Eating experiences in people living with dementia: A concept analysis using Rodgers's methodology

AIMS

To analyse the concept of eating experiences in people living with dementia.

DESIGN

Rodgers' evolutionary method of concept analysis was used as a framework for the paper.

DATA SOURCES

The literature was searched using electronic databases PubMed, Google Scholar, CINHAL, PsycInfo, Web of Science, Embase and Elsevier databases. These databases cover a variety of disciplines, including but not limited to nursing, medicine and occupational therapy. The relevant literature published from 1989 to April 2023 was thoroughly examined. Any quantitative or qualitative studies published in English focused on eating or dining experiences in people with dementia were included.

REVIEW METHODS

Rodgers' evolutionary method for concept analysis was used. The attributes, antecedents, consequences and case examples of the concept were identified.

RESULTS

Twenty-two articles met the inclusion criteria, identifying key attributes of self-connection, the special journey of life and self-interpretation. Antecedents, as framed by the socio-ecological model, were categorized to represent intrapersonal (personal preferences, individual culture, mealtime routines), interpersonal (social interaction) and environmental (dining room environment, policies) factors. Consequences were divided into external (nutritional health, physical health and quality of life) and internal (personhood, autonomy and independence, dignity and feeling valued and mental well-being) domains.

CONCLUSION

A theoretical definition and conceptual model of eating experiences in people living with dementia was developed. The identified attributes, antecedents and consequences can be utilized in nursing education, research and intervention approaches.

IMPACT

This article allows nurses and other healthcare professionals to better understand people living with dementia through the relationship between eating and interpersonal, intrapersonal and environmental aspects to develop personalized interventions and care strategies to achieve an optimal quality of life.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable.

Evaluating Cognitive Impairment in a Large Health Care System: The Cognition in Primary Care Program

Background

The prevalence of Alzheimer's disease and related disorders (ADRD) is rising. Primary care providers (PCPs) will increasingly be required to play a role in its detection but lack the training to do so.

Objective

To develop a model for cognitive evaluation which is feasible in primary care and evaluate its implementation in a large health system.

Methods

The Cognition in Primary Care Program consists of web-based training together with integrated tools built into the electronic record. We implemented the program among PCPs at 14 clinics in a large health system. We (1) surveyed PCPs to assess the impact of training on their confidence to evaluate cognition, (2) measured the number of cognitive assessments they performed, and (3) tracked the number of patients diagnosed with mild cognitive impairment (MCI).

Results

Thirty-nine PCPs completed the training which covered how to evaluate cognition. Survey response rate from those PCPs was 74%. Six months after the end of the training, they reported confidence in assessing cognition (mean 4.6 on 5-point scale). Cognitive assessments documented in the health record increased from 0.8 per month before the training to 2.5 in the six months after the training. Patients who were newly diagnosed with MCI increased from 4.2 per month before the training to 6.0 per month in the six months after the training.

Conclusions

This model for cognitive evaluation in a large health system was shown to increase cognitive testing and increase diagnoses of MCI. Such improvements are essential for the timely detection of ADRD.

Developing a cognitive assessment toolkit for primary care: qualitative assessment of providers' needs and perceptions of usability in clinical practice

BACKGROUND

Burden of dementia is expected to substantially increase. Early dementia is underdiagnosed in primary care. Given the benefits of active management of dementia, earlier detection in primary care is imperative. The aim of this study was to understand primary care provider (PCP) perceptions of implementing a cognitive assessment toolkit in primary care.

METHODS

PCPs in a large health system in the US were recruited to a qualitative study utilizing semi-structured interviews. Interviews captured provider perceptions of options for implementing a cognitive assessment toolkit derived from the Gerontological Society of America (GSA) KAER (Kickstart, Assess, Evaluate, Refer) toolkit, including a workflow and adapted clinical tools. A content analysis approach distinguished themes and exemplary quotes.

RESULTS

Ten PCPs were interviewed. They found the toolkit useful, felt the term Kickstart was not specific to dementia care, and stressed that addressing cognitive evaluation would need to be easy to implement in a clinical workflow. Finally, providers knew many resources for referral but were unsure how to help patients navigate options.

CONCLUSIONS

Providers stressed simplicity, ease, and efficiency for implementation of a cognitive assessment toolkit. Incorporating these findings into the development of clinical tools and workflows may increase cognitive evaluations conducted by PCPs.

Association of Perceived Neighborhood Environments With Cognitive Function in Older Adults

The current study examined the associations between perceptions of the social and physical neighborhood environments and cognitive function in older adults. This cross-sectional study analyzed 821 adults aged ≥65 years from the Adult Changes in Thought study. Perceived neighborhood attributes were measured by the Physical Activity Neighborhood Environment Scale. Cognitive function was assessed using the Cognitive Ability Screening Instrument. The associations were tested using multivariate linear regression. One point greater perceived access to public transit was associated with 0.56 points greater cognitive function score (95% confidence interval [CI] [0.25, 0.88]), and an additional one point of perceived sidewalk coverage was related to 0.22 points higher cognitive function score (95% CI [0.00, 0.45]) after controlling for sociodemographic factors. The perception of neighborhood attributes alongside physical infrastructure may play an important role in supporting older adults' cognitive function. [Journal of Gerontological Nursing, 49(8), 35-41.].

Implementation and impact of a Dementia Friends pilot

INTRODUCTION

Dementia Friends is a dementia awareness program that trains lay leaders (called "dementia champions") to give presentations about dementia to combat stigma in their community.

OBJECTIVE

In this mixed methods study, we aimed to evaluate the impact and implementation of a pilot Dementia Friends program in Washington State to assess whether it improved attitudes towards people living with dementia.

METHOD

Fifteen champions were recruited, who organized 22 Dementia Friends sessions, reaching 214 Dementia Friends participants. We collected data through interviews with champions and surveys administered to Dementia Friends participants before, immediately after, and 1-month after attending a Dementia Friends session. The survey collected demographic information and measured respondent attitudes towards people living with dementia using the Dementia Attitudes Scale.

RESULTS

Quantitative analysis showed that Dementia Attitude scores improved after a Dementia Friends session; this improvement was maintained through the 1-month follow-up. In qualitative analysis of champion interviews, we identified several suggestions regarding implementation of the Dementia Friends program, which could strengthen the program and better support champions in their role, such as increasing logistical assistance during participant recruitment.

CONCLUSION

Dementia Friends sessions were effective in improving participant attitudes towards people living with dementia and inspiring ongoing action towards building Dementia-Friendly communities. Champions found deep meaning in their role, but would benefit from increased support to make the volunteer role more sustainable. Our findings can inform efforts to successfully deliver Dementia Friends in other locations.

Mediating role of walking between perceived and objective walkability and cognitive function in older adults

The aim of this study was to examine the role of walking in explaining associations between perceived and objective measures of walkability and cognitive function among older adults. The study employed a cross-sectional design analyzing existing data. Data were obtained from the Adult Changes in Thought Activity Monitor study. Cognitive function and perceived walkability were measured by a survey. Objective walkability was measured using geographic information systems (GIS). Walking was measured using an accelerometer. We tested the mediating relationship based on 1,000 bootstrapped samples. Perceived walkability was associated with a 0.04 point higher cognitive function score through walking (p = 0.006). The mediating relationship accounted for 34% of the total relationship between perceived walkability and cognitive function. Walking did not have a significant indirect relationship on the association between objective walkability and cognitive function. Perceived walkability may be more relevant to walking behavior than objective walkability among older adults. Greater levels of perceived walkability may encourage older adults to undertake more walking, and more walking may in turn improve cognitive function in older adults.

EVALUATION OF COGNITION IN PRIMARY CARE (CPC): A PILOT STUDY TO INCREASE EARLY DETECTION AND MANAGEMENT OF DEMENTIA

Despite evidence that early detection of mild cognitive impairment and dementia leads to improved patient care, these conditions remain under-diagnosed in primary care. To address this gap at University of Washington Medicine, we have developed and pilot-tested a program to increase cognitive evaluations and improve dementia care by primary care providers (PCPs). The Cognition in Primary Care (CPC) program was designed utilizing stakeholder-selected components of the GSA KAER (Kickstart-Assess-Evaluate and Refer) Model and Toolkit (2020 Edition), developed by the Gerontological Society of America (GSA). In this presentation we will describe evaluation of the CPC Program including (a) education training; (b) use of assessment tools integrated within the electronic health record (e.g. potentially harmful medications, depressive symptoms, alcohol use, sleep apnea, etc.); (c) practice recommendations such as dedicated evaluation appointments, diagnoses and referrals, and (d) PCP use of community resources for post-diagnosis support. A total of 66 PCPs participated in the series of 3 CME educational seminars. Over 93% of participants reported the content to be highly relevant and expected to incorporate it into their practice; commitments to use specific tools were made. Analysis is underway to determine impact of the program by comparing the above metrics before and after the training as well as between trained and untrained PCPs. Results from this evaluation will inform modifications to increase utilization of the CPC Model within UW Medicine, will be used to package the program to share with other primary care systems, and will guide future enhancements to the GSA KAER Toolkit.

Engaging With Aging: A Qualitative Study of Age-Related Changes and Adaptations

Background and Objectives

In the context of global aging, there is a need to better understand how older adults adapt to their changing health status. Engaging with aging (EWA) is an emerging framework proposed by Carnevali, which provides a new lens to understand an active, conscious daily-living process of managing age-related changes (ARCs) taken on by older adults. Study aims were to (a) describe the ARCs experienced by community-dwelling older adults and (b) identify the strategies and resources used by older adults to accommodate the daily-living challenges caused by the associated ARCs.

Research Design and Methods

We conducted semistructured interviews using a virtual card sort to gather qualitative data about ARCs and strategies to manage ARCs. Interviews were conducted virtually due to coronavirus disease 2019 (COVID-19) restrictions.

Results

Participants included 19 females and 10 males. The mean age was 77.45 years old (range from 64 to 98). Sixteen ARCs (e.g., changes in hearing, changes in stability, changes in sleep, etc.) were mentioned by participants, and their corresponding adaptations were discussed. Participants linked their adaptations to their ARCs based on their changing capacities and needs. Examples of commonly used adaptations included, for example, conserving energy, utilizing tools or technology, and being more conscious before and while taking actions. The challenges caused by COVID-19 in implementing the adaptations were also discussed.

Discussion and Implications

Findings from this study demonstrate how older adults explore, generate, and utilize adaptive behaviors to address their ARCS. This study substantiates the EWA framework by showing common patterns among older adults in linking ARCs with adaptations. Implications for clinicians include using EWA to help older adults identify personalized health solutions that fit their capacities. Researchers may use EWA to design and test interventions by considering the specific ARCs older adults encounter and the attitudes they hold towards the ARCs.

Perceptions and Beliefs of Memory Loss and Dementia Among Korean, Samoan, Cambodian, and Chinese Older Adults: A Cross-Cultural Qualitative Study

Older adults who are Asian American and Pacific Islander (AAPI) represent one of the fastest growing populations in the United States and face a significant burden of Alzheimer's disease and related dementias (ADRD). Little is known about ADRD among AAPI subgroups. The current study aimed to: (a) explore perceptions and beliefs of memory loss and dementia among Korean, Samoan, Cambodian, and Chinese older adults in the United States; and (b) identify culturally relevant facilitators and barriers of participation in a brain health program among four AAPI subgroups. Seven focus groups comprising 14 Cambodian, 21 Chinese, 14 Korean, and 13 Samoan older adults were conducted. Data were analyzed using inductive and indigenous coding approaches. Similar and unique perceptions and experiences related to memory loss were identified. Future research could include developing and testing culturally tailored and language congruent strategies regarding ADRD education and resources to facilitate ADRD early detection among AAPI older adults. [Journal of Gerontological Nursing, 48(6), 40-48.].

Training the next generation of aging and cognitive health researchers

Dementia is a growing public health concern, and African Americans and Latinos are disproportionately affected compared to White Americans. Improving cognitive health outcomes and reducing disparities requires a diverse, interdisciplinary workforce. The US Centers for Disease Control and Prevention's Healthy Brain Research Network (HBRN) Scholars Program trained racially/ethnically and gender-diverse scholars through mentored, collaborative research. Entry, exit, and alumni surveys and a Scholar Spotlight Series queried motivation, goals, acquired skills, accomplishments, program impact, and scholar perspectives. Scholars (n = 41) were majority female (n = 31, 75.6%), graduate students (n = 23, 56.1%), and racially/ethnically diverse (n = 20, 48.7%). Scholars primarily represented Medicine (n = 19, 46.3%) and Public Health (n = 12, 29.3%). Exiting scholars (n = 25) secured faculty/professional positions (n = 9, 36.0%), awards/funding (n = 12, 48.0%), and publications (n = 8, 32.0%). Alumni (n = 10) secured cognitive health-related positions/fellowships (n = 7, 70.0%). The HBRN Scholars Program is an adaptable model for other thematic networks to prepare scholars in collaborative skills critical for effective research and practice.

Evaluating a system to promote timely detection of cognitive impairment in primary care practice

BACKGROUND

Dementia and mild cognitive impairment (MCI) are underdiagnosed with evidence indicating that clinical diagnoses frequently occur late in the process of cognitive decline. Increasing evidence that dementia may be preventable or delayed has led to an international focus on earlier evaluation, diagnosis and intervention.

METHOD

Using the impetus of "Memory Brain Wellness" as a priority growth program at University of Washington (UW) Medicine, we are developing synergistic strategies to improve timely detection of cognitive impairment across primary care in 15 neighborhood clinics in the Pacific Northwest. This presentation will describe current quality-improvement efforts to promote engagement across multiple stakeholders including health-care system leadership, practice care management, primary care providers (PCPs) and clinic staff. This lifespan approach is based on the KAER (Kickstart-Assess-Evaluate and Refer) Model and Toolkit (2020 Edition) developed by the Gerontological Society of America (GSA).

RESULTS

Program activities to be described include 1) results of interviews with the primary care team to determine acceptability and support needed to implement timely cognitive evaluation; 2) implementation of a training intervention to initiate discussions, conduct cognitive assessment, and manage care; and 3) identification of support services and resources to be used in provider consultation. Input from a Technical Advisory Committee and local Community Advisory Board were incorporated into the training and resource inventory for patient/caregiver support. Topics in the training include normalizing the conversation, team approach, moving toward evaluation, assessment tools, alternate diagnoses/modifiable risk factors, multi-disciplinary and community referrals, patient counseling, long-term management, and advance care planning. Changes in practice patterns of PCPs will be reviewed using extracted data from the electronic health record (EHR). Details of each strategy will be provided to explain system-wide decisions, pragmatic applications, results of trainings held to-date and feed-back from the primary care team.

CONCLUSION

This is the first study to refine and utilize the GSA KAER toolkit addressing change in practice patterns in a large multi-clinic primary care system. Results of this program will be used to extend efforts beyond the Seattle region to address timely cognitive evaluation across the 5-state WWAMI region (Washington, Wyoming, Alaska. Montana and Idaho) served by UW Medicine.

Cognition in Primary Care Community Resource Directory for Individuals, Caregivers, and Providers

A KAER Model recommendation is to refer individuals diagnosed with dementia to resources that help them prepare for the future and services that provide ongoing support. The purpose of this project was to locate local quality services and develop a resource directory for persons with cognitive impairment for use by providers, staff, individuals, families, and caregivers. We worked with a Community Advisory Board and interviewed individuals and caregivers to understand what resources are useful and important to include in the resource directory. We built a web-based resource directory that allows users to query resources based on specific needs. We integrated the resource directory within the electronic health record for providers to include after visit summaries. A resource directory was deployed for community use, with goals of sustainability and longevity after this project is completed.

Dementia Care Coaching: A Pilot to Evaluate Acceptability and Feasibility in Care Communities

Personal care aides (PCAs), along with other direct care workers, provide the hands-on care, including help with activities of daily living for individuals receiving care in residential care communities (RCC) and adult day services centers (ADSC). Recruitment and retention of such workers is a challenge as low pay, inadequate training, unsatisfactory roles and lack of benefits contribute to turnover. Using data from the 2018 National Study of Long-Term Care Providers, the only nationally representative data about PCAs in RCCs and ADSCs, this study will assess differences in training hours, benefits, and work roles among PCAs in these settings. About 76% of RCCs and 66% of ADSCs employed aides. On average, PCAs received 32 hours and 51 hours of initial training in ADSCs and RCCs, respectively. Results from bivariate analyses (accounting for complex survey design), showed that benefits received by PCAs varied by sector. A higher percentage of PCAs in ADSCs than in RCCs received health insurance for employees (60% vs. 46%), and pension (51% vs. 40%). About 51% of ADSCs and 46% of RCCs reported that PCAs rarely or sometimes attended care plan meetings. Further, 11% of RCCs and 15% of ADSCs reported that aides rarely or sometimes worked with the same care recipient. This overview of PCA activities, training and benefits may provide insights into approaches to improve the retention of PCAs and subsequently the quality of care provided across sectors.

Engaging with Aging: A Qualitative Study of Age-Related Changes and Adaptations

Engaging with Aging is an emerging framework proposed by Carnevali which provides a new lens to understand an active, conscious daily living process of coping with age-related changes (ARCs) taken on by older adults. Study aims were to 1) describe the ARCs experienced by community-dwelling older adults; 2) identify the strategies and resources used by older adults to accommodate the daily living challenges caused by the associated ARCs; and 3) evaluate the framework of EWA based on findings from aims 1 and 2. We conducted semi-structured interviews with 29 participants aged 64 to 98 online due to COVID-19 restrictions. We used a virtual card sort to assist data gathering. Fifteen ARCs (e.g., changes in hearing, changes in stability, changes in sleep, etc.) were mentioned by participants and their corresponding adaptations were discussed. We found that older adults linked their adaptations to their ARCs based on their changing capacities and needs. Commonly used adaptations included conserving energy, utilizing tools or technology, and being more conscious before and while taking actions. The challenges caused by COVID-19 in implementing the adaptations were also discussed (e.g., increased difficulty in understanding others due to mask-wearing). Our study substantiates the EWA framework by showing the commonality among older adults in linking ARCs with adaptations. Implications for clinicians and researchers include using EWA to help older adults identify personalized solutions that fit their capacities. Our study is late-breaking as we recently finished data analysis and the information included was not yet available by the previous submission deadline.

Integrating the GSA KAER Toolkit Into Practical Training for Primary Care Clinics

Education is central to driving change in clinical practice. First, primary care providers and their clinic team members need to understand why detecting cognitive impairment is important, how it can be done efficiently, and what the next steps in referral and management are. To engage primary care clinics in this change process, we developed a continuing education intervention, based on the KAER Model, using a live video format. Four evidence-based, 45-minute training modules presented core knowledge skills, including how to have difficult conversations, which are essential to diagnosing cognitive impairment. To overcome the obstacles to doing so in primary care, our team relied on a deep understanding of busy primary care practice. With a combined 35 years of direct experience in primary care, our collaborative interdisciplinary team was able to use the KAER Model to develop a highly acceptable intervention for primary care.

Implementation of the GSA KAER Toolkit in a Large Clinic System: Workflow Modifications and EMR Tools

We implemented the KAER toolkit in the University of Washington primary care clinics. In this session we share the workflows implemented to promote the KAER model and share the tools we developed within EPIC, the system's electronic medical record (EMR). We collaborated with clinic staff to develop interdisciplinary workflows including: training patient service representatives, social workers, nurses, and medical assistants (MAs) about 'red flags;' training medical assistants to complete the Patient Health Questionnaire (PHQ-9) and Montreal Cognitive Assessment (MoCA); and assuring they are appropriately entered into flowsheets in EPIC. We created a checklist (EPIC 'SmartPhrase') and educated the clinics' interdisciplinary teams to utilize it within their scope of practice. Additionally, we created an order set (EPIC 'SmartSet') of commonly ordered tests and referrals to expedite evaluation of patients with suspected cognitive impairment. Lastly, we created a direct link from our EMR to our website containing community resources.

Frailty measurements in hospitalised orthopaedic populations age 65 and older: A scoping review

Aims and Objectives

To identify and compare frailty instruments used with hospitalised orthopaedic patients aged over 65.

Background

Frailty predicts clinical events in orthopaedic patients aged over 65. However, the strengths and limitations of different approaches to measuring frailty in this population are rarely discussed. As such, a comprehensive review to address the gap is needed.

Design

Scoping review using Arksey and O’Malley framework.

Methods

PubMed, CINAHL, PsycINFO, Scopus and EMBASE databases were searched to identify studies published from 2006 to 2020 regarding frailty instruments in older orthopaedic patients. The Preferred Reporting Items for Systematic Reviews and Meta‐analyses were followed.

Results

The initial search resulted in 1,471 articles. After review against inclusion and exclusion criteria, a final set of 31 articles containing 15 unique frailty instruments were evaluated. Most of the articles were from Western countries. Fried's phenotype and Frailty Index were commonly used. The frailty index was mostly modified to measure frailty. In hip fracture, physical function items were frequently modified in the measurement of frailty. Trained physicians and nurses administered most frailty instruments. Frailty screening was commonly conducted at hospital admission and used to prognosticate both postoperative complications and hospital outcomes. Most instruments could be completed within 10 min. Reported psychometrics had acceptable reliability and validity.

Conclusion

Many reliable frailty measures have been used in the inpatient orthopaedic settings; however, evidence is still lacking for a gold standard frailty instrument. More research is needed to identify the best‐performing measure. Frailty evaluation in patients with physical limitations is challenging with existing instruments. Clinical context, resources required and instrument quality are essential factors in selecting a frailty instrument.

Relevance to clinical practice

Musculoskeletal symptoms in older patients may bias frailty assessment. Proactive frailty screening with valid and practical instruments is vital to strengthen preoperative risk stratification and improve post‐surgical outcomes.

Exploring the impact of workforce turnover on the sustainability of evidence-based programs: A scoping review

Background

Evidence-based programs (EBPs) are used across disciplines to integrate research into practice and improve outcomes at the individual and/or community level. Despite widespread development and implementation of EBPs, many programs are not sustained beyond the initial implementation period due to many factors, including workforce turnover. This scoping review summarizes research on the impact of workforce turnover on the sustainability of EBPs and recommendations for mitigating these impacts.

Methods

We searched 10 databases for articles that focused on an EBP and described an association between workforce turnover and the sustainment or sustainability of the program. We created a data abstraction tool to extract relevant information from each article and applied the data abstraction tool to all included articles to create the dataset. Data were mapped and analyzed using the program sustainability framework (PSF).

Results and Discussion

A total of 30 articles were included in this scoping review and mapped to the PSF. Twenty-nine articles described impacts of workforce turnover and 18 articles proposed recommendations to address the impacts. The most frequent impacts of workforce turnover included increased need for training, loss of organizational knowledge, lack of EBP fidelity, and financial stress. Recommendations to address the impact of workforce turnover included affordable and alternative training modalities, the use of champions or volunteers, increasing program alignment with organizational goals, and generating diverse funding portfolios.

Conclusion

The sustainment of EBPs is critical to ensure and maintain the short- and long-term benefits of the EBP for all participants and communities. Understanding the impacts of workforce turnover, a determinant of sustainability, can create awareness among EBP-implementing organizations and allow for proactive planning to increase the likelihood of program sustainability.

A Typical Week With Mild Cognitive Impairment

BACKGROUND AND OBJECTIVES

Identifying the experience of people with mild cognitive impairment (MCI) may help develop research agendas, interventions, and other supports to better match individuals' needs. The purpose of this study was to explore the subjective experience of a "typical week" living with MCI to document (a) important activities, (b) barriers to usual activities, and (c) facilitators and supports.

RESEARCH DESIGN AND METHODS

We conducted remote individual photo-elicitation interviews with 11 community-dwelling adults aged 55 years or older with MCI. Participants each provided 5-10 photographs of daily life taken over 1 week to facilitate a semistructured qualitative interview. Interview transcriptions were coded in Dedoose software and analyzed using thematic analysis.

RESULTS

Participants shared photos and narratives highlighting the important activities in a typical week, in which physical activity, social engagement, spiritual and religious practice, hobbies, and cognitive stimulation were central. Many also shared disruptions to former routines and reduction of activities alongside increased use of new strategies and environmental supports (e.g., calendars, smartphones). Finally, emergent themes centered on disclosure of their diagnosis and reflections about the future.

DISCUSSION AND IMPLICATIONS

Participant-generated images aided data collection and facilitated discussion of sensitive topics with individuals with MCI. Such narratives may illustrate the needs and opportunities to promote well-being in individuals with MCI, including engagement in meaningful and health-promoting activities, assessing barriers to important daily activities, and considering supports that match the experience and needs of those with MCI.

Bearing Witness in Oncology Nursing: Sharing in Suffering Across the Cancer Care Trajectory

Bearing witness in oncology nursing is a critical practice for supporting patients with cancer, and yet it is an understudied phenomenon most described at the end of life. A literature review was performed to better understand the importance of bearing witness across the cancer care trajectory and to elucidate how the practicing oncology nurse can operationalize this skill in the clinical setting. Studies suggest that oncology nurses who successfully bear witness in their practice not only assist patients and families in meaning-finding, but also sustain themselves for the difficult work of oncology through the deeply gratifying gift they receive from the experience.

Predicting Hospital Outcomes Using the Reported Edmonton Frail Scale-Thai Version

Backgrounds Frailty is a common geriatric condition leading to poor surgical outcomes. Having a valid frailty measure has the potential to improve surgical care quality. Objectives To test the ability of the Reported Edmonton Frailty Scale-Thai version (REFS-Thai) in predicting hospital outcomes compared with the American Society of Anesthesiologists physical status classification (ASA) and the Elixhauser Comorbidity Measure (EMC) in older Thai orthopedic patients. Methods A prospective study was conducted on hospitalized older adults scheduled for elective orthopedic surgery. Multiple Firth logistic regression modeled the effect of frailty on postoperative complications, postoperative delirium (POD), and discharge disposition, while the length of stay (LOS) was examined by Poisson regression. The area under the receiver operating characteristic curve (AUC) and mean squared errors (MSE) were used to compare the predictive ability of the instruments. Results Two hundred participants with mean age of 72 (range 60-94 years) were mostly female, 23% were frail. Adjusting for other variables, frailty was significantly associated with postoperative complications (OR = 2.38, p = 0.049), POD (OR = 3.52, p = 0.034), and prolonged LOS (relative risk [RR] = 1.42, p = 0.043). The REFS-Thai alone shows good performance in predicting postoperative complications (AUC = 0.81, 95% CI = 0.74-0.88) and POD (AUC = 0.81, 95% CI = 0.72-0.90). The combination of REFS-Thai with ASA and EMC demonstrates an improved predictability. Conclusion The REFS-Thai was useful in predicting adverse outcomes in surgical orthopaedic older adults. Integrating the REFS-Thai for preoperative assessment may be useful for enhancing care quality.

Associations of Depression and Social Isolation Risk Among Adults Age 60 and Older

Background. Depression and social isolation are believed to be strongly interrelated. Social isolation can lead to depression because of reduced human contact and connectivity. Depression can cause withdrawal from interpersonal encounters and fuel feelings of social isolation. Despite causality, this study aimed to examine the relationship between depression and social isolation risk among older adults. Methods. Using an internet-delivered survey, data were analyzed from a national sample of 4,082 adults age 60 years and older. The survey intended to validate the Upstream Social Isolation Risk Screener (U-SIRS), a 13-item screener (Cronbach’s alpha=0.80) to assesses physical, emotional, and social support aspects of social isolation. Theta scores for the U-SIRS served as the primary independent variable, which were generated using Item Response Theory. Depression was the dependent variable for this study, which was identified using the PHQ-2 (scores of 3+ indicated risk for depression). Binary logistic regression was used to identify factors associated with depression. Results. Participants’ average age was 69.6(±5.2) years, 59% of participants were female, and 9% met depression criterion. Depressive symptomology and U-SIRS theta scores were positively significantly correlated (r=0.56, P<0.001). Participants with higher U-SIRS theta scores (OR=3.52, P<0.001), with more chronic conditions (OR=1.16, P<0.001), and without people they felt close to and could call for help (OR=1.76, P=0.004) were more likely to report depression. Conclusion. Given the strong interrelation of depression and social isolation risk, coordinated efforts are needed to both treat depressive symptomology and link older adults to resources and services that facilitate meaningful interactions with others.

Predicting hospital outcomes with the reported edmonton frail scale-Thai version in orthopaedic older patients

AIMS AND OBJECTIVES

To test the ability of the Reported Edmonton Frail Scale-Thai version to predict hospital outcomes compared with standard preoperative assessment measures (American Society of Anesthesiologists physical status classification and the Elixhauser Comorbidity Measure) in older Thai orthopaedic patients.

BACKGROUND

Frailty is a common geriatric condition. No previous studies have assessed frailty among orthopaedic patients in Thailand. Effective frailty screening could enhance quality of care.

DESIGN

Prospective cohort study in a university hospital.

METHODS

Two hundred hospitalised patients, aged 60 years or older and scheduled for orthopaedic surgery, participated in the study. Frailty was evaluated using the Reported Edmonton Frail Scale-Thai version. Multiple Firth logistic regression was used to model the effect of frailty on postoperative complications, postoperative delirium and discharge disposition. Length of stay was examined using Poisson regression. Comparing predictability of the instruments, the area under the receiver operating characteristic curve and mean squared errors were evaluated. The STROBE guideline was used.

RESULTS

Participants' mean age was 72 years; mostly were female, frail and underwent knee, spine and/or hip surgery. Poor health outcomes including postoperative complications, postoperative delirium, and not being discharged to the home were commonly identified. The length of stay varied from three days to more than ten weeks. Frailty was significantly associated with postoperative complications, postoperative delirium and prolonged length of stay. The Reported Edmonton Frail Scale-Thai version revealed good performance for predicting postoperative complications and postoperative delirium and was improved by combining with standard assessments.

CONCLUSION

The Reported Edmonton Frail Scale-Thai version, alone or combined with standard assessment, was useful for predicting adverse outcomes in older adults undergoing orthopaedic surgery.

RELEVANCE TO CLINICAL PRACTICE

These findings indicate that nurse professionals should apply culturally sensitive frailty screening to proactively identify patients' risk of frailty, improve care quality and prevent adverse outcomes.

The Reported Edmonton Frail Scale-Thai version: Development and Validation of a Culturally-Sensitive Instrument

Frailty may lead to increased vulnerability, disability, and adverse health outcomes in older adults. Early detection has been described as the best approach to manage frailty; however, frailty instruments are not widely available, particularly in the Thai language. The purpose of this cross-sectional study was to develop a culturally adapted Thai version of the Reported Edmonton Frail Scale and to validate the psychometric properties of the new instrument in hospitalized older Thai adults. Reliability and validity were examined. Participants completed questionnaires that included demographic and health information, and the Reported Edmonton Frail Scale-Thai version. Results revealed that the new instrument was reliable and had good content validity. Inter-rater reliability was strong. Confirmatory factor analysis showed a fair fit for the whole model, but most domains were strongly associated with frailty. On average, the instrument was completed under 7 minutes. The Thai version of the frailty instrument may be a practical tool for frailty evaluation, and could inform inpatient care, both locally and internationally; future research is needed to confirm predictability and feasibility in other clinical settings and populations.

Terms and Measures of Cognitive Health Associated With Dementia and Alzheimer's Disease: A Scoping Review

The Healthy Brain Initiative: National Public Health Road Map to Maintaining Cognitive Health (2007) called on the research community to disseminate its work on cognitive aging and cognitive health. The purpose of this scoping review was to (1) identify terminology that cognitive, social, and behavioral scientists use to describe cognitive aging and cognitive health, in association with dementia and Alzheimer's disease, among older adults; (2) demonstrate how such terms are defined; and (3) illustrate how these constructs are measured in research settings. Empirical studies published 2007-2018 were examined for terminology, definitions, disciplinary orientation, and measurement mechanisms. Analysis of the corpus and a detailed review of the terms "cognitive impairment" and "mild cognitive impairment" reveal that formal definitions are provided infrequently and measurement of constructs ranges widely. Overall, the variability in terminology, definitions, and measures reflects a need for greater specificity in research communication, such that cross-disciplinary collaboration can be facilitated.

A Scoping Review of Physical Performance Outcome Measures Used in Exercise Interventions for Older Adults With Alzheimer Disease and Related Dementias

BACKGROUND AND PURPOSE

There is growing evidence that exercise interventions can mitigate functional decline and reduce fall risk in older adults with Alzheimer disease and related dementias (ADRD). Although physical performance outcome measures have been successfully used in older adults without cognitive impairment, additional research is needed regarding their use with individuals who have ADRD, and who may have difficulty following instructions regarding performance of these measures. The purpose of this scoping review was to identify commonly used physical performance outcome measures, for exercise interventions, that are responsive and reliable in older adults with ADRD. Ultimately, we aimed to provide recommendations regarding the use of outcome measures for individuals with ADRD across several domains of physical performance.

METHODS

A scoping review was conducted to broadly assess physical performance outcome measures used in exercise interventions for older adults with ADRD. Exercise intervention studies that included at least 1 measure of physical performance were included. All physical performance outcome measures were abstracted, coded, and categorized into 5 domains of physical performance: fitness, functional mobility, gait, balance, and strength. Criteria for recommendations were based on (1) the frequency of use, (2) responsiveness, and (3) reliability. Frequency was determined by the number of studies that used the outcome measure per physical performance domain. Responsiveness was assessed via calculated effect size of the outcome measures across studies within physical performance domains. Reliability was evaluated via published studies of psychometric properties.

RESULTS AND DISCUSSION

A total of 20 physical performance outcome measures were extracted from 48 articles that met study inclusion criteria. The most frequently used outcome measures were the 6-minute walk test, Timed Up and Go, repeated chair stand tests, short-distance gait speed, the Berg Balance Scale, and isometric strength measures. These outcome measures demonstrated a small, medium, or large effect in at least 50% of the exercise intervention studies. Good to excellent reliability was reported in samples of older adults with mild to moderate dementia. Fitness, functional mobility, gait, balance, and strength represent important domains of physical performance for older adults. The 6-minute walk test, Timed Up and Go, repeated chair stand tests, short-distance gait speed, Berg Balance Scale, and isometric strength are recommended as commonly used and reliable physical performance outcome measures for exercise interventions in older adults with mild to moderate ADRD. Further research is needed on optimal measures for individuals with severe ADRD.

CONCLUSIONS

The results of this review will aid clinicians and researchers in selecting reliable measures to evaluate physical performance outcomes in response to exercise interventions in older adults with ADRD.

"It May Be a Bit Uncertain But It's Never Boring": Thematic Analysis of a Blog About Engaging With Aging

Online blogs about healthy aging written by health care professionals and others are increasing. The purpose of the current study was to analyze a first-person narrative blog about engaging with aging (EWA), with a goal of better understanding the process used to manage daily life and inform healthy aging for older adults. Using a thematic analysis approach, 67 blog posts written by a nonagenarian, retired nursing professor were analyzed. Emergent themes revealed the identification of age-related changes (e.g., physical, cognitive, functional, social, societal, psychological), characteristics of the age-related changes process, responses to age-related changes (e.g., feelings, attitudes), approaches and strategies to addressing age-related changes (i.e., the use of internal and external resources), and the outcomes of the approaches. The EWA blog posts help understand the aging experience from the perspective of an older adult, especially functional changes and how they affect daily life, as well as strategies used to adapt to changes. [Journal of Gerontological Nursing, 45(12), 21-27.].

BUILDING DISASTER RESILIENCE FOR OLDER ADULTS AGING IN PLACE: THE ROLE OF COMMUNITY-BASED ORGANIZATIONS

Older adults are more susceptible to adverse health outcomes during and after a disaster compared with their younger counterparts. Developing community resilience, or strengthening communities to reduce the negative impacts of disasters, has the potential support older adults’ health and well-being. Community-based organizations (CBOs), such as senior centers and Villages, provide social services and programming that support aging in place and may support older adults’ resilience to disasters. This study examines CBO leadership perspectives on the role of CBOs in building disaster resilience for older adults aging in place, as well as perceived barriers and facilitators to incorporating disaster resilience activities into organizational programming. In-depth interviews were conducted with a purposive sample of staff-members of CBOs serving older adults aging in place in King County, Washington. Participants included representatives from 14 organizations that varied in size, geographic setting, organizational structure, and ethnic, linguistic, and socio-economic backgrounds of organizational members. The sample included five government-run senior centers, seven non-profit senior centers, and two Villages. Interviews were audio-recorded and transcribed verbatim. We used a combined inductive and deductive approach to code and thematically analyze the data. Results indicate that local context, leadership risk perception, collaborations, and existing services and programming influence CBOs’ willingness to engage in activities supporting disaster resilience for older adults aging in place. Findings suggest that CBOs supporting aging in place may support disaster resilience for older adults by serving as a trusted source of disaster preparedness information and tailoring disaster-related messages for an older adult audience.

TERMS AND MEASURES OF COGNITIVE AGING AND COGNITIVE HEALTH: A SCOPING REVIEW

The Healthy Brain Initiative: National Public Health Road Map to Maintaining Cognitive Health (2007) called on the research community to more widely disseminate its work on cognitive aging and cognitive health. However, communication beyond individual disciplines is complex. We identified terminology that social scientists use to describe cognitive aging and cognitive health among older adults, demonstrated how such terms are defined, and illustrated how these constructs are being measured. We searched terms such as Alzheimer* and dementia in studies between 2007 and 2018 (n=209). Geriatrics (n=95), neurology (n=81), psychiatry (n=65), and psychology (n=30) were most common disciplines; however, there was no consistency in how terms were used within and across disciplines. A detailed review of “cognitive impairment” and “mild cognitive impairment” demonstrated that formal definitions were provided infrequently and measurement of constructs ranged widely. The variability in terminology, definitions and measures reflects a need for greater specificity in research communication.

OUTCOMES MEASUREMENT IN EARLY-STAGE MEMORY LOSS INTERVENTIONS: A SCOPING REVIEW

Psychosocial and psychoeducational groups are widely recommended for individuals with early stage Alzheimer’s disease and related dementias (ADRD). However, measurement challenges have hindered researchers’ efforts to demonstrate the efficacy of these groups. The purpose of this scoping review was to identify common measurement tools used in interventions for individuals with early stage ADRD and to develop suggestions for future investigations. CINAHL, Embase, PsycINFO, and PubMed were searched; 102 studies were reviewed. Inclusion criteria were set to capture intervention studies that utilized quantifiable measures with participants over age 50. Eleven articles met inclusion criteria. The majority of studies (73%) employed randomized controlled trial designs. Sample sizes ranged from N=20-236. Most commonly measured outcomes included depression, self-efficacy, self-esteem, and quality of life, but there was little consensus on how to best measure these outcomes. Standardization of psychosocial assessment tools are needed for future intervention studies with early stage ADRD.

Effects of Osteoarthritis Pain and Concurrent Insomnia and Depression on Health Care Use in a Primary Care Population of Older Adults

OBJECTIVE

To examine independent and combined effects of pain with concurrent insomnia and depression symptoms on the use of health care services in older adults with osteoarthritis (OA).

METHODS

Patients were Group Health Cooperative (GHC) patients with a primary diagnosis of OA (n = 2,976). We used survey data on pain (Graded Chronic Pain Scale), insomnia (Insomnia Severity Index), and depression (Patient Health Questionnaire-8), and health care use extracted from GHC electronic health records (office visits, length of stay, outpatient and inpatient costs, and hip or knee replacement) for 3 years after the survey. Negative binomial, logistic, and generalized linear models were used to assess predictors of health care use.

RESULTS

Approximately 34% and 29% of patients displayed at least subclinical insomnia and at least subclinical depression symptoms, respectively, in addition to moderate-to-severe pain. Pain had the greatest independent effects on increasing all types of health care use, followed by depression (moderate effects) on increased office visits, length of stay, outpatient and inpatient costs, and insomnia (mild effects) on decreased length of stay. No synergistic effects of the 3 symptoms on use of health care services were observed. The combined effects of pain plus insomnia and pain plus depression were significant for all types of health care use and increased greatly with increasing severity of insomnia and depression, except for hip/knee replacement.

CONCLUSION

Pain is the main driver for health care use in patients with OA. In addition to pain, insomnia plus depression jointly increased diverse types of health care use, and these combined effects increased greatly with increasing severity of insomnia and depression. These findings indicate the important role that concurrent symptomatic conditions may play in increasing use of health care services.

Building community-clinical linkages to increase older adult physical activity: The PT-REFER trial protocol and participant baseline characteristics

Background

Physical activity is important for maintaining older adult health, but a majority of older adults are not meeting recommended physical activity levels. This paper describes the protocol and participant baseline characteristics for a trial (named "PT-REFER") to test an intervention focused on developing community-clinical linkages to increase older adult referrals from physical therapy clinics to an evidence-based group exercise program (Enhance®Fitness) (EF) offered by YMCA associations.

Methods

We designed a two-arm cluster-randomized controlled trial with YMCA associations. We conducted formative research with YMCA staff and physical therapists to inform intervention format and content. The primary outcome is the number of new participants enrolled in EF over the course of 30 months. We also collect process information on cost and implementation though structured surveys and semi-structured qualitative interviews.

Results

The PT-REFER intervention creates a learning collaborative for YMCA associations, which are tasked with implementing a number of capacity- and partnership-building activities over the course of seven months, and participating in monthly group technical assistance calls. We recruited 20 YMCA associations from 13 states. At baseline, the average number of EF sites per association was 3.9 and the monthly average number of new EF participants was 3.7.

Conclusions

This study will test an approach to increasing the capacity of YMCAs for conducting outreach to physical therapy clinics, and evaluate the factors that may influence its implementation. As a result, it has the potential to contribute to our understanding of how to develop viable and sustainable community-clinical linkages for older adult health.

Effects of Pain, Insomnia, and Depression on Psychoactive Medication Supply in Older Adults With Osteoarthritis

BACKGROUND

Determinants of prescribing psychoactive medications for symptom management in older adults remain underexamined despite known risks and cautions concerning these medications.

OBJECTIVE

To examine independent and combined effects of pain, concurrent insomnia and depression symptoms on psychoactive medications supplied to older adults with osteoarthritis (OA).

RESEARCH DESIGN

Survey data on pain, insomnia, and depression obtained from OA patients screened for a randomized controlled trial were used to identify predictors of psychoactive medication supply [opioids, sedatives, tricyclic antidepressants (TCAs), and non-TCAs] over a 4-year period.

SUBJECTS

Group Health Cooperative patients with a diagnosis of OA (N=2976).

MEASURES

Survey data on pain (Graded Chronic Pain Scale), insomnia (Insomnia Severity Index), and depression (Patient Health Questionnaire-8); and medications supply assessed from electronic medical records.

RESULTS

In negative binomial models, pain [incidence rate ratio (IRR), 2.8-3.5; P<0.001], insomnia (IRR, 2.0; P<0.001), and depression (IRR, 1.5; P<0.05) each independently predicted opioid supply. Insomnia (IRR, 3.2; P<0.001) and depression (IRR, 3.0; P<0.001) each independently predicted sedative supply. Pain (IRR, 2.1; P<0.05) and insomnia (IRR, 2.0; P<0.05) independently predicted TCA supply, whereas only depression (IRR, 2.2; P<0.001) independently predicted non-TCA supply. Combined effects of pain and insomnia/depression on these medications were additive and increased the rate of medication supply 1.5-7.5 times. Combined effects increased with insomnia or depression severity.

CONCLUSIONS

Concurrent insomnia and depressive symptoms predicted increased supply of opioids, sedatives, and antidepressants after accounting for pain, indicating the importance of sleep and mood disorders as factors increasing supply of these medications.

Experiences of caregivers by care recipient's health condition: A study of caregivers for Alzheimer's disease and related dementias versus other chronic conditions

This study described experiences of caregivers of persons with Alzheimer's disease and other dementias (ADRD) and caregivers of persons with other chronic conditions on self-reported health, type of assistance they provide, perceptions of how caregiving interferes with their lives, and perceived level of support. A secondary analysis was conducted of the 2013 Porter Novelli SummerStyles survey data. Of the 4033 respondents, 650 adults self-identified as caregivers with 11.6% caring for people with ADRD. Over half of all caregivers reported that caregiving interfered with their lives to some extent. The greater the perceived support caregivers reported, the less they thought that caregiving interfered with their lives (p < .001). No significant differences were found between ADRD and non-ADRD caregivers regarding general health, types of assistance they provided, and perceived level of support. These findings have the potential to inform future research and practice in the development of supportive services for caregivers.

Community readiness assessment for disseminating evidence-based physical activity programs to older adults in Changsha, China: a case for Enhance®Fitness

Physical activity (PA) has declined in China due to urbanization in the past two decades. Evidence-based programs are good approaches to promote PA, but are limited in China. Adopting existing programs can be a viable option. Prior to that, readiness assessment is needed. This study aimed to assess community readiness levels for disseminating evidence-based PA programs to older adults in Changsha, China. In-person interviews were conducted with 33 participants of five districts in Changsha to assess the community readiness level in five dimensions: community knowledge of efforts, community climate, community knowledge about the issue, leadership and resources. Data was transcribed, reviewed and compared with an anchored rating scale to provide a stage of readiness score ranging from 1 (no awareness) to 9 (high level of community ownership). Participants included 14 community staff, 13 older adults, four community leaders and three health professionals. The top three barriers to disseminating PA programs were lack of appropriate locations, funding and instructors. The top three resources were availability of indoor space, chairs and loudspeakers. Community leadership was the highest-rated readiness dimension (3.3 out of 9) followed by community climate (3.2), community knowledge of efforts (3.1) and resources (2.8); knowledge about the issue scored the lowest (2.7). The overall community stage readiness score of Changsha was 3.0 out of 9. The stage of readiness for communities in Changsha, China is 'vague awareness'. Developing strategies to improve community readiness levels may increase evidence-based PA program dissemination in Changsha, China.