Childhood growth and cardiovascular reactivity to psychological stressors in late adulthood.

OBJECTIVE: Specific childhood growth patterns relate to risk of cardiovascular (CV) disease later in life, but the underlying mechanisms are unclear. We studied whether CV reactivity, a predictor of CV disease risk, is associated with childhood growth trajectories. METHODS: A total of 144 (77 women and 67 men) participants of the Helsinki Birth Cohort Study born 1934-1944, whose height and weight were recorded repeatedly during the first 11 years, underwent the Trier Social Stress Test at the average age of 63 years. Beat-to-beat blood pressure was monitored via noninvasive finger photoplethysmograph (Finometer), and CV reactivity scores were determined as the mean increment from baseline. RESULTS: In both women and men, systolic blood pressure (SBP) reactivity increased by 3.8 mmHg (95% CI 0.8-6.9) and diastolic BP (DBP) reactivity by 1.4 mmHg (95% CI 0.0-2.8) for every standard deviation increase in gain in body mass index (kg m(-2)) between 7 and 11 years. By contrast, effects of height gain were dissimilar between sexes. In women, higher DBP reactivity was associated with a slow gain in height between 0 and 2 years, whilst in men higher SBP reactivity was associated with a slow gain in height between 2 and 7 years, which was preceded by a more rapid gain in height between 0 and 2 years. Adjusting for adult body size, body size at birth or childhood socio-economic status did not change the results. CONCLUSIONS: We found that growth during childhood is associated with CV reactivity to stress later in adulthood. Early life programming of CV reactivity may partly underlie the link between early growth and CV disease.

Cardiovascular reactivity to psychological stressors in late adulthood is predicted by gestational age at birth.

The relationships of body size and gestational age at birth with adult blood pressure (BP) are relatively modest compared to their stronger associations with cardiovascular disease. BP reactivity is a strong predictor of cardiovascular morbidity, and it is possible that reactivity, rather than resting level, is determined in utero. We investigated whether body size and gestational age at birth predict BP reactivity during experimentally induced psychosocial stress in late adulthood. A total of 73 men and 80 women born after 36 weeks' gestation in Helsinki, Finland, during 1934-1944 underwent the Trier Social Stress Test (TSST); a standardized psychosocial stress test consisting of a public speech and an arithmetic task. Changes in BP were monitored continuously by a non-invasive finger photoplethysmography (Finometer, FMS, Amsterdam, The Netherlands). The results showed that the most robust early determinant of BP reactivity was gestational age; however, with opposite relationships between the sexes (P for interaction <0.001). A 1-week increase in gestational age was associated with a 3.1 mm Hg (95% confidence interval (CI), 0.2 to 6.0) and 1.2 mm Hg (95% CI, -0.1 to 2.6) decreases in systolic and diastolic BP reactivity in women, but with 5.2 mm Hg (95% CI, 1.9 to 8.4) and 2.3 mm Hg (95% CI, 0.9 to 3.8) increases in men. In conclusion, normal variation in gestational age at birth predicts cardiovascular stress reactivity in later adulthood. Given that hypothalamic-pituitary-adrenal axis contributes to the regulation of autonomic nervous system function and the timing of parturition, and shows well-established sex differences, we speculate a role for early programming of this axis in explaining the findings.

GM-1 treatment of Alzheimer's disease. A pilot study of safety and efficacy.

A double-blind, placebo-controlled pilot study was conducted to evaluate the safety and efficacy of treatment of patients with Alzheimer's disease using monosialoganglioside GM-1, a neurotrophic factor. Of 46 patients enrolled, 42 completed all study requirements. Nineteen patients received 100 mg of GM-1 by daily intramuscular injection for 12 weeks. Twenty-three patients received placebo. Case evaluations were done at baseline, week 12, and week 24 and included both cognitive and psychosocial scales. Study results suggested that the treatment was safe, yet offered no overall symptomatic benefit to patients with mild-to-moderate Alzheimer's disease. Whether or not GM-1 therapy may offer protective benefit by slowing or arresting the progression of the disease remains unclear, since the results of the cognitive evaluations suggested that neither the GM-1 group nor the placebo group declined significantly during the 24-week study.

Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip-fracture.

OBJECTIVE: To compare the experience of pain and treatment of pain in cognitively impaired and cognitively intact older adults after surgical repair of a hip fracture. DESIGN: Prospective comparative survey design. PARTICIPANTS: A convenience sample of 88 hip fracture patients (53 cognitively impaired, 35 cognitively intact) from three Midwestern urban hospital orthopedic units was interviewed between days 2 and 5 postoperatively. Subjects whose Folstein Mini-Mental State Exam (MMSE) score was less than or equal to 23 were categorized as impaired. RESULTS: Pain report and intensity did not differ significantly between the two groups. One-third of the subjects in both groups rated pain as severe or worse. Cognitively impaired subjects scored significantly higher on the Checklist of Nonverbal Pain Indicators observed with movement (CNPI-m) than did cognitively intact subjects. Cognitively impaired subjects received significantly less opioid analgesics than cognitively intact subjects in the first and second 48 hours postoperatively. Both groups received less than 25% of the mean prescribed amount of opioid analgesics. Age, MMSE, and CNPI-m score accounted for 27% of the variance in the amount of opioid analgesic administered in the first 48 hours postoperatively. CONCLUSIONS: Pain is treated poorly in older postoperative patients. Cognitive impairment and age strongly influence the amount of analgesic nurses administer to older patients after surgical repair of hip fracture. Provision for patient comfort is a fundamental ethical obligation of healthcare providers. Clinicians need to pursue this goal more aggressively, especially for cognitively impaired, postoperative older adults.

Assessing patient satisfaction across the continuum of ambulatory care: a revalidation and validation of care-specific surveys.

The need to develop reliable and valid measures of patient satisfaction in ambulatory care settings is underscored by the rapid growth and changes in this health care arena as well as the requirement to monitor and gauge quality of care. The purpose of this article is to provide evidence for the reliability and validity of patient satisfaction questionnaires designed specifically for three points of care across the ambulatory care continuum. These points are outpatient testing and physical therapy services, outpatient surgery, and home health care. The present effort represents an evaluation of revised questionnaires for the first two points and an initial assessment of the psychometric properties of the questionnaire for the third. The present results support the internal reliability and construct validity of each questionnaire. In addition, differences were found on select facility characteristics based on each questionnaire.

A nursing challenge: methicillin-resistant Staphylococcus aureus in long-term care.

1. Methicillin-resistant Staphylococcus aureus (MRSA) are gram-positive cocci, differing from methicillin-resistant species of S epidermidis because they produce coagulase. MRSA is distinguished from methicillin-sensitive S aureus by its resistance to methicillin and other antibiotics. MRSA has not been found to be an organism of greater virulence than methicillin-sensitive strains of S aureus, but infections caused by MRSA are sometimes of greater concern because of the limited antibiotic treatment options. 2. In the past 25 years there has been an increase in the number of reported infections in patients caused by MRSA. As infections with MRSA have become more prevalent in community hospitals throughout the country, the difficulty in controlling the spread within the community hospitals has mirrored the experiences of the tertiary care centers. 3. Education regarding the transmission of microorganisms and the caregiver's role in prevention is essential for every nursing facility. Interfacility communication is essential for hospital and nursing home staff to plan and manage the care of infected or colonized residents. 4. A facility-specific MRSA policy should optimize the opportunity for infected persons to receive nursing home care--without jeopardizing other residents.

Aggressive behavior. Educating nursing assistants.

Caring for cognitively impaired aggressive residents presents a challenge to nursing assistants in long-term care facilities. Nursing assistants participated in an educational program that included content about cognitive losses, precipitants of aggression, communication techniques, strategies for preventing aggressive behavior, and managing personal feelings. Following the educational intervention in this study, nursing assistants reported that caring for cognitively impaired residents was significantly more rewarding and less frustrating. The use of the clinical nurse specialist to teach and assist in role modeling direct care of residents was effective in improving nursing assistant skill in working with aggressive cognitively impaired residents.

Goal-directed care: caring for aggressive nursing home residents with dementia.

1. Aggressive behavior in elders with dementia occurs most often during personal care. It is often a response to invasion of private space and may be prevented or reduced by interpersonal approaches that reflect a set of individualized goals for the resident. 2. Five resident goals for preventing or reducing aggressive behavior are to feel safe, to feel physically comfortable, to experience a sense of control, to experience optimal stress, and to experience pleasure. 3. These goals provide a framework for humane care that respects the personhood of the individual and minimizes the need for psychotropic medications and physical restraints.

Examining pain in aggressive cognitively impaired older adults.

Few studies have explored the phenomenon of pain in people with severe cognitive impairment. Pain assessment, which depends primarily on people's ability to describe dimensions of pain, becomes problematic when clients' cognitive impairment is so severe they cannot respond to pain assessment tools. The purpose of this study was to describe the phenomenon of pain for a subgroup of aggressive cognitively impaired nursing home residents who were enrolled in a larger study of aggressive behavior. To determine if pain was a possible factor influencing aggression, information was sought from five sources: family members, nursing assistant (NA) caregivers, medical record listings of pain-related diagnoses, use of analgesics, and observations of aggressive behaviors. Families reported pain in 44% of subjects, while NAs reported pain in 66% of subjects. Seventy-six percent of subjects had one or more pain-causing diagnoses. Sixty-four percent of subjects whose family members thought they may have pain were being treated with analgesics, compared to 44% of subjects whose NA reported they may be experiencing pain. Aggression scores were significantly higher in subjects who had two or more pain-related diagnoses and in subjects with arthritis. Nurses who are aware of a history of pain, reports of pain by families and caregivers, presence of pain-related medical diagnoses, and who realize pain may be a trigger for aggressive behavior may be more likely to recognize pain in cognitively impaired older adults. Better pain assessment should lead to improved treatment of pain in this population.

Pain and hip fracture outcomes for older adults.

PURPOSE: To determine if postoperative pain is a predictor of functional outcomes for elderly hip fracture patients who were previously independent ambulators (with or without assistive device). DESIGN: Prospective comparative survey design. SAMPLE: Convenience sample. 85 hip fracture patients age 65 years or older from two Midwestern urban hospital orthopaedic units. METHODS: Subjects were interviewed between day 2 and 5 (M = 2.6) postoperatively and again 2 months postoperatively. Independent variables of cognitive status and pain status were measured using the Folstein Mini Mental State Exam (MMSE) and two pain measures, the Verbal Descriptor Scale (VDS) and Ferrell's Pain Experience Interview (FPEI). The dependent variable, functional outcome, was measured using the degree of assistance required for basic ADLs from Jette's Functional Status Index (FSI). FINDINGS: Pain with movement was significantly higher than pain at rest (p < .0001). Mental status, pain report with movement (during hospital interview), illness severity, and age accounted for 51% of the variance in functional outcomes 2 months postoperatively. CONCLUSIONS: Undertreated postoperative pain contributes to poor functional outcomes. IMPLICATIONS FOR NURSING PRACTICE: Pain assessment of postoperative older patients should be conducted during movement. Efforts to reduce postoperative pain severity in the immediate postoperative period may yield better functional outcomes months later.

Body size at birth and cardiovascular response to and recovery from mental stress in children.

Cardiovascular (CV) response to mental stress, a predictor of CV disease risk, may be determined already in utero. However, the underlying mechanisms remain unclear, and previous studies have used adult subjects and neglected CV recovery. We investigated 147 girls and 136 boys aged 8 years who underwent the Trier Social Stress Test for children to determine whether body size at birth is associated with CV activity. Blood pressure (BP), electrocardiogram and impedance-derived indices were recorded and analyzed from continuous measurements using Vasotrac APM205A and Biopac MP150 systems. Among girls, lower birth weight was associated with lower baseline systolic BP (SBP) and diastolic BP (DBP) values (1.9 mm Hg and 1.5 mm Hg per 1 s.d. birth weight for gestational age, respectively), higher SBP and DBP response to mental stress (1.6 mm Hg and 1.1 mm Hg per 1 s.d. birth weight for gestational age, respectively), slower BP recovery and overall higher cardiac sympathetic activity. In contrast, among boys lower birth weight was associated with higher baseline levels of SBP (2.1 mm Hg per 1 s.d. birth weight for gestational age) and total peripheral resistance (TPR), overall lower cardiac sympathetic activity, lower TPR response to mental stress and a more rapid BP and cardiac sympathetic recovery. In boys, the associations with baseline levels and cardiac sympathetic activity became significant only after adjusting for current body size. These sex-specific results suggest that individual differences in childhood CV response to and recovery from mental stress may have prenatal origins. This phenomenon may be important in linking smaller body size at birth to adult CV disease.

The checklist of nonverbal pain indicators (CNPI).

This article critiques the literature on existing pain assessment instruments for cognitively impaired elders and reports findings of pilot testing of the Checklist of Nonverbal Pain Indicators. This instrument was designed to measure pain behaviors in cognitively impaired elders. Instrument testing was conducted on a population of elderly patients with hip fractures. Interrater reliability showed 93% agreement on the dichotomous checklist items. Behaviors occurred more frequently during movement in this population. Of the six pain-related behaviors in the instrument, facial grimaces/winces occurred in 44% of the patients tested. Observed pain behaviors were positively correlated with self-report of pain. No differences between observed pain behaviors in cognitively intact versus cognitively impaired older adults with hip fractures were noted. Limitations of the instrument and recommendations for tool use are discussed.

Community surveillance of stroke in persons under 70 years old: contribution of uncontrolled hypertension.

In 1979, a community-wide hospital surveillance system was established in Monroe County, New York (population 702,000), to investigate the continuing contribution of uncontrolled high blood pressure (HBP) to the occurrence of stroke. This paper reports findings among 200 consecutive strokes in persons under 71 years of age. Average age was 58. There was a prestroke history of HBP in 129 (65 per cent) cases. Two-thirds of the 129 had other predisposing conditions (heart disease, diabetes, previous cerebrovascular accident) and 95 per cent had one or more other cardiovascular risk factors (smoking, elevated cholesterol, obesity). Over 90 per cent had visited a physician during the year prior to stroke (average of four visits). Elevated pressures (DBP greater than or equal to 95 or SBP greater than or equal to 160) were recorded at half or more of the visits for 45 per cent of the patients; these cases were classified as uncontrolled. Reduction of "unnecessary" strokes in persons under age 71 should be achievable by giving increased attention to those already under medical care for hypertension who have co-existing stroke risk conditions and cardiovascular risk factors.

Assessment of hospital admission surveillance of stroke in a metropolitan community.

A system of hospital admission surveillance, developed to facilitate the communitywide study of incident stroke, has been evaluated in Monroe County, New York. Of 1604 consecutive patients admitted to the county's seven acute hospitals with a stroke-related diagnosis, 903 were subsequently confirmed as strokes, (predictive value positive = 56%). Among the 701 false positives, 52% were due to TIA or carotid stenosis, while 48% were due to other conditions mimicking stroke. Sensitivity was 68%. Among missed stroke cases 42% were admitted with non stroke-related diagnoses; 25% occurred in hospital; and 32% were missed for clerical reasons. Predictive value positive and sensitivity rates of admission screening were not significantly affected by patient age or sex. In conclusion, admission surveillance has identified a representative sample of hospitalized strokes in a practical and timely manner for studying factors effecting stroke incidence and outcomes on a communitywide basis.

Relationships between aggressive behavior in cognitively impaired nursing home residents and use of restraints, psychoactive drugs, and secured units.

This study examined relationships between aggressive behavior in cognitively impaired nursing home residents and physical restraints, psychoactive drugs, and placement on a secured unit. Data were obtained from 116 residents who were consistently aggressive as measured by the Ryden Aggression Scale 2. Subjects averaged 9.5 aggressive behaviors per day. Forty-seven percent of subjects were restrained, and 62% were regularly receiving psychoactive drugs. Use of restraints, antipsychotics, and placement on a secured unit were all significantly related to increased physical aggression scores. Four variables accounted for 23% of the variance in physical aggression scores: location on a secured unit, not receiving an antidepressant, being restrained, and number of psychotropic and/or anxiolytic medications administered. Significantly lower physical aggression scores were noted for subjects receiving antidepressants.