Testing the feasibility and preliminary efficacy of Meaningful Activity for Managing Behavioral Symptoms of Distress (MAC-4-BSD) intervention for residents with dementia in assisted living: Protocol description.

The purpose of this manuscript is to describe the protocol for an Alzheimer's Association-funded cluster randomized trial that focuses on engaging assisted living residents with dementia in meaningful activity to help address their behavioral symptoms of distress using a theoretically based approach, Meaningful Activity for Managing Behavioral Symptoms of Distress (MAC-4-BSD). The development of MAC-4-BSD was based on the Social Ecological Model and Social Cognitive Theory. The MAC-4-BSD intervention includes the following four steps: (1) Assessment of the assisted living physical environment and policies to facilitate meaningful activity; (2) Education of staff about implementation of meaningful activity; (3) Assessment of resident preferences and goals for meaningful activity; (4) Mentoring and motivating staff and residents to facilitate engagement in meaningful activity. The overall aim of this study will be to determine the feasibility and preliminary efficacy of implementing the MAC-4-BSD intervention and test whether it will improve residents' engagement in meaningful activity, behavioral symptoms of distress, and quality of life as well as the environment and policies to promote meaningful activity in assisted living.

Examining the association of physical activity and mortality among recently hospitalized older adults with dementia.

INTRODUCTION: This study aimed to examine the association between physical activity one month post discharge and mortality over the first-year post discharge among recently hospitalized older adults with dementia. METHODS: For this descriptive sub-study, among 42 participants, we obtained physical activity data via accelerometry at one month post discharge and death status via phone call at 6 months and 1 year post discharge. We performed logistic regression. RESULTS: We found that participants' amount of time spent in physical activity one month post hospital discharge was not statistically significantly associated with mortality within the first-year post hospital discharge (OR=.996, CI=.992,1.000; p=.053). However, we did observe a strong trend. CONCLUSIONS: Given the small sample of participants, this trend is salient and should be examined in a larger sample. The results highlight a specific patient profile, recently hospitalized older adults with dementia, that would greatly benefit from physical activity interventions.

Measurement of Physical Activity Among Hospitalized Older Adults Living With Dementia.

ABSTRACT: The purpose of this secondary data analysis was to describe physical activity and the factors associated with physical activity among older adults living with dementia on medical units in acute care settings. Measures included accelerometry data from the MotionWatch 8, behavioral and psychological symptoms associated with dementia, use of psychotropic medications, subjective reports of activities of daily living and other types of physical activity (e.g., walking to the bathroom, participating in therapy), delirium severity, and medications. The majority of the 204 participants were White (70%) and female (62%), with a mean age of 83 years. Over 24 hours of assessment, participants engaged in 15 ( SD = 46) minutes of vigorous activity, 43 ( SD = 54) minutes of moderate activity, 2 hours 50 ( SD = 2) minutes of low-level activity, and 20 ( SD = 3) hours of sedentary activity. Subjective walking activities, toileting, evidence of disinhibition, delirium severity, agitation, and use of psychotropic medications were associated with increased physical activity based on the MotionWatch 8. The findings provide information for rehabilitation nurses regarding factors associated with physical activity among patients with dementia admitted to acute care settings as well as some of the challenges associated with measurement of physical activity. Future research needs to continue to explore the impact of behavioral symptoms associated with dementia on physical activity and increase participation in activities that are functionally relevant.

The association between patient engagement and quality of care interactions among acute care patients with dementia.

Effective staff-patient communication is critical in acute care settings, particularly for patients with dementia. Limited work has examined the impact of quality of staff-patient care interactions on patient engagement. The purpose of this study was to determine whether the quality of staff-patient care interactions were associated with active patient engagement during the interaction after controlling for relevant covariates. The study was a secondary data analysis using baseline data from the Function Focused Care for Acute Care intervention study, with a total sample of 286 patients. Descriptive statistics and a generalized linear mixed model were used. The findings indicated that there was a significant relationship between the quality of care interactions and patient engagement such that receiving positive care interactions resulted in higher odds of active patient engagement. These findings can inform future interventions and training for acute care staff to improve quality of care interactions and patient engagement.

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

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

Pilot testing implementation of the pain management clinical practice guideline in nursing homes.

Pain is a common symptom for older adults living with dementia in nursing homes. Unfortunately, there are many challenges to pain assessment, diagnosis and management for these individuals. The purpose of this study was to pilot test the implementation of the newly published Pain Management Clinical Practice Guideline from AMDA: The Society of Post Acute and Long-Term Care using our theoretically based Pain-CPG-EIT approach. Implementation was provided by a research nurse facilitator and included four components: Component I: Establishing and working with a stakeholder team monthly; Component II: Education of the staff; Component III: Mentoring and motivating the staff; and Component IV: Ongoing monitoring of pain assessment, diagnosis and management for residents. Findings provide some preliminary support for the feasibility and effectiveness of our implementation approach.

Delirium Severity and Physical Function in Hospitalized Persons Living With Dementia: Moderation by Age, Sex, and Race.

OBJECTIVE: This study investigated whether demographic characteristics (age, sex, and race) moderated delirium severity as a predictor of physical function in hospitalized persons living with dementia. METHODS: The sample consisted of 351 patients enrolled in a randomized controlled trial (Function Focused Care for Acute Care Using the Evidence Integration Triangle). Preliminary analysis was conducted to assess the main effect, and multiple linear regression was used to examine the moderating effect of demographic characteristics between delirium severity and physical function. RESULTS: Both age and sex were found to have significant moderating effects on the relationship between delirium severity and physical function (ß = 2.22; P = 0.02 and ß = 1.34; P = 0.04, respectively). Older adults aged 85 years or older with higher levels of delirium severity reported lower levels of physical function compared with older adults aged 65 to 84 years. Males with higher levels of delirium severity reported lower levels of physical function compared with females. Race did not significantly moderate the association between delirium severity and physical function (ß = 0.22; P = 0.90). CONCLUSIONS: Our findings suggest that age and sex may have differential effects on physical function across different levels of delirium severity in hospitalized persons living with dementia.

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

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

A Descriptive Study Using Rasch Analysis and Hypothesis Testing to Evaluate the Psychometric Properties of the UMOVE Mobility Screen Tested With Hospitalized Older Adults.

The purpose of this study was to test the reliability and validity of the UMOVE Mobility Screen in older adults living with dementia using a Rasch analysis and hypothesis testing. The UMOVE Mobility Screen (UMOVE) focuses on nine activities: following commands, muscle strength, and basic functional mobility tasks. Trained evaluators completed assessments on 244 patients, the majority of whom were female (62%), and White (71%). Based on Rasch Analysis, there was evidence of good item and person reliability (indexes > 0.80), good INFIT statistics, and only one item fitting the model based on OUTFIT statistics. Validity was supported based on hypothesis testing. There was no evidence of Differential Item Functioning between races and genders. Item mapping raised concerns about the spread of the items across the full spectrum of mobility assessed in the UMOVE Mobility Screen. Future testing should consider adding some easier and some more difficult items.

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

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

Differential Gene Expression in Pain-Related Genes are not Affected by the Presence of Dementia.

BACKGROUND: Prior work has demonstrated differences in the transcriptome between those with and without chronic musculoskeletal pain. AIMS: The aim of this study was to explore whether pain-related gene expression is similar between individuals with and without dementia. DESIGN: This was a descriptive study using a one-time assessment. SETTINGS: PARTICIPANTS/SUBJECTS: A total of 20 older adults living in a continuing care retirement community, 50% of whom had dementia were inlcuded in this study. All were female and the mean age of participants was 89 (SD = 6). METHODS: Pain was evaluated based on the PROMIS Pain Intensity Short Form 3a. Whole blood was collected by venipuncture into Tempus vacutainer tubes (3 ml) and the RNA was extracted at the Translational Genomics Laboratory at the University of Maryland Baltimore. Analyses included a differential expression analysis, a weighted gene co-expression network analysis, and a pathway enrichment analysis. RESULTS: Eighty-three genes were differentially expressed between individuals with and without pain (p <.05). After normalizing gene counts and removing the low expressed genes, 18,028 genes were left in the final analysis. There was no clustering of the samples related to study variables of pain or dementia. CONCLUSION: The findings from this study provided some preliminary support that pain-related gene expression is similar between individuals with and without dementia.

Motivating older adults through immersive virtual exercise (MOTIVE): A randomized pilot study.

BACKGROUND: This study aimed to: 1) determine the feasibility of a virtual reality physical activity intervention among older adults and 2) test the preliminary effectiveness of the intervention at increasing physical activity and 3) decreasing depressive symptoms. METHODS: We included 10 older adults randomized into the Motivating Older Adults Through Immersive Virtual Exercise (MOTIVE) intervention group and 10 randomized into the physical activity education only control group. We analyzed the data using descriptive statistics and linear mixed models, testing the interaction of time and the treatment condition. RESULTS: Participants in the intervention group attended an average of 15 out of the 16 sessions. A total of 90% of MOTIVE intervention group participants "completely agreed" that the intervention was acceptable, (compared to 30% of education control group participants). CONCLUSION: This study supports testing the effectiveness of the intervention at improving physical activity and depressive symptoms in a larger sample of older adults.

Differences in Medication Use by Gender and Race in Hospitalized Persons Living with Dementia.

The purpose of this study was to describe differences in treatment of White versus Black older adults, males versus females, and those living at home, assisted living, or nursing home communities with regard to the use of psychotropic, pain, and cardiovascular medications. Baseline data from the first 352 participants in the study, implementation of Function-Focused Care for Acute Care Using the Evidence Integration Triangle, were used. Data included age, gender, race, comorbidities, admission diagnosis, and living location prior to hospitalization, the Saint Louis University Mental Status exam, the modified Charlson Comorbidity Index, the Pain Assessment in Advanced Dementia scale, the Confusion Assessment Method, and medications prescribed. Generalized linear mixed model analyses were done, controlling for race or gender (depending on which comparison analysis was being done), age, cognitive status, hospital, delirium, and comorbidities. Medication use was significantly higher for White older adults, compared to Black older adults, for antidepressants, anxiolytics, non-opioid pain medications, and opioids and lower for antihypertensives. Females received more anxiolytics than their male counterparts. There were differences in medication use by living location with regard to non-opioid pain medication, antipsychotics, statins, and anticoagulants. The findings provide some current information about differences in medication use across groups of individuals and can help guide future research and hypothesis testing for approaches to minimizing these differences in treatment.

In too deep? A systematic literature review of fully-immersive virtual reality and cybersickness among older adults.

BACKGROUND: Virtual reality technology holds great promise in improving the health and well-being of older adults; however, this technology is associated with potential risks that may outweigh the benefits. The purpose of this systematic review is to synthesize and critique the existing literature on fully-immersive virtual reality interventions for older adults and the associated risk of cybersickness. METHODS: We searched eight databases for studies that utilized fully-immersive virtual reality, stated the population as older adults, provided outcomes related to cybersickness, and were written or translated into the English language. Our search generated 332 articles, 39 of which were selected for inclusion in this systematic synthesis and appraisal. RESULTS: We found that the majority of studies utilized a one-time session. The studies generally had weak sample generalizability and methodological design, but strong data collection and participant retention. The studies nearly all used the Simulator Sickness Questionnaire to measure cybersickness, but the scoring for the Simulator Sickness Questionnaire varied or was not mentioned. Most included studies reported only minor cybersickness among older adult participants. CONCLUSION: Researchers might conclude that the benefits of virtual reality interventions outweigh the risk of cybersickness in this population. Going forward, researchers should concentrate on the efficacy of virtual reality interventions among older adults, using larger samples and randomized controlled study design, along with measuring dosage effects.

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

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

Factors Associated With Function-Focused Care Among Hospitalized Older Adults With Dementia.

BACKGROUND: Function-focused care is an approach used to increase physical activity in hospitalized older adults with dementia. OBJECTIVE: To explore factors associated with participation in function-focused care in this patient population. METHODS: This was a cross-sectional descriptive study using baseline data from the first 294 participants in an ongoing study on testing function-focused care for acute care using the evidence integration triangle. Structural equation modeling was used for model testing. RESULTS: The mean (SD) age of the study participants was 83.2 (8.0) years, and the majority were women (64%) and White (69%). Sixteen of the 29 hypothesized paths were significant and explained 25% of the variance in participation in function-focused care. Cognition, quality of care interactions, behavioral and psychological symptoms associated with dementia, physical resilience, comorbidities, tethers, and pain were all indirectly associated with function-focused care through function and/or pain. Tethers, function, and quality of care interactions were all directly associated with function-focused care. The χ2/df was 47.7/7, the normed fit index was 0.88, and the root mean square error of approximation was 0.14. CONCLUSION: For hospitalized patients with dementia, the focus of care should be on treating pain and behavioral symptoms, reducing the use of tethers, and improving the quality of care interactions in order to optimize physical resilience, function, and participation in function-focused care.

Psychotropic Medication Use and Changes During Hospitalization for Older Adults Living With Dementia.

To describe the use of psychotropic medications among older hospitalized patients. This was a descriptive study using baseline data from the first 308 older patients in a function focused care intervention study. Age, gender, race, comorbidities, admitting diagnosis, and medications (antidepressants, antianxiety medications, anticonvulsants, dementia drugs, antipsychotics, sedative-hypnotics, and opioids) were obtained at baseline and discharge. To compare change over time, generalized estimating equations were used. Participants were mostly female (63%) and White (69%) and were 83.1 years old on average. Antidepressant, antianxiety, anticonvulsant, dementia medication, sedative-hypnotic, and opioid use remained essentially unchanged between admission and discharge. Antipsychotic medication use increased significantly from 16% to 21% at discharge. There was persistent use of psychotropic medication among hospitalized older adults living with dementia and little evidence of deprescribing. There was some indication of changes made during hospitalization that may be appropriate, even without a focused deprescribing initiative.

Factors Associated With Function-Focused Care Among Hospitalized Older Adults Living With Dementia.

This article reports a study that was designed to describe the incidence of pain among older hospitalized patients with dementia and to evaluate the factors that influence pain among these individuals. It was hypothesized that function, behavioral and psychological symptoms of dementia, delirium, pain treatment, and patient exposure to care interventions would be associated with pain. Patients who performed more functional activities had less delirium. They also experienced higher quality-of-care interactions and were less likely to have pain. The findings from this study support the relationship between function, delirium, and quality-of-care interactions and pain. It suggests that it may be useful to encourage patients with dementia to engage in functional and physical activity to prevent or manage pain. This study serves as a reminder to avoid neutral or negative care interactions among patients with dementia as a strategy to mediate delirium and pain.

Factors Associated With Physical Activity in Hospitalized Patients With Dementia.

Older adults continue to spend little time engaged in physical activity when hospitalized. The purpose of this study was to (a) describe activity among hospitalized older adults with dementia and (b) identify the association between specific factors (gender, ambulation independence, comorbidities, race, and hospital setting) and their physical activity. This descriptive study utilized baseline data on the first 79 participants from the Function Focused Care for Acute Care using the Evidence Integration Triangle. Multiple linear regression models were run using accelerometry data from the first full day of hospitalization. The participants spent an average of 83.7% of their time being sedentary. Male gender, ambulation independence, and hospital setting (the hospital in which the patient was admitted) were associated with greater activity. This study reports on the limited time spent in activity for older adults with dementia when hospitalized and highlights patient profiles that are particularly vulnerable to sedentary behavior in the hospital setting.