The Relationships between Caregiver Burden, Physical Frailty, Race, Behavioral and Psychological Symptoms (BPSD), and Other Associated Variables: An Exploratory Study.

Background and Objectives: For persons with dementia, the relationships between caregiver burden, physical frailty, race, behavioral and psychological symptoms (BPSD), and other associated variables are poorly understood. Only one prior study examined the relationships among these variables but did not include race, which is an important social determinant of health outcomes in the United States. To examine these interactions, we conducted a cross-sectional exploratory study based on a model by Sugimoto and colleagues. Materials and Methods: The sample comprised 85 patient-caregiver dyads (58% White) seen in four centers in diverse regions of New York State. All patients met DSM5 criteria for a major neurocognitive disorder, had a Clinical Dementia Rating sum score of ≥3, and Mini-Mental State Examination (MMSE) score of 10 to 26. Other measures included the SHARE-Frailty Instrument(FI), the Neuropsychiatric Inventory (NPI) to assess BPSD, Zarit's Caregiver Burden Interview (CBI), Lawton's Activities of Daily Living (ADL) Scale, the MMSE, the Cumulative Illness Rating Scale for Geriatrics (CIRSG), age, and gender. Results: In our sample, 59% met the criteria for prefrail/subsyndromal or frail/syndromal (SSF) on the SHARE-FI. SSF had significant direct effects on the NPI and significant indirect effects on the CBI mediated through the NPI; the NPI had significant direct effects on the CBI. Race (White) had significant direct effects on the CBI (higher) and SSF (lower) but did not have significant indirect effects on the CBI. MMSE, ADL, and CIRSG were not significantly associated with the NPI or the CBI. Conclusions: Our analysis demonstrated that frailty, race, BPSD, and caregiver burden may directly or indirectly influence one another, and therefore should be considered essential elements of dementia assessment, care, and research. These results must be viewed as provisional and should be replicated longitudinally with larger samples.

Spinal Fractures in Older Adult Patients Admitted After Low-Level Falls: 10-Year Incidence and Outcomes.

OBJECTIVES: To evaluate the incidence of spinal fractures and their outcomes in the elderly who fall from low-levels in a suburban county. DESIGN: Retrospective county-wide trauma registry review from 2004 to 2013. SETTING: Suburban county with regionalized trauma care consisting of 11 hospitals. PARTICIPANTS: Adult trauma patients aged ≥65 years who were admitted after falling from <3 feet. MEASUREMENTS: Demographic characteristics, comorbidities, and outcomes. RESULTS: Spinal fractures occurred in 18% of 4,202 older adult patients admitted following trauma over this 10-year time period, in the following distribution: 43% cervical spine, 5.7% thoracic, 4.9% lumbar spine, 36% sacrococcygeal, and 9.6% multiple spinal regions. As compared to non-spinal fracture patients, more spinal fracture patients went to acute/subacute rehabilitation (47% vs 34%, P < .001) and fewer were discharged home (21% vs 35%, P < .001). In-hospital mortality rate in spinal and non-spinal fracture patients was similar (8.5% vs 9.3%, P = .5). CONCLUSION: Low-level falls often resulted in a spinal fracture at a variety of levels. Vigilance in evaluation of the entire spine in this population is suggested.

Use of quality measures for Medicaid behavioral health services by state agencies: implications for health care reform.

OBJECTIVE: The structure-process-outcome quality framework espoused by Donabedian provides a conceptual way to examine and prioritize behavioral health quality measures used by states. This report presents an environmental scan of the quality measures and satisfaction surveys that state Medicaid managed care and behavioral health agencies used prior to Medicaid expansion in 2014. METHODS: Data were collected by reviewing online documents related to Medicaid managed care contracts for behavioral health, quality strategies, quality improvement plans, quality and performance indicators data, annual outcomes reports, performance measure specification manuals, legislative reports, and Medicaid waiver requests for proposals. RESULTS: Information was publicly available for 29 states. Most states relied on process measures, along with some structure and outcome measures. Although all states reported on at least one process measure of behavioral health quality, 52% of states did not use any outcomes measures and 48% of states had no structure measures. A majority of the states (69%) used behavioral health measures from the National Committee for Quality Assurance's Healthcare Effectiveness Data and Information Set, and all but one state in the sample (97%) used consumer experience-of-care surveys. Many states supplemented these data with locally developed behavioral health indicators that rely on administrative and nonadministrative data. CONCLUSIONS: State Medicaid agencies are using nationally recognized as well as local measures to assess quality of behavioral health care. Findings indicate a need for additional nationally endorsed measures in the area of substance use disorders and treatment outcomes.

The role of the CNA Pain Assessment Tool (CPAT) in the pain management of nursing home residents with dementia.

Implementation and testing of the CPAT in two hundred fifteen dementia residents of three regional skilled nursing facilities. To examine the effect of incorporating the CPAT into an AMDA long-term care pain management clinical practice guideline on nursing home residents with dementia. To evaluate changes in CPAT scores after treatment for pain. A non-randomized pre and post intervention design was used. Main outcome measures of the number of falls, episodes of distressed behavior and rates of antipsychotic usage were compared pre and post CPAT/AMDA guideline implementation. CPAT score changes were calculated after pain management. Falls and verbally aggressive behavior were reduced post intervention but did not achieve statistical significance. Antipsychotic usage declined significantly post intervention. CPAT scores declined significantly after treatment for pain. The implementation of a CPAT/AMDA guideline in skilled nursing facilities may reduce falls, verbally aggressive behaviors and antipsychotic usage in residents with dementia. The CPAT is useful in evaluating the effects of pain treatment in nursing home residents with dementia.

Building psychosocial programming in geriatrics fellowships: a consortium model.

Geriatric psychosocial problems are prevalent and significantly affect the physical health and overall well-being of older adults. Geriatrics fellows require psychosocial education, and yet to date, geriatrics fellowship programs have not developed a comprehensive geriatric psychosocial curriculum. Fellowship programs in the New York tristate area collaboratively created the New York Metropolitan Area Consortium to Strengthen Psychosocial Programming in Geriatrics Fellowships in 2007 to address this shortfall. The goal of the Consortium is to develop model educational programs for geriatrics fellows that highlight psychosocial issues affecting elder care, share interinstitutional resources, and energize fellowship program directors and faculty. In 2008, 2009, and 2010, Consortium faculty collaboratively designed and implemented a psychosocial educational conference for geriatrics fellows. Cumulative participation at the conferences included 146 geriatrics fellows from 20 academic institutions taught by interdisciplinary Consortium faculty. Formal evaluations from the participants indicated that the conference: a) positively affected fellows' knowledge of, interest in, and comfort with psychosocial issues; b) would have a positive impact on the quality of care provided to older patients; and c) encouraged valuable interactions with fellows and faculty from other institutions. The Consortium, as an educational model for psychosocial learning, has a positive impact on geriatrics fellowship training and may be replicable in other localities.

Pain assessment in nursing home residents with dementia: psychometric properties and clinical utility of the CNA Pain Assessment Tool (CPAT).

OBJECTIVES: To examine the psychometric properties and clinical utility of the CPAT, an instrument to assess pain in nursing home residents with dementia. DESIGN: Instrument development and testing. SETTING: Three regional skilled nursing facilities. PARTICIPANTS: One hundred forty-five residents of 3 skilled nursing facilities. MEASUREMENTS: The inter-rater reliability, test-retest reliability, construct validity, and criterion validity of the CPAT was measured after initial CNA training. Measurement of inter-rater reliability and test-retest reliability was repeated after modified CNA training. Internal consistency (Cronbach's alpha) was calculated for all reliability measures. The clinical utility/feasibility of the CPAT was measured by means of a practicality survey. RESULTS: The CPAT was found to have acceptable levels of both interrater reliability (ICC=0.71) and test-retest reliability (ICC=0.67). Construct validity as measured by a paired t test was statistically significant (P=.043). Criterion validity as measured by Spearman's rank correlation coefficient was also statistically significant (P=.048). Internal consistency was acceptable for all measures as calculated by Cronbach's alpha, which ranged from 0.72 to 0.84. As determined by a practicality survey, the CPAT was shown to be a clinically useful and feasible instrument. CONCLUSION: This study provides evidence that the CPAT is a reliable and valid pain assessment instrument when used in nursing home residents with dementia. It has also been shown to be a tool with suitable clinical utility and feasibility. Further study is warranted to ascertain if its use will lead to improved resident function and quality of life and whether the results of this study are reproducible in other dementia populations. The CPAT's ability to quantify pain and measure treatment response has not been determined.

Appraising a guideline for preventing acute care falls.

Although falling may seem like a simple event, in reality it is a complex medical issue leading to serious injuries including fractures, lacerations, soft tissue and traumatic brain injuries, and even death. The Nurses Improving Care for Health System Elders (NICHE) guideline for falls prevention in acute care unit was formulated by incorporating recommendations from systematic reviews of the literature and advice from expert consensus. Recommendations include pre-fall risk assessment, utilization of a post-fall assessment tool, follow-up monitoring for 48 hours, and implementation of an individualized, multidisciplinary plan of care to address treatable problems that contributed to the fall and to prevent future falls. The guideline also calls for staff education.

Evidence-based review of interventions to improve palliation of pain, dyspnea, depression.

This review of the guideline developed by the Clinical Efficacy Subcommittee of the American College of Physicians and the accompanying systematic review offers clinicians evidence-based recommendations for palliative care. Seriously ill patients should be assessed for pain, dyspnea, and depression. Clinicians should use therapies of proven effectiveness to manage pain, depression, and dyspnea, including opioids in patients with unrelieved dyspnea and oxygen for short-term relief of hypoxemia. Clinicians should ensure that advance care planning, including completion of advance directives, occurs.