Advancing the Science on Unexpected Episodes of Clarity and Lucidity in People With Dementia

Abstract People with late-stage Alzheimer’s disease and related dementias (ADRD) have been reported, largely by way of anecdote, to exhibit unexpected episodes of spontaneous, meaningful, and relevant communication or behavior. These episodes of lucidity (EL) are characterized by spontaneous mental clarity in people living with dementia (PLWD) who are assumed to have lost coherent cognitive capacity. Given the transient nature and limited understanding of underlying mechanisms responsible for this phenomenon, these episodes are frequently overlooked and have received little scientific attention. Few studies have documented EL among PLWD with precision; scientific understanding is limited to anecdotes and case studies, which have not operationalized EL. Thus, there is a critical need for an evidence-based understanding and systematic operationalization of EL. Precise and robust operationalizations of EL will allow future research to assess if EL has different effects on ADRD prognosis or alters how family members manage and adapt to ADRD progression in their care recipient. The National Institute on Aging (NIA) has funded six studies to advance the scientific understanding of EL in dementia. These studies use a variety of methodological approaches to capture EL experiences, and together, they will provide evidence-based operational definitions of EL, novel approaches for measurement of this phenomenon, and estimates of its prevalence. This symposium will provide an overview of the funded studies and three different methodological approaches that are being used to better operationalize and understand EL.

were recognized as having a critical role in implementation, serving as a referral source and liaison between the CLC, Veteran/family, and community facility. Early implementation focused on team and program development with barriers including unprotected time for Team members. In the first year, the nine teams enrolled 70 Veterans, discharging 86% to community facilities. Characteristics of the Veterans suggest Teams are reaching the complex Veteran targeted by the model. Barriers to successful discharge include community facility inexperience/training and confidence to manage complex residents. COVID emerged as the leading barrier to outreach to internal and external partners and providing transitional support to the Veteran after discharge. We discuss the impact of these preliminary findings on future implementation and dissemination of the model.

THE BEHAVIORAL RECOVERY OUTREACH (BRO) TEAM: A TRANSITIONAL CARE MODEL FOR VETERANS WITH COMPLEX CARE NEEDS
Kathleen Matthews, 1 Grant Bauste, 2 and Emily Luitjens, 3 1. VISN 23,Des Moines,Iowa,United States,2. Minneapolis VA Medical Center,Minneapolis,Minnesota,United States,3. St. Cloud VA Health Care System,St. Cloud,Minnesota,United States In 2012, VA Central Iowa developed a novel program known as the Behavioral Recovery Outreach (BRO) Team to address unmet needs of our aging Veteran population with complex medical, psychological, neurocognitive and behavioral concerns. BRO Teams provide evidence-informed treatments in inpatient VA settings, and transitional care/support post-discharge to ensure successful placement and stability in the community. We will discuss how implementation science informed the expansion of this model from a local pilot to a nationally disseminated program. We will explore the challenges of ensuring program fidelity while fostering innovation and adaptation. Given the challenges of national dissemination, we will highlight the predicted and unforeseen aspects of program evaluation and policy implications. Finally, we will discuss the impacts of the COVID-19 pandemic on delivery of care methods and community-based interactions, as well as how this program has improved the lives and quality of care for this high-risk Veteran population.

ROLLING OUT BEHAVIORAL RECOVERY OUTREACH (BRO) TEAMS: PERSPECTIVES FROM AN INAUGURAL PARTNER SITE Trisha Gaudig, Sioux Falls VA, Sioux Falls, South Dakota, United States
The Sioux Falls VA Community Living Center (CLC) is a partner site for the Behavioral Recovery Outreach (BRO) Team dissemination. This CLC is home to over 55 Veterans requiring a variety of specialty needs such as dementia care, short-term rehabilitation, respite, hospice, and/or psychosocial needs. Many of the Veterans followed by the BRO Team on the CLC experienced frequent rehospitalizations and difficult placement in the community due to behavioral concerns. Local leadership encouraged participation in the BRO Team dissemination due to the growing need in this VA system to open access to dementia and mental health care, successfully discharge Veterans to appropriate community settings, and reduce unnecessary rehospitalizations. This presentation will discuss BRO Team development, including several factors facilitating successful BRO Team implementation (e.g., leadership support, community outreach approaches, staff partner buy-in), and identify barriers impacting successful implementation with a case example to illustrate strategies to overcome such barriers.

ADVANCING THE SCIENCE ON UNEXPECTED EPISODES OF CLARITY AND LUCIDITY IN PEOPLE WITH DEMENTIA
Chair: Joan Griffin Discussant: Basil Eldadah dementias (ADRD) have been reported, largely by way of anecdote, to exhibit unexpected episodes of spontaneous, meaningful, and relevant communication or behavior. These episodes of lucidity (EL) are characterized by spontaneous mental clarity in people living with dementia (PLWD) who are assumed to have lost coherent cognitive capacity. Given the transient nature and limited understanding of underlying mechanisms responsible for this phenomenon, these episodes are frequently overlooked and have received little scientific attention. Few studies have documented EL among PLWD with precision; scientific understanding is limited to anecdotes and case studies, which have not operationalized EL. Thus, there is a critical need for an evidence-based understanding and systematic operationalization of EL. Precise and robust operationalizations of EL will allow future research to assess if EL has different effects on ADRD prognosis or alters how family members manage and adapt to ADRD progression in their care recipient. The National Institute on Aging (NIA) has funded six studies to advance the scientific understanding of EL in dementia. These studies use a variety of methodological approaches to capture EL experiences, and together, they will provide evidence-based operational definitions of EL, novel approaches for measurement of this phenomenon, and estimates of its prevalence. This symposium will provide an overview of the funded studies and three different methodological approaches that are being used to better operationalize and understand EL.

WHAT IS PARADOXICAL LUCIDITY?
Andrew Peterson, 1 and Jason Karlawish, 2 1. George Mason University, George Mason University, Virginia, United States, 2. University of Pennsylvania, Philadelphia, Pennsylvania, United States In this presentation, I provide a conceptual background from which the other symposium speakers can describe detailed methods for investigating paradoxical lucidity (PL) in dementia. First, I outline the clinical and ethical significance of studying PL. Second, I describes how PL is understudied and so difficult to measure. A working definition of PL has been formulated from case reports, but aspects of this definition remain vague. I argue that this vagueness challenges the measurement of PL and the generalizability of study results. I conclude by proposing ways to address these problems.

EARLY DESCRIPTIONS OF FAMILY CAREGIVERS' EXPERIENCES WITH UNEXPECTED LUCIDITY
Kyungmin Kim, 1 Joan Griffin, 2 Lauren Bangerter, 3 Virginia Biggar, 4 Dawn Finnie, 5 Theresa Frangiosa, 4 Joseph Gaugler, 6 and Maria Lapid, 7 1. Seoul National University,Seoul,Republic of Korea,2. Mayo Clinic College of Medicine,Rochester,Minnesota,United States,3. UnitedHealth Group,Minnetonka,Minnesota,United States,4. UsAgainstAlzheimer's,Washington,District of Columbia,United States,5. Mayo Clinic,Rocheste,Minnesota,United States,6. University of Minnesota,Minneapolis,Minnesota,United States,7. Mayo Clinic,Rochester,Minnesota,United States To develop an operational definition of and typologies for episodes of lucidity (EL), we conducted a cross-sectional study of former/current family caregivers from UsAgainstAlzheimer's A_LIST (N = 538). More than 60% of caregivers (n = 294, 62%) reported witnessing EL with their care recipient over the course of their dementia. Most episodes happened in late stages of dementia (71%). Only 10% happened within 7 days before death. The majority of episodes (71%) lasted <30 minutes. About half the episodes were characterized by uncharacteristic speech and communication. Caregivers perceived these experiences positively (M = 4.10; range = 1-5), but also expressed desire to know why/when EL occurs and how to best respond to it. Data will be used to refine definitions and typologies, and then a prospective, demographically diverse survey will be administered to family caregivers to assess predictors of EL, linking EL to caregiver well-being and bereavement response. Though episodes of lucidity (EL) in Alzheimer's disease and related dementia (ADRD), reportedly more common near end of life, have significant implications for care, they are poorly understood due to underdeveloped methodological approaches for capturing and measuring these events. This prospective observational study addresses these gaps through audiovisual observation among persons with ADRD surrounding end of life to inform data-driven definitions for EL and distinguish EL from routine fluctuations in ADRD. Audiovisual observation is well-suited to addressing gaps in operationalization of EL, providing an objective data source to assess verbal and nonverbal communication, the primary means through which EL are evidenced. Our study is designed to establish optimal procedures for capturing audiovisual data of targeted populations and timeframes to maximize opportunities for detecting EL. Operationalization of EL will be informed by computational linguistic and behavioral-event coding of linguistic and non-linguistic communication features of EL and associated temporal qualities.