Pharmacist-led telehealth deprescribing for people living with dementia and polypharmacy in primary care: A pilot study

BACKGROUND

People living with dementia (PLWD) have complex medication regimens, exposing them to increased risk of harm. Pragmatic deprescribing strategies that align with patient-care partner goals are needed.

METHODS

A pilot study of a pharmacist-led intervention to optimize medications with patient-care partner priorities, ran May 2021-2022 at two health systems. PLWD with ≥7 medications in primary care and a care partner were enrolled. After an introductory mailing, dyads were randomized to a pharmacist telehealth intervention immediately (intervention) or delayed by 3 months (control). Feasibility outcomes were enrollment, intervention completion, pharmacist time, and primary care provider (PCP) acceptance of recommendations. To refine pragmatic data collection protocols, we assessed the Medication Regimen Complexity Index (MRCI; primary efficacy outcome) and the Family Caregiver Medication Administration Hassles Scale (FCMAHS).

RESULTS

69 dyads enrolled; 27 of 34 (79%) randomized to intervention and 28 of 35 (80%) randomized to control completed the intervention. Most visits (93%) took more than 20 min and required multiple follow-up interactions (62%). PCPs responded to 82% of the pharmacists' first messages and agreed with 98% of recommendations. At 3 months, 22 (81%) patients in the intervention and 14 (50%) in the control had ≥1 medication discontinued; 21 (78%) and 12 (43%), respectively, had ≥1 new medication added. The mean number of medications decreased by 0.6 (3.4) in the intervention and 0.2 (1.7) in the control, reflecting a non-clinically meaningful 1.0 (±12.4) point reduction in the MRCI among intervention patients and a 1.2 (±12.9) point increase among control. FCMAHS scores decreased by 3.3 (±18.8) points in the intervention and 2.5 (±14.4) points in the control.

CONCLUSION

Though complex, pharmacist-led telehealth deprescribing is feasible and may reduce medication burden in PLWD. To align with patient-care partner goals, pharmacists recommended deprescribing and prescribing. If scalable, such interventions may optimize goal-concordant care for PLWD.

Promising Impact of Telenovela Intervention for Caregivers of Hospice Patients: A Pilot Study

BACKGROUND

Hospice family caregivers (HFCGs) support the needs of their loved ones but are at risk of developing distress and anxiety. NOVELA is a four-chapter telenovela-style educational video to support topics related to hospice caregiving. Telehealth visits are scheduled in 4 weekly sessions consisting of a chapter and subsequent discussion with an interventionist. This feasibility pilot study tested NOVELA's effect to change HFCGs' outcomes, session and outcome measure completion (defined a priori as >70%).

METHODS

This is a single-group pretest-posttest study of HFCGs of care recipients with PPS score >20% from 3 hospices in the U.S. Mid-Atlantic region. At baseline and at final posttest, participants completed a web-based survey assessing 3 outcomes: anxiety, self-efficacy, and satisfaction with intervention. Descriptive, t-test, and chi-square statistics were computed.

RESULTS

Participants in our study (N = 59) were mainly collage educated, White, female, adult children of home-bound people with a non-cancer diagnosis. Outcomes changed in the expected direction (P > .05) with higher self-efficacy (Cohen's d = -.08 [95% CI -.4 to .2) and lower anxiety (Cohen's d = .2 [95% CI -.1 to .5]) scores from final to baseline, 86% of HFCGs were satisfied or very satisfied with NOVELA, session (33/59) and outcome measure (43/59) completion averaged 68%.

CONCLUSION

Encouraging trends in NOVELA's estimation of effect suggests that NOVELA may buffer stressful aspects of hospice caregiving. However, further refinement of NOVELA is needed. Supporting HFCGs through supportive educational interventions may reduce distress and anxiety with broad implications for quality improvement.

"At least we finally found out what it was": Dementia diagnosis in minoritized populations

BACKGROUND

Disparities in diagnosis persist among persons living with dementia (PLWD); most research on delayed diagnosis relies on medical records or administrative claims. This study aimed to identify factors that delay or facilitate dementia diagnoses in racial or ethnic minoritized PLWD and elicit care partner perspectives on timing and effects of diagnosis.

METHODS

Maryland-based participants cared for a PLWD age 60 or older, self-identified as Black/African/African-American, Asian, or Hispanic/Latino, and spoke English. Nineteen care partner in-depth, semi-structured interviews were conducted and analyzed using conventional qualitative content analysis methods.

RESULTS

Biological, sociocultural, and environmental factors delayed dementia diagnosis. Memory loss was the most common early symptom, but the onset was often subtle or perceived as normal aging. Stigma and secrecy surrounding dementia influenced recognition and discussion of dementia among families and communities. Diagnoses were family-initiated and started in primary care. Care partners were divided in their perceptions of diagnosis timeliness and whether earlier diagnosis would have changed outcomes. Family reactions to dementia diagnoses varied; most participants expressed a strong sentiment of service and duty to care for older family members. Participants overwhelmingly felt the benefits of obtaining a dementia diagnosis outweighed harms.

CONCLUSIONS

Numerous factors affect dementia diagnosis in racial and ethnic minoritized PLWD. Normalization of brain health discussions and systematic, proactive discussion and detection of dementia in primary care may address multilevel barriers and facilitators to diagnosis. Systems-level and community-led public health interventions may also help address disparities in brain health education and dementia diagnosis.

Recruitment, Retention and Intervention Delivery Experiences With Hospice Family Caregivers

BACKGROUND

Recruitment and attrition are inherently challenging issues in hospice research. We sought to describe strategies of recruitment, retention, and delivery of NOVELA (short for telenovela), an intervention for hospice family caregivers (HFCG).

METHODS

Statistics were kept of every referral, consenting participant, visit session, and intervention activity. We used the Social Marketing Mix Framework to describe recruiting strategies employed and lessons learned.

RESULTS

Two hospices in the U.S. Mid-Atlantic region referred 47 HFCG and N = 20 agreed to participate, out of which 50% (N = 10) completed all 4 sessions with an average of 2.8 sessions per person, each lasting an average duration of 13.5 minutes (range 8.0-25.7). The main reason for missing a session was a patient's death (N = 8). Successful recruitment strategies employed in NOVELA included: (a) intensive start-up hospice engagement, (b) remote recruitment and delivery of NOVELA, and (c) scheduling flexibility to work around caregivers' other demands.

CONCLUSION

The recruitment and intervention delivery had successes and challenges resulting in the identification of multiple opportunities to strengthen our strategy and inform future studies with HFCGs.

The combined effects of physical frailty and cognitive impairment on emergency department- versus direct-admission hospitalizations

BACKGROUND

We aimed to study whether physical frailty and cognitive impairment (CI) increase the risk of recurrent hospitalizations in older adults, independent of comorbidity, and disability.

METHODS

Two thousand five hundred forty-nine community-dwelling participants from the National Health and Aging Trends Study (NHATS) with 3 + years of continuous Medicare coverage from linked claims data were included. We used the marginal means/rates recurrent events model to investigate the association of baseline CI (mild CI or dementia) and physical frailty, separately and synergistically, with the number of all-source vs. Emergency Department (ED)-admission vs. direct admission hospitalizations over 2 years.

RESULTS

17.8% of participants had at least one ED-admission hospitalization; 12.7% had at least one direct admission hospitalization. Frailty and CI, modeled separately, were both significantly associated with risk of recurrent all-source (Rate Ratio (RR) = 1.24 for frailty, 1.21 for CI; p < .05) and ED-admission (RR = 1.49 for frailty, 1.41 for CI; p < .05) hospitalizations but not direct admission, adjusting for socio-demographics, obesity, comorbidity and disability. When CI and frailty were examined together, 64.3% had neither (Unimpaired); 28.1% CI only; 3.5% Frailty only; 4.1% CI + Frailty. Compared to those Unimpaired, CI alone and CI + Frailty were predictive of all-source (RR = 1.20, 1.48, p < .05) and ED-admission (RR = 1.36, 2.14, p < .05) hospitalizations, but not direct admission, in our adjusted model.

CONCLUSIONS

Older adults with both CI and frailty experienced the highest risk for recurrent ED-admission hospitalizations. Timely recognition of older adults with CI and frailty is needed, paying special attention to managing cognitive impairment to mitigate preventable causes of ED admissions and potentiate alternatives to hospitalization.

Telomere shortening and the transition to family caregiving in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study

Telomere length (TL) is widely studied as a possible biomarker for stress-related cellular aging and decreased longevity. There have been conflicting findings about the relationship between family caregiving stress and TL. Several initial cross-sectional studies have found associations between longer duration of caregiving or perceived stressfulness of caregiving and shortened TL, suggesting that caregiving poses grave risks to health. Previous reviews have suggested the need for longitudinal methods to investigate this topic. This study examined the association between the transition to family caregiving and change in TL across ~9 years. Data was utilized from the Caregiving Transitions Study, an ancillary study to the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. TL was assayed using qPCR and analyzed as the telomere-to-single copy gene ratio for each participant at baseline and follow-up. General linear models examined the association between caregiving status and the change in TL for 208 incident caregivers and 205 controls, as well as associations between perceived stress and TL among caregivers. No association was found between TL change and caregiving (p = 0.494), and fully adjusted models controlling for health and socioeconomic factors did not change the null relationship (p = 0.305). Among caregivers, no association was found between perceived caregiving stress and change in TL (p = 0.336). In contrast to earlier cross-sectional studies, this longitudinal, population-based study did not detect a significant relationship between the transition into a family caregiving role and changes in TL over time. Given the widespread citation of previous findings suggesting that caregiving shortens telomeres and places caregivers at risk of early mortality, these results demonstrate the potential need of a more balanced narrative about caregiving.

Hospice Family Caregiver Perceptions of Benefits and Challenges of a Telenovela Educational Intervention

Background: Telenovelas show significant promise as a mode of education that could potentially enhance hospice family caregivers' (HFCG) ability to manage distress or pain for themselves and the care recipient. Objectives: We sought to understand HFCGs' perceived benefits and challenges of NOVELA using the Levels of Kirkpatrick as a conceptual framework. Setting/Subjects: HFCGs from two hospices in the Mid-Atlantic region of the United States. Measurements: Semistructured interviews were conducted to understand perceptions of HFCGs on the benefits and challenges of the NOVELA intervention. Results: Participants (N = 20) in our study were mainly homebound, well educated, White female, and adult children of people with advanced cancer who reported mild anxiety and moderate self-efficacy at baseline. Three unique themes were identified: acceptability of NOVELA, usability and relevance of NOVELA, and the effect of NOVELA. According to our conceptual model, the intervention positively affects all three adult learning categories: reaction, learning, and behavior. Conclusion: Our findings suggest that HFCGs support the proposed NOVELA intervention and it appears to be an acceptable educational tool during hospice care (NCT04533594).

Sleep Quality Reports From Family Caregivers and Matched Non-caregiving Controls in a Population-Based Study

The stress of family caregiving may affect many health-related variables, including sleep. We evaluated differences in self-reported sleep quality between incident caregivers and matched non-caregiving controls from a national population-based study. Caregivers and controls were identified in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study and matched on seven different demographic and health history factors. Caregivers reported significantly longer sleep onset latency than controls, before and after adjusting for covariates (ps < .05). No differences were found on measures of total sleep time or sleep efficiency. Among caregivers only, employed persons reported less total sleep time and number of care hours was a significant predictor of total sleep time. Dementia caregivers did not differ from other caregivers. This is one of the few population-based studies of sleep quality in family caregivers. Additional research is needed to examine whether sleep disturbance contributes to greater health problems among caregivers.

Family caregivers emphasise patience and personal growth: a qualitative analysis from the Caregiving Transitions Study

Background

informal caregiving for family and friends is becoming increasingly common due to the rising prevalence of chronic conditions and a shortage of affordable care options. While the impact of caregiving on caregivers’ health is well-documented, nuances in caregivers’ experiences may not be captured in quantitative studies. We aimed to better understand caregivers’ perception of their experiences through qualitative analysis.

Methods

participants were from the Caregiving Transitions Study (CTS), which is ancillary to the REasons for Geographic and Racial Differences in Stroke Study. We analysed responses from 150 caregivers to an open-ended question at the end of the CTS telephone interview concerning additional information about their caregiving experiences. We identified main themes and examined differences by sex, condition and relationship to the care recipient.

Results

four major themes were identified: cultural/family expectations; growth opportunities; and reciprocity; stressors and challenges and recommendations. Male caregivers more often indicated that their motivation for taking on this role was their sense of duty towards family, while female caregivers focused on the challenges and burden of caregiving that they experienced. Overall, caregivers highlighted the importance of patience and the positive impact of caregiving, such as opportunities for personal growth, acquiring new skills, and finding fulfillment and gratitude.

Conclusions

family caregivers shared both positive and challenging experiences as well as the impact that these experiences had on their lives. Understanding the full spectrum of the caregiving experience will help inform how the community and the health care system can best support caregivers in their roles.

Can volunteer medical visit companions support older adults in the United States?

BACKGROUND

Older adults are encouraged to use Medical Visit Companions (MVCs) for routine medical encounters; however, many vulnerable older adults attend alone or fail to attend. In the absence of available family or friends, community volunteers could potentially fill this gap. We aimed to understand the role and acceptability of volunteer MVCs accompanying older adults to medical visits and explore potential barriers and facilitators of increasing MVC availability and expanding roles beyond transportation.

METHODS

Two moderators conducted 4 focus groups with 29 volunteers grouped by whether they provided (n = 15) or received (n = 14) rides to medical visits. All were members of Partners In Care (PIC), a community organization in Maryland, United States which offers a range of programs and services that support the independence of older adults including the provision of volunteer MVCs. Participants were asked to discuss why they were involved with PIC, and to describe their experiences with providing or receiving companionship during medical visits. Inductive thematic analysis was used to explore the views and experiences of participants, particularly around the roles played by MVCs and the feasibility of expanding these roles.

RESULTS

All participants reported benefits from their role whether that was giving or receiving rides. Many accompanied participants reported missing medical appointments prior to joining PIC and being able to avail of the services of a MVC. Volunteer roles varied and ranged from transportation only, help with care coordination and in some cases accompanying the person into their medical visit. A subgroup of volunteers expressed a willingness to take on additional roles during the physician visit following additional training and isolated older adults welcomed the prospect of their assistance.

CONCLUSION

Our qualitative data indicate that non-family, volunteer MVCs are willing and able to assist older people going to a medical visit. With appropriate training and support, volunteer companions could do much to improve the healthcare experience for those who otherwise would attend alone or would not attend medical visits.

Developing a sensor-based mobile application for in-home frailty assessment: a qualitative study

BACKGROUND

Frailty syndrome disproportionately affects older people, including 15% of non-nursing home population, and is known to be a strong predictor of poor health outcomes. There is a growing interest in incorporating frailty assessment into research and clinical practice, which may provide an opportunity to improve in home frailty assessment and improve doctor patient communication.

METHODS

We conducted focus groups discussions to solicit input from older adult care recipients (non-frail, pre-frail, and frail), their informal caregivers, and medical providers about their preferences to tailor a mobile app to measure frailty in the home using sensor based technologies. Focus groups were recorded, transcribed, and analyzed thematically.

RESULTS

We identified three major themes: 1) perspectives of frailty; 2) perceptions of home based sensors; and 3) data management concerns. These relate to the participants' insight, attitudes and concerns about having sensor-based technology to measure frailty in the home. Our qualitative findings indicate that knowing frailty status is important and useful and would allow older adults to remain independent longer. Participants also noted concerns with data management and the hope that this technology would not replace in-person visits with their healthcare provider.

CONCLUSIONS

This study found that study participants of each frailty status expressed high interest and acceptance of sensor-based technologies. Based on the qualitative findings of this study, sensor-based technologies show promise for frailty assessment of older adults with care needs. The main concerns identified related to the volume of data collected and strategies for responsible and secure transfer, reporting, and distillation of data into useful and timely care information. Sensor-based technologies should be piloted for feasibility and utility. This will inform the larger goal of helping older adults to maintain independence while tracking potential health declines, especially among the most vulnerable, for early detection and intervention.

Change in Life's Simple 7 Measure of Cardiovascular Health After Incident Stroke: The REGARDS Study

BACKGROUND AND PURPOSE

Life's Simple 7 (LS7) is a metric for cardiovascular health based on the 7 domains of smoking, diet, physical activity, body mass index, blood pressure, total cholesterol, and fasting glucose. Because they may be targeted for secondary prevention purposes, we hypothesized that stroke survivors would experience improvement in LS7 score over time compared with people who did not experience a stroke. We addressed this hypothesis in the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) cohort of Black and White adults enrolled between 2003 and 2007.

METHODS

Participants who had LS7 data at baseline, were stroke-free at baseline, had a 10-year follow-up visit, and either did not have a stroke or had an ischemic stroke >1 year before follow-up were included (N=7569). Among these participants, 149 (2.0%) had an adjudicated ischemic stroke between the LS7 assessments. LS7 scores were classified as 0 to 2 points for each domain for a maximum score of 14, with higher scores representing better health. Multivariable linear regression was used to test the association of ischemic stroke with change in LS7 score. Covariates included baseline LS7 score, age, race, sex, education, and geographic region.

RESULTS

The 149 stroke survivors had an average of 4.9 years (SD=2.5) of follow-up from the stroke event to the second LS7 assessment. After adjusting for covariates, participants who experienced an ischemic stroke showed 0.28 points more decline in total LS7 score (P=0.03) than those who did not experience a stroke.

CONCLUSIONS

Stroke survivors did not experience improvements in cardiovascular health due to secondary prevention after ischemic stroke. On the contrary, they experienced significantly greater decline, indicating the need for greater efforts in secondary prevention after a stroke.

Effects of Transitions to Family Caregiving on Well-Being: A Longitudinal Population-Based Study

BACKGROUND/OBJECTIVES

Few studies have rigorously examined the magnitude of changes in well-being after a transition into sustained and substantial caregiving, especially in population-based studies, compared with matched noncaregiving controls.

DESIGN

We identified individuals from a national epidemiological investigation who transitioned into caregiving over a 10- to 13-year follow-up and provided continuous in-home care for at least 18 months and at least 5 hours per week. Individuals who did not become caregivers were individually matched with caregivers on age, sex, race, education, marital status, self-rated health, and history of cardiovascular disease at baseline. Both groups were assessed at baseline and follow-up.

SETTING

REasons for Geographic And Racial Differences in Stroke study.

PARTICIPANTS

A total of 251 incident caregivers and 251 matched controls.

MEASUREMENTS

Perceived Stress Scale (PSS), 10-Item Center for Epidemiological Studies-Depression (CES-D), and 12-item Short-Form Health Survey quality-of-life mental (MCS) and physical (PCS) component scores.

RESULTS

Caregivers showed significantly greater worsening in PSS, CES-D, and MCS, with standardized effect sizes ranging from 0.676 to 0.796 compared with changes in noncaregivers. A significant but smaller effect size was found for worsening PCS in caregivers (0.242). Taking on sustained caregiving was associated with almost a tripling of increased risk of transitioning to clinically significant depressive symptoms at follow-up. Effects were not moderated by race, sex, or relationship to care recipient, but younger caregivers showed greater increases in CES-D than older caregivers.

CONCLUSION

Persons who began substantial, sustained family caregiving had marked worsening of psychological well-being, and relatively smaller worsening of self-reported physical health, compared with carefully matched noncaregivers. Previous estimates of effect sizes on caregiver well-being have had serious limitations due to use of convenience sampling and cross-sectional comparisons. Researchers, public policy makers, and clinicians should note these strong effects, and caregiver assessment and service provision for psychological well-being deserve increased priority.

Abstract 92: Stroke Survivors Experience Greater Decline in Life’s Simple 7 Score for Cardiovascular Health Over 10-Year Follow-Up

Introduction: Life’s Simple 7 (LS7) is a measure of cardiovascular health based on seven domains of smoking, diet, physical activity, body mass index, blood pressure, total cholesterol, and fasting glucose. Due to secondary prevention efforts, stroke survivors may experience improvements in LS7 scores over time compared to those who did not experience a stroke.

Methods: We included participants over 45 years of age enrolled in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study who had LS7 data at baseline and 10-year follow-up and did not report a history of stroke at baseline (N=7568). Of these, 361 had an adjudicated ischemic stroke between the LS7 assessments. Scores on each domain of LS7 range from 1-3 for a maximum total score of 21, where a higher score represents better cardiovascular health. A general linear model was used to test the association of having an ischemic stroke on the change in LS7 score. Covariates included the LS7 score at baseline, age, race, gender, cognitive status, and education.

Results: Findings indicated that those who were younger, African American, and had lower levels of education, experienced significant decline in LS7 scores from baseline to follow-up (Table 1). Those who had a stroke also experienced, on average, 0.25 points more decline in total LS7 scores than those who did not have a stroke (p=0.048).

Conclusions: Stroke survivors did not experience improvements in cardiovascular health due to secondary prevention after an ischemic stroke. On the contrary, they experienced significantly greater decline, indicating the need for greater efforts in lifestyle modification and secondary prevention after a stroke.

DEVELOPING A SENSOR-BASED MOBILE APPLICATION FOR IN-HOME FRAILTY ASSESSMENT: A QUALITATIVE STUDY

Frailty is an important concept in the care of older adults, and there is great interest in incorporating user-friendly frailty assessments into research and clinical settings. In-home, sensor-based technologies may provide a more dynamic, sensitive, and accurate assessment of frailty measures. To investigate user perspectives for use of sensor-based technologies and mobile applications, we held five focus groups with community-dwelling older adults (n= 10), their informal caregivers (n=9), and medical professionals (n=8). We used qualitative inductive analysis to organize thematic content. Caregivers and care-recipients viewed the early identification of frailty as beneficial, but highlighted the need for secure data infrastructure and clear demonstration of how frailty assessment would improve care. They also expressed concerns that technology-based communication could reduce in-person interactions. Medical providers noted the utility of objective data for difficult conversations with caregivers of frail patients, but worried about resources for analyses and interpretation of sensor-based health information.

Screening, brief intervention, and referral to treatment (SBIRT) curriculum integration and sustainability: Social work and nursing faculty perspectives

BACKGROUND

The Substance Abuse and Mental Health Services Administration (SAMHSA) has funded grants to universities to provide training and conduct research on the dissemination of Screening, Brief Intervention, and Referral to Treatment (SBIRT) to health care professionals. However, when it comes to integrating SBIRT content into an existing curriculum, difficulties can arise. When there is so much content already in the curriculum, adding more can be challenging. Additionally, some faculty believe that course curricula should be driven by the expertise and knowledge of faculty, not by opportunities afforded because of grant funding.

METHODS

Using qualitative semi-structured faculty interviews and thematic data analysis, this study explored the process and content issues surrounding the integration of SBIRT content into the Masters of Social Work (MSW) and Masters of Science in Nursing (MSN) curricula at one university.

RESULTS

Guidelines for the successful integration of SBIRT content into MSW and MSN curricula fall into two thematic areas: 1. Encourage buy-in and ownership of SBIRT curriculum development by current faculty. 2. Use a scaffolded approach. SBIRT includes several unique content areas which should be integrated per competencies addressed in each course. SBIRT content areas lend themselves to integration into a range of courses, employing an array of learning techniques and teaching materials. Scaffolding content requires creativity, which serves as the basis of the six subthemes that guide a scaffolded SBIRT integration approach.

CONCLUSIONS

SBIRT offers an evidence based intervention that uses a public health approach to reduce harm from substance use. As such, professional nursing and social work education programs should teach SBIRT to their master's level practitioners. This paper proposes guidelines for integrating that content into existing curricula.