Hillary D. Lum

Alzheimer’s Disease and Related Dementias (ADRD) disproportionately affect Americans who identify as Hispanic/Latino and their family caregivers. Existing dementia care approaches may have limited responsiveness to their cultural needs. We partnered with a Hispanic/Latino dementia caregiver advisory board for input on outpatient dementia care approaches, including how to address palliative care needs. Eleven caregiver advisors from two U.S. states participated in six virtual meetings. Meetings were transcribed and researchers used a composite narrative approach to summarize the advisors’ perspectives on outpatient dementia care as lived experience stories. Composite narratives represented their (a) experiences as an informal care coordinator, reflections on their support system, and care planning; (b) unmet needs and barriers to culturally aligned care, and (c) need for reliable care coordination that incorporates cultural values in dementia palliative care approaches. Caregivers emphasized their caregiving struggles and said that even when they had ample support for their loved ones, they lacked emotional support for themselves. Caregivers noted the vital role of culture, faith, family, and language in shaping their experiences. They described needing guidance from trusted clinicians to navigate challenges. They requested linguistically and culturally adapted education on dementia and caregiving. In conclusion, through this community engagement process, we illustrated the importance of outpatient dementia care approaches that are linguistically accessible, culturally relevant, and attentive to input from Hispanic/Latino caregivers to address palliative care needs in the context of dementia.

Background: Little is known about whether primary caregiver relationship is associated with hospice use or advance care planning (ACP) in later life. This study examined variation in hospice use and ACP across primary caregiver relationships. Methods: Gateway Harmonized Health and Retirement Study End‐of‐Life data were restricted to Wave 12 and later. The sample included 3952 decedents aged 60 years or older. Caregiving category identified the primary caregiver as spouse/partner, child/grandchild, extended family, or non‐kin informal, with formal care only and no identified caregiver as additional categories. Multivariable logistic regression estimated hospice use; a joint Wald test assessed overall differences across four informal primary‐caregiver categories, and probability‐scale decomposition examined indirect associations through ACP. Results: Among decedents with an identified informal primary caregiver, hospice use did not vary overall by caregiver relationship. Relative to spouse/partner primary caregiving, hospice use was lower among decedents with no identified caregiver (OR, 0.46) and those receiving formal care only (OR, 0.62), while child/grandchild primary caregiving was associated with a 3.87‐percentage‐point higher probability of ACP. The indirect association through ACP for child/grandchild primary caregiving was small (0.39 percentage points). Conclusions: Hospice use was not concentrated within a particular informal primary caregiver relationship, whereas differences by caregiver relationship were more apparent in ACP. These findings highlight a distinction between care planning and eventual service use and suggest that caregiver availability and broader caregiving circumstances may be important to consider alongside relationship type.

Background: Falls are a leading cause of emergency department (ED) visits among older adults and represent a critical opportunity to identify cognitive and functional impairments that influence treatment and recovery. While smartphone‐ and wearable‐based assessments are increasingly used to assess cognitive and physical function in older adults, their feasibility in the ED setting, particularly after a fall, remains unclear. Methods: From August 2021 to January 2024, community‐dwelling older ED patients (≥ 65 years) were screened for cognitive impairment (six‐item screener) and functional limitations (modified Barthel Index, mobility equipment). Apple ResearchKit digital assessments measured cognition (Stroop, Trail Making, reaction time) and physical function (gait/balance, timed walk). Wearable devices monitored movement. Feasibility was examined via attempt and completion rates. Reasons for non‐attempt/non‐completion and associations with patient characteristics were explored. Results: Among 196 patients (mean age 78.2 ± 7.6 years, 68% women), 77% attempted at least one digital assessment. Cognitive tests had moderate‐to‐high completion rates (68%–87%) among those who attempted, and completion was associated with lack of cognitive impairment ( p = 0.002, 0.002, 0.01, for Stroop, Trail Making, and reaction time tests, respectively). Non‐completion was due most often to lack of glasses, not feeling well, or technology issues. Physical function tests had much lower completion rates (18%–20%), and completion was associated with functional status (Barthel Index; p = 0.02, 0.01 for gait and balance and timed walk tests) and mobility equipment use ( p = 0.02, 0.03). Low completion rates were mainly due to safety concerns, pain, and injury. Conclusions: Digital assessment of cognitive function is feasible in most older adults presenting to the ED for falls, but physical function tests had low feasibility in this population. Future research will explore whether such data predict clinically relevant outcomes (e.g., time to injury recovery, ED revisits) and can inform personalized intervention (e.g., physical therapy referrals, skilled nursing facility placement). Trial Registration: Clinical Trial Number: NCT04304495

The value of palliative care (PC) is increasingly recognized in the care of people with Parkinson disease (PWP) and their carepartners. While clinical trials demonstrate PC improves quality of life for PWP and carepartners, little is known about the impact of PC on their experiences of receiving care in real-world settings. We designed and implemented a national outpatient PC project at the Parkinson's Foundation US-based Centers of Excellence (COEs) between August 2021 and November 2023. We aimed to assess preimplementation vs postimplementation changes in perceptions and experiences of PWP and carepartners related to the receipt of PC. Between September and October 2023, an electronic survey was distributed through the Parkinson's Foundation to PWP and carepartners who received care at US-based COEs and non-COEs. Survey questions assessed knowledge, perceptions, and experiences related to PC. Preimplementation and postimplementation data were compared. Surveys were distributed to 12,946 PWP and carepartners; 1,778 participants (1,247 PWP, 531 carepartners) responded. At COEs, PWP reported significant increases in non-motor symptom (NMS) assessment (76.5%-86.7%, p = 0.001) and pain management (45.1%-57.6%, p = 0.01). Emotional and spiritual needs were addressed more frequently (33.3%-44.7%, p = 0.01). Advance care planning (ACP) discussions rose from 18.7% to 27.9% (PWP, p = 0.01) and ACP documentation from 8% to 18.1% (p = 0.001). At non-COEs, similar gains were observed in NMS assessment (65.5%-73.7%, p < 0.001), pain management (31.5%-45.1%, p < 0.001), emotional/spiritual discussions (25.3%-33.6%, p = 0.001), and assessment of carepartner needs (21.6%-29.7%, p = 0.002). Carepartners reported similar improvements. Communication ratings and knowledge of PC were high (>85%) and stable across surveys. PWP and carepartners' perceptions and experiences of care were stronger postimplementation in many, but not all, aspects of PC. As changes were seen in both COEs and non-COEs, it is unclear to what degree findings relate to direct or indirect impacts of team-based implementation of PC vs other broader temporal trends, such as community-level increased awareness of PC. Findings highlight progress and gaps, underscoring the need for continued efforts for cultural and systemic changes to integrate PC into routine PD care.

Background/Objectives: Frailty is an under-recognized preoperative risk factor for poor surgical outcomes. Recovery of preoperative ambulation levels one month after surgery represents an important patient-centered outcome. The purpose of this study was to (1) identify a preoperative daily step count threshold associated with frailty, and (2) characterize the one-month ambulation recovery (steps/day) of older adults (≥60 years) with and without frailty following major elective inpatient operations. Methods: This single-center observational pilot study included older adults undergoing elective inpatient operations at a Veterans Affairs Hospital. Frailty was assessed before surgery. Ambulation (steps/day) was measured continuously from ≥3 full days before surgery, to at least 28 days after surgery, using a wrist-worn accelerometer. Sensitivity analysis identified a step count threshold associated with frailty. The primary outcome was the percentage of daily steps recovered at 28 days. Results: The average age of participants (n = 109) was 69 years, and 37.6% (41/109) were identified as prefrail or frail. Preoperative steps/day were lower in the frail cohort (3322.00 [2654.70, 5483.20] versus 4993.95 [3540.90, 6599.97], p < 0.05). Sensitivity analysis showed 4137 steps/day to be associated with preoperative frailty, and this remained significant in multivariate analysis. At 28 days, the percentage of daily steps recovered did not differ between groups (72.57% [49.15, 92.06] overall). Conclusions: Preoperative frailty is associated with lower daily step counts (<4137 steps/day), identifying individuals at increased likelihood of frailty in this older Veteran cohort undergoing major surgery. The median daily step count, regardless of frailty status, was <5000 steps/day, consistent with a sedentary lifestyle, and likely too low to show a difference in one-month ambulation recovery. This finding underscores the need to explore walking interventions in older Veterans awaiting surgery.

Background: High utilization of the emergency department (ED) by older adults contributes to adverse health outcomes and increased cost of care. Studies have investigated interventions aimed at reducing low acuity ED visits, with increased primary care accessibility being among the most effective. This paper aims to describe the implementation of a novel acute care clinic model to improve same‐day availability for urgent concerns within geriatric primary care. Methods: We conducted a quasi‐experimental difference‐in‐differences (DID) analysis to evaluate the impact of an Acute Care Clinic (ACC) model implemented within an outpatient geriatrics clinic between March 2022 and August 2023. Patient‐level descriptive statistics were used to characterize ACC patients. Clinic‐level outcomes were compared between geriatrics clinic patients (including ACC patients) and a reference group of patients who receive primary care at internal medicine clinics within the same health system using monthly aggregated data over a 24‐month period (6 months pre‐ and 18 months post‐intervention). Results: There were 1102 ACC visits (764 distinct patients) in the implementation period. ACC patients were more medically complex than both the geriatrics clinic overall and the reference group (average HCC score 2.4). Same‐day labs were ordered in 34% of ACC visits and same‐day imaging was ordered in 15% of ACC visits. Compared to the reference group, the geriatrics clinic showed a potentially greater reduction in calls escalated due to lack of same‐day access (−3.1%; p = 0.08) and a larger increase in same‐day scheduling (+2.8%; p = 0.13), though neither reached statistical significance. Conclusions: An ACC model was successfully implemented within a geriatric primary care clinic and there was a trend toward improvement in same‐day clinic access for these medically complex older adults. Further review of patient triage processes, financial impact, and patient satisfaction is needed for program evaluation, refinement, and expansion.

As dementia diagnoses rise, the need for comprehensive, person‐centered care becomes more urgent. This part of the session explores the real‐world application of the Guiding and Improved Dementia Experience (GUIDE) Model in dementia care navigation.

BACKGROUND Healthcare settings serving older adults often encounter challenges in rapidly translating qualitative feedback into program improvements, with the resource-intensive nature of traditional qualitative methods serving as a significant barrier. Large language models (LLMs) offer potential to streamline qualitative data analysis for quality improvement. However, existing research on LLM-based qualitative methods primarily focuses on accelerating or augmenting the work of experienced qualitative researchers, which may not be applicable to lower-resource settings where collaboration with qualitative researchers is infeasible. Furthermore, there is limited evidence on the applicability of LLM-based qualitative analysis to programs serving older adults, people with dementia, and caregivers. This gap hinders efforts to identify scalable solutions to support programs under increasing strain to meet the needs of a growing population of older adults. OBJECTIVE This study examines the strengths and limitations of LLM-based thematic analysis in healthcare contexts where qualitative research experts are unavailable, using open-ended survey responses from caregivers participating in the Care Ecosystem dementia care program. Additionally, it proposes a workflow for human-LLM collaboration tailored to such settings. METHODS Caregiver participants (N=603) in a dementia care intervention provided survey feedback on what was most helpful and what could be improved. Responses were analyzed using two methods: traditional thematic analysis conducted by qualitative researchers and LLM-based thematic analysis using GPT-4o, an LLM produced by OpenAI. LLM outputs were evaluated for alignment with traditionally identified themes, ability to capture meaningful insights in the data, and production of relevant and accurate illustrative quotations. GPT-4o was accessed through a UCSF enterprise platform that enables HIPAA-compliant use of LLMs. RESULTS LLM themes were mostly aligned with traditionally identified themes and captured actionable feedback in the dataset, although two LLM themes misinterpreted caregiver feedback and one traditionally identified theme was not captured. The LLM correctly identified support responding to emergencies as a key benefit of the program, a theme missed by qualitative researchers. Challenges included the fabrication of illustrative quotations not found in the dataset, although only 3.5% of all LLM-produced quotations misrepresented caregiver feedback. CONCLUSIONS The LLM’s rapid synthesis of survey responses highlights LLMs’ potential to facilitate timely qualitative analysis for program improvement in healthcare settings serving older adults, such as dementia care programs. To ensure accuracy, we propose a workflow for human-LLM collaboration involving staff review of data prior to LLM analysis. Careful integration of LLMs is needed to promote accuracy, protect participant privacy, and ensure alignment with patient and caregiver priorities.