Effects of a 12-Session Symptom Self-Management Course on Forensic Psychiatric Inpatients' Auditory Hallucinations and Anxiety.

The purpose of this clinical dissemination project was to evaluate changes in intensity of unpleasant auditory hallucinations (AH) and level of anxiety after forensic psychiatric inpatients attended an evidence-based symptom self-management course. The course was taught twice to patients with schizophrenic disorders. Data were collected using five self-rating measures. Seventy percent of participants reported reduced AH and anxiety; 100% reported helpfulness of being with others with similar symptoms; 90% would recommend the course to others. The course facilitator reported: improved communication, comfort, and effectiveness working with people with AH, plans to teach the course again and recommend it to colleagues.

Integrating Anxiety Reduction into an Existing Self-Management of Auditory Hallucinations Course.

High levels of anxiety were found to interfere with voice hearers' ability to benefit from a 10-Session Behavioral Management of Auditory Hallucinations Course. The 10-session course was revised, adding anxiety reduction strategies to the first four classes and reinforcing those strategies in the remaining eight classes. A multi-site study (N = 27) used repeated measures to determine whether the new 12-session course would significantly reduce anxiety. Ten course leaders were trained and taught the course six times at three different outpatient mental health sites. Three measures of anxiety were used. The 12-session course was found to significantly reduce anxiety after the first four classes with further reduction at the end of the course. Eighty-eight percent of course participants reported the course was moderately to extremely helpful. They also reported that being in a group with others with similar symptoms was valuable. Course leaders reported learning about the prevalence and importance of treating voice hearers' anxiety. [Journal of Psychosocial Nursing and Mental Health Services, 55(5), 29-39.].

Auditory hallucinations interview guide: promoting recovery with an interactive assessment tool.

The Auditory Hallucinations Interview Guide (AHIG) is a 32-item tool that helps psychiatric-mental health (PMH) nurses assess past and current experiences of voice hearers so they can provide more individualized care. The AHIG was developed as a research tool but has also been found to be clinically useful in both inpatient and outpatient settings to help voice hearers and nurses develop a shared terminology of auditory hallucinations (AH). Using the AHIG, voice hearers are able to tell their stories in a structured and safe environment, thus encouraging recovery. Through respect and active listening, PMH nurses can communicate unconditional acceptance, caring, and hope for recovery, which helps develop rapport and promote trust in the nurse-patient relationship. Once trust is developed, voice hearers and PMH nurses can work together to find effective strategies for managing AH, including commands to harm self and others.

Life enhancing activities for family caregivers of people with frontotemporal dementia.

Aberrant psychological and behavioral symptoms are common in patients with dementia. These symptoms have negative consequences for family caregivers, causing stress and burden. Frontotemporal dementia (FTD) symptoms cause more pronounced stress and burden on caregivers than those associated with Alzheimer dementia. In this randomized, attention control pilot study, we delivered 5-weekly, one-on-one, positive affect intervention sessions to family caregivers of people with FTD. The program, Life Enhancing Activities for Family Caregivers: LEAF was conducted in-person or by videoconference with caregivers across the United States. Measures of affect, caregiver mood, stress, distress, and caregiver burden were assessed at baseline, end of sessions, and 1 month after completion. Twenty-four caregivers (12 intervention and 12 attention control) participated. At the end of the intervention, scores on positive affect, negative affect, burden, and stress all improved in the intervention compared with the control group. These scores continued to show improvement at the assessment done 1 month after intervention. Subjects were receptive to the skills and the delivery methods. The positive emotion skill-building intervention proved feasible especially in the internet videoconference delivery format. The intervention promoted positive affect and improved psychological outcomes for family caregivers of people with FTD.

Sleep in persons with frontotemporal dementia and their family caregivers.

BACKGROUND: Dementia is associated with disruptions in sleep and sleep quality for patients and their family caregivers. Little is known about the impact of frontotemporal dementia (FTD) on sleep. OBJECTIVE: The purpose of this study was to characterize sleep in patients with FTD and their family caregivers. METHODS: Twenty-two patient-caregiver dyads were enrolled: Thirteen behavioral variant FTD (bvFTD) and nine semantic dementia (SD). Sleep and sleep quality data were collected for 2 weeks using diaries and Actiwatches. RESULTS: Patients with bvFTD and SD spent more time in bed at night compared to their caregivers. Nighttime behaviors were reported more frequently by caregivers for the bvFTD patients and strongly correlated with caregiver distress. Actigraphy data showed normal sleep efficiency and timing of the nighttime sleep period for both patients and their caregivers. Caregivers of patients with bvFTD reported poorer sleep quality compared to the SD caregivers. A greater number of bvFTD caregivers compared to SD reported negative aspects of sleep quality for themselves and used sleep medications more frequently. CONCLUSION: The clinical manifestations of bvFTD appear to be associated with different and more distressing impacts on the caregiver sleep quality than SD.

Disseminating an evidence-based course to teach self-management of auditory hallucinations.

This multi-site project extended course dissemination of the 10-session Behavioral Management of Auditory Hallucinations Course to U.S. Department of Veterans Affairs (VA) mental health outpatient settings. The VA Quality Enhancement Research Initiative (QUERI) model and Rogers' theory of diffusion of innovations served as the theoretical framework. The course was taught to mental health professionals using teleconferencing, electronic media, and monthly conference calls across 24 VA mental health outpatient sites. Twenty course leaders provided feedback. One hundred percent reported being better able to communicate with patients about their voices and 96% reported improved understanding of the voice-hearing experience. Thirty-three course participants provided feedback. Ninety-four percent would recommend the course, 85% reported being better able to communicate with staff about their voices, and 66% reported being better able to manage their voices. Facilitators and barriers to course implementation are described.

Characterization of apathy in persons with frontotemporal dementia and the impact on family caregivers.

This study characterized daytime activity and apathy in patients with behavioral variant frontotemporal dementia (bvFTD) and semantic dementia (SD) and their family caregivers. Twenty-two patient-caregiver dyads were enrolled: 13 bvFTD and 9 SD. Data were collected on behavior and movement. Patients and caregivers wore Actiwatches for 2 weeks to record activity. We predicted that bvFTD patients would show greater caregiver report of apathy and less daytime activity compared with patients diagnosed with SD. Patients with bvFTD spent 25% of their day immobile, whereas patients with SD spent 16% of their day inactive. BvFTD caregivers spent 11% of their day immobile and SD caregivers were immobile 9% of their day. Apathy was present in all of the patients with bvFTD and in all but one patient with SD; the severity of apathy was greater in bvFTD compared with SD. Apathy correlated with caregiver emotional distress in both groups. In conclusion, apathy has been defined as a condition of diminished motivation that is difficult to operationalize. Among patients with frontotemporal dementia, apathy was associated with lower levels of activity, greater number of bouts of immobility, and longer immobility bout duration. Apathy and diminished daytime activity appeared to have an impact on the caregiver. Objective measures of behavioral output may help in formulation of a more precise definition of apathy.

Feasibility of adapting a classroom balance training program to a video game platform for people with Parkinson's disease.

OBJECTIVE: Decreased postural stability in people with Parkinson's disease (PD) is a major component of disability. Rehabilitation interventions are therefore targeted to improve balance, mobility, and strength. Virtual environment and gaming platforms can encourage therapeutic activity in the home and be challenging and fun. The aims of the project were to demonstrate the technical feasibility of adapting a classroom-based gait-and-balance training program to a video game platform. Ease of use, appeal, and safety of the proposed games were tested for both clinic and in-home use. SUBJECTS AND METHODS: This cross-sectional observational study was carried out in three phases. Modifications in the game platform were made in an iterative fashion based on feedback from subjects and the observations of clinical and design team members. The first two phases of testing were performed in a laboratory setting, and the final phase was carried out in subjects' homes. RESULTS: Subjects (n=20) scored the primary "Rail Runner" game 3.6 for ease of use (1=hard, 5=easy) and 3.9 for appeal (1=did not like at all, 5=liked very much). There were no safety issues encountered, and the games performed without technical flaws in the final phase of testing. CONCLUSIONS: A computer-based video game that incorporates therapeutic movements to improve gait and balance for people with PD was appealing to subjects and feasible for home use.

Self-management of unpleasant auditory hallucinations: a tested practice model.

Individuals who experience auditory hallucinations (AH) frequently report hearing unpleasant voices saying disturbing things to them, making derogatory remarks about them, or commanding them to do something, including harming themselves or someone else. The Self-Management of Unpleasant Auditory Hallucinations Practice Model was developed to help psychiatric-mental health nurses in both inpatient and outpatient settings implement evidence-based nursing care for voice hearers who are distressed by unpleasant voices. The model's utility extends to nursing education, administration, and research. The model is comprised of three parts: (a) Assessment of Voice Hearer's Experience, (b) Nursing Interventions, and (c) Voice Hearer's Expected Positive Outcomes. These three parts of the model describe nursing assessments conducted with an interview guide and two self-report tools, nursing interventions that teach strategies to manage unpleasant AH in a 10-session course or individually, and evaluation of voice hearer outcomes with two self-report tools.

Changes in heel skin temperature under pressure in hip surgery patients.

OBJECTIVE: The aim of the study was to examine the effect of external pressure of the bed surface on heel skin temperature in adults in the first 3 days after hip surgery. DESIGN: A quasi-experimental study in a prospective, within-subjects, repeated-measures design. SETTING: This study was performed at 2 acute-care hospitals. PARTICIPANTS: Eighteen subjects (9 men and 9 women) with a mean age of 58.3 (±16.1) years were recruited after hip surgery at the 2 hospitals. METHODS: Temperature sensors were placed on the plantar surface of each foot, close to the heels. Measures were taken when the heels were (1) suspended above the bed surface for 20 minutes (preload), (2) on the bed surface for 15 minutes (loading), and (3) suspended again above the bed surface for 15 minutes (unloading). MAIN OUTCOME MEASURES: Heel skin temperature and demographic data. RESULTS: Heel temperature increased during loading and unloading in both legs on postoperative days 1 (P = .003) and 3 (P = .04) but not on postoperative day 2. Heel temperature in the nonoperative leg decreased in the first 3 minutes of unloading on postoperative days 2 (P = .02) and 3 (P = .01). CONCLUSION: Heel temperature increased with loading and unloading on postoperative days 1 and 3. Upon immediate unloading, hyperemic response was present only in the nonoperative leg. Keeping the heels off the bed surface at all times may avoid heel skin temperature changes and prevent tissue damage. Further research is needed to identify the mechanisms that explain the effect of external pressure on heel temperature.

Sleep in older adults with Alzheimer's disease.

Sleep in older adults with Alzheimer's disease can often be extremely fragmented, thus disturbing normal sleep-wake rhythms. This poor-quality sleep is challenging for caregivers and frequently results in admitting older adults to long-term care institutions. Many variables, such as genes, medications, depression, and environmental factors, influence sleep in persons with Alzheimer's disease. Interventions, such as exposure to light, melatonin therapy, sleep hygiene, and physical activity, are commonly used to treat or to prevent sleep problems. Neuroscience nurses can play an important role in assessing sleep characteristics and related factors, educating caregivers and staff, providing family members with emotional support, and conducting research.

Responding to command hallucinations to harm: the unpleasant voices scale and harm command safety protocol.

Command hallucinations are relatively common in voice hearers and are taken seriously because of the potential threat to self and others. Many variables mediate the relationship between hearing commands and acting on them. This article describes the implementation of the Harm Command Safety Protocol and the Unpleasant Voices Scale to respond to command hallucinations to harm in the context of the dissemination of a multisite, evidence-based behavioral management course for patients with auditory hallucinations.

Rest-activity patterns in institutionalized Korean older adults with dementia: a pilot study.

This pilot study examined rest-activity patterns and related factors in institutionalized older adults with dementia in Korea. Twelve individuals, residing in either a nursing home or an assisted living facility, participated in the study. Actigraphic measurements were collected for seven consecutive 24-hour periods to assess rest-activity patterns. The participants' demographic characteristics, cognitive function, problematic behaviors, and light exposure were also assessed. The results indicated the participants experienced sleep disturbances, including multiple awakenings at night and excessive daytime napping. Those in the nursing home had significantly more interdaily stability and less intradaily variability, with higher relative amplitude in their rest-activity rhythms, indicating more stable and stronger rest-activity rhythms than those in the assisted living facility. These findings emphasize the importance of the institutional environment in care planning to improve sleep and rest-activity rhythm for older adults with dementia.

Behavioral management of auditory hallucinations.

A 10-session behavioral course for self-management of auditory hallucinations in patients with schizophrenia has demonstrated positive outcomes. This article evaluates both the course's implementation and benefits to patients attending the course. Teleconferencing, electronic media, and 26 monthly conference calls were used to educate six advanced practice nurses (APNs) at six sites about the course implementation. Thirty-two patients within the U.S. Department of Veterans Affairs participated in the course. All of the APNs reported course helpfulness, improved communication with patients about voices, and improved harm assessment. Of the patients, 96% found the course helpful: 67% no longer heard voices to harm self or others, and 60% had improved auditory hallucination intensity scores. The project demonstrated successful implementation and practice integration with APNs' activities corresponding to Rogers' stages of innovation adoption. Facilitators and barriers to implementation are also described.

Randomized controlled trial of a facilitated online positive emotion regulation intervention for dementia caregivers.

OBJECTIVE: To test the effects of Life Enhancing Activities for Family Caregivers (LEAF), a 6-week positive emotion regulation intervention, on outcomes of positive emotion, depression, anxiety, and physical health as measured by the Patient-Reported Outcomes Measurement Information System® (PROMIS®). METHOD: A randomized controlled trial (N = 170) comparing LEAF (N = 86) to an emotion reporting/waitlist condition (N = 84) in dementia caregivers. LEAF was individually delivered online by trained facilitators. Participants in the control condition completed daily online emotion reports and then crossed over into the intervention condition after 6 weeks. The study was registered with Clinicaltrials.gov (NCT01825681) and funded by R01NR014435. RESULTS: Analyses of difference in change from baseline to 6 weeks demonstrated significantly greater decreases in PROMIS® depression (d = -.25; p = .02) and Quality of Life in Neurological Disorders (NeuroQOL) anxiety (d = -.33; p < .01), as well as improvements in PROMIS® physical health (d = .24; p = .02) in the intervention condition compared to the emotion reporting/waitlist control. The intervention also showed greater improvements in positive emotion (d = .58; p < .01) and positive aspects of caregiving (d = .36; p < .01). Increases in positive emotion significantly mediated the effect of LEAF on depression over time. CONCLUSIONS: This randomized controlled trial of the online-facilitated positive emotion regulation intervention in dementia caregivers demonstrated small to medium effect sizes on caregiver well-being and shows promise for remotely delivered programs to improve psychological well-being in caregivers of people with dementia and other chronic illnesses. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Mentalizing Imagery Therapy Mobile App to Enhance the Mood of Family Dementia Caregivers: Feasibility and Limited Efficacy Testing.

BACKGROUND: Family caregivers of patients with Alzheimer disease and related dementias (AD and ADRD) often experience high stress and are at high risk for depression. Technologically delivered therapy is attractive for AD and ADRD caregivers because of the time demands associated with in-person participation. OBJECTIVE: We aimed to study the feasibility and conduct limited efficacy testing of a mobile app intervention delivering mentalizing imagery therapy (MIT) for family caregivers. METHODS: A 4-week trial of the MIT app for family AD and ADRD caregivers was conducted to assess the feasibility of use and investigate changes in depression symptoms, mood, and caregiving experience. Semistructured interviews were conducted to characterize participants' perceived feasibility and benefits. RESULTS: A total of 17 of the 21 (80%) consented participants (mean age 67 years, range 54-79) utilized the app at least once and were further analyzed. Average usage of audio recordings was on 14 (SD 10) days out of 28 possible and comprised 29 (SD 28) individual sessions. There were improvements in depression with a large effect size for those who used the app at least moderately (P=.008), increases in positive mood postintervention (P<.05), and acute increases in mood following daily guided imagery practice (Stretching and Breathing, P<.001; Eye in the Center, P<.001; Nesting Doll, P=.002; Situation Solver, P=.003; and Life Globe, P=.006). Semistructured interviews revealed perceived benefits such as greater ability to remain "centered" despite caregiving challenges and positive reframing of the caregiver experience. CONCLUSIONS: App delivery of MIT is feasible for family AD and ADRD caregivers, including aging seniors. Results showed moderate to high usage of the app for a majority of users. Limited efficacy testing provides justification for studying the MIT app for AD and ADRD caregivers to improve mood and reduce depression in larger, controlled trials.

Preliminary results of a longitudinal study of changes in cognitive function in breast cancer patients undergoing chemotherapy with doxorubicin and cyclophosphamide.

OBJECTIVES: Recent studies suggest that standard dose chemotherapy for breast cancer may cross the blood-brain barrier. However, the evidence for chemotherapy-induced cognitive impairments in breast cancer patients is inconsistent. The purposes of this study in a sample of newly diagnosed patients with breast cancer were to (1) evaluate cognitive function prior to the administration of chemotherapy; (2) assess changes in cognitive function over time; and (3) evaluate potential relationships between cognitive function and anxiety, depression, fatigue, hemoglobin level, menopausal status, and perception of cognitive function. METHODS: Thirty women with breast cancer completed neuropsychological testing before the initiation of chemotherapy and after four cycles of doxorubicin and cyclophosphamide. Descriptive statistics were used to summarize sample characteristics, and paired t-tests were carried out to evaluate for changes in neuropsychological test scores prior to and following completion of chemotherapy. Linear mixed model analyses were used to determine whether significant changes in neuropsychological test scores remained after controlling for anxiety, depression, fatigue, hemoglobin level, menopausal status, and perceived cognitive function. RESULTS: Significant decreases in visuospatial skill (p<0.001) and total cognitive scores (p=0.001) were found following chemotherapy. In addition, a significant improvement was found in executive function (p=0.014). Of note, these changes remained significant even after controlling for anxiety, depression, fatigue, hemoglobin level, menopausal status, and perceived cognitive function. CONCLUSIONS: Data from this study supported the hypothesis that chemotherapy may have a negative impact on select domains of cognitive function.

Life Enhancing Activities for Family Caregivers of people with dementia: protocol for a randomized controlled trial of a positive affect skills intervention.

Given the increasing number of family caregivers of persons with dementia (PWD) and the associated burden and detriments to both physical and mental health, interventions that aim to improve such outcomes are important. Studies are increasingly demonstrating the unique importance of positive emotions in coping with stress, independent from the impact of negative emotions. However, none have examined the benefits of interventions that target positive emotions for caregivers of individuals with a chronic and debilitating disease such as dementia. This paper presents the design and methods for a randomized controlled trial (RCT) of a positive affect skills intervention for family caregivers of PWD. The RCT is of a skills-based intervention that seeks to increase the frequency and intensity of positive affect in order to improve outcomes such as well-being, coping, and physical and mental health. The skills are delivered by trained facilitators via five one-to-one Internet video sessions with family caregivers of persons diagnosed with dementia (eg, Alzheimer's disease, vascular dementia, unspecified). The control group is an emotion reporting/waitlist control. Follow-up assessments are conducted post-intervention and at 1, 3, and 6 months post-completion of the intervention. This study promises to be an important and needed step toward improving the lives of caregivers of PWD.

Light treatment for neuropsychiatric behaviors in Alzheimer's disease.

Neuropsychiatric behaviors are common in people with Alzheimer's disease (AD) and make both professional and lay caregiving difficult. Light therapy has been somewhat successful in ameliorating disruptive behaviors. This randomized trial tested the effects of morning or afternoon bright light exposure compared with usual indoor light on the presence, frequency, severity, and occupational disruptiveness of neuropsychiatric behaviors in nursing home residents with AD. Light was administered for 1 hr daily (Monday-Friday) for 10 weeks. The Neuropsychiatric Inventory-Nursing Home was used to assess behavior at baseline and end of the intervention. Analyses revealed statistically significant differences between groups on agitation/aggression, depression/dysphoria, aberrant motor behavior, and appetite/eating disorders. The magnitude of change was small and may not represent clinically significant findings. Agitation/aggression and nighttime behaviors commonly occurred and were highly correlated with occupational disruptiveness. Interventions that decrease the presence and/or severity of neuropsychiatric behaviors have the potential to significantly decrease caregiver burden.

Melatonin for sleep disturbances in Parkinson's disease.

BACKGROUND AND PURPOSE: Many patients with Parkinson's disease (PD) experience sleep-related symptoms. Studies in other populations indicate that melatonin can increase sleep efficiency, decrease nighttime activity, and shorten sleep latency, but there has been little research on the use of melatonin in PD. The purpose of this study was to compare the effects of two doses of melatonin to placebo on sleep, daytime sleepiness, and level of function in patients with PD who complained of sleep disturbances. PATIENTS AND METHODS: A multi-site double-blind placebo-controlled cross-over trial was employed; 40 subjects completed the 10-week protocol. There was a 2-week screening period, 2-week treatment periods, and 1-week washouts between treatments. Nocturnal sleep was assessed by actigraphy and diaries, whereas daytime sleepiness and function were assessed by the Epworth Sleepiness Scale (ESS), Stanford Sleepiness Scale (SSS), and General Sleep Disturbance Scale (GSDS). RESULTS: Repeated measures analysis of variance revealed a significant improvement in total nighttime sleep time during the 50 mg melatonin treatment compared to placebo. There was significant improvement in subjective sleep disturbance, sleep quantity, and daytime sleepiness during the 5 mg melatonin treatment compared to placebo as assessed by the GSDS. CONCLUSIONS: Although we found a statistically significant improvement in actigraphically measured total sleep time on 50 mg melatonin compared to 5 mg or placebo, this small improvement (10 min) may not be clinically significant. However, the significant improvement found in subjective sleep disturbance suggests that these modest effects may be clinically relevant in this patient population.