Abstract Background Family caregivers provide most of the emotional, physical, and logistical support for people living with Alzheimer’s disease and related dementias (ADRD). As the caregiving role intensifies with advancing illness, family caregivers navigate the cognitive and functional decline of the care recipient. They also must reconcile the shift from a mutual relationship to one of a primary caregiving role. The unique nature of ADRD makes pre-death grief highly prevalent among family caregivers. Reminiscence therapy, which uses memory prompts to evoke meaningful past experiences, has shown promise in improving psychosocial outcomes for individuals with dementia. Its potential to benefit caregivers through strengthened emotional connections, shared meaning, and mutual engagement among the dyad, however, has been largely underexplored. Guided by the Interdependence Model of Communal Coping and the Micro-Sociological Theory of Adjustment to Loss, the current study aims to assess the feasibility and acceptability of Living Memory Home for Dementia Care Pairs (LMH-4-DCP), a reminiscence-based online intervention for family caregivers and their care-recipients. Methods This multisite pilot randomized controlled trial (RCT) will evaluate the feasibility, acceptability, and preliminary efficacy of LMH-4-DCP. Seventy ADRD family caregivers will be targeted for randomization to a 1:1 ratio to the intervention (n = 35) or attention control (n = 35) conditions and will participate for 2 weeks. Recruitment will be facilitated by the project’s two study sites located in urban metropolitan areas of the USA. Primary feasibility outcomes include recruitment, retention, and completion rates, website usability (e.g., perceived usefulness and ease of use), and intervention satisfaction. Exploratory analyses will be conducted to assess the preliminary efficacy of LMH-4-DCP in reducing pre-death grief and improving relationship quality. Outcomes will be measured using validated questionnaires at baseline and 2-week follow-up, along with semi-structured interviews with LMH-4-DCP participants. Discussion This pilot trial will offer foundational evidence regarding the feasibility and acceptability of the LMH-4-DCP intervention. Study findings will guide intervention refinements and inform the design of a larger-scale, fully powered RCT to evaluate its efficacy in reducing pre-death grief and enhancing relationship quality among ADRD family caregivers. Trial registration Clinicaltrials.gov: NCT06225986, Registered: January 9, 2024, ClinicalTrials.gov; https://clinicaltrials.gov/study/NCT06225986?term=living%20memory%20home&rank=1
BACKGROUND:Veterans enrolled in both Veterans Affairs (VA) health care and Medicare Part D can choose to obtain medications through the VA, Medicare Part D, or both, with each option differing in cost, coverage, and coordination of care. Poorly informed choices can lead to veteran frustration when their expectations are not met, delays in medication access, and increased risks. This study aimed to develop a decision aid (DA) to help veterans with diabetes make informed choices about medication sourcing (ie, whether to fill medications through VA health care only, Part D only, or both). METHODS:DA development was guided by the International Patient DA Standards and the Ottawa Decision Support Framework. Interviews with veterans and care partners informed the prototype design. Alpha testing with 18 end users (mostly veterans) and 12 stakeholders (pharmacists, doctors, payers, Medicare counselors, and others) assessed comprehensibility, usability, and acceptability. During beta testing, the feasibility of the revised DA was assessed during interviews with 20 end users and 8 stakeholders. For end-user interviews, a survey assessing decisional conflict, satisfaction, and knowledge was provided before and after respondents filled out the DA. RESULTS:Alpha testing feedback led to simplifying the cost and formulary comparison chart and expanding the medication list template to include more medications, fill location, and prescriber contact information. Based on beta testing responses (n = 16), the mean system usability scale score for the DA was 77.5 (SD = 14.4), suggesting usability. Beta testers also reported the DA to be acceptable in length (94%), balance (88%), and amount of information (81%). Based on pre- vs post-DA survey responses, decisional conflict was reduced, as indicated by an increase in the mean Sure of myself; Understand information; Risk-benefit ratio; Encouragement (SURE) score (pre-DA: 3.1, SD = 1.4 to all 16 respondents reporting a maximum SURE score of 4.0). Knowledge about VA and Medicare coverage of diabetes medications also improved: the proportion who answered all 5 comprehension questions correctly increased from 57% to 81%. Last, the proportion of respondents who reported being "very satisfied" with how they were currently filling their diabetes medicines (VA only, Part D only, or both) improved from 64% pre-DA to 81% post-DA. CONCLUSIONS:The DA developed iteratively was usable and acceptable and showed potential in reducing decisional conflict, increasing knowledge, and increasing satisfaction, so it may help Part D-enrolled veterans with decisions about medication sourcing.
Research shows care coordination contributes to integrated care experiences. Yet evidence from system-level initiatives is lacking. Using a survey of Veterans Health Administration (VHA) patients linked with clinical records, this nonrandomized, cross-sectional study compares perceived care integration among patients at high risk of hospitalization or mortality who did and did not receive care coordination services at 31 VHA sites during early implementation of a national initiative. Six validated dimensions included: knowledge about patient's medical history among staff, providers, and specialists; provider support for self-directed care and for medication adherence and home care; and test results communication. Among 714 respondents, 48% had received care coordination services, 78% were 65 or older, and 95% were male. Regression models suggest little association between receipt of care coordination and perceived care integration. Implementation monitoring followed by responsive adaptations may be needed to boost patient perceptions of care integration.
BACKGROUND:Discontinuation of medications with limited benefits (LBM) in patients nearing the end of life can reduce burden, adverse events, and costs, and enhance quality of life. However, most research on end-of-life prescribing has focused on nursing homes or hospice settings. AIMS:To describe the prevalence of LBM use and discontinuation or deintensification over the last year of life in community-dwelling older veterans with advanced life-limiting conditions. DESIGN:Retrospective, national cohort study of U.S. veteran decedents (≥ 65 years) with advanced life-limiting conditions who died between October 2016 and September 2017. SETTING:Community-residing, non-hospice older veterans. LBM users were identified using consensus-based criteria and assessed for discontinuation over the last year of life. We estimated LBM discontinuation rate ratios using multivariable robust Poisson regression. RESULTS:Among 37,193 decedents (mean age 78 years), 73% were on at least one LBM (e.g., statins, oral antidiabetics, antihypertensives, antithrombotics, anti-ulcer, or antidementia drugs) entering the last year (baseline). Of these baseline LBM users, 22.0% experienced at least one LBM discontinuation over their final year. Veterans residing in more rural counties had lower LBM discontinuation rates than those in large metropolitan counties. Discontinuation rates were also higher in the Midwest or South compared to the Northeast or West. Veterans with documented clinical indicators of limited life expectancy (e.g., pressure ulcers, malnutrition) or those receiving specialty palliative care, were more likely to have LBMs discontinued. CONCLUSION:Among community-dwelling older veterans in their final year of life, 73% were receiving at least one LBM at the start of that year, and 78% of these individuals continued LBM use until death. These rates parallel those reported in long-term care populations and underscore the need for community-based healthcare providers to routinely screen for LBMs and support appropriate medication discontinuation in older patients with advanced illnesses and limited life expectancy.
ImportanceMetacognitive Reflection and Insight Therapy for Occupational Therapy (MERIT-OT) is a novel adaptation of an evidence-based psychotherapy model designed to enhance metacognitive capacity and support recovery. Its philosophical alignment with occupational therapy-particularly the emphasis on meaning-making and life participation-makes it a promising intervention for Veterans with serious mental illness. However, to date no implementation studies of MERIT-OT have been conducted.ObjectiveTo evaluate the implementation of MERIT-OT within a Veterans Affairs (VA) occupational therapy setting and to explore preliminary findings regarding clinical effectiveness.DesignPilot study evaluating the implementation and preliminary effectiveness of MERIT-OT when delivered by occupational therapists in a VA setting.SettingOne VA Medical Center across four occupational therapy practice areas: psychosocial rehabilitation, outpatient mental health, home health, and women's health.ParticipantsFive occupational therapists; three implemented MERIT-OT with nine Veterans over 37 sessions.Outcomes and MeasuresImplementation outcomes were assessed using the Consolidated Framework for Implementation Research when analyzing interviews and chart review data. Clinical outcomes were measured using the Metacognition Assessment Scale-Abbreviated (MAS-A).ResultsFacilitators included perceived relative advantage and tension for change. Barriers included competing priorities and documentation challenges. Quantitative analysis showed early gains in metacognitive mastery; other subscales showed limited change.Conclusions and RelevancePreliminary findings suggest ongoing consultation, additional training, and improved tools and resources may facilitate MERIT-OT implementation in VA outpatient mental health.What This Article AddsMERIT-OT offers a structured, recovery-oriented approach aligned with occupational therapy values and shows promise for enhancing metacognitive outcomes in mental health settings.
