• We partner with clinicians and families to develop and test innovative models of dementia care focused on pain and neuropsychiatric symptom management. 

• We lead and collaborate on research aimed at elucidating determinants and consequences of neuropsychiatric symptoms.

• We conduct research on the perspectives, needs, and strengths of caregivers and persons with dementia.

Project:  Advancing Our Understanding of Lucidity in Dementia

People living with Alzheimer’s disease and related dementias experience progressive losses in memory and thinking abilities. Yet, lucid episodes, described as periods of a remarkable return to previous abilities and awareness, have been reported by family members and health care providers. A better understanding of lucid episodes, particularly in advanced stages of dementia, has important implications for our understanding of disease progression, retained abilities, and care. Our team will lead one of the first large -scale studies focused on lucidity in dementia, with the goal of advancing observational and computational linguistic approaches for capturing and characterizing these events and their distinguishing features. Funding: National Institute on Aging

Project: The Personalized Approach and Targeted Interventions (PROACTIVE) Treatment Approach

Neuropsychiatric symptoms (such as agitation) are common and persistent for persons with dementia and often increase in number and severity during hospitalization. To address the need for interventional approaches to managing neuropsychiatric symptoms in the acute care environment, we partnered with clinicians to develop, pilot, and evaluate the Personalized Approach and Targeted Interventions (PROACTIVE) Treatment Approach– a low-cost, multi-faceted, nurse-led intervention designed to improve prevention and management of dementia-related neuropsychiatric symptoms in acute care. Funding: National Institute on Aging

Project: The Stakeholders Understanding of Prevention Protection & Opportunities to Reduce Frequent Hospitalizations (SUPPORT) Study

The SUPPORT Study (Stakeholders Understanding of Prevention Protection & Opportunities to Reduce FrequenT Hospitalizations) is a multi-site qualitative study aimed at understanding diverse stakeholders perspectives regarding preventable hospitalization and re-hospitalization events among people with dementia. This study is one part of a broader nation-wide effort to inform and improve national re-hospitalization policies, and identify effective community and caregiver-responsive strategies for bolstering resilience and supports that are protective against hospitalization. Funding: National Institute on Minority Health and Health Disparities

• We design informatics-driven solutions to improve recognition of Alzheimer’s and related dementias among under-represented and high-risk populations.

• We investigate disparities in health and social services utilization among diverse populations with dementia.

Project: Care Coordination Following Acute Illness Care

People with dementia experience frequent transitions in care that are often poorly managed and have disproportionately higher utilization rates of unscheduled acute care, which is associated with various negative outcomes. To mitigate these risks and outcomes, comprehensively addressing the transitional care needs of people with dementia during the post-acute care period is critical. Drawing from end-user input, electronic health record data, and Medicare claims data sources, we identify and evaluate coordination and communication of important care needs surrounding and following acute illness care episodes. Major areas of foci for this work have included: transitional care needs and communication during hospital to skilled nursing facility transitions, discharge communication quality regarding high-risk care needs (follow-up care specification, high-risk medications), pain management, and coordination related to dementia-specific care needs (neuropsychiatric symptoms). Funding: National Hartford Center of Gerontological Nursing Excellence, Mayday Fund

Project: Electronic Health Record-Based Phenotyping for Cognitive Impairment

Dementia and cognitive impairment are under-recognized during hospitalization, limiting opportunities to improve detection, diagnosis, and connection to appropriate care and services for cognitively vulnerable populations. Automated electronic health record (EHR) driven approaches hold promise for improving detection and supporting clinicians in recognition of potential cognitive impairment. Yet, these algorithms rely heavily on structured data sources (i.e., ICD codes, medication events), which limit utility among underrepresented populations who are systematically less likely to receive care, diagnosis, and treatment. Our team has derived an electronic health record-based phenotype definition for identifying potential cognitive impairment during acute illness care by harnessing unstructured (free text) notes in the electronic health record. We are now leading validation of this and other phenotype models in community-based and longitudinal cohorts. Funding: National Institute on Aging