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The Checklist for Evidence of Person-Centered Care Approaches for Behavioral and Psychological Symptoms of Distress (BPSD) in Care Plans was developed to assess the person-centeredness of care plans for nursing home residents living with behavioral and psychological symptoms associated with dementia. The purpose of the current study was to evaluate the reliability and validity of a revised version of the Checklist. Data from a larger randomized clinical trial testing the implementation of the Evidence of Integration Triangle for BPSD were used. One hundred seventy-nine care plans for 103 residents were examined. Descriptive statistics, Rasch analysis, and inter-rater reliability were used. The Checklist demonstrated evidence of inter-rater reliability and validity based on model fit and acceptable INFIT and OUTFIT statistics. This study serves as pilot work for future Checklist use and validation efforts on a larger scale. Findings encourage a discourse on the inclusion of BPSD and person-centered approaches in care plans for those living with dementia. [ Research in Gerontological Nursing, 15 (6), 303-311.].

The Centers for Medicare and Medicaid Services mandate the provision of person-centered care (PCC), but there is limited evidence on how PCC impacts nursing home (NH) residents' care experiences. This study examined the relationship between n = 163 NH residents' ratings of satisfaction with care related to their preferences and their satisfaction with overall care. Residents with higher preference satisfaction ratings reported significantly higher levels of satisfaction with overall care. Using preference satisfaction ratings has the potential to improve PCC planning and delivery in nursing homes.

Nursing home (NH) providers would benefit from adopting evidence-based measures for gathering and utilizing resident preference information in their daily care activities. However, providers face barriers when implementing assessment tools used to promote person-centered care (PCC). Although Agile methodology is not commonly used in NH settings, this case study shows how it can be used to achieve the goal of delivering preference-based, PCC, within a large NH. We present a road map for breaking down care processes, prioritizing, and implementing iterative plan, do, study, act cycles using Agile methodology to enhance group collaboration on quality improvement cycles, to achieve our goal of providing preference-based PCC. We first determined if care plans reflected each resident's important preferences, developed a method for tracking whether residents attended activities that matched their preferences, and determined if residents were satisfied that their preferences were being met. These efforts had positive effects throughout the NH particularly when COVID-19 limited visitors and significantly modified staff workflow. Specifically, Agile processes helped staff to know how to honor preferences during quarantines which necessitated a shift to individualized (and not group) approaches for meeting preferences for social contact, comfort, and belonging. The ready availability of preference-based reporting was critical to quickly informing new staff on how to meet residents' most important preferences. Based on lessons learned, we describe a developmental approach that other providers can consider for adoption. Implications of this work are discussed in terms of the need for provider training in Agile methodologies to support iterative improvements, the need for policies that reimburse providers for their efforts, and additional research around workflow processes., (Copyright © 2022 AMDA – The Society for Post-Acute and Long-Term Care Medicine. All rights reserved.)

Objectives: Emotional expressions in late-stage dementia have traditionally been studied within a deficit paradigm. Moving the narrative of the dementia trajectory from a solely negative pathological experience to one that acknowledges the potential for positive experiences aligns with international recommendations for living well with dementia. The purpose of this study was to extend prior research by examining the pattern of well-being using affect balance, the ratio of positive to negative affect, in nursing home residents living with dementia over 12 months and its association to factors that could potentially influence resident well-being. Method: This study was a secondary analysis of baseline, 4 and 12-month data from a pragmatic clinical trial. A total of 536 residents with moderate to severe cognitive impairments from 55 nursing homes were included in the multivariable linear mixed model regression analyses. Results: Resident function, the number of registered nurse hours devoted to care in the facility, and the quality of staff interaction predicted higher affect balance over time after controlling for other variables. Conclusion: The findings provide support for the utility of affect balance as a meaningful outcome measure of well-being for persons living with dementia. In addition, results point to specific interventions (i.e. maintaining/improving resident function, providing adequate nurse staffing levels, and improving staff communications skills) that can serve as the focus for both research and practice to help residents live well with dementia. Clinicaltrials.gov (NCT03014570).

Long-term stability of nursing home (NH) residents' everyday preference remains unknown. We examined 1-year stability in reports of importance of 34-recreational activity preferences (8-MDS 3.0 Section F items; 26- Preferences for Everyday Living Inventory-NH items) by NH residents ( N = 161). We examined mean differences on demographic and clinical characteristics of residents for preferences showing change. Importance ratings of preferences were highly stable over 1-year, with 91% of items retaining the same valence of importance for the majority of the sample (<20% change). Three preferences showed greater change. More functionally able residents were more likely to change their importance on "being with groups of people," and older residents were more likely to change their preferences for being "involved in religious practices" and "around animals such as pets". Overall, annual assessments of recreational activity preferences capture an accurate representation of preferences with reassessment only needed in a few circumstances.

Objectives: The purpose of this study was to expand on prior work testing invariance on several depression measures in community-based older adults and explore the psychometric properties and evidence of invariance between racial groups based on the Cornell Scale for Depression in Dementia., Design: This was a descriptive measurement study., Setting and Participants: This was a secondary data analysis using baseline data from 2 studies: Testing the Implementation of the Evidence Integration Triangle for Behavioral and Psychological Symptoms Associated with Dementia and the study Testing the Impact of Function and Behavior Focused Care for Nursing Home Residents with Dementia. Combined, 67 nursing homes participated from 2 states and 889 residents were recruited. The mean age of the participants was 86.58 (SD 10.31) and most were women (72%) and White (70%)., Methods: This was a descriptive study, and a Rasch analysis was done to establish reliability based on internal consistency and evidence of differential item functioning (DIF) across races. Validity was based on item fit and model testing with structural equation modeling to compare models between White and Black participants., Results: There was evidence of internal consistency (alpha coefficient of 0.98) and no significant evidence of DIF. The item related to suicide had a high logit and did not significantly load onto the measurement model for Black individuals. There was not a good spread of the items across the concept of depression. The model had a better fit with the items when used with White versus Black participants., Conclusions and Implications: The findings indicate that it would be helpful to add some additional items that reflect depressive symptoms among this population. Further, the findings serve as a reminder that this measure may be biased toward identification of symptoms of depression among White versus Black residents., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: With the increase in Black nursing home residents, racial and ethnic disparities in quality of care have been raised., Purpose: The purpose of this study was to evaluate racial disparities in care and outcomes over 12 months., Methods: This was a secondary data analysis using data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia study. A total of 553 residents, 24% Black residents and 76% White residents, from 55 nursing homes were included., Results: Differences favoring Black resident were noted in agitation, quality of life, inclusion of person-centered care approaches in care plans, and fewer falls and hospitalizations. Differences in quality-of-care interactions favored White residents. There were no differences in depression, resistiveness to care, function, pain, or transfers to the emergency department., Conclusions: Disparities in clinical outcomes were small and generally favored Black versus White residents except for quality-of-care interactions., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

In residential care communities (CCs), implementation strategies can improve the use of person-centered approaches for residents' behavioral symptoms of distress. We examined staff perceptions of how well their organizational goals for achieving person-centered care (PCC) were met following implementation of the strategy, Evidence Integration Triangle for Behavioral and Psychological Symptoms of Distress. We also identified organizational characteristics and indicators of staff adoption associated with perceived goal attainment. Goal attainment was evaluated by staff using goal attainment scaling (GAS) at the completion of the implementation trial in 26 CCs. Correlations, t tests, and linear regression were used to determine which factors were associated with goal attainment. Total time spent with the research facilitator, stable staff group membership, and presence of a survey deficiency during the study period explained 63% of the variance in goal attainment. Staff can set achievable organizational goals to improve PCC for residents' behavioral symptoms of distress. [ Journal of Gerontological Nursing, 48 (5), 5-12.].

Background: This study evaluated the association between age, sex, comorbidities, cognition, and administration of opioids with pain and the impact of all of these variables plus function, agitation, resistiveness to care, and depression on quality of life among residents in nursing home with severe dementia., Design: This was a descriptive study using baseline data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia implementation study., Methods: Model testing was done using structural equation modeling. The sample included 553 residents from 55 nursing homes with a mean age of 83.88 (standard deviation = 10.44) and mean Brief Interview of Mental Status of 4.30 (standard deviation = 3.50)., Results: There were significant associations showing those who were older, male, had fewer comorbidities, better cognition, and were black were more likely to have pain. Pain, in combination with the demographic and descriptive variables, explained 32% of the variance in function, 75% of the variance in depression, 88% of the variance in agitation, 98% of the variance in resistiveness to care, and 92% of the variance in quality of life. The model however did not show a good fit to the data., Setting: The study was done in 55 nursing homes in Maryland and Pennsylvania., Participants/subjects: A total of 553 residents were included in the study., Conclusions: The model did not have a good fit with the data which likely was due to the lack of variance in outcomes. The hypothesized paths, with the exception of opioid use, were significant., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

The purpose of this study was to test the reliability and validity of the Pain Assessment in Advanced Dementia (PAINAD) and particularly consider whether or not this measure was invariant when used among the Black and White residents. Baseline data from an implementation study testing that included a sample of 553 residents, 30% of who were Black, from 55 nursing were included in this study. The Winsteps statistical program was used to perform the Rasch analysis and evaluate the reliability and validity of the measure based on internal consistency, infit and outfit statistics, mapping, and a differential item functioning (DIF) analysis. The AMOS statistical program was used for confirmatory factor analysis. The findings supported the reliability and validity of the PAINAD when used with these individuals and demonstrated that there was no evidence of invariance between the Black and White residents. All the items fit the model, but there was not a good spread of the items across the pain level of the participants. The majority of the participants (75%) were so low in pain signs or symptoms that they could not be differentiated. Based on the clinical practice and observations, it is recommended that additional items can be added to the measure such as observing the individual for evidence of resisting care, retropulsion when trying to stand, hitting or kicking when turning in bed, hitting or kicking when transferring from bed to chair, hitting or kicking when ambulating, or hitting or kicking when raising arms, less engagement with others, and decreased participation in the activities previously enjoyed., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Resnick, Van Haitsma, Kolanowski, Galik, Boltz, Ellis, Behrens, Eshraghi, Renn and Dorsey.)

Lack of identification and management of behavioral and psychological symptoms of dementia (BPSD) can negatively impact female residents. The purpose of this secondary data analysis was to explore gender differences in presentation and management of BPSD and quality of interactions between residents and staff. A total of 553 residents from 55 nursing homes were included. Males exhibited more apathy and sexually inappropriate behavior and females exhibited more anxiety and sadness. Anxiety and sexually inappropriate behavior were more likely to be addressed in care plans for males than females. There was no difference in how staff interacted with males or females.

Background: Federal regulations stipulate that behavioral interventions be used for behavioral and psychological symptoms of distress in dementia (BPSD). Care community staff have difficulty implementing these approaches., Purpose: This study tested an implementation strategy, the Evidence Integration Triangle for BPSD (EIT-4-BPSD), for assisting staff in the use of evidence-based behavioral approaches for BPSD., Methods: About 55 care communities were randomized to EIT-4-BPSD or usual care; 553 residents were enrolled. The implementation strategy was delivered by research facilitators, staff, stakeholders, and champions over 12 months. It involved four components: Environment and policy assessments; Staff education; Establishment of person-centered care plans; and Mentoring and motivating staff. The implementation strategy was evaluated using the Reach, Effectiveness, Adoption, Implementation, Maintenance model., Findings: There was no evidence for resident or care community effectiveness. There was evidence of adoption and implementation., Discussion: EIT-4-BPSD was helpful as an implementation strategy and staff altered how care was provided., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Behavioral and psychological symptoms of distress in dementia (BPSD) are major drivers of poor quality of life, caregiver burden, institutionalization, and cost of care in nursing homes. The Evidence Integration Triangle (EIT)-4-BPSD in nursing homes was a pragmatic Hybrid III trial of an implementation strategy to help staff use evidence-based non-pharmacological interventions to prevent and manage BPSD. This study aimed to describe and explore the stakeholders' perceptions of the process to implement the EIT-4-BPSD strategy including its utility, and the barriers and facilitators to implementation in real-world settings., Methods: EIT-4-BPSD was a multi-layer implementation strategy that engaged nursing home stakeholder groups to define community specific goals towards reducing BPSD over a 12-month period. Stakeholder groups from nursing homes that completed all 12-months of the implementation strategy were invited to participate in this process evaluation study. Qualitative data from focus group transcripts were analyzed using a conventional content analysis. Emerging codes were sorted into categories, then organized in meaningful clusters based on the domains of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework., Results: The EIT-4-BPSD implementation strategy was completed in 21 nursing homes; 93 stakeholders participated in focus groups. Over half of participating nursing homes reported meeting their BPSD goals as expected or more. Challenges, facilitators, and contextual factors reported by stakeholder members explains variability in the implementation of EIT-4-BPSD strategy in 11 key categories: family; staff; organizational; staff, environmental, and resident outcomes; utility of EIT resources; adoption barriers and facilitators; care process adaptations; and future planning., Conclusion: Stakeholders offered guidance on salient factors influencing the feasibility and utility of EIT-4-BPSD adoption and implementation to consider in future implementation research that aims to improve behavioral well-being in NH residents living with dementia. Engagement of family and staff at all levels of the organization (Management, leadership, and direct care); and measurement of staff, environmental, and resident outcomes were perceived as critical for future implementation success. While regulations, finances, and competing demands on staff time were perceived as reducing implementation success., Trial Registration: The Testing the Implementation of EIT-4-BPSD study was registered in the ClinicalTrials.gov ( NCT03014570 ) January 9, 2017., (© 2021. The Author(s).)

Background and Purpose: The purpose of this study was to test the reliability and validity of the Quality of Interactions Schedule (QuIS) using a quantification scoring approach., Methods: Baseline data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) study was used., Results: A total of 553 residents participated. There was evidence of inter-rater reliability with Kappa scores of .86 to 1.00 and internal consistency based on the Rasch analysis (item reliability of .98). There was some support for validity based on item fit and hypothesis testing as resistiveness to care was significantly associated with total QuIS scores., Conclusion: This study supports the use of the quantified QuIS to evaluate the quality of interactions over time and to test interventions to improve interactions., (© Copyright 2021 Springer Publishing Company, LLC.)

Person-centered care (PCC) involves shared decision-making between the individual and provider and is widely recognized as the gold standard of care. However, not all organizations have successfully implemented PCC, especially those in rural settings with limited resources. Implementation strategies, such as clinical champions, are key to PCC uptake. The purpose of the current article is to illustrate how Appreciative Inquiry, a strengths-based framework for transformational change, can be used to optimize a successful PCC champion training program. Appreciative Inquiry employs the quality improvement processes of (a) define, (b) discover, (c) dream, (d) design, and (e) deliver/destiny. Using Appreciative Inquiry, we were able to identify three new long-term goals and add supporting features to an existing champion training program. The methods developed herein could be implemented by researchers and evidence-based practice councils to improve the care of older adults in any care setting to make it more person-centered. [ Journal of Gerontological Nursing, 47 (8), 7-12.].

This study described current use and predictors of psychotropics among residents with moderate to severe cognitive impairment. This was a secondary data analysis using baseline data from the first 341 residents in an ongoing trial. Predictive measures included age, gender, race, depressive symptoms, agitation, resistiveness to care, depression, cognition, pain, comorbidities, facility factors, and state. Overall 63% ( n = 211) received at least one psychotropic medication, 16% ( n = 52) an anti-seizure medication, 23% ( n = 77) an anxiolytic, 30% ( n = 99) an antidepressant, 2% ( n = 8) a sedative hypnotic, 28% ( n = 93) an antipsychotic medication, and 9% ( n = 29) an opioid. Testing of models explained 9% to 15% of psychotropic medication use. There were high rates of psychotropic medication use and a limited association between demographic factors, behavioral symptoms, and psychotropic medication use. Continued research is needed to explore the impact of deprescribing, person-centered behavioral interventions, and beliefs of providers on psychotropic medication use.

Background and Purpose: The purpose of this study was to test the reliability and validity of the Knowledge of Person-Centered Behavioral Approaches for BPSD based on a Rasch analysis., Methods: This study used baseline data from the Implementation of the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) clinical trial., Results: A total 1,071 nurses completed the test. There was evidence of reliability (alpha coefficient of .99), construct validity with INFIT and OUTFIT statistics in the .6 to 1.4 range, and hypothesis testing with a significant correlation between the Knowledge of Person-Centered Behavioral Approaches for BPSD and positive care interactions., Conclusions: Future use of the measure should include more challenging items to differentiate those very high in knowledge of person-centered behavioral approaches for BPSD., (© Copyright 2020 Springer Publishing Company, LLC.)

Well-being is an important outcome for people with dementia. The current study is a secondary analysis of baseline data from an ongoing pragmatic trial. Affect balance, the ratio of positive to negative affect, was used as a measure of well-being, and factors related to it were examined in a sample of 325 nursing home residents. Measures of staff interaction during caregiving, staff knowledge of person-centered approaches for dementia care, staff hours of care, the physical environment, person-centered policies, resident function, and quality of life were obtained using direct observation, staff interview, and medical chart review. The results of the quantile multivariable regression analysis indicated that positive staff interaction and higher resident function were significantly associated with higher affect balance after controlling for other variables. The findings have heuristic value for the development of conceptual frameworks that focus on meaningful outcomes for residents with dementia and future research. [Research in Gerontological Nursing, 13(1), 21-30.]., (Copyright 2019, SLACK Incorporated.)

The purpose of this study was to test the reliability and validity of the Assessment of the Environment for Person-Centered Management of BPSD and the Assessment of Policies for Person-Centered Management of BPSD. The sample included 35 long term care facilities. There was evidence of reliability based on internal consistency and test-retest reliability of both measures. There was some evidence of validity based on Rasch model testing and INFIT and OUTFIT statistics. Across both measures there were six items with that were endorsed as present by all facilities. The INFIT and OUTFIT statistics were all within the expected range of .5 to 1.5 with the exception of four high OUTFIT statistics for the Assessment of the Environment for Person-Centered Management of BPSD. For the Assessment of Policies for Person-Centered Management of BPSD there were two items that had high INFIT statistics and six with low OUTFIT statistics and one with high OUTFIT statistics. Measure revisions are suggested including removal of some poor fitting items, items with no variance, and adding items to differentiate those very high in evidence of environments and policies that manage BPSD.

Nursing home (NH) residents routinely complete surveys that assess their health, well-being, preferences, and care needs. Such surveys reveal important information, however, are largely based on the concerns of providers as opposed to the concerns of residents. Thus, researchers must enhance efforts to ensure that these surveys are guided by the priorities, needs, and concerns of residents. We present a case study to demonstrate how spontaneous commentary of NH residents holds particular efficacy for ensuring that measurement tools are guided by the needs, concerns, and priorities of residents. Spontaneous comments from NH residents (N = 370) collected as part of a study developing the Preferences for Everyday Living Inventory for NH residents (PELI-NH) were used to refine the PELI-NH across key phases of measurement development. This work demonstrates how the spontaneous commentary of NH residents may contribute to the refinement of NH measurement tools, and allow researchers to base these tools on the needs and priorities of NH residents., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose of the Study: Understanding and honoring preferences are fundamental in the promotion of well-being for frail elders. This study aims to understand and describe nursing home residents' perspectives on why the importance of their preferences may change in daily care., Design and Methods: Secondary data analyses of cognitive interviews with 39 cognitively capable nursing home residents regarding their importance of preferences for everyday living were completed. Interviews were coded by 5 team members for reasons why residents may change their minds about the importance of their preferences or why their preferences may be restricted; discrepancies were reconciled through consensus., Results: Content analysis revealed 4 major domains: within person (e.g., functional ability, personal schedule), facility environment (e.g., facility schedule, facility policy), social environment (e.g., quality and type of interactions), and global environment (e.g., weather, current events, special occasions). Residents reflected that the importance of their preferences fluctuated "depending upon" the circumstances related to these factors or their ability to perform the preference (i.e., barriers they encountered). A total of 27 themes for dependencies and barriers were identified., Implications: Findings indicate that nursing home residents' preferences may change in importance or fulfillment in relation to personal or environmental circumstances. In order to develop formal care that matches older adults' preferences, regular assessment of both elders' preferences and the contextual factors affecting preferences is needed. However, given the changing nature of preference importance, there is also a need to determine how to best balance older adults' changing preferences within care delivery environments., (© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Preferences are the expression of an individual's basic psychosocial needs and are related to care outcomes. The current study tested the consistency of 87 individuals' everyday preferences over 1 week, comparing responses of nursing home residents (n = 37; mean age = 82) and university students (n = 50; mean age = 20). Participants completed the Preferences for Everyday Living Inventory at baseline and 5 to 7 days later. Preference consistency was calculated three ways: (a) correlations (range = 0.11 to 0.90); (b) overall percent of exact agreement (e.g., response was "very important" at both time points) (66.1%); and (c) responses collapsed as "important" or "not important" (increase in percent agreement to 86.6%). Personal care preferences were more stable, whereas leisure activities were less stable. The groups did not have significant differences in consistency. Some preferences are more consistent than others; age and frailty do not appear to be related to preference instability.

Background: Increasingly, nursing home (NH) providers are adopting a person-centered care (PCC) philosophy; yet, they currently lack methods to measure their progress toward this goal. Few PCC tools meet criteria for ease of use and feasibility in NHs. The purpose of this article is to report on the development of the concept and measurement of preference congruence among NH residents (phase 1), its refinement into a set of quality indicators by Advancing Excellence in America's Nursing Homes (phase 2), and its pilot evaluation in a sample of 12 early adopting NHs prior to national rollout (phase 3). The recommended toolkit for providers to use to measure PCC consists of (1) interview materials for 16 personal care and activity preferences from Minimum Data Set 3.0, plus follow-up questions that ask residents how satisfied they are with fulfillment of important preferences; and (2) an easy to use Excel spreadsheet that calculates graphic displays of quality measures of preference congruence and care conference attendance for an individual, household or NH. Twelve NHs interviewed residents (N = 146) using the toolkit; 10 also completed a follow-up survey and 9 took part in an interview evaluating their experience., Results: NH staff gave strong positive ratings to the toolkit. All would recommend it to other NHs. Staff reported that the toolkit helped them identify opportunities to improve PCC (100%), and found that the Excel tool was comprehensive (100%), easy to use (90%), and provided high quality information (100%). Providers anticipated using the toolkit to strengthen staff training as well as to enhance care planning, programming and quality improvement., Conclusions: The no-cost PCC toolkit provides a new means to measure the quality of PCC delivery. As of February 2014, over 700 nursing homes have selected the Advancing Excellence in America's Nursing Homes PCC goal as a focus for quality improvement. The toolkit enables providers to incorporate quality improvement by moving beyond anecdote, and advancing more systematically toward honoring resident preferences., (Copyright © 2014 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)