People Living With Dementia: Dementia Characteristics and Family Caregiver Pain Assessment.

People living with dementia (PLWD) experience pain like other older adults, but with changes due to dementia, they rely more on family caregivers for pain assessment. Many different elements contribute to a pain assessment. Changes in characteristics of PLWD may be associated with changes in the use of these different pain assessment elements. The current study reports associations between PLWD's agitation, cognitive function, and dementia severity and the frequency with which family caregivers use pain assessment elements. In a sample of family caregivers (N = 48), statistically significant associations were found between worsening cognitive function and greater use of rechecking for pain after intervention (rho = 0.36, p = 0.013), and between lower cognitive scores on a subscale of dementia severity and asking others if they have noticed a behavior change in the PLWD (rho = 0.30, p = 0.044). Limited statistically significant associations suggest that, overall, family caregivers of PLWD do not use pain assessment elements more frequently with changes in characteristics of PLWD. [Journal of Gerontological Nursing, 49(7), 17-23.].

Readiness to Plan for Aging and Frailty: Examining Contextual Factors.

As older adults live longer, individual and societal efforts must be directed toward strategies to promote healthy and successful aging. Planning for aging and frailty offers an opportunity for older adults to optimize their well-being and proactively prepare across their aging trajectory. The current study evaluated the relationship between contextual factors (functional status, frailty, health status, social support) that influence older adults' readiness to engage in planning in five domains of aging (communication, environmental, financial, physical care, cognitive) through the transtheoretical stages of change. Results showed that factors influencing active planning include older age, vulnerability, living situation, and social support. These results add to the discourse on future care planning through a comprehensive approach to planning across a life course perspective, while highlighting the importance of future research at individual and societal levels. Gerontological nurses are well-positioned to lead planning efforts for older adults that promote well-being, patient-centered care, and healthy aging. [Journal of Gerontological Nursing, 49(2), 27-35.].

Caregiving self-efficacy and pain assessment by family caregivers of people living with dementia.

Like other older adults, people living with dementia (PLWD) experience pain, and the task of pain assessment often falls to family caregivers. In this study, we surveyed family caregivers of PLWD to determine the frequency with which they use different elements of pain assessment. We also determined correlations of family caregivers' characteristics (caregiving self-efficacy, relationship duration and type, mood, education level, and health literacy) with their use of the elements of pain assessment. Participants reported frequent use of many pain assessment elements. Statistically significant correlations were found between caregiving self-efficacy for obtaining respite and asking others about noticed behavior change (rho=.0.41, p=.007); and for responding to disruptive patient behaviors for multiple pain assessment elements including observing pain behaviors (rho=0.49, p<.001), asking others about noticed behavior change (rho=0.54, p<.001) and rechecking (rho=0.56, p<.001). Continued efforts are needed to describe pain assessments by family caregivers of PLWD.

The impact of COVID on end-of-life planning views, social connection, and quality of life for low-income, older adults: A qualitative study.

OBJECTIVES: Low-income, older adults are less likely than those with high income to participate in advance care planning (ACP); however, the pandemic may have influenced their views. The aim of this report was to explore the perceptions of COVID-19 related to everyday life and ACP. METHODS: We embedded ACP behavior inequities within the Social Ecological Model to highlight the importance of considering social inequities within an environmental context. Using a qualitative descriptive design, twenty individual interviews were conducted. Thematic analysis consisted of multiple rounds of independent and iterative coding by 2 coders that resulted in a hierarchically organized coding system. Final themes emerged through the inductive consideration of the transcript data and the deductive contribution of our theoretical framework. RESULTS: Three major themes emerged: social connection, quality of life, and end-of-life planning views. COVID-19 had not changed ACP views, i.e., those with existing ACP maintained it and those without ACP still avoided planning. SIGNIFICANCE OF RESULTS: Low-income, older adults experienced lower social connection and quality of life during COVID-19 but did not express changes to ACP views. Our findings of the loss of regular social practices and mental health struggles may have competed with participants' perception that this crisis had little, if any, effect on ACP. While clinicians should monitor low-income, older adults for ACP barriers during COVID-19, policymakers should prioritize ACP at the systems level. We plan to use participatory research methods to explore for the minimal ACP impact, focusing on barriers to ACP opportunities.

Caregivers' experience with Tele-Savvy Caregiver Program post-hospitalization.

Despite the frequent hospitalizations and readmissions of persons living with dementia (PLWD), no telehealth transitional care interventions focus on PLWDs' unpaid caregivers. Tele-Savvy Caregiver Program is a 43-day evidence-based online psychoeducational intervention for PLWDs' caregivers. The aim of this formative evaluation was to explore caregivers' acceptability of and experience with their participation in Tele-Savvy after their PLWDs' hospital discharge. Additionally, we gathered caregivers' feedback on the recommended features of a transitional care intervention, suitable for caregivers' schedule and needs post-discharge. Fifteen caregivers completed the interviews. Data were analyzed via conventional content analysis. Four categories were identified: (1) Tele-Savvy improved participants' understanding of dementia and caregiving; (2) hospitalization started a "new level of normal"; (3) PLWDs' health concerns; and (4) transitional care intervention development. Participation in Tele-Savvy was acceptable for most caregivers. Participants' feedback provides content and structural guidance for the development of a new transitional care intervention for PLWDs' caregivers.

PLAN: Preparing and Living for Aging Now; A descriptive study investigating older adults' readiness to plan for aging and frailty.

OBJECTIVES: Many older adults want to age in place but do not make plans. Understanding how and under what conditions adults prepare/plan ahead is vital given population aging and increasing frailty. This study examines the stages of change and experiences (personal/others) related to readiness to plan for aging and frailty. METHODS: Descriptive cross-sectional. SETTING: Community-dwelling. PARTICIPANTS: Adults aged 50-80(N = 252). DATA COLLECTION: demographics, other characteristics, stages of change, experiences (personal/others) was assessed with survey questions. DATA ANALYSIS: frequencies/percentages, McNemar test, Chi-square. RESULTS: Among domains, participants' percentages in action/maintenance stages ranged from 28.2% (cognitive) to 68.7% (financial). Participants had increased experience with others across domains rather than self. Older participants (≥ 70) vs. younger (50-69) reported statistically significant greater planning in action/maintenance stages for all domains (p < .05) with the exception of cognitive. DISCUSSION: Examining the concept of planning for aging and frailty provides a foundation for future work to develop/test interventions aimed at increasing readiness for aging.

Immigrants and dementia: Literature update.

The population of immigrants in the U.S. is increasing with older immigrants experiencing age-related decline more rapidly than the U.S.-born white population. Immigrants have a higher prevalence and risk of dementia, including undiagnosed dementia. Older immigrants face unique obstacles in terms of their cognitive health, including language barriers, economic constraints, depressive symptoms, social isolation, low acculturation to the U.S., stigma related to dementia, and lacking education about dementia. Nurses, including advanced practice registered nurses, are well-positioned to enhance immigrants' access to accurate information about dementia and to promote immigrants' timely diagnosis and treatment of dementia symptoms. Several interventions have been developed specifically for immigrant caregivers. Immigrant families need interventions that provide education about dementia, offer resources for caregivers nationally and locally, and are targeted towards specific ethnic groups.

"This Is Me!" Perceptions of Older Adult Simulated Participants in an Aging and Injury Simulation Experience.

BACKGROUND: Older adults played the role of frail and prefrail geriatric trauma patients in a frailty-focused communication workshop for nurses. Although subjects played a role (acting) as simulated participants (SPs) for simulation, workshop content and role-play also applied to them personally. We aimed to explore the effect that learning frailty-focused content, scripts, and portrayal of prefrail and frail older adults has on older adult SPs. METHODS: Qualitative focus group. Participants included older adults older than 70 years (N = 6). PROCEDURE: Focus group questions pertained to (1) the SP experience, (2) thoughts and emotions throughout the SP experience, and (3) applicability of workshop content and SP experience to personal life. The focus group lasted 90 min, was digitally recorded, and transcribed verbatim. Authors independently coded transcripts to identify categories and supporting quotations. Categories and subcategories were condensed and modified through iterative discussions. Descriptive content analysis was utilized for data analysis. RESULTS: Six categories and 2 subcategories emerged, including (1) inevitability of aging: not playing a role (sub: inevitability of death), (2) shifting perceptions: how aging impacts thought and actions, (3) time as a factor: getting information sooner, (4) changing behavior/safety: mental recalibration, (5) attitude as a determining factor (sub: loss of independence), and (6) sharing information with others. CONCLUSION: The study supports the use of frailty-focused communication with older adults to prompt contemplation of aging and frailty and eventual decline/death. Providing information earlier in the aging trajectory enables time for behavior change that can prevent and delay frailty and mitigate untoward outcomes (falls, hospitalizations).

Development and testing of a frailty-focused communication (FCOM) aid for older adults.

The concept of frailty as it pertains to aging, health and well-being is poorly understood by older adults and the public-at-large. We developed an aging and frailty education tool designed to improve layperson understanding of frailty and promote behavior change to prevent and/or delay frailty. We subsequently tested the education tool among adults who attended education sessions at 16 community sites. Specific aims were to: 1) determine acceptability (likeability, understandability) of content, and 2) assess the likelihood of behavior change after exposure to education tool content. Results: Over 90% of participants "liked" or "loved" the content and found it understandable. Eighty-five percent of participants indicated that the content triggered a desire to "probably" or "definitely" change behavior. The desire to change was particularly motivated by information about aging, frailty and energy production. Eight focus areas for proactive planning were rated as important or extremely important by over 90% of participants.

Knowledge and perceptions about aging and frailty: An integrative review of the literature.

A growing body of evidence indicates that biological aging or frailty is a determinant of health-related outcomes, however, frailty is likely poorly understood and under-recognized by the public-at-large. Using Whittemore and Knafl's methodology, we aimed to conduct an integrative review of research on public knowledge and perceptions of aging and frailty, and to create a conceptual model of our findings. Twenty-three studies are presented. The conceptual model suggests that culture, knowledge of aging, and stereotypes influence adults' beliefs and perceptions. Adults determine priorities about aging, and then subconsciously or consciously determine which parts of are controllable. If deemed controllable and important, they may participate in health behaviors to mediate aging. If deemed uncontrollable or less important, adults may aim to control their own peace of mind through acceptance. Scant findings suggest that frailty is a more subjective term in which participants often optimistically do not identify themselves as frail.

Home Health Nurses' Perspectives and Care Processes Related to Older Persons with Frailty and Depression: A Mixed Method Pilot Study.

The objectives of this study were (1) to describe home health care (HHC) nurses' perception of and care processes related to geriatric depression and frailty, and (2) to identify barriers to care delivery for older persons with these two conditions. Ten semi-structured interviews were conducted with HHC nurses, and 16 HHC nursing visits to 16 older patients (≥65 years) were observed. Mixed method analysis showed that HHC nurses did not routinely assess for frailty and depression. Major barriers to care delivery included insufficient training, documentation burden, limited reimbursement, and high caseload. Addressing these barriers would facilitate HHC nursing care for frail, depressed elders.

The FRAIL Questionnaire: A Useful Tool for Bedside Screening of Geriatric Trauma Patients.

Frailty screening is a priority in acute care. Using secondary data from our prior study, we derived a 5-item FRAIL Questionnaire (instrument) score for 188 geriatric trauma patients and aimed to examine the influence of preinjury physical frailty (as measured by FRAIL) on 1-year outcomes. The study used a secondary data analysis design. Patients were 65 years and older admitted through the emergency department (ED) between October 2013 and March 2014. The 5 items of the FRAIL instrument were identified within data sources of our prior study, and a preinjury FRAIL score was created for each patient. For data analysis, frequencies, measures of central tendency, and linear and logistic regression models were used. Median age of the patients was 77 years (interquartile range [IQR] = 69-86), and median Injury Severity Score = 10 (IQR = 9-17). Upon admission to the ED, 63 patients (34%) were screened as frail (FRAIL score ≥3), 71 (38%) as prefrail (score = 1-2), and 54 (29%) as nonfrail (score = 0). Frequencies for components of the FRAIL score were as follows: fatigue (N = 123; 65%), resistance (N = 61; 32%), ambulation (N = 76; 40%), illnesses (N = 51; 27%), and loss of weight (N = 11; 6%). After controlling for age, comorbidities, injury severity, and cognitive status, preinjury FRAIL scores explained 13% of the variability in function as measured by the Barthel Index (N = 129, ß = .36, p < .001). Forty-seven patients died (26%) within 1 year. Logistic regression analysis revealed that the higher the preinjury FRAIL score, the greater the likelihood of mortality within 1 year (OR = 1.74, p = .001; 95% CI [1.27, 2.39)]. The FRAIL Questionnaire predicts 1-year functional status and mortality and is a useful tool for bedside screening.

Reliability and Utility of the Surprise Question in CKD Stages 4 to 5.

BACKGROUND: Prognostic uncertainty is one barrier to engaging in goals-of-care discussions in chronic kidney disease (CKD). The surprise question ("Would you be surprised if this patient died in the next 12 months?") is a tool to assist in prognostication. However, it has not been studied in non-dialysis-dependent CKD and its reliability is unknown. STUDY DESIGN: Observational study. SETTING & PARTICIPANTS: 388 patients at least 60 years of age with non-dialysis-dependent CKD stages 4 to 5 who were seen at an outpatient nephrology clinic. PREDICTOR: Trinary (ie, Yes, Neutral, or No) and binary (Yes or No) surprise question response. OUTCOMES: Mortality, test-retest reliability, and blinded inter-rater reliability. MEASUREMENTS: Baseline comorbid conditions, Charlson Comorbidity Index, cause of CKD, and baseline laboratory values (ie, serum creatinine/estimated glomerular filtration rate, serum albumin, and hemoglobin). RESULTS: Median patient age was 71 years with median follow-up of 1.4 years, during which time 52 (13%) patients died. Using the trinary surprise question, providers responded Yes, Neutral, and No for 202 (52%), 80 (21%), and 106 (27%) patients, respectively. About 5%, 15%, and 27% of Yes, Neutral, and No patients died, respectively (P<0.001). Trinary surprise question inter-rater reliability was 0.58 (95% CI, 0.42-0.72), and test-retest reliability was 0.63 (95% CI, 0.54-0.72). The trinary surprise question No response had sensitivity and specificity of 55% and 76%, respectively (95% CIs, 38%-71% and 71%-80%, respectively). The binary surprise question had sensitivity of 66% (95% CI, 49%-80%; P=0.3 vs trinary), but lower specificity of 68% (95% CI, 63%-73%; P=0.02 vs trinary). LIMITATIONS: Single center, small number of deaths. CONCLUSIONS: The surprise question associates with mortality in CKD stages 4 to 5 and demonstrates moderate to good reliability. Future studies should examine how best to deploy the surprise question to facilitate advance care planning in advanced non-dialysis-dependent CKD.

Hospitals' adoption of targeted cognitive and functional status quality indicators for vulnerable elders.

Cognitive and functional impairments are leading predictors of poor outcomes in hospitalized older adults. This study reports adoption rates of 9 Assessing Care of Vulnerable Elders quality indicators in a sample of US hospitals (N = 128). Chief nursing officers were surveyed using a 6-point scale (no activity to full implementation) for each Assessing Care of Vulnerable Elders quality indicator. Adoption rates were low, highlighting the need for greater efforts to heighten awareness among senior executives and nursing leaders.

Availability of selected Institute of Medicine recommendations for geriatric care in hospitals providing care to injured older adults.

This study evaluated the presence of eight geriatric care Institute of Medicine (IOM) recommendations in a representative sample of hospitals (N = 128) that provide care to injured older adults. Four data sources were utilized to form a dataset. Descriptive statistics were conducted and Chi-square analyses were used to examine differences among trauma center levels and non-trauma centers. Six IOM recommendations were present in less than 50% of hospitals. Recommendations related to computerized support for risk assessment of two geriatric-specific conditions (CAUTI, pressure ulcers) were present in more than 70% of hospitals. Level I and II trauma centers had greater adoption of recommendations than level III/IV trauma centers and non-trauma centers. Continued efforts are needed to promote and support the advancement of IOM recommendations throughout U.S. hospitals.

Essential Advance Care Planning Intervention Features in Low-Income Communities: A Qualitative Study.

CONTEXT: Older adults with low socioeconomic status (SES) participate in advance care planning (ACP) at lower rates than those with higher SES. Community feedback is an essential component of intervention design for communities with fewer social and health resources to ensure that the intervention is relevant and meaningful. OBJECTIVES: To understand the perspectives for potential interventions, we aimed to qualitatively explore participant priorities for ACP intervention development. METHODS: Using a qualitative descriptive design, we recruited and conducted individual and one-time, semi-structured interviews with older adults (aged 50+) with low income (< $20,000/year) (n = 20), Recruitment methods included flyers and in-person recruitment and purposive and snowball sampling methods. Following a thematic analysis plan, themes emerged from recursive transcript review by two independent coders and inductive categorization of the most robust codes. RESULTS: Two themes captured participants' perspectives regarding ACP intervention development: 1) specialist advocacy and reliability and 2) person-centered communication. Older adults with low SES prioritize ACP communication that is driven by their goals and that is led by trustworthy specialists that advocate for their needs. CONCLUSION: Our work highlights that intervention preferences were informed by the prior strain and struggle of waiting on other kinds of health and social services. We propose an adapted model for community research collaboration to promote equity in addition to practice and policy recommendations.

Using the Age-Friendly Environment Framework to Assess Advance Care Planning Factors Among Older Adults With Limited Income: A Cross-Sectional, Descriptive Survey Study.

BACKGROUND AND OBJECTIVES: The World Health Organization created the Age-Friendly Environment (AFE) framework to design communities that support healthy aging and equitable decision making. This framework's resource domains may account for disparately lower advance care planning (ACP) among older adults with limited incomes compared to those with high incomes. We aimed to describe and examine associations of AFE factors with ACP. RESEARCH DESIGN AND METHODS: We recruited and conducted cross-sectional surveys among older adults with limited incomes in 7 community-based settings in Nashville, TN. ACP and AFE item scales were dichotomized and analyzed with unadjusted phi correlation coefficients. RESULTS: Survey participants (N = 100) included 59 women, 70 Black/African American, and 70 ≥60 years old. Most participants agreed that their community was age friendly (≥58%) and varied in ACP participation (22%-67%). Participants who perceived easy travel and service access and sufficient social isolation outreach were more likely to have had family or doctor quality-of-life discussions (phi = 0.22-0.29, p < .05). Having a healthcare decision maker was positively associated with age-friendly travel, housing, and meet-up places (phi = 0.20-0.26, p < .05). DISCUSSION AND IMPLICATIONS: The AFE framework is useful for exploring the environmental factors of ACP, but further research is warranted to identify specific and immediate resources to support successful ACP among populations with socioeconomic disadvantage.

Life-Stage and Contextual Factors of Advance Care Planning Among Older Adults With Limited Income.

Patient perspectives are essential to understand healthcare disparities such as low rates of advance care planning (ACP) among adults with limited income. We completed twenty semi-structured interviews using purposive and snowball sampling. Initial and final themes emerged from inductive inclusion of recurring codes and deductive application of the cumulative disadvantage theory. Four themes emerged: (1) structural, (2) life-stage, (3) social stressors and resources, and (4) individual stress responses and ACP readiness. ACP resources among participants included positive structural and social support and previous familial death experiences that were mitigated by stress avoidance and competing priorities. Structural resources and healthcare stressors should be addressed with policy and research to improve continuous healthcare participation and support early, comprehensive ACP.

Screening hospitalized injured older adults for cognitive impairment and pre-injury functional impairment.

Cognitive and functional impairments are leading predictors of poor outcomes among older adults, yet few hospitals collect these variables for injured older adults (IOAs). In this prospective descriptive study, we sought to determine the feasibility of screening IOAs for cognitive and pre-injury functional impairment; and to examine the prevalence of impairment at two acute care hospitals, using the Mini-Cog or Informant Questionnaire on Cognitive Decline in the Elderly (IQCDE), and Vulnerable Elder Survey (VES-13). Eighty patients were screened. Demographics included: mean age 78.7; female gender 83%; falls 89%. Cognitive impairment was present in 36 (44%) patients, and pre-injury functional impairment was present in 62 (78%) patients. Screening respondents included: patients: 53 (66%); adult children: 18 (23%); spouses: 5 (6%), and other 4 (5%). A combination of brief screening instruments for use with IOAs or surrogates is useful for capturing important variables for risk adjustment and care management.