Nursing Home Characteristics Associated with Antipsychotic Prescribing After Implementation of the National Antipsychotic Reduction Initiative (ARI).

OBJECTIVES: To describe nursing home (NH) characteristics associated with antipsychotic use and test whether associations changed after implementation of the National Partnership to Improve Dementia Care's antipsychotic reduction initiative (ARI). METHODS: Longitudinal quasi-experimental design using data from multiple sources and piecewise linear mixed models were used for statistical analyses. RESULTS: There was a significant decrease in monthly antipsychotic use across the study period (pre-ARI b = -0.0003, p <.001; post-ARI b = -0.0012, p <.001), which held after adjusting for NH characteristics. Registered nurse hours (b = -0.0026, p <.001), licensed practical nurse hours (b = -0.0019, p <.001), facility chain membership (b = -0.0013, p <.01), and health inspection ratings (b = -0.0003, p >.01) were associated with decreased antipsychotic use. Post-ARI changes in associations between NH characteristics and antipsychotic use were small and not statistically significant. CONCLUSIONS: Decreases in antipsychotic use were associated with most NH characteristics, and associations persisted post-ARI. Further research is warranted to examine the interactions between ARI policy and NH characteristics on antipsychotic prescribing, as well as other NH factors, such as facility prescribing cultures and clinical specialty of staff. CLINICAL IMPLICATIONS: Decreases in monthly antipsychotic use were observed following the ARI. The decreases in monthly antipsychotic use were associated with most NH characteristics, and these associations persisted during the post-ARI period.

Examining pain, function, behavioral symptoms and associations with engagement in meaningful activity for residents with dementia in assisted living.

OBJECTIVES: The purpose of this study was to examine factors associated with engagement in meaningful activity among residents with dementia in assisted living. We hypothesized that greater functional independence, less pain, and lower behavioral and psychological symptom severity would be associated with higher engagement in meaningful activity after controlling for residents' age, gender, comorbidities, and cognition. Understanding factors associated with engagement in meaningful activity can help to inform strategies for optimizing engagement among residents with dementia in assisted living. METHOD: This descriptive study used baseline data from a randomized controlled trial, Meaningful Activity for Managing Behavioral Symptoms of Distress (MAC-4-BSD). Linear regression was used to examine factors associated with engagement in meaningful activity. RESULTS: A total of 71 residents from 5 assisted living settings were included in the sample. Most participants were female (n = 52, 73%), White (n = 62, 87%), and mean age was 85 years old (SD = 8.2). Controlling for age, gender, comorbidities, and cognition, pain was significantly associated with engagement in meaningful activity (b= -2.09, p < 0.05). There were no associations found between function and behavioral symptoms with engagement in meaningful activity. CONCLUSION: Findings from this study show that pain is a significant factor that is negatively associated with residents' engagement in meaningful activity. Ongoing research is needed to help improve pain management for residents with dementia in assisted living and support their engagement in meaningful activity.

Examining transitions of care among nursing home residents with and without antipsychotic medication use.

OBJECTIVES: This study examines the association between antipsychotic (AP) medication use and care transitions in the nursing home (NH) population. METHODS: This cross-sectional study used data from a 5% random sample of Medicare beneficiaries between 2011 and 2015. Propensity score adjusted negative binomial regression was performed and conditional probabilities of having a first transition from the NH to specific locations were calculated. RESULTS: Among 150,284 eligible beneficiaries, the majority were female (67%), white (84%), and >75 years old (63%). Controlling for resident characteristics, the odds of having any transition was 5% lower among those with AP use [IRR (95% confidence interval (CI))=0.95(0.94-0.96)] relative to those with no AP use. Residents with AP use had higher proportions of transitions to hospital (22.7% vs. 19.5%, p < 0.01), emergency department (19.6% vs. 10.7%, p < 0.01), and different NH (1.5% vs. 0.4%, p < 0.01), and lower proportions of transition to non-healthcare locations compared to those without AP use. CONCLUSIONS: Findings demonstrate that residents with AP use had higher probabilities of transitions to more costly care settings such as the emergency department and hospital compared to those without AP use. Future longitudinal studies will help to inform clinical interventions aimed at improving the quality of care for this population.

Developing and Testing A Model of the Assisted Living Environment.

The assisted living (AL) environment plays an important role in supporting residents' satisfaction and helping them to age in place. The AL environment is multidimensional and has many interrelated components including staffing (e.g. direct care workers, nursing, activity staff), services provided (e.g. medical, mental health, pharmacy), amenities offered at the setting (e.g. beauty salon, library, exercise facilities), and the physical environment. Evidence suggests that aspects of the AL environment can enhance or detract from the physical function, well-being, social engagement, and behavioral outcomes among residents. The purpose of this study was to develop and test a multidimensional AL environment measurement model that includes indicators of staffing, services, amenities, and the physical environment. Baseline data was used from a study testing the Dissemination and Implementation of Function Focused Care in AL. A total of 54 AL facilities across three states were included in the sample. Settings ranged in size from 31 to 164 beds with an average size of 82.2 (SD=26.2) beds and the majority were for profit facilities (n=41, 74.5%). Structural equation modeling was used to test the proposed model. Results showed that the model fit the data (χ2/df=1.861, p<.05; CFI=.858, RMSEA=.126). Having a comprehensive AL environment measurement model will advance future research that explores the impact of the environment on resident outcomes. Findings from this study will inform interventions and programs designed to modify AL environments to optimize residents' satisfaction with AL.

A Cluster Randomized Controlled Trial Testing the Impact of Function and Behavior Focused Care for Nursing Home Residents With Dementia.

OBJECTIVE: The purpose of this study was to test the effectiveness of the Function and Behavior Focused Care for the Cognitively Impaired (FBFC-CI) intervention on function, physical activity, and behavioral symptoms among nursing home residents with dementia, and to explore the adoption of the intervention at the facility level. DESIGN: This study was a clustered, randomized controlled trial with a repeated measures design that was implemented in 12 nursing homes randomized to either treatment (FBFC-CI) or educational control [Function and Behavior Focused Care Education (FBFC-ED)]. SETTING AND PARTICIPANTS: Twelve nursing homes (6 treatment and 6 control) and 336 residents (173 treatment and 163 control) with moderate to severe cognitive impairment. MEASURES: Outcomes included functional ability (Barthel Index), physical activity (actigraphy and survey), behavioral symptoms (Resistiveness to Care Scale, Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia), and psychotropic medication use. RESULTS: The participants were 82.6 (SD = 10.1) years of age, mostly female, and were moderate to severely cognitively impaired (Mini-Mental State Exam of 7.8, SD = 5.1). There was a significantly greater increase in time spent in total activity (P = .004), moderate activity (P = .012), light activity (P = .002), and a decrease in resistiveness to care (P = .004) in the treatment versus control group at 4 months. There was no change in mood, agitation, and the use of psychotropic medications. There was some evidence of adoption of the intervention at treatment sites. CONCLUSIONS AND IMPLICATIONS: This study provides some support for the use of the FBFC-CI Intervention to increase time spent in physical activity and decrease resistive behaviors during care commonly noted among nursing home residents with moderate to severe cognitive impairment.

Reliability and Validity of the Resident Satisfaction Index in Assisted Living.

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

Students' perceptions of interprofessional education in geriatrics: A qualitative analysis.

Interprofessional education (IPE) is critical for ensuring that students are prepared to collaborate with team members across disciplines once they enter clinical practice; particularly, in the complex care of the geriatric population. This qualitative study explored the experiences of interdisciplinary students in a clinical based IPE experience at a senior housing residence. Reflective journals were examined from students (n = 23) in nursing, social work, pharmacy, and medicine participating in an IPE program. Four core themes emerged in the analysis: exposure to geriatrics, IPE advantages for students, IPE advantages for older adults, and IPE challenges. Findings from this study confirmed advantages of IPE in a real-world clinical setting in terms of students learning the value and scope of practice of interdisciplinary team members. The exposure to geriatrics helped students to gain an in-depth understanding of issues affecting older adults in the community and increase professional confidence in their future clinical practice.

Providing Care for Persons with Dementia in Rural Communities: Informal Caregivers' Perceptions of Supports and Services.

Dementia is one of the costliest and most time-consuming diseases among older persons. Although informal caregivers provide the majority of care for persons with dementia, little is known about the self-perceived need for social services of caregivers of persons with dementia within rural areas. This pilot study examined the knowledge, access and intent of the practice-oriented service model of caregivers of persons with dementia in rural communities in the Midwest U.S. After a systematic training, researchers interviewed 11 rural caregivers of persons with dementia (n = 11). Data were analyzed using thematic analysis. Although similarities with other caregivers of persons with dementia were found, important differences suggesting unique issues among these rural caregivers of persons with dementia. Many participants found strength in their community, which often served as a safety net of support. Consistent with existing literature, participants expressed financial concerns, geographic barriers and lack of dementia-specific services when using formal services. The need for more specialized formal services in rural areas to supplement existing informal care networks is discussed. Policies and services based on rural caregivers' unique concerns and challenges and that build upon their existing care networks are recommended.

Electrophysiological repetition effects in persons with mild cognitive impairment depend upon working memory demand.

Forms of implicit memory, including repetition effects, are preserved relative to explicit memory in clinical Alzheimer's disease. Consequently, cognitive interventions for persons with Alzheimer's disease have been developed that leverage this fact. However, despite the clinical robustness of behavioral repetition effects, altered neural mechanisms of repetition effects are studied as biomarkers of both clinical Alzheimer's disease and pre-morbid Alzheimer's changes in the brain. We hypothesized that the clinical preservation of behavioral repetition effects results in part from concurrent operation of discrete memory systems. We developed two experiments that included probes of emotional repetition effects differing in that one included an embedded working memory task. We found that neural repetition effects manifested in patients with amnestic mild cognitive impairment, the earliest form of clinical Alzheimer's disease, during emotional working memory tasks, but they did not manifest during the task that lacked the embedded working memory manipulation. Specifically, the working memory task evoked neural repetition effects in the P600 time-window, but the same neural mechanism was only minimally implicated in the task without a working memory component. We also found that group differences in behavioral repetition effects were smaller in the experiment with a working memory task. We suggest that cross-domain cognitive challenge can expose "defunct" neural capabilities of individuals with amnestic mild cognitive impairment.

Motivators for Alzheimer's disease clinical trial participation.

BACKGROUND: Alzheimer's disease (AD) research progress is impeded due to participant recruitment challenges. This study seeks to better understand, from the perspective of individuals engaged in clinical trials (CTs), research motivations. METHODS: Participants, or their caregivers, from AD treatment and prevention CTs were surveyed about research motivators. RESULTS: The 87 respondents had a mean age of 72.2, were predominantly Caucasian, 55.2% were male, and 56.3% had cognitive impairment. An overwhelming majority rated the potential to help themselves or a loved one and the potential to help others in the future as important motivators. Relatively few respondents were motivated by free healthcare, monetary rewards, or to make others happy. CONCLUSIONS: Recruitment efforts should focus on the potential benefit for the individual, their loved ones, and others in the future rather than free healthcare or monetary rewards.

Low Arousal Positive Emotional Stimuli Attenuate Aberrant Working Memory Processing in Persons with Mild Cognitive Impairment.

Emotional enhancement effects on memory have been reported to mitigate the pathophysiology of Alzheimer's disease (AD). However, relative to their manifestation in persons without pathologic aging, these effects may be reduced in magnitude or even deleterious, especially in tasks that more closely model ecologic memory performance. Based upon a synthesis of such reports, we hypothesized that in persons with AD low arousal positive stimuli would evoke relatively intact emotional enhancement effects, but that high arousal negative stimuli would evoke disordered emotional enhancement effects. To assess this, participants with and without mild cognitive impairment (MCI) presumed to be due to AD performed an emotionally-valenced short-term memory task while encephalography was recorded. Results indicated that for persons with MCI, high arousal negative stimuli led to working memory processing patterns previously associated with MCI presumed due to AD and dementia of the Alzheimer-type. In contrast, low arousal positive stimuli evoked a processing pattern similar to MCI participants' unaffected spouses. Our current findings suggest that low arousal positive stimuli attenuate working memory deficits of MCI due to AD.

Factors that Influence Physical Activity among Residents in Assisted Living.

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