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Residents with Alzheimer's disease and related dementias (ADRD) in nursing homes (NHs) rely on direct care workers (DCWs) to assist with activities of daily living, such as oral hygiene. The current quality improvement project was implemented to evaluate the effectiveness of teaching a standardized positive physical approach to oral hygiene completion for patients with ADRD residing in a NH. A pre-/postintervention evaluation incorporating a video presentation coupled with a hands-on simulation experience showed a statistically significant improvement in DCWs' overall Sense of Competency in Dementia score, as well as all subcategories of the Sense of Competence in Dementia Care Staff survey. In addition, residents' day shift oral hygiene care completion rates increased monthly pre- to postintervention. NHs should consider implementing training that includes hands-on experiences to equip DCWs with the knowledge and skill needed to improve oral hygiene among residents with ADRD. [ Journal of Gerontological Nursing, 48 (11), 15–20.]

Transitional care components are well studied, but their coordination has not been systematically reviewed. Viewing transitional care through a social network framework can focus attention on processes leading to information and relationship transferal to ensure continuity and may lead to new strategies to improve transitional care.The aim of this study was to examine care coordination processes in transitional care interventions for older adults with heart failure by integrating a social network analysis approach.PubMed, Scopus, and CINAHL were searched to capture transitional care interventions ( a ) involving care coordination for older adults with heart failure transitioning from hospital to home and ( b ) published in the United States from 2010 to 2020. Study characteristics, intervention characteristics, and care coordination processes (ie, participants, interactions among participants, and their characteristics) were extracted.In 17 studies reviewed, the number of individual roles involved in care coordination varied from 3 to 32. Nurses and pharmacists were the most common interventionists. Six studies involved informal caregivers. In-person interactions were most common among individuals within settings; interactions across settings were typically assisted by technology. Despite high variability among the individuals and interactions involved, a common triadic process was found through which interventionists, patients, and primary care providers or outpatient cardiologists aimed to facilitate the transfer of information and care relationships from hospital to community.High variability in transitional care is likely because the processes are highly relational. Using a network analysis may help uncover the relational structures and processes underlying transitional care to inform intervention development.

This retrospective cohort study used electronic health records to explore the effect of race/ethnicity, insurance status, and area deprivation on post-discharge outcomes in older patients undergoing hip fracture surgery between 2015 and 2018 ( N = 1,150). Inverse probability of treatment weight-adjusted regression analysis was used to identify the effects of the predictors on outcomes. White patients had higher 90- and 365-day readmission risks than Black patients and higher all-period readmissions than the Other racial/ethnic (Hispanic, Asian, American Indian, and Multicultural) group ( p

Clinical care interactions influence important health outcomes in older adults such as nosocomial infections, falls, and care satisfaction. However, traditional measurements of interactions are often time-consuming, costly, biased, or they interfere with normal clinical care. Wearable sensors measure interpersonal contact with a high degree of spatial and temporal detail and accuracy when applied to examining the spread of infection. This study aims to test the feasibility of implementing two types of commercially available wearable sensors to collect spatial and temporal data for measuring care interactions in health care settings. EMBC02 (Bluetooth) and OpenBeacon (RFID) sensors were tested in a simulation laboratory. Five nursing students wore the sensors along with name tags and enacted a scenario of a fallen nursing home resident. Sensor data were plotted in Python and compared with video recordings of the simulated care interaction to determine sensor usability, accuracy, and precision. EMBC02 and OpenBeacon detected multiple wearers and provided spatial and temporal data. OpenBeacon showed better usability and validity than EMBC02 for using proximity data collected by sensors to infer care interactions. Both OpenBeacon and EMCB02 showed some limitations in accuracy and precision, such as increased data missingness due to idling function and high data noise. Bluetooth and RFID sensors measure different aspects of proximity. OpenBeacon outperformed EMBC02 for measuring care interactions. Combining Bluetooth with RFID may provide richer information for measuring and understanding care interactions. Simulation laboratories can be leveraged to test health technology before use in clinical research.

Purpose The purpose of this project was to identify additional facets of diabetes distress (DD) in veterans that may be present due to the veteran’s military-related experience. Methods The study team completed cognitive interviews with veterans with type 2 diabetes mellitus (T2DM) to examine how they answered the Diabetes Distress Scale (DD Scale), a tool that assesses DD. The DD Scale was used because of its strong associations with self-management challenges, physician-related distress, and clinical outcomes. Results The veterans sample (n= 15) was 73% male, mean age of 61 (SD = 8.6), 53% Black, 53% with glycosylated hemoglobin level Conclusions This study describes how a veteran’s military experience may contribute to DD in the context of T2DM self-management. Findings indicate clinicians and researchers should account for additional domains when developing self-management interventions and discussing self-management behaviors with individuals with T2DM.

Background Effective patient care transitions require consideration of social and clinical context, yet how these factors and relational processes in care coordination relate remains poorly described. This case report aims to describe provider networks and the clinical care and social context involved during longitudinal care transitions across settings. Case We examined the utilization and provider networks of an oldest old woman with heart failure (HF) before and after her first hospitalization for HF. She used primary care for care management and had insurance, strong caregiver support, and comprehensive discharge planning; however, after the hospitalization, Mrs. A's ambulatory provider networks were more diverse yet sparser and less strongly connected. Conclusions Turbulence in care transition can result from sources other than transitioning between settings. The data-driven case report approach using electronic health records uncovered relational processes important for care coordination and may inform patient-centered approaches to improve care for patients with HF.

OBJECTIVES To explore whether caregiver characteristics were associated with cognitive complaints reported by women with breast cancer undergoing chemotherapy. SAMPLE A SETTING 61 dyads of women with breast cancer and their caregivers were recruited at Duke Women's Cancer Care Raleigh in North Carolina. METHODS A VARIABLES An exploratory, cross-sectional design was used. Data were obtained on patients and caregivers. Patient cognitive complaints were represented by cognitive impairment (CI) and cognitive ability (CA). RESULTS Two significant associations were found. IMPLICATIONS FOR NURSING Healthcare providers should consider caregivers when assessing and managing patients' cognitive symptoms. This study suggests the value of including caregivers when establishing interventions for patients who have cognitive complaints.

Aims To explore how behavioural symptoms of dementia are manifested among veterans in residential long-term care settings, in the context of personal, interpersonal/social and environmental triggers and how the manifestations differ between veterans with and without posttraumatic stress disorder. Design Secondary analysis using a mixed methods approach. Methods We analysed text data from a stratified random sample of 66 cases derived from the programme evaluation dataset of the Staff Training in Assisted Living Residences-Veterans Health Administration (STAR-VA) intervention from 2013 to 2016, using framework analysis. The detailed behavioural assessment descriptions in this dataset are consistent with contemporary non-pharmacologic symptom management. Qualitative categories were converted to quantitative variables for two group comparisons. Results Four patterns emerged linking specific types of triggers and behavioural symptoms: (1) unmet physical needs or emotional distress triggers non-aggressive behaviours; (2) unsolicited direct care approach triggers care refusal, resistance or combativeness; (3) interpersonal interactions interfering with self-direction trigger aggressive behaviours; and (4) uncontrolled stimulation from environments trigger non-aggressive behaviours. The organisational culture of care influenced how staff conceptualised behavioural symptoms. Veterans with co-existing posttraumatic stress disorder and dementia tended to exhibit rejection of care with aggression compared to those with dementia alone. Conclusion Contextualised accounts of behavioural symptoms of dementia revealed symptom heterogeneity, with different clusters of multi-level triggers arising from specific personal, interpersonal and environmental circumstances. Distinct patterns of symptom manifestations between veterans with and without posttraumatic stress disorder suggest a tailored approach is required to meet each veteran's unique biopsychosocial needs. Impact Classifying behavioural symptoms with their triggers rather than solely by behaviours provides important new information for developing person-centred, non-pharmacological interventions to improve outcomes for veterans with dementia. Multi-level interventions should be considered to meet veteran's needs that account for their earlier life history and current life circumstances.

Background and Objectives Social networks affect the health and well-being of older adults. Advancements in technology (e.g., digital devices and mHealth) enrich our ability to collect social networks and health data. The purpose of this scoping review was to identify and map the use of technology in measuring older adults’ social networks for health and social care. Research Design and Methods The Joanna Briggs Institute methodology was followed. PubMed (MEDLINE), Sociological Abstracts, SocINDEX, CINAHL, and Web of Science were searched for relevant articles. Conference abstracts and proceedings were searched via Conference Papers Index, the American Sociological Society, and The Gerontological Society of America. Studies published in English from January 2004 to March 2020 that aimed to improve health or social care for older adults and used technology to measure social networks were included. Data were extracted by 2 independent reviewers using an a priori extraction tool. Results The majority of the 18 reviewed studies were pilot or simulation research conducted in Europe that focused on older adults living in the community. The various types of technologies used can be categorized as environment-based, person-based, and data-based. Discussion and Implications Technology facilitates objective and longitudinal data collection on the social interactions and activities of older adults. The use of technology to measure older adults’ social networks, however, is primarily in an exploratory phase. Multidisciplinary collaborations are needed to overcome operational, analytical, and implementation challenges. Future studies should leverage technologies for addressing social isolation and care for older adults, especially during the coronavirus disease 2019 pandemic.

Supplemental digital content is available in the text., Background Understanding the factors underlying health disparities is vital to developing strategies to improve health equity in old age. Such efforts should be encouraged in Korea. Objective This study explored how material, behavioral, psychological, and social-relational factors contribute to income-related disparities in cardiovascular risk among Korean adults 65 years and older. Methods This was a secondary analysis of Korean National Health and Nutrition Examination Survey data (2013–2017), targeting 7347 older adults (≥65 years). Socioeconomic position, defined as income, was the primary indicator. The outcome was binary for predicted cardiovascular risk (

Diabetes Distress (DD, i.e., regimen, emotional, interpersonal, clinician) in adults with type 2 diabetes (T2DM) is associated with poor glycemic control, poorer diet and exercise, and more T2DM complications. We describe a multi-phased study to develop and test a tailored intervention to reduce DD to improve health outcomes. Phases 1-3 identified factors related to DD in Veterans with T2DM to inform intervention development. We used an explanatory sequential mixed methods design to identify how Veterans with T2DM experienced DD. Veterans (n=210) completed measures (DD, depression, empowerment, stigma) . A subset of Veterans (n=36) also completed in-depth qualitative interviews. We fit a multivariable linear regression to examine associations with DD score. We completed thematic analysis on interview transcripts. We integrated measurement and interview data using matrices and analyzed results by medication type, hemoglobin A1c (HbA1c) , and severity of DD (low, moderate, high) . Mean age was 63 years (SD 10.2) ; 15% female; 69% non-white; 56% on insulin; mean A1c 8.9% (SD 2.0) ; mean DD score was 2.0 (SD 0.9) , indicating moderate distress. In the regression model, female gender (β= -0.31; 95% CI: -0.57, -0.04) , diagnosis of multiple mental health comorbidities vs. one condition (β=-0.29; 95% CI: -0.55, -0.03) , higher depression symptom (β=0.15; severity (95% CI: 0.08, 0.23) and stigma (β=0.02; 95% CI: 0.01, 0.04) were associated with higher DD. Higher T2DM self-efficacy (β=-0.34; 95% CI: -0.51, -0.18) was associated with lower DD. Interviews elaborated on themes including the impact of pain and comorbidities on DD. Integrating the measurement and interview data indicated that experiences of DD varies by many characteristics based on medication type, HbA1c, and severity of DD. Elucidating contributors to DD in Veterans using mixed methods will improve our ability to develop a tailored intervention addressing DD in a manner relevant to Veteran populations. Disclosure A.Lewinski: Other Relationship; Otsuka America Pharmaceutical, Inc., PhRMA Foundation. S.J.Barcinas: None. H.B.Bosworth: Advisory Panel; Sanofi, Board Member; preventics diagnostics, Consultant; VIDYA, webmed, Research Support; Boehringer Ingelheim International GmbH, improved Patient Outcomes, Merck & Co., Inc., Novo Nordisk, Otsuka America Pharmaceutical, Inc. M.J.Crowley: None. A.S.Jeffreys: None. C.Coffman: None. C.Whitfield: None. T.Howard: None. A.Shapiro: None. E.S.Mcconnell: None. P.Tanabe: None. Funding Durham Center of Innovation to Accelerate Discovery and Practice Transformation (CIN 13-4) and VA HSR&D grants #18-234 (to AAL) and #08-027 (to HBB) .

BACKGROUND/OBJECTIVES To better understand the role of sensory loss as a potentially modifiable risk factor for cognitive decline, this study examined cognitive decline in relation to single modality hearing or vision loss and dual sensory loss. DESIGN Longitudinal secondary data analysis. SETTING The Health and Retirement Study (HRS) and its supplement: The Aging, Demographics, and Memory Study (ADAMS). PARTICIPANTS Individuals aged 73 and older (N = 295). MEASUREMENTS Hearing loss was defined by an inability to hear sounds of 25 dB at frequencies between 0.5 and 4.0 kHz in either ear. Vision loss was defined as having corrected binocular vision worse than 20/40. Dual sensory loss was defined as having both hearing and vision loss. We used one time point of hearing and vision data objectively measured in ADAMS Wave C (June 2006-May 2008) and five waves of cognitive function data measured by the HRS version of the Telephone Interview for Cognitive Status in HRS (2006-2014). Multilevel mixed models were used. RESULTS Among the participants, 271 completed a hearing assessment and 120 had hearing loss; 292 completed a vision assessment and 115 had vision loss; 52 had dual sensory loss. Older adults with hearing loss had a significantly faster rate of cognitive decline as they aged compared to those with normal hearing (β = -0.16, P

SIGNIFICANCE Outpatient vision rehabilitation improves function in veterans with vision impairment, but the prevalence of cognitive impairment and the degree to which it may affect rehabilitation outcomes in the Veterans Affairs system are unknown. PURPOSE The purpose of this study was to determine the prevalence of cognitive impairment among veterans receiving outpatient vision rehabilitation in the Veterans Affairs system and compare the benefits of rehabilitation in veterans with and without cognitive impairment. METHODS We conducted cognitive assessments and a nested longitudinal cohort study in veterans with eye disorders at two outpatient rehabilitation sites. Cognition was assessed with the Modified Telephone Interview for Cognitive Status administered in person. Eligible veterans and their companions in the longitudinal study responded to questions about the veteran's function at baseline and 90 days later. Visual function was measured with the 48-item Low Vision Visual Function Questionnaire (LV-VFQ-48) and items from the Activity Inventory. RESULTS Of 291 veterans assessed (mean ± standard deviation age, 78.2 ± 12 years), 136 (46.7%) were cognitively intact (Modified Telephone Interview for Cognitive Status scores, ≥33), whereas 58 (19.9%) had borderline scores of 30 to 32, 82 (28.2%) had scores suggesting mild/moderate cognitive impairment (scores of 20 to 29), and 15 (5.2%) had scores suggesting severe cognitive impairment (score of

Aims and objectives To explore nursing home residents' perspectives on their relationships with other residents, family members and staff. Background The cultivation of social relationships is central to promoting well-being in nursing homes, as these relationships allow residents, family members and staff to be valued as unique persons and empowered as partners in care. Few studies have examined how nursing home residents perceive the relationships in their social networks, both within and beyond the facility. Design Qualitative secondary analysis. Methods We analysed individual and group interviews obtained during "stakeholder engagement sessions" with cognitively intact residents (N = 11 sessions; N = 13 participants) from two nursing homes in North Carolina. The interviews were conducted as part of a larger study on person-directed care planning. We integrated thematic and narrative analytic approaches to guide the analysis of interview data, using a three-cycle coding approach. The COREQ checklist was followed. Results Four broad themes emerged from this analysis: (a) peer relationships foster a sense of belonging, purpose, achievement and significance; (b) residents' relationships with family members support a sense of belonging, continuity and significance; (c) mutual respect and reciprocity between residents and nursing home staff promote a sense of belonging and significance; and (d) organisational factors pose barriers to forging meaningful relationships. Each type of relationship-peer, family and staff-made distinctive contributions residents' psychosocial well-being. Conclusion Recognising the diverse roles of different actors from residents' social networks raises questions for future research to optimise the distinctive contributions of network members that promote residents' psychosocial well-being. Relevance to clinical practice This study highlights the need for nursing home staff to understand how residents' social relationships influence residents' psychosocial outcomes. Staff training programmes are needed to support residents' rights and to dispel inaccurate interpretations of regulations that threaten sustained meaningful relationships.

Purpose: Preference assessment is integral to person-centered treatment planning for older adults with communication impairments. There is a need to validate photographs used in preference assessment for this population. Therefore, this study aimed to establish preliminary face validity of photographs selected to enhance comprehension of questions from the Preferences for Everyday Living Inventory–Nursing Home (PELI-NH) and describe themes in older adults' recommendations for revising photographic stimuli. Method: This qualitative, cognitive interviewing study included 21 participants with an average age of 75 years and no known cognitive or communication deficits. Photographic stimuli were randomized and evaluated across one to two interview sessions. Participants were asked to describe what the preference stimuli represented to them. Responses were scored to assess face validity. Participants were then shown the PELI-NH written prompt and asked to evaluate how well the photograph(s) represented the preference. A semideductive thematic analysis was conducted on interview transcripts to summarize themes in participant feedback. Results: Forty-six (64%) stimuli achieved face validity criteria without revisions. Six (8%) stimuli achieved face validity after one partial revision. Twenty (28%) stimuli required multiple revisions and reached feedback saturation, requiring team review for finalization. Thematic analysis revealed challenges interpreting stimuli (e.g., multiple meanings) and participant preferences for improving photographs (e.g., aesthetics). Conclusions: Cognitive interviewing was useful for improving face validity of stimuli pertaining to personal care topics. Abstract and subjective preferences (e.g., cultural traditions) may be more challenging to represent. This study provides a framework for further testing with older adults with cognitive, communication, and hearing impairments.

Older adults with dementia are at higher risk for sustaining hip fracture and their long-term health outcomes after surgery are usually worse than those without dementia. Widespread adoption of electronic health records (EHRs) may allow hospitals to better monitor long-term health outcomes in patients with dementia after hospitalization. This study aimed to (1) estimate how dementia influences discharge location, mortality, and readmission 180 days and 1 year after hip fracture surgery in older adults, and (2) demonstrate the feasibility of using selection-bias reduced EHR data for research and long-term health outcomes monitoring.Retrospective observational cohort study using EHRs.A cohort of 1171 patients over age 65 years who had an initial hip fracture surgery between October 2015 and December 2018 was extracted from EHRs of one health system; 376 of these patients had dementia.Logistic regression was applied to estimate influences of dementia on discharge disposition and Cox proportional hazards model for mortality. The Fine and Gray regression model was used to analyze readmission, accounting for the competing risk of death. To reduce selection bias in EHRs, inverse probability of treatment weighting using propensity scores was implemented before modeling.Dementia had significant impacts on all outcomes: being discharged to facilities [odds ratio (OR) = 2.11, 95% confidence interval (CI) 1.19-3.74], 180-day mortality [hazard ratio [HR] = 1.69, 95% CI 1.20-2.38), 1-year mortality (HR = 1.78, 95% CI 1.33-2.38), 180-day readmission (HR = 1.62, 95% CI 1.39-1.89), and 1 year readmission (HR = 1.39, 95% CI 1.21-1.58).Dementia was a significant risk factor for worse long-term outcomes. The inverse probability of treatment weighting approach can be used to reduce selection bias in EHR data for research and monitoring long-term health outcomes in the target population. Such monitoring could foster collaborations with post-acute and long-term health care services to improve recovery outcomes in patients with dementia after hip fracture surgery.

Background and Objectives Engaging residents, their proxies, and skilled nursing facility (SNF) staff through effective communication has potential for improving fall-related injury prevention. The purpose of this study was to understand how multiple stakeholders develop and communicate fall-related injury prevention plans to enhance sustained implementation. Research Design and Methods Descriptive qualitative study using framework analysis applied to open-ended semistructured interviews (n = 28) regarding experiences of communication regarding fall-related injury prevention, guided by the Patient and Family Engaged Care framework. Participants included residents at high risk of injury and their proxies, nursing assistants, nurses, and a nurse practitioner from 3 SNFs in the Eastern United States (Massachusetts and North Carolina). Results Interdisciplinary teams were viewed as essential for injury prevention. However, the roles of the interdisciplinary team members were sometimes unclear. Communication structures were often hierarchical, which reduced engagement of nursing assistants and frustrated proxies. Practices that enhanced engagement included knowing the residents, active listening skills, and use of strategies for respecting autonomy. Engagement was inhibited by time constraints, lack of proactive communication among staff, and by challenges eliciting the perspectives of residents with dementia. Resident barriers included desire for autonomy, strong preferences, and language differences. Discussion and Implications Strengthening team meeting processes and cultivating open communication and collaboration could facilitate staff, resident, and proxy engagement in injury prevention planning and implementation. Skill building and targeting resources to improve communication can address barriers related to staff practices, resident characteristics, and time constraints.

Objective Nursing homes (NHs) provide care to residents with serious illness and related complex health care needs. As such, discussions about end-of-life care between NH staff and residents and families are necessary to ensure residents receive care consistent with their goals. Interventions such as video decision aids have been developed to promote discussions and improve advance care planning, but few studies have examined how NH characteristics may relate to the implementation of these interventions; such information might lead toward more use of successful interventions. The purpose of this study is to understand NH characteristics that are associated with the implementation of the Goals of Care (GOC) intervention, which combined a video decision aid with a structured discussion to guide decision-making in advanced dementia. Design A multiple case study. Setting and Participants Staff surveys were conducted to examine factors related to implementation effectiveness in 11 NHs in North Carolina that participated in the GOC trial. Methods Questions measured the dependent variable of implementation effectiveness: the consistency and quality of use of the GOC intervention. NH organizational characteristics were measured using publicly available data and an administrator survey. The analysis consisted of pattern matching logic. Results High management support aligned with implementation effectiveness within NHs. In addition, the within case pattern analysis indicated additional characteristics related to implementation effectiveness. Facility size, Medicare beds, residents’ racial composition, and star rating were related to implementation effectiveness across 6 of the 11 NHs. NH financial resources, such as size and number of Medicare beds, may be important factors for successful implementation. Conclusion and Implications NHs seeking to implement advance care planning interventions should focus on within and across NH differences, such as adequate management and financial support prior to implementation to increase the likelihood of implementation effectiveness.

Objective This study aims to examine gender differences in the association between migration and cognitive function among adults in China and India. Methods Data from the World Health Organization Study on global AGEing and adult health (SAGE) study were used that included adults aged 50 + from China (N = 12,937) and India (N = 6244). Migration status included: urban residents, rural residents, urban-to-urban, rural-to-urban, rural-to-rural, and urban-to-rural migrants. Cognitive function was assessed by immediate and delayed recall tests, digit span tests, and verbal fluency test. Ordinary least square regression models were used to adjust for sociodemographic characteristics, psychosocial factors, health behaviors, and physical health status. Results Controlling for multiple covariates, significant differences in cognitive function were found between men and women, and across migration groups. A consistent female disadvantage was found in China and India for cognitive function. Women who were rural residents or rural-to-rural migrants had the poorest cognitive function in both the Chinese and the Indian samples. Among males in China, rural residents had poorer cognitive function than urban residents, while urban-to-urban migrants had highest cognition scores; however, for male counterparts in India, rural-to-rural migrants had the poorest cognitive function. Conclusions The results suggest that the association between migration and cognitive function differs by gender and country. In our study populations, major sociodemographic characteristics play a key role in accounting for the differences in cognitive function.

Objectives Posttraumatic stress disorder (PTSD) is associated with neurocognitive and psychiatric comorbidities, and older adults experience comorbid illnesses disproportionately. Little is known about the comorbidities of PTSD among older veterans. This systematic review examines the prevalence, incidence, and patterns of neurocognitive and psychiatric comorbidities of PTSD among older veterans and explores the factors associated with these comorbidities. Methods A systematic literature review was performed using PubMed, CINAHL, and PsycINFO databases. The search was limited to peer-reviewed articles published in English from January 1980 to October 2018. Eligible studies examined the comorbid neurocognitive and psychiatric disorders of PTSD among veterans aged 60 and older. Results Twenty-four studies met the criteria for inclusion. The risk for dementia was higher in veterans with PTSD than those without PTSD; hazard ratios ranged from 1.21 to 1.77. Depressive disorder was the most prevalent psychiatric comorbidity with estimates ranging from 33% to 52.3%, followed by generalized anxiety disorder (14%-15%) and substance use disorders (1.9%-11.3%). Factors consistently associated with PTSD comorbidities included age, combat-related exposures, clinical conditions, and health-related and psychosocial outcomes. Conclusions Despite heterogeneity in research designs and methodological limitations, this review highlights the need to consider comorbid neurocognitive and psychiatric disorders among older veterans with PTSD in order to individualize care approaches. Future research should incorporate factors associated with neurocognitive and psychiatric comorbidities of PTSD into study designs that can help improve prediction of comorbidity and generate evidence for developing and implementing tailored treatments in older veterans.

Background Behavioral symptoms during mealtime can prohibit persons living with dementia from obtaining sufficient nutrition. However, little research has examined the relationship between behavioral symptoms and caregiving approaches. This study examines this relationship and further explores which specific caregiver behaviors were related to behavioral symptoms among persons living with dementia. Methods A secondary data analysis was performed using 86 mealtime videos from a longitudinal, observational study. The videos were repeatedly taken at months 0, 3, and 6 with 30 persons living with dementia in one of four long-term care facilities. Video coding was performed using coding schemes modified from the Cohen-Mansfield Agitation Inventory for behavioral symptoms and the Person-/Task-Centered Behavior Inventory for caregiving approaches. Coding schemes for behavioral symptoms consisted of four categories: total duration, aggressive behavior, physically nonaggressive behavior, and verbally agitated behavior. Caregiving approaches consisted of ten-verbal/seven-nonverbal person-centered behavior codes, four-verbal/four-nonverbal task-centered behavior codes, and no-verbal/no-nonverbal interaction codes. A mixed-effect model was conducted using variables such as demographics, medical information, cognitive status, depression, function, and caregiving approaches as fixed effects, participant as a random effect, and four categories of behavioral symptoms as dependent variables. Results The total duration of the Cohen-Mansfield Agitation Inventory was associated with no verbal response (β = 9.09) and task-centered verbal behavior (β = 8.43), specifically verbal controlling (β = 7.87). Physically nonaggressive behavior was associated with no verbal response (β = 9.36). Verbally agitated behavior was associated with task-centered nonverbal behavior (β = 51.29), and specifically inappropriate touch (β = 59.05). Conclusions Mealtime is indispensable to dementia care for ensuring adequate nutrition and promoting personhood. Our findings revealed caregivers’ task-centered behaviors and no interaction were related to behavioral symptoms of persons living with dementia. When caregivers encounter behavioral symptoms during mealtime, it is recommended to avoid no response and task-centered behaviors, especially verbal controlling and inappropriate touch, and to promote person-centered behaviors.

Objectives Although cardiovascular disease (CVD) risk has lessened in Korea, it is unclear whether older adults in all socioeconomic strata have benefited equally. This study explored trends in income disparities in CVD risk among older adults in Korea. Methods This was a secondary analysis of Korean National Health and Nutrition Examination Survey data (2008–2017), targeting 14,836 older adults (≥65 years). Socioeconomic position, defined as income and use of welfare benefits, was the primary indicator. The outcome was binary for predicted CVD risk ( 0.19, RII > 7). Conclusions These results may inform and improve policies regarding income disparity reduction and cardiovascular health., Highlights • Income disparities in CVD risk have persisted since 2012, with a worsening trend seen for Medicaid recipients. • Our results highlight the need to improve CVD risk management services offered to the economically disadvantaged. • It is important to consider both the absolute and relative terms when examining the disparity trends.

BACKGROUND After a hospital stay, many older adults rely on their caregivers for assistance at home. Empirical evidence demonstrates that caregiver support programs in hospital-to-home transitions are associated with favorable caregiver and patient outcomes. We tested the feasibility of implementing the Duke Elder Family/Caregiver Training (DEFT) program in an academic medical center.METHODS: We recruited adult caregivers of homebound patients who were aged 55 years or older from Duke University Hospital in Durham, North Carolina. Caregivers attended a face-to-face caregiver training and received two telephone checks after hospital discharge with DEFT services ending at 14 days of hospital discharge. We used a one-item survey to measure overall DEFT satisfaction. We also monitored 30-day readmissions of patients whose caregivers completed the DEFT program.RESULTS: The DEFT Center received 104 consult orders in six months. Of these, 61 agreed to participate but nine caregivers were unable to schedule the DEFT training and three decided to eventually withdraw from participation. Forty-nine caregivers received the DEFT training, 12 of whom were ineligible to continue because of change in patients' disposition plan. Of the remaining 37 caregivers, 15 completed the full program and reported high satisfaction; one patient was readmitted within 30 days of discharge.LIMITATIONS: The DEFT implementation was based on academic-medical partnership and relied on electronic medical records for consult and documentation. Replicability and generalizability of findings are limited to settings with similar capabilities and resources.CONCLUSION: The implementation of a caregiver training and support program in an academic medical center was feasible and was associated with favorable preliminary outcomes.

UNSTRUCTURED The coronavirus disease (COVID-19) pandemic has been particularly challenging for nursing home staff and residents. Centers for Medicare & Medicaid Services regulation waivers are burdening staff and affecting how care is delivered. Residents are experiencing social isolation, which can result in physical and behavioral health issues, particularly for persons with dementia. These challenges can be addressed in part through technology adaptations. Full integration of electronic health record systems can improve workflow and care quality. Telehealth can improve access to outside providers, provide remote monitoring, and improve social connectedness. Electronic and audiovisual programs can be used for end-of-life planning and information sharing between nursing home staff and families. Online learning systems and other online resources provide flexible options for staff education and training. Investing in and adapting technology can help mitigate workforce stress and improve the quality of nursing home care during and after the COVID-19 crisis.

Aims The aim of this systematic review was to examine the characteristics and the efficacy of dementia caregiving interventions among the Chinese population. Background In recent years, an increasing number of dementia caregiving interventions have been developed for Chinese older adults living in Asia that aim to reduce caregivers' burden, depression and distress, and enhance quality of life. Little is known, however, on the nature and the efficacy of these interventions. Design Systematic review with narrative summary. Data sources We searched four databases for studies published in English between 1 January 1994-30 December 2017. Nineteen studies reported in 23 articles were included in the final analysis. Review methods We used a set of criteria from the Cochrane Collaboration tool to assess for the risk of bias across studies. Results We found that interventions varied in length, frequency, approach, and content, making comparisons across studies challenging. Caregivers' burden, depression, and distress were improved among most included studies. All studies that examined quality of life of caregivers (N = 6) showed improvement. Most of the interventions showed beneficial effects on care recipients' behavioural symptoms, agitation, and depression; cognitive function, however, failed to improve. Conclusion Although the review found mixed results on intervention outcomes, the majority of interventions showed a potential to improve the health and well-being of dementia caregivers and care recipients. This review provides suggestions for future dementia caregiving research in the Chinese population, such as inclusion of relevant theoretical frameworks and more rigorous research designs.

The need to provide evidence-based, person-centered care for long-term care (LTC) residents, which often include individuals with dementia, has led to a surge of interest in the implementation of individualized music (IM) programs. An exploratory study was conducted over a 6-month period using the Promoting Action on Research in Health Systems (PARiHS) framework to examine the implementation of an IM program with 19 residents in a LTC facility. All residents using IM had the device available at the end of the program, and 53% received IM at least two times per week. Qualitative analysis of stakeholder interviews with six staff members and three residents after using the PARiHS framework as an implementation guide revealed two themes: Overcoming Resistance to Innovation and Person-Centered Care Through IM . Identification of barriers and facilitators through the PARiHS elements of evidence, context, and facilitation supported the IM implementation process and should enable its replication in other facilities. [ Journal of Gerontological Nursing, 44 (8), 29–38.]

Oral hygiene care is neglected in long-term care (LTC) due to patient-, staff-, and systems-level barriers. A dementia-specific oral hygiene program, implemented and evaluated in a Department of Veterans Affairs LTC unit, addressed barriers to oral care at multiple levels. Improved staff competency, access to oral care supplies, and standardized documentation systems were accompanied by reduced oral plaque and gingivitis, demonstrating the feasibility and benefits of direct care staff providing improved oral hygiene in LTC.

We sought to understand strategies reported by members of the nursing home management team used to prevent falls in short-stay nursing home patients. Using Donabedian's model of structure, process, and outcomes, we interviewed 16 managers from 4 nursing homes in central North Carolina. Nursing home managers identified specific barriers to fall prevention among short-stay patients including rapid changes in functional and cognitive status, staff unfamiliarity with short-stay patient needs and patterns, and policies impacting care. Few interventions for reducing falls among short-stay patients were used at the structure level (eg, specialized units, workload ratio, and staffing consistency); however, many process-level interventions were used (eg, patient education on problem solving, self-care/mobility, and safety). We described several barriers to fall prevention among short-stay patients in nursing homes. From these descriptions, we propose three interventions that might reduce falls for short-stay patients and could be tested in future research: (1) clustering short-stay patients within a physical location to permit higher staff-patient ratios and enhanced surveillance, (2) population-based prevention interventions to supplement existing individually tailored prevention strategies (eg, toileting schedules, medication review for all), and (3) transitional care interventions that transmit key information from hospitals to nursing homes.

Long-term hospital utilization trajectories in the context of surgery are understudied. Heart Failure (HF) is associated with an increased risk for rehospitalization after hip fracture surgery. This study aimed to examine whether older adults (>= 65 years old) have distinct patterns of long-term hospital utilization trajectories and whether HF influences these trajectories before and after hip fracture surgery. An initial cohort of 1,172 older adults hospitalized for hip fracture surgery between October 2015 and December 2018 was extracted from electronic health records. To adjust selection bias in baseline characteristics, we used propensity score 1:1 ratio matching to identify a final cohort of older adults with (n = 288) and without (n = 288) HF. Monthly frequencies of emergency department (ED) and inpatient encounters 1-year before and after the hip fracture surgery were used to identify distinct utilization trajectories from group-based trajectory analysis. Logistic regression models were used to compare the differences in ED and inpatient trajectories among patients with and without HF. High ED users (9.5%) had constant high ED use, and high inpatient users (20.1%) had significantly higher inpatient usage around the index hip fracture surgery hospitalization. Both low ED (90.5%) and inpatient (79.9%) users had low but slightly increased use around the index hospitalization. Compared with older adults without HF, older adults with HF were more likely to be long-term high inpatient user (OR = 1.94, 95% CI 1.25-3.01, p = 0.003), but not significantly different in long-term ED utilization (OR=1.87, 95% CI 0.97-3.59, p = 0.62).

To test relationships among background factors, interpersonal triggers, rejection of care, and aggression among veterans living with dementia in residential long-term care settings, based on the need-driven dementia-compromised behavior model.A mixed methods secondary analysis of program evaluation data from the Staff Training in Assisted Living Residences-Veterans Health Administration intervention implemented by the US Department of Veterans Affairs healthcare system.In total, 315 older veterans who participated in the 2013‒2016 Staff Training in Assisted Living Residences-Veterans Health Administration program at 76 Community Living Centers (Veterans Affairs-operated nursing homes).Text data that captured the interdisciplinary team observations of distressed behaviors of concern and their circumstances were coded into categorical variables and then combined with existing quantitative data to test hypothesized relationships using structural equation modeling.Rejection of care was directly affected by interpersonal triggers (β = 0.32, P .005) and background factors such as depression (β = 0.29, P .018), anxiety (β = -0.18, P .023), and cognitive status (β = 0.10, P .049). Depression also had an indirect effect on rejection of care through interpersonal triggers (α × β = 0.13 × 0.32 = 0.04, P .012). Aggression was directly affected by both interpersonal triggers (β = 0.19, P .009) and functional status (β = 0.17, P .011). Both function (α × β = 0.12 × 0.19 = 0.02, P .035) and depression (α × β = 0.13 × 0.19 = 0.03, P .005) had indirect effects on aggression through interpersonal triggers.Interpersonal triggers influenced rejection of care and aggression in veterans with dementia. Background factors such as depression and severity of functional impairment increased the likelihood of these symptoms. Study findings emphasize the importance of developing and implementing interventions that improve interpersonal relationships and developing targeted interventions for those with depressive symptoms.

Objectives Little is known about how nursing home staff use resident characteristics to individualize care delivery or whether care is affected by implicit bias. Design Randomized factorial clinical vignette survey. Setting Sixteen nursing homes in North Carolina. Participants Nursing, rehabilitation, and social services staff (n = 433). Measurements Vignettes describing hypothetical residents were generated from a matrix of clinical and demographic characteristics. Resident age, race and gender were suggested by a photo. Participants completed up to four randomly assigned vignettes (n = 1615), rating the likelihood that 12 fall prevention activities would be used for the resident. Fixed and random effects mixed model analysis examined the impact of vignette resident characteristics and staff characteristics on four intervention categories. Results Staff reported a higher likelihood of fall prevention activities in all four categories for residents with a prior fall (0.2–0.5 points higher, 10 point scale, P < 0.05), but other risk factors did not affect scores. There was little evidence of individualization; only dementia increased the reported likelihood of environmental modification (0.3, P < 0.001, 95% CI 0.2–0.5). Individualization did not vary with staff licensure category or clinical experience. Registered nurses consistently reported higher likelihoods of all fall prevention activities than did licensed practical nurses, unlicensed staff and other professional staff (1.0–2.7 points, P < 0.001 to 0.005). There was a small degree of implicit racial bias; staff indicated that environmental modification would be less likely to occur in otherwise identical vignettes including a photo of a black rather than a white resident (−0.2 points, 95% CI −0.3 to −0.1). Conclusion Nursing home staff report a standardized approach to fall prevention without individualization. We found a small impact from implicit racial bias that should be further explored.

Background Nursing home (NH) residents who require assistance during mealtimes are at risk for malnutrition. Supportive handfeeding is recommended, yet there is limited evidence supporting use of a specific handfeeding technique to increase meal intake. Objectives To compare efficacy of three handfeeding techniques for assisting NH residents with dementia with meals: Direct Hand (DH), Over Hand (OH), and Under Hand (UH). Design A prospective pilot study using a within-subjects experimental Latin square design with randomization to one of three handfeeding technique sequences. Setting and Participants 30 residents living with advanced dementia in 11 U.S. NHs. Measurements Time required for assistance; meal intake (% eaten); and feeding behaviors, measured by the Edinburgh Feeding Evaluation in Dementia (EdFED) scale. Intervention Research Assistants provided feeding assistance for 18 video-recorded meals per resident (N = 540 meals). Residents were assisted with one designated technique for 6 consecutive meals, changing technique every 2 days. Results Mean time spent providing meal assistance did not differ significantly between techniques. Mean meal intake was greater for DH (67 ± 15.2%) and UH (65 ± 15.0%) with both significantly greater than OH (60 ± 15.1%). Feeding behaviors were more frequent with OH (8.3 ± 1.8%), relative to DH (8.0 ± 1.8) and UH (7.7 ± 1.8). Conclusion All three techniques are time neutral. UH and DH are viable options to increase meal intake among NH residents with advanced dementia and reduce feeding behaviors relative to OH feeding.

Objectives To perform an economic evaluation of a primary care-based physical activity counseling intervention that improved physical activity levels and rapid gait speed in older veterans. Design Secondary objective of randomized trial that assessed the effect of exercise counseling (relative to usual care) on physical performance, physical activity, function, disability, and medical resource use and cost. Setting Veterans Affairs Medical Center, Durham, North Carolina. Participants Male veterans aged ≥70 years (n = 398). Intervention An experienced health counselor provided baseline in-person exercise counseling, followed by telephone counseling at 2, 4, and 6 weeks, and monthly thereafter through one year. Each participant's primary care physician provided initial endorsement of the intervention, followed by monthly automated telephone messages tailored to the patient. Individualized progress reports were mailed quarterly. Measurements Intervention costs were assessed. Health care resource use and costs were estimated from enrollment through one year follow-up. The incremental cost of achieving clinically significant changes in major trial endpoints was calculated. Results The total direct cost of the intervention per participant was $459, 85% of which was counselor effort. With overhead, program cost totaled $696 per participant. Medical costs during follow-up reached $10,418 with the intervention, versus $12,052 with usual care (difference = −$1,634 (95% confidence interval = −$4,683 to $1,416; P = .29)). Expressed in terms of short-term clinical outcomes, the intervention cost $4,971 per additional patient reaching target exercise levels, or $4,640 per patient achieving a clinically significant change in rapid gait speed. Conclusion Improvements in physical activity and rapid gait speed in the physical activity counseling group were obtained at a cost that represents a small fraction of patients' annual health care costs.

Multimorbidity resilience may mitigate the adverse effects of multiple chronic diseases on older adults’ health. Wister et al.’s (2018) multimorbidity resilience index was developed and tested in a cross-sectional sample of older adults in Canada. Building on these findings, we examined the reciprocal relationships of resilience on outcomes to test these potentially mitigating effects in a community-based, U.S. sample of older adults over time. The study sample includes 1,054 older adults from waves 2 and 3 of the National Social Life, Health, and Aging Project (NSHAP) study (Waite et al 2020). Wister et al.’s (2018) index was mapped to NSHAP measures, and reciprocal relationships of multimorbidity resilience and health outcomes over a 5-year period was tested using structural equation modeling (SEM). Results indicated significant effects of multimorbidity resilience on self-rated physical health and pain. Interestingly, a better functional resilience at baseline conferred better self-rated physical health at follow-up, while better psychological resilience predicted lower pain level. By contrast, the influence of health outcomes on any domain of multimorbidity resilience was not detectable at all, supporting the direction of these associations from resilience to outcomes. The study systematically investigated the dynamic hypotheses between multimorbidity resilience and health outcomes. That is, whether they are determinants or consequences, or both. Our findings suggest multimorbidity resilience predicts subsequent 5-year change in health outcomes, especially self-rated physical health and pain level, but not vice versa, strengthening the evidence of the importance of resilience in the health of older adults.