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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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

This study aimed to test a model of factors associated with resilience and physical activity post-hip fracture and compare model fit between men and women. We used data from the seventh Baltimore Hip Study that included 339 participants. Model testing indicated that health status (men: β =.237, p =.002; women: β =.265, p = <.001), depression (men: β = −.245, p =.001; women: β = −.241, p = <.001), and optimism (men: β =.320, p = <.001; women: β =.282, p = <.001) were associated with resilience in men and women, but resilience was only associated with physical activity in men (β =.203, p =.038) and not in women. Social interaction was related to physical activity only among women (β =.206, p =.044). This study provides support for the relationship between resilience and physical activity at least among men. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to evaluate the psychometric properties of the modified 25-item Resilience Scale (RS-25) in older adults post-hip fracture using Rasch analysis. Methods: This was a descriptive study using baseline data from the Seventh Baltimore Hip Studies (BHS-7). There were 339 hip fracture patients included in this analysis. Results: Findings suggest there was support for reliability of the measure based on person and item separation index. The INFIT and OUTFIT statistics for testing validity were all in the acceptable range indicating that each item on the modified RS-25 fits the appropriate concept. There was no evidence of Differential Item Functioning (DIF) between genders. Conclusions: This study demonstrated evidence that the modified RS-25 is a reliable and valid measure to evaluate resilience among older adults post-hip fracture and therefore can be used in this population in clinical practice and research. [ABSTRACT FROM AUTHOR]

The purpose of this study was to test the impact of function-focused care on adverse outcomes in assisted living. This was a randomized trial including 85 settings. The age of the 794 recruited participants was 89.48 (SD = 7.43) years, the majority was female (n = 561, 71%) and White (n = 771, 97%). The percentage of residents in the treatment group experiencing a fall decreased at 12 months from 26% to 20% and the control group increased from 24% to 25%, p =.02. A greater percentage of residents in the treatment group transferred to nursing facilities at 4 months (4–1% in control vs. 4–5% in treatment, p =.02) and 12 months (4–2% in control and 4–7% in treatment, p =.01). There was no treatment effect on emergency room or hospital transfers. The findings support the safety of function-focused care related to falls and need for hospital transfers. [ABSTRACT FROM AUTHOR]

Background: Virtual reality technology holds great promise in improving the health and well‐being of older adults; however, this technology is associated with potential risks that may outweigh the benefits. The purpose of this systematic review is to synthesize and critique the existing literature on fully‐immersive virtual reality interventions for older adults and the associated risk of cybersickness. Methods: We searched eight databases for studies that utilized fully‐immersive virtual reality, stated the population as older adults, provided outcomes related to cybersickness, and were written or translated into the English language. Our search generated 332 articles, 39 of which were selected for inclusion in this systematic synthesis and appraisal. Results: We found that the majority of studies utilized a one‐time session. The studies generally had weak sample generalizability and methodological design, but strong data collection and participant retention. The studies nearly all used the Simulator Sickness Questionnaire to measure cybersickness, but the scoring for the Simulator Sickness Questionnaire varied or was not mentioned. Most included studies reported only minor cybersickness among older adult participants. Conclusion: Researchers might conclude that the benefits of virtual reality interventions outweigh the risk of cybersickness in this population. Going forward, researchers should concentrate on the efficacy of virtual reality interventions among older adults, using larger samples and randomized controlled study design, along with measuring dosage effects. [ABSTRACT FROM AUTHOR]

This study tested the feasibility, reliability, and validity of the MotionWatch 8 among assisted living residents with and without cognitive impairment. Data from the Dissemination and Implementation of Function Focused Care in Assisted Living Using the Evidence Integration Triangle study were used. The sample included 781 individuals from 85 facilities with a mean age of 89.48 (SD = 7.43) years. The majority were female (71%), White (97%), and overall (44%) had cognitive impairment. A total of 70% were willing to wear the MotionWatch 8. Reliability was supported as there was no difference in time spent in activity across three consecutive wear days. Validity was based on hypothesis testing, and function was associated with counts of activity at baseline (p =.001) and 4 months (p =.001). Those with cognitive impairment engaged in less physical activity (p =.04). The MotionWatch 8 is a useful option for measuring physical activity in older adults with and without cognitive impairment. [ABSTRACT FROM AUTHOR]

Alzheimer's disease or a related dementia (ADRD) disproportionately affects women with two-thirds of individuals with ADRD comprised of women. This study examined gender-related differences in the quality of staff-patient interactions and depressive symptoms among hospitalized older patients living with dementia. This secondary analysis utilized baseline data of 140 hospitalized older patients with dementia who participated in the final cohort of a randomized controlled trial (ClinicalTrials.gov identifier: NCT03046121) implementing Family centered Function-focused Care (Fam-FFC). On average, the participants (male = 46.1%, female = 52.9%) were 81.43 years old (SD = 8.29), had positive interactions with staff and lower depressive symptoms based on Quality of Interaction Schedule (QUIS) scores and Cornell Scale for Depression in Dementia (CSDD) scores, respectively. Although males had more positive interactions (male = 6.06, SD = 1.13; female = 5.59, SD = 1.51) and lesser depressive symptoms (male = 7.52, SD = 4.77; female = 8.03, SD = 6.25) than females, no statistically significant gender differences were observed in linear models with appropriate covariates or multivariant analysis of covariant (MANCOVA). However, the multigroup regression conducted to further probe marginally significant moderation effect of gender and pain on staff-patient interactions demonstrated that greater pain was significantly related to lower quality or less positive staff-patient interactions for females compared to males (χ2diff (1) = 4.84, p =.03). Continued evaluation of gender differences is warranted to inform care delivery and interventions to improve care for hospitalized older patients with dementia. [ABSTRACT FROM AUTHOR]

Background: Function-focused care is an approach used to increase physical activity in hospitalized older adults with dementia. Objective: To explore factors associated with participation in function-focused care in this patient population. Methods: This was a cross-sectional descriptive study using baseline data from the first 294 participants in an ongoing study on testing function-focused care for acute care using the evidence integration triangle. Structural equation modeling was used for model testing. Results: The mean (SD) age of the study participants was 83.2 (8.0) years, and the majority were women (64%) and White (69%). Sixteen of the 29 hypothesized paths were significant and explained 25% of the variance in participation in function-focused care. Cognition, quality of care interactions, behavioral and psychological symptoms associated with dementia, physical resilience, comorbidities, tethers, and pain were all indirectly associated with function-focused care through function and/or pain. Tethers, function, and quality of care interactions were all directly associated with function-focused care. The χ2/df was 47.7/7, the normed fit index was 0.88, and the root mean square error of approximation was 0.14. Conclusion: For hospitalized patients with dementia, the focus of care should be on treating pain and behavioral symptoms, reducing the use of tethers, and improving the quality of care interactions in order to optimize physical resilience, function, and participation in function-focused care. [ABSTRACT FROM AUTHOR]

Current measures for inpatient protein intake are imprecise. This study tested the reliability and validity of the PHOTOFOOD tool for assessment of protein intake among hospitalized older adults. Agreement was found between participant recall of protein intake and PHOTOFOOD assessments. [ABSTRACT FROM AUTHOR]

The purpose of this study was to describe physical activity and function of older adults in assisted living communities and test the association between moderate and vigorous activity and falls. This study used baseline data from 393 participants from the first two cohorts in the Function-Focused Care in Assisted Living Using the Evidence Integration Triangle study. The majority of participants were female (N = 276, 70%) and White (N = 383, 97%) with a mean age of 87 years (SD = 7). Controlling for age, cognition, gender, setting, and function, the time spent in moderate or vigorous levels of physical activity was associated with having a fall in the prior 4 months. Those who engaged in more moderate physical activity were 0.6% less likely to have a fall (OR = 0.994, Wald statistic = 5.54, p = .02), and those who engaged in more vigorous activity were 2% less likely to have a fall (OR = 0.980, Wald statistic = 3.88, p = .05). [ABSTRACT FROM AUTHOR]

To describe the use of psychotropic medications among older hospitalized patients. This was a descriptive study using baseline data from the first 308 older patients in a function focused care intervention study. Age, gender, race, comorbidities, admitting diagnosis, and medications (antidepressants, antianxiety medications, anticonvulsants, dementia drugs, antipsychotics, sedative-hypnotics, and opioids) were obtained at baseline and discharge. To compare change over time, generalized estimating equations were used. Participants were mostly female (63%) and White (69%) and were 83.1 years old on average. Antidepressant, antianxiety, anticonvulsant, dementia medication, sedative-hypnotic, and opioid use remained essentially unchanged between admission and discharge. Antipsychotic medication use increased significantly from 16% to 21% at discharge. There was persistent use of psychotropic medication among hospitalized older adults living with dementia and little evidence of deprescribing. There was some indication of changes made during hospitalization that may be appropriate, even without a focused deprescribing initiative. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background and Purpose: The purpose of this study was to expand on the limited psychometric testing of the NPI-Q, and extend testing to include hospitalized older adults. Method: This was a descriptive study using data from 318 dyads in an ongoing cluster randomized clinical trial. Rasch analysis and hypothesis testing were done. Results: The majority of the participants were female (62%), non-Hispanic (98%), and black (50%) with a mean age of 81.62 (SD = 8.43). There was evidence of internal consistency and invariance across race and gender. The items fit with each subscale. Hypothesis testing was supported with a significant association between the NPI-Q and dementia and caregiver distress. Conclusions: The NPI-Q is short, easy to complete, and reliable and valid when used with hospitalized older adults. [ABSTRACT FROM AUTHOR]

Objectives: The aims of this study were to: (1) describe the prevalence of behavioral and psychological symptoms of dementia in hospitalized older adults living with dementia and (2) examine the association of physical activity and behavioral and psychological symptoms of dementia among hospitalized older adults living with dementia, after controlling for covariates. Methods: Physical activity was measured using the Physical Activity Survey and behavioral and psychological symptoms of dementia were measured using the Neuropsychiatric Inventory. Descriptive analysis and multiple linear regressions were run using baseline data on 294 older adults with dementia hospitalized on general medical units from an ongoing study entitled Function Focused Care for Acute Care Using the Evidence Integration Triangle. Results: Participants performed an average of 7.92 (SD = 4.49) of 34 possible activities "in the last 24 h" prior to the Physical Activity Survey administration. A total of 132 participants (45.5%) had at least one behavioral and psychological symptom of dementia. We found that physical activity was not associated with behavioral and psychological symptoms of dementia (b = 0.01; p = 0.56), after controlling for covariates. Conclusions: Although this study found no evidence of an association between physical activity and behavioral and psychological symptoms of dementia, evidence of physical activity did not exacerbate these behaviors. Thus, given the benefits of physical activity, it is important to continue to encourage patients living with dementia to engage in activity. Key Points: Older adults with dementia spend little time engaged in activity when hospitalized.At the beginning of their hospitalization, nearly half of older adults with dementia had at least one behavioral or psychological symptom of dementia.Physical activity was not associated with behavioral and psychological symptoms of dementia among older adults with dementia in the hospital.Given the benefits of physical activity, it is important to continue to encourage patients living with dementia to engage in activity when hospitalized. [ABSTRACT FROM AUTHOR]

Purpose: Psychotropic medications are used to manage behavioral symptoms of dementia in nursing homes despite limited efficacy and the risk of adverse effects, and may be considered an easier solution for the treatment of behavioral symptoms. However, non‐pharmacologic interventions are preferable but are most effective with consistent staffing. To address this, the Centers for Medicare and Medicaid Services implemented additional regulatory scrutiny through F‐tag for deficiencies of care, targeting inappropriate psychotropic medication use (F‐758 tag). The purpose of this study was to examine associations between nurse staffing levels and the occurrence of deficiency citations for inappropriate psychotropic medication use in residents with dementia symptoms. Design This was secondary data analysis of a cross‐sectional study using CASPER (Certification and Survey Provider Enhanced Reporting) and PBJ (Payroll‐Based Journal) data from 14,548 Medicare or Medicaid‐certified facilities surveyed between December 1, 2017 and December 31, 2018. Methods: Staffing measures included nursing hours per resident day and registered nurse skill‐mix. Generalized linear mixed models with facilities nested within states, were used to estimate the magnitude of the associations between the occurrence of inappropriate psychotropics use deficiency citations and nurse staffing levels. Covariates included facility location, size, ownership, the presence of dementia special care units, and the proportion of residents with dementia, depression, psychiatric disorders, mental behavioral symptoms, and residents with Medicare/Medicaid. Results: There were 1875 facilities with deficiency citations regarding inappropriate psychotropics use for residents with dementia. When controlling for covariates, facilities with greater hours per resident day for registered nurses (odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.44–0.67), certified nursing assistants (OR = 0.87, 95% CI = 0.77–0.99) and total nurse staff (OR = 0.87, 95% CI = 0.79–0.96) had significantly lower odds of inappropriate psychotropics use deficiency citations. Nursing homes with greater registered nurse skill‐mix had significantly lower odds of receiving the deficiency tags (OR = 0.10, 95% CI = 0.04–0.26). Conclusion: Citations for inappropriate psychotropic medication use among residents with dementia were less likely to occur in facilities with higher staffing levels for registered nurses, certified nursing assistants, total nurse staff, and greater registered nurse skill‐mix. Facilities need to be equipped with adequate nurse staffing levels to facilitate the use of non‐pharmacological interventions and reduce inappropriate psychotropic medication use. Clinical Relevance: Adequate nursing staffing is associated with fewer deficiencies related to the use of psychotropic medications to treat behavioral symptoms. Nursing home administrators and policymakers need to focus on assuring adequate nurse staffing levels to provide safe and high‐quality dementia care. [ABSTRACT FROM AUTHOR]

The purpose of this study was to test the preliminary effectiveness and feasibility of implementation of Function Focused Care for Assisted Living Using the Evidence Integration Triangle in Assisted Living Communities with Residents with Dementia (FFC-AL-EIT-D) during the pandemic. This was a single group pre-post study design including 51 communities in a single state. The communities ranged in size from 8 to 50 residents with a mean of 13 (SD = 7). The majority (99%) were for profit. Following implementation of FFC-AL-EIT-D there was significant improvement in environments and policies supporting physical activity and some evidence suggesting they used new supplies to engage residents in physical activity. There was no change in falls, emergency room, hospital, or nursing home transfers. [ABSTRACT FROM AUTHOR]

The purpose of this study was to consider gender differences in depressive symptoms, agitation, resistiveness to care, physical function, and use of psychotropic medications in older adults with moderate to severe dementia in nursing homes. Sixty-seven nursing homes and 889 residents from two states were included. The majority of the participants were female (n = 640, 72%) and White (n = 618, 70%) with a mean age of 86.58 years (SD = 10.31). Differences by gender with regard to age, physical function, depressive symptoms, agitation/aggression, and resistiveness to care were tested using multivariate analysis of variance. Older females with moderate to severe dementia present with more depressive symptoms (anxiety, sadness, and somatic complaints) than males. Males present with more aggressive behavior and are more likely to receive anticonvulsants. Caregivers should focus on preventing and managing depressive symptoms including anxiety, sadness, and somatic complaints among older females and aggressive behavior in older males with dementia. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To describe and compare the use of antidepressants between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment. DESIGN: This was a secondary data analysis using baseline data from the Function and Behavior Focused Care for Nursing Facility Residents with Dementia randomized control trial. SETTING: Participants were recruited from 10 urban and two rural nursing facilities from Maryland. METHODS: Participants had to be 55 years of age or older, English-speaking, reside in long-term care at time of recruitment, and score a 15 or less on the Mini Mental-State Examination. A total of 336 residents participated at baseline. Data were collected by a research evaluator through observation, proxy report from staff caring for the resident the day of testing, and patient charts. MAIN OUTCOMES: A significant difference of antidepressant use between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment would be noted when controlling for depression, age, gender, functional status, agitation, and number of co-morbidities. RESULTS: In adjusted models, Black or African descent residents were less likely to be prescribed antidepressants compared with White residents. CONCLUSION: Racial differences were noted regarding antidepressant use among nursing facility residents with moderate to severe cognitive impairment, but it is unknown if race could impact prescribing practices when indications for use are known. Further research is needed to ascertain if knowing the specific indications for use might contribute to racial disparities with antidepressant prescribing in nursing facility residents with moderate to severe cognitive impairment. [ABSTRACT FROM AUTHOR]

The current study aimed to test the feasibility and preliminary efficacy of the Promoting Positive Care Interactions (PPCI) intervention designed to establish positive care interactions between staff and residents in assisted living (AL) using an online approach. PPCI was implemented in one AL community using a single group pre-/posttest design; 17 care staff were recruited from the memory care unit. Delivery, receipt, and enactment of the PPCI were assessed for feasibility. Change in staff outcomes and facility outcomes were examined for preliminary efficacy. The four steps of the PPCI were implemented as intended with 100% staff exposure to education and considerable staff engagement in weekly mentoring sessions. Although there was an improvement in AL environment and policy, no significant changes were observed in staff outcomes. Future testing of the PPCI should include a longer timeline and explore a hybrid model that includes online education and in-person mentoring and coaching of staff to improve care interactions. [Journal of Gerontological Nursing, 48(8), 17–25.] [ABSTRACT FROM AUTHOR]

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). [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To test the impact of the Function Focused Care Intervention on use of psychotropic medications and opioids over a 12-month period in assisted living residents. SETTING: The study included 794 residents from 85 general assisted living communities in the United States. The general assisted living communities that had at least 25 beds and 10 residents per community were enrolled. RESULTS: There was no significant difference in the treatment groups regarding medication use except for a decrease in opioid use at 4 months (P = 0.03). In the full sample there was a significant increase in use of benzodiazepines from baseline to 12 months (P = 0.04) and an increase in the use of antipsychotics between 4 and 12 months (P = 0.04). CONCLUSION: Function-focused care does not increase the need for psychotropic medications or opioids and may help decrease the need for opioids. Further, we recommend the involvement of a pharmacy consultant to provide oversight and medication reviews for all residents in assisted living to consider deprescribing, if possible, for potentially unnecessary use of psychotropic medications or opioids. [ABSTRACT FROM AUTHOR]

As a method of research, pragmatic trials are recommended so as to generate results that are applicable to real‐world care. This intent is especially important for the millions of older adults who receive long‐term care in thousands of nursing homes and assisted living communities across the country—and many millions more around the globe. This article presents key points raised by experts participating in a conference funded by the National Institute of Aging held at the 2021 conference of the Society for Post‐Acute and Long‐term Care Medicine. The purpose of the conference was to convene leading clinicians, researchers, and industry partners to address special considerations of pragmatic trials in long‐term care. Cross‐cutting and unique challenges and solutions to conducting pragmatic trials were discussed focusing on 3 areas of clinical relevance to long‐term care: (1) functional care and outcomes, (2) psychosocial care and quality of life, and (3) medical care and outcomes, with a special focus on persons with dementia. Challenges and innovative solutions were organized across the 9 domains of the revised Pragmatic‐Explanatory Continuum Indicator Summary (PRECIS) Tool, and future research recommendations for pragmatic trials in long‐term care were identified. See related editorial by Zimmerman et al. and Special Articles by Gurwitz et al. and Levy et al. in this issue. [ABSTRACT FROM AUTHOR]

The purpose of this study was to describe differences in pain, behavioral symptoms, quality of staff-resident interactions, participation in function focused care and physical activity among residents with and without cognitive impairment in assisted living. This was a secondary data analysis using baseline data from an ongoing trial testing Function Focused Care for Assisted Living using the Evidence Integration Triangle (FFC-AL-EIT). A total of 550 residents were recruited from 59 communities. The average age of participants was 89.30 (SD = 7.63), the majority were white (98%), female (69%), had evidence of cognitive impairment (75%), and 5.16 (SD = 1.86) comorbidities. Those with cognitive impairment had more pain, were more sedentary and less likely to engage in function focused care activities. Addressing pain and implementing interventions for those with cognitive impairment to participate in function focused care may help optimize function and physical activity in assisted living residents. [ABSTRACT FROM AUTHOR]

The purpose of this study was to test a model of factors associated with participating in function focused care. Function focused care is a philosophy of care in which residents are encouraged to engage in functional and physical activities during care interactions. This was a secondary data analysis using data from the Dissemination and Implementation of Function Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT) study. Residents (n = 550) were recruited from 59 AL settings. The majority were female (n = 380, 69%) and White (n = 536, 97%). Model testing was done. Comorbidities, quality of interactions, environments, profit status, cognitive impairment, depression, and function were associated with function focused care and accounted for 17% of the variance. Next steps should include intervening on changeable factors (e.g., environments) and adding factors to better explain performance of function focused care such as motivation, resilience, and staff satisfaction. [ABSTRACT FROM AUTHOR]

Background and Purpose: The Cohen-Mansfield Agitation Inventory (CMAI) is a widely used measure of agitation. The purpose of this study was to test the internal consistency, reliability, and validity of short-form CMAI in a sample of nursing home residents with cognitive impairment and examine if it is invariant across gender. Methods: This study utilized baseline data from a randomized trial including 553 residents from 55 nursing homes. Data was analyzed using structural equation modeling. Results: Confirmatory factory analysis supported the three-factor structure including aggressive (α =.794), physically nonaggressive (α =.617), and verbally agitated (α =.718) behaviors. Invariance testing confirmed that the shortened measure is invariant across gender. Conclusions: Findings provide validity evidence of short-form CMAI to assess agitation and gender differences in agitation in nursing home population. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Positive social and care interactions are vital to understand and successfully accomplish the daily care needs of the residents in assisted living (AL) and optimize their quality of life. The purpose of this study was to explore and describe the staff-resident interactions in AL. This descriptive analysis utilized baseline data in a randomized trial that included 379 residents from 59 AL facilities. The majority of the interactions observed were positive; almost 25% were neutral or negative. Most interactions were care-related (31.9%) or one-on-one (27.4%), occurred with nursing (40.2%) or support staff (e.g., dining aide; 24.6%), and involved close interpersonal distance (64.6%). Future research should focus on the transition of neutral or negative interactions to positive and explore the factors that might influence neutral and negative interactions. Additionally, innovative approaches are needed to optimize interactions amid physical distancing in the context of the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Objectives: This study examined differences in physical function, delirium, depressive symptoms, and behavioral and psychological symptoms of dementia (BPSD) in hospitalized African American and white older adults with dementia. Methods: This secondary data analysis using baseline data from an ongoing trial testing family-centered function-focused care included African American (n = 159) and white persons (n =135) with dementia. Results: A multivariate analysis of covariance showed that controlling for relevant demographic and health characteristics, African Americans with dementia had lower physical function, more delirium, and more depressive symptoms upon admission than white participants. There were no significant differences in BPSD between African American and white persons. Discussion: To our knowledge, this is the first study to examine racial differences in admission symptoms of hospitalized persons with dementia. While the findings are preliminary, they can be used to inform the design of future research, including identifying the causes of disparities. [ABSTRACT FROM AUTHOR]

Understanding satisfaction with assisted living (AL) from the residents' perspective is essential for creating supportive environments that are targeted toward the needs and desires of residents. Few measures have been tested to evaluate residents' satisfaction with AL. This study tested the reliability and validity of the Resident Satisfaction Index (RSI) in a sample of 501 AL residents. Based on Rasch analysis, there was support for item reliability and construct validity. Differential item functional (DIF) analysis was done to examine differences in item responses by age, gender, and cognition. Significant and substantive differences were identified for five items by gender, one item by cognition, and no differences were found by age group. Findings suggest the RSI is a reliable and valid measure to assess residents' satisfaction with AL and can be used to guide administrators and clinicians in making changes in these settings to increase residents' satisfaction. [ABSTRACT FROM AUTHOR]

The purpose of the current study was to describe gender differences in the quality of interactions between nursing home residents with behavioral and psychological symptoms of dementia and staff. Data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) implementation study were used for the current study. A total of 535 residents (72% female and 28% male) from 55 settings were included in the analyses. The highest percentage of interactions occurred in dining rooms (38.4%) and with nursing staff (68%). There were no significant differences in the quality of staff interactions with male or female residents. Most interactions were positive social (n = 360, 71% males, 66% females), positive care (n = 312, 60% males, 58% females), or neutral (n = 123, 25% males, 22% females). There were 31 (7% males, 6% females) negative protective and 23 (3% male, 5% female) negative restrictive interactions. Future work should focus on eliminating neutral and negative interactions across both genders and address whether the gender of staff is related to the quality of staff-resident interaction. [ABSTRACT FROM AUTHOR]

Background and Objectives Apathy is a common symptom in dementia and is associated with rapid cognitive decline, poor quality of life, and higher mortality. Lawton's Competence and Environmental Press model suggests that an individual's behavior and affect are influenced by the fit of their functional abilities with the environmental demands. Yet, empirical evidence on the association between person–environment (P–E) fit and apathy is lacking. Thus, this study examined the relationship between P–E fit and apathy in dementia. Specifically, this study focused on the extent the physical environment fits individual functional limitations. Research Design and Methods This is a cross-sectional study using the baseline data from long-term care residents with dementia. The sample included 199 residents with moderate-to-severe cognitive impairment from 4 assisted living and 4 nursing homes. Function-focused P–E fit was measured using the Housing Enabler scale. Apathy was measured using the Apathy Evaluation Scale. Multilevel linear models were used to analyze the relationship between P–E fit and apathy. Results Findings revealed that greater P–E fit, specifically indoor environment, was significantly associated with lower apathy after controlling for age, gender, and years living in the facility. Yet, the association became not significant after controlling for individual physical function. Discussion and Implications Findings support the association between function-focused P–E fit and apathy, but the association is no longer significant after physical function is adjusted. Future research may explore other aspects of P–E fit and the impact of social and organizational environment on apathy in dementia. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to test a modified version of the Technology Acceptance Model, which describes users' technology adoption, to examine the relations between patient portal use and potential influencing factors in adult patients who have used patient portals. The modified model posits that patient portal use can be explained by attitude and self‐efficacy for using patient portals, perceived usefulness and ease of use, data privacy and security concerns, eHealth literacy, education level, and age. Design: A cross‐sectional anonymous online survey was conducted for adult patients who had used their patient portals in the past 12 months. Methods: Participants were recruited from 20 settings selected in a large integrated health care system. Data from 743 patients were subject to structural equation modeling for model testing. Findings: Sixty‐eight percent were White and female, with a mean age of 53.1 years (SD = 15.34). Forty‐seven percent used patient portals about monthly or more frequently. Scores for perceived usefulness and ease of use of patient portals were relatively high (as measured using the modified Perceived Health Web Site Usability Questionnaire; each item mean, 6.0–6.2; range, 1–7). The final model adequately fit the data (comparative fit index =.983, standardized root mean square residual =.064, root mean square error of approximation =.059). Patient portal self‐efficacy and data privacy and security concerns had a direct impact on patient portal use. Perceived usefulness and ease of use, eHealth literacy, education level, and age indirectly influenced patient portal use. Conclusions: This study contributes to expanding a theoretical understanding of adult patients' patient portal use in a real health care environment. Future studies need to include more diverse populations in various settings. Clinical Relevance: Knowledge gained from this study can be used by technology experts to make patient portals more user friendly and by administrators to implement patient portals more effectively. [ABSTRACT FROM AUTHOR]

BACKGROUND: This study tested the impact of Function Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC‐AL‐EIT) on: (1) care interactions between residents and direct care staff; and (2) behavior and psychological symptoms associated with dementia among residents. DESIGN: This was a randomized controlled trial. SETTING: A total of 59 assisted living facilities in Maryland, Pennsylvania, and Massachusetts participated. PARTICIPANTS: The sample included 550 mostly White (98%), female (69%) residents with a mean age of 89.30 (standard deviation = 7.63) years. INTERVENTION: The four‐step FFC‐AL‐EIT intervention was implemented by a function focused care nurse facilitator working with a facility champion over 12 months. The steps included: (1) environment and policy assessments; (2) education; (3) establishing resident function focused care service plans; and (4) mentoring and motivating. MEASURES: Resident descriptive data (e.g., age, sex, education, and comorbidities), depression, agitation, resistiveness to care, and the quality of care interactions were obtained at baseline and 4 and 12 months. Treatment fidelity data included environment and policy assessments, performance of function focused care by staff, and service plan assessments. RESULTS: There was a significant positive treatment effect related to depression, agitation, resistiveness to care, and quality of care interactions with either less decline or some improvement in these behaviors and symptoms in the treatment versus control group. CONCLUSION: The study provides some statistical support, which may not necessarily be clinically significant evidence, for psychosocial outcomes of residents and care interactions between staff and residents in assisted living settings. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The assisted living (AL) environment plays an important role in supporting residents' satisfaction and helping them to age in place. The AL environment is multidimensional and has many interrelated components including staffing (e.g. direct care workers, nursing, activity staff), services provided (e.g. medical, mental health, pharmacy), amenities offered at the setting (e.g. beauty salon, library, exercise facilities), and the physical environment. Evidence suggests that aspects of the AL environment can enhance or detract from the physical function, well-being, social engagement, and behavioral outcomes among residents. The purpose of this study was to develop and test a multidimensional AL environment measurement model that includes indicators of staffing, services, amenities, and the physical environment. Baseline data was used from a study testing the Dissemination and Implementation of Function Focused Care in AL. A total of 54 AL facilities across three states were included in the sample. Settings ranged in size from 31 to 164 beds with an average size of 82.2 (SD = 26.2) beds and the majority were for profit facilities (n = 41, 74.5%). Structural equation modeling was used to test the proposed model. Results showed that the model fit the data (χ2/df = 1.861, p <.05; CFI =.858, RMSEA =.126). Having a comprehensive AL environment measurement model will advance future research that explores the impact of the environment on resident outcomes. Findings from this study will inform interventions and programs designed to modify AL environments to optimize residents' satisfaction with AL. [ABSTRACT FROM AUTHOR]