Designing a mobile application to promote physical activity in spousal care partners of persons living with dementia and their care-recipient.

Background: Care partners of persons living with dementia and their care-recipient have low levels of physical activity. Mobile applications have demonstrated effectiveness in promoting physical activity among older adults. The purpose of this study was to explore the perceptions of spousal care partners of persons with dementia and their care-recipient on the design and content of a mobile application intended to promote physical activity.Methods: Semi-structured interviews were conducted with 14 care partners and their care-recipient. After the interviews were transcribed verbatim, thematic analysis was performed.Results: Four themes emerged from the participants' responses related to the design and content of a mobile application to promote physical activity: 1) exercise preferences and habits, 2) barriers to exercise, 3) motivations for exercise, and 4) mobile application preferences and supportive features.Conclusion: Findings lay the foundation for designing an effective user-friendly mobile application to promote physical activity that caters to the diverse needs, preferences, and challenges among spousal care partners of persons with dementia and their care-recipient.

Dementia Care Partner Preparedness and Desire to Seek Long-Term Care at Hospital Discharge: Mediating Roles of Care Receiver Clinical Factors.

OBJECTIVES: The purpose of this study was to explore the mediating roles of care receiver clinical factors on the relationship between care partner preparedness and care partner desire to seek long-term care admission for persons living with dementia at hospital discharge. METHODS: This study analyzed data from the Family centered Function-focused Care (Fam-FFC), which included 424 care receiver and care partner dyads. A multiple mediation model examined the indirect effects of care partner preparedness on the desire to seek long-term care through care receiver clinical factors (behavioral and psychological symptoms of dementia [BPSD], comorbidities, delirium severity, physical function, and cognition). RESULTS: Delirium severity and physical function partially mediated the relationship between care partner preparedness and care partner desire to seek long-term care admission (B = -.011; 95% CI = -.019, -.003, and B = -.013; 95% CI = -.027, -.001, respectively). CONCLUSIONS: Interventions should enhance care partner preparedness and address delirium severity and physical function in hospitalized persons with dementia to prevent unwanted nursing home placement at hospital discharge. CLINICAL IMPLICATIONS: Integrating care partner preparedness and care receiver clinical factors (delirium severity and physical function) into discharge planning may minimize care partner desire to seek long-term care.

Leadership Perspectives on Nursing Home Operations From Crisis to Control: A Mixed Methods Study.

OBJECTIVES: Nursing home (NH) leaders remain challenged to deliver quality care, despite the COVID-19 transition to an endemic phase. This study describes NH leadership perspectives on preparing and maintaining quality care during times of diminishing resources as experienced through the COVID-19 pandemic to gain insight on how best to support NHs moving forward. DESIGN: This was a cross-sectional, parallel convergent mixed methods study. SETTING AND PARTICIPANTS: This study reports quantitative data from N = 5001 NHs across 12 states along with qualitative data from a subsample of NH leaders (N = 15). METHODS: Publicly reported survey data were analyzed using descriptive statistics. Individual in-depth interviews with NH leaders conducted at 12-month follow-up were analyzed using inductive thematic coding organized by a guiding framework. Data were integrated using convergent analysis and a joint display. RESULTS: NH leaders (licensed administrators, clinical directors, and managers) reported resident and staff infection rates, and access to resources (such as personal protective equipment and testing supplies) that aligned with national trends. Leaders described their NHs (n = 14; 43% rural; 71% not for profit) to be in varied states of operational readiness (standard, contingency, crisis) to support quality infection prevention and control (IPC) at the transition to the endemic COVID-19 phase. Leadership reported continued challenges in addressing resident and staff vaccinations, securing testing supplies, obtaining financial resources to maintain acceptable levels of personal protective equipment, continued staffing shortages, and issues in implementing isolation practices in current facilities. CONCLUSION AND IMPLICATIONS: NH leaders continue to struggle delivering quality IPC care post-pandemic and require focused support in several areas. Clinical practice guidelines should include IPC practices to prevent the infection and spread of any COVID-19 variant in this endemic phase. Policies should support continued reporting of IPC-related metrics and adequate funding to account for the long-term financial burden NHs face.

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.

Mediating role of care partner burden among dementia care partners during post-hospital transition.

OBJECTIVES: This study examined the mediating role of care partner burden on the relationship between patient clinical factors (i.e. cognition, physical function, and behavioral and psychological symptoms of dementia [BPSD]) and care partner mental health (i.e. anxiety and depression) among dementia care partners at hospital discharge. METHOD: The sample consisted of 431 patient and care partner dyads enrolled in the Family centered Function-focused Care (Fam-FFC) study; ClinicalTrials.gov identifier NCT03046121. Mediation analyses were conducted to test the role of care partner burden on the associations between patient clinical factors, and care partner anxiety and depression. RESULTS: Mediation models demonstrated that care partner burden partially mediated the relationship between patient physical function and care partner anxiety and depression, as well as patient BPSD and care partner anxiety and depression. CONCLUSION: Findings highlight the need for clinicians and service providers to implement comprehensive strategies that address both patient clinical factors (i.e. physical function and BPSD) and care partner burden, to optimize care partner mental health outcomes during post-hospital transition.

Pilot Process Evaluation of the Supporting Older Adults at Risk Model: A RE-AIM Approach.

ABSTRACT: Despite evidence supporting transitional care models, hospitals report challenges implementing and sustaining them. The Discharge to Assess (D2A) Model is an innovative solution to this problem but required translation from a national health system context to an U.S.-based context. We translated the central tenets of the D2A model to establish the Supporting Older Adults at Risk (SOAR) Model, which unfolds in three phases: Prepare, Transition, and Support. The purpose of this project was to conduct a process evaluation of the SOAR Model in practice using the RE-AIM Framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). Forty patients completed all SOAR Model components for a Reach of 21%. Patients averaged 80 years of age, 53% were female, and 64% Black/AA. SOAR significantly improved discharge before noon, time to first home visit, and use of the in-house pharmacy. SOAR also improved length of hospital stay, emergency department visits, and readmissions. Twenty-one of the 26 Implementation measures unfolded with 75% or greater fidelity. Sixteen of the 24 Adoption measures unfolded with 75% or greater fidelity. COVID-19 limited Maintenance. Given the model unfolds across settings over time, requiring adoption from interprofessional team members, patients, and families, future work should focus on improving reach and adoption.

Ready or Not: A Conceptual Model of Organizational Readiness for Embedded Pragmatic Dementia Research.

The National Institute on Aging Alzheimer's Disease/Alzheimer's Disease and Related Dementias Research Implementation Milestones emphasize the need for implementation research that maximizes up-take and scale-up of evidence-based dementia care practices across settings, diverse populations, and disease trajectories. Organizational readiness for implementation is a salient consideration when planning and conducting embedded pragmatic trials, in which interventions are implemented by provider staff. The current article examines the conceptual and theoretical underpinnings of organizational readiness for implementation and the operationalization of this construct. We offer a preliminary conceptual model for explicating and measuring organizational readiness and describe the unique characteristics and demands of implementing evidence-based interventions targeting persons with dementia and/or their care partners. [Research in Gerontological Nursing, 17(3), 149-160.].

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.

" I'm not a risk taker " : Risk Perceptions of Nursing Home Residents With Dementia.

BACKGROUND: Persons living with Alzheimer disease and related dementia (ADRD) in nursing homes (NH) are often excluded from conversations about their health/safety. These omissions impinge on personhood and the rights to have care preferences heard and honored. While persons with ADRD maintain the ability to communicate their preferences long after their decision-making abilities are affected, little is known about how persons with ADRD understand the risks associated with their preferences. METHODS: As part of a larger focused ethnography, in-depth interviews and an adapted risk propensity questionnaire explored the risk perceptions of NH residents with ADRD (N=7) associated with their preferences for care and activities of daily living. RESULTS: Residents generally self-identified as risk avoiders ( M =3.2±1.84) on the risk propensity scale and were able to rate risk associated with preferences described within 5 thematic categories: 1) participation in decision-making, 2) risk awareness, 3) paying attention to safety, 4) reliance on nursing home staff and family, and 5) impacts on quality of life and quality of care. DISCUSSION: Results suggest NH residents with ADRD can express risk surrounding their preferences and should be encouraged to participate in discussions about their health and safety.

Trends in observation stays for Medicare beneficiaries with and without Alzheimer's disease and related dementias.

BACKGROUND: There has been a marked rise in the use of observation care for Medicare beneficiaries visiting the emergency department (ED) in recent years. Whether trends in observation use differ for people with Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) is unknown. METHODS: Using a national 20% sample of Medicare beneficiaries ages 68+ from 2012 to 2018, we compared trends in ED visits and observation stays by AD/ADRD status for beneficiaries visiting the ED. We then examined the degree to which trends differed by nursing home (NH) residency status, assigning beneficiaries to four groups: AD/ADRD residing in NH (AD/ADRD+ NH+), AD/ADRD not residing in NH (AD/ADRD+ NH-), no AD/ADRD residing in NH (AD/ADRD- NH+), and no AD/ADRD not residing in NH (AD/ADRD- NH-). RESULTS: Of 7,489,780 unique beneficiaries, 18.6% had an AD/ADRD diagnosis. Beneficiaries with AD/ADRD had more than double the number of ED visits per 1000 in all years compared to those without AD/ADRD and saw a faster adjusted increase over time (+26.7 vs. +8.2 visits/year; p < 0.001 for interaction). The annual increase in the adjusted proportion of ED visits ending in observation was also greater among people with AD/ADRD (+0.78%/year, 95% CI 0.77-0.80%) compared to those without AD/ADRD (+0.63%/year, 95% CI 0.59-0.66%; p < 0.001 for interaction). Observation utilization was greatest for the AD/ADRD+ NH+ population and lowest for the AD/ADRD- NH- population, but the AD/ADRD+ NH- group saw the greatest increase in observation stays over time (+15.4 stays per 1000 people per year, 95% CI 15.0-15.7). CONCLUSIONS: Medicare beneficiaries with AD/ADRD have seen a disproportionate increase in observation utilization in recent years, driven by both an increase in ED visits and an increase in the proportion of ED visits ending in observation.

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.

Behavioral and psychological symptoms of dementia and adverse patient outcomes post-hospitalization.

OBJECTIVES: The occurrence of behavioral and psychological symptoms of dementia (BPSD) are associated with adverse outcomes but have largely been studied in populations outside of acute care. The current study examines (1) the prevalence of BPSD during acute hospitalization and (2) if BPSD are predictive of adverse patient outcomes. METHODS: A secondary analysis of Family-centered Function-focused Care (Fam-FFC) data including 461 patients with dementia/care partner dyads assessed at hospital admission, discharge, 2 months, and 6 months post-discharge, was conducted. Prevalence of BPSD (Neuropsychiatric Inventory-Questionnaire total and Frontal, Hyperactivity, Mood, and Psychosis sub-categories), associations with patient and care partner characteristics, and prediction of adverse events (falls, emergency room [ER] visits, hospitalizations, injury) were examined. RESULTS: BPSD were highly prevalent (93.9% admission, 86.7% discharge). The most common symptom cluster at admission was Hyperactivity (76.7%) followed by Mood (72.3%) and Psychosis (71.9%), and Frontal (25.9%). Higher admission Hyperactivity was associated with ER admissions at 2 months, higher discharge Hyperactivity was associated with ER admissions and hospitalizations at 2 months, and change in Psychosis was associated with ER admissions at 2 months. CONCLUSIONS: These findings highlight BPSD during hospitalization as potentially modifiable risk factors of adverse outcomes.

An exploration of the cultural appropriateness of the family-centered function-focused care intervention.

The Family-centered Function Focused Care (Fam-FFC) intervention, is a nurse-family care partnership model aimed to improve the physical and cognitive recovery in hospitalized persons living with Alzheimer's Disease Related Dementias (ADRD) while improving the care partner's experiences. Discussions of patients' needs and preferences between nurses and the patient's close family members have been found to be useful in preventing excessive stress in persons with dementia, while lessening the anxiety of care partners. However, the efficacy of dementia-specific interventions is influenced in part by the degree to which the interventions are flexible and sensitive to the patient's and care-partner's condition, needs, and preferences, including cultural preferences. Therefore, the purpose of this study is to assess the cultural appropriateness of Fam-FFC using the Ecological Validity Model (EVM). This qualitative, descriptive study included 28 consented care partners drawn from a sample of 455 dyads enrolled in the Fam-FFC intervention. An interview guide was created based on the EVM. Participants provided demographic data. Thematic analysis was conducted to analyze transcribed interviews. The majority of the sample was female (79%), Non-Hispanic (96%) and half were married. One-half of the sample represented Black care partners and one-half were White. Seventy-nine percent lived with their family member with ADRD. Three major themes were identified from the thematic analysis including Care Partner Identity, Care Partner Preferences, and Goals of Care for functional recovery of their family member living with dementia. In this study care partners wanted more social services as well as home care that supported not just physical needs but also social and recreational needs. Findings from the study offer guidance on improving the Fam-FFC intervention including strengthening education and resources on partner self-care.

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.

Factors associated with disagreement between clinician app-based ultra-brief Confusion Assessment Method and reference standard delirium assessments.

BACKGROUND: Recently, the Ultra-Brief Confusion Assessment Method (UB-CAM), designed to help physicians and nurses to recognize delirium, showed high, but imperfect, accuracy compared with Research Reference Standard Delirium Assessments (RRSDAs). The aim of this study is to identify factors associated with disagreement between clinicians' app-based UB-CAM assessments and RRSDAs. METHODS: This is a secondary analysis of a prospective diagnostic test study. The study was conducted at two hospitals and included 527 inpatients (≥70 years old) and 289 clinicians (53 physicians, 236 nurses). Trained research associates performed RRSDAs and determined delirium presence using the CAM. Clinicians administered the UB-CAM using an iPad app. Disagreement factors considered were clinician, patient, and delirium characteristics. We report odds ratios and 95% confidence intervals. RESULTS: One thousand seven hundred and ninety-five clinician UB-CAM assessments paired with RRSDAs were administered. The prevalence of delirium was 17%. The rate of disagreement between clinician UB-CAM assessments and RRSDAs was 12%. Significant factors associated with disagreement between clinician UB-CAM assessments and RRSDAs (OR [95% CI]) included: presence of dementia (2.7 [1.8-4.1]), patient education high school or less (1.9 [1.3-2.9]), psychomotor retardation (2.5 [1.4-4.2]), and the presence of mild delirium or subsyndromal delirium (5.5 [3.5-8.7]). Significant risk factors for false negatives were patient age less than 80 (2.2 [1.1-4.3]) and mild delirium (3.5 [1.6-7.4]). Significant risk factors for false positives were presence of dementia (4.0 [2.3-7.0]), subsyndromal delirium (5.1 [2.9-9.1]), and patient education high school or less (2.0 [1.2-3.6]). Clinician characteristics were not significantly associated with disagreement. CONCLUSIONS: The strongest factors associated with disagreement between clinician UB-CAM screens and RRSDAs were the presence of dementia and subsyndromal delirium as risk factors for false positives, and mild delirium and younger age as a risk factor for false negatives. These disagreement factors contrast with previous studies of risk factors for incorrect clinician delirium screening, and better align screening results with patient outcomes.

Using Hybrid Effectiveness Studies to Facilitate Implementation in Community-Based Settings: Three Case Studies in Dementia Care Research.

The pipeline from discovery to testing and then implementing evidence-based innovations in real-world contexts may take 2 decades or more to achieve. Implementation science innovations, such as hybrid studies that combine effectiveness and implementation research questions, may help to bridge the chasm between intervention testing and implementation in dementia care. This paper describes hybrid effectiveness studies and presents 3 examples of dementia care interventions conducted in various community-based settings. Studies that focus on outcomes and implementation processes simultaneously may result in a truncated and more efficient implementation pipeline, thereby providing older persons, their families, health care providers, and communities with the best evidence to improve quality of life and care more rapidly. We offer post-acute and long-term care researchers considerations related to study design, sampling, data collection, and analysis that they can apply to their own dementia and other chronic disease care investigations.

Testing an Intervention to Improve Posthospital Outcomes in Persons Living With Dementia and Their Family Care Partners.

Background and Objectives: Hospitalized persons living with dementia are at risk for functional decline, behavioral symptoms of distress, and delirium, all persisting in the postacute period. In turn, family care partners (FCPs) experience increased anxiety and lack of preparedness for caregiving, compounding existing strain and burden. Family-centered Function-focused Care (Fam-FFC) purposefully engages FCPs in assessment, decision-making, care delivery, and evaluation of function-focused care during and after hospitalization (within 48 hours of discharge, weekly telephone calls for a total of 7 additional weeks, then monthly for 4 months). The objective of this study was to test the efficacy of Fam-FFC. Research Design and Methods: A cluster randomized controlled trial included 455 dyads of persons living with dementia and FCPs in 6 medical units in 3 hospitals. Patient outcomes included return to baseline physical function, behavioral symptoms of distress, depressive symptoms, and delirium severity. Family care partner measures included preparedness for caregiving, anxiety, strain, and burden. Results: Multilevel level modeling demonstrated that the likelihood of returning to baseline function across time for Fam-FFC participants was twice that of the control group by the end of 6 months (OR = 2.4, p = .01, 95% CI 1.2-4.7). Family-centered Function-focused Care was also associated with fewer symptoms of distress (b = -1.1, SE = 0.56, p = .05) but no differences in the amount of moderate physical activity, depressive symptoms, and delirium severity. Preparedness for caregiving increased significantly only from 2 to 6 months (b = 0.89, SE = 0.45, d = 0.21, overall p = .02) in the intervention group, with no group differences in anxiety, strain, and burden. Discussion and Implications: Family-centered Function-focused Care may help prevent some of the postacute functional decline and behavioral symptoms in hospitalized persons living with dementia. Further research is needed to promote sustained improvements in these symptoms with more attention to the postacute needs of the care partner.

Gender, Pain, and Function Associated With Physical Activity After Hospitalization in Persons Living With Dementia.

BACKGROUND: The purpose of this study was to identify factors that are associated with physical activity after hospitalization in persons living with dementia. METHODS: Multiple linear regressions were conducted to test factors associated with objective activity levels (sedentary, low, moderate, and vigorous) among 244 patients living with dementia from a randomized controlled trial. RESULTS: Within 48 hours of hospital discharge, time in sedentary behavior was associated with increased pain (ß=0.164, P =0.015). Time in low activity was associated with less pain (ß=-0.130, P =0.049) and higher physical function (ß=0.300, P =<0.001). Time in moderate activity was associated with increased physical function (ß=0.190, P =0.008) and male gender (ß=0.155, P =0.016). No significant associations of potential factors were found with time in vigorous activity. CONCLUSIONS: Our findings suggest that managing or reducing pain, encouraging individual functional level, and gender could influence time spent in physical activity after acute hospitalization in persons living with dementia.