It’s no secret that the largest population of older adults is about to come knocking on senior living’s door. What worries dementia care expert Teepa Snow is how unprepared operators may be to handle the incoming “dementia shockwave.”

In a recent webinar on the state of dementia care hosted by workforce education provider Relias, Snow, an occupational therapist and CEO of Positive Approach to Care, said that there are 120-plus types, causes and forms of brain change under the dementia umbrella. 

In 2020, approximately 7 million people aged 65 or more years were living with dementia. That number is anticipated to increase to 9 million by 2030, and 12 million by 2040. And Snow said that 60% to 70% of people moving into long-term care have cognitive changes consistent with the early signs of various forms of dementia. According to the Centers for Disease Control and Prevention’s National Center for Health Statistics, 42% of assisted living residents have Alzheimer’s disease or another form of dementia.

Communities are unprepared

Senior living communities are missing the signs of the disease because they aren’t preparing staff members to recognize them at the earliest stages, Snow said. 

In most cases, she added, certified nursing assistants are required to have the most dementia training of staff members, but that requirement averages only six hours. Most skilled care providers are not required to have any dementia care training, she said. 

“The challenge is, when we’re talking about somebody whose brain is dramatically shifting and abilities are variable, we are asking people to step forward into this role without preparation,” Snow said, adding that the situation sets up staff members for job dissatisfaction. “If we can’t get people to want to work with us, we can’t serve the population.”

The brains of people with dementia change over time, taking an average of 10 years to change from a neurotypical brain to a brain with Alzheimer’s disease, Snow said. And 80% of cases of individuals experiencing brain changes are not identified in the early stages, when interventions would be most effective, she said.

Providing truly person-centered care involves supporting the right culture and environment, building competence through education and training and practice, and working with families, Snow said. The “state of dementia care” is not where it needs to be, she added, but she said she knows it can get to where it needs to be — with collaboration. 

Adding family to the care team

Senior living communities may be admitting people who have more complex care needs than anticipated, resulting not only in untrained and unprepared staff members but unprepared families, Snow said. 

The baby boomers aging into long-term care, she added, will be moving in at a more advanced age than members of previous generations, will have more chronic conditions and will be at higher risk for dementia.

“Not only are there more of us getting older; there are more of us getting older and having brain changes,” Snow said, opining that society already is poorly equipped to understand what aging typically looks like, let alone understand the brain changes that come with dementia.

Educating residents’ family members about the progression of dementia is just as important as training staff, she said. 

“Somewhere around 75% to 80% of family members have little to no awareness that the diagnosis of dementia is going to lead to somebody’s gradual decline no matter what we do,” Snow said. “It will change their ability to live their life.”

Family members are additional team members and need to be involved and engaged with creating a care plan for their loved ones, she said.

Marnina B. Stimmel, PhD, from Albert Einstein College of Medicine in New York City, and colleagues examined the utility and discriminative validity of the Spanish and English MoCA versions to identify cognitive impairment among diverse community-dwelling older adults. The analysis included 231 older adults (aged 65 years and older; 43% Hispanic and 39% Black/African American) with cognitive concerns attending outpatient primary care.

The researchers found that neuropsychological assessment identified 90 participants as cognitively normal with subjective cognitive concerns (average MoCA, 19.9), 133 with MCI (average MoCA, 16.6), and eight with dementia (average MoCA, 10.6). The mean English MoCA average was 18.6 versus 16.7 for Spanish. There was a high false-positive rate using the published cutpoint ≤23 for MCI (79%). Using the English MoCA, ≤18.5 was identified as the score to identify MCI or dementia (65% sensitivity; 77% specificity) and ≤16.5 for the Spanish MoCA (64% sensitivity; 73 percent specificity).

“Lower Spanish and English MoCA cutpoints may improve diagnostic accuracy for identifying cognitive impairment in this group, highlighting the need for the creation and validation of accurate cognitive screeners for ethnoculturally and linguistically diverse older adults,” the authors write.

One author disclosed ties to MedRhythms.

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Mark Zuckerberg has the Metaverse. Spiderman has the Spiderverse. And now seniors have the “Great American Elderverse,” an immersive space for seniors who want to use virtual reality to socialize. 

The Elderverse concept, co-developed by Mynd Immersive as an expansion of their existing VR programming, was unveiled at the CES conference in Las Vegas last week. 

Mynd’s existing VR tools, which include a headset and tablet, were already meant as a way to get seniors to interact with peers — or in the case of long-term care communities, with their caregivers — Mynd executives had previously said.

The new Elderverse differs in several ways, Mynd CEO Chris Brickler told McKnight’s Tuesday. 

The new platform does away with the tablet and starts users out on a lush virtual coastline, from which they can jump to any number of entertainment or therapy options, including a meditation island, “world tours,” or even virtual church sessions. 

“From a tech point of view, it’s a big evolution for the company,” Brickler said. “For a senior who is cognitively healthy and can handle the adventurous aspect of navigating the world, it’s a foray into what younger adult audiences do [with open world video games].”

Not only is the idea for seniors to use the Elderverse world to interact with one another, but their family members also can use the tech or follow along with their smartphone, viewing a 2D replication of what an Elderverse user is looking at, and talking with them in real time, Brickler explained.

The concept of communal virtual spaces is gaining traction within senior living. While tech companies like Mynd are trying to create virtual worlds, the more grassroots Thrive Pavilion, which runs off Meta Quest headsets, has been steadily growing and offers a suite of VR programs for seniors to socialize, McKnight’s reported over the summer.

The overall picture of VR, mixed and augmented reality, for seniors and everyone else, has been termed “extended reality” by tech users and developers alike.

In addition to Mynd Immersive, other partners in the Elderverse project include: VR goggles maker HTC VIVE, the CTA Foundation and AT&T. 

The Elderverse won’t be available until the second quarter of this year, Brickler said, adding that they are still “rounding up” donors for the company’s project goal to introduce VR therapeutics to 500 underserved senior care communities over the next few years.

The company continues to work on its VR therapy program for seniors in memory care, Brickler said, noting that, among its current pool of content is a VR “medication management” tool that lets seniors practice organizing their pills without real-world consequences.

Other innovations could include custom avatars for individual seniors, as well as a continual revamping of VIVE’s headset gear as technology switches from bulkier helmets to goggles and glasses. 

A high number of senior living and care residents have dementia on admission, or develop it during their stay, despite never receiving a formal diagnosis. 

When these “secret” dementia patients, however, have an emergency – say, a fall – and are hospitalized, they can catch the new care team unaware and struggling to make appropriate clinical decisions. 

To avoid this pitfall, new research is looking at electronic health records to flag individuals who might have dementia, possibly undiagnosed, so that when they arrive at a hospital, the care team is ready. 

The study authors used the example of a person who has had a fall and being unable to accurately describe his condition and medical history, or to communicate his own sound judgments about future care to a hospital team.

Up to 40% of older adults with mild or early-onset dementia do not have dementia diagnoses, one study shows. The new research, led by a team from Cedars–Sinai Medical Center in Los Angeles, noted that “early detection of dementia in the inpatient setting” is less than 50%. 

The research found similar numbers when using AI to analyze EHR records of study participants: Of the 64 patient records reviewed that had no dementia diagnosis, the AI found 33 shown signs of altered mental status or cognitive dysfunction. Overall, that involved approximately 10% of the EHR records reviewed, which included both people with confirmed dementia and those who showed no record of cognitive decline.

“These types of algorithms provide an opportunity to accurately identify hospitalized older individuals for inclusion in quality improvement projects, clinical trials, pay-for-performance programs and other initiatives,” the study authors concluded.

To make sure clinicians are able to take advantage of the new information the AI can give them about patients, Cedars-Sinai also instituted a training program to make sure all care staff knew how to respond to possible dementia. 

Data sharing between points of care and different EHR systems is becoming increasingly important for healthcare providers, as health records are constantly updated from new data collection tools. 

Although the dementia research foretells a positive outcome for both patients and their caregivers, the flip side of that is the unintentionally morbid study on EHR discrepancies — also from California — that showed that care teams were filling medications and appointments for patients who already had died, the McKnight’s Tech Daily recently reported.

The past year has held major breakthroughs in Alzheimer’s treatment, including new drugs to tackle the disease. Now researchers may have found a way to deliver those drugs faster.

Should the technology prove viable, it adds a powerful new wrinkle in how assisted living and memory care providers can aid residents living with Alzheimer’s and help families weigh options.

By using focused ultrasound technology, the researchers were able to “open” the blood-brain barrier and deliver more of a drug, Biogen’s aducanumab (Aduhelm), in certain areas of the patient’s brain. In the brain regions that the ultrasound targeted — the scientists limited the ultrasound to one hemisphere — the treatment was more effective, the study showed. 

Many Alzheimer’s drugs, including aducanumab, target toxic beta-amyloid proteins that have built up in the brain, thought to be responsible for the disease and cognitive decline. 

Early last year, the US Food and Drug Administration approved a new Alzheimer’s drug, lecanemab (Leqembi), that targets amyloid plaques in the early stages of the disease. The drug’s effectiveness is promising enough that it has prompted a review of policies around how and when people can get PET scans. 

The inability for many drugs to effectively cross the blood-brain barrier has meant that many treatments for Alzheimer’s require stronger doses and more frequent therapies, the researchers noted. 

The investigators noted that the pilot study would need to be followed up by further studies before the drug-delivery practice could go into widespread use. 

The research was conducted by scientists at the West Virginia University Rockefeller Neuroscience Institute. 

“This is an exciting time in the treatment of Alzheimer’s disease,” study co-author Marc Haut, PhD, director of the RNI Memory Health Clinic, said in a statement. “We are hopeful that the work we are doing may lead to improvements in outcome for many other patients and their families coping with Alzheimer’s.”

The study was published Thursday in The New England Journal of Medicine.

Although virtual reality systems often are seen as solitary entertainment in a fabricated world, the use of VR systems in senior living appears to motivate people to interact and socialize more vibrantly with elements of the real world, a new study shows.

Older adults who used a VR program that involved walking around a cityscape ended up being more active, both physically and socially, even if the VR itself didn’t involve social interaction, the study found.

Most senior living and care providers play up the socializing benefits of living in their communities for residents, but nevertheless residents may struggle with the major life change constituted by moving from different communities or having already faced isolation due to the deaths of friends and family. 

In addition, many older adults who have needs for specialized care, such as for dementia, sadly are isolated by their conditions. 

“This result is really interesting because positive impacts exist even if the time spent to use the [immersive rirtual reality] decreased,” the study authors noted. “If the IVR led to reduced loneliness, it is probably because physical activity created opportunities to meet people in the real/physical world, that is being an indirect effect of the IVR.”

The VR citywalk was one of two dual studies conducted by the researchers. The first study was comparative and tried to find a baseline evaluation and acceptance of VR among older adults. It found that seniors significantly prefer VR compared with wearables such as smartwatches. 

Interestingly, one of the main reasons the study participants said they were more accepting of VR tech was that they believed that it was less intrusive to their privacy than wearables — despite the fact that many VR tools can and do collect a variety of data, and some clinical-VR programs are now being used exclusively for the purpose of collected better diagnostics. 

The conclusion that VR is, often indirectly, improving social ties for senior living residents dovetails with another recent study that indicates that using some VR can help enhance the relationship between older adults and their immediate caregivers, the McKnight’s Tech Daily recently reported.

The persistence of a pandemic-associated increase in antipsychotic, antidepressant and anticonvulsant medication use in assisted living residents — and a greater increase in antipsychotic use in dementia care settings — raises concerns about the risks for residents, say the authors of a study published in the January issue of JAMDA–The Journal of Post-Acute and Long-Term Care Medicine.

Prescriptions for antipsychotic medications in assisted living communities increased during the first two years of the COVID-19 pandemic, especially in residents living with dementia, according to the researchers. They examined the proportion of assisted living residents in Alberta, Canada, who were prescribed an antipsychotic, antidepressant, benzodiazepine, anticonvulsant or opioid medication between January 2018 and December 2021. 

Antipsychotic medication use prevalence increased to a larger degree than antidepressant use and was approximately 8% higher for memory care compared with other assisted living residents during the latter two pandemic waves — wave 3 (March to May 2021) and wave 4 (September to December 2021). Assisted living residents not living in memory care settings also showed a statistically significant but small increase in anticonvulsant use during the pandemic waves 2 (September to November 2020, and December 2020 to February 2021) through 4. 

For both assisted living and memory care residents, the pandemic was associated with a statistically significant decrease in benzodiazepine use and no significant change in opioid use, they found.

The study results revealed that the increase in antipsychotic use among assisted living residents in dementia care (3.5% to 7%) was larger than estimates previously reported for nursing home residents living with dementia (more than 1.7%). 

“The significantly greater increase in antipsychotic use among residents of dementia care was surprising given our hypothesis that the presence of specialized dementia care staff and environments might mitigate behavioral changes and antipsychotic use in this population,” the authors noted.

Lead author Colleen Maxwell, PhD, a professor in the University of Waterloo School of Pharmacy in Ontario, told McKnight’s Senior Living that she and colleagues believe that the substantial challenges and losses faced by assisted living communities and nursing homes during the pandemic partially explain the increase in use of the medications. Those challenges included staffing shortages, declines in services and comprehensive integrated care, loss of family caregivers, an increase in resident pain and mental health conditions due to pandemic-related restrictions, and difficulties in implementing nonpharmacologic interventions to address pain, sleep, mental health concerns and responsive behaviors among residents. 

The researchers also said that the increased use of antipsychotic medications in assisted living likely was “inappropriate.” Although they acknowledged that the mental health distress that assisted living residents likely experienced, as well as the lack of nonpharmacologic alternatives early in the pandemic, might have supported the short-term use of antidepressants and antipsychotics, their use remained elevated throughout the pandemic. 

“Prior to the pandemic, there is strong evidence that once started, these medications tend to persist beyond what might be considered an appropriate period of treatment, leading to an increased risk of polypharmacy / hyperpolypharmacy and medication-related adverse events,” Maxwell said. 

She added that when faced with public health crises, it is important that the senior living industry direct careful attention to implementing strategies for the appropriate oversight and administration of high-risk medications, particularly among at-risk residents and those living with dementia. 

A spokesperson from the American Health Care Association / National Center for Assisted Living told McKnight’s Senior Living that the groups have been active partners in a national effort to reduce the unnecessary use of antipsychotics in assisted living and skilled nursing and has made progress in the past decade, including focusing more on nonpharmacologic interventions.

“Along with prescribing physicians and family decision-makers, we must continue to educate ourselves about these conditions and the proper use of medications, as well as explore and promote innovative memory care techniques to help individuals with dementia thrive,” the spokesperson said.

A continuing challenge in assisted living

More than two-thirds of assisted living residents have dementia or cognitive impairment, and antipsychotics commonly are prescribed off-label for behaviors that include aggression, agitation, anxiety, delusions, hallucinations and sleeplessness, according to a 2023 study also published in JAMDA, by researchers from Brown University and the University of Michigan. 

In the early 2000s, studies showed that the off-label use of antipsychotic medications for older adults living with dementia was associated with a higher risk of early mortality, leading the US Food and Drug Administration to issue a “black box” warning on the use of the drugs in this population.

The Centers for Medicare & Medicaid Services, through the National Partnership for Quality Dementia Care, developed quality improvement efforts related to the use of antipsychotics in nursing homes. But evidence was lacking about antipsychotic medication use in assisted living / residential care facilities, staff training and use of nonpharmaceutical interventions and potential discrimination against older adults whose behaviors were deemed challenging, according to a study published in early 2023. 

Reducing the off-label use of antipsychotics in assisted living communities has been a goal of the senior living industry. One of the performance measures used by an assisted living community accreditation program launched in 2021 by The Joint Commission is medication management, specifically, off-label antipsychotic drug use. The National Center for Assisted Living’s Quality Initiative also lists antipsychotic medication use among its goals. 

David M. Levine, MD, MPH, from Brigham and Women’s Hospital and Harvard Medical School in Boston, and colleagues report on the early national experience of the AHCaH waiver, issued in November 2020, creating a regulatory and payment pathway for hospitals to deliver AHCaH. A total of 5,132 patients with a medical diagnosis who received AHCaH between July 1, 2022, and June 30, 2023, were identified, representing 5,551 admissions.

The researchers found that patients receiving AHCaH were medically complex, with a mean hierarchical condition category score of 3.15; 42.5, 43.3, 22.1 and 16.1% had heart failure, chronic obstructive pulmonary disease, cancer and dementia, respectively. Heart failure, respiratory infection, sepsis, kidney or urinary tract infection, and cellulitis were the five most common discharge diagnoses. The mean length of stay was 6.3 days; the escalation rate was 6.2% and the mortality rate was 0.5% during hospitalization. At 30 days after discharge, the mortality, skilled nursing facility use, and readmission rates were 3.2, 2.6 and 15.6%, respectively.

“Our data provide preliminary evidence on national uptake and suggest that AHCaH is an important care model to manage acute illness, including among socially vulnerable and medically complex patients,” the authors write.

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Newly available non-prescription hearing aids could do more than just return aural function to users: Restoring hearing function can have major overall health benefits and reduces the risk of dementia, experts say.

Almost 25% of adults aged 65 and 74 years, and half of those older than 75, have “disabling” hearing loss, according to the National Institute on Deafness.

Unfortunately, among those who have such significant hearing loss, only one-third use hearing aids, the institute says. 

That is partly due to the fact that many hearing aids are both costly and require prescriptions. Newer models, however, are form-fitting and commercially available, according to a recent story by CNN. 

Those newer models have come following a decision by the US Food and Drug Administration in 2022 to allow consumers to purchase hearing aids online or over the counter. 

Two recent studies have expanded on the link between hearing loss and dementia risk, McKnight’s Senior Living reported last week. 

Prior research also connected hearing loss with a greater risk for falling and overall cognitive decline. Overall, hearing loss was linked to a 7% higher risk for developing dementia and was 20% higher for those with hearing loss who didn’t use hearing aids.

Other research went as far as to report that those who used hearing aids reduced their mortality risk by 24%. 

The newer over-the-counter hearing aid models differ from previous models in several ways, with most options targeting more mild forms of hearing loss. New innovations include more form-fitting designs or are made to look more like earbuds or Bluetooth pieces and less like medical appendages. Some new models include functionality that can be controlled using smartphone apps, McKnight’s reported last year.

It’s yet another acronym senior living and memory care providers should familiarize themselves with: CCT. It stands for computerized cognitive training. 

The terminology refers to digital exercise options that older adults living with dementia can use to improve cognitive function or slow down decline. This is usually by stimulating visual, verbal or working memory.

For the most part, those kinds of exercises have been supervised by caregivers or clinicians. Older adults who took on CCT training independently, however, showed equal progress in bolstering their memory, a new study shows.

“Although the supervised approach showed greater effects,” the study authors wrote, “the unsupervised approach can improve verbal memory while allowing users to receive CCT at home without engaging as many healthcare resources.”

The report suggests that those new CCT programs could benefit older adults living independently, but senior living operators also could look to those options as a way to provide dementia interventions while dealing with staffing shortages and limited resources. 

Newer CCT programs not only are designed to be conducted without clinical supervision; some make use of virtual reality, the study noted. Overall, the CCT programs reviewed in the study required about one to two hours a week over a period of two weeks to six months. 

The researchers did qualify their meta-analysis by suggesting that most of the success stories occurred in older adults who had lower levels of dementia or early-stage Alzheimer’s disease.

Dementia is becoming a major care burden as the number of older adults increases worldwide. In the United States alone, 18% of all assisted living communities now include a specialized dementia care unit, and 11% are devoted to dementia or memory care entirely, according to the National Center for Assisted Living.

The combination of CCT, physical exercise and vitamin D makes for a true triple threat to empower older adults’ cognition, the McKnight’s Clinical Daily reported over the summer.