Development and Initial Evaluation of Web-Based Cognitive Behavioral Therapy for Insomnia in Rural Family Caregivers of People With Dementia (NiteCAPP): Mixed Methods Study.

BACKGROUND: Informal caregivers of people with dementia frequently experience chronic insomnia, contributing to stress and poor health outcomes. Rural caregivers are particularly vulnerable but have limited access to cognitive behavioral therapy for insomnia (CBT-I), a recommended frontline treatment for chronic insomnia. Web-based delivery promises to improve insomnia, particularly for rural caregivers who have limited access to traditional in-person treatments. Our team translated an efficacious 4-session standard CBT-I content protocol into digital format to create NiteCAPP. OBJECTIVE: This study aimed to (1) adapt NiteCAPP for dementia caregivers to create NiteCAPP CARES, a tailored digital format with standard CBT-I content plus caregiver-focused modifications; (2) conduct usability testing and evaluate acceptability of NiteCAPP CARES' content and features; and (3) pilot-test the adapted intervention to evaluate feasibility and preliminary effects on sleep and related health outcomes. METHODS: We followed Medical Research Council recommendations for evaluating complex medical interventions to explore user needs and adapt and validate content using a stepwise approach: (1) a rural dementia caregiver (n=5) and primary care provider (n=5) advisory panel gave feedback that was used to adapt NiteCAPP; (2) caregiver (n=5) and primary care provider (n=7) focus groups reviewed the newly adapted NiteCAPP CARES and provided feedback that guided further adaptations; and (3) NiteCAPP CARES was pilot-tested in caregivers (n=5) for feasibility and to establish preliminary effects. Self-report usability measures were collected following intervention. Before and after treatment, 14 daily electronic sleep diaries and questionnaires were collected to evaluate arousal, health, mood, burden, subjective cognition, and interpersonal processes. RESULTS: The stepped approach provided user and expert feedback on satisfaction, usefulness, and content, resulting in a new digital CBT-I tailored for rural dementia caregivers: NiteCAPP CARES. The advisory panel recommended streamlining content, eliminating jargon, and including caregiver-focused content. Focus groups gave NiteCAPP CARES high usefulness ratings (mean score 4.4, SD 0.79, scored from 1=least to 5=most favorable; score range 4.2-4.8). Multiple features were evaluated positively, including the intervention's comprehensive and engaging information, caregiver focus, good layout, easy-to-access intervention material, and easy-to-understand sleep graphs. Suggestions for improvement included the provision of day and night viewing options, collapsible text, font size options, tabbed access to videos, and a glossary of terms. Pilot-test users rated usefulness (mean score 4.3, SD 0.83; range 4.1-4.5) and satisfaction (mean score 8.4, SD 1.41, scored from 1=least to 10=most satisfied; range 7.4-9.0) highly. Preliminary effects on caregiver sleep, arousal, health, mood, burden, cognition, and interpersonal processes (all P<.05) were promising. CONCLUSIONS: Adaptations made to standard digital CBT-I created a feasible, tailored digital intervention for rural dementia caregivers. Important next steps include further examination of feasibility and efficacy in a randomized controlled trial with an active control condition, a multisite effectiveness trial, and eventual broad dissemination. TRIAL REGISTRATION: ClinicalTrials.gov NCT04632628; https://clinicaltrials.gov/ct2/show/NCT04632628.

Noticing Acute Changes in Health in Long-Term Care Residents.

PURPOSE: Early signs of acute conditions and increased fall risk often go unrecognized in patients in long-term care facilities. The aim of this study was to examine how healthcare staff identify and act on changes in health status in this patient population. DESIGN: A qualitative study design was used for this study. METHODS: Six focus groups across two Department of Veterans Affairs long-term care facilities were conducted with 26 interdisciplinary healthcare staff members. Using thematic content analysis, the team preliminarily coded based on interview questions, reviewed and discussed emerging themes, and agreed on the resultant coding scheme for each category with additional independent scientist review. RESULTS: Themes included describing and explaining how "normal" or expected behavior is identified by staff, noticing changes in a resident, determining the significance of the change, hypothesizing reasons for an observed change, response to an observed change, and resolution of the clinical change. CONCLUSIONS: Despite limited training in formal assessment methods, long-term care staff have developed methods to conduct ongoing assessments of the residents. This technique, individual phenotyping, often identifies acute changes; however, the lack of formal methods, language, or tools to communicate the changes means that these assessments are not often formalized in a manner that informs the residents' changing care needs. CLINICAL RELEVANCE TO THE PRACTICE OF REHABILITATION NURSING: More formal objective measures of health change are needed to assist long-term care staff in expressing and interpreting the subjective phenotype changes into objective, easily communicated health status changes. This is particularly important for acute health changes and impending falls, both of which are associated with acute hospitalization.

Impact of Web-Based Cognitive Behavioral Therapy for Insomnia on Stress, Health, Mood, Cognitive, Inflammatory, and Neurodegenerative Outcomes in Rural Dementia Caregivers: Protocol for the NiteCAPP CARES and NiteCAPP SHARES Randomized Controlled Trial.

BACKGROUND: Chronic insomnia affects up to 63% of family dementia caregivers. Research suggests that chronic insomnia prompts changes in central stress processing that have downstream negative effects on health and mood, as well as on cognitive, inflammatory, and neurodegenerative functioning. We hypothesize that cognitive behavioral therapy for insomnia (CBT-I) will reverse those downstream effects by improving insomnia and restoring healthy central stress processing. Rural caregivers are particularly vulnerable, but they have limited access to CBT-I; therefore, we developed an accessible digital version using community input (NiteCAPP CARES). OBJECTIVE: This trial will evaluate the acceptability, feasibility, and short-term and long-term effects of NiteCAPP CARES on the sleep and stress mechanisms underlying poor caregiver health and functioning. METHODS: Dyads (n=100) consisting of caregivers with chronic insomnia and their coresiding persons with dementia will be recruited from Columbia and surrounding areas in Missouri, United States. Participant dyads will be randomized to 4 weeks (plus 4 bimonthly booster sessions) of NiteCAPP CARES or a web-based sleep hygiene control (NiteCAPP SHARES). Participants will be assessed at baseline, after treatment, and 6- and 12-month follow-ups. The following assessments will be completed by caregivers: 1 week of actigraphy and daily diaries measuring sleep, Insomnia Severity Index, arousal (heart rate variability), inflammation (blood-derived biomarkers: interleukin-6 and C-reactive protein), neurodegeneration (blood-derived biomarkers: plasma amyloid beta [Aß40 and Aß42], total tau, and phosphorylated tau [p-tau181 and p-tau217]), cognition (Joggle battery, NIH Toolbox for Assessment of Neurological and Behavioral Function, and Cognitive Failures Questionnaire), stress and burden, health, and mood (depression and anxiety). Persons with dementia will complete 1 week of actigraphy at each time point. RESULTS: Recruitment procedures started in February 2022. All data are expected to be collected by 2026. Full trial results are planned to be published by 2027. Secondary analyses of baseline data will be subsequently published. CONCLUSIONS: This randomized controlled trial tests NiteCAPP CARES, a web-based CBT-I for rural caregivers. The knowledge obtained will address not only what outcomes improve but also how and why they improve and for how long, which will help us to modify NiteCAPP CARES to optimize treatment potency and support future pragmatic testing and dissemination. TRIAL REGISTRATION: ClinicalTrials.gov NCT04896775; https://clinicaltrials.gov/ct2/show/NCT04896775. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/37874.

Using Telehealth to Deliver Cognitive Behavioral Treatment of Insomnia to a Caregiver of a Person With Alzheimer's Disease.

Cognitive behavioral therapy for Insomnia (CBT-I) is the gold standard treatment for insomnia. There is limited access to qualified providers to deliver CBT-I; moreover, there are patient populations who struggle with access to insomnia care due to limited time and resources. This includes caregivers for persons with Alzheimer's disease, for whom sleep disturbance is a common concern. Utilizing telehealth to deliver CBT-I may be particularly important for vulnerable populations such as caregivers of persons with dementia, as it can offer an accessible, safe, and cost-effective treatment option that can be tailored to meet the needs of a specific population. This case study illustrates the successful implementation of a four-session CBT-I protocol through telehealth with a caregiver of a person with Alzheimer's disease. Given the success of this case and the conditions for psychological care the recent pandemic has created, continued research into the efficacy of sleep-related interventions through telehealth is warranted.

Characteristics of Nursing Home Resident Movement Patterns: Results from the TEAM-UP Trial.

OBJECTIVE: To determine movement patterns of nursing home residents, specifically those with dementia or obesity, to improve repositioning approaches to pressure injury (PrI) prevention. METHODS: A descriptive exploratory study was conducted using secondary data from the Turn Everyone And Move for Ulcer Prevention (TEAM-UP) clinical trial examining PrI prevention repositioning intervals. K-means cluster analysis used the average of each resident's multiple days' observations of four summary mean daily variables to create homogeneous movement pattern clusters. Growth mixture models examined movement pattern changes over time. Logistic regression analyses predicted resident and nursing home cluster group membership. RESULTS: Three optimal clusters partitioned 913 residents into mutually exclusive groups with significantly different upright and lying patterns. The models indicated stable movement pattern trajectories across the 28-day intervention period. Cluster profiles were not differentiated by residents with dementia (n = 450) or obesity (n = 285) diagnosis; significant cluster differences were associated with age and Braden Scale total scores or risk categories. Within clusters 2 and 3, residents with dementia were older (P < .0001) and, in cluster 2, were also at greater PrI risk (P < .0001) compared with residents with obesity; neither group differed in cluster 1. CONCLUSIONS: Study results determined three movement pattern clusters and advanced understanding of the effects of dementia and obesity on movement with the potential to improve repositioning protocols for more effective PrI prevention. Lying and upright position frequencies and durations provide foundational knowledge to support tailoring of PrI prevention interventions despite few significant differences in repositioning patterns for residents with dementia or obesity.

Cognitive Function and Sleep in Caregivers of Persons Living with Dementia.

Poor sleep is prevalent among caregivers of persons living with dementia and increases their risk for cognitive impairment and decline. In this cross-sectional, correlational study, we compared the cognitive function scores of caregivers with poor sleep with the demographically adjusted normed scores of the National Institutes of Health Toolbox Cognition Battery. Caregivers completed a 14-day sleep diary. On average, caregivers (n = 28) were 65.14 (±10.08) years, female, and White. Their average crystallized cognitive function composite score was significantly higher and their average fluid cognitive function composite score was significantly lower than the normative scores. Caregivers performed significantly worse on the processing speed domain measure. Poor sleep may affect how caregivers, including highly educated caregivers, process and respond to information, thus can influence how they safely perform complex caregiving tasks. Health care providers should consistently assess caregivers' sleep and cognitive abilities to promptly identify changes and provide timely interventions.

To Turn or Not to Turn: Exploring Nurses' Decision-Making Processes Concerning Regular Turning of Nursing Home Residents.

Background: Nursing home (NH) residents are at high-risk for pressure injuries (PrIs), and those living with Alzheimer's Disease and Related Dementias (ADRD) are at even greater risk. Understanding how nursing staff approach repositioning remains critical. Methods: As part of an ongoing clinical trial, this mixed-method prospective, exploratory, descriptive study examined repositioning efforts for PrI prevention. An investigator-developed checklist guided researcher observations, and focus groups revealed staff perspective on resident behaviors and corresponding repositioning approaches. Focus group transcripts were analyzed using the constant comparative coding method. Results: Repositioning observations were conducted for 88 residents. Resident behaviors and nursing approaches were similar between the ADRD (n = 62, 70%) and non-ADRD (n = 26, 30%) groups. Thirty-six staff participated in one of six focus group sessions. A conceptual model was developed to depict the repositioning process. Staff revealed care is guided by clinical frameworks and guidelines, along with resident preferences and behaviors. Conclusions: Protocol-driven, standardized PrI prevention care may limit the capacity to honor repositioning preferences. Insights from the focus groups highlight the importance of being cognizant of competing factors that may interfere with successful repositioning. Approaches by staff may be protocol-driven or an integrated method of care.

A research proposal testing a new model of ambulation activity among long-term care residents with dementia/cognitive impairment: the study protocol of a prospective longitudinal natural history study.

BACKGROUND: Excessive and patterned ambulation is associated with falls, urinary tract infections, co-occurring delirium and other acute events among long-term care residents with cognitive impairment/dementia. This study will test a predictive longitudinal data model that may lead to the preservation of function of this vulnerable population. METHODS/DESIGN: This is a single group, longitudinal study with natural observations. Data from a real-time locating system (RTLS) will be used to objectively and continuously measure ambulation activity for up to 2 years. These data will be combined with longitudinal acute event and functional status data to capture patterns of change in health status over time. Theory-driven multilevel models will be used to test the trajectories of falls and other acute conditions as a function of the ambulation activity and demographic, functional status, gait quality and balance ability including potential mediation and/or moderation effects. Data-driven machine learning algorithms will be applied to run screening of the high dimensional RTLS data together with other variables to discover new and robust predictors of acute events. DISCUSSION: The findings from this study will lead to the early identification of older adults at risk for falls and the onset of acute medical conditions and interventions for individualized care.

CE: Original Research: New Acute Symptoms in Older Adults with Cognitive Impairment: What Should Family Caregivers Do?

: Background: When older adults with cognitive impairment develop new physical or behavioral symptoms, their family caregivers face a difficult decision: whether and when to seek professional medical care. Most family caregivers lack formal training in assessment and may have difficulty making such decisions. The Veterans Health Administration's home-based primary care (HBPC) program, which is widely available, offers community-dwelling frail veterans and their family caregivers guidance, with the goal of reducing hospitalization and institutionalization in long-term care facilities. OBJECTIVE: This study sought to assess the frequency with which family caregivers of cognitively impaired older adults sought prehospital guidance from health care professionals when that resource was available to them, and to describe the characteristics of such events. METHODS: This study used a retrospective chart review of patients who were enrolled in the Orlando Veterans Affairs Medical Center HBPC program for at least one month between October 1, 2013, and September 30, 2014; had a diagnosis indicative of cognitive impairment (Alzheimer's disease, vascular dementia, or mild cognitive impairment); had a dedicated family caregiver; and were not enrolled in hospice care. Data were collected from data collection templates and nurses' narrative notes. Univariate descriptive analyses were conducted regarding the type of staff contacted by family caregivers, the presenting diagnoses, the guidance offered by staff, and the number of unplanned acute care encounters. RESULTS: Among the 215 patients studied, there were 254 unplanned acute care encounters (including ED visits followed by discharge to home and ED visits resulting in hospital admission). Family caregivers sought guidance from a health care professional 22% of the time before such an encounter. The presenting clinical issues were most often new problems (43%) that included falls, feeding tube problems, fever, new pain, rash or other skin problems, and unexplained edema. Overall, 25% of all unplanned acute care encounters were for reasons considered potentially avoidable. About half of the patients who were subsequently hospitalized had symptoms of delirium, indicating that their illness had significantly advanced before presentation. CONCLUSIONS: It's important for health care professionals to ensure that family caregivers of cognitively impaired older adults can access professional guidance readily when facing decisions about a loved one's care, especially when there is an acute onset of new symptoms. Teaching caregivers how to recognize such symptoms early in order to prevent exacerbations of chronic illness and subsequent hospitalization should be a high priority. Our findings underscore the need to do so, so that caregivers can best use the resources that HBPC programs have (or ought to have) in place, in particular 24/7 guidance and decision assistance.

Wandering Behaviors and Activities of Daily Living Among Older Adults With Cognitive Impairment.

PURPOSE: The aim of the study was to examine the characteristics of wandering associated with preserved versus worsened activities of daily living (ADL) function. DESIGN: Longitudinal prospective design. Twenty-two cognitively impaired residents of an assisted living facility with over 450 observations were followed up to 8 months. METHODS: Hierarchical linear modeling techniques examine how wandering activity (episodes, distance traveled, gait speed), measured by a real-time locating system, may affect ADL (the Barthel index, the Functional Independence Measure [FIM]). FINDINGS: Wandering episodes were associated with increased ADL (B = 0.11, p ≤ .05, FIM); wandering distance (B = -4.52, p ≤ .05, the Barthel index; B = -2.14, p ≤ .05, FIM) was associated with decreased ADL. CONCLUSION: Walking an average of 0.81 miles per week with 18 or fewer wandering episodes is associated with decreased ability to perform ADL. CLINICAL RELEVANCE: Tailored protocols that allow productive wandering with ongoing assessment for fatigue/other physiological needs to appropriately limit distance walked within wandering episodes are needed for this population.

The Physical and Cognitive Performance Test for Residents in Assisted Living Facilities.

OBJECTIVES: To develop and evaluate the psychometric properties of a new performance-based instrument (Physical and Cognitive Performance Test for Assisted Living Facilities (PCPT ALF)) designed to assess the physical and cognitive skills associated with performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). DESIGN: There were three stages in this study: development of instrument items and validity testing, a feasibility pilot study, and a cross-sectional trial to establish construct and criterion validity and reliability. SETTING: One 116-bed assisted living facility (ALF). PARTICIPANTS: After a pilot test with 10 residents, a cross-sectional trial was conducted with 55 additional residents. MEASUREMENTS: The Barthel Index and Functional Independence Measure were used to estimate criterion validity. Construct validity was examined using exploratory factor analyses (EFAs). RESULTS: Disattenuated correlations between the PCPT ALF and other tools were all greater than 0.72, supporting criterion validity. Internal consistency (physical ability, α = 0.95; cognitive support, α = 0.92) and 1-week test-retest reliability (PCPT ALF, P = .93) were high, as was interrater reliability (IRR) (physical ability, 0.99; cognitive support, 1.00). In two EFAs, a one-factor solution accounted for 64.1% of the variance for the physical ability subscale and 63.5% of the variance for the cognitive support subscale. CONCLUSION: The findings provide early evidence of the PCPT ALF's validity and reliability. If confirmed, this study's findings may be used in future work to assess the success of interventions to prevent or slow decline in the skills associated with ADL and IADL performance in ALFs.

Intraindividual Changes in Ambulation Associated With Falls in a Population of Vulnerable Older Adults in Long-Term Care.

OBJECTIVE: To examine how intraindividual changes in ambulation characteristics may be used to predict falls. DESIGN: Longitudinal study design. SETTING: Assisted living facility. PARTICIPANTS: Ambulatory older adults (N=26; mean age, 79y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Continuous measure of average weekly ambulation characteristics (time and distance walked, speed, path measures [eg, path time and distance, number of paths (where a path is at least 60s of uninterrupted walking separated by at least a 30-s stop)]), accounting for weekly changes in these ambulation characteristics on an individual level over time along with falls (yes/no) and cognitive impairment (CI) (measured by the Montreal Cognitive Assessment). RESULTS: In hierarchical linear models accounting for intraindividual changes in ambulation characteristics over the 8-month course of the study and level of CI, path distance (odds ratio, 1.02; P≤.001) was associated with an increased risk of a fall. In the short-term, intraindividual changes in path distance were associated with a fall within the 4-week interval the change was noted. Path distance had fair sensitivity (.74) and specificity (.66) to a fall (area under the curve, .70). CONCLUSIONS: Study findings suggest that falls may have specific predictors, specifically that older adults with CI are more likely to fall when walking continuously with little/no breaks. Interventions focused on reducing path-associated fatigue may effectively reduce fall incidence in this population.

Enhancing the Communication of Suddenly Speechless Critical Care Patients.

BACKGROUND: Sudden speechlessness is common in critically ill patients who are intubated or have had surgery for head and neck cancer. Sudden inability to speak poses challenges for hospitalized patients because strategies to facilitate communication are often limited and unreliable. OBJECTIVE: To determine the impact of a technology-based communication intervention on patients' perception of communication difficulty, satisfaction with communication methods, and frustration with communication. METHODS: A quasi-experimental, 4-cohort (control and intervention) repeated-measures design was used. Data were collected daily for up to 10 days. Patients in adult critical care units were followed up as they were transferred to other units within the institutions selected for the study. The impact of a technology-based communication system (intervention) was compared with usual care (control). Patients' communication outcomes pertinent to communication with nursing staff that were evaluated included perception of communication ease, satisfaction with methods used for communication, and frustration with communication. RESULTS: Compared with participants in the control group, participants in the intervention group reported lower mean frustration levels (-2.68; SE, 0.17; 95% CI, -3.02 to -2.34; P < .001) and higher mean satisfaction levels (0.59; SE, 0.16; 95% CI, 0.27 to 0.91; P < .001) with use of the communication intervention. Participants in the intervention group reported a consistent increase in perception of communication ease during the hospital stay. CONCLUSIONS: The results facilitated evaluation of a bedside technology-based communication intervention tailored to the needs of suddenly speechless critically ill patients.

Field Evaluations of Tracking/Locating Technologies for Prevention of Missing Incidents.

BACKGROUND: Persons with dementia are at risk of a missing incident, which is defined as an instance in which a demented person's whereabouts are unknown to the caregiver and the individual is not in an expected location. Since it is critical to determine the missing person's location as quickly as possible, we evaluated whether commercially available tracking technologies can assist in a rapid recovery. METHODS: This study examined 7 commercially available tracking devices: 3 radio frequency (RF) based and 4 global positioning system (GPS) based, employing realistic tracking scenarios. Outcome measures were time to discovery and degree of deviation from a straight intercept course. RESULTS/CONCLUSION: Across all scenarios tested, GPS devices were found to be approximately twice as efficient as the RF devices in locating a "missing person." While the RF devices showed reasonable performance at close proximity, the GPS devices were found to be more appropriate overall for tracking/locating missing persons over unknown and larger distances.

Changes in Sleep Predict Changes in Affect in Older Caregivers of Individuals with Alzheimer's Dementia: A Multilevel Model Approach.

OBJECTIVES: Understanding predictors of older dementia caregivers' mood could provide insight into potential treatments which may delay institutionalization of their care recipient. Research with older noncaregivers has shown that nights characterized by better subjective sleep were associated with days characterized by higher positive and lower negative affect, and vice versa. Examining daily relationships is important, as sleep and affect are state-like behaviors that fluctuate within individuals, across time. This study was a preliminary examination of whether a sample with a greater proportion of older dementia caregivers exhibits similar daily sleep/affect associations. METHODS: Sleep diaries, actigraphy, and affect data were collected concurrently for 7 days in 55 community-dwelling, dementia caregivers (M = 62.80 years, SD = 12.21; 77.8% female). Sleep and affect were examined within- (day-to-day level) and between-persons (mean level). RESULTS: Findings for older noncaregivers were replicated for negative affect only. Specifically, nights characterized by better subjective sleep were characterized by lower negative affect, and vice versa. DISCUSSION: Examining older caregivers' daily sleep/affect association is important, because caregiving-related awakenings are unavoidable, often unpredictable, and can impact mood. Future research is needed to examine whether regularization in awakenings and/or negative affect represent important secondary, or even target, treatment outcomes for this vulnerable population.

Patterns of Disruptive Feeding Behaviors in Infants With Neonatal Abstinence Syndrome.

BACKGROUND: Severe irritability in infants with neonatal abstinence syndrome often impacts their ability to feed successfully, which challenges a mother's ability to demonstrate this most basic parenting skill. There is little empiric evidence to guide recommendations for practice in this population. PURPOSE: Describe the infant behaviors that disrupt feeding in infants with neonatal abstinence syndrome. METHODS: A mixed-method approach was used to describe digitally recorded infant feeding behaviors. Qualitative methodology was first used to identify categories of behaviors during the feeding. The categories were used as a coding scheme to identify the temporal sequence, duration, and frequency of behaviors observed during a feeding. RESULTS: The behavior categories that disrupted feeding were identified as fussing, resting, crying, and sleeping/sedated. Infants spent almost twice as much time in fussing as in feeding. The majority of the infants were fussing between 1 and 11 minutes during the feeding, and fussing disrupted feeding in every subject at least once. Feeding behavior occurred only 24% of the time, while fussing and crying occurred 51%. Fussing was the primary transitional behavior from one category to another. Infants who did not complete their feeding had nearly twice the mean number of fussing episodes as those who completed their feeding. IMPLICATIONS FOR PRACTICE: Fussing is a transitional state and appears to provide an opportunity to test interventions that help the mothers re-engage their infants in feeding. The frequency of the behavioral transitions provides a measure of irritability that has not been previously described in this population. IMPLICATIONS FOR RESEARCH: Additional study is needed to evaluate the impact and contributions of maternal behaviors and external variables on infant behavioral transition.

Characteristics of and Barriers to Functional Status Assessment in Assisted Living.

The most commonly used functional status (FS) instruments were examined to determine the validity, reliability, sensitivity, and specificity to change and feasibility in residents in an assisted living facility (ALF). Twenty-six ALF residents were assessed weekly for up to 8 months using six instruments. Group and single-subject analyses were used to examine associations between instruments and acute events. Two were problematic initially (Katz Index of Independence in Activities of Daily Living and hand grip) and were excluded early in the study. Of the remaining instruments, only the Barthel Index and Resident Assessment Instrument had acceptable psychometric profiles. However, these instruments were either not feasible in this environment or did not capture the full range of FS in this population. The current study's findings suggest that instruments commonly used to measure FS may be inadequate for this population and environment. These findings may be used to develop assessment methods for ALF residents that capture both the full range of FS in ALF settings as well as acute and long-term changes in functioning.

The Concept of Missing Incidents in Persons with Dementia.

Behavioral symptoms of dementia often present the greatest challenge for informal caregivers. One behavior, that is a constant concern for caregivers, is the person with dementia leaving a designated area such that their whereabouts become unknown to the caregiver or a missing incident. Based on an extensive literature review and published findings of their own research, members of the International Consortium on Wandering and Missing Incidents constructed a preliminary missing incidents model. Examining the evidence base, specific factors within each category of the model were further described, reviewed and modified until consensus was reached regarding the final model. The model begins to explain in particular the variety of antecedents that are related to missing incidents. The model presented in this paper is designed to be heuristic and may be used to stimulate discussion and the development of effective preventative and response strategies for missing incidents among persons with dementia.

Sleep and Cognition in Community-Dwelling Older Adults: A Review of Literature.

Changes in sleep and cognition occur with advancing age. While both may occur independently of each other, it is possible that alterations in sleep parameters may increase the risk of age-related cognitive changes. This review aimed to understand the relationship between sleep parameters (sleep latency, wake after sleep onset, sleep efficiency, sleep duration, general sleep complaints) and cognition in community-dwelling adults aged 60 years and older without sleep disorders. Systematic, computer-aided searches were conducted using multiple sleep and cognition-related search terms in PubMed, PsycINFO, and CINAHL. Twenty-nine manuscripts met the inclusion criteria. Results suggest an inconsistent relationship between sleep parameters and cognition in older adults and modifiers such as depressive symptoms, undiagnosed sleep apnea and other medical conditions may influence their association. Measures of sleep and cognition were heterogeneous. Future studies should aim to further clarify the association between sleep parameters and cognitive domains by simultaneously using both objective and subjective measures of sleep parameters. Identifying which sleep parameters to target may lead to the development of novel targets for interventions and reduce the risk of cognitive changes with aging.

Nurses' experiences of communicating with hospitalized, suddenly speechless patients.

We used a qualitative focus group design to explore the experiences and challenges of nurses who work with hospitalized patients experiencing the sudden inability to verbalize their needs, also known as sudden speechlessness. In response to open-ended questions in facilitated focus groups, 18 nurses discussed issues around the care and communication needs of suddenly speechless (SS) patients. Nurses identified multiple, commonly occurring communication challenges when caring for SS patients. They believed these challenges led to poorer recognition of patient needs, with the potential for compromised patient care. Nurses described how the lack of reliable strategies to facilitate communication sometimes resulted in negative patient outcomes, including unmet psychosocial needs and the potential that informed consent and educational issues were being inadequately addressed for the SS patients. Even experienced nurses indicated ongoing problems in communicating with SS patients, despite using a multitude of strategies, leaving many to deal with issues of frustration and role conflict.