Accelerated Resolution Therapy for Early Maladaptive Grief Study Protocol.

The objective of this manuscript is to present the protocol of a study aiming to test the effects of Accelerated Resolution Therapy® (ART) on pre-loss grief and prolonged grief among older adult family caregivers. This study also aims to better understand predictors of response to ART®, and cognitive processes that occur among grieving individuals following ART®. DESIGN: The study is a double-blinded, randomized clinical trial. SETTING: This study takes place at both inpatient and outpatient palliative care and hospice programs at two Mayo Clinic sites. PARTICIPANTS: Participants include older adult (≥ 60 years) immediate family members who are primary caregivers of someone with an advanced illness and life expectancy of less than 12 months. INTERVENTION: Participants are randomized to either the ART® intervention group or the attention control group. In the ART® intervention, caregivers engage in imaginal exposure, lateral eye movements, and imagery rescripting via 4 sessions lasting 1-1.5 hours each. The attention control group receives a standard social work intervention, including education, resources, and active listening, which is matched for time and attention. Both interventions will longitudinally follow caregivers from active caregiving into bereavement. OUTCOMES MEASURED: The primary outcomes of pre-loss grief and prolonged grief will be measured with the Pre-Loss Grief 12 item (PG-12-R) before the care recipient's death, and with the Prolonged Grief-13 (PG-13-R) afterwards.

Assessing Heart Failure Self-management Knowledge Through Vignettes.

BACKGROUND: Heart failure (HF) self-care is key to managing symptoms, but current HF knowledge instruments are at risk for social desirability bias (ie, tendency to respond in a way that is viewed favorably). Vignettes may be a useful method to mitigate this bias by measuring knowledge via scenarios in which individuals with HF are invited to respond to fictional characters' self-management problems rather than disclosing their own practices. OBJECTIVE: The aims of the study were to develop and test the content validity of vignettes measuring individuals' knowledge of HF symptom self-management. METHODS: The study had 3 phases. In phase 1, two vignettes were developed. One focused on psychological symptom self-management (ie, anxiety, depression), and the other focused on physical symptom self-management (ie, edema, fatigue). In phase 2, the research team and lay experts made improvements to the vignettes' readability. In phase 3, five HF self-care nurse experts evaluated the vignettes' clarity and importance with a 3-point Likert-type scale using Delphi methods. We calculated the vignettes' content validity using the scale-level content validity index. RESULTS: The final content validation encompassed 2 Delphi rounds (phase 3), yielding a scale-level content validity index of 0.92 and 0.94 for the psychological and physical symptom vignettes, respectively. These results indicate excellent initial content validity. CONCLUSIONS: The content of vignettes measuring individuals' knowledge of HF symptom self-management is valid based on the opinions of nurse experts. The vignettes offer a promising method to assess knowledge about HF self-care management without the pressure of disclosing individual patient practices.

Usability of the 4Ms Worksheet in the Emergency Department for Older Patients: A Qualitative Study.

Introduction: Older adults often have multiple comorbidities; therefore, they are at high risk for adverse events after discharge. The 4Ms framework-what matters, medications, mentation, mobility-has been used in acute and ambulatory care settings to identify risk factors for adverse events in older adults, although it has not been used in the emergency department (ED). We aimed to determine whether 1) use of the 4Ms worksheet would help emergency clinicians understand older adult patients' goals of care and 2) use of the worksheet was feasible in the ED. Methods: We conducted a qualitative, descriptive study among patients aged ≥60 years and emergency clinicians from January-June 2022. Patients were asked to fill out a 4Ms worksheet; following this, semi-structured interviews were conducted with patients and clinicians separately. We analysed data to create codes, which were divided into categories and sub-categories. Results: A total of 20 older patients and 19 emergency clinicians were interviewed. We identified two categories based on our aims: understanding patient goals of care (sub-categories: clinician/ patient concordance; understanding underlying goals of care; underlying goals of care discrepancy) and use of 4Ms Worksheet (sub-categories: worksheet to discussion discrepancy; challenges using worksheet; challenge completing worksheet before discharge). Rates of concordance between patient and clinician on main concern/goal of care and underlying goals of care were 82.4% and 15.4%, respectively. Conclusion: We found that most patients and emergency clinicians agreed on the main goal of care, although clinicians often failed to elicit patients' underlying goal(s) of care. Additionally, many patients preferred to have the interviewer fill out the worksheet for them. There was often discrepancy between what was written and what was discussed with the interviewer. More research is needed to determine the best way to integrate the 4Ms framework within emergency care.

Exploring the interplay of psychological and biological components of stress response and telomere length in the transition from middle age to late adulthood: A systematic review.

Ageing and chronic stress have been linked to reduced telomere length (TL) in mixed-age groups. Whether stress response components are linked to TL during the midlife-to-late adulthood transition remains unclear. Our study aimed to synthesise evidence on the relationship between psychological and biological components of stress response on TL in middle-aged and older adults. We conducted a systematic review of studies obtained from six databases (PubMed, CINAHL, EMBASE, PsycINFO, Web of Science, and Scopus) and evaluated by two independent reviewers. Original research measuring psychological and biological components of stress response and TL in human individuals were included. From an initial pool of 614 studies, 15 were included (n = 9446 participants). Synthesis of evidence showed that higher psychological components of the stress response (i.e., global perceived stress or within a specific life domain and cognitive appraisal to social-evaluative stressors) were linked to shorter TL, specifically in women or under major life stressors. For the biological stress response, cortisol, dehydroepiandrosterone sulphate and IGF-1/cortisol imbalance, IL-6, MCP-1, blood pressure, and heart rate presented a significant association with TL, but this relationship depended on major life stressors and the stress context (manipulated vs. non-manipulated conditions). This comprehensive review showed that psychological and biological components of the stress response are linked to shorter TL, but mainly in women or those under a major life stressor and stress-induced conditions. The interaction between stressor attributes and psychological and biological reactions in the transition from middle to late adulthood still needs to be fully understood, and examining it is a critical step to expanding our understanding of stress's impact on ageing trajectories.

Caregivers' Contributions to Heart Failure Self-care: An Updated Systematic Review.

BACKGROUND: A previous systematic review reporting the contributions of informal, unpaid caregivers to patient heart failure (HF) self-care requires updating to better inform research, practice, and policy. OBJECTIVE: The aim of this study was to provide an updated review answering the questions: (1) What specific activities do informal caregivers of adults with HF take part in related to HF self-care? (2) Have the activities that informal caregivers of adults with HF take part in related to HF self-care changed over time? (3) What are the gaps in the science? METHODS: This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, CINAHL, EMBASE, and Cochrane CENTRAL databases were searched. Eligible studies involved an informal, unpaid caregiver of an adult with HF as a study variable or participant. Caregiving activities were benchmarked using the theory of self-care in chronic illness. RESULTS: Two thousand one hundred fifty-four research reports were identified, of which 64 met criteria. Caregivers' contributions occurred in self-care maintenance (91%), monitoring (54%), and management (46%). Activities performed directly on or to the patient were reported more frequently than activities performed for the patient. Change over time involved the 3 domains differentially. Gaps include ambiguous self-care activity descriptions, inadequate caregiving time quantification, and underrepresented self-care monitoring, supportive, and communication activities. CONCLUSIONS: Newly identified caregiver-reported activities support updating the theory of self-care in chronic illness to include activities currently considered ancillary to HF self-care. Identified gaps highlight the need to define specific caregiving activities, determine task difficulty and burden, and identify caregiver self-care strategy and education needs. Exposing the hidden work of caregiving is essential to inform policy and practice.

Older Adults' Process of Collaborating With a Support Team During Transitions From Hospital to Home: A Grounded Theory Study.

BACKGROUND AND OBJECTIVES: Little is known about how older adults engage with multiple sources of support and resources during transitions from hospital to home, a period of high vulnerability. This study aims to describe how older adults identify and collaborate with a support team, including unpaid/family caregivers, health care providers, and professional and social networks, during the transition. RESEARCH DESIGN AND METHODS: This study utilized grounded theory methodology. One-on-one interviews were conducted with adults aged 60 and older following their discharge from a medical/surgical inpatient unit in a large midwestern teaching hospital. Data were analyzed using open, axial, and selective coding. RESULTS: Participants (N = 25) ranged from 60 to 82 years of age, 11 were female, and all participants were White, non-Hispanic. They described a process of identifying a support team and collaborating with that team to manage at home and progress their health, mobility, and engagement. Support teams varied, but included collaborations between the older person, unpaid/family caregiver(s), and their health care providers. Their collaboration was impacted by the participant's professional and social networks. DISCUSSION AND IMPLICATIONS: Older adults collaborate with multiple sources of support and this collaboration is a dynamic process that varies across phases of their transition from hospital to home. Findings reveal opportunities for assessing individual's support and social networks, in addition to health and functional status, to determine needs and leverage resources during transitions in care.

Feasibility of the Palliative Care Education in Assisted Living Intervention for Dementia Care Providers: A Cluster Randomized Trial.

BACKGROUND AND OBJECTIVES: Alzheimer's disease and related dementia (ADRD) is a major cause of death in the United States. While effective interventions have been developed to deliver palliative care to nursing home residents with ADRD, little work has identified effective interventions to reach assisted living (AL) residents with dementia. RESEARCH DESIGN AND METHODS: One hundred and eighteen AL residents with dementia from 10 different ALs in Florida participated. A pilot study using a cluster randomized trial was conducted, with 6 sites randomized to receive a palliative care educational intervention for staff (N = 23) to deliver care to residents; 4 sites were usual care. The feasibility of the intervention was assessed by examining recruitment, retention, and treatment fidelity at 6 months. Cohen's d statistic was used to calculate facility-level treatment effect sizes on key outcomes (documentation of advance care planning [ACP] discussions, hospice admission, and documentation of pain screening). RESULTS: The intervention proved feasible with high ratings of treatment fidelity. The intervention also demonstrated preliminary evidence for efficacy of the intervention, with effect sizes for the treatment group over 0.80 for increases in documentation of ACP discussions compared to the control group. Hospice admissions had a smaller effect size (0.16) and documentation of pain screenings had no effect. DISCUSSION AND IMPLICATIONS: The pilot results suggest that the intervention shows promise as a resource for educating and empowering AL staff on implementing person-centered palliative care delivery to persons with dementia in AL. A larger, fully powered randomized trial is needed to test for its efficacy.

Critical Elements of Care Coordination for Older Persons in Rural Communities: An Evaluation of the Iowa Return to Community Service Demonstration.

We evaluated the Iowa Return to Community, a service demonstration designed to coordinate care and reduce preventable healthcare utilization among at-risk older persons living at home in rural communities. During 2021, 262 older persons elected to participate in the IRTC program. Individuals who participated were more likely to live in micropolitan areas (OR = 2.30, 95% CI 1.34-3.95) relative to metropolitan locations. Individuals who used recommended services were more likely to be men (OR 3.65, 95% CI 1.16-11.51) and more likely to live in rural (OR 17.48, 95% CI 1.37-223.68) and micropolitan areas (OR 3.17, 95% CI 1.00-10.05). However, prevention of health care use corresponded more with consistent and prolonged IRTC program engagement rather than volume of service use. The IRTC constitutes a population aging and rural health strategy to reduce unnecessary health care use while supporting individual preferences to remain at home.

A scoping review of unpaid caregivers' experiences during older adults' hospital-to-home transitions.

The objective of this scoping review is to examine current evidence regarding unpaid/family caregivers' experiences during older adults' hospital-to-home transitions to identify gaps and opportunities to involve caregivers in transitional care improvement efforts. Eligible articles focused on caregiver experience, outcomes, or interventions during older adults' hospital-to-home transitions. Our review identified several descriptive studies focused on exploring the caregiver experience of older adult hospital-to-home transitions and caregiver outcomes (such as preparedness, strain, burden, health, and well-being). Qualitative studies revealed challenges at multiple levels, including individual, interpersonal, and systemic. Few interventions have targeted or included caregivers to improve discharge education and address support needs during the transition. Future work should target underrepresented and marginalized groups of caregivers, and caregivers' collaboration with community-based services, social networks, or professional services. Work remains in developing and implementing interventions to support both older adult and caregiver needs.

Older adults' goals of care in the emergency department setting: A qualitative study guided by the 4Ms framework.

Background: We sought to identify what matters to older adults (60 years and older) presenting to the emergency department (ED) and the challenges or concerns they identify related to medication, mobility, and mentation to inform how the 4Ms framework could improve care of older adults in the ED setting. Methods: A qualitative study was conducted using the 4Ms to identify what matters to older adults (≥60 years old) presenting to the ED and what challenges or concerns they identify related to medication, mobility, and mentation. We conducted semi-structured interviews with a convenience sample of patients in a single ED. Interview guide responses and interviewer field notes were entered into REDCap. Interviews were reviewed by the research team (2 coders per interview) who inductively assigned codes. A codebook was created through an iterative process and was used to group codes into themes and sub-themes within the 4Ms framework. Results: A total of 20 ED patients participated in the interviews lasting 30-60 minutes. Codes identified for "what matters" included problem-oriented expectation, coordination and continuity, staying engaged, being with family, and getting back home. Codes related to the other 4Ms (medication, mobility, and mentation) described challenges. Medication challenges included: non-adherence, side effects, polypharmacy, and knowledge. Mobility challenges included physical activity and independence. Last, mentation challenges included memory concerns, depressed mood, and stress and worry. Conclusions: Our study used the 4Ms to identify "what matters" to older adults presenting to the ED and the challenges they face regarding medication, mobility, and mentation. Understanding what matters to patients and the specific challenges they face can help shape and individualize a patient-centered approach to care to facilitate the goals of care discussion and handoff to the next care team.

Adaption of the Casey-Fink Survey Tool for Nurse Residency Programs: Making It Relevant for Hospice and Palliative Care Nurse Residency Programs.

OBJECTIVE: This evaluation project focused on assessing the content validity of an adapted version of the Casey-Fink (CF) Graduate Nurse Experience Survey, which is aimed at measuring role transitions in nursing. BACKGROUND: Registered nurses in the hospice and palliative care field need training and confidence to be proficient in core skills including communication, interprofessional competence, and clinical skills required to care for the dying patient. However, a review of the literature revealed a gap in the availability of survey instruments to measure the confidence of nurses entering the field of hospice and palliative care. METHODS: Ten items from the CF survey were revised by the project team and then evaluated for relevance by a group of 7 national hospice and palliative experts. The content validity index (CVI) was used to determine item relevance. RESULTS: Item-level CVI (I-CVI) calculations ranged from 0.57 to 1.0. The 8 items scored between 0.80 and 1.0 were retained as written. One item required further revision (I-CVI, 0.71), and 1 item revision was eliminated (I-CVI, 0.57). Experts also suggested 5 additional items in the original CF-survey need modification. CONCLUSION: The adapted CF-survey tool is ready for further psychometric testing, and next steps include administration to a new sample of nurse residents to determine construct validity.

Rural age-friendly ecosystems for older adults: An international scoping review with recommendations to support age-friendly communities.

Background and Aims: The population of older adults in rural areas is rising, and they experience higher rates of poverty and chronic illness, have poorer health behaviors, and experience different challenges than those in urban areas. This scoping review seeks to (1) map the state of the science of age-friendly systems in rural areas regarding structural characteristics, processes for delivering age-friendly practices, and outcomes of age-friendly systems, (2) analyze strengths, weakness, opportunities, and threats of age-friendly system implementation, and (3) make person, practice, and policy-level recommendations to support active aging and development of age-friendly communities. Methods: An international scoping review was conducted of articles that used age-friendly framing, had a sample age of 45 years of age or older, self-identified as rural, and reported empiric data. Searches were conducted in PubMed, CINAHL, AgeLine, PsychINFO, EMBASE, Scopus, and Academic Search Elite on October 26, 2021, and rerun March 10, 2023. Data were charted across three analytic layers: socioecological model, Donabedian's framework, and SWOT analysis. Results: Results reveal limited data on outcomes relevant to organizations, such as return on investment or healthcare utilization. While the SWOT analysis revealed many strengths of age-friendly systems, including their impact on persons' outcomes, it also revealed several weaknesses, threats, and gaps. Namely, age-friendly systems have weaknesses due to reliance on trained volunteers and staff, communication, and teamwork. System-level threats include community and health system barriers, and challenges in poor/developing areas. Conclusions: While age-friendly systems in this review were heterogeneous, there is an opportunity to focus on unifying elements including the World Health Organization age-friendly cities framework or 4Ms framework for age-friendly care. Despite the many benefits of age-friendly systems, we must acknowledge limitations of the evidence base, pursue opportunities to examine organizational metrics to support implementation and sustainability of age-friendly systems, and leverage improvements in age-friendliness at a community level.

Readiness to Plan for Aging and Frailty: Examining Contextual Factors.

As older adults live longer, individual and societal efforts must be directed toward strategies to promote healthy and successful aging. Planning for aging and frailty offers an opportunity for older adults to optimize their well-being and proactively prepare across their aging trajectory. The current study evaluated the relationship between contextual factors (functional status, frailty, health status, social support) that influence older adults' readiness to engage in planning in five domains of aging (communication, environmental, financial, physical care, cognitive) through the transtheoretical stages of change. Results showed that factors influencing active planning include older age, vulnerability, living situation, and social support. These results add to the discourse on future care planning through a comprehensive approach to planning across a life course perspective, while highlighting the importance of future research at individual and societal levels. Gerontological nurses are well-positioned to lead planning efforts for older adults that promote well-being, patient-centered care, and healthy aging. [Journal of Gerontological Nursing, 49(2), 27-35.].

Examining how congruence in and satisfaction with dyadic care type appraisal contribute to quality of life in heart failure care dyads.

AIMS: Given the complexity of heart failure (HF) management, persons with HF and their informal caregivers often engage in dyadic illness management. It is unknown how congruent appraisal of dyadic HF care type is associated with dyadic health. Our aim was to examine how congruence in and satisfaction with appraisal of dyadic HF care type contribute to quality of life (QOL) for dyads. METHODS AND RESULTS: This is a secondary analysis of cross-sectional data on 275 HF care dyads (patients 45.1% female, caregivers 70.5% female). Congruent appraisal and satisfaction were assessed using the Dyadic Symptom Management Type instrument. Quality of life was measured using the Short Form-12. Multilevel dyadic models were estimated to examine the contribution of congruence and satisfaction with dyadic care type to physical and mental QOL. Congruent appraisal of dyadic care type was positively associated with caregivers' mental QOL (B = 2.69, P = 0.026). Satisfaction with dyadic care type was positively associated with physical and mental QOL for persons with HF (B = 1.58, P = 0.011 and B = 2.09, P = 0.002, respectively) and informal caregivers (B = 1.70, P = 0.004 and B = 2.90, P < 0.001, respectively), while controlling for age, New York Heart Association class, daily hours spent together, relationship type, and congruence with dyadic care type. CONCLUSION: Satisfaction with dyadic care type appraisal was a stronger contributor to QOL for HF care dyads, compared with congruent appraisals. It is important to understand reasons for dissatisfaction within the dyad to assist dyad members in reaching shared appraisals while managing HF.

Classifying Heart Failure Caregivers as Adequately or Inadequately Resourced to Care: A Latent Class Analysis.

OBJECTIVES: To identify classes of heart failure (HF) caregivers based upon indicators of coping resources and stress, and then, to examine the relationships between the identified caregiver classes and depression, caregiver burden, and life changes. METHODS: Cross-sectional data from 530 HF caregivers were analyzed in this secondary analysis using a three-step latent class mixture model to classify caregivers based on level of resources and examine the relationship between the identified classes and depression, caregiver burden, and life changes. Using an online survey, caregivers reported on social support, problem-solving, family function, depression, caregiver burden, and life changes. RESULTS: Caregivers were 41.39 (± 10.38) years of age, 49.1% women, 78.3% white, 77.6% urban-dwelling, and 61.7% college/postgraduate educated. Three classes of caregivers (42.3% Adequately Resourced, 25.1% At Risk for Decompensation, 32.6% Inadequately Resourced) were identified. Inadequately Resourced caregivers had the lowest levels of social support, problem-solving, and family function and the highest levels of depression and caregiver burden. Caregivers At Risk for Decompensation had the best family function and reported the most positive perceptions of life changes despite low levels of social support and problem-solving. CONCLUSION: Social support, problem-solving, and family function are modifiable coping resources which may buffer stress and influence stress indicators. Caregivers with few coping resources may experience higher degrees of depression and burden, and less positive perceptions of life changes. More research is needed to examine the influence of these coping resources on caregiver adaptation to facilitate the development of targeted interventions which support caregiver mental health.

Systematic review of conceptual and theoretical frameworks used in palliative care and end-of-life care research studies.

BACKGROUND: Frameworks are the conceptual underpinnings of the study. Both conceptual and theoretical frameworks are often used in palliative and end-of-life care studies to help with study design, guide, and conduct investigations. While an increasing number of investigators have included frameworks in their study, to date, there has not been a comprehensive review of frameworks that were utilized in palliative and end-of-life care research studies. AIM: To summarize conceptual and theoretical frameworks used in palliative and end-of-life care research studies. And to synthesize which of eight domains from the National Consensus Project's Clinical Practice Guidelines for Quality Palliative Care (fourth edition) each framework belongs to. DESIGN: Systematic review. DATA SOURCES: Four electronic databases (EMBASE, the Cumulative Index to Nursing and Allied Health, PsychINFO, and PubMed) were searched from July 2010 to September 2021. RESULTS: A total 2231 citations were retrieved, of which 44 articles met eligibility. Across primary studies, 33,801 study participants were captured. Twenty-six investigators (59.1%) proposed previously unpublished frameworks. In 10 studies, investigators modified existing frameworks, mainly to overcome inherent limitations. In eight studies, investigators utilized existing frameworks referenced in previously published studies. There were eight orientations identified among 44 frameworks we reviewed (e.g. system, patient, patient-doctor). CONCLUSIONS: We examined palliative and end-of-life research studies to identify and characterize conceptual or theoretical frameworks proposed or utilized. Of 44 frameworks we reviewed, 21 studies (47.7%) were aligned with a Clinical Practice Guideline's single domain, while the rest two or more of eight guidelines in quality palliative care domains.

Development of a Planning for Aging and Frailty Questionnaire.

There is a gap in understanding adults' readiness to plan for adaptions across the aging trajectory. The purpose of the current psychometric project was to develop and test the Planning for Aging and Frailty Questionnaire. Clinical experience and extant literature formed the basis for creating items measuring planning for aging. Content validity was established with gerontology and health service research experts. Face validity testing was conducted through two cognitive interviewing and debriefing sessions at a senior center. All survey questions resulted in a content validity index ≥0.80 from experts. Face validity testing involved successful completion of the survey by 12 adults followed by cognitive interviewing/debriefing, resulting in minor changes. The 21-item Planning for Aging and Frailty Questionnaire demonstrates good initial validity and can be used to measure readiness in planning for aging and personal experiences and experiences with others. Further testing with additional usage is warranted. [Research in Gerontological Nursing, 15(5), 239-244.].

PLAN: Preparing and Living for Aging Now; A descriptive study investigating older adults' readiness to plan for aging and frailty.

OBJECTIVES: Many older adults want to age in place but do not make plans. Understanding how and under what conditions adults prepare/plan ahead is vital given population aging and increasing frailty. This study examines the stages of change and experiences (personal/others) related to readiness to plan for aging and frailty. METHODS: Descriptive cross-sectional. SETTING: Community-dwelling. PARTICIPANTS: Adults aged 50-80(N = 252). DATA COLLECTION: demographics, other characteristics, stages of change, experiences (personal/others) was assessed with survey questions. DATA ANALYSIS: frequencies/percentages, McNemar test, Chi-square. RESULTS: Among domains, participants' percentages in action/maintenance stages ranged from 28.2% (cognitive) to 68.7% (financial). Participants had increased experience with others across domains rather than self. Older participants (≥ 70) vs. younger (50-69) reported statistically significant greater planning in action/maintenance stages for all domains (p < .05) with the exception of cognitive. DISCUSSION: Examining the concept of planning for aging and frailty provides a foundation for future work to develop/test interventions aimed at increasing readiness for aging.

Understanding and Optimizing Family Caregiver Participation in Dyadic Research.

BACKGROUND: Research to understand self-care behaviors increasingly engages patient-caregiver dyads. However, collecting data on dyads requires both members to complete the research protocol, potentially resulting in biased information if caregivers who do not participate differ from caregivers who do. OBJECTIVES: The aim of the study was to examine how recruitment conditions and patients' appraisal of dyadic engagement in heart failure management are related to caregiver participation across two research studies. METHODS: We used logistic regression to examine whether recruitment strategy and patients' responses on the dyadic symptom management-type instrument were associated with caregivers' participation. RESULTS: Caregivers not present at the initial recruitment were less likely to participate in the study. Regardless of recruitment strategy, caregivers were less likely to participate if the patient indicated primary responsibility for heart failure management. In the restricted recruitment study (recruiting both dyad members simultaneously), caregiver participation was significantly higher when patients selected a collaborative-oriented care type relative to patient- or caregiver-oriented type. DISCUSSION: Instruments assessing dyad-level information could aid researchers in deploying resources at recruitment, as well as in adjusting results for data that could bias results and conclusions. Our findings support the importance of considering the recruitment strategy as well as dyadic care type as part of the recruitment process.

Quality of Life of Older Adults With Complicated Grief: A Mixed Methods Exploration.

The current mixed methods study investigated what changes in quality of life (QOL) mean to older adults with complicated grief treated with Accelerated Resolution Therapy (ART) post-hospice services. An informational matrix, which included select patient characteristics (e.g., number of comorbidities, single versus multiple deaths, relationship role), four identified qualitative themes, end of study QOL scores measured by the Centers for Disease Control and Prevention Health-Related QOL Healthy Days Module, and changes in scores from baseline to end of study, was created to analyze the data. Results showed that although a history of multiple deaths may contribute to greater improvements in QOL with therapy, having at least one comorbidity resulted in a richer description and endorsement of QOL in response to treatment. This is the first longitudinal, randomized controlled trial using a mixed methods approach to examine QOL of hospice family caregivers with complicated grief who are receiving ART. This study identifies potential links of QOL and caregiver characteristics, providing nurses with foundational knowledge for assessment, care, and further research on the experiences of complicated grief. [Journal of Gerontological Nursing, 48(5), 19-26.].