Reducing disability via a family centered intervention for acutely ill persons with Alzheimer's disease and related dementias: protocol of a cluster-randomized controlled trial (Fam-FFC study)

Nursing Use of Function-Focused Care with Hospitalized Patients Living with Dementia

Older adults living with dementia engage in little physical activity when hospitalized. This has negative implications including functional decline, infections, and longer lengths of stay, and reflects a lower quality of care. One of the approaches used to help overcome challenges to engaging patients in physical activity and optimizing the quality of care provided is referred to as function-focused care. Function-focused care is a philosophy of care in which patients are helped to engage in physical activity, including mobility and self-care, at their highest level during all care interactions. The focus of this study was to describe the function-focused care provided by nurses at 2 and 6 months after exposure to the implementation of Function-Focused Care for Acute Care Using the Evidence Integration Triangle (FFC-AC-EIT). It was hypothesized that in treatment sites there would be an increase in the percentage of routine activities in which nurses provided function-focused care to patients between 2 and 6 months. This was a descriptive study of nurse-patient interactions. At 2 months, 54 nurse-patient observations were done, and at 6 months, 69 nurse-patient observations were done. Out of 19 possible activities in which the nurse could provide function-focused care, the mean number of function-focused care activities performed by nurses at 2 months was 3.2 (SD = 2.0), or 83% of the observed activities. At 6 months, 2.6 (SD = 2.6) function-focused care activities were performed and this increased to 86% of the activities observed. There was a mean of 0.5 (SD = 1.1) or 16% of the observed function-focused care activities not performed at 2 months and .3 (SD = 0.8) or 11% of observed activities not performed at 6 months. Although there was a limited engagement of patients in physical activity during routine care overall, more function-focused care was provided to patients following the implementation of FFC-AC-EIT, the longer the staff were exposed to the intervention.

Mediating role of care partner burden among dementia care partners during post-hospital transition

OBJECTIVES

This study examined the mediating role of care partner burden on the relationship between patient clinical factors (i.e. cognition, physical function, and behavioral and psychological symptoms of dementia [BPSD]) and care partner mental health (i.e. anxiety and depression) among dementia care partners at hospital discharge.

METHOD

The sample consisted of 431 patient and care partner dyads enrolled in the Family centered Function-focused Care (Fam-FFC) study; ClinicalTrials.gov identifier NCT03046121. Mediation analyses were conducted to test the role of care partner burden on the associations between patient clinical factors, and care partner anxiety and depression.

RESULTS

Mediation models demonstrated that care partner burden partially mediated the relationship between patient physical function and care partner anxiety and depression, as well as patient BPSD and care partner anxiety and depression.

CONCLUSION

Findings highlight the need for clinicians and service providers to implement comprehensive strategies that address both patient clinical factors (i.e. physical function and BPSD) and care partner burden, to optimize care partner mental health outcomes during post-hospital transition.

Stressors and coping strategies in older people hospitalised for hip surgery following a fall: a multiple case study

BACKGROUND

More than half of older persons admitted to an emergency department after a fall have a hip fracture and require surgery for a total hip replacement. This procedure has a high risk of postoperative complications and consequences for older persons, their informal caregivers, and the healthcare system. This study aimed to explore the perceptions of older persons, their informal caregivers and health professionals about intra-personal, inter-personal and extra-personal stressors arising from hip surgery following the fall of an older person hospitalised in orthopaedics, as well as the coping strategies used and the results obtained.

METHODS

A qualitative multiple case study. The sample consisted of eight cases. Each case consisted of one older person, their informal caregiver and the professionals involved in their care: a nurse, an orthopaedic surgeon and a physiotherapist. A total of 32 participants were recruited. Data were collected between August 2018 and February 2019 in a public hospital in French-speaking Switzerland. Intra- and inter-case analyses were performed.

RESULTS

Five topics emerged: two concerning stressors for older persons (the physical and psychological consequences of the fall and hospitalisation; the loss of relational and environmental markers and habits); two relating to the coping strategies used to face the stressors (being resilient and involved in their own care; partially meeting the older person's needs); and one regarding the results of the strategies used (reassurance through consideration of some of their needs).

CONCLUSIONS

Older persons hospitalised for hip surgery after a fall are confronted with various intra-, inter- and extra-personal stressors and have to explore, together with their informal caregivers, strategies to cope with the consequences of these stressors. Healthcare professionals should possess efficient intervention strategies to help identify and support older persons who experience various types of stressors during hospitalisation for hip surgery following a fall.

Dementia Care Partner Preparedness and Desire to Seek Long-Term Care at Hospital Discharge: Mediating Roles of Care Receiver Clinical Factors

OBJECTIVES

The purpose of this study was to explore the mediating roles of care receiver clinical factors on the relationship between care partner preparedness and care partner desire to seek long-term care admission for persons living with dementia at hospital discharge.

METHODS

This study analyzed data from the Family centered Function-focused Care (Fam-FFC), which included 424 care receiver and care partner dyads. A multiple mediation model examined the indirect effects of care partner preparedness on the desire to seek long-term care through care receiver clinical factors (behavioral and psychological symptoms of dementia [BPSD], comorbidities, delirium severity, physical function, and cognition).

RESULTS

Delirium severity and physical function partially mediated the relationship between care partner preparedness and care partner desire to seek long-term care admission (B = -.011; 95% CI = -.019, -.003, and B = -.013; 95% CI = -.027, -.001, respectively).

CONCLUSIONS

Interventions should enhance care partner preparedness and address delirium severity and physical function in hospitalized persons with dementia to prevent unwanted nursing home placement at hospital discharge.

CLINICAL IMPLICATIONS

Integrating care partner preparedness and care receiver clinical factors (delirium severity and physical function) into discharge planning may minimize care partner desire to seek long-term care.

Behavioral and psychological symptoms of dementia and adverse patient outcomes post-hospitalization

OBJECTIVES

The occurrence of behavioral and psychological symptoms of dementia (BPSD) are associated with adverse outcomes but have largely been studied in populations outside of acute care. The current study examines (1) the prevalence of BPSD during acute hospitalization and (2) if BPSD are predictive of adverse patient outcomes.

METHODS

A secondary analysis of Family-centered Function-focused Care (Fam-FFC) data including 461 patients with dementia/care partner dyads assessed at hospital admission, discharge, 2 months, and 6 months post-discharge, was conducted. Prevalence of BPSD (Neuropsychiatric Inventory-Questionnaire total and Frontal, Hyperactivity, Mood, and Psychosis sub-categories), associations with patient and care partner characteristics, and prediction of adverse events (falls, emergency room [ER] visits, hospitalizations, injury) were examined.

RESULTS

BPSD were highly prevalent (93.9% admission, 86.7% discharge). The most common symptom cluster at admission was Hyperactivity (76.7%) followed by Mood (72.3%) and Psychosis (71.9%), and Frontal (25.9%). Higher admission Hyperactivity was associated with ER admissions at 2 months, higher discharge Hyperactivity was associated with ER admissions and hospitalizations at 2 months, and change in Psychosis was associated with ER admissions at 2 months.

CONCLUSIONS

These findings highlight BPSD during hospitalization as potentially modifiable risk factors of adverse outcomes.

A Descriptive Study Using Rasch Analysis and Hypothesis Testing to Evaluate the Psychometric Properties of the UMOVE Mobility Screen Tested With Hospitalized Older Adults

The purpose of this study was to test the reliability and validity of the UMOVE Mobility Screen in older adults living with dementia using a Rasch analysis and hypothesis testing. The UMOVE Mobility Screen (UMOVE) focuses on nine activities: following commands, muscle strength, and basic functional mobility tasks. Trained evaluators completed assessments on 244 patients, the majority of whom were female (62%), and White (71%). Based on Rasch Analysis, there was evidence of good item and person reliability (indexes > 0.80), good INFIT statistics, and only one item fitting the model based on OUTFIT statistics. Validity was supported based on hypothesis testing. There was no evidence of Differential Item Functioning between races and genders. Item mapping raised concerns about the spread of the items across the full spectrum of mobility assessed in the UMOVE Mobility Screen. Future testing should consider adding some easier and some more difficult items.

Implementation of the UMove Mobility Program to Promote Safe Patient Mobility and Reduce Falls in the Hospital Setting

The purpose of the current quality improvement (QI) project was to implement the UMove Early Mobility Program to engage patients in safe out of bed (OOB) activities and reduce falls, specifically focusing on toileting-related falls, during the hospital stay. Eight nursing units implemented the UMove program, including the UMove Mobility Screen (UMove MS), to select strategies to reduce toileting-related falls while increasing mobility. De-identified, unit-based data were collected from hospital reports. Nursing had a 95% documentation compliance rate for the UMove MS, and OOB activities and ambulation were documented at 50% and 57%, respectively. There was no statistical difference found in reducing toileting-related falls or sustaining increased OOB activities across the 15-month QI project. Toileting-related falls approached significance with a rate reduction from 1.77 pre-implementation to 0.23 at 6 months and no toileting-related falls at 12 months. Despite no significant findings, there is evidence that clinical changes occurred with nurses assessing and promoting mobility, while implementing strategies to reduce toileting-related falls. [Research in Gerontological Nursing, 17(1), 19-29.].

An exploration of the cultural appropriateness of the family-centered function-focused care intervention

The Family-centered Function Focused Care (Fam-FFC) intervention, is a nurse-family care partnership model aimed to improve the physical and cognitive recovery in hospitalized persons living with Alzheimer's Disease Related Dementias (ADRD) while improving the care partner's experiences. Discussions of patients' needs and preferences between nurses and the patient's close family members have been found to be useful in preventing excessive stress in persons with dementia, while lessening the anxiety of care partners. However, the efficacy of dementia-specific interventions is influenced in part by the degree to which the interventions are flexible and sensitive to the patient's and care-partner's condition, needs, and preferences, including cultural preferences. Therefore, the purpose of this study is to assess the cultural appropriateness of Fam-FFC using the Ecological Validity Model (EVM). This qualitative, descriptive study included 28 consented care partners drawn from a sample of 455 dyads enrolled in the Fam-FFC intervention. An interview guide was created based on the EVM. Participants provided demographic data. Thematic analysis was conducted to analyze transcribed interviews. The majority of the sample was female (79%), Non-Hispanic (96%) and half were married. One-half of the sample represented Black care partners and one-half were White. Seventy-nine percent lived with their family member with ADRD. Three major themes were identified from the thematic analysis including Care Partner Identity, Care Partner Preferences, and Goals of Care for functional recovery of their family member living with dementia. In this study care partners wanted more social services as well as home care that supported not just physical needs but also social and recreational needs. Findings from the study offer guidance on improving the Fam-FFC intervention including strengthening education and resources on partner self-care.

Association between tea drinking and disability levels in older Chinese adults: a longitudinal analysis

Objective

As the global population ages, disability among the elderly presents unprecedented challenges for healthcare systems. However, limited research has examined whether dietary interventions like tea consumption may alleviate and prevent disability in older adults. As an important dietary therapy, the health benefits of tea drinking have gained recognition across research disciplines. Therefore, this study aimed to investigate the association between tea drinking habits and disability levels in the elderly Chinese population.

Methods

Leveraging data from the 2008 to 2018 waves of the Chinese Longitudinal Healthy Longevity Survey, we disaggregated tea drinking frequency and activities of daily living (ADL) measures and deployed fixed-effect ordered logit models to examine the tea-disability association for the first time. We statistically adjusted for potential confounders and conducted stratified analyses to assess heterogeneity across subpopulations.

Results

Multivariable fixed-effect ordered logistic regression suggested tea drinking has protective effects against ADL disability. However, only daily tea drinking was associated with lower risks of basic activities of daily living (BADL) disability [odds ratio (OR) = 0.61; 95% confidence interval (CI), 0.41-0.92] and lower levels of instrumental activities of daily living (IADL) disability (OR = 0.78; 95% CI, 0.64-0.95). Stratified analyses indicated heterogeneous effects across age and income groups. Daily tea drinking protected against BADL (OR = 0.26 and OR = 0.28) and IADL disability (OR = 0.48 and OR = 0.45) for adults over 83 years old and high-income households, respectively.

Conclusion

We found that drinking tea almost daily was protective against disability in elderly people, warranting further research into optimal dosages. Future studies should utilize more rigorous causal inference methods and control for confounders.

Gender, Pain, and Function Associated With Physical Activity After Hospitalization in Persons Living With Dementia

BACKGROUND

The purpose of this study was to identify factors that are associated with physical activity after hospitalization in persons living with dementia.

METHODS

Multiple linear regressions were conducted to test factors associated with objective activity levels (sedentary, low, moderate, and vigorous) among 244 patients living with dementia from a randomized controlled trial.

RESULTS

Within 48 hours of hospital discharge, time in sedentary behavior was associated with increased pain (β=0.164, P =0.015). Time in low activity was associated with less pain (β=-0.130, P =0.049) and higher physical function (β=0.300, P =<0.001). Time in moderate activity was associated with increased physical function (β=0.190, P =0.008) and male gender (β=0.155, P =0.016). No significant associations of potential factors were found with time in vigorous activity.

CONCLUSIONS

Our findings suggest that managing or reducing pain, encouraging individual functional level, and gender could influence time spent in physical activity after acute hospitalization in persons living with dementia.

The Association of Cognitive Impairment With Depressive Symptoms, Function, and Pain in Hospitalized Older Patients With Dementia

This study examined the associations between cognition and depressive symptoms, function, and pain among hospitalized older patients with dementia. We utilized baseline data of 461 hospitalized older patients with dementia who participated in an intervention study implementing Family-centered Function-focused Care (Fam-FFC) and conducted stepwise linear regression. On average, the participants (males = 189; 41% and females = 272; 59%) were 81.64 years old (Standard Deviation, SD = 8.38). There was a statistically significant association of cognition with depressive symptoms (b = -0.184, p < .001), functional status (b = 1.324, p < .001), and pain (b = -0.045, p < .001) when controlling for covariates. This study utilized a large sample of a relatively underrepresented population, hospitalized older adults with dementia, and addressed a topic with great clinical significance. Specific focus on testing and implementing best practices or interventions to support the clinical outcomes, and the cognitive function of hospitalized older adults with dementia is warranted in both practice and research.

Gender differences in interactions and depressive symptoms among hospitalized older patients living with dementia

Alzheimer's disease or a related dementia (ADRD) disproportionately affects women with two-thirds of individuals with ADRD comprised of women. This study examined gender-related differences in the quality of staff-patient interactions and depressive symptoms among hospitalized older patients living with dementia. This secondary analysis utilized baseline data of 140 hospitalized older patients with dementia who participated in the final cohort of a randomized controlled trial (ClinicalTrials.gov identifier: NCT03046121) implementing Family centered Function-focused Care (Fam-FFC). On average, the participants (male = 46.1%, female = 52.9%) were 81.43 years old (SD = 8.29), had positive interactions with staff and lower depressive symptoms based on Quality of Interaction Schedule (QUIS) scores and Cornell Scale for Depression in Dementia (CSDD) scores, respectively. Although males had more positive interactions (male = 6.06, SD = 1.13; female = 5.59, SD = 1.51) and lesser depressive symptoms (male = 7.52, SD = 4.77; female = 8.03, SD = 6.25) than females, no statistically significant gender differences were observed in linear models with appropriate covariates or multivariant analysis of covariant (MANCOVA). However, the multigroup regression conducted to further probe marginally significant moderation effect of gender and pain on staff-patient interactions demonstrated that greater pain was significantly related to lower quality or less positive staff-patient interactions for females compared to males (χ2diff (1) = 4.84, p = .03). Continued evaluation of gender differences is warranted to inform care delivery and interventions to improve care for hospitalized older patients with dementia.

Testing an Intervention to Improve Posthospital Outcomes in Persons Living With Dementia and Their Family Care Partners

Background and Objectives

Hospitalized persons living with dementia are at risk for functional decline, behavioral symptoms of distress, and delirium, all persisting in the postacute period. In turn, family care partners (FCPs) experience increased anxiety and lack of preparedness for caregiving, compounding existing strain and burden. Family-centered Function-focused Care (Fam-FFC) purposefully engages FCPs in assessment, decision-making, care delivery, and evaluation of function-focused care during and after hospitalization (within 48 hours of discharge, weekly telephone calls for a total of 7 additional weeks, then monthly for 4 months). The objective of this study was to test the efficacy of Fam-FFC.

Research Design and Methods

A cluster randomized controlled trial included 455 dyads of persons living with dementia and FCPs in 6 medical units in 3 hospitals. Patient outcomes included return to baseline physical function, behavioral symptoms of distress, depressive symptoms, and delirium severity. Family care partner measures included preparedness for caregiving, anxiety, strain, and burden.

Results

Multilevel level modeling demonstrated that the likelihood of returning to baseline function across time for Fam-FFC participants was twice that of the control group by the end of 6 months (OR = 2.4, p = .01, 95% CI 1.2-4.7). Family-centered Function-focused Care was also associated with fewer symptoms of distress (b = -1.1, SE = 0.56, p = .05) but no differences in the amount of moderate physical activity, depressive symptoms, and delirium severity. Preparedness for caregiving increased significantly only from 2 to 6 months (b = 0.89, SE = 0.45, d = 0.21, overall p = .02) in the intervention group, with no group differences in anxiety, strain, and burden.

Discussion and Implications

Family-centered Function-focused Care may help prevent some of the postacute functional decline and behavioral symptoms in hospitalized persons living with dementia. Further research is needed to promote sustained improvements in these symptoms with more attention to the postacute needs of the care partner.

Treatment Fidelity of the Family-Centered Function-Focused Care Intervention

The purpose of the current study was to evaluate treatment fidelity (i.e., the extent to which an intervention is provided as intended) in the Family-Centered Function-Focused Care (Fam-FFC) intervention. This was a descriptive study using data collected during intervention activities throughout the course of the Fam-FFC study. Specific measures included Environment and Policy Assessments, Fam-FFC Knowledge Test, Goal Attainment Scale, Function-Focused Care Behavior Checklist, and completion of the FamPath Audit. Delivery was provided as intended. Staff demonstrated intervention skills with only one Fam-FFC research nurse needing retraining. Receipt was based on Fam-FFC Knowledge Test scores >80%, with the majority of participants reporting goal achievement as expected or higher than expected and slight improvement in environments and policies to better support Fam-FFC. Lastly, enactment was based on evidence that in 67% of observations staff provided at least one function-focused care intervention. Findings from this study will be used to adapt the intervention to reach all staff, increase ways to change environments and policies, consider ways to more comprehensively evaluate enactment of function-focused care during real-world interactions, and consider the characteristics of nursing staff and whether a relationship exists between staff characteristics and providing function-focused care. [Research in Gerontological Nursing, 16(4), 165-171.].

The Modified Caregiver Strain Index in Black and White Dementia Caregivers at Hospital Discharge

OBJECTIVES

This study aimed to examine psychometric properties of the Modified Caregiver Strain Index (MCSI) in Black and White caregivers of persons living with dementia at hospital discharge.

METHODS

This was a cross-sectional study using baseline data of 423 family caregivers recruited from a cluster randomized clinical control trial. Factor structure, measurement invariance, and concurrent validity of the MCSI were analyzed. The moderating role of race on the relationship between MCSI score and anxiety, depression, and burden was also examined.

RESULTS

The two-factor model fits the data best and was invariant across race. Regarding concurrent validity, higher MCSI scores were significantly associated with higher scores on the (HADS-A; anxiety), (HADS-D; depression), and (ZBI; burden). Race moderated the relationship between MCSI score and anxiety, depression, and burden.

CONCLUSIONS

The MCSI is a valid tool to assess caregiver strain in Black and White caregivers of persons living with dementia during hospital discharge. Results suggest that the effect of MCSI score on anxiety, depression, and burden varies by race.

CLINICAL IMPLICATIONS

MCSI can be used by clinicians and service providers to help support the needs of Black and White caregivers of people living with dementia during post-hospital transition.

Delirium Mediates Incidence of Hospital-Associated Disability Among Older Adults

OBJECTIVE

To examine whether delirium predicts occurrence of hospital-associated disability (HAD), or functional decline after admission, among hospitalized older adults.

DESIGN

Retrospective cross-sectional study.

SETTING AND PARTICIPANTS

General inpatient (non-ICU) units of a large regional Southeastern US academic medical center, involving 33,111 older adults ≥65 years of age admitted from January 1, 2015, to December 31, 2019.

METHODS

Delirium was defined as a score ≥2 on the Nursing Delirium Screening Scale (NuDESC) during hospital admission. HAD was defined as a decline on the Katz Activities of Daily Living (ADL) scale from hospital admission to discharge. Generalized linear mixed models were used to examine the association between delirium and HAD, adjusting for covariates and repeated observations with multiple admissions. We performed multivariate and mediation analyses to examine strength and direction of association between delirium and HAD.

RESULTS

One-fifth (21.6%) of older adults developed HAD during hospitalization and experienced higher delirium rates compared to those not developing HAD (24.3% vs 14.3%, P < .001). Age, presence of delirium, Elixhauser Comorbidity Score, admission cognitive status, admission ADL function, and length of stay were associated (all P < .001) with incident HAD. Mediational analyses found 46.7% of the effect of dementia and 16.7% of the effect of comorbidity was due to delirium (P < .001).

CONCLUSIONS AND IMPLICATIONS

Delirium significantly increased the likelihood of HAD within a multivariate predictor model that included comorbidity, demographics, and length of stay. For dementia and comorbidity, mediation analysis showed a significant portion of their effect attributable to delirium. Overall, these findings suggest that reducing delirium rates may diminish HAD rates.

The effect of family-centered empowerment model on the quality of life of adults with chronic diseases: An updated systematic review and meta-analysis

BACKGROUND

Family-centered empowerment model (FCEM) is a concept that strengthens the family to help a chronic patient to obtain a better quality of life (QoL). The effects of FCEM on QoL of chronic patients are still inconclusive. Therefore, this meta-analysis was conducted to evaluate the effect of FCEM on QoL of adult patients with chronic diseases.

METHODS

Following an online search PubMed/MEDLINE, Scopus, Web of Science, ProQuest, OVID, EMBASE, EBSCO, PsycINFO and Persian databases (Irandoc, IranMedex, SID and MagIran), all studies that tested the impact of FCEM on QoL of patients with chronic diseases were included. Cochrane Risk of Bias Tool was used to assessment the quality of included randomized clinical trials (RCTs) and before/after studies. Analyses were conducted by STATA16.

RESULTS

Six hundred and ninety-seven studies were identified for screening. After screening process, 11 eligible studies were included in this meta-analysis. There were significant intervention effects in all QoL dimensions, physical and mental subscales and QoL total score (All P < 0.05). The minimum lower bound for SMD was 0.61 (95%CI: 0.96 to 1.66), indicating an increasing effect of the intervention on all QOL dimensions. The results showed substantial heterogeneity between the studies for all QoL dimensions, physical and mental subscales and QoL total scores (P < 0.001).

CONCLUSION

FCEM is an appropriate model with a simple and effective application for families with a patient suffering from a chronic illness. Nursing education planners and healthcare providers could benefit from this model for improving the nursing education curriculum and accrediting programs.

Reliability and Validity of the Neuropsychiatric Inventory-Questionnaire Using a Rasch Analysis

BACKGROUND AND PURPOSE

The purpose of this study was to expand on the limited psychometric testing of the NPI-Q, and extend testing to include hospitalized older adults.

METHOD

This was a descriptive study using data from 318 dyads in an ongoing cluster randomized clinical trial. Rasch analysis and hypothesis testing were done.

RESULTS

The majority of the participants were female (62%), non-Hispanic (98%), and black (50%) with a mean age of 81.62 (SD = 8.43). There was evidence of internal consistency and invariance across race and gender. The items fit with each subscale. Hypothesis testing was supported with a significant association between the NPI-Q and dementia and caregiver distress.

CONCLUSIONS

The NPI-Q is short, easy to complete, and reliable and valid when used with hospitalized older adults.

Factors Associated With Sleep Quality in Hospitalized Persons With Dementia

BACKGROUND

Factors associated with sleep quality have not been well examined in hospitalized older persons with dementia, who are at high risk for impaired sleep. The aim was to identify factors associated with sleep quality among hospitalized persons with dementia.

METHODS

This secondary analysis used baseline data from a cluster randomized trial. Factors examined included delirium severity, pain, depression, behavioral and psychological symptoms of dementia (BPSD), and daytime physical activity. Multiple stepwise linear regressions evaluated factors related to dimensions of sleep quality (sleep duration, efficiency, latency, and fragmentation; measured by the MotionWatch 8).

RESULTS

Increased daytime physical activity was associated with higher sleep duration [β=0.164; 95% confidence interval (CI), 0.111-0.717; P=0.008; 7.7% variance] and sleep efficiency (β=0.158; 95% CI, 0.020-0.147; P=0.010; 5.4% variance), and less sleep fragmentation (β=-0.223; 95% CI, -0.251 to -0.077; P<0.001; 10.4% variance). Higher BPSD was significantly associated with prolonged sleep latency (β=0.130; 95% CI, 0.098-2.748; P=0.035; 3.7% variance).

CONCLUSION

Results suggest the need to encourage daytime physical activity and reduce or manage BPSD to improve sleep quality among hospitalized persons with dementia.

Testing Function Focused Care for Acute Care using the Evidence Integration Triangle: Protocol description

This manuscript provides the protocol for a National Institute of Aging-funded cluster randomized clinical trial that focuses on helping nurses in acute care to engage patients with dementia in physical activity while hospitalized using an approach referred to as function-focused care. Physical activity is defined as bodily movement produced by skeletal muscles resulting in the expenditure of energy and includes functional tasks such as bathing and dressing, leisure activity, ambulation, and moderate and vigorous intensity physical activity such as dancing, bike riding, or walking upstairs. The development of Function Focused Care for Acute Care (FFC-AC) was based on the Social Ecological Model and Social Cognitive Theory and includes four steps: (1) Environment and Policy Assessments; (2) Education; (3) Establishing Patient Goals; and (4) Mentoring and Motivating of Staff (all levels of nursing staff), Patients, and Families. Function-focused care activities include motivating older patients to participate in bed mobility; personal care activities such as bathing, dressing, ambulating as they are able; and other types of physical activities. The integration of the intervention among the nurses on the units is guided by the Evidence Integration Triangle (EIT), which includes the participation of a stakeholder team and practical outcome measures. The intervention is therefore referred to as FFC-AC-EIT. In addition to describing the protocol developed to test the effectiveness and feasibility of FFC-AC-EIT, a description of ways to overcome some of the barriers and challenges that can be encountered with this study is provided.

Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients

BACKGROUND

Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention.  OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU).

SEARCH METHODS

We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium.  DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium.

MAIN RESULTS

We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies.  Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain.  Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I2 = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias).  There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I2 = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision).  No studies of multicomponent interventions reported data on new diagnoses of dementia.  Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I2 = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I2=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I2=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited.  Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm.  Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial.  Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I2 = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias).  Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention.  AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.

Evaluation of the Caregiver Preparedness Scale in African American and White Caregivers of Persons With Dementia During Post-Hospitalization Transition

BACKGROUND AND PURPOSE

The Preparedness for Caregiving Scale (PCS) is a widely used instrument to measure caregiver preparedness. The purpose was to evaluate the PCS in African American and White caregivers of patients with dementia upon discharge from the hospital.

METHODS

Factor structure, measurement invariance, and predictive validity of the PCS were assessed in a sample of 292 family caregivers/patient dyads.

RESULTS

One-factor structure of the PCS and measurement invariance by race was fully supported. Predicative validity revealed significant association between the PCS and anxiety (β = -.41, t = -7.61(287), p < .001), depression (β = -.44, t = -8.39(287), p < .001), and strain (β = -.48, t = -9.29(287), p < .001).

CONCLUSION

The PCS is a valid and meaningful tool to measure preparedness in African American and White family caregivers of persons with dementia during post-hospitalization transition.

Function-Focused Goal Attainment and Discharge Outcomes in Hospitalized Persons With Dementia

Hospitalized persons with dementia are at higher risk for functional decline and cognitive loss related to delirium. Family-centered, function-focused care (Fam-FFC) engages the family care partner in education and active participation in function-focused goal setting, implementation, and evaluation to support delirium prevention and abatement and return to baseline physical function. The purpose of the current study was to examine the association of function-focused goal attainment with two discharge outcomes, return to baseline physical function and delirium severity at discharge, in hospitalized persons with dementia. In the ongoing Fam-FFC clinical trial, the majority of goals (N = 433) developed by 134 care partner/patient dyads and nurses address mobility, cognitive stimulation, and self-care. Regression techniques demonstrated that goal attainment was significantly associated with return to baseline function (B = 0.826, Wald = 4.17 [1], p = 0.041) and lower delirium severity at discharge (B = 0.175, t = 2.239, p = 0.027). Results support the contribution of family engagement in promoting functional recovery of hospitalized persons with dementia. [Journal of Gerontological Nursing, 47(9), 13-20.].

Recruiting and Retaining Dyads of Hospitalized Persons with Dementia and Family Caregivers

Persons with dementia have high rates of hospitalization, and along with their caregivers commonly experience negative hospital outcomes. The recruitment and retention of acutely ill older adults with dementia and caregivers can pose a challenge to investigators and threaten the validity of findings. The challenges encountered in an ongoing cluster randomized clinical trial in dyads of hospitalized persons with dementia and family care partners are described. The trial tests the efficacy of a nurse-family partnership model that aims to improve the following: (a) the physical and cognitive recovery in hospitalized persons with dementia, and (b) caregiver preparedness and anxiety. Strategies that address challenges include careful preplanning and preparation with the hospital site, strong communication with dyads and between team members, and honoring preferences and needs related to communication.

Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients

BACKGROUND

Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention.  OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU).

SEARCH METHODS

We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium.  DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium.

MAIN RESULTS

We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies.  Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain.  Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I2 = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias).  There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I2 = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision).  No studies of multicomponent interventions reported data on new diagnoses of dementia.  Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I2 = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I2=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I2=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited.  Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm.  Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial.  Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I2 = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias).  Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention.  AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.

Physical Activity in Hospitalized Persons With Dementia: Feasibility and Validity of the MotionWatch 8

Persons with dementia are at high risk for hospital-acquired disability, associated with low physical activity during hospitalizations. To determine the effectiveness of efforts to increase physical activity, a valid and reliable measurement approach is required. Data from an ongoing cluster randomized clinical trial examined the feasibility and validity of the MotionWatch 8 (MW8) triaxial actigraphy device. The sample included 321 participants of which 259 (81%) were willing to wear the MW8 for 24 hr. Regression analysis revealed that time in low activity, β = 0.17, t(255) = 2.9, p = .004, and time in moderate activity, β = 0.14, t(255) = 2.4, p = .017, measured by the MW8, were associated with participants' physical function. Engagement in moderate physical activity was associated with return to baseline function at discharge (Wald χ2 = 4.10, df = 1, p = .043). The study provides preliminary support for the feasibility and validity of the MW8 in hospitalized persons with dementia.

Pain Incidence, Treatment, and Associated Symptoms in Hospitalized Persons with Dementia

BACKGROUND

Moderate to severe pain has been frequently reported in hospitalized older adults. Pain in hospitalized persons with dementia within the context of other common symptoms, functional decline, delirium, and behavioral and psychological symptoms of dementia (BPSD), has received little attention.

AIMS

Describe the incidence of pain, the pharmacologic management of pain, and the association of pain with physical function, delirium, and BPSD in hospitalized persons with dementia.

DESIGN

Descriptive, cross-sectional study.

SETTING

Six medical units in three hospitals.

PARTICIPANTS

Baseline data from 299 hospitalized persons with dementia enrolled in the Family-centered Function-focused Care (Fam-FFC) cluster randomized trial.

METHODS

Descriptive analyses of pain used the Pain Assessment in Advanced Dementia (PAINAD) scale and the use of medication for pain management. Linear regression analyses tested relationships between pain and:1) physical function (Barthel Index), 2) delirium severity (Confusion Assessment Method Severity Short Form) and 3) BPSD severity (Neuropsychiatric Inventory- Questionnaire).

RESULTS

The majority of the sample was female (61.9%), non-Hispanic (98%), and Black (53.2%), with a mean age of 81.58 (SD=8.54).Of the 299 patients, 166 (56%) received pain medication. Of the 108 individuals who demonstrated pain, 40% (n=43) did not receive pain medication. When controlling for age, gender, cognition, and comorbidities, pain was significantly associated with function, delirium severity, and BPSD severity.

CONCLUSIONS

Results suggest that pain may be undertreated in hospitalized persons with dementia, and should be considered upon admission to optimize function, decrease delirium, and prevent or decrease BPSD.

Disparities in Physical and Psychological Symptoms in Hospitalized African American and White Persons with Dementia

Objectives: This study examined differences in physical function, delirium, depressive symptoms, and behavioral and psychological symptoms of dementia (BPSD) in hospitalized African American and white older adults with dementia. Methods: This secondary data analysis using baseline data from an ongoing trial testing family-centered function-focused care included African American (n = 159) and white persons (n =135) with dementia. Results: A multivariate analysis of covariance showed that controlling for relevant demographic and health characteristics, African Americans with dementia had lower physical function, more delirium, and more depressive symptoms upon admission than white participants. There were no significant differences in BPSD between African American and white persons. Discussion: To our knowledge, this is the first study to examine racial differences in admission symptoms of hospitalized persons with dementia. While the findings are preliminary, they can be used to inform the design of future research, including identifying the causes of disparities.

Hospital Disparities between Native Hawaiian and Other Pacific Islanders and Non-Hispanic Whites with Alzheimer's Disease and Related Dementias

Objective: To compare important indicators of quality of care between Native Hawaiians and other Pacific Islanders (NHOPIs) and non-Hispanic Whites (NHWs) with Alzheimer's disease and related dementias (ADRD). Methods: We used the Health Care Cost and Utilization Project, Hawaii State Inpatient Databases, 2010-2014. They included 10,645 inpatient encounters from 7,145 NHOPI or NHW patients age ≥ 50 years, residing in Hawaii, and with at least one ADRD diagnosis in the discharge record. Outcome variables were inpatient mortality, length of hospital stay, and hospital readmission. Results: NHOPIs with ADRD had, on average, a hospital stay of .94 days less than NHWs with ADRD but were 1.16 times more likely than NHWs to be readmitted. Discussion: These patterns have important clinical care implications for NHOPIs and NHWs with ADRD as they are important indicators of quality of care. Future studies should consider specific contributors to these differences in order to develop appropriate interventions.