Nursing Home Characteristics Associated with Antipsychotic Prescribing After Implementation of the National Antipsychotic Reduction Initiative (ARI).

OBJECTIVES: To describe nursing home (NH) characteristics associated with antipsychotic use and test whether associations changed after implementation of the National Partnership to Improve Dementia Care's antipsychotic reduction initiative (ARI). METHODS: Longitudinal quasi-experimental design using data from multiple sources and piecewise linear mixed models were used for statistical analyses. RESULTS: There was a significant decrease in monthly antipsychotic use across the study period (pre-ARI b = -0.0003, p <.001; post-ARI b = -0.0012, p <.001), which held after adjusting for NH characteristics. Registered nurse hours (b = -0.0026, p <.001), licensed practical nurse hours (b = -0.0019, p <.001), facility chain membership (b = -0.0013, p <.01), and health inspection ratings (b = -0.0003, p >.01) were associated with decreased antipsychotic use. Post-ARI changes in associations between NH characteristics and antipsychotic use were small and not statistically significant. CONCLUSIONS: Decreases in antipsychotic use were associated with most NH characteristics, and associations persisted post-ARI. Further research is warranted to examine the interactions between ARI policy and NH characteristics on antipsychotic prescribing, as well as other NH factors, such as facility prescribing cultures and clinical specialty of staff. CLINICAL IMPLICATIONS: Decreases in monthly antipsychotic use were observed following the ARI. The decreases in monthly antipsychotic use were associated with most NH characteristics, and these associations persisted during the post-ARI period.

Examining pain, function, behavioral symptoms and associations with engagement in meaningful activity for residents with dementia in assisted living.

OBJECTIVES: The purpose of this study was to examine factors associated with engagement in meaningful activity among residents with dementia in assisted living. We hypothesized that greater functional independence, less pain, and lower behavioral and psychological symptom severity would be associated with higher engagement in meaningful activity after controlling for residents' age, gender, comorbidities, and cognition. Understanding factors associated with engagement in meaningful activity can help to inform strategies for optimizing engagement among residents with dementia in assisted living. METHOD: This descriptive study used baseline data from a randomized controlled trial, Meaningful Activity for Managing Behavioral Symptoms of Distress (MAC-4-BSD). Linear regression was used to examine factors associated with engagement in meaningful activity. RESULTS: A total of 71 residents from 5 assisted living settings were included in the sample. Most participants were female (n = 52, 73%), White (n = 62, 87%), and mean age was 85 years old (SD = 8.2). Controlling for age, gender, comorbidities, and cognition, pain was significantly associated with engagement in meaningful activity (b= -2.09, p < 0.05). There were no associations found between function and behavioral symptoms with engagement in meaningful activity. CONCLUSION: Findings from this study show that pain is a significant factor that is negatively associated with residents' engagement in meaningful activity. Ongoing research is needed to help improve pain management for residents with dementia in assisted living and support their engagement in meaningful activity.

Recovery of isolated lithium through discharged state calendar ageing.

Rechargeable Li-metal batteries have the potential to more than double the specific energy of the state-of-the-art rechargeable Li-ion batteries, making Li-metal batteries a prime candidate for next-generation high-energy battery technology1-3. However, current Li-metal batteries suffer from fast cycle degradation compared with their Li-ion battery counterparts2,3, preventing their practical adoption. A main contributor to capacity degradation is the disconnection of Li from the electrochemical circuit, forming isolated Li4-8. Calendar ageing studies have shown that resting in the charged state promotes further reaction of active Li with the surrounding electrolyte9-12. Here we discover that calendar ageing in the discharged state improves capacity retention through isolated Li recovery, which is in contrast with the well-known phenomenon of capacity degradation observed during the charged state calendar ageing. Inactive capacity recovery is verified through observation of Coulombic efficiency greater than 100% on both Li||Cu half-cells and anode-free cells using a hybrid continuous-resting cycling protocol and with titration gas chromatography. An operando optical setup further confirms excess isolated Li reactivation as the predominant contributor to the increased capacity recovery. These insights into a previously unknown pathway for capacity recovery through discharged state resting emphasize the marked impact of cycling strategies on Li-metal battery performance.

A diagnostic framework to identify vestibular involvement in multi-sensory neurological disease.

BACKGROUND AND PURPOSE: Identifying vestibular causes of dizziness and unsteadiness in multi-sensory neurological disease can be challenging, with problems typically attributed to central or peripheral nerve involvement. Acknowledging vestibular dysfunction as part of the presentation provides an opportunity to access targeted vestibular rehabilitation, for which extensive evidence exists. A diagnostic framework was developed and validated to detect vestibular dysfunction, benign paroxysmal positional vertigo or vestibular migraine. The specificity and sensitivity of the diagnostic framework was tested in patients with primary mitochondrial disease. METHODS: Adults with a confirmed diagnosis of primary mitochondrial disease were consented, between September 2020 and February 2022. Participants with and without dizziness or unsteadiness underwent remote physiotherapy assessment and had in-person detailed neuro-otological assessment. The six framework question responses were compared against objective neuro-otological assessment or medical notes. The output was binary, with sensitivity and specificity calculated. RESULTS: Seventy-four adults completed the study: age range 20-81 years (mean 48 years, ±SD 15.05 years); ratio 2:1 female to male. The framework identified a vestibular diagnosis in 35 participants, with seven having two diagnoses. The framework was able to identify vestibular diagnoses in adults with primary mitochondrial disease, with a moderate (40-59) to very high (90-100) sensitivity and positive predictive value, and moderate to high (60-74) to very high (90-100) specificity and negative predictive value. CONCLUSIONS: Overall, the clinical framework identified common vestibular diagnoses with a moderate to very high specificity and sensitivity. This presents an opportunity for patients to access effective treatment in a timely manner, to reduce falls and improve quality of life.

Psychometric Properties of the Resilience Scale in Older Adults Post-Hip Fracture.

Objectives: The purpose of this study was to evaluate the psychometric properties of the modified 25-item Resilience Scale (RS-25) in older adults post-hip fracture using Rasch analysis. Methods: This was a descriptive study using baseline data from the Seventh Baltimore Hip Studies (BHS-7). There were 339 hip fracture patients included in this analysis. Results: Findings suggest there was support for reliability of the measure based on person and item separation index. The INFIT and OUTFIT statistics for testing validity were all in the acceptable range indicating that each item on the modified RS-25 fits the appropriate concept. There was no evidence of Differential Item Functioning (DIF) between genders. Conclusions: This study demonstrated evidence that the modified RS-25 is a reliable and valid measure to evaluate resilience among older adults post-hip fracture and therefore can be used in this population in clinical practice and research.

Exploring Factors Associated With Resilience and Physical Activity in Older Men and Women Post-Hip Fracture.

This study aimed to test a model of factors associated with resilience and physical activity post-hip fracture and compare model fit between men and women. We used data from the seventh Baltimore Hip Study that included 339 participants. Model testing indicated that health status (men: ß = .237, p = .002; women: ß = .265, p = <.001), depression (men: ß = -.245, p = .001; women: ß = -.241, p = <.001), and optimism (men: ß = .320, p = <.001; women: ß = .282, p = <.001) were associated with resilience in men and women, but resilience was only associated with physical activity in men (ß = .203, p = .038) and not in women. Social interaction was related to physical activity only among women (ß = .206, p = .044). This study provides support for the relationship between resilience and physical activity at least among men.

Model Testing of the Factors that are Associated with Care Interactions among Nursing Home Residents with Dementia.

OBJECTIVE: The purpose of this study was to test a model of the resident and community factors that are associated with quality of care interactions among nursing home (NH) residents living with dementia and test for invariance between model fit when tested with the Black versus White residents and female versus male residents. It was hypothesized that resident age, gender, race, pain, comorbidities, quality of life, resistiveness to care, function, cognition, community profit status, overall community star rating, community size, and staffing star rating would be directly and/or indirectly associated with quality of care interactions. It was also hypothesized that the model fit would be invariant by resident race and gender. DESIGN: This was a secondary data analysis using baseline, cross-sectional data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) intervention study. SETTING AND PARTICIPANTS: The study included 528 residents from 55 NH facilities. METHODS: Descriptive statistics and structural equation modeling was used to test the proposed model. RESULTS: The results showed that the final model with significant paths only had a poor fit to the data (χ2/df = 10.79, comparative fit index = 0.57, Tucker-Lewis index = 0.15, normed fit index = 0.57, root mean square error of approximation = 0.13). However, the findings indicated that comorbidities, pain, profit status, and overall community star rating were significantly associated with quality of care interactions. There was no difference in model fit between Black residents versus White residents, and between male versus female residents. CONCLUSIONS AND IMPLICATIONS: This study suggests factors that may influence quality of care interactions. Managing comorbidities, managing pain, and supporting higher quality of care in NH communities will likely help increase the frequency of positive care interactions. These findings can inform future interventions and training curricula for NH care staff to promote positive care interactions.

Cancer Cell Culture: The Basics and Two-Dimensional Cultures.

Despite significant advances in investigative and therapeutic methodologies for cancer, 2D cell culture remains an essential and evolving competency in this fast-paced industry. From basic monolayer cultures and functional assays to more recent and ever-advancing cell-based cancer interventions, 2D cell culture plays a crucial role in cancer diagnosis, prognosis, and treatment. Research and development in this field call for a great deal of optimization, while the heterogenous nature of cancer itself demands personalized precision for its intervention. In this way, 2D cell culture is ideal, providing a highly adaptive and responsive platform, where skills can be honed and techniques modified. Furthermore, it is arguably the most efficient, economical, and sustainable methodology available to researchers and clinicians alike.In this chapter, we discuss the history of cell culture and the varying types of cell and cell lines used today, the techniques used to characterize and authenticate them, the applications of 2D cell culture in cancer diagnosis and prognosis, and more recent developments in the area of cell-based cancer interventions and vaccines.

Dissolution of the Solid Electrolyte Interphase and Its Effects on Lithium Metal Anode Cyclability.

At >95% Coulombic efficiencies, most of the capacity loss for Li metal anodes (LMAs) is through the formation and growth of the solid electrolyte interphase (SEI). However, the mechanism through which this happens remains unclear. One property of the SEI that directly affects its formation and growth is the SEI's solubility in the electrolyte. Here, we systematically quantify and compare the solubility of SEIs derived from ether-based electrolytes optimized for LMAs using in-operando electrochemical quartz crystal microbalance (EQCM). A correlation among solubility, passivity, and cyclability established in this work reveals that SEI dissolution is a major contributor to the differences in passivity and electrochemical performance among battery electrolytes. Together with our EQCM, X-ray photoelectron spectroscopy (XPS), and nuclear magnetic resonance (NMR) spectroscopy results, we show that solubility depends on not only the SEI's composition but also the properties of the electrolyte. This provides a crucial piece of information that could help minimize capacity loss due to SEI formation and growth during battery cycling and aging.

The Association of Cognitive Impairment With Depressive Symptoms, Function, and Pain in Hospitalized Older Patients With Dementia.

This study examined the associations between cognition and depressive symptoms, function, and pain among hospitalized older patients with dementia. We utilized baseline data of 461 hospitalized older patients with dementia who participated in an intervention study implementing Family-centered Function-focused Care (Fam-FFC) and conducted stepwise linear regression. On average, the participants (males = 189; 41% and females = 272; 59%) were 81.64 years old (Standard Deviation, SD = 8.38). There was a statistically significant association of cognition with depressive symptoms (b = -0.184, p < .001), functional status (b = 1.324, p < .001), and pain (b = -0.045, p < .001) when controlling for covariates. This study utilized a large sample of a relatively underrepresented population, hospitalized older adults with dementia, and addressed a topic with great clinical significance. Specific focus on testing and implementing best practices or interventions to support the clinical outcomes, and the cognitive function of hospitalized older adults with dementia is warranted in both practice and research.

Prevalence of genetically confirmed skeletal muscle channelopathies in the era of next generation sequencing.

We provide an up-to-date and accurate minimum point prevalence of genetically defined skeletal muscle channelopathies which is important for understanding the population impact, planning for treatment needs and future clinical trials. Skeletal muscle channelopathies include myotonia congenita (MC), sodium channel myotonia (SCM), paramyotonia congenita (PMC), hyperkalemic periodic paralysis (hyperPP), hypokalemic periodic paralysis (hypoPP) and Andersen- Tawil Syndrome (ATS). Patients referred to the UK national referral centre for skeletal muscle channelopathies and living in UK were included to calculate the minimum point prevalence using the latest data from the Office for National Statistics population estimate. We calculated a minimum point prevalence of all skeletal muscle channelopathies of 1.99/100 000 (95% CI 1.981-1.999). The minimum point prevalence of MC due to CLCN1 variants is 1.13/100 000 (95% CI 1.123-1.137), SCN4A variants which encode for PMC and SCM is 0.35/100 000 (95% CI 0.346 - 0.354) and for periodic paralysis (HyperPP and HypoPP) 0.41/100 000 (95% CI 0.406-0.414). The minimum point prevalence for ATS is 0.1/100 000 (95% CI 0.098-0.102). There has been an overall increase in point prevalence in skeletal muscle channelopathies compared to previous reports, with the biggest increase found to be in MC. This can be attributed to next generation sequencing and advances in clinical, electrophysiological and genetic characterisation of skeletal muscle channelopathies.

The Association Between Engagement in Activities of Daily Living and Care Interactions for Residents Living With Dementia.

BACKGROUND: Care interactions are essential to residents with dementia. PURPOSE: The purpose of the study was to describe the characteristics and quality of staff-resident care interactions among nursing home residents living with dementia and to test whether the quality of staff-resident care interactions varied by resident level of engagement in the interaction. Specifically, it was hypothesized that controlling for age, gender, comorbidities, cognition, and function, actively engaged residents would have more positive care interactions with staff compared with passively engaged residents. METHODS: This was a secondary data analysis using baseline data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia intervention study. RESULTS: A total of 532 residents were included. Actively engaged residents had significantly more positive interactions compared to passively engaged residents. CONCLUSIONS: Passively engaged residents may be at risk to receive poor quality care interactions. Strategies and interventions to optimize care interactions for these individuals are needed.

The association of physical activity and behavioral and psychological symptoms among a sample of hospitalized older adults living with dementia.

OBJECTIVES: The aims of this study were to: (1) describe the prevalence of behavioral and psychological symptoms of dementia in hospitalized older adults living with dementia and (2) examine the association of physical activity and behavioral and psychological symptoms of dementia among hospitalized older adults living with dementia, after controlling for covariates. METHODS: Physical activity was measured using the Physical Activity Survey and behavioral and psychological symptoms of dementia were measured using the Neuropsychiatric Inventory. Descriptive analysis and multiple linear regressions were run using baseline data on 294 older adults with dementia hospitalized on general medical units from an ongoing study entitled Function Focused Care for Acute Care Using the Evidence Integration Triangle. RESULTS: Participants performed an average of 7.92 (SD = 4.49) of 34 possible activities "in the last 24 h" prior to the Physical Activity Survey administration. A total of 132 participants (45.5%) had at least one behavioral and psychological symptom of dementia. We found that physical activity was not associated with behavioral and psychological symptoms of dementia (b = 0.01; p = 0.56), after controlling for covariates. CONCLUSIONS: Although this study found no evidence of an association between physical activity and behavioral and psychological symptoms of dementia, evidence of physical activity did not exacerbate these behaviors. Thus, given the benefits of physical activity, it is important to continue to encourage patients living with dementia to engage in activity.

Unintended impacts of a national antipsychotic reduction initiative among nursing facility residents with and without Alzheimer's disease.

BACKGROUND: In July 2012, the Centers for Medicare & Medicaid services launched an antipsychotic reduction initiative (ARI) to improve care for nursing facility residents with Alzheimer's disease and related dementias (ADRD). We examined the impact of this policy on antipsychotic and psychotropic medication (PM) utilization and diagnosis patterns in long-stay nursing facility residents with ADRD and other conditions in which antipsychotics are indicated. METHODS: Using an 80% sample of fee-for-service Medicare beneficiaries with Part D, we conducted a retrospective cohort study of nursing facility residents with ADRD, bipolar disorder, psychosis, Parkinson's disease, and residents exempt from the policy due to diagnoses of schizophrenia, Tourette syndrome, and/or Huntington's disease. We used interrupted time-series analyses to compare changes in diagnoses, antipsychotic use, and PM utilization before (January 1, 2011-June 30, 2012) and after (July 1, 2012-September 30, 2015) ARI implementation. RESULTS: We identified 874,487 long-stay nursing facility residents with a diagnosis of ADRD (n = 358,518), exempt (n = 92,859), bipolar (n = 128,298), psychosis (n = 93,402), and Parkinson's disease (n = 80,211). In all cohorts, antipsychotic use declined prior to the ARI; upon policy implementation, antipsychotic use reductions were sustained throughout the study period, including statistically significant ARI-associated accelerated declines in all cohorts. PM changes varied by cohort, with ARI-associated increases in non-benzodiazepine sedatives and/or muscle relaxants noted in ADRD, psychosis, and Parkinson's cohorts. Although anticonvulsant use increased throughout the study period in all groups, with the exception of the bipolar cohort, these increases were not associated with ARI implementation. Findings are minimally explained by increased post-ARI membership in the psychosis and Parkinson's cohorts. CONCLUSIONS: Our study documents antipsychotic use significantly declined in non-ADRD clinical and exempt cohorts, where such reductions may not be clinically warranted. Furthermore, ARI-associated compensatory increases in PMs do not offset these reductions. Changes in PM utilization and diagnostic make-up of residents using PMs require further investigation to assess the potential for adverse clinical and economic outcomes.

Examining transitions of care among nursing home residents with and without antipsychotic medication use.

OBJECTIVES: This study examines the association between antipsychotic (AP) medication use and care transitions in the nursing home (NH) population. METHODS: This cross-sectional study used data from a 5% random sample of Medicare beneficiaries between 2011 and 2015. Propensity score adjusted negative binomial regression was performed and conditional probabilities of having a first transition from the NH to specific locations were calculated. RESULTS: Among 150,284 eligible beneficiaries, the majority were female (67%), white (84%), and >75 years old (63%). Controlling for resident characteristics, the odds of having any transition was 5% lower among those with AP use [IRR (95% confidence interval (CI))=0.95(0.94-0.96)] relative to those with no AP use. Residents with AP use had higher proportions of transitions to hospital (22.7% vs. 19.5%, p < 0.01), emergency department (19.6% vs. 10.7%, p < 0.01), and different NH (1.5% vs. 0.4%, p < 0.01), and lower proportions of transition to non-healthcare locations compared to those without AP use. CONCLUSIONS: Findings demonstrate that residents with AP use had higher probabilities of transitions to more costly care settings such as the emergency department and hospital compared to those without AP use. Future longitudinal studies will help to inform clinical interventions aimed at improving the quality of care for this population.

Effects of and preference for student- and teacher-implemented good behavior game in early elementary classes.

Disruptive behavior during instruction is a common problem in elementary classrooms. One intervention to reduce disruptive behavior is the Good Behavior Game (GBG). In this study, the students of 2 early elementary classrooms experienced 3 versions of the GBG: experimenter-implemented, teacher-implemented, and student-implemented. The effects of the GBG on disruptive behavior and peer interactions were evaluated using a combined reversal and multielement design. Student preference for conditions was assessed via a group arrangement of a concurrent-chains preference assessment. All versions of the game reduced disruptive behavior compared to baseline, but the rate of disruptive behavior was slightly higher during the teacher-implemented sessions in Class 1. Few peer interactions occurred during the game; however, negative interactions increased slightly in both classes during the GBG. Students overwhelmingly preferred the student-implemented version of the game. This study provides support for student implementation of the GBG and offers an approach to student shared governance in the classroom.

Patient Outcomes After Delirium Screening and Incident Alzheimer's Disease or Related Dementias in Skilled Nursing Facilities.

BACKGROUND: The extent to which a positive delirium screening and new diagnosis of Alzheimer's disease or related dementias (ADRD) increases the risk for re-hospitalization, long-term nursing home placement, and death remains unknown. OBJECTIVE: To compare long-term outcomes among newly admitted skilled nursing facility (SNF) patients with delirium, incident ADRD, and both conditions. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of Medicare beneficiaries who entered a SNF from hospital with a minimum 14-day stay (n = 100,832) from 2015 to 2016. MAIN MEASURES: Return to home, hospital readmission, admission to a long-term care facility, or death. KEY RESULTS: Patients with delirium were as likely to be discharged home as patients diagnosed with ADRD (HR: 0.63, 95% CI: 0.59, 0.67; HR: 0.65, 95% CI: 0.64, 0.67). Patients with both delirium and ADRD were less likely to be discharged home (HR: 0.49, 95% CI: 0.47, 0.52) and showed increased risk of death (HR: 1.30, 95% CI: 1.17, 1.45). Patients with ADRD, regardless of delirium screening status, had increased risk for long-term nursing home care transfer (HR: 1.66, 95% CI: 1.63, 1.70; HR: 1.76, 95% CI: 1.69, 1.82). Patients with delirium and no ADRD showed increased risk of transfer to long-term nursing home care (HR: 1.25, 95% CI: 1.18, 1.33). The rate of deaths was higher among patients who screened positive for delirium without ADRD compared to the no delirium and no ADRD groups (HR: 2.35, 95% CI: 2.11, 2.61). CONCLUSION: A positive delirium screening increased risk of death and transfer to long-term care in the first 100 days after admission regardless of incident ADRD diagnosis. Patients with delirium and/or ADRD also are less likely to be discharged home. Our study builds on the evidence base that delirium is important to address in older adults as it is associated with negative outcomes.

Investigating the Cyclability and Stability at the Interfaces of Composite Solid Electrolytes in Li Metal Batteries.

Despite the fact that much work has been dedicated to finding the ideal additive for composite solid electrolytes (CSEs) for lithium-based solid-state batteries, little is known about the properties of a CSE that enable stable cycling with a lithium metal anode. In this work, we use three CSEs based on lithium nitride (Li3N), a fast lithium-ion conductor, and lithium hydroxide (LiOH) to investigate the properties and interfacial interactions that impact the cyclability of CSEs. We present a method for stabilizing Li3N with a shell of LiOH, and we incorporate Li3N, core-shell particles, and LiOH into CSEs using polyethylene oxide (PEO) and lithium bis(trifluoromethanesulfonyl)imide. Through improved interfacial chemistry, CSEs with core-shell particles have superior electrochemical cycling performance compared to those with unprotected Li3N in symmetric Li-Li cells. This CSE features a high ionic conductivity of 0.66 mS cm-1 at 60 °C, a high critical current density of 1.2 mA cm-2, and a wide voltage window of 0-5.1 V. Full cells with the core-shell CSE and lithium iron phosphate cathodes exhibit stable cycling and high reversible specific capacities in cells as high as 2.5 mAh cm-2. We report that the improved ionic conductivity and amorphous PEO content have a limited effect on the solid-state electrolyte performance, while improving the electrolyte-Li metal anode interface is key to cycling longevity.