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We applied machine learning algorithms to examine the relationship between demographics and outcomes of the social work services used by Hispanic family caregivers of persons with dementia recruited for a clinical trial in New York City. The social work service needs were largely concentrated on instrumental support to gain access to the healthcare system rather than other concrete services (e.g., housing or food programs) or to address psychological needs among the caregivers with relatively higher income. A finding from the machine learning approach was that among those who receive medical-related social work services, frequent users (≥10 times) with high family friend support(>4) were more likely than frequent users without such support to have their issues resolved (Accuracy: 81.9%, AUC: 0.82, F-measure: 0.86 by J48). Even though half of the participants received social work services multiple times, the needs of the caregivers remained unmet unless they sought social work services frequently (more than ten times).

Objectives: To compare the effectiveness of 2 caregiver interventions with known efficacy: the Resources for Enhancing Caregiver Health-Offering Useful Treatment (REACH-OUT) and the New York University Caregiver Intervention (NYUCI)., Design: 1:1 randomized pragmatic trial., Setting: New York City., Participants: Informal Hispanic caregivers of persons with dementia (N=221; mean age 58.2, 82.8% female, 63.3% adult children, 31.7% spouses)., Intervention: Participants were randomized to 6 months of NYUCI (n=110) or REACH-OUT (n=111), balanced on characteristics at baseline. All participants were referred for social supportive services., Measurements: The primary outcomes were changes between baseline and 6 months in depressive symptoms, measured using the Geriatric Depression Scale (GDS), and caregiver burden, measured using the Zarit Caregiver Burden Scale (ZCBS)., Results: There were no differences in outcomes between NYUCI and REACH-OUT. Both interventions showed a reduction in burden (REACH-OUT: 5.2 points, 95% confidence interval (CI)=2.2-8.1, p<.001; NYUCI: 4.6-points, 95% CI=1.7-7.5, p=.002). There were no significant changes on the GDS. Effects for the ZCBS were significant only for spouses and older caregivers., Conclusion: Although there were no significant intervention group differences, both interventions resulted in significantly reduced burden for Hispanic caregivers at 6 months, particularly for spouses and older caregivers., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Objectives: Little is known about the patterns of psychotropic medication use in community-dwelling minority persons with dementia (PWD). The purpose of this study was to investigate racial/ethnic differences in psychotropic medication use across a diverse population of community-dwelling PWD and to examine the extent to which caregiver characteristics influence this use., Method: Data were drawn from the baseline assessment of the Resources for Enhancing Alzheimer's Caregiver Health II trial. Generalized linear models were used to identify racial/ethnic differences in psychotropic medication use. Akaike Information Criterion (AIC) model selection was used to evaluate possible explanations for observed differences across racial/ethnic group., Results: Differences in anxiolytic and antipsychotic medication use were observed across racial/ethnic groups; however, race/ethnicity alone was not sufficient to explain those differences. Perceptions of caregiving and caregiver socioeconomic status were important predictors of anxiolytic use while PWD characteristics, including cognitive impairment, functional impairment, problem behavior frequency, pain, relationship to the caregiver, sex, and age were important for antipsychotic use., Conclusion: Racial/ethnic differences in psychotropic medication use among community-dwelling PWD cannot be explained by race/ethnicity alone. The importance of caregiver characteristics in predicting anxiolytic medication use suggest that interventions aimed at caregivers may hold promise as an effective alternative to pharmacotherapy.

Objectives: The current practice of prescribing psychotropic medication for the management of dementia-related behavioral disturbances is under substantial debate. Using Pearlin's stress process model as theoretical underpinning, the aim of this investigation is to identify caregiver and care recipient characteristics as predictors of anxiolytic, antipsychotic, and antidepressant use among community-dwelling dementia patients. We hypothesized that caregiving burden and patient characteristics, particularly behavior disturbances and pain, would be positively associated with psychotropic medication use., Methods: Data for this exploratory, cross-sectional study were drawn from the baseline assessment of the Resources for Enhancing Alzheimer's Caregiver Health II trial. Only participants with full baseline information were examined (N = 598). Caregiver characteristics, such as confidence managing problematic behaviors, and care recipient characteristics including pain, problem behaviors, cognitive impairment, and functional impairment, were examined in relation to care recipient psychotropic medication use., Results: Contrary to our hypothesis, behavioral disturbances and burden associated with these disturbances were not significantly associated with psychotropic use. Rather, caregiver characteristics such as race and overall vigilance, and care recipient characteristics such as cognitive status, functional status, and pain were significantly associated with the use of psychotropic medication. Findings differed by class of medication., Conclusion: These exploratory findings suggest the utility of a holistic approach to understanding the factors associated with pharmacotherapy among community-dwelling elders with dementia. Significant associations between caregiver characteristics and care recipient psychotropic medication use suggest that educating caregivers in non-pharmacologic strategies hold promise for a more balanced biopsychosocial approach to maintaining dementia patients in the community.

Introduction: The prevalence of dementia is increasing without a known cure, resulting in an increasing number of informal caregivers. Caring for a person with dementia results in increased stress and depressive symptoms. There are several behavioural interventions designed to alleviate stress and depressive symptoms in caregivers of persons with dementia with evidence of efficacy. Two of the best-known interventions are the New York University Caregiver Intervention (NYUCI) and the Resources for Enhancing Alzheimer's Caregivers Health (REACH). The effectiveness of the NYUCI and REACH has never been compared. There is also a paucity of data on which interventions are more effective in Hispanics in New York City. Thus, we proposed the Northern Manhattan Hispanic Caregiver intervention Effectiveness Study (NHiCE), a pragmatic clinical trial designed to compare the effectiveness of adaptations of the NYUCI and the REACH in informal Hispanic caregivers of persons with dementia in New York City., Methods and Analysis: NHiCE is a 6-month randomised controlled trial comparing the effectiveness of adaptations of the NYUCI and REACH among 200 Hispanic informal adult caregivers of persons with dementia. The planned number of sessions of the NYUCI and REACH are similar. The primary outcome measures are changes from baseline to 6 months in the Zarit Caregiver Burden Scale and Geriatric Depression Scale. Our primary approach to analyses will be intent-to-treat. The primary analyses will use mixed random effects models, and a full information maximum likelihood approach, with sensitivity analyses using generalised estimating equation., Ethics and Dissemination: NHiCE is approved by the Institutional Review Board of Columbia University Medical Center (protocol AAAM5150). A Data Safety Monitoring Board monitors the progress of the study. Dissemination will include reports of the characteristics of the study participants, as well as a report of the results of the clinical trial., Trial Registration Number: NCT02092987, Pre-results., Competing Interests: MM is the developer of the NYUCI and has received consulting fees for training providers. She is currently working on a Small Business Innovation Research grant to develop online training for the NYUCI. It is possible that MM will benefit in the future from the distribution of NYUCI training materials. LB is the developer of the REACH OUT caregiver support program and has received consulting fees for training providers. He is currently working with Oxford University Press to publish a version of the REACH OUT training manual. It is possible that LB will benefit in the future from the distribution of REACH OUT training materials. The other author(s) declare that they have no competing interests., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objectives: The purpose of this pilot study was to conduct limited-efficacy testing of the newly developed Preserving Identity and Planning for Advance Care (PIPAC) intervention on self-reported and proxy-reported emotional and health-related outcomes of individuals in the early stages of dementia., Method: A two-group comparison design was implemented. Blocked randomization was used to assign individuals with mild dementia and a family contact to either (1) the four-session, multi-component intervention group focused on reminiscence and future planning or (2) the minimal support phone contact comparison group. Of the 19 enrolled dyads, 18completed post-treatment assessments (i.e. 10 intervention and 8 comparison group). Individuals with dementia were M=82.8 (SD=6.46) years old; 31.6% were men and 68.4% were women. Participants were predominantly white/Caucasian (n=18, 94.7%) with one black/African-American (5.3%)., Results: Analyses of covariance controlling for baseline differences revealed clinically meaningful differences (with medium to large effect sizes) between groups at post-treatment for depressive symptoms, quality of life, health-related quality of life indicators, and decisional conflict. Individuals in the intervention group were also observed to exhibit higher levels of coping. Feasibility data collected from participants and interventionists were encouraging., Conclusion: Emotion-focused, patient-centered interventions like PIPAC hold promise for advancing treatment options in the early and mild stages of dementia. A full-scale, randomized clinical trial of this intervention is warranted to determine both short-term and long-term impacts on clinical outcomes including improved depressive symptomatology, quality of life, and health-related factors that impact daily functioning in social environments.

Purpose: Literature on institutionalization of patients with dementia has not considered the role of caregivers' quality of care, which encompasses caregivers' exemplary care (EC) behaviors and caregivers' potentially harmful behaviors (PHBs) toward care recipients. This study sought to understand the role of quality of care in mediating between caregiving stressors and caregiver desire to institutionalize (DTI) a patient with dementia., Design and Methods: A sample of 612 family caregivers from diverse racial/ethnic backgrounds was drawn from the baseline data of the Resources for Enhancing Alzheimer's Caregiver Heath (REACH II) project. Multiple mediator models were run using Preacher and Hayes asymptotic and resampling strategies to assess direct and indirect effects of caregiver stressors (daily care bother, behavioral bother, and burden) on caregiver desire to institutionalize a patient with dementia., Results: Overall, PHB was positively related to caregiver desire to institutionalize their care recipients. Specifically, PHB was found to mediate the relationship between caregiving stressors and DTI in the Caucasian and Latino groups, whereas only the mediation effect of EC was significant in the African American group., Implications: Caregivers' perceptions of quality of care helped explain their desire to institutionalize their care recipients with dementia. Including assessment of EC and PHB in clinical and social service settings is recommended for all ethnic groups. Interventions should facilitate EC behaviors among African American caregivers and address concerns of PHBs in Caucasian and Latino caregivers.

Purpose: Exemplary care (EC) is a new construct encompassing care behaviors that warrants further study within stress process models of dementia caregiving. Previous research has examined EC within the context of cognitively intact older adult care recipients (CRs) and their caregivers (CGs). This study sought to expand our knowledge of quality of care by investigating EC within a diverse sample of dementia CGs., Design and Methods: We examined the relation between CG subjective appraisal (daily care bother, burden, and behavioral bother), EC, and CG emotional outcomes (depression and positive aspects of caregiving [PAC]). Specifically, EC was examined as a possible mediator of the effects of CG subjective appraisals on emotional outcomes. Using a bootstrapping method and an SPSS macro developed by Preacher and Hayes (2008 Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models), we tested the indirect effect of EC on the relation between CG subjective appraisals and CG emotional outcomes., Results: Overall, EC partially mediates the relation between the subjective appraisal variables (daily care bother, burden, and behavioral bother) and PAC. Results for depression were similar except that EC did not mediate the relation between burden and depression. This pattern of results varied by race/ethnicity., Implications: Overall, CGs' perception of providing EC to individuals with dementia partially explains the relation between subjective appraisal and symptoms of depression and PAC. Results of this study suggest that interventions may benefit from training CGs to engage in EC to improve their emotional outcomes and quality of care.

Objective: We examined predictors of staff-reported need-driven behaviors and resistiveness to care in nursing home residents with dementia and predictors of certified nursing assistant (CNA) burden related to both constructs. Background and proximal factors from the need-driven dementia-compromised behavior model [Algase, D.L., Beck, C., Kolanowski, A., Whall, A., Berent, S., Richards, K., et al. (1996). Need-driven dementia-compromised behavior: An alternative view of disruptive behavior. American Journal of Alzheimer's Disease, 5, 10-19] were examined as potential predictors of need-driven behaviors (NDBs) and resistiveness to care and CNA burden., Method: We used secondary data analysis of prospective data from 10 nursing homes in Birmingham, Alabama. One-hundred and sixty-one residents (83.43 +/- 8.56 years) with mini mental state examination (MMSE) score = 6.41 (+/- 6.66) were assessed via chart review, resident surveys, and surveys of CNAs., Results: Multiple regression models revealed that cognitive functioning, activities of daily living functioning, race, gender, and CNA-reported weekly resident pain intensity were associated with resident NDBs. Regression models also revealed that weekly pain intensity and medical comorbidity were associated with CNA burden associated with the resident NDBs. However, we were unable to explain a significant amount of variance in the resistiveness to care or CNA burden associated with resistiveness to care., Discussion: Results underscore the role of pain in both resident NDBs and associated CNA burden. Future research should focus on predictors of resident resistiveness to care and the relation of pain assessment and management practices to CNA burden. Moreover, interventions to improve resident care should seek to include CNAs in institutional pain assessment and management processes.

Background: It is currently estimated that the resident population of individuals over the age of 65 living in nursing homes will double by 2020. Nearly one-third of all nursing home residents have difficulty seeing or hearing, 46% have some form of dementia, and 30-84% of those with dementia in nursing homes show some form of agitation. Nursing home residents who do not receive appropriate audiological services may experience social isolation, cognitive decline and decreased mobility., Purpose: To examine the effectiveness of standard audiological testing procedures for nursing home residents and to discuss the purpose of adapting assessment procedures that can lead to more effective audiological assessments for this population., Research Design: A retrospective chart analyses. A 33-item coding form was used to complete descriptive analysis of original audiological data and demographic data for 307 nursing home residents for a study to examine the effects of auditory stimulation on dementia-related behavior problems exhibited by nursing home residents through audiotape exposure to environmental sounds or soothing voice., Results: Although 77% (n = 235) of the 307 residents were considered compliant for the testing process and 74% (n = 288) tolerated putting on headphones, audiological assessment using air conduction testing could be completed in both ears on 32% (n = 100) of the residents. In fact, only 5% (n = 16) of the 307 residents were able to complete a full traditional audiometric assessment protocol., Conclusions: Proper identification of hearing impairment through effective and appropriate audiological assessment is crucial for preserving and enhancing quality-of-life in nursing home residents. This study served as an introduction to the problem of using traditional behavioral testing for hearing assessment of nursing home residents. Much work needs to be done to establish best practices for audiometric assessment in this population.

Previous studies have suggested that 4 latent constructs (depressed affect, well-being, interpersonal problems, somatic symptoms) underlie the item responses on the Center for Epidemiological Studies Depression (CES-D) Scale. This instrument has been widely used in dementia caregiving research, but the fit of this multifactor model and the explanatory contributions of multifactor models have not been sufficiently examined for caregiving samples. The authors subjected CES-D data (N = 1,183) from the initial Resources for Enhancing Alzheimer's Caregiver Health Study to confirmatory factor analysis methods and found that the 4-factor model provided excellent fit to the observed data. Invariance analyses suggested only minimal item-loading differences across race subgroups and supported the validity of race comparisons on the latent factors. Significant race differences were found on 3 of the 4 latent factors both before and after controlling for demographic covariates. African Americans reported less depressed affect and better well-being than White caregivers, who reported better well-being and fewer interpersonal problems than Hispanic caregivers. These findings clarify and extend previous studies of race differences in depression among diverse samples of dementia caregivers., ((c) 2008 APA, all rights reserved)

This study explored differences and similarities in the experiences of African American and White family caregivers of dementia patients living in rural Alabama. This cross-sectional survey used a caregiving stress model to investigate the interrelationships between caregiving burden, mediators, and outcomes. Random-digit-dialing telephone interviews were used to obtain data on a probability sample of 74 non-Hispanic White and 67 African American caregivers. White caregivers were more likely to be married and older, used acceptance and humor as coping styles, and had fewer financial problems. African American caregivers gave more hours of care, used religion and denial as coping styles, and were less burdened. The authors have developed a methodology for obtaining a representative sample of African American and White rural caregivers. Further investigations are needed of the interactions between urban/rural location and ethnic/racial backgrounds of dementia caregivers for heuristic and applied reasons.

Background: Caring for a family member with dementia is extremely stressful, contributes to psychiatric and physical illness among caregivers, and increases the risk for caregiver death. Finding better ways to support family caregivers is a major public health challenge., Objective: To test the effects of a structured multicomponent intervention on quality of life and clinical depression in caregivers and on rates of institutional placement of care recipients in 3 diverse racial or ethnic groups., Design: Randomized, controlled trial., Setting: In-home caregivers in 5 U.S. cities., Participants: 212 Hispanic or Latino, 219 white or Caucasian, and 211 black or African-American caregivers and their care recipients with Alzheimer disease or related disorders., Intervention: Caregivers within each racial or ethnic group were randomly assigned to an intervention or to a control group. The intervention addressed caregiver depression, burden, self-care, and social support and care recipient problem behaviors through 12 in-home and telephone sessions over 6 months. Caregivers in the control group received 2 brief "check-in" telephone calls during the 6-month intervention., Measurements: The primary outcome was a quality-of-life indicator comprising measures of 6-month caregiver depression, burden, self-care, and social support and care recipient problem behaviors. Secondary outcomes were caregiver clinical depression and institutional placement of the care recipient at 6 months., Results: Hispanic or Latino and white or Caucasian caregivers in the intervention group experienced significantly greater improvement in quality of life than those in the control group (P < 0.001 and P = 0.037, respectively). Black or African-American spouse caregivers also improved significantly more (P = 0.003). Prevalence of clinical depression was lower among caregivers in the intervention group (12.6% vs. 22.7%; P = 0.001). There were no statistically significant differences in institutionalization at 6 months., Limitations: The study used only a single 6-month follow-up assessment, combined heterogeneous cultures and ethnicities into a single group, and excluded some ethnic groups., Conclusions: A structured multicomponent intervention adapted to individual risk profiles can increase the quality of life of ethnically diverse dementia caregivers. ClinicalTrials.gov identifier: NCT00177489.

Purpose: The purpose of this study was to examine group differences in verbal agitation, verbal interaction, bed restraint, pain, analgesic and neuroleptic medication use, and medical comorbidity among agitated nursing home residents who died during a 6-month clinical trial compared with residents of the same gender and similar initial cognitive status who did not die during the trial., Design and Methods: We conducted a two-group secondary data analysis of prospective observational data from 10 nursing homes in Birmingham, Alabama. By means of chart review, resident assessments, surveys of certified nursing assistants, and direct observation of residents' daily behaviors and environment, 32 residents (87.34 +/- 7.29 years) with a Mini-Mental State Examination (MMSE) score = 4.31 (+/-5.54) who died were compared with 32 residents (84 +/- 6.96 years) with a mean MMSE score = 4.28 (+/-5.49) who did not die during the clinical trial., Results: Residents who died displayed more verbal agitation, less time in verbal interaction with staff, and almost twice as much time restrained in bed during observation time in comparison with residents who did not die during the clinical trial. However, groups did not differ significantly in severity of comorbid illness, functional status, number of painful diagnoses, certified nursing assistants' reports of residents' pain, or opioid or nonopioid analgesic prescription or dosage. Surviving residents were more likely to receive neuroleptic medication than residents who died., Implications: Results suggest that agitated nursing home residents may exhibit a heightened level of verbal agitation, decreased verbal interaction with staff, and increased bed restraint up to 3 months prior to death. Prospective observational studies are needed to identify markers for imminent mortality among nursing home residents.

Unlabelled: To evaluate psychometric properties and response patterns of the Care-giver Assessment of Function and Upset (CAFU), a 15-item multidimensional measure of dependence in dementia patients and caregiver reaction., Method: 640 families were administered the CAFU (53% White, 43% African American, and 4% mixed race and ethnicity). We created a random split of the sample and conducted exploratory factor analyses on Sample 1 and confirmatory factor analyses on Sample 2. Convergent and discriminant validity were evaluated using Spearman rank correlation coefficients., Results: A two-factor structure for functional items was derived, and excellent factorial validity was obtained. Convergent and discriminant validity were obtained for function and upset measures. Differential response patterns for dependence and caregiver upset were found for caregiver race, relationship, and care recipient gender but not for caregiver gender., Discussion: The CAFU is easily administered, reliable, and valid for evaluating appraisals of dependencies and upsetting care areas.

Confirmatory factor analysis of the Revised Memory and Behavior Problems Checklist--Nursing Home (RMBPC) replicated the factor structure of the community-based RMBPC (L. Teri et al., 1992). The reliability of the total score was high as indexed by estimates of internal consistency (alpha = .95), test-retest reliability (r = .86), and interrater reliability between 2 interviewers (r = .88). Notably, the interrater reliability between 2 independent certified nursing assistants (CNAs) regarding residents' behavior problem frequency was more modest (r = .46), possibly reflecting the degree to which resident behaviors capture individual CNA's attention. This may have implications for the interpretation of data from the Minimum Data Set. CNAs reported moderately severe burden associated with behavior problems in 47% of residents under their care.

The Resources for Enhancing Alzheimer's Cargiver Health (REACH) project was designed to test promising interventions for enhancing family caregiving for persons with dementia. The purpose of this article is to describe the research design, interventions, and outcome measures used in REACH and to characterize the sample recruited for the study. Nine interventions and 2 control conditions were implemented at 6 sites; 1,222 dyads were randomly assigned to an intervention or a control condition. The caregiver sample was 18.6% male with an average age of 62.3 years (56% Caucasian, 24% Black, and 19% Hispanic). Caregivers reported high levels of depressive symptoms and moderate burden. Care recipients were older, with a mean age of 79, and were moderately to severely impaired with mean Mini-Mental State Exam scores of 13/30.

Meta-analysis was used to examine pooled parameter estimates of 9 active compared with 6 control conditions of the Resources for Enhancing Alzheimer's Caregiver Health (REACH) project at 6 months on caregiver burden and depressive symptoms. Associations of caregiver characteristics and outcomes were examined. For burden, active interventions were superior to control conditions (p = .022). Also, active interventions were superior to control conditions for women versus men and for caregivers with lower education versus those with higher education. For depressive symptoms, a statistically significant association of group assignment was found for Miami's family therapy and computer technology intervention (p = .034). Also, active interventions were superior to control conditions for Hispanics, nonspouses, and caregivers with lower education. Results suggest interventions should be multicomponent and tailored.

Purpose: We developed manual-guided, replicable interventions based on common needs and cultural preferences of White and African American family caregivers (CGs) of individuals with dementia, and we evaluated these interventions after a 6-month follow-up., Design and Methods: We randomly assigned White (n = 70) and African American (n = 48) CGs of individuals with dementia to either a skills training condition or a minimal support control condition., Results: The degree of treatment implementation was methodically assessed, and findings demonstrated that both interventions were delivered according to protocol and were well received by CGs. CGs in both groups reported decreasing levels of problem behaviors and appraisals of behavioral bother, and increased satisfaction with leisure activities over time. On a measure of appraisal of distress related to behavior problems, White CGs showed more improvement in the minimal support control condition, and African American CGs showed the greatest improvements in the skills training condition. Spouse and nonspouse CGs also showed differential responses to intervention., Implications: Brief manual-guided interventions can be effective with White and African American CGs, and greater attention should be paid to possible differential responses to interventions by race and relationship to care recipient.

Objective: To determine if caregivers of dementia patients can validly report (a) the level of patient activities of daily living (ADL) dependence and (b) the amount of time they spend providing ADL assistance., Design: Seven ADLs were assessed through caregiver report using the Functional Independence Measure (FIM) and then videotaped. Videotapes were coded using a computer-assisted data collection system that documented the nature and duration of caregiver assistance provided during ADLs., Setting: The study took place in the homes of the caregiver-patient dyads., Subjects: Twenty-one people with dementia and their primary caregivers participated in the study., Main Outcome Measures: Data analysis examined (a) the degree to which caregiver-reported FIM scores corresponded to FIM scores derived from the observational data and (b) the extent to which caregivers' estimates of ADL assistance time corresponded to the assistance time observed during ADL interactions., Results: For all ADLs, caregiver-reported FIM scores were correlated significantly with observation-derived FIM scores (r(s) values ranged from 0.620 to 0.909), and means were similar. Assistance durations were also significantly correlated for some ADLs, but means were significantly different, indicating poor correspondence., Conclusions: Although caregivers of dementia patients can describe the nature of their ADL assistance with reasonable accuracy, they consistently overestimate their ADL assistance time, suggesting that caregiver reports of ADL assistance duration be used with caution. Additionally, the degree to which the assistance provided corresponds to the assistance actually needed needs to be addressed in future studies.

Purpose: Agitation frequently accompanies cognitive decline among nursing home residents. This study used cross-sectional and longitudinal (up to 18 months) methods to examine agitation among profoundly and moderately impaired residents using both staff report and direct observation methods. Design and Methods: The study included participants (N = 78) from a larger study who completed either 12 or 18 months of data collection. There were four measurement points, each separated by 6-month intervals. We recorded agitation using two measures: (a) the computer-assisted behavioral observation system (CABOS) and (b) the staff-completed Nursing Home Behavior Problem Scale. We used longitudinal hierarchical linear modeling to capture the dynamic nature of behavior change as a function of individual resident characteristics and time. Results: The profoundly cognitively impaired residents (M Mini-Mental State Examination [MMSE] score = 1.7) displayed more agitation than the moderately impaired group (M MMSE score = 15.4) at Epoch 1 (cross-sectional analyses). Longitudinal analysis found a significant linear and quadratic trend only with the profoundly impaired residents using the CABOS. These residents showed slight improvements in agitation up to 12 months, with agitation increasing significantly from 12 to 18 months. Implications: With nursing homes receiving an increasing number of profoundly cognitively impaired residents, these results have potential cost and policy implications. Measuring agitation over time by using both staff report and observation measures presents various problems, and we present an alternative measure that may help to avoid these difficulties. (Contains 2 tables and 2 figures.) [Preparation of the article was partially supported by The University of Alabama and the Center for Mental Health and Aging.]

Purpose: The purpose of this study was to examine group differences in verbal agitation, verbal interaction, bed restraint, pain, analgesic and neuroleptic medication use, and medical comorbidity among agitated nursing home residents who died during a 6-month clinical trial compared with residents of the same gender and similar initial cognitive status who did not die during the trial. Design and Methods: We conducted a two-group secondary data analysis of prospective observational data from 10 nursing homes in Birmingham, Alabama. By means of chart review, resident assessments, surveys of certified nursing assistants, and direct observation of residents' daily behaviors and environment, 32 residents (87.34 [+ or -] 7.29 years) with a Mini-Mental State Examination (MMSE) score = 4.31 ([+ or -]5.54) who died were compared with 32 residents (84 [+ or -] 6.96 years) with a mean MMSE score = 4.28 ([+ or -] 5.49) who did not die during the clinical trial. Results: Residents who died displayed more verbal agitation, less time in verbal interaction with staff, and almost twice as much time restrained in bed during observation time in comparison with residents who did not die during the clinical trial. However, groups did not differ significantly in severity of comorbid illness, functional status, number of painful diagnoses, certified nursing assistants' reports of residents' pain, or opioid or nonopioid analgesic prescription or dosage. Surviving residents were more likely to receive neuroleptic medication than residents who died. Implications: Results suggest that agitated nursing home residents may exhibit a heightened level of verbal agitation, decreased verbal interaction with staff, and increased bed restraint up to 3 months prior to death. Prospective observational studies are needed to identify markers for imminent mortality among nursing home residents.

Purpose: We developed manual-guided, replicable interventions based on common needs and cultural preferences of White and African American family caregivers (CGs) of individuals with dementia, and we evaluated these interventions after a 6-month follow-up. Design and Methods: We randomly assigned White (n = 70) and African American (n = 48) CGs of individuals with dementia to either a skills training condition or a minimal support control condition. Results: The degree of treatment implementation was methodically assessed, and findings demonstrated that both interventions were delivered according to protocol and were well received by CGs. CGs in both groups reported decreasing levels of problem behaviors and appraisals of behavioral bother, and increased satisfaction with leisure activities over time. On a measure of appraisal of distress related to behavior problems, White CGs showed more improvement in the minimal support control condition, and African American CGs showed the greatest improvements in the skills training condition. Spouse and nonspouse CGs also showed differential responses to intervention. Implications: Brief manual-guided interventions can be effective with White and African American CGs, and greater attention should be paid to possible differential responses to interventions by race and relationship to care recipient.

The current study translated the Resources for Enhancing Alzheimer's Caregiver Health: Offering Useful Treatments (REACH OUT), a skills-building stress and burden intervention, for the primary care setting and pilot the resulting intervention. The 16-week intervention consisted of a combination of clinic-based group and one-on-one sessions offered within a medical home, geriatrics clinic. A quasi-experimental pre- and post-test study design without a control group tested the resulting intervention. Semi-structured qualitative exit interviews evaluated program satisfaction. Twenty-five caregivers participated in one of four intervention groups; 21 caregivers completed the intervention (attended at least five of six group sessions). Caregiver burden on standardized assessments was significantly reduced between pre- and post-intervention, specifically for physical/emotional strain and caregiving uncertainty. Significant reductions were found in the frequency of reported disruptive behaviors; increased caregiver confidence in handling behavior problem frequency, depressive symptoms, disruptive behaviors, and memory-related problems; and decreased bother with respect to behavioral problem frequency and care recipient depression. Program satisfaction was high. This work suggests that the REACH OUT program can be successfully modified for use within a primary-care medical home setting. [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]

Purpose: The aim of this study was to translate the evidence-based Resources for Enhancing Alzheimer's Caregiver Health (REACH) II intervention for use in 4 Area Agencies on Aging (AAAs). A secondary aim was to examine possible moderators of treatment outcome. Design and Methods: We used a quasi-experimental pre-post treatment design with no control group. A partnership was formed between the Alabama Department of Senior Services and the University of Alabama. The partnership trimmed the REACH II intervention used in the clinical trial for feasible use in a social service agency. The condensed REACH intervention, termed REACH OUT, was delivered to 272 dementia caregivers during 4 home visits and 3 phone calls for a period of 4 months. The assessment examined pre-post treatment effects on a number of outcomes, including care recipient risk, mood, memory, and behavior problems; caregiver stress and emotional well-being; caregiver health; and program satisfaction. All aspects of the program except for training, periodic consultation, and data analysis were controlled by the AAA staff. Results: Analyses were conducted on the 236 dyads that completed at least 3 of the 4 planned sessions. Significant positive pre-post effects were found on caregiver subjective burden, social support, caregiver frustration, depression, caregiver health, care recipient behavior problems and mood, and 2 of 4 care recipient risk behaviors. Site of intervention and certain participant characteristics (e.g., caregiver relationship) moderated several pre-post differences. A caregiver survey and interventionist focus group reported high acceptability of the program Implications: This project suggests that the REACH II intervention can be modified for feasible and effective use in AAAs. The next step is to integrate the intervention into usual service delivery to achieve sustainability. [ABSTRACT FROM AUTHOR]

Although proxy reports of activities of daily living (ADLs) are commonly used, especially when the care recipient has dementia, how well these caregiver reports correspond to professionals' ratings is not always clear. In this study, dementia caregivers completed an orally administered version of the Self-Care subscale of the Functional Independence Measure (FIM). ADL interactions were videotaped in the home, and independent raters assigned a FIM score to these interactions. An occupational therapist later viewed the videotaped ADLs and assigned FIM scores to those interactions. These three sets of scores were then compared. All possible correlations were significant (n = 21; p ≤.005; rs = .620 to .933; Mdn = .862), and there were no significant differences among ratings obtained from the different sources. These results support earlier conclusions regarding the validity and clinical utility of caregiver proxy ratings of functional ability in elders with dementia. [ABSTRACT FROM AUTHOR]

Purpose: We developed and evaluated an explicit procedure for obtaining self-report pain data from nursing home residents across a broad range of cognitive status, and we evaluated the consistency, stability, and concurrent validity of resident responses. Design and Methods: Using a modification of the Geriatric Pain Measure (GPM-M2), we interviewed 61 residents from two nursing homes (Mini-Mental State Examination score, M = 15 ± 7) once a week for 4 consecutive weeks. We collected additional data by means of chart review, cognitive status assessments, and surveys of certified nursing assistants. We used descriptive and correlational analyses to address our primary aims. Results: Eighty-nine percent of residents completed all four scheduled interviews. Cognitive status was not significantly correlated with number of nonresponses and prompts for yes-no questions, but it was significantly correlated with nonresponses and prompts for Likert-scale questions (r = -.48, p < .001 and r = -.59, p < .001, respectively). Completion time for the 17-item pain measure (M = 13 min) was not predicted by cognitive status. Residents' scores on the GPM-M2 were significantly correlated with number of chronic pain-associated diagnoses, r = .37, p < .01, and internal consistency was excellent, = 0.87 - 0.91. Residents' GPM-M2 scores were stable over time, r = .74-.80, p < .0001, for all comparisons. Implications: Using explicit protocols and reporting procedural data allows researchers and clinicians to better understand and apply results of self-report studies with cognitively impaired elders. Results suggest that many nursing home residents can provide consistent and reliable self-report pain data, given appropriate time and assistance. [ABSTRACT FROM AUTHOR]

This study is a critical analysis of the components of a communication skills training program designed to increase the quantity and quality of nursing aides' (N = 126) verbal interactions with residents with dementia (N = 125) during care routines. Training included a didactic in-service, one-on-one, criterion-based training during care interactions, the use of memory books, and a staff management system. Results indicated that this communication skills program significantly improved nursing aides' effective skills (p > .001), effective instructions (p > .01) and manner of communication during care interactions with residents. One-on-one performance training and feedback was required to master and maintain skill use 3 months beyond program termination. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine correlates of analgesic medication prescription and administration in communicative, cognitively impaired nursing home residents. Residents' behaviors were assessed using computer-assisted real-time observations as potential adjunctive indicators of pain. DESIGN: Cross-sectional study over a 4-week period. SETTING: Five nursing homes in the greater Birmingham, Alabama, area. PARTICIPANTS: Ninety-two residents (mean age ± standard deviation = 83.86 ± 8.55) with a mean Mini-Mental State Examination (MMSE) score of 13.81 ± 6.34. MEASUREMENTS: Data were obtained via chart review, resident assessments, questionnaire completion by certified nursing assistants familiar with residents' care, and direct observation of residents' daily behaviors. RESULTS: Receipt of analgesic medication was related to self-report of pain (F 2,89 = 9.89, P = .0001), MMSE (F 2,88 = 3.98, P = .022), and time spent inactive (F 2,89 = 3.04, P = .053). Residents who received analgesic medication reported greater intensity of pain than other residents. Residents who received analgesics had higher MMSE scores than those who did not receive analgesics. Residents who received analgesics spent less time being inactive than those not prescribed analgesics. Receipt of higher dosage of opioid analgesic medication was associated with more time spent with others in verbal interaction (r = .22, P = .03). CONCLUSION: This study refines the methodology of measuring analgesic medication dosage and its effect on resident behavior. Analgesic prescription and administration patterns are related to time residents spend being inactive. Results suggest that opioid analgesics may hold particular promise in alleviating pain, as indicated by resident behaviors. [ABSTRACT FROM AUTHOR]

Investigates the association between certified nursing assistant on pain in Birmingham, Alabama. Medication used in cognitive impaired nursing home resident; Assessment by three-mile proxy pain questionnaires; Reliability of coefficients for test-retest items.

The effects of a 12-week intervention on a patient-focused skills training group and a caregiver-focused skills training group were compared with those on a control group that received comparable attention, but no training. Intervention effects were monitored at the completion of the treatment phase and at 3- and 6-months postintervention. Treatment implementation was documented in a comprehensive fashion to ensure replicability. Both training groups acquired skills that enabled them to improve targeted behaviors (patient problem behaviors and caregiver mood, respectively). Weaker effects were found for more distal outcomes, such as depression, perceived stress, caregiver strain, and self-efficacy. [ABSTRACT FROM AUTHOR]

This study used computer-assisted real-time data collection procedures to study temporal patterns of disruptive vocalization (DV) in demented nursing home residents. Residents (N = 68) were observed from 8 a.m. to 8 p.m. and total mean duration of DV within hourly blocks was calculated. Analysis of the temporal distribution of DV exhibited by the group of 68 residents indicated a significant cubic trend. Exploratory cluster analysis uncovered three distinct temporal patterns of DV; although two of the patterns are generally supportive of sundowning. Cluster 1 showed a relatively constant pattern of low rate DV. Clusters 2 and 3 showed cyclic trends. Peaks in DV were observed during noontime and in the evening for Cluster 2. Cluster 3 showed peaks in DV in the early morning hours and late afternoon. MANOVA was employed to examine any differences among clusters in age, cognitive status, and ADL status. Univariate analyses indicated that cognitive status was the only factor that differed significantly among clusters, with members of Cluster 1 (constant low rate DV) manifesting higher cognitive status scores than Clusters 2 and 3. A step-wise discriminant function analysis also showed cognitive status to be the only statistically significant predictor of cluster membership. The authors' note that the scientific literature on agitation is fraught with contradictory findings and assert that inconsistencies may be due to differences across studies in problem definition, method of measurement, and sample size. The results are discussed in relation to these methodological issues and clinical implications of the findings. Copyright © 2001 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

This paper provides a selective review of behavioral intervention research aimed at successfully decreasing dementia-related challenging behaviors in nursing homes. The authors include separate discussions of behavioral excesses (disruptive vocalization, wandering, physical and verbal aggression) and deficits (excess dependency, therapeutic activities, social interaction/communication). Descriptions of interventions used to address each behavior problem are followed by methodological evaluations of the research. Discussions are augmented by inclusion of the authors' ongoing intervention research. The paper concludes with a description of a comprehensive program for teaching behavior management skills to nurse aides and a motivational system for maintaining the performance of these skills over the long term. Copyright © 1999 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

We report the results of a pilot study examining the dose-response of buspirone for the treatment of agitated and disruptive behaviors in dementia patients. Patients were identified by physician referral, chart review and caregiver response to newspaper advertisements. All subjects met NINCDS—ADRDA criteria for probable Aiz-heimer's disease. Twenty subjects were entered into the study, 12 completed the protocol. After a washout period. all subjects received 1 week of placebo followed by approximately 2 weeks each of buspirone 15 mg, 30 mg, 45 mg and 60 mg daily. The primary outcome measure was the total score on Reisberg's Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD), which was administered at baseline, the end of the placebo phase and at the end of each dosage interval. Significant improvement in the mean score was seen at a daily dosage of 30 mg (p < 0.05 vs placebo). Significant improvement was also seen on the delusion, aggression and anxiety subscales of the BEHAVE-AD. Few side-effects were noted. These data suggest that the optimal starting dosage of buspirone for the treatment of behavioral pathology in dementia patients is 30 mg daily. Individual patients may have their best response at dosages ranging from 15 to 60 mg daily. Confirmation of these findings requires a double-blind, placebo-controlled clinical trail. [ABSTRACT FROM AUTHOR]

The purpose of this study was to compare the discourse profiles of 30 nursing home residents with dementia and of 30 healthy older adults. A total of 60 transcripts of interview style conversations were analyzed using a discourse analysis schema. The results revealed a higher frequency of discourse building features, such as coherence and cohesion, for healthy adults compared to adults with dementia. Conversely, discourse-impairing features, such as disruptive topic shifts and empty phrases, were found more often in conversations of adults with dementia compared to healthy adults. Conversational partners deviated from their conversation protocol when talking to adults with dementia by including facilitative strategies in the conversation. Discourse features in interview style conversations in adults with dementia reflect declines in their memory. [Copyright &y& Elsevier]

Researchers have examined numerous psychosocial and behavioral interventions intended to alleviate distress among family caregivers of persons with dementia. Many of these interventions are complex, combining numerous treatment components. Although some multicomponent interventions have been successful in reducing caregiver distress, the impact of specific elements of these interventions on outcomes is not known. The article presents results of an analytic approach that allows researchers to describe the individual elements of multicomponent interventions and to examine the relationships between those components and outcomes. This approach is successfully applied to interventions being evaluated in the Resources for Enhancing Alzheimer's Caregiver Health (REACH) program. The results indicate that actively targeting caregiver behavior is effective in achieving positive outcomes with respect to caregiver depression. [ABSTRACT FROM AUTHOR]