Correlates of Sleep Disturbance Experienced by Informal Caregivers of Persons Living with Dementia: A Systematic Review

OBJECTIVES

This study aims to comprehensively review and update the literature concerning the correlates of sleep disturbance among caregivers of persons living with Alzheimer's disease and related dementias to identify gaps in the literature and antecedent targets for interventions.

METHODS

We searched PubMed, CINAHL, PsycINFO, and Embase using terms related to "sleep," "caregiver," and "dementia."

RESULTS

Thirty-six articles were included in this review. Based on the antecedents within the 3P model of insomnia, predisposing factors associated with caregiver sleep included caregiver demographics, and physiological factors like genotype and biomarkers. Precipitating factors related to caregiver sleep included caregiving status and responsibilities, and person living with dementia factors.

CONCLUSIONS

Sleep disturbance is a significant issue for caregivers of persons living with dementia. However, this review has identified multiple precipitating factors that are modifiable targets for interventions to improve or enhance caregiver sleep.

CLINICAL IMPLICATIONS

Numerous predisposing and precipitating factors contribute to caregivers of persons living with dementia being susceptible to sleep disturbance. Healthcare providers should ask patients about their caregiving status during annual visits. Healthcare providers should also evaluate caregivers' sleep patterns, and the predisposing and precipitating factors of sleep disturbance, with a focus on the modifiable factors, to enable timely intervention.

Dementia Caregiver Experiences: Insights From a Telephone-Based Support Program

Dementia caregivers face daunting challenges as both the oldest subpopulation of those providing unpaid care and the most at risk of adverse health outcomes as a result of their role, including depression, anxiety, and increased mortality. To better understand the experiences and needs of dementia caregivers, a qualitative content analysis was conducted of secondary data extracted from call logs (N = 569) recorded by a provider-initiated, telephone-based support program. Experiences identified from the call logs were coded, categorized, and ranked to determine the most prevalent dementia caregiving-related experiences. Features of the program, particularly the semi-structured call format and directionality of calls, helped to uniquely capture common experiences of family caregivers and their day-to-day concerns. Findings from this analysis reflect the high prevalence of caregiver mental and emotional health-related concerns. This analysis supports the development of interventions that align with the experiences of dementia caregivers.

"Just Join Them": Improv and Dementia Care

Improvisational (improv) theatre skill development holds promise for improving the dementia capability of care partners. In this report, we present analysis of data from an ongoing study on meaningful engagement and quality of life among assisted living (AL) residents with dementia. Using ethnographic methods, we collected data from persons with dementia (n = 59) and their care partners (n = 165) in six diverse AL communities each studied for one year. Building cumulatively on past work and existing literature, we demonstrate the potential benefits of training care partners to use improv skills. We discuss implications, including the need for intervention research.

Caregiving While Black: A novel, online culturally tailored psychoeducation course for Black dementia caregivers

BACKGROUND AND OBJECTIVES

Psychoeducation interventions using distance learning modalities to engage caregivers in active learning environments have demonstrated benefits in enhancing caregiving mastery. However, few of these programs have been specifically adapted to develop mastery in Black caregivers.

RESEARCH DESIGN AND METHODS

A multi-method approach was carried out to assess Caregiving While Black (CWB), including pre-post surveys and in-depth interviews. This psychoeducation course addresses the cultural realities of caring for a person living with dementia as a Black American. Caregivers engaged in online asynchronous education related to healthcare navigation, home life management, and self-care. Primary (caregiving mastery) and secondary outcomes (anxiety, depression, perceived stress, burden, perceived ability to manage behavioral & psychological symptoms) were assessed at baseline and post-course (10 weeks).

RESULTS

Thirty-two Black caregivers from across the United States completed the course within the allotted timeframe. Paired sample t-test analyses revealed significant reductions in caregiver burden and role strain. Caregiver mastery from baseline to completion increased by 0.45 points with an effect size of 0.26 (Cohen's d). Twenty-nine caregivers participated in an optional post-course interview, and thematic analysis led to the construction of 5 overarching themes: Comfortability with a Culturally Tailored Course; Experiences Navigating the Course Platform; Utility of Course Resources; Time as a Barrier and Facilitator; Familial and Community Engagement.

DISCUSSION AND IMPLICATIONS

Pilot findings convey a need to continue creating and receiving feedback on culturally tailored psychoeducation programs for dementia caregivers. The next steps include applying results to fuel the success of the next iteration of CWB.

Synthesizing Best Practices to Promote Health Equity for Older Adults Through Community-Engaged Research

Achieving health equity requires creating evidence that reflects the nuance and diversity of experiences among populations disproportionately impacted by age- and race-related disparities. Community-engaged research (CEnR) is one way to pursue equity in research on health and aging to ensure the relevance and translational potential of findings. The current review synthesizes best practices regarding CEnR that promote health equity among older adults, including an overview of CEnR, benefits, and fundamental principles, and three research exemplars from the authors' CEnR. Finally, we discuss these best practices and considerations for advancing CEnR to reduce health disparities experienced by historically underserved older adults and their families. [Research in Gerontological Nursing, 17(1), 9-16.].

Tele-Savvy Outcomes of Non-Hispanic Black American and White Caregivers

BACKGROUND AND OBJECTIVES

Tele-Savvy is a synchronous/asynchronous psychoeducation program for caregivers of community-dwelling persons living with Alzheimer's disease and related dementias (ADRD) designed to increase caregivers' competence and confidence (mastery) in caregiving. Its overall efficacy was tested in a randomized controlled trial.

RESEARCH DESIGN AND METHODS

This secondary data analysis examined the caregiver mastery and psychological health (i.e., perceived stress, depressive symptoms, and burden) outcome of 153 non-Hispanic Black American and White caregivers (31 non-Hispanic Black American and 122 White caregivers) from baseline to 6 months postintervention. Given the difference in the sample sizes of Black and White caregivers, a descriptive post hoc subgroup analysis was conducted of 21 non-Hispanic Black American and 20 White adult children and grandchildren caregivers.

RESULTS

In the overall sample, Black American caregivers demonstrated higher levels of mastery and lower levels of distress than White caregivers at baseline and across all time points. Over time, White caregivers, but not Black American caregivers, experienced significantly improved levels of mastery and significantly lowered levels of depression. Within the subgroup analysis, except for a moderate effect size in the management of situation scores over time among Black American adult children caregivers, similar results were obtained.

DISCUSSION AND IMPLICATIONS

The findings highlight the strengths and shortcomings of the Tele-Savvy program in improving caregiver mastery and reducing negative psychological health outcomes. Intentionally tailoring the Tele-Savvy program to certain racial and caregiving groups may hold promise in meeting the needs of more ADRD caregivers.

CLINICAL TRIAL REGISTRATION

NCT03033875.

The Effect of Tele-Savvy on Sleep Quality and Insomnia in Caregivers of Persons Living with Dementia

Introduction

Sleep disturbance is prevalent in caregivers of persons living with dementia (PLwD). Tele-Savvy, a 7-week virtual psychoeducational intervention, enhances caregivers' competence and self-care, and reduces depression. While not explicitly designed to do so, Tele-Savvy can potentially improve caregivers' disturbed sleep. The present study aimed to examine the longitudinal effects of Tele-Savvy on caregivers' sleep quality and insomnia.

Methods

This was a secondary data analysis of a 3-arm randomized control trial [Tele-Savvy (active treatment), Healthy Living (attention control), and usual care (waitlist control)]. Multilevel mixed modeling with intent-to-treat principles tested for group, time, and group-by-time effects. Effect sizes were estimated for all changes from baseline to the initial 6-month post-intervention point. Following completion of the 6-month post-randomization delay, we examined combined outcomes for Tele-Savvy.

Results

Participants (n=137; mean age 64.7 years) were predominantly female (68.6%) and White (68.6%). We found no initial group-by-time effects for the Pittsburgh Sleep Quality Index (PSQI) and the Insomnia Severity Index (ISI). For the combined Tele-Savvy group, there was a statistically significant improvement in ISI scores across time (p=0.050). The combined Tele-Savvy effect size for PSQI was d=0.126 and ISI was d=0.310.

Discussion

Tele-Savvy resulted in a significant long-term reduction in insomnia symptoms in this sample of caregivers of PLwD and demonstrated a positive trend for improvement in their sleep quality. Since sleep disturbance is so prevalent among caregivers of PLwD, the inclusion of sleep health education into psychoeducation caregiver interventions may yield even better outcomes for caregivers.

The intersection of social determinants of health and family care of people living with Alzheimer's disease and related dementias: A public health opportunity

In this Perspective article, we highlight current research to illustrate the intersection of social determinants of health (SDOHs) and Alzheimer's disease and related dementia (ADRD) caregiving. We then outline how public health can support ADRD family caregivers in the United States. Emerging research suggests that family care for persons with ADRD is influenced by SDOHs. Public health actions that address these intersections such as improved surveillance and identification of ADRD caregivers; building and enhancing community partnerships; advancing dementia-capable health care and related payment incentives; and reducing the stigma of dementia and ADRD caregiving can potentially enhance the health and well-being of dementia caregivers. By engaging in one or all of these actions, public health practitioners could more effectively address the myriad of challenges facing ADRD caregivers most at risk for emotional, social, financial, psychological, and health disruption.

"I Didn't Know I Needed to Be Still": Experiences of Black Dementia Caregivers Attending Tailored Online Worship Services

The current study aimed to determine the feasibility and preliminary efficacy of culturally appropriate online worship services for Black dementia caregivers. Researchers met online with families six times over 8 weeks. Each meeting consisted of families viewing a short, uniquely tailored worship service. Preand post-surveys were conducted, and caregivers participated in in-depth, semi-structured interviews to discuss their experiences with the online worship services. All caregivers (N = 24) identified as Christian and African American. There was no significant mean difference between pre- and post-survey results, but there was a trend toward improving perception of caregiver role, caregiver burden, and dyadic relationship. Observations and interviews revealed two themes, Experiences and Feasibility of Engaging With Culturally Appropriate Online Worship Services. Although the preliminary efficacy of the online worship services remains to be investigated, our results suggest resources developed for caregivers of people living with dementia should be carefully tailored to ensure they are culturally appropriate and responsive. [Research in Gerontological Nursing, 16(6), 273-282.].

Sleep Profiles of Caregivers for Persons Living with Dementia: A Qualitative Study

Sleep disturbance is prevalent among caregivers of people living with dementia. However, gaps exist about caregivers' sleep patterns before and during their caregiving trajectory. This exploratory secondary analysis using a qualitative descriptive approach aimed to (1) identify and describe current caregivers' patterns of change in sleep before and during caregiving, and (2) understand caregivers' perceptions of their current sleep compared to their pre-caregiving sleep. We conducted semi-structured interviews with 19 caregivers taking part in a larger randomized controlled trial. Participants were female (n = 11), white (n = 13) and on average 63 years of age. Interview questions focused on caregivers' sleep patterns. The interviews were audio-recorded using a videoconferencing platform and ranged from 20 to 45 minutes. We conducted thematic analysis of the interview transcripts. Three distinct caregiver-sleep profiles emerged from the qualitative data: changed and dissatisfied, changed and satisfied, and unchanged and dissatisfied. Caregivers whose sleep was categorized as changed reported a difference when comparing their current sleep pattern to their pre-caregiving sleep pattern. This was usually a change from good to poor sleep. Caregivers whose sleep was unchanged had poor sleep pre-caregiving and continued to have poor sleep during caregiving. Caregivers also reported being satisfied or dissatisfied with their current sleep pattern, defined in terms of distress and impairment. These three subtypes highlight the heterogeneity of caregivers' sleep experiences and debut a useful clinical framework with which to identify, categorize, and target caregivers at risk for sleep disturbance, many who may be ready to engage in behaviors to improve their sleep. Knowing caregivers' sleep profiles will enable health care providers and researchers to determine caregivers' needs and readiness for interventions then work collaboratively with them to improve their sleep problems.

Black and white proxy experiences and perceptions that influence advanced dementia care in nursing homes: The ADVANCE study

BACKGROUND

Regional, facility, and racial variability in intensity of care provided to nursing home (NH) residents with advanced dementia is poorly understood.

MATERIALS AND METHODS

Assessment of Disparities and Variation for Alzheimer's disease NH Care at End of life (ADVANCE) is a multisite qualitative study of 14 NHs from four hospital referral regions providing varied intensity of advanced dementia care based on tube-feeding and hospital transfer rates. This report explored the perceptions and experiences of Black and White proxies (N = 44) of residents with advanced dementia to elucidate factors driving these variations. Framework analyses revealed themes and subthemes within the following a priori domains: understanding of advanced dementia and care decisions, preferences related to end-of-life care, advance care planning, decision-making about managing feeding problems and acute illness, communication and trust in NH providers, support, and spirituality in decision-making. Matrix analyses explored similarities/differences by proxy race. Data were collected from June 1, 2018 to July 31, 2021.

RESULTS

Among 44 proxies interviewed, 19 (43.1%) were Black, 36 (81.8%) were female, and 26 (59.0%) were adult children of residents. In facilities with the lowest intensity of care, Black and White proxies consistently reported having had previous conversations with residents about wishes for end-of-life care and generally better communication with providers. Black proxies held numerous misconceptions about the clinical course of advanced dementia and effectiveness of treatment options, notably tube-feeding and cardiopulmonary resuscitation. Black and White proxies described mistrust of NH staff but did so towards different staffing roles. Religious and spiritual beliefs commonly thought to underlie preferences for more intense care among Black residents, were rarely, but equally mentioned by race.

CONCLUSIONS

This report refuted commonly held assumptions about religiosity and spirituality as drivers of racial variations in advanced dementia care and revealed several actionable facility-level factors, which may help reduce these variations.

Transgender Adults From Minoritized Ethnoracial Groups in the U.S. Report Greater Subjective Cognitive Decline

OBJECTIVES

Investigate subjective cognitive decline (SCD) among 4 study groups consisting of cisgender and transgender adults who are from minoritized ethnoracial groups (i.e., minoritized ethnoracial transgender, minoritized ethnoracial cisgender) and White cisgender and transgender adults aged 45+ (i.e., White transgender, White cisgender) to determine the odds of SCD by group and to test for group differences.

METHODS

Data from the 2015-2020 Behavioral Risk Factor Surveillance System were used in a modified case-control approach to perform an intercategorical intersectional study. Each transgender participant was matched to 2 cisgender men and 2 cisgender women, on state, ethnoracial identity, and age. Multivariable logistic regressions modeled SCD odds by group and post hoc contrasts estimated pairwise odds ratios comparing the SCD odds for each combination of groups.

RESULTS

SCD prevalence was highest among minoritized ethnoracial transgender (21.6%), followed by White transgender (15.0%), minoritized ethnoracial cisgender (12.0%), and White cisgender (9.0%). After accounting for age, education, and survey year, the odds of SCD were higher in minoritized ethnoracial transgender when compared to White cisgender (adjusted odds ratio [aOR] = 2.51, 95% confidence interval [CI]: 1.59-3.96) and minoritized ethnoracial cisgender (aOR = 1.89, 95% CI: 1.16-3.09). The odds of SCD were higher in White transgender compared to White cisgender (aOR = 1.66, 95% CI: 1.20-2.30).

DISCUSSION

When considering the intersection of transgender and ethnoracial identities, we found that transgender adults from minoritized ethnoracial groups reported higher odds of SCD when compared to cisgender adults from minoritized ethnoracial groups. Additional studies are needed to understand the relationship between racialized and gendered inequities in cognitive impairment and how specific mechanisms of systemic transphobia and racism may contribute to this inequity.

Spiritual Needs of Older Adults Living with Dementia: An Integrative Review

Older adults living with dementia experience progressive decline, prompting reliance on others for spiritual care and support. Despite a growing interest in studying persons living with dementia (PLwDs), empirical evidence on the spiritual needs of PLwDs has not been synthesized. Using the Whittemore and Knafl method, this integrative review examined the literature from 2000 to 2022 on the spiritual care needs of PLwDs. We sought to identify characteristics of the spiritual needs of PLwDs and ways to address them. The ATLA Religion, CINAHL, PsycINFO, PubMed, and Socindex databases were used to search the literature, and 12 peer-reviewed articles met the inclusion criteria. Spiritual care needs varied across studies. Overall, findings support the importance of identifying PLwDs' religious and spiritual backgrounds to inform person-centered care. Spiritual needs were identified as verbal and non-verbal expressions related to past meaning and religious and spiritual background and were not consistently addressed in care. Providers reported observing spiritual distress in the mild stage prompting the need for spiritual care. There is a great need for dementia-specific spiritual assessment tools and spiritual care interventions to support spiritual well-being in dementia care. Spiritual care involves facilitating religious rituals and providing spiritual group therapy and religious and spiritual activities.

Using meta-research to foster diverse, equitable, and inclusive collaborative research networks

Fostering diverse, equitable, and inclusive collaborative research networks is important for advancing the field of aging research. Despite sizeable investment in research consortia and career development programs, there has been only moderate progress toward diversifying the research workforce studying aging. Without critically examining what works and what does not, continuing to place more resources into these same strategies may not result in a substantial improvement in diversity or the creation of collaborative networks. Using meta-research to rigorously evaluate potential strategies to promote diversity and collaboration may yield important insights that can be used to improve upon current efforts. For this reason, we sought to describe meta-research and highlight how its principles can be used to achieve the aging research community's collaboration and diversity goals.

Validation of a Measure of Role Overload and Gains for End-of-Life Dementia Caregivers

OBJECTIVES

Caregiving stress process models suggest that heterogeneous contexts differentially contribute to caregivers' experiences of role overload and gains. End-of-life (EOL) caregivers, especially EOL dementia caregivers, facing unique challenges and care tasks, may experience role overload and gains in different ways than other caregivers. This study evaluates measurement invariance of role overload and gains between EOL caregivers and non-EOL caregivers and between EOL dementia and EOL non-dementia caregivers.

METHODS

We utilized role gains and overload data from 1,859 family caregivers who participated in Round 7 of the National Study of Caregiving. We ran confirmatory factor analyses to investigate the factorial structure across all caregivers and then examined the structure's configural, metric, and scalar invariance between (a) EOL caregivers and non-EOL caregivers and (b) EOL dementia and EOL non-dementia caregivers.

RESULTS

Across the entire sample, the two-factor overload and gains model had good fit (χ 2(19) = 121.37, p < .0001; RMSEA = .053, 90% CI = [.044, .062]; CFI = .954; TLI = .932). Tests of invariance comparing EOL caregivers to non-EOL caregivers and EOL dementia caregivers to EOL non-dementia caregivers maintained configural, metric, and partial scalar invariance. Latent mean comparisons revealed that EOL caregivers had higher role overload (p = .0002), but no different role gains (p = .45), than non-EOL caregivers. Likewise, EOL dementia caregivers had higher role overload (p = .05), but no different role gains (p = .42), than EOL non-dementia caregivers.

DISCUSSION

Results offer both a deeper theoretical understanding of end-of-life dementia caregivers' experiences of role overload and gains, and a practical tool to measure those experiences.

Interrupting Biases in the Experience and Management of Pain Nurses can help address challenges faced by racially and ethnically diverse patients and caregivers

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. The articles in this new installment of the series provide practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses. Cite this article as: Booker, S.Q., et al. Interrupting Biases in the Experience and Management of Pain. Am J Nurs 2022; 122(9): 48-54.

Using a Multiple-Case Study Design to Explore the Worship Experiences of Black Families Affected by Dementia

OBJECTIVES

The purpose of this multiple-case study was to report on the worship experiences of Black families affected by dementia.

METHODS

Data were collected through participant observations of family caregivers (n = 4) and persons living with dementia (n = 4) during worship services and semi-structured interviews with the family caregivers over six months. Data were initially analyzed case-by-case, then across-cases.

RESULTS

Four overarching themes emerged: Welcoming church culture, Community support from the church, Engagement during worship service, and Connectedness between the caregiver and their family member living with dementia. Family caregivers reported that their family member with dementia was attentive and expressed moments of clarity during and immediately after worship services.

CONCLUSIONS

Worship services can be tailored to support families affected by dementia and can promote engagement of the person living with dementia with church activities and family members.

CLINICAL IMPLICATIONS

Health practitioners are encouraged to acknowledge the influence of religious practices within Black families affected by dementia and integrate them into interdisciplinary care plans and programs.

TELE-SAVVY@HOME: CONVERTING TO A COMPLETELY ASYNCHRONOUS DELIVERY APPROACH

It is well established that family caregiving is taxing and stressful. Group-based psychoeducational programs such as the Tele-Savvy program demonstrated that the acquisition of skills, knowledge, and caregiving mastery can ameliorate caregiving stress – and enhance PLWD quality of life. Many factors, however, preclude caregivers’ attendance in the synchronous portions of Tele-Savvy limiting the program’s scalability. To make Tele-Savvy more accessible and available to a growing number of dementia family caregivers, we designed a fully asynchronous version of the Tele-Savvy program, Tele-Savvy@Home. To accomplish this, we consulted facilitators and caregivers who participated in Tele-Savvy. We also reviewed the existing curriculum, re-wrote portions, reordered modules, and created new videos to cover synchronous content. In addition, we partnered with education design specialists to create interactive and reflection exercises to maintain a psychoeducation orientation and strengthen caregivers’ self-efficacy. This strategy may help investigators in their augmentation of the delivery strategies of established interventions.

Restoring trust in research among historically underrepresented communities: A call to action for antiracism research in nursing

BACKGROUND

Health disparities and inequities among historically underrepresented populations represent a public health crisis.

PURPOSE

This manuscript describes how use of an antiracism framework, an evidence-based approach to addressing systemic barriers, can assist with restoring trust in historically underrepresented communities that have experienced harm by researchers.

METHODS

We also discuss the necessity of inclusive research teams and provide exemplars of how antiracism research principles and inclusive research teams can be used to mitigate harm and restore trust in historically underrepresented communities.

DISCUSSION

Historical trauma and research misconduct have resulted in the mistrust of healthcare providers and health care systems among historically underrepresented individuals and communities.

CONCLUSION

Nurse scientists are positioned to appreciate historical inequities and trauma and to intervene by developing culturally relevant interventions. This work, however, will only happen if communities that have suffered harm trust nurse scientists.

Experiences of Black American Dementia Caregivers During the COVID-19 Pandemic

Dementia caregivers are responsible for the daily care and management of individuals who are among the most vulnerable to the serious consequences of COVID-19. This qualitative study explores the experience of Black dementia caregivers during the COVID-19 pandemic in the United States. Nineteen Black dementia caregivers were recruited to participate in semi-structured focus groups held in April 2021. Four overarching themes were constructed during analysis: social isolation, decreased well-being, the good and bad of telehealth, and challenges fulfilling health care needs. The results indicate the experience of Black dementia caregivers overlaps with existing literature on the experiences of dementia caregivers of other races during COVID-19. These results can assist in addressing the specific needs and improving the experiences of dementia caregivers in current and future public health crises.

Stressors and Acceptability of Services Among Black Caregivers of Persons With Memory Problems

The purpose of the current study was to identify stressors of Black family caregivers (FCGs) of persons with memory problems (PWMPs), services of interest, and barriers to use of these services. Black FCGs were recruited from the Alzheimer's family program at the University of Alabama at Birmingham and affiliated geriatric clinics, media sources, and word-of-mouth referrals. Of 38 Black FCGs interviewed, 26 (68%) were female, 18 (47%) were employed, and 21 (55%) were adult children. Average age of FCGs was 52.11 years. Mean scores for the AD8 Dementia Screening Scale (mean = 13.95, SD = 2.17) and Clinical Dementia Scale Sum of Boxes (mean = 7.29, SD = 0.87) were higher than clinical cutoffs. The most common stressors for Black FCGs were PWMPs' inability to remember who they were, managing care recipients' financial affairs, and managing PWMPs' comorbid conditions. FCGs were most interested in educational material regarding treatment and diagnosis (55.3%), caring for people with dementia (52.6%), understanding dementia (52.6%), and financial/legal services (52.6%). FCGs stated that transportation difficulties and the need for a relief person were barriers to use of services. Results suggest that Black FCGs may be more likely to participate in interventions that include virtual conferencing modalities. [Journal of Gerontological Nursing, 48(6), 13-18.].

Promoting Caregiver Mastery in Black American Dementia Caregivers

Over 6 million older Americans live with Alzheimer's disease and related dementias; Black American older adults' prevalence is more than twice that of non-Hispanic White older adults. The Black American dementia caregiving experience can be encapsulated within the Black Family Socioecological Context Model, which provides a conceptual basis for examining social determinants of health at individual, family, community, and societal levels with careful consideration for how the intersection of race, gender, and class of Black American dementia caregivers influences the multiple dimensions of their caregiving experiences. Family dynamics, community setting, and health care systems have a potentially bidirectional influence on these caregivers, which is shaped by historical and ongoing systemic and institutional racism and general disenfranchisement. This Forum article outlines how the Social Cognitive Theory offers ways for Black American dementia caregivers to achieve a sense of mastery within the complicated and fraught ecology within which their caregiving occurs. We propose a research agenda to create programs and interventions for enhancing a sense of mastery among Black American dementia caregivers. Two concepts in particular, "constraints" and "efficacy expectations," provide ways to create a systematic approach to developing successful coping strategies for the constraints perceived by individuals as they undertake and function in the caregiving role. The recognition of the complexity of the caregiving ecosystem and intersectionality of caregivers' experience and identity emphasize the importance of individualization: Each caregiver's experience of this ecosystem-and therefore each Black American dementia caregiver's way to mastery within it-will be uniquely shaped and experienced.

Association of Nursing Home Organizational Culture and Staff Perspectives With Variability in Advanced Dementia Care: The ADVANCE Study

IMPORTANCE

Regional, facility, and racial and ethnic variability in intensity of care provided to nursing home residents with advanced dementia is well documented but poorly understood.

OBJECTIVE

To assess the factors associated with facility and regional variation in the intensity of care for nursing home residents with advanced dementia.

DESIGN, SETTING, AND PARTICIPANTS

In the ADVANCE (Assessment of Disparities and Variation for Alzheimer Disease Nursing Home Care at End of Life) qualitative study, conducted from June 1, 2018, to July 31, 2021, nationwide 2016-2017 Medicare Minimum Data Set information identified 4 hospital referral regions (HRRs) with high (n = 2) and low (n = 2) intensity of care for patients with advanced dementia based on hospital transfer and tube-feeding rates. Within those HRRs, 14 facilities providing relatively high-intensity and low-intensity care were recruited. A total of 169 nursing home staff members were interviewed, including administrators, directors of nursing, nurses, certified nursing assistants, social workers, occupational therapists, speech-language pathologists, dieticians, medical clinicians, and chaplains.

MAIN OUTCOMES AND MEASURES

Data included 275 hours of observation, 169 staff interviews, and abstraction of public nursing home material (eg, websites). Framework analyses explored organizational factors and staff perceptions across HRRs and nursing homes in the following 4 domains: physical environment, care processes, decision-making processes, and implicit and explicit values.

RESULTS

Among 169 staff members interviewed, 153 (90.5%) were women, the mean (SD) age was 47.6 (4.7) years, and 54 (32.0%) were Black. Tube-feeding rates ranged from 0% in 5 low-intensity facilities to 44.3% in 1 high-intensity facility, and hospital transfer rates ranged from 0 transfers per resident-year in 2 low-intensity facilities to 1.6 transfers per resident-year in 1 high-intensity facility. The proportion of Black residents in facilities ranged from 2.9% in 1 low-intensity facility to 71.6% in 1 high-intensity facility, and the proportion of Medicaid recipients ranged from 45.3% in 1 low-intensity facility to 81.3% in 1 high-intensity facility. Factors distinguishing facilities providing the lowest-intensity care from those providing the highest-intensity care facilities included more pleasant physical environment (eg, good repair and nonmalodorous), standardized advance care planning, greater staff engagement in shared decision-making, and staff implicit values unfavorable to tube feeding. Many staff perceptions were ubiquitous (eg, adequate staffing needs), with no distinct pattern across nursing homes or HRRs. Staff in all nursing homes expressed assumptions that proxies for Black residents were reluctant to engage in advance care planning and favored more aggressive care. Except in nursing homes providing the lowest-intensity care, many staff believed that feeding tubes prolonged life and had other clinical benefits.

CONCLUSIONS AND RELEVANCE

This study found that variability in the care of patients with advanced dementia may be reduced by addressing modifiable nursing home factors, including enhancing support for low-resource facilities, standardizing advance care planning, and educating staff about evidence-based care and shared decision-making. Given pervasive staff biases toward proxies of Black residents, achieving health equity for nursing home residents with advanced dementia must be the goal behind all efforts aimed at reducing disparities in their care.

"Falling between the cracks": Experiences of Black dementia caregivers navigating U.S. health systems

In addition to numerous care responsibilities, family caregivers are expected to navigate health systems and engage in healthcare management tasks on behalf of their persons living with dementia (PLWD). These challenging tasks pose additional difficulties for Black dementia caregivers. Due to the centuries-old, disadvantaged social history of Black Americans, several unique stressors, vulnerabilities, and resources have emerged which inform and affect Black dementia caregivers' experiences and well-being. Focus groups were held with Black caregivers (N = 19) from the United States to explore the unique experiences and perspectives of this population navigating the U.S. health system on behalf of their PLWD. Five overarching themes were constructed during thematic analysis: Forced Advocacy, Poor Provider Interaction, Payor Source Dictates Care, Discrimination, and Broken Health System. Black dementia caregivers unanimously concurred that the health system that they experience in America is "broken." Gaps in the health system can lead to people [as one caregiver passionately expressed] "falling between the cracks," in terms of care, services, and resources needed. Caregivers agreed that class, sex, utilizing public health insurance, and being a "person of color" contribute to their difficulties navigating the health system. Caregivers perceived being dismissed by providers, forcing them to advocate for both themselves and their PLWD. Healthcare providers and researchers can utilize these findings to improve the experiences and healthcare outcomes of Black persons living with dementia and their caregivers. Additionally, these findings can lead to the development of culturally tailored caregiver education programs.

Using a Warm Hand-Off Approach to Enroll African American Caregivers in a Multi-Site Clinical Trial: The Handshake Protocol

"Testing Tele-Savvy" was a three-arm randomized controlled trial that recruited participants from four National Institute on Aging (NIA)-funded Alzheimer's Disease Centers with Emory University serving as the coordinating center. The enrollment process involved each center providing a list of eligible caregivers to the coordinating center to consent. Initially, the site proposed to recruit primarily African American caregivers generated a significant amount of referrals to the coordinating center, but a gap occurred in translating them into enrolled participants. To increase the enrollment rate, a "Handshake Protocol" was established, which included a warm handoff approach. During preset phone calls each week, the research site coordinator introduced potential participants to a culturally congruent co-investigator from the coordinating center who then completed the consent process. Within the first month of implementation, the team was 97% effective in meeting its goals. This protocol is an example of a successful, innovative approach to enrolling minority participants in multi-site clinical trials.

The Alter Program: A Nurse-Led, Dementia-Friendly Program for African American Faith Communities and Families Living With Dementia

Dementia is a stigmatizing condition requiring enhanced awareness and understanding. Churches are a trusted source of support for African Americans, a demographic disproportionately affected by dementia. However, many African American churches are not equipped with the knowledge and means to provide safe environments, resources, and spiritual and social support for their parishioners living with dementia and their families. This protocol is written to detail the design and implementation of a nurse-led, dementia-friendly congregation program, Alter. The Alter program was developed to increase dementia awareness, develop a supportive, faith-based dementia-friendly infrastructure, and create a community supporting the well-being of African Americans living with dementia and their families. Engagement in this program aims to improve brain health status of older adults, improve physical and mental health outcomes, reduce dementia stigma, and enhance personal agency. Improved outcomes for persons living with dementia translate into lower use of acute and emergency services due to more stability in community care. It is expected that the churches participating in this program will be recognized by their community as a great resource for dementia information and support. The long-term goal of the Alter program is to be widely adapted in various health systems to reduce health disparities associated with dementia in the African American community.

Falling Between the Cracks: Experiences of Black Dementia Caregivers Navigating U.S. Health Systems

In addition to numerous care responsibilities, family caregivers are expected to navigate health systems and engage in healthcare management tasks on behalf of their persons living with dementia (PLWD). These challenging tasks pose additional difficulties for Black dementia caregivers. Due to the centuries-old, disadvantaged social history of Black Americans, several unique stressors, vulnerabilities, and resources have emerged which inform and affect Black dementia caregivers’ experiences and well-being. Focus groups were held with Black caregivers (N = 19) from the United States (U.S.) to explore the unique experiences and perspectives of this population navigating the U.S. health system on behalf of their PLWD. Five overarching themes were developed during thematic analysis: Forced Advocacy, Poor Provider Interaction, Payor Source Dictates Care, Discrimination, and Broken Health System. Black dementia caregivers unanimously concurred that the health system that they experience in America is “broken.” Gaps in the health system can lead to people [as one caregiver passionately expressed] “falling between the cracks,” in terms of care, services, and resources needed. Caregivers agreed that class, sex, utilizing public health insurance, and being a “person of color” contribute to their difficulties navigating the health system. Caregivers perceived being dismissed by providers, forcing them to advocate for both themselves and their PLWD. Healthcare providers and researchers can utilize these findings to improve the experiences and healthcare outcomes of Black patients with dementia and their caregivers. Additionally, these findings can lead to the development of culturally tailored caregiver education programs.

Gender-specific predictors of poor sleep quality and insomnia among caregivers of persons living with dementia

Caregiving for a person living with dementia (PLwD) may influence sleep patterns. Gaps exists about whether caregiver and PLwD factors impact sleep differentially based on caregivers’ gender. The aim of this secondary data analysis was to identify predictors of sleep quality and insomnia in a sample of caregivers, stratified by gender, participating in a randomized controlled trial of a psychoeducational intervention. Outcome measures were sleep quality (Pittsburgh Sleep Quality Index, PSQI) and insomnia (Insomnia Severity Index, ISI). Participants (n=261) also completed measures about caregivers’ perceived stress, burden, depression, and self-care, and PLwD’s behaviors (i.e., apathy, sleep disorders). Linear regression modeling was used to identify the overall predictors of poor sleep quality (PSQI > 5; 52% of the sample) and insomnia (ISI > 7; 41% of the sample). Caregivers were primarily female (70.5%), White (73.6%), mean age of 64.6 (±11.2) years, and typically caring for a spouse (65.9%). For male caregivers, predictors of poor sleep quality were assisting the PLwD with instrumental activities of daily living and PLwD neuropsychiatric symptoms (F=4.45, p<.001); while caregiver self-care and PLwD neuropsychiatric symptoms predicted insomnia (F=4.49, p<.001). For female caregivers, the predictors of poor sleep quality were caregiver depressive symptoms and burden, and frequency of PLwD behavioral problems (F=4.46, p<.001); however, only perceived stress predicted insomnia (F=4.32, p<.001). Various factors related to caregiving appear to be more important than others in predicting sleep outcomes of male/female caregivers. Health care professionals should acknowledge gender differences when designing and implementing programs and interventions to improve sleep.

Worship Experiences of Black Families at Dementia-Friendly Churches: A Multiple-Case Study Design

It has been proposed that switching cost deficit in executive control (Velichkovsky et al., 2020) could be used as an early marker for abnormal aging processes. Although research with technology-based intervention has shown benefits in improving cognitive performance with older adults, the overall results are mixed (Ge et al, 2018). This study aims to investigate whether computerized intervention program (e.g., DISC) would help to reduce the switching costs deficits in mild-to-moderate cognitively-impaired older adults (MCI-OA). Fourteen MCI-OA (79.75±6,94) and 9 cognitively-healthy OA (age 77,25±6,9) were randomly assigned to an experimental group or a control group (a final sample size of 30 MCI and 40 cognitive-healthy older adults would be ready by conference time). All participants first completed a set of cognitive tasks as part of a larger study (i.e., pre-tests) (e.g., MMSE, Ravens, cued-base Task Switching Task). The experimental group then played cognitive games on a touch-screen tablet for about 30-40 minutes per session with a total of 24 sessions over 8-12 weeks. The control group continued their daily activity as per usual for 8-12 weeks. Participants were then asked to complete the same set of cognitive tasks again post-test. Control group MCI-OA performed worse for the local costs in the cued Task Switching task (p<.05), whereas experimental group MCI-OA maintained their performance (p=.40) post-test compared to pre-test. All cognitively-healthy OA did not show any difference in performance irrespective of condition. This suggests that the DISC program could be an effective tool in slowing down the abnormal accelerated aging process.

Learning Needs of Dementia Family Caregivers during the Pandemic

The COVID-19 pandemic has dominated and transformed all caregiving contexts and situations. In a time of COVID-19, caregivers now have to learn how to take all of the complicated precautions to keep themselves and their persons from being exposed to the virus given their population’s mortality rate from COVID-19 infections exceed 40%. As part of a larger initiative to develop an asynchronous online education program for family caregivers of persons living with dementia illnesses (PLWD) to prepare them to master the new demands of their caregiving role in this extraordinary circumstance of the COVID-19 pandemic, we conducted three focus groups with 13 dementia family caregivers to inform the structure, content, and “feel” of the course. Focus groups were conducted with a lead interviewer, via Zoom, audio and video recorded and transcribed for analysis. Participants were asked two groups of questions: their lived experience over the past year and course content for caregiving during crisis. Caregivers identified 4 themes regarding their lived experience of caregiving during the pandemic: (a) mixed feeling about the stay-at-home orders; (b) positive adaptation to telemedicine, (c) vaccine risks and benefits; and (d) impact of social isolation on the PLWD. The groups also recommended specific course content based on their experiences. Participants recommended specific course content based on their experiences, such as health system navigation and the logistics of what to do following the death of a PLWD. Results from these groups have been incorporated into an asynchronous online course to be pilot tested in coming months.

Experiences of African American Dementia Caregivers During the COVID-19 Pandemic

African American caregivers are often confronted with the complexities of caregiving through the lens of race and associated health disparities. The COVID-19 pandemic has both exacerbated the systemic disparities and deeply rooted inequities experienced by African Americans and laid bare their effects on the community of caregivers. The purpose of this project was to explore the experiences of African American dementia caregivers during the COVID-19 pandemic. Nineteen African American caregivers of persons living with dementia were recruited by primary investigators and community partners with purposeful sampling techniques to participate in semi-structured focus groups that were held April 2021. Four overarching themes were constructed during thematic analysis: social isolation, decreased well-being, the good and bad of telehealth, and challenges in fulfilling the caregiver role. Caregivers expressed that they became socially isolated from family and friends, which led to them becoming depressed and mentally strained. Several caregivers felt they could not carry out their caregiver duties due to the constraints surrounding the pandemic. The varying levels of interaction with and the comfort level of physicians utilizing telehealth led to caregivers having mixed reviews on the popularized service. The results of this study will be used to culturally adapt caregiving education courses and programs promoting mastery and competency during a pandemic. In preparations for future public health crises, healthcare professionals will be able to use the results of this study to address the specific needs and improve the experiences of African American dementia caregivers.

Mastery Goals for Black American Dementia Caregivers

About 5.8 million older American adults live with Alzheimer’s disease and related dementias; Black American older adults’ prevalence is more than twice that of non-Hispanic white older adults. The Black American dementia caregiving experience can be pictured within the Black Family Social-Ecological Context Model, which provides a conceptual basis for examining social determinants of health at individual, family, community, and societal levels with careful consideration for how the intersecting identities of race, gender, and class of Black American caregivers influence the multiple dimensions of their caregiving experiences. Family dynamics, community setting, and healthcare systems have a potentially bidirectional influence on these caregivers, which is informed by the larger historical reality of systemic racism and general disenfranchisement. This paper outlines how Stress Process and Perceived Control frameworks offer ways for Black American dementia caregivers to achieve a sense of mastery within the complicated and fraught ecology within which their caregiving occurs. We propose a research and development agenda to create a program for enhancing a sense of mastery among Black American dementia caregivers. Two concepts in particular, “constraints” and “efficacy expectations,” provide ways to develop a systematic approach to developing successful coping strategies for the constraints perceived by individuals as they undertake and function in the caregiving role. The recognition of the complexity of the caregiving ecosystem and intersectionality of caregivers’ experience emphasize the importance of individualization: each caregiver’s experience of this ecosystem– and therefore each Black American caregiver’s way to mastery within it– will be uniquely shaped and experienced.

Either Sent by God or Used by God: Impact of COVID-19 on the Religious Lives of Black Families With Dementia

The COVID-19 pandemic has underscored systemic disparities and laid its effects on the Black community. Often overlooked is how health disparities heighten stress and affect the emotional well-being of Black American caregivers. The purpose of this study is to explore the impact of COVID-19 on church engagement for Black families affected by dementia. A qualitative design was employed to collect data from current caregivers, faith/church leaders, and persons with cognitive impairment. Participants (n = 17) were predominantly female, all identified as Black. During semi-structured interviews, participants were asked how COVID-19 has impacted their participation in faith practices. The following themes emerged: (a) ability to continue faith practices, (b) increased church engagement, (c) new normal, (d) importance of fellowship, and (e) role of technology. Participants believed COVID-19 did not impact their faith practice partly due to the ability to continue with faith traditions in a virtual format. Online worship services enabled more families affected by dementia to participate. Many church leaders expressed the intent of continuing to provide online worship services post-pandemic. Families highlighted their need to have fellowship with other parishioners. Technology was perceived as a double-edged sword that serves as both a motivator and a barrier to religious engagement. These findings will support faith leaders and churches in understanding the needs of their congregation during the COVID-19 pandemic, specifically, it will allow families living with dementia to continue engaging in religious activity and living in meaningful ways.

Learning Needs of Dementia Family Caregivers during the Pandemic

The COVID-19 pandemic has dominated and transformed all caregiving contexts and situations. In a time of COVID-19, caregivers now have to learn how to take all of the complicated precautions to keep themselves and their persons from being exposed to the virus given their population’s mortality rate from COVID-19 infections exceed 40%. As part of a larger initiative to develop an asynchronous online education program for family caregivers of persons living with dementia illnesses (PLWD) to prepare them to master the new demands of their caregiving role in this extraordinary circumstance of the COVID-19 pandemic, we conducted three focus groups with 13 dementia family caregivers to inform the structure, content, and “feel” of the course. Focus groups were conducted with a lead interviewer, via Zoom, audio and video recorded and transcribed for analysis. Participants were asked two groups of questions: their lived experience over the past year and course content for caregiving during crisis. Caregivers identified 4 themes regarding their lived experience of caregiving during the pandemic: (a) mixed feeling about the stay-at-home orders; (b) positive adaptation to telemedicine, (c) vaccine risks and benefits; and (d) impact of social isolation on the PLWD. The groups also recommended specific course content based on their experiences. Participants recommended specific course content based on their experiences, such as health system navigation and the logistics of what to do following the death of a PLWD. Results from these groups have been incorporated into an asynchronous online course to be pilot tested in coming months.

Sleep Phenotypes of Caregivers for Persons Living With Dementia

Sleep disturbance is prevalent among caregivers of people living with dementia. Gaps exist regarding when caregivers begin to experience sleep disturbance along their caregiving trajectory. This study aimed to identify and describe phenotypes of current caregivers’ sleep patterns before and during caregiving and describe caregivers’ perception of their current sleep quality relative to their pre-caregiving sleep. We conducted semi-structured interviews with 19 caregivers participating in a larger, randomized controlled trial. Interviews were about caregivers’ sleep patterns and were conducted after caregivers completed the first 6 months of the study. Interviews were audio-recorded using a videoconferencing platform and ranged from 20 to 45 minutes. We conducted thematic analysis of the interview transcripts. Four distinct caregiver-sleep phenotypes emerged from the qualitative data: Changed and Dissatisfied, Changed and Satisfied, Unchanged and Dissatisfied, and Unchanged and Satisfied. Caregivers whose sleep was categorized as Changed experienced a difference in their pre-caregiving sleep, usually from good to poor sleep. Caregivers whose sleep was Unchanged had poor sleep pre-caregiving and continued to have poor sleep during caregiving. Caregivers also reported being Satisfied or Dissatisfied with their current sleep pattern, defined in terms of daily distress and impairment. These 4 subtypes highlight the heterogeneity of caregivers’ sleep experiences and debut a useful clinical framework with which to identify, categorize, and target caregivers at risk for sleep disturbance. Identifying caregivers’ sleep phenotypes will enable healthcare providers to determine caregivers’ needs and readiness for interventions.

Using Advisory Boards to Develop a Faith-Based Toolbox to Support African American Families Facing Dementia

For this project, we are designing and testing the feasibility of employing components of a Faith-based Home Activity Toolbox (Faith-HAT). The goal of this NIH stage 1 intervention development project is to go beyond the four walls of the church to find ways to meet the spiritual needs of persons living with moderate and severe dementia “where they are” to help them remain religiously and spiritually engaged. This mixed-methods project is designed in 2 phases: (a) developing a prototype Faith-HAT and (b) testing the feasibility and exploring preliminary effectiveness. To successfully conduct this project, we have included a community advisory board of church leaders, caregivers, and persons living with dementia as members of the research design team to advise on the design and implementation of the Faith-HAT. Brainstorming workshops with the board are used to ensure the research is meeting the needs of the African American families affected by dementia.

Trust of Nursing Home Staff Caring for Residents with Advanced Dementia: A Qualitative Descriptive Study of Family Caregivers' Perspectives

BACKGROUND/OBJECTIVES

Studies of interpersonal trust within nursing homes (NHs) is limited. This study aimed to describe the perspectives of interpersonal trust in NH staff among family caregivers of residents with advanced dementia. Additionally, comparisons of Black and White caregivers' perspectives were also explored.

DESIGN

We used data generated from a parent study, Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life (ADVANCE) to examine the experience of trust from the family caregivers' perspectives.

PARTICIPANTS

Data generated from interviews with 44 family caregivers of residents with advanced dementia (Black n = 19 and White n = 25) were analyzed using thematic analysis.

RESULTS/CONCLUSIONS

While both Black and White family caregivers experienced trust and mistrust, Black caregivers more often experienced differential mistrust. As differential mistrust is a new concept relative to trust, additional research is required to elucidate its meaning.

DESIGN

We used data generated from a parent study, Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life (ADVANCE) to examine the experience of trust from the family caregivers' perspectives.

PARTICIPANTS

Data generated from interviews with 44 family caregivers of residents with advanced dementia (Black n = 19 and White n = 25) were analyzed using thematic analysis.

RESULTS/CONCLUSIONS

While both Black and White family caregivers experienced trust and mistrust, Black caregivers more often experienced differential mistrust, trust for certain staff members and mistrust of others. As differential mistrust is a new concept relative to trust, additional research is required to elucidate its meaning.

Perceptions and Attitudes Toward Dementia in Predominantly African American Congregants

The purpose of this study was to identify the perceptions and attitudes of African American congregants toward dementia before and after attending a dementia-focused workshop. Six churches in Metropolitan Atlanta, Georgia, hosted the workshops. Attendees (N = 171) participated in a free association exercise to evaluate their perceptions and attitudes toward dementia. Before and after the workshop, participants wrote words and phrases that occurred to them when they thought of dementia. Content analysis was used to identify themes. Before the workshop, participants' responses tended to include negative language (e.g., fear, memory loss, sadness). After the workshop, participants expressed more positive words (e.g., support, hopefulness, caring). These findings suggest that education can change congregants' perceptions about dementia and potentially reduce dementia-associated stigma. This change will allow families to feel comfortable both interacting with and seeking help from those in their faith communities.

"Everything is Either Sent by God or Used by God": An Exploratory Study on the Impact of COVID-19 Upon the Religious Lives of Black Families Living with Dementia

The purpose of this research study was to explore the impact of COVID-19 on church engagement for Black families affected by dementia in the USA. Semi-structured interviews were conducted with current caregivers, church leaders, and persons with dementia (n = 16). The following themes emerged: (a) Ability to continue religious practices, (b) Increased church engagement, (c) Importance of fellowship, (d) Role of technology, and (e) New normal. As the Internet becomes the new church building, online worship services enabled more families affected by dementia to engage. Many church leaders expressed the intent of continuing to provide online worship services post-pandemic. Families highlighted their need to fellowship with other congregants. Technology was perceived as a double-edged sword serving as both a motivator and a barrier to religious engagement. These findings will support faith leaders in understanding the needs of their congregants during the COVID-19 pandemic, such as allowing families living with dementia to continue engaging in religious practices and living in meaningful ways.

A Framework for Mobilizing Health Care to Respond to the Community Within the COVID-19 Pandemic

Cultural mistrust of government with regard to health issues has pressed the need to engage trusted community leaders with influence and reach in disproportionately affected communities to ensure that essential public health activities related to COVID-19 occur among populations experiencing disproportionate impact from the pandemic. In April of 2020, a Georgia-based integrated academic health care system created a Community Outreach and Health Disparities Collaborative to unite trusted community leaders from faith-based, civic, and health-sector organizations to work with the health system and Emory University to develop tailored approaches and mobilize support within the context of the communities' cultural and individual needs to reduce the burden of COVID-19. We describe the framework used to join health care and academic collaborators with community partners to mobilize efforts to address the disproportionate impact of COVID-19 on racial, ethnic, and socioeconomic minority groups. The framework outlines a series of steps taken that led to a community-driven collaboration designed to engage local influential community leaders as partners in improving access to care for disproportionately affected communities, collaborations that could be replicated by other large health care systems. This framework can also be applied to other chronic diseases or future public health emergencies to improve communication, education, and health care access for communities experiencing disproportionate impact.

Results of a Randomized Trial Testing the Efficacy of Tele-Savvy, an Online Synchronous/Asynchronous Psychoeducation Program for Family Caregivers of Persons Living with Dementia

BACKGROUND AND OBJECTIVES

Family caregivers will grow in number as dementia prevalence increases, underscoring the continued importance of equipping these individuals for their new roles and ameliorating the adverse effects of caregiving.

RESEARCH DESIGN AND METHODS

A three-armed, waitlist, randomized trial design tested Tele-Savvy, an online adaptation of a successful in-person psychoeducation program, the Savvy Caregiver. Tele-Savvy is delivered over 43 days to groups of 6-8 caregivers in 7 weekly synchronous sessions accompanied by 36 brief asynchronous video lessons. We enrolled 23 cohorts of 15 eligible caregivers (N = 261), randomized 2:2:1 to active, attention control, and usual care arms. We assessed caregiver psychological well-being and caregiving mastery at baseline and 3, 6, 9, and 12 months. Multilevel linear models assessed outcomes over the 3 time points examined. The trial was slightly truncated, with Data and Safety Monitoring Board approval, because of the apparent confounding psychological effects of coronavirus disease 2019 restrictions.

RESULTS

Study findings indicate statistically and clinically significant benefits to Tele-Savvy arm caregivers (with moderate to large effect sizes) in the areas of depression, perceived stress, reaction to care recipients' behaviors, and enhancement of caregiver mastery. Expected benefits for caregiver burden and anxiety were not found.

DISCUSSION AND IMPLICATIONS

Findings attest to program efficacy and the viability of employing distance means to improve family caregivers' emotional well-being and sense of mastery in the caregiving role over a 6-month period. Next steps entail finding alternate ways to deliver the program to those with connectivity and/or time constraint problems.

Wireless, continuous monitoring of daily stress and management practice via soft bioelectronics

Stress has become a significant factor, directly affecting human health. Due to the numerous sources of stress that are inevitable in daily life, effective management of stress is essential to maintain a healthy life. Recent advancements in wearable devices allow monitoring stress levels via the detection of galvanic skin response on the skin. Some of these devices show the capability of assessing stress relief methods. However, prior works have been limited in a controlled laboratory setting with a short period assessment (<1 h) of stress intervention. The existing systems' main issues include motion artifacts and discomfort caused by rigid and bulky electronics and mandatory device connection on active fingers. Here, we introduce soft, wireless, skin-like electronics (SKINTRONICS) that offers continuous, portable daily stress and management practice monitoring. The ultrathin, lightweight, all-in-one device captures the change of a subject's stress over six continuous hours during everyday activities, including desk work, cleaning, and resting. At the same time, the SKINTRONICS proves that typical stress alleviation methods (mindfulness and meditation) can reduce stress levels, even in the middle of the day, which is supported by statistical analysis. The low-profile, wireless, gel-free device shows enhanced breathability and minimized motion artifacts compared to a commercial stress monitor. Collectively, this study shows the first demonstration of soft, nanomembrane bioelectronics for long-term, continuous assessment of stress and intervention effectiveness throughout daily life.

Interest in Supportive Services Among Black Working and Non-Working Caregivers in the Deep South

The current investigation provides information on supportive services caregivers said they would be interested in if they were made available. Participants were recruited from the Birmingham, AL metro area and received a $25 gift card for completing a telephone interview. Of the 38 caregivers enrolled, 18 (47.37%) reported being currently employed and working an average of 33.92 hours per week (range = 5 – 60). Participants were caring for individuals with average scores on the AD8 Dementia Screening Scale of 7.3 and 10.4 on the Clinical Dementia Scale Sum of Boxes (above the cutoffs for probable dementia). Thirty-three caregivers (87%) reported being interested in at least one of the services listed with differences observed for services that would be preferred by working vs. non-working caregivers. These data will be utilized to provide initial support for a multicomponent intervention that may be effective in reducing negative outcomes within Black caregivers.

Content Analysis of Church Leaders’ Perceptions and Attitudes Toward Dementia

Individuals with dementia face many challenges, including the reactions others have to their diagnoses and associated symptoms. Those affected by dementia often seek support from their faith communities and find many of their faith leaders are unable to respond to their needs due to a lack of awareness. In an effort to transform the perception of dementia within the faith community, dementia educational workshops for church leaders were held at three African American churches in Metropolitan Atlanta. As part of the dementia workshop education, an exercise was used to assess attendees’ perceptions and attitudes toward dementia pre and post workshop. One hundred and eight participants took part in this exercise. At the beginning and end of the workshop, participants were asked to write a word or short phrase that came to mind when they thought of dementia. Qualitative content analysis was conducted and 15 codes were extracted and categorized into 3 groups: positive (e.g., supportive); negative (e.g., horrified); and neutral (e.g., information-seeking). Before the workshop, participant responses trended towards negative responses (e.g., fear, loss, damn). After the workshop, participants expressed in writing more neutral and positive phrases and words (e.g., support, hopefulness, caring). The findings indicate that with training, church leaders can change their perceptions and attitudes toward dementia to a more accepting and positive stance. Ultimately, continued education in the faith communities may allow for families affected by dementia to feel comfortable seeking help from their church, a very important resource in their community.

Partnering With African American Churches to Support Families Affected by Dementia Through Research

African Americans (AA) are disproportionately impacted by dementia when compared to the non-Hispanic white population, yet are significantly underrepresented in research. Often times, families in the AA community turn to their church for help when in distress. Recognizing that churches are frequently the cornerstone of AA communities, they are an ideal setting for health promotion, research, and education. However, many AA churches do not have the resources to support their congregants affected by dementia. To build capacity within churches to address brain health promotion and facilitate research access/participation, we partnered with 6 predominantly AA churches in the metropolitan Atlanta area to facilitate research and develop dementia-related programs. While stakeholders were initially reluctant, continual engagement with senior faith leaders helped to facilitate the successful development of a research registry of congregants interested in participating in faith-based and clinical research and establishment of new programs to congregants around brain health and dementia.

Screening for Cognitive Impairment in African American Congregations

Having access to memory screenings is pivotal to early detection in the African American (AA) community. The purpose of this report is to describe the willingness and perceived barriers of AA congregants to participate in memory screenings. Out of 283 attendees to dementia-related church forums, 26% (n = 73) of the attendees participated in private memory screenings. The majority of the participants were female (88%, n = 64). Under half of the participants (37%, n = 27) scored below normal with 81% (n =22) being female. Several attendees declined the opportunity to have their memory screened for various reasons. These results support how women are disproportionately affected by cognitive impairment. Another alarming point was the low participation in memory screenings of event attendees. This report is important because it raises awareness of the need within the AA community, who are at a higher risk for memory loss, to receive screening. Part of a symposium sponsored by the Alzheimer’s Disease Research Interest Group.