Medical comorbidity, particularly cardiovascular diseases, contributes to high rates of hospital admission and early mortality in people with schizophrenia. The 30 days following hospital discharge represents a critical period for mitigating adverse outcomes. This study examined the odds of successful community discharge among Veterans with schizophrenia compared to those with major affective disorders and those without serious mental illness (SMI) after a heart failure hospital admission. Data for Veterans hospitalized for heart failure were obtained from the Veterans Health Administration (VHA) and Centers for Medicare & Medicaid Services between 2011 and 2019. Psychiatric diagnoses and medical comorbidities were assessed in the year prior to hospitalization. Successful community discharge was defined as remaining in the community without hospital readmission, death, or hospice for 30 days after hospital discharge. Logistic regression analyses adjusting for relevant factors were used to examine whether individuals with a schizophrenia diagnosis showed lower odds of successful community discharge versus both comparison groups. Out of 309,750 total Veterans in the sample, 7377 (2.4%) had schizophrenia or schizoaffective disorder and 32,472 (10.5%) had major affective disorders (bipolar disorder or recurrent major depressive disorder). Results from adjusted logistic regression analyses demonstrated significantly lower odds of successful community discharge for Veterans with schizophrenia compared to the non-SMI (Odds Ratio [OR]: 0.63; 95% Confidence Interval [CI]: 0.60, 0.66) and major affective disorders (OR: 0.65, 95%; CI: 0.62, 0.69) groups. Intervention efforts should target the transition from hospital to home in the subgroup of Veterans with schizophrenia.

Background: Accurate and timely diagnosis of dementia is necessary to allow affected individuals to make informed decisions and access appropriate resources. When dementia goes undetected until a hospitalization or nursing home stay, this could reflect delayed diagnosis or misdiagnosis, and may reflect underlying disparities in healthcare access. Methods: In this retrospective cohort study, we used 2012-2020 Medicare claims and other administrative data to examine variation in setting of dementia diagnosis among fee-for-service Medicare beneficiaries with an initial claims-based dementia diagnosis in 2016. We used multinomial logistic regression to evaluate the association of person and geographic factors with diagnosis location, and Cox proportional hazards regression to examine 4-year survival relative to diagnosis location. Results: Among 754,204 Medicare beneficiaries newly diagnosed with dementia in 2016, 60.3% were diagnosed in the community, 17.2% in hospitals, and 22.5% in nursing homes. Adjusted 4-year survival rates were significantly lower among those diagnosed in hospitals [-16.1 percentage points (95% CI: -17.0, -15.1)] and nursing homes [-16.8 percentage points (95% CI: -17.7, -15.9)], compared to those diagnosed in the community. Community-diagnosed beneficiaries were more often female, younger, Asian or Pacific Islander, Native American or Alaskan Native, Hispanic, had fewer baseline hospitalizations and higher homecare use, and resided in wealthier ZIP codes. Rural beneficiaries were more likely to be diagnosed in hospitals. Conclusions: Many older adults are diagnosed with dementia in a hospital or nursing home. These individuals have significantly lower survival than those diagnosed in the community, which may indicate diagnosis during an acute illness or care transition, or at a later disease stage, all of which are suboptimal. These results highlight the need for improved dementia screening in the general population, particularly for individuals in rural areas and communities with higher social deprivation.

ObjectiveAdults with serious mental illness (SMI) have high rates of cardiovascular disease, particularly heart failure, which contribute to premature mortality. The aims were to examine 90- and 365-day all-cause medical or surgical hospital readmission in Veterans with SMI discharged from a heart failure hospitalization. The exploratory aim was to evaluate 180-day post-discharge engagement in cardiac rehabilitation, an effective intervention for heart failure.MethodsThis study used administrative data from the Veterans Health Administration (VHA) and Centers for Medicare & Medicaid Services between 2011 and 2019. SMI status and medical comorbidity were assessed in the year prior to hospitalization. Cox proportional hazards models (competing risk of death) were used to evaluate the relationship between SMI status and outcomes. Models were adjusted for VHA hospital site, demographics, and medical characteristics.ResultsThe sample comprised 189,767 Veterans of which 23,671 (12.5%) had SMI. Compared to those without SMI, Veterans with SMI had significantly higher readmission rates at 90 (16.1% vs. 13.9%) and 365 (42.6% vs. 37.1%) days. After adjustment, risk of readmission remained significant (90 days: HR: 1.07, 95% CI: 1.03, 1.11; 365 days: HR: 1.10, 95% CI: 1.07, 1.12). SMI status was not significantly associated with 180-day cardiac rehabilitation engagement (HR: 0.98, 95% CI: 0.91, 1.07).ConclusionsVeterans with SMI and heart failure have higher 90- and 365-day hospital readmission rates even after adjustment. There were no differences in cardiac rehabilitation engagement based on SMI status. Future work should consider a broader range of post-discharge interventions to understand contributors to readmission.

OBJECTIVE:Wandering behavior in nursing home (NH) residents could increase risk of infection. The objective of this study was to assess the association of wandering behavior with SARS-CoV-2 infection in Veterans Affairs (VA) Community Living Center (CLC) residents. DESIGN:Retrospective cohort study. SETTING & PARTICIPANTS:Veterans residing in 133 VA CLCs. METHODS:We included residents with SARS-CoV-2 test from March 1, 2020 to December 31, 2020 from VA electronic medical records. We identified CLC residents with wandering on Minimum Data Set 3.0 assessments and compared them with residents without wandering. The outcome was SARS-CoV-2 infection, as tested for surveillance testing, in those with and without wandering. Generalized linear model with Poisson link adjusted for relevant covariates was used. RESULTS:Residents (n = 9995) were included in the analytic cohort mean, (SD) age 73.4 (10.7); 388 (3.9%) women. The mean (SD) activities of daily living score in the overall cohort was 13.6 (8.25). Wandering was noted in 379 (3.8%) (n = 379) of the cohort. The exposure groups differed in prior dementia (92.6% vs 62.1%, standardized mean difference [SMD] = 0.8) and psychoses (41.4% vs 28.1%, SMD = 0.3). Overall, 12.5% (n = 1248) tested positive for SARS-CoV-2 and more residents among the wandering group were SARS-CoV-2 positive as compared with those in the group without wandering (19% [n = 72] vs 12.2% [n = 1176], SMD = 0.19). Adjusting for covariates, residents with wandering had 34% higher relative risk for SARS-CoV-2 infection (adjusted relative risk, 1.34; 95% CI, 1.04-1.69). CONCLUSIONS AND IMPLICATIONS:CLC residents with wandering had a higher risk of SARS-CoV-2 infection. This may inform implementation of infection control and isolation policies as NHs attempt to balance ethical concepts of resident autonomy, proportionality, equity, and utilitarianism.

OBJECTIVES:Skilled therapies (STs), including audiology, speech-language therapy, occupational therapy, and physical therapy, can address functional deficits in dementia. This study aims to quantify the association between ST and successful discharge after heart failure (HF) hospitalization in persons living with dementia. DESIGN:Retrospective cohort study. SETTING AND PARTICIPANTS:We included veterans with dementia (VwD) hospitalized for HF in Veterans Affairs (VA) medical centers and then admitted to non-VA skilled nursing facilities (SNFs) from January 2011 to June 2019. METHODS:Follow-up continued 120 days after SNF admission. We measured ST hours per week using MDS admission assessments. We defined successful discharge as SNF discharge occurring within 90 days of SNF admission with MDS discharge status not hospital or institutional setting, and 30 days' survival after discharge without Medicare or VA-paid rehospitalization or reinstitutionalization. We estimated relative risk using multiple variable regression to adjust for measured sources of confounding. RESULTS:Our final sample included 8255 VwD. The mean (SD) age was 80 (10) years, and 8074 (98%) were male. Successful discharge occurred in 2776 (34%) of the sample. The median (IQR) weekly hours of ST was 10.4 (7.1-12.1). Sextile 1 received less than 5.2 hours per week of ST. The adjusted relative risk (95% CI) for sextiles 2-6 compared with sextile 1 were, respectively, 2.20 (1.85-2.62), 2.48 (2.09-2.94), 2.52 (2.12-2.99), 2.62 (2.21-3.11), and 2.69 (2.27-3.19). DISCUSSION:During SNF care after HF hospitalization, 5.3 or more hours of STs per week was associated with a higher rate of successful discharge, in a roughly dose-dependent fashion, up to a 170% increase in the highest sextile of ST hours. CONCLUSIONS AND IMPLICATIONS:Higher ST hours are associated with successful discharge from SNF after HF hospitalization.

Background: Older adults with heart failure are at elevated risk of Alzheimer’s disease and related dementias (AD/ADRD). Research suggests that insomnia and depressive episodes contribute somewhat dissociable impacts on risk for AD/ADRD in this patient population, although the temporal ordering of effects is unknown. Objective: This study examined time to dementia diagnosis among patients with comorbid insomnia and/or depressive episodes in an epidemiological sample. Methods: Secondary data analyses were conducted using a cohort study of 203,819 Veterans with a primary admission diagnosis of heart failure in 129 VA Medical Centers. Results: Patients with diagnoses of both insomnia and depressive episodes had the shortest time to a dementia diagnosis at both 1-year (Hazard ratio = 1.43, 95% CI [1.36, 1.51]) and 3-year follow-up time points (Hazard ratio = 1.40, 95% CI [1.34, 1.47]) versus patients with one or neither comorbidity. Conclusions: Individuals with both comorbidities had the shortest time to dementia onset. Screening for these comorbidities may help to identify patients at elevated risk of dementia who could benefit from enhanced monitoring or early intervention strategies for more rapid detection and management of dementia symptoms.

ImportanceAlthough older adults may use potentially driver-impairing (PDI) medications that can produce psychomotor impairment, little is known about changes to PDI medication use among older adults from the time before to the time after a motor vehicle crash (MVC).ObjectiveTo quantify use of and changes in PDI medications among older adults before and after an MVC.Design, Setting, and ParticipantsThis cohort study used linked Medicare claims and police-reported MVC data on 154 096 person-crashes among 121 846 older drivers. Eligible persons were drivers aged 66 years or older, involved in a police-reported MVC in New Jersey from May 1, 2007, through December 31, 2017, and with continuous enrollment in Medicare fee-for-service Parts A and B for at least 12 months and Part D for at least 120 days prior to the MVC. Data were analyzed from January 2022 to May 2024.Main Outcomes and MeasuresUse of benzodiazepines, nonbenzodiazepine hypnotics, opioid analgesics, and other PDI medications in the 120 days before and 120 days after the MVC. Because each person could contribute multiple MVCs during the study period if they met eligibility criteria, the unit of analysis was the number of person-crashes. The proportion of person-crashes after which PDI medications were started, discontinued, or continued was quantified as well.ResultsAmong 154 096 eligible person-crashes, the mean (SD) age of the drivers was 75.2 (6.7) years at the time of the MVC. Of 121 846 unique persons, 51.6% were women. In 80.0% of the person-crashes, drivers used 1 or more PDI medications before the crash, and in 81.0% of the person-crashes, drivers used 1 or more PDI medications after the crash. Use of benzodiazepines (8.1% before the crash and 8.8% after the crash), nonbenzodiazepine hypnotics (5.9% before the crash and 6.0% after the crash), and opioid analgesics (15.4% before the crash and 17.5% after the crash) was slightly higher after the MVC. After the MVC, drivers in 2.1% of person-crashes started benzodiazepines and 1.4% stopped benzodiazepines, drivers in 1.2% of person-crashes started nonbenzodiazepine hypnotics and 1.2% stopped nonbenzodiazepine hypnotics, and drivers in 8.4% of person-crashes started opioid analgesics and 6.3% stopped opioid analgesics.Conclusions and RelevanceThis cohort study suggests that most older drivers involved in MVCs did not use fewer PDI medications after crashes than before crashes. Qualitative research of perceived risks vs benefits of PDI medications is necessary to understand the reasons why MVCs do not appear to motivate clinicians to deprescribe PDI medications as a strategy to avert potential harms, including additional MVCs.

OBJECTIVES:Examine physical function change and physical therapy (PT) use in short-stay and long-stay residents not infected by CoVID-19 within Veterans Affairs (VA) Community Living Centers (CLCs). DESIGN:Retrospective cohort study using Minimum Data Set (MDS) 3.0 assessments. SETTINGS AND PARTICIPANTS:12,606 Veterans in 133 VA CLCs between September 2019 and September 2020. METHODS:Difference in physical function [MDS Activities of Daily Living Score (MDS-ADL)] and PT use (minutes in past 7 days) from admission to last assessment in a period were compared between the pre-CoVID-19 (September 2019 to February 2020) and early CoVID-19 (April 2020 to September 2020) period using mixed effects regression with multivariable adjustment. Assessments after a positive CoVID-19 test were excluded. Differences were examined in the sample and repeated after stratifying into short- and long-stay stratums. RESULTS:Veterans admitted during early CoVID-19 had more comorbidities, worse MDS-ADL scores, and were more often long-stay residents compared with those admitted during pre-CoVID-19. In comparison to pre-CoVID-19, Veterans in VA CLCs during early CoVID-19 experienced greater improvements in their MDS-ADL (-0.49 points, 95% CI -0.27, -0.71) and received similar minutes of therapy (2.6 minutes, 95% CI -0.8, 6.0). Stratification revealed short-stay residents had relative improvements in their function (-0.69 points, 95% CI -0.44, -0.94) and higher minutes of PT (5.1 minutes, 95% CI 0.9, 9.2) during early CoVID-19 whereas long-stay residents did not see differences in functional change (0.08 points, 95% CI -0.36, 0.51) or PT use (-0.6 minutes, 95% CI -6.1, 4.9). CONCLUSIONS AND IMPLICATIONS:During early CoVID-19, physical function improved while the amount of PT received was maintained compared with pre-CoVID-19 for Veterans in VA CLCs. Short-stay residents experienced greater improvements in physical function and increases in PT use. These findings may be partly due to selection bias relating to Veterans admitted to CLCs during early CoVID-19.

Audiology, speech-language therapy, and occupational therapy (OSLA) can address functional deficits of dementia, but we do not know this set of services' effect on successful discharge after heart failure hospitalization in persons living with dementia. We hypothesize that increased OSLA time was associated with successful discharge home from skilled nursing facilities (SNFs) in Veterans with dementia (VwD) after heart failure (HF) hospitalization.

Objective To examine prevalence of Alzheimer Disease and related dementias (ADRD) and patient characteristics as a function of comorbid insomnia and/or depression among heart failure (HF) patients discharged from hospitals. Design Retrospective cohort descriptive epidemiology study. Setting VA Hospitals. Participants N = 373,897 Veterans hospitalized with heart failure from October 1, 2011 until September 30, 2020. Measurements We examined VA and Center for Medicare & Medicaid Services (CMS) coding in the year prior to admission using published ICD-9/10 codes for dementia, insomnia, and depression. The primary outcome was the prevalence of ADRD and the secondary outcomes were 30-day and 365-day mortality. Results The cohort were predominantly older adults (mean age = 72 years, SD = 11), male (97%), and White (73%). Dementia prevalence in participants without insomnia or depression was 12%. In those with both insomnia and depression, dementia prevalence was 34%. For insomnia alone and depression alone, dementia prevalence was 21% and 24%, respectively. Mortality followed a similar pattern with highest 30-day and 365-day mortality higher in those with both insomnia and depression. Conclusions These results suggest that persons with both insomnia and depression are at an increased risk of ADRD and mortality compared to persons with one or neither condition. Screening for both insomnia and depression, especially in patients with other ADRD risk factors, could lead to earlier identification of ADRD. Understanding comorbid conditions which may represent earlier signs of ADRD may be critical in the identification of ADRD risk.

Background: Hospitalization with heart failure (HF) may signal an increased risk of Alzheimer’s disease and related dementias (ADRD). Nursing homes routinely assess cognition but the association of these results with new ADRD diagnosis in a population at high risk of ADRD is not known. Objective: To determine the association between nursing home cognitive assessment results and new diagnosis of dementia after heart failure hospitalization. Methods: This retrospective cohort study included Veterans hospitalized for HF and discharged to nursing homes, from 2010 to 2015, without a prior diagnosis of ADRD. We determined mild, moderate, or severe cognitive impairment using multiple items of the nursing home admission assessment. We used Cox regression to determine the association of cognitive impairment with new ADRD diagnosis during 365 days of follow-up. Results: The cohort included 7,472 residents, new diagnosis of ADRD occurred in 4,182 (56%). The adjusted hazard ratio of ADRD diagnosis was 4.5 (95% CI 4.2, 4.8) for the mild impairment group, 5.4 (95% CI 4.8, 5.9) for moderate impairment, and 4.0 (95% CI 3.2, 5.0) for severe impairment compared to the cognitively intact group. Conclusion: New ADRD diagnoses occurred in more than half of Veterans with HF admitted to nursing homes for post-acute care.

OBJECTIVES:This study aimed to better understand Class II/III obesity prevalence trends among older adults residing in nursing homes (NH) nationwide.METHODS:Our retrospective cross-sectional study evaluated Class II/III obesity (BMI ≥35 kg/m²) prevalence among NH residents in two independent national NH cohorts. We used databases from Veterans Administration NHs called Community Living Centers (CLCs) covering 7 years to 2022, and Rhode Island Medicare data covering 20 years ending in 2020. We also performed forecasting regression analysis of obesity trends.RESULTS:While VA CLC resident obesity prevalence was less overall and dipped during the COVID-19 pandemic, obesity prevalence increased in NH residents in both cohorts over the last decade and is predicted to do so through 2030.CONCLUSION:Obesity prevalence in NHs is on the rise. It will be important to understand clinical, functional, and financial implications for NHs, particularly if predictions on increases materialize.

INTRODUCTION:Adult day health centers (ADHCs) provide an important service to community-dwelling adults with functional dependency. This includes persons living with dementia (PLWD) and their caregivers, but we don't know how well ADHC capacity matches the distribution of PLWD.METHODS:For this cross-sectional study, we identified community-dwelling PLWD using Medicare claims, and ADHC capacity using licensure data. We aggregated both features by Hospital Service Area. By linear regression, we determined the association between ADHC capacity and community-dwelling PLWD.RESULTS:We identified 3836 community-dwelling Medicare beneficiaries living with dementia. We included 28 ADHCs, with licensed capacity for 2127 clients. The linear regression coefficient (95% Confidence Interval) for number of community-dwelling beneficiaries with dementia was 1.07 (0.6-1.53).DISCUSSION:Rhode Island's ADHC capacity distribution roughly approximates the distribution of persons with dementia. Plans for the future of dementia care in Rhode Island should consider these findings.

Claims data are a valuable resource for studying Alzheimer's disease and related dementias (ADRD). Alzheimer's disease and related dementias is often identified using a list of claims codes and a fixed lookback period of 3 years of data. However, a 1-year lookback or an approach using all-available lookback data could be beneficial based on different research questions. Thus, the purpose of this study was to compare 1-year and all-available lookback approaches to ascertaining ADRD compared to the standard 3-year approach. Using a cohort of Veterans hospitalized for heart failure (N = 373, 897), our results suggested high agreement (93% or greater) between the lookback periods. The 1-year lookback period had lower sensitivity (60%) and underestimated the prevalence of ADRD. These results suggest that 1-year and all-available lookback periods are viable approaches when using claims data.

Alzheimer's disease and related dementias (ADRD) impact the diagnosis and infection control of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS‐CoV‐2) in nursing homes (NH) by influencing the behavior of residents and their caregivers. Health system data show an association between ADRD and SARS‐CoV‐2. Whether this association is present in NH populations remains unknown. How increased SARS‐CoV‐2 risk among residents with ADRD impacts the greater NH population also remains unknown.

Aging increases susceptibility to medical and psychiatric comorbidity via interrelated biological, psychological, and social mechanisms. Mental status changes or other psychiatric symptoms occurring in older adults with medical disorders most often result from delirium, depression, or the onset of Alzheimer’s disease and related dementias (ADRD). Clinicians can use evidence-based tools to evaluate such symptoms including the 4A’s Test for delirium, the Saint Louis University Mental Status Exam, and the Geriatric Depression Scale . Innovative models such as collaborative care can improve the outcome of care of older adults with medical disorders requiring treatment for depression or ADRD..

and dual-diagnosis services.A personalized treatment planning approach was developed in each case and included the time period of the COVID-19 quarantine.Results: Mr A: 64 year old man with Generalized Anxiety Disorder, Panic Disorder, Opioid Use Disorder in sustained remission on Methadone 270mg daily and Sedative Hypnotic Use Disorder.The patient entered treatment for impending Benzodiazepine withdrawal after losing his provider.He was taking alprazolam 2mg, clonazepam 6m and zolpidem 10mg daily over the past 30 years.Following treatment for acute withdrawal and treatment with a slow taper of clonazepam the patient has been struggling with episodic anxiety and feelings of loss.Isolation and boredom related to COVID-19 quarantine conditions have contributed to this making the issue of worsening anxiety with protracted withdrawal symptoms difficult to delineate.Ms B:74 year old woman with Generalized Anxiety Disorder entered treatment after her provider closed his practice.The patient was prescribed diazepam 40mg, lorazepam 2mg and zolpidem 10mg daily for the past 5 years.In addition she was prescribed dextroamphetamine 20 mg daily for 3 years for fatigue.Over a 2 year period the medications were tapered using clonazepam; the dextroamphetamine was discontinued.While being maintained on clonazepam 0.5mg daily she started to complain of fearfulness, loneliness, insonia and chronic pain which increased with the onset of the COVID-19 quarantine.Mirtazpine 7.5mg was started at bedtime with improvement.Ms D: 59 year old woman with PTSD, Major Depressive Disorder, Alcohol Use Disorder, Cannabis Use Disorder and Cocaine Use Disorder treated with lorazepam 2 mg daily entered treatment after a previous provider was unable to administer Naltrexone LAI.The dose was reduces by 25% every 3 to 4 weeks while mirtazapine was utilized to manage emerging symptoms of depression and insomnia.Conclusions: We found that patients often entered treatment as a result of prior providers either refusing to continue prescribing benzodiazepines or limiting their practice.Patients responded well to engagement but under the increased stress of COVID-19 quarantine conditions symptoms increasingly emerged.Our population included patients who were also receiving MAT for sustained remission of Opioid Use Disorder and faced greater risks related to benzodiazepine use.Patients were receptive to educational interventions regarding the risks of continuing use and were able to engage in treatment.Despite the proven negative outcomes of chronic use providers continue to prescribe benzodiazepines inappropriately to older adults.The need to care for patients treated with these agents is high.Post-acute withdrawal syndrome is poorly understood and under recognized in older adults.Efforts such as de-prescribing, patient centered approaches to rational prescribing and use remote education programs should be increased.COVID-19 pandemic conditions lead to an increase in overall symptoms reported but did not prevent patients from engaging in successful treatment.