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The Centers for Medicare and Medicaid (CMS) initiated the National Partnership to Improve Dementia Care in Nursing Homes in 2012, which helped decrease antipsychotics use. However, inappropriate use of antipsychotics and other psychotropic medications to control behavioral symptoms associated with dementia persists. Nursing homes (NHs) can be flagged for inappropriate psychotropics use as a deficiency of care citation (F-758 tag). The purpose of this study was to comprehensively explore inappropriate psychotropic medication use deficiency, F-758 citations, in caring for NH residents with dementia.A mixed-methods study was performed.During the first quarter of 2018 (January-March), 3526 NHs were surveyed, of which 642 received F-758 tags. Of the 642, the sample was confined to the 444 NHs that received the citation for the care of residents with dementia. Information on deficiencies was obtained from 2018 Certification and Survey Provider Enhanced Reporting data. Inspection reports for deficiencies were obtained from Centers for Medicare and Medicaid Nursing Home Compare and ProPublica.Quantitative analysis was used to examine the frequency of involved psychotropic medications, scope/severity of F-758 deficiency citations, and reasons for the citations. Reasons for F-758 citations by psychotropic medication categories and scope/severity of the citations were also examined using χAntipsychotics were the most involved drug category for F-758 tag citations. The 3 most common reasons for F-758 citations included failure to identify and/or monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs), and maintain 14-day limitations on Pro Re Nata (PRN) psychotropic orders (121 NHs). Compared with those with no involvement of antipsychotic drugs, facilities with antipsychotics-related F-758 tags had higher rates of failure to identify/monitor behavioral symptoms (P .001), attempt gradual drug reduction (P.001), and provide adequate indications for psychotropics use (P.001). NHs with F-758 tags related to inappropriate antianxiety medication use had a higher prevalence of failure to maintain 14-day limitation on PRN orders (P.001) and provide nonpharmacologic interventions (P.001).This study suggests areas for improvement that could potentially reduce inappropriate psychotropics use. Supporting quality of dementia care workforce and improving cooperation within healthcare staff and professionals are recommended to ensure proper nonpharmacologic and pharmacologic interventions.

As a method of research, pragmatic trials are recommended so as to generate results that are applicable to real-world care. This intent is especially important for the millions of older adults who receive long-term care in thousands of nursing homes and assisted living communities across the country-and many millions more around the globe. This article presents key points raised by experts participating in a conference funded by the National Institute of Aging held at the 2021 conference of the Society for Post-Acute and Long-term Care Medicine. The purpose of the conference was to convene leading clinicians, researchers, and industry partners to address special considerations of pragmatic trials in long-term care. Cross-cutting and unique challenges and solutions to conducting pragmatic trials were discussed focusing on 3 areas of clinical relevance to long-term care: (1) functional care and outcomes, (2) psychosocial care and quality of life, and (3) medical care and outcomes, with a special focus on persons with dementia. Challenges and innovative solutions were organized across the 9 domains of the revised Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) Tool, and future research recommendations for pragmatic trials in long-term care were identified.

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.

Emotional expressions in late-stage dementia have traditionally been studied within a deficit paradigm. Moving the narrative of the dementia trajectory from a solely negative pathological experience to one that acknowledges the potential for positive experiences aligns with international recommendations for living well with dementia. The purpose of this study was to extend prior research by examining the pattern of well-being using affect balance, the ratio of positive to negative affect, in nursing home residents living with dementia over 12 months and its association to factors that could potentially influence resident well-being. This study was a secondary analysis of baseline, 4 and 12-month data from a pragmatic clinical trial. A total of 536 residents with moderate to severe cognitive impairments from 55 nursing homes were included in the analyses. Results of the multivariable linear mixed model regression analysis indicated that resident function, the number of registered nurse hours devoted to care in the facility, and the quality of staff interaction predicted higher affect balance over time after controlling for other variables. The findings provide support for the utility of affect balance as a meaningful outcome measure of well-being for persons living with dementia. In addition, results point to specific interventions (i.e., maintaining/improving resident function, providing adequate nurse staffing levels, and improving staff communications skills) that can serve as the focus for both research and practice to help residents live well with dementia. Clinicaltrials.gov (NCT03014570).

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 and PurposeThe purpose of this study was to test the reliability and validity of the Knowledge of Person-Centered Behavioral Approaches for BPSD based on a Rasch analysis.MethodsThis study used baseline data from the Implementation of the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) clinical trial.ResultsA total 1,071 nurses completed the test. There was evidence of reliability (alpha coefficient of .99), construct validity with INFIT and OUTFIT statistics in the .6 to 1.4 range, and hypothesis testing with a significant correlation between the Knowledge of Person-Centered Behavioral Approaches for BPSD and positive care interactions.ConclusionsFuture use of the measure should include more challenging items to differentiate those very high in knowledge of person-centered behavioral approaches for BPSD.

Background and Objectives Apathy is a common symptom in dementia and is associated with rapid cognitive decline, poor quality of life, and higher mortality. Lawton’s Competence and Environmental Press model suggests that an individual’s behavior and affect are influenced by the fit of their functional abilities with the environmental demands. Yet, empirical evidence on the association between person–environment (P–E) fit and apathy is lacking. Thus, this study examined the relationship between P–E fit and apathy in dementia. Specifically, this study focused on the extent the physical environment fits individual functional limitations. Research Design and Methods This is a cross-sectional study using the baseline data from long-term care residents with dementia. The sample included 199 residents with moderate-to-severe cognitive impairment from 4 assisted living and 4 nursing homes. Function-focused P–E fit was measured using the Housing Enabler scale. Apathy was measured using the Apathy Evaluation Scale. Multilevel linear models were used to analyze the relationship between P–E fit and apathy. Results Findings revealed that greater P–E fit, specifically indoor environment, was significantly associated with lower apathy after controlling for age, gender, and years living in the facility. Yet, the association became not significant after controlling for individual physical function. Discussion and Implications Findings support the association between function-focused P–E fit and apathy, but the association is no longer significant after physical function is adjusted. Future research may explore other aspects of P–E fit and the impact of social and organizational environment on apathy in dementia.

Psychotropic medications are used to manage behavioral symptoms of dementia in nursing homes despite limited efficacy and the risk of adverse effects, and may be considered an easier solution for the treatment of behavioral symptoms. However, non-pharmacologic interventions are preferable but are most effective with consistent staffing. To address this, the Centers for Medicare and Medicaid Services implemented additional regulatory scrutiny through F-tag for deficiencies of care, targeting inappropriate psychotropic medication use (F-758 tag). The purpose of this study was to examine associations between nurse staffing levels and the occurrence of deficiency citations for inappropriate psychotropic medication use in residents with dementia symptoms.This was secondary data analysis of a cross-sectional study using CASPER (Certification and Survey Provider Enhanced Reporting) and PBJ (Payroll-Based Journal) data from 14,548 Medicare or Medicaid-certified facilities surveyed between December 1, 2017 and December 31, 2018.Staffing measures included nursing hours per resident day and registered nurse skill-mix. Generalized linear mixed models with facilities nested within states, were used to estimate the magnitude of the associations between the occurrence of inappropriate psychotropics use deficiency citations and nurse staffing levels. Covariates included facility location, size, ownership, the presence of dementia special care units, and the proportion of residents with dementia, depression, psychiatric disorders, mental behavioral symptoms, and residents with Medicare/Medicaid.There were 1875 facilities with deficiency citations regarding inappropriate psychotropics use for residents with dementia. When controlling for covariates, facilities with greater hours per resident day for registered nurses (odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.44-0.67), certified nursing assistants (OR = 0.87, 95% CI = 0.77-0.99) and total nurse staff (OR = 0.87, 95% CI = 0.79-0.96) had significantly lower odds of inappropriate psychotropics use deficiency citations. Nursing homes with greater registered nurse skill-mix had significantly lower odds of receiving the deficiency tags (OR = 0.10, 95% CI = 0.04-0.26).Citations for inappropriate psychotropic medication use among residents with dementia were less likely to occur in facilities with higher staffing levels for registered nurses, certified nursing assistants, total nurse staff, and greater registered nurse skill-mix. Facilities need to be equipped with adequate nurse staffing levels to facilitate the use of non-pharmacological interventions and reduce inappropriate psychotropic medication use.Adequate nursing staffing is associated with fewer deficiencies related to the use of psychotropic medications to treat behavioral symptoms. Nursing home administrators and policymakers need to focus on assuring adequate nurse staffing levels to provide safe and high-quality dementia care.

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.

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.

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.

OBJECTIVES: The purpose of this study was to expand on prior work testing invariance on several depression measures in community based older adults and explore the psychometric properties and evidence of invariance between racial groups based on the Cornell Scale for Depression in Dementia DESIGN: This was a descriptive measurement study. SETTING AND PARTICIPANTS: This was a secondary data analysis using baseline data from two studies: Testing the Implementation of the Evidence Integration Triangle for Behavioral and Psychological Symptoms Associated with Dementia and the study Testing the Impact of Function and Behavior Focused Care for Nursing Home Residents with Dementia. Combined, 67 nursing homes participated from two states and 889 residents were recruited. The mean age of the participants was 86.58 (SD=10.31) and the majority was female (72%) and White (70%). METHODS: This was a descriptive study and a Rasch analysis was done to establish reliability based on internal consistency and evidence of Differential Item Functioning (DIF) across races. Validity was based on item fit and model testing with Structural Equation Modeling to compare models between White and Black participants. RESULTS: There was evidence of internal consistency (Alpha Coefficient of.98) and no significant evidence of DIF. The item related to suicide had a high logit and did not significantly load onto the measurement model for Blacks. There was not a good spread of the items across the concept of depression. The model had a better fit with the items when used with White versus Black participants. CONCLUSIONS AND IMPLICATIONS: The findings indicate that it would be helpful to add some additional items that reflect depressive symptoms among this population. Further the findings serve as a reminder that this measure may be biased toward identification of symptoms of depression among White versus Black residents.

Background Federal regulations stipulate that behavioral interventions be used for behavioral and psychological symptoms of distress in dementia (BPSD). Care community staff have difficulty implementing these approaches. Purpose This study tested an implementation strategy, the Evidence Integration Triangle for BPSD (EIT-4-BPSD), for assisting staff in the use of evidence-based behavioral approaches for BPSD. Methods About 55 care communities were randomized to EIT-4-BPSD or usual care; 553 residents were enrolled. The implementation strategy was delivered by research facilitators, staff, stakeholders, and champions over 12 months. It involved four components: Environment and policy assessments; Staff education; Establishment of person-centered care plans; and Mentoring and motivating staff. The implementation strategy was evaluated using the Reach, Effectiveness, Adoption, Implementation, Maintenance model. Findings There was no evidence for resident or care community effectiveness. There was evidence of adoption and implementation. Discussion EIT-4-BPSD was helpful as an implementation strategy and staff altered how care was provided.

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

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.

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.]

Well-being is an important outcome for people with dementia. The current study is a secondary analysis of baseline data from an ongoing pragmatic trial. Affect balance, the ratio of positive to negative affect, was used as a measure of well-being, and factors related to it were examined in a sample of 325 nursing home residents. Measures of staff interaction during caregiving, staff knowledge of person-centered approaches for dementia care, staff hours of care, the physical environment, person-centered policies, resident function, and quality of life were obtained using direct observation, staff interview, and medical chart review. The results of the quantile multivariable regression analysis indicated that positive staff interaction and higher resident function were significantly associated with higher affect balance after controlling for other variables. The findings have heuristic value for the development of conceptual frameworks that focus on meaningful outcomes for residents with dementia and future research. [ Research in Gerontological Nursing, 13 (1), 21–30.]

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 and PurposeThe purpose of this study was to test the reliability and validity of the Quality of Interaction Survey (QuIS) using a quantification scoring approach.MethodsBaseline data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) study was used.ResultsA total of 553 residents participated. There was evidence of inter-rater reliability with Kappa scores of .86 to 1.00 and internal consistency based on the Rasch analysis (item reliability of .98). There was some support for validity based on item fit and hypothesis testing as resistiveness to care was significantly associated with total QuIS scores.ConclusionThis study supports the use of the quantified QuIS to evaluate the quality of interactions over time and to test interventions to improve interactions.

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.

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.

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

INTRODUCTION The purpose of this study was to test differences in psychotropic medication, function, physical activity, agitation, resistiveness to care, comorbidities, and depression among moderate to severely cognitively impaired nursing home residents who were fallers versus nonfallers. METHODS This was a secondary data analysis using baseline data from a randomized controlled trial testing the Function and Behavior Focused Care intervention across 12 nursing homes. The sample included 336 older adults, the majority of whom were female and white. RESULTS There was a significant difference in the total number of comorbidities, agitation, the total number of psychotropic medications, depressive symptoms, and physical activity between those who fell and those who did not fall (Pillai-Bartlett trace = 4.91; P < .001). DISCUSSION Findings support prior work except with regard to medication use, cognition, and function. Due to inconsistent findings, additional research is recommended particularly with regard to the use of specific drug groups and medications.

Aims The aim of this study was to examine the association of specific personal and environmental factors with eating performance among long-term care residents with moderate-to-severe cognitive impairment. Background Eating is the one of the most basic and easiest activities of daily living to perform. While multilevel factors can be associated with eating performance, the evidence among those with dementia was insufficient. Design A secondary analysis of baseline data collected between March and September in 2012 from 199 residents in eight long-term care facilities. Methods Eating performance was conceptualized using the single self-care ‘feeding’ item in the Barthel Index and was scored based on four levels of dependence and assistance required. Binary logistic regression was used to examine the adjusted association of specific factors with eating performance. Results Almost one-third of the residents needed help with eating. After adjusting the type of facility, number of comorbidities, chair-sitting balance, agitation and depression, compromised eating performance was associated with severe cognitive impairment and low physical capability. Conclusion This study supported the association of eating performance with cognitive impairment and physical capability among long-term care residents with moderate-to-severe cognitive impairment. Targeted interventions should be implemented to reduce the impact of cognitive decline on eating performance and promote physical capability to optimize eating performance. Future work need to use validated multiple-item measures for eating performance and test the association of personal and environmental factors with eating performance among a larger heterogeneous group of long-term care residents to enhance understanding of the factors.

Background Review of research to date has been focusing on maintaining weight and nutrition with little attention on optimizing eating performance. Objective To evaluate the effectiveness of interventions on eating performance for older adults with dementia in long-term care (LTC). Methods A systematic review was performed. Five databases including Pubmed, Medline (OVID), EBM Reviews (OVID), PsychINFO (OVID), and CINAHL (EBSCOHost) were searched between January 1980 and June 2014. Keywords included dementia, Alzheimer, feed(ing), eat(ing), mealtime(s), oral intake, autonomy, and intervention. Intervention studies that optimize eating performance and evaluate change of self-feeding or eating performance among older adults (≥65 years) with dementia in LTC were eligible. Studies were screened by title and abstract, and full texts were reviewed for eligibility. Eligible studies were classified by intervention type. Study quality was accessed using the Quality Assessment Tool for Quantitative Studies, and level of evidence using the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence. Results Eleven intervention studies (five randomized controlled trials [RCTs]) were identified, and classified into four types: training program, mealtime assistance, environmental modification, and multicomponent intervention. The quality of the 11 studies was generally moderate (four studies were rated as strong, four moderate, and three weak in quality), with the main threats as weak designs, lack of blinding and control for confounders, and inadequate psychometric evidence for measures. Training programs targeting older adults (Montessori methods and spaced retrieval) demonstrated good evidence in decreasing feeding difficulty. Mealtime assistance offered by nursing staff (e.g., verbal prompts and cues, positive reinforcement, appropriate praise and encouragement) also showed effectiveness in improving eating performance. Linking evidence to action This review provided preliminary support for using training and mealtime assistance to optimize eating performance for older adults with dementia in LTC. Future effectiveness studies may focus on training nursing caregivers as interventionists, lengthening intervention duration, and including residents with varying levels of cognitive impairment in diverse cultures. The effectiveness of training combined with mealtime assistance may also be tested to achieve better resident outcomes in eating performance.

The benefits of an early diagnosis of dementia are well documented. According to a 2015 Alzheimer’s Association policy brief, early detection and diagnosis offers a number of benefits for affected individuals and their families (Alzheimer’s Association, 2015). Early detection and diagnosis allows people living with dementia to access available treatments when they are more likely to provide some benefit, build a care team, participate in support services, complete appropriate advanced directives, and enroll in clinical trials or engage in experimental types of treatment options. Further people who know they have the disease and their care partners can make additional financial and legal arrangements before they are deemed unable to do so. Early detection means that people may be diagnosed while still working or just as they are beginning to enjoy retirement and a period in life when their children have moved out of the home. Despite some of the advantages of an early diagnosis, knowledge of this diagnosis is still devastating to individuals and requires significant coping, resilience and support.

Behavioral and psychological symptoms of dementia (BPSD) include aggression, agitation, resistiveness to care, depression, anxiety, apathy, and hallucinations. BPSD are common in nursing home residents and can be ameliorated using person-centered approaches. Despite regulatory requirements, less than 2% of nursing homes consistently implement person-centered behavioral approaches. In a National Institute of Nursing Research-funded research protocol, we are implementing a pragmatic cluster randomized clinical trial designed to enable staff in nursing homes to reduce BPSD using behavioral approaches while optimizing function, preventing adverse events, and improving quality of life of residents. The implementation is based on use of the Evidence Integration Triangle (EIT), a parsimonious, community-engaged participatory framework that is well suited to the complexity and variability in the nursing home environment. A total of 50 nursing home communities will be randomized to EIT-4-BPSD or education only. Primary Aim 1 is to determine if communities exposed to EIT-4-BPSD demonstrate evidence of implementation evaluated by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) criteria. Primary Aim 2 is to evaluate the feasibility, utility, and cost of the EIT approach in EIT-4-BPSD communities.