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Inequities with regard to brain health, economic costs, and the evidence base for dementia care continue. Achieving health equity in dementia care requires rigorous efforts that ensure disproportionately affected populations participate fully in—and benefit from—clinical research. Embedding‐proven interventions under real‐world conditions and within existing healthcare systems have the potential to examine the effectiveness of an intervention, improve dementia care, and leverage the use of existing resources. Developing embedded pragmatic controlled trials (ePCT) research designs for nonpharmacological dementia care interventions involves a plethora of a priori assumptions and decisions. Although frameworks exist to determine whether interventions are "ready" for ePCT, there is no heuristic to assess health equity‐readiness. We discuss health equity considerations, case examples, and research strategies across ePCT study domains of evidence, risk, and alignment. Future discussions regarding health equity considerations across other domains are needed. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Six million Americans live with Alzheimer's disease and Alzheimer's disease and related dementias (AD/ADRD), a major health‐care cost driver. We evaluated the cost effectiveness of non‐pharmacologic interventions that reduce nursing home admissions for people living with AD/ADRD. METHODS: We used a person‐level microsimulation to model the hazard ratios (HR) on nursing home admission for four evidence‐based interventions compared to usual care: Maximizing Independence at Home (MIND), NYU Caregiver (NYU); Alzheimer's and Dementia Care (ADC); and Adult Day Service Plus (ADS Plus). We evaluated societal costs, quality‐adjusted life years and incremental cost‐effectiveness ratios. RESULTS: All four interventions cost less and are more effective (i.e., cost savings) than usual care from a societal perspective. Results did not materially change in 1‐way, 2‐way, structural, and probabilistic sensitivity analyses. CONCLUSION: Dementia‐care interventions that reduce nursing home admissions save societal costs compared to usual care. Policies should incentivize providers and health systems to implement non‐pharmacologic interventions. [ABSTRACT FROM AUTHOR]

Background: Prior to implementing new programmes or practices, it is essential to understand the context, barriers and enablers to support successful use. The tailored activity programme (TAP) is an evidence‐based intervention provided by occupational therapists to support community‐dwelling people living with dementia and their carers. The programme was developed in the United States, and although it is not currently available for routine use in Australia, its implementation would address the needs of many Australians with dementia and their carers. Aim: The aim of the study is to understand the perspectives of occupational therapists and their managers regarding barriers and enablers to the delivery and implementation of the TAP in Queensland, Australia. Methods: A qualitative descriptive methodology was employed. Semistructured interviews were undertaken with occupational therapists (n = 18) who work with community‐dwelling people with dementia and their carers, and their managers (n = 10). Participants were recruited from a range of organisations across Queensland, and they were asked about potential barriers and enablers to implementing TAP. Interviews were recorded and transcribed verbatim. Data were mapped using framework analysis whilst remaining open to other themes. Findings: Themes were identified, and facilitating factors included the close alignment of TAP with occupational therapists' scope of practice; their acceptance of, and optimism about the programme and its perceived benefits including improved client outcomes; and an opportunity for occupational therapists to further develop their skills. Managerial support and carers' readiness and willingness to participate were also identified as important factors for success, whereas barriers were cost to clients and the capacity of the occupational therapy workforce to provide TAP. Conclusion: Occupational therapists and their managers expressed enthusiasm for TAP and awareness of its likely benefits, while also identifying barriers that will need to be addressed if implementation of the programme is to be successful in Australia. [ABSTRACT FROM AUTHOR]

Background: Although nonpharmacological approaches are considered first‐line treatments for dementia‐related behaviors, it is unclear as to their effectiveness for different racial groups. We evaluated the effects of the Tailored Activity Program (TAP) on agitated and aggressive behaviors in Black and White families. Methods: We conducted a single‐blind, two‐arm randomized controlled trial involving Black (N = 90) and White (N = 145) families. TAP involved eight home sessions by occupational therapists who provided activities tailored to abilities and interests and instructed caregivers in their use over 3 months. An attention control group received eight sessions by research assistants who provided disease education and home safety tips. Measures included caregiver ratings of frequency by severity for the agitation and aggression subscales of the Neuropsychiatric Inventory‐Clinician (NPI‐C) at 3 months (main trial primary outcome), number of completed sessions and time spent, changes in behavioral subcomponents of the subscales (frequency, severity, caregiver distress), and percent improving/worsening. Results: Black and White families completed similar numbers of treatment sessions, but White dyads averaged nearly two contact hours more than Black dyads (p = 0.008). At 3 months, an interaction effect (treatment by race) indicated significantly greater reductions in frequency by severity scores for the agitation and aggression subscales for Black TAP dyads versus White TAP dyads and White and Black attention control dyads. Also, significant interaction effects favoring TAP Black dyads were observed for select behavioral components. For TAP dyads with elevated baseline agitation/aggression levels (N = 71), 34.5% of Black versus 11.9% of White dyads improved; whereas 2.6% of Black versus 16.7% of White dyads had worsened agitation/aggression scores. Conclusion: Black families compared to White families derived greater behavioral benefits from TAP for PLWD at 3 months despite having less treatment exposure. Examining differential race effects may enhance precision in using nonpharmacological approaches and promote equity in dementia care for underserved populations. [ABSTRACT FROM AUTHOR]

Background: Programs to reduce disability are crucial to the quality of life for older adults with disabilities. Reducing disability is also important to avert unnecessary and costly hospitalizations, relocation, or nursing home placements. Few programs reduce disability and few have been replicated and scaled beyond initial research settings. CAPABLE is one such program initially tested in a randomized control trial and has now been tested and replicated in multiple settings. CAPABLE, a 10‐session, home‐based interprofessional program, provides an occupational therapist, nurse, and handyworker to address older adults' self‐identified functional goals by enhancing individual capacity and home environmental supports. We examine evidence for the CAPABLE program from clinical trials embedded in different health systems on outcomes that matter most to older adults with disability. Methods: Six trials with peer‐reviewed publications or reports were identified and included in this review. Participants' outcomes included basic and instrumental activities of daily living (ADLs, IADLs), fall efficacy, depression, pain, and cost savings. Results: A total of 1144 low‐income, community‐dwelling older adults with disabilities and 4236 matched comparators were included in the six trials. Participants were on average ≥74–79 years old, cognitively intact, and with self‐reported difficulty with ≥1 ADLs. All six studies demonstrated improvements in ADLs and IADLs, with small to strong effect sizes (0.41–1.47). Outcomes for other factors were mixed. Studies implementing the full‐tested dose of CAPABLE showed more improvement in ADLS and cost savings than studies implementing a decreased dose. Conclusions: The CAPABLE program resulted in substantial improvements in ADLs and IADLs in all six trials with other outcomes varying across studies. A dose lower than the original protocol tested resulted in less benefit. The four studies examining cost showed that CAPABLE saved more than it costs to implement. See related editorial by Thomas M. Gill. [ABSTRACT FROM AUTHOR]

Background: This project evaluated a model of care integrating evidence‐based dementia rehabilitation strategies into a time‐limited, home‐based, interdisciplinary rehabilitation package: Interdisciplinary Home‐bAsed Reablement Program (I‐HARP). The aims were: to determine I‐HARP effectiveness on functional independence, mobility, quality of life and depression among people with dementia, their home environmental safety, carer burden and quality of life, and I‐HARP cost‐effectiveness; and to evaluate processes, outcomes and influencing factors of the I‐HARP implementation. Method: The project was mixed‐methods action research combining a multi‐centre pragmatic RCT and realist evaluation. I‐HARP was a 4‐month model of care for community‐dwelling people with mild‐moderate dementia and family carers, incorporated into community aged care services and hospital‐based geriatric services in Sydney, Australia (2018‐22) and compared with usual care. Outcome assessments were conducted at baseline, 4‐ and 12‐month. Semi‐structured interviews with participants and focus groups with I‐HARP interventionists and participating site managers occurred post intervention. (ACTRN12618000600246) Result: Of 130 dyads of clients and their carers recruited, 116 dyads (58 per group) completed the trial (89% retention). The I‐HARP group had somewhat better mean results for most outcome measures than usual care at both 4 and 12 months, but the only statistically significant difference was a reduction in home environment hazards at 4 months. Post‐hoc sub‐group analysis of 66 clients with mild‐dementia found significantly better functional independence in the intervention group: 11.2 on Disability Assessment for Dementia (95% CI: 3.4,19.1; p =.005; ES 0.69) at 4 months and 13.7 (95% CI: 3.7,23.7; p =.007; ES 0.69) at 12 months. Preliminary results of economic evaluation pointed to potential benefits of I‐HARP over usual care. Interviews and focus group findings highlighted system and research design barriers (e.g., workforce, hospital system, communication, blinding and recruitment) and program facilitators (focus on enablement, interdisciplinary and teamwork). Conclusion: The I‐HARP model enhanced functional independence of participants with mild‐dementia but not in those with moderate‐dementia, so did not result in better outcomes in the group overall. A different type of rehabilitation model or strategies may be required as dementia becomes more severe. Key facilitators and barriers to I‐HARP implementation provide further insights to developing dementia rehabilitation model of care. [ABSTRACT FROM AUTHOR]

Background: Older adults with visual impairments experience a higher risk of falling, and are more vulnerable to adverse health consequences associated with falls than those with normal vision. This study characterizes longitudinal changes in objectively measured physical activity and fear of falling (FoF) occurring after various types of falls in visually impaired older adults. Design: Prospective cohort study. Setting: Hospital‐based enrollment. Participants: People with glaucoma or suspected glaucoma. Measurements: Falls were defined as unintentionally coming to rest on the ground or a lower level, and injurious falls were determined though follow‐up calls. Study participants were categorized into three groups–fallers with injurious consequences, fallers without injurious consequences, and non‐fallers based on fall status in the first year. Physical activity was assessed by waist‐bound accelerometer. FoF was evaluated by questionnaire, with Rasch modeling generating FoF scores where higher scores reflected worse FoF. The 3‐year longitudinal changes of physical activity and FoF were modeled using mixed‐effects models. Results: In linear models fully adjusted for visual field damage and other covariates, physical activity among injurious fallers showed greater annual (per year) declines in daily steps (−425 steps/d, 95% confidence interval (CI) = −793, −57), daily active minutes (−13 min/d, 95% CI = −21, −6), and daily moderate and vigorous physical activity (MVPA) minutes (−3 MVPA minutes/d, 95% CI = −5, 0) over the 3‐year period as compared to non‐fallers; however, physical activity did not significantly decline among non‐injurious fallers. No longitudinal increases in FoF scores were observed in injurious or non‐injurious fallers when compared to non‐fallers. Conclusion: Among visually impaired older adults, injurious falls identified prospectively over 12 months contributed to a significant decline in physical activity over a 3‐year period, while minimal changes were observed in FoF. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate the effects of a home‐based disability prevention program on life‐space and falls efficacy among low‐income older adults. DESIGN: Single‐blind two‐arm randomized controlled trial. SETTING: Participants' homes. PARTICIPANTS: Participants were low‐income cognitively intact older adults (≥65 years old) with restricted daily activities. Our analytic sample for life‐space (n = 194) and falls efficacy (n = 233) varied as the life‐space measure was introduced 4 months after the trial began. INTERVENTION: Up to six 1‐hour home visits with an occupational therapist; up to four 1‐hour home visits with a registered nurse; and up to $1,300 worth of home repairs, modifications, and assistive devices with a handyman, during a course of 4 months. MEASUREMENTS: Life‐space was measured by the Homebound Mobility Assessment; falls efficacy was measured using the 10‐item Tinetti Falls Efficacy Scale at baseline and 5 months. RESULTS: Participants were on average 75 years old, predominantly Black (86%) and female (85%–86%). Compared with participants in the control group, participants receiving the intervention were more likely to have improved versus decreased life‐space in areas of bathroom (adjusted odds ratio (OR) = 3.95; 95% confidence interval (CI) = 1.20–12.97), front or back porch, patio, or deck (adjusted OR = 2.67; 95% CI = 1.05–6.79), stairs (adjusted OR = 4.09; 95% CI = 1.34–12.48), leaving the house for any reason other than for health care (adjusted OR = 2.40; 95% CI = 1.01–5.73), and overall life‐space (adjusted OR = 2.15; 95% CI = 1.10–4.19). Participants who received the intervention also had an 11% improvement in falls efficacy in performing daily activities (exponentiated coefficient = 1.12; 95% CI = 1.04–1.21). CONCLUSION: Life‐space and falls efficacy were improved through a multicomponent, person‐directed, home‐based disability prevention intervention. Findings suggest that this intervention should be translated into different settings to promote independent aging. [ABSTRACT FROM AUTHOR]

Sleep disruption in older adults living with Alzheimer's disease and related dementias (ADRD) is debilitating and contributes to increased institutionalization, reduced cognitive function, and accelerated disease progression. Furthermore, sleep disruption is linked to poor health outcomes in caregivers, such as decreased quality of life and increased caregiver burden. Given the potentially harmful side effects of pharmacologic treatment, nonpharmacologic approaches, such as music, may provide a safer alternative to reducing sleep disruption in this vulnerable population. A growing body of literature suggests that calming tailored music may improve sleep quality in older adults with memory loss, but its efficacy has not been demonstrated in older adults with ADRD in the community, where most older adults with ADRD live. If shown to be feasible and acceptable, tailored music interventions can then be tested for efficacy in reducing sleep disruption. This protocol details a wait‐list randomized controlled trial (NCT04157244), the purpose of which is to test the feasibility, acceptability, and examine the preliminary efficacy of a tailored music listening intervention in older adults with ADRD who report sleep disruption. Music selections will be tailored to the music genre preferences of older adults with ADRD and account for known sleep‐inducing properties. The feasibility of processes that is key to the success of the subsequent study will be examined. Preliminary efficacy of the intervention will be assessed using objective (actigraphy) and subjective (proxy‐reported) sleep quality measures. In addition, qualitative data will be solicited, examining the acceptability and satisfaction with the intervention by individuals with ADRD. [ABSTRACT FROM AUTHOR]

Objectives: Most persons living with dementia (PLWD) will develop neuropsychiatric symptoms (NPS) at some point. NPS are often clustered into subsyndromes with other related symptoms, but the evidence supporting commonly used clusters is insufficient. We reexamine behavioral clusters in community-dwelling PLWD and identify associated risk factors and potential contributors.Methods: This study used baseline data from a longitudinal behavioral intervention study of 250 community-dwelling older adults with dementia and their caregivers. Using exploratory factor analysis (principal component analysis [PCA]), the factor structure of NPS frequency scores of the Neuropsychiatric Inventory (NPI-C) was evaluated. Multiple linear regressions assessed the association of the derived behavioral clusters with caregiver burden, caregiver depression, and quality of life of the PLWD.Results: PCA yielded eight behavioral clusters (factors): 1 = Aggression/Rejection of Care, 2 = Apathy/Withdrawal, 3 = Restlessness/Agitation, 4 = Anxiety, 5 = Impulsivity/Disinhibition, 6 = Psychosis, 7 = Circadian Disturbance, and 8 = Depression. In multiple linear regressions, caregiver burden was significantly influenced by the anxiety cluster, caregiver depression was significantly influenced by the apathy/withdrawal cluster, and quality of life of the PLWD was significantly associated with the anxiety and circadian disturbance clusters.Conclusions: Our eight derived behavioral clusters suggest that commonly accepted clusters of NPS may not reflect the clinical reality for community-dwelling PLWD. Behavioral clusters appear to differentially impact and put caregivers and PLWD at risk such that personalized intervention strategies are warranted. J Am Geriatr Soc 68:-, 2020. [ABSTRACT FROM AUTHOR]

OBJECTIVE Fear of falling (FoF) may alter mobility in older adults, especially among those with visual impairment. Using a longitudinal prospective cohort of older glaucoma patients, we investigated whether and how FoF is associated with future falls and physical activity. DESIGN Prospective observational cohort study. SETTING Hospital‐based single‐center recruitment. PARTICIPANTS Individuals with glaucoma or suspected glaucoma. MEASUREMENTS FoF was measured annually over a 3‐year period using the University of Illinois at Chicago FoF Questionnaire, with lower Rasch‐analyzed FoF scores (in logit units) indicating less fear. Participants recorded falls prospectively over the 3‐year period using monthly mail‐in calendars. Daily steps were collected annually over 7 days using an accelerometer. Visual field (VF) sensitivity was derived by combining sensitivities from monocular VF results. Participants completed questionnaires to determine other demographic/health characteristics. Multivariate random effects models evaluated within‐participant changes in fall rates and physical activity across study years. RESULTS: At lower FoF levels (FoF≤0), each one‐unit worsening in FoF score across study years was associated with 2.73 times higher odds of reporting at least one fall in the next year (95% confidence interval [CI] = 1.55‐4.81) but was not associated with average daily steps (P =.44). Similar results were seen when fall rates were normalized by number of steps taken (P =.97). At higher FoF levels (FoF > 0), inter‐year changes in FoF scores were not significantly associated with reporting a fall in the following year (P =.78) but were associated with 407 fewer average daily steps per one‐unit change in FoF (95% CI = −743 to −71). CONCLUSION: FoF is an important psychological factor associated with mobility in glaucoma patients, although specific aspects of mobility (fall rates vs activity levels) affected vary by the degree of FoF. Our findings suggest that customizing behavioral interventions for older adults based on their levels of FoF may be an important strategy for fall prevention and activity promotion. J Am Geriatr Soc 68:1847‐1851, 2020. [ABSTRACT FROM AUTHOR]

There are many nonpharmacologic interventions tested in randomized clinical trials that demonstrate significant benefits for people living with Alzheimer's disease (AD) and AD‐related dementia, their care partners, or professional care providers. Nevertheless, with few exceptions, proven interventions have not been translated for delivery in real‐world settings, such as home care, primary care, hospitals, community‐based services, adult day services, assisted living, nursing homes, or other healthcare systems (HCSs). Using embedded pragmatic clinical trial (ePCT) methods is one approach that can facilitate dissemination and implementation (D&I) of dementia care interventions. The science of D&I can inform the integration of evidence‐based dementia care in HCSs by offering theoretical frameworks that capture field complexities and guiding evaluation of implementation processes. Also, D&I science can suggest evidence‐based strategies for implementing dementia care in HCSs. Although D&I considerations can inform each stage of dementia care intervention development, it is particularly critical when designing ePCTs. This article examines fundamental considerations for implementing dementia‐specific interventions in HCSs and how best to prepare for successful dissemination upstream in the context of ePCTs, thereby illustrating the critical role of the D&I Core of the National Institute on Aging Imbedded Pragmatic Alzheimer's Disease and AD‐Related Dementias Clinical Trials Collaboratory. The scientific premise of the D&I Core is that having the "end" in mind, upfront in the design and testing of dementia care programs, can lead to decision‐making that optimizes the ultimate goal of wide‐scale D&I of evidence‐based dementia care programs in HCSs. J Am Geriatr Soc 68:S28–S36, 2020. [ABSTRACT FROM AUTHOR]

From its inception in 1980, advancement of research was one of the primary missions of the Alzheimer's Association (also known as Alzheimer's Disease and Related Disorders Association) in addition to leading in family caregiver support, better care, public education, and awareness. Over the past 30 years, the Association has grown and expanded its engagement with the scientific community. In the past 10 years, its research budget has more than doubled, greatly increasing the number of research grants funded and the number of strategic projects supported. The leadership and members of the Medical and Scientific Advisory Council recognized that the growth of the Alzheimer's Association and the expanded mission of Medical & Scientific Relations Division necessitated a change in the mission and charge of the external scientific advisory function to the Association. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the efficacy of the tailored activity program-outpatient version (TAP-O) and to reduce neuropsychiatric symptoms (NPS) in patients with dementia and caregiver burden compared with a control group (psychoeducation intervention).Methods: Twenty-one persons with dementia and their caregivers were recruited and randomized. The intervention group received TAP-O, designed for outpatients with dementia and their caregivers. TAP-O consisted of eight sessions in which an occupational therapist assessed the patient's abilities and interests; prescribed tailored activities; and educated caregivers about dementia, NPS, and how to implement meaningful activities in the daily routine. The control group received eight sessions of a psychoeducation intervention about dementia and NPS.Results: Compared with controls, patients receiving TAP-O had a significant decrease in hallucination (P = 0.04), agitation (P = 0.03), anxiety (P = 0.02), aggression (P = 0.01), sleep disorder (P = 0.02), aberrant motor behavior (P = 0.02), and in caregiver burden (P = 0.003).Conclusions: Findings suggest that TAP-O may be an effective nonpharmacological strategy to reduce NPS of outpatients with dementia and to minimize caregiver burden. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVE: Adult day services (ADSs) that provide community‐based supervised support for persons with dementia (PWD) may also function as a respite for familial caregivers to attend to self‐care needs. Guided by a revised version of the Andersen Healthcare Utilization Model, the objective of this study was to identify the association between use of ADSs and a missed physician's appointment among family caregivers for community‐dwelling familial PWD. A secondary objective was to identify other predisposing, enabling, and need factors associated with a missed physician's appointment. DESIGN: Secondary analysis of baseline, cross‐sectional data from two randomized controlled trials (Advancing Caregiver Training, n = 272; and Care of Persons With Dementia in Their Environments, n = 237). SETTING: Community. PARTICIPANTS: Community‐dwelling caregivers for PWD (n = 509). MEASUREMENTS: Missed physician's appointment was measured using the caregivers' self‐report of one or more missed physician's appointments (yes/no) in the past 6 months. ADS use was measured using the caregivers' self‐report of ADS use (yes/no). RESULTS: Over a third of the caregivers utilized ADSs for their PWD. Caregivers who utilized ADSs for their familial PWD were 49% less likely (95% confidence interval = 0.32‐0.81) to miss a physician's appointment in the past 6 months. More black compared to white caregivers missed appointments regardless of ADS use. Caregivers with increased chronic health conditions were more likely to miss a physician's appointment compared to those with fewer conditions. CONCLUSION: ADSs' provision of respite enables caregivers the time to address self‐care needs by decreasing the likelihood that caregivers miss a physician's appointment. Findings suggest that ADSs may promote positive health behaviors for caregivers and should be expanded as part of comprehensive dementia care for families. Factors associated with missed physician appointments need further examination and intervention to support black caregivers. [ABSTRACT FROM AUTHOR]

Objective: The relationship of specific dementia-related behaviors to caregiver depression and moderating factors is unclear. We examined the role of rejection of care, aggression, and agitation to caregiver depression and if social support and mastery independently moderated associations.Methods: The method used was a cross-sectional, secondary analysis using baseline data from two community-based clinical trials. We examined frequency of occurrence of presenting behaviors and their combinations in persons with dementia. Multiple logistic regression analyses examined associations between nonoverlapping behavioral clusters (agitation alone, agitation + rejection, agitation + aggression, and agitation + rejection + aggression) and caregiver depression. Multiple logistic regression with interaction terms was also used to investigate whether social support or caregiver mastery moderated the relationship between behavioral symptom clusters and caregiver depression.Results: Three of four symptom clusters (all three behaviors [adjusted odds ratio (AOR) = 2.22; 95% CI, 1.02-4.83], agitation + rejection of care [AOR = 2.55; 95% CI, 1.06-6.13], and agitation + aggression [AOR = 2.63; 95% CI, 1.17-5.89]) had a positive association with caregiver depression, whereas agitation alone was not significantly associated with caregiver depression. Neither social support nor mastery significantly moderated the relationship between these three behavioral clusters and caregiver depression.Conclusion: Caregiver depression was associated with different combinations of behaviors but not with agitation alone. These results have implications for intervention development and identifying caregivers at risk for depression. Level of social support and mastery does not appear to moderate impact on caregiver depression. [ABSTRACT FROM AUTHOR]

This commentary comments on the article by Janice Bell et al. [ABSTRACT FROM AUTHOR]

Background: Despite a large literature on the stress process, little attention has focused on how caregivers for persons living with dementia (PLWDs) provide care and how this may impact care outcomes. Criticism is a management strategy caregivers may use to respond to behavioral symptoms. We consider whether criticism is associated with caregivers' mental health and service utilization.Methods: Data are drawn from the Advancing Caregiver Training intervention study including 256 informal caregivers living with a PLWD. In multiple linear regressions controlling for caregivers' demographics and PLWDs' clinical factors, we consider criticism (criticism subscale of the Dementia Management Strategies Scale) as a predictor of caregiver burden, depressive symptoms, desire to institutionalize the PLWD, level of frustration with care, and the number of home-based, social, and health services utilized.Results: On average, 15% of the sample sometimes reported using criticism as a management strategy to manage the challenges of care. Greater use of criticism was associated with significantly more caregiver burden (β = 0.26, P < 0.001) and frustration with caregiving (β = 0.66, P < 0.001), but not depressive symptoms or a desire to institutionalize the PLWD. Criticism was also associated with significantly greater utilization of home-based (β = 0.14, P < 0.05) and social services (β = 0.15, P < 0.05), but not health care services.Conclusion: Criticism appears to be used by more burdened and frustrated caregivers. The association of criticism with social and home-based services potentially reflects a need for greater support among this group of caregivers. Behavioral interventions that can help caregivers manage behavioral symptoms with positive, empirically validated strategies may be helpful. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: Of older adults, 42% report problems with daily function, and physical function is the most important consideration for aging individuals. Thus, we implemented a model of care focused on improving physical function and examined health and use outcomes and satisfaction. DESIGN: A 3‐year participatory, single‐group pretrial/posttrial benchmarked to a usual care cohort that was evaluated prior to the study. SETTING: Four Medicaid home and community‐based waiver sites in Michigan. PARTICIPANTS: The participants included 34 clinicians and 270 Medicaid beneficiaries 50 years and older. INTERVENTION: Community Aging in Place, Advancing Better Living for Elders (CAPABLE), an evidence‐based model of care that improved physical function in older adults, was implemented using evidence‐based strategies. MEASUREMENT: Characteristics (age, race, and sex), health outcomes (comorbidities, instrumental/activities of daily living [I/ADLs], pain, depression, and falls), and emergency department and hospitalization visits preintervention/postintervention and in the usual care cohort were examined. We also measured Medicaid beneficiary's satisfaction with care for those who received CAPABLE. RESULTS: Improved mean ± SD ADLs (preintervention, 8.51 ± 3.08; postintervention, 7.80 ± 2.86; P =.01) and IADLs (preintervention, 6.43 ± 1.31; postintervention, 5.62 ± 1.09; P <.01), a decrease in falls by 14% (from 34.8% preintervention to 20.8% postintervention; P <.01), and fewer hospitalizations (from 0.43 ± 1.51 preintervention to 0.23 ± 0.60 postintervention; P =.03) were found. Post‐CAPABLE means were significantly better compared with a usual care cohort for IADLs (6.73 ± 1.27; P <.01) and hospitalizations (0.47 ± 2.66; P <.01). Satisfaction with care was high, and 98.1% recommended CAPABLE as a way to help remain living in the community. CONCLUSION: Improved ADLs and IADLs, a reduction in fall rates, fewer hospitalizations, and high satisfaction with care occurred in this population as a result of the use of CAPABLE. CAPABLE may be one solution to helping vulnerable, low‐income older adults with poor physical function to remain living in the community. J Am Geriatr Soc 67:363–370, 2019. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether visual field (VF) damage or other factors confer a similar risk of falling when falls are ascertained as a rate over time (falls/year) as when ascertained over activity (falls/step). Design: Prospective, observational cohort study. Setting: Clinic‐based recruitment with real‐world monitoring of falls and physical activity. Particpants: Individuals with glaucoma or suspected glaucoma (N=230). Measurements: Participants recorded falls using daily calendars, with injuries identified in a follow‐up questionnaire. Annual 1‐week accelerometer trials were used to estimate steps. VF results from both eyes were merged to determine integrated VF sensitivity, with lower sensitivity indicating greater VF damage. Other potential risk factors for falls (age, sex, race, comorbid illness, polypharmacy) were determined using questionnaires. Results: The cumulative probability of falls was 45.2% at 12 months and 61.6% at 24 months; cumulative probability of injurious falls was 23.3% at 12 months and 40.0% at 24 months. Greater VF damage was associated with higher rates of falls/steps (incident rate ratio = 1.40/5 dB decrement in sensitivity; p =.004) but not with more falls/year (incident rate ratio = 1.25/5 dB decrement in sensitivity; p =.07). Several additional variables (older age, female sex, more comorbid disease) were also associated with a higher rate of falls/step (p <.02 for all) but not with falls/year (p > 0.10). Black participants had fewer falls/year than whites (p =.002) but did not differ in falls/step (p =.07). Similar results were obtained when injurious falls were analyzed. Conclusions: Risk factors associated with frequent falls when walking (falls/step) are not properly identified when analyzing falls as a rate over time (falls/year). Given the clinical importance of preventing falls while preserving physical activity, falls assessment integrated with activity measurement is recommended when determining whether a risk factor is associated with falls. J Am Geriatr Soc 67:87–92, 2019. [ABSTRACT FROM AUTHOR]

Background: The Good Life Model is an evidence‐informed service extension program that seeks to improve the quality of daily life for people living with dementia (PLWD) and their caregivers through an integrated, replicable health professional learning service approach. To provide this service, caregivers referred from a neurology clinic are matched to Dementia Ambassadors (DAs), nursing and health profession faculty and graduate students who are trained in family‐centric and nonpharmacological approaches. DAs serve as coaches to telephonically provide disease education, referrals and linkages, support and skills in managing caregiver‐identified care challenges. Good Life offers a service‐learning approach for developing a workforce that is prepared to care for families living with dementia, while improving the quality of daily life for both people living with dementia and their caregivers. Methods: DAs involve various health professionals and students and receive training tailored to their level of expertise in dementia care. Regardless of dementia expertise, key competencies include 1) knowledge about dementia types and etiologies, 2) core clinical signs (e.g., behavioral and psychological symptoms, cognitive and functional decline), 3) knowledge of caregiver experiences, 4) ability to assess care challenges and serve as a coach, and 5) ability to rapidly develop rapport and engage in active listening. Caregivers receive support through bimonthly one hour telephone sessions for up to 12 sessions over 6 months. Biweekly case debriefings provide ongoing oversight and support for DAs. Results: To date, 36 caregivers have been referred, with 19 enrolled having completed 123 sessions. Of the 8 caregivers who have completed the 6 month program, all have elected to continue optional post‐program sessions. Conclusions: In providing access and support to underserved populations with a nonpharmacological phone intervention, Good Life demonstrates not only the need for service extension practices as part of standard dementia care to support PLWD and caregivers, but highlights the importance of preparing a workforce to help caregivers manage challenges. Furthermore, caregivers to date having unanimously elected to continue post‐program sessions attests to the rapid and powerful relationship developed between DAs trained in these practices and the caregivers who gain value from participating. [ABSTRACT FROM AUTHOR]

Background: With COVID‐19, online opportunities to support families living with dementia are becoming increasingly important. However, academic institutions are typically not prepared to develop and test online platforms. We present a case study to describe steps for creating an infrastructure to test an online platform, WeCareAdvisor (WCA). WCA provides caregivers disease education and tailored strategies to manage dementia‐related behavioral symptoms using the DICE Approach. WCA was previously tested in a small, randomized trial demonstrating positive caregiver outcomes. To advance its evidence‐base, WCA is being tested in a NIA‐funded Stage III efficacy trial with a national sample of 326 caregivers. Method: To test WCA, an infrastructure in the academic institution had to be created to address HIPAA compliance, privacy considerations, integrate user and developer input, and support rigorous trial methodologies. Through key informant interviews and literature reviews, we established a six‐step process: 1) Identifying and engaging key stakeholders (legal, Information Technology offices, research team, software company); 2) Creating software development agreement with stakeholder input; 3) Detailing scope of work and an oversight structure of software company, 4) Developing formal agreements with the software company, 5) Conducting security assessments with university IT offices; and 6) Establishing formal vendor status of the software company. This also necessitated new roles and responsibilities of research team members. Result: The six‐step process was labor intensive, transpired over 12 months, and involved over 15 iterative meetings with investigators, project staff, and stakeholders. Careful coordination of stakeholders to provide practical and iterative guidance at each of the six steps was essential. Deliberations resulted in app store access, URLs and domains, and compliance and privacy statements reviewed and approved by various university offices, and then launching WCA on app stores for access by study participants. Conclusion: Researchers and academic institutions have varying levels of understanding and readiness to engage in infrastructure development to rigorously test online platforms. Our approach resulted in an effective infrastructure for testing WCA which can be used by other researchers. Development of an infrastructure requires new skills for investigators, engaging multiple stakeholders, appropriately budgeting for this activity, and allocating sufficient start‐up time. [ABSTRACT FROM AUTHOR]

Background/Objectives: Little is known about cost savings of programs that reduce disability in older adults. The objective was to determine whether the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program saves Medicaid more money than it costs to provide. Design: Single‐arm clinical trial (N = 204) with a comparison group of individuals (N = 2,013) dually eligible for Medicaid and Medicare matched on baseline geographic and demographic characteristics, chronic conditions, and healthcare use. We used finite mixture model regression estimates in a Markov model. Setting: Baltimore, MD Participants: Individuals aged 65 and older with reported difficulty with at least one activity of daily living. Intervention: CAPABLE is a 5‐month program to reduce the health effects of impaired physical function in low‐income older adults by addressing individual capacity and the home environment. CAPABLE uses an interprofessional team (occupational therapist, registered nurse, handyman) to help older adults attain self‐identified functional goals. Measurements: Monthly average Medicaid expenditure and likelihood of high‐ or low‐cost use of eight healthcare service categories. Results: Average Medicaid spending per CAPABLE participant was $867 less per month than that of their matched comparison counterparts (observation period average 17 months, range 1–31 months). The largest differential reduction in expenditures were for inpatient care and long‐term services and supports. Conclusion: CAPABLE is associated with lower likelihood of inpatient and long‐term service use and lower overall Medicaid spending. The magnitude of reduced Medicaid spending could pay for CAPABLE delivery and provide further Medicaid program savings due to averted services use. Clinical trial registration: CAPABLE for Frail dually eligible older adults NCT01743495 https://clinicaltrials.gov/ct2/show/NCT01743495 [ABSTRACT FROM AUTHOR]

Background/Objectives: Dementia‐related behavioral symptoms and functional dependence result in poor quality of life for persons with dementia and their caregivers. The goal was to determine whether a home‐based activity program (Tailored Activity Program; TAP‐VA) would reduce behavioral symptoms and functional dependence of veterans with dementia and caregiver burden. Design: Single‐blind (interviewer), parallel, randomized, controlled trial (Clinicaltrials.gov: NCT01357564). Setting: Veteran's homes. Participants: Veterans with dementia and their family caregivers (N = 160 dyads). Intervention: Dyads in TAP‐VA underwent 8 sessions with occupational therapists to customize activities to the interests and abilities of the veterans and educate their caregivers about dementia and use of customized activity. Caregivers assigned to attention control received up to 8 telephone‐based dementia education sessions with a research team member. Measurements: Primary outcomes included number of behaviors and frequency of their occurrence multiplied by severity of occurrence; secondary outcomes were functional dependence, pain, emotional well‐being, caregiver burden (time spent caregiving, upset with behaviors) and affect at 4 (primary endpoint) and 8 months. Results: Of 160 dyads (n = 76 TAP‐VA; n = 84 control), 111 completed 4‐month interviews (n = 51 TAP‐VA; n = 60 control), and 103 completed 8‐month interviews (n = 50 TAP‐VA; n = 53 control). At 4 months, compared to controls, the TAP‐VA group showed reductions in number (difference in mean change from baseline = −0.68, 95% CI = −1.23 to −0.13) and frequency by severity (−24.3, 95% CI = −45.6 to −3.1) of behavioral symptoms, number of activities needing assistance with (−0.80, 95% CI = −1.41 to −0.20), functional dependence level (4.09, 95% CI = 1.06, 7.13), and pain (−1.18, 95% CI = −2.10 to −0.26). Caregivers of veterans in TAP‐VA reported less behavior‐related distress. Benefits did not extend to 8 months. Conclusion: TAP‐VA had positive immediate effects and no adverse events. Because TAP‐VA reduces behavioral symptoms, slows functional dependence, and alleviates pain and caregiver distress, it is a viable treatment option for families. [ABSTRACT FROM AUTHOR]

Objective: To investigate effects of a novel dementia care coordination program on health services utilization.Data Sources/study Setting: A total of 303 community-dwelling adults aged ≥70 with a cognitive disorder in Baltimore, Maryland (2008-2011).Study Design: Single-blind RCT evaluating efficacy of an 18-month care coordination intervention delivered through community-based nonclinical care coordinators, supported by an interdisciplinary clinical team.Data Collection/extraction Methods: Study partners reported acute care/inpatient, outpatient, and home- and community-based service utilization at baseline, 9, and 18 months.Principal Findings: From baseline to 18 months, there were no significant group differences in acute care/inpatient or total outpatient services use, although intervention participants had significantly increased outpatient dementia/mental health visits from 9 to 18 months (p = .04) relative to controls. Home and community-based support service use significantly increased from baseline to 18 months in the intervention compared to control (p = .005).Conclusions: While this dementia care coordination program did not impact acute care/inpatient services utilization, it increased use of dementia-related outpatient medical care and nonmedical supportive community services, a combination that may have helped participants remain at home longer. Future care model modifications that emphasize delirium, falls prevention, and behavior management may be needed to influence inpatient service use. [ABSTRACT FROM AUTHOR]

Objective: Dementia-related restlessness is commonly endorsed by caregivers but not well understood. This study examines differences in characteristics (demographics, cognitive status, physical function, pain, and mood) of persons with dementia whose caregivers endorse restlessness versus those who do not. We also examine the relationship of restlessness to caregiver well-being including burden, upset with behaviors, mastery, and depressive symptomatology.Methods: We combined baseline data from three caregiver intervention studies of community-dwelling persons with dementia who exhibited neuropsychiatric symptoms (n = 569) as measured by the Agitated Behaviors in Dementia Scale. We conducted bivariate correlations and independent t-tests by using the Agitated Behaviors in Dementia Scale restlessness item.Results: Nearly 65% (n = 367) of dementia caregivers reported restlessness. There were no significant differences between those with and without (n = 202) reported restlessness concerning functional status (physical or cognitive). However, persons with restlessness had significantly higher pain scores (p < 0.01), were more likely to be on behavioral medications (p < 0.001), and had more neuropsychiatric symptoms as compared with persons without restlessness (M = 11.11, nonrestless; M = 6.61, restless) (p < 0.001). Caregivers of persons with dementia-related restlessness reported greater burden (p < 0.001), behavioral upset (p < 0.001), depression (p < 0.001), and lower mastery providing care (p < 0.01) compared with caregivers of persons without dementia-related restlessness.Conclusions: Restlessness is a common neuropsychiatric symptom that appears to be associated with poorer functioning in persons with dementia and greater distress in their caregivers. Further research is needed to understand the unique contributions of restlessness to care burden and quality of life of persons with dementia, as well as ways to address this distressing symptom. Copyright © 2017 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective: Previously, we showed that Get Busy Get Better (GBGB), a 10-session multicomponent home-based, behavioral intervention, reduced depressive symptom severity in older African Americans. As appraising the value of life is associated with depressive symptoms, this study examined whether GBGB enhanced positive appraisals of life and if, in turn, this mediated treatment effects on depressive symptoms.Methods: Data were from a single-blind parallel randomized trial involving 208 African Americans (≥55 years old) with depressive symptoms (Patient Health Questionnaire, PHQ-9 ≥5). GBGB involved five components: care management, referral/linkage, stress reduction, depression education, and behavioral activation. A 13-item Valuation of Life (VOL) scale with two subfactors (optimism and engagement) was examined as an outcome and as mediating GBGB effects on PHQ-9 scores at 4 months.Results: Of 208 enrolled African Americans, 180 completed the 4-month interview (87 = GBGB; 93 = control). At 4 months, compared with wait-list control group participants, the GBGB group had improved VOL (difference in mean changes from baseline = 4.67, 95% confidence interval 2.53, 6.80). Structural equation models indicated that enhanced VOL mediated a significant proportion of GBGB's impact on depressive symptoms, explaining 71% of its total effect, and its subfactors (optimism, explaining 67%; engagement, 52%).Conclusion: Valuation of Life appears malleable through an intervention providing resources and activation skills. GBGB's impact on depressive symptoms is attributed in large part to participants' enhanced attachment to life. Attention to VOL as mediator and outcome and the reciprocal relationship between mood and attachment to life is warranted. Copyright © 2017 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Introduction: A national consensus panel was convened to develop recommendations on future directions for home‐based dementia care (HBDC). Methods: The panel summarized advantages and challenges of shifting to HBDC as the nexus of care and developed consensus‐based recommendations. Results: The panel developed five core recommendations: (1) HBDC should be considered the nexus of new dementia models, from diagnosis to end of life in dementia; (2) new payment models are needed to support HBDC and reward integration of care; (3) a diverse new workforce that spans the care continuum should be prepared urgently; (4) new technologies to promote communication, monitoring/safety, and symptoms management must be tested, integrated, and deployed; and (5) targeted dissemination efforts for HBDC must be employed. Discussion: HBDC represents a promising paradigm shift to improve care for those living with dementia and their family caregivers: these recommendations provide a framework to chart a course forward for HBDC. Highlights: Five core BrightFocus Foundation panel recommendations:Home‐based dementia care should be considered the nexus of new long‐term care models.New payment models are needed to stimulate, reward, and support home care practices.A skilled new workforce spanning long‐term care needs to be developed and equipped.New technologies to promote best practices must be tested, integrated, and deployed.Value propositions and improved public health communication are needed. [ABSTRACT FROM AUTHOR]

Objective: Cognitive impairment poses communication challenges in primary care. Although family "companions" commonly attend primary care visits of older adults with cognitive impairment, little is known about how their involvement affects communication. Therefore, we sought to understand how companion involvement affects the quality of primary care visit communication for older adults with cognitive impairment.Methods: Cross-sectional, descriptive qualitative study participants were as follows: (1) English-speaking adults age 65 or older with mild, moderate, or severe cognitive impairment; (2) family members or other unpaid companions who accompany older adults to primary care visits; and (3) primary care clinicians. Twenty semi-structured and in-depth qualitative interviews of older adults and their companions (N = 20 dyads) and two focus groups (N = 10 primary care clinicians) were conducted. Interviews and focus groups were transcribed and analyzed thematically.Results: Family companions commonly facilitate communication by advocating for patients, ensuring the accuracy of information exchange and understanding, and preserving rapport. Significant communication challenges were also identified, including patient and companion role ambiguity, competing visit agendas, and primary care clinician confusion regarding the most accurate source of information. Patients, companions, and clinicians each identified strategies to improve communication, chief among them being to identify, differentiate, and respect both patient and companion priorities and perspectives.Conclusions: Family companions actively participate in primary care visits of older adults with cognitive impairment in ways that promote and inhibit effective communication. Findings suggest the need for strategies that more effectively and purposefully involve family in the care of primary care patients with cognitive impairment. Copyright © 2017 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective: Few instruments evaluate family caregiver perceptions of challenges caring for persons with dementia and improvement or worsening in these areas. To address this measurement gap, we examine psychometric properties of a Spanish version of the 13-item Perceived Change Index (PCI-S), originally validated with English-speaking caregivers.Methods: Cross-sectional study with 94 caregivers of persons with mild to moderate dementia in Chile. Interviews included caregiver demographics, burden, health perception, distress with behaviours, dementia severity, behavioural symptoms and functionality.Results: Caregiver mean age was 55.9 (SD ± 14.14) years and mean years caregiving was 3 (SD ± 2.60). The scale had strong internal consistency (Cronbach α = 0.94), and inter-observer consistency (CCI = 0.99; 95% CI = 0.95-0.99). Two factors were identified: Management skills (α = 0.89), and somatic well-being and affects (α = 0.92), explaining 63% of scale variance. Significant associations supporting convergent validity were observed for PCI-S and subscales with caregiver burden (p < 0.01), health perceptions (p < 0.01), depressive symptoms (p < 0.01) and distress with behaviours (p < 0.01); and in persons with dementia, functionality (p < 0.05), dementia severity (p < 0.05) and behavioural symptoms (p < 0.01) in expected directions. In logistic regression models, perceived worsening (PCI-S and subscale scores) was associated with more behavioural symptoms (OR = 1.07; 95% CI = 1.03-1.15) and caregiver burden (OR = 1.48; 95% CI = 1.18-1.86); whereas perceived improvement was associated with higher physical functioning (OR = 0.95; 95% CI = 0.91-0.99) in persons with dementia. PCI-S scores were not associated with socio-demographic characteristics reflecting divergent validity.Conclusions: Spanish version of the 13-item Perceived Change Index and its two-factor solution is a valid and reliable measure with clinical utility to detect improvement or worsening in caregivers concerning daily care challenges. Copyright © 2017 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: The Tailored Activity Program (TAP) is a nonpharmacological approach shown to reduce neuropsychiatric symptoms and other dementia‐related clinical symptoms in people living with dementia and family caregivers. Method: TAP has been tested in 8 different randomized trials (stage 3 efficacy) in four different countries and is currently used in over 9 countries with varying results. Result: Across 8 trials, TAP was found to have a wide range of benefits including reducing functional dependence and neuropsychiatric symptoms, improving quality of life of both people living with dementia and their caregivers, and enhancing caregiver well‐being. Findings from trials also demonstrate differences in outcomes among samples. For example in a USA trial involving 250 families, TAP compared to attention control resulted in differential effects for Black and White families. Statistically and clinically significant reductions in agitation and aggression (frequency and severity scores) were found for Black families in TAP compared to White families in TAP and those in the control group. In contrast, White caregivers receiving TAP reported less depressive symptoms than other groups. Conclusion: Comparing outcomes across trials highlights the role of contextual factors and how country specific needs for dementia care may impact outcomes from nonpharmacological interventions. The comparison also reveals multiple challenges concerning dissemination and implementation of TAP (stage 4 and 5) such as lack of workforce preparation, payment mechanisms, and knowledge and acceptability of nonpharmacological approaches. [ABSTRACT FROM AUTHOR]

Objectives To determine whether an enhanced occupational therapy discharge planning intervention that involved pre- and postdischarge home visits, goal setting, and follow-up (the HOME program) would be superior to a usual care intervention in which an occupational therapy in-hospital consultation for planning and supporting discharge to home is provided to individuals receiving acute care. Design Randomized controlled trial. Setting Acute and medical wards. Participants Individuals aged 70 and older (N = 400). Measurements Primary outcomes: activities daily living ( ADLs; Nottingham Extended Activities of Daily Living) and participation in life roles and activities (Late Life Disability Index ( LLDI)). Results Occupational therapist recommendations differed significantly between groups ( P < .001) ( HOME n = 892 recommendations; control n = 329 recommendations). There was no difference between groups in ADLs (Nottingham Extended Activities of Daily Living scale ( NEADL): β = −0.17, 95% confidence interval ( CI) = −0.99-0.66) or participation ( LLDI-Frequency: β = −0.23, 95% CI = −2.05-1.59; LLDI-Limitation: β = −0.14, 95% CI = −2.86-2.58). Both groups maintained prehospital functional status at 90 days, and there was no difference between groups in the number of people with unplanned readmissions ( HOME 23.5%, n = 43; control 21.9%, n = 37). When groups were combined, being male ( P = .03) or having lower perceived participation because of physical problems ( P = .04) resulted in higher risk of unplanned readmissions. Conclusion HOME discharge planning, which had a strong emphasis on task modification, well-being, and prevention strategies, implemented twice as many occupational therapy recommendations as the in-hospital only consultation, which had a greater emphasis on equipment provision, but HOME did not demonstrate greater benefit in global measures of ADLs or participation in life tasks than in-hospital consultation alone. It is not recommended that home visits be conducted routinely as part of discharge planning for acutely hospitalized medical patients. Further work should develop guidelines for quality in-hospital consultation. [ABSTRACT FROM AUTHOR]

Background: Previous research shows that nonpharmacological strategies may effectively manage behavioral symptoms (agitation, wandering) in persons with dementia and improve caregiver wellbeing. However, strategies depend upon caregivers for their implementation. We examine the impact of caregiver readiness to use nonpharmacological strategies on treatment outcomes.Methods: Data were from a randomized trial involving 110 family caregivers in the treatment group which received nonpharmacologic strategies for managing behavioral symptoms. Interventionists rated caregiver readiness to use nonpharmacologic strategies as pre-action (precontemplation, contemplation, preparation) or action at treatment initiation and conclusion. Caregivers in pre-action and action stages by treatment conclusion (16 weeks) were compared on proximal (frequency of, and caregiver upset and confidence with targeted behaviors) and more distal (caregiver burden and wellbeing) outcomes at 16 and 24-week follow-ups.Results: By treatment conclusion, 28.2% (n = 31) and 71.8% (n = 79) of caregivers were rated at pre-action and action respectively. Means for proximal outcomes differed between the groups at 16 and 24 weeks; those at action showed greater improvement on all proximal and distal outcomes. Hierarchical regressions showed significant relationships of readiness to targeted outcomes. By 24 weeks, caregiver readiness predicted lower frequency estimates of targeted behaviors (β = -.180, p = .041) and higher confidence (β = .27, p = .009). Readiness was not a significant predictor of caregiver burden and wellbeing at 16 or 24 weeks.Conclusion: By treatment conclusion, >25% of participants were not activated to use nonpharmacologic strategies. Activated caregivers reported greater decline in distressing behavioral symptoms, and more confidence than non-activated participants. Activation is needed to impact behavioral management but not other caregiver outcomes. Copyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives To determine whether there are racial and ethnicity group differences in Resources for Enhancing Alzheimer's Caregiver Health ( REACH II) intervention delivery. Design Randomized controlled trial. Setting Community-based intervention delivered at five sites across the United States. Participants Family caregivers of persons with dementia who were randomized to the active intervention condition (N = 323). Intervention Nine in-home sessions (90 minutes each) and three telephone sessions (30 minutes each) were intended to be delivered and designed to reduce caregiver burden and depression, improve caregiver self-care and social support, and help caregivers manage behavior problems in persons with dementia. Measurements Interventionists recorded the type of intervention (home or telephone), start and stop times, and whether specific intervention content modules (e.g., stress management, social support) were administered in each session. Results Overall, REACH II intervention delivery was high, with more than 80% of randomized caregivers completing at least five in-home sessions and receiving eight or more hours of intervention contact, but black caregivers completed fewer in-home sessions (mean 6.98) than Hispanics (mean 7.84) or whites (mean 8.25) and received less total intervention contact time (mean 683 minutes) than Hispanics (mean 842 minutes) or whites (mean 798 minutes). No significant differences in exposure to content according to race or ethnicity were found after controlling for demographic covariates. Conclusion Blacks in REACH II received significantly less intervention contact. Similar multicomponent interventions should examine whether there are systematic differences in intervention delivery across specific demographic subgroups and explore implications for treatment outcomes. [ABSTRACT FROM AUTHOR]

Background: Traumatic brain injury (TBI) creates many challenges for families as well as for patients. Few intervention studies have considered both the needs of the person with TBI and his or her family and included both in the intervention process. To address this gap, we designed an innovative intervention for veterans with TBI and families-the Veterans' In-home Program (VIP)-targeting veterans' environment, delivered in veterans' homes, and involving their families.Objectives: To determine whether the VIP is more effective than standard outpatient clinic care in improving family members' well-being in 3 domains (depressive symptoms, burden, and satisfaction) and to assess its acceptability to family members.Design: In this randomized controlled trial, 81 dyads (veteran/family member) were randomly assigned to VIP or an enhanced usual care control condition. Randomization occurred after the baseline interview. Follow-up interviews occurred 3-4 months after baseline, and the interviewer was blinded to group assignment.Setting: Interviews and intervention sessions were conducted in veterans' homes or by telephone.Participants: A total of 81 veterans with TBI recruited from a Veterans Affairs (VA) polytrauma program and a key family member for each participated. Of the 81 family members, 63 completed the follow-up interview.Intervention: The VIP, guided by the person-environment fit model, consisted of 6 home visits and 2 telephone calls delivered by occupational therapists over a 3- to 4-month period. Family members were invited to participate in the 6 home sessions.Main Outcome Measures: Family member well-being was operationally defined as depressive symptomatology, caregiver burden, and caregiver satisfaction 3-4 months after baseline. Acceptability was operationally defined through 3 indicators.Results: Family members in the VIP showed significantly lower depressive symptom scores and lower burden scores when compared to controls at follow-up. Satisfaction with caregiving did not differ between groups. Family members' acceptance of the intervention was high.Conclusions: VIP represents the first evidence-based intervention that considers both the veteran with TBI and the family. VIP had a significant impact on family member well-being and thus addresses a large gap in previous research and services for families of veterans with TBI. [ABSTRACT FROM AUTHOR]

Current medical models frequently overlook functional limitations and the home environment even though they partially determine healthcare usage and quality of life. The Centers for Medicare and Medicaid Services ( CMS) Innovation Center funds projects that have potential to affect the 'triple aim,' a framework for decreasing costs while improving health and quality of life. This article presents preliminary data from Community Aging in Place, Advancing Better Living for Elders ( CAPABLE), a model funded by the CMS Innovation Center and designed to overcome the functional and home environmental barriers of older adults. CAPABLE is a patient-directed, team-based intervention comprising an occupational therapist, a registered nurse, and a handyman to decrease hospitalization and nursing home usage of community-dwelling older adults with functional limitations who are dually eligible for Medicare and Medicaid. Activity of daily living limitations improved in 79% of the first 100 people who completed the intervention. Preliminary findings of this novel intervention may have implications for other older adults with functional limitations. [ABSTRACT FROM AUTHOR]

Objectives To determine factors mediating the effects of a depression intervention for older African Americans on functional disability and, secondarily, whether functional improvements mediate intervention effects on depressive symptoms. Design Structural equation modeling to examine mediators in a secondary analysis of a randomized trial with 4-month follow-up. Setting Philadelphia region. Participants Community-dwelling African Americans (≥55) with depressive symptoms living in an urban area (N = 208). Intervention Up to 10 one-hour sessions over 4 months conducted by licensed social workers who provided care management, referrals and linkages, stress reduction techniques, depression knowledge and symptom recognition, and behavioral activation techniques. Measurements Main outcome was self-reported functional difficulty level for 18 basic activities. Mediators included depression severity (Patient Health Questionnaire), depression knowledge and symptom recognition, behavioral activation, and anxiety. Results At 4 months, the intervention had positive effects on functional difficulty and all mediators ( P < .001). Separate structural equation models indicated that two factors (reduced depressive symptoms (23.5% mediated) and improved depression knowledge and symptom recognition (52.9% mediated)) significantly mediated the intervention's effect on functional disability. Enhancing behavioral activation and decreasing anxiety were not found to mediate improvements in functional disability. The two significant mediators jointly explained 62.5% of the intervention's total effect on functional disability. Functional improvement was not found to mediate the intervention's effect on depressive symptoms. Conclusion This multicomponent depression intervention for African Americans has an effect on functional disability that is driven primarily by enhancing symptom recognition and decreasing depressive symptoms. Reduction of functional difficulties did not account for improvements in depressive symptoms. Nonpharmacological treatments for depressive symptoms that enhance symptom recognition in older African Americans can also reduce their functional difficulties with daily living activities. [ABSTRACT FROM AUTHOR]

Objectives To test the cost-effectiveness of a home-based depression program: Beat the Blues ( BTB). Design A cost-effectiveness analysis as part of a previously reported randomized controlled trial that compared BTB with a wait-list control group. Setting Community. Participants English-speaking, cognitively intact (Mini-Mental State Examination score ≥24), African Americans aged 55 and older with depressive symptoms (Patient Health Questionnaire score ≥5) (N = 129). Intervention Participants randomly assigned to BTB received up to 10 home visits over 4 months from licensed social workers who provided care management, referral and linkage, stress reduction, depression education, and behavioral activation to help participants achieve self-identified goals. Measurements Incremental cost-effectiveness ratios ( ICERs) of BTB versus wait-list controls during the 4-month study period. The primary ICER was defined as cost per quality-adjusted life year ( QALY) using the Euro Quality of Life 5D ( EQ-5D) and secondarily using the Health Utilities Index-3 ( HUI-3). Additional ICERs were calculated using clinical measures (cost per depression improvement, cost per depression remission). Costs included BTB intervention, depression-related healthcare visits and medications, caregiver time, and social services. Results BTB cost per participant per month was $146. Base case ICERs were $64,896 per QALY ( EQ-5D) and $36,875 per QALY ( HUI-3). Incremental cost was $2,906 per depression improvement and $3,507 per remission. Univariate and probabilistic sensitivity analyses yielded a cost/ QALY range of $20,500 to $76,500. Conclusion Based on the range of cost-effectiveness values resulting from this study, BTB is a cost-effective treatment for managing depressive symptoms in older African Americans that compares favorably with the cost-effectiveness of previously tested approaches. [ABSTRACT FROM AUTHOR]

Noncognitive neuropsychiatric symptoms ( NPS) of dementia (aggression, agitation, depression, anxiety, delusions, hallucinations, apathy, disinhibition) affect individuals with dementia nearly universally across dementia stages and etiologies. NPS are associated with poor outcomes for individuals with dementia and caregivers, including excess morbidity and mortality, greater healthcare use, and earlier nursing home placement, as well as caregiver stress, depression, and difficulty with employment. Although the Food and Drug Administration has not approved pharmacotherapy for NPS, psychotropic medications are frequently used to manage these symptoms, but in the few cases of proven pharmacological efficacy, significant risk of adverse effects may offset benefits. There is evidence of efficacy and limited potential for adverse effects of nonpharmacological treatments, typically considered first line, but their uptake as preferred treatments remains inadequate in real-world clinical settings. Thus, the field currently finds itself in a predicament in terms of management of these difficult symptoms. It was in this context that the University of Michigan Program for Positive Aging, working in collaboration with the Johns Hopkins Alzheimer's Disease Research Center and Center for Innovative Care in Aging sponsored and convened a multidisciplinary expert panel in Detroit, Michigan, in fall 2011 with three objectives: to define critical elements of care for NPS in dementia; to construct an approach describing the sequential and iterative steps of managing NPS in real-world clinical settings that can be used as a basis for integrating nonpharmacological and pharmacological approaches; and to discuss how the approach generated could be implemented in research and clinical care. [ABSTRACT FROM AUTHOR]

Professional and advocacy organizations have long urged that dementia should be recognized and properly diagnosed. With the passage of the National Alzheimer's Project Act in 2011, an Advisory Council for Alzheimer's Research, Care, and Services was convened to advise the Department of Health and Human Services. In May 2012, the Council produced the first National Plan to address Alzheimer's disease, and prominent in its recommendations is a call for quality measures suitable for evaluating and tracking dementia care in clinical settings. Although other efforts have been made to set dementia care quality standards, such as those pioneered by RAND in its series Assessing Care of Vulnerable Elders ( ACOVE), practitioners, healthcare systems, and insurers have not widely embraced implementation. This executive summary (full manuscript available at ) reports on a new measurement set for dementia management developed by an interdisciplinary Dementia Measures Work Group ( DWG) representing the major national organizations and advocacy organizations concerned with the care of individuals with dementia. The American Academy of Neurology ( AAN), the American Geriatrics Society, the American Medical Directors Association, the American Psychiatric Association, and the American Medical Association-convened Physician Consortium for Performance Improvement led this effort. The ACOVE measures and the measurement set described here apply to individuals whose dementia has already been identified and properly diagnosed. Although similar in concept to ACOVE, the DWG measurement set differs in several important ways; it includes all stages of dementia in a single measure set, calls for the use of functional staging in planning care, prompts the use of validated instruments in patient and caregiver assessment and intervention, highlights the relevance of using palliative care concepts to guide care before the advanced stages of illness, and provides evidence-based support for its recommendations and guidance on the selection of instruments useful in tracking patient-centered outcomes. It also specifies annual reassessment and updating of interventions and care plans for dementia-related problems that affect families and other caregivers as well as individuals with dementia. Here, a brief synopsis of why major reforms in healthcare design and delivery are needed to achieve substantive improvements in the quality of care is first provided, and then the final measures approved for publication, dissemination, and implementation are listed. [ABSTRACT FROM AUTHOR]

Objectives To determine the acceptability of a pre-consultation checklist for older adults who attend medical visits with an unpaid companion and to evaluate its effects on visit communication. Design Randomized controlled pilot study. Setting Academic geriatrics ambulatory clinic. Participants Thirty-two individuals aged 65 and older and their unpaid companions. Intervention A self-administered checklist was compared with usual care. The checklist was designed to elicit and align patient and companion perspectives regarding health concerns to discuss with the doctor and stimulate discussion about the companion's role in the visit. Measurement Primary outcome: ratio of patient-centered communication, coded from visit audiotapes. Secondary outcomes: checklist acceptability; visit duration; patient-companion verbal activity; patient- and physician-reported perspectives of the visit. Results All intervention patients and companions (n = 17) completed the checklist, and all participants (n = 32 dyads) completed the study. Patients and companions stated that the checklist was easy to complete (88%) and useful (91%), and they uniformly (100%) recommended it to other patients. Communication was significantly more patient-centered in intervention group visits (ratio of 1.22 vs 0.71; P = .03). Visit duration (35.0 and 30.6 minutes; P = .34) and percentage of total verbal activity contributed by patients and companions (58.2% and 56.3% of visit statements; P = .50) were comparable in the intervention and control groups, respectively. Physicians were more likely to indicate that intervention companions 'helped them provide good care to the patient' (94% vs 60%; P = .02). Intervention patients were more likely to indicate that they 'better understood their doctor's advice and explanations' because their companion was present (82% vs 47%; P = .03). Conclusion A checklist to elicit and align perspectives of older adults and their companions resulted in enhanced patient-centered medical visit communication. [ABSTRACT FROM AUTHOR]

Background Nonpharmacologic strategies to manage dementia-related behavioral symptoms depend upon caregiver implementation. Caregivers may vary in readiness to use strategies. We examined characteristics associated with readiness, extent readiness changed during intervention, and predictors of change in readiness. Methods Data came from a randomized trial involving 119 caregivers in a nonpharmacologic intervention for managing behavioral symptoms. Baseline measures included caregiver, patient, and treatment-related factors. At initial (2 weeks from baseline) and final (16 weeks) intervention sessions, interventionists rated caregiver readiness as pre-action (precontemplation = 1; contemplation = 2; preparation = 3) or action (= 4). Ordinal logistic regression identified baseline characteristics associated with initial readiness. Mc Nemar-Bowker test of symmetry described change in readiness; binary logistic regression identified baseline predictors of change in readiness (initial to final sessions). One-way multivariate analysis of variance identified treatment factors (dose/intensity, number of strategies used, perceived benefits, and therapeutic engagement) associated with change in readiness. Results At initial intervention session, 67.2% ( N = 80) of caregivers were in pre-action and 32.8% ( N = 39) in action. Initial high readiness was associated with better caregiver mood, less financial difficulty, lower patient cognition, and more behavioral symptoms. By final session, 72% ( N = 79) were in action and 28% ( N = 31) in pre-action; caregivers with less financial difficulty improved in readiness ( B = −0.70, p = 0.017); those in action were more therapeutically engaged ( F[2,107] = 3.61, p = 0.030) and perceived greater intervention benefits ( F[2, 88] = 6.06, p = 0.003). Conclusion Whereas patient and caregiver-related factors were associated with initial readiness, financial stability, therapeutic engagement, and perceived benefits enhanced probability of change. Understanding caregiver readiness and factors associated with its change may be important considerations in nonpharmacologic interventions. Copyright © 2013 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Abstract: Neuropsychiatric symptoms (NPS) in Alzheimer's disease (AD) are widespread and disabling. This has been known since Dr. Alois Alzheimer's first case, Frau Auguste D., presented with emotional distress and delusions of infidelity/excessive jealousy, followed by cognitive symptoms. Being cognizant of this, in 2010 the Alzheimer's Association convened a research roundtable on the topic of NPS in AD. A major outcome of the roundtable was the founding of a Professional Interest Area (PIA) within the International Society to Advance Alzheimer's Research and Treatment (ISTAART). The NPS-PIA has prepared a series of documents that are intended to summarize the literature and provide more detailed specific recommendations for NPS research. This overview paper is the first of these living documents that will be updated periodically as the science advances. The overview is followed by syndrome-specific synthetic reviews and recommendations prepared by NPS-PIA workgroups on depression, apathy, sleep, agitation, and psychosis. [Copyright &y& Elsevier]

Objectives Although older adults are often accompanied to routine physician visits and commonly receive disability-related task assistance, the overlap and persistence of this help is not well understood. This study investigates whether older adults who are accompanied to routine physician visits (1) also receive task assistance and (2) continue to be accompanied at 12-months by the same family companion. Design Observational study. Setting Nationally representative survey. Participants Community-dwelling adults aged 65 and older who responded to the Medicare Current Beneficiary Survey ( MCBS) in 2006 (n = 11,582) and a subset (n = 7,510) who responded in 2005 and 2006. Measurements Accompaniment to physician visits by a family companion and receipt of task assistance with activities of daily living ( ADLs) or instrumental activities of daily living ( IADLs). Persistent accompaniment and consistent family companion involvement was ascertained from 2005 and 2006 survey responses. Results Among community-dwelling older adults, 18.6% were accompanied to physician visits only, and 12.7% were accompanied to physician visits and received task assistance. Accompanied older adults who received task assistance were older, less educated, and had worse self-rated health than their counterparts who were accompanied only. Family companions who provided task assistance (vs those who did not) were more actively engaged in physician visit processes and more often identified as always present. Three-fourths (74.5%) of accompanied older adults were persistently accompanied to physician visits at 12 months, nearly always (87.9%) by the same family companion. Receipt of task assistance was strongly associated with persistent accompaniment (aOR = 2.52; 95% CI: 1.93-3.29). Conclusions Older adults' accompaniment to physician visits typically persists, most often by consistently involved family companions. Findings have implications for the patient-physician partnership and the patient-centered medical home. [ABSTRACT FROM AUTHOR]

Objectives To determine effect size and acceptability of a multicomponent behavior and home repair intervention for low-income disabled older adults. Design Prospective randomized controlled pilot trial. Setting Participants' homes. Participants Forty low-income older adults with difficulties in one or more activities of daily living ( ADLs) or two or more instrumental activities of daily living ( IADLs). Intervention The Community Aging in Place, Advancing Better Living for Elders ( CAPABLE), coordinated occupational therapy, nursing, and handyman visits, was compared with attention-control visits. The intervention consisted of up to six visits with an occupational therapist, up to four visits with a nurse, and an average of $1,300 in handyman repairs and modifications. Each intervention participant received all components of the intervention clinically individualized to risk profile and goals. Each attention-control participant received the same number of visits as the intervention participants, involving sedentary activities of their choice. Measurement Primary outcome: difficulty in performing ADLs and IADLs. Secondary outcomes: health-related quality of life and falls efficacy. Results Thirty-five of 40 adults (87%) completed the 6-month trial, and 93% and 100% of the control and intervention group, respectively, stated that the study benefited them. The intervention group improved on all outcomes. When comparing mean change in the intervention group with mean change in the control group from baseline to follow-up, the CAPABLE intervention had effect sizes of 0.63 for reducing difficulty in ADLs, 0.62 for reducing difficulty in IADLs, 0.89 for quality of life, and 0.55 for falls efficacy. Conclusion The CAPABLE intervention was acceptable to participants and feasible to provide and showed promising results, suggesting that this multicomponent intervention to reduce disability should be evaluated in a larger trial. [ABSTRACT FROM AUTHOR]

The quality of the relationship between individuals with dementia and their family caregivers has an impact on important clinical outcomes for both. It is unclear, however, how quality of relationship (QoR) affects caregivers' desire to place their relative in a nursing home. We examined the association of QoR with caregivers' desire to institutionalize (DTI), using a sample of 237 male and female caregivers of community-dwelling individuals with dementia. Findings revealed an interaction between QoR and caregiver gender, with stronger DTI significantly associated with lower QoR for male but not female caregivers. Health care providers should recognize poor QoR as a risk factor for institutionalization, especially among male caregivers. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To test the effects of an intervention that helps families manage distressing behaviors in family members with dementia. DESIGN: Two-group randomized trial. SETTING: In home. PARTICIPANTS: Two hundred seventy-two caregivers and people with dementia. INTERVENTION: Up to 11 home and telephone contacts over 16 weeks by health professionals who identified potential triggers of patient behaviors, including communication and environmental factors and patient undiagnosed medical conditions (by obtaining blood and urine samples) and trained caregivers in strategies to modify triggers and reduce their upset. Between 16 and 24 weeks, three telephone contacts reinforced strategy use. MEASUREMENTS: Primary outcomes were frequency of targeted problem behavior and caregiver upset with and confidence managing it at 16 weeks. Secondary outcomes were caregiver well-being and management skills at 16 and 24 weeks and caregiver perceived benefits. Prevalence of medical conditions for intervention patients were also examined. RESULTS: At 16 weeks, 67.5% of intervention caregivers reported improvement in targeted problem behavior, compared with 45.8% of caregivers in a no-treatment control group ( P=.002), and reduced upset with ( P=.03) and enhanced confidence managing ( P=.01) the behavior. Additionally, intervention caregivers reported less upset with all problem behaviors ( P=.001), less negative communication ( P=.02), less burden ( P=.05), and better well-being ( P=.001) than controls. Fewer intervention caregivers had depressive symptoms (53.0%) than control group caregivers (67.8%, P=.02). Similar caregiver outcomes occurred at 24 weeks. Intervention caregivers perceived more study benefits ( P<.05), including ability to keep family members home, than controls. Blood and urine samples of intervention patients with dementia showed that 40 (34.1%) had undiagnosed illnesses requiring physician follow-up. CONCLUSION: Targeting behaviors upsetting to caregivers and modifying potential triggers improves symptomatology in people with dementia and caregiver well-being and skills. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To develop and validate a brief screening measure for use in research, healthcare, and community settings to systematically assess well-being and identify needed areas of support for caregivers of patients with dementia. DESIGN: This study used data from Resources for Enhancing Alzheimer's Caregiver Health (REACH II), a multisite randomized clinical trial of a behavioral intervention designed to improve the quality of life of caregivers in multiple domains. SETTING: REACH II. PARTICIPANTS: Two hundred twelve Hispanic, 211 black, and 219 white family caregivers providing in-home care to patients with dementia. MEASUREMENT: Based on conceptual and psychometric analyses, a 16-item measure was developed that assesses six domains linked to caregiver risk and amenable to intervention: depression, burden, self-care and health behaviors, social support, safety, and patient problem behaviors. The reliability and validity of the instrument was evaluated with 642 dementia caregiver dyads from the REACH II program. RESULTS: The measure was found to have acceptable internal consistency for a multidimensional scale and similar measurement properties for each of the racial and ethnic groups. Concurrent validity was also demonstrated for the measure. CONCLUSION: The REACH Risk Appraisal Measure developed in this study shows promise as an assessment tool that can be used in research, clinical, and community settings to guide, prioritize, and target needed areas of support for caregivers of patients with dementia. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate the long-term mortality effect of a home-based intervention previously shown to reduce functional difficulties and whether survivorship benefits differ according to initial mortality risk level. DESIGN: Two-group randomized trial with survivorship followed up to 4 years from study entry. SETTING: Homes of urban community-living elderly people. PARTICIPANTS: Three hundred nineteen adults aged 70 and older with difficulties performing daily activities. INTERVENTION: Occupational and physical therapy sessions to instruct participants in compensatory strategies, home modifications, home safety, fall recovery techniques, and balance and muscle strength exercises. MEASUREMENTS: Survival time was number of days between baseline interview and date of death, as determined using data from the National Death Index or December 31, 2005. Participants were stratified according to baseline mortality risk (low, moderate, high) using a prognostic indicator. RESULTS: At 2 years, intervention participants (n=160) had a 5.6% mortality rate (n=9 deaths) and controls (n=159) a 13.2% rate (n=21 deaths; P=.02). Mortality rates remained lower for intervention participants up to 3.5 years from study entry. At 2 years, intervention participants with moderate mortality risk had a 16.7% mortality rate (n=16 deaths/96), compared with 28.2% for equivalent control group participants (n=24 deaths/85; P=.02). By 3 years, mortality rates were not statistically significantly different between the experimental and control groups. CONCLUSIONS: The intervention extended survivorship up to 3.5 years and maintained statistically significant differences for 2 years. Subjects at moderate mortality risk derived the most intervention benefit. Findings suggest that the intervention could be a low-cost clinical tool to delay functional decline and mortality. [ABSTRACT FROM AUTHOR]

Background: While dementia caregivers report need for assistance, formal service utilization remains low (apprx. 25%). Research suggests demographic characteristics associated with service use, but caregivers' cognitive and behavioral approach to care has not been considered. Prior work by this team has identified five distinct caregiving styles through qualitative analysis: "Externalizers" (superficial understanding, self‐focused, anger, frustration), "Individualists" (go it alone, emotionally removed), "Learners" (recognize need to change approach but stuck, emotionally turbulent), "Nurturers" (positive affect, empathy, natural mastery), and "Adapters" (arsenal of acquired management strategies, adaptable). We examine variation in formal care service utilization of the caregiving styles and hypothesize that styles showing greater adaptation to the care role (Adapters, Nurturers) will be more likely to utilize formal care services. We also explore reported barriers to use of formal services among those caregivers reporting non‐use. Method: Participants included 100 primary caregivers for a person living with dementia (PLwD) who were 64 years old on average, 74% female, and 18% non‐White. Use (vs. non‐use) of formal services was a dichotomous outcome in a logistic regression with caregiving style classifications as the key predictors also adjusting for caregiver demographics, length of care, co‐residence, and dementia severity. Result: Rates of service utilization varied by caregiving style (20%‐70%). Relative to nurturers (style least likely to use formal services), adapters had greater odds of utilizing formal services (OR=14.4, 95% CI= 1.8‐115.1). Additionally, caregivers who were older and providing care for a PLwD with greater dementia severity had greater odds of formal service use, while caregivers living with the PLwD reported lower odds of service use. Among those not using services, there were not significant differences in barriers to use (e.g. expense) across styles, however, over half cited not needing the assistance. Conclusion: Being an Adapter was significantly associated with service use suggesting that certain caregivers may have greater comfort in accessing such services. Styles showing less adaptability and more rigidity in care approach (e.g. Externalists, Individualists) may not recognize need for formal supports or benefit from support in selecting assistance that meets their needs. Future work may consider measuring for caregiving styles before making service recommendations. [ABSTRACT FROM AUTHOR]