Advancing Late-Life Trauma-Informed Care Education: Development and Evaluation of an Educational Podcast.

Posttraumatic stress disorder (PTSD) may emerge in late life in the context of illness, role changes, and life review, leading to complications in disease management. The "Talking Later" podcast was developed as an accessible educational product to improve knowledge about late-life PTSD. We describe the process of systematically developing a ten-episode podcast following Kern's six-step curricular model. Following release, the podcast was evaluated via listenership analytics, external clinician feedback survey (N = 45), and internal team survey (N = 9). In 22 months since release, the podcast was played or downloaded 10,124 times across 45 countries. In the external survey, 97% of clinician experts reported the episodes as engaging and informational; 87% stated that no more than general knowledge of PTSD was required to enjoy the podcast. Qualitative analysis of open-ended feedback items found that participants were interested in learning about additional comorbidities and diversity issues related to late-life trauma reengagement. Both the external and internal survey identified discrete elements for improvement. Results suggest the podcast was engaging and informational to a diverse clinical audience. Podcasts represent a relatively new way to deliver educational content. Further consideration of their pedagogical value and limits is warranted.

Implementation of STAR-VA for behavioral symptoms of dementia in acute care: Lessons learned.

As the population grows, the incidence of dementia will increase. A common occurrence in people with dementia is behavioral and psychological symptoms of dementia (BPSD). BPSD can include apathy, aggression, resistance to care, and agitation. BPSD can start or worsen during an acute hospitalization, but these units are not well-equipped to handle BPSD, often relying on pharmacological interventions to address distress behaviors. One known behavioral intervention for BPSD is STAR-VA, an interdisciplinary approach to managing these behaviors. However, this intervention has not been utilized in acute care. Our team implemented STAR-VA in acute care at a Veterans Affairs hospital in the northeastern United States. Using the VA's Quality Enhancement Research Initiative (QUERI) implementation roadmap to guide our work, we first outlined the problem, completed a needs assessment with staff, and began implementation. Results from this quality improvement project demonstrated the feasibility and efficacy of STAR-VA in an acute care setting.

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.

Trauma re-engagement and PTSD in older medically ill veterans: implications for trauma-informed care.

OBJECTIVES: We characterize rates and correlates of PTSD and of trauma re-engagement without PTSD in medically ill older Veterans, as well as supportive strategies, with the goal of advancing trauma-informed care. METHODS: We interviewed medically ill older Veterans (N = 88, M age 75.13, SD = 6.14) with primary care screening measures for PTSD and trauma re-engagement, and open-ended questions to assess supportive strategies. RESULTS: One-fifth (20.5%) presented with probable PTSD, associated with greater trauma exposures (r=.57, p<.001), whereas two-fifths (43.2%) reported re-engagement with military memories without PTSD, associated with having a spouse/partner (t = 2.27, p=.028). Of those who experienced trauma, half reported thinking more about the trauma recently and becoming more emotional on certain days. In response to the question 'What gives you strength as you think about the future with your illness' Veterans described support of family, healthcare, worldview, personal control, acceptance, and health behaviors. CONCLUSION: Memories of trauma are common with medical illness. Age-friendly trauma-informed care could consider factors that patients describe as sources of strength with illness.

An Environmental Scan of Suicide Prevention Resources for Older Veterans in Primary Care.

OBJECTIVES: Previous research has identified the critical role of primary care for suicide prevention. Although several suicide prevention resources for primary care already exist, it is unclear how many have been created specifically for older veterans. This environmental scan sought to assemble a compendium of suicide prevention resources to be utilized in primary care. METHODS: We searched four academic databases, Google Scholar, and Google to identify available suicide prevention resources. Data from 64 resources was extracted and summarized; 15 were general resources and did not meet inclusion criteria. RESULTS: Our scan identified 49 resources with three resources specifically developed for older veterans in primary care. Identified resources shared overlapping content, including implementing a safety plan and lethal means reduction. CONCLUSION: Although only 10 of the identified resources were exclusively primary care focused, many of the resources had content applicable to suicide prevention in primary care. CLINICAL IMPLICATIONS: Primary care providers can use this compendium of resources to strengthen suicide prevention work within their clinics including: safety planning, lethal means reduction, assessing for risk factors that place older veteran at increased risk of suicide, and mitigating risk factors through referral to programs designed to support older adult health and well-being.

Supporting Veterans with dementia to remain in the community: strategies used in 12 Veterans Health Administration programs.

The Veterans Health Administration (VA) provides services to growing numbers of Veterans with dementIa, individuals at heightened risk for hospitalizations and nursing home placement. Beginning in 2010, the VA funded 12 innovative pilot programs to improve dementia care and help Veterans remain at home. We conducted a retrospective qualitative analysis of program materials and interviews with physicians, nurses, social workers, and other personnel (n = 33) to understand the strategies these programs adopted. Interviews were conducted every 6 months between 2010-2013 (4-5 interviews per program) and focused on factors affecting program design and implementation, challenges, and strategies to reduce hospitalizations and nursing home placements. Programs varied considerably yet shared three overarching strategies to improve dementia care: involving and supporting family caregivers; engaging interdisciplinary teams; and improving coordination with other healthcare providers. Our results highlight the importance of adapting common dementia care strategies based on the local context and needs of individuals served.

Validation of a Comprehensive Measure of the Family Caregiver Experience: The Caregiver Reaction Scale.

OBJECTIVES: The Caregiver Reaction Scale (CRS) is a multi-dimensional measure of the family caregiving experience that assesses role conflict, challenges, and positive aspects of caregiving. The CRS has been validated in a sample of older adult caregivers who sought counseling, but its validity and reliability in a broader population of caregivers had not been established. This study aimed to explore how well the CRS assesses the multiple dimensions of the caregiving experience in a sample of family caregivers who match the national profile of caregivers and to confirm the validity and structure of the subscales. METHODS: Family caregivers (N = 452), age 18-89 (M = 48.56, SD = 17.15) were recruited online and completed the CRS and questionnaires of burden and positive aspects of caregiving. A confirmatory factor analysis (CFA) was conducted to confirm the underlying factor structure of the CRS, and convergent and discriminant validity was examined. RESULTS: CFA supported the existing structure of the CRS; all subscales demonstrated very good internal consistency reliability (α ≤.88), convergent validity (r ≥.39), and discriminant validity (r ≤.12). CONCLUSIONS: The CRS offers a valid and reliable assessment of the caregiving experience as evidenced by the convergent and discriminant validity of CRS subscales with well-validated measures of burden and positive aspects of caregiving. CLINICAL IMPLICATIONS: The CRS assesses multiple dimensions of caregiving that can be used to better understand the caregiver's experience, guide clinical interventions and referrals, and identify caregiver strengths.

Hospice and palliative care clinicians' perceptions of posttraumatic stress disorder at end-of-life in military veterans.

At the end of life, individuals may re-engage with earlier life trauma as they reflect on life experiences and confront their mortality. As such, posttraumatic stress disorder (PTSD) symptoms at the end of life may worsen the quality of death experience. This is a concern for military veterans, who tend to have more trauma exposures and higher rates of PTSD, and particularly for veterans receiving care in rural areas where access to PTSD specialty services is limited. To better understand this issue, we conducted 10 focus groups with clinicians serving veterans in rural communities across five U.S. states. The aims of this project were to evaluate: (1) do hospice and palliative care providers/staff observe PTSD symptoms in veterans at the end of life? (2) if so, how are symptoms similar to and different from existing DSM-5 criteria for PTSD? We used qualitative content analysis with mixed deductive and inductive approaches to code 151 anonymized statements. Analyses found descriptions of PTSD symptoms aligned broadly with existing diagnostic nomenclature, but descriptions revealed specific presentations relevant to the end of life setting such as resistance to care, agitation, restlessness, and effects of delirium. In addition, some veterans expressed pride in service and openness to discussing military experiences. Further, clinicians noted that PTSD symptoms were relevant to family dynamics. Future research should further characterize these symptom differences through direct patient assessment and develop resources to improve quality of death experience for veterans with PTSD symptoms.

Application of treatment fidelity in tailored caregiver interventions.

OBJECTIVES: Demonstrations of the effectiveness of interventions requires evidence that the model can be implemented with fidelity. Caregiving interventions that are tailored to the individual or family require flexibility, which adds some challenges to the assessment of fidelity. This paper outlines the components necessary for examining treatment fidelity and common barriers to implementing fidelity studies, offers considerations for designing fidelity studies with tailored caregiver interventions, and aims to provide a set of procedures that can be used to guide future fidelity studies. METHOD: Case study methods are used to illustrate the processes and findings, drawing on two research studies of fidelity in tailored caregiver interventions. RESULTS: Fidelity studies consist of core components (i.e. training on intervention delivery, adherence to the intervention, therapist competence, acceptability and outcomes) that should be maintained and monitored throughout the study to elucidate the relationship between the intervention and outcomes. These components are applicable to tailored caregiver interventions and can be implemented with the consideration of some key issues that are addressed prior to the evaluation. The two cases presented utilized similar methods to evaluate fidelity of two different tailored caregiver interventions. CONCLUSION: Treatment fidelity can be assessed for tailored caregiving interventions, which increases confidence about the potency of the active ingredients in the interventions. Standard fidelity guidelines can be implemented with minor additional considerations.

Preliminary Evidence for the Validity and Reliability of the Caregiver Reaction Scale.

OBJECTIVE: Reliable and valid measures of caregiver experience are critical components of researching the caregiver experience and providing effective care to family caregivers. Assessments should be comprehensive, including positive aspects of caregiving as well as multiple dimensions of stress and burden (Family Caregiver Alliance, 2006). One such measure is the Caregiver Reaction Scale (CRS), a clinical tool adapted from research protocols in 1990. METHODS: This study is a preliminary examination of the psychometric properties of the CRS using a sample of family caregivers (N = 502) seeking services at a community based mental health and aging family service agency. RESULTS: The eight subscales of the CRS exhibited very good internal reliability α ≥ .81. Test-retest reliability was r ≥ .62, and convergent validity evidence is positive. Means and standard deviations are reported. CONCLUSIONS: Initial psychometrics suggest the CRS offers a reliable and valid assessment of multiple dimensions of the caregiving experience and warrants further research.

Calciphylaxis and Intractable Pain in a Veteran with Psychological Trauma History.

Guidelines are lacking for patients with calciphylaxis on renal replacement therapy, often leading to difficulty optimally treating these patients. A 60-year-old male veteran receiving hemodialysis presented with calciphylaxis of the left lower extremity and intractable pain. His condition was complicated by chronic back pain, long-term opioid therapy, and psychological trauma history. He was ultimately transferred to a calciphylaxis treatment center but was unable to tolerate further treatments due to sepsis and hemodynamic instability. He was transitioned to comfort measures and died in the hospital. Addressing complicated pain physiologies and complex trauma is challenging even in well-resourced tertiary medical centers. Despite the availability of calciphylaxis therapies and trauma-informed care, there remains a high rate of suffering and mortality in this patient population. There is much work to be done in this cohort, particularly when considering the implications of past traumatic experiences on health care engagement and pain management.

Maximizing Veterans Health Affairs Community Hospice Collaborations: Review of Perceived Resource Needs to Support Veterans at End of Life.

Within the United States, approximately 330 000 military veterans die annually, but only 5% of deaths occur in Veterans Health Administration (VHA) facilities. To help provide end-of-life care for veterans, the VHA built community partnerships with community hospice and palliative care (HPC) organizations. Veterans experience unique psychosocial factors making it vital to ensure HPC organizations have access to veteran-specific knowledge and resources to reduce suffering. To better understand the strengths and limitations of these partnerships, community HPC staff (N = 483) responded to quantitative and qualitative survey questions developed using an access to care theory for veterans. Survey responses demonstrated variable perceptions of access to VHA care and resources. Respondents reported excellent experiences (44%) and relationships with their local facility (50%) and had a reliable contact who provided needed assistance (92%). Thematic analysis identified a need for VHA care and barriers to access, which were associated with technical characteristics, and geographical and cultural issues. These findings can help inform future research and policy regarding access to VHA resources for end-of-life care for veterans in the community and guide resource development for community HPC providers.

Early clinical and quality impacts of the Age-Friendly Health System in a Veterans Affairs skilled nursing facility.

BACKGROUND: Skilled nursing facilities (SNFs) are an ideal setting to implement the Age-Friendly Health System (AFHS) approach, an initiative by the Institute for Healthcare Improvement (IHI) centered on the 4Ms: what matters, mobility, mentation, and medication. AFHS implementation has not been well studied in SNFs. METHODS: A 112-bed VA SNF implemented a facility-wide AFHS initiative including the following: (1) participating in a national IHI Age-Friendly Action Community; (2) establishing an AFHS workgroup centered on the 4Ms; (3) identifying meaningful clinical tools and frameworks for capturing each M; and (4) developing sustainment methods. Clinical (life-sustaining treatment, falls, disruptive behaviors, and medication deprescribing) and quality outcomes (rehospitalization, emergency department utilization, and discharge to the community) in addition to patient satisfaction were compared pre- and post-AFHS implementation (bed days of care [BDOC] 17413) to post-implementation (BDOC 20880). RESULTS: Clinical outcomes demonstrated improvements in the 4Ms, including: (1) what matters: 14% increase in life-sustaining treatment documentation (82%-96%; p < 0.01); (2) mobility: reduction in fall rate by 34% (8.15 falls/1000 BDOC to 5.41; p < 0.01); (3) mentation: decrease in disruptive behavior reporting system (DBRS) by 62% (5.11 DBRS/1000 BDOC to 1.96; p = 0.04); (4) medications: 53% increase in average potentially inappropriate medications (PIMs) deprescribing (0.38-0.80 interventions/patient; p < 0.01). Quality outcomes improved including rehospitalization (25.6%-17.9%) and emergency department utilization (5.3%-2.8%) within 30 days of admission. Patient satisfaction scores improved from a mean of 77.2 (n = 31, scale 1-100) to 81.3 (n = 42). CONCLUSIONS: Implementation of the AFHS initiative in a SNF was associated with improved clinical and quality outcomes and patient satisfaction. We describe here a sustainable, interprofessional approach to implementing the AFHS in a SNF.

Trauma-Informed Care in Long-Term Care Settings: From Policy to Practice.

By older adulthood, nearly all older adults will have been exposed to at least one potentially traumatic event, and the majority (93%) of older veterans report exposure to at least one event. Some may have developed posttraumatic stress disorder (PTSD) during their lifetimes; however, most do not, as the prevalence of PTSD in later adulthood is low. Nevertheless, the long-lasting psychological effects of trauma may manifest in later life, exacerbated by the normative experiences of aging (e.g., medical illness, loss of loved ones, and retirement) and encounters with medical settings. Receiving care in skilled nursing settings may trigger traumatic memories or may aggravate PTSD of symptoms. As the population ages, more individuals will receive care in long-term care environments, leading to increased risk of worsening PTSD. Staff and facilities may not have skills or knowledge needed to address symptoms or reduce retraumatization. Implementing trauma-informed care practices can mitigate these effects and is mandated in skilled nursing facilities; however, no models of trauma-informed care practice in long-term care exist. This article reviews the effects of trauma and PTSD in later life, the effects of medical settings on PTSD, and provides a framework for implementing trauma-informed care in long-term care settings.

Lived Experience: A Case-Based Review of Trauma-Informed Hospice and Palliative Care at a Veterans Affairs Medical Center.

Many individuals who present for hospice or palliative care might have experienced trauma during their lives, with some progressing to post-traumatic stress disorder. As these individuals face life-limiting illness, trauma might resurface. Consequently, physical and emotional health might suffer due to exacerbation of trauma-related symptoms, such as anxiety, irritability, or flashbacks. Providing trauma-informed care can help mitigate the effects of trauma for those facing life-limiting illness who might not be able to tolerate formal trauma treatment due to limited prognosis, fatigue, or lack of willingness to engage in treatment. The goal of this narrative review is to describe how aging and the end-of-life experience can lead to a re-engagement with previous traumatic experiences and, using case-based examples, provide recommendations for all members of the interprofessional hospice or palliative care team on how to elicit and respond to a history of trauma to minimize the potential negative impact of trauma at end-of-life.

Development, adaptation, and clinical implementation of the Later-Adulthood Trauma Reengagement (LATR) group intervention for older veterans.

Later in life Veterans may report increased thoughts and memories of traumatic military experience in the context of age-related changes, a process called Later-Adulthood Trauma Reengagement (LATR); this process may lead to resilience or distress. We describe the development of a 10-session group intervention with goals of providing psychoeducation about LATR, enhancing stress management and coping skills, and fostering meaning making. We characterize implementation and outcome characteristics for seven group cohorts over 5 years; groups were completed in-person or virtually. Outcomes were measured with the Connor-Davidson Resilience Scale, Meaning in Life Scale, Satisfaction with Life Scale, Positive Appraisals of Military experience (PAMES), Posttraumatic Stress Disorder Checklist-5, and Patient Health Questionnaire-9. Forty-seven Veterans (aged 65-93) began the group, 37 (87%) completed at least six sessions. These 37 Veterans reported an average of eight stressful events in the prior year, mostly major illness, death of a friend, and decline in memory and enjoyable activities, which may have set the stage for LATR. Veterans resonated with the LATR concept on standardized scales and qualitative comments. In pre-post comparisons, participants reported higher levels of PAMES (η² = .225), resilience (η² = .208), and meaning in life (η² = .145), with fewer symptoms of PTSD (η² = .199) and depression (η² = .124). There were no significant differences in outcomes for those who completed the group in-person or virtually. The LATR protocol may provide a framework for working with older adults reporting emergence or exacerbation of thoughts and memories of earlier trauma in later life, fostering positive adaptation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Advancing Trauma-Informed Care Education for Hospice and Palliative Staff: Development and Evaluation of Educational Videos.

Nurses play an essential role in managing mental health conditions, such as posttraumatic stress disorder (PTSD), especially in rural areas where access to mental health care is limited. Posttraumatic stress disorder may emerge at the end of life and complicate health care and is a particular concern for aging Vietnam veterans. We describe the development of 3 videos that illustrate how to recognize PTSD, respond to trauma disclosures, and manage PTSD in cognitive impairment during an in-home hospice nurse visit. Through problem identification and needs assessment, we identified 6 goals and 28 specific content objectives presented through cinematic action with flashbacks or voice-over narration with graphics. Videos were evaluated through a survey (N = 155) and analysis of "chat" responses (N = 186) to targeted questions during a webinar presentation to clinicians (N = 345). Approximately 75% rated videos as "very much" relevant to needs, having helped learn something new, and realistic. Analysis of chat responses showed videos conveyed most content objectives (92%). In addition, participants stated videos were helpful in demonstrating nursing skills of listening, responding, and displaying empathy, as well as showing case presentations involving cognitive impairment and the patient experience. Participants expressed a desire for longer videos/more information including a wider range of PTSD presentations and comorbidities.

A Citation Review of 83 Dissemination and Implementation Theories, Models, or Frameworks Utilized in U.S.-Based Aging Research.

BACKGROUND AND OBJECTIVES: Dissemination-implementation.org outlines 110 theories, models, and frameworks (TMFs): we conducted a citation analysis on 83 TMFs, searching Web of Science and PubMed databases. RESEARCH DESIGN AND METHODS: Search terms were broad and included "aging," "older," "elderly," and "geriatric." We extracted each TMF in identified articles from inception through January 28, 2022. Included articles must have used a TMF in research or quality improvement work directly linked to older adults within the United States. RESULTS: We reviewed 2,681 articles of which 295 articles cited at least one of 56 TMFs. Five TMFs represented 50% of the citations: Reach, Effectiveness, Adoption, Implementation, and Maintenance 1.0, Consolidated Framework for Implementation Research, Greenhalgh Diffusion of Innovation in Service Organizations, Quality Enhancement Research Initiative, Community-Based Participatory Research, and Promoting Action on Research Implementation in Health Services. TMF application varied and there was a steady increase in TMF citations over time, with a 2- to 3-fold increase in citations in 2020-2021. We identified that only 41% of TMF use was meaningful. DISCUSSION AND IMPLICATIONS: Our results suggest TMF utilization is increasing in aging research, but there is a need to more meaningful utilize TMFs. As the population of older adults continues to grow, there will be increasing demand for effective evidence-based practices and models of care to be quickly and effectively translated into routine care. Use of TMFs is critical to building such evidence and to identifying and evaluating methods to support this translation.

Mental healthcare and palliative care: barriers.

CONTEXT: Psychological symptoms are common among palliative care patients with advanced illness, and their effect on quality of life can be as significant as physical illness. The demand to address these issues in palliative care is evident, yet barriers exist to adequately meet patients' psychological needs. OBJECTIVES: This article provides an overview of mental health issues encountered in palliative care, highlights the ways psychologists and psychiatrists care for these issues, describes current approaches to mental health services in palliative care, and reviews barriers and facilitators to psychology and psychiatry services in palliative care, along with recommendations to overcome barriers. RESULTS: Patients in palliative care can present with specific mental health concerns that may exceed palliative care teams' available resources. Palliative care teams in the USA typically do not include psychologists or psychiatrists, but in palliative care teams where psychologists and psychiatrists are core members of the treatment team, patient well-being is improved. CONCLUSION: Psychologists and psychiatrists can help meet the complex mental health needs of palliative care patients, reduce demands on treatment teams to meet these needs and are interested in doing so; however, barriers to providing this care exist. The focus on integrated care teams, changing attitudes about mental health, and increasing interest and training opportunities for psychologists and psychiatrists to be involved in palliative care, may help facilitate the integration of psychology and psychiatry into palliative care teams.