Psychologists in Long-Term Care (PLTC) Guidelines for Psychological and Behavioral Health Services in Long-Term Care Settings.

To address concerns about limited training of psychologists working in long-term care (LTC) facilities, the Psychologists in Long-Term Care (PLTC) organization published Standards for Psychological Services in Long-Term Care Facilities (Lichtenberg et al., 1998). The expanding evidence base for knowledge and skills, the increasing diversity of LTC residents, and the complexity of presenting problems have compounded the guidance psychologists need when providing services in this setting. In this article, the PLTC Guidelines Revision Task Force presents PLTC guidelines based on the original prescriptive PLTC Standards. The content of the PLTC Standards was updated and the format changed from prescriptive standards to aspirational guidelines. We begin with general guidelines regarding knowledge and skills in LTC (education and training. understanding of LTC systems. end-of-life care), followed by specific guidelines covering the basic psychological service activities in LTC (referral, assessment, treatment, ethical issues, and advocacy). The PLTC Guidelines are designed to provide direction for psychologists who work, or plan to work, in LTC and to guide continuing education pursuits.

Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients.

In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition;emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; andrecognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time.

Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients.

In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition; emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; and recognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time.

Soluble Fiber Use in Pediatric Short Bowel Syndrome: A Survey on Prevailing Practices.

BACKGROUND: In pediatric short bowel syndrome (SBS), adding fiber to enteral feedings is 1 treatment method to manage increased stool output. However, there are no standardized recommendations on the use of fiber in this setting, including type, dosage, titration strategies, etc. OBJECTIVE: The aim of this study is to determine current prevailing practices on the use of fiber in the treatment of chronic high stool output in the pediatric SBS population. METHODS: An anonymous electronic survey with 13 questions was sent through health professional electronic mailing lists. The survey was completed by healthcare professionals including physicians (primary care, subspecialists, and surgeons), nurse practitioners, and registered dietitians. RESULTS: A total of 94 responses were received. The most common supplemental fiber used was pectin (62.8%). The 2 major factors considered when initiating fiber therapy were consistency of stool (74.5%) and volume of stool output (85.1%). The major factor that determined discontinuation of fiber was abdominal distention (67%). A majority of providers waited 2 weeks or less to see improvement following fiber initiation before discontinuing it. CONCLUSIONS: The goal of the survey was to gather more information with regard to fiber use in the management of SBS patients. The data collected can be used to provide future direction on determining best practices for fiber use in SBS patients.

Independent evaluation of point source fossil fuel CO2 emissions to better than 10%.

Independent estimates of fossil fuel CO2 (CO2ff) emissions are key to ensuring that emission reductions and regulations are effective and provide needed transparency and trust. Point source emissions are a key target because a small number of power plants represent a large portion of total global emissions. Currently, emission rates are known only from self-reported data. Atmospheric observations have the potential to meet the need for independent evaluation, but useful results from this method have been elusive, due to challenges in distinguishing CO2ff emissions from the large and varying CO2 background and in relating atmospheric observations to emission flux rates with high accuracy. Here we use time-integrated observations of the radiocarbon content of CO2 ((14)CO2) to quantify the recently added CO2ff mole fraction at surface sites surrounding a point source. We demonstrate that both fast-growing plant material (grass) and CO2 collected by absorption into sodium hydroxide solution provide excellent time-integrated records of atmospheric (14)CO2 These time-integrated samples allow us to evaluate emissions over a period of days to weeks with only a modest number of measurements. Applying the same time integration in an atmospheric transport model eliminates the need to resolve highly variable short-term turbulence. Together these techniques allow us to independently evaluate point source CO2ff emission rates from atmospheric observations with uncertainties of better than 10%. This uncertainty represents an improvement by a factor of 2 over current bottom-up inventory estimates and previous atmospheric observation estimates and allows reliable independent evaluation of emissions.

Knowledge of and attitudes toward nonpharmacological interventions for treatment of behavior symptoms associated with dementia: a comparison of physicians, psychologists, and nurse practitioners.

PURPOSE OF THE STUDY: Behavior problems are common in nursing homes. Current guidelines recommend nonpharmacological interventions (NPHIs) as first-line treatment, but pharmacological regimens (PIs) continue to be used. Given differences in background and training of those who treat behavior problems in residents, we compared attitudes of physicians (MDs), psychologists (PhDs), and nurse practitioners (NPs) concerning PI and NPHI usage as well as knowledge of NPHIs. DESIGN AND METHODS: One hundred and eight MDs, 36 PhDs, and 89 NPs responded to a web-based questionnaire that captured level of agreement with statements concerning treatment of behavior symptoms and familiarity with NPHIs. RESULTS: NPs were the most favorable toward NPHIs. MDs were significantly more favorable to the use of PIs than were PhDs, with attitudes of NPs falling in between. All felt that NPHI usage should increase and that NPHIs should be implemented before using PIs but also believed that PIs work well for behavior problems. MDs had significantly lower knowledge of NPHIs than PhDs or NPs. Overall, NPHI knowledge was similar for PhDs and NPs, although they differed on their use of specific interventions. IMPLICATIONS: As levels of knowledge and familiarity with NPHIs differed among providers, it is conceivable that all might benefit from training and experience with a wider range of NPHIs. Future studies might evaluate the impact of a uniform understanding of NPHI on communication and teamwork in nursing homes and examine ways to enhance a multidisciplinary approach that would allow for the tailoring and individualization that is required of successful interventions.

Assessment and treatment of behavior problems in dementia in nursing home residents: a comparison of the approaches of physicians, psychologists, and nurse practitioners.

OBJECTIVE: To compare physicians (MDs), psychologists (PhDs), and nurse practitioners (NPs) regarding their approach to dementia-associated behavior problems in nursing home residents. METHODS: A web-based questionnaire solicited information about symptoms, assessment methods, suspected etiologies, and interventions with respect to the last resident treated for dementia-associated behavior problems. RESULTS: Responses were obtained from 108 MDs, 38 PhDs, and 100 NPs. All groups relied similarly on information from the nursing staff, speaking with nursing assistants, and care team meetings in assessment; NPs were more likely to consult with family members. A standard assessment instrument was used most frequently by PhDs (50%), but this generally assessed cognitive status rather than problem behaviors. PhDs most frequently noted depression in residents. Groups were similar in attributing the behavioral symptoms to dementia and to underlying medical conditions, but PhDs were more likely to indicate depression, loneliness/boredom, staff-resident communication, and insufficient activities as etiologies. Use of pharmacological and nonpharmacological interventions of MDs and NPs were similar. PhDs reported least satisfaction with treatment. CONCLUSION: Awareness of similarities and differences in the approaches of different health professionals can facilitate interdisciplinary interaction in providing care for dementia-associated behavior problems in nursing home residents.

Quality of nursing home care: perceptions of physicians, psychologists, and nurse practitioners.

Physicians, psychologists, and nurse practitioners rated the quality of nursing home care and the importance and feasibility of improvement strategies. Overall care was rated better than care of residents, followed by treatment of staff. Physicians rated care highest and nurse practitioners rated it lowest. In terms of suggestions for quality improvement, improving treatment of frontline staff and of families was rated as most important overall. We found differences across professional groups in recommended improvements, a finding that suggests the importance of interdisciplinary communication and developing an integrated viewpoint in optimizing care for older persons.

Public mental health care utilization by older adults.

The present study examined the extent to which older adults began public mental health treatment throughout Texas in 1999, the types of services they used, and how they compared on demographic and clinical variables to younger consumers. Notwithstanding recent policy and related developments, older adults were found to use public mental health services at substantially low rates, as in past decades. Significantly, older consumers tended to be relatively healthy and independent. Among younger and, even more so, older consumers, there were relatively high proportions of rural residents and minorities, groups previously found to be unlikely to utilize private mental health services. Overall, the findings urge that greater attention be devoted to public mental health outreach and service delivery with the elderly, and raise the question of what role the public mental health system should have in nursing homes and other long-term care settings.

Factors affecting deficit awareness in persons with dementia.

OBJECTIVE: This study examined factors affecting deficit awareness (DA) and the effects of diagnostic status (dementia and depression), measurement method and DA dimension on these relationships. METHODS: One hundred and twenty-one participants (66 persons with dementia and 55 persons without dementia, matched for depression diagnosis) were enrolled, each with a family informant. Participant DA (clinician and informant rated), cognitive impairment, physical illness, functional disability and caregiver burden were assessed. RESULTS: Factors affecting DA included presence of dementia, presence of depression, cognitive impairment, caregiver burden, and functional disability. The relationship between these factors and DA varied by DA dimension. CONCLUSIONS: DA measurement method was an important moderating variable; clinicians may be better at evaluating cognitive DA whereas informants may be better at evaluating functional and emotional/behavioral DA.

Accuracy of self-reported depression in persons with dementia.

OBJECTIVES: To investigate the reliability and validity of self-reported depression in demented elderly patients. DESIGN: This is the first study to combine the use of multiple depression criteria with dementia and depression control groups. SETTING: Houston Veterans Affairs nursing home and geropsychiatric inpatient unit and outpatient clinic, Baylor College of Medicine's Alzheimer's Disease Research Center. PARTICIPANTS: The total sample included 121 volunteer participants, their informants, and their clinicians, forming four diagnostic groups (27 controls, 37 dementia only, 28 depression only, 29 dementia and depression). MEASUREMENTS: Scales assessing depression, deficit awareness, physical illness, functional disability, caregiver burden, and severity of cognitive impairment were used. RESULTS: Analyses of variance using informant- and clinician-rated depression categories found main effects on patient-reported depression scores for deficit awareness and depression diagnosis but not for dementia diagnosis. Chi-square analyses revealed that demented and depressed patients underreported depression at similarly high rates compared with clinician and informant reports. Regression analyses revealed that deficit awareness accounted for significant variance in self-reported depression accuracy, whereas clinician- or informant-rated depression, severity of cognitive impairment, physical disability, functional status, and caregiver burden were not significant. CONCLUSION: The results of this investigation suggest that the presence of dementia per se does not predict inaccurate depression self-reports. Deficit awareness, which covaries with dementia, appears to account for the majority of the variance in self-report accuracy. These findings were stable across informant- and clinician-rated depression criteria and multiple analyses.

Dementia Deficits Scale. Rating self-awareness of deficits.

Impaired deficit awareness is important to detect because of its clinical implications; for example, patients with impaired awareness are more likely to engage in potentially dangerous activities, such as operating the stove. This study evaluated the reliability and validity of the Dementia Deficits Scale (DDS), a new multidimensional instrument for the assessment of self-awareness of cognitive, emotional, and functional deficits associated with dementia. Three parallel forms of the DDS were independently completed by the patient, clinician, and informant. The DDS yields two measures of deficit awareness: the discrepancy between clinician and patient assessments of the patient's deficits, and the discrepancy between informant and patient assessments. The DDS demonstrated adequate reliability and good divergent and convergent validity. Clinician and informant reports each added unique information, highlighting the importance of including both perspectives in the awareness assessment process. The DDS is recommended as a reliable and valid tool for the clinical and empirical assessment of deficit awareness in patients with dementia.

Active and passive coping strategies in chronic pain patients.

This study assessed the validity of active and passive coping dimensions in chronic pain patients (n = 76) using the Coping Strategies Questionnaire and the Vanderbilt Pain Management Inventory. The validity of active and passive coping dimensions was supported; passive coping was strongly related to general psychological distress and depression, and active coping was associated with activity level and was inversely related to psychological distress. In addition, the Coping Strategies Questionnaire was found to be a more psychometrically sound measure of active and passive coping than the Vanderbilt Pain Management Inventory.