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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.

Purpose The purpose of this study was to test the reliability and validity of the Function-Focused Care Checklist for Caregivers using Rasch analysis. Design This was a descriptive study using data from the study "Testing the Dissemination and Implementation of Function-Focused Care for Assisted Living Using the Evidence Integration Triangle." The study was approved by a university institutional review board. Methods A Rasch analysis was completed, which included 691 staff-resident observations from 85 assisted living facilities. Findings There was evidence of internal consistency (alpha coefficient of .93), construct validity except for a high OUTFIT statistic for wheelchair mobility, and hypothesis testing based on an increase in performance of function-focused care by caregivers over 12 months. Conclusions The findings provided psychometric support for the measure and guidance for revisions. Clinical relevance This measure can be used clinically to teach caregivers to provide function-focused care to residents in assisted living.

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.

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.

OBJECTIVES: The purpose of this study was to evaluate the Function Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT) intervention. DESIGN: FFC-AL-EIT was a randomized controlled pragmatic trial including 85 sites and 794 residents. INTERVENTION: FFC-AL-EIT was implemented by a Research Nurse Facilitator working with a facility champion and stakeholder team for 12 months to increase function and physical activity among residents. FFC-AL-EIT included: (Step I) Environment and Policy Assessments; (Step II) Edusscation; (Step III) Establishing Resident Function Focused Care Service Plans; and (Step IV) Mentoring and Motivating. SETTING AND PARTICIPANTS: The age of participants was 89.48 (SD=7.43), the majority was female (N=561, 71%) and white (N=771, 97%). METHODS: Resident measures, obtained at baseline, four and 12 months, included function, physical activity, and performance of function focused care. Setting outcomes, obtained at baseline and 12 months, included environment and policy assessments and service plans. RESULTS: Reach was based on 85 of 90 sites that volunteered (94%) participating. Effectiveness was based on less decline in function (p

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.

Older adults can benefit from using patient portals. Little is known whether the perceptions and use of patient portals differ among diverse older adult populations. The aim of this study was to assess the difference in perceived usability of patient portals, self-efficacy for using patient portals, and patient portal use between two adult samples aged 65 years or older. One sample was recruited from a health care system, including hospitals and clinics (n = 174), and the other sample was recruited from nationwide communities (n = 126). Conducting a secondary data analysis using two survey datasets, this study performed a series of linear and ordinal logistic regression analyses. The health care system sample had a higher mean number of chronic diseases and proportion of recent hospitalization than the community sample. The health care system sample showed higher perceived usability, self-efficacy, and usage frequency of patient portals compared to the community sample. eHealth literacy was a significant predictor of perceived usability and self-efficacy. Perceived usability was another significant predictor of self-efficacy. Self-efficacy and health condition variables significantly predicted the more frequent use of patient portals. Compared to the health care system sample, the relationship between perceived usability and use of patient portals was stronger and significant in the community sample. These findings suggest that approaches for promoting patient portal use should consider personal characteristics and health conditions of diverse older adult populations. Future research needs to focus on assessing the impact of using patient portals on older adults’ health care outcomes.

Resistiveness to care (RTC) is a behavioral and psychological symptom of dementia that is common among dementia residents in assisted living facilities. RTC encompasses verbal and nonverbal behaviors that oppose care, such as crying, grabbing, hitting, or yelling, among many other resistive behaviors. The quality of care interactions which can be positive, neutral or negative, have been associated with increased RTC. The purpose of this study was to test the association between quality of care and RTC. This was a secondary data analysis using baseline data from the Function-Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT) implementation study. Controlling for cognition, age, gender, medication use, and comorbidities, it was hypothesized that quality of care interactions would be associated with resistiveness to care. A linear regression analysis was conducted to test the hypothesis. The sample included 794 participants the majority of whom were white women with a mean age of 89.48 (SD=7.61). The mean RTC was .09 (SD=.41, range 0-13) and the mean quality of care interactions were 5.96 (SD=1.44, range 0-7). Based on the regression analysis there was no significant association between quality of care and RTC. These findings may be due to the high quality of care provided and limited RTC in this sample. Ongoing research is needed, however, to continue to explore these relationships and assure that all RTC is being reported among staff and that there is no evidence of negative quality of care interactions in these settings.

The effectiveness of EIT-4-BPSD was based on testing the following hypotheses: (1) Settings exposed to EIT-4-BPSD will demonstrate improvements in Environment and Policy assessments, better quality of care interactions, and more person-centered care approaches for management of behavioral symptoms in care plans compared to Education Only settings; and (2) Residents in EIT-4-BPSD settings will have fewer behavioral symptoms and less pain, maintain or improve function, use fewer psychotropic medications, and have improved quality of life compared to residents in Education Only settings. There was not a significant treatment effect at the setting or resident level. Reasons for lack of effectiveness include limited evidence of behavioral symptoms at baseline, nationally based environment and policy requirements related to behavioral management, and measurement challenges in identifying behaviors and other outcomes. Future work should focus more on process and changing how staff approach care which was demonstrated in this trial.

This study included a subset of 59 communities and 550 residents from the full FFC-AL-EIT study. Participants were mostly white (98%), female (69%) and had a mean age of 89.30 (SD=7.63). Sites were randomized to the four step FFC-AL-EIT intervention implemented by a function focused care nurse facilitator working with a facility champion over 12 months versus education only. Resident measures included depression, agitation, resistiveness to care and the quality of care interactions and were obtained at baseline, 4 and 12 months. 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 and improvement in the quality of care provided between the treatment versus control group. The study suggests there is some benefit to implementing FFC-AL-EIT for psychosocial outcomes and care interactions among residents in assisted living communities.

Understanding residents’ satisfaction with assisted living (AL) is essential for creating supportive environments that are focused on residents’ needs and preferences. Nearly half of AL residents experience some level of cognitive impairment, although limited research has examined residents’ satisfaction with AL particularly among those with cognitive impairment. The purpose of this study was to compare satisfaction with AL between residents with and without dementia. Baseline data from the Dissemination and Implementation of Function Focused Care in AL study was used in this analysis. A total of 481 AL residents were included in the sample. Measures included demographic information, Saint Louis University Mental Status Exam (SLUMS), and the Resident Satisfaction Index. Controlling for age, gender, and comorbidities, multivariate analyses of variance was performed to consider the impact of cognitive status on residents’ satisfaction with health care services, physical environment, relationships with staff, and social activities. The majority of participants were female (71%), White (97%), mean age was 89 years old (SD=7.43), and mean SLUMS score was 15.90 (SD=4.74). On average, residents were highly satisfied with AL reporting a mean score of 19.17 (SD=3.15). There were no significant differences in residents’ satisfaction scores (p>.05) between residents with dementia and without dementia across all subdomains of satisfaction: health care services, physical environment, relationships with staff, and social activities. There may have been some bias in results due to social desirability. Further research should explore additional aspects of residents’ satisfaction with staff such as whether or not person-centered care is provided.

Function and Behavior Focused Care (FBFC) is a two tiered intervention based on the Social Ecological Model and Social Cognitive Theory that focuses on training long term care staff to cue, model, and assist residents with dementia to engage in physical activity and perform functional tasks. FBFC was implemented by a Research Nurse and a facility based Champion for 12 months and involved a four step approach: (1) Environment and Policy Assessments; (2) Staff Education; (3) Establishing Resident Care Plans; and (4) Mentoring and Motivating of Staff and Residents. Facilitators of implementation included administrative support, an identified champion, and supportive environments and policies. Challenges and barriers included the fear of falls, fear of behavioral symptom exacerbation, competing priorities, and lack of facility specific goals. Innovative approaches to overcoming these barriers will be reviewed.

BackgroundThere continues to be a belief among nurses, patients, and families that physical activity increases the risk of falling.PurposeThe purpose of this study was to test the hypothesis that controlling for age, function, cognition, medication use, gender, comorbidities, and cognition, residents who are exposed to Function Focused Care for Assisted Living (FFC-AL-EIT) and engage in moderate levels of physical activity would not be more likely to fall.MethodsThis was a secondary data analysis using data from the first two cohorts of a randomized trial testing FFC-AL-EIT in the United States.ResultsThe study included 381 residents, the majority of whom were female (70%), white (97%), with a mean age of 87.72 (standard deviation = 7.47). Those who engaged in more moderate-intensity physical activity were 1% less likely to fall (odds ratio = .99, p = .03). There was no significant association between exposure to function focused care and falling (odds ratio = 1.58, p = .09).ConclusionThere was no indication that those who were exposed to function focused care or those who engaged in moderate-level physical activity were more likely to fall. In fact, engaging in moderate-level physical activity was noted to be slightly protective of falling.

Long term care residents with dementia are sedentary, experience rapid functional decline, and frequently exhibit behavioral and psychological symptoms of dementia. Our prior cluster, randomized controlled trial among 336 residents with moderate to severe dementia in 12 nursing homes demonstrated that it is possible to increase time spent in physical activity and decrease resistiveness to care through a theory based intervention, Function and Behavior Focused Care (FBFC). FBFC is based on the Social Ecological Model and Social Cognitive Theory and focuses on having long term care staff cue, model, and assist residents with dementia to engage in physical activity and perform functional tasks. Learning from prior work, it was noted that future implementation of FBFC would benefit from de-implementing inaccurate care practices, such as restricting resident mobility and providing custodial care and also by engaging a full stakeholder team in intervention activities. Additionally, there were measurement issues, such as the use of actigraphy with a sedentary, cognitively impaired population, and the need to assess the quality of care interactions between residents and staff. This symposium will review lessons learned from the FBFC trial and will discuss 1) facilitators and barriers to the implementation of the FBFC intervention within long term care settings; 2) measurement opportunities and challenges with a cognitively impaired long term care population; and 3) adaptation of the FBFC intervention to be appropriate for a dissemination and implementation trial that incorporates the Synthesis Model of De-Adoption and the Evidence Integration Triangle implementation strategy.

Psychotropics are often used to manage behavioral and psychological symptoms of dementia (BPSD) in nursing homes (NHs), despite their adverse effects and lack of efficacy. NHs can be flagged for inappropriate psychotropics use as a deficiency of care (F-tag 758). To improve dementia care, 15 states require dementia-specific in-service training for NH nursing staff with specific training content and hours. The study aimed to relate the occurrence of F-758 citations to the presence of dementia-specific in-service training regulations, stratified by nurse staffing levels (

The purpose of this study was to test the effectiveness of the Function and Behavior Focused Care (FBFC) intervention on function, physical activity and behavioral symptoms among nursing home residents with dementia. This study was a clustered, randomized controlled trial with a repeated measures design in 12 nursing homes. The participants (N=336) were 82.6 (SD=10.1) years of age, mostly female and were moderate to severely cognitively impaired (MMSE of 7.8, SD=5.1). There were a statistically significant improvements in time spent in light, moderate and overall physical activity based on actigraphy and a decrease in resistiveness to care at 4 months among participants in the treatment group. There was no change in mood, agitation, and the use of psychotropic medications. This study provides some support for the use of the FBFC intervention to increase time spent in physical activity and decrease resistive behaviors during care among nursing home residents with dementia. Part of a symposium sponsored by Nursing Care of Older Adults Interest Group.

Treatment fidelity was evaluated in the FBFC-CI trial based on delivery, receipt and enactment. Evidence of delivery was noted based on completion of Component I, evaluation of environments and policies; Component II, education of nurses; and Component III, motivational techniques (completion of goal forms for residents and use of self-efficacy based interventions). There was evidence of delivery of the intervention as 583 staff were educated (80% of all staff), environment and policy assessments were completed and motivation provided. Evidence of receipt was based on a mean test score after education of 9.79 (98% correct, SD=.56) and evidence of improvement in environments [baseline 13.5 (SD=2.07) increased to 15.12(.99)] and policies [8.50(SD=3.85) increased to 10.87(SD=2.41)] that facilitate function and physical activity. Evidence of enactment was based on direct observation of staff indicating that the staff provided more function focused care for residents over the course of the 12 month study period study.

Service plans should clearly articulate the care needs and preferences of the resident, how and when that care will be provided. The purpose of this study was to test the reliability and validity of the Checklist for Function Focused Care in Service Plans. Function Focused Care is a care approach that optimizes function and physical activity during all care interactions. A total of 249 participants were recruited from 26 assisted living facilities. The majority of participants were white, female and unmarried. There was support for internal consistency with an alpha coefficient of .96, inter-rater reliability with a correlation of .80, construct validity based on Rasch analysis and INFIT statistics ranging from .69 to 1.29, and a significant association with function focused care activities. This measure can be used to evaluate whether service plans are completed in such a way as to optimize the residents function and physical activity.

Neuropsychiatric symptoms, such as delusions, hallucinations, depression, aggression, and agitation occur in two-thirds of nursing home residents with dementia. These behavioral symptoms are most likely to occur during personal care interactions and challenge and frustrate caregivers. Pharmacologic management of behavioral symptoms among residents with dementia has been minimally effective and is fraught with significant risks, such as, falls, fractures, delirium, parkinsonism, stroke, pneumonia, and death. FBFC-CI is a behavioral intervention focused on optimizing function and physical activity of residents with dementia during all care interactions. Residents in settings in which FBFC-CI was implemented had a decrease in resistiveness to care and a decrease in use of antipsychotics at four months post implementation of the intervention. There was no change in mood, agitation, use of antidepressants, anxiolytics or mood stabilizing medications. Importantly, there was no evidence that engaging residents with dementia in function and physical activity exacerbated behavioral symptoms.

The EIT-4-BPSD incorporates a focus on the assessment and alteration of the environment and policies to assure use of behavioral interventions. The purpose of this study was to test the reliability and validity of The Environment and Policy Assessments in 14 nursing homes. Based on Rasch analysis there was evidence of internal consistency for the Environment Assessment (alpha coefficient of .70) and the Policy Assessment (alpha coefficient of .81). Inter-rater reliability was .58 for the Environment Assessment and .45 for the Policy Assessment. Based on Rasch analysis there was evidence of item fit and construct validity of both measures and a good spread of the items across the full continuum of both concepts. Clarification of definitions of some items is needed to improve reliability. The measures are useful for helping settings assure that the environment and policies support the use of person centered behavioral interventions for BPSD.

Residents with cognitive impairment are at risk for functional decline and decreased physical activity once they enter nursing homes. Contributors to this decline include cognitive status, age, multiple comorbidities, pain, behavioral symptoms (depression, apathy and aggression) and environmental factors (tethering patients with restraints, the use of alarms, restrictive positioning, limited space and unsafe areas). Twelve settings were randomized to FBFC-CI or education-only and 336 residents included. The residents were 82 (SD=10) years of age, mostly female (n=242,72%), and white (n= 199, 59%) with a mean Mini Mental State Exam score of 7.8 (SD=5.06). Exposure to FBFC-CI resulted in increased time in physical activity based on actigraphy and subjective reporting of activity. There was no change in function or chair rise. Increasing physical activity via exposure to FBFC-CI has the potential to help with overall health status and quality of life of residents with dementia.

Residents in assisted living engage in limited amounts of physical activity and decline functionally more rapidly than their peers in nursing homes. To address this functional decline and increased time in sedentary activity a dissemination and implementation approach was used to help nursing staff integrate focused care (FFC) into routine care. Twenty-six settings across Maryland, Pennsylvania, and Massachusetts were recruited into the first cohort. A total of 274 direct care workers were exposed to education about FFC and overall they scored 87% on the FFC Knowledge Test. Direct observations using the FFC Behavior Checklist for Direct Care Workers showed that FFC was provided in 10.55 (SD=3.81) out of 19 activities and was not performed in a mean of 3.01 (SD=3.03) activities observed. FFC was least likely to be encouraged during wheelchair mobility, lower extremity bathing, range of motion activities and bladder training/toileting and should be the focus of future interventions.

Approximately 25–84% of nursing home residents with dementia experience apathy. Apathy is characterized by lack of motivation, lack of initiative, decreased responsiveness to environmental stimulation, and a flat mood. Apathy 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, the relationship between environment and apathy is understudied. Therefore, this study examined the relationship between functional person-environment fit and apathy in dementia. This is a cross-sectional study using the baseline data from two trials of Function Focused Care for residents with moderate to severe cognitive impairment. The sample included 199 residents with dementia recruited from four nursing homes and four assisted living facilities. Functional person-environment fit was measured using the Enabler scale. Apathy was measured using the Apathy Evaluation Scale. Multilevel linear models were used for analysis. Participants were 84 years old on average and the majority were Caucasian female. Findings revealed that greater person-environment fit was associated with lower apathy (β=.017, P=.025). The association was not significant after controlling for age, gender, type of care setting, cognitive function, depression, agitation, and physical function. In conclusion, findings are insufficient to support the association between functional person-environment fit and apathy. Future research may further examine the impact of individual characteristics on the relationship between environment and apathy and explore the impact of social environment on apathy in dementia.

The purpose of this study was to consider the feasibility, reliability, and validity of MotionWatch 8. A total of 249 residents were recruited from 26 assisted living settings. Data collection included demographics, comorbidities, function (Barthel Index), physical activity (MotionWatch 8), and falls. The mean age of participants was 86.86 ( SD = 7.0), the majority were women 179 (74%) and White ( N = 232, 96%). A total of 86% of participants wore the MotionWatch 8. There were no significant differences in physical activity over 3 days of testing. The MotionWatch 8 findings were significantly associated with activities of daily living (ADL) function. There were no significant differences in ADL function or physical activity between those who did and did not fall. The study provides additional support for the feasibility, reliability, and validity of the MotionWatch 8 and confirms that older adults living in assisted living settings spend the majority of their time in sedentary activity.

Understanding the factors that influence psychotropic can guide reduction in use of these medications. This study described predictors of psychotropics use among residents with moderate to severe cognitive impairment. This was a secondary data analysis using baseline data from the first 341 residents in the EIT-4-BPSD trial. Predictive measures included demographics, agitation, resistiveness to care, depression, cognition, pain, 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. Model testing 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 additional factors associated with psychotropic medication use such as beliefs of providers.

Background Behavioral and psychological symptoms of dementia (BPSD) are prevalent in people with neurodegenerative diseases. Purpose In this scoping review the Kales, Gitlin and Lykestos framework is used to answer the question: What high quality evidence exists for the patient, caregiver and environmental determinants of five specific BPSD: aggression, agitation, apathy, depression and psychosis? Method An a priori review protocol was developed; 692 of 6013 articles retrieved in the search were deemed eligible for review. Gough’s Weight of Evidence Framework and the Cochrane Collaboration’s tool for assessing risk of bias were used. The findings from 56 high quality/low bias articles are summarized. Discussion Each symptom had its own set of determinants, but many were common across several symptoms: neurodegeneration, type of dementia, severity of cognitive impairments, and declining functional abilities, and to a lesser extent, caregiver burden and communication. Conclusion Research and policy implications are relevant to the National Plan to Address Alzheimer’s Disease.

To overcome challenges associated with optimizing function and physical activity among hospitalized older adults, we developed function-focused care for acute care (FFC-AC). The purpose of this study was to test the feasibility and preliminary effectiveness of this intervention. We hypothesized that hospitalized trauma patients exposed to FFC-AC would (1) maintain or improve function, spend more time in physical activity, and have fewer adverse events between admission and discharge; and (2) maintain or improve function, have less fear of falling, fewer depressive symptoms, less pain, be more physically resilient, and be less likely to experience adverse events at 1 month postdischarge compared with those exposed to FFC-education only (EO). FFC-AC was implemented by a research function-focused care nurse who worked on the participating units for 20 hr a week for 16 months to implement the three components of FFC-AC. The sample included 89 older orthopedic trauma patients the majority of whom were female (N = 59, 66%), white (N = 82, 92%), and not married (N = 53, 59%). At discharge and/or 30 days postdischarge, participants in the treatment site showed greater improvement in function, less fear of falling, and better physical resilience when compared with those in the FFC-EO site. Future research is needed to continue to work on engaging staff in function-focused care approaches and optimizing the hospital environment and policies to support nurses in this type of care approach.