Looking back, moving forward: A practical guide to implementing the updated ACGME geriatric medicine Milestones 2.0.

The Accreditation Council for Graduate Medical Education (ACGME) developed the Milestones as a tool to aid trainee assessment based on the framework of the six core competencies of practice. Variability in the interpretation and application of the original Milestones prompted the ACGME to convene work groups within the different specialties and subspecialties to update the Milestones. The Geriatric Medicine work group was convened in 2019 with the goal of clarifying and simplifying the language of the Milestones, revising content to be specific to geriatrics, and developing supplemental resources to aid in implementation and use. We suggest using a practical, four-step process to implement the updated Milestones, called the Milestones 2.0, in fellowship programs by: (1) training faculty in the use of the Milestones 2.0, including an overview of the background and updates, (2) mapping the Milestones 2.0 to existing assessments, (3) educating fellows about the Milestones 2.0 and (4) presenting and discussing the Milestones 2.0 at Clinical Competency Committee meetings. This systematic approach promotes the development of a shared mental model for trainee assessments.

Dual Caregivers of Persons living with Dementia: The Added Stress of COVID-19 Pandemic.

Serving in dual caregiving roles presents challenges and has consequences for caregivers' physical and mental health. Forty-six dual caregivers in rural southwest Virginia participated in one semi-structured telephone interview pre-pandemic. Of these caregivers, nine dual caregivers of multiple older adults (MOA) and six caregivers of multiple generations (MG) participated in two telephone interviews during the COVID-19 pandemic. Pre-pandemic health, stress, and support data were used to compare dual caregivers of MOA and MG; differences were minimal. Responses to interviews conducted during the pandemic highlighted the effects of social restrictions on MOA and MG caregivers, revealing five themes (1) Increased isolation, (2) Increased need for vigilance, (3) Negative impact on mental health, (4) Tendency to "do it all," and (5) Increased informal help. MOA and MG caregivers differed on managing care responsibilities and ensuring the health of care recipients. In general, dual caregivers experienced decreased mental health, increased social isolation, and increased caregiving responsibilities. Antecedents of the pandemic experiences differentiated MOA and MG caregiver. Findings suggest that programs and services should target dual caregivers' unique needs.

Family Caregivers in Rural Appalachia Caring for Older Relatives With Dementia: Predictors of Service Use.

BACKGROUND AND OBJECTIVES: Residents of rural Appalachia tend to experience poorer health and greater economic distress than rural dwellers elsewhere in the United States. Although family is the first line of support for older adults needing care, it is unclear whether dementia caregivers in Appalachia assume these care responsibilities because of strong informal networks that support them in their caregiving role, underresourced formal services for persons with dementia, or culture-based reluctance to accept help from outsiders. This research examines how rural residents of Appalachia manage the care of relatives with dementia. RESEARCH DESIGN AND METHODS: The study was grounded in the Andersen Behavioral Model, supplemented with culturally relevant variables. Family caregivers from rural Appalachian counties in Virginia caring for community-dwelling relatives with dementia participated in a structured phone interview (N = 163). Generalized structural equation models were estimated, with predisposing, need, and enabling variables as predictors. Use of support services (e.g., meal delivery) and personal services (e.g., home health nurse) by family caregivers to care for the person with dementia were the dependent variables, and caregiver's rural community identity and attitude toward services were moderators. RESULTS: Approximately half the sample utilized at least one support service and one personal service. Predisposing and need factors predicted the use of support services, whereas predisposing, need, and enabling factors predicted personal services. Caregivers who strongly identified with their cultural roots were less likely to use personal services unless they held a generally positive view of formal services. DISCUSSION AND IMPLICATIONS: Although the extent of needs and the caregiver's economic situation were essential influences on formal service utilization, the main drivers were the caregiver's identification with rural Appalachian culture and attitude toward services. Findings point to within-group heterogeneity that requires differential approaches to delivery of community-based services accounting for varying attitudes, preferences, and family resources.

Dementia Family Caregiving in Rural Appalachia: A Sociocultural Model of Care Decisions and Service Use.

OBJECTIVES: Examinations of cultural variations in caregiving experiences and practices tend to focus on racially and ethnically diverse family caregivers. We extended this research by exploring the role of place-based cultural constructs on care decisions of family caregivers for persons living with dementia in rural Appalachia whose experiences and backgrounds dwell outside the lines of dominant culture. METHODS: Guided by our sociocultural conceptual model of service use and a descriptive qualitative study design, we conducted in-depth interviews with 30 caregivers for persons living with dementia to understand how predisposing and enabling factors influence caregiving decisions, including the use of services to care for persons living with dementia. RESULTS: Three predisposing factors reflecting the culture of rural Appalachian counties in Virginia (reasons for becoming a caregiver, previous caregiving experience, and deference to the person living with dementia) shaped decisions about caregiving responsibilities and service use. Three place-based enabling factors (a personal sense of belonging, knowledge of services, and family support for service use) played an important role in facilitating access to services. DISCUSSION: Findings revealed subtle variation across caregivers in this study and in comparison, to caregivers' experiences more generally. We interpret these variations in light of culturally influenced attitudes, family norms, and sources of information about formal services. Place-based cultural experience influenced dementia family caregivers' behaviors and choices regarding formal service use, suggesting that investigators should pay more attention to cultural influences in future caregiving research.

Dementia Caregiving During the "Stay-at-Home" Phase of COVID-19 Pandemic.

OBJECTIVE: The objective of this study was to assess family caregivers' primary appraisal of stressors related to COVID-19 stay-at-home orders, secondary appraisal of resources and support availability, and use of coping strategies as predictors of perceived role overload during the stay-at-home phase of the pandemic. METHOD: Telephone interviews with 53 family caregivers of persons with dementia from rural Virginia 2 weeks after enactment of the governor's stay-at-home order using structured and open-ended questions were conducted. RESULTS: Caregivers who were more concerned about the COVID-19 pandemic were at greater odds of experiencing high role overload than those who recognized positive aspects of the pandemic, as were those who received insufficient support from family and friends. DISCUSSION: Use of the transactional model of stress responses yielded important insights about families coping with dementia. Caregivers' perceptions of the pandemic's impact varied, with differential effects on their well-being.

Affect enhances object-background associations: evidence from behaviour and mathematical modelling.

In recognition memory paradigms, emotional details are often recognised better than neutral ones, but at the cost of memory for peripheral details. We previously provided evidence that, when peripheral details must be recalled using central details as cues, peripheral details from emotional scenes are at least as likely to be recalled as those from neutral scenes. Here we replicated and explicated this result by implementing a mathematical modelling approach to disambiguate the influence of target type, scene emotionality, scene valence, and their interactions. After incidentally encoding scenes that included neutral backgrounds with a positive, negative, or neutral foreground objects, participants showed equal or better cued recall of components from emotional scenes compared to neutral scenes. There was no evidence of emotion-based impairment in cued recall in either of two experiments, including one in which we replicated the emotion-induced memory trade-off in recognition. Mathematical model fits indicated that the emotionality of the encoded scene was the primary driver of improved cued-recall performance. Thus, even when emotion impairs recognition of peripheral components of scenes, it can preserve the ability to recall which scene components were studied together.

Assessment of progressively delayed prompts on guided skill learning in rats.

We examined the controlling factors that allow a prompted skill to become autonomous in a discrete-trials implementation of Touchette's (1971) progressively delayed prompting procedure, but our subjects were rats rather than children with disabilities. Our prompted skill was a left-right lever-press sequence guided by two panel lights. We manipulated (a) the effectiveness of the guiding lights prompt and (b) the presence or absence of a progressively delayed prompt in four groups of rats. The less effective prompt yielded greater autonomy than the more effective prompt. The ability of the progressively delayed prompt procedure to produce behavioral autonomy depended upon characteristics of the obtained delay (trial duration) rather than on the pending prompt. Sequence accuracy was reliably higher in unprompted trials than in prompted trials, and this difference was maintained in the 2 groups that received no prompts but yielded equivalent trial durations. Overall sequence accuracy decreased systematically as trial duration increased. Shorter trials and their greater accuracy were correlated with higher overall reinforcement rates for faster responding. Waiting for delayed prompts (even if no actual prompt was provided) was associated with lower overall reinforcement rate by decreasing accuracy and by lengthening trials. These findings extend results from previous studies regarding the controlling factors in delayed prompting procedures applied to children with disabilities.

Neutral details associated with emotional events are encoded: evidence from a cued recall paradigm.

Enhanced emotional memory often comes at the cost of memory for surrounding background information. Narrowed-encoding theories suggest that this is due to narrowed attention for emotional information at encoding, leading to impaired encoding of background information. Recent work has suggested that an encoding-based theory may be insufficient. Here, we examined whether cued recall-instead of previously used recognition memory tasks-would reveal evidence that non-emotional information associated with emotional information was effectively encoded. Participants encoded positive, negative, or neutral objects on neutral backgrounds. At retrieval, they were given either the item or the background as a memory cue and were asked to recall the associated scene element. Counter to narrowed-encoding theories, emotional items were more likely than neutral items to trigger recall of the associated background. This finding suggests that there is a memory trace of this contextual information and that emotional cues may facilitate retrieval of this information.

Validation of noninvasive body sensor network technology in the detection of agitation in dementia.

OBJECTIVE: Agitated behaviors are one of the most frequent reasons that patients with dementia are placed in long-term care settings. This study aims to validate the ability of a custom Body Sensor Network (BSN) to capture the presence of agitation against currently accepted subjective measures, the Cohen-Mansfield Agitation Inventory (CMAI) and the Aggressive Behavior Scale (ABS) and to discriminate between agitation and cognitive decline. METHODS: Six patients identified as being at high risk for agitated behaviors were enrolled in this study. The devices were applied at three sites for three hours while behaviors were annotated simultaneously and subsequently repeated twice for each enrolled subject. RESULTS: We found that the BSN was a valid measure of agitation based on construct validity testing and secondary validation using non-parametric ANOVAs. DISCUSSION: The BSN shows promise from these pilot results. Further testing with a larger sample is needed to replicate these results.