Purpose: A strong association between stress due to loneliness and sleep problems has been reported. Social interactions when patients are hospitalized for weeks or longer may decrease or be limited. Elderly patients in skilled care units receive daily physical, occupational, and/or speech therapy often requiring longer hospitalization, which can lead to increased social isolation. However, this has not been studied in the inpatient skilled care unit or during the COVID-19 pandemic. The purpose of this study is to prospectively evaluate changes of loneliness, sleep quality, and quality of life in elderly in-patients (>65 years) admitted to a skilled care unit at a midwestern Magnet®- recognized hospital.

Methods: A longitudinal research design measured subject’s loneliness, sleep patterns, and quality of life. Subjects were asked to complete the Pittsburg Sleep Quality Index (PSQI), UCLA Loneliness Scale (ULS), (version 3) Ferrans and Powers Quality of Life Index (QLI) Nursing Home version III at admission and weekly until discharge.

Results: Descriptive statistics and repeated measures ANOVA (SPSS for windows version 16) were used to determine effect sizes, Cohen D, at baseline and weekly until discharge (level of significance p < 0.05 for all analyses). Twelve subjects (mean age 77 years; 84% female, white, college educated; 42% married) completed the study. Improvements from baseline to week 2 were consistently positive for the QLI and ranged from small (d=.2) to medium (d= .5). The overall improvement in total scores was a d=.184. For the loneliness scale the week 1-2 effect was very small and this was similar for the PSQI.

Conclusions: COVID-19 pandemic changed the whole dynamics in the healthcare environment and the skilled care unit was not an exception. This study was started before the visitor restrictions and continued to when visitors were prohibited. Opportunities to decrease loneliness, improve sleep habits, and quality of life were identified in the elderly population requiring inpatient skilled care. Providers should consider objective assessment loneliness, sleep, and QOL to promote optimal care for this population. The results from this study will be used to inform future interventional research aimed at decreasing loneliness for older patients requiring skill care. 

Learning Outcome: After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

Affecting 6.1 million people, atrial fibrillation (AF) increases the risk for stroke five-fold and heart failure three-fold, causes significant morbidity and mortality, and is the leading arrhythmogenic cause for hospitalization. With the prevalence of AF projected to triple by 2050, incident AF primarily occurs in people 65 years and older and increases exponentially with age. Lifetime and cumulative risk of incident AF is estimated to be 1 in 4 people 55 years and older. As an independent risk factor for AF, obstructive sleep apnea (OSA) increases the risk for incident AF three-fold, remains undiagnosed in 80% of the general population, and is present in nearly half of people with AF. While OSA treatment with continuous positive airway pressure reduces the relative risk for recurrent AF by 42%, approximately 66% of people with AF have never had OSA screening. The purpose of this quality improvement project is to promote early OSA screening, diagnosis, and treatment in adult patients with AF by implementing an inpatient OSA bundle.  Pender’s Health Promotion Model underpins implementation; people are more likely to commit to health-promoting behaviors when they understand what health benefits are achievable. Eligible hospitalized patients with AF activate an OSA bundle, beginning with screening using the STOP-Bang questionnaire. A STOP-Bang score of three or higher initiates patient-targeted education about OSA and AF's arrhythmogenic relationship. At discharge, patients receive a sleep test appointment, sleep clinic appointment, or an ambulatory referral to a sleep clinic. After three months, a retrospective evaluation will determine if patients were seen in a sleep clinic, completed sleep testing, were diagnosed with OSA, or started positive-airway pressure therapy. Results are expected Fall 2021. As the general population ages, nurse practitioners will care for a growing number of patients with AF. This population experiences serious and life-threatening complications and a predisposition to frequent hospitalization, contributing to diminished quality of life. Importantly, this project aligns with Healthy People 2030’s national objective to reduce stroke deaths over the next ten years. Reliable and expeditious screening, diagnosis, and treatment of OSA in people with AF aim to reduce morbidity and mortality and improve resource utilization. 

Learning Outcome: After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

Evidence-based guidelines: An estimated 15.7% of adults aged 60 and older are at risk to becoming a victim of elder abuse and its prevalence transcends all socioeconomic, ethnic, race and gender domains. The World Health Organization defines elder abuse as "a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person." Elder abuse may be intentional or unintentional and can be classified as physical, sexual, financial, psychological, and/or neglect.

Educational project: Increased vulnerability to elder abuse exists when the older adult (OA) experiences cognitive and functional decline. Clinicians are encouraged to use validated tools for determination of cognitive and functional impairment. When these tools are unavailable, clinicians must rely on their observations, assessments, available health records and conversations with other individuals such as caregivers, family, and neighbors. The Decision Matrix for Elder Safety (DMES) classification system, created by the authors, was designed to aid in identifying OAs at increased risk for elder abuse using observations or historical narrative of functioning over time.

The DMES guides through cognitive status assessments, using the mini-mental state evaluation, a proprietary assessment tool used to screen and estimate global cognitive function and dementia, or the Mini-Cog, a free resource that has a positive association with identifying moderate to severe cognitive impairment. Tools measuring functional capabilities include Katz Index of Independence in Activities of Daily Living and Lawton Instrumental Activities of Daily Living Scale.

Enhancing quality of care: Utilizing the DMES classification system, the risk threat for elder abuse is quantified as a threat for elder maltreatment, which increases as the OA loses cognitive and functional capabilities. The authors created case studies to engage clinicians to think about the OA as a target for maltreatment based on their vulnerabilities. The scenarios help clinicians use the proposed DMES classification to estimate risk and identify vulnerabilities related to the OA’s cognition and functional needs, specifically physical, sexual, financial, psychological and/or neglect, when abuse is suspected or confirmed.

Learning Outcome: After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

The Center for Healthy Aging applied to age-friendly health system (AFHS) in 2019 with the intention of advancing the level of geriatric care in our clinic through the adoption of 4Ms of AFHS. Prior to applying to participate in AFHS, we assumed that our geriatric care was complete. The clinic was providing three of the 4Ms: mentation with the PHQ9 and dementia assessments, mobility assessments with the get-up-and-go test, and medication review with every appointment. The last M was the what matters most (WMM) question. The 4Ms framework was developed using evidence-based intervention with 2 important drivers, assessment and action.

In order to become recognized by AFHS, the clinic began a quality improvement process over several months. Initially, we surveyed our team to determine which what matters most question (WMM) we would ask our patients. The Allscripts team provides a monthly report of the number of patients asked what matters most including the actual answers and patient demographics. Regular communications and progress reports were submitted to AFHS for review. Most patients were pleased and surprised when asked what matter most to them. The answers became a permanent part of their chart. The clinic achieved recognition after 3 months of PDSA. 

Learning Outcome: After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

Aim: The aim of the pilot study was to train primary care clinic staff to identify and address medication nonadherence among minority patients in a low-income urban community, thereby improving patient adherence through enhanced provider-patient communication.

Rationale: Non-adherence to medications is a common persistent medical problem which has significant association with hospitalization and long-term mortality risk in older adults. Between 50-80% of patients are nonadherent causing 125,000 deaths annually, 10% of hospitalizations, and costing $300 billion annually.

Supporting literature: A systematic review of nurse-led interventions found eight studies significantly improved medication adherence. Another study demonstrated a single educational workshop can result in nurse-led practice change. Research indicates African Americans have higher risk of non-adherence, as do low-income, urban communities; thus, a nurse-led intervention in a low-income urban community may have a significant impact.

Methods: The study used a quasi-experimental mixed methods pre-/post-design. The researchers implemented a one-time training intervention to enable clinic staff to address patient medication adherence during routine patient visits.

Training learning objectives
• Recognize the scope and urgency of medication non-adherence.
• Apply tools to assess patients for medication non-adherence.
• Initiate evidence-based interventions that align with identified barriers.
• Implement new conversation techniques to increase patient honesty in reporting medication non-adherence.

Intervention: The project was implemented at a federally qualified health center serving an urban, minority low-income community and approved by the healthcare system’s quality improvement committee. Eight clinicians attended a single session workshop. Pre-intervention, immediate post-intervention, and 4-weeks post-workshop surveys assessed knowledge and commitment to implementing adherence discussions. Challenges included a nursing strike, change in administration, and COVID-19. The New World Kirkpatrick model guided implementation and program evaluation.

Outcomes: The objectives were met with an average increase in clinic staff knowledge of 29% and 77% increase in the number of adherence patient discussions.

Applicability to APRN practice: As leaders in the clinic, APRNs can initiate efforts to train staff to work together as a team toward this collective goal. Findings suggest training with one educational workshop which includes tools to assess for adherence and chosen patient-specific interventions results in nurse-led practice change. 

Learning Outcome: After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

Purpose: This pilot study will provide the first published study examining NP students’ self-efficacy in caring for community dwelling older adults. The specific aims include evaluating NP students’ self-efficacy in treating community dwelling older adults and establishing validity of self-efficacy tool developed for NP students.

Rationale/framework: Faculty utilize evaluative modalities to assess students’ mastery of NP competencies, however determining NP students’ self-efficacy in translating knowledge into practice is seldom assessed. Self-efficacy, a component of Bandura’s social cognitive theory, is the belief in one’s ability to perform specific activities.

Methods: Adult/gerontology primary NP students will complete an unfolding case study (UCS) created by NLN for undergraduate nursing simulation experiences. The authors expanded the UCS, creating an assignment for NP students that assesses critical thinking and diagnostic reasoning skills. The story follows the fictional life of an 80-year-old widower, living alone and managing his diabetes independently. After developing a diabetic foot ulcer, his condition worsens resulting in frequent NP office visits and hospitalization. As students listen to audio monologues and read written narratives, they must identify diagnoses, determine changes in treatment plans, and develop a transitional care plan. This UCS closely parallels the trajectory of medical, functional, and psychosocial problems that confront community dwelling older adults living alone.

Bandura opines that there is no self-efficacy scale that can be used for all settings; suggesting that a scale should be developed to assess the domain one is evaluating. The authors have developed a 9-item self-efficacy scale, Caring for Community Dwelling Older Adults Self-Efficacy Scale (CCDOASES), to assess NP students’ confidence in recognizing and implementing alterations in treatment given evolving medical condition changes. Participating students will complete the CCDOASES and general self-efficacy scale (popular validated tool) before and after the UCS assignment.

Results: The study will be completed summer 2021, results will be available prior to GAPNA conference.

Applicability: NP students transition into the role of healthcare provider, ultimately being responsible for managing complex geriatric health conditions. 

Learning Outcome: After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

Rationale: Urinary incontinence (UI) is highly prevalent in residents of long-term care (LTC) facilities. LTC residents with UI are more likely than those without UI to have comorbidities, polypharmacy, and increased healthcare resource utilization. Managing UI is burdensome and costly to LTC facilities with respect to staff time, incontinence product use, and quality measures. We evaluated the impact of UI on staff, residents, care processes, and quality measures in LTC settings.

Methods: A 70-question quantitative online survey was sent to directors of nursing (DONs). DONs were eligible if they worked for ≥1 year in a facility with ≥100 beds, where ≥80% were LTC beds. Survey topics included facility characteristics and resident care, incontinence product costs and burden, quality measures, and treatment (in the context of UI). Data are reported at an aggregate facility level and are presented descriptively.

Results: A total of 71 DONs completed the survey. The mean number of residents per facility was 115; 68% of residents were female, and 62% had UI. Of residents with UI, 40% were always incontinent, 81% consistently used UI products, and only 14% were treated with medication. About half (54%) of DONs considered UI product costs to be higher than other facility supplies. DONs reported that certified nursing assistants (CNAs) spend 56% of a shift managing UI needs (eg, assistance with toileting and incontinence products), and 59% reported that UI management is a cause of high CNA turnover. Resident falls occurred at a mean of 14.3 per month per facility, with 36% of falls occurring while accessing the bathroom. LTC quality measures reported as significantly impacted by UI included urinary tract infection and falls with major injury. A total of 74.6% of DONs were unaware of any link between anticholinergics and risk of cognitive side effects.

Applicability: Management of UI in LTC settings can be burdensome to facilities and staff. Low treatment rates, low awareness of treatment-related cognitive effects, high incidence of falls due to urinary urgency, and high CNA turnover highlight the need for improved understanding of treatment and management in this population. 

Learning Outcome: After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

This presentation will assist advanced practice registered nurses (APRNs) in any setting to describe the early signs, symptoms, and progression of the cognitive decline of Alzheimer’s disease (AD), including the pathophysiological changes that occur in the AD brain. APRNs will be able to discuss the public health impacts of AD, including the impact on caregivers and society.

APRNs will learn to recognize the early signs of mild cognitive impairment (MCI) that often lead to the progression of dementia to the late-stages of AD and will learn to integrate evidence-based screening tools that can be used to assess for early cognitive decline in primary care settings. APRNs will be able to apply knowledge gained in this presentation to the care of AD patients in all clinical settings, including initiating and managing medications. APRNs will learn the current state of research on medications, diagnostic testing, new therapeutic modalities, and alternative therapies for Alzheimer’s disease, including the most current supporting research, and the importance of caregiver support in the care and outcomes of the AD patient. A review of choosing which medication or treatment modality to use for patients with early, moderate, or late cognitive decline in AD will be discussed. 

Learning Outcome: After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

Older adults are more susceptible to infectious diseases and have an altered immune response to vaccinations; therefore, all advanced practice registered nurses (APRNs) need to be up to date with current immunization recommendations for older adults in various settings. Influenza and pneumonia remain common causes of death in older adults, and most recently, COVID-19 has the potential to result in premature mortality for all age groups, including those who are older and especially for those who live in congregate settings. This presentation will describe the rationale for the vaccination of older adults throughout their lifespan, including the timing, contraindications, and adverse effects of vaccines used to prevent influenza, pneumonia, herpes zoster, pertussis, and tetanus in older adults. An update on the efficacy of the COVID-19 vaccine in the elderly, especially those in nursing homes and congregate settings, will be provided as well as current statistical data on how many have been immunized. Current guidelines for the advanced practice nurse to follow for vaccination of the older adult when the vaccine history is incomplete or not available will be presented. The need and implications for vaccination of special populations such as the homeless, older immigrants, international travelers, cancer patients, men who have sex with men, renal patients, and nursing home and hospice patients will be discussed. Vaccination is critical in promoting healthy aging.  

Learning Outcome: After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

As older adult veterans age and seek care in various settings, many factors can impact their health. Veterans have unique healthcare needs as they age, including frequent multi-morbidity, which can impact their quality of life and functional status1. Some veterans have sustained injuries during their prior military service, and nurse practitioners are often evaluating and treating these problems2.

Recent political changes have expanded veteran’s access to care in the community and support for their caregivers through the creation of the Mission Act of 2018, which includes the Program of Comprehensive Assistance for Family Caregivers (PCAFC)3,4. Providing care to these individuals both within veteran administration (VA) and knowing veteran’s access through community care can be difficult to navigate for non-VA and VA providers. This presentation will provide a detailed description of the expansions of access to care (primary, mental health, specialty, and urgent) and caregiver benefits5,6,7,8,9,10,11. By nurse practitioners increasing their awareness of these increased veteran benefits across the continuum of healthcare, they can become better equipped to help veterans seeking care.

References
1. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1532-5415.2004.52355.x
2. https://www.pewsocialtrends.org/2011/11/08/for-many-injured-veterans-a-lifetime-of-consequences/
3. https://missionact.va.gov/
4. https://www.congress.gov/115/bills/s2372/BILLS-115s2372enr.pdf
5. https://www.va.gov/COMMUNITYCARE/pubs/factsheets.asp
6. https://www.va.gov/COMMUNITYCARE/docs/pubfiles/factsheets/MISSION-Act_Current-Future-State.pdf
7. https://www.va.gov/COMMUNITYCARE/docs/pubfiles/factsheets/VHA-FS_MISSION-Act.pdf
8. https://www.va.gov/COMMUNITYCARE/docs/programs/UC_Assistance_Cards.pdf#
9. https://www.va.gov/find-locations/
10. https://www.va.gov/COMMUNITYCARE/programs/veterans/General_Care.asp
11. https://www.caregiver.va.gov/support/support_benefits.asp  

Learning Outcome: After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.