Faculty Bibliography

In the current study, we conducted one-on-one interviews with primary care providers (PCPs) and family care partners (FCPs) and held focus groups with interdisciplinary adult day service center (ADSC) staff to understand the perspectives of care providers across community settings regarding early warning signs of acute illnesses in persons living with dementia (PLWD). We used content analysis to analyze qualitative data. Warning signs of acute illnesses in PLWD fell into one of five categories, including new onset changes in (a) physical functions, (b) moods or behaviors (psychological), (c) social interactions, (d) speech, or (e) appearance. FCPs (n = 11) focused on physical changes, whereas ADSC staff (n = 33) emphasized changes in speech and social interactions in addition to the other categories. Although ADSC staff and PCPs (n = 22) focused on changes in functions and moods, each group described these changes differently. ADSC staff possess rich information that can be used to identify acute changes in PLWD and describe a broader range of warning signs compared to PCPs and FCPs. FCPs may benefit from further training in distinguishing between normal disease progression and acute illness. Future research should focus on the implementation of standardized tools across community-based care providers to simplify the identification and reporting of early warning signs in PLWD. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].

BACKGROUND/UNASSIGNED:There has been a call by both patients and health professionals for the integration of palliative care with nephrology care, yet there is little evidence describing the effect of this approach. The objective of this paper is to report the feasibility and acceptability of a pilot randomized controlled trial testing the efficacy of integrated palliative and nephrology care. METHODS/UNASSIGNED:English speaking patients with CKD stage 5 were randomized to monthly palliative care visits for 3 months in addition to their usual care, as compared with usual nephrology care. Feasibility of recruitment, retention, completion of intervention processes, and feedback on participation was measured. Other outcomes included differences in symptom burden change, measured by the Integrated Palliative Outcome Scale-Renal, and change in quality of life, measured by the Kidney Disease Quality of Life questionnaire and completion of advance care planning documents. RESULTS/UNASSIGNED:Of the 67 patients approached, 45 (67%) provided informed consent. Of these, 27 patients completed the study (60%), and 14 (74%) of those in the intervention group completed all visits. We found small improvements in overall symptom burden (-2.92 versus 1.57) and physical symptom burden scores (-1.92 versus 1.79) in the intervention group. We did not see improvements in the quality-of-life scores, with the exception of the physical component score. The intervention group completed more advance care planning documents than controls (five health care proxy forms completed versus one, nine Medical Orders for Life Sustaining Treatment forms versus none). CONCLUSIONS/UNASSIGNED:We found that pilot testing through a randomized controlled trial of an ambulatory integrated palliative and nephrology care clinical program was feasible and acceptable to participants. This intervention has the potential to improve the disease experience for those with nondialysis CKD and should be tested in other CKD populations with longer follow-up. CLINICAL TRIALS REGISTRY NAME AND REGISTRATION NUMBER/UNASSIGNED:Pilot Randomized-controlled Trial of Integrated Palliative and Nephrology Care Versus Usual Nephrology Care, NCT04520984.

In order to reduce care partner strain and support aging in place for people living with Alzheimer's Disease and Alzheimer's Disease Related Dementias (AD/ADRD), adult day centers (ADCs) must manage behavioral and psychological symptoms of dementia (BPSD). The purpose of this paper is to identify person-centered care strategies used by center staff to manage BPSD. Six focus groups with center staff (n = 31) were conducted. Data were analyzed using directed content analysis guided by Kitwood's conceptual approach to cultivating personhood in dementia care. Themes were identified and organized within Kitwood's framework. The results demonstrate that staff incorporate evidence-based person-centered approaches to AD/ADRD care that align with Kitwood's principles of comfort, attachment, inclusion, and identity. Staff individualize their approach to people with AD/ADRD within a group setting. They monitor, engage, socially stimulate, and, when needed, de-stimulate them. Centers are flexible social environments with underrecognized expertise managing BPSD using person-centered approaches.

Importance/UNASSIGNED:Use of hospice has been demonstrated to be cost saving to the Medicare program and yet the extent to which hospice saves money across all payers, including whether it shifts costs to families, is unknown. Objective/UNASSIGNED:To estimate the association between hospice use and total health care costs including family out-of-pocket health care spending. Design Setting and Participants/UNASSIGNED:This retrospective cohort study of health care spending in the last 6 months of life used data from the nationally representative Medicare Current Beneficiary Survey (MCBS) between the years 2002 and 2018. Participants were MCBS participants who resided in the community and died between 2002 and 2018. Exposures/UNASSIGNED:Covariate balancing propensity scores were used to compare participants who used hospice (n = 2113) and those who did not (n = 3351), stratified by duration of hospice use. Main Outcomes and Measures/UNASSIGNED:Total health care expenditures were measured across payers (family out-of-pocket, Medicare, Medicare Advantage, Medicaid, private insurance, private health maintenance organizations, Veteran's Administration, and other) and by expenditure type (inpatient care, outpatient care, medical visits, skilled nursing, home health, hospice, durable medical equipment, and prescription drugs). Results/UNASSIGNED:The study population included 5464 decedents (mean age 78.7 years; 48% female) and 38% enrolled with hospice. Total health care expenditures were lower for those who used hospice compared with propensity score weighted non-hospice control participants for the last 3 days of life ($2813 lower; 95% CI, $2396-$3230); last week of life ($6806 lower; 95% CI, $6261-$7350); last 2 weeks of life ($8785 lower; 95% CI, $7971-$9600); last month of life ($11 747 lower; 95% CI, $10 072-$13 422); and last 3 months of life ($10 908 lower; 95% CI, $7283-$14 533). Family out-of-pocket expenditures were lower for hospice enrollees in the last 3 days of life ($71; 95% CI, $43-$100); last week of life ($216; 95% CI, $175-$256); last 2 weeks of life ($265; 95% CI, $149-$382); and last month of life ($670; 95% CI, $530-$811) compared with those who did not use hospice. Health care savings were associated with reductions in inpatient care. Conclusions and Relevance/UNASSIGNED:In this population-based cohort study of community-dwelling Medicare beneficiaries, hospice enrollment was associated with lower total health care costs for the last 3 days to 3 months of life. Importantly, we found no evidence of cost shifting from Medicare to families related to hospice enrollment. The magnitude of lower out-of-pocket spending to families who enrolled with hospice is meaningful to many Americans, particularly those with lower socioeconomic status.

Background: Overlapping symptoms between delirium and behavioral and psychological symptoms of dementia (BPSD) often makes diagnosis of delirium superimposed on dementia (DSD) complex. This study aimed to examine differences in BPSD expression in PLWD with and without DSD at start of home healthcare (HHC) to help elucidate differences in expression.
Method(s): A cross-sectional analysis of baseline data from 107 PLWD (age 65+) enrolled into a semi-pragmatic, randomized controlled trial was performed. Baseline data were collected <=3 days of HHC admission. BPSD was measured by the Neuropsychiatric Inventory Questionnaire and delirium a modified 3-Mintue Diagnostic Interview for Confusion Assessment Method. Descriptive statistics and chi² or Fisher's exact tests were performed as appropriate to compare BPSD between groups.
Result(s): Of the 107 PLWD (mean age: 83 years; 61% female; 62% White; 14% Hispanic/Latino),19.6% had DSD; 93.5% had 1 BPSD; 79.4% had 3 BPSD. Of the 12 BPSD assessed, 10 were more prevalent in the DSD group: agitation, hallucinations, appetite changes, and delusions were >10% more prevalent; motor disturbance and nighttime behaviors were >20% more prevalent; motor disturbance was statistically significantly more prevalent (p=0.043). See Table 1.
Conclusion(s): Motor disturbance is statistically significantly more prevalent in DSD upon HHC admission; thus, if observed in PLWD, a follow-up DSD assessment may be warranted. Another 5 BPSD were >10%-20% more prevalent in DSD, though not statistically significant, the magnitude of the difference still suggests clinical importance

Background: Significant racial and ethnic disparities exist in the community in underprescribing analgesics for pain and overprescribing antipsychotics for behavioral symptoms in persons with dementia. In hospice these drugs are commonly used to provide comfort, but little is known about prescription patterns in minoritized populations. We aimed to identify prescribing patterns in minoritized racial and ethnic groups among persons with living advanced dementia in home hospice.
Method(s): A cross-sectional study of 6,874 participants with advanced dementia from eight hospices across the United States. Demographics, antipsychotic (typical, atypical) and analgesic (opioid, non-opioid) prescriptions at admission, days of prescription use in hospice and length of stay were collected from electronic records. Descriptive statistics were calculated and hurdle regression models estimated to examine the association between race/ethnicity and prescription rates for each drug (days of drug use per 100 person-days).
Result(s): Participants were 10.7% Black, 34.8% Hispanic, 51.1% white, and 3.3% from other racial and ethnic groups. On admission, Hispanics and Blacks had similar rates of antipsychotic prescription that were lower than whites (11.9% & 12.3% vs 16.8%) and Hispanics had substantially lower non-opioid analgesic prescription vs Blacks and whites (23.3% vs 36.0% & 37.3%); During the hospice stay, Hispanics were prescribed antipsychotics (atypical RR =1.03, 95 % CI: 1.02-1.04; typical RR:1.04, 95% CI: 1.01-1.07) and analgesics (opioid RR =1.03, 95% CI: 1.02-1.04; non-opioid RR = 1.03, 95% CI = 1.02-1.03) for more days than whites. Blacks were prescribed analgesics (opioid RR =1.09, 95% CI 1.08-1.11; non-opioid RR = 1.01, 95% CI: 1-1.02) for more days than whites.
Conclusion(s): Disparities in analgesic and antipsychotic use on admission amongst Blacks and Hispanics were found, yet hospice narrowed this gap significantly. While less likely to be prescribed opioids, Blacks and Hispanics had more person days on analgesics overall. However, there was divergence in antipsychotic use over time between groups that requires further investigation given the controversial role of antipsychotics in management of dementia symptoms