A Descriptive Study of Treatment of Pain in Acute Care for Patients Living With Dementia.

BACKGROUND: During the hospital stay pain is very common among patients living with dementia. METHODS: Descriptive data was obtained from chart review and included age, gender, race, comorbidities and admitting diagnosis. AIMS: The purpose of this study was to describe pain among patients living with dementia, the use of pharmacologic and nonpharmacologic treatment, and to compare treatments among those with and without pain. DESIGN: This was a descriptive study using baseline data from the first 233 participants from the study "Testing the Implementation of Function Focused Care for Acute Care Using the Evidence Integration Triangle (FFC-AC-EIT)". PARTICIPANTS/SUBJECTS: The mean age of participants was 83 (SD=5) and the majority was female (65%) and White (67%) with evidence of dementia (based on a mean Saint Louis University Mental Status Test = 7.23, SD=5.85). RESULTS: Overall 98 (42%) participants had pain and 135 (58%) no pain. Only 14 (6%) participants received no nonpharmacologic or pharmacologic interventions for pain and five of these individuals had pain. The most frequently used pharmacologic intervention among all participants was acetaminophen (n = 121, 52%), then tramadol (n = 19, 8%). Comfort measures and general nonpharmacologic approaches were the most frequently used non-pharmacologic approaches, then physical activity and therapeutic communication. From admission to discharge, there was a trend towards a decrease in pain. There was more use of opioids, physical activity, and therapeutic communication in the no pain group versus the pain group. CONCLUSIONS: The majority of hospitalized medical patients living with dementia were treated for pain, but an ongoing focus is needed to assure optimal pain management for all patients.

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.

12-month trajectory and predictors of affect balance in nursing home residents living with dementia.

Objectives:Emotional expressions in late-stage dementia have traditionally been studied within a deficit paradigm. Moving the narrative of the dementia trajectory from a solely negative pathological experience to one that acknowledges the potential for positive experiences aligns with international recommendations for living well with dementia. The purpose of this study was to extend prior research by examining the pattern of well-being using affect balance, the ratio of positive to negative affect, in nursing home residents living with dementia over 12 months and its association to factors that could potentially influence resident well-being.Method:This study was a secondary analysis of baseline, 4 and 12-month data from a pragmatic clinical trial. A total of 536 residents with moderate to severe cognitive impairments from 55 nursing homes were included in the multivariable linear mixed model regression analyses.Results:Resident function, the number of registered nurse hours devoted to care in the facility, and the quality of staff interaction predicted higher affect balance over time after controlling for other variables.Conclusion:The findings provide support for the utility of affect balance as a meaningful outcome measure of well-being for persons living with dementia. In addition, results point to specific interventions (i.e. maintaining/improving resident function, providing adequate nurse staffing levels, and improving staff communications skills) that can serve as the focus for both research and practice to help residents live well with dementia. Clinicaltrials.gov (NCT03014570).

The Relationship Between Pain, Function, Behavioral, and Psychological Symptoms of Dementia and Quality of Life.

BACKGROUND: This study evaluated the association between age, sex, comorbidities, cognition, and administration of opioids with pain and the impact of all of these variables plus function, agitation, resistiveness to care, and depression on quality of life among residents in nursing home with severe dementia. DESIGN: This was a descriptive study using baseline data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia implementation study. METHODS: Model testing was done using structural equation modeling. The sample included 553 residents from 55 nursing homes with a mean age of 83.88 (standard deviation = 10.44) and mean Brief Interview of Mental Status of 4.30 (standard deviation = 3.50). RESULTS: There were significant associations showing those who were older, male, had fewer comorbidities, better cognition, and were black were more likely to have pain. Pain, in combination with the demographic and descriptive variables, explained 32% of the variance in function, 75% of the variance in depression, 88% of the variance in agitation, 98% of the variance in resistiveness to care, and 92% of the variance in quality of life. The model however did not show a good fit to the data. SETTING: The study was done in 55 nursing homes in Maryland and Pennsylvania. PARTICIPANTS/SUBJECTS: A total of 553 residents were included in the study. CONCLUSIONS: The model did not have a good fit with the data which likely was due to the lack of variance in outcomes. The hypothesized paths, with the exception of opioid use, were significant.

Testing Function Focused Care for Acute Care using the Evidence Integration Triangle: Protocol description.

This manuscript provides the protocol for a National Institute of Aging-funded cluster randomized clinical trial that focuses on helping nurses in acute care to engage patients with dementia in physical activity while hospitalized using an approach referred to as function-focused care. Physical activity is defined as bodily movement produced by skeletal muscles resulting in the expenditure of energy and includes functional tasks such as bathing and dressing, leisure activity, ambulation, and moderate and vigorous intensity physical activity such as dancing, bike riding, or walking upstairs. The development of Function Focused Care for Acute Care (FFC-AC) was based on the Social Ecological Model and Social Cognitive Theory and includes four steps: (1) Environment and Policy Assessments; (2) Education; (3) Establishing Patient Goals; and (4) Mentoring and Motivating of Staff (all levels of nursing staff), Patients, and Families. Function-focused care activities include motivating older patients to participate in bed mobility; personal care activities such as bathing, dressing, ambulating as they are able; and other types of physical activities. The integration of the intervention among the nurses on the units is guided by the Evidence Integration Triangle (EIT), which includes the participation of a stakeholder team and practical outcome measures. The intervention is therefore referred to as FFC-AC-EIT. In addition to describing the protocol developed to test the effectiveness and feasibility of FFC-AC-EIT, a description of ways to overcome some of the barriers and challenges that can be encountered with this study is provided.

Racial Disparities in Care Interactions and Clinical Outcomes in Black Versus White Nursing Home Residents With Dementia.

BACKGROUND: With the increase in Black nursing home residents, racial and ethnic disparities in quality of care have been raised. PURPOSE: The purpose of this study was to evaluate racial disparities in care and outcomes over 12 months. METHODS: This was a secondary data analysis using data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia study. A total of 553 residents, 24% Black residents and 76% White residents, from 55 nursing homes were included. RESULTS: Differences favoring Black resident were noted in agitation, quality of life, inclusion of person-centered care approaches in care plans, and fewer falls and hospitalizations. Differences in quality-of-care interactions favored White residents. There were no differences in depression, resistiveness to care, function, pain, or transfers to the emergency department. CONCLUSIONS: Disparities in clinical outcomes were small and generally favored Black versus White residents except for quality-of-care interactions.

Community Goal Setting and Attainment: Organizational Characteristics and Indicators of Staff Adoption.

In residential care communities (CCs), implementation strategies can improve the use of person-centered approaches for residents' behavioral symptoms of distress. We examined staff perceptions of how well their organizational goals for achieving person-centered care (PCC) were met following implementation of the strategy, Evidence Integration Triangle for Behavioral and Psychological Symptoms of Distress. We also identified organizational characteristics and indicators of staff adoption associated with perceived goal attainment. Goal attainment was evaluated by staff using goal attainment scaling (GAS) at the completion of the implementation trial in 26 CCs. Correlations, t tests, and linear regression were used to determine which factors were associated with goal attainment. Total time spent with the research facilitator, stable staff group membership, and presence of a survey deficiency during the study period explained 63% of the variance in goal attainment. Staff can set achievable organizational goals to improve PCC for residents' behavioral symptoms of distress. [Journal of Gerontological Nursing, 48(5), 5-12.].

Process evaluation of an implementation study in dementia care (EIT-4-BPSD): stakeholder perspectives.

BACKGROUND: Behavioral and psychological symptoms of distress in dementia (BPSD) are major drivers of poor quality of life, caregiver burden, institutionalization, and cost of care in nursing homes. The Evidence Integration Triangle (EIT)-4-BPSD in nursing homes was a pragmatic Hybrid III trial of an implementation strategy to help staff use evidence-based non-pharmacological interventions to prevent and manage BPSD. This study aimed to describe and explore the stakeholders' perceptions of the process to implement the EIT-4-BPSD strategy including its utility, and the barriers and facilitators to implementation in real-world settings. METHODS: EIT-4-BPSD was a multi-layer implementation strategy that engaged nursing home stakeholder groups to define community specific goals towards reducing BPSD over a 12-month period. Stakeholder groups from nursing homes that completed all 12-months of the implementation strategy were invited to participate in this process evaluation study. Qualitative data from focus group transcripts were analyzed using a conventional content analysis. Emerging codes were sorted into categories, then organized in meaningful clusters based on the domains of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. RESULTS: The EIT-4-BPSD implementation strategy was completed in 21 nursing homes; 93 stakeholders participated in focus groups. Over half of participating nursing homes reported meeting their BPSD goals as expected or more. Challenges, facilitators, and contextual factors reported by stakeholder members explains variability in the implementation of EIT-4-BPSD strategy in 11 key categories: family; staff; organizational; staff, environmental, and resident outcomes; utility of EIT resources; adoption barriers and facilitators; care process adaptations; and future planning. CONCLUSION: Stakeholders offered guidance on salient factors influencing the feasibility and utility of EIT-4-BPSD adoption and implementation to consider in future implementation research that aims to improve behavioral well-being in NH residents living with dementia. Engagement of family and staff at all levels of the organization (Management, leadership, and direct care); and measurement of staff, environmental, and resident outcomes were perceived as critical for future implementation success. While regulations, finances, and competing demands on staff time were perceived as reducing implementation success. TRIAL REGISTRATION: The Testing the Implementation of EIT-4-BPSD study was registered in the ClinicalTrials.gov ( NCT03014570 ) January 9, 2017.

Implementation of the Evidence Integration Triangle for behavioral and psychological symptoms of dementia (EIT-4-BPSD) in care communities.

BACKGROUND: Federal regulations stipulate that behavioral interventions be used for behavioral and psychological symptoms of distress in dementia (BPSD). Care community staff have difficulty implementing these approaches. PURPOSE: This study tested an implementation strategy, the Evidence Integration Triangle for BPSD (EIT-4-BPSD), for assisting staff in the use of evidence-based behavioral approaches for BPSD. METHODS: About 55 care communities were randomized to EIT-4-BPSD or usual care; 553 residents were enrolled. The implementation strategy was delivered by research facilitators, staff, stakeholders, and champions over 12 months. It involved four components: Environment and policy assessments; Staff education; Establishment of person-centered care plans; and Mentoring and motivating staff. The implementation strategy was evaluated using the Reach, Effectiveness, Adoption, Implementation, Maintenance model. FINDINGS: There was no evidence for resident or care community effectiveness. There was evidence of adoption and implementation. DISCUSSION: EIT-4-BPSD was helpful as an implementation strategy and staff altered how care was provided.

Gender differences in presentation and management of behavioral and psychological symptoms associated with dementia among nursing home residents with moderate to severe dementia.

Lack of identification and management of behavioral and psychological symptoms of dementia (BPSD) can negatively impact female residents. The purpose of this secondary data analysis was to explore gender differences in presentation and management of BPSD and quality of interactions between residents and staff. A total of 553 residents from 55 nursing homes were included. Males exhibited more apathy and sexually inappropriate behavior and females exhibited more anxiety and sadness. Anxiety and sexually inappropriate behavior were more likely to be addressed in care plans for males than females. There was no difference in how staff interacted with males or females.

Testing the evidence integration triangle for implementation of interventions to manage behavioral and psychological symptoms associated with dementia: Protocol for a pragmatic trial.

Behavioral and psychological symptoms of dementia (BPSD) include aggression, agitation, resistiveness to care, depression, anxiety, apathy, and hallucinations. BPSD are common in nursing home residents and can be ameliorated using person-centered approaches. Despite regulatory requirements, less than 2% of nursing homes consistently implement person-centered behavioral approaches. In a National Institute of Nursing Research-funded research protocol, we are implementing a pragmatic cluster randomized clinical trial designed to enable staff in nursing homes to reduce BPSD using behavioral approaches while optimizing function, preventing adverse events, and improving quality of life of residents. The implementation is based on use of the Evidence Integration Triangle (EIT), a parsimonious, community-engaged participatory framework that is well suited to the complexity and variability in the nursing home environment. A total of 50 nursing home communities will be randomized to EIT-4-BPSD or education only. Primary Aim 1 is to determine if communities exposed to EIT-4-BPSD demonstrate evidence of implementation evaluated by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) criteria. Primary Aim 2 is to evaluate the feasibility, utility, and cost of the EIT approach in EIT-4-BPSD communities.

Optimal Approach for Assessing Evidence of Dementia for Research Studies.

The purpose of this study was to describe a process to determine the presence of dementia and test the psychometric properties of the proposed measurement model for dementia. The model included the AD8, the Functional Activities Questionnaire, the Clinical Dementia Rating Scale, and the Saint Louis University Mental Status Examination. A total of 346 patients consented and 176 of those were determined to be eligible as a result of screening with this measurement model. The mean age of the participants was 80.70 (SD = 9.60) and the majority were female (64%), white (66%), not Latinx (99%), and not married (67%). There was evidence of reliability based on the internal consistency of the items on all measures and the limited error associated with each item. There was evidence of construct validity based on model fit. All four measures are recommended as a pragmatic way in which to comprehensively determine evidence of dementia for research studies.

Psychometrics of the Physical Resilience Scale in Older Adults Living with Dementia: Proxy Responses.

Objectives: The purpose of this study was to determine if proxies can complete the Physical Resilience Scale for older adults living with dementia. Methods: This was a descriptive study using Rasch analysis and baseline data from the Function Focused Care for Acute Care Using the Evidence Integration Triangle trial. The first 240 patients living with dementia were included in this analysis. Results: There was evidence of reliability based on person and item separation index. There was no evidence of Differential Item Functioning (DIF) between genders and a DIF by race on Item 7. Validity was supported based on items fitting the model with the exception of one item, and a significant relationship between physical resilience and pain and function. Discussion: There is some evidence that the Physical Resilience Scale is reliable and valid when completed by proxy reports. Future use should remove one of the items due to redundancy.

Testing the Reliability and Validity of the Revised Care Plan Checklist for Evidence of Person-Centered Care Approaches for Behavioral and Psychological Symptoms of Distress in Persons With Dementia.

The Checklist for Evidence of Person-Centered Care Approaches for Behavioral and Psychological Symptoms of Distress (BPSD) in Care Plans was developed to assess the person-centeredness of care plans for nursing home residents living with behavioral and psychological symptoms associated with dementia. The purpose of the current study was to evaluate the reliability and validity of a revised version of the Checklist. Data from a larger randomized clinical trial testing the implementation of the Evidence of Integration Triangle for BPSD were used. One hundred seventy-nine care plans for 103 residents were examined. Descriptive statistics, Rasch analysis, and inter-rater reliability were used. The Checklist demonstrated evidence of inter-rater reliability and validity based on model fit and acceptable INFIT and OUTFIT statistics. This study serves as pilot work for future Checklist use and validation efforts on a larger scale. Findings encourage a discourse on the inclusion of BPSD and person-centered approaches in care plans for those living with dementia. [Research in Gerontological Nursing, 15(6), 303-311.].

Reliability and Validity of the Cornell Scale for Depression in Dementia and Invariance Between Black Versus White Residents in Nursing Homes.

OBJECTIVES: The purpose of this study was to expand on prior work testing invariance on several depression measures in community-based older adults and explore the psychometric properties and evidence of invariance between racial groups based on the Cornell Scale for Depression in Dementia. DESIGN: This was a descriptive measurement study. SETTING AND PARTICIPANTS: This was a secondary data analysis using baseline data from 2 studies: Testing the Implementation of the Evidence Integration Triangle for Behavioral and Psychological Symptoms Associated with Dementia and the study Testing the Impact of Function and Behavior Focused Care for Nursing Home Residents with Dementia. Combined, 67 nursing homes participated from 2 states and 889 residents were recruited. The mean age of the participants was 86.58 (SD 10.31) and most were women (72%) and White (70%). METHODS: This was a descriptive study, and a Rasch analysis was done to establish reliability based on internal consistency and evidence of differential item functioning (DIF) across races. Validity was based on item fit and model testing with structural equation modeling to compare models between White and Black participants. RESULTS: There was evidence of internal consistency (alpha coefficient of 0.98) and no significant evidence of DIF. The item related to suicide had a high logit and did not significantly load onto the measurement model for Black individuals. There was not a good spread of the items across the concept of depression. The model had a better fit with the items when used with White versus Black participants. CONCLUSIONS AND IMPLICATIONS: The findings indicate that it would be helpful to add some additional items that reflect depressive symptoms among this population. Further, the findings serve as a reminder that this measure may be biased toward identification of symptoms of depression among White versus Black residents.

A Cluster Randomized Controlled Trial Testing the Impact of Function and Behavior Focused Care for Nursing Home Residents With Dementia.

OBJECTIVE: The purpose of this study was to test the effectiveness of the Function and Behavior Focused Care for the Cognitively Impaired (FBFC-CI) intervention on function, physical activity, and behavioral symptoms among nursing home residents with dementia, and to explore the adoption of the intervention at the facility level. DESIGN: This study was a clustered, randomized controlled trial with a repeated measures design that was implemented in 12 nursing homes randomized to either treatment (FBFC-CI) or educational control [Function and Behavior Focused Care Education (FBFC-ED)]. SETTING AND PARTICIPANTS: Twelve nursing homes (6 treatment and 6 control) and 336 residents (173 treatment and 163 control) with moderate to severe cognitive impairment. MEASURES: Outcomes included functional ability (Barthel Index), physical activity (actigraphy and survey), behavioral symptoms (Resistiveness to Care Scale, Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia), and psychotropic medication use. RESULTS: The participants were 82.6 (SD = 10.1) years of age, mostly female, and were moderate to severely cognitively impaired (Mini-Mental State Exam of 7.8, SD = 5.1). There was a significantly greater increase in time spent in total activity (P = .004), moderate activity (P = .012), light activity (P = .002), and a decrease in resistiveness to care (P = .004) in the treatment versus control group at 4 months. There was no change in mood, agitation, and the use of psychotropic medications. There was some evidence of adoption of the intervention at treatment sites. CONCLUSIONS AND IMPLICATIONS: This study provides some support for the use of the FBFC-CI Intervention to increase time spent in physical activity and decrease resistive behaviors during care commonly noted among nursing home residents with moderate to severe cognitive impairment.

Current Psychotropic Medication Use and Contributing Factors Among Nursing Home Residents With Cognitive Impairment.

This study described current use and predictors of psychotropics among residents with moderate to severe cognitive impairment. This was a secondary data analysis using baseline data from the first 341 residents in an ongoing trial. Predictive measures included age, gender, race, depressive symptoms, agitation, resistiveness to care, depression, cognition, pain, comorbidities, facility factors, and state. Overall 63% (n = 211) received at least one psychotropic medication, 16% (n = 52) an anti-seizure medication, 23% (n = 77) an anxiolytic, 30% (n = 99) an antidepressant, 2% (n = 8) a sedative hypnotic, 28% (n = 93) an antipsychotic medication, and 9% (n = 29) an opioid. Testing of models explained 9% to 15% of psychotropic medication use. There were high rates of psychotropic medication use and a limited association between demographic factors, behavioral symptoms, and psychotropic medication use. Continued research is needed to explore the impact of deprescribing, person-centered behavioral interventions, and beliefs of providers on psychotropic medication use.

Invariance of the PAINAD Scale Between the Black and White Residents Living With Dementia.

The purpose of this study was to test the reliability and validity of the Pain Assessment in Advanced Dementia (PAINAD) and particularly consider whether or not this measure was invariant when used among the Black and White residents. Baseline data from an implementation study testing that included a sample of 553 residents, 30% of who were Black, from 55 nursing were included in this study. The Winsteps statistical program was used to perform the Rasch analysis and evaluate the reliability and validity of the measure based on internal consistency, infit and outfit statistics, mapping, and a differential item functioning (DIF) analysis. The AMOS statistical program was used for confirmatory factor analysis. The findings supported the reliability and validity of the PAINAD when used with these individuals and demonstrated that there was no evidence of invariance between the Black and White residents. All the items fit the model, but there was not a good spread of the items across the pain level of the participants. The majority of the participants (75%) were so low in pain signs or symptoms that they could not be differentiated. Based on the clinical practice and observations, it is recommended that additional items can be added to the measure such as observing the individual for evidence of resisting care, retropulsion when trying to stand, hitting or kicking when turning in bed, hitting or kicking when transferring from bed to chair, hitting or kicking when ambulating, or hitting or kicking when raising arms, less engagement with others, and decreased participation in the activities previously enjoyed.

Reliability and Validity Testing of the Quantified Quality of Interaction Schedule.

BACKGROUND AND PURPOSE: The purpose of this study was to test the reliability and validity of the Quality of Interactions Schedule (QuIS) using a quantification scoring approach. METHODS: Baseline data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) study was used. RESULTS: A total of 553 residents participated. There was evidence of inter-rater reliability with Kappa scores of .86 to 1.00 and internal consistency based on the Rasch analysis (item reliability of .98). There was some support for validity based on item fit and hypothesis testing as resistiveness to care was significantly associated with total QuIS scores. CONCLUSION: This study supports the use of the quantified QuIS to evaluate the quality of interactions over time and to test interventions to improve interactions.