Evaluating the Implementation Fidelity of a Pilot Pragmatic Randomized Clinical Trial Comparing Daily-Delivered Meals to Mailed Frozen Meals

In pragmatic clinical trials (PCTs), the intervention is carried out by participating sites instead of research staff. In this paper, we evaluate study sites' implementation adherence during a pilot PCT of home-delivered meals for older adults with dementia. Participants at three home-delivered meal programs were randomized to receive either (1) meals delivered daily or (2) frozen meals mailed every two weeks; participants' outcomes were tracked for six months. Using the adherence domains from the Framework for Implementation Fidelity, we identified six metrics to assess adherence, with a total possible adherence score ranging from 6 (low adherence) to 18 (high adherence); all three sites scored within the top quartile of adherence. Despite challenges to meal delivery during the COVID-19 pandemic, sites successfully implemented the intervention, justifying a follow-on PCT to test the comparative effectiveness of models of meal delivery on the time to nursing home placement for people living with dementia.

Spreading pride in all who served: A health education program to improve access and mental health outcomes for sexual and gender minority veterans

Access to effective, replicable services is critical to reduce known mental health disparities for sexual and gender minority or LGBTQ+ veterans (lesbian, gay, bisexual, transgender, queer, questioning, and related identities). This paper examines the impact of a manualized 10-week health education group, called PRIDE in All Who Served on veteran patient experience, protective factors (e.g., identity acceptance), and mental health outcomes (e.g., suicide risk) at 10 Department of Veterans Affairs (VA) facilities. Implementation facilitation strategies (e.g., consultation, staff training) supported adoption at new sites and initial facilitators and barriers are described. Forty-four veterans (M = 47.21 years old) completed outcome surveys before and after the group. Significant improvement in acceptance concerns, identity uncertainty, community involvement, and likelihood of future suicide attempts were observed; other changes in mental health symptoms were not replicated in this sample (e.g., depression, anxiety). Open-ended veteran feedback reflected improved social support and engagement and increased self-understanding as the most frequent themes. At the facility level, Healthcare Equality Index scores (a Human Rights Campaign measure of affirmative care climate) improved from 30% to 90% achieving top-performer/leader status from pre- to postimplementation. Manualized approaches, like PRIDE in All Who Served, that are based on established minority stress models and can be spread for use with diverse LGBTQ+ veterans (e.g., age, race, gender identity, sexual orientation, rurality, housing) are needed. The PRIDE in All Who Served program is an increasingly available resource to VA clinicians advocating for greater health equity within a national healthcare setting. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Illustrating Resource Needs through Data Visualization: Creation of Life-Space Maps for Rural Veterans with Dementia and their Caregivers

Rural-dwelling individuals with dementia and their caregivers face unique challenges compared to urban-dwelling peers. Barriers to accessing services and supports are common, and individual resources and informal networks available to support rural families can be difficult to track for providers and healthcare systems outside of the local community. This study uses qualitative data from rural-dwelling dyads, individuals with dementia (n = 12) and informal caregivers (n = 18), to demonstrate how rural patients' daily life needs can be summarized through life-space map visualizations. Thirty semi-structured qualitative interviews were analyzed using a two-step process. First, rapid qualitative analysis was completed to generate daily-life needs of the participants' home and community context. Next, life-space maps were developed to synthesize and visualize dyads' met and unmet needs. Results suggest life-space mapping may offer a pathway for improved needs-based information integration for busy care providers and time-sensitive quality improvement efforts by learning healthcare systems.

Rolling out PRIDE in All Who Served: Barriers and Facilitators for Sites Implementing an LGBTQ+ Health Education Group for Military Veterans

BACKGROUND/OBJECTIVE

The Veterans Health Administration (VHA) PRIDE in All Who Served health education group (PRIDE) was developed to improve health equity and access to care for military veterans who are lesbian, gay, bisexual, transgender, queer, and/or other sexual/gender-diverse identities (LGBTQ+). This 10-week program rapidly spread to over 30 VHA facilities in 4 years. Veterans receiving PRIDE experience improved LGBTQ+ identity-related resilience and reductions in suicide attempt likelihood. Despite PRIDE's rapid spread across facilities, information is lacking on implementation determinants. The current study's goal was to clarify determinants of PRIDE group implementation and sustainment.

METHODS

A purposive sample of VHA staff (N = 19) with experience delivering or implementing PRIDE completed teleconference interviews January-April 2021. The interview guide was informed by the Consolidated Framework for Implementation Research. Rapid qualitative matrix analysis was completed with methods to ensure rigor (e.g., triangulation and investigator reflexivity).

RESULTS

Key barriers and facilitators of PRIDE implementation were heavily related to facility inner setting (what is happening inside the facility), including implementation readiness (e.g., leadership support for LGBTQ+-affirming programming, access to LGBTQ+-affirming care training) and facility culture (e.g., systemic anti-LGBTQ+ stigma). Several implementation process facilitators enhanced engagement at sites, such as a centrally facilitated PRIDE learning collaborative and a formal process of contracting/training for new PRIDE sites.

DISCUSSION/CONCLUSION

Although aspects of the outer setting and larger societal influences were mentioned, the majority of factors impacting implementation success were at the VHA facility level and therefore may be more readily addressable through tailored implementation support. The importance of LGBTQ+ equity at the facility level indicates that implementation facilitation should ideally address institutional equity in addition to implementation logistics. Combining effective interventions with attention to local implementation needs will be required before LGBTQ+ veterans in all areas will benefit from PRIDE and other health equity-focused interventions.

A Spotlight on Adaptation: Preimplementation of Montessori-Based Activity Programming in Long-Term Care Using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME)

BACKGROUND AND OBJECTIVES

Effectively adapting evidence-based interventions for nursing home (NH) implementation is a critical, yet underexamined, component of improving care quality. Montessori-based activity programming (MAP) is an evidence-based intervention that promotes person-centered care, engages persons living with dementia, and mitigates distress behaviors. Currently, there is sparse evidence of MAP in Department of Veterans Affairs NHs (i.e., community living centers [CLCs]). CLCs differ significantly from community NHs and require adaptations to support MAP use and sustainability. This study uses the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) to track changes made to MAP as an exemplar for clinicians and implementation scientists. This work fills a gap in adapting interventions through a detailed examination of the adaptation process in NHs.

RESEARCH DESIGN AND METHODS

Qualitative and quantitative data were collected across 8 CLCs (e.g., advisory panel, staff interviews, training evaluations, field notes, and fidelity assessments). We used an iterative, rapid content analytic approach to triangulate findings and identify needed adaptations for the CLC setting.

RESULTS

Thirty-six adaptations were made. Most adaptions occurred during the preimplementation phase, were reactive, focused on training/evaluation, and involved researchers, intervention developers, and practitioners. All were fidelity-consistent with MAP. The most common goal across adaptations was increased reach/engagement of the intervention.

DISCUSSION AND IMPLICATIONS

CLCs and community NHs can use findings to support intervention adaptation, and adapt and implement MAP to improve meaningful engagement for persons living with dementia and other residents. Future research should further evaluate and standardize FRAME for diverse users of complex interventions.

A pilot evaluation of sexual and gender minority identity measures in a treatment-engaged military veteran sample

Sexual and gender minority (SGM) military veterans have endured a history of discriminatory policies and hetero- and cis-sexist-related military culture that can negatively impact identity and mental health. The present pilot evaluation examined measure characteristics of the Lesbian, Gay, and Bisexual Identity Scale (LGBIS) and lesbian, gay, and bisexual positive identity measure (LGB-PIM) in a clinical sample of SGM military veterans in order to assess the potential use of these instruments in understanding identity and mental health in the context of program implementation. A cross-sectional pilot survey of 83 SGM veterans was conducted in 10 veterans affairs sites. Self-report data were collected as part of a quality improvement project across 2018 and 2019. Results showed that the sample was characterized by low internalized prejudice and identity uncertainty, as well as generally high positive aspects of identity (e.g., identity affirmation, authenticity, social justice beliefs). LGB-PIM subscale internal consistency values were acceptable (α range = .89-.92), whereas LGBIS subscale values varied (α range = .51-.87). Acceptance concerns, identity uncertainty, and social justice beliefs distinguished mental health symptom severity levels. Higher identity uncertainty and social justice beliefs were associated with worse symptoms of depression, anxiety, and suicide risk. Preliminary results support further application and study of the LGB-PIM and some LGBIS subscales as possible tools in program development and improvement within military veteran samples. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A Pilot Study Comparing Two Measures of Perceived Health Services Access Among Military Veterans With Musculoskeletal Injuries and Mental Health Conditions

INTRODUCTION

Service members endure a number of musculoskeletal injuries (MSIs) during service (e.g., ankle sprains and chronic back pain). Musculoskeletal injuries can reduce engagement in physical activity after military service and contribute to a sedentary lifestyle that diminishes physical health and elevates the risk for psychological distress including suicide-related behaviors. Yet, little is known about barriers and facilitators to accessing care in veterans with co-occurring MSI and mental health conditions. The purpose of this study was to pilot two brief measures of barriers and facilitators to rehabilitation and mental health services in military veterans with musculoskeletal and mental health conditions. Self-report tools vary in their response formats in ways that can impact usability, data quality, and completeness. We examine two response styles (i.e., checklist vs. thermometer) for two health services (mental health and rehabilitation) to determine usability, patterns in item endorsement, and veteran preference.

MATERIALS AND METHODS

Barriers and facilitators informed by the Fortney Veterans Healthcare Access model were assessed by veterans (n = 31) on the newly developed 22-item, paper-and-pencil scale with separate ratings for mental health and rehabilitation services. All participants completed scales with both response styles and the order of administration was randomized (i.e., either the checklist first or the thermometer-style response first). Data also included self-reported demographics, musculoskeletal and mental health diagnoses, health-related quality of life, physical activity levels, mental health symptoms, suicide risk, and coronavirus disease of 2019 pandemic-related stress.

RESULTS

Veterans reported no differences in ease of use across response formats; however, 83.9% (n = 26) preferred the checklist style, with only 3.22% (n = 1) preferring the thermometer format. Checklist items also resulted in less missing data (i.e., range 0.00%-6.45%) than the thermometer-style option (i.e., range 6.45%-61.30%). On the checklist, total number of perceived barriers was low for mental health and rehabilitation services (i.e., M = 1.58 and M = 1.61, respectively). Distance to care and problems related to symptoms were the most frequently identified barriers for both services. Facilitators outnumbered barriers for mental and rehabilitation services, and nearness of the clinic/hospital was the top-rated facilitator for both. On the thermometer, the perceived strength of each mental health (M = 39.37) and rehabilitation (M = 39.81) service barrier was moderate (0-100 scale), while the average perceived strength of each mental health (M = 61.66) and rehabilitation service (M = 61.84) facilitator was higher. Associations between barrier and facilitator scores with mental and physical health indicators were small with exceptions. For instance, suicide attempt likelihood was positively correlated with rehabilitation services barriers; mental health burden was positively associated with both barriers and facilitators.

CONCLUSIONS

Results of this pilot comparing two measurement approaches identified actionable next steps. Brief barriers and facilitators checklists were viable for veteran ratings across type of health. The thermometer-based tool captured the perceived strength of barriers and facilitators but yielded problematic rates of missing data in its current form and was not preferred by veterans.

Links between Savoring, Rumination, and Sleep-Related Experiences across Adulthood: Implications for Older Adults

OBJECTIVES

Sleep problems are pervasive, particularly in older adults. Much work examines psychological factors that adversely affect sleep; fewer studies examine those with a positive effect. Savoring is a form of positive repetitive thought that is linked to several aspects of health but has been understudied in relation to sleep. We examined cross-sectional associations of both savoring and rumination with subjective sleep experiences, and assessed if these associations vary by age.

METHODS

Adults and older adults (N = 216) ranging from 20-80 years in age (M = 44.9 ± 15.6 years) completed an online survey of validated measures of savoring, rumination, sleep disturbance, and sleep-related impairment.

RESULTS

Higher levels of savoring were significantly associated with lower levels of sleep-related impairment but not sleep disturbance in regression analyses. Higher levels of rumination were significantly associated with higher levels of sleep disturbance and sleep-related impairment. Associations of savoring and rumination with sleep-related experiences did not vary by age.

CONCLUSIONS

Savoring and rumination are relevant to sleep-related experiences in adults ranging from younger to older. Further investigation of the potential positive impact of savoring on sleep-related experiences is needed.

CLINICAL IMPLICATIONS

Engagement in savoring and rumination should be considered when assessing sleep and sleep-related impairment in adults.

Improving Suicide Risk Detection and Clinical Follow-up after Discharge from Nursing Homes

Objectives: Suicide Awareness for Veterans Exiting Community Living Centers (SAVE-CLC) is a brief intervention to standardize suicide-risk screening and clinical follow-up after VA nursing home discharge. This paper examines the outcomes of SAVE-CLC compared to care as usual.Methods: A quasi-experimental evaluation was conducted (N = 124) with SAVE-CLC patients (n = 62) matched 1:1 to a pre-implementation comparison group. Data were obtained through VA Corporate Data Warehouse resources and chart reviews. Outcomes examined (within 30/90 days of discharge) included mortality rates, frequency of outpatient mental health visits, emergency department visits, rehospitalizations, depression screens (PHQ-2), and the latency period for outpatient mental health care.Results: A greater portion of SAVE-CLC patients received a depression screen after discharge, n = 42, 67.7% versus n = 8, 12.9%, OR = 14.2 (5.7, 35.3), p < .001. The number of days between discharge and first mental health visit was also substantially shorter for SAVE-CLC patients, M = 8.9, SD = 8.2 versus M = 17.6, SD = 9.1; t = 2.47 (122), p = .02. Significant differences were not observed in emergency department visits, hospitalizations, or mortality.Conclusions: SAVE-CLC is a time-limited intervention for detecting risk and speeding engagement in mental health care in the immediate high-risk post-discharge period.Clinical Implications: Care transitions present an important opportunity for addressing older adults' suicide risk; brief telephone-based interventions like SAVE-CLC may provide needed support to individuals returning home.

Potentially traumatic events and health among lesbian, gay, bisexual and heterosexual Vietnam veterans: Results from the Vietnam Era Health Retrospective Observational study

Objectives: To examine differences in potentially traumatic events (PTEs), probable PTSD, and health-related quality of life (HRQoL) between lesbian, gay, and bisexual (LGB) and heterosexual Vietnam Era veterans. Method: Data are from the 2016-2017 Vietnam Era Health Retrospective Observational study survey (n = 18,866; 45% response rate). PTEs were defined using the 10-item Brief Trauma Questionnaire and a dichotomous item about whether respondents witnessed sexual assault during military service. Current probable PTSD was measured with the Primary Care PTSD Screen, and mental and physical HRQoL was assessed with the SF-8™. Multivariable regression analyses were first adjusted for sociodemographic and military-related characteristics, and then with PTEs as a count variable ranging from 0-11. Survey weights accounted for the complex sampling design and nonresponse. Results: Approximately 1.5% of veterans were LGB. Compared to heterosexual veterans, LGB veterans were more likely to report exposure to natural disasters, childhood physical abuse, adulthood physical assault, and sexual assault, and they were less likely to report combat exposure, witnessing someone being seriously injured or killed, or witnessing sexual assault while in the military. Compared to heterosexual veterans, LGB veterans had greater odds of current probable PTSD (adjusted odds ratio [aOR] = 1.50, 95% CI [1.04, 2.16]) and poorer mental HRQoL (B = -1.70, SE = .72, p = .018). PTEs attenuated sexual orientation differences in probable PTSD (aOR = 1.27, 95% CI [.82, 1.97]) and poorer mental HRQoL (B = -1.22, SE = .67, p = .067). Conclusions: Among Vietnam Era veterans, PTEs differ based on sexual orientation, and contribute to LGB veterans' greater prevalence of current probable PTSD and poorer mental HRQoL relative to heterosexual veterans. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Pride in all Who Served: Development, Feasibility, and Initial Efficacy of a Health Education Group For LGBT Veterans

Many of the more than 1 million military veterans who identify as lesbian, gay, bisexual, and/or transgender (LGBT) have encountered "rejecting experiences in the military" and stigma from prior "Don't Ask Don't Tell" policies. Associated minority stress and social isolation have been linked to a disproportionate risk for depression and suicide, as well as a reluctance to seek medical care at Veterans Health Administration (VHA) facilities. This paper describes feasibility and preliminary outcomes of the newly developed, Pride in All Who Served Health Education Group created to meet the unique needs of sexual and gender minority veterans. The 10-week, closed, health education group (e.g., continuums of identity, military culture) enables open dialogue, fosters social connectedness, and empowers veterans to be more effective self-advocates within the healthcare system. Feedback from formative evaluations (n = 29 LGBT veterans and n = 25 VHA stakeholders) was incorporated before conducting a small scale, non-randomized pilot. Preliminary pre-post surveys (n = 18) show promise (i.e., Cohen's d range ± 0.40 to 1.59) on mental health symptoms (depression/anxiety, suicidal ideation), resilience indicators (identity affirmation, community involvement, problem-focused coping), and willingness to access care within the VA system (satisfaction with VA services, perception of staff competence). Results suggest that the 10-week Pride Group may be an effective tool for addressing minority-related stress in LGBT veterans. A full-scale, randomized clinical trial of this intervention is needed to determine short and long-term impacts on clinical and healthcare access-related outcomes.

Developing a Pain Intensity Measure for Persons with Dementia: Initial Construction and Testing

OBJECTIVE

The goal of this study was to identify a limited set of pain indicators that were most predicive of physical pain. We began with 140 items culled from existing pain observation tools and used a modified Delphi approach followed by statistical analyses to reduce the item pool.

METHODS

Through the Delphi Method, we created a candidate item set of behavioral indicators. Next, trained staff observed nursing home residents and rated the items on scales of behavior intensity and frequency. We evaluated associations among the items and expert clinicians' assessment of pain intensity.

SETTING

Four government-owned nursing homes and 12 community nursing homes in Alabama and Southeastern Pennsylvania.

PARTICIPANTS

Ninety-five residents (mean age = 84.9 years) with moderate to severe cognitive impairment.

RESULTS

Using the least absolute shrinkage and selection operator model, we identified seven items that best predicted clinicians' evaluations of pain intensity. These items were rigid/stiff body or body parts, bracing, complaining, expressive eyes, grimacing, frowning, and sighing. We also found that a model based on ratings of frequency of behaviors did not have better predictive ability than a model based on ratings of intensity of behaviors.

CONCLUSIONS

We used two complementary approaches-expert opinion and statistical analysis-to reduce a large pool of behavioral indicators to a parsimonious set of items to predict pain intensity in persons with dementia. Future studies are needed to examine the psychometric properties of this scale, which is called the Pain Intensity Measure for Persons with Dementia.

Psychometric Evaluation of a Pain Intensity Measure for Persons with Dementia

OBJECTIVE

The goal of this study was to conduct initial psychometric analyses of a seven-item pain intensity measure for persons with dementia (PIMD) that was developed using items from existing pain observational measures.

DESIGN AND METHODS

We evaluated validity by examining associations with an expert clinician's pain intensity rating (ECPIR) and an established pain observation tool (Mobilization Observation Behaviour Intensity Dementia [MOBID]). We also examined correlations between the PIMD and known correlates of pain: depression, sleep disturbances, agitation, painful diagnoses, and caregiver pain reports. We examined the differences between PIMD scores for "at rest" and "during movement" observations. We assessed reliability by calculating Cronbach's alpha and estimating inter-rater reliability using intraclass correlations (ICCs). Finally, we examined whether six additional "recent changes in behavior" items improved the PIMD's ability to predict expert clinicians' pain ratings.

SETTING

Sixteen nursing homes located in Alabama, Georgia, Pennsylvania, and New Jersey.

PARTICIPANTS

One hundred ninety residents with moderate to severe cognitive impairment, mean age of 84 years, 49.5% female, and 70% white.

RESULTS

PIMD during movement scores were highly correlated with the ECPIR and overall MOBID scores. As expected, there were large differences between at rest and during movement PIMD scores. Associations of PIMD with known correlates of pain were generally low and statistically nonsignificant. Internal consistency was supported with a Cronbach alpha of 0.72 and an inter-rater ICC of 0.82 for during movement PIMD scores.

CONCLUSIONS

Initial evaluation of the PIMD supports its validity and reliability. Additional testing is needed to evaluate the tool's sensitivity to changes in pain intensity.

SAVE-CLC: An Intervention to Reduce Suicide Risk in Older Veterans following Discharge from VA Nursing Facilities

Objective: We describe the development and implementation of a telephonic intervention (SAVE-CLC) piloted at three VA sites for Veterans returning to the community from VA nursing facilities (Community Living Centers or "CLCs"). Care transitions present a known period of medical risk for older adults and may pose increased risk for suicide. Veterans discharging from CLCs are at elevated risk compared to age and gender matched controls.Methods: Using a quality improvement approach, input was gathered from key stakeholders to aid in the development of the intervention. Veterans were screened for depressive symptoms and need for additional support by phone.Results: Of the Veterans who received the SAVE-CLC intervention, 87.9% had at least one prior mental health diagnosis, though only 19.7% had an outpatient mental health appointment arranged at CLC discharge. Results suggest that the intervention is feasible across multiple outpatient settings and is generally well-received by Veterans and caregivers, with 97% of those contacted reporting that the telephone calls were helpful.Conclusion: This flexible, telephone-based intervention addresses the unmet need of integrating mental health care into discharge planning during care transitions.Clinical Implications: SAVE-CLC offers a feasible and acceptable solution to suicide risk in older Veterans exiting a CLC.

Pain Patterns and Treatment Among Nursing Home Residents With Moderate-Severe Cognitive Impairment

OBJECTIVES

To examine the frequency and severity of pain and use of pain therapies among long-term care residents with moderate to severe dementia and to explore the factors associated with increased pain severity.

DESIGN

Prospective individual data were collected over 1 to 3 days for each participant.

SETTING

Sixteen long-term care facilities in Alabama, Georgia, Pennsylvania, and New Jersey.

PARTICIPANTS

Residents with moderate to severe cognitive impairment residing in a long-term care facility for at least 7 days were enrolled (N = 205). Residents were 47% female, predominantly white (69%), and 84 years old, on average (SD = 10 years).

MEASUREMENTS

A comprehensive pain assessment protocol was used to evaluate pain severity and characteristics through medical record review, interviews with nursing home staff, physical examinations, as well as pain observation tools (Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale and Pain Intensity Measure for Persons With Dementia). Known correlates were also assessed (agitation, depression, and sleep).

RESULTS

Experts' pain evaluations indicated that residents' usual pain was mild (mean = 1.6/10), and most experienced only intermittent pain (70%). However, 45% of residents experienced moderate to severe worst pain. Of residents, 90% received a pain therapy, with acetaminophen (87%) and opioids (32%) commonly utilized. Only 3% had a nondrug therapy documented in the medical record. The only resident characteristic that was significantly associated with pain severity was receipt of an opioid in the past week.

CONCLUSION

Using a comprehensive pain assessment protocol, we found that most nursing home residents with moderate to severe dementia had mild usual, intermittent pain and the vast majority received at least one pain therapy in the previous week. Although these findings reflect improvements in pain management compared with older studies, there is still room for improvement in that 45% of the sample experienced moderate to severe pain at some point in the previous week. J Am Geriatr Soc 68:794-802, 2020.

TOGETHER THROUGH DEMENTIA: MEASURING RELATIONSHIP SATISFACTION FOR VETERANS WITH DEMENTIA AND THEIR SPOUSES

Current and prior relationship quality can have significant impacts on the mental and physical health of individuals with dementia (IWD) and their spousal caregivers (CGs). Yet, marital satisfaction is not often assessed. This poster examines use of the Dyadic Adjustment Scale (DAS), a widely-researched marriage counseling tool, for contextualizing interpersonal factors beyond established measures of quality-of-life (QoL), burden, and depression. Community-dwelling spousal CGs (n = 49) and Veterans with dementia (n = 37) completed self-report measures including dyadic relationship satisfaction/distress, mutuality, QoL, depression, burden, and the IWD’s cognitive status. Descriptive statistics, bivariate correlations, and regressions were performed. Scores on the DAS significantly correlated with CG QoL (.567, p < .001), CG depression (-.525, p < .001), CG burden (-.428, p = .002), IWD’s cognitive status (.355, p = .034), and IWD social engagement (-.424, p = .011). IWD-reported DAS scores were positively correlated with IWD QoL (.381, p = .024), CG QoL (.340, p = .043), and IWD subjective health (.360, p =.031). Regression analysis showed CG DAS (b = .188, β = .464, p = .002) and IWD social engagement (b = -2.806, β = -.37, p = .012) are significantly predictive of CG QoL; F(2, 32) = 15.865, p < .001; R2 = .495. Findings suggest that the DAS provides important relationship quality insights and may improve QoL needs assessments for caregiving support and respite services, including CG willingness to continue in the CG role. Examining the DAS longitudinally could also inform intervention delivery as dementia severity progresses.

ADAPTING MINDFULNESS-BASED COUNSELING FOR THE TELEPHONE: A PILOT STUDY FOR CAREGIVERS AND VETERANS WITH DEMENTIA

Optimizing Dementia Care in Veterans with Dementia is a randomized, controlled, pilot study examining outcomes for Veterans and their caregivers at 6- and 12-months for two telephone-based interventions: a) Benjamin Rose Institute’s (BRI) Care Consultation (CC), and b) CC + Counseling (CC+C). Counseling modules are integrated into the existing BRI CC framework using guided mindfulness-based skill-building exercises on various content domains (e.g., grief, identity, intimacy, stress management). Sixty-four caregivers and 47 Veterans (M = 74.3 years, MOCA Score M = 15.5) have been randomized in this ongoing pilot study. Caregivers are 91% female, 32% Black/African American, and 72% spouses. Preliminary implementation and 6-month outcome data is discussed (e.g., reaction to behavioral distress, mindfulness, depression, quality of life) using within-group paired samples t-tests for the 32 dyads randomized to CC+C. Lessons learned include strategies for adapting mindfulness-based approaches over the telephone to enhance access for Veterans and caregivers across geographic regions.

Use of the Montreal Cognitive Assessment (MoCA) in a Rural Outreach Program for Military Veterans

The Montreal Cognitive Assessment (MoCA) is a free, easily accessible screener ideal for rural areas where resources are limited. We examined administration and scoring by Veteran Community Outreach Health Workers (VCOHWs); compared positive screening rates using two cutoff scores; and examined predictors of education-adjusted scores in N = 168 rural military Veterans from the Alabama Veteran Rural Health Initiative. Accuracy of administration (95 percent) and scoring (68 percent) was calculated and recommendations are offered. Higher than expected rates of positive screens were observed (40 percent using 24/30 cutoff) in this relatively young (M = 55 years) community-dwelling sample. Age, education, and race but not subjective health predicted differences in domain and total education-adjusted scores on multivariate and univariate tests. This study advances social science research in rural communities by being the first to: (1) examine MoCA scores in a rural, Deep South U.S. sample; and (2) report fidelity administration data for VCOHWs.

QUALITY IMPROVEMENT IN LTC: EFFECTIVENESS OF MONTESSORI-BASED ACTIVITY PROGRAMMING IN VA COMMUNITY LIVING CENTER

Montessori-based Activity Programming (MAP) was adapted for Veterans Affairs (VA) Community Living Centers (CLCs) and aims to increase independence and meaningful engagement in residents with cognitive impairment. The Montessori model prioritizes offering choice, knowing and harnessing a resident’s abilities, and enabling them to carry out purposeful roles and activities. Any perceived deficit in cognitive functioning is “circumvented” by preparing the environment to support maximum independence. The implementation of MAP-VA in VA Western NY CLC involved 3 lodges, 52 staff, 16 champions, and 65 CLC residents. Standardized implementation measures demonstrated improvements over six months in five domains assessing development of a resident-directed community. Hypothesized outcomes included improved national percentile quality improvement (QI) rankings related to psychological symptoms and medications (e.g., depressive symptoms and use of antipsychotic/antianxiety medications) and physical functioning (e.g., less falls and ability to move independently). Scores six months prior to the implementation of MAP-VA (April, 2018 to September, 2018) were compared with scores during six months of implementation post training (November, 2018 to March, 2019). Compared to pre-intervention QI measures related to psychological symptoms, a clinically meaningful trajectory of symptom decrease was observed with rankings during implementation (e.g., depressive symptoms, amount of antipsychotic medications). Likewise, compared to pre-intervention QI rankings regarding physical functioning, post-training rankings showed a trajectory of improvement (e.g., help with ADLs, ability to move independently). Implementation of the MAP-VA intervention demonstrates preliminary evidence for improvement in QI measures related to psychological symptoms and physical functioning. Implications for QI efforts in VA CLCs will be presented.

Psychometric Evaluation of the MOBID Dementia Pain Scale in U.S. Nursing Homes

PURPOSE

The Mobilization-Observation-Behavior-Intensity-Dementia (MOBID) Pain Scale is an observational tool in which raters estimate pain intensity on a 0-10 scale following five standardized movements. The tool has been shown to be valid and reliable in northern European samples and could be useful in the United States (US) for research and clinical purposes. The goal of this study was to examine the validity and reliability of the MOBID among English-speaking nursing home residents in the US.

DESIGN

Cross-sectional study.

SETTINGS

Sixteen nursing homes in Pennsylvania, New Jersey, Georgia and Alabama.

PARTICIPANTS

One hundred thirty-eight older adults with dementia and moderate to severe cognitive impairment.

METHODS

Validity was evaluated using Spearman correlations between the MOBID overall pain intensity score and 1) an expert clinician's pain intensity rating (ECPIR), 2) nursing staff surrogate pain intensity ratings, and 3) known correlates of pain. We assessed internal consistency by Cronbach's alpha.

RESULTS

MOBID overall scores were significantly associated with expert clinician's rating of current and worst pain in the past week (rho = 0.54, and 0.57; p < .001, respectively). Statistically significant associations also were found between the MOBID overall score and nursing staff current and worst pain intensity ratings as well as the Cornell Scale for Depression in Dementia (rho = 0.29; p < .001). Internal consistency was acceptable (α = 0.83).

CONCLUSIONS AND CLINICAL IMPLICATIONS

Result of this study support the use of the MOBID in English-speaking staff and residents in the US. Findings also suggest that the tool can be completed by trained, nonclinical staff.

Enabling Advance Directive Completion: Feasibility of a New Nurse-Supported Advance Care Planning Intervention

Adults who complete an advance directive (AD) are not consistently offered information about the risks, benefits, or alternatives (RBA) of the life-sustaining medical procedures addressed on standardized forms. The current article describes a new patient-centered nurse-supported advance care planning (NSACP) intervention focused on providing information about RBA of life-sustaining procedures. Fifty participants (mean age = 50.26 years) at a Veterans Affairs medical center were randomized to the NSACP intervention or a comparison condition. Before randomization, 78% (n = 39) expressed interest in RBA information. Of participants in the NSACP group, 94% (n = 30) completed an AD. Participants who received NSACP made more decisions to decline life-sustaining treatment than those who were randomized to the comparison group. Promising feasibility data include brevity (mean = 46 minutes), high patient satisfaction, participant retention, and treatment fidelity. The NSACP holds promise as a brief, educational intervention to support patients in completing an AD. [Journal of Gerontological Nursing, 44(7), 31-42.].

Development of a New Tool for Systematic Observation of Nursing Home Resident and Staff Engagement and Relationship

Purpose of Study

To develop a structured observational tool, the Resident-centered Assessment of Interactions with Staff and Engagement tool (RAISE), to measure 2 critical, multi-faceted, organizational-level aspects of person-centered care (PCC) in nursing homes: (a) resident engagement and (b) the quality and frequency of staff-resident interactions.

Design and Methods

In this multi-method psychometric development study, we conducted (a) 120 hr of ethnographic observations in one nursing home and (b) a targeted literature review to enable construct development. Two constructs for which no current structured observation measures existed emerged from this phase: nursing home resident-staff engagement and interaction. We developed the preliminary RAISE to measure these constructs and used the tool in 8 nursing homes at an average of 16 times. We conducted 8 iterative psychometric testing and refinement cycles with multi-disciplinary research team members. Each cycle consisted of observations using the draft tool, results review, and tool modification.

Results

The final RAISE included a set of coding rules and procedures enabling simultaneously efficient, non-reactive, and representative quantitative measurement of the interaction and engagement components of nursing home life for staff and residents. It comprised 8 observational variables, each represented by extensive numeric codes. Raters achieved adequate to high reliability with all variables. There is preliminary evidence of face and construct validity via expert panel review.

Implications

The RAISE represents a valuable step forward in the measurement of PCC, providing objective, reliable data based on systematic observation.

Identity processes as a predictor of memory beliefs in older adults

OBJECTIVES

The impact of identity processes (identity assimilation, identity accommodation, and identity balance) on memory beliefs was explored.

METHOD

Individually administered questionnaires (e.g. depressive symptoms, subjective health, identity processes, memory beliefs) and a brief neuropsychological assessment of cognitive abilities were completed during a one-time interview with 82 participants aged 58-92 years-old (M = 74.68, SD = 10.95). Forty (49.4%) identified their race as White/Caucasian, 38 (46.9%) identified their race as Black/African American, and 3 (3.7%) indicated no primary racial/ethnic group.

RESULTS

Hierarchical regression analyses revealed that identity processes account for differences in memory beliefs beyond established predictors. Specifically, identity accommodation and identity balance predicted memory self-efficacy beyond depression and subjective health. These findings are congruent with identity process theory; however, the impact of identity assimilation in this population was unremarkable. Exploratory analyses also indicated that the identity processes have a stronger relationship to some domains of memory self-efficacy (i.e. anxiety, capacity) than others (i.e. perceived change, locus of control).

CONCLUSION

Beliefs about memory and their integration into an adaptable, yet consistent self-concept are an important element of identity for aging individuals. Additional research is needed to determine the unique role of identity accommodation and identity balance in understanding cognitive functioning and ultimately the impact on potential clinical applications, such as related health-seeking behavior among older adults. Tailored interventions could be developed to facilitate optimal utilization of health care services at a time when early diagnosis of memory-related disorders is critical for future planning and care decisions.

Preserving Identity and Planning for Advance Care (PIPAC): preliminary outcomes from a patient-centered intervention for individuals with mild dementia

OBJECTIVES

The purpose of this pilot study was to conduct limited-efficacy testing of the newly developed Preserving Identity and Planning for Advance Care (PIPAC) intervention on self-reported and proxy-reported emotional and health-related outcomes of individuals in the early stages of dementia.

METHOD

A two-group comparison design was implemented. Blocked randomization was used to assign individuals with mild dementia and a family contact to either (1) the four-session, multi-component intervention group focused on reminiscence and future planning or (2) the minimal support phone contact comparison group. Of the 19 enrolled dyads, 18completed post-treatment assessments (i.e. 10 intervention and 8 comparison group). Individuals with dementia were M=82.8 (SD=6.46) years old; 31.6% were men and 68.4% were women. Participants were predominantly white/Caucasian (n=18, 94.7%) with one black/African-American (5.3%).

RESULTS

Analyses of covariance controlling for baseline differences revealed clinically meaningful differences (with medium to large effect sizes) between groups at post-treatment for depressive symptoms, quality of life, health-related quality of life indicators, and decisional conflict. Individuals in the intervention group were also observed to exhibit higher levels of coping. Feasibility data collected from participants and interventionists were encouraging.

CONCLUSION

Emotion-focused, patient-centered interventions like PIPAC hold promise for advancing treatment options in the early and mild stages of dementia. A full-scale, randomized clinical trial of this intervention is warranted to determine both short-term and long-term impacts on clinical outcomes including improved depressive symptomatology, quality of life, and health-related factors that impact daily functioning in social environments.

Predicting desire for institutional placement among racially diverse dementia family caregivers: the role of quality of care

PURPOSE

Literature on institutionalization of patients with dementia has not considered the role of caregivers' quality of care, which encompasses caregivers' exemplary care (EC) behaviors and caregivers' potentially harmful behaviors (PHBs) toward care recipients. This study sought to understand the role of quality of care in mediating between caregiving stressors and caregiver desire to institutionalize (DTI) a patient with dementia.

DESIGN AND METHODS

A sample of 612 family caregivers from diverse racial/ethnic backgrounds was drawn from the baseline data of the Resources for Enhancing Alzheimer's Caregiver Heath (REACH II) project. Multiple mediator models were run using Preacher and Hayes asymptotic and resampling strategies to assess direct and indirect effects of caregiver stressors (daily care bother, behavioral bother, and burden) on caregiver desire to institutionalize a patient with dementia.

RESULTS

Overall, PHB was positively related to caregiver desire to institutionalize their care recipients. Specifically, PHB was found to mediate the relationship between caregiving stressors and DTI in the Caucasian and Latino groups, whereas only the mediation effect of EC was significant in the African American group.

IMPLICATIONS

Caregivers' perceptions of quality of care helped explain their desire to institutionalize their care recipients with dementia. Including assessment of EC and PHB in clinical and social service settings is recommended for all ethnic groups. Interventions should facilitate EC behaviors among African American caregivers and address concerns of PHBs in Caucasian and Latino caregivers.

Internet connectivity among rural Alabama veterans: baseline findings from the Alabama Veterans Rural Health Initiative Project

INTRODUCTION

The purpose of this secondary data analysis was to characterize the Internet usage of rural veterans (n=201) who had either never enrolled, or had previously enrolled but not accessed, Veterans Affairs (VA) health services in at least 2 years. The VA Office of Rural Health (ORH)(ie part of the United States Government Department of Veterans Affairs) is a government agency with the mission to improve access and quality of care for enrolled rural and highly rural US veterans. The ORH seeks to use evidence-based policies and innovative practices to support the unique needs of enrolled veterans residing in geographically remote areas. These individuals represent a population considered to experience health disparities secondary to reduced health care access.

METHODS

This study explored the role of the Internet in providing health information and information regarding VA services to rural Caucasian and African American veterans in the southeastern USA. African Americans were significantly younger (50.32 years, SD=13.50, range 22-85 years) than Caucasian rural veterans (58.50 years, SD=13.82, range 21-85 years).

RESULTS

A small majority of veterans (n=107; 53.23%) reported 'going on-line to use the Internet or World Wide Web, or to send and receive e-mail'. Among Internet users, multivariate logistic regression showed that neither age nor race/ethnicity predicted using the Internet to access health information or information regarding VA services.

CONCLUSION

In comparison with population norms, rural veterans displayed lower usage of the Internet; however, there were few practical age differences between young, middle-aged and older rural veterans in use of the Internet for seeking health information. These results suggest a tremendous potential for online outreach efforts to rural veterans seeking health information and information regarding VA services and benefits. The US Federal Government's VA Office of Rural Health is investing in technology-based services and will need to disseminate information regarding the availability of these services to rural veterans.

In the Veteran's Voice: Psychosocial Needs After Cancer Treatment

To better understand psychosocial distress in veterans treated for cancer, these researchers conducted a series of 3 focus groups. Emerging themes suggest that cancer survivorship is a process, and interventions need to be tailored to each patient.

Religiosity and spirituality in military veteran cancer survivors: a qualitative perspective

Religiosity/spirituality (R/S) is often involved in coping with cancer. Qualitative research effectively captures the individuality of R/S constructs. Fourteen military veteran cancer survivors participated in focus groups. R/S questions included "How have your religious/spiritual beliefs affected how you cope with your cancer" and "How have your religious/spiritual beliefs changed as a result of your experience with cancer?" Five primary themes emerged: impact of cancer on R/S, meaning-making, prayer, religious/spiritual role of others, and facing death. Consistency and individuality characterized the role of R/S in cancer survivorship across themes. Implications for future research are discussed.

Prospective end-of-life treatment decisions and perceived vulnerability: Future time left to live and memory self-efficacy

OBJECTIVE

Public policy and opinion support autonomous medical decision-making; however, research on perceptions related to future functioning that may influence health-related decisions is limited. Additional research is needed to understand individual perceptions for engaging in future life-sustaining treatment decisions.

METHODS

Perceived time left to live and memory self-efficacy were assessed among 77 adults (M = 74.5 ± 7.18 years) indicating preferences for cardiopulmonary resuscitation, mechanical ventilation, and artificial feeding and fluids in hypothetical illness scenarios.

RESULTS

Participants with a more expansive perspective of future time, less perceived change in memory, greater perceived memory capacity, and greater depressive symptomatology and Blacks/African Americans had greater overall desire for treatment.

CONCLUSION

Differences in perceived time left to live and memory beliefs affect treatment desires in ways that may not be recognized by families and/or physicians. Identifying perceptions associated with end-of-life treatment preferences may improve interventions that facilitate quality care through patient autonomy.

Perceived income inadequacy as a predictor of psychological distress in Alzheimer's caregivers

The authors examined perceived income inadequacy as a predictor of self-reported depressive symptomatology and anxiety in the original sites of the Resources for Enhancing Alzheimer's Caregiver Health I project. Perceived income inadequacy, self-reported household income, and control factors (e.g., subjective health) were entered into hierarchical regression analyses predicting psychological distress. Findings suggest that perceived income inadequacy and not household income significantly predicted more self-reported depressive symptomatology and greater self-reported anxiety. This supports previous findings that objective income measures alone are not adequate indicators of socioeconomic status in older adults.

Testing a theoretical model of the stress process in Alzheimer's caregivers with race as a moderator

PURPOSE

The primary aim of this study was to test the stress process model (SPM; Pearlin, Mullan, Semple, & Skaff, 1990) in a racially diverse sample of Alzheimer's caregivers (CGs) using structural equation modeling (SEM) and regression techniques. A secondary aim was to examine race or ethnicity as a moderator of the relation between latent constructs (e.g., subjective stressors and role strain) in the SPM.

SAMPLE

Participants included White or Caucasian (n = 212), Black or African American (n = 201), and Hispanic or Latino (n = 196) Alzheimer's CGs from the Resources for Enhancing Alzheimer's Caregiver Health (REACH) II clinical trial.

RESULTS

SEM revealed that the Pearlin model obtains a satisfactory fit across race or ethnicity in the REACH II data, despite significant racial differences in each of the latent constructs. Race or ethnicity moderated the impact of resources on intrapsychic strain, such that CGs reported similar intrapsychic strain across race at lower levels of resources, but White or Caucasian CGs reported more intrapsychic strain than Black or African American or Hispanic or Latino CGs when resources are higher.

IMPLICATIONS

Strengths and weaknesses for each race or ethnicity vary considerably, suggesting that interventions must target different aspects of the stress process to provide optimal benefit for individuals of different cultural or ethnic backgrounds.

Legacy activities as interventions approaching the end of life

We examined the efficacy of an innovative family-based intervention designed to decrease caregiving stress and increase family communication among individuals with chronic, life-limiting illnesses and their family caregivers in a randomized, contact control group design. The intervention group received three home visits in which the interventionist actively worked with the family to construct a personal Legacy, usually a scrapbook with photographs or audiotaped stories. Control group families received three supportive telephone calls. Of the 42 families that entered the project, 31 families completed follow-up assessments within 9 to 10 weeks (14 control; 17 intervention; 72% African American) for a retention rate of 74%. Intervention caregivers showed reduced caregiving stress in comparison with control group caregivers, who showed increases in stress. Intervention patients reported decreased breathing difficulty and increased religious meaning. Caregivers and patients reported greater social interaction on the part of the patient. All participants in the intervention group initiated a Legacy activity and reported that Legacy improved family communication. Legacy interventions hold promise and are simple to implement.

End-of-life decision-making, decisional conflict, and enhanced information: race effects

OBJECTIVES

To examine the effect of enhanced information regarding the risks, benefits, and life-sustaining treatment alternatives on hypothetical medical decisions and decisional conflict in older, community-dwelling Caucasian and African-American adults.

DESIGN

Two-group (enhanced information; no information) between-subjects design.

SETTING

Community-based dwellings, two assisted living facilities, and one senior citizen center.

PARTICIPANTS

Seventy-eight adults (aged 74.5+/-7.18) with a mean Telephone Interview for Cognitive Status--Modified (TICS-m) score of 31.5+/-4.7 were recruited through personal contacts and informational talks held at the recruitment sites.

MEASUREMENTS

Measures included the Life Support Preferences/Predictions Questionnaire--modified (LSPQ-m); the Decisional Conflict Scale; and enhanced information, including detailed descriptions of life-sustaining treatment options for each LSPQ-m illness scenario, risks of the treatment, benefits of the treatment, and alternatives for each treatment (called medical information stimuli).

RESULTS

Enhanced information (e.g., medical information stimuli) reduced decisional conflict (P=.049, d=0.47) for hypothetical life-sustaining treatment decisions. A mixed analysis of variance with group and race as between-subjects variables and illness and treatment as within-subjects variables revealed significant main effects of race, illness, and treatment, as well as a significant race-by-illness-by-group interaction (Wilk's lambda=0.923, F(2, 73)=3.05, P=.05, partial eta(2)=0.08). Enhanced information produced different patterns of desire for life-sustaining treatments in African Americans and Caucasians.

CONCLUSION

Physicians and other healthcare professionals can reduce decisional conflict in patients by providing enhanced information regarding treatment risks, benefits, and alternatives. Such decision aids may provide new information or knowledge and thus reduce desire for treatment in African Americans.

Positive aspects of caregiving as a moderator of treatment outcome over 12 months

The authors examined the influence of positive aspects of caregiving (PAC) as a moderator of treatment outcome across 12 months in 1 of the original sites of the Resources for Enhancing Alzheimer's Caregiver Health I project. They used multilevel random coefficients regression analysis to predict time-varying PAC, depression, behavioral bother, and daily care burden in Alzheimer's caregivers (N = 243; mean age = 60.89, SD = 14.19). They found that time-varying PAC was predicted by time-varying daily care burden. They also found significant effects of time-varying PAC for depression, behavioral bother, and daily care burden. Notably, a PAC x Phase x Treatment effect was found for daily care burden, such that individuals who endorsed less PAC benefited most from the intervention across 12 months. The tendency to positively appraise the caregiving experience (i.e., PAC) in response to chronic stressors such as Alzheimer's caregiving may affect individuals' responsiveness to, and benefit from, interventions, whereas only daily care burden affected the tendency to find enjoyment in caregiving across 12 months. Future intervention research should assess individual PAC in order to better tailor interventions to caregiving needs.