursing Homes.

PURPOSE: To provide contemporary estimates of pain by level of cognitive impairment among US nursing home residents without cancer. METHODS: Newly admitted US nursing home residents without cancer assessed with the Minimum Data Set 3.0 at admission (2010-2016) were eligible (n=8,613,080). The Cognitive Function Scale was used to categorize level of cognitive impairment. Self-report or staff-assessed pain was used based on a 5-day look-back period. Estimates of adjusted prevalence ratios (aPR) were derived from modified Poisson models. RESULTS: Documented prevalence of pain decreased with increased levels of cognitive impairment in those who self-reported pain (68.9% no/mild, 32.9% severe) and those with staff-assessed pain (50.6% no/mild, 37.2% severe staff-assessed pain). Relative to residents with no/mild cognitive impairment, pharmacologic pain management was less prevalent in those with severe cognitive impairment (self-reported: 51.3% severe vs 76.9% in those with no/mild; staff assessed: 52.0% severe vs 67.7% no/mild). CONCLUSION: Pain was less frequently documented in those with severe cognitive impairment relative to those with no/mild impairments. Failure to identify pain may result in untreated or undertreated pain. Interventions to improve evaluation of pain in nursing home residents with cognitive impairment are needed.

Differences in Staff-Assessed Pain Behaviors among Newly Admitted Nursing Home Residents by Level of Cognitive Impairment.

OBJECTIVE: Pain is common among nursing home residents with cognitive impairment and dementia. Pain is often underdiagnosed and undertreated, which may lead to adverse health outcomes. Nonverbal behaviors are valid indicators of pain, but the extent to which these behavioral expressions vary across levels of cognitive impairment is unknown. This study sought to examine differences in the prevalence of pain behaviors among nursing home residents with varying levels of cognitive impairment. METHODS: The Minimum Data Set, version 3.0, was used to identify newly admitted nursing home residents with staff-assessed pain (2010-2016, n = 1,036,806). Staff-assessed pain behaviors included nonverbal sounds, vocal complaints, facial expressions, and protective body movements or postures over a 5-day look-back period for residents unable or unwilling to self-report pain. The Cognitive Function Scale was used to categorize residents as having no/mild, moderate, or severe cognitive impairment. Modified Poisson models provided adjusted prevalence ratios (aPR) and 95% CIs. RESULTS: Compared to residents with no/mild cognitive impairments (any pain: 48.1%), residents with moderate cognitive impairment (any pain: 42.4%; aPR: 0.94 [95% CI 0.93-0.95]) and severe cognitive impairment (any pain: 38.4%; aPR: 0.86 [95% CI 0.85-0.88]) were less likely to have any pain behavior documented. Vocal pain behaviors were common (43.5% in residents with no/mild cognitive impairment), but less so in those with severe cognitive impairment (20.1%). Documentation of facial expressions and nonverbal pain behaviors was more frequent for residents with moderate and severe cognitive impairment than those with no/mild cognitive impairment. CONCLUSIONS: The prevalence of behaviors indicative of pain differs by level of cognitive impairment. Pain evaluation and management plays an important role in treatment and care outcomes. Future work should examine how practitioners' perceptions of pain behaviors influence their ratings of pain intensity and treatment choices.

Adjuvant Use and the Intensification of Pharmacologic Management for Pain in Nursing Home Residents with Cancer: Data from a US National Database.

OBJECTIVES: Our objective was to describe the prevalence of adjuvants to opioid therapy and changes in these agents for pharmacologic management in nursing home residents with cancer. METHODS: We included Medicare beneficiaries with cancer and documented opioid use at nursing home admission in 2011-2013 (N = 3268). The Minimum Data Set 3.0 provided information on sociodemographic and clinical characteristics. Part D claims provided information on opioid and adjuvant use during the 7 days after admission and 90 days later. Proportions of changes in these agents were estimated. Separate logistic models estimated associations between resident characteristics and (1) use of adjuvants at admission and (2) intensification of pharmacologic management at 90 days. RESULTS: Nearly 20% of patients received adjuvants to opioids at admission, with gabapentin the most common adjuvant (34.4%). After 90 days, approximately 25% had maintained or intensified pharmacologic management. While advanced age (≥ 85 vs. 65-74 years, adjusted odds ratio [aOR] 0.80; 95% confidence interval [CI] 0.63-1.02) and comorbidities, including dementia (aOR 0.65; 95% CI 0.53-0.82) and depression (aOR 1.55; 95% CI 1.29-1.87), were associated with adjuvant use at admission, worse cognitive impairment (severe vs. no/mild, aOR 0.80; 95% CI 0.64-0.99) and presence of more severe pain (moderate/severe vs. no pain, aOR 1.60; 95% CI 1.26-2.03) were associated with intensification of drug regimen. CONCLUSION: Given aging-related changes and the presence of comorbid conditions in older adults, safety studies of these practices are warranted.

Longterm Effectiveness of Intraarticular Injections on Patient-reported Symptoms in Knee Osteoarthritis.

OBJECTIVE: We examined the longterm effectiveness of corticosteroid or hyaluronic acid injections in relieving symptoms among persons with knee osteoarthritis (OA). METHODS: Using Osteoarthritis Initiative data, a new-user design was applied to identify participants initiating corticosteroid or hyaluronic acid injections (n = 412). Knee symptoms (pain, stiffness, function) were measured using The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). We used marginal structural models adjusting for time-varying confounders to estimate the effect on symptoms of newly initiated injection use compared to nonusers over 2 years of followup. RESULTS: Among 412 participants initiating injections, 77.2% used corticosteroid injections and 22.8% used hyaluronic acid injections. About 18.9% had additional injection use after initiation, but switching between injection types was common. Compared to nonusers, on average, participants initiating a corticosteroid injection experienced a worsening of pain (yearly worsening: 1.24 points, 95% CI 0.82-1.66), stiffness (yearly worsening: 0.30 points, 95% CI 0.10-0.49), and physical functioning (yearly worsening: 2.62 points, 95% CI 0.94-4.29) after adjusting for potential confounders with marginal structural models. Participants initiating hyaluronic acid injections did not show improvements of WOMAC subscales (pain: 0.50, 95% CI -0.11 to 1.11; stiffness: -0.07, 95% CI -0.38 to 0.24; and functioning: 0.49, 95% CI -1.34 to 2.32). CONCLUSION: Although intraarticular injections may support the effectiveness of reducing symptoms in short-term clinical trials, the initiation of corticosteroid or hyaluronic acid injections did not appear to provide sustained symptom relief over 2 years of followup for persons with knee OA.

Cognitive Impairment and Pain Among Nursing Home Residents With Cancer.

CONTEXT: The prevalence of pain and its management has been shown to be inversely associated with greater levels of cognitive impairment. OBJECTIVES: To evaluate whether the documentation and management of pain varies by level of cognitive impairment among nursing home residents with cancer. METHODS: Using a cross-sectional study, we identified all newly admitted U.S. nursing home residents with a cancer diagnosis in 2011-2012 (n = 367,462). Minimum Data Set 3.0 admission assessment was used to evaluate pain/pain management in the past five days and cognitive impairment (assessed via the Brief Interview for Mental Status or the Cognitive Performance Scale for 91.6% and 8.4%, respectively). Adjusted prevalence ratios with 95% CI were estimated from robust Poisson regression models. RESULTS: For those with staff-assessed pain, pain prevalence was 55.5% with no/mild cognitive impairment and 50.5% in those severely impaired. Pain was common in those able to self-report (67.9% no/mild, 55.9% moderate, and 41.8% severe cognitive impairment). Greater cognitive impairment was associated with reduced prevalence of any pain (adjusted prevalence ratio severe vs. no/mild cognitive impairment; self-assessed pain 0.77; 95% CI 0.76-0.78; staff-assessed pain 0.96; 95% CI 0.93-0.99). Pharmacologic pain management was less prevalent in those with severe cognitive impairment (59.4% vs. 74.9% in those with no/mild cognitive impairment). CONCLUSION: In nursing home residents with cancer, pain was less frequently documented in those with severe cognitive impairment, which may lead to less frequent use of treatments for pain. Techniques to improve documentation and treatment of pain in nursing home residents with cognitive impairment are needed.