Shared Activities as a Protective Factor Against Behavioral and Psychological Symptoms of Dementia and Caregiver Stress

Background and Objectives

Most persons with dementia experience behavioral and psychological symptoms (BPSD). While there is evidence that structured activity programs can be beneficial for persons with dementia and their caregivers, it is not well understood how joint engagement in shared activities affects BPSD and caregiver stress. The purpose of this study was to examine the moderating effect of doing a shared activity on the BPSD and caregiver stress.

Research Design and Methods

This study used an intensive longitudinal observational design in which caregivers completed baseline and once-a-day diary surveys for 21 days. Caregivers were asked whether they did a pleasant noncare activity with their relative, the presence of 8 BPSD, and their stress level. A moderation model in a structural equation model examined the relationship between these variables.

Results

Our sample consisted of 453 caregivers (87.4% female, 51.4% non-Hispanic White, mean age 53 years [standard deviation {SD}: 14]) and person living with dementia whose mean age was 79 years (SD: 9). On days when the caregivers engaged in a shared activity together with person living with dementia, there was a significant decrease in the BPSD (estimate -0.038, standard error [SE] = 0.016, 95% confidence interval [CI]: -0.069, -0.007, p value = 0.018). The effects of engaging in a shared activity decreased the impact of caregiver stress by 0.052 (estimate -0.052, SE = 0.018, 95% CI: -0.087, -0.017, p value = 0.004). At the between-person level, no differences were found in BPSD across caregivers who engaged or did not engage in shared activities.

Discussion and Implications

The results of our study indicate that doing a shared activity is associated with reduced BPSD among persons with dementia and may buffer the impact of caregiver stress on BPSD. Shared activities should be considered a key intervention component for dementia caregivers.

Caregiver Experiences Participating in a Home-Based Primary Care Program: A Pragmatic Evaluation Including Qualitative Interviews and Quantitative Surveys

The aim of this evaluation was to assess caregiver experience and burden during their first year in a geriatric home-based primary care (HBPC) program with qualitative interviews and surveys. HBPC included in-home visits for homebound, older adult patients. Seventeen caregivers, with varied amount of experience with HBPC, participated in semi-structured interviews. Change in caregiver burden from baseline was captured for 44 caregivers at 3 months post-enrollment, 27 caregivers at 6 months, and 22 caregivers at 12 months. Satisfaction survey was administered at these timepoints, but the last response of 48 caregivers was analyzed. Caregiver interviews revealed three themes: caregiving stressors, reliance on HBPC in relation to other medical care, and healthcare in the home. Surveyed caregivers were highly satisfied, but burden did not change substantially over the 1 year intervention. Caregivers appreciated HBPC reduced patient transportation and provided satisfactory primary care, but additional research is needed to tailor this care to reduce caregiver burden.

Using Digital phenotyping to understand health-related outcomes: A scoping review

BACKGROUND

Digital phenotyping may detect changes in health outcomes and potentially lead to proactive measures to mitigate health declines and avoid major medical events. While health-related outcomes have traditionally been acquired through self-report measures, those approaches have numerous limitations, such as recall bias, and social desirability bias. Digital phenotyping may offer a potential solution to these limitations.

OBJECTIVES

The purpose of this scoping review was to identify and summarize how passive smartphone data are processed and evaluated analytically, including the relationship between these data and health-related outcomes.

METHODS

A search of PubMed, Scopus, Compendex, and HTA databases was conducted for all articles in April 2021 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Review (PRISMA-ScR) guidelines.

RESULTS

A total of 40 articles were included and went through an analysis based on data collection approaches, feature extraction, data analytics, behavioral markers, and health-related outcomes. This review demonstrated a layer of features derived from raw sensor data that can then be integrated to estimate and predict behaviors, emotions, and health-related outcomes. Most studies collected data from a combination of sensors. GPS was the most used digital phenotyping data. Feature types included physical activity, location, mobility, social activity, sleep, and in-phone activity. Studies involved a broad range of the features used: data preprocessing, analysis approaches, analytic techniques, and algorithms tested. 55% of the studies (n = 22) focused on mental health-related outcomes.

CONCLUSION

This scoping review catalogued in detail the research to date regarding the approaches to using passive smartphone sensor data to derive behavioral markers to correlate with or predict health-related outcomes. Findings will serve as a central resource for researchers to survey the field of research designs and approaches performed to date and move this emerging domain of research forward towards ultimately providing clinical utility in patient care.

"It Isn't the Same": Experiences of Informal Caregivers of Older Adults Enrolled in a Home-Based Senior Care Program During COVID-19

The coronavirus disease 2019 (COVID-19) pandemic placed new strains on informal caregivers, who are already vulnerable to negative psychosocial effects due to demands of the caregiving role. The current study aimed to explore the early impact of COVID-19 on caregivers living with and apart from care recipients. Semi-structured qualitative interviews with seven cohabitating and 10 distanced caregivers of patients in a home-based primary care program were conducted from April to November 2020. A framework matrix was used to identify patterns in caregiver experiences. Cohabitating and distanced caregivers reported shared concerns about COVID-19 and unique concerns dependent on cohabitation status. Cohabitating caregivers reported financial worries, care recipients with dementia being unable to understand restrictions, and concerns about community business changes. Distanced caregivers reported communication challenges with cognitively impaired care recipients and challenges with visitation policies. During pandemics, caregivers' clinical and policy support needs may differ depending on their place of residence relative to care recipients. [Journal of Gerontological Nursing, 49(3), 19-26.].

Home-Based Primary Care for Older Adults: Matched Case-Control Evaluation of Program’s Impact on Healthcare Utilization

Home-based Primary Care (HBPC) is an alternative model for homebound older adults. Healthcare utilization in HBPC was evaluated with a matched case-control design. Medical providers and social workers provided in-home visits. Enrolled patients were matched to controls on age, prior hospitalizations, and frailty risk. Difference-in-differences in utilization of primary care, specialty, and hospital services between 1-year pre- and 1-year post-enrollment were evaluated with hierarchical linear models. Analyses included 117 HBPC cases and 328 controls. HBPC cases had a significant increase in primary care visits compared to controls (7.8 ± 0.6; p < .0001) but significantly decreased utilization of in-clinic primary care visits (−3.2 ± 0.6; p < .0001). In-clinic specialty visits and hospital services did not differ between cases and controls (all p’s ≥ .75). Homebound patients accessed high-touch primary and social care, which is typically unachievable in clinic settings; however, additional work is needed to optimize services and target in-home care to impact healthcare utilization.

Patient Characteristics Associated With Occurrence of Preoperative Goals-of-Care Conversations

Importance

Communication about patients' goals and planned and potential treatment is central to advance care planning. Undertaking or confirming advance care plans is also essential to preoperative preparation, particularly among patients who are frail or will undergo high-risk surgery.

Objective

To evaluate the association between patient risk of hospitalization or death and goals-of-care conversations documented with a completed Life-Sustaining Treatment (LST) Decisions Initiative note among veterans undergoing surgery.

Design, Setting, and Participants

This retrospective cross-sectional study included 190 040 veterans who underwent operations between January 1, 2017, and February 28, 2020. Statistical analysis took place from November 1, 2021, to November 17, 2022.

Exposure

Patient risk of hospitalization or death, evaluated with a Care Assessment Need (CAN) score (range, 0-99, with a higher score representing a greater risk of hospitalization or death), dichotomized as less than 80 or 80 or more.

Main Outcomes and Measures

Preoperative LST note completion (30 days before or on the day of surgery) or no LST note completion within the 30-day preoperative period prior to or on the day of the index operation.

Results

Of 190 040 veterans (90.8% men; mean [SD] age, 65.2 [11.9] years), 3.8% completed an LST note before surgery, and 96.2% did not complete an LST note. In the groups with and without LST note completion before surgery, most were aged between 65 and 84 years (62.1% vs 56.7%), male (94.3% vs 90.7%), and White (82.2% vs 78.3%). Compared with patients who completed an LST note before surgery, patients who did not complete an LST note before surgery tended to be female (9.3% vs 5.7%), Black (19.2% vs 15.7%), married (50.2% vs 46.5%), and in better health (Charlson Comorbidity Index score of 0, 25.9% vs 15.2%); to have a lower risk of hospitalization or death (CAN score <80, 98.3% vs 96.9%); or to undergo neurosurgical (9.8% vs 6.2%) or urologic surgical procedures (5.9% vs 2.0%). Over the 3-year interval, unadjusted rates of LST note completion before surgery increased from 0.1% to 9.6%. Covariate-adjusted estimates of LST note completion indicated that veterans at a relatively elevated risk of hospitalization or death (CAN score ≥80) had higher odds of completing an LST note before surgery (odds ratio [OR], 1.29; 95% CI, 1.09-1.53) compared with those with CAN scores less than 80. High-risk surgery was not associated with increased LST note completion before surgery (OR, 0.93; 95% CI, 0.86-1.01). Veterans who underwent cardiothoracic surgery had the highest likelihood of LST note completion before surgery (OR, 1.35; 95% CI, 1.24-1.47).

Conclusions and Relevance

Despite increasing LST note implementation, a minority of veterans completed an LST note preoperatively. Although doing so was more common among veterans with an elevated risk compared with those at lower risk, improving proactive communication and documentation of goals, particularly among higher-risk veterans, is needed. Doing so may promote goal-concordant surgical care and outcomes.

PROGRESSIVELY LOWERED STRESS THRESHOLD FOR BEHAVIORAL SYMPTOMS OF DEMENTIA: A DYNAMIC STRUCTURAL EQUATION MODEL

The progressively lowered stress threshold model suggests that due to impairments in coping, persons living with dementia have a reduced threshold for stress and respond with more behavioral symptoms of dementia as stress accumulates throughout the day. While the propositions of the model have not been evaluated, this model serves as the basis of non-pharmacological interventions for behavioral symptom management aimed at modifying the environment to reduce stressors. These interventions have mixed success, which may be due to traditional longitudinal measurement models that don’t account for the dynamic temporal nature of behavioral symptoms. This paper evaluates the progressively lowered stress threshold conceptual model as an explanation for behavioral symptoms of dementia and tests several of its hypothesized propositions using an intensive longitudinal design. A sample of N=165 family caregivers completed brief daily diary surveys for 21 days (n=2841) reporting on behavioral symptoms of their care recipients. Dynamic structural equation modeling was used as the analytic technique to examine the impact of caregiver and care recipient environmental stressors on the diversity of behavioral symptoms of dementia (number of different symptoms) to account for the nested data structure and autoregressive relationships. Results show direct relationships between environmental stressors and diversity of behavioral symptoms of dementia that same day and the following day. Findings provide support for the progressively lowered stress threshold model. Further, findings suggest an extension to the conceptual model is warranted given evidence of an exposure/recovery trajectory and the lagged effects of stress exposure on behavioral symptoms of dementia presentation.

Using Family Narrative Reports to Identify Practices for Improving End-of-Life Care Quality

CONTEXT

Patient experiences should be considered by healthcare systems when implementing care practices to improve quality of end-of-life care. Families and caregivers of recent in-patient decedents may be best positioned to recommend practices for quality improvement.

OBJECTIVES

To identify actionable practices that bereaved families highlight as contributing to high quality end-of-life care.

METHODS

We conducted qualitative content analysis of narrative responses to the Bereaved Family Surveys Veterans Health Administration inpatient decedents. Out of 5964 completed surveys in 2017, 4604 (77%) contained at least one word in response to the open-ended questions. For feasibility, 1500/4604 responses were randomly selected for analysis. An additional 300 randomly selected responses were analyzed to confirm saturation.

RESULTS

Over 23% percent (355/1500) of the initially analyzed narrative responses contained actionable practices. By synthesizing narrative responses to the BFS in a national healthcare system, we identified 98 actionable practices reported by the bereaved families that have potential for implementation in QI efforts. Specifically, we identified 67 end-of-life practices and 31 practices in patient-centered care domains of physical environment, food, staffing, coordination, technology and transportation. The 67 cluster into domains including respectful care and communication, emotional and spiritual support, death benefits, symptom management. Sorting these practices by target levels for organizational change illuminated opportunities for implementation.

CONCLUSION

Narrative responses from bereaved family members can yield approaches for systematic quality improvement. These approaches can serve as a menu in diverse contexts looking for approaches to improve patient quality of death in in-patient settings.

Early Stages of COVID-19 Pandemic Had No Discernable Impact on Risk of Elder Abuse and Neglect Among Dementia Family Caregivers: A Daily Diary Study

There is widespread concern that elder abuse and neglect (EAN) incidents increased during the onset of the COVID-19 pandemic due in part to increases in risk factors. Initial reports relying on administrative systems such as adult protective services records produced mixed results regarding whether or not there was a change in EAN incidents. Using data from an ongoing longitudinal study on EAN in dementia family caregiving that started before the pandemic, we assessed the hypothesis that the pandemic is related to a change in probability of EAN and EAN protective factors. Family caregivers to persons with dementia completed two waves of 21 daily diaries, 6-months apart, assessing their daily use of EAN behaviors. The first group (n = 32) completed their first wave before the pandemic and their second wave during the pandemic. The second group (n = 32) completed both waves during the pandemic. For this cohort, the generalized linear mixed logistic model results showed inconsistent associations between the onset of COVID-19 and the probability of a caregiver engaging in elder abuse or neglect behaviors. In terms of protective factors, the use of formal services was not significantly impacted by COVID-19; however, the likelihood of receiving informal support from family and friends increased significantly during the pandemic period. Dementia family caregivers were not likely impacted negatively by initial pandemic restrictions, such as shelter-in-place orders, as anticipated. These findings contribute to our understanding of how distal, disruptive processes may influence more proximal caregiver stresses and the likelihood of EAN.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10896-022-00392-8.

Dynamic structural equation modelling evaluating the progressively lowered stress threshold as an explanation for behavioural symptoms of dementia

Aim

To evaluate the progressively lowered stress threshold (PLST) conceptual model as an explanation for behavioural symptoms of dementia and test several of its hypothesized propositions. The PLST model suggests that due to impairments in coping, persons living with dementia have a reduced threshold for stress and respond with more behavioural symptoms of dementia as stress accumulates throughout the day.

Design

Intensive longitudinal design.

Methods

A sample of N = 165 family caregivers completed brief daily diary surveys for 21 days between the dates of 7/2019 and 8/2020, reporting on a total of 2841 days. Dynamic structural equation modelling was used as the analytic technique to examine the impact of caregiver and care recipient environmental stressors on the diversity of behavioural symptoms of dementia to account for the nested data structure and autoregressive relationships.

Findings

Results show direct relationships between environmental stressors and diversity of behavioural symptoms of dementia that same day and the following day.

Conclusion

Findings provide support for the PLST model propositions. Further, findings suggest an extension to the conceptual model is warranted given evidence of an exposure/recovery trajectory and the lagged effects of stress exposure on behavioural symptoms of dementia presentation.

Impact

This study tested whether a commonly used nursing model does in fact explain the occurrence of behavioural symptoms of dementia. The main findings support using the model as an intervention framework and suggest the model should be adapted to consider recovery trajectories. Since behavioural symptoms of dementia represent complex and dynamic temporal phenomena, traditional longitudinal assessments and analyses are an insufficient measurement modality for testing models. Findings inform the design of environmental‐modification type interventions for behavioural symptoms of dementia management and the methods to evaluate such interventions.

Adherence to the Use of Home Telehealth Technologies and Emergency Room Visits in Veterans with Heart Failure

Background: Prior studies have posited poor patient adherence to remote patient monitoring as the reason for observed lack of benefits. Introduction: The purpose of this study was to examine the relationship between average adherence to the daily use of home telehealth (HT) and emergency room (ER) visits in Veterans with heart failure. Materials and Methods: This was a retrospective study using administrative data of Veterans with heart failure enrolled in Veterans Affairs (VA) HT Program in the first half of 2014. Zero-inflated negative binomial regression was used to determine which predictors affect the probability of having an ER visit and the number of ER visits. Results: The final sample size was 3,449 with most being white and male. There were fewer ER visits after HT enrollment (mean ± standard deviation of 1.85 ± 2.8) compared with the year before (2.2 ± 3.4). Patient adherence was not significantly associated with ER visits. Age and being from a racial minority group (not white or black) and belonging to a large HT program were associated with having an ER visit. Being in poorer health was associated with higher expected count of ER visits. Discussion: Subgroups of patients (e.g., with depression, sicker, or from a racial minority group) may benefit from added interventions to decrease ER use. Conclusions: This study found that adherence was not associated with ER visits. Reasons other than adherence should be considered when looking at ER use in patients with heart failure enrolled in remote patient monitoring programs.

Operationalizing a Pandemic-Ready, Telemedicine-Enabled Drive-Through and Walk-In Coronavirus Disease Garage Care System as an Alternative Care Area: A Novel Approach in Pandemic Management

OBJECTIVE

Emergency departments face unforeseen surges in patients classified as low acuity during pandemics such as the coronavirus disease pandemic. Streamlining patient flow using telemedicine in an alternative care area can reduce crowding and promote physical distancing between patients and clinicians, thus limiting personal protective equipment use. This quality improvement project describes critical elements and processes in the operationalization of a telemedicine-enabled drive-through and walk-in garage care system to improve ED throughput and conserve personal protective equipment during 3 coronavirus disease surges in 2020.

METHODS

Standardized workflows were established for the operationalization of the telemedicine-enabled drive-through and walk-in garage care system for patients presenting with respiratory illness as quality improvement during disaster. Statistical control charts present interrupted time series data on the ED length of stay and personal protective equipment use in the week before and after deployment in March, July, and November 2020.

RESULTS

Physical space, technology infrastructure, equipment, and staff workflows were critical to the operationalization of the telemedicine-enabled drive-through and walk-in garage care system. On average, the ED length of stay decreased 17%, from 4.24 hours during the week before opening to 3.54 hours during the telemedicine-enabled drive-through and walk-in garage care system operation. There was an estimated 25% to 41% reduction in personal protective equipment use during this time.

CONCLUSION

Lessons learned from this telemedicine-enabled alternative care area implementation can be used for disaster preparedness and management in the ED setting to reduce crowding, improve throughput, and conserve personal protective equipment during a pandemic.

Identifying OT Practice Areas for Improving End-of-Life Health Care Experience From Narrative Responses to Bereaved Family Surveys

Date Presented 04/200/21

Using narrative responses to the Veterans Affairs Bereaved Family Survey, we have identified practice areas that fall within the OT Practice Framework (3rd ed.). Intervention in the identified OT practice areas could improve the end-of-life health care experience for both patients and providers. Narrative responses can be used to identify areas to improve quality of care and may provide initial support for implementing innovative practices.

Primary Author and Speaker: Matthew Donald McCaa

Additional Authors and Speakers: Megan Bewernitz, LaTonya Summers

Gender Differences in Caregiver Burden Among Family Caregivers of Persons With Dementia

The current study aimed to identify gender-dependent factors that influence caregiver burden among family caregivers of persons with dementia through secondary data analysis. We used a nationally representative survey of 379 family caregivers of persons with dementia completed in 2014. We examined factors affecting the burden experience of male and female caregivers, guided by the stress process model, using hierarchical regression. The analytic sample included 159 males (42%) and 220 females (58%). For males, age of care recipient, being an adult child, social support, instrumental activities of daily living performed, and caregiving impact on caregivers' health influenced burden. For females, co-residence, social support, caregivers' current health, and caregiving impact on caregivers' health impacted burden. Understanding gender differences related to caregiving burden is beneficial for developing effective targeted interventions that support the caregiving role and improve the quality of life of caregivers. [Journal of Gerontological Nursing, 47(7), 33-42.].

Organizational and External Factors Associated with Video Telehealth Use in the Veterans Health Administration Before and During the COVID-19 Pandemic

Objectives: To identify organizational and external factors associated with medical center video telehealth uptake (i.e., the proportion of patients using telemedicine) before and early in the coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: We conducted a retrospective, observational study using cross-sectional data for all 139 U.S. Veterans Affairs Medical Centers (VAMCs). We used logistic regression analyses to identify factors that predicted whether a VAMC was in the top quartile of VA Video Connect (VVC) telehealth uptake for primary care and mental health care. Results: All 139 VAMCs increased their VVC uptake at least 2-fold early in the pandemic, with most increasing uptake between 5- and 10-fold. Pre-COVID-19, higher VVC uptake in primary care was weakly and positively associated with having more high-risk patients, negatively associated with having more long-distance patients, and positively associated with the prior fiscal year's VVC uptake. During COVID-19, the positive association with high-risk patients and the negative association with long-distance patients strengthened, while weaker broadband coverage was negatively associated with VVC uptake. For mental health care, having more long-distance patients was positively associated with higher VVC uptake pre-COVID-19, but this relationship reversed during COVID-19. Discussion: Despite the marked increase in VVC uptake early in the COVID-19 pandemic, significant VAMC-level variation indicates that VVC adoption was more difficult for some medical centers, particularly those with poorer broadband coverage and less prior VVC experience. Conclusions and Relevance: These findings highlight opportunities for medical centers, VA Central Office, and other federal entities to ensure equitable access to video telehealth.

Virtual care expansion in the Veterans Health Administration during the COVID-19 pandemic: clinical services and patient characteristics associated with utilization

Objectives

To describe the shift from in-person to virtual care within Veterans Affairs (VA) during the early phase of the COVID-19 pandemic and to identify at-risk patient populations who require greater resources to overcome access barriers to virtual care.

Materials and Methods

Outpatient encounters (N = 42 916 349) were categorized by care type (eg, primary, mental health, etc) and delivery method (eg, in-person, video). For 5 400 878 Veterans, we used generalized linear models to identify patient sociodemographic and clinical characteristics associated with: 1) use of virtual (phone or video) care versus no virtual care and 2) use of video care versus no video care between March 11, 2020 and June 6, 2020.

Results

By June, 58% of VA care was provided virtually compared to only 14% prior. Patients with lower income, higher disability, and more chronic conditions were more likely to receive virtual care during the pandemic. Yet, Veterans aged 45–64 and 65+ were less likely to use video care compared to those aged 18–44 (aRR 0.80 [95% confidence interval (CI) 0.79, 0.82] and 0.50 [95% CI 0.48, 0.52], respectively). Rural and homeless Veterans were 12% and 11% less likely to use video care compared to urban (0.88 [95% CI 0.86, 0.90]) and nonhomeless Veterans (0.89 [95% CI 0.86, 0.92]).

Discussion

Veterans with high clinical or social need had higher likelihood of virtual service use early in the COVID-19 pandemic; however, older, homeless, and rural Veterans were less likely to have video visits, raising concerns for access barriers.

Conclusions and Relevance

While virtual care may expand access, access barriers must be addressed to avoid exacerbating disparities.

The Half Life of Stress: Caregiver Stress Increases Next-Day Severity of Behavioral Symptoms of Dementia

The progressively lowered stress threshold theory posits that behavioral symptoms of dementia (BSD) are reactions to environmental and care related stressors. In line with this theory, this study tests whether the stress experienced the caregiver impacts BSD expression. Caregivers to persons with dementia recruited online completed daily diary surveys for 21 days reporting on daily contextual and environmental factors of caregiving life. Using multi-level modeling of diaries (n=911) nested within participants (N=51), two daily caregiver stressors (conflict with someone other than the person with dementia, stress about own personal health) were examined as predictors of BSD. The outcome of BSD was measured as severity (a rating on a Likert scale of 1-5 that was then person-centered to represent deviations from average severity). Covariates in the model included relationship type, caregiver age, as well as stressors to the care recipient known to increase BSD. On days when a caregiver had a conflict with others the severity of the care recipient’s BSD increased by 1.44 points from average (p<.001, CI 1.05-1.75). In a time-lagged model, we observe that a caregiver having a conflict yesterday impacts today’s BSD severity by an increase of 0.43 points from average (p = 0.027, CI 0.05-0.81). Caregivers’ stress about their own health did not have a significant impact on the same day or next day BSD severity rating. These findings demonstrate that the well-being of the caregiver has measurable immediate impacts on the well-being of the person living with dementia, and suggests not all stress is equal.

Using Big Data for Clinical Decision Making

The current workforce is ill prepared for the rise in Americans 65 and older from 46.3 million in 2010 to 98.2 million by 2050, a national increase of 112.2 % accompanied by increasing chronic conditions. The increase in older Americans, the prevalence of those with dementia, accompanied by behavioral symptoms of dementia (BSD) is increasing. Innovative technology may alert health providers to early signs of decline in frail older adults with multiple chronic conditions. Remote monitoring in the home and community living spaces can address complex care needs for older adults. Monitoring may identify and predict deviations in a person’s daily routine that herald a change in a chronic condition. We present two examples that can potentially assist in clinical decision making. The first exemplar used 24/7 sensor data to identify changes, potentially clinically significant, such that early intervention may prevent hospitalizations; the second exemplar presents the use of pattern recognition software (THEME TM) for temporal pattern analysis, to identify and quantify behavior patterns with regard to intensity, frequency and complexity, such that interventions may be individually tailored and timed. Clinical researchers and technology developers need to collaborate early in the process to consider the sources and frequency of clinical measures for meaningful predictions. One major challenge lies in the interpretation of the vast amounts of within individual data. Our insights strive to improve future interdisciplinary development of monitoring systems to support aging in place and support clinical decisions for timely and effective care for frail older adults.

Use of Video-Enabled Tablet for Virtual Care Among Older Veterans

With the proliferation of virtual care, healthcare systems are exploring ways to bridge the digital divide among vulnerable patients. Department of Veterans Affairs (VA) is distributing devices for qualifying Veterans to enable video visits with medical providers at home, yet their use among older patients is unknown. This retrospective cohort study used administrative data to characterize the use of VA-loaned iPads among older Veterans compared to younger Veterans and identify demographic predictors of utilization. Among 16,385 patients who were shipped a VA-loaned iPad in 2014-2019, 33.66% (n=5,516) were over 65 years old, and 3.1% (n=503) were over the age of 85. Two thirds (n=6799) of younger patients had a video visit (mean=3 visits) with provider using iPad in the 6 months since shipment, compared to 50% (n=253) of 85+ year-olds (mean=1.8 visits). Most common types of virtual visits for the oldest old patients were for geriatrics or home-based primary care, compared to mental health visits among younger patients. Logistic regression identified characteristics of older patients who were more likely to use iPads, such a marital status, urban location, and lower disease burden, which is similar to their younger counterparts. While older age groups used VA-loaned tablets less frequently, those who engaged with the devices were similar in demographics as their younger counterparts. Older patients used iPads differently, with higher engagement in geriatric and primary care services. Providing devices for virtual care may allow health systems to more easily reach older patients in the comfort of their home.

Developing Unique Insights From Narrative Responses to Bereaved Family Surveys

CONTEXT

Although bereaved family surveys (BFS) are routinely used quantitatively for quality assessment, open-ended and narrative responses are rarely systematically analyzed. Analysis of narrative responses may identify opportunities for improving end-of-life (EOL) care delivery.

OBJECTIVES

To highlight the value of routine and systematic analysis of narrative responses and to thematically summarize narrative responses to the BFS of Veterans Affairs.

METHODS

We analyzed more than 4600 open-ended responses to the BFS for all 2017 inpatient decedents across Veterans Affairs facilities. We used a descriptive qualitative approach to identify major themes.

RESULTS

Thematic findings clustered into three domains: patient needs, family needs, and facility and organizational characteristics. Patient needs include maintenance of veteran's hygiene, appropriately prescribing medications, adhering to patient wishes, physical presence in patient's final hours, and spiritual and religious care at EOL. Family and caregiver needs included enhanced communication with the patient's care team, assistance with administrative and logistical challenges after death, emotional support, and displays of respect and gratitude for the patient's life. Facility and organizational characteristics included care team coordination, optimal staffing, the importance of nonclinical staff to care, and optimizing facilities to be welcoming, equipped for individuals with disabilities, and able to provide high-quality food.

CONCLUSION

Systematic analysis of narrative survey data yields unique findings not routinely available through quantitative data collection and analysis. Organizations may benefit from the collection and regular analysis of narrative survey responses, which facilitate identification of needed improvements in palliative and EOL care that may improve the overall experiences for patients and families.

Daily Context for Abusive and Neglectful Behavior in Family Caregiving for Dementia

BACKGROUND AND OBJECTIVES

The purpose of this study was to identify risk and protective factors for abusive and neglectful behavior in the context of daily caregiving.

RESEARCH DESIGN AND METHODS

Family caregivers who co-reside with a care recipient with Alzheimer's disease and related dementia, recruited from social media, completed 21-days of diaries. Multilevel modeling with days (n = 831) nested within caregivers (N = 50) was used to evaluate relationships between hypothesized risk and protective factors and the odds of an abusive or neglectful behavior on a given day.

RESULTS

Disruptions in the daily routine and stress of the caregiver related to behavioral symptoms of the care recipient are significant risk factors for abusive and neglectful behavior. Participating in a meaningful activity with the care recipient when it occurs twice in a day is a significant protective factor against use of a neglect behavior (OR = 0.19; CI 0.06-0.64; p = .01), but not for abusive behavior. Hypotheses that spending the full day together would increase risk, and that receipt of instrumental support and caregiver participation in self-care would decrease risk, were not supported.

DISCUSSION AND IMPLICATIONS

Findings demonstrate that risk of an abusive or neglectful behavior varies from day-to-day in the presence and absence of contextual factors, and that the majority of the variance in the odds an abusive or neglectful behavior occurring is related to day-level factors. Findings demonstrate that diary surveys are critical to identifying ecologically valid modifiable risk and protective factors for abusive and neglectful behaviors that can be targeted in future interventions.

Palliative Care and End-of-Life Outcomes Following High-risk Surgery

Importance

Palliative care has the potential to improve care for patients and families undergoing high-risk surgery.

Objective

To characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation.

Design, Setting, and Participants

This secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included.

Exposures

Palliative-care consultation within 30 days before or 90 days after surgery.

Main Outcomes and Measures

The outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes.

Results

A total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 [72.8%]), and the most common procedures were cardiothoracic (31 157 [32.7%]) or vascular (23 517 [24.7%]). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 [3.8%] in urologic surgery to 875 of 6223 patients [14.1%] in neurosurgery). A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P = .007), after adjusting for patient's characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 [95% CI, 1.09-1.87]; P = .004) and support (OR, 1.31 [95% CI, 1.01-1.71]; P = .05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery.

Conclusions and Relevance

Receipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.

Home Telehealth Technologies for Heart Failure: An Examination of Adherence Among Veterans

The current retrospective cohort study uses Department of Veterans Affairs (VA) clinical and facility data of Veterans with heart failure enrolled in the VA Home Tele-health (HT) Program. General estimating equations with facility as a covariate were used to model percent average adherence at 1, 3, 6, and 12 months post-enrollment. Most HT patients were White, male, and of older age (mean = 71 years). Average adherence increased the longer patients remained in the HT program. Number of weekly reports of HT use, not having depression, and being of older age were all associated with higher adherence. Compared to White Veterans, Black and other non-White Veterans had lower adherence. These findings identify subgroups of patients (e.g., those with depression, of younger age, non-White) that may benefit from additional efforts to improve adherence to HT technologies. [Journal of Gerontological Nursing, 46(7), 26-34.].

RISK AND PROTECTIVE FACTORS FOR ABUSE AND NEGLECT IN DAILY CAREGIVING

The stress-process model suggests a variety of factors related to the stress-experience as important in the formation of outcomes including elder abuse and neglect (EAN). Multi-level modeling with days (n=831) nested within caregivers (N=50) was used to evaluate relationships between theoretically-based risk and protective factors and odds of EAN. Disruptions in the daily routine are a significant risk factor for abuse and neglect. Participating in a meaningful activity at least twice a day with the care recipient is a significant protective factor for neglect (OR=0.19; CI=0.06-0.64; p=0.01), but not abuse. Hypotheses that spending the full day together would increase the risk of EAN, and receipt of instrumental support and caregiver participation in self-care would decrease risk, were not supported. Findings demonstrate that the risk of EAN varies from day-to-day in the presence and absence of contextual factors. Moreover, abuse and neglect may have different etiologic pathways.

CO-OCCURRENCE OF ABUSE AND NEGLECT AS REPORTED BY DEMENTIA FAMILY CAREGIVERS

Understanding the co-occurrence or overlap among multiple forms of elder abuse and neglect (EAN) is important for designing effective interventions. This paper reports patterns of family caregiver’s daily behaviors related to physical assault, psychological mistreatment, and neglect. Majority of participants self-reported at least one EAN behavior (74%), with most reporting using multiple forms of EAN over the 21-day period (52%). On a given day, psychological mistreatment and neglect were more likely to happen in isolation, while physical assault was more likely to co-occur with psychological mistreatment. The mixed model’s intra-class coefficient suggests the daily context, rather than personal characteristics, explain the variance in the use of EAN. These findings highlight the importance of never minimizing a single event of EAN reported in clinical practice, give the high rate of polyvictimization, and reinforces the need to understand why caregivers use one form of EAN over another on a given day.

CONTEXTS SURROUNDING PSYCHOLOGICAL MISTREATMENT AND NEGLECT BY CAREGIVERS TO PEOPLE WITH DEMENTIA

This presentation examines the individual experiences of caregivers using psychological mistreatment and neglect. When a caregiver indicated psychological mistreatment (e.g., yelling) or neglect (e.g., skipping necessary care) occurred on their daily diary, they were asked what they were doing and how they felt when the event occurred. Text responses were analyzed using content analysis. When psychological mistreatment occurred, there was often a triggering event. For example, 43.8% of caregivers reported they were responding to a behavioral symptom, and 28% indicated something inconvenient occurred. Caregivers were mostly frustrated/angry (68.8%) and annoyed (21.9%) when they used psychological mistreatment. When the caregiver neglected the recipient, 43.5% of caregivers reported the recipient refused to receive care and 30% reported prioritizing other care activities. In cases of neglect, caregivers were frustrated/angry (39.1%) and worried/anxious (30.4%). Findings indicate psychological mistreatment and neglect occur in unique contexts; prevention of these behaviors likely will require distinct intervention strategies.

Myelinosome-like vesicles in human seminal plasma: A cryo-electron microscopy study

Seminal plasma is particularly rich in extracellular vesicles. Myelinosomes are membranous organelles described throughout the seminiferous epithelium of the testis but never reported in semen. Our aim was to determine the presence of myelinosomes in human seminal plasma. Transmission electron microscopy and cryo electron microscopy analysis of standard myelinosome preparation from TM4 Sertoli cells and human seminal plasma samples. We have specified by cryo-EM the morphological aspect of "standard" myelinosomes isolated from the culture media of TM4 Sertoli cells. Vesicles with the same morphological appearance were revealed in human seminal plasma samples. Human seminal plasma contains a population of large EV (average diameter 200 nm) whose morphological appearance resemble those of myelinosomes. Defining the specific biomarkers and functionalities of myelinosome in human seminal plasma are the concerns to be addressed in our further research.

Update on the cellular and molecular aspects of cystic fibrosis transmembrane conductance regulator (CFTR) and male fertility

CFTR protein regulates electrolyte and fluid transport in almost all tissues with exocrine function, including male reproductive tract. Mutation of CFTR gene causes cystic fibrosis (CF), which affects the function of several organs, and impairs male fertility. The role of CFTR protein in different compartments of male reproductive tract (testis, epididymis, sperm) as well as an impact of CFTR mutation(s) on male fertility phenotype is discussed in relation with the choice of optimal technique for Assisted Reproductive Techniques (ART) management.

Detecting daily routines of older adults using sensor time series clustering

The aim of this paper is to develop an algorithm to identify deviations in patterns of day-to-day activities of older adults to generate alerts to the healthcare providers for timely interventions. Daily routines, such as bathroom visits, can be monitored by automated in-home sensor systems. We present a novel approach that finds periodicity in sensor time series data using clustering approach. For this study, we used data set from TigerPlace, a retirement community in Columbia, MO, where apartments are equipped with a network of motion, pressure and depth sensors. A retrospective multiple case study (N=3) design was used to quantify bathroom visits as parts of the older adult's daily routine, over a 10-day period. The distribution of duration, number, and average time between sensor hits was used to define the confidence level for routine visit extraction. Then, a hierarchical clustering was applied to extract periodic patterns. The performance of the proposed method was evaluated through experimental results.

Evening cortisol is associated with intra-individual instability in daytime napping in nursing home residents with dementia: an allostatic load perspective

BACKGROUND

Circadian rhythm disruption, reflected in alterations in sleep-wake activity and daytime napping behavior, is consistently reported in nursing home (NH) residents with dementia. This disruption may be reflected in day-to-day instability. The concept of allostatic load (AL), a measure of cumulative biological burden over a lifetime, may be a helpful model for understanding cortisol diurnal rhythm and daytime napping activity in this population. The purpose of this study was to examine the association between intra-individual daytime napping episodes and basal cortisol diurnal rhythm in NH residents with dementia in the context of AL.

METHOD

U sing a within-individual longitudinal design (N = 51), the authors observed and recorded daytime napping activity every 20 min for 10 hr per day across 4 consecutive days. The authors obtained saliva samples 4 times each day (upon participants' waking and within 1 hr, 6 hr, and 12 hr of participants' wake time) for cortisol analysis.

RESULTS

The authors categorized participants as high changers (HCs; day-to-day instability in napping activity) or low changers (LCs; day-to-day stability). There were no significant differences in resident characteristics between groups. There was a significant difference between HCs and LCs in napping episodes (F = 4.86, p = .03), with an interaction effect of evening cortisol on napping episodes in the HC group (F = 10.161, p = .001).

CONCLUSIONS

NH residents with unstable day-to-day napping episodes are more responsive to alterations in evening cortisol, an index of a dysregulated hypothalamic-pituitary-adrenal (HPA) axis. They may also be more amenable to environmental intervention, an avenue for further research.

To nap or not to nap: excessive daytime napping is associated with elevated evening cortisol in nursing home residents with dementia

BACKGROUND

Alterations in the sleep-wake cycle, including daytime napping, are consistently reported in persons with dementia (PWD). A dysregulation in the hypothalamic-pituitary-adrenal (HPA) axis, indexed by elevated evening cortisol, may offer one explanation for these alterations. Alternatively, excessive daytime sleeping may alter cortisol rhythm and increase intraindividual variability, potentially contributing to increased environmental reactivity and behavioral symptoms. The purpose of this substudy (N = 12) was to examine the association between daytime napping and basal cortisol diurnal rhythm in nursing home residents with dementia.

METHOD

In this within-individual longitudinal design, saliva samples were obtained daily for 5 consecutive days upon waking and 30-45 min, 6 hr, and 12 hr after waking to obtain a cortisol diurnal rhythm. Behavior and sleep-wake state (nap/no nap) were observed and recorded every 20 min for 12 hr per day for 5 days.

RESULTS

Participants were categorized as high nappers (HNs) or low nappers (LNs). There was a significant difference in evening cortisol levels (t = -2.38, p = .032) and continence (t = 3.37, p = .007) between groups, with HNs exhibiting higher evening cortisol levels. There were no other significant differences in resident characteristics between the two groups.

CONCLUSIONS

These data suggest a link between excessive daytime napping and elevated evening cortisol in PWD consistent with findings in children. Elevated evening cortisol is an indication of a dysregulation in the HPA axis. These preliminary data support a close association between the sleep-wake cycle and HPA-axis regulation in PWD.

Morning Cortisol in Relation to Behavioral Symptoms of Nursing Home Residents With Dementia

Behavioral symptoms of dementia (BSD) are a significant challenge for elders, their caregivers, and clinicians, with a prevalence ranging between 66% and 98%. Although several studies have examined BSD type and frequency, few studies have examined a possible neuroendocrine basis of BSD. The purpose of this study was to examine the association between morning cortisol levels and BSD in nursing home (NH) residents. Method: Using a within-subject longitudinal design, saliva was collected four times daily for 5 days to obtain basal cortisol levels from 30 NH residents, aged 80 to 102. Behavior was observed every 20 min for 12 hr/day for 5 days. Mixed-model analysis was used to test the association between morning cortisol (MC) and BSD. To examine the association between MC and BSD across time, participants were divided into low (LM) and high morning (HM) cortisol groups. Results: A significant inverse association between mean overall BSD and morning cortisol (F = 12.71, p = .000) was found. A significant inverse association between low and high morning cortisol and behavior variability across time (F = 15.36. p = .000) was found. The LM group exhibited significantly more behavioral variability across the day than the HM cortisol group. There was a significant group difference between two co-occurring behaviors, vocalization, and restlessness (F = 19.59, p = .000). Conclusion: Although preliminary, these results suggest an association between morning cortisol and BSD. Low morning cortisol, potentially indicating HPA axis dysregulation, may increase vulnerability to BSD.