Insomnia Symptoms and Environmental Disruptors: A Preliminary Evaluation of Veterans in a Subacute Rehabilitation.

OBJECTIVES: Evaluate insomnia symptoms and environmental disruptors at admission and discharge in a subacute rehabilitation care setting. METHODS: Veterans (age ≥50) admitted to a Veterans Health Administration (VA) Hospital subacute rehabilitation between March and August 2022 completed baseline (N = 46) and follow up (N = 33) assessments with the Insomnia Severity Index (ISI), Sleep Need Questionnaire (SNQ), Epworth Sleepiness Scale (ESS), and an assessment of environmental sleep disruptors. Veterans were offered sleep resources after admission evaluations and outpatient referrals after discharge evaluations. Pearson correlation determined associations between length of stay (LOS), ISI, SNQ, and ESS scores at admission and discharge; chi-square and Wilcoxon Signed Rank Tests compared insomnia at admission and discharge. RESULTS: One-half of participants reported clinically meaningful insomnia symptoms and sleep needs at baseline with no significant change at discharge. Almost all (89.1%) Veterans reported sleep was disturbed by environmental factors, primarily staff awakenings. LOS was correlated with ESS scores at discharge (r = .52, p = .002). CONCLUSIONS: Environmental sleep disruption was common during a subacute rehabilitation admission and were not adequately addressed through sleep resources and treatment due to low uptake. CLINICAL IMPLICATIONS: Providers should assess sleep at admission and lessen environmental sleep disruptors by reducing noise, light, and non-essential awakenings at night.

Mobility in Older Adults Receiving Maintenance Hemodialysis: A Qualitative Study.

RATIONALE & OBJECTIVE: For older adults, maintaining mobility is a major priority, especially for those with advanced chronic diseases like kidney failure. However, our understanding of the factors affecting mobility in older adults receiving maintenance hemodialysis is limited. STUDY DESIGN: Descriptive qualitative study. SETTING & PARTICIPANTS: Using purposive sampling, we recruited (1) persons aged≥60 years receiving maintenance hemodialysis; and (2) care partners (≥18 years) providing regular support to an older adult receiving hemodialysis. During a single in-person home visit, we assessed mobility using the Short Physical Performance Battery (SPPB) and conducted individual one-on-one interviews regarding important personal factors related to mobility. ANALYTICAL APPROACH: Descriptive statistics were used for demographic and SPPB data. Transcripts underwent thematic coding, informed by the International Classification of Function framework of mobility. We used conceptual content analysis to inductively extract themes and subthemes. RESULTS: We enrolled 31 older adults receiving hemodialysis (42% female, 68% Black) with a mean age of 73±8 years and mean dialysis vintage of 4.6±3.5 years; their mean SPPB score was 3.6±2.8 points. Among 12 care partners (75% female, 33% Black), the mean age was 54±16 years and mean SPPB score was 10.1±2.4 points. Major themes extracted were (1) mobility represents independence; (2) mobility is precarious; (3) limitations in mobility cause distress; (4) sources of encouragement and motivation are critical; and (5) adaptability is key. LIMITATIONS: Modest sample from single geographic area. CONCLUSIONS: For older adults receiving hemodialysis, mobility is severely limited and is often precarious in nature, causing distress. Older adults receiving hemodialysis and their care partners have identified sources of encouragement and motivation for mobility, and cite an adaptable mindset as important. Future studies should conceptualize mobility as a variable condition and build on this outlook of adaptability in the development of interventions.

Capacity assessment training in geropsychology: Creating and evaluating an outpatient capacity clinic to fill a training gap.

Assessment of decision-making capacity of older adults is a growing area of practice but training opportunities are lacking. We present a needs assessment, program characteristics, pilot clinic process (n= 52 referrals) and outcome training (n= 4 interns) data for a capacity training clinic. Process data reveal that the training clinic provided consistent referrals (1 per week) across multiple capacity domains (independent living, treatment consent, and financial capacities), with 27% of referrals providing opportunities for training in protective services. Outcome data found three of the four interns reported proficient skills in capacity assessment, as well as improved skills in six areas related to capacity assessment: knowledge of limitations of assessment methods, person-environment interaction, identifying and applying ethical and legal standards, utilizing cognitive assessments, communicating results and recommendations, and assessing risk. The discussion shares lessons learned for the development of future training rotations and clinics in the capacity assessment.

PTSD is a chronic, fluctuating disorder affecting the mental quality of life in older adults.

OBJECTIVES: Examine the longitudinal course of posttraumatic stress disorder (PTSD) in older adults and its influence on mental health quality of life (MHQoL). DESIGN: Evaluation performed at baseline, and 3 and 6 months postrandomization as part of a longitudinal trial. PARTICIPANTS AND SETTINGS: A total of 1,185 participants, with a mean (±SD) age of 73.53 (±5.98) years, at seven primary care sites (including five Veterans Affairs clinics), were divided into four groups, namely, no trauma (n = 661), trauma only (n = 319), partial PTSD (n = 114), and PTSD (n = 81), based on reports of trauma and associated PTSD symptoms. MEASUREMENTS: The prevalence of comorbid depression, anxiety, and alcohol use disorders, assessed using the Diagnostic and Statistical Manual, Fourth Edition, criteria and changes in MHQoL, as assessed by the Short Form-36 mental component score. RESULTS: At baseline, the PTSD group had higher frequencies of comorbid depression and anxiety disorders and worse MHQoL than the other groups. Both chronic (participants diagnosed with PTSD at all three assessments) and fluctuating (participants moving to or from one of the other groups) trajectories of course were observed during the follow-up period, which appeared to be separate from that of the comorbid disorders. Even after accounting for those comorbid disorders, PTSD had an independent association with poorer MHQoL at multiple time points, especially in men, whereas trauma without PTSD symptoms (trauma only) had better MHQoL. CONCLUSIONS: PTSD had chronic and fluctuating courses, with negative effects on MHQoL, while partial PTSD might represent a transitional state, underscoring the need to better identify and treat PTSD at any phase in later life.

Depression Moderates Physical Functioning Over Time in Survivors of Cancer.

Background: Cancer survivors are at risk for declines in physical functioning (PF). The strongest predictor of PF is prior PF. Clinically significant depression predicts declines in PF; however, the extent to which depression symptoms moderate the association between self-reported and performance-based measures of PF over time is unknown. Objective/Purpose: To examine whether level of depression symptoms in cancer survivors moderates the association of repeated self- and performance-based measures of PF at 6 and 18 months after cancer diagnosis. Methods: Prospective, observational study with assessment at 6 (T1), 12 (T2), and 18 months after cancer diagnosis (T3). Setting and Patients: Community-dwelling US veterans with newly diagnosed head and neck, esophageal, gastric, or colorectal cancers. Measurements: Measures included demographics, cancer variables (type, stage, severity, and treatment), depression symptoms (Patient Health Questionnaire-9 [PHQ-9]), Short Physical Performance Battery (SPPB), and self-reported PF (Patient-Reported Outcomes Measurement Information System-29 [PROMIS-29]). Results: Using hierarchical regression models, after adjustment for covariates, depression symptoms at T2 moderated the relationship between performance-based PF, SPPB (ß = -0.24, P = .001) but not self-reported PF, PROMIS (ß = -0.14, P = .05). In moderation analyses, SPPB T1 was only related to SPPB T3 when the PHQ-9 score was less than 9. Limitations: Majority White, male participants, did not measure chronicity of depression. Conclusions: Depression symptoms moderate the relationship of performance-based PF from baseline to 18 months.

A controlled trial of Partners in Dementia Care: veteran outcomes after six and twelve months.

INTRODUCTION: "Partners in Dementia Care" (PDC) tested the effectiveness of a care-coordination program integrating healthcare and community services and supporting veterans with dementia and their caregivers. Delivered via partnerships between Veterans Affairs medical centers and Alzheimer's Association chapters, PDC targeted both patients and caregivers, distinguishing it from many non-pharmacological interventions. Hypotheses posited PDC would improve five veteran self-reported outcomes: 1) unmet need, 2) embarrassment about memory problems, 3) isolation, 4) relationship strain and 5) depression. Greater impact was expected for more impaired veterans. A unique feature was self-reported research data collected from veterans with dementia. METHODS AND FINDINGS: Five matched communities were study sites. Two randomly selected sites received PDC for 12 months; comparison sites received usual care. Three structured telephone interviews were completed every 6 months with veterans who could participate. RESULTS: Of 508 consenting veterans, 333 (65.6%) completed baseline interviews. Among those who completed baseline interviews, 263 (79.0%) completed 6-month follow-ups and 194 (58.3%) completed 12-month follow-ups. Regression analyses showed PDC veterans had significantly less adverse outcomes than those receiving usual care, particularly for more impaired veterans after 6 months, including reduced relationship strain (B = -0.09; p = 0.05), depression (B = -0.10; p = 0.03), and unmet need (B = -0.28; p = 0.02; and B = -0.52; p = 0.08). PDC veterans also had less embarrassment about memory problems (B = -0.24; p = 0.08). At 12 months, more impaired veterans had further reductions in unmet need (B = -0.96; p < 0.01) and embarrassment (B = -0.05; p = 0.02). Limitations included use of matched comparison sites rather than within-site randomization and lack of consideration for variation within the PDC group in amounts and types of assistance provided. CONCLUSIONS: Partnerships between community and health organizations have the potential to meet the dementia-related needs and improve the psychosocial functioning of persons with dementia. TRIAL REGISTRY: NCT00291161.

Caregiver outcomes of partners in dementia care: effect of a care coordination program for veterans with dementia and their family members and friends.

The objective is to test the effectiveness of Partners in Dementia Care (PDC), a care-coordination program that integrates and improves access to medical and nonmedical services, while strengthening the informal care network and providing information, coaching, and emotional support. PDC was delivered via a partnership between Veterans Affairs (VA) Medical Centers (VAMCs) and Alzheimer's Association chapters, for caregivers of veterans with dementia living in the community and receiving primary care from the VA. The initial sample was 486 caregivers of 508 veterans with diagnosed dementia. Outcomes were evaluated for 394 and 324 caregivers who completed 6- and 12- month follow-up, respectively. PDC had a standardized protocol that included assessment and reassessment, action planning, and ongoing monitoring. It was delivered by telephone and e-mail for cost efficiency and the ability to handle caseloads of 100 to 125. Care coordinators from VAMCs and Alzheimer's Association chapters worked as a team using a shared computerized record. A variety of caregiver outcomes was measured after 6 and 12 months. Intervention group caregivers had significant improvements in outcomes representing unmet needs, three types of caregiver strains, depression, and two support resources. Most improvements were evident after 6 months, with more-limited improvements from Months 6 to 12. Some outcomes improved for all caregivers, whereas some improved for caregivers experiencing more initial difficulties or caring for veterans with more-severe impairments. PDC is a promising model that improves linkages between healthcare services and community services, which is a goal of several new national initiatives such as the National Plan to Address Alzheimer's Disease and a proposed amendment to the Older Americans Act.

Utilization of legal and financial services of partners in dementia care study.

Financial and legal services are unique needs of persons with dementia and their caregivers. This study examines their need for legal and financial assistance and the kinds of legal and financial services provided within Partners in Dementia Care, a telephone-based, care coordination and support service intervention delivered through a partnership between Veterans Affairs (VA) medical centers and local Alzheimer's Association chapters. Based on comprehensive assessment, and needs prioritization, care coordinators collaboratively planned action steps (specific behavioral tasks) with each caregiver/person with dementia to address the dyad's identified unmet needs. Results show that 51 (54.8%) of 93 dyads reported a need for legal and financial services. Action steps related to legal and financial need included education or assistance with legal services (27.27%), nonhealth-related financial benefits (32.32%), health-related financial benefits (21.21%), financial management/planning (9.09%), and financial support (10.1%). Comparable numbers of action steps were directed to VA (41.4%) and non-VA (58.6%) services.