Browsing by Author "McConnell, Eleanor S"

Behavioral symptoms of dementia cause considerable distress for persons with dementia and their caregivers and are related to adverse outcomes that have significant social and economic impact. Thus, behavioral symptoms represent one of the most challenging aspects of dementia care. Over the past three decades, research on behavioral symptoms of dementia has laid the foundation for development of non-pharmacological interventions by identifying underlying mechanisms of symptom development. However, the research has largely overlooked how the needs of military veterans may influence development and treatment of behavioral symptoms of dementia, including those needs associated with co-occurring dementia and posttraumatic stress disorder (PTSD). This dissertation aimed to develop knowledge related to behavioral symptoms of dementia among older veterans with and without PTSD by synthesizing current understanding of neurocognitive and psychiatric comorbidities of PTSD among veterans as well as explicating relationships among background factors, proximal factors, and behavioral symptoms of dementia among veterans living in residential care using the need-driven, dementia-compromised behavior (NDB) model.

This dissertation includes a systematic review in Chapter 2 that synthesized the patterns of neurocognitive and psychiatric comorbidities of PTSD in older veterans and revealed a substantial gap in the literature with regards to understanding manifestations and treatment of behavioral symptoms of dementia among older veterans with co-occurring dementia and PTSD. The primary study of this dissertation that encompasses Chapters 3 and 4 utilized an exploratory sequential mixed methods design using secondary data derived from the evaluation dataset of the STAR-VA training program. In Chapter 3, a qualitative study, as the first phase of the mixed methods study, analyzed text data that captured the interdisciplinary care team’s observation of behavioral symptoms of dementia and their circumstances for the subsample of 33 veterans from the STAR-VA dataset. This qualitative study described how behavioral symptoms of dementia are manifested among veterans with and without PTSD in the context of personal, interpersonal/social, and environmental factors that trigger the symptoms. Findings demonstrated that behavioral symptoms of dementia are heterogeneous, with distinct clusters of triggers that are multi-level, thereby warranting an interdisciplinary, multi-level approach to developing person-centered interventions. In addition, findings from this qualitative study informed the development of the second phase of the sequential mixed methods study in Chapter 4 that aimed to test hypothesized pathways between background factors, interpersonal triggers (proximal factors), and behavioral symptoms of rejection of care and aggression and to explore the moderating effect of PTSD on the hypothesized pathways. The mixed methods approach integrated quantitative data measured by standardized scales and text data for 315 veterans derived from the STAR-VA dataset. After converting text data into categorical variables, structural equation modeling (SEM) was performed to compare the patterns of relationships among background factors, interpersonal triggers, and behavioral symptoms of rejection of care and aggression between veterans with and without PTSD. The direct effect of interpersonal triggers and the indirect effect of background factors through interpersonal triggers on rejection of care and aggression emphasizes the importance of developing and implementing psychosocial interventions that improve interpersonal relationships. The multi-group SEM revealed that the full model was not moderated by PTSD. However, the differential direct and indirect effect of background factors and interpersonal triggers as a proximal factor on the behavioral outcomes between veterans with and without PTSD suggest potential different mechanisms of behavioral outcomes between veterans depending upon whether or not PTSD is present. Evidence for the PTSD-moderated mediating effect of interpersonal triggers on the relationship between depression and rejection of care was demonstrated, suggesting the need to develop targeted interventions for veterans with dementia and PTSD who have greater depressive symptoms.

The new knowledge generated from this dissertation helps to clarify complex patterns of associations among background factors such as PTSD and proximal factors and behavioral symptoms of dementia consistent with the NDB model, strengthening the foundation for development of novel approaches to designing and implementing person-centered care for veterans with co-occurring dementia and PTSD.

Effective patient care transitions require consideration of the patient’s social and clinical contexts, yet how these factors relate to the processes in care coordination remains poorly described. This dissertation aimed to describe provider networks and clinical care and social contexts involved during longitudinal care transitions across settings. The overall purpose of this dissertation is to uncover the longitudinal patterns of utilization and relational processes needed for effective care coordination in transitional care, so we can redesign interventions that focus on informational and relationship networks to improve interaction patterns and system performance for people living with heart failure (HF) as they undergo transitions across settings and over time. This dissertation was a retrospective exploratory study. Chapter 2 is an integrative review examining coordination processes in transitional care interventions for older adults with HF by integrating a social network analysis framework. We subsequently selected a cohort of patients aged 18 years or older (n = 1269) with an initial hospitalization for HF at Duke University Health System between January 1, 2016 and December 31, 2018 based on encounter, sociodemographic, and clinical data extracted from electronic health records (EHR). In Chapter 3, a latent growth trajectory analysis was used to identify distinct subgroups of patients based on the frequency of outpatient, as well as emergency department (ED) and inpatient encounters 1 year before and 1 year after the index hospitalization; multinomial logistic regression was then used to evaluate how outpatient utilization was related to acute care utilization. Based on findings (described in Chapter 3), we purposively sampled 11 patients from the Chapter 3 cohort for a second empirical study (described in Chapter 4) with a mixed-methods sequential explanatory design. These 11 patients had a full spectrum of experience in socioeconomic disadvantages based on three strata (race, insurance, and Area Deprivation Index), but they had similar levels of comorbidity and average severity of illness and displayed the same change in the severity of illness during the study period. We used quantitative and qualitative data available from clinical notes in the EHR, and integrated results from quantitative and qualitative analysis to better understand the social and clinical context and social structure essential for care coordination. High variability in transitional care is likely because care coordination processes are highly relational. The relational structure of transitional care interventions varied from triadic to complex network structures. Use of a network analysis framework helped to uncover relational structures and processes underlying transitional care to inform intervention development. Chapter 3 revealed that high heterogeneity exists in patients’ utilization patterns. A small subgroup of high users utilized a substantial amount of the resources. Patients with high outpatient utilization had more than 4 times the likelihood of also having high acute care utilization, and change in the severity of illness had the highest level of significance and strongest magnitude of effect on influencing high acute care utilization. Chapter 4 demonstrated the feasibility of using clinical notes and social network analysis (SNA) to assess the provider networks for patients with HF in care transitions. People who were experiencing more socioeconomic disadvantages and social instability were less likely to have densely connected provider teams and providers who were central and influential in the system network. Lacking consistent and reciprocal relationships with outpatient provider teams, especially primary care provider and cardiology teams, was precedent to poor care management and coordination. Turbulence in care transition can result from sources other than transitioning between settings. This dissertation demonstrated the (a) importance of understanding relational processes and structure during patients’ utilization of acute and outpatient care services and (b) potential to capture structural inequalities that may influence the efficiency of care coordination and health outcomes for patients with HF.

In the context of rapid global aging, cognitive decline among older adults has become a major public health and social issue. A better understanding of the risk factors for cognitive decline is important for developing interventions to preserve cognitive function among older adults. Knowledge gaps still exist in understanding the impact of sensory loss (i.e., hearing loss and vision loss) and psychosocial factors (i.e., social support and loneliness) on cognitive function and cognitive decline. This dissertation aims to fill these knowledge gaps by (1) examining the relationship between psychosocial factors and cognitive function in a unique population: community-dwelling Chinese older adults in the United States (U.S.); (2) understanding the longitudinal relationship between sensory loss and cognitive decline among community-dwelling older adults in the United States; and (3) exploring the mechanisms that accelerate or decelerate cognitive decline by examining the inter-relationships between sensory loss, psychosocial factors, and cognitive decline. The primary study conducted for this dissertation used structural equational modeling (SEM) to model the potential moderation or mediation effect of psychosocial factors on the relationship between sensory loss and cognitive decline over time. Findings from this dissertation deepen our understanding of the important roles that social support, loneliness, and sensory loss can play in cognitive function and decline among community-dwelling older adults. Findings from this dissertation also highlight the importance of adequately addressing the physical and psychological challenges encountered by older adults. Subsequent recommendations are provided to health providers and policy makers to help better preserve and promote cognitive health among older adults using a more holistic approach.

Older persons with dementia are disproportionately affected by acute injuries such as a hip fracture and they experience significantly worse recovery outcomes than their peers without dementia. The overarching goal of this dissertation is to delineate physical function recovery trajectories after hip fracture in persons with dementia and examine how recovery is affected by multimorbidity, through the lens of physical resilience. This dissertation comprises five chapters designed to: 1) introduce the scope of the problem of recovery from hip fracture among older adults with dementia, 2) identify gaps in knowledge by conducting scoping review on health recovery trajectories in older adults after hip fracture, 3) delineate trajectories of physical function recovery and examine patient characteristics associated with membership of physical function trajectory categories in a national sample of 16,255 older adults with dementia residing in long-term care facilities for one year, 4) examine the longitudinal mediation effects of severity of behavioral symptoms between level of cognitive impairment and physical function recovery and the moderation effects of vision loss among a subset of long-stay nursing home residents with dementia and behavioral symptoms following hip fracture (n=2,824), and 5) summarize conclusions and implications for research, practice, and policy. Five heterogeneous trajectories of recovery of activities of daily living and three trajectories of range of motion were described, along with clinical and sociodemographic factors associated with membership in each category. Among the subset of residents with behavioral symptoms after hip fracture, behavioral symptoms were a partial mediator with a small effect size; vision loss did not moderate these relationships. The findings of this dissertation project contribute new knowledge regarding how older adults with dementia recover physical function (physical resilience) and how their recovery relates to symptoms caused by dementia and vision loss after hip fracture. These findings provide a novel empirical foundation for clinicians to improve individualized care plans based on predicted trajectories of recovery for those with dementia after hip fracture.

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Globally there is a rapid growth in the population of older adults ≥65 years. In the United States similar trends are evident and the increasing number of older adults is driving demands for Long-term Care (LTC); however, there is a shortage of registered nurses (RNs) to provide skilled care. Older adults experience higher rates of multiple chronic illnesses that require skilled care and recruiting Foreign Educated Nurses (FENs) is one strategy used in the United States. FEN migration increases racial and ethnic, cultural, and linguistic diversity, and the proportion of baccalaureate prepared RNs in the US. However, research on FENs in LTC is limited, yet most studies focus on acute care settings. The acute care-based research indicates FENs are vulnerable to inequitable compensation, racism, communication challenges and exploitation. If FENs in LTC have similar experiences, this may contribute to burnout and turnover which may further destabilize the RN workforce. To maintain workforce stability, improve inclusive work environments and advance person-centered care for older adults, more research is needed to deepen our understanding of employment outcomes and professional experiences of FENs in LTC. Therefore, the goals of this dissertation are: 1) to generate knowledge to inform culturally appropriate interventions for creating an inclusive environment for all RNs to provide quality person-centered care, and to inform health policies to improve workforce planning for FEN retention in LTC. Chapter 2 presents an integrative review that synthesized peer-reviewed studies and grey literature on RN migration and the impact on LTC in the US. Findings indicated FENs mainly migrated from Low and Middle Income Countries (LMICs) due to socio-economic factors, workplace characteristics, and contextual factors. Increased FEN staffing was mainly associated with significantly improved health outcomes. Further, FENs had higher qualifications, and typically earned higher income relative to US educated nurses (USENs); however, FENs experience multiple forms of discrimination. Chapter 3 presents a secondary analysis of the National Sample Survey of Registered Nurses (NSSRN) 2017 data which compared employment-outcomes (annual salaries, hourly wages, annual RN work hours, job satisfaction) and human capital among FENs and USENs. Findings showed that most FENs belong to racial and ethnic minority groups and have significantly higher human capital, make significantly higher hourly wages and worked significantly fewer annual hours relative to USENs. While FENs and USENs had similar annual salaries and job satisfaction, human capital partially accounted for differences in hourly wages only. Chapter 4 presents findings qualitative study that explored barriers and facilitators for FENs from racial and ethnic minority groups to provide quality care. Cultural barriers, discrimination, ineffective workplace integration, and negative facility characteristics (eg. poor staffing and lack of preceptorship and orientation programs) are major barriers for FENs to provide quality care. However, facilitators to providing quality care identified were positive support, effective workplace integration, acculturation, and positive facility characteristics (eg. having preceptorship and mentorship programs, adequate staffing). The knowledge generated from this dissertation filled critical gaps in the LTC literature. Our mixed methods review was the first to evaluate the state of the science on FENs’ impact on LTC. The state of the science is underdeveloped, however, the integrative review highlighted the very complex experiences of FENs and their unique contributions to LTC. The COVID 19 pandemic highlighted how essential FENs are in supporting the LTC workforce and the health system struggle to maintain adequate staffing levels. Our innovative statistical method of developing the human capital variable holds promise for informing future research to get more accurate measures of its impact on employment outcomes. Examining employment outcomes allowed us to determine that FENs are paid equitable; however, the existence of pay disparity among males and females indicate policies need to be implemented to ensure clinical ladders are free of bias and discrimination. Qualitative findings indicate FENs have mixed professional experiences, however, the knowledge generated could inform potential interventions like structured mentorship and preceptorship programs to improve onboarding practices. Further, this dissertation confirmed the need for policies and interventions that help with language support and cultural sensitivity training for the workforce since LTC is a multicultural environment.