Measurement of Allostatic Load in Caregivers of Older Hispanic People With Alzheimer Disease and Related Disorders.

BACKGROUND: Allostatic load (AL) has been studied in the context of biomarkers that may be affected by environmental and contextual stressors, including social determinants of health. The specific stressor studied here is the provision of caregiving to older persons with Alzheimer disease and related disorders. The aims were to examine the factor structure of stress and nonstress biomarkers, different methods for calculating AL, and the relationship of AL with other variables. METHODS: Latent variable models were used to examine biomarkers. Regression analyses were performed with the outcomes: AL calculated as percentile-based and clinically-based for both stress and nonstress components. The sample was 187 Hispanic caregivers to individuals with dementia. RESULTS: The results of the confirmatory factor analyses (CFAs) suggested defining 2 factors: nonstress and stress-related. Performance was better for the CFA results and the associations with covariates when stress and nonstress components were examined separately. Despite some limitations, this is one of the first studies of biomarkers in Hispanic caregivers to patients with dementia. It was possible to explain almost 30% of the variance in the nonstress AL component. CONCLUSION: It may be important to differentiate among biomarkers indicative of cardiovascular, metabolic, and immune response as contrasted with the more stress-related biomarkers.

Reports About Paradoxical Lucidity from Health Care Professionals: A Pilot Study.

Although clinicians caring for persons at the end of life recognize the phenomenon of paradoxical/terminal lucidity, systematic evidence is scant. The current pilot study aimed to develop a structured interview instrument for health care professionals to report lucidity. A questionnaire measuring lucidity length, degree, content, coinciding circumstances, and time from episode to death was expanded to include time of day, expressive and receptive communication, and speech during the month prior to and during the event. Thirty-three interviews were conducted; 73% of participants reported ever witnessing paradoxical lucidity. Among 29 events reported, 31% lasted several days, 20.7% lasted 1 day, and 24.1% lasted <1 day. In 78.6% of events, the person engaged in unexpected activity; 22.2% died within 3 days, and 14.8% died within 3 months of the event. The phenomenological complexity of lucidity presents challenges to eliciting reports in a systematic fashion; however, staff respondents were able to report lucidity events and detailed descriptions of person-specific characteristics. [Journal of Gerontological Nursing, 49(1), 18-26.].

The use of subjective cognitive complaints for detecting mild cognitive impairment in older adults across cultural and linguistic groups: A comparison of the Cognitive Function Instrument to the Montreal Cognitive Assessment.

INTRODUCTION: This pilot study aims to explore the psychometric properties of the Cognitive Function Instrument (CFI) as a measure of subjective cognitive complaints (SCC) and its performance in distinguishing mild cognitive impairment (MCI) from normal control (NC) compared to an objective cognitive screen (Montreal Cognitive Assessment [MoCA]). METHODS: One hundred ninety-four community-dwelling non-demented older adults with racial/ethnic diversity were included. Unidimensionality and internal consistency of the CFI were examined using factor analysis, Cronbach's alpha, and McDonald's omega. Logistic regression models and receiver operating characteristic (ROC) analysis were used to examine the performance of CFI. RESULTS: The CFI demonstrated adequate internal consistency; however, the fit for a unidimensional model was suboptimal. The CFI distinguished MCI from NC alone or in combination with MoCA. ROC analysis showed comparable performance of the CFI and the MoCA. DISCUSSION: Our findings support the use of CFI as a brief and easy-to-use screen to detect MCI in culturally/linguistically diverse older adults. HIGHLIGHT: What is the key scientific question or problem of central interest of the paper? Subjective cognitive complaints (SCCs) are considered the earliest sign of dementia in older adults. However, it is unclear if SCC are equivalent in different cultures. The Cognitive Function Instrument (CFI) is a 14-item measure of SCC. This study provides pilot data suggesting that CFI is sensitive for detecting mild cognitive impairment in a cohort of older adults with racial/ethnic diversity. Comparing performance, CFI demonstrates comparable sensitivity to the Montreal Cognitive Assessment, an objective cognitive screening test. Overall, SCC may provide a non-invasive, easy-to-use method to flag possible cognitive impairment in both research and clinical settings.

Factors associated with resident-to-resident elder mistreatment in nursing homes.

BACKGROUND: Resident-to-resident elder mistreatment (RREM) in nursing homes has serious physical and psychological consequences, but factors related to RREM occurrence remain unclear. This study identifies individual and environmental characteristics associated with involvement in RREM episodes. METHODS: The design was an observational study carried out in five urban and five suburban New York state nursing homes randomly selected on the basis of size and location. The sample consisted of 2011 residents in 10 facilities; 83% of facilities and 84% of eligible residents participated. RREM and potential correlates were identified through resident interviews, staff interviews, shift coupons, observation, chart review, and accident or incident reports. RESULTS: A multivariate analysis controlling for relevant covariates found that individuals involved in RREM incidents exhibit milder dementia, show behavioral symptoms, and are less functionally impaired. Although special care units (SCU) for dementia have benefits for residents, one potential hazard for SCU residents is elevated risk for RREM. CONCLUSIONS: Interventions to prevent and intervene in RREM incidents are greatly needed. The correlates identified in this research point to the need for targeted interventions, specifically for residents with milder impairment and with behavioral symptoms and individuals in SCUs.

Prevalence and correlates of depression among black and Latino stroke survivors with uncontrolled hypertension: a cross-sectional study.

OBJECTIVE: To examine the prevalence and correlates of depression in a cohort of black and Hispanic stroke survivors with uncontrolled hypertension. SETTING: Baseline survey data from 10 stroke centres across New York City. PARTICIPANTS: Black and Hispanic stroke survivors with uncontrolled hypertension (n=450). OUTCOME MEASURES: Depressive symptoms were assessed with the 8-item Patient Reported Outcomes Measurement Information System (PROMIS) measure. Depression was defined as a PROMIS score ≥55. Other data collected included clinical factors, health-related quality of life (EuroQoL five dimensions (EQ-5D)), functional independence (Barthel Index, BI), stroke-related disability (Modified Rankin Score), physical function (PROMIS Physical Function) and executive functioning (Frontal Assessment Battery). RESULTS: The mean age was 61.7±11.1 years, 44% of participants were women and 51% were black. Poststroke depression was noted in 32% of the cohort. Examining bivariate relationships, patients with depression were observed to have poorer function and quality of life as evidenced by significantly lower PROMIS physical function scores (36.9±8.32 vs 43.4±10.19, p<0.001); BI scores (79.9±19.2 vs 88.1±15.1, p<0.001); EQ-5D scores (0.66±0.24 vs 0.83±0.17, p<0.001) and higher Rankin scores (2.10±1.00 vs 1.46±1.01, p<0.001) compared with those without depression. Multivariate (model adjusted) significant correlates of depression included lower self-reported quality of life (OR=0.02 (CI 0.004 to 0.12) being younger (OR=0.94; 95% CI 0.91 to 0.97); not married (OR=0.46; CI 0.24 to 0.89)); and foreign-born (OR=3.34, 95% CI 1.4 to 7.97). There was a trend for higher comorbidity to be uniquely associated with depression (≥3 comorbid conditions, OR=1.49, 95% CI 1.00 to 2.23). CONCLUSIONS: Poststroke depression is common among black and Hispanic stroke survivors with higher rates noted among foreign-born patients and those with high comorbidity. These findings highlight the importance of screening for depression in minority stroke survivors. TRIAL REGISTRATION NUMBER: http://www.clinicaltrials.gov. Unique identifier: NCT01070056.

Caregiver-Reported Quality Measures and Their Correlates in Home Hospice Care.

Background: A majority of hospice care is delivered at home, with significant caregiver involvement. Identifying factors associated with caregiver-reported quality measures could help improve hospice care in the United States. Objectives: To identify correlates of caregiver-reported quality measures: burden, satisfaction, and quality of end-of-life (EoL) care in home hospice care. Design: A cross-sectional study was conducted from April 2017 through February 2018. Setting/Subjects: A nonprofit, urban hospice organization. We recruited caregivers whose patients were discharged from home hospice care. Eligible caregiver participants had to be 18 years or older, English-speaking, and listed as a primary caregiver at the time the patient was admitted to hospice. Measures: The (1) short version of the Burden Scale for Family Caregivers; (2) Family Satisfaction with Care; and (3) Caregiver Evaluation of the Quality of End-Of-Life Care. Results: Caregivers (n = 391) had a mean age of 59 years and most were female (n = 297, 76.0%), children of the patient (n = 233, 59.7%), and non-Hispanic White (n = 180, 46.0%). The mean age of home hospice patients was 83 years; a majority had a non-cancer diagnosis (n = 235, 60.1%), were female (n = 250, 63.9%), and were non-Hispanic White (n = 210, 53.7%). Higher symptom scores were significantly associated with greater caregiver burden and lower satisfaction with care; but not lower quality of EoL care. Caregivers who were less comfortable managing patient symptoms during the last week on hospice had higher caregiver burden, lower caregiver satisfaction, and lower ratings of quality of EoL care. Conclusion: Potentially modifiable symptom-related variables were correlated with caregiver-reported quality measures. Our study reinforces the important relationship between the perceived suffering/symptoms of patients and caregivers' hospice experiences.

Resident-to-resident elder mistreatment (R-REM) intervention for direct care staff in assisted living residences: study protocol for a cluster randomized controlled trial.

BACKGROUND: Resident-to-resident elder mistreatment (R-REM) is defined as negative and aggressive physical, sexual, or verbal interactions between (long-term care) residents that in a community setting would likely be construed as unwelcome and have high potential to cause physical and/or psychological harm and distress. R-REM has been established as a serious problem that has a negative impact on the safety, physical well-being, and quality-of-life of residents living in nursing homes. Although there are no in-depth studies, there is evidence that it is prevalent in assisted living residences and associated with a variety of person, environmental, and facility characteristics. The authors conducted the first systematic, prospective study of resident-to-resident elder mistreatment in nursing homes and developed an intervention for direct care staff to enhance knowledge of R-REM and increase reporting and resident safety by reducing falls and associated injuries. The study aim was to examine the effects of this intervention in assisted living residences. The primary distal outcome is falls and injuries, and the key process outcomes are staff knowledge and reporting. METHODS: Twelve larger licensed assisted living residences with special care dementia units in two New York State regions will be enrolled on a rolling basis and randomized to intervention or usual care. Data derived from five sources, (1) resident interviews, (2) staff informants, (3) observational data, (4) chart, and (5) incident/accident report data, will be collected at baseline and 6 and 12 months with respect to 1050 residents (750 "downstate" and 300 "upstate"). The intervention is three training modules delivered on-site after baseline data collection for front line staff on all shifts in facilities randomized to the intervention. Modules relate to recognition, management, and reporting of resident-to-resident elder mistreatment. DISCUSSION: Given the movement toward alternative congregate living arrangements for older individuals with significant comorbidities, including cognitive impairment; it is critical to enhance resident safety measured by falls, accidents, and injuries and staff knowledge related to recognition, reporting, and treatment of resident-to-resident aggressive and related negative interactions in such settings. This project is important in developing approaches for ameliorating and preventing R-REM in assisted living residences and enhancing resident safety and quality of life. TRIAL REGISTRATION: ClinicalTrials.gov NCT03383289 . Registered on 26 December 2017.

Hospital Elder Life Program in Long-Term Care (HELP-LTC): A Cluster Randomized Controlled Trial.

BACKGROUND/OBJECTIVES: The Hospital Elder Life Program (HELP) has been shown to prevent delirium in hospitalized older adults. The objective of this study was to test the efficacy of HELP adapted to long-term care (HELP-LTC). DESIGN: Cluster randomized controlled trial. SETTING: A 514-bed academic urban nursing home. PARTICIPANTS: A total of 219 long-term nursing home residents who developed an acute illness or change in condition were randomly assigned to HELP-LTC (n = 105) or usual care (n = 114) by unit. INTERVENTION: HELP-LTC is a multicomponent intervention targeting delirium risk factors of cognitive impairment, immobility, dehydration, and malnutrition. Two certified nursing assistants (CNAs) delivered HELP-LTC components twice daily 7 days per week. In addition, recommendations were given to primary providers to reduce medications associated with delirium. MEASUREMENTS: Delirium (primary outcome) and delirium severity were ascertained each weekday by a research assistant blinded to group assignment, using the Confusion Assessment Method (CAM) and CAM severity score (CAM-S), respectively. Cognitive function was determined using the Cognitive Performance Scale (CPS). Hospitalization was ascertained by chart review. RESULTS: Participants were 81.7 years of age on average and 65.3% female. At baseline, usual care group participants had better cognitive function than intervention group participants (CPS = 1.33 vs 2.25; P = .004). Delirium symptoms declined over the course of the episode (mean CAM-S = 3.63 at start vs 3.27 at end). Overall, 33.8% of the total sample experienced incident delirium. After adjusting for baseline cognitive function, no significant differences were found in delirium or delirium severity between intervention and usual care groups. Hospitalization was not significantly different between groups. CONCLUSION: An intervention targeting delirium risk in long-term nursing home residents did not prevent delirium or reduce delirium symptoms. Baseline differences in cognitive function between groups, greater than expected improvements in both groups, quality-enhancing practices such as consistent assignments delivered to both groups, and adaptations of the intervention may have biased results toward null. J Am Geriatr Soc 68:2329-2335, 2020.

Identifying the Prevalence and Correlates of Caregiver-Reported Symptoms in Home Hospice Patients at the End of Life.

Background: Symptoms (e.g., pain, shortness of breath, and fatigue) at the end of life (EoL) are common. Although symptoms can contribute to poor quality of life at the EoL, much remains unknown regarding their prevalence and correlates in home hospice care. Objectives: To determine the prevalence and correlates of caregiver-reported symptoms in home hospice patients during the last week before discharge using the Edmonton Symptom Assessment Scale (ESAS). Design: This is a cross-sectional study measuring perceived patient symptoms using caregiver proxy data. Bivariate and multivariate analyses were conducted to examine patient and caregiver characteristics associated with ESAS scores. Setting/Subjects: Subjects were from an urban nonprofit home hospice organization. Measurements: Symptoms were measured using the ESAS. Results: The mean ESAS score was 51.2 (SD ±17.4). In bivariate analyses, higher perceived symptom score was associated with younger patient age (p < 0.001), younger caregiver age (p < 0.001), having a cancer diagnosis (p = 0.006), and lower caregiver comfort level managing symptoms (p < 0.001). Regression model analyses showed that younger patient age (p = 0.0009, p = 0.0036) and lower caregiver comfort level managing symptoms (p = 0.0047, p < 0.0001) were associated uniquely with higher symptom scores. Conclusions: Multiple symptoms of high severity were perceived by caregivers in the last week on home hospice. Patient age and caregiver comfort level in managing symptoms were associated with higher symptom scores. Further work is needed to improve management and treatment of symptoms in this care setting.

Effect of Stroke Education Pamphlets vs a 12-Minute Culturally Tailored Stroke Film on Stroke Preparedness Among Black and Hispanic Churchgoers: A Cluster Randomized Clinical Trial.

IMPORTANCE: Black individuals and Hispanic individuals are less likely to recognize stroke and call 911 (stroke preparedness), contributing to racial/ethnic disparities in intravenous tissue plasminogen activator use. OBJECTIVE: To evaluate the effect of culturally tailored 12-minute stroke films on stroke preparedness vs the usual care practice of distributing stroke education pamphlets. DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized clinical trial between July 26, 2013, and August 16, 2018, with randomization of 13 black and Hispanic churches located in urban neighborhoods to intervention or usual care. In total, 883 congregants were approached, 503 expressed interest, 375 completed eligibility screening, and 312 were randomized. Sixty-three individuals were ineligible (younger than 34 years and/or did not have at least 1 traditional stroke risk factor). INTERVENTIONS: Two 12-minute stroke films on stroke preparedness for black and Hispanic audiences. MAIN OUTCOMES AND MEASURES: The primary outcome was the Stroke Action Test (STAT), assessed at baseline, 6 months, and 12 months. RESULTS: In total, 261 of 312 individuals completed the study (83.7% retention rate). Most participants were female (79.1%). The mean (SD) age of participants was 58.57 (11.66) years; 51.1% (n = 159) were non-Hispanic black, 48.9% (n = 152) were Hispanic, and 31.7% (n = 99) had low levels of education. There were no significant end-point differences for the STAT at follow-up periods. The mean (SD) baseline STAT scores were 59.05% (29.12%) correct for intervention and 58.35% (28.83%) correct for usual care. At 12 months, the mean (SD) STAT scores were 64.38% (26.39%) correct for intervention and 61.58% (28.01%) correct for usual care. Adjusted by education, a post hoc subgroup analysis revealed a mean (SE) intervention effect of 1.03% (0.44%) (P = .02) increase per month in the low-education subgroup (about a 10% increase in 12 months). In the high-education subgroup, the mean (SE) intervention effect was -0.05% (0.30%) (P = .86). Regarding percentage correct, the low-education intervention subgroup improved from 52.4% (7 of 21) to 66.7% (14 of 21) compared with the other subgroups. CONCLUSIONS AND RELEVANCE: No difference was observed in stroke preparedness at 12 months in response to culturally tailored 12-minute stroke films or conventional stroke education pamphlets. Additional studies are required to confirm findings from a post hoc subgroup analysis that suggested a significant education effect. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01909271.

Resident-to-Resident Mistreatment: Evaluation of a Staff Training Program in the Reduction of Falls and Injuries.

Resident-to-resident elder mistreatment (R-REM) occurs frequently in long-term services and support settings. The purpose of the current study was to evaluate the effect of a R-REM training program for nursing and other frontline staff on resident falls and injuries in a cluster randomized trial of units within four nursing homes. Interview and observational data from a sample of 1,201 residents (n = 600 and n = 601 in the usual care and intervention groups, respectively) and staff were collected at baseline and 6 and 12 months. A generalized linear model was used to model the falls/injuries outcome. The net reduction in falls and injuries was 5%, translating to 10 saved events per year in an averagesized facility. Although the result did not reach statistical significance due to low power, the findings of fall prevention associated with implementing the intervention in long-term care facilities is clinically important. [Journal of Gerontological Nursing, 44(6), 15-23.].

Improving Community Stroke Preparedness in the HHS (Hip-Hop Stroke) Randomized Clinical Trial.

BACKGROUND AND PURPOSE: Deficiencies in stroke preparedness cause major delays to stroke thrombolysis, particularly among economically disadvantaged minorities. We evaluated the effectiveness of a stroke preparedness intervention delivered to preadolescent urban public school children on the stroke knowledge/preparedness of their parents. METHODS: We recruited 3070 fourth through sixth graders and 1144 parents from 22 schools into a cluster randomized trial with schools randomized to the HHS (Hip-Hop Stroke) intervention or attentional control (nutrition classes). HHS is a 3-hour culturally tailored, theory-based, multimedia stroke literacy intervention targeting school children, which systematically empowers children to share stroke information with parents. Our main outcome measures were stroke knowledge/preparedness of children and parents using validated surrogates. RESULTS: Among children, it was estimated that 1% (95% confidence interval [CI], 0%-1%) of controls and 2% (95% CI, 1%-4%; P=0.09) of the intervention group demonstrated optimal stroke preparedness (perfect scores on the knowledge/preparedness test) at baseline, increasing to 57% (95% CI, 44%-69%) immediately after the program in the intervention group compared with 1% (95% CI, 0%-1%; P<0.001) among controls. At 3-month follow-up, 24% (95% CI, 15%-33%) of the intervention group retained optimal preparedness, compared with 2% (95% CI, 0%-3%; P<0.001) of controls. Only 3% (95% CI, 2%-4%) of parents in the intervention group could identify all 4 letters of the stroke FAST (Facial droop, Arm weakness, Speech disturbance, Time to call 911) acronym at baseline, increasing to 20% at immediate post-test (95% CI, 16%-24%) and 17% at 3-month delayed post-test (95% CI, 13%-21%; P=0.0062), with no significant changes (3% identification) among controls. Four children, all in the intervention group, called 911 for real-life stroke symptoms, in 1 case overruling a parent's wait-and-see approach. CONCLUSIONS: HHS is an effective, intergenerational model for increasing stroke preparedness among economically disadvantaged minorities. CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov. Unique identifier: NCT01497886.

Development of a Menu Board Literacy and Self-efficacy Scale for Children.

OBJECTIVE: An instrument to measure menu board literacy (MBL) was developed to capture children's understanding of menu board nutrition information, including abbreviations, serving sizes and calorie ranges, and self-efficacy for using this information. METHODS: A list of 55 potential items (47 MBL and 8 self-efficacy) was generated. Content validity was established by 29 registered dietitians. Cognitive interviews were conducted with 24 black and Hispanic fourth- and fifth-grade students to assess comprehension and readability. The researchers assessed reliability in 2 fourth- and fifth-grade convenience samples (n = 32 and 141, respectively) of similarly representative students. RESULTS: The final instrument included 20 MBL and 7 self-efficacy items. Internal consistency estimates at both pretest and posttest for the first sample were 0.88 for the MBL scale and 0.80 for the self-efficacy scale. Results for the larger sample were similar. CONCLUSIONS AND IMPLICATIONS: This instrument could be used for assessing MBL and self-efficacy among fourth- and fifth-grade children. The MBL scale provides researchers and practitioners with a tool to measure the role of nutrition literacy and numeracy in point-of-purchase dietary decisions of children, with the potential for use with low-literacy adults as well.

Reliability and Validity of the Lichtenberg Financial Decision Screening Scale.

The scarcity of empirically validated assessment instruments continues to impede the work of professionals in a number of fields, including medicine, finance, and estate planning; adult protective services; and criminal justice-and, more importantly, it impedes their ability to effectively assist and, in some case, protect their clients. Other professionals (e.g. legal, financial, medical, mental health services) are in a position to prevent financial exploitation and would benefit from access to new instruments. The Lichtenberg Financial Decision Screening Scale (LFDSS) was introduced in 2016, along with evidence for its convergent validity (Lichtenberg et al., 2016). Using a sample of 213 participants, this study investigated the internal consistency of the LFDSS and its criterion validity based on ratings by professionals using the scale. Results demonstrate that the LFDSS has excellent internal consistency and clinical utility properties. This paper provides support for use of the LFDSS as a reliable and valid instrument. The LFDSS and instructions for its use are included in the article, along with information about online tools and support.

Depression recognition and capacity for self-report among ethnically diverse nursing homes residents: Evidence of disparities in screening.

AIMS AND OBJECTIVES: To examine agreement between Minimum Data Set clinician ratings and researcher assessments of depression among ethnically diverse nursing home residents using the 9-item Patient Health Questionnaire. BACKGROUND: Although depression is common among nursing homes residents, its recognition remains a challenge. DESIGN: Observational baseline data from a longitudinal intervention study. METHODS: Sample of 155 residents from 12 long-term care units in one US facility; 50 were interviewed in Spanish. Convergence between clinician and researcher ratings was examined for (i) self-report capacity, (ii) suicidal ideation, (iii) at least moderate depression, (iv) Patient Health Questionnaire severity scores. Experiences by clinical raters using the depression assessment were analysed. The intraclass correlation coefficient was used to examine concordance and Cohen's kappa to examine agreement between clinicians and researchers. RESULTS: Moderate agreement (κ = 0.52) was observed in determination of capacity and poor to fair agreement in reporting suicidal ideation (κ = 0.10-0.37) across time intervals. Poor agreement was observed in classification of at least moderate depression (κ = -0.02 to 0.24), lower than the maximum kappa obtainable (0.58-0.85). Eight assessors indicated problems assessing Spanish-speaking residents. Among Spanish speakers, researchers identified 16% with Patient Health Questionnaire scores of 10 or greater, and 14% with thoughts of self-harm whilst clinicians identified 6% and 0%, respectively. CONCLUSION: This study advances the field of depression recognition in long-term care by identification of possible challenges in assessing Spanish speakers. RELEVANCE TO CLINICAL PRACTICE: Use of the Patient Health Questionnaire requires further investigation, particularly among non-English speakers. Depression screening for ethnically diverse nursing home residents is required, as underreporting of depression and suicidal ideation among Spanish speakers may result in lack of depression recognition and referral for evaluation and treatment. Training in depression recognition is imperative to improve the recognition, evaluation and treatment of depression in older people living in nursing homes.

Methodological issues in measuring subjective well-being and quality-of-life: Applications to assessment of affect in older, chronically and cognitively impaired, ethnically diverse groups using the Feeling Tone Questionnaire.

Quality of life assessment includes measurement of positive affect. Methods artifacts associated with positively and negatively worded items can manifest as negative items loading on a second factor, despite the conceptual view that the items are measuring one underlying latent construct. Negatively worded items may elicit biased responses. Additionally, item-level response bias across ethnically diverse groups may compromise group comparisons. The aim was to illustrate methodological approaches to examining method factors and measurement equivalence in an affect measure with 9 positively and 7 negatively worded items: The Feeling Tone Questionnaire (FTQ). The sample included 4,960 non-Hispanic White, 1,144 non-Hispanic Black, and 517 Hispanic community and institutional residents receiving long-term supportive services. The mean age was 82 (s.d.=11.0); 73% were female. Two thirds were cognitively impaired. Methods effects were assessed using confirmatory factor analyses (CFA), and reliability with McDonald's omega and item response theory (IRT) generated estimates. Measurement equivalence was examined using IRT-based Wald tests. Methods effects associated with negatively worded items were observed; these provided little IRT information, and as a composite evidenced lower reliability. Both 13 and 9 item positive affect scales performed well in terms of model fit, reliability, IRT information, and evidenced little differential item functioning of high magnitude or impact. Both CFA and IRT approaches provided complementary methodological information about scale performance. The 9-item affect scale based on the FTQ can be recommended as a brief quality-of-life measure among frail and cognitively impaired individuals in palliative and long-term care settings.

Music Upper Limb Therapy-Integrated: An Enriched Collaborative Approach for Stroke Rehabilitation.

Stroke is a leading cause of disability worldwide. It leads to a sudden and overwhelming disruption in one's physical body, and alters the stroke survivors' sense of self. Long-term recovery requires that bodily perception, social participation and sense of self are restored; this is challenging to achieve, particularly with a single intervention. However, rhythmic synchronization of movement to external stimuli facilitates sensorimotor coupling for movement recovery, enhances emotional engagement and has positive effects on interpersonal relationships. In this proof-of-concept study, we designed a group music-making intervention, Music Upper Limb Therapy-Integrated (MULT-I), to address the physical, psychological and social domains of rehabilitation simultaneously, and investigated its effects on long-term post-stroke upper limb recovery. The study used a mixed-method pre-post design with 1-year follow up. Thirteen subjects completed the 45-min intervention twice a week for 6 weeks. The primary outcome was reduced upper limb motor impairment on the Fugl-Meyer Scale (FMS). Secondary outcomes included sensory impairment (two-point discrimination test), activity limitation (Modified Rankin Scale, MRS), well-being (WHO well-being index), and participation (Stroke Impact Scale, SIS). Repeated measures analysis of variance (ANOVA) was used to test for differences between pre- and post-intervention, and 1-year follow up scores. Significant improvement was found in upper limb motor impairment, sensory impairment, activity limitation and well-being immediately post-intervention that persisted at 1 year. Activities of daily living and social participation improved only from post-intervention to 1-year follow up. The improvement in upper limb motor impairment was more pronounced in a subset of lower functioning individuals as determined by their pre-intervention wrist range of motion. Qualitatively, subjects reported new feelings of ownership of their impaired limb, more spontaneous movement, and enhanced emotional engagement. The results suggest that the MULT-I intervention may help stroke survivors re-create their sense of self by integrating sensorimotor, emotional and interoceptive information and facilitate long-term recovery across multiple domains of disability, even in the chronic stage post-stroke. Randomized controlled trials are warranted to confirm the efficacy of this approach. CLINICAL TRIAL REGISTRATION: National Institutes of Health, clinicaltrials.gov, NCT01586221.

The Prevalence of Resident-to-Resident Elder Mistreatment in Nursing Homes.

BACKGROUND: Resident-to-resident elder mistreatment (R-REM) in nursing homes can cause physical and psychological injury and death, yet its prevalence remains unknown. OBJECTIVE: To estimate the prevalence of physical, verbal, and sexual R-REM in nursing home residents and subgroups. DESIGN: 1-month observational prevalence study. SETTING: 5 urban and 5 suburban New York state nursing homes. PARTICIPANTS: 2011 residents in 10 facilities randomly selected on the basis of size and location; 83% of facilities and 84% of eligible residents participated. MEASUREMENTS: R-REM was identified through resident interviews, staff interviews, shift coupons, observation, chart review, and accident or incident reports. RESULTS: 407 of 2011 residents experienced at least 1 R-REM event; the total 1-month prevalence was 20.2% (95% CI, 18.1% to 22.5%). The most common forms were verbal (9.1% [CI, 7.7% to 10.8%]), other (such as invasion of privacy or menacing gestures) (5.3% [CI, 4.4% to 6.4%]), physical (5.2% [CI, 4.1% to 6.5%]), and sexual (0.6% [CI, 0.3% to 1.1%]). Several clinical and contextual factors (for example, lower vs. severe levels of cognitive impairment, residing on a dementia unit, and higher nurse aide caseload) were associated with higher estimated rates of R-REM. LIMITATIONS: Most facilities were relatively large. All R-REM cases may not have been detected; resident and staff reporting may be subject to recall bias. CONCLUSION: R-REM in nursing homes is highly prevalent. Verbal R-REM is most common, but physical mistreatment also occurs frequently. Because R-REM can cause injury or death, strategies are urgently needed to better understand its causes so that prevention strategies can be developed. PRIMARY FUNDING SOURCE: National Institute on Aging.

More with Less: A Trial of Reduced-Intensity Treatment in Transplant-Ineligible Hemodialysis Patients.

BACKGROUND: An increasing proportion of hemodialysis patients are ineligible for transplant. Often these patients are elderly, with multiple comorbidities and decreased functional status. Such patients may benefit from modified treatment goals to reduce symptom burden. OBJECTIVE: To demonstrate the feasibility of a trial of reduced-intensity treatment in nontransplantable patients with end-stage renal disease (ESRD). STUDY DESIGN: A 6-week study randomized patients to a reduced-intensity intervention versus usual care. Intervention subjects were treated with liberalized goals for serum phosphorus and parathyroid hormone (PTH) as well as predialysis blood pressure in comparison with usual care subjects. Outcomes included assessed feasibility of recruitment, randomization, and data collection. SETTING AND POPULATION: Sixteen transplant-ineligible hemodialysis patients were recruited from two urban units. MEASUREMENTS: Blood pressure was recorded weekly, while serum PTH and phosphorus were assessed every 10 days. A quality-of-life measure was administered before and after the trial. RESULTS: Of 300 patients, 51 were eligible and 16 consented. All were randomized and completed the trial. Patients in the intervention group received significantly lower doses of phosphorus binders and vitamin D analogues, and were less likely to have their dry weight reduced. All patient surveys were completed. CONCLUSIONS: High-risk hemodialysis patients may benefit from liberalized treatment guidelines but larger studies are necessary.

Measurement Equivalence of the Patient Reported Outcomes Measurement Information System® (PROMIS®) Applied Cognition - General Concerns, Short Forms in Ethnically Diverse Groups.

AIMS: The goals of these analyses were to examine the psychometric properties and measurement equivalence of a self-reported cognition measure, the Patient Reported Outcome Measurement Information System® (PROMIS®) Applied Cognition - General Concerns short form. These items are also found in the PROMIS Cognitive Function (version 2) item bank. This scale consists of eight items related to subjective cognitive concerns. Differential item functioning (DIF) analyses of gender, education, race, age, and (Spanish) language were performed using an ethnically diverse sample (n = 5,477) of individuals with cancer. This is the first analysis examining DIF in this item set across ethnic and racial groups. METHODS: DIF hypotheses were derived by asking content experts to indicate whether they posited DIF for each item and to specify the direction. The principal DIF analytic model was item response theory (IRT) using the graded response model for polytomous data, with accompanying Wald tests and measures of magnitude. Sensitivity analyses were conducted using ordinal logistic regression (OLR) with a latent conditioning variable. IRT-based reliability, precision and information indices were estimated. RESULTS: DIF was identified consistently only for the item, brain not working as well as usual. After correction for multiple comparisons, this item showed significant DIF for both the primary and sensitivity analyses. Black respondents and Hispanics in comparison to White non-Hispanic respondents evidenced a lower conditional probability of endorsing the item, brain not working as well as usual. The same pattern was observed for the education grouping variable: as compared to those with a graduate degree, conditioning on overall level of subjective cognitive concerns, those with less than high school education also had a lower probability of endorsing this item. DIF was also observed for age for two items after correction for multiple comparisons for both the IRT and OLR-based models: "I have had to work really hard to pay attention or I would make a mistake" and "I have had trouble shifting back and forth between different activities that require thinking". For both items, conditional on cognitive complaints, older respondents had a higher likelihood than younger respondents of endorsing the item in the cognitive complaints direction. The magnitude and impact of DIF was minimal. The scale showed high precision along much of the subjective cognitive concerns continuum; the overall IRT-based reliability estimate for the total sample was 0.88 and the estimates for subgroups ranged from 0.87 to 0.92. CONCLUSION: Little DIF of high magnitude or impact was observed in the PROMIS Applied Cognition - General Concerns short form item set. One item, "It has seemed like my brain was not working as well as usual" might be singled out for further study. However, in general the short form item set was highly reliable, informative, and invariant across differing race/ethnic, educational, age, gender, and language groups.