Testing the Usefulness of the Evidence Integration Triangle for Implementation of EIT-4-BPSD

The effectiveness of evidence-based practices, such as use of behavioral interventions, can be improved when delivered under conditions of an implementation framework. This pragmatic trial used the Evidence Integration Triangle (EIT) which is a parsimonious, community-engaged participatory framework that brings evidence and facility stakeholders together. Active engagement empowers key stakeholders to integrate evidence into practice using a simple three-pronged framework: (1) A participatory implementation process which was done via monthly meetings and weekly emails between stakeholders and a clinical expert as they worked on facility based goals; (2) Implementation of the four steps delineated in the EIT-4-BPSD; and (3) evaluation using practical progress measures. There was some evidence of implementation of the EIT-4-BPSD based on participation in Stakeholder team meetings, settings working towards goal achievement, and increased use of behavioral interventions among staff. The EIT approach is a useful implementation framework to help change staff behavior in long term care.

The Value of the Evidence Integration Triangle

The Evidence Integration Triangle involved engaging stakeholders in the 12 month FFC-AL-EIT activities including identifying community specific goals, supporting the staff implementing the intervention, and intervening when champions or staff were not engaged in intervention activities. Ongoing participation of the stakeholder team occurred through monthly meetings. Evaluation of implementation was based on the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) Model. Reach was based on 85 of 90 communities participating and 794 residents recruited. Effectiveness was supported based on less functional decline and more function focused care performed by residents. Adoption was based on evidence that monthly meetings were held, 77% of settings engaged as, or more than expected, and caregivers increased the amount of function focused care provided. The intervention was implemented as intended, knowledge was received, and environments and policies supporting function focused care were maintained. The Evidence Integration Triangle is an effective implementation approach for assisted living.

Testing Implementation of FFC-AL-EIT

Residents in assisted living settings engage in limited amounts of physical activity and decline functionally more rapidly than peers in nursing homes. To address the persistent functional decline and increased time spent in sedentary activity Function Focused Care was developed. Function Focused Care involves teaching caregivers to evaluate residents’ underlying functional capability and physical activity and engage them in physical activity during all care interactions. Prior research has demonstrated that implementing function focused care improves or maintains function and increases physical activity, improves mood and decreases behavioral symptoms among residents. To optimize implementation of Function Focused Care a theoretically based implementation strategy, Function Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT), was developed. FFC-AL-EIT combines the social ecological model, social cognitive theory and the Evidence Integration Triangle. The social ecological model includes intrapersonal, interpersonal, environmental, and policy factors that influence behavior. Social cognitive theory guides the interpersonal interactions that motivate caregivers and residents to engage in function focused care. Lastly, the Evidence Integration Triangle facilitates systemic implementation of function focused care. A total of 85 facilities from three states were randomized (FFC-AL-EIT versus Education Only) and 794 residents consented. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model was used to evaluate outcomes. This symposium will provide the implementation outcomes and value of the Evidence Integration Triangle, the effectiveness of FFC-AL-EIT on function and physical activity and the effectiveness on psychosocial outcomes and care interactions.

A weighted constraint satisfaction approach to human goal-directed decision making

When we choose actions aimed at achieving long-range goals, proximal information cannot be exploited in a blindly myopic way, as relevant future information must often be taken into account. However, when long-range information is irrelevant to achieving proximal subgoals, it can be desirable to focus exclusively on subgoal-relevant considerations. Here, we consider how an underlying parallel mechanism simultaneously influenced by proximal and future information may be at work when decision makers confront both types of situations. Participants were asked to find the shortest path in a simple maze where the optimal path depended on both starting-point and goal-proximal constraints. This simple task was then embedded in a more complex maze where the same two constraints, but not the final goal position, determined the optimal path to the subgoal. In both tasks, initial choice responses predominantly reflected the joint influence from relevant immediate and future constraints, yet we also found systematic deviations from optimality. We modeled initial path choice as an evidence integration process and found that participants weighted the starting-point more than the equally relevant goal in the simple task. In the complex task, there was no evidence of a separate processing stage where participants first zeroed in on the subgoal as would be expected if task decomposition occurred strictly prior to choosing a path to the subgoal. Participants again placed slightly more weight on the starting point than the subgoal as in the simple task, and also placing some weight on the irrelevant final goal. These results suggest that optimizing decision making can be viewed as adjusting the weighting of constraints toward values that favor relevant ones in a given task context, and that the dynamic re-weighting of constraints at different points in a decision process can allow an inherently parallel process to exhibit approximate emergent hierarchical structure.

Causal evidence for a domain-specific role of left superior frontal sulcus in human perceptual decision-making

Humans and animals can flexibly choose their actions based on different information, ranging from objective states of the environment (e.g., apples are bigger than cherries) to subjective preferences (e.g., cherries are tastier than apples). Whether the brain instantiates these different choices by recruiting either specialized or shared neural circuitry remains debated. Specifically, domain-general theories of prefrontal cortex (PFC) function propose that prefrontal areas flexibly process either perceptual or value-based evidence depending on what is required for the present choice, whereas domain-specific theories posit that PFC sub- areas, such as the left superior frontal sulcus (SFS), selectively integrate evidence relevant for perceptual decisions. Here we comprehensively test the functional role of the left SFS for choices based on perceptual and value-based evidence, by combining fMRI with a behavioural paradigm, computational modelling, and transcranial magnetic stimulation. Confirming predictions by a sequential sampling model, we show that TMS-induced excitability reduction of the left SFS selectively changes the processing of decision-relevant perceptual information and associated neural processes. In contrast, value-based decision making and associated neural processes remain unaffected. This specificity of SFS function is evident at all levels of analysis (behavioural, computational, and neural, including functional connectivity), demonstrating that the left SFS causally contributes to evidence integration for perceptual but not value-based decisions.

209 - The Impact of Function Focused Care in Assisted Living Communities in the United States during the COVID-19 Pandemic

The purpose of this study was to test the preliminary effectiveness and feasibility of implementation of a function focused care intervention, referred to as Function Focused Care for Assisted Living Using the Evidence Integration Triangle in Assisted Living Communities with Residents with Dementia, and consider the impact of COVID-19 restrictions on incidences of COVID-19 and worsening of behavioral symptoms. The intervention was designed to facilitate a philosophy of care in which staff are educated and helped to actively engage residents in functional and physical activity during all care interactions. This was a single group pre-post intervention study including 51 assisted living communities in a single state in the United States. The communities ranged in size from 8 to 50 beds with the mean number of beds being 13.25 (SD=7.69). The majority (99%) were for profit. There was significant improvement in the support of the environments (p=.01) and policies (p=.04) for physical activity. There was no significant change in falls, emergency room transfers, hospitalizations or nursing community transfers over time. Overall there were only 7 (18%) communities that had COVID-19 positive patients with the numbers ranging from 1-16 residents and percentage ranging from 0-31% and a mean percentage of 17%. The majority did not require that the residents quarantine in their rooms (87%) although they did restrict visitation with the exception of 3 (8%) communities that let families visit after training and with exposure and symptom risk assessments completed at each visit. Communities in which residents were quarantined in their rooms had a 40% greater likelihood of having COVID-19 positive residents than communities that did not quarantine residents. None of the restrictions imposed were associated with worsening of behavioral symptoms. The findings are descriptive and pilot in nature but can be used to guide future research around prevention and management of infections in assisted living.

The Impact of Cognitive impairment on Clinical Symptoms, Physical Activity and Care Interactions among Residents in Assisted Living Settings

The purpose of this study was to describe differences in pain, behavioral symptoms, quality of staff-resident interactions, participation in function focused care and physical activity among residents with and without cognitive impairment in assisted living. This was a secondary data analysis using baseline data from an ongoing trial testing Function Focused Care for Assisted Living using the Evidence Integration Triangle (FFC-AL-EIT). A total of 550 residents were recruited from 59 communities. The average age of participants was 89.30 ( SD = 7.63), the majority were white (98%), female (69%), had evidence of cognitive impairment (75%), and 5.16 ( SD = 1.86) comorbidities. Those with cognitive impairment had more pain, were more sedentary and less likely to engage in function focused care activities. Addressing pain and implementing interventions for those with cognitive impairment to participate in function focused care may help optimize function and physical activity in assisted living residents.

Best Paper Selection

Jin Q, Tan C, Chen M, Liu X, Huang S. Predicting clinical trial results by implicit evidence integration. https://arxiv.org/abs/2010.05639 Poerner N, Waltinger U, Schütze H. Inexpensive Domain Adaptation of Pre-trained Language Models: Case Studies on Biomedical NER and Covid-19 QA. https://arxiv.org/abs/2004.03354 Ive J, Viani N, Kam J, Yin L, Verma S, Puntis S, Cardinal R, Roberts A, Stewart R, Velupillai S. Generation and evaluation of artificial mental health records for Natural Language Processing. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7224173/