This study utilized the Medical Symptom Validity Test (MSVT) and a set of standard neuropsychological instruments to determine the underlying construct of the MSVT that accounts for effort in mild traumatic brain injury (mTBI) patients by comparing/contrasting mTBI with dementia and an analog simulation. The results indicate that a common underlying neurocognitive construct (memory) exists between mTBI and dementia patients, which may account for poor effort as measured by the MSVT. Other underlying factors emerged for both groups, though they did not point to a common construct. This finding suggests that the overall effect of brain injury in neurologically impaired groups also impacts effort performance as measured by the MSVT. Similarly impaired performance patterns also emerged between mTBI and dementia groups in sub-groups that failed effort measures. Thus, failed effort tests may be a function of more pronounced deficits in these groups, rather than a function of effort. Finally, although similar effort profiles were noted between mTBI and analog simulators, the analog group was unable to mimic the neurocognitive effects of mTBI.

Currently, 6 million Americans have Alzheimer’s disease and Alzheimer’s disease-related dementias (AD/ADRD). As the segment of Americans aged 65 and older continues to increase, the number of older adults with AD/ADRD (referred to as Persons Living with Dementia [PLWD]) also grows. Additionally, the use of health care services, such as hospitalizations, is increasing among PLWD. Indeed, hospitalizations are more prevalent among PLWD compared to older adults without dementia. Some of these hospitalizations are ambulatory care sensitive condition hospitalizations that can be prevented if individuals have better access to high-quality primary care. However, delivering high-quality primary care is becoming increasingly challenging given the projected PLWD population increase and the shortage of primary care providers. On the other hand, the number of primary care nurse practitioners who can deliver high-quality and cost-effective care to older adults has grown in recent years and will continue to increase with demand. Nonetheless, little is known about how to strengthen essential practice features (i.e., structural capabilities) needed to deliver high-quality care in practices where nurse practitioners provide care to PLWD. Enhancing primary care delivery by strengthening structural capabilities in primary care, such as electronic health records, care coordination, community integration, and reminder systems, can be an effective way to reduce hospitalizations among PLWD. The overall objective of this dissertation is to assess the effects of primary care structural capabilities in practices employing nurse practitioners on both ambulatory care sensitive conditions and all-cause hospitalizations among PLWD. This dissertation entails five chapters. Chapter 1 describes the significance of structural capabilities and related outcomes among PLWD. Chapter 2 includes a systematic review of existing dementia care models in various ambulatory care settings and summarizes the impact of dementia care models on hospitalizations among community-residing PLWD in the United States. Chapter 3 describes the availability of the selected structural capabilities in primary care practices where nurse practitioners provide care to PLWD. The structural capabilities of practices that provide care to a high volume of PLWD are also compared to those caring for a low volume of PLWD in this chapter. Chapter 4 assesses the impact of structural capabilities in primary care practices employing nurse practitioners on hospitalizations among PLWD. Finally, Chapter 5 summarizes the findings from Chapters 2 to 4 and includes information on the strengths, limitations, and implications of the research and findings of the dissertation.

The number of elderly people moving into long-term care facilities is expected to increase as the population of people 65 and older continues to rise at a significantly high rate. Simultaneously, the number of people expected to be diagnosed with dementia will also increase unless a cure for this devastating disease is found. In the meantime, caregivers face many problems in providing healthy and humane treatments. One such problem that is a major concern for caregivers is controlling wandering behavior. This behavior often places patients in life threatening situations, and the current methods used by many facilities do not promote a high quality of life. The purpose of this study was to examine the effects of various tape patterns on the wandering behaviors of residents living in a special dementia care unit in Heritage Hall Nursing Home, Blacksburg, Virginia. Similar studies revealed that alternative methods using tape patterns could reduce exiting attempts at a fire exit door or could possibly increase these attempts. In order to address these inconsistencies, exiting attempts at a fire exit door were recorded during one baseline and two similar test conditions. It was found that exiting attempts was a serious problem in this unit as 40% of the residents attempted to exit the faci I ity during the study. The use of tape patterns reduced exiting attempts by 19.05% and 11.12%; however, this reduction was not statistically significant. In conclusion, the use of these tape patterns affected wandering behavior differently for each of the residents, suggesting that a multi-method approach for controlling exiting behavior may prove to be more successful when dealing with a heterogeneous sample and their multi-needs. / Master of Science

Unsafe exits from dementia care units present problems for residents and pose ethical dilemmas for caregivers. The purpose of this experimental research was to determine whether visual barriers reduced the exiting behavior of residents in a long-term care facility. A visual barrier was defined as one that appeared to be an obstruction, but that did not impede egress through the door. The study was conducted in a 30-bed dementia care unit and was limited to the emergency exit door where an alarm sounded each time the panic bar was touched. An “exit" was defined as a resident touching the panic bar and sounding the alarm. The sample consisted of 3 females and 6 males who attempted to exit the unit at least once during baseline condition. All residents were diagnosed with some form of dementia. The tests were conducted under three visual barriers and one baseline condition. Each condition was observed for seven days from 2:00 to 4:00 p.m. The schedule was as follows: Baseline Condition: No experimental manipulation was used. This observation provided a comparison for the three test conditions. Test Condition 1: Mini-blinds that covered the glazing of the door. Test Condition 2: Cloth panel that covered the panic bar of the door. Test Condition 3: Both the mini blind and the cloth panel. During baseline collection, 9 residents triggered the alarm for a total of 120 attempted exits. Test condition 1 decreased exiting to 73 attempts. During test condition 2, 5 attempted exits occurred, and 18 attempted exits occurred during test condition 3. Statistical analysis included Friedman’s Rank test for correlated samples and Wilcoxon Sign Rank tests for treatment versus control comparisons. Test conditions 2 and 3 significantly reduced attempted exits while test condition 1 was not statistically significant. In conclusion, visual barriers were a safe and effective method for deterring resident exiting for this particular nursing home. / Master of Science

The present architectural proposal aims to foster engagement, support independence, and promote a sense of meaning, comfort, and safety for dementia residents of care facilities. The proposed Iron Heart Memory Village aims to improve the quality of life for dementia residents by redesigning healthcare facilities and integrating everyday lifestyles into their living spaces. Dementia, characterized by cognitive decline and functional impairments, poses significant challenges to individuals and their caregivers. By reimagining program spaces within low-density housing and providing access to public amenities, entertainment, and natural environments, healthcare facilities can emulate familiar everyday settings. In terms of design, Iron Heart Memory Village offers a setting that prioritizes interactions between residents, healthcare professionals, and visitors through low-density residences, individual courtyards designed for the different stages of dementia, shopping, cooking, entertainment, public amenities, and simple living. This proposal considers the proposed site's history, climate, site, demographics, economics, and other factors to best design a building that serves not only dementia residents but also the neighborhood. The proposal addresses the multifaceted needs of dementia residents and their caregivers through sustainable architecture and construction. Innovative architecture, such as green roofs, solar panels, locally sourced materials, open designs, and more, are some of the elements used to enhance mobility, stimulate mental abilities, and create environments conducive to holistic well-being. Through a deeper understanding of dementia as a condition influenced by various factors, including brain damage and other underlying conditions, this project underscores the importance of design and architecture as a means to alleviate symptoms and improve overall outcomes for individuals affected by dementia. / Master of Architecture / Dementia is a big challenge for people, families, and healthcare systems worldwide because it affects memory and everyday activities. As more people get older, dementia is becoming more common. This means we need new ideas to help those with dementia. Many traditional healthcare places struggle to help people with dementia properly, which can make life harder for them and their caregivers. However, new research shows that changing how healthcare buildings are designed and including things from everyday life can make a big difference for people with dementia. This sets the stage for a proposal to improve healthcare places for people with dementia by redesigning them to feel like regular homes. The proposal suggests making healthcare buildings more like real homes by adding things like places to hang out, entertainment options, and nature views. It also suggests activities people enjoy, like shopping and cooking, to help them stay social. Plus, it includes changes to make the buildings easier to get around for people with mobility issues. Overall, the goal is to make life better for people with dementia by making healthcare places feel more like home and helping them stay active and independent. This could also make things easier for their caregivers. The proposal is a plan for this and could be a model for future dementia care.

This research project was a systematic evaluation of the effects of a personalized system of prosthetic aids to memory established in the home environment for individuals with mild to moderate dementia. The system of aids developed were in the form of a free-standing "Memory Center" unit. Caregivers were responsible for actively training their relatives to use the aids to compensate for deficits in orientation and memory for information necessary for daily functioning. The investigation was conducted in two phases, using a modified multiple baseline across subjects design. The two clients in Phase I met research criteria for Alzheimer type dementia and received a clinical dementia rating of moderate progression. Of the three clients in Phase II, two satisfied research criteria for Alzheimer type dementia, while one met research criteria for vascular dementia. All three were determined to have mild dementia. The effects of the intervention on the clients and the caregivers were examined over a four week intervention period and at a one month follow-up. The primary question addressed was whether clients could be trained to effectively use the prosthetic aids to orient themselves and compensate for deficits in memory function. This was assessed via daily assessments of verbal orientation. Weekly ratings of the behavioral functioning of clients were provided by the caregivers. And finally, caregivers rated their own stress and mood levels on a weekly basis throughout the study. Although the rates of learning varied, all of the clients increased their levels of verbal orientation following the introduction of the prosthetic aids and training. Evidence for generalized effects on the behavioral functioning of the clients was found. Overall, the clients were rated as expressing fewer negative emotions and as evidencing more oriented behaviors and less confused and disturbed behaviors during the intervention and at follow-up. Overall, the caregivers reported a consistent pattern of decline in their levels of stress and dysphoric mood. A common area of improvement was a reduction in negative emotions felt and expressed toward their relatives. Factors related to the success of the intervention and potential causal elements of change were discussed. Finally, recommendations for clinical practice and future research were provided. / Ph. D.

Exploratory case studies investigated the day care benefit from the multiple perspectives of the person with dementia, caregiver, and day care worker. The routines, daily processes, and factors promoting benefit were reported. The day care client was also queried to explore their ability to contribute useful information about their care environment. The adult day care is primarily a social occasion for its clients, who enjoy the benefits of companionship and interaction. Day cares were differentiated by the environmental features: worker:client ratio, size, suitability of the site for intended purpose, quality of client-worker relationships, and quality of the activities offered. The quality of each of these features is an important component in the day care environment. All components at their highest quality are not necessary for the environment to be beneficial. The most important factors contributing to day care quality were workers who (1) communicated safety to the client through a relaxed, uncritical environment, and (2) facilitated client stimulation through activity and personal interaction, satisfying the clients’ basic needs to be safe and occupied. This evaluation was comprised of: two sets of case studies. Each evaluation was concurrently conducted and consistently designed. Participant observation and survey were the primary methods of data collection. Informed consent was sought from day care clients with dementia, family caregivers, and day care workers.

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The aim of this thesis is to demonstrate that new and varied views of dementia surface when the concept of intersectionality is applied to dementia research; and that these perspectives pose challenges to our assumptions about what it is like to have dementia. Grounded theory research from a feminist and anti-oppression perspective was undertaken to explore the question of the relationships between older people‘s experiences of dementia and the intersections of gender, class, ‘race’, and ethnicity. During nine months of field research in Canada, interviews, participant observation, photography, and focus groups were undertaken with eight older people with dementia and their significant others. The participants ranged from multiply marginalized to multiply privileged on the basis of their ‘race’, ethnicity, gender, and class. The grounded theory arising from this research explains the complex nature of the relationships between the subjective experiences of older people living with dementia and the intersections of ethnicity, ‘race’, class, and gender. I argue that there is a connection between social location and lived experiences of dementia; and that these relationships can be observed across and within the categories of experiencing, othering, and theorising. Experiencing captures the diversity of older people’s experiences of dementia, which range from ‘not a big deal’ to ‘a nuisance’ to ‘hellish’: these views are associated with social location, with the multiply privileged older people holding the most negative views of dementia and the multiply marginalized older people dismissing the significance of dementia. Othering refers to the marginalisation to which people with dementia are subject: it is shown to be a marked feature of life with dementia and to be connected to social location, with the multiply privileged people being othered more often as a result of their dementia status; the more marginalised participants demonstrating resilience (as an acquired characteristic); and all being subject to both othering practices and enabling behaviours enacted by members of their social worlds, such as their significant others. The theorising category refers to people with dementia being active meaning makers who theorise about dementia: the outcome of this intellectual activity is shown to be related to social location, with the most privileged participants being the only ones to view dementia as a brain disease; and all others making strategic use of the normal aging theory to avoid marginalisation due to dementia. The result of the theorising done by older people with dementia is a dialectical theory of dementia that positions dementia as a bio-psycho-social phenomenon, disrupts the false dichotomy between normal and pathological, and integrates emic and etic perspectives on dementia.

The objectives of this thesis were to explore the effects of receptive individualised live and recorded-music on interactions within participating dyads consisting of a person with dementia who was in their final phase of life (resident), and a person with whom he or she shared a close connection (carer), as well as on each individual participant. A 'Receptive' music intervention is one where participants are not required to do anything but listen. METHODS The conceptual frameworks of realist evaluation, ethnography, symbolic interactionism, and dramaturgical actionism influenced the design of this study. There were two phases: during phase-1, fifteen semi-structured interviews were conducted with 'key-consultants', who were specialists in topics related to this thesis, to inform the design of 'phase-2'. During 'phase-2', musical interventions were conducted at five non-NHS care homes in Scotland over a period of nine-months. Each intervention consisted of either individualised live-music (3 sessions) or the same or similar music pre-recorded (three sessions); all music was played by the researcher on the solo cello. Interventions took place in residents' private bedrooms, and lasted between fifteen and seventy-minutes. The order of live and recorded-music interventions was switched for approximately half the dyads. Each intervention was video-recorded for later observation. Semi-structured interviews and Visual Analogue Scales (VAS) were administered with each participating carer before and after the conclusion of their series of interventions, to compare their expectations with their actual experiences and to better understand their experience. Whenever possible, key-staff and managers were also interviewed to learn what their perceptions of this study had been: its effects on them and on participants. ANALYSIS required repeated visits to the raw data: beginning with thickly-describing all video-footage; then thematically coding all thick-descriptions and transcribed audio-interviews; and lastly revisiting all video-footage via a self-modified version of an evaluative observation instrument; 'Person Interaction Environment Care Experience in Dementia' (PIECE-dem). FINDINGS support prior research regarding the beneficial effects of individualised receptive music on listeners who have dementia. This study suggests that both live and recorded-music promote wellbeing, and enhance dyad interaction in the moment of listening. These findings demonstrate the potential for receptive music to create an embodied sense of 'haven' for people with dementia who are nearing the end of life and for those sharing the experience with them: by capturing and holding their attention, and transporting them either back in time, or entirely out of time into a state of 'flow', or into an 'intense musical experience'.