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

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

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

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

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

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

Activity Recognition (AR) in older adults living with Neurocognitive disorders caused by diseases such as Alzheimer’s is still a challenging research problem. The inherent natural variation in performing an activity increases while repeating the same activity for an older adult, let alone the variation introduced when another older adult performs the same activity. Moreover, the challenges in acquiring the labeled data while preserving the privacy, availability of annotators with domain knowledge, aversion towards cameras even for a minimal amount of time for ground truth data collection, and psychological and mental health status make AR for older adults challenging. In this paper, we postulate a self-taught learning-based approach that helps recognize activities with variations that are not being directly seen during the training phase. We hypothesize that the features extracted using deep architectures from unlabeled data instances can learn general underlying representations of activities efficiently and help improve activity classification in a supervised setting, although the data instances in labeled data do not follow the generative distribution of that of unlabeled data. We posit real data from a retirement community center using our in-house SenseBox infrastructure and survey-based assessments concurrently done by a clinical evaluator to study the relationship between activities and functional/behavioral health of older adults. We evaluate our proposed self-taught learning-based approach, STAR, using the presented in-house Alzheimer’s Activity Recognition (AAR) dataset acquired in a real-world deployment in 25 homes which outperforms the state-of-the-art algorithm by about 20%.

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

OBJECTIVES: The purpose of this study was to describe the incidence, pharmacologic management and impact of pain on function, agitation, and resistiveness to care among assisted living residents. DESIGN: This was a descriptive study. DATA SOURCES: Baseline data from 260 residents in the second cohort of the study, Dissemination and Implementation of Function Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT). REVIEW/ANALYSIS METHODS: Descriptive analyses for the Pain Assessment in Advanced Dementia (PAINAD), Visual Descriptor Scale (VDS), and use of medication for pain management and hypothesis testing using linear regression analyses were performed. RESULTS: The majority of the sample was female (71%) and white (96%) with a mean age of 87 (SD=7). Fifty-two out of the 260 residents (20%) reported pain based on either the PAINAD or the VDS. Out of the total 260 residents, 75 (29%) received pain medication. Twenty-two out of the 52 individuals (42%) reporting pain were not getting pain medication. Controlling for age, gender and cognition, the PAINAD was significantly associated with agitation, function, and resistiveness to care and the VDS was only associated with function. CONCLUSIONS: The incidence of pain was low among participants based on the PAINAD or the VDS. Pain measured by the PAINAD was significantly associated with function, agitation and resistiveness to care. NURSING PRACTICE IMPLICATIONS: Pain assessments should include both objective and subjective measures and management of pain should be considered as it may help to optimize function and decrease behavioral symptoms among assisted living residents.

The purpose of this pilot study was to evaluate the feasibility of the self-efficacy based Epilepsy-Motivate and Outcome Expectations for Vigorous Exercise (EMOVE) intervention and report on the preliminary efficacy of this intervention aimed at improving exercise behaviors in adults with epilepsy. Methods: A single-group, repeated-measures design was used in 30 outpatients. Data were collected at baseline and 12 weeks after the intervention. Participant outcomes included Self-Efficacy and Outcome Expectations for Exercise in Epilepsy, Beck Depression Inventory-II, Quality of Life in Epilepsy Inventory-31, seizure frequency, average daily steps, and body mass index. Daily number of steps was measured using a wrist-worn activity monitor. Feasibility data were assessed using evidence of treatment fidelity including intervention delivery, receipt, and enactment. Results: Participants were single (63%), white (53%), female (63%), had a mean (SD) age of 46.7 (13) years (range, 26-68 years), had low levels of self-efficacy (mean, 5.10; range, 0-10) and high outcome expectations (mean, 3.90; range, 0-5), took under the recommended 10 000 steps per day (mean, 5107), and had an average of 6 seizures per month. Postintervention testing showed statistical improvement in depressive symptoms (mean [SD], 9.95 [9.47]; P < .05). There were no significant differences found for the other study outcomes. Our study showed the EMOVE intervention was feasible. Study participants had improved depressive symptoms. Future research should focus on increasing the sample size, improving exercise performance through group or individualized exercise sessions, and adding a control group to better evaluate the relationship between the intervention and improved depressive symptoms.

In recent research involving assisted-living residents with mild to moderate cognitive impairment, a structured 12-week Pet Assisted Living (PAL) intervention led to improved physical activity (PA)...

The purpose of this study was to use routinely collected resident assessment data from a single site to evaluate the impact of COVID-19 restrictions on cognition, physical function and behavioral symptoms of residents with dementia. Specifically, it was hypothesized that controlling for age and sex, there would be a decline in cognition and function and an increase in behavioral symptoms at 12 months post implementation of COVID-19 restrictions. Twelve residents from a single memory care site with required Resident Assessments completed prior to and 12 month post initiation of the pandemic and associated quarantines were included. No significant change was noted in function or behavioral symptoms but there was a statistically significant decline in cognition over the 12 month period. Although this study did not support our hypothesis, the findings supported some prior research also noting little significant change among the majority of individuals over the course of the pandemic regardless of regulations.

The purpose of the current study was to describe gender differences in the quality of interactions between nursing home residents with behavioral and psychological symptoms of dementia and staff. Data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) implementation study were used for the current study. A total of 535 residents (72% female and 28% male) from 55 settings were included in the analyses. The highest percentage of interactions occurred in dining rooms (38.4%) and with nursing staff (68%). There were no significant differences in the quality of staff interactions with male or female residents. Most interactions were positive social ( n = 360, 71% males, 66% females), positive care ( n = 312, 60% males, 58% females), or neutral ( n = 123, 25% males, 22% females). There were 31 (7% males, 6% females) negative protective and 23 (3% male, 5% female) negative restrictive interactions. Future work should focus on eliminating neutral and negative interactions across both genders and address whether the gender of staff is related to the quality of staff–resident interaction. [ Journal of Gerontological Nursing, 47 (5), 19–25.]

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

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

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

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

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

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

Purpose The purpose of this study was to test the reliability and validity of the Care Plan Checklist for Evidence of Person-Centered Approaches for Behavioral and Psychological Symptoms Associated with Dementia (BPSD). Methods This study used baseline data from the first cohort of a larger randomized clinical trial testing the implementation of the Evidence of Integration Triangle for BPSD. Fourteen settings volunteered to participate, 8 from Maryland and 6 from Pennsylvania, and a total of 137 residents were recruited. In addition to completing the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD, assessments of depressive symptoms (Cornell Scale for Depression in Dementia), resistiveness to care (Resistiveness to Care Scale), and agitation (Cohen-Mansfield Agitation Inventory) were also completed on each participant. Reliability was tested based on evidence of internal consistency and inter-rater reliability. Construct validity was tested using a Rasch measurement model to determine item fit and hypothesis testing using bivariate correlations. Item mapping was also performed. Results The majority of the sample was female (69%), Caucasian (69%), non-Hispanic (98%), and not married (78%). The mean age of the sample was 82.01 years (standard deviation = 11.44). There was evidence of reliability based on internal consistency with a Cronbach alpha of 0.96 and inter-rater reliability with correlations between 2 evaluators of r = 0.93, P = .001. There was evidence of validity of the scale based on item fit as the infit statistics and outfit statistics were all within the acceptable range with the exception of the outfit statistic for the item focused on sexually inappropriate behaviors. Lastly, there was evidence of significant relationships between the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD and the Cornell Scale for Depression in Dementia (r = 0.38, P Conclusions There was sufficient evidence for the reliability and validity of the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD. Additional items should be considered to better differentiate those low on the Checklist for Evidence of Person-Centered Approaches for BPSD.

The purpose of this study was to test the preliminary effectiveness and feasibility of implementation of a function focused care intervention, referred to as Function Focused Care for Assisted Living Using the Evidence Integration Triangle in Assisted Living Communities with Residents with Dementia, and consider the impact of COVID-19 restrictions on incidences of COVID-19 and worsening of behavioral symptoms. The intervention was designed to facilitate a philosophy of care in which staff are educated and helped to actively engage residents in functional and physical activity during all care interactions. This was a single group pre-post intervention study including 51 assisted living communities in a single state in the United States. The communities ranged in size from 8 to 50 beds with the mean number of beds being 13.25 (SD=7.69). The majority (99%) were for profit. There was significant improvement in the support of the environments (p=.01) and policies (p=.04) for physical activity. There was no significant change in falls, emergency room transfers, hospitalizations or nursing community transfers over time. Overall there were only 7 (18%) communities that had COVID-19 positive patients with the numbers ranging from 1-16 residents and percentage ranging from 0-31% and a mean percentage of 17%. The majority did not require that the residents quarantine in their rooms (87%) although they did restrict visitation with the exception of 3 (8%) communities that let families visit after training and with exposure and symptom risk assessments completed at each visit. Communities in which residents were quarantined in their rooms had a 40% greater likelihood of having COVID-19 positive residents than communities that did not quarantine residents. None of the restrictions imposed were associated with worsening of behavioral symptoms. The findings are descriptive and pilot in nature but can be used to guide future research around prevention and management of infections in assisted living.

Background Nursing home (NH) residents with moderate-to-severe cognitive impairment experience mostly sedentary lifestyles. Aim Previous research has examined racial differences in physical activity (PA) levels in community-dwelling older adults but not in NH residents with cognitive impairment, and the current study aimed to examine these differences. Methods This was a secondary data analysis of baseline data from the Function and Behavior Focused Care Intervention (FBFC) study. The sample included 247 cognitively impaired residents from 12 NHs who wore an ActiGraph to measure PA. Results The residents' mean age was 82.6 (SD = 10.1) and had an average MMSE score of 7.8 (SD = 5.0). The sample (N = 247) was 41% African American and 59% White. African American and White residents engaged in only 50.6 and 46.2 min of light- and 1.5 and 1.1 min of moderate-level PA, respectively. Based on a multivariate analysis of covariance (MANCOVA), there was not a statistically significant difference between African American and White residents on combined dependent PA measures [F (8, 237) = 1.067, p = .387, Wilks' Λ = 0.962]. There was a trend that direct care providers subjectively reported that White residents engaged in more PA than their African American counterparts [F(8, 237) = 2.741, p = .09]. Conclusions These findings are not consistent with prior research. However, these findings indicate severely low levels of PA in NH residents, regardless of racial group. Future research should prioritize PA interventions that make accommodations for all NH residents, and especially consider their underlying physical comorbidities and cognitive function.

Psychotropics use to manage behavioral and psychological symptoms of dementia (BPSD) in nursing homes (NHs) has been the focus of policy attention due to their adverse effects. We hypothesized that NHs with lower nursing staffing would have greater reliance on psychotropics use to control BPSD. A NH deficiency of care can be cited for inappropriate psychotropics use (F-tag 758). The association between the occurrence of F-758 tags and nurse staffing in residents with dementia was examined using the 2017-18 Certification and Survey Provider Enhanced Reporting data (n=14,548 NHs). Staffing measures included nursing hours per resident day (HPRD) and registered nurse (RN) skill-mix. Generalized linear mixed models that included covariates (NH location, bed size, ownership, proportion of residents with dementia/depression/psychiatric disorders and with Medicare/Medicaid) estimated the magnitude of the associations. There were 1,872 NHs with F-758 tags indicating inappropriate psychotropics use for NH residents with dementia. NHs with greater RN and certified nurse assistant (CNA) HPRD had significantly lower odds of F-758 tags (OR=0.59 54, 95% CI=0.47 44-0.73 66; OR=0.87, 95% CI=0.77-0.99, respectively) and similar findings were found in NHs with greater RN skill-mix (OR=0.14 10, 95% CI=0.05 04-0.37 25). There were no significant associations between the occurrence of F-758 tags and licensed practice nurse and unlicensed nurse aide HPRD. This study found that RN and CNA staffing had inverse associations with inappropriate psychotropic use citations among residents with dementia. NHs with higher RN staffing ratios may be better able to implement alternatives to pharmacological approaches for BPSD. It is suggested that NHs be equipped with adequate nurse staffing levels to reduce unnecessary psychotropics use.

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

Little literature exists examining the development and implementation of person-centered care (PCC) plans focused on behavioral and psychological symptoms of dementia (BPSD). The current study aimed to describe BPSD documented in nursing home (NH) residents' care plans, the types of approaches staff document in addressing those symptoms, and whether resident and/or facility characteristics are associated with documentation of PCC approaches. The sample included 553 residents from 55 NHs in two East Coast states. Resistiveness to care (44.9%), agitation (42.2%), and aggression (42%) were most frequently documented in care plans. PCC approaches were documented in care plans in 21.3% to 62.7% of cases depending on BPSD type. Resident (e.g., younger age, lower functional ability, lower cognitive ability, longer length of stay, male gender) and facility (e.g., less certified nursing assistant staffing hours, greater percentage of residents taking antipsychotic medications, non-profit status) characteristics were associated with increased odds of PCC approaches being documented. Optimal PCC planning is discussed, and a sample PCC plan is provided. [ Journal of Gerontological Nursing, 46 (11), 17–27.]

Cognitive impairment has become epidemic in older adult population. The recent advent of tiny wearable and ambient devices, a.k.a Internet of Things (IoT) provides ample platforms for continuous functional and cognitive health assessment of older adults. In this paper, we design, implement and evaluate AutoCogniSys, a context-aware automated cognitive health assessment system, combining the sensing powers of wearable physiological (Electrodermal Activity, Photoplethysmography) and physical (Accelerometer, Object) sensors in conjunction with ambient sensors. We design appropriate signal processing and machine learning techniques, and develop an automatic cognitive health assessment system in a natural older adults living environment. We validate our approaches using two datasets: (i) a naturalistic sensor data streams related to Activities of Daily Living and mental arousal of 22 older adults recruited in a retirement community center, individually living in their own apartments using a customized inexpensive IoT system (IRB #HP-00064387) and (ii) a publicly available dataset for emotion detection. The performance of AutoCogniSys attests max. 93\% of accuracy in assessing cognitive health of older adults.

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

The purpose of the current study was to test for gender differences among residents living in assisted living settings. This was a secondary data analysis using data from the first 64 facilities participating in the ongoing Function Focused Care for Assisted Living study using the Evidence Integration Triangle (FFC-AL-EIT). A total of 593 residents were recruited. Differences by gender with regard to function, physical activity, falls, total number of medications, and satisfaction with assisted living were tested using multivariate analysis of variance. There were 166 (28%) men and 427 (72%) women with a mean age of 88 ( SD = 7.5 years). Participants had five ( SD = 2) comorbidities and took on average 6.88 medications ( SD = 3.47). Participants had moderate functional impairment with a mean of 64.13 ( SD = 19.09) on the Barthel Index and engaged in 43.8 ( SD = 76.12) minutes daily of moderate level physical activity. Women reported higher satisfaction with activities (4.32 [ SD = 1.14]) than men (3.85 [ SD = 1.51]), and women received more medications than men (7.09 [ SD = 3.51] vs. 6.34 [ SD = 3.31]). Current study findings suggest that deprescribing may be particularly important for women versus men and focusing on expanding activity options to include those preferred by men should be considered in assisted living settings. [ Research in Gerontological Nursing, 13 (1), 31–40.]

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

OBJECTIVE: The purpose of this study was to test the effectiveness of the Function and Behavior Focused Care for the Cognitively Impaired (FBFC-CI) intervention on function, physical activity and behavioral symptoms among nursing home residents with dementia, and to explore the adoption of the intervention at the facility level. DESIGN: This study was a clustered, randomized controlled trial with a repeated measures design that was implemented in 12 nursing homes randomized to either treatment (Function and Behavior Focused Care for the Cognitively Impaired Intervention (FBFC-CI) or educational control (Function and Behavior Focused Care Education (FBFC-ED). SETTING AND PARTICIPANTS: 12 nursing homes (6 treatment and 6 control) and 336 residents (173 treatment and 163 control) with moderate to severe cognitive impairment. MEASURES: Outcomes included functional ability (Barthel Index), physical activity (actigraphy and survey), behavioral symptoms (Resistiveness to Care Scale, Cohen Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia) and psychotropic medication use. RESULTS: The participants 82.6 (SD=10.1) years of age, mostly female and were moderate to severely cognitively impaired (MMSE of 7.8, SD=5.1). There was a significantly greater increase in time spent in total activity (p=0.004), moderate activity (p=0.012) light activity (p=0.002), and a decrease in resistivenes to care (p=0.004) in the treatment versus control group at 4 months. There was no change in mood, agitation, and the use of psychotropic medications. There was some evidence of adoption of the intervention in treatment sites. CONCLUSIONS AND IMPLICATIONS: This study provides some support for the use of the FBFC-CI intervention to increase time spent in physical activity and decrease resistive behaviors during care commonly noted among nursing home residents with moderate to severe cognitive impairment.

Background Resistiveness to care is behavior that prevents or interferes with caregivers’ performing or assisting with activities of daily living and puts residents at risk for inappropriate use of antipsychotic drugs, other restraining interventions, social isolation, and physical abuse. The purpose of this study was to establish the psychometric properties of a previously developed Resistiveness to Care measure. Procedures This was a descriptive study using baseline data from an ongoing randomized controlled trial testing a Function and Behavior Focused Care (FBFC) intervention. Residents were eligible to participate if they were 55 years of age or older, had a Mini-Mental State Exam (MMSE) score of 15 or less, and were not enrolled in hospice or admitted for subacute care. Descriptive information included age, race, gender, cognitive status, and marital status. In addition to the Resistance to Care Scale, the Barthel Index, the Physical Activity Survey in Long Term Care (PAS-LTC), and the Cohen-Mansfield Agitation Inventory (CMAI) were completed. Psychometric testing was done using Rasch analysis and the Winsteps statistical program. Main findings The participants were moderate to severely cognitively impaired (MMSE of 7.23), functionally dependent (Barthel Index 47.31, SD 27.59), and engaged in only 134.17 (SD = 207.32) minutes of physical activity daily. Reliability was supported based on a Cronbach alpha of 0.84 and the DIF analysis, as there was no difference in function of the items between male and female participants. Validity was supported as all items fit the measurement model based on INFIT and OUTFIT statistics. Conclusions The findings support the reliability and validity of the Resistiveness to Care Scale for use with older adults with dementia in nursing home settings. Future work with the measure may benefit from the addition of items that are easier to endorse with regard to resistiveness to care (shutting eyes or spitting out food may be useful additions).

Pain has a significant effect on physical and psychological outcomes for older adults post orthopedic trauma. The purpose of this study was to describe the management of pain among older trauma patients and consider differences between those who received 3 or more dosages daily of opioids versus those who did not. This was a secondary data analysis using data from an intervention study testing the effect of Function Focused Care among older orthopedic trauma patients (FFC-AC). The FFC-AC study was done on trauma units in two acute care settings designated as Level I or II trauma centers from September 2014 to September 2015. All participants from the parent FFC-AC study were included. Data collection for the parent study was done within 24 hours of admission and within 24 hours of discharge and included demographics, medications, assessment of function, physical activity, mood, physical resilience, and whether the patient had pain and their pain intensity. Patient records included all 89 individuals from the parent study, 59 (66%) of whom were female and 82 (92%) were white. Records indicated that those who received more than three dosages per day of opioids had a shorter length of stay, were younger, had more intense pain, and were more resilient compared with those who received less than three dosages per day. This secondary data analysis provides support for the importance of considering pain and pain management among older adults post trauma.

Behavioral and psychological symptoms of dementia are common in nursing home residents, and the Centers for Medicare and Medicaid Services now require that nonpharmacological interventions be used as a first-line treatment. Few staff know how to implement these interventions. The purpose of this study was to pilot test an implementation strategy, Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD), which was developed to help staff integrate behavioral interventions into routine care. The EIT-4-BPSD was implemented in 2 nursing homes, and 21 residents were recruited. A research nurse facilitator worked with facility champions and a stakeholder team to implement the 4 steps of EIT-4-BPSD. There was evidence of reach to all staff; effectiveness with improvement in residents’ quality of life and a decrease in agitation; adoption based on the environment, policy, and care plan changes; and implementation and plans for maintenance beyond the 6-month intervention period.

Measuring clinical outcomes among older adults with moderate to severe dementia present practical and psychometric challenges. Proxy report surveys, direct observations, chart abstraction, and objective measures, such as actigraphy are frequently used with this population. The purpose of this paper is to describe issues related to measurement in the FBFC trial. Challenges to actigraphy included the resistance of residents and removal of devices, inability to detect limited movement and/or the type of activity performed. The combined use of the three measures to optimize understanding of physical activity will be addressed. Behavioral outcome measures included the Cornell Scale for Depression in Dementia, the Cohen Mansfield Agitation Inventory, and the Resistiveness to Care Scale. Despite the use of these multiple measures, limited behaviors were identified due to timing of assessments and items included within the measures. Optimal ways in which to capture behavioral symptoms will be reviewed.

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

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

There exist significant race disparities in the prevalence of dementia, with black persons with dementia (PWD) showing higher co-morbidity and more frequent hospitalizations, yet little is known how clinical presentations compare. This study compared physical function, delirium, depressive symptoms, and behavioral and psychological symptoms of distress (BPSD) in black and white PWDs when hospitalized. A multivariate analysis of covariance showed that, controlling for age, gender, cognitive status, and comorbidities, black PWD had more delirium (mean= 3.8, SD= 2.9) as compared to white PWDs (mean=2.4, SD= 2.2, F=4.8, p =.029). Additionally, black PWD had more depressive symptoms (mean= 11.7, SD= 6.7) as compared to white PWD (mean = 9.0, SD= 5.2, F=6.6, p =.011), and less improvement in functional status admission to discharge (mean =12.4, SD= 18.9) as compared to white PWD (mean=17.8, SD=18.8, F=12.3, p=.001). There were no differences in BPSD. Continued research examining factors influencing differences in race cohorts is warranted.

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

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