An eye toward the future: Pressing questions for our discipline in today's academic and research climate.

This paper seeks to open a dialogue concerning the current trend in hiring non-nurse faculty (NNF) to tenure track positions in schools/colleges of nursing. The evolution of non-nurses as faculty, including a review of contemporary papers in affecting this trend, is offered. Three means of involving non-nurses in advancing our discipline are presented. The impact of the growing trend of NNF is discussed relative to the integrity of our discipline and effects on education. We conclude by suggesting a manner of proceeding and raise questions for furthering dialogue.

Sleep-Wake Disturbances and Episodic Memory in Older Adults.

Sleep-wake disturbances have been associated with episodic memory loss, but past studies were limited by use of single measures of objective or perceived disturbances. Notably, cognitive reserve and depressive symptoms have been associated with sleep-wake disturbances and poorer episodic memory in older adults. The aims of this study were to determine the relationship between episodic memory and sleep-wake disturbances using objective and perceived measures in older adults and to examine cognitive reserve and depressive symptoms as moderators of this relationship. In this descriptive study, 62 healthy older adults (mean age: 69.9 years; 75.8% women) were recruited from the University of Michigan Clinical Research Program. Objective sleep-wake disturbances were measured by 7-day actigraphy and perceived sleep-wake disturbances by the Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale. Episodic memory was measured by the Hopkins Verbal Learning Test-Revised. Analyses involved Pearson's correlation coefficients and hierarchical multiple regression. Results showed that more objectively measured sleep disruption was associated with poorer episodic memory and more perceived daytime sleepiness was associated with better episodic memory. Cognitive reserve and depressive symptoms were not moderators of this relationship. In this study, the relationship between sleep-wake disturbances and episodic memory differed by type of measure, objective or perceived. Future studies are needed using multiple measures of episodic memory to further understand the sleep-wake disturbances and episodic memory relationship in a larger diverse sample of healthy older adults.

Does Social Interaction Matter Psychological Well-Being in Persons With Dementia?

BACKGROUND: Social interaction between residents and staff is an important factor influencing sense of well-being. This study examined the relationship between staff-resident interactions and psychological well-being of persons with dementia. METHODS: A total of 831 observations of 110 persons with dementia in 17 nursing homes and 6 assisted living facilities were included. Psychological well-being was measured by observed displays of positive and negative emotional expressions. Social interaction was determined by the type of social interaction (ie, verbal interaction, nonverbal interaction, and both verbal and nonverbal interactions) and the quality of interaction (ie, positive, negative, and neutral). RESULTS: Verbal or both verbal and nonverbal interactions showed significant relationship with positive and negative emotional expressions. Positive interaction was significantly associated with more positive emotional expression, whereas negative interaction was not. CONCLUSION: Staff-resident interactions are important to promote the psychological well-being of persons with dementia in residential care.

Is an Engaging or Soothing Environment Associated With the Psychological Well-Being of People With Dementia in Long-Term Care?

PURPOSE: To examine the relationship between environmental ambience and psychological well-being of persons with dementia. DESIGN: A secondary analysis was conducted using observational data with repeated measures. A total of 1,857 observations from 177 persons with dementia in 17 nursing homes and 6 assisted living facilities were included. METHODS: Psychological well-being was measured by observed displays of positive and negative emotional expressions. The environmental ambience was assessed by two subscales of the Ambiance Scale: Engaging and Soothing. Multilevel modeling was used to account for hierarchical structures in the data. FINDINGS: An engaging environment was associated with more positive emotional expressions after controlling for covariates. However, a soothing environment was associated with neither positive nor negative emotional expressions. CONCLUSIONS: Results suggest that the environment is an important consideration for administrators and clinicians as they respond to the mandate to actively plan and provide care to persons with dementia. CLINICAL RELEVANCE: An environment that is relevant and interesting may promote a sense of well-being and support resident-centered care.

Recruitment and Retention Challenges of Examining Cognitive Dysfunction in Older Adults Hospitalized for Acute Heart Failure.

BACKGROUND: Barriers to recruiting and retaining acutely ill older adults in clinical research include complexity of illness, fatigue, and early discharge. OBJECTIVE: To describe recruitment and retention challenges of examining cognitive dysfunction in older adults hospitalized for acute heart failure. METHODS: An examination of the reasons for recruitment and retention issues within an acute care, university-affiliated health care system. RESULTS: Sixty-two patients refused to participate for a variety of reasons; 11 were ineligible, and 27 participants who completed initial data collection refused to participate further because they were too tired, were being discharged on the day of data collection, or were discharged before the next data collection day. CONCLUSIONS: Multiple barriers to the recruitment and retention of older adults hospitalized for acute heart failure were identified. Strategies are needed to augment recruitment and retention efforts, including expanding the number of data collection sites and allocating sufficient support resources.

Caregiver and care recipient characteristics as predictors of psychotropic medication use in community-dwelling dementia patients.

OBJECTIVES: The current practice of prescribing psychotropic medication for the management of dementia-related behavioral disturbances is under substantial debate. Using Pearlin's stress process model as theoretical underpinning, the aim of this investigation is to identify caregiver and care recipient characteristics as predictors of anxiolytic, antipsychotic, and antidepressant use among community-dwelling dementia patients. We hypothesized that caregiving burden and patient characteristics, particularly behavior disturbances and pain, would be positively associated with psychotropic medication use. METHODS: Data for this exploratory, cross-sectional study were drawn from the baseline assessment of the Resources for Enhancing Alzheimer's Caregiver Health II trial. Only participants with full baseline information were examined (N = 598). Caregiver characteristics, such as confidence managing problematic behaviors, and care recipient characteristics including pain, problem behaviors, cognitive impairment, and functional impairment, were examined in relation to care recipient psychotropic medication use. RESULTS: Contrary to our hypothesis, behavioral disturbances and burden associated with these disturbances were not significantly associated with psychotropic use. Rather, caregiver characteristics such as race and overall vigilance, and care recipient characteristics such as cognitive status, functional status, and pain were significantly associated with the use of psychotropic medication. Findings differed by class of medication. CONCLUSION: These exploratory findings suggest the utility of a holistic approach to understanding the factors associated with pharmacotherapy among community-dwelling elders with dementia. Significant associations between caregiver characteristics and care recipient psychotropic medication use suggest that educating caregivers in non-pharmacologic strategies hold promise for a more balanced biopsychosocial approach to maintaining dementia patients in the community.

Developing the Person-Environment Apathy Rating for persons with dementia.

OBJECTIVES: To develop the Person-Environment Apathy Rating (PEAR) scale that measures environmental stimulation and apathy in persons with dementia and to evaluate its psychometrics. METHOD: The PEAR scale consists of the PEAR-Environment subscale and PEAR-Apathy subscales. The items were developed via literature review, field testing, expert review, and pilot testing. The construct validity and reliability were examined through video observation. The parent study enrolled 185 institutionalized residents with dementia. For this study, 96 videos were selected from 24 participants. The PEAR-Environment subscale was validated using the Ambiance Scale and the Crowding Index. The PEAR-Apathy subscale was validated using the Neuropsychiatric Inventory (NPI)-Apathy, Passivity in Dementia Scale (PDS), and NPI-Depression. RESULTS: The PEAR-Environment subscale and PEAR-Apathy subscales each consists of six items rated on a 1-4 scale. For validity, the Crowding Index slightly, yet significantly, correlated with the PEAR-Environment subscale total score and three of the individual scores. Ambiance Scale scores, both engaging and soothing, did not correlate with the PEAR-Environment subscale. The PEAR-Apathy highly correlated with the PDS and NPI-Apathy and moderately correlated with the NPI-Depression, suggesting good convergent validity and moderate discriminant validity. For reliability, both environment and apathy subscales demonstrated excellent internal consistency. Although facial expression and eye contact showed moderate inter-rater reliability, all other items showed good to excellent inter-rater and intra-rater reliability. CONCLUSION: This study has successfully developed the PEAR scale and established its psychometrics based on the compatible scales available. The PEAR scale is the first scale that concurrently assesses apathy and environmental stimulation, and is recommended for use in persons with dementia.

The Association Between Characteristics of Care Environments and Apathy in Residents With Dementia in Long-term Care Facilities.

PURPOSE: Apathy is highly prevalent in dementia but often overlooked. Environment-based interventions have demonstrated positive impact on apathy, yet, influential environmental components are largely understudied. This study examined the relationship between care environments and apathy in long-term care residents with dementia. DESIGN AND METHODS: This study was exploratory and employed a descriptive and repeated observation design. A sample of 40 was selected from a parent study with 185 participants from 28 facilities. Three videos from each participant were coded to measure apathy and environmental stimulation. Data on ambiance, crowding, staff familiarity, light, and sounds were extracted from the parent study. Generalized linear mixed models were used for analysis. RESULTS: The clarity and strength of environmental stimulation were significantly associated with a lower apathy level. An increase of 1 point on stimulation clarity and strength corresponded to a decrease of 1.3 and 1.9 points on apathy score, respectively (p < .0001). Other environmental factors did not show significant effect on apathy. IMPLICATIONS: This study explored influential environmental features on apathy in dementia. Findings suggest that care environments that contain clear and sufficient environmental stimulation are significantly associated with lower resident apathy levels. Findings will guide environmental design and interventions for dementia care.

Pain and psychological well-being among people with dementia in long-term care.

OBJECTIVE: To examine the relationship between self-reported pain and psychological well-being of people with dementia (PWD) living in residential long-term care as indicated by displays of observed emotional expression over the daytime period. DESIGN: Secondary analysis using repeated measures of self-report and observational data. SETTING AND SUBJECTS: A total of 177 PWD were included from 17 nursing homes and six assisted living facilities in Michigan and Pennsylvania. METHODS: Negative emotional expression was used as an indicator of reduced psychological well-being. Pain was assessed through PWD's response to a question about presence of pain obtained at each observation. Cognitive impairment was assessed using the Mini-Mental Status Examination. Linear mixed models were used that accounted for correlation of negative emotional expression measurements over time for each participant and between participants within the same facility. RESULTS: Among 171 participants who were able to express their pain, 44% of PWD reported pain once or more during the daytime period. Severity of cognitive impairment was related to expression of negative emotion. PWD with pain displayed more negative emotional expression than PWD without pain. CONCLUSIONS: Routine pain assessment is feasible among PWD with moderate to severe dementia and positive report of pain is associated with greater observed negative emotional expression, an indicator of reduced psychological well-being. Improving pain management holds potential for enhancing psychological well-being among PWD living in residential long-term care.

Cognitive dysfunction in older adults hospitalized for acute heart failure.

BACKGROUND: Few studies have measured cognitive dysfunction in older adults during acute exacerbations of heart failure (HF), even though 25% of patients are readmitted within 30 days. The aims of this study were to examine cognitive dysfunction and acute HF symptoms in older adults hospitalized for HF and to evaluate the relationship between cognitive dysfunction and 30-day rehospitalization rates for acute HF. METHODS AND RESULTS: A cross-sectional descriptive design was used to characterize cognitive function in 53 older adults hospitalized for acute HF with the use of Cogstate computerized neuropsychologic tests. Demographic characteristics, HF symptoms (dyspnea, fatigue, pain, and depressed mood), comorbidity, and 30-day readmission HF rates were also measured. Dyspnea was measured with the use of the Parshall Brief Clinical Dyspnea Rating Questionnaire while fatigue was measured with the use of the Chalder et al Brief Fatigue Scale. We measured pain with the use of the Short-Form McGill Pain Questionnaire and depressed mood with the use of the depression subscale of the Hospital Anxiety and Depression Scale. Comorbid conditions were measured with the use of the Charlson comorbidity index. With the use of linear regression, dyspnea (ß = -.281; P = .030), pain (ß = .323; P = .011), and depressed mood (ß = .406, P = .003) were associated with reduced attention and working memory speed, and pain (ß = -.372; P = .005) and fatigue (ß = -.275; P = .033) were associated with reduced accuracy of attention and working memory. Ten patients were readmitted within 30 days for HF. According to Mann-Whitney U analysis, cognitive dysfunction measures (P = .090-.803) failed to show differences in HF readmission. CONCLUSIONS: Participants with more and worse symptoms had decreased speed and decreased accuracy in the cognitive domains tested. Cognitive dysfunction measures did not differentiate participants who were readmitted versus those who were not readmitted within 30 days for acute HF.

Relationship between observable emotional expression and wandering behavior of people with dementia.

OBJECTIVE: This study explored the relationship between observable emotional expression and wandering behaviors of people with dementia (PWD). METHODS: A secondary data analysis was conducted of a multi-site study that used a cross-sectional design with repeated measures nested within subjects. Participants included 142 PWD residing in 17 nursing homes and six assisted-living facilities in Michigan and Pennsylvania who were randomly assigned to six 20-min videotaped observation periods, conducted on two non-consecutive days. Poisson hierarchical linear modeling was used to examine associations between emotional expression and wandering. RESULTS: Participants exhibited an average of 13.5 (standard deviation [SD] ± 12.4) episodes of positive emotional expression per observation; only 1.5 (SD ± 2.3) episodes of negative emotional expression per observation were noted. The mean wandering rate was 2.9 episodes (SD ± 6.9) per hour. Positive emotional expression was positively related to wandering rates, whereas negative emotional expression and higher cognitive status were negatively related to wandering rates after controlling for other predictors (age, education, gender, facility type, mobility, and time of day). CONCLUSIONS: Both positive and negative emotional expressions, along with cognitive status, should be considered when developing interventions to improve wandering behaviors of PWD.