A pilot, randomized, feasibility study to improve health self-management behaviors in older adults with multiple chronic conditions and functional limitations: Protocol for the Behavioral Activation and Occupational Therapy Trial (BA+OT).

Background: Approximately 45% of older adults in the U.S. have 2 or more chronic health conditions (e.g., arthritis, hypertension, diabetes) in addition to functional limitations that prevent performance of health self-management activities. Self-management continues to be the gold standard for managing MCC, but functional limitations create difficulty with these activities (e.g., physical activity, symptom monitoring). Restricted self-management accelerates the downward spiral of disability and accumulating chronic conditions which, in turn, increases rates of institutionalization and death by 5-fold. Currently, there are no tested interventions designed to improve independence in health self-management activities in older adults with MCC and functional limitations. Research suggests that older adults are more likely to change behavior with interventions that assist with planning health-promoting daily activities, especially when contending with complex medical regimens and functional limitations. Our team asserts that combining occupational therapy (OT) and behavioral activation (BA) shows promise to improve health self-management in populations with chronic conditions and/or functional limitations. This innovative combination uses the goal setting, scheduling/monitoring activities, and problem-solving components of the BA approach as well as the environmental modification, activity adaptation, and focus on daily routines from OT practice. Objectives: We will test the effect of this combined approach in a Stage I, randomized controlled pilot feasibility study compared to enhanced usual care. We will recruit 40 older adults with MCC and functional limitation and randomize 20 to the PI- delivered BA-OT protocol. This research will inform modification and larger-scale testing of this novel intervention.

Natural, longitudinal recovery of adults with COVID-19 using standardized rehabilitation measures.

Background: While studies recommend rehabilitation following post-hospitalization recovery from COVID-19, few implement standardized tools to assess continued needs. The aim of this study was to identify post-hospitalization recommendations using an interdisciplinary needs assessment with standardized rehabilitation measures. A secondary aim was to use these tools to measure recovery over a 30-day period. Materials and methods: Using a 30-day longitudinal design, we completed weekly rapid needs assessments in this convenience sample of 20 people diagnosed with COVID-19 discharged from the hospital to home. We computed summary statistics and used the Wilcoxon Signed Rank Test to assess change over the 4-week course of the study with alpha level = 0.05. Results: Our sample (65% male, 47% over 50 years of age, 35% White, 37% with a confirmed diagnosis of diabetes, and 47% obese) included no patients who had required mechanical ventilation. Initial assessments demonstrated the majority of our participants were at an increased risk of falls, had disability in activities of daily living (ADL) and instrumental activities of daily living (IADL), mild cognitive impairment, and dyspnea. At the 30-day follow-up, most were independent in mobility and basic ADLs, with continued disability in IADLs and cognitive function. Discussion: In this sample of patients who were not mechanically-ventilated, early and individualized rehabilitation was necessary. The results of this study suggest patients would benefit from a multi-disciplinary team needs assessment after medical stabilization to minimize fall risk and disability, and to prevent secondary complications resulting from post-hospital deconditioning due to COVID-19.

Sex differences in brain functional connectivity of hippocampus in mild cognitive impairment.

Mild cognitive impairment (MCI) is the prodromal stage of Alzheimer's Disease (AD). Prior research shows that females are more impacted by MCI than males. On average females have a greater incidence rate of any dementia and current evidence suggests that they suffer greater cognitive deterioration than males in the same disease stage. Recent research has linked these sex differences to neuroimaging markers of brain pathology, such as hippocampal volumes. Specifically, the rate of hippocampal atrophy affects the progression of AD in females more than males. This study was designed to extend our understanding of the sex-related differences in the brain of participants with MCI. Specifically, we investigated the difference in the hippocampal connectivity to different areas of the brain. The Resting State fMRI and T2 MRI of cognitively normal individuals (n = 40, female = 20) and individuals with MCI (n = 40, female = 20) from the Alzheimer's Disease Neuroimaging Initiative (ADNI) were analyzed using the Functional Connectivity Toolbox (CONN). Our results demonstrate that connectivity of hippocampus to the precuneus cortex and brain stem was significantly stronger in males than in females. These results improve our current understanding of the role of hippocampus-precuneus cortex and hippocampus-brainstem connectivity in sex differences in MCI. Understanding the contribution of impaired functional connectivity sex differences may aid in the development of sex specific precision medicine to manipulate hippocampal-precuneus cortex and hippocampal-brainstem connectivity to decrease the progression of MCI to AD.

The Impact of Amplification on Cognitive Screening Test Scores.

Hearing loss is associated with cognitive decline in older adults. Research has shown that hearing loss negatively affects cognitive screening test measures as patients may mishear verbally administered questions. The purpose of the current study was to investigate the impact of amplification on performance on a commonly used cognitive screening test. Thirty older adults with hearing loss underwent testing with the Mini-Mental State Examination (MMSE) in three conditions: without hearing aids, with hearing aids, and with a personal listening device (PLD). Performance on the MMSE significantly improved with the use of hearing aids or a PLD. Amplification and the use of communication strategies should be considered when administering cognitive screening measures to older adults. Failure to account for hearing status may lead to invalid results and can increase the likelihood of over-referral for further assessment. [Journal of Gerontological Nursing, 48(7), 31-37.].

Stimulating Research to Enhance Aging in Place.

Older adults may benefit from interventions to successfully age in place. Research has an opportunity to test interventions and implementation strategies to fulfill the needs of older adults through collective evidence building. The purpose of this article is to describe the proceedings of the American Occupational Therapy Foundation (AOTF) 2019 Planning Grant Collective and describe the areas of research that were identified as critical. The AOTF convened scientists with expertise in the area of aging in place to catalyze research on aging in place for older adults. Four priority areas in the aging in place literature were highlighted: (a) identification of factors that support aging in place, (b) classification of processes by which family members and care partners are included in aging in place efforts, (c) categorization of technology supporting older adults to age in place, and (d) development of science that clarifies implementation of evidence-based practice.

Revisiting the attitudes toward health care teams scale: Developing a short version for graduate health care education.

As interprofessional education (IPE) becomes more common in student training programs, reliable and valid scales are needed to measure students' perceptions of the experience. The Attitudes Toward Health Care Teams Scale (ATHCTS) was developed to measure students' attitudes toward IPE programs using 14 items loaded on two factors. In this paper, we used the ATHCTS scale to assess the effects of a three-semester long health care IPE program on three cohorts of nurse practitioner, occupational therapy, and physical therapy graduate students with three measurement points across two university sites (N = 367). Confirmatory factor analysis on the baseline data of the first cohort revealed unacceptable fit indices; in addition, not all items were applicable, some items had double or low factor loadings, and positively and negatively worded items loaded on separate factors, indicating potential answering bias, and both factors were highly correlated. We thus conducted further item analyses and propose a short version of the ATHCTS using six items with one reverse coded item, describing the quality of interprofessional care in a more parsimonious way. The factor structure of the six-item version was tested using confirmatory factor analysis on the baseline data of cohort 2 and 3. Results were compared to the 14-item version, and fit indices confirmed a better fit to the data than the old version. Using the shortened scale, student attitudes were compared over the course of the program and between both sites. Results showed that site 2 students' attitudes remained very positive over time, while site 1 students' attitudes declined significantly. We suggest this finding is related to the consistency of team membership at site 2 and discuss the implications for IPE program design.

Identity and perceptions of quality of life in Alzheimer's disease.

BACKGROUND: With life expectancy on the rise and the baby boomer generation growing older, Alzheimer's disease (AD) will affect more individuals and families than ever before. Therefore, it is imperative that healthcare providers identify the objective and perceived factors which positively and negatively affect the experience of progressing through AD. AIM: The goal of this exploratory qualitative research is to begin to develop an in-depth description of the perceptions related to life satisfaction in early-to mid-AD from the patient and caregiver perspectives. METHODS: A convenience sample of four community-dwelling AD patients and caregivers were recruited from a local Alzheimer's Association support group. Semi-structured interviews were conducted together with participants and caregivers. RESULTS: The major findings of this study uncovered a process by which 1) changes in activity occur in response to the diagnosis 2) dyads discover new ways in which to mutually adapt and cope and 3) the person with dementia remains meaningfully engaged in their lives with a generally positive perception of quality of life (QoL). CONCLUSIONS: These preliminary findings are a promising line of research and have implications for Alzheimer's patients, their families, and person-centered care. By accounting for individual levels of baseline engagement and taking each patient's perspective into account, nurses have the ability to identify individual changes over time and positively impact the patient's QoL. Further studies with larger and more diverse samples are needed to expand upon this preliminary framework.

Effect of Reduced Audibility on Mini-Mental State Examination Scores.

BACKGROUND: The interaction of audition and cognition has been of interest to researchers and clinicians, especially as the prevalence of hearing loss and cognitive decline increases with advancing age. Cognitive screening tests are commonly used to assess cognitive status in individuals reporting changes in memory or function or to monitor cognitive status over time. These assessments are administered verbally, so performance may be adversely affected by hearing loss. Previous research on the impact of reduced audibility on cognitive screening test scores has been limited to older adults with sensorineural hearing loss (SNHL) or young adults with normal hearing and simulated audibility loss. No comparisons have been conducted to determine whether age-related SNHL and its impact on cognitive screening tests is successfully modeled by audibility reduction. PURPOSE: The purpose of this study was to examine the effects of reduced audibility on the Mini-Mental State Examination (MMSE), a common bedside cognitive screening instrument, by comparing performance of cognitively normal older adults with SNHL and young adults with normal hearing. DESIGN: A 1:1 gender-matched case-control design was used for this study. STUDY SAMPLE: Thirty older adults (60-80 years old) with mild to moderately severe SNHL (cases) and 30 young adults (18-35 years old) with normal hearing (controls) served as participants for this study. Participants in both groups were selected for inclusion if their cognitive status was within normal limits on the Montreal Cognitive Assessment. DATA COLLECTION AND ANALYSIS: Case participants were administered a recorded version of the MMSE in background noise at a signal-to-noise ratio of +25-dB SNR. Control participants were administered a digitally filtered version of the MMSE that reflected the loss of audibility (i.e., threshold elevation) of the matched case participant at a signal-to-noise ratio of +25-dB SNR. Performance on the MMSE was scored using standard criteria. RESULTS: Between-group analyses revealed no significant difference in the MMSE score. However, within-group analyses showed that education was a significant effect modifier for the case participants. CONCLUSIONS: Reduced audibility has a negative effect on MMSE score in cognitively intact participants, which contributes to and confirms the findings of earlier studies. The findings suggest that observed reductions in score on the MMSE were primarily due to loss of audibility of the test item. The negative effects of audibility loss may be greater in individuals who have lower levels of educational attainment. Higher levels of educational attainment may offset decreased performance on the MMSE because of reduced audibility. Failure to consider audibility and optimize communication when administering these assessments can lead to invalid results (e.g., false positives or missed information), misdiagnosis, and inappropriate recommendations for medication or intervention.

Perspectives on ethnic and racial disparities in Alzheimer's disease and related dementias: Update and areas of immediate need.

Alzheimer's disease and related dementias (ADRDs) are a global crisis facing the aging population and society as a whole. With the numbers of people with ADRDs predicted to rise dramatically across the world, the scientific community can no longer neglect the need for research focusing on ADRDs among underrepresented ethnoracial diverse groups. The Alzheimer's Association International Society to Advance Alzheimer's Research and Treatment (ISTAART; alz.org/ISTAART) comprises a number of professional interest areas (PIAs), each focusing on a major scientific area associated with ADRDs. We leverage the expertise of the existing international cadre of ISTAART scientists and experts to synthesize a cross-PIA white paper that provides both a concise "state-of-the-science" report of ethnoracial factors across PIA foci and updated recommendations to address immediate needs to advance ADRD science across ethnoracial populations.

Exploring families' experiences of health: contributions to a model of family health.

Child health and developmental outcomes are influenced by the health of the family and the context created. Research suggests symptoms of poor family health (e.g. suboptimal family interactions, parenting stress) yet there is limited understanding of the factors which contribute to robust family health which may unveil opportunities for targeted intervention and family health promotion. The present study examined families' experiences of family health and factors contributing to family health. We performed a qualitative study using constructivist grounded theory methods to guide our understanding of family health for families with typically developing children aged 5-18. Interviews were conducted in family homes and all members were invited to participate. Data from interviews were transcribed, coded, thematically analyzed, and verified with select families. Ten families, including 10 mothers, 8 fathers, and 15 children participated in the study. Participants described family health as a process of balance, living purposefully, and sharing experiences together in alignment with family identity. Mediating family health were processes of awareness and reflection, and adapting, adjusting, and changing in response to family life including external stress factors. Results highlight the possibility for healthcare practitioners to facilitate families' self-reflection and awareness about their health in order to mediate family health development.

Simulating Interprofessional Geriatric Patient Care Using Telehealth: A Team-Based Learning Activity.

INTRODUCTION: More than one-third of Oklahomans live in rural counties, and 63 of Oklahoma's 77 counties are classified as health professional shortage areas, where telemedicine would be beneficial. In response to this need, in 2012, the Colleges of Nursing and Allied Health at the University of Oklahoma Health Sciences Center implemented a sequence of interprofessional learning experiences to prepare nurse practitioner, physical therapy, and occupational therapy students in team-based geriatric care using telehealth technologies. METHODS: The sequence included modules on interprofessional competencies, a simulated patient case, and clinical experiences. This publication includes instructional materials and evaluation tools for replicating this sequence. RESULTS: Student responses to the guided reflection exercise provided a snapshot of their thoughts and reactions during this learning activity. Overall, their reflections suggested that they were highly motivated and actively thinking about how to work together effectively as a team to care for their standardized patient. DISCUSSION: This case is most applicable for educators who own telehealth equipment; however, a telehealth patient encounter could be simulated with other technologies.

Improving Personal Characterization of Meaningful Activity in Adults with Chronic Conditions Living in a Low-Income Housing Community.

PURPOSE: To understand how adults living in a low-income, public housing community characterize meaningful activity (activity that gives life purpose) and if through short-term intervention, could overcome identified individual and environmental barriers to activity engagement. METHODS: We used a mixed methods design where Phase 1 (qualitative) informed the development of Phase 2 (quantitative). Focus groups were conducted with residents of two low-income, public housing communities to understand their characterization of meaningful activity and health. From these results, we developed a theory-based group intervention for overcoming barriers to engagement in meaningful activity. Finally, we examined change in self-report scores from the Meaningful Activity Participation Assessment (MAPA) and the Engagement in Meaningful Activity Survey (EMAS). RESULTS: Health literacy appeared to impact understanding of the questions in Phase 1. Activity availability, transportation, income and functional limitations were reported as barriers to meaningful activity. Phase 2 within group analysis revealed a significant difference in MAPA pre-post scores (p =0.007), but not EMAS (p =0.33). DISCUSSION: Health literacy should be assessed and addressed in this population prior to intervention. After a group intervention, participants had a change in characterization of what is considered healthy, meaningful activity but reported fewer changes to how their activities aligned with their values.

Instrumental activities of daily living performance and role satisfaction in people with and without mild cognitive impairment: a pilot project.

OBJECTIVE: We investigated differences in observed performance of instrumental activities of daily living (IADLs) and self-reported satisfaction with social role performance between people with amnestic mild cognitive impairment (a-MCI) and age- and gender-matched control participants. METHOD: We measured observed performance of 14 IADLs using the Independence, Safety, and Adequacy domains of the Performance Assessment of Self-Care Skills (PASS) and the Patient-Reported Outcomes Measurement Information Systems (PROMIS) to examine satisfaction with social role performance. RESULTS: Total PASS scores were significantly lower in participants with a-MCI (median=40.6) than in control participants (median=44.2; p=.006). Adequacy scores were also significantly lower. No significant differences were found between groups on the PROMIS measures. CONCLUSION: IADL differences between groups were related more to errors in adequacy than to safety and independence. Occupational therapy practitioners can play a key role in the diagnosis and treatment of subtle IADL deficits in people with MCI.

Maximizing ADL performance to facilitate aging in place for people with dementia.

The purpose of this article is to review the effect of dementia on activities of daily living and consequently on the ability to age in place. Types of evaluation and information conferred from different types of assessment are discussed. Evidence-based interventions for preventing and minimizing activities-of-daily-living disability are outlined.

Enhanced task-oriented training in a person with dementia with Lewy bodies.

Despite the inevitable loss of function seen in people with progressive dementias, interventions for reversing or minimizing functional loss are understudied. Research supports task-oriented training, but practical gaps in how to best evaluate clients for this training and how to implement it in clinical settings may be thwarting translation to occupational therapy practice. We structured an intervention model called STOMP (Skill-building through Task-Oriented Motor Practice) using a unique blend of task-oriented training and motor-learning principles. In this article, we describe through a case study the process and outcome of using STOMP to improve functional skills in a woman with moderate dementia with Lewy bodies. Our findings suggest that STOMP has the potential to serve as a structure for the evaluation and treatment of occupational performance deficits in people with dementia and that this model warrants further investigation.

Population-centered life skills groups: perceptions of satisfaction and engagement.

PURPOSE. We examined the satisfaction with and engagement in population-centered life skills groups of women in a residential facility for substance dependence. METHOD. This study was a retrospective, cross-sectional analysis of 561 surveys designed to elicit Likert scale client ratings. Descriptive statistics were used to examine client satisfaction. Differences in client engagement by content focus and activity process were also examined by analyzing the median scores of eight life skills development questions using the Kruskal-Wallis test of medians. RESULTS. Collectively, 96.8% of those who completed the surveys were satisfied with the living skills groups; 73.3% strongly agreed, and 23.4% agreed. No significant differences (p > .05) were found in the median scores of the engagement responses by either content focus or activity process. CONCLUSION. Population-centered life skills groups conceptualized within a holistic Person-Environment-Occupation model appear to be satisfactory and engaging interventions for women in recovery.

Self-development groups among women in recovery: client perceptions of satisfaction and engagement.

PURPOSE: We examined engagement in and satisfaction with occupational therapy self-development groups among women in a residential facility for substance dependence. METHOD: We performed a retrospective, cross-sectional analysis of 1,488 Likert-scale surveys completed anonymously between 2006 and 2010. Descriptive statistics were used to examine client satisfaction in self-development groups. Differences in engagement by content focus and activity process were also examined by analyzing the median scores of eight self-development questions using the Kruskal-Wallis test of medians. RESULTS: Of those who completed surveys, 73.6% strongly agreed and 23.4% agreed (collectively, 97%) that they were satisfied with the group. No significant differences (p > .05) were found in the median scores of the questions by content focus or activity process. CONCLUSION: Self-development activity groups with salient recovery themes conceptualized within a person-environment-occupation model appear to be a satisfactory and engaging intervention for women in recovery from substance abuse.

Patterns and correlates of depression in hospitalized older adults.

Depression is often associated with illness or injury requiring acute hospitalization, particularly in older adults. We sought to determine patterns of change in depressive symptoms in older adults from hospitalization to 3 months post discharge and to examine factors associated with depressive symptoms 3 months after discharge. The study included 197 patients aged 65 years or older hospitalized with an acute medical illness. Sociodemographic and clinical measures, including depressive symptoms using the Center for Epidemiologic Study-Depression (CES-D) scale, were collected during the inpatient stay and at 3 months post discharge. Mean age was 75.3 ± 7.5 (± S.D.) years, 59% of the participants were female, 61% unmarried, and 72% had a high school education or more. High depressive symptoms (i.e., CES-D ≥ 16) were reported in 37% at admission. Of the 8% depressed at follow-up, 81% were also depressed at admission; 19% were new cases of depression. Depressive symptoms 3 months post-hospitalization were significantly associated with follow-up daily living skills (p=0.001) and social support (p<0.0001). Patients with persistent depressive symptoms make up the majority of post-hospitalization depression cases. Post-hospitalization social support and daily living skills appear to be important in the management of follow-up depressive symptoms.

Enhancing our collective research acumen by using an epidemiological perspective.

Nearly 50 million Americans report some level of disability in activities of daily living or instrumental activities of daily living. Public health officials advocate for a fresh perspective on disability by considering disability through an epidemiological approach. Should occupational therapists perform this research, and what are the benefits for our profession if we do? This article advocates for enhancing our research knowledge base by including an epidemiological perspective in our research design. The benefits to occupational therapy of this research include (1) increased understanding of the extent and nature of occupational performance disability, (2) advancement of the scope and depth of research for prevention and intervention programs, and (3) improved visibility of the profession as informants for public health policy. Suggestions for preparing researchers to perform these studies and students and practitioners to interpret the studies are provided.