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.

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.

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.

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.

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.

Daytime observed emotional expressions of people with dementia.

BACKGROUND: Emotional expression among people with dementia (PWD) may inform person-centered approaches to care and improvements in dementia-related quality of life. OBJECTIVES: The aim of this study was to examine frequency and variability of positive and negative emotional expressions, personal factors influencing positive and negative emotional expressions, and trajectories of emotional expression among PWD during daytime hours. METHODS: We conducted a secondary analysis of daytime positive and negative emotional expressions of 30 PWD living in residential long-term care who completed twelve 20-minute observation periods occurring hourly as part of a multi-site study of wandering behavior. Hierarchical linear modeling was used to examine relationships between influencing factors and frequency of emotional expressions; group-based trajectory analysis was applied to identify clusters of individuals with similar daytime patterns of emotional expression. RESULTS: Time of day (rate ratio [RR] = 1.05) and impaired mobility (RR = 1.37) significantly influenced positive emotional expression; gender (RR = 1.85), age (RR = 1.03), and education (RR = 0.54) were significantly related to negative emotional expression. Three distinct trajectory groups were identified for positive emotional expression: a low stable group, a fluctuating group displaying afternoon peaking, and a fluctuating group displaying morning peaking. Two trajectory groups were identified for negative emotional expression: a consistent pattern and an inconsistent pattern. DISCUSSION: PWD showed a broad range of emotional expression and significant within-person variation in daytime positive and negative emotional expressions. Observed emotional display is a promising measure of psychological well-being among PWD that, if more fully understood, could guide care approaches to improve quality of life.

Validation of the Chinese Revised Algase Wandering Scale-Community Version for persons with dementia in northern Taiwan.

OBJECTIVE: Wandering in persons with dementia is perceived as significant due to its prevalence and negative outcomes. However, lack of a validated wandering measure in Taiwan has limited scientific investigation and clinical practice. Therefore, the purpose of this study was to validate the Chinese Revised Algase Wandering Scale-Community Version (CRAWS-CV) in northern Taiwan. METHOD: For this cross-sectional study, the sample comprised 180 elders with dementia and their family caregivers (FCs). FCs responded to the CRAWS-CV in interviews with trained research assistants. RESULTS: The structure of CRAWS-CV was examined by exploratory principal component analysis with varimax rotation. This analysis derived nine factors, explaining 71.48% of variance: eloping behavior (EB), mealtime impulsivity/temporal aspects, getting lost inside the house (GLI), pacing, impulsivity, negative outcomes, random pattern (RANDOM), and getting lost outside. The total scale and subscales showed excellent internal consistency. Good construct validity was shown by significant inter-scale correlation coefficients, and significant correlations between scores on the total CRAWS-CV and its subscales with scores on the Mini-Mental State Examination and Chinese Neuropsychiatric Inventory. The receiver operating characteristic curve showed a cutoff score of 67, with sensitivity and specificity of 83.6% and 76.9%, respectively. CRAWS-CV scores were significantly different for wanderers and non-wanderers. The one-week test-retest reliability using intra-class correlation coefficients (ICCs) showed significant correlations except for the EB and RANDOM subscales. Inter-rater reliability using an ICC was significant and acceptable except for GLI. CONCLUSION: This study supports the CRAWS-CV as a valid measure of wandering in community-dwelling elders with dementia in northern Taiwan.

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.

Longitudinal investigation of wandering behavior in Department of Veterans Affairs nursing home care units.

OBJECTIVES: To explore the extent of and factors associated with male residents who change wandering status post nursing home admission. DESIGN: Longitudinal design with secondary data analyses. Admissions over a 4-year period were examined using repeat assessments with the Minimum Data Set (MDS) to formulate a model understanding the development of wandering behavior. SETTING: One hundred thirty-four Veterans Administration (VA) nursing homes throughout the United States. PARTICIPANTS: Included 6673 residents admitted to VA nursing homes between October 2000 and October 2004. MEASUREMENTS: MDS variables (cognitive impairment, mood, behavior problems, activities of daily living and wandering) included ratings recorded at residents' admission to the nursing home and a minimum of two other time points at quarterly intervals. RESULTS: The majority (86%) of the sample were classified as non-wanderers at admission and most of these (94%) remained non-wanderers until discharge or the end of the study. Fifty-one per cent of the wanderers changed status to non-wanderers with 6% of these residents fluctuating in status more than two times. Admission variables associated with an increased risk of changing status from non-wandering to wandering included older age, greater cognitive impairment, more socially inappropriate behavior, resisting care, easier distractibility, and needing less help with personal hygiene. Requiring assistance with locomotion and having three or more medical comorbidities were associated with a decreased chance of changing from non-wandering to wandering status. CONCLUSION: A resident's change from non-wandering to wandering status may reflect an undetected medical event that affects cognition, but spares mobility.

Are wandering and physically nonaggressive agitation equivalent?

OBJECTIVE: The authors examined equivalence of wandering and physically nonaggressive agitation (PNA) as concepts. DESIGN: A cross-sectional correlational design was used. SETTING: Participants were recruited from 22 nursing homes and 6 assisted living facilities in two states. PARTICIPANTS: Ambulatory residents meeting DSM-IV criteria for dementia (N = 181) were studied. MEASUREMENTS: Video-tapes for up to twelve 20-minute observations per participant were coded for wandering using an empirically derived taxonomy of ambulation patterns. Separate raters coded the same tapes for six PNA behaviors on the agitation behavior mapping instrument. RESULTS: Most participants (73.5%) wandered; all showed PNA behaviors. Factor analyses yielded an one-factor solution for wandering (explained variance = 43.66%) and a two-factor solution for PNA (explained variance = 53.45%). Overall wandering correlated significantly with PNA Factor 1 (df =179, r = 0.68, p <0.001) and Factor 2, but at a lower value (df = 179, r = 0.26, p <0.01). CONCLUSION: Findings depict wandering and PNA as overlapping, but nonequivalent phenomena. Evidence supporting construct validity of wandering was more robust than that for PNA. Results have implications for accuracy in scientific and clinical detection and labeling of wandering and agitation.

Premorbid characteristics and wandering behavior in persons with dementia.

This study aimed to explore relationships of premorbid personality and behavioral responses to stress with wandering behavior of persons with dementia in long-term care facilities. Ambulatory residents (N = 108) with dementia were selected from 21 long-term care facilities. The Mini-Mental State Examination, the NEO Five-Factor Personality Inventory, the Behavioral Responses to Stress Scale, and the Revised Algase Wandering Scale-Nursing Home Version (RAWS-NH) were used as data collection tools. When the MMSE and age were controlled, regression analyses revealed that premorbid extroversion and premorbid negative verbalization stress response were significant negative predictors for the overall RAWS-NH and some subscales.

Emotional intervention strategies for dementia-related behavior: a theory synthesis.

Behavioral disturbances of elders with dementia are prevalent. Yet the science guiding development and testing of effective intervention strategies is limited by rudimentary and often-conflicting theories. Using a theory-synthesis approach conducted within the perspective of the need-driven dementia-compromised behavior model, this article presents the locomoting responses to environment in elders with dementia (LRE-EWD) model. This new model, based on empirical and theoretical evidence, integrates the role of emotion with that of cognition in explicating a person-environment dynamic supporting wandering and other dementia-related disturbances. Included is evidence of the theory's testability and elaboration of its implications. The LRE-EWD model resolves conflicting views and evidence from current research on environmental interventions for behavior disturbances and opens new avenues to advance this field of study and practice.

"That model is sooooo last millennium!" Residential long term care as a system, not a place.

The current quandary with the design of existing long term care (LTC) settings results from focus on structures ("institutions") instead of on a system of supports and services that transcends physical and traditional boundaries across settings, including nursing homes, assisted living residences and the home. Supported by analysis of the commonalities, socio-historical and political contexts, core values and fallacies of social and medical models in existing and emerging LTC options, a holistic model is proposed based on new core values which facilitate community and family integration, and which asserts dignity and personhood as universal attributes in an array of settings.

Initial psychometric evaluation of the Wayfinding Effectiveness Scale.

This study evaluates three versions of the Wayfinding Effectiveness Scale (WES), developed to differentiate problems of wayfinding and wandering behavior of community-residing elders with dementia (EWD), in 266 dyads (EWD and caregiver) recruited from Alzheimer's Association chapters. Factor analyses yield a five-factor solution (explained variance = 62.6%): complex wayfinding goals, analytic strategies, global strategies, simple wayfinding goals, and being stimulus bound. Overall, internal consistencies are high: WES (.94-.95), and subscales are stable across all versions. Test-retest reliability is acceptable for the overall WES and two subscales (complex and simple wayfinding goals) for the care recipient current behavior version. Construct validity is supported by the pattern of correlations among subscales and analyses of variance (ANOVAs) showing significant differences among the care recipient (current vs. prior behavior) and caregiver versions overall and for all subscales. Results support the WES as a valid and reliable measure of wayfinding effectiveness in persons with dementia.

Families' perceptions of services in assisted living residences.

Assisted living residences (ALRs) are increasingly used to deliver services to older adults. Proposed policies for ALRs are gradually evolving. Although families are partners in this process, little is known about their understanding of nursing services available, compared with services needed and desired. A survey was conducted to better inform the inclusion of ALRs in Michigan's regulatory process. A total of 46 respondents reported assistance with activities of daily living as the most frequently offered ALR service. Respondents found all 13 nursing services asked about in the survey highly desirable and, for each category, the current need exceeds the availability of the service.

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.

Environmental ambiance as a new window on wandering.

This cross-sectional study explored relations between environmental ambiance and locomotion behaviors of elders with dementia (EWD), addressing the larger goal of developing theory explaining how environment affects wandering and other behaviors, thereby illuminating a pathway to intervention. A sample of 47 EWD (older than age 65, Mini-Mental State Examination [MMSE] < or =23) from nursing homes and assisted-living facilities were studied through a random, cluster, sampling strategy. Participants were measured once for stable characteristics and videotaped for 12, randomly chosen, 20-minute periods over 2 separate days at least 48 hours apart. Hierarchical liner modeling was used to analyze data that focused on the observation as the unit of analysis, with repeated observations nested within participants. Results validated an influence of ambiance on locomoting behaviors, highlighting the importance of addressing the emotional valence of social and physical environments in care of EWD.