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BACKGROUND: Resident-to-resident elder mistreatment (RREM) in nursing homes has serious physical and psychological consequences, but factors related to RREM occurrence remain unclear. This study identifies individual and environmental characteristics associated with involvement in RREM episodes. METHODS: The design was an observational study carried out in five urban and five suburban New York state nursing homes randomly selected on the basis of size and location. The sample consisted of 2011 residents in 10 facilities; 83% of facilities and 84% of eligible residents participated. RREM and potential correlates were identified through resident interviews, staff interviews, shift coupons, observation, chart review, and accident or incident reports. RESULTS: A multivariate analysis controlling for relevant covariates found that individuals involved in RREM incidents exhibit milder dementia, show behavioral symptoms, and are less functionally impaired. Although special care units (SCU) for dementia have benefits for residents, one potential hazard for SCU residents is elevated risk for RREM. CONCLUSIONS: Interventions to prevent and intervene in RREM incidents are greatly needed. The correlates identified in this research point to the need for targeted interventions, specifically for residents with milder impairment and with behavioral symptoms and individuals in SCUs.

Background/objectives The Hospital Elder Life Program (HELP) has been shown to prevent delirium in hospitalized older adults. The objective of this study was to test the efficacy of HELP adapted to long-term care (HELP-LTC). Design Cluster randomized controlled trial. Setting A 514-bed academic urban nursing home. Participants A total of 219 long-term nursing home residents who developed an acute illness or change in condition were randomly assigned to HELP-LTC (n = 105) or usual care (n = 114) by unit. Intervention HELP-LTC is a multicomponent intervention targeting delirium risk factors of cognitive impairment, immobility, dehydration, and malnutrition. Two certified nursing assistants (CNAs) delivered HELP-LTC components twice daily 7 days per week. In addition, recommendations were given to primary providers to reduce medications associated with delirium. Measurements Delirium (primary outcome) and delirium severity were ascertained each weekday by a research assistant blinded to group assignment, using the Confusion Assessment Method (CAM) and CAM severity score (CAM-S), respectively. Cognitive function was determined using the Cognitive Performance Scale (CPS). Hospitalization was ascertained by chart review. Results Participants were 81.7 years of age on average and 65.3% female. At baseline, usual care group participants had better cognitive function than intervention group participants (CPS = 1.33 vs 2.25; P = .004). Delirium symptoms declined over the course of the episode (mean CAM-S = 3.63 at start vs 3.27 at end). Overall, 33.8% of the total sample experienced incident delirium. After adjusting for baseline cognitive function, no significant differences were found in delirium or delirium severity between intervention and usual care groups. Hospitalization was not significantly different between groups. Conclusion An intervention targeting delirium risk in long-term nursing home residents did not prevent delirium or reduce delirium symptoms. Baseline differences in cognitive function between groups, greater than expected improvements in both groups, quality-enhancing practices such as consistent assignments delivered to both groups, and adaptations of the intervention may have biased results toward null. J Am Geriatr Soc 68:2329-2335, 2020.

Objectives To compare the effectiveness of 2 caregiver interventions with known efficacy: the Resources for Enhancing Caregiver Health‐Offering Useful Treatment (REACH‐OUT) and the New York University Caregiver Intervention (NYUCI). Design 1:1 randomized pragmatic trial. Setting New York City. Participants Informal Hispanic caregivers of persons with dementia (N=221; mean age 58.2, 82.8% female, 63.3% adult children, 31.7% spouses). Intervention Participants were randomized to 6 months of NYUCI (n=110) or REACH‐OUT (n=111), balanced on characteristics at baseline. All participants were referred for social supportive services. Measurements The primary outcomes were changes between baseline and 6 months in depressive symptoms, measured using the Geriatric Depression Scale (GDS), and caregiver burden, measured using the Zarit Caregiver Burden Scale (ZCBS). Results There were no differences in outcomes between NYUCI and REACH‐OUT. Both interventions showed a reduction in burden (REACH‐OUT: 5.2 points, 95% confidence interval (CI)=2.2–8.1, p

Nursing home (NH) residents have a high prevalence of delirium risk factors, experience two to four acute medical conditions (e.g., infections) each year, and have an incidence of delirium during these conditions similar to that of hospitalized older adults. Many NH residents with delirium do not return to their prior level of cognitive function. They are more likely to die, be hospitalized, and less likely to be discharged home than those without delirium. Research on the prevention or treatment of delirium in NHs is limited. This article describes the development and pilot testing of a multicomponent delirium prevention intervention in the NH setting adapted from the Hospital Elder Life Program (HELP-LTC). Activities to reduce the risk of delirium that were appropriate for functionally impaired NH residents were developed and delivered during treatment for and recovery from acute illness, a novel resident-targeting approach. Expertly trained certified nursing assistants (CNAs - a total of 1.4 full-time equivalent (FTE) positions-) visited residents throughout the facility and delivered the activities. The current study reports on incident delirium, delirium remission, cognitive and physical function change, hospitalization, and death associated with acute medical conditions as ascertained by a program coordinator. The integration and acceptance of the CNAs' activities by residents and staff are also reported on. Hospitalization and death were ascertained in a nonintervention comparison group. Findings support a test of the intervention in a controlled trial. The potential effect is great; there are approximately 1.4 million NH residents in the United States and an estimated 1 million with dementia or cognitive impairment, an important delirium risk factor. An intervention would be broadly adoptable if a reduction in healthcare costs through prevention of hospitalization offset the cost of the program's CNAs.

OBJECTIVE: There are no data comparing the effectiveness of counseling interventions for caregivers of persons with dementia. We compared for the first time the effectiveness of two caregiver interventions with known efficacy, the Resources for Enhancing Caregiver Health- Offering Useful Treatment (REACH-OUT), and the New York University Caregiver Intervention (NYUCI). DESIGN: 1:1 randomized pragmatic trial SETTING: New York City. PARTICIPANTS: 221 informal Hispanic caregivers of persons with dementia. INTERVENTION: Participants were randomized to 6 months of NYUCI or REACH-OUT. All participants were referred for social supportive services. MEASUREMENTS: The primary outcomes were changes between baseline and 6 months in depressive symptoms, measured with the Geriatric Depression Scale (GDS), and caregiver burden, measured with the Zarit Caregiver Burden Scale (ZCBS). RESULTS: The mean age was 58.2 years, 82.8% were women, 63.3% were adult children, and 31.7% were spouses; 110 were randomized to the NYUCI, and 111 to REACH-OUT. The groups were balanced on characteristics at baseline. There were no differences in outcomes between NYUCI and REACH-OUT. Both interventions showed a reduction in burden (REACH-OUT = 5.2 points, 95 % confidence interval [CI] = 2.2, 8.1, p < 0.001; NYUCI = 4.6-points, 95% CI: 1.7, 7.5, p = 0.002). There were no significant changes in the GDS. Effects for the ZCBS were significant only among spouses and older caregivers. CONCLUSIONS: Although there were no significant intervention group differences, both interventions resulted in significantly reduced burden among Hispanic caregivers at 6 months, particularly among spouse and older caregivers, as contrasted with other subgroups.

OBJECTIVES: To more fully characterize the spectrum of resident-to-resident aggression (RRA). DESIGN: A focus group study of nursing home staff members and residents who could reliably self-report. SETTING: A large, urban, long-term care facility. PARTICIPANTS: Seven residents and 96 staff members from multiple clinical and nonclinical occupational groups. MEASUREMENTS: Sixteen focus groups were conducted. Content was analyzed using nVivo 7 software for qualitative data. RESULTS: Thirty-five different types of physical, verbal, and sexual RRA were described, with screaming or yelling being the most common. Calling out and making noise were the most frequent of 29 antecedents identified as instigating episodes of RRA. RRA was most frequent in dining and residents' rooms, and in the afternoon, although it occurred regularly throughout the facility at all times. Although no proven strategies exist to manage RRA, staff described 25 self-initiated techniques to address the problem. CONCLUSION: RRA is a ubiquitous phenomenon in nursing home settings, with important consequences for affected individuals and facilities. Further epidemiological research is necessary to more fully describe the phenomenon and identify risk factors and preventative strategies. Language: en

OBJECTIVES: To determine whether the Alzheimer's Disease Screen for Primary Care (ADS-PC) is more sensitive to early dementia than the Mini-Mental State Examination (MMSE) and whether it has as high a misclassification rate in minority patients and patients with limited education. DESIGN: Cross-sectional validation study. SETTING: Urban geriatric primary care practice. PARTICIPANTS: Three hundred sixteen African-American and Caucasian patients, including 55 patients with early dementia (Clinical Demential Rating of 0.5). MEASUREMENTS: The ADS-PC is a two-stage strategy for identifying early dementia that consists of a brief high-sensitivity dementia screen, applied to all patients aged 65 and older, and a second stage to identify memory impairment, applied to patients who fail the first stage. Differences in the sensitivities or specificities of the ADS-PC and the MMSE were evaluated using the McNemar test. RESULTS: Receiver operating characteristic curves were used to examine differences in the operating characteristics of the ADS-PC across a range of cutscores. When the specificities of both tests were equated (0.90), the sensitivities were significantly different (ADS-PC, 0.75; MMSE, 0.56). The MMSE failed to identify five times as many cases of dementia as the ADS-PC. When the sensitivities were equated, the specificities differed significantly (ADS-PC, 0.95; MMSE, 0.73). The MMSE misclassified five times as many noncases as the ADS-PC. This pattern of significantly higher sensitivity and specificity for the ADS-PC than for the MMSE was repeated in the results according to race and for individuals with high school or more education but not in individuals with less education. CONCLUSION: The ADS-PC outperformed the MMSE in identifying early dementia in a racially and educationally diverse primary care cohort.

To more fully characterize the spectrum of resident-to-resident aggression (RRA).A focus group study of nursing home staff members and residents who could reliably self-report.A large, urban, long-term care facility.Seven residents and 96 staff members from multiple clinical and nonclinical occupational groups.Sixteen focus groups were conducted. Content was analyzed using nVivo 7 software for qualitative data.Thirty-five different types of physical, verbal, and sexual RRA were described, with screaming or yelling being the most common. Calling out and making noise were the most frequent of 29 antecedents identified as instigating episodes of RRA. RRA was most frequent in dining and residents' rooms, and in the afternoon, although it occurred regularly throughout the facility at all times. Although no proven strategies exist to manage RRA, staff described 25 self-initiated techniques to address the problem.RRA is a ubiquitous phenomenon in nursing home settings, with important consequences for affected individuals and facilities. Further epidemiological research is necessary to more fully describe the phenomenon and identify risk factors and preventative strategies.

To determine whether the Alzheimer's Disease Screen for Primary Care (ADS-PC) is more sensitive to early dementia than the Mini-Mental State Examination (MMSE) and whether it has as high a misclassification rate in minority patients and patients with limited education.Cross-sectional validation study.Urban geriatric primary care practice.Three hundred sixteen African-American and Caucasian patients, including 55 patients with early dementia (Clinical Demential Rating of 0.5).The ADS-PC is a two-stage strategy for identifying early dementia that consists of a brief high-sensitivity dementia screen, applied to all patients aged 65 and older, and a second stage to identify memory impairment, applied to patients who fail the first stage. Differences in the sensitivities or specificities of the ADS-PC and the MMSE were evaluated using the McNemar test.Receiver operating characteristic curves were used to examine differences in the operating characteristics of the ADS-PC across a range of cutscores. When the specificities of both tests were equated (0.90), the sensitivities were significantly different (ADS-PC, 0.75; MMSE, 0.56). The MMSE failed to identify five times as many cases of dementia as the ADS-PC. When the sensitivities were equated, the specificities differed significantly (ADS-PC, 0.95; MMSE, 0.73). The MMSE misclassified five times as many noncases as the ADS-PC. This pattern of significantly higher sensitivity and specificity for the ADS-PC than for the MMSE was repeated in the results according to race and for individuals with high school or more education but not in individuals with less education.The ADS-PC outperformed the MMSE in identifying early dementia in a racially and educationally diverse primary care cohort.

OBJECTIVE: To evaluate the reliability and validity of guidelines to determine the capacity of nursing home residents to execute a health care proxy (HCP). DESIGN: A cross-sectional study. SETTING: A 750-bed not-for-profit nursing home located in New York City. PARTICIPANTS: A random sample of 200 nursing home residents: average age, 87; 99% white; 83% female; average length of stay, 3.05 years; mean Mini-Mental State Exam (MMSE) score, 15.9. MEASUREMENTS: Demographic characteristics (Minimum Data Set (MDS)); function and cognitive status (Institutional Comprehensive Assessment and Referral Evaluation (INCARE)); Reisberg Dementia Staging; MMSE; Minimum Data Set-Cognitive Performance Scale (MDS-COGS)); an investigator-developed measure of a nursing home resident's capacity to execute a health care proxy (Health Care Proxy (HCP) Guidelines.) RESULTS: The internal consistency of the decision-making scales in the HCP Guidelines, paraphrased recall and recognition, reached acceptable levels, alphas of .85 and .73, respectively. Interrater reliability estimates were .92 and .94, respectively, for the recall and recognition scales; test-retest reliability estimates were .83 and .90. The discriminant validity of these scales is promising. For example, the MMSE correlation was .51 with the Recall scale and .57 with the Recognition scale. Of residents with severe cognitive impairment (MMSE < 10), 71% completed 50% or more of the scaled items in the HCP guidelines and 95% consistently named a proxy. CONCLUSIONS: Seventy-three percent of testable residents, approximately three-quarters of whom were cognitively impaired, evidenced sufficient capacity to execute an HCP. Of residents with severe cognitive impairment, the HCP guidelines are potentially useful in identifying those with the capacity to execute a HCP. The guidelines are more predictive than the MMSE in identifying residents able to execute a HCP. J Am Geriatr Soc 48: 179–187, 2000.

The Systolic Hypertension in the Elderly Program (SHEP) was designed as a feasibility study and in part dealt with the effects of the treatment of isolated systolic hypertension on cognitive status and depression. Subjects were 60 years of age or older with a systolic blood pressure of 160 mmHg or greater and diastolic of less than 90 mmHg; free of several specified illnesses or chronic conditions. These volunteers were randomly assigned to treatment (n = 443) and placebo (n = 108) groups. The behavioral assessments at baseline and 1 year later were the SHORT-CARE instrument for depression, cognitive impairment, and disability and other tests of cognitive status (Digit Symbol Substitution and the Trail Making tests). Although the treatment regime was highly successful in controlling the hypertension, it did not have a significant impact on changes in cognitive function or level of depression; a behavioral benefit was not evident but the results are consistent with the view that an effective treatment regime for isolated systolic hypertension in the elderly can be behaviorally safe.

The recent focus on the young homeless mentally ill has diverted attention from other subgroups of the homeless, particularly the aging, who compose one fourth of the homeless population. A total of 86 street-dwelling and 195 non-street-dwelling (177 flophouse-, 18 apartment-dwelling) men aged 50 and older on the Bowery in New York City were studied. Although 23% evidenced psychosis or had prior psychiatric hospitalization (PPH group), depression was more prevalent with one third of all men categorized as clinically depressed. Only 5% evidenced gross organic mental disease. Several groups were identified for intervention because of their increased susceptibility to depression: alcoholics, relatively younger men, those with organic mental symptoms, street men. With respect to the PPH men, they did not appear to be distinct from the other homeless men on various social and health indices, although they differed substantially from age-matched community men. Thus these men must be viewed as homeless first, and in addition, as having the handicap of mental illness. Contrary to the popular stereotype, there was no evidence of widespread isolation among the PPH men, and despite their disturbances, most showed an adequate capacity for survival.