Improving safety and preventing falls using an evidence-based, front-line staff huddling practice: protocol for a pragmatic trial to increase quality of care in State Veterans Homes

INTRODUCTION

Falls in nursing homes are a major cause for decreases in residents' quality of life and overall health. This study aims to reduce resident falls by implementing the LOCK Falls Programme, an evidence-based quality improvement intervention. The LOCK Falls Programme involves the entire front-line care team in (1) focusing on evidence of positive change, (2) collecting data through systematic observation and (3) facilitating communication and coordination of care through the practice of front-line staff huddles.

METHODS AND ANALYSIS

The study protocol describes a mixed-methods, 4-year hybrid (type 2) effectiveness-implementation study in State Veterans Homes in the USA. The study uses a pragmatic stepped-wedge randomised trial design and employs relational coordination theory and the Reach, Effectiveness, Adoption, Implementation and Maintenance framework to guide implementation and evaluation. A total of eight State Veterans Homes will participate and data will be collected over an 18-month period. Administrative data inclusive of all clinical assessments and Minimum Data Set assessments for Veterans with a State Veterans Home admission or stay during the study period will be collected (8480 residents total). The primary outcome is a resident having any fall. The primary analysis will be a partial intention-to-treat analysis using the rate of participants experiencing any fall. A staff survey (n=1200) and qualitative interviews with residents (n=80) and staff (n=400) will also be conducted. This research seeks to systematically address known barriers to nursing home quality improvement efforts associated with reducing falls.

ETHICS AND DISSEMINATION

This study is approved by the Central Institutional Review Board (#167059-11). All participants will be recruited voluntarily and will sign informed consent as required. Collection, assessment and managing of solicited and spontaneously reported adverse events, including required protocol alterations, will be communicated and approved directly with the Central Institutional Review Board, the data safety monitoring board and the Office of Research and Development. Study results will be disseminated through peer-reviewed publications and conference presentations at the Academy Health Annual Research Meeting, the Gerontological Society of America Annual Scientific Meeting and the American Geriatrics Society Annual Meeting. Key stakeholders will also help disseminate lessons learnt.

TRIAL REGISTRATION NUMBER

NCT05906095.

Diabetes distress in Veterans with type 2 diabetes mellitus: Qualitative descriptive study

Diabetes distress (DD) is a negative psychosocial response to living with type 2 diabetes mellitus (T2DM). We sought insight into Veterans' experiences with DD in the context of T2DM self-management. The four domains in the Diabetes Distress Scale (i.e. regimen, emotional, interpersonal, healthcare provider) informed the interview guide and analysis (structural coding using thematic analysis). The mean age of the cohort (n = 36) was 59.1 years (SD 10.4); 8.3% of patients were female and 63.9% were Black or Mixed Race; mean A1C was 8.8% (SD 2.0); and mean DDS score was 2.4 (SD 1.1), indicating moderate distress. Veterans described DD and challenges to T2DM self-management across the four domains in the Diabetes Distress Scale. We found that (1) Veterans' challenges with their T2DM self-management routines influenced DD and (2) Veterans experienced DD across a wide range of domains, indicating that clinical interventions should take a "whole-person" approach.Trial Registration: NCT04587336.

A call to action to improve the completeness of older adult sexual and gender minority data in electronic health records

Sexual and gender minority (SGM) older adults experience greater health disparities compared to non-SGM older adults. The SGM older adult population is growing rapidly. To address this disparity and gain a better understanding of their unique challenges in healthcare relies on accurate data collection. We conducted a secondary data analysis of 2018-2022 electronic health record data for older adults aged ≥50 years, in 1 large academic health system to determine the source, magnitude, and correlates of missing sexual orientation and gender identity (SOGI) data among hospitalized older adults. Among 153 827 older adults discharged from the hospital, SOGI data missingness was 67.6% for sexual orientation and 63.0% for gender identity. SOGI data are underreported, leading to bias findings when studying health disparities. Without complete SOGI data, healthcare systems will not fully understand the unique needs of SGM individuals and develop tailored interventions and programs to reduce health disparities among these populations.

BARRIERS AND FACILITATORS FOR FOREIGN EDUCATED NURSES TO PROVIDE QUALITY LONG-TERM CARE

Unprecedented registered nursing shortages in long-term care (LTC) threaten the provision of person-centered care for older adults in the United States (US). LTC facilities recruit Foreign Educated Nurses (FENs) to address shortages, which raises concerns about care quality due to cultural, linguistic and communication differences among nurses; yet studies have not thoroughly explored FENs’ perspectives on these issues. The purpose of this study was to advance our understanding of FENs’ professional experiences as they began employment in LTC by exploring factors that inhibit or facilitate their provision of quality care. This qualitative descriptive study used purposive sampling to recruit FENs through professional organizations. Eligible FENs were ≥ 18 years old, worked ≥1 year in LTC, and represented racial and ethnic minority groups from Low and Middle Income Countries. In-depth narrative interviews, ranging from 45–60 minutes, were conducted. Applying content analysis, a priori and inductive coding generated themes. Participants (n=12) interviewed were all married females. Most were 50–59 years old (41.7%), Asian (75.0%), BSN-prepared (58.3%), and reported 31–50 years of nursing experience (50%). Positive facility characteristics, acculturation, effective workplace integration and positive support from colleagues, residents, and their families facilitated the provision of quality care. Conversely, negative facility characteristics, cultural barriers, discrimination and ineffective workplace integration were barriers to providing quality care. FENs highlighted culturally-sensitive strategies such as providing structured mentorship and preceptorship programs that supported them in providing person-centered care. FENs confirmed the need to address racial and anti-immigrant discrimination for achieving more equitable and inclusive workplaces.

SHORT- AND LONG-TERM OUTCOMES AFTER HIP SURGERY IN OLDER ADULTS WITH AND WITHOUT HEART FAILURE

Older adults with heart failure (HF) have a higher risk for adverse outcomes after hip fracture surgery than those without. Propensity score matching (PSM) reduces selection bias and makes a direct group comparison (older adults with and without HF) possible. Thus, this study aimed to assess the impact of HF on short-and long-term outcomes after hip fracture surgery in older adults living with and without HF. Electronic health records data of older adults (n = 1171) hospitalized for hip fracture surgery between October 2015 and December 2018 were extracted. Comparison groups (with and without HF) were identified using 1:1 ratio PSM to control for observed differences in baseline characteristics. Regression models were used to compare group differences in outcomes. Although in analyses without PSM, older adults with HF were more likely to have higher 90-day readmission, and 30-, 90-, and 365-day mortality, this association was not significant after controlling for selection bias. However, the associations between having HF with 30-day readmission and longer length of stay were significant before and after PSM. Additionally, if patients did not receive hip fracture surgery procedures within two days of admission, they had a 3.6-day longer inpatient stay (P-value < 0.0001) and were 47.8 times more likely to die during hospitalization (95%CI 4.9–482.0, P-value < 0.001). Being non-white was significantly associated with higher 90- and 365-day mortality. Future research should consider PSM approach on national representative datasets to rigorously evaluate the effects of HF on mortality and readmission following hip fracture surgery in older adults.

IMPACTS OF SOCIAL RELATIONSHIPS ON CO-OCCURRING SYMPTOMS AND FUNCTIONING IN OLDER ADULTS WITH COGNITIVE IMPAIRMENT

Social relationships are crucial for well-being of older adults with cognitive impairment (CI), however, evidence is lacking on how social relationships may influence symptom experience and functioning among those living with CI. This study aimed to identify subgroups of older adults with CI with distinct symptom and functioning profiles and to examine the association between latent class membership and social relationships. The sample included 927 older adults who were screened as having moderate or severe CI from wave 2 of the National Social Life, Health and Aging Project. Symptom (i.e., pain, fatigue, sleep disturbance, depression, anxiety, and stress) and functioning (i.e., instrumental activities of daily living, activities of daily living, and urinary incontinence) variables were used to identify subgroups. Latent profile analyses identified five distinct groups: most (51.7%) belonged to the low-symptom-high-functioning; few (7%) belonged to the high-symptom-low-functioning; while two groups had average symptom burden, one group (25%) had frequent urinary incontinence and normal daily functioning (poor-urinary-functioning), and the other group (5%) had normal urinary functioning and the worst daily functioning (worst-daily-functioning); interestingly, 13% belonged to high-symptom-normal-functioning group. Multinomial logistic regression modeling showed that, among social networks, support, strain, and engagement, members in groups with worse symptom burden and daily functioning were significantly more likely to have social strain, after adjusting for covariates (p-values < 0.01). Only severe CI was associated with worst-daily-functioning (OR = 3.24, p-value = 0.002). Interventions that ameliorate social strain may benefit symptom management and promote independent daily living among older adults with CI.

COGNITIVE TRAINING FOR OLDER CHINESE IMMIGRANTS IN THE US: AN EXPERIENCE-BASED CO-DESIGN APPROACH

Older Chinese Americans face many socioeconomic barriers including limited English proficiency, low educational levels, and limited access to care. These socioeconomic disadvantages not only contribute to an increased risk of developing dementia but also worsen inequitable access to effective strategies to promote cognitive health. Cognitive training is shown to be beneficial to maintain or enhance cognitive function. However, most prior interventions were tested exclusively in non-Hispanic Whites. To address this gap, we aim to adapt empirically supported cognitive training activities into a culturally and linguistically relevant mHealth cognitive training intervention. The adaptation process of the cognitive training includes focus groups (n=6/group) with older Chinese Americans (3 groups) and adult children (2 groups) to adapt cognitive training components to our target population. We will then organize an experience-based co-design workshop to further refine the intervention. Engaging end-users early will optimize the development of a culturally and linguistically relevant cognitive training intervention.

REJECTION OF CARE AND AGGRESSION AMONG OLDER VETERANS WITH DEMENTIA WITH AND WITHOUT POSTTRAUMATIC STRESS DISORDER

Veterans with co-occurring dementia and posttraumatic stress disorder (PTSD) living in residential long-term care encounter a range of physical and social stimuli, which may trigger trauma-related distress that can be exacerbated and manifested with care rejection and aggression. Yet, it is largely unknown how PTSD influences manifestation of care rejection and aggression in older veterans with dementia. Guided by the need-driven dementia-compromised model, this study examined the moderation effect of PTSD on pathways from background factors, and interpersonal triggers to care rejection and aggression among veterans with dementia with and without co-occurring PTSD. In this secondary analysis study, a multi-group structural equation modeling was conducted using program evaluation data of 315 veterans with dementia from the STAR-VA behavioral intervention implemented in 76 Veterans Health Administration-operated nursing homes. Although no moderation effect of PTSD on the overall model was found, findings revealed distinct patterns of relationships among background factors, interpersonal triggers, and care rejection and aggression between veterans with dementia with and without PTSD. The magnitude of the direct effects of interpersonal triggers on care rejection was greater in veterans with PTSD. Findings on the indirect effect of depression via interpersonal triggers on care rejection and direct effect of functional status on aggression only in veterans with PTSD implies that different mechanisms may underlie distressed behavior depending upon whether or not a veteran has PTSD. This study also underscores the importance of an enhanced focus on trauma-informed care, and individualized multi-component symptom management approach for veterans with dementia and PTSD.

IMPLEMENTATION BARRIERS AND FACILITATORS OF COGNITIVE STIMULATION THERAPY ACROSS CARE SETTINGS

Cognitive Stimulation Therapy (CST) is an evidence-based treatment for people living with dementia that is not in widespread use in the United States. To better understand barriers and facilitators to implementation of CST, we conducted virtual focus groups of newly trained facilitators of Cognitive Stimulation Therapy (CST). Of 12 facilitators trained, representing two settings of care (The Program for All-inclusive Care of the Elderly and a Continuing Care Retirement Community), 4 facilitators, representing Social Work n = 2, Speech Therapy n = 1, and Recreation Therapy n = 1, participated. We analyzed interview transcriptions using framework analysis guided by constructs from the Consolidated Framework for Implementation Research (CFIR). Themes that emerged across constructs were 1) balancing competing personal, stakeholder, and organizational needs; 2) lack of mastery experiences and the need for opportunities for more practice, reflection, and feedback from trainers; 3) building a community of facilitators to provide peer support; 4) logistical concerns; and 5) identifying appropriate participants who would most benefit from CST. The barriers to implementation imposed by the ongoing COVID-19 pandemic were also a cross-cutting theme. Many of these barriers are readily managed, and professionals who implement CST in their sites should be aware of and take into consideration these barriers and facilitators.

TRAJECTORIES OF HEALTH RECOVERY AFTER HIP FRACTURE IN OLDER ADULTS: A SCOPING REVIEW

Hip fracture recovery outcomes in older adults are characterized by high mortality, lowered functional status, and feelings of being disrupted from a normal life. Studying recovery trajectories through the lens of resilience can provide novel perspectives for developing interventions targeting to promote recovery. However, the lack of knowledge of recovery trajectories and their variations in hip fracture patients impedes such efforts. This review aims to synthesize current evidence on how multiple health domains change longitudinally after hip fracture in older adults. The Joanna Briggs Institute scoping review methodology was followed, and seven databases were searched including Medline (PubMed), EMBASE, Web of Science Core Collection, CINAHL, Proquest Dissertations and Theses, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. No date limits were applied, and the final search resulted in 7,515 articles. Articles in English with participants aged 60 years and above who experienced a low-energy, nonpharmacological hip fracture in any health setting were selected. Results regarding multiple domains of health outcomes will be synthesized, including physical health (e.g. functional status, pain, nutrition, and mobility/physical performance), cognition, psychosocial health (e.g. depression, anxiety, social isolation, loneliness, and behavioral and psychological symptoms of dementia when individuals with dementia were included), and multidimensional outcomes such as health-related quality of life. Methodological challenges and limitations will be discussed. This review has important implications for clinicians and researchers to improve individualized treatment plans and research methodologies by providing a comprehensive, critical review of knowledge regarding health trajectories in older adults after hip fracture.

Improving shared decision-making for osteoporosis pharmacologic therapy in nursing homes: a qualitative analysis

Decisions on whether to use pharmacologic osteoporosis therapy in skilled nursing facility residents are complex and require shared decision-making. Residents, proxies, and staff desire individualized fracture risk estimates that consider advanced age, dementia, and mobility. They want options for reducing administration burden, monitoring instructions, and periodic reassessment of risk vs. benefit.

PURPOSE

Decisions about pharmacologic osteoporosis treatment in nursing home (NH) residents with advanced age and multimorbidity are complex and should occur using shared decision-making. Our objective was to identify processes and tools to improve shared decision-making about pharmacologic osteoporosis treatment in NHs.

METHODS

Qualitative analysis of data collected in three NHs from residents at high fracture risk, their proxies, nursing assistants, nurses, and one nurse practitioner (n = 28). Interviews explored participants' stories, attitudes, and experiences with oral osteoporosis medication management. Framework analysis was used to identify barriers to shared decision-making regarding osteoporosis treatment in this setting.

RESULTS

Participants wanted individualized fracture risk estimates that consider immobility, advanced age, and comorbid dementia. Residents and proxies expected nursing staff to be involved in the decision-making; nursing staff wished to be informed on the relative risks vs. benefits of medications and given monitoring instructions. Two important competing demands to address during the shared decision-making process were burdensome administration requirements and polypharmacy. Participants wanted to reassess pharmacologic treatment appropriateness over time as clinical status or goals of care change.

CONCLUSIONS

Shared decision-making using strategies and tools identified in this analysis may move osteoporosis pharmacologic treatment in NHs and for other older adults with multimorbidity from inappropriate inertia to appropriate prescribing or appropriate inaction.

Heart Failure and Hospital Utilization Trajectories Before and After Hip Fracture Surgery

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).

Impacts of Social Capital Factors on Blood Glucose Control and Depressive Symptoms

Social capital, conceptualized as resources arising from social networks, is receiving increased attention for its role in prevention and management of chronic conditions such as diabetes and depression that commonly co-occur. Although social capital has been linked to control of blood glucose and depression, previous research has not considered these two outcomes simultaneously while distinguishing between cognitive (i.e., perceived social support, shared values and trust in community) and structural (i.e., social connectedness and participation) domains. This study examined how these two domains of social capital relate to glucose control and depressive symptoms, and whether physical exercise and care access mediate those relationships, using structural equation modeling. The sample included 3,043 older adults aged 57 and above from wave 2 of the National Social Life, Health and Aging Project. Although a higher level of cognitive social capital was associated with higher levels of physical exercise (b=.38, p<.001), access to care (b=.40, p=.007), lower levels of blood glucose (b=-.43, p<.001) and depressive symptoms (b=-.84, p<.001), a higher level of structural social capital was associated only with a higher level of physical exercise (b=.16, p=.002). The mediating effects of physical exercise and access to care were not significant. Findings suggest that cognitive social capital may have greater influence on blood glucose and depressive symptoms than structural social capital, and therefore have different implications for practice, especially in the context of pandemic-related disruptions to social capital. Future research should examine other mediators and investigate how promotion of cognitive social capital might improve health outcomes.

Cognitive Interviewing to Evaluate the Content Validity of a Photo-Supported Preference Assessment

Photo-supported verbal assessments have shown to improve comprehension and expression of choices by older adults living with cognitive-communication challenges. The purpose of this study was to assess content validity (CV) of photographs used to supplement the Preferences for Everyday Living Inventory-Nursing Home (PELI-NH) from the perspective of older adults, using cognitive interviewing methods. Participants (N=21) were average age 75 (SD=5.67), mostly male (62%) and white (90%), living in residential communities (86%), with no known cognitive or communication deficits. Interview data was used to iteratively assess and revise photographs. A total of 46 photographs demonstrated CV; 26 demonstrated CV after revisions; 3 did not demonstrate CV after revisions. Content analysis revealed thematic codes describing participants’ photograph preferences including image quality, context, subject diversity, and relevance to long-term care. Discussion will include implications for clinicians and researchers on how to evaluate and improve CV of photo-supported verbal assessments.

Human Capital and Employment Outcomes Among Foreign Educated and US Nurses Working in Long Term Care

Employing Foreign Educated Nurses (FENs) helps address Registered Nurse (RN) shortages in long-term care (LTC) in the United States (US). However, examination of factors explaining differences in their employment outcomes relative to US Educated Nurses (USENs) is limited. This study uses 2018 National Sample Survey of Registered Nurses data to compare income, work hours, job satisfaction, and human capital, defined as personal characteristics (knowledge, work experience) and behaviors (job mobility), of FENS and USENs working full-time in LTC. A human capital score, consisting of highest nursing education, skill certifications, state licensures, years of experience, multi-state employment history, and multi-lingual status was constructed. Covariates included nurse demographics, direct care role, and ability to practice to full scope. Covariate-adjusted group differences in employment outcomes and human capital were compared using ANCOVA and logistic regression. Mediation analyses explored whether human capital explained FEN vs USEN differences. FENs earned higher hourly wages (p=0.0169), worked fewer hours annually (p=0.0163), and reported greater human capital (p<.0001) compared to USENs. FENs and USENs, however, had similar annual salaries (p=0.3101) and job satisfaction (p=0.1674). Human capital mediated FEN vs USEN effects on hourly wages but not annual work hours. FENs’ higher levels of human capital partially account for FEN vs USEN differences in hourly wages. Application of the human capital concept advanced our ability to examine differences in employment outcomes and highlight aspects of the value that FENs contribute to LTC settings.

Heart Failure and Hospital Utilization Trajectories Before and After Hip Fracture Surgery

According to the World Dementia Council, three components are important to effectively engage a community to become dementia inclusive, 1) raising awareness and consequently decreasing stigma, 2) enabling participation, and 3) providing support—including in health and care settings. Too many times these components are separate initiatives thus limiting their effectiveness and sustainability. By applying the collective impact model and utilizing the Dementia Friends program as the link between the three, all dementia inclusive efforts can be enhanced and sustained regardless of the range of activities and approaches a community chooses to adopt. This symposium provides both evidence and examples of how to personalize and employ the Dementia Friends program to optimize the process, outcome, and impact of dementia inclusive initiatives. By engaging the entire community, awareness is raised, the structure is in place to enable action, and cross-sector collaboration will ensure continuation and sustainability of these important efforts.

Veterans' Interpretation of Diabetes Distress in Diabetes Self-Management: Findings From Cognitive Interviews

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 <9%, and 67% with prescribed insulin. The DD Scale is readily understood by veterans and interpreted. Thematic analysis indicated additional domains affecting DD and T2DM self-management, including access to care, comorbidities, disruptions in routine, fluctuations in emotions and behaviors, interactions with providers, lifelong nature of diabetes, mental health concerns, military as culture, personal characteristics, physical limitations, physical pain, sources of information and support, spirituality, and stigma.

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.

Caregiver Characteristics Associated With Cognitive Complaints in Women With Breast Cancer

OBJECTIVES

To explore whether caregiver characteristics were associated with cognitive complaints reported by women with breast cancer undergoing chemotherapy.

SAMPLE & SETTING

61 dyads of women with breast cancer and their caregivers were recruited at Duke Women's Cancer Care Raleigh in North Carolina.

METHODS & 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.

Dynamics of Multimorbidity Resilience and Health Outcomes Over Time in Community-Residing Older Adults

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.

Sensory Loss and Cognitive Decline among Older Adults: An Analysis of Mediation and Moderation Effects of Loneliness

Multiple studies have reported that hearing and vision loss are linked to cognitive decline. Yet little is known about factors that may influence the association between sensory loss and cognitive decline. This study examined if loneliness mediates or moderates the impact of sensory loss on cognitive decline as individuals age. This was a longitudinal study using data (N = 243) from the Health and Retirement Study (HRS) (2006 – 2014) and its supplement: The Aging, Demographics, and Memory Study (ADAMS) (Wave C). Hearing loss was defined by an inability to hear pure-tone stimuli of 25 dB at frequencies between 0.5 – 4.0 kHz in either ear. Vision loss was defined as having corrected binocular vision worse than 20/40. Loneliness was measured by the 3-item UCLA Loneliness Scale. Longitudinal parallel-process (LPP) analysis was conducted at a significance level of α = .05 (one-tailed). Loneliness moderated but did not mediate the associations between vision loss and the rate of cognitive decline (standardized β = -.108, p < .05). No moderation or mediation effect of loneliness was found for the association between hearing loss and cognitive decline. Both hearing and vision loss were significantly associated with increased severity of loneliness. Vision loss combined with an elevated level of loneliness may produce a more synergistic, deleterious impact on older adults’ cognitive function than vision loss alone. This study highlights the importance of promoting a healthy social and psychological status for older adults with vision loss.

Experience-Based Co-Design to Develop an Injury Prevention Intervention in Skilled Nursing Facilities

Experience-based co-design (EBCD) improves clinical effectiveness and safety by incorporating end-user perspectives in the design of clinical interventions. To refine a centralized, multi-component fall-related injury prevention service (IPS) to be tested in skilled nursing facilities (SNFs) in a pragmatic trial, we employed a modified EBCD process. We first conducted in-depth interviews with SNF residents, family members, and staff (n = 28; three facilities in two states) regarding their experiences in falls prevention. We then engaged these and other stakeholders from multiple institutions (n=4) in a day-long co-design workshop with our interdisciplinary research team. Building upon themes drawn from the analysis of interviews, we targeted three intervention components that were refined during the workshop: de-prescribing process, osteoporosis treatment, and educational videoconferences. Key outcomes from the ECBD process included development of strategies to ensure that: (1) residents, families, and SNF staff are involved in communication about residents identified as high risk for fall-related injury, and in related treatment decisions; (2) approaches to monitoring for unintended consequences from the injury prevention plan are clearly understood by direct care staff and are compatible with existing workflow; (3) treatment plan risks and benefits are presented in a manner easily understood by stakeholders; and (4) staff education conferences build trust with the IPS nurse and provide direct care staff with support and advice about challenging cases. EBCD is a feasible approach to strengthen intervention development in SNFs and can lead to testable new ideas for protocol refinement to address diverse stakeholder perspectives.

Dyadic Experiences of Living With Cognitive Impairment Through a 3-Year Longitudinal Qualitative Study

The fastest growth of population living with cognitive impairment takes place in China. The estimated prevalence of cognitive impairment among older adults in China is between 13% and 20%. This study focused on persons with cognitive impairment (PWCI) and their spousal care partners to explore how spousal relationships impact dyadic experiences of living with cognitive impairment through a person-centered care lens. We conducted a longitudinal qualitative study of 10 dyads of PWCI and their care partners over three years with three data collection time points. Our findings suggest that the complexity of changing experience of living with cognitive impairment is interpreted in the dynamic nature of their spousal relationship and relationship with others, patterns of communication, daily activities and care during the extended period of cognitive decline. It is crucial to help them nurture the belief that there is a significant meaning in the journey of living with cognitive impairment.

Influences of Dementia on Long-Term Surgical Outcomes in Older Adults After Hip Fracture

Older adults with dementia are more prone to have adverse health outcomes following hip fracture surgery. However, individuals with dementia and hip fracture are older and have more co-morbidities; these baseline differences can bias estimates of the influence of dementia. This study aims to investigate how dementia influences disposition, mortality rates and readmission rates at 365 days after hip surgery in older adults over age 65, after accounting for baseline factors such as socioeconomic status, health behaviors, co-morbidities, and type of hip fracture repair. A cohort of 1172 patients who had hip fracture surgery between October 2015 and December 2018 was extracted from electronic health records; among those, 376 had a diagnosis of dementia. Inverse probability of treatment weighting using propensity scores method was used to reduce the influence of factors that may confound the relationship between dementia status and hip surgery outcomes. Logistic regression was applied to estimate influences on discharge disposition and Cox proportional hazards model for one-year mortality. To account for competing risk of death, a Fine and Gray regression model was used to calculate subdistribution hazard ratios of readmission. Disparities in long-term surgical outcomes in patients with dementia were found. Results show that dementia was a significant predictor for being discharged to facilities (OR=1.92, 95% CI 1.09, 3.39, p=.025), death (HR=1.98, 95% CI 1.50-2.62, p&lt;.0001) and being readmitted within one year (HR=1.31, 95% CI 1.15-1.50, p&lt;.0001). These findings call for more efforts in developing effective multidisciplinary perioperative assessments and rehabilitation for patients with dementia.

Academic-Practice Partnership for Caregiver Training and Support: The Duke Elder Family/Caregiver Training (DEFT) Center

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.

Resident Challenges With Pain and Functional Limitations in Chinese Residential Care Facilities

BACKGROUND AND OBJECTIVES

Pain and functional limitations can severely impede older adults' quality of life. In Chinese residential care facilities, limited research suggests that residents potentially have significant unmet care needs with pain and related functional limitations. Therefore, we aimed to explore residents' challenges and self-management strategies in these two areas. This knowledge is essential to developing care interventions to improve quality of care and quality of life in Chinese residential care facilities.

RESEARCH DESIGN AND METHODS

We conducted semi-structured open-ended interviews with residents (n = 21) in two facilities in eastern and central China and assessed their pain and functional status using self-report measures from Minimum Data Set 3.0. We applied descriptive statistics to the self-reported data and analyzed the interview data using thematic analysis by drawing on the Adaptive Leadership Framework. This framework proposes that individuals living with chronic conditions need to engage in work to address their complex health concerns and that they need support from the environment to facilitate problem-solving.

RESULTS

Residents described significant unmet care needs with pain and functional limitations. To address these care needs, they adopted a substantial number of self-management strategies. While doing so, they faced significant barriers, including service gaps and inadequate direct care.

DISCUSSION AND IMPLICATIONS

The findings suggest further research to explore long-term care policy change that is needed to provide comprehensive health and medical services and adequate direct care in these facilities. The importance of establishing various types of long-term care facilities is also highlighted.

MULTIMORBIDITY RESILIENCE IN COMMUNITY-RESIDING OLDER ADULTS: MEASUREMENT AND HEALTH OUTCOMES

Multimorbidity is widespread, costly, and associated with a range of deleterious outcomes; it affects an estimated 67-80% of older adults. This study tests the validity of a multimorbidity resilience index developed in a Canadian sample of older adults by Wister et al., (2018), with a U.S.-based sample, using National Social Life, Health, and Aging Project (NSHAP) data, and draws upon the index to investigate the effects of resilience on outcomes over time. We mapped Wister et al.’s (2018) index to NSHAP measures, and assessed cross-sectional associations with health outcomes, using logistic regression. To assess the effects of resilience on health outcomes over time, we estimated mixed models of the relationships between resilience on outcomes over a 5-year interval. Total resilience was consistently associated with improved outcomes, including pain level (OR=.51, CI .41-.64); reduced utilization (OR=.45, CI .33-.60); improved mental health (OR=9.13, CI 6.20-13.44); self-rated physical health (OR=6.97, CI 4.76 10.19); and sleep quality (OR=3.66, CI 2.76-4.86). Longitudinal model results indicate change in multimorbidity resilience and number of chronic diseases predict (α=.001) pain level and self-rated physical health. Effects were moderated by socio-demographic factors. Our findings validate Wister et al.’s (2018) resilience index in a U.S. sample, supporting the importance of this measure to capture core components of older adults’ capacity to sustain well-being in the context of living with multiple, chronic conditions. Results from the longitudinal models provide beginning insights into the effects of resilience on symptom experience and perceived health over time, highlighting potential levers for change.

USE OF SENSOR TECHNOLOGY TO MAP THE SOCIAL NETWORKS OF PEOPLE LIVING WITH DEMENTIA: A FEASIBILITY STUDY

For older adults living with dementia, social network quality influences health outcomes. However, current social network measurement methods are time consuming and mentally draining for people living with dementia. This study aimed to accurately measure social networks using sensor technology. Bluetooth and radio-frequency identification (RFID) sensors were used to collect social network data in a simulation of a falling nursing home resident living with dementia. Participants wore sensors on their clothing, and video recordings were compared to sensor data. Bluetooth data reflected general direction of movement and instances of idling but were neither precise or accurate. RFID data was accurate after applying data filters. Both systems detected multiple sensors simultaneously. The Bluetooth system is not feasible for clinical use, but the RFID system shows potential for clinical application and accurate measurement of social network factors as interaction frequency and duration.

RELATIONSHIP-CENTERED CARE: ADULT DAY CARE FOR PERSONS LIVING WITH DEMENTIA AND THE SENSES FRAMEWORK

Relationship-centered dementia care (RCDC) has been related to improved quality of residential long-term care for persons living with dementia (PLWD). The senses framework supports accomplishing RCDC, whereby PLWD meet fundamental needs or senses through caregiving relationships. This study explored the application of the senses framework to a non-residential, long-term care setting, and included relationships across formal and informal caregivers. The study design is a qualitative, descriptive study of PLWD (N=3), with matched formal (N=3) and informal (N=3) caregivers in one adult day care setting in North Carolina. Semi-structured individual interviews explored each of the six senses of security, belonging, continuity, purpose, achievement, and significance. Interviews were analyzed using both inductive and deductive thematic analysis. Themes elucidate convergence and divergence of how senses are met or not met across triads of caregiving relationships. Findings inform our understanding of how to integrate the larger social network of PLWD for relationship-centered care.

MHEALTH PROTOTYPE AND PILOT PROTOCOL TO ENHANCE SOCIAL SUPPORT FOR PERSONS LIVING WITH DEMENTIA

An emerging component of mHealth is the use of tailored mobile applications (app) to facilitate self-management of chronic illnesses, including the mapping of social networks to assist adults living with chronic illnesses to help them be able to identify sources of social support. The purpose of this study is to describe a prototype app to support persons living with dementia (PLWD) in the community and their informal caregivers to map social networks and identify sources of emotional, instrumental, informational, and appraisal of social support. Adapting the Network Canvas open-source software and drawing upon a previously-developed mobile application for adults to self-manage chronic illnesses, we share the key specifications, including health care provider output, preliminary end user feedback, and the pilot protocol designed to test the feasibility. Findings illustrate the importance of leveraging social network data in novel ways to enhance self-management and well-being among PLWD and their caregivers

EVALUATING GERIATRIC WORKFORCE DEVELOPMENT NEEDS AMONG HOSPITALS USING NICHE BENCHMARKING DATA

The Nurses Improving Care for Health System Elders (NICHE) program aims to improve geriatric care competencies for improved care quality. A quantitative descriptive design utilizing secondary data analysis was done to evaluate geriatric workforce enhancement efforts in one acute healthcare system. Data were collected using the Geriatric Institutional Assessment Profile (GIAP) from 2008 and 2013. The GIAP measures perceived professional issues (disagreements among staff and families, limited access to geriatric services, vulnerability to legal action, intensity and burden of behavioral problems) on a Likert scale from best=0 to poor=10. Staff perception of the Geriatric Care Environment was scored by the GIAP as: age sensitive care delivery (0-40), institutional values (0-28), resource availability (0-32) and capacity for collaboration (0-12). Higher scores on the Geriatric Care Environment reflected improvements. Independent sample t-tests examined changes in baseline scores. Post-NICHE implementation, compared to peer hospitals by teaching status and bed size in 3 hospitals there were significantly (p<0.05) improved scores for: access to geriatric services (2.79-3.21), burden of behavioral problems (2.40-3.15), aging sensitivity care delivery (26.05-29.53), institutional values (18.85-19.59) and resource availability (19.51-19.97). Peer hospitals had significantly (p<0.05) better scores for: disagreements among staff about treatment of older adults (1.63-1.94) and capacity for collaboration (7.72-7.99). Findings indicate improvement in perceived professional issues and need for improvement in the geriatric care environment and care redesign to progress to becoming an Age-Friendly health system. This was an initial step in a health system to improve care quality through health workforce development.

Community Health Centers: a Key Partner to Achieve Medicaid Expansion

Medicaid expansion is an important feature of the "Affordable Care Act" and also is proposed as a component of some incremental plans for universal healthcare coverage. We describe (1) obstacles encountered with Medicaid coverage, (2) their potential resolution by federally qualified community health centers (CHCs), (3) the current status and limitations of CHCs, and (4) a proposed mega CHC model which could help assure access to care under Medicaid coverage expansion. Proposed development of the mega CHC model involves a three-component system featuring (1) satellite neighborhood outreach clinics, with team care directed by primary care nurse practitioners, (2) a hub central CHC which would closely correspond to the logistics and administration of current CHCs, and (3) a teaching hospital facilitating subspecialty care for CHC patients, with high-quality and cost-effectiveness. We believe that this new model, designated as a mega CHC, will demonstrate that CHCs can achieve their potential as a key partner to insure care under Medicaid expansion.

Person-directed care planning in nursing homes: A scoping review

AIM

Federal regulations require nursing homes in the United States to support residents in directing their own care rather than having their care plans developed for them without their engagement, but knowledge of person-directed approaches to care planning in nursing homes is limited. The purpose of this study was to advance understanding of person-directed care planning (PDCP).

METHODS

A multidisciplinary research team conducted a scoping review on individual and family involvement in care planning, including literature from a variety of care contexts. Search results were systematically screened to identify literature that addressed individual or family involvement in care planning as a primary concern, and then analysed using thematic content analysis.

RESULTS

Several themes were identified, including definitions of the concept of PDCP, essential elements of PDCP, barriers, facilitators and outcomes. The concept of PDCP is informed by multiple disciplines, including humanist philosophy, disability rights and end-of-life care. Essential elements of PDCP include knowing the person, integrating the person's goals in care planning and updating care plans as individuals' needs or preferences change. Limited time for care planning in nursing homes hinders PDCP. Facilitators include regulatory mandates and humanist social trends. Outcomes of PDCP were found to be positive (e.g., increased independence), but were inconsistently assessed across studies.

CONCLUSION

This study offers pragmatic information that can support PDCP within nursing homes and insights for policy reform that may more effectively support PDCP.

IMPLICATIONS FOR PRACTICE

These findings can be used to guide implementation of PDCP.

A New Community Health Center/Academic Medicine Partnership for Medicaid Cost Control, Powered by the Mega Teaching Health Center

Community health centers (CHCs), a principal source of primary care for over 24 million patients, provide high-quality affordable care for medically underserved and lower-income populations in urban and rural communities. The authors propose that CHCs can assume an important role in the quest for health care reform by serving substantially more Medicaid patients. Major expansion of CHCs, powered by mega teaching health centers (THCs) in partnership with regional academic medical centers (AMCs) or teaching hospitals, could increase Medicaid beneficiaries' access to cost-effective care. The authors propose that this CHC expansion could be instrumental in limiting the added cost of Medicaid expansion via the Affordable Care Act (ACA) or subsequent legislation. Nevertheless, expansion cannot succeed without developing this CHC-AMC partnership both (1) to fuel the currently deficient primary care provider workforce pipeline, which now greatly limits expansion of CHCs; and (2) to provide more CHC-affiliated community outreach sites to enhance access to care. The authors describe the current status of Medicaid and CHCs, plus the evolution and vulnerability of current THCs. They also explain multiple features of a mega THC demonstration project designed to test this new paradigm for Medicaid cost control. The authors contend that the demonstration's potential for success in controlling costs could provide help to preserve the viability of current and future expanded state Medicaid programs, despite a potential ultimate decrease in federal funding over time. Thus, the authors believe that the new AMC-CHC partnership paradigm they propose could potentially facilitate bipartisan support for repairing the ACA.

Nursing home staff perspectives on adoption of an innovation in goals of care communication

Nursing homes (NH) are important settings for end-of-life care, but limited implementation may impede goals of care discussions. The purpose of this study was to understand NH staff perceptions of adoption and sustainability of the Goals of Care video decision aid for families of residents with advanced dementia. Study design was a cross-sectional survey of staff at 11 NHs in North Carolina who participated in the Goals of Care (GOC) cluster randomized clinical trial. Staff perceived the GOC decision aid intervention as a positive innovation; it was perceived as more compatible with current practices by male staff, nurses, and more experienced NH staff. Perceptions were correlated with experience, implying that experience with an innovative approach may help to promote improved GOC communication in nursing homes. Nurses and social work staff could be effective champions for implementing a communication technique, like the GOC intervention.

Study of Individualization and Bias in Nursing Home Fall Prevention Practices

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.

Surfing the Net in Later Life: A Review of the Literature and Pilot Study of Computer Use and Quality of Life

The Internet offers new opportunities for communication that can help older adults avoid social isolation. Although elders may need more time and assistance in learning computer systems, many are embracing this new technology. There is growing potential not only for recreation and communication through the Internet but also the delivery of services. This study examines the feasibility of providing Internet and electronic mail access to older adults in a retirement community and the extent to which this improves psychosocial well-being. In contrast to members of a comparison group, a trend toward decreased loneliness was observed among participants. In addition, the number of computer-related problems decreased and use of the applications increased throughout the study. These preliminary results support the feasibility of implementing computer-based interventions with the potential of improving psychosocial well-being among older adults.

Delirium detection and improved delirium management in older patients hospitalized for hip fracture

Delirium is a common and potentially devastating problem for older patients following hip fracture. Although early detection is recommended, description and evaluation of standardized approaches are scarce. The aims of this quality improvement project were to: (1) implement a clinical algorithm for improving delirium detection and management and (2) assess the impact of the clinical algorithm on length of stay, discharge disposition and patient satisfaction. The pilot study was implemented on an orthopedic unit to evaluate the effectiveness of a clinical protocol for delirium detection and management to improve outcomes. Outcomes of 33 elderly post-operative hip fracture patients were compared to historical controls from the same unit. Delirium was detected in 18% of patients. Length of stay was reduced by 22% (P < .001), discharge disposition showed a 13% improvement (P = .17) and patient satisfaction scores showed a 15% (P = .15) improvement post-intervention. Implementation of a clinical algorithm to promote early detection and treatment of delirium in post-operative hip fracture patients is feasible and associated with improved outcomes.

Identifying risk of readmission in hospitalized elderly adults through inpatient medication exposure

OBJECTIVE

To use electronic health record (EHR) data to examine the association between inpatient medication exposure and risk of hospital readmission.

DESIGN

Retrospective, observational study.

SETTING

Tertiary and quaternary care academic health system in Durham, North Carolina.

PARTICIPANTS

All individuals aged 60 and older who were residents of Durham County, North Carolina and were hospitalized and discharged alive from Duke University Hospital between 2007 and 2009 (N = 4,627).

MEASUREMENTS

Independent variables were inpatient exposure to individual medication classes. Primary outcome was readmission to a Duke Health System hospital within 30 days.

RESULTS

Readmission rate was 21% (n = 955). In adjusted models, exposure to anticonvulsants (odds ratio OR 1.26, 95% confidence interval (CI) = 1.08-1.48), benzodiazepines (OR = 1.23, 95% CI = 1.04-1.44), corticosteroids (OR = 1.26, 95% CI = 1.07-1.50), and opioids (OR = 1.25, 95% CI = 1.06-1.47) was associated with greater likelihood of readmission. Exposure to antidepressants (OR = 1.85, 95% CI = 1.16-2.96) and opioids on the cardiology service (OR = 1.76, 95% CI = 1.01-3.07) and exposure to opioids on the medicine service (OR = 1.94, 95% CI = 1.17-3.22) were associated with greater odds of readmission than for individuals on the surgery service.

CONCLUSION

Exposure of hospitalized elderly adults to certain medication classes was associated with greater likelihood of readmission. Incorporating medication data from EHRs may improve the performance of hospital readmission prediction models.

CONNECT for better fall prevention in nursing homes: results from a pilot intervention study

OBJECTIVES

To determine whether an intervention that improves nursing home (NH) staff connections, communication, and problem solving (CONNECT) would improve implementation of a falls reduction education program (FALLS).

DESIGN

Cluster randomized trial.

SETTING

Community (n=4) and Veterans Affairs (VA) NHs (n=4).

PARTICIPANTS

Staff in any role with resident contact (n=497).

INTERVENTION

NHs received FALLS alone (control) or CONNECT followed by FALLS (intervention), each delivered over 3 months. CONNECT used storytelling, relationship mapping, mentoring, self-monitoring, and feedback to help staff identify communication gaps and practice interaction strategies. FALLS included group training, modules, teleconferences, academic detailing, and audit and feedback.

MEASUREMENTS

NH staff completed surveys about interactions at baseline, 3 months (immediately after CONNECT or control period), and 6 months (immediately after FALLS). A random sample of resident charts was abstracted for fall risk reduction documentation (n=651). Change in facility fall rates was an exploratory outcome. Focus groups were conducted to explore changes in organizational learning.

RESULTS

Significant improvements in staff perceptions of communication quality, participation in decision-making, safety climate, caregiving quality, and use of local interaction strategies were observed in intervention community NHs (treatment-by-time effect P=.01) but not in VA NHs, where a ceiling effect was observed. Fall risk reduction documentation did not change significantly, and the direction of change in individual facilities did not relate to observed direction of change in fall rates. Fall rates did not change in control facilities (falls/bed per year: baseline, 2.61; after intervention, 2.64) but decreased by 12% in intervention facilities (falls/bed per year: baseline, 2.34; after intervention, 2.06); the effect of treatment on rate of change was 0.81 (95% confidence interval=0.55-1.20).

CONCLUSION

CONNECT has the potential to improve care delivery in NHs, but the trend toward improving fall rates requires confirmation in a larger ongoing study.

A low-vision rehabilitation program for patients with mild cognitive deficits

IMPORTANCE

We are unaware of any standardized protocols within low-vision rehabilitation (LVR) to address cognitive impairment.

OBJECTIVE

To design and pilot-test an LVR program for patients with macular disease and cognitive deficits.

DESIGN

The Memory or Reasoning Enhanced Low Vision Rehabilitation (MORE-LVR) program was created by a team representing optometry, occupational therapy, ophthalmology, neuropsychology, and geriatrics. This pilot study compares outcomes before and after participation in the MORE-LVR program.

SETTING

Eligible patients were recruited from an LVR clinic from October 1, 2010, through March 31, 2011.

PARTICIPANTS

Twelve patients completed the intervention, and 11 companions attended at least 1 training session.

INTERVENTION

Key components of the MORE-LVR intervention are as follows: (1) repetitive training with a therapist twice weekly during a 6-week period, (2) simplified training experience addressing no more than 3 individualized goals in a minimally distracting environment, and (3) involvement of an informal companion (friend or family member).

MAIN OUTCOME MEASURES

Version 2000 National Eye Institute Vision Function Questionnaire-25; timed performance measures, Telephone Interview for Cognitive Status-modified(TICS-m), Logical Memory tests, satisfaction with activities of daily living, and goal attainment scales.

RESULTS

Twelve patients without dementia (mean age, 84.5 years; 75% female) who screened positive for cognitive deficits completed the MORE-LVR program. Participants demonstrated improved mean (SD) scores on the National Eye Institute's Visual Function Questionnaire-25 composite score (47.2 [16.3] to 54.8 [13.8], P = .01) and near-activities score (21.5 [14.0] to 41.0 [23.1], P = .02), timed performance measures (writing a grocery list [P = .03], filling in a crossword puzzle answer [P = .003]), a score indicating satisfaction with independence (P = .05), and logical memory (P = .02). All patients and companions reported progress toward at least 1 individualized goal; more than 70% reported progress toward all 3 goals.

CONCLUSIONS AND RELEVANCE

This pilot study demonstrates feasibility of an LVR program for patients with macular disease and mild cognitive deficits. Participants demonstrated improvements in vision-related function and cognitive measures and expressed high satisfaction. Future work is needed to determine whether MORE-LVR is superior to usual outpatient LVR for persons with coexisting visual and cognitive impairments.