Assessing Delirium Severity in Dementia: Item Development and Psychometric Validation for a Delirium Severity Instrument.

PURPOSE: Despite the importance of measuring delirium severity in patients with Alzheimer's disease and related dementias (ADRD), no validated instrument currently exists. Our goal was to generate items for use in such an instrument. METHOD: An interdisciplinary expert panel developed items to assess seven domains and 21 subdomains of delirium severity. Nursing experts provided input on items. RESULTS: Experts achieved consensus on 21 items, including best respondents for each item, and appropriate look-back periods. Nursing experts emphasized the need for educating nursing staff and obtaining information from caregivers. CONCLUSION: Careful, nuanced identification of distinguishing features is key for generating items for measuring delirium severity in persons with ADRD. Once developed, engaging nurses will be essential to facilitate adoption and relevance of the tool. [Journal of Gerontological Nursing, 50(9), 24-30.].

High school quality is associated with cognition 58 years later.

We leveraged a unique school-based longitudinal cohort-the Project Talent Aging Study-to examine whether attending higher quality schools is associated with cognitive performance among older adults in the United States (mean age = 74.8). Participants (n = 2,289) completed telephone neurocognitive testing. Six indicators of high school quality, reported by principals at the time of schooling, were predictors of respondents' cognitive function 58 years later. To account for school-clustering, multilevel linear and logistic models were applied. We found that attending schools with a higher number of teachers with graduate training was the clearest predictor of later-life cognition, and school quality mattered especially for language abilities. Importantly, Black respondents (n = 239; 10.5 percentage) were disproportionately exposed to low quality high schools. Therefore, increased investment in schools, especially those that serve Black children, could be a powerful strategy to improve later life cognitive health among older adults in the United States.

High-Need Phenotypes in Medicare Beneficiaries: Drivers of Variation in Utilization and Outcomes.

OBJECTIVES: High-need (HN) Medicare beneficiaries heavily use healthcare services at a high cost. This population is heterogeneous, composed of individuals with varying degrees of medical complexity and healthcare needs. To improve healthcare delivery and decrease costs, it is critical to identify the subpopulations present within this population. We aimed to (1) identify distinct clinical phenotypes present within HN Medicare beneficiaries, and (2) examine differences in outcomes between phenotypes. DESIGN: Latent class analysis was used to identify phenotypes within a sample of HN fee-for-service (FFS) Medicare beneficiaries aged 65 years and older using Medicare claims and post-acute assessment data. SETTING: Not applicable. PARTICIPANTS: Two cross-sectional cohorts were used to identify phenotypes. Cohorts included FFS Medicare beneficiaries aged 65 and older who survived through 2014 (n = 415 659) and 2015 (n = 416 643). MEASUREMENTS: The following variables were used to identify phenotypes: acute and post-acute care use, functional dependency in one or more activities of daily living, presence of six or more chronic conditions, and complex chronic conditions. Mortality, hospitalizations, healthcare expenditures, and days in the community were compared between phenotypes. RESULTS: Five phenotypes were identified: (1) comorbid ischemic heart disease with hospitalization and skilled nursing facility use (22% of the HN sample), (2) comorbid ischemic heart disease with home care use (23%), (3) home care use (12%), (4) high comorbidity with hospitalization (32%), and (5) Alzheimer's disease/related dementias with functional dependency and nursing home use (11%). Mortality was highest in phenotypes 1 and 2; hospitalizations and expenditures were highest in phenotypes 1, 3, and 4. CONCLUSIONS: Our findings represent a first step toward classifying the heterogeneity among HN Medicare beneficiaries. Further work is needed to identify modifiable utilization patterns between phenotypes to improve the value of healthcare provided to these subpopulations. J Am Geriatr Soc 68:70-77, 2019.

Reserve and Alzheimer's disease genetic risk: Effects on hospitalization and mortality.

INTRODUCTION: Cognitive reserve predicts delayed diagnosis of Alzheimer's disease (AD) and faster postdiagnosis decline. The net impact of cognitive reserve, combining both prediagnosis and postdiagnosis risk, on adverse AD-related outcomes is unknown. We adopted a novel approach, using AD genetic risk scores (AD-GRS), to evaluate this. METHODS: Using 242,959 UK Biobank participants age 56+ years, we evaluated whether cognitive reserve (operationalized as education) modified associations between AD-GRS and mortality or hospitalization (total count, fall-related, and urinary tract infection-related). RESULTS: AD-GRS predicted mortality and hospitalization outcomes. Education did not modify AD-GRS effects on mortality, but had a nonsignificantly (interaction P = .10) worse effect on hospitalizations due to urinary tract infection or falls among low education (OR = 1.07 [95% CI: 1.02, 1.12]) than high education (OR = 1.01 [0.95, 1.07]) individuals. DISCUSSION: Education did not convey differential survival advantages to individuals with higher genetic risk of AD, but may reduce hospitalization risk associated with AD genetic risk.

Weekly assessment of number of yoga classes and amount of yoga home practice: Agreement with daily diaries.

OBJECTIVE: To evaluate a weekly yoga practice assessment instrument designed to assess number of classes attended in the previous week, number of times engaged in formal home yoga practice, total number of minutes engaged in formal home yoga practice in the past week, and number of times engaged in informal home yoga practice. "Informal" practice was defined as "in the middle of other activities, you spent a few moments engaged in asanas/postures, focus on breath, body awareness, or very brief meditation, for less than 5 min at a time." We assessed agreement between this weekly assessment and a daily home practice log. DESIGN AND SETTING: Seventy-two community yoga practitioners completed online daily yoga logs for 28 days as well as the weekly yoga practice assessment four times over the 28 day period. RESULTS: We examined agreement between the two methods on the four indices of amount of weekly yoga practice. We found acceptable agreement between the two methods for number of classes, number of times engaged in formal home practice, and total number of minutes engaged in formal home practice. Agreement was lower for number of times engaged in informal practice. CONCLUSIONS: These data provide support for use of a weekly yoga practice assessment to assess number of classes attended and amount of formal but not informal home practice.

Evaluating Alzheimer's disease biomarkers as mediators of age-related cognitive decline.

Age-related changes in cognition are partially mediated by the presence of neuropathology and neurodegeneration. This manuscript evaluates the degree to which biomarkers of Alzheimer's disease, (AD) neuropathology and longitudinal changes in brain structure, account for age-related differences in cognition. Data from the AD Neuroimaging Initiative (n = 1012) were analyzed, including individuals with normal cognition and mild cognitive impairment. Parallel process mixed effects regression models characterized longitudinal trajectories of cognitive variables and time-varying changes in brain volumes. Baseline age was associated with both memory and executive function at baseline (p's < 0.001) and change in memory and executive function performances over time (p's < 0.05). After adjusting for clinical diagnosis, baseline, and longitudinal changes in brain volume, and baseline levels of cerebrospinal fluid biomarkers, age effects on change in episodic memory and executive function were fully attenuated, age effects on baseline memory were substantially attenuated, but an association remained between age and baseline executive function. Results support previous studies that show that age effects on cognitive decline are fully mediated by disease and neurodegeneration variables but also show domain-specific age effects on baseline cognition, specifically an age pathway to executive function that is independent of brain and disease pathways.

Pain characteristics associated with the onset of disability in older adults: the maintenance of balance, independent living, intellect, and zest in the Elderly Boston Study.

OBJECTIVES: To determine the effects of chronic pain on the development of disability and decline in physical performance over time in older adults. DESIGN: Longitudinal cohort study with 18 months of follow-up. SETTING: Urban and suburban communities. PARTICIPANTS: Community-dwelling older adults aged 65 and older (N = 634). MEASUREMENTS: Chronic pain assessment consisted of musculoskeletal pain locations and pain severity and pain interference according to the subscales of the Brief Pain Inventory. Disability was self-reported as any difficulty in mobility and basic and instrumental activities of daily living (ADLs, IADLs). Mobility performance was measured using the Short Physical Performance Battery (SPPB). Relationships between baseline pain and incident disability in 18 months were determined using risk ratios (RRs) from multivariable Poisson regression models. RESULTS: Almost 65% of participants reported chronic musculoskeletal pain at baseline. New onset of mobility difficulty at 18 months was strongly associated with baseline pain distribution: 7% (no sites), 18% (1 site), 24% (multisite), and 39% (widespread pain, P-value for trend < .001). Similar graded effects were found for other disability measures. Elderly adults with multisite or widespread pain had at a risk of onset of mobility difficulty at least three times as great as that of their peers without pain after adjusting for disability risk factors (multisite pain: risk ratio (RR) = 2.95, 95% confidence interval (CI) 1.58-5.50; widespread pain: RR = 3.57, 95% CI = 1.71-7.48). Widespread pain contributed to decline in mobility performance (1-point decline in SPPB, RR = 1.47, 95% CI = 1.08-2.01). Similar associations were found for baseline pain interference predicting subsequent mobility decline and ADL and IADL disability. Weaker and less-consistent associations were observed with pain severity. CONCLUSION: Older community-dwelling adults living with chronic pain in multiple musculoskeletal locations have a substantially greater risk for developing disability over time and for clinically meaningful decline in mobility performance than those without pain.

Depressive symptoms, chronic pain, and falls in older community-dwelling adults: the MOBILIZE Boston Study.

OBJECTIVES: To examine whether overall depressive symptoms and symptom clusters are associated with fall risk and to determine whether chronic pain mediates the relationship between depression and fall risk in aging. DESIGN: Prospective cohort study. SETTING: Boston, Massachusetts, and surrounding communities. PARTICIPANTS: Older community-dwelling adults (N = 722, mean age 78.3). MEASUREMENTS: Depressive symptomatology was assessed at baseline using the 20-item Hopkins Revision of the Center for Epidemiologic Studies Depression Scale (CESDR) as overall depression and two separate domains: cognitive and somatic symptoms. Chronic pain was examined at baseline as number of pain sites (none, single site, or multisite), pain severity, and pain interference with activities of daily living. Participants recorded falls on monthly postcards during a subsequent 18-month period. RESULTS: According to negative binomial regression, the rate of incident falls was highest in those with the highest burden of depressive symptoms (according to total CESDR and the cognitive and somatic CESDR domains). After adjustment for multiple confounders and fall risk factors, fall rate ratios comparing the highest three CESDR quartiles with the lowest quartile were 1.91, 1.26, and 1.11, respectively. Similarly graded associations were observed according to the CESDR domains. Although pain location and interference were mediators of the relationship between depression and falls, adjustment for pain reduced fall risk estimates only modestly. There was no interaction between depression and pain in relation to fall risk. CONCLUSION: Depressive symptoms are associated with fall risk in older adults and are mediated in part by chronic pain. Research is needed to determine effective strategies for reducing fall risk and related injuries in older people with pain and depressive symptoms.

Mental health and exposure to patient distress among families of nursing home residents with advanced dementia.

CONTEXT: The effect of suffering among patients with advanced dementia on their family members' mental health has not been investigated. OBJECTIVES: To describe family members' exposure to distressing symptoms among nursing home (NH) residents with advanced dementia and associations between such exposure and family members' mental health. METHODS: Data were obtained from an 18-month prospective cohort study of NH residents with advanced dementia and their family member health care proxies (HCPs). Exposure to resident symptoms and associated fear and helplessness was measured quarterly using the Stressful Caregiving Adult Reactions to Experiences of Dying (SCARED) scale (range 0-120). HCP mental health was assessed quarterly using the Composite International Diagnostic Interview Short Form (CIDI-SF) (depression), K6 (psychological distress, range 0-24), and SF-12(®) mental health subscale. RESULTS: Seven hundred seventy-nine SCARED scale assessments were completed by 225 HCPs. The most frequent distressing symptoms were the following: feeling the resident had had enough (33.2%), choking (21.1%), and pain (18.9%). The symptoms eliciting the greatest fear were thinking the resident was dead and seeing them choke. A sense of helplessness was highest when the resident was observed to be in pain or choking. Family members with SCARED scores >0 were more likely to meet criteria for depression on the CIDI-SF (adjusted odds ratio [AOR] 2.59, 95% confidence interval [CI] 1.14, 5.85), have a K6 score >0 (AOR 2.31, 95% CI 1.55, 3.43), and have lower SF-12 scores (adjusted parameter estimate -1.51, 95% CI -2.56, -0.47). CONCLUSION: Family member exposure to distressing symptoms experienced by their loved ones with advanced dementia is not uncommon and is associated with worse mental health.

The role of the advanced practice nurse in neuroscience nursing: results of the 2006 AANN membership survey.

The need for a scope of practice for advanced practice neuroscience nurses was identified by the American Association of Neuroscience Nurses (AANN) in 2006. A task force consisting of advanced practice nurses (nurse practitioners and clinical nurse specialists) was commissioned by AANN and charged with the development of the document. Current information regarding the practices of advanced practice neuroscience nurses was needed as the task force began to develop this document. To best obtain this information, an electronic survey was created and distributed to advanced practice nurses within the AANN database. The survey questions included basic demographic data and sought information regarding activities and procedures performed by the advanced practice nurse. The results of this survey clearly reflect the diversity in practice and the integral role advanced practice neuroscience nurses play in the management of patients' care.

Depressive symptom trajectories and associated risks among bereaved Alzheimer disease caregivers.

OBJECTIVES: A recent study concluded that depressive symptoms among caregivers decline on average from before to after the Alzheimer disease (AD) patient's death. The present study sought to determine if subgroups of bereaved AD caregivers follow distinctive depressive symptom trajectories and the characteristics associated with membership in depressive symptom subgroups. DESIGN: Latent class mixture models sought to identify clusters of homogeneous participants in the Resources for Enhancing Alzheimer's Caregiver Health study-a multisite, randomized caregiver intervention trial. PARTICIPANTS: One hundred eighty-two community-based bereaved caregivers were included in the study. MEASUREMENTS: The Center for Epidemiologic Studies Depression Scale assessed depressive symptoms among the AD caregivers at baseline and three follow-up visits. RESULTS: Three postloss depressive symptom trajectories emerged: persistently syndromal depression (N = 30, 16.5%); syndromal-becoming-threshold level depression (N = 62, 34.0%); and persistently absent depression (N = 90, 49.5%). Lower income, higher preloss depression levels, greater caregiver behavioral burden, less family support, and adverse health behaviors (e.g., smoking, skipped meals, and lack of exercise) after loss were risk factors for syndromal and syndromal-becoming-threshold level depression after loss. CONCLUSIONS: Early intervention to reduce caregiving behavioral burden and enhance family support and promote healthier behaviors of bereaved AD caregivers may decrease the risk of syndromal or syndromal-becoming-threshold level depression after loss.

Musculoskeletal pain and risk for falls in older disabled women living in the community.

OBJECTIVES: To determine whether musculoskeletal pain increased risk for falls in older women with disabilities. DESIGN: Prospective population-based cohort study. SETTING: The city and county of the eastern area of Baltimore. PARTICIPANTS: One thousand two women aged 65 and older, participants in the Women's Health and Aging Study, representing the one-third of older women who were living at home with disabilities, followed semiannually for 3 years beginning in 1991. MEASUREMENTS: Pain was categorized into four groups according to severity and location. Widespread pain was defined as pain in the upper and lower extremities and in the axial skeletal region, with moderate to severe pain in at least one region (> or = 4 on a 10-point numeric rating scale, 10 = excruciating pain). Moderate to severe lower extremity pain that did not meet criteria for widespread pain was the next category. The reference category was no pain or mild pain in one site. The additional category of "other pain" was pain that did not fit into the other three groups. The occurrence of falls and fall-related injuries were assessed at each interview. RESULTS: Of the 940 women who participated in at least one follow-up examination, 39% fell in first year; of the survivors, 36% fell in Year 2, and 39% in Year 3. After adjusting for several major risk factors for falls, women with widespread pain had an increased likelihood of falling during follow-up (adjusted odds ratio (AOR) = 1.66, 95% confidence interval (CI) = 1.25-2.21) compared with those with no or mild pain in only one musculoskeletal site. Women who had other musculoskeletal pain but not widespread pain or lower extremity pain also had an increased risk of falls (AOR = 1.36, 95% CI = 1.02-1.82). Among women with musculoskeletal pain, risk for falls was lower in those who used daily analgesic medication. Risk for recurrent falls and self-reported fractures due to falls was also elevated in women with musculoskeletal pain, most consistently in women with widespread pain. CONCLUSIONS: Musculoskeletal pain, particularly widespread pain, is a substantial risk factor for falls in older women with disabilities. These findings add an important dimension to our understanding of the multifactorial processes leading to falls in older persons.