Using social risks to predict unplanned hospital readmission and emergency care among hospitalized Veterans.

OBJECTIVES: (1) To estimate the association of social risk factors with unplanned readmission and emergency care after a hospital stay. (2) To create a social risk scoring index. DATA SOURCES AND SETTING: We analyzed administrative data from the Department of Veterans Affairs (VA) Corporate Data Warehouse. Settings were VA medical centers that participated in a national social work staffing program. STUDY DESIGN: We grouped socially relevant diagnoses, screenings, assessments, and procedure codes into nine social risk domains. We used logistic regression to examine the extent to which domains predicted unplanned hospital readmission and emergency department (ED) use in 30 days after hospital discharge. Covariates were age, sex, and medical readmission risk score. We used model estimates to create a percentile score signaling Veterans' health-related social risk. DATA EXTRACTION: We included 156,690 Veterans' admissions to a VA hospital with discharged to home from 1 October, 2016 to 30 September, 2022. PRINCIPAL FINDINGS: The 30-day rate of unplanned readmission was 0.074 and of ED use was 0.240. After adjustment, the social risks with greatest probability of readmission were food insecurity (adjusted probability = 0.091 [95% confidence interval: 0.082, 0.101]), legal need (0.090 [0.079, 0.102]), and neighborhood deprivation (0.081 [0.081, 0.108]); versus no social risk (0.052). The greatest adjusted probabilities of ED use were among those who had experienced food insecurity (adjusted probability 0.28 [0.26, 0.30]), legal problems (0.28 [0.26, 0.30]), and violence (0.27 [0.25, 0.29]), versus no social risk (0.21). Veterans with social risk scores in the 95th percentile had greater rates of unplanned care than those with 95th percentile Care Assessment Needs score, a clinical prediction tool used in the VA. CONCLUSIONS: Veterans with social risks may need specialized interventions and targeted resources after a hospital stay. We propose a scoring method to rate social risk for use in clinical practice and future research.

Changes in Physical Function and Physical Therapy Use in Older Veterans Not Infected by CoVID-19 Residing in Community Living Centers During the CoVID-19 Pandemic.

OBJECTIVES: Examine physical function change and physical therapy (PT) use in short-stay and long-stay residents not infected by CoVID-19 within Veterans Affairs (VA) Community Living Centers (CLCs). DESIGN: Retrospective cohort study using Minimum Data Set (MDS) 3.0 assessments. SETTINGS AND PARTICIPANTS: 12,606 Veterans in 133 VA CLCs between September 2019 and September 2020. METHODS: Difference in physical function [MDS Activities of Daily Living Score (MDS-ADL)] and PT use (minutes in past 7 days) from admission to last assessment in a period were compared between the pre-CoVID-19 (September 2019 to February 2020) and early CoVID-19 (April 2020 to September 2020) period using mixed effects regression with multivariable adjustment. Assessments after a positive CoVID-19 test were excluded. Differences were examined in the sample and repeated after stratifying into short- and long-stay stratums. RESULTS: Veterans admitted during early CoVID-19 had more comorbidities, worse MDS-ADL scores, and were more often long-stay residents compared with those admitted during pre-CoVID-19. In comparison to pre-CoVID-19, Veterans in VA CLCs during early CoVID-19 experienced greater improvements in their MDS-ADL (-0.49 points, 95% CI -0.27, -0.71) and received similar minutes of therapy (2.6 minutes, 95% CI -0.8, 6.0). Stratification revealed short-stay residents had relative improvements in their function (-0.69 points, 95% CI -0.44, -0.94) and higher minutes of PT (5.1 minutes, 95% CI 0.9, 9.2) during early CoVID-19 whereas long-stay residents did not see differences in functional change (0.08 points, 95% CI -0.36, 0.51) or PT use (-0.6 minutes, 95% CI -6.1, 4.9). CONCLUSIONS AND IMPLICATIONS: During early CoVID-19, physical function improved while the amount of PT received was maintained compared with pre-CoVID-19 for Veterans in VA CLCs. Short-stay residents experienced greater improvements in physical function and increases in PT use. These findings may be partly due to selection bias relating to Veterans admitted to CLCs during early CoVID-19.

Durability of immunity and clinical protection in nursing home residents following bivalent SARS-CoV-2 vaccination.

BACKGROUND: Bivalent SARS-CoV-2 vaccines were developed to counter increasing susceptibility to emerging SARS-CoV-2 variants. We evaluated the durability of immunity and protection following first bivalent vaccination among nursing home residents. METHODS: We evaluated anti-spike and neutralization titers from blood in 653 community nursing home residents before and after each monovalent booster, and a bivalent vaccine. Concurrent clinical outcomes were evaluated using electronic health record data from a separate cohort of 3783 residents of Veterans Affairs (VA) nursing homes who had received at least the primary series monovalent vaccination. Using target trial emulation, we compared VA residents who did and did not receive the bivalent vaccine to measure vaccine effectiveness against infection, hospitalization, and death. FINDINGS: In the community cohort, Omicron BA.5 neutralization activity rose after each monovalent and bivalent booster vaccination regardless of prior infection history. Titers declined over time but six months post-bivalent vaccination, BA.5 neutralization persisted at detectable levels in 75% of infection-naive and 98% of prior-infected individuals. In the VA nursing home cohort, bivalent vaccine added effectiveness to monovalent booster vaccination by 18.5% for infection (95% confidence interval (CI) -5.6, 34.0%), and 29.2% for hospitalization or death (95% CI -14.2, 56.2%) over five months. INTERPRETATION: The level of protection declined after bivalent vaccination over a 6 month period and may open a window of added vulnerability before the next updated vaccine becomes available, suggesting a subset of nursing home residents may benefit from an additional vaccination booster. FUNDING: CDC, NIH, VHA.

Wandering Behavior and SARS-CoV-2 Infection in Veterans Affairs Community Living Center Residents.

OBJECTIVE: Wandering behavior in nursing home (NH) residents could increase risk of infection. The objective of this study was to assess the association of wandering behavior with SARS-CoV-2 infection in Veterans Affairs (VA) Community Living Center (CLC) residents. DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Veterans residing in 133 VA CLCs. METHODS: We included residents with SARS-CoV-2 test from March 1, 2020 to December 31, 2020 from VA electronic medical records. We identified CLC residents with wandering on Minimum Data Set 3.0 assessments and compared them with residents without wandering. The outcome was SARS-CoV-2 infection, as tested for surveillance testing, in those with and without wandering. Generalized linear model with Poisson link adjusted for relevant covariates was used. RESULTS: Residents (n = 9995) were included in the analytic cohort mean, (SD) age 73.4 (10.7); 388 (3.9%) women. The mean (SD) activities of daily living score in the overall cohort was 13.6 (8.25). Wandering was noted in 379 (3.8%) (n = 379) of the cohort. The exposure groups differed in prior dementia (92.6% vs 62.1%, standardized mean difference [SMD] = 0.8) and psychoses (41.4% vs 28.1%, SMD = 0.3). Overall, 12.5% (n = 1248) tested positive for SARS-CoV-2 and more residents among the wandering group were SARS-CoV-2 positive as compared with those in the group without wandering (19% [n = 72] vs 12.2% [n = 1176], SMD = 0.19). Adjusting for covariates, residents with wandering had 34% higher relative risk for SARS-CoV-2 infection (adjusted relative risk, 1.34; 95% CI, 1.04-1.69). CONCLUSIONS AND IMPLICATIONS: CLC residents with wandering had a higher risk of SARS-CoV-2 infection. This may inform implementation of infection control and isolation policies as NHs attempt to balance ethical concepts of resident autonomy, proportionality, equity, and utilitarianism.

Differential effects of a social work staffing intervention on social work access among rural and highly rural Veterans: A cohort study.

OBJECTIVE: To evaluate the impact on rural Veterans' access to social work services of a Department of Veterans Affairs (VA) national program to increase social work staffing, by Veterans' rurality, race, and complex care needs. DATA SOURCES AND STUDY SETTING: Data obtained from VA Corporate Data Warehouse, including sites that participated in the social work program between October 1, 2016 and September 30, 2021. STUDY DESIGN: The study outcome was monthly number of Veterans per 1000 individuals with 1+ social work encounters. We used difference-in-differences to estimate the program effect on urban, rural, and highly rural Veterans. Among rural and highly rural Veterans, we stratified by race (American Indian or Alaskan Native, Asian, Black, Native Hawaiian or Other Pacific Islander, and White) and complex care needs (homelessness, high hospitalization risk, and dementia). DATA COLLECTION: We defined a cohort of 740,669 Veterans (32,434,001 monthly observations) who received primary care at a participating site. PRINCIPAL FINDINGS: Average monthly social work use was 8.7 Veterans per 1000 individuals. The program increased access by 49% (4.3 per 1000; 95% confidence interval, 2.2-6.3). Rural Veterans' social work access increased by 57% (5.0; 3.6-6.3). Among rural/highly rural Veterans, the program increased social work access for those with high hospitalization risk by 63% (24.5; 18.2-30.9), and for Veterans experiencing homelessness, 35% (13.4; 5.2-21.7). By race, the program increased access for Black Veterans by 53% (6.1; 2.1-10.2) and for Asian Veterans by 82% (5.1; 2.2-7.9). CONCLUSIONS: At rural VA primary care sites with social work staffing below recommended levels, Black and Asian Veterans and those experiencing homelessness and high hospitalization risk may have unmet needs warranting social work services.

Utility of cerebrovascular imaging biomarkers to detect cerebral amyloidosis.

INTRODUCTION: The relationship between cerebrovascular disease (CVD) and amyloid-ß (Aß) in Alzheimer disease (AD) is understudied. We hypothesized that magnetic resonance imaging (MRI)-based CVD biomarkers, including cerebral microbleeds (CMBs), ischemic infarction, and white matter hyperintensities (WMH), would correlate with Aß positivity on positron emission tomography (Aß-PET). METHODS: We cross-sectionally analyzed data from the Alzheimer's Disease Neuroimaging Initiative (ADNI, N=1,352). Logistic regression was used to calculate odds ratios (ORs), with Aß-PET positivity as the standard-of-truth. RESULTS: Following adjustment, WMH (OR=1.25) and superficial CMBs (OR=1.45) remained positively associated with Aß-PET positivity (p<.001). Deep CMBs and infarcts exhibited a varied relationship with Aß-PET in cognitive subgroups. The combined diagnostic model, which included CVD biomarkers and other accessible measures, significantly predicted Aß-PET (pseudo-R 2 =.41). DISCUSSION: The study highlights the translational value of CVD biomarkers in diagnosing AD, and underscores the need for more research on their inclusion in diagnostic criteria. ClinicalTrials.gov: ADNI-2 ( NCT01231971 ), ADNI-3 ( NCT02854033 ).

Clinical Outcomes After Acute Coronary Syndromes or Revascularization Among People Living With HIV: A Systematic Review and Meta-Analysis.

Importance: Clinical outcomes after acute coronary syndromes (ACS) or percutaneous coronary interventions (PCIs) in people living with HIV have not been characterized in sufficient detail, and extant data have not been synthesized adequately. Objective: To better characterize clinical outcomes and postdischarge treatment of patients living with HIV after ACS or PCIs compared with patients in an HIV-negative control group. Data Sources: Ovid MEDLINE, Embase, and Web of Science were searched for all available longitudinal studies of patients living with HIV after ACS or PCIs from inception until August 2023. Study Selection: Included studies met the following criteria: patients living with HIV and HIV-negative comparator group included, patients presenting with ACS or undergoing PCI included, and longitudinal follow-up data collected after the initial event. Data Extraction and Synthesis: Data extraction was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Clinical outcome data were pooled using a random-effects model meta-analysis. Main Outcome and Measures: The following clinical outcomes were studied: all-cause mortality, major adverse cardiovascular events, cardiovascular death, recurrent ACS, stroke, new heart failure, total lesion revascularization, and total vessel revascularization. The maximally adjusted relative risk (RR) of clinical outcomes on follow-up comparing patients living with HIV with patients in control groups was taken as the main outcome measure. Results: A total of 15 studies including 9499 patients living with HIV (pooled proportion [range], 76.4% [64.3%-100%] male; pooled mean [range] age, 56.2 [47.0-63.0] years) and 1 531 117 patients without HIV in a control group (pooled proportion [range], 61.7% [59.7%-100%] male; pooled mean [range] age, 67.7 [42.0-69.4] years) were included; both populations were predominantly male, but patients living with HIV were younger by approximately 11 years. Patients living with HIV were also significantly more likely to be current smokers (pooled proportion [range], 59.1% [24.0%-75.0%] smokers vs 42.8% [26.0%-64.1%] smokers) and engage in illicit drug use (pooled proportion [range], 31.2% [2.0%-33.7%] drug use vs 6.8% [0%-11.5%] drug use) and had higher triglyceride (pooled mean [range], 233 [167-268] vs 171 [148-220] mg/dL) and lower high-density lipoprotein-cholesterol (pooled mean [range], 40 [26-43] vs 46 [29-46] mg/dL) levels. Populations with and without HIV were followed up for a pooled mean (range) of 16.2 (3.0-60.8) months and 11.9 (3.0-60.8) months, respectively. On postdischarge follow-up, patients living with HIV had lower prevalence of statin (pooled proportion [range], 53.3% [45.8%-96.1%] vs 59.9% [58.4%-99.0%]) and ß-blocker (pooled proportion [range], 54.0% [51.3%-90.0%] vs 60.6% [59.6%-93.6%]) prescriptions compared with those in the control group, but these differences were not statistically significant. There was a significantly increased risk among patients living with HIV vs those without HIV for all-cause mortality (RR, 1.64; 95% CI, 1.32-2.04), major adverse cardiovascular events (RR, 1.11; 95% CI, 1.01-1.22), recurrent ACS (RR, 1.83; 95% CI, 1.12-2.97), and admissions for new heart failure (RR, 3.39; 95% CI, 1.73-6.62). Conclusions and Relevance: These findings suggest the need for attention toward secondary prevention strategies to address poor outcomes of cardiovascular disease among patients living with HIV.

Detection of delirium in older patients-A point prevalence study in surgical and non-surgical hospital wards.

AIMS AND OBJECTIVES: To (i) determine the prevalence of delirium and identify delirium subtypes in surgical and non-surgical patients aged ≥65 years, (ii) determine whether certain precipitating factors affect the prevalence of delirium and (iii) review patients' medical records for description of delirium symptoms and the presence of International Classification of Diseases (ICD-10) coding for delirium in discharge summaries. METHODOLOGICAL DESIGN AND JUSTIFICATIONS: Despite being a robust predictor of morbidity and mortality in older adults, delirium might be inadequately recognised and under-reported in patients' medical records and discharge summaries. A point prevalence study (24-h) of patients ≥65 years from surgical and non-surgical wards was therefore conducted in a tertiary university hospital. ETHICAL ISSUES AND APPROVAL: The study was approved by the Data Protection Officer at the university hospital (2018/3454). RESEARCH METHODS, INSTRUMENTS AND/OR INTERVENTIONS: Patients were assessed for delirium with 4AT and delirium subtypes with the Delirium Motor Subtype Scale. Information about room transfers, need and use of sensory aids and medical equipment was collected onsite. Patients' medical records were reviewed for description of delirium symptoms and of ICD-10 codes. RESULTS: Overall, 123 patients were screened (52% female). Delirium was identified in 27% of them. Prevalence was associated with advanced age (≥85 years). The uncharacterised delirium subtype was most common (36%), followed by hypoactive (30%), hyperactive (24%) and mixed (9%). There were significant associations between positive screening tests and the need and use of sensory aids. Delirium symptoms were described in 58% of the patients who tested positive for delirium and the ICD-10 code for delirium was registered in 12% of these patients' discharge summaries. CONCLUSIONS: The high prevalence of delirium and limited use of discharge codes highlight the need to improve the identification of delirium in hospital settings and at discharge. Increased awareness and detection of delirium in hospital settings are vital to improve patient care.

Factors Associated With Early Palliative Care Among Patients With Heart Failure.

Background: Heart failure (HF) is a progressive, life-limiting illness for which palliative care (PC) is considered standard of care. Among patients that do receive PC, consultation tends to occur late in the illness course. Objective: Our primary aim was to examine patient factors associated with receiving PC in HF. Secondarily, we sought to determine factors associated with early PC encounters. Design: This was a retrospective cohort study of U.S. Veterans with prior hospitalization who died between January 1, 2011 and December 31, 2020. Setting/Subjects: Subjects were Veterans with HF who died with a prior admission to a Veterans Affairs hospital in the United States. Measurements: We calculated the time from PC encounter to death. We characterized HF patients who died without PC, with late PC (≤90 days before death), and with early PC (>90 days before death). Results: We identified 232,079 Veterans with a mean age of (76.5 ± 10.7) years. Within the cohort, 56.5% (n = 131,122) of Veterans died with no PC, 22.5% (n = 52,114) had PC <90 days before death, and 21.0% (n = 48,843) had PC >90 days before death. Veterans who died without PC tended to be younger with fewer comorbidities. Conclusions: While more than 20% of HF patients in our cohort had PC well in advance of death, more than half died without PC. PC involvement seemed to be driven by comorbidities rather than HF. Effective collaboration with Cardiology is needed to identify patients who would benefit from earlier PC involvement.

Trends and geographic differences in social work telehealth utilization.

We plotted trends in social work telehealth use among Veterans in a U.S. national social work staffing program and examined the relationship between geographic factors (rurality and neighborhood disadvantage) and telehealth use (audio and video) using linear probability models. Social work telehealth use increased among Veterans during the COVID-19 pandemic. There were no geographic differences in telephone telehealth use. Video telehealth use was less common among Veterans in isolated rural areas and among Veterans in highly disadvantaged areas. Outreach efforts can address barriers that Veterans who live in rural and disadvantaged areas may experience in using video telehealth.

Lower odds of successful community discharge after medical hospitalization for Veterans with schizophrenia: A retrospective cohort study of national data.

Medical comorbidity, particularly cardiovascular diseases, contributes to high rates of hospital admission and early mortality in people with schizophrenia. The 30 days following hospital discharge represents a critical period for mitigating adverse outcomes. This study examined the odds of successful community discharge among Veterans with schizophrenia compared to those with major affective disorders and those without serious mental illness (SMI) after a heart failure hospital admission. Data for Veterans hospitalized for heart failure were obtained from the Veterans Health Administration (VHA) and Centers for Medicare & Medicaid Services between 2011 and 2019. Psychiatric diagnoses and medical comorbidities were assessed in the year prior to hospitalization. Successful community discharge was defined as remaining in the community without hospital readmission, death, or hospice for 30 days after hospital discharge. Logistic regression analyses adjusting for relevant factors were used to examine whether individuals with a schizophrenia diagnosis showed lower odds of successful community discharge versus both comparison groups. Out of 309,750 total Veterans in the sample, 7377 (2.4%) had schizophrenia or schizoaffective disorder and 32,472 (10.5%) had major affective disorders (bipolar disorder or recurrent major depressive disorder). Results from adjusted logistic regression analyses demonstrated significantly lower odds of successful community discharge for Veterans with schizophrenia compared to the non-SMI (Odds Ratio [OR]: 0.63; 95% Confidence Interval [CI]: 0.60, 0.66) and major affective disorders (OR: 0.65, 95%; CI: 0.62, 0.69) groups. Intervention efforts should target the transition from hospital to home in the subgroup of Veterans with schizophrenia.

Serious mental illness is associated with elevated risk of hospital readmission in veterans with heart failure.

OBJECTIVE: Adults with serious mental illness (SMI) have high rates of cardiovascular disease, particularly heart failure, which contribute to premature mortality. The aims were to examine 90- and 365-day all-cause medical or surgical hospital readmission in Veterans with SMI discharged from a heart failure hospitalization. The exploratory aim was to evaluate 180-day post-discharge engagement in cardiac rehabilitation, an effective intervention for heart failure. METHODS: This study used administrative data from the Veterans Health Administration (VHA) and Centers for Medicare & Medicaid Services between 2011 and 2019. SMI status and medical comorbidity were assessed in the year prior to hospitalization. Cox proportional hazards models (competing risk of death) were used to evaluate the relationship between SMI status and outcomes. Models were adjusted for VHA hospital site, demographics, and medical characteristics. RESULTS: The sample comprised 189,767 Veterans of which 23,671 (12.5%) had SMI. Compared to those without SMI, Veterans with SMI had significantly higher readmission rates at 90 (16.1% vs. 13.9%) and 365 (42.6% vs. 37.1%) days. After adjustment, risk of readmission remained significant (90 days: HR: 1.07, 95% CI: 1.03, 1.11; 365 days: HR: 1.10, 95% CI: 1.07, 1.12). SMI status was not significantly associated with 180-day cardiac rehabilitation engagement (HR: 0.98, 95% CI: 0.91, 1.07). CONCLUSIONS: Veterans with SMI and heart failure have higher 90- and 365-day hospital readmission rates even after adjustment. There were no differences in cardiac rehabilitation engagement based on SMI status. Future work should consider a broader range of post-discharge interventions to understand contributors to readmission.

Changes in Homelessness Among US Veterans After Implementation of the Ending Veteran Homelessness Initiative.

Importance: Homelessness is a persistent and growing problem. What role health systems should play and how that role is incorporated into larger strategic efforts are not well-defined. Objective: To compare homelessness among veterans with that in the general population during a 16-year study period before and after implementation of the Ending Veteran Homelessness Initiative, a program to rehouse veterans experiencing homelessness. Design, Setting, and Participants: This national retrospective cohort study using a mixed-methods approach examined annualized administrative (January 1, 2007, to December 31, 2022) and population data prior to (2007-2009) and during (2010-2022) the Ending Veteran Homelessness initiative. Participants included unhoused adults in the US between 2007 and 2022. Exposure: Enrollment in Veterans Health Administration (VHA) Homeless Program Office components providing housing, case management, and wrap-around clinical and supportive services. Main Outcomes and Measures: Point-in-time (PIT) count data for unhoused veterans and nonveterans during the study period, number of Section 8 housing vouchers provided by Housing and Urban Development-Veterans Administration Supportive Housing, number of community grants awarded by Supportive Services for Veterans and Families, and total number of veterans housed each year. Semistructured interviews with VHA leadership were performed to gain insight into the strategy. Results: In 2022, 33 129 veterans were identified in the PIT count. They were predominantly male (88.7%), and 40.9% were unsheltered. During the active years of the Ending Veteran Homelessness initiative, veteran homelessness decreased 55.3% compared with 8.6% for the general population. The proportion of veterans in this cohort also declined from 11.6% to 5.3%. This change occurred during a shift to "housing first" as agency policy to create low-barrier housing availability. It was also coupled with substantial growth in housing vouchers, grants to community partner agencies, and growth in VHA clinical and social programming to provide homeless-tailored wrap-around services and support once participants were housed. Key respondent interviews consistently cited the shift to housing first, the engagement with community partners, and use of real-time data as critical. Conclusions and Relevance: In this cohort study of the federal Ending Veteran Homelessness initiative, after program implementation, there was a substantially greater decrease in homelessness among veterans than in the general population. These findings suggest an important role for health systems in addressing complex social determinants of health. While some conditions unique to the VHA facilitated the change in homelessness, lessons learned here are applicable to other health systems.

Protocols to reduce seclusion in inpatient mental health units.

The use of seclusion to manage conflict behaviours in psychiatric inpatient settings is increasingly viewed as an intervention of last resort. Many protocols have, thus, been developed to reduce the practice. We conducted a systematic review to determine the effectiveness of protocols to reduce seclusion on process outcomes (e.g., seclusion, restraint), patient outcomes (e.g., injuries, aggressive incidents, satisfaction), and staff outcomes (e.g., injuries, satisfaction). We searched Medline, Embase, the Cochrane Register of Clinical Trials, PsycINFO, CINAHL, cairn.info, and ClinicalTrials.gov for protocols to reduce seclusion practices for adult patients on inpatient mental health units (from inception to September 6, 2022). We summarised and categorised reported elements of the protocols designed to reduce seclusion using the Behaviour Change Wheel Intervention Functions and resources needed to implement the protocol in psychiatric units. We assessed risk of bias and determined certainty of evidence using GRADE. Forty-eight reports addressed five approaches to reduce seclusion: hospital/unit restructuring (N = 4), staff education/training (N = 3), sensory modulation rooms (N = 7), risk assessment and management protocols (N = 7), and comprehensive/mixed interventions (N = 22; N = 6 without empirical data). The relationship between the various protocols and outcomes was mixed. Psychiatric units that implement architecturally positive designs, sensory rooms, the Brøset Violence Checklist, and various multi-component comprehensive interventions may reduce seclusion events, though our certainty in these findings is low due to studies' methodological limitations. Future research and practice may benefit from standardised reporting of process and outcome measures and analyses that account for confounders.

Using Structured Observations to Evaluate the Effects of a Personalized Music Intervention on Agitated Behaviors and Mood in Nursing Home Residents With Dementia: Results From an Embedded, Pragmatic Randomized Controlled Trial.

OBJECTIVE: The objective of this research was to determine if a personalized music intervention reduced the frequency of agitated behaviors as measured by structured observations of nursing home (NH) residents with dementia. DESIGN: The design was a parallel, cluster-randomized, controlled trial. SETTING: The setting was 54 NH (27 intervention, 27 control) from four geographically-diverse, multifacility NH corporations. PARTICIPANTS: The participants were 976 NH residents (483 intervention, 493 control) with Alzheimer's disease or related dementias (66% with moderate to severe symptoms); average age 80.3 years (SD: 12.3) and 25.1% were Black. INTERVENTION: The intervention was individuals' preferred music delivered via a personalized music device. MEASUREMENT: The measurement tool was the Agitated Behavior Mapping Instrument, which captures the frequency of 13 agitated behaviors and five mood states during 3-minute observations. RESULTS: The results show that no verbally agitated behaviors were reported in a higher proportion of observations among residents in NHs randomized to receive the intervention compared to similar residents in NHs randomized to usual care (marginal interaction effect (MIE): 0.061, 95% CI: 0.028-0.061). Residents in NHs randomized to receive the intervention were also more likely to be observed experiencing pleasure compared to residents in usual care NHs (MIE: 0.038; 95% CI: 0.008-0.073)). There was no significant effect of the intervention on physically agitated behaviors, anger, fear, alertness, or sadness. CONCLUSIONS: The conclusions are that personalized music may be effective at reducing verbally-agitated behaviors. Using structured observations to measure behaviors may avoid biases of staff-reported measures.

Pragmatic Implementation of a Music Intervention in Nursing Homes Before and During COVID-19.

OBJECTIVES: We conducted 2 trials of a music intervention for managing behaviors in nursing home (NH) residents with dementia, before (2019) and during (2021) the pandemic. In this report, we compare adherence fidelity across the trials using the Framework for Implementation Fidelity (FIF). DESIGN: Cross-sectional, descriptive implementation comparison. SETTING AND PARTICIPANTS: Fifty-four NHs randomized to receive the intervention (27 pre-COVID, 27 during COVID) METHODS: We compare the trials on the following FIF criteria: coverage (number of residents receiving the intervention); duration (minutes of music received per exposed day); frequency (percentage of residents with nursing staff use of music in the past week); and details of content (adherence to core components of the intervention). We report NH-level performance in each domain and compare characteristics of NHs in the bottom (low) and top (high) terciles of adherence. RESULTS: Across FIF domains, adherence fidelity was lower during COVID compared with pre-COVID: coverage, residents exposed (COVID: 7.5, SD 5.6; pre-COVID: 12.7, SD 3.6); duration, music minutes per exposed day (COVID: 2.5, SD 5.1; pre-COVID: 27.1, SD 23.9); frequency, percentage of residents with nursing use of intervention in the past week (COVID: 15.0, SD 31.5; pre-COVID 40.4, SD 25.6); and details of content, compliance with core components of the intervention (COVID: 8.3, SD 1.9; pre-COVID 9.6, SD 2.0). In both trials, high-adherence fidelity NHs had better nursing staff ratios, greater percentages of Medicare residents, and lower percentages of Black residents, compared with low-fidelity NHs. CONCLUSIONS AND IMPLICATIONS: Adherence fidelity was worse in the COVID vs pre-COVID trial, despite adaptations between trials intended to reduce staff burden and increase clinical targeting of the intervention. Results may point to the long-term effects of COVID on quality improvement capacity in NHs and/or a lack of available resources in most NHs to implement complex behavioral interventions without direct research support.

Pre-hospitalization dysphagia and feeding tube placement in nursing home residents with advanced dementia.

BACKGROUND: Despite research demonstrating the risks of using feeding tubes in persons with advanced dementia, they continue to be placed. The natural history of dysphagia among patients with advanced dementia has not been examined. We conducted a secondary analysis of a national cohort of persons with advanced dementia staying at a nursing home stay before hospitalization to examine (1) pre-hospitalization dysphagia prevalence and (2) risk of feeding tube placement during hospitalization based on preexisting dysphagia. METHODS: A retrospective cohort study consisting of all nursing home (NH) residents (≥66 years) with advanced dementia (Cognitive Function Scale score ≥2), a hospitalization between 2013-2017, and a Minimum Data Set (MDS) 3.0 assessment within 120 days before hospitalization. Pre-hospitalization dysphagia status and surgically placed feeding tube insertion during hospitalization were determined by MDS 3.0 swallowing items and ICD-9 codes, respectively. A multivariate logistic model clustering on hospital was used to examine the association of dysphagia with percutaneous endoscopic gastrostomy (PEG) feeding tube placement after adjustment for confounders. RESULTS: Between 2013 and 2017, 889,983 persons with NH stay with advanced dementia (mean age: 84.5, SD: 7.5, and 63.5% female) were hospitalized. Pre-hospitalization dysphagia was documented in 5.4% (n = 47,574) and characterized by oral dysphagia (n = 21,438, 2.4%), pharyngeal dysphagia (n = 24,257, 2.7%), and general swallowing complaints/pain (n = 14,928, 1.7%). Overall, PEG feeding tubes were placed in 3529 patients (11.2%) with pre-hospitalization dysphagia, whereas 27,893 (88.8%) did not have pre-hospitalization dysphagia according to MDS 3.0 items. Feeding tube placement risk increased with the number of dysphagia items noted on the pre-hospitalization MDS (6 vs. 0 dysphagia variables: OR = 5.43, 95% CI: 3.19-9.27). CONCLUSIONS: Based on MDS 3.0 assessment, only 11% of PEG feeding tubes were inserted in persons with prior dysphagia. Future research is needed on whether this represents inadequate assessment or the impact of potentially reversible intercurrent illness resulting in feeding tube placement.