The dementia care study (D-CARE): Recruitment strategies and demographic characteristics of participants in a pragmatic randomized trial of dementia care.

INTRODUCTION: Pragmatic research studies that include diverse dyads of persons living with dementia (PLWD) and their family caregivers are rare. METHODS: Community-dwelling dyads were recruited for a pragmatic clinical trial evaluating three approaches to dementia care. Four clinical trial sites used shared and site-specific recruitment strategies to enroll health system patients. RESULTS: Electronic health record (EHR) queries of patients with a diagnosis of dementia and engagement of their clinicians were the main recruitment strategies. A total of 2176 dyads were enrolled, with 80% recruited after the onset of the pandemic. PLWD had a mean age of 80.6 years (SD 8.5), 58.4% were women, and 8.8% were Hispanic/Latino, and 11.9% were Black/African American. Caregivers were mostly children of the PLWD (46.5%) or spouses/partners (45.2%), 75.8% were women, 9.4% were Hispanic/Latino, and 11.6% were Black/African American. DISCUSSION: Health systems can successfully enroll diverse dyads in a pragmatic clinical trial.

Feasibility of a 4-Week Manual Therapy and Exercise Intervention on Posture and Function in Community-Dwelling Older Adults: A Pilot Study.

BACKGROUND AND PURPOSE: Thoracic hyperkyphosis is a common condition that progresses with aging and has been associated with impaired functional performance, increased risk of falls, and even mortality. Previous studies to improve posture primarily used exercise for durations of 3 months or longer. The purpose of this pilot study was to examine the feasibility of a manual therapy intervention in community-dwelling older adults over a 4-week time frame that is comparable to the typical clinical setting, to test the appropriateness and procedures for the measurement of posture and function in the older population with hyperkyphosis, and to collect preliminary data to describe change in posture and function measures. METHODS: Twenty-four participants with hyperkyphosis or forward head posture were recruited, and 22 participants completed this pilot study. Feasibility was measured based on attendance, tolerance, safety, and retention. Issues with measurement procedures were recorded. The intervention included manual therapy and exercise 3 times a week for 4 weeks to target spinal and peripheral joint stiffness, muscle lengthening, and muscle activation. Outcomes included height, kyphotic index (KI), Block Test, Acromion to Table (ATT), Timed Up and Go (TUG), 5 times sit-to-stand (5XSTS), Functional Reach (FR), 2-minute walk test (2MWT), and Patient-Specific Functional Scale (PSFS). Data collected at visits 1, 6, and 12 were analyzed using 1-way repeated-measures multivariate analysis of variance. RESULTS AND DISCUSSION: Measurement and intervention protocols were found to be feasible. A significant effect for the aggregate dependent variables change over time was found. Univariate analysis of each dependent variable showed significance except for FR. All postural measures (height, KI, Block Test, and ATT) significantly improved statistically. The KI and ATT exceed the minimal detectable change for clinical significance. Function showed statistical improvements in the TUG, 5XSTS, 2MWT, and PSFS. Clinical significance was reached with the PSFS. Seven of 9 measures showed a statistically significant change in just 2 weeks. CONCLUSIONS: This pilot study suggests that manual therapy and exercise applied to older adults shows promise for improvement in measures of posture and functional performance in a clinically feasible 4-week time frame.

Pilot study examining the association between ambulatory activity and falls among hospitalized older adults.

OBJECTIVE: To examine the ambulatory activity of older patients who had a documented fall during hospitalization for acute illness. DESIGN: A retrospective case-control design was used in a pilot study of patients (n=10; ≥65y) who had a documented fall during their hospital stay and matched controls (n=25) who did not fall. SETTING: Acute care medical/surgical unit. PARTICIPANTS: Men and women 65 years and older who wore a step activity monitor while hospitalized. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Fall incidents during the hospital stay were documented by the nurse in a standardized patient safety event report in accordance with hospital policy. The number of steps per 24-hour interval, time spent walking, and total number of activity episodes were determined for patients and controls. RESULTS: On average ± SD, patients who fell took 480.3 ± 432.2 steps per hospital day, spent 53.8 ± 36.9 minutes walking, and engaged in 25.8 ± 16.9 episodes of activity. Mean daily steps, time spent walking, and number of activity episodes for patients who did not fall were 680.1 ± 876.0, 50.1 ± 58.6, and 21.6 ± 23.8, respectively. Logistic regression results indicated no association between the fall outcome and mean daily steps (odds ratio=.95; 95% confidence interval, 0.84-1.06). CONCLUSIONS: Ambulatory activity among patients who fell varied widely. Mean daily steps, time spent walking, and number of episodes of activity were comparable with matched controls who did not fall. Patient falls were more likely to be associated with cognitive and hospital environmental factors than actual amount of walking.

Pain-Reducing Effects of Physical Therapist-Delivered Interventions: A Systematic Review of Randomized Trials Among Older Adults With Dementia.

BACKGROUND AND PURPOSE: Pain is common among older adults with dementia. There are nonpharmacological options for managing pain in this population. However, the effects of physical therapist-delivered interventions have not been summarized. The purpose of this systematic review was to summarize the literature on physical therapist-delivered interventions in randomized trials for reducing pain among older adults with dementia. METHODS: A systematic search of MEDLINE/PubMed, CINAHL, PsycINFO, and Web of Science was conducted for randomized trials of pain management in individuals 60 years or older with medically diagnosed dementia of any severity. Included studies addressed the effects of nonpharmacological physical therapist-delivered interventions on pain outcomes. Pain outcomes included patient or caregiver self-report, observational or interactive measures. Independent reviewers extracted relevant data and assessed methodological quality using the PEDro scale. RESULTS AND DISCUSSION: Three studies (total = 222 participants; mean age range = 82.2-84.0 years; 178 [80.2%] females) met inclusion criteria. PEDro scores ranged from 4 to 8/10. Interventions included passive movement and massage. Pain outcomes included the observational measures Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC), Pain in Advanced Dementia (PAINAD), and Doloplus-2 Scale. Passive movement did not show better results when compared with no treatment, while massage showed pain-reducing effects in 1 study compared with no treatment. CONCLUSIONS: The evidence supporting pain-reducing physical therapy interventions for patients with dementia is limited. There is a clear gap in knowledge related to evidence-based physical therapy for managing pain in this population. Future studies should examine active physical therapist-delivered interventions and utilize interactive pain measures.

D-CARE: The Dementia Care Study: Design of a Pragmatic Trial of the Effectiveness and Cost Effectiveness of Health System-Based Versus Community-Based Dementia Care Versus Usual Dementia Care.

BACKGROUND/OBJECTIVES: Although several approaches have been developed to provide comprehensive care for persons living with dementia (PWD) and their family or friend caregivers, the relative effectiveness and cost effectiveness of community-based dementia care (CBDC) versus health system-based dementia care (CBDC) and the effectiveness of both approaches compared with usual care (UC) are unknown. DESIGN: Pragmatic randomized three-arm superiority trial. The unit of randomization is the PWD/caregiver dyad. SETTING: Four clinical trial sites (CTSs) based in academic and clinical health systems. PARTICIPANTS: A total of 2,150 English- or Spanish-speaking PWD who are not receiving hospice or residing in a nursing home and their caregivers. INTERVENTIONS: Eighteen months of (1) HSDC provided by a nurse practitioner or physician's assistant dementia care specialist who works within the health system, or (2) CBDC provided by a social worker or nurse care consultant who works at a community-based organization, or (3) UC with as needed referral to the Alzheimer's Association Helpline. MEASUREMENTS: Primary outcomes: PWD behavioral symptoms and caregiver distress as measured by the Neuropsychiatric Inventory Questionnaire (NPI-Q) Severity and Modified Caregiver Strain Index scales. SECONDARY OUTCOMES: NPI-Q Distress, caregiver unmet needs and confidence, and caregiver depressive symptoms. Tertiary outcomes: PWD long-term nursing home placement rates, caregiver-reported PWD functional status, cognition, goal attainment, "time spent at home," Dementia Burden Scale-Caregiver, a composite measure of clinical benefit, Quality of Life of persons with dementia, Positive Aspects of Caregiving, and cost effectiveness using intervention costs and Medicare claims. RESULTS: The results will be reported in the spring of 2024. CONCLUSION: D-CARE will address whether emphasis on clinical support and tighter integration with other medical services has greater benefit than emphasis on social support that is tied more closely to community resources. It will also assess the effectiveness of both interventions compared with UC and will evaluate the cost effectiveness of each intervention.

Screening practices of patients presenting for resection of a colorectal neoplasm.

Multiple studies demonstrate the efficacy of colorectal cancer (CRC) screening in patients over 50 years of age. However, there is a lack of consensus regarding which screening method to use, and compliance has been poor. The objective of this study was to identify the CRC screening practices at two institutions and determine the relationship between screening and pathologic stage for patients presenting with a colorectal neoplasm. This study, conducted at the University of Virginia (UVA) Health System and the Salem Veterans Affairs Medical Center (VAMC) between October 30, 2000, and September 1, 2004, included 198 patients > or = 50 years who presented for resection of a primary colorectal neoplasm. Pathologic stage and prior screening were identified retrospectively through chart review and patient response to an anonymous survey. Prior screening was demonstrated in 71 per cent of patients. Colonoscopy was the most commonly used modality. There was a higher percentage of CRC screening at VAMC compared with UVA (80% vs 62%, P < 0.0008). Patients at UVA were more likely screened with colonoscopy, whereas fecal occult blood testing (FOBT) was most common at VAMC (P < 0.0001). Prior CRC screening and cancer stage were inversely related. Ninety-one per cent of patients with benign polyps had been screened prior to diagnosis, compared with 72 per cent of patients with stage I and II cancer and 54 per cent of patients with stage III and IV cancer (P < 0.05). Of patients presenting for surgery, 71 per cent underwent CRC screening. Variability exists in the methods employed for CRC screening. CRC screening facilitates diagnosis at an early stage.

Hospital Readmission Following Discharge From Inpatient Rehabilitation for Older Adults With Debility.

BACKGROUND: Debility accounts for 10% of inpatient rehabilitation cases among Medicare beneficiaries. Debility has the highest 30-day readmission rate among 6 impairment groups most commonly admitted to inpatient rehabilitation. OBJECTIVE: The purpose of this study was to examine rates, temporal distribution, and factors associated with hospital readmission for patients with debility up to 90 days following discharge from inpatient rehabilitation. DESIGN: A retrospective cohort study was conducted using records for 45,424 Medicare fee-for-service beneficiaries with debility discharged to community from 1,199 facilities during 2006-2009. METHODS: Cox proportional hazard regression models were used to estimate hazard ratios for readmission. Schoenfeld residuals were examined to identify covariate-time interactions. Factor-time interactions were included in the full model for Functional Independence Measure (FIM) discharge motor functional status, comorbidity tier, and chronic pulmonary disease. Most prevalent reasons for readmission were summarized by Medicare severity diagnosis related groups. RESULTS: Hospital readmission rates for patients with debility were 19% for 30 days and 34% for 90 days. The highest readmission count occurred on day 3 after discharge, and 56% of readmissions occurred within 30 days. A higher FIM discharge motor rating was associated with lower hazard for readmissions prior to 60 days (30-day hazard ratio=0.987; 95% confidence interval=0.986, 0.989). Comorbidities with hazard ratios >1.0 included comorbidity tier and 11 Elixhauser conditions, 3 of which (heart failure, renal failure, and chronic pulmonary disease) were among the most prevalent reasons for readmission. LIMITATIONS: Analysis of Medicare data permitted only use of variables reported for administrative purposes. Comorbidity data were analyzed only for inpatient diagnoses. CONCLUSIONS: One-third of patients were readmitted to acute hospitals within 90 days following rehabilitation for debility. Protective effect of greater motor function was diminished by 60 days after discharge from inpatient rehabilitation.

The Uniform Data System for Medical Rehabilitation: report of patients with debility discharged from inpatient rehabilitation programs in 2000-2010.

OBJECTIVE: Benchmark data are provided for a national sample of patients who received inpatient rehabilitation for debility. DESIGN: Patients with debility from 830 inpatient rehabilitation facilities in the United States contributing to the Uniform Data System for Medical Rehabilitation from 2000 to 2010 were examined. Demographic information (age, marital status, sex, race/ethnicity, prehospital living setting, and discharge setting), hospital information (length of stay, program interruptions, payer, and codes for admitting diagnosis), and functional status (Functional Independence Measure [FIM] instrument ratings at admission and discharge, FIM change, and FIM efficiency) were analyzed. RESULTS: Data from 2000 to 2010 (N = 260,373) revealed a decrease in mean (SD) FIM total admission ratings from 73.9 (16.2) to 62.5 (15.8). The FIM total discharge ratings decreased from 95.0 (19.7) to 88.2 (19.8). Mean (SD) length of stay decreased from 14.3 (9.1) to 12.1 (6.2) days. The FIM efficiency (change/day) increased from 1.9 (1.7) to 2.4 (1.9). Discharge to community decreased from 80% to 75%. Acute care discharges accounted for 12% of the cases. Policy changes affecting classification, reimbursement, and/or documentation processes may have influenced the results. CONCLUSIONS: National data indicate that the number of debility cases is increasing with diverse composition of etiologic diagnoses. A high proportion of these patients is discharged to acute care compared with other impairment groups.