Minimal clinically important difference in the World Health Organization Quality of Life Brief (WHOQOL-BREF) for adults with neurofibromatosis

PURPOSE

This study aimed to estimate minimal clinically important difference (MCID) values for the World Health Organization Quality of Life Brief version (WHOQOL-BREF) among adults with neurofibromatosis (NF). An MCID is needed to demonstrate clinical meaningfulness of interventions for NF.

METHODS

We estimated MCID for the WHOQOL-BREF: the quality of life (QoL) measure recommended by the Response Evaluation in Neurofibromatosis and Schwannomatosis International Collaboration. We used data from 228 clinical trial participants with NF type 1, NF type 2-related schwannomatosis, or schwannomatosis (SCHWN) who completed 10 weeks of a virtual group mind-body program targeting resiliency or a time- and attention-matched control. Following established guidelines, we estimated MCIDs using both anchor-based and distribution-based methods for physical, psychological, social relationships, and environmental domains of the WHOQOL-BREF.

RESULTS

MCID results varied across method and QoL domain. Three anchor-based methods, average change (AC), change difference (CD), and regression (REG), yielded the most consistent and comparable MCID across QoL domains. Based on these methods, we recommend ranges for each QoL domain: Physical QoL (3.9-7.3), Psychological QoL (4.7-8.1), Social QoL (2.6-5.9), and Environmental QoL (4.1-6.6).

CONCLUSION

Establishing a rigorous MCID for QoL in NF is a critical step toward evaluating meaningful change in response to psychosocial interventions.

Exploring mechanisms of improvement in the Active Brains intervention for older adults with chronic pain and early cognitive decline

OBJECTIVES

We iteratively developed, optimized, and established the feasibility of a virtual, group-based, mind-body activity program (Active Brains, AB), supported by Fitbit for older adults with chronic pain (CP) and early cognitive decline (ECD). Guided by the principles of the NIH stage model we 1) explore signals of improvement in AB outcomes and hypothesized mechanisms of action and 2) explore relationships between changes in outcomes with changes in mechanisms.

METHODS

Participants were N = 15 older adults (age ≥ 60) with CP-ECD from two NIH stage 1 pilot studies of AB. We conducted paired t-tests to explore pre-post improvements, and correlations to investigate associations between changes in outcomes and mechanisms.

RESULTS

We observed small to large improvements across co-primary and secondary outcomes (d = 0.24-1.09). We observed small to medium improvements in 4 out of 5 hypothesized mechanisms (d = 0.23-0.47). Overall, improvements in outcomes had moderate to large associations with improvements in hypothesized mechanisms.

CONCLUSION

AB was associated with improvements across several co-primary and secondary outcomes, and hypothesized mechanisms. Pain-specific coping and general coping skills are promising treatment targets to address the CP-ECD comorbidity among older adults.

Breaking the Disability Spiral: A Case Series Report Illustrating the Delivery of a Brief Skills Based Coaching Intervention to Prevent Chronic Dysfunction and Pain After Orthopedic Injury

Orthopedic traumas are common, costly, and burdensome - particularly for patients who transition from acute to chronic pain. Psychosocial factors, such as pain catastrophizing and pain anxiety, increase risk for poor outcomes after injury. The Toolkit for Optimal Recovery (TOR) is a novel multi-component mind-body intervention informed by the fear-avoidance model to promote re-engagement in daily activities and prevent transition toward chronic pain and physical dysfunction. The current case series aims to 1) describe the intervention and 2) showcase the treatment course of three TOR completers from diverse geographic locations in the U.S. with distinct injury types and varying personal identities to illustrate how the intervention can be delivered flexibly. Results indicate pre-to-post program improvement in physical function, pain severity, pain catastrophizing, pain anxiety, and other relevant outcomes targeted by the intervention (i.e., depression, mindfulness, coping). Experiences of our three TOR completers suggest that integrating TOR with standard orthopedic care may promote physical recovery after injury.

Palliative Care Interventions for Persons With Neurodegenerative Disease: A Scoping Review of Clinical Trial Study Design Features

Background: Within palliative care research, best practice guidelines to conduct scientifically rigorous clinical trials for neurodegenerative diseases are underexplored. This patient population experiences unique challenges, including fluctuations in cognitive capacity, care partner (CP) and proxy involvement, and high adverse events (AEs), that necessitate special consideration when designing clinical trials. Objective: The objective of this study was to describe and identify clinical trial design features that have been documented in studies involving a neuropalliative intervention for persons with neurodegenerative diseases, highlighting features that have been adapted for this unique patient population. Design: We conducted a scoping review of clinical trials with a neuropalliative intervention for persons with neurodegenerative disease. We searched Cochrane, Web of Science, EMBASE, Scopus, and PubMed (MEDLINE) databases for articles published in English between 1950 and 2023. Two reviewers screened, extracted, and synthesized data from the included articles. A third reviewer adjudicated instances of conflict. The data were analyzed using a thematic framework approach. Results: Of 1025 texts, 44 articles were included. Seven study design features were analyzed: (1) consent, (2) proxies and CPs, (3) recruitment strategies, (4) retention strategies, (5) choice of comparator, (6) AEs, and (7) internal validity. This scoping review found disparities in study design features around structured consent, proxies and CPs, comparators, and AEs. Conclusions: To date, neuropalliative care clinical trials have had varied study designs and the majority of research has focused on dementia. Research guideline development for high-quality neuropalliative care clinical trials is greatly needed across the range of neurodegenerative diseases. To increase the scientific rigor of clinical trials and neuropalliative care, we recommend a standardized capacity assessment for consent, defining conditions for the CP, proxy, and AEs, systematizing appropriate comparators, and outlining preemptive recruitment and retention strategies to address the broader unpredictable challenges of palliative care research.

Depression Negatively Impacts Dyadic Quality of Life Following Neuro-ICU Admission: A Prospective Study of Cognitively Intact Patients and Caregivers

BACKGROUND

Admission to a neurological intensive care unit (Neuro-ICU) can increase risk for depressive and anxiety symptoms for both patients and caregivers. To better understand the long-term mental health impact of a Neuro-ICU admission, we examined the dyadic interdependence between depression and anxiety at Neuro-ICU admission with 3-month quality of life (QoL) for patients and caregivers in a longitudinal, observational cohort study.

METHOD

We assessed depressive and anxiety symptoms (Hospital Anxiety and Depression Scale; HADS) reported by neurologically intact patients (n = 72) and their caregivers (n = 72) within 2 weeks of Neuro-ICU admission (baseline) and 3-months post-discharge (follow-up). We examined the longitudinal association between dyadic depression and anxiety at Neuro-ICU admission and 3-month QoL (World Health Organization; QOL-BREF) across four domains (Physical, Psychological, Social relationships, and Environmental QoL) in separate actor-partner interdependence models (APIM) for patients and caregivers.

RESULTS

In the overall models, patients' own baseline depression levels were negatively associated with their own 3-month QoL in all domains (β =  - 0.53 to - 0.64, p < 0.001), and for caregivers, only in the psychological (β =  - 0.73, p < .001) and social relationships (β =  - 0.56, p < .001) domains. No actor effects were found for one's own baseline anxiety impacting one's own 3-month QoL. Partner effects for one's own depression were significant for caregivers on patients' 3-month psychological (β =  - 0.26, p < .02) and environmental (β =  - 0.29, p < .03) QoL, as well as for patients on caregiver's 3-month psychological QoL (β = 0.25, p < .02). No partner effects were significant in association with baseline anxiety and 3-month QoL in both patients and caregivers.

CONCLUSION

Neuro-ICU patients' and caregivers' baseline depression has significant negative impacts on their own long-term QoL. Caregivers demonstrate significant negative impacts on patient long-term QoL in domains related to emotional distress and caregiver burden. Early identification of mental health symptoms, especially depression, during Neuro-ICU admission may provide an intervention opportunity to improve QoL post-discharge for both dyad members.

Association Between Subjective Cognitive Decline and Twice-Weekly Muscle-Strengthening Activities in Middle-Aged and Older US Adults: An Analysis of the 2019 Behavioral Risk Factor Surveillance System

PURPOSE

Adults with subjective cognitive decline (SCD), the self-reported concern of reduced cognitive function, are recommended to do physical activity for its brain health benefits. US adults aged ≥45 with SCD are less likely to meet the American College of Sports Medicine (ACSM) aerobic activity recommendations. Their engagement in muscle-strengthening activities is unknown. We aimed to identify if US adults aged ≥45 with SCD are less likely to do twice-weekly muscle-strengthening activities compared to those without SCD.

DESIGN

Secondary analysis of the 2019 Behavioral Risk Factor Surveillance System (BRFSS) data.

SAMPLE

114 164 respondents, representing approximately 59 million US adults aged ≥45.

MEASURES

SCD was indicated if the respondent reported confusion or memory loss during the past 12 months (yes/no). Respondents reported the frequency of muscle-strengthening activities, which we categorized as meeting the ACSM's recommendations (2+ times per week) or not (<2 times per week).

ANALYSIS

Crude and adjusted logistic regression models controlling for variables associated with SCD and muscle-strengthening activities. The models used sample weights to represent US adults in the included 31 states and Washington D.C.

RESULTS

US adults aged ≥45 with SCD were less likely to do twice-weekly muscle-strengthening activities than those without SCD (28.6% [SE: .8%] vs 33.5% [SE: .3%], adjusted OR, .9; 95% CI: .9-1.0).

CONCLUSION

Primary care providers should encourage middle-aged and older patients to engage in muscle-strengthening and aerobic activities.

Association of Osteoarthritis and Functional Limitations With Cognitive Impairment Among Older Adults in the United States

Objective: Given overlapping pathophysiology, this study sought to assess the association between osteoarthritis (OA), functional impairment, and cognitive impairment in the aging population. Methods: The National Health and Nutrition Examination Survey was used to identify participants >60 years of age. We analyzed multivariable associations of grouped participants that underwent cognitive function testing using linear and logistic regression, adjusting for sex, age, race, and ethnicity. Results: Of 2776 identified participants representing a population of 50,242,917, 40% did not report OA or functional limitations; 21% had OA but not functional limitations; 15% did not have OA but had functional limitations; 17% had OA and related functional limitations; and 7% had OA and non-arthritic functional limitations. OA was not independently associated with cognitive impairment. Contrarily, functional limitations were associated with cognitive impairment regardless of OA diagnosis. Discussion: Cognitive impairment is not associated with OA, but rather functional limitations, potentially guiding future intervention.

Addressing the Chronic Pain-Early Cognitive Decline Comorbidity Among Older Adults: Protocol for the Active Brains Remote Efficacy Trial

BACKGROUND

Chronic pain and early cognitive decline, which are costly to treat and highly prevalent among older adults, commonly co-occur, exacerbate one another over time, and can accelerate the development and progression of Alzheimer disease and related dementias. We developed the first mind-body activity program (Active Brains [AB]) tailored to the needs of older adults with chronic pain and early cognitive decline. Results from our previous study strongly supported the feasibility of conducting AB remotely and provided evidence for improvements in outcomes.

OBJECTIVE

We are conducting a single-blinded, National Institutes of Health stage-2, randomized clinical trial to establish the efficacy of AB versus a time-matched and dose-matched education control (Health Enhancement Program [HEP]) in improving self-reported and objective outcomes of physical, cognitive, and emotional functions in 260 participants. The methodology described in this paper was informed by the lessons learned from the first year of the trial.

METHODS

Participants are identified and recruited through multidisciplinary clinician-referred individuals (eg, pain psychologists and geriatricians), the Rally Research platform, social media, and community partnerships. Interested participants complete eligibility screening and electronic informed consent. Baseline assessments include self-report, performance-based measures (eg, 6-min walk test) and objective measures (eg, Repeatable Battery for the Assessment of Neuropsychological Status). Participants are mailed a wrist-worn ActiGraph device (ActiGraph LLC) to passively monitor objective function (eg, steps) during the week between the baseline assessment and the beginning of the programs, which they continue to wear throughout the programs. After baseline assessments, participants are randomized to either AB or HEP and complete 8 weekly, remote, group sessions with a Massachusetts General Hospital psychologist. The AB group receives a Fitbit (Fitbit Inc) to help reinforce increased activity. Assessments are repeated after the intervention and at the 6-month follow-up. Coprimary outcomes include multimodal physical function (self-report, performance based, and objective). Secondary outcomes are cognitive function (self-report and objective), emotional function, and pain.

RESULTS

We began recruitment in July 2022 and recruited 37 participants across 4 cohorts. Of them, all (n=37, 100%) have completed the baseline assessment, 26 (70%) have completed the posttest assessment, and 9 (24%) are actively enrolled in the intervention (total dropout: n=2, 5%). In the three cohorts (26/37, 70%) that have completed the AB or HEP, 26 (100%) participants completed all 8 group sessions (including minimal makeups), and watch adherence (1937/2072, 93.48%, average across ActiGraph and Fitbit devices) has been excellent. The fourth cohort is ongoing (9/37, 24%), and we plan to complete enrollment by March 2026.

CONCLUSIONS

We aim to establish the efficacy of the AB program over a time-matched and dose-matched control in a live video-based trial and test the mechanisms through theoretically driven mediators and moderators. Findings will inform the development of a future multisite effectiveness-implementation trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05373745; https://classic.clinicaltrials.gov/ct2/show/NCT05373745.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47319.

Increasing the Repertoire for Depression Care: Methods and Challenges of a Randomized Controlled Trial of Peer Support for Vulnerable Older Adults

OBJECTIVE

Low-income White and older adults of color face barriers to depression care. Our purpose is to describe the methods and challenges encountered during the implementation of a randomized controlled trial to test the effectiveness of a peer support depression care intervention for low-income White and older adults of color during the COVID-19 pandemic.

METHODS

Peer Enhanced Depression Care (Peers) is an 8-week community-based intervention that uses peer mentors who are trained and supervised to provide social support and self-care skills to depressed older adults. The effectiveness of the intervention in reducing depression will be evaluated by following a sample of older adults recruited in the community over a 12-month period. Target enrollment is 160 older adults. We hypothesize that participants randomized to the Peer Enhanced Depression Care intervention will experience greater decrease in depressive symptoms compared to participants randomized to the social interaction control. We provide lessons learned regarding the recruitment of BIPOC and White low-income older adults and peer mentors during the COVID-19 pandemic.

RESULTS

Recruitment challenges occurred in primary care clinics that were unable to accommodate recruitment efforts during the pandemic. This led to focused outreach to community-based organizations serving older adults. Challenges to participant recruitment have included barriers related to stigma, distrust, as well as unfamiliarity with research. Peer mentor recruitment was facilitated by existing government-supported resources.

CONCLUSIONS

This study will provide knowledge regarding the effectiveness, mechanism, and processes of delivering an informal psychosocial intervention such as peer support to a vulnerable older adult population.

Fitbit Activity, Quota-Based Pacing, and Physical and Emotional Functioning Among Adults With Chronic Pain

Physical activity can improve function in patients with chronic pain, however, adherence is low, in part due to inconsistent activity patterns. Smart wearable activity trackers, such as Fitbits, may help promote activity. In our program for chronic pain, we examined: 1) Fitbit activity patterns (ie, step count, moderate-to-vigorous physical activity (MVPA), sedentary behavior), and 2) whether achievement of weekly, individualized Fitbit step goals was associated with functional outcomes. We conducted a secondary analysis of Fitbit data from our 10-week mind-body activity program for chronic pain (GetActive-Fitbit arm, N = 41). Participants self-reported emotional and physical function and completed performance-based and accelerometer-based assessments. From week 1 to week 10, 30% of participants increased >800 steps; 32.5% increased MVPA; and 30% decreased sedentary behavior. Only step count significantly changed across time with mean steps peaking at week 8 (M = +1897.60, SD = 467.67). Fitbit step goal achievement was associated with improvements in anxiety (ß = -.35, CI [-2.80, -.43]), self-reported physical function (ß = -.34, CI [-5.17, 8.05]), and performance-based physical function (ß = .29, CI [-71.93, 28.38]), but not accelerometer-based physical function or depression. Adhering to individualized Fitbit step goals in the context of a mind-body activity program may improve anxiety and self-reported and performance-based physical function. PERSPECTIVE: We examine Fitbit activity patterns and the association between quota-based pacing and functional outcomes within a mind-body activity program for adults with chronic pain. Complementing quota-based pacing and coping skills with Fitbits may be a useful approach to promote activity engagement and behavior change in chronic pain populations.

Older adults can use technology: why healthcare professionals must overcome ageism in digital health

Older adults rapidly adopted technology for healthcare, known as digital health, during the COVID-19 pandemic. Older adults are increasingly using telehealth, smartphone apps, and other digital health technologies to reduce barriers to care, maintain patient-provider communication, and promote disease self-management. Yet, many healthcare professionals have maintained outdated beliefs rooted in societal ageism that digital health and older adults are incompatible. As a result, older adults have been disproportionally excluded from health services and clinical trials that use digital health relative to their younger counterparts. In this commentary, we urge all healthcare disciplines to challenge ageist beliefs and practices that have contributed to the "digital health divide" among older patients. We provide examples of evidence-based strategies and current scientific initiatives that can promote digital health inclusion in research, clinical practice, and training. By achieving digital health inclusion, we can increase access, provide preventative and comprehensive care, and decrease healthcare costs for older patients.

My Healthy Brain: a multimodal lifestyle program to promote brain health

BACKGROUND

Promoting brain health depends on sustaining healthy behaviors across the lifespan. Yet, public adoption of lifestyle behaviors and knowledge of cognitive decline (CD) prevention remains poor. Our multidisciplinary team developed My Healthy Brain (MHB) to promote a healthy lifestyle (e.g. diet, exercise, alcohol, sleep) and build cognitive reserve (e.g. memory compensatory strategies). Our objective was to demonstrate early proof-of-concept for MHB by exploring the feasibility, acceptability, and improvement in primary lifestyle outcomes as well as secondary outcomes of self-determination and subjective wellbeing.

MATERIALS AND METHODS

Older adults with subjective (self-report only) or objective (confirmed by cognitive testing) CD, referred by neurologists to modify lifestyle risk factors (e.g. sedentary), participated in a non-randomized open pilot of MHB (N = 24). Participants completed the 8-week MHB group (90 min each) and pre-post outcome measures.

RESULTS

MHB met all a-priori set benchmarks, including good feasibility of recruitment (71% of patients screened) and enrollment (75% completed baseline), and good acceptability of treatment (75% completed 6 of 8 sessions and post-testing). Program satisfaction was excellent (100% of participants) and no adverse events were reported. We also observed improvements in primary lifestyle outcomes as well as secondary outcomes of self-determination and subjective well-being.

DISCUSSION

While MHB demonstrated preliminary feasibility and the potential to modify lifestyle risk factors for CD, the program can be improved. Future work will explore the integration of mindfulness skills with behavioral principles to bolster multidomain lifestyle change, and the live video delivery format to bypass barriers to participation.

Emotional distress in neuro-ICU survivor-caregiver dyads: The recovering together randomized clinical trial

OBJECTIVE

Emotional distress is common in both survivors and their informal caregivers following admission to a neuroscience intensive care unit (Neuro-ICU) and can negatively affect their individual recovery and quality of life. Neuro-ICU survivor-caregiver dyads can influence each other's emotional distress over time, but whether such influence emerges during dyadic treatment remains unknown. The present study involved secondary data analysis of Neuro-ICU dyads enrolled in a randomized clinical trial of a dyadic resiliency intervention, Recovering Together (RT), versus a health education attention placebo control to test dyadic similarities in emotional distress before and after treatment.

METHOD

Data were collected from 58 dyads following Neuro-ICU admission. Emotional distress (depression, anxiety, and posttraumatic stress) was assessed at baseline, 6 weeks (postintervention), and 12 weeks later. Nonindependence within survivor-caregiver dyads was examined (i.e., correlations between cross-sectional symptoms and changes in symptoms over time); mutual influence of emotional functioning over time (i.e., "partner effects") was examined using cross-lagged path analyses.

RESULTS

There were strong, positive cross-sectional correlations between survivor and caregiver distress at postintervention and follow-up and between changes in survivor and caregiver distress from baseline to postintervention and postintervention to follow-up. There were no partner effects.

CONCLUSIONS

Neuro-ICU survivors and their informal caregivers show similar changes in emotional distress after treatment. These findings highlight the potential benefits of intervening on both survivor and caregiver distress following Neuro-ICU admission. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Adaptation and virtual feasibility pilot of a mindfulness-based lifestyle program targeting modifiable dementia risk factors in older adults

OBJECTIVES

We developed a group-based program (My Healthy Brain, MHB) to engage older adults at-risk for dementia in healthy lifestyles. We report on a two-part study to adapt MHB by incorporating mindfulness skills, using mobile health technology to monitor and reinforce behaviors, and delivering it via live video.

METHODS

Participants were older adults (age ≥ 60) with subjective cognitive decline (SCD) and at least one lifestyle risk factor. In Aim 1 (n = 11, 2 groups), we conducted focus groups to obtain qualitative feedback on proposed adaptations. In Aim 2 (n = 10), we conducted a virtual open pilot with exit interviews to explore the feasibility and outcomes of the adapted MHB.

RESULTS

Thematic analysis revealed: (1) barriers and facilitators to healthy lifestyles, (2) positive impressions of MHB, (3) interest in mindfulness skills, and (4) openness to study technologies. MHB met a-priori feasibility benchmarks and was associated with improvements in cognition, lifestyle (e.g. physical function), and proposed mechanisms (e.g. mindfulness). Exit interviews confirmed high feasibility and satisfaction.

CONCLUSION

The integration of mindfulness, live video, and mobile health technologies was feasible and promising for improving healthier lifestyles. The results inform the next feasibility RCT of MHB to prepare for efficacy testing.

Supplemental data for this article is available online at http://dx.doi.org/10.1080/13607863.2022.2032600.

My Healthy Brain: Rationale and Case Report of a Virtual Group Lifestyle Program Targeting Modifiable Risk Factors for Dementia

Nearly half of dementia cases may be explained by modifiable lifestyle risk factors. Multidomain interventions are needed to bypass cognitive decline (CD) and aging-related barriers to sustained healthy lifestyles in at-risk older adults. We iteratively developed  My Healthy Brain, a group-based lifestyle program (8 weeks, 90 min sessions) delivered via live video that applies behavioral principles to target multiple risk factors for dementia. We describe the program structure, virtual delivery, and outcomes for a group of older adults with subjective CD or mild cognitive impairment and lifestyle risk factors (e.g., sedentary, poor sleep or diet). We also conducted a group exit interview to qualitatively assess participant experiences and elicit feedback to improve My Healthy Brain. This case report demonstrates that delivering evidence-based brain health education and behavior change skills in a group setting via live video is feasible, acceptable, and has the potential to improve lifestyle, cognitive, and psychosocial outcomes in older adults with CD.

Can a Dyadic Resiliency Program Improve Quality of Life in Cognitively Intact Dyads of Neuro-ICU Survivors and Informal Caregivers? Results from a Pilot RCT

BACKGROUND

Neuro-ICU hospitalization for an acute neurological illness is often traumatic and associated with heightened emotional distress and reduced quality of life (QoL) for both survivors and their informal caregivers (i.e., family and friends providing unpaid care). In a pilot study, we previously showed that a dyadic (survivor and caregiver together) resiliency intervention (Recovering Together [RT]) was feasible and associated with sustained improvement in emotional distress when compared with an attention placebo educational control. Here we report on changes in secondary outcomes assessing QoL.

METHODS

Survivors (n = 58) and informal caregivers (n = 58) completed assessments at bedside and were randomly assigned to participate together as a dyad in the RT or control intervention (both 6 weeks, two in-person sessions at bedside and four sessions via live video post discharge). We measured QoL domain scores (physical health, psychological, social relations, and environmental), general QoL, and QoL satisfaction using the World Health Organization Quality of Life Abbreviated Instrument at baseline, post treatment, and 3 months' follow-up. We conducted mixed model analyses of variance with linear contrasts to estimate (1) within-group changes in QoL from baseline to post treatment and from post treatment to 3 months' follow-up and (2) between-group differences in changes in QoL from baseline to post treatment and from post treatment to 3 months' follow-up.

RESULTS

We found significant within-group improvements from baseline to post treatment among RT survivors for physical health QoL (mean difference 1.73; 95% confidence interval [CI] 0.39-3.06; p = 0.012), environmental QoL (mean difference 1.29; 95% CI 0.21-2.36; p = 0.020), general QoL (mean difference 0.55; 95% CI 0.13-0.973; p = 0.011), and QoL satisfaction (mean difference 0.87; 95% CI 0.36-1.37; p = 0.001), and those improvements sustained through the 3-month follow-up. We found no significant between-group improvements for survivors or caregivers from baseline to post treatment or from post treatment to 3 months' follow-up for any QoL variables (i.e., domains, general QoL, and QoL satisfaction together).

CONCLUSIONS

In this pilot study, we found improved QoL among survivors, but not in caregivers, who received RT and improvements sustained over time. These RT-related improvements were not significantly greater than those observed in the control. Results support a fully powered randomized controlled trial to allow for a definitive evaluation of RT-related effects among dyads of survivors of acute brain injury and their caregivers.

Virtual Mind-Body Program for Obese Knee Osteoarthritis Patients with Comorbid Depression: Development and Feasibility Pilot (Preprint)

Background

Knee osteoarthritis (KOA) is the most common joint disorder in the United States and a leading cause of disability. Depression and obesity are highly comorbid with KOA and accelerate knee degeneration and disability through biopsychosocial mechanisms. Mind-body physical activity programs can engage biological, mechanical, and psychological mechanisms to improve outcomes in KOA, but such programs are not currently available.

Objective

This mixed methods study aims to adapt a mind-body activity program for the unique needs of patients with KOA, depression, and obesity (GetActive-OA) delivered via live video.

Methods

Participants were adults (aged ≥45 years) from rural Kentucky with obesity (BMI≥30 kg/m²), idiopathic KOA with mild to moderate radiographic changes, and elevated depressive symptoms (9-item Patient Health Questionnaire ≥10) recruited from 2 orthopedic centers. In phase 1, we developed GetActive-OA and the study protocol using qualitative focus group feedback from the study population (N=9; 2 focus groups, 90 minutes) and multidisciplinary expertise from clinical psychologists and orthopedic researchers. In phase 2, we explored the initial feasibility, credibility, and acceptability of GetActive-OA, live video delivery, and study procedures via an open pilot with exit interviews (N=5; 1 group). This research was guided by National Institutes of Health (NIH) model stage IA.

Results

Phase 1 qualitative analyses revealed nuanced information about challenges with coping and increasing activity, high interest in a mind-body activity program, program participation facilitators (flexibility with technology) and barriers (amotivation and forgetfulness), and perceived challenges with data collection procedures (blood and urine samples and homework). Phase 2 quantitative analyses showed that GetActive-OA met most a priori feasibility markers: acceptability (80%), expectancy (100%), credibility (100%), clinician adherence (90%), homework adherence (80%), questionnaire data collection (100%), program satisfaction (100%), and safety (100%). Adherence to ActiGraph wear (80% baseline, 20% posttest) and collection of blood samples (60%) were low. Participation in GetActive-OA was associated with signals of improvements in general coping (Cohen d=2.41), pain catastrophizing (Cohen d=1.24), depression (Cohen d=0.88), anxiety (Cohen d=0.78), self-efficacy (Cohen d=0.73), pain (Cohen d=0.39), and KOA symptoms (Cohen d=0.36). Qualitative exit interviews confirmed quantitative findings and provided valuable information to optimize the program and protocol.

Conclusions

Patients with KOA, depression, and obesity from rural Kentucky were interested in a live video mind-body activity program. GetActive-OA shows promise; however, the program and protocol require further NIH stage I refinement before formal efficacy testing (NIH model stage II).

International Registered Report Identifier (IRRID)

RR2-10.1016/j.conctc.2021.100720

Psychological resiliency explains the relationship between emotional distress and quality of life in neurofibromatosis

PURPOSE

Neurofibromatoses (NF; NF1, NF2, and schwannomatosis) are incurable tumor suppressor syndromes with heterogeneous symptoms. Emotional distress (e.g., depression, anxiety, stress) is common in NF and impairs quality of life (QoL). Several modifiable dimensions of resiliency can contribute to enhanced QoL in medical populations but have been overlooked as treatment mechanisms for NF. Our goal was to determine, using data from an ongoing efficacy RCT testing a mind-body program for NF, if resiliency explains the relationship between emotional distress and QoL.

METHODS

We performed structural equation modeling mediation analysis on baseline measures of QoL (physical health, psychological, social relationships, environmental), emotional distress (depression, anxiety, stress), and resiliency (gratitude, optimism, coping, mindfulness, empathy) completed by adults with NF (N = 228). We controlled for variables known to impact psychosocial functioning in NF (age, diagnosis, learning disability, and education).

RESULTS

After adjusting for covariates, resiliency had a significant and large indirect effect on the negative relationship between emotional distress and QoL (CSIE = - 0.31, 95% CI = - 0.59 to - 0.19, p = .001). The direct effect of emotional distress on QoL was smaller but remained significant (β = - 0.23, 95% CI = - 0.44 to - 0.03, p = .03), suggesting partial mediation through resiliency.

CONCLUSIONS

Resiliency may buffer the high rates of emotional distress in NF. Mind-body interventions targeting multiple modifiable resiliency factors may be a promising path toward promoting QoL in adults with NF.

TRIAL REGISTRATION

Clinical Trials.gov Identifier: NCT03406208.

Understanding barriers and facilitators to implementation of psychosocial care within orthopedic trauma centers: a qualitative study with multidisciplinary stakeholders from geographically diverse settings

Background

Psychosocial factors are pivotal in recovery after acute orthopedic traumatic injuries. Addressing psychosocial factors is an important opportunity for preventing persistent pain and disability. We aim to identify barriers and facilitators to the implementation of psychosocial care within outpatient orthopedic trauma settings using the Consolidated Framework for Implementation Research (CFIR) and Proctor’s taxonomy of implementation outcomes, and to provide implementation strategies derived from qualitative data and supplemented by the Expert Recommendations for Implementing Change.

Methods

We conducted live video qualitative focus groups, exit interviews and individual interviews with stakeholders within 3 geographically diverse level 1 trauma settings (N = 79; 20 attendings, 28 residents, 10 nurses, 13 medical assistants, 5 physical therapists/social workers, and 3 fellows) at 3 trauma centers in Texas, Kentucky, and Massachusetts. We used directed and conventional content analyses to derive information on barriers, facilitators, and implementation strategies within 26 CFIR constructs nested within 3 relevant Proctor outcomes of acceptability, appropriateness, and feasibility.

Results

Stakeholders noted that implementing psychosocial care within their practice can be acceptable, appropriate, and feasible. Many perceived integrated psychosocial care as crucial for preventing persistent pain and reducing provider burden, noting they lack the time and specialized training to address patients’ psychosocial needs. Providers suggested strategies for integrating psychosocial care within orthopedic settings, including obtaining buy-in from leadership, providing concise and data-driven education to providers, bypassing stigma, and flexibly adapting to fast-paced clinics.

Conclusions

Results provide a blueprint for successful implementation of psychosocial care in orthopedic trauma settings, with important implications for prevention of persistent pain and disability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00208-8.

Feasibility randomized controlled trial of a mind-body activity program for older adults with chronic pain and cognitive decline: The virtual "Active Brains" study

BACKGROUND AND OBJECTIVES

Chronic pain (CP) and cognitive decline (CD) are highly co-morbid and debilitating among older adults. We iteratively developed Active Brains-Fitbit (AB-F), a group mind-body activity program aided by a Fitbit that is feasible and associated with improvements in physical, cognitive, and emotional functioning when delivered in person to older adults with CP and CD. We adapted our intervention and methodology for remote delivery to bypass barriers to participation. Here we report on a feasibility randomized controlled trial of the virtual AB-F versus a Health Enhancement Program (HEP) educational control followed by qualitative exit interviews.

RESEARCH DESIGN AND METHODS

Older adults (age ≥ 60) with CP and CD (2 cohorts) completed eight weeks of AB-F (n = 8) or HEP (n = 11). Study procedures were fully remote via live video. Quantitative analyses explored feasibility and acceptability markers and within group improvements in outcomes. Qualitative analyses were primarily deductive using the Framework Method.

RESULTS

AB-F met a-priori set feasibility benchmarks, similar to our in-person pilot. Participation in AB-F was associated with preliminary signals of improvement in multimodal physical function, emotional function (anxiety), cognitive function, pain intensity, and coping (e.g., pain self-efficacy, catastrophizing). Participation in HEP was associated with smaller or negligible improvements. Exit interviews confirmed feasibility and satisfaction with our completely remote interventions and methodology.

DISCUSSION AND IMPLICATIONS

Results provide evidence for the feasibility of our completely remote study, and for initial markers of improvement after AB-F. The results will inform a fully powered remote efficacy trial.

Mechanisms of change in depression and anxiety within a mind-body activity intervention for chronic pain

BACKGROUND

Chronic pain is challenging and costly to treat. Depression and anxiety co-occur with chronic pain. Identifying psychosocial mechanisms contributing to emotional outcomes among chronic pain patients can inform future iterations of this intervention.

METHODS

We examined explanatory mechanisms of change in emotional distress following a mind-body and activity intervention among 82 participants (21 - 79 years old, 65.85% female, 80.48% White). With depression and anxiety as outcomes, we hypothesized that potential mediators would include pain catastrophizing, mindfulness, and pain resilience. We used mixed-effects modeling to assess the indirect effects of time on each outcome variable through hypothesized mediators simultaneously.

RESULTS

Improvements in depression from baseline to post-treatment were most explained by pain catastrophizing (b = -2.53, CI = [-3.82, -1.43]), followed by mindfulness (b = -1.21, CI = [-2.15, -0.46]), and pain resilience (b = -0.76, CI = [-1.54, -1.66]). Improvements in anxiety from baseline to post-treatment were most explained by pain catastrophizing(b = -2.16, CI = [-3.45, -1.08]) and mindfulness (b = -1.51, CI = [-2.60, -0.65]), but not by pain resilience, (b = -0.47, CI = [-1.26, 0.17]).

LIMITATIONS

Findings are limited by the lack of a control group, relatively small sample, and two timepoints. However, findings can guide future mind-body intervention efficacy testing trials.

CONCLUSIONS

Pain catastrophizing and mindfulness appear to be important intervention targets to enhance emotional functioning for chronic pain patients, and should be considered simultaneously in interventions for chronic pain.

The Columbia Behavior Scale for Dementia (CBS-8): Validity and Reliability of a Rapidly Administered New Instrument for Dementia-Related Behaviors in Long-Term Care Settings

We developed and evaluated the psychometric properties of the Columbia Behavior Scale for Dementia (CBS-8), a rapid instrument that assesses positive symptoms, to enhance behavioral and psychological symptoms of dementia (BPSD) assessment and treatment in long-term care. Psychometric analyses were performed on CBS-8 data from residents (N = 350, age ≥50 years) in 47 Maryland long-term care facilities referred for neurocognitive and mood evaluation. The CBS-8 demonstrated acceptable internal consistency (α = 0.78) and strong interrater reliability (intraclass correlation coefficient = 1.00). CBS-8 scores were correlated with greater cognitive impairment severity (r = -0.34). The diagnosis of dementia with behavioral disturbance had higher CBS-8 scores than other dementia types (e.g., vascular, unspecified) (p < 0.001, η² = 0.40). Three CBS-8 factors-motor disinhibition, aggression, and psychosis-explained 65% of the variance in overall BPSD. The CBS-8 could enhance BPSD tracking and treatment, strengthen interdisciplinary collaboration, and aid nursing homes in meeting regulations on unnecessary medication use. [Research in Gerontological Nursing, 14(3), 160-168.].

Age-dependent relationship of cardiorespiratory fitness and white matter integrity

Growing evidence has linked cardiorespiratory fitness (CRF) to more conserved white matter (WM) microstructure. Additional research is needed to determine which WM tracts are most strongly related to CRF and if the neuroprotective effects of CRF are age-dependent. Participants were community-dwelling adults (N = 499; ages 20-85) from the open-access Nathan Kline Institute - Rockland Sample (NKI-RS) with CRF (bike test) and diffusion tensor imaging (DTI) data. Mixed-effect modeling tested the interaction between CRF and age on global (main effect across 9 tracts) and local (individual tract effects) WM microstructure. Among older participants (age ≥ 60), CRF was significantly related to whole-brain (z-score slope = 0.11) and local WM microstructure within several tracts (| z-score slope | range = 0.13 - 0.27). Significant interactions with age indicated that the CRF-WM relationship was weaker (z-score slope ≤ 0.11) and more limited (one WM tract) in younger adults. The findings highlight the importance of aerobic exercise to maintain brain health into senescence. CRF may preferentially preserve a collection of anterior and posterior WM connections related to visuomotor function.

Development of a Novel Mind-Body Activity and Pain Management Program for Older Adults With Cognitive Decline

BACKGROUND AND OBJECTIVES

Chronic pain (CP) and cognitive decline (CD) often co-occur in older adults, which can reinforce a "disability spiral." Early interventions teaching pain coping skills and gradual increases in activity (walking) are needed to promote overall well-being and potentially delay further decline of cognition and daily functioning. The goal of this mixed-methods study was to guide the development of two mind-body activity programs for CP and CD which focus on increasing walking using time goals (Active Brains) or step count reinforced by a Fitbit (Active Brains-Fitbit).

RESEARCH DESIGN AND METHODS

Older adults with CP and CD (N = 23) participated in a one-time focus group (four total) and completed measures of physical, emotional, and cognitive functioning. Qualitative analyses identified population-specific needs, preferences, and perceptions of proposed program skills. Quantitative analysis compared clinical characteristics to population norms and explored intercorrelations among treatment targets.

RESULTS

Thematic analyses revealed six main themes: (1) challenges living with CP and (2) CD, (3) current walking, (4) technology (Fitbit) to increase walking, (5) perceptions of proposed program skills (e.g., mind-body, pain, and increased walking), and (6) program barriers and facilitators. Quantitative analyses showed that (a) participants had physical function below reference values and (b) higher self-efficacy correlated with higher cognitive, emotional, and physical functioning.

DISCUSSION AND IMPLICATIONS

Focus group participants were enthusiastic about the proposed program skills. Current work includes open pilot testing, qualitative interviews, and a small randomized controlled trial to optimize the programs and methodology in preparation for efficacy testing against an educational control.

A New Tool for Detecting COVID-19 Psychological Burden Among Postacute and Long-term Care Residents (Mood-5 Scale): Observational Study

BACKGROUND

Older adults are at high risk for developing serious somatic and psychological symptoms associated with COVID-19. Currently available instruments may not be sensitive to the concerns about COVID-19 in postacute and long-term care and their applications in telehealth remain to be clarified.

OBJECTIVE

We investigated the psychometric properties of the Mood-5 Scale (M5) as a rapid self-assessment of the COVID-19 psychological burden among postacute and long-term care residents.

METHODS

Residents (N=131), aged 50 years and above, from 20 postacute and long-term care facilities in Maryland, USA, were evaluated in-person or via telehealth (43/131, 32.8%) across a 4-week period (May 11 to June 5, 2020) during the COVID-19 pandemic. The COVID-19 psychological burden experienced by the residents was rated by geriatric psychologists who independently reviewed their clinical documentation. Psychometric analyses were performed on the M5 in relation to psychological tests, COVID-19 psychological burden, and diagnostic data collected during the evaluation.

RESULTS

The M5 demonstrated acceptable internal consistency (Cronbach α=.77). M5 scores were not confounded by demographic variables or telehealth administration (P>.08). Convergent validity for the M5 was established via positive associations with anxiety (r=0.56, P<.001) and depressive (r=0.49, P<.001) symptoms. An M5 cutoff score of 3 demonstrated strong sensitivity (0.92) and adequate specificity (0.75) for identifying COVID-19 psychological distress among postacute and long-term care residents (area under the curve of 0.89, positive predictive value=0.79, negative predictive value=0.91).

CONCLUSIONS

The M5 is a reliable and valid tool for self-assessment of mood that can help identify postacute and long-term care residents with significant psychological burden associated with COVID-19. It can be completed in less than 1 minute and is appropriate for use in both in-person and virtual visits.

Development of a mind body program for obese knee osteoarthritis patients with comorbid depression

Knee osteoarthritis (OA) is the most common joint disorder in the U.S. and a leading cause of disability. Depression and obesity are highly comorbid among knee OA patients, and the combination of obesity and depression is associated with decreased physical activity, higher pain and disability, and more rapid cartilage degradation. Depression, obesity and OA exacerbate one another and share a common pathophysiology involving systemic inflammation and pro-inflammatory cytokines, reflecting a complex mind-body interaction. Current treatments for knee OA offer little to no benefit over placebo, and do not emphasize mind-body practices or physical activity to target the underlying pathophysiology. Mind-body interventions to lessen depressive symptoms and increase physical activity offer the ability to target biological, mechanical and psychological mechanisms of OA progression. Our long-term goals are to evaluate the mechanisms by which the Relaxation Response Resiliency Program (3RP) delivered via secure telehealth, and adapted for patients with depression, obesity and knee OA (GetActive-OA) promotes increases in physical activity and improved knee health. We hypothesize that the synergistic interaction between mindfulness, adaptive thinking, positive psychology and healthy living skills of the GetActive-OA will slow the progression of symptomatic knee OA by reducing pro-inflammatory cytokine expression and promoting optimal mechanical loading of the cartilage. Here we present the protocol for a mixed methods study that will adapt the 3RP for the needs of knee OA patients with depression and obesity with a focus on increasing physical activity (GetActive-OA), and iteratively maximize the feasibility, credibility and acceptability of the programs and research procedures.

An Exploratory Analysis of Accelerometer-Measured Physical Activity and Emotional Functioning in Patients With Chronic Pain

BACKGROUND

Physical activity (PA) can benefit pain and emotional functioning for patients with chronic pain. However, associations between different intensities of PA (moderate-to-vigorous PA, light PA, and sedentary behavior), pain, and emotional functioning are not well understood in patients with chronic pain.

OBJECTIVE

The goals of this study were to (1) describe PA patterns of adult patients with chronic pain using accelerometers and (2) explore preliminary associations between PA intensities, pain, and emotional functioning.

METHODS

Thirteen patients with chronic pain completed self-report measures of pain, cognitive and emotional reactions to pain, depression and anxiety, and wore ActiGraph accelerometers for 1 week before participating in a pilot mind-body PA intervention.

RESULTS

Sedentary behavior and light activity were strongly inversely correlated (r = -0.93, P < 0.01). Greater sedentary behavior was associated with lower pain during activity (r = -0.55, P = 0.05), and greater light activity was correlated with higher pain during activity (r = 0.63, P = 0.02) and pain at rest (r = 0.54, P = 0.06). However, greater moderate-to-vigorous PA was correlated with lower pain at rest (r = -0.66, P = 0.01), pain catastrophizing (r = -0.53, P = 0.06), depression (r = -0.44, P = 0.14), and anxiety (r = -0.57, P = 0.04).

CONCLUSIONS

Objective accelerometer-measured PA has the potential to reveal differential associations between PA intensities, pain, and emotional functioning. Findings here suggest preliminary recommendations to focus on interconnections between moderate-to-vigorous PA, pain at rest, pain catastrophizing, anxiety, and depression for patients with chronic pain.

Mind-Body Activity Program for Chronic Pain: Exploring Mechanisms of Improvement in Patient-Reported, Performance-Based and Ambulatory Physical Function

BACKGROUND

Improving physical function among patients with chronic pain is critical for reducing disability and healthcare costs. However, mechanisms underlying improvement in patient-reported, performance-based, and ambulatory physical function in chronic pain remain poorly understood.

PURPOSE

To explore psychosocial mediators of improvement in patient-reported, performance-based, and objective/accelerometer-measured physical function among participants in a mind-body activity program.

METHODS

Individuals with chronic pain were randomized to one of two identical 10-week mind-body activity interventions aimed at improving physical function with (GetActive-Fitbit; N=41) or without (GetActive; N=41) a Fitbit device. They completed self-reported (WHODAS 2.0), performance-based (6-minute walk test), and objective (accelerometer-measured step-count) measures of physical function, as well as measures of kinesiophobia (Tampa Kinesiophobia Scale), mindfulness (CAMS-R), and pain resilience (Pain Resilience Scale) before and after the intervention. We conducted secondary data analyses to test mediation via mixed-effects modeline.

RESULTS

Improvements in patient-reported physical function were fully and uniquely mediated by kinesiophobia (Completely Standardized Indirect Effect (CSIE)=.18; CI=0.08, 0.30; medium-large effect size), mindfulness (CSIE=-.14; CI=-25, -.05; medium effect size) and pain resilience (CSIE=-.07; CI=-.16, -.005; small-medium effect size). Improvements in performance-based physical function were mediated only by kinesiophobia (CSIE=-.11; CI=-23, -.008; medium effect size). No measures mediated improvements in objective (accelerometer measured) physical function.

CONCLUSION

Interventions aiming to improve patient-reported physical function in patients with chronic pain may benefit from skills that target kinesiophobia, mindfulness, and pain resilience, while those focused on improving performance-based physical function should target primarily kinesiophobia. More research is needed to understand mechanisms of improvement in objective, accelerometer-measured physical function.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03412916.

Live Video Adaptations to a Mind-Body Activity Program for Chronic Pain and Cognitive Decline: Protocol for the Virtual Active Brains Study

BACKGROUND

Chronic pain (CP) and cognitive decline (CD) are costly, challenging to treat, prevalent among older adults, and worsen each other over time. We are iteratively developing Active Brains-Fitbit (AB-F), a live video program for older adults with CP and CD that teaches mind-body skills and gradual increases in step count. AB-F has demonstrated feasibility; acceptability; and signs of improvement in emotional, physical, and cognitive functions when delivered in person to older adults.

OBJECTIVE

We are conducting a feasibility randomized controlled trial (RCT) of AB-F versus a time- and dose-matched educational control (health enhancement program [HEP]) in older adults with CP and CD. Here, we describe virtual adaptions to our study protocol, manualized treatments, evaluation plan, and study design in response to feedback from former participants and COVID-19. We will evaluate the feasibility benchmarks and the potential of AB-F to improve physical, emotional, and cognitive functions.

METHODS

This is a single-blind pilot RCT. Participants are randomized to AB-F or HEP. Patients are recruited through pain clinic referrals, institutional registries, and flyers. Interested participants are screened for eligibility via telephone and provide electronic informed consent. After randomization, participants are mailed all study documents, including their treatment manual, an ActiGraph accelerometer, and a Fitbit (separate envelope for AB-F only). Both conditions are manualized and delivered over 8 weekly sessions via Zoom. Participants complete self-report and performance-based (6-min walk test and Montreal Cognitive Assessment) outcome measures via Zoom at baseline and post intervention. Primary outcomes are a priori set feasibility (recruitment, quantitative measures, and adherence), acceptability, credibility, expectancy, and satisfaction benchmarks. Secondary outcomes are physical, cognitive, and emotional functions as well as intervention targets (social function, pain intensity, pain-specific coping, and mindfulness).

RESULTS

The trial is ongoing. We have recruited 21 participants (10 AB-F and 11 HEP) across 2 rounds. Only 2 participants have withdrawn (1 before baseline and 1 before the first session). All 19 remaining participants have completed the baseline assessment. In the first round, attendance is high (11 out of 12 participants completed all 4 sessions so far), and AB-F participants are adherent to their Fitbit and step goals (5 out of 6 participants).

CONCLUSIONS

Preliminary findings are promising for the feasibility of our completely virtual AB-F intervention. However, these findings need to be confirmed at the trial conclusion. This study will answer important questions about the feasibility of delivering a completely virtual mind-body activity program to older adults with comorbid CP and CD, which, to our knowledge, is unprecedented. Details on integrating multiple digital platforms for virtual assessments and intervention delivery will inform treatment development for older adults and those with comorbid CP and CD, which is crucial during the COVID-19 pandemic.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04044183; https://clinicaltrials.gov/ct2/show/NCT04044183.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/25351.

The role of social isolation in physical and emotional outcomes among patients with chronic pain

OBJECTIVE

Social isolation negatively impacts early-disease processes and long-term health. Individuals with chronic pain are more vulnerable to social isolation, which exacerbates symptoms. It is currently unclear whether: 1. group-based programs for chronic pain improve social isolation, 2. improvements in social isolation account for improvements in outcomes. This study involved secondary data analysis of participants in a 10-week mind-body physical activity program. We examined whether social isolation improved during treatment, and whether such improvements accounted for improvements in emotional and physical functioning.

METHODS

Participants (N = 82) with chronic pain were randomized to a group-based mind-body physical activity intervention with (GetActive-Fitbit; n = 41) or without a Fitbit device (GetActive; n = 41). Participants completed self-reported measures of social isolation, emotional functioning (depression and anxiety symptoms), and multimodal physical functioning (self-report, performance-based, and objective). We used linear mixed effects modeling to examine pre-post treatment changes in social isolation and whether these changes accounted for improvements in emotional and physical functioning.

RESULTS

Both interventions were associated with significant and comparable improvements in social isolation from baseline to end of treatment, and improvements in social isolation accounted for significant improvements in self-reported emotional and physical functioning.

CONCLUSION

Interventions may target social isolation in chronic pain to optimize treatment outcomes.

Feasibility Trial of a Mind-Body Activity Pain Management Program for Older Adults With Cognitive Decline

BACKGROUND AND OBJECTIVES

The relationship between chronic pain (CP) and cognitive decline (CD) is bidirectional among older adults. The CP-CD comorbidity can progressively worsen cognitive, physical, emotional, and social functioning with aging. We explored the feasibility and outcomes associated with two mind-body activity programs for CP and CD that focus on increasing walking using time goals (Active Brains) or step-count reinforced via Fitbit (Active Brains-Fitbit).

RESEARCH DESIGN AND METHODS

Older adults with CP and CD participated in a non-randomized open pilot of Active Brains (n = 6) and Active Brains-Fitbit (n = 6) followed by exit interviews. Quantitative analysis explored feasibility markers and signals of improvement on physical, cognitive, and emotional function, as well as additional program targets. Qualitative analyses were predominantly deductive and applied the Framework Method to enhance the programs and methodology.

RESULTS

Both programs met a-priori feasibility benchmarks. We found within-group improvements for pain intensity, pain-specific coping, physical function, and cognitive function in both programs. Exit interviews confirmed high satisfaction with both programs.

DISCUSSION AND IMPLICATIONS

Our mixed methods data provide preliminary evidence of feasibility, showed promise for improving outcomes, and yielded critical information to further enhance the programs. We discuss "lessons learned" and future directions.

Psychosocial Correlates of Objective, Performance-Based, and Patient-Reported Physical Function Among Patients with Heterogeneous Chronic Pain

BACKGROUND

Improving all aspects of physical function is an important goal of chronic pain management. Few studies follow recent guidelines to comprehensively assess physical function via patient-reported, performance-based, and objective/ambulatory measures.

PURPOSE

To test 1) the interrelation between the 3 types of physical function measurement and 2) the association between psychosocial factors and each type of physical function measurement.

METHODS

Patients with chronic pain (N=79) completed measures of: 1) physical function (patient-reported disability; performance-based 6-minute walk-test; objective accelerometer step count); 2) pain and non-adaptive coping (pain during rest and activity, pain-catastrophizing, kinesiophobia); 3) adaptive coping (mindfulness, general coping, pain-resilience); and 4) social-emotional dysfunction (anxiety, depression, social isolation and emotional support). First, we tested the interrelation among the 3 aspects of physical function. Second, we used structural equation modeling to test associations between psychosocial factors (pain and non-adaptive coping, adaptive coping, and social-emotional dysfunction) and each measurement of physical function.

RESULTS

Performance-based and objective physical function were significantly interrelated (r=0.48, p<0.001) but did not correlate with patient-reported disability. Pain and non-adaptive coping (β=0.68, p<0.001), adaptive coping (β=-0.65, p<0.001) and social-emotional dysfunction (β=0.65, p<0.001) were associated with patient-reported disability but not to performance-based or objective physical function (ps>0.1).

CONCLUSION

Results suggest that patient-reported physical function may provide limited information about patients' physical capacity or ambulatory activity. While pain and non-adaptive reactions to it, adaptive coping, and social-emotional dysfunction may potentially improve patient-reported physical function, additional targets may be needed to improve functional capacity and ambulatory activity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03412916.

A path to early diagnosis of mild cognitive impairment and dementia: validity and reliability of the myMemCheck® self-administered screening tool

BACKGROUND

Barriers to the early detection of mild cognitive impairment (MCI) and dementia can delay diagnosis and treatment. myMemCheck® was developed as a rapid free cognitive self-assessment tool that can be completed at home to identify older adults that would benefit from a more comprehensive cognitive evaluation.

OBJECTIVE

Two prospective cross-sectional studies were conducted to examine the psychometric properties and clinical utility of myMemCheck®.

METHODS

In Study 1, participants were independent living residents referred to an outpatient memory clinic (N = 59); older adults in the community and post-acute nursing home residents (N = 357) comprised Study 2.

RESULTS

Psychometric analyses were performed on cognitive and psychological testing data, including myMemCheck®. myMemCheck® evidenced adequate reliability and strong construct validity. Receiver operating characteristic analysis evidenced an optional myMemCheck® cut score for identifying older adults at risk for MCI or dementia. myMemCheck® explained 25% of cognitive status beyond basic patient information.

CONCLUSIONS

myMemCheck® may help fast-track the diagnostic process, facilitate appropriate referrals for cognitive and neuropsychological evaluation, reduce assessment burden in health care and prevent negative outcomes associated with undetected cognitive impairment.

Predicting Functional Dependence in Mild Cognitive Impairment: Differential Contributions of Memory and Executive Functions

BACKGROUND AND OBJECTIVES

Diagnostic criteria for mild cognitive impairment (MCI) exclude functional deficits, yet recent studies suggest that older adults with MCI can exhibit impairment in instrumental activities of daily living (IADL). To assist health care providers in detecting functional vulnerabilities that often precipitate loss of independence, we: (a) compared IADL dependence in MCI to older adults without cognitive impairment and those with dementia, (b) estimated the odds of dependence on specific IADLs in MCI, and (c) investigated the differential contributions of memory and executive functions to IADL dependence.

RESEARCH DESIGN AND METHODS

Participants were older adults (Mage = 77.58 ± 11.05) in Maryland, USA (N = 512) community and postacute rehabilitation settings. Analysis was performed on Brief Cognitive Assessment Tool (BCAT) and the Functional Activities Questionnaire (FAQ) data that assessed participants' cognitive functioning and IADL dependence, respectively.

RESULTS

61.04% of participants with MCI were dependent on one or more IADLs. MCI was associated with significantly greater odds of dependence than normal cognition on 7 of the 10 IADLs (odds ratios = 2.62-4.66). Impairment in memory and executive functions significantly predicted IADL dependence (18.52% of variance beyond demographics); executive functions were the stronger predictor, particularly for complex finances, complex cooking, and remembering events.

DISCUSSION AND IMPLICATIONS

IADL dependence can occur even in MCI. Testing suggestive of MCI should alert clinicians to further investigate the older adult's profile of cognitive and functional limitations to highlight targets for caregiver support and promote independence by "right-sizing" community or facility resources.

Disparities in Dementia Occurrence and Rate of Cognitive Decline Between African American and White Long-Term Care Residents

The objective of the current study was to investigate possible racial disparities in dementia among long-term care (LTC) residents. Participants were 1,239 residents (age ≥50) from 61 nursing home and assisted living facilities in Maryland. Retrospective analysis was performed to compare Brief Cognitive Assessment Tool (BCAT®) scores between African American and White participants. African American participants had 1.43 times greater odds of dementia and 1.86 times greater odds of severe-stage dementia than White residents. African American residents were significantly younger than their White peers by approximately 9 years within mild-moderate dementia levels and by 5 years at the severe stage. The rate of cognitive decline did not significantly differ by race despite a more negative curvilinear relationship between BCAT scores and age for African American participants than White participants. Implications of these findings are discussed for successful resident-centered care in LTC settings as well as for care transitions. [Research in Gerontological Nursing, xx(x), xx-xx.].

Components of executive function model regional prefrontal volumes

OBJECTIVE

Designed to measure a diversity of executive functioning (EF) through classical neuropsychological tests, the Delis-Kaplan Executive Function Scale (D-KEFS) allows for the investigation of the neural architecture of EF. We examined how the D-KEFS Tower, Verbal Fluency, Design Fluency, Color-Word Interference, and Trail Making Test tasks related to frontal lobe volumes, quantifying the regional specificity of EF components.

METHOD

Adults from the Nathan Kline Institute-Rockland Sample (NKI-RS), an open-access community study of brain development, with complete MRI (3T scanner) and D-KEFS data were selected for analysis (N = 478; ages 20-85). In a mixed-effects model predicting volume, D-KEFS task, D-KEFS score, region of interest (ROI; 13 frontal, 1 occipital control), were entered as fixed effects with intercepts for participants as random effects.

RESULTS

"Unitary" EF (aggregate of D-KEFS scores) was positively associated with superior frontal, rostral middle frontal, and lateral orbitofrontal volumes; a negative association was observed with frontal pole volume (| z-score slope | range = 0.040 to 0.051). "Diverse" EF skills (individual D-KEFS task scores) were differentially associated with two or three ROIs, respectively, but to a stronger extent (| z-score slope | range = 0.053 to 0.103).

CONCLUSIONS

The neural correlates found for the D-KEFS support the prefrontal modularity of both unitary (aspects of EF ability common to all tasks) and diverse EF. Our findings contribute to emerging evidence that aggregate measurements of EF may serve broader but less robust frontal neural correlates than distinct EF skills. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Verbal test of practical judgment (VPJ): a new test of judgment that predicts functional skills for older adults

OBJECTIVES

The clinical assessment of older adults' judgment is important for mitigating safety risks that often precipitate loss of independence. Our national survey of geriatric healthcare providers (N = 496; M years of experience = 17.11 ± 10.60) indicated that formal judgment tests are underutilized in clinical practice. We developed the Verbal Test of Practical Judgment (VPJ) as a new test of judgment for older adults intended to identify difficulty performing instrumental activities of daily living (IADL).

METHOD

In two prospective studies, participants were long-term care facility residents (age ≥ 50) in Maryland, USA (Study 1, N = 51; Study 2, N = 110) referred to licensed psychologists for neuro-cognitive and mood evaluation by facility attending physicians. Psychometric analyses were performed to examine the construct validity of the VPJ.

RESULTS

The VPJ evidenced adequate reliability and strong construct validity across both studies. Receiver operating characteristic analysis yielded an optimal VPJ cut score for identifying impaired judgment. The VPJ significantly predicted IADL performance beyond clinician and participant ratings.

CONCLUSION

The VPJ appears to be a valid tool for assessing judgment among older adults with suspected cognitive impairment. VPJ score inferences can inform clinicians on the odds of requiring assistance for specific IADLs.

Meaningful Activity for Long-Term Care Residents With Dementia: A Comparison of Activities and Raters

Purpose of the Study

Engagement in meaningful activities is associated with positive outcomes for persons with dementia, yet studies demonstrating quantitative evidence for which activities can be considered meaningful are lacking. We investigated MemPics™, a program designed to promote meaningful activity for individuals with dementia through engagement and cognitive stimulation. It was compared with other recreation activities offered in U.S. long-term care facilities to determine whether MemPics™ was rated as having more meaningful activity from both the perspectives of participants and recreation staff.

Design and Methods

Long-term care residents with mild to moderate dementia that met eligibility criteria were randomly assigned to an activity group (treatment, control). Participants completed 2 sessions of either the experimental or control group activity with facility recreation staff. Both participants and staff rated each activity in terms of meaningfulness following each session.

Results

Of the enrolled participants (N = 126), study analyses were based on the 94 participants (n = 48 treatment and n = 46 control; M age = 82.98±9.63) who completed the activity sessions. Compared to the control group activities, MemPics™ had significantly higher participant and staff ratings of meaningfulness. Scores between the 2 rater types were significantly different, with staff reporting higher meaningful activity than participants. Further support for MemPics™ was found in exit survey responses from participating staff.

Implications

We discuss the merits and shortcoming of this study, the utility of MemPics™ for providing meaningful engagement in long-term care residents with mild to moderate dementia, and ideas for future research.

The Brief Cognitive Impairment Scale (BCIS): preliminary investigation of a severe-stage dementia test emphasizing cognitive processing and interpersonal tolerance

We describe the development and validation of The Brief Cognitive Impairment Scale (BCIS), a cognitive screening instrument designed for persons with severe-stage dementia. Psychometric analyses were performed on neuropsychological data from long-term care residents (N = 247) who completed a brief battery of tests, including the BCIS. A principle component analysis yielded three factors that provide insight into how persons with severe dementia cognitively process information and may tolerate specific aspects of social stimulation, such as during personal care. A BCIS cut score can be used to identify severe dementia with a sensitivity of .82, a specificity of .84, and an area under the curve of .89. It may be used by clinicians or caregivers when advanced dementia is suspected, as an alternative to measures with suspected floor effects, when residents cannot tolerate more demanding assessment tools, and as part of non-pharmacologic treatment plans for behavior disturbances associated with dementia.

Therapeutic relationship in the treatment of geriatric depression with executive dysfunction

BACKGROUND

The effects of therapeutic relationship (TR) in elder mental health are understudied. A greater understanding of TR in geriatric psychotherapy is particularly needed for treating late-life depression with executive dysfunction, which predicts poor response to antidepressant medication and presents unique clinical challenges.

METHODS

Participants were older patients (N = 220) with major depression and executive dysfunction who received 12 weeks of problem-solving therapy or supportive therapy in a randomized control trial. Multilevel growth curve modeling and latent change scores were used to analyze TR dimensions of Understanding and Accepting at the patient level (individual patient ratings, N = 194) and therapist level (ratings of each therapist averaged across participants, N = 10).

RESULTS

TR predicted reduction of depression in both treatment groups, while treatment×TR interactions were not significant. Patients treated by therapists with higher average Understanding (patient and therapist level) and Accepting (therapist level) ratings had greater decreases in depression. The patient level×therapist level interaction for Understanding approached statistical significance (p=.065), suggesting a synergistic effect on treatment outcome. Together, Understanding and Accepting predicted 21% of variance in depression level changes.

LIMITATIONS

TR was not assessed throughout the course of treatment (only after the first therapy session and at post-treatment) and did not include ratings from an objective evaluator.

CONCLUSIONS

Assessment of patient's experience of the TR and of therapist ability to foster Understanding and Accepting can play a significant role in the delivery of geriatric psychosocial interventions.

Mild cognitive impairment (MCI) in long-term care patients: subtype classification and occurrence

OBJECTIVES

This study examines mild cognitive impairment (MCI) in long-term care settings by identifying and quantifying MCI subtypes in a combined sample of nursing home and assisted-living patients. We compared impairment thresholds of 1-SD and 1.5-SD to determine if different cut-offs differentially affect occurrence rates.

METHOD

One hundred and eight participants who met general criteria for MCI were included for the purposes of this study. The general diagnosis of MCI was based on criteria. Participants were further grouped into MCI subtypes. Based on previously established norms, Brief Cognitive Assessment Tool (BCAT) factor scores were used to assess whether MCI participants met either the 1-SD and 1.5-SD impairment thresholds for memory, executive functions, and attentional capacity.

RESULTS

Using both 1-SD and 1.5-SD impairment thresholds, three clear MCI subtypes were identified: amnestic, single-domain; non-amnestic, single-domain (executive); and amnestic, multi-domain (memory and executive). A fourth category (undifferentiated) was identified in patients who did not meet criteria for a distinct MCI subtype, but still had cognitive impairments. The stricter impairment threshold of 1.5-SD resulted in fewer patients classified as having any of the three domain-specific subtypes.

CONCLUSION

Based on a sample of nursing home and assisted-living patients, we identified three MCI subtypes, and a fourth category consisting of participants with general MCI, but without clear evidence of domain-specific cognitive impairment. When selecting impairment thresholds, one should consider the impact on the identification of MCI subtypes and the probability of misdiagnoses.

Predicting Off-Label Antipsychotic Medication Use in a Randomly Selected Nursing Home Sample Based on Resident and Facility Characteristics

Reducing off-label antipsychotic medication use for behavioral and psychological symptoms of dementia (BPSD) in nursing home residents has been a centerpiece of government regulation, but without insight into utilization differences based on resident and facility characteristics. To examine whether resident and facility characteristics can predict off-label antipsychotic medication treatment for BPSD, residents prescribed antipsychotic medication (N = 216) from 17 Maryland nursing facilities were randomly selected. Based on physician diagnoses, 59.7% of participants were taking off-label antipsychotic medications for BPSD. Hierarchical logistic regression results suggest that dementia level (indicated by Brief Cognitive Assessment Tool scores) and age, but not facility characteristics, significantly predict greater likelihood of using off-label antipsychotic medications for BPSD. Having moderate-severe dementia was associated with more than a four-fold increase in off-label antipsychotic medication use for BPSD. Off-label use of antipsychotic medications for BPSD remains high, especially for older nursing home residents with more severe dementia, indicating that more targeted reduction approaches are needed. [Res Gerontol Nurs. 2016; 9(6):257-266.].

A comparison of the diagnostic accuracy of the AD8 and BCAT-SF in identifying dementia and mild cognitive impairment in long-term care residents

We compared the accuracy of the Brief Cognitive Assessment Tool-Short Form (BCAT-SF) and AD8 in identifying mild cognitive impairment (MCI) and dementia among long-term care residents. Psychometric analyses of 357 long-term care residents (n = 228, nursing home; n = 129, assisted living) in Maryland referred for neuropsychological evaluation evidenced robust internal consistency reliability and construct validity for the BCAT-SF. Furthermore, hierarchical logistic regression and receiver operating characteristic curve analyses demonstrated superior predictive validity for the BCAT-SF in identifying MCI and dementia relative to the AD8. In contrast, previously reported psychometric properties or cut scores for the AD8 could not be cross-validated in this long-term care sample. Based on these findings, the BCAT-SF appears to be a more reliable and valid screening instrument than the AD8 for rapidly identifying MCI and dementia in long-term care residents.