Reflections on 3 Years of Innovation: Recognizing the Need for Innovation Beyond the Clinical Care Pathway

The Susan and Richard Levy Healthcare Delivery Incubator is designed to bring about rapid, sustainable, scalable, and transformational health care redesign. All 10 projects in the initial 3 cohorts of teams embraced the Incubator process-forming diverse teams and following a design-thinking informed curriculum-and each successfully implemented improvements or innovations by the end of their project. The purpose of this article is to identify the key features of teams' work that may help account for projects' success. For the 10 projects completed, findings from debrief interviews and staff observations were examined to identify processes key to project's success. Analysis highlighted cross-project learnings that indicate nonclinical aspects of care delivery that play a critical role in project innovation success. Innovating health care delivery requires considering social and political determinants of health. The Incubator's process and structures enable teams to identify and respond to a broad range of health determinants.

Coproduction of Low-Barrier Hepatitis C Virus and HIV Care for People Who Use Drugs in a Rural Community: Brief Qualitative Report

BACKGROUND

People who inject drugs are experiencing syndemic conditions with increasing risk of infection with hepatitis C (HCV) and HIV. However, rates of accessing HCV and HIV testing and treatment among people who inject drugs are low for various reasons, including the criminalization of drug use, which leads to a focus on treating drug use rather than caring for drug users. For many people who inject drugs, health care becomes a form of structural violence, resulting in traumatic experiences, fear of police violence, unmet needs, and avoidance of medical care. There is a clear need for novel approaches to health care delivery for people who inject drugs.

OBJECTIVE

This study aimed to analyze the process of a multidisciplinary team-encompassing health care professionals, community representatives, researchers, and people with lived experience using drugs-that was formed to develop a deep understanding of the experiences of people who inject drugs and local ecosystem opportunities and constraints to inform the cocreation of low-barrier, innovative HCV or HIV care in a rural community. Given the need for innovative approaches to redesigning health care, we sought to identify challenges and tensions encountered in this process and strategies for overcoming these challenges.

METHODS

Analysis was based on an in-depth review of meeting notes from the project year, followed by member-checking with the project team to revise and expand upon the challenges encountered and strategies identified to navigate these challenges.

RESULTS

Challenges and tensions included: scoping the project, setting the pace and urgency of the work, adapting to web-based work, navigating ethics and practice of payment, defining success, and situating the project for sustainability. Strategies to navigate these challenges included: dedicated effort to building personal and meaningful connections, fostering mutual respect, identifying common ground to make shared decisions, and redefining successes.

CONCLUSIONS

While cocreated care presents challenges, the resulting program is strengthened by challenging assumptions and carefully considering various perspectives to think creatively and productively about solutions.

Assessing and Identifying Improvements for Lung Cancer Screening in a Rural Population: A Human-Centered Design and Systems Approach

Although lung cancer claims more lives than any other cancer in the United States, screening is severely underutilized, with <6% of eligible patients screened nationally in 2021 versus 76% for breast cancer and 67% for colorectal cancer. This article describes an effort to identify key reasons for the underutilization of lung cancer screening in a rural population and to develop interventions to address these barriers suitable for both a large health system and local community clinics. Data were generated from 26 stakeholder interviews (clinicians, clinical staff, and eligible patients), a review of key systems (Electronic Health Record and billing records), and feedback on the feasibility of several potential interventions by health care system staff. These data informed a human-centered design approach to identify possible interventions within a complex health care system by exposing gaps in care processes and electronic health record platforms that can lead patients to be overlooked for potentially life-saving screening. Deployed interventions included communication efforts focused on (1) increasing patient awareness, (2) improving physician patient identification, and (3) supporting patient management. Preliminary outcomes are discussed.

Designing a Health Care Delivery Innovation Lab: Reflections From The First Year

This article shares initial experiences designing and operating a new health care delivery innovation program at a rural academic medical center. The program was designed with the belief that dedicated team member time, senior leadership engagement, deliberate project/team selection, and robust, tailored project support would enable rapid and transformative health care redesign. Three teams were supported in the initial 1-year funding cycle; all 3 teams successfully designed, implemented, and tested new care models for different serious illness populations. Results demonstrated improved satisfaction, decreased length of stay, and a positive return on investment. Critical evaluation of current structures and processes will help identify refined strategies to support diverse teams that will challenge the norms of health care delivery and explore novel partnerships, approaches, and settings for care delivery. This article helps advance the conversation on how to think strategically and critically about current and future health care innovation efforts.

Redesigning care to support earlier discharge from a neonatal intensive care unit: a design thinking informed pilot

Background

Preterm infants may remain in neonatal intensive care units (NICUs) to receive proper nutrition via nasogastric tube feedings. However, prolonged NICU stays can have negative effects for the patient, the family and the health system.

Aim

To demonstrate how a patient-centred, design thinking informed approach supported the development of a pilot programme to enable earlier discharge of preterm babies.

Method

We report on our design thinking-empathy building approach to programme design, initial outcomes and considerations for ongoing study.

Results

Through the use of design thinking methods, we identified unique needs, preferences and concerns that guided the development of our novel early discharge programme. We found that stable, preterm infants unable to feed by mouth and requiring nasogastric tubes can be cared for at home with remote patient monitoring and telehealth support. In addition, novel feeding strategies can help address parental preferences without compromising infant growth.

Conclusion

A patient-centred, design thinking informed approach supported the development of a pilot programme to enable earlier discharge of preterm babies. The programme resulted in a reduced length of stay, thereby increasing NICU bed capacity and limiting hospital turn-aways.

Comparison of behaviors characteristic of autism spectrum disorder behaviors and behavioral and psychiatric symptoms of dementia

BACKGROUND

Similarities exist in behavioral expression of autism spectrum disorder (ASD) and Alzheimer's disease and related dementias (ADRD). The purpose of this study was to assess presence of behavioral and psychiatric symptoms of dementia (BPSD) and ASD-like behaviors in adults with ADRD.

METHODS

Using a cross-sectional design, data from University of Kentucky Alzheimer's Disease Center participant cohort were used. Hierarchical linear regression was used to assess (1) the relationship between ASD-like behaviors (measured by the Gilliam Autism Rating Scale-Second Edition, GARS-2) and BPSD measured by the Neuropsychiatric Inventory (NPI), and (2) the relationship between ASD-like behaviors and dementia severity (measured by the Clinical Dementia Rating [CDR] sum of boxes), when controlling for BPSD.

RESULTS

Complete data were available for 142 participants. Using α of 0.05, analyses identified ASD behaviors were significantly associated with BPSD severity ratings (r = 0.47; p < 0.001) and dementia severity (r = 0.46; p < 0.001). GARS-2 explained 6.1% (p < 0.001) of variance in CDR sum of boxes when controlling for NPI and other covariates.

DISCUSSION

There is significant overlap in behaviors characteristic of ASD and BPSD as assessed by the NPI and GARS-2, despite the use of these instruments in disparate developmental vs. aging settings. ASD behaviors appear to not be solely present in early childhood as a manifestation of ASD but are also present in older adults with neurodegenerative cognitive impairment. Such associations warrant additional research into causation, assessment, and behavioral interventions to further enable new therapeutic approaches targeting ASD behaviors across the lifespan.

Sensory Processing Abnormalities in Community-Dwelling Older Adults with Cognitive Impairment: A Mixed Methods Study

Mild cognitive impairment (MCI) or dementia often leads to behavioral and psychiatric symptoms of dementia (BPSD). Sensory processing abnormalities may be associated with BPSD. The purpose of this study was to explore relationships among sensory processing, behavior, and environmental features within the homes of people with MCI or dementia. This project used mixed methods to assess participants' sensory processing, care partner perspectives on behaviors, and in situ observations of the home environment. Nine participants with cognitive impairment (MCI n = 8, early dementia = 1) and their care partners were included. Seven participants with cognitive impairment were reported to have abnormal sensory processing. Findings suggest that unique environmental adaptations, tailored to personal and sensory preferences for each participant, were associated with a decreased level of behavioral disruption during the observation periods. Implementing sensory-based approaches to maximize environment adaptation may be beneficial in reducing disruptive behaviors for adults with cognitive impairment.

Exploring older adults' experiences using technology during a viral pandemic

Background

Older adults are at greater risk for morbidity and mortality associated with COVID‐19. Spatial distancing and sequestering practices are recommended to limit viral exposure. Older adults adopting these practices are at increased risk of social isolation and adverse health outcomes. Remote technologies offer various platforms for satisfying socialization and healthcare needs while sequestering. Understanding how older adults are using technology has implications for wellbeing during a pandemic.

Method

Researchers attempted to contact all participants enrolled in the University of Kentucky Alzheimer's Disease Research Center longitudinal study via telephone to survey technology use (n = 706). Participants were contacted directly, except for demented participants, whose primary caregivers were contacted to respond on their behalf, when possible. Participants and caregivers gave their assent verbally to complete the voluntary survey, the procedures of which were approved by the IRB. The surveys consisted of validated instruments to gauge the extent of use of and comfort with technology. Spearman correlations, chi‐square tests, and t‐tests were used to explore data.

Result

Ultimately, 384 participants were reached and 332 consented to participate. Most reported reliable home internet access (91.5%) and some internet use (90.6%). Recent feelings of loneliness were not related to any technology‐related variables (all ps > 0.29) other than decreasing with greater willingness to use telehealth (Rho = ‐0.11, p = 0.06). Those who reported a lack of comfort with technology (n = 76) were less likely to text messaging (67% vs 78%) and social media (56% vs 69%), ps ≤ 0.06, but felt socially connected using technology at similar levels (82% vs 75%), p = 0.22. Nearly 70% of this group reported they would use technology more with training. Across all participants, willingness to use telehealth was not related to frequency of frustration with tech (Rho = 0, p = 0.99).

Conclusion

The results suggest that some older adults’ use of technology is limited by familiarity. Lack of familiarity does not appear to create a barrier to using telehealth nor does frustration with technology appear to limit telehealth use. The findings have implications for supporting older adults sequestered during a pandemic but potentially more broadly.

Associations of Future Cognitive Decline with Sexual Satisfaction among Married Older Adults

Objectives: This study sought to explore changes in longitudinal cognitive status in relation to baseline measures of intimacy and sexuality in cognitively intact, married older adults.Methods: Baseline intimacy and sexuality survey data from 155, cognitively intact, married, older adults were collected using a novel survey instrument that explored the domains of: 1) romance with one's partner, 2) sexual satisfaction, 3) beliefs about sexuality, and 4) social support and emotional intimacy. These data were analyzed in relation to change in cognitive status over a 10-year follow-up period using binary logistic regression modeling. Exploratory factor analysis was used to assess the shared variance of survey items attributable to intimacy and sexuality without specification of an a priori hypothesis regarding the association of intimacy and sexuality with future change in cognitive status.Results: Over the 10-year study period, 33.5% (n = 52) of individuals developed cognitive impairment. Participants with greater sexual satisfaction scores at baseline were statistically less likely to convert from cognitively intact to mild cognitive impairment or dementia in the future (p = .01). The domains of romance with one's partner, beliefs about sexuality, and social support/emotional intimacy were not predictive of future longitudinal changes in cognitive status.Conclusions: Sexual satisfaction is associated with longitudinal cognitive outcomes in cognitively intact, married, older adults.Clinical implications: Clinicians should routinely assess for sexual satisfaction among older adults and refer to appropriate providers, such as couples or sex therapists, when appropriate.

Real-world Site Experiences With GeneMatch: The Role of a Recruitment-related Registry in the Context of Local Site Effort to Support Alzheimer Disease Prevention Research

BACKGROUND

Registries have been proposed as a novel way to accelerate targeted recruitment for Alzheimer disease prevention clinical trials. However, there are limited data regarding registry effectiveness at accelerating recruitment and enrollment in research opportunities. This manuscript explores one site's experience with GeneMatch, a novel genetic registry for Alzheimer disease research.

METHODS

Referrals from GeneMatch to the site were tracked to understand the demographics of those referred and ultimate research enrollment outcomes. Referrals were cross-referenced with the site's existing recruitment database, to better understand the role of GeneMatch in the context of existing recruitment efforts.

RESULTS

GeneMatch referred 86 individuals to the site, resulting in 54 individuals coming into the site to pursue research involvement further. The majority of referrals (52/86, 60.47%) did not have prior contact with the site about research engagement, and having prior site contact did not significantly relate to engaging in on-site research.

CONCLUSIONS

GeneMatch helped identify new individuals for participation in Alzheimer disease prevention studies. Results highlight the value of continuing local site-level efforts while also taking advantage of registries to enhance research recruitment. Ongoing efforts to further develop these and other novel strategies for outreach and engagement are much needed.

Older Adults' Adaptations to the Call for Social Distancing and Use of Technology: Insights From Socioemotional Selectivity Theory and Lived Experiences

Social distancing guidelines during COVID can be isolating, especially for older adults, with potential for poor health outcomes. Technology offers opportunities for remote connection, yet, older adults' use of and perspectives on technology during this time remain largely unknown. The purpose of this study was to gain insight into older adults' technology use and preferences to inform the development of a technology training intervention to support older adult well-being. Semi-structured interviews were conducted with 30 older adults. Interviews were analyzed using an iterative, constant comparison approach. Findings were consistent with Socioemotional Selectivity Theory; respondents were primarily interested in technology to support emotionally meaningful goals. Participants indicated limited interest in technology training, referencing diminished future time perspectives to explain disinterest. Findings suggest that efforts to encourage older adults' expanded technology adoption should highlight how use supports emotionally meaningful goals and provide low-effort, timely training, tied to specific and clear applications.

Rural Caregivers: Identification of Informational Needs Through Telemedicine Questions

OBJECTIVES

The prevalence of Alzheimer's disease and associated disorders is increasing. Rural residents in the United States have less access to memory care specialists and educational and community resources than in other areas of the country. Over a decade ago, we initiated an interdisciplinary rural caregiving telemedicine program to reach Kentucky residents in areas of the state where resources for supporting individuals with dementia are limited. Telemedicine programs involve a short informational presentation followed by a question and answer session; programs are offered 4 times a year. The purpose of this study was to explore questions asked over 1 year of the rural caregiving telemedicine program-encompassing 5 programs-to identify the scope of dementia-related knowledge gaps among attendees.

METHODS

Questions from the 5 programs were recorded and content analyzed to identify areas of frequent informational requests.

RESULTS

There were a total of 69 questions over the 5 sessions. For each program, questions ended due to time constraints rather than exhausting all inquiries. The most common topical areas of questions related to risk factors, behavioral management, diagnosis, and medications.

DISCUSSION AND IMPLICATIONS

This study highlights that rural caregivers in Kentucky have diverse dementia educational needs. Rural communities may benefit from additional, targeted resources addressing these common areas of unmet informational needs.

Alzheimer Disease Worries, Fears, and Stigma and Their Relationship to Genetic and Interventional Research Engagement

BACKGROUND

Alzheimer disease (AD) research increasingly requires healthy individuals willing to undergo genetic testing.

OBJECTIVE

This study seeks to: (1) describe older adults' beliefs about AD genetic testing, worry about AD, and fear of AD stigma, and (2) explore how these constructs relate to research participation.

METHODS

Surveys were sent to participants active in AD-observational research and those that were not. Three measures of research participation were explored: (1) being a current research participant, (2) self-report of clinical trial participation, and (3) expressing genetic registry interest.

RESULTS

The majority of the 502 respondents perceived greater benefit than the risk associated with AD genetic testing. AD worry and perceptions of AD stigma were low. Higher levels of AD worry and lower perceptions of AD stigma were associated with being a current AD research volunteer. AD worry and stigma were unrelated to clinical trial participation or genetic registry interest; these research participation measures were associated with AD genetic testing benefit.

CONCLUSIONS

Beliefs about AD genetic testing, AD worry, and AD stigma are related to research participation, but relationships vary based on the research participation investigated. Future work should identify how these findings can inform outreach and recruitment efforts.

The Effectiveness of Community-based Outreach Events for the Promotion of African American Research Participation

INTRODUCTION

African Americans (AA) are disproportionately affected by Alzheimer's disease and related dementias yet are under-represented in clinical research. Outreach events for AA are offered to encourage research participation; however, this approach's effectiveness remains largely unexplored.

METHODS

To explore the effectiveness of AA-focused versus general audience events, the authors examined attendance data over 5 years, encompassing 10 general audience events and 4 events focused on AA. For each individual, the authors searched center records for recruitment contacts and research enrollment. Summary scores for attendance at AA-focused events, general audience events, and total events were compared between those with and without research involvement.

RESULTS

Out of 773 unique AA that attended ≥1 event, 88 became or were involved in research (11.4% engagement). AA-focused events achieved greater AA attendance than general audience events. Although research-engaged individuals were more likely to have ever attended an AA-focused event than a general audience event, attendance at AA-focused events did not statistically relate to research engagement. In contrast, attendance at events focused on the general public was related to an increased likelihood of research participation.

DISCUSSION

These findings have important implications for designing and implementing community events to encourage AA research participation.

Genetic Sample Provision Among National Alzheimer's Coordinating Center Participants

BACKGROUND

Genetic data help detect preclinical Alzheimer's disease and target individuals for clinical trials, making genetic research engagement critical for continued advancement in dementia prevention and treatment.

OBJECTIVE

To understand what individual and institutional factors may relate to provision of genetic samples within the Alzheimer's Disease Centers.

METHODS

Data from the National Alzheimer's Coordinating Center Uniform Data Set (2009-2016) were obtained along with genetic sample availability. Logistic regression was used to assess independent contributions of demographic and clinical characteristics to the probability of sample provision. Sites contributing data completed a brief survey exploring regulatory and scientific issues related to genetic research engagement.

RESULTS

Just over half (52.1%) of the 27,519 unique participants had genetic data available. Female sex, white race, non-Hispanic ethnicity, normal cognition, and greater than 5 years of follow-up were associated with greater probability of availability. Sites identified refusals as the most frequent barrier to sample provision, followed by staff availability.

CONCLUSION

These results highlight the importance of strategies to promote minority engagement and encourage earlier genetic research participation.

Will "social distancing" lead to future "research distancing": A reflection on COVID-19 impacts on Alzheimer's disease research

Coronavirus disease 19 (COVID‐19) has dramatically altered everyday life, including the field of Alzheimer's disease (AD) research. This perspective article explores some of the ways in which COVID‐19 has already impacted the field, anticipates some of the long‐lasting effects, and explores strategies for addressing current and future needs. Areas of impact include study integrity, regulatory and industry issues, and participant engagement. Proposed strategies for addressing these challenges include analytic methods to deal with large degrees of missing data and development of patient‐centered, user‐friendly, remote data collection tools and assessments. We also highlight the importance of maintaining participant well‐being as a first and constant priority.

Identifying Adaptive and Maladaptive Behaviors Following a Diagnosis of Mild Cognitive Impairment

INTRODUCTION

Individual reactions to a diagnosis of mild cognitive impairment (MCI) can vary in a wide range of both adaptive and maladaptive responses. Understanding such reactions to diagnosis is important to maximize adaptive responses that can promote continued independence.

METHODS

In this pilot study, the Aging and Memory Quality of Life survey was developed to facilitate an understanding of adaptive and maladaptive behaviors results from a diagnosis of MCI. The Aging and Memory Quality of Life was administered to 45 individuals diagnosed with MCI and 45 cognitively normal participants serving as control subjects matched for age, sex, and education. Study partners were surveyed to collect corroborating and or discrepant observer responses.

RESULTS

Inconsistent with study partners' reporting, MCI subjects may be underreporting physical limitations, and overreporting medication compliance. MCI subjects identified challenges to managing financial affairs.

DISCUSSION

Developing strategies to circumvent the development of maladaptive behaviors could significantly reduce morbidity and mortality in MCI patients.

"From Victimhood to Warriors": Super-researchers' Insights Into Alzheimer's Disease Clinical Trial Participation Motivations

BACKGROUND AND OBJECTIVES

Recruitment and retention of research participant serve as a significant challenge in the search for ways to slow or prevent Alzheimer's disease. While barriers to participation are well documented, less is known about motivations for Alzheimer's disease clinical research participation. The purpose of this study was to explore what motivates individuals-who ultimately develop an ongoing connection to research and frequently participate-to engage and stay involved in Alzheimer's disease research.

RESEARCH DESIGN AND METHODS

Individuals who had participated in multiple Alzheimer's disease-related clinical trials, or their study partners, were interviewed about their decisions to engage and remain in research.

FINDINGS

Interviews were completed with 33 individuals, 28 research participants, and 5 study partners. All interviews were audio-recorded and transcribed verbatim for analysis. Respondents indicated learning about research opportunities through the media, community events, doctors, and other research participants. While many were initially motivated by a family history or knowing someone with Alzheimer's disease, others had no personal exposure. Individuals in prevention studies were generally proactive and viewed research as a constructive way to address memory concerns. While several individuals acknowledged personal benefits of research participation, most indicated an understanding of the importance of research and being motivated to help others in the future, frequently referencing a sense of social responsibility or moral obligation to help. Positive relationships with personnel at the site encouraged continued involvement.

DISCUSSION AND IMPLICATIONS

These findings suggest that efforts to identify research participants should highlight the value of research and help illuminate how participation may contribute to well-being of future generations.

Insights From African American Older Adults on Brain Health Research Engagement: "Need to See the Need"

African Americans (AAs) have an elevated risk of developing dementia, yet are underrepresented in clinical research. This project uses a community-engaged photovoice approach to add to existing understanding of barriers and facilitators to AA participation in Alzheimer's disease research and identify strategies to enhance engagement. Three AA research advocates served as community facilitators to identify and guide groups of AA adults through an eight to nine session photovoice project. Group sessions involved discussions and sharing of images pertaining to various prompts in the area of brain health and research participation. Sessions were audiotaped and transcribed verbatim. Participants identified three categories of barriers to AA research participation: (a) Mistrust, (b) avoidance and fear of acknowledging problems, and (c) seeing the risks of research but not the need. Participants shared suggestions and approaches for ameliorating each of these barriers. This process revealed unique insights into barriers and opportunities for increasing AA engagement in aging and dementia research.

Post-acquisition processing confounds in brain volumetric quantification of white matter hyperintensities

BACKGROUND

Disparate research sites using identical or near-identical magnetic resonance imaging (MRI) acquisition techniques often produce results that demonstrate significant variability regarding volumetric quantification of white matter hyperintensities (WMH) in the aging population. The sources of such variability have not previously been fully explored.

NEW METHOD

3D FLAIR sequences from a group of randomly selected aged subjects were analyzed to identify sources-of-variability in post-acquisition processing that can be problematic when comparing WMH volumetric data across disparate sites. The methods developed focused on standardizing post-acquisition protocol processing methods to develop a protocol with less than 0.5% inter-rater variance.

RESULTS

A series of experiments using standard MRI acquisition sequences explored post-acquisition sources-of-variability in the quantification of WMH volumetric data. Sources-of-variability included: the choice of image center, software suite and version, thresholding selection, and manual editing procedures (when used). Controlling for the identified sources-of-variability led to a protocol with less than 0.5% variability between independent raters in post-acquisition WMH volumetric quantification.

COMPARISON WITH EXISTING METHOD(S)

Post-acquisition processing techniques can introduce an average variance approaching 15% in WMH volume quantification despite identical scan acquisitions. Understanding and controlling for such sources-of-variability can reduce post-acquisition quantitative image processing variance to less than 0.5%.

DISCUSSION

Considerations of potential sources-of-variability in MRI volume quantification techniques and reduction in such variability is imperative to allow for reliable cross-site and cross-study comparisons.

Health Behaviors in Rural Appalachia

OBJECTIVES

To better understand the disproportionate burdens from cancer, cardiovascular disease, diabetes mellitus, stroke, and other chronic conditions related to energy balance, we studied diet and physical activity patterns in younger and older adults in rural Appalachia by using a nonclinical, cross-sectional, community-based sampling approach.

METHODS

A total of 651 younger (ages 18-59) and 254 older (ages ≥60) Appalachians were recruited from 43 churches or community organizations. Participants answered questions about fruit and vegetable intake and physical activity. Analyses were adjusted for clustering within churches.

RESULTS

Compared with older Appalachians, younger Appalachians consumed significantly fewer fruits and vegetables (P = 0.01) and reported significantly more moderate-to-vigorous physical activity (P = 0.01). Regardless of age, engagement in healthy behaviors was suboptimal and well below national averages.

CONCLUSIONS

This community-based sample demonstrated elevated behavioral risk factors that likely contribute to some of the nation's highest rates of premature mortality. Despite suboptimal dietary intake and physical activity, results indicate some potential leverage points between the generations that may be used to improve health. For example, the older generation could benefit from engaging with their younger relatives in physical activities while advocating for a better-rounded diet. Given traditions of intergenerational connectedness, mutual aid, and self-reliance, transmission of healthier behaviors across the generations may be beneficial in the rural Appalachian context.

Public Understanding and Opinions regarding Genetic Research on Alzheimer's Disease

BACKGROUND

Participants willing to provide genetic samples are needed to propel research on Alzheimer's disease (AD) treatment and prevention forward. A limited public understanding of what AD genetic research entails and concerns about participation may constitute recruitment challenges.

OBJECTIVES

This study seeks to understand how well older adults understand AD genetic research and whether their understanding is related to concerns about participation or willingness to engage.

METHODS

Our surveys included a mock consent form with corresponding knowledge and opinion questions regarding AD. The surveys were mailed to participants from the University of Kentucky Alzheimer's Disease Center and to a list of randomly selected individuals within the same age range from a local voter registration list. Descriptive and multivariable linear regression analyses were conducted.

RESULTS

The returned surveys (n = 502) demonstrated limits to what the respondents understood immediately after reading the relevant material, with a mean summary knowledge score of 74.5 out of 100. While comprehension gaps were not related to level of concern or willingness to engage, concerns were related to willingness to engage. Concerns were greater among individuals not actively involved in research, individuals from minority groups, and those with higher levels of education.

CONCLUSIONS

Focusing on concerns specifically, rather than on knowledge more generally, may help increase participation.

The Role of Primary Care Providers in Encouraging Older Patients to Change Their Lifestyle Behaviors

OBJECTIVES

This study sought to identify older patients' perceptions of primary care providers' influence on their likelihood of improving diet and physical activity.

METHODS

104 adults ages 65 and older were interviewed immediately following a routine primary care visit about their plans and motivations for behavior change and how their clinic visit would influence their likelihood of making lifestyle changes. All interviews were recorded, transcribed and analyzed using a constant comparison approach.

RESULTS

Participants reported that their providers influence their health behaviors by developing strong relationships, addressing concerns and encouraging change, and providing concrete instruction. When providers did not discuss diet or physical activity, or mentioned these topics only briefly, participants often perceived the message that they should continue their current behaviors.

CONCLUSIONS

Whether and how diet and physical activity are discussed in primary care influences the likelihood that older adults will make changes in these behaviors.

CLINICAL IMPLICATIONS

These findings highlight the need for a patient-centered counseling approach and caution providers to think twice before omitting discussion of the need for lifestyle change.

Visual Arts Education improves self-esteem for persons with dementia and reduces caregiver burden: A randomized controlled trial

A Visual Arts Education program was tested among 26 pairs of persons with dementia and their caregivers. Pairs were randomized to Visual Arts Education or control groups, and each group met once per week for two months (8 weeks) to participate in activities with a trained arts instructor. Groups were assessed at baseline, two months, and six months. The Visual Arts Education group received instruction and produced a different type of artistic work each week. The pedagogical strategy was designed so that each activity was increasingly novel, challenging, and complex. The control group viewed slide shows, participated in discussions about art, and made paintings. At the six-month follow-up, significant improvements in caregiver burden and self-esteem for the persons with dementia were found in the Visual Arts Education group. The Visual Arts Education pedagogical approach shows the potential for effectiveness for improving quality of life for persons with dementia and their caregivers.

Motivators for Alzheimer's disease clinical trial participation

BACKGROUND

Alzheimer's disease (AD) research progress is impeded due to participant recruitment challenges. This study seeks to better understand, from the perspective of individuals engaged in clinical trials (CTs), research motivations.

METHODS

Participants, or their caregivers, from AD treatment and prevention CTs were surveyed about research motivators.

RESULTS

The 87 respondents had a mean age of 72.2, were predominantly Caucasian, 55.2% were male, and 56.3% had cognitive impairment. An overwhelming majority rated the potential to help themselves or a loved one and the potential to help others in the future as important motivators. Relatively few respondents were motivated by free healthcare, monetary rewards, or to make others happy.

CONCLUSIONS

Recruitment efforts should focus on the potential benefit for the individual, their loved ones, and others in the future rather than free healthcare or monetary rewards.

Potential Cognitive Benefits From Playing Music Among Cognitively Intact Older Adults: A Scoping Review

The aging population is growing rapidly, raising rates of cognitive impairment, which makes strategies for protection against cognitive impairment increasingly important. There is little evidence indicating highly effective interventions preventing or slowing onset of cognitive impairment. Music playing influences brain and cognitive function, activating multiple brain areas and using cognitive and motor functions as well as multiple sensory systems, simultaneously. The purpose of this study was to review the current evidence related to playing a musical instrument being a potentially protective mechanism against cognitive decline among older adults. Using scoping review procedures, four databases were searched. Paired reviewers analyzed articles for content, design, and bias. Eleven studies met study criteria and were included in the review. All studies showed that music playing was correlated with positive outcomes on cognitive ability; more high-quality research is needed in this area to understand mechanisms behind potential cognitive protection of music.

Global Cerebral Atrophy Detected by Routine Imaging: Relationship with Age, Hippocampal Atrophy, and White Matter Hyperintensities

BACKGROUND AND PURPOSE

Interpreting the clinical significance of moderate-to-severe global cerebral atrophy (GCA) is a conundrum for many clinicians, who visually interpret brain imaging studies in routine clinical practice. GCA may be attributed to normal aging, Alzheimer's disease (AD), or cerebrovascular disease (CVD). Understanding the relationships of GCA with aging, AD, and CVD is important for accurate diagnosis and treatment decisions for cognitive complaints.

METHODS

To elucidate the relative associations of age, moderate-to-severe white matter hyperintensities (WMHs), and moderate-to-severe medial temporal lobe atrophy (MTA), with moderate-to-severe GCA, we visually rated clinical brain imaging studies of 325 participants from a community based sample. Logistic regression analysis was conducted to assess the relations of GCA with age, WMH, and MTA.

RESULTS

The mean age was 76.2 (±9.6) years, 40.6% were male, and the mean educational attainment was 15.1 (±3.7) years. Logistic regression results demonstrated that while a 1-year increase in age was associated with GCA (OR = 1.04; P = .04), MTA (OR = 3.7; P < .001), and WMH (OR = 8.80; P < .001) were strongly associated with GCA in our study population. Partial correlation analysis showed that the variance of GCA explained by age is less than the variance attributed to MTA and WMH (r = .13, .21, and .43, respectively).

CONCLUSIONS

Moderate-to-severe GCA is most likely to occur in the presence of AD or CVD and should not be solely attributed to age when evaluating clinical imaging findings in the workup of cognitive complaints. Developing optimal diagnostic and treatment strategies for cognitive decline in the setting of GCA requires an understanding of its risk factors in the aging population.

The Role of the Built Environment: How Decentralized Nurse Stations Shape Communication, Patient Care Processes, and Patient Outcomes

Increasingly, health communication scholars are attending to how hospital built environments shape communication, patient care processes, and patient outcomes. This multimethod study was conducted on two floors of a newly designed urban hospital. Nine focus groups interviews were conducted with 35 health care professionals from 10 provider groups. Seven of the groups were homogeneous by profession or level: nursing (three groups), nurse managers (two groups), and one group each of nurse care technicians ("techs") and physicians. Two mixed groups were comprised of staff from pharmacy, occupational therapy, patient care facilitators, physical therapy, social work, and pastoral care. Systematic qualitative analysis was conducted using a conceptual framework based on systems theory and prior health care design and communication research. Additionally, quantitative modeling was employed to assess walking distances in two different hospital designs. Results indicate nurses walked significantly more in the new hospital environment. Qualitative analysis revealed three insights developed in relationship to system structures, processes, and outcomes. First, decentralized nurse stations changed system interdependencies by reducing nurse-to-nurse interactions and teamwork while heightening nurse interdependencies and teamwork with other health care occupations. Second, many nursing-related processes remained centralized while nurse stations were decentralized, creating systems-based problems for nursing care. Third, nursing communities of practices were adversely affected by the new design. Implications of this study suggest that nurse station design shapes communication, patient care processes, and patient outcomes. Further, it is important to understand how the built environment, often treated as invisible in communication research, is crucial to understanding communication within complex health care systems.

Perspectives of healthcare practitioners: An exploration of interprofessional communication using electronic medical records

Contemporary state-of-the-art healthcare facilities are incorporating technology into their building design to improve communication and patient care. However, technological innovations may also have unintended consequences. This study seeks to better understand how technology influences interprofessional communication within a hospital setting based in the United States. Nine focus groups were conducted including a range of healthcare professions. The focus groups explored practitioners' experiences working on two floors of a newly designed hospital and included questions about the ways in which technology shaped communication with other healthcare professionals. All focus groups were recorded, transcribed, and coded to identify themes. Participant responses focused on the electronic medical record, and while some benefits of the electronic medical record were discussed, participants indicated use of the electronic medical record has resulted in a reduction of in-person communication. Different charting approaches resulted in barriers to communication between specialties and reduced confidence that other practitioners had received one's notes. Limitations in technology-including limited computer availability, documentation complexity, and sluggish sign-in processes-also were identified as barriers to effective and timely communication between practitioners. Given the ways in which technology shapes interprofessional communication, future research should explore how to create standardised electronic medical record use across professions at the optimal level to support communication and patient care.

Challenges and Considerations Related to Studying Dementia in Blacks/African Americans

Blacks/African Americans have been reported to be ∼2-4 times more likely to develop clinical Alzheimer's disease (AD) compared to Whites. Unfortunately, study design challenges (e.g., recruitment bias), racism, mistrust of healthcare providers and biomedical researchers, confounders related to socioeconomic status, and other sources of bias are often ignored when interpreting differences in human subjects categorized by race. Failure to account for these factors can lead to misinterpretation of results, reification of race as biology, discrimination, and missed or delayed diagnoses. Here we provide a selected historical background, discuss challenges, present opportunities, and suggest considerations for studying health outcomes among racial/ethnic groups. We encourage neuroscientists to consider shifting away from using biologic determination to interpret data, and work instead toward a paradigm of incorporating both biological and socio-environmental factors known to affect health outcomes with the goal of understanding and improving dementia treatments for Blacks/African Americans and other underserved populations.

Older Patients' Recall of Lifestyle Discussions in Primary Care

Despite the known benefits of engaging in healthy diet and physical activity across the life span, suboptimal diet and physical inactivity are pervasive among older adults. While health care providers can promote patients' engagement in health behaviors, patient recall of recommendations tends to be imperfect. This study sought to better understand older adults' recall of dietary and physical activity discussions in primary care. One hundred and fifteen adults aged 65 and older were interviewed immediately following a routine primary care visit on whether and what they recalled discussing pertaining to diet and physical activity. Compared against transcripts, most patients accurately recalled their diet and physical activity discussions. The inclusion of a recommendation, and for diet discussions longer duration, increased the likelihood of patient recall for these health behavior discussions. These findings suggest that specific recommendations and an extra minute of discussion, at least for dietary discussions, increase the likelihood of accurate patient recall.

The content of diet and physical activity consultations with older adults in primary care

OBJECTIVE

Despite numerous benefits of consuming a healthy diet and receiving regular physical activity, engagement in these behaviors is suboptimal. Since primary care visits are influential in promoting healthy behaviors, we sought to describe whether and how diet and physical activity are discussed during older adults' primary care visits.

METHODS

115 adults aged 65 and older consented to have their routine primary care visits recorded. Audio-recorded visits were transcribed and diet and physical activity content was coded and analyzed.

RESULTS

Diet and physical activity were discussed in the majority of visits. When these discussions occurred, they lasted an average of a minute and a half. Encouragement and broad discussion of benefits of improved diet and physical activity levels were the common type of exchange. Discussions rarely involved patient behavioral self-assessments, patient questions, or providers' recommendations.

CONCLUSIONS

The majority of patient visits include discussion of diet and physical activity, but these discussions are often brief and rarely include recommendations.

PRACTICE IMPLICATIONS

Providers may want to consider ways to expand their lifestyle behavior discussions to increase patient involvement and provide more detailed, actionable recommendations for behavior change. Additionally, given time constraints, a wider array of approaches to lifestyle counseling may be necessary.

Patient and provider perspectives on the relationship between multiple morbidity management and disease prevention

Despite competing demands of multiple morbidity (MM) management and disease prevention, our recent survey of 1,153 Appalachian residents aged 50 to 76 documented that individuals with MM were more likely to obtain colorectal cancer screening (CRCS) than those without MM. Nearly two thirds of respondents obtained CRCS, and the more MM, the greater the likelihood of screening. To gain insight into this relationship, we conducted nine focus groups, six with providers and three with patients. Three main explanations emerged: (a) patients' MM increases providers' vigilance for other health vulnerabilities; (b) having MM increases patients' own vigilance; and (c) patients' vigilance may stem from experiencing more symptoms, having a family history of cancer, and having successfully obtained health care. More frequent contact with health care providers appears to encourage preventive referral, especially in low-income populations that otherwise may not receive such counselling. We highlight participant recommendations to improve MM management and prevention.

Primary care physicians' prevention counseling with patients with multiple morbidity

The prevalence of multiple health conditions, or multiple morbidity (MM), is increasing. Providing medical care for adults with MM presents challenges, including balancing disease management with prevention. We conducted in-depth semistructured interviews with 12 primary care physicians to explore their perspectives on prevention counseling among patients with MM. Participants described the complex relationship between disease management and prevention, highlighted the importance of patient motivation, and discussed various strategies to promote receptivity to prevention recommendations. The perceived potential benefits of prevention recommendations encouraged physicians to persist with such counseling, despite challenges presented by visit time constraints, reimbursement procedures, and concerns over futility. Physicians recommended the development of alternate care delivery and reimbursement models to overcome challenges of the existing health care system and to meet the prevention needs of patients with MM. We explore the implications of these findings for maximizing the health and quality of life of adults with MM.

Geriatric education in the health professions: are we making progress?

PURPOSE

Relative to the overall population, older adults consume a disproportionally large percentage of health care resources. Despite advocacy and efforts initiated more than 30 years ago, the number of providers with specialized training in geriatrics is still not commensurate with the growing population of older adults. This contribution provides a contemporary update on the status of geriatric education and explores how geriatric coverage is valued, how geriatric competence is defined, and how students are evaluated for geriatric competencies.

DESIGN AND METHODS

Semi-structured interviews were conducted with curriculum representatives from 7 health profession disciplines in a case study of one academic medical center.

FINDINGS

Geriatric training varies across health professions' disciplines. Although participants recognized the unique needs of older patients and valued geriatric coverage, they identified shortage of time in packed curricula, lack of geriatrics-trained educators, absence of financial incentive, and low student demand (resulting from limited exposure to older adults and gerontological stereotyping) as barriers to improving geriatric training.

IMPLICATIONS

Progress in including geriatric training within curricula across the health professions continues to lag behind need as a result of the continuing presence of barriers identified several decades ago. There remains an urgent need for institutional commitment to enhance geriatric education as a component of health professions curricula.

The role of social support in multiple morbidity: self-management among rural residents

Social support generally is considered a valuable asset that may compensate for health service deficiencies among rural populations. Employing a mixed methods approach, we explored how vulnerable rural residents described social support in the context of self-management for multiple chronic conditions. Participants generally felt support was available, though emotional/informational support was perceived as less available than other types of support. Participants did not rely heavily on informal support to help them manage their multiple morbidities, preferring to call on their doctor and their own resources. We discuss implications of these findings for meeting this vulnerable population's self-management needs.