Leveraging emergency department visits to connect older adults at risk for malnutrition and food insecurity to community resources: design and protocol development for the BRIDGE study.

BACKGROUND: Malnutrition is a complex and costly condition that is common among older adults in the United States (US), with up to half at risk for malnutrition. Malnutrition is associated with several non-medical (i.e., social) factors, including food insecurity. Being at risk for both malnutrition and food insecurity likely identifies a subset of older adults with complex care needs and a high burden of social vulnerability (e.g., difficulty accessing or preparing meals, lack of transportation, and social isolation). US emergency departments (EDs) are a unique and important setting for identifying older patients who may benefit from the provision of health-related social services. This paper describes the protocol development for the Building Resilience and InDependence for Geriatric Patients in the Emergency Department (BRIDGE) study. BRIDGE was designed to assess the feasibility of an ED-based screening process to systematically identify older patients who are at risk for malnutrition and food insecurity and link them to health-related social services to address unmet social needs and support their health and well-being. METHODS: Phase 1 efforts will be formative and focused on identifying screening tools, establishing screening and referral workflows, and conducting initial feasibility testing with a cohort of older patients and ED staff. In phase 2, which includes process and outcome evaluation, the screening and referral process will be piloted in the ED. A partnership will be formed with an Area Agency on Aging (AAA) identified in phase 1, to assess resource needs and identify community-based social services for older ED patients who screen positive for both malnutrition risk and food insecurity. Data on screening, referrals, linkage to community-based social services, and patient-reported quality of life and healthcare utilization will be used to assess feasibility. DISCUSSION: The tools and workflows developed and tested in this study, as well as learnings related to forming and maintaining cross-sector partnerships, may serve as a model for future efforts to utilize EDs as a setting for bridging the gap between healthcare and social services for vulnerable patients.

Indicators of potential health-related social needs and the association with perceived health and well-being outcomes among community-dwelling medicare beneficiaries.

PURPOSE: Health-related social needs (HRSNs) can make older adults' more vulnerable and impact their health, well-being, and ability to age-in-place. The current study assessed the prevalence of potential HRSNs (pHRSNs) across several domains (e.g., transportation, social isolation) and explored the associations with health and well-being outcomes in a sample of Medicare beneficiaries. METHODS: Cross-sectional analyses were conducted with a representative sample of community-dwelling Medicare beneficiaries (N = 5758) from the 2012 National Health and Aging Trends Study. Binary indicators of pHRSNs were created for five domains: medical and utility financial needs (MUFN), housing, nutrition, social isolation, and transportation. Outcomes were depression/anxiety, self-rated health, meaning/satisfaction, perceived control/adaptability. Variables were weighted, and multivariate regression models assessed associations between pHRSN variables and outcomes, controlling for sociodemographics and health conditions. RESULTS: Of the estimated 32 million community-dwelling beneficiaries, approximately 13.3 million were positive for ≥ 1 pHRSN and 11.4 million for ≥ 2 pHRSNs. The prevalence by domain was 7% for housing, 8% for transportation, 12% for UMFN and nutrition, and 33% for social isolation. Each domain, except for housing, was significantly (p < .05) associated with at least two of the four outcomes, where being positive for a pHRSN was associated with greater depression/anxiety and poorer self-rated general health. CONCLUSIONS: Over 40% of Medicare beneficiaries had ≥ 1 pHRSN indicators, which means they are more vulnerable and that may limit their ability to age-in-place. Given the growing aging population, better measures and methods are needed to identify, monitor, and address HRSNs. For example, leveraging existing community-based services through coordinated care may be an effective strategy to address older adults' HRSNs.

"It's Not Just a Simple Meal. It's So Much More": Interactions Between Meals on Wheels Clients and Drivers.

Background and Objectives: Meals on Wheels (MOW) programs provide home-delivered meals to over 1.5 million older adults; yet, very little is known about the drivers who make meal deliveries possible. Specifically, we do not have clear insight into their interaction with clients or the benefits that they may receive through their service. The objective of this article is to describe the characteristics of MOW drivers, the interactions among drivers and clients, and the benefits of the program to both. Research Design and Method: This qualitative research study reports on interviews with 84 MOW staff (leadership, case managers/client assessors, volunteer coordinators) and drivers at six geographically and operationally distinct programs across the United States. Results: Qualitative analysis of the interviews with MOW staff and drivers revealed the following key themes: (a) clients have multiple vulnerabilities; (b) clients appear to derive social, as well as nutritional benefit from receiving meals; (c) drivers report they provide additional support to their clients beyond delivering the meal; (d) social bonds between drivers and clients were reported to strengthen over time; (e) drivers claim that they, too, derive validation and personal benefit through their meal delivery. Discussion and Implications: This research highlights the significant contributions that meal delivery drivers made in the lives of MOW clients beyond the actual meal itself. This research also spotlights the perceived benefits experienced by the drivers and points to the importance of conducting further research to determine the effects of meal delivery on client and drivers' outcomes, more broadly.

Leveraging Home-Delivered Meal Programs to Address Unmet Needs for At-Risk Older Adults: Preliminary Data.

BACKGROUND: Home-delivered meal programs serve a predominantly homebound older adult population, characterized by multiple chronic conditions, functional limitations, and a variety of complex care needs, both medical and social. DESIGN: A pilot study was designed to test the feasibility of leveraging routine meal-delivery service in two home-delivered meal programs to proactively identify changes in older adult meal recipients' (clients') health, safety, and well-being and address unmet needs. INTERVENTION: Meal delivery personnel (drivers) were trained to use a mobile application to submit electronic alerts when they had a concern or observed a change in a client's condition. Alerts were received by care coordinators, who followed up with clients to offer support and help connect them to health and community services. RESULTS: Over a 12-month period, drivers submitted a total of 429 alerts for 189 clients across two pilot sites. The most frequent alerts were submitted for changes in health (56%), followed by self-care or personal safety (12%) and mobility (11%). On follow-up, a total of 132 referrals were issued, with most referrals for self-care (33%), health (17%), and care management services (17%). Focus groups conducted with drivers indicated that most found the mobile application easy to use and valued change of condition monitoring as an important contribution. CONCLUSION: Findings suggest that this is a feasible approach to address unmet needs for vulnerable older adults and may serve as an early-warning system to prevent further decline and improve quality of life. Efforts are underway to test the protocol across additional home-delivered meal programs. J Am Geriatr Soc 67:1946-1952, 2019.

Home and community-based services coordination for homebound older adults in home-based primary care.

BACKGROUND: Medically complex vulnerable older adults often face social challenges that affect compliance with their medical care plans, and thus require home and community-based services (HCBS). This study describes how non-medical social needs of homebound older adults are assessed and addressed within home-based primary care (HBPC) practices, and to identify barriers to coordinating HCBS for patients. METHODS: An online survey of members of the American Academy of Home Care Medicine (AAHCM) was conducted between March through November 2016 in the United States. A 56-item survey was developed to assess HBPC practice characteristics and how practices identify social needs and coordinate and evaluate HCBS. Data from 101 of the 150 surveys received were included in the analyses. Forty-four percent of respondents were physicians, 24% were nurse practitioners, and 32% were administrators or other HBPC team members. RESULTS: Nearly all practices (98%) assessed patient social needs, with 78% conducting an assessment during the intake visit, and 88% providing ongoing periodic assessments. Seventy-four percent indicated 'most' or 'all' of their patients needed HCBS in the past 12 months. The most common needs were personal care (84%) and medication adherence (40%), and caregiver support (38%). Of the 86% of practices reporting they coordinate HCBS, 91% followed-up with patients, 84% assisted with applications, and 83% made service referrals. Fifty-seven percent reported that coordination was 'difficult.' The most common barriers to coordinating HCBS included cost to patient (65%), and eligibility requirements (63%). Four of the five most frequently reported barriers were associated with practices reporting it was 'difficult' or 'very difficult' to coordinate HCBS (OR from 2.49 to 3.94, p-values < .05). CONCLUSIONS: Despite the barriers to addressing non-medical social needs, most HBPC practices provided some level of coordination of HCBS for their high-need, high-cost homebound patients. More efforts are needed to implement and scale care model partnerships between medical and non-medical service providers within HBPC practices.

Operation and challenges of home-based medical practices in the US: findings from six aggregated case studies.

BACKGROUND: Home-based primary care (HBPC) is a multidisciplinary, ongoing care strategy that can provide cost-effective, in-home treatment to meet the needs of the approximately four million homebound, medically complex seniors in the U.S. Because there is no single model of HBPC that can be adopted across all types of health organizations and U.S. geographic regions, we conducted a six-site HBPC practice assessment to better understand different operation structures, common challenges, and approaches to delivering HBPC. METHODS: Six practices varying in size, care team composition and location agreed to participate. At each site we conducted unstructured interviews with key informants and directly observed practices and procedures in the field and back office. RESULTS: The aggregated case studies revealed important issues focused on team composition, patient characteristics, use of technology and urgent care delivery. Common challenges across the practices included provider retention and unmet community demand for home-based care services. Most practices, regardless of size, faced challenges around using electronic medical records (EMRs) and scheduling systems not designed for use in a mobile practice. Although many practices offered urgent care, practices varied in the methods used to provide care including the use of community paramedics and telehealth technology. CONCLUSIONS: Learnings compiled from these observations can inform other HBPC practices as to potential best practices that can be implemented in an effort to improve efficiency and scalability of HBPC so that seniors with multiple chronic conditions can receive comprehensive primary care services in their homes.

Personal and professional challenges confronted by hospital staff following hurricane sandy: a qualitative assessment of management perspectives.

BACKGROUND: Adequate hospital staffing during and after a disaster is critical to meet increased health care demands and to ensure continuity of care and patient safety. However, when a disaster occurs, staff may become both victim and responder, decreasing their ability and willingness to report for work. This qualitative study assessed the personal and professional challenges that affected staff decisions to report to work following a natural disaster and examined the role of management in addressing staff needs and concerns. METHODS: Semi-structured interviews were conducted with individuals who filled key management roles in the United States Department of Veterans Affairs New York Harbor Healthcare System's response to Superstorm Sandy and during the facility's initial recovery phase. All interviews were audio recorded and transcribed. Three major themes were identified: 1) Barriers to reporting ("Barriers"), 2) Facilitators to reporting ("Facilitators"), and 3) Responses to staff needs and concerns ("Responses"). Atlas.ti 7.1.6 software program was used for the management and analysis of the transcripts. RESULTS: Results indicated that staff encountered several barriers that impeded their ability to report to work at mobile vans at the temporarily nonoperational Manhattan campus or at two other VA facilities in Brooklyn and the Bronx in the initial post-Sandy period including transportation problems, personal property damage, and communication issues. In addition, we found evidence of facilitators to reporting as expressed through descriptions of professional duty. Our findings also revealed that management was aware of the challenges that staff was facing and made efforts to reduce barriers and accommodate staff affected by the storm. CONCLUSIONS: During and after a disaster event, hospital staff is often confronted with challenges that affect decisions to report for work and perform effectively under potentially harsh conditions. This study examined barriers and facilitators that hospital staff encountered following a major natural disaster from the management perspective. Insights gained from this study can be used to inform future disaster planning and preparedness efforts, and help ensure that there is adequate staffing to mount an effective response when a disaster occurs, and to recover from its aftermath.

Memory for sequences of events impaired in typical aging.

Typical aging is associated with diminished episodic memory performance. To improve our understanding of the fundamental mechanisms underlying this age-related memory deficit, we previously developed an integrated, cross-species approach to link converging evidence from human and animal research. This novel approach focuses on the ability to remember sequences of events, an important feature of episodic memory. Unlike existing paradigms, this task is nonspatial, nonverbal, and can be used to isolate different cognitive processes that may be differentially affected in aging. Here, we used this task to make a comprehensive comparison of sequence memory performance between younger (18-22 yr) and older adults (62-86 yr). Specifically, participants viewed repeated sequences of six colored, fractal images and indicated whether each item was presented "in sequence" or "out of sequence." Several out of sequence probe trials were used to provide a detailed assessment of sequence memory, including: (i) repeating an item from earlier in the sequence ("Repeats"; e.g., AB A: DEF), (ii) skipping ahead in the sequence ("Skips"; e.g., AB D: DEF), and (iii) inserting an item from a different sequence into the same ordinal position ("Ordinal Transfers"; e.g., AB 3: DEF). We found that older adults performed as well as younger controls when tested on well-known and predictable sequences, but were severely impaired when tested using novel sequences. Importantly, overall sequence memory performance in older adults steadily declined with age, a decline not detected with other measures (RAVLT or BPS-O). We further characterized this deficit by showing that performance of older adults was severely impaired on specific probe trials that required detailed knowledge of the sequence (Skips and Ordinal Transfers), and was associated with a shift in their underlying mnemonic representation of the sequences. Collectively, these findings provide unambiguous evidence that the capacity to remember sequences of events is fundamentally affected by typical aging.

A Sequence of events model of episodic memory shows parallels in rats and humans.

A critical feature of episodic memory is the ability to remember the order of events as they occurred in time, a capacity shared across species including humans, nonhuman primates, and rodents. Accumulating evidence suggests that this capacity depends on a network of structures including the hippocampus and the prefrontal cortex, but their respective contributions remain poorly understood. As addressing this important issue will require converging evidence from complementary investigative techniques, we developed a cross-species, nonspatial sequence memory task suitable for behavioral and neurophysiological studies in rodents and in humans. The task involves the repeated presentation of sequences of items (odors in rats and images in humans) and requires subjects to make a judgment as to whether each item is presented "in sequence" or "out of sequence." To shed light on the cognitive processes and sequence representations supporting performance, different types of "out of sequence" probe trials were used including: (i) repeating an item from earlier in the sequence (Repeats; e.g., ABAD), (ii) skipping ahead in the sequence (Skips; e.g., ABD), and (iii) inserting an item from a different sequence into the same ordinal position (Ordinal Transfers; e.g., A2CD). We found a remarkable similarity in the performance of rats and humans, particularly in the pattern of results across probe trial types. Thus, the results suggest that rats and humans not only remember the sequences of events, but also use similar underlying cognitive processes and mnemonic representations. This strong cross-species correspondence validates this task for use in future basic and clinical interdisciplinary studies aimed at examining the neural mechanisms underlying episodic memory.

Temporal associations for spatial events: the role of the dentate gyrus.

Previous research suggests that the dorsal dentate gyrus (DG) hippocampal subregion mediates spatial processing functions. However, a novel role for the DG in temporal processing for spatial information has begun to emerge based on the development of a computational model of neurogenesis. According to this model, adult born granule cells in the DG contribute to a temporal associative integration process for events presented closer in time. Currently, there is a paucity of behavioral evidence to support the temporal integration theory. Therefore, we developed a novel behavioral paradigm to investigate the role of the dDG in temporal integration for proximal and distal spatial events. Male Long-Evans rats were randomly assigned to a control group or to receive bilateral intracranial infusions of colchicine into the dDG. Following recovery from surgery, each rat was tested on a cued-recall of sequence paradigm. In this task, animals were allowed to explore identical objects placed in designated spatial locations on a cheeseboard maze across 2 days (e.g., Day 1: A and B; Day 2: C and D). One week later, animals were given a brief cue (A or C) followed by a preference test between spatial location B and D. Control animals had a significant preference for the spatial location previously paired with the cue (the temporal associate) whereas dDG lesioned animals failed to show a preference. These findings suggest that selective colchicine-induced dDG lesions are capable of disrupting the formation of temporal associations between spatial events presented close in time.

Age-related changes in place learning for adjacent and separate locations.

The effect of spatial interference on place learning was examined in young and old rats. Rats were trained on a radial 8-arm maze to discriminate between a reward arm and a nonreward arm that either were adjacent to each other (high spatial interference) or separated by a distance of 2 arm positions (low spatial interference). Each rat was tested until reaching a criterion of 9 correct choices out of 10 trials across 2 consecutive days. The data revealed that old rats committed significantly more errors than young rats when the arms were adjacent and spatial interference was high. However, no group differences were detected when the arms were separated and spatial interference was low. Group differences also were not detected in the number of trials required to reach the learning criterion in either condition. The results indicate that age-related brain changes result in increased errors during place learning, particularly when spatial interference is high, suggesting that spatial pattern separation might be less efficient in aged animals.

The role of the dentate gyrus in the formation of contextual representations.

The hippocampus is involved in encoding and integrating contextual information. Recently, it has been suggested that the dorsal dentate gyrus (dDG) hippocampal subregion may mediate the formation of contextual representations of the spatial environment through a conjunctive encoding process whereby incoming multimodal information is integrated into a single higher-order representation. Despite anatomical evidence in support of this claim, behavioral evidence is limited. Therefore, a contextual associative learning paradigm was used to determine whether the dDG supports the formation of integrated contextual representations. Male Long-Evans rats were randomly assigned as controls or to receive bilateral intracranial infusions of colchicine into the dDG. Following recovery from surgery, each rat was tested on an appetitive task that required animals to form an association between a cue (odor) and a context to receive a food reward. Each rat received 10 trials per day and was tested for 10 consecutive days. Upon completion of testing, animals were tested on an additional two-choice olfactory and contextual discrimination task. The testing order was counterbalanced across animals. Results showed that control animals successfully acquired the contextual associative learning task for olfactory stimuli as indicated by improved performance across the 10 testing days. In contrast, animals with dDG lesions were impaired in the ability to acquire the odor-context associations. Results from follow-up odor and context discrimination tests indicated that both groups acquired the discriminations at similar rates. Therefore, it is unlikely that deficits in performance on the contextual associative learning task were due to an inability to discriminate between odors or contexts. The present findings provide further support for DG involvement in the formation of conjunctive contextual representations.

Selective lesions of the dentate gyrus produce disruptions in place learning for adjacent spatial locations.

The hippocampus (HPP) plays a known role in learning novel spatial information. More specifically, the dentate gyrus (DG) hippocampal subregion is thought to support pattern separation, a mechanism for encoding and separating spatially similar events into distinct representations. Several studies have shown that lesions of the dorsal DG (dDG) in rodents result in inefficient spatial pattern separation for working memory; however, it is unclear whether selective dDG lesions disrupt spatial pattern separation for reference memory. Therefore, the current study investigated the role of the dDG in pattern separation using a spatial reference memory paradigm to determine whether the dDG is necessary for acquiring spatial discriminations for adjacent locations. Male Long-Evans rats were randomly assigned to receive bilateral intracranial infusions of colchicine or saline (control) into the dDG. Following recovery from surgery, each rat was pseudo-randomly assigned to an adjacent arm or separate arm condition and subsequently tested on a place-learning task using an eight-arm radial maze. Rats were trained to discriminate between a rewarded arm and a nonrewarded arm that were either adjacent to one another or separated by a distance of two arm positions. Each rat received 10 trials per day and was tested until the animal reached a criterion of nine correct choices out of 10 consecutive trials across 2 consecutive days of testing. Both groups acquired spatial discriminations for the separate condition at similar rates. However, in the adjacent condition, dDG lesioned animals required significantly more trials to reach the learning criterion than controls. The results suggest that dDG lesions decrease efficiency in pattern separation resulting in impairments in the adjacent condition involving greater overlap among the distal cues. Conversely, in the separate condition, there was less overlap among distal cues during encoding and less need for pattern separation. These findings provide further support for a critical role for the dDG in spatial pattern separation by demonstrating the importance of a processing mechanism that is capable of reducing interference among overlapping spatial inputs across a variety of memory demands.

Age-related source memory deficits persist despite superior item memory.

Source and item memory for faces of former United States Presidents were assessed in nondemented older adults over 65 years of age (n = 20) and young adults 18 to 25 years of age (n = 20). During the study phase, a male and a female source each presented pictures of faces to the participant one at a time. To assess source memory, the participant was asked to indicate whether a face from the study phase was presented by the male or female. To assess item memory, a study phase face and distractor face were presented and the participant was asked to indicate which was presented previously. Older adults displayed significantly better item memory for the faces of presidents compared to young adults. However, despite showing superior item memory, source memory still was impaired in older adults compared to young adults. The ability of older adults to efficiently integrate source and item information may be compromised to such a large extent that enhanced item memory does not appear to minimize or negate age-related source memory deficits. The findings demonstrate the robust effects of aging on source memory.

Prefrontal and hippocampal contributions to encoding and retrieval of spatial memory.

The prefrontal cortex is thought to be critical for goal-directed action and the hippocampus is known to be importantly involved in spatial memory. Several studies have been suggestive of a role for the orbitofrontal cortex (OFC) in spatial navigation. However, the medial prefrontal cortex (mPFC) receives projections directly from the intermediate CA1 (iCA1) region of hippocampus and this link may be critical for spatial navigation. The purpose of the present investigation was to test the performance of rats receiving bilateral or disconnection infusions of lidocaine into OFC, mPFC, or iCA1 to determine the contribution of these structures to encoding and retrieval of spatial memory using the Hebb-Williams maze. A total of 92 male Long-Evans rats received chronic bilateral, contralateral, or ipsilateral implantation of cannulas into OFC, mPFC, or iCA1. Prior to testing on day 1 or day 2, subjects received central infusions of saline or lidocaine. The number of errors committed on the first five trials compared to the second five trials of day 1 was used to determine encoding, whereas retrieval was determined by comparing the second five trials of day 1 with the first five trials of day 2. The present findings suggest that mPFC and iCA1 are necessary and interact during encoding and retrieval; however, the OFC does not appear to be essential for either process. While the nature of the interaction between mPFC and iCA1 during encoding and retrieval is unclear, it may be supported by the integration of goals and spatial cues or strategy switching.

Interactions between the prefrontal cortex and amygdala during delay discounting and reversal.

Interactions between the prefrontal cortex and amygdala are thought to be critical for reward anticipation. Alterations in reward anticipation that lead to an inability to wait for rewards or a diminished capacity to change behavior when doing so would be optimal are often termed impulsivity and compulsivity, respectively. Distinct regions of the prefrontal cortex may support decreased impulsivity through self-control and decreased compulsivity through flexibility. However, both self-control and flexibility appear to involve the amygdala. Using a delay discounting paradigm, the current investigation found that inactivation and disconnection of the medial prefrontal cortex and basolateral amygdala led rats to become more impulsive by affecting preference for smaller immediate over larger delayed rewards. Conversely, inactivation and disconnection of the orbitofrontal cortex and amygdala led rats to become more compulsive as demonstrated by an inability to flexibly reverse stimulus-reward relationships in an odor reversal task. The current findings support a double dissociation between orbitofrontal cortex-amygdala interactions for odor reversal and medial prefrontal cortex-amygdala interactions for delay discounting.