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Older adults continue to spend little time engaged in physical activity when hospitalized. The purpose of this study was to (a) describe activity among hospitalized older adults with dementia and (b) identify the association between specific factors (gender, ambulation independence, comorbidities, race, and hospital setting) and their physical activity. This descriptive study utilized baseline data on the first 79 participants from the Function Focused Care for Acute Care using the Evidence Integration Triangle. Multiple linear regression models were run using accelerometry data from the first full day of hospitalization. The participants spent an average of 83.7% of their time being sedentary. Male gender, ambulation independence, and hospital setting (the hospital in which the patient was admitted) were associated with greater activity. This study reports on the limited time spent in activity for older adults with dementia when hospitalized and highlights patient profiles that are particularly vulnerable to sedentary behavior in the hospital setting.

The current study aimed to test the feasibility and preliminary efficacy of the Promoting Positive Care Interactions (PPCI) intervention designed to establish positive care interactions between staff and residents in assisted living (AL) using an online approach. PPCI was implemented in one AL community using a single group pre-/posttest design; 17 care staff were recruited from the memory care unit. Delivery, receipt, and enactment of the PPCI were assessed for feasibility. Change in staff outcomes and facility outcomes were examined for preliminary efficacy. The four steps of the PPCI were implemented as intended with 100% staff exposure to education and considerable staff engagement in weekly mentoring sessions. Although there was an improvement in AL environment and policy, no significant changes were observed in staff outcomes. Future testing of the PPCI should include a longer timeline and explore a hybrid model that includes online education and in-person mentoring and coaching of staff to improve care interactions. [ Journal of Gerontological Nursing, 48 (8), 17–25.]

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.

Care interactions are essential to understand and respond to resident needs in assisted living (AL). The factors that influence care interactions in AL have not been directly examined. In this study, we explored the factors associated with the quality of care interactions in AL. It was hypothesized that resident functional status, agitation, depression, and resistiveness to care as well as facility size and ownership would be significantly associated with the quality of care interactions in AL after controlling for resident demographics (age, gender, marital status), comorbidities, and cognition. To test the hypothesis, we utilized baseline data including 379 residents from the second and third cohorts recruited in a randomized trial titled ‘Dissemination and Implementation of Function Focused Care for Assisted Living Using the Evidence Integration Triangle’. Regression analysis was performed using a stepwise method. The care interactions were mostly positive (mean=6.3; range = 0-7). Resident agitation and facility ownership were significantly associated with care interactions and accounted for 8.2% of the variance. Increased resident agitation was associated with negative or neutral interaction while for-profit ownership was associated with positive interactions. To promote positive care interactions, staff should be educated about strategies to minimize resident agitation (e.g., calm posture and respectful listening) and encouraged to engage with residents using resident-centered care and communication approach. Findings also suggest the need to work towards optimizing care interactions in nonprofit stings. Future research could further explore the impact of facility-level factors (e.g., staffing ratios, staff longevity, and job satisfaction) on care interactions.

Objectives: The purpose of this study was to determine if proxies can complete the Physical Resilience Scale for older adults living with dementia. Methods: This was a descriptive study using Rasch analysis and baseline data from the Function Focused Care for Acute Care Using the Evidence Integration Triangle trial. The first 240 patients living with dementia were included in this analysis. Results: There was evidence of reliability based on person and item separation index. There was no evidence of Differential Item Functioning (DIF) between genders and a DIF by race on Item 7. Validity was supported based on items fitting the model with the exception of one item, and a significant relationship between physical resilience and pain and function. Discussion: There is some evidence that the Physical Resilience Scale is reliable and valid when completed by proxy reports. Future use should remove one of the items due to redundancy.

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).

In residential care communities (CCs), implementation strategies can improve the use of person-centered approaches for residents' behavioral symptoms of distress. We examined staff perceptions of how well their organizational goals for achieving person-centered care (PCC) were met following implementation of the strategy, Evidence Integration Triangle for Behavioral and Psychological Symptoms of Distress. We also identified organizational characteristics and indicators of staff adoption associated with perceived goal attainment. Goal attainment was evaluated by staff using goal attainment scaling (GAS) at the completion of the implementation trial in 26 CCs. Correlations, t tests, and linear regression were used to determine which factors were associated with goal attainment. Total time spent with the research facilitator, stable staff group membership, and presence of a survey deficiency during the study period explained 63% of the variance in goal attainment. Staff can set achievable organizational goals to improve PCC for residents' behavioral symptoms of distress. [ Journal of Gerontological Nursing, 48 (5), 5–12.]

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 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.

The assisted living (AL) environment plays an important role in supporting residents’ satisfaction and helping them to age in place. The AL environment is multidimensional and has many interrelated components including staffing (e.g. direct care workers, nursing, activity staff), services provided (e.g. medical, mental health, pharmacy), amenities offered at the setting (e.g. beauty salon, library, exercise facilities), and the physical environment. Evidence suggests that aspects of the AL environment can enhance or detract from the physical function, well-being, social engagement, and behavioral outcomes among residents. The purpose of this study was to develop and test a multidimensional AL environment measurement model that includes indicators of staffing, services, amenities, and the physical environment. Baseline data was used from a study testing the Dissemination and Implementation of Function Focused Care in AL. A total of 54 AL facilities across three states were included in the sample. Settings ranged in size from 31 to 164 beds with an average size of 82.2 (SD=26.2) beds and the majority were for profit facilities (n=41, 74.5%). Structural equation modeling was used to test the proposed model. Results showed that the model fit the data (χ(2)/df=1.861, p

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

The purpose of this study was to test the reliability and validity of the Assessment of the Environment for Person-Centered Management of BPSD and the Assessment of Policies for Person-Centered Management of BPSD. The sample included 35 long term care facilities. There was evidence of reliability based on internal consistency and test-retest reliability of both measures. There was some evidence of validity based on Rasch model testing and INFIT and OUTFIT statistics. Across both measures there were six items with that were endorsed as present by all facilities. The INFIT and OUTFIT statistics were all within the expected range of .5 to 1.5 with the exception of four high OUTFIT statistics for the Assessment of the Environment for Person-Centered Management of BPSD. For the Assessment of Policies for Person-Centered Management of BPSD there were two items that had high INFIT statistics and six with low OUTFIT statistics and one with high OUTFIT statistics. Measure revisions are suggested including removal of some poor fitting items, items with no variance, and adding items to differentiate those very high in evidence of environments and policies that manage BPSD.

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

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: Positive and effective staff–resident interactions are imperative to adequately assess and meet the needs of cognitively impaired residents in nursing homes and optimize their quality of life. Purpose: The purpose of this study was to quantify, describe, and analyze the interaction between staff and cognitively impaired residents in nursing homes, using the Quality of Interaction Schedule (QuIS). Specifically, the following aims were addressed— Aim 1: To quantify and describe the quality of interactions between staff and cognitively impaired residents in nursing homes. Aim 2: To analyze whether the quality of staff–resident interactions vary by resident cognitive status (moderate vs severe) and interaction characteristics (interaction location, interaction situation, interpersonal distance, type of staff, and resident level of participation). Method: This descriptive analysis utilized baseline data from the first 2 cohorts in a randomized clinical trial including 341 residents from 35 nursing homes. Results: Five hundred fifty-six staff–resident interactions were evaluated; majority were positive (n = 466, 83.8%) and the remaining were either neutral (n = 60, 10.8%) or negative (n = 30, 5.4%). The quality of interactions varied by interaction location, interpersonal distance, and resident participation. Conclusion: This study provides some current descriptive information about the quality of staff-resident interactions in nursing homes and the interaction characteristics that might impact these interactions. Future research should focus on decreasing the negative/neutral interactions and explore staff characteristics (e.g., gender, level of experience) and facility factors (e.g., size, ownership) that might influence the quality of interactions.

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.

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

Understanding satisfaction with assisted living (AL) from the residents’ perspective is essential for creating supportive environments that are targeted toward the needs and desires of residents. Few measures have been tested to evaluate residents’ satisfaction with AL. This study tested the reliability and validity of the Resident Satisfaction Index (RSI) in a sample of 501 AL residents. Based on Rasch analysis, there was support for item reliability and construct validity. Differential item functional (DIF) analysis was done to examine differences in item responses by age, gender, and cognition. Significant and substantive differences were identified for five items by gender, one item by cognition, and no differences were found by age group. Findings suggest the RSI is a reliable and valid measure to assess residents’ satisfaction with AL and can be used to guide administrators and clinicians in making changes in these settings to increase residents’ satisfaction.

This study examined whether residents' level of resilience mediated the relationship between social support for exercise from staff and resident satisfaction in assisted living. This was a secondar...

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

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

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.]

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

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.]

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

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

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.

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.

Communication and interactions are an integral part of care in long-term care settings. Resident variables, such as race and gender, shape communication and interaction between staff and residents. The Quality of Interactions Schedule (QuIS) was developed to measure the quality of verbal and nonverbal interactions among nursing staff and older adults initially for those in acute care and later used as well in a variety of long term care settings. A quantified measurement of the quality of interactions between residents and staff was created to quantify the QuIS. The purpose of this study was to describe the gender and racial differences in scored quality of interactions. Data for the present study was based on baseline data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) implementation study. A total of 535 residents from 55 settings were included in the analyses. An analysis of covariance was conducted to determine a difference in QuIS scores between males and females while controlling for age. The second model tested for differences in QuIS scores between blacks and whites while controlling for age and gender. There was not a statistically significant difference in QuIS scores between male and female residents. There was a significant difference in QuIS scores between those who were black versus white, such that those who were black received more positive interactions from staff than those who were white. Future work should focus on a deeper examination of resident factors and staff factors that may influence these interactions.

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

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

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.

Background and Purpose: This study examines the underlying factor structure of the Self-Efficacy for Functional Abilities (SEFA) scale among older adults in long-term care settings. Methods: A secondary analysis of SEFA data for 568 residents in 16 long-term care facilities was applied. The sample was randomly split into 2 subsamples. A 2-level exploratory and confirmatory factor analysis adjusting for clustering effect of facilities was used to identify and determine the factor structures respectively. Results: There were 1- and 2-factor models that were identified. Both models demonstrated acceptably mixed model fit. The 2-factor model had poor discriminant validity with high correlation between factors (r = .92, p Keywords: factor analysis; long-term care; Self-Efficacy for Functional Abilities (SEFA) scale; older adultsThe ability to perform activities of daily living (ADLs) is the most basic function for older adults in long-term care settings, and decreased functional abilities has significant impact on health (Hjaltadottir, Hallberg, Ekwall, & Nyberg, 2011). Older adults demonstrate functional decline in performing various ADLs over time after admission to long-term care facilities (Carpenter, Hastie, Morris, Fries, & Ankri, 2006; Gillen, Spore, Mor, & Freiberger, 1996; Hjaltadottir, Hallberg, Ekwall, & Nyberg, 2012) and that functional decline is frequently beyond what is anticipated with aging-related deteriorations and various comorbidities (Wang, Kane, Eberly, Virnig, & Chang, 2009). Long-term care residents may experience risk of greater functional decline because of various personal and institutional factors. These factors included caregivers' perception that residents are unable to actively perform functional activities with or without assistance (Galik, Resnick, & Pretzer-Aboff, 2009), custodial care practice that focuses on task completion, which reinforces excessive dependence (Bowers, Esmond, & Jacobson, 2000), and institutional policies that restrict activities for safety reasons (Galik et al., 2009). It is imperative to evaluate residents' current confidence and motivation in doing ADLs so as to reduce excessive dependence and enhance autonomy in performing functional activities at appropriate time (Resnick, 1998b, 2000). Increased independence and participation in these activities not only improves and maintains function but also enhances physical and emotional health and quality of life (Galik et al., 2008; Resnick, Galik, Gruber-Baldini, & Zimmerman, 2009; Resnick, Gruber-Baldini, et al., 2009).The Self-Efficacy for Functional Abilities (SEFA) scale assesses individuals' confidence in doing daily functional activities. Previous studies that have used the SEFA scale employed the total score by summing up the responses of 11 items, instead of using the score of any single item or a subgroup of items, with the underlying assumption that the 11 items cluster together (Pretzer-Aboff, Galik, & Resnick, 2011; Resnick, Galik, et al., 2009; Resnick, Galik, Gruber-Baldini, & Zimmerman, 2011; Resnick, Gruber-Baldini, et al., 2009). Prior research also pointed out the need of continued testing of the scale to ensure that the items have a direct relationship with the latent variable of self-efficacy for functional abilities, indicating the need of factor analysis (Resnick, 2003). The purpose of this study is to examine the underlying factor structure of the 11 SEFA items among older adults in long-term care using factor analysis modeling approaches. We conducted two-level exploratory factor analysis (EFA) to identify initial empirical factor structures in one randomly selected half of the sample and then two-level confirmatory factor analysis (CFA) to evaluate the identified factor structures in the other half of sample. …

Approximately 25% of all nursing home residents take antipsychotics for behavioral disturbances, despite limited efficacy and warnings against their use. The purpose of this quality improvement project was to test the utility of an educational in-service to facilitate the appropriate use of antipsychotics for nursing home residents with dementia. A single group pre/post design targeting the reduction of antipsychotic medications in older adults was guided by Rogers' Diffusion of Innovations theory. Descriptive analyses were done to evaluate antipsychotic use and supporting documentation at baseline and 2 months following an educational intervention that focused on appropriate antipsychotic use, documentation requirements and non-pharmacologic interventions. The prescribing rate for antipsychotics showed a reduction from 20.3% to 15.4% and nursing documentation of non-pharmacological interventions increased from 16.7% to 75%. Assuring appropriate use of antipsychotics is currently mandated and is consistent with high quality, person centered care. This simple, yet individualized educational intervention and assessment can serve as a model for use in other long term care facilities.

Purpose of the Study: The purpose of this study was to test the impact of Function-Focused Care for the Cognitively Impaired Intervention on nursing home residents with dementia and the nursing assistants who care for them. Design and Methods: This was a cluster-randomized controlled trial using repeated measures. A total of 103 cognitively impaired residents and 77 nursing assistants were recruited from four nursing homes. For residents, outcome measures included function, physical activity (survey and actigraphy), mood, behavior, and adverse events (falls and hospitalization). Main outcome measures for nursing assistants included knowledge, beliefs, and performance of function focused care. Results: There were significant improvements in the amount and intensity of physical activity (by survey and actigraphy) and physical function in the treatment group. In addition, there was a significant decrease in the number of residents who fell during the treatment period with those in the treatment sites having fewer falls (28% vs. 50% in the control group). Nursing assistants were also observed to be providing a greater percentage of function focused care during resident care interactions in the treatment group at 6 months following the completion of baseline measures. Implications: This study provides some evidence that nursing home residents with severe cognitive impairment can safely and successfully be engaged in physical and functional activities.

The purpose of this study was to examine factors that influence physical activity among residents in assisted living. This was a secondary data analysis using baseline data from a function-focused care intervention study including 171 residents from 4 assisted living facilities. Using structural equation modeling, we found that mood, satisfaction with staff and activities, and social support for exercise were directly associated with time spent in physical activity. Gender, cognition, depression, and comorbidities were indirectly associated with physical activity and accounted for 13% of the total variance in physical activity. Implications for future research and social work practice are presented.

Job satisfaction among nursing assistants (NAs) is associated with NA retention, resident satisfaction, and residents' quality of care. The purpose of this study was to provide psychometric support for a measure of job satisfaction, the Job Attitude Scale (JAS), used with NAs that work in long-term care facilities. We performed a secondary data analysis and used traditional test theory and Rasch analysis to assess the reliability and validity of the JAS. The sample consisted of 508 NAs from 12 nursing homes and 96 NAs from 4 assisted living communities. We found evidence of reliability, validity, and generalizability when the measure was used in both settings and evidence that the JAS has the ability to assess variability in job satisfaction.

Resistiveness to care generally occurs when an individual with cognitive impairment interferes with caregivers’ attempts to provide care, and commonly occurs during personal care interactions such as bathing, toileting, and oral care. The purpose of this study was to test the reliability and validity of the Resistiveness to Care Scale (Mahoney et al., 1999) using a Rasch Measurement Model among a larger group of nursing home residents with moderate to severe dementia. This was a descriptive study using baseline data from 261 residents participating in an ongoing trial testing a Function and Behavior Focused Care intervention for cognitively impaired nursing home residents (FBFC). The average age of the residents was 84.64 (SD=9.60) and the majority were female (N=198, 74%), white (N=161, 61%), and not married (N=185, 69%). The mean MMSE was 7.23 (SD=5.10). There was sufficient evidence of internal consistency with findings similar to the original scale development which was done with a non-independent sample of 68 residents younger residents (mean age of 72) providing 232 observations in which the alpha coefficient was .82. Psychometric testing using Rasch analysis supported the validity of the measure. The findings from this study provide new support for the reliability and validity of the Resistiveness to Care Scale for use with older adults with dementia in nursing home settings. Future work with the measure may benefit, however, from the addition of items that are easier to endorse or express with regard to resistiveness to care.

Objectives: To develop and test the Function-Focused Care in Assisted Living (FFC-AL) intervention so as to alter the decline that older adults in AL experience. Design: Cluster-randomized controlled trial using repeated measures to test the effect of FFC-AL. Setting: Four AL facilities with at least 100 beds. Participants: One hundred seventy-one residents and 96 direct care workers (DCWs) were recruited. Ninety-five of the DCWs were female (99%), and 59 were black (62%), with a mean age of 41.7 ± 13.8. The residents were mostly female (80%), white (93%), and widowed (80%), with a mean age of 87.7 ± 5.7. Intervention: FFC-AL included four components implemented by a research-supported function focused-care nurse (FFCN) and a site-identified champion over a 12-month period. Control sites were exposed to FFC education only. Measurements: Outcomes for residents included psychosocial domains (mood, resilience, self-efficacy, and outcome expectations for function and physical activity), function, gait and balance, and actigraphy. Outcomes for DCWs included knowledge, performance, and beliefs associated with FFC. Results: DCWs in treatment sites provided more FFC by 12 months than those in control sites. Residents in treatment sites demonstrated less decline in function, a greater percentage returned to ambulatory status, and there were positive trends demonstrating more time in moderate-level physical activity at 4 months and more overall counts of activity at 12 months than for residents in control sites. Conclusion: Using a function-focused approach in AL may help prevent some of the functional decline commonly noted in these settings.