Cardiopulmonary resuscitation policies and practices. A statewide nursing home study.

We determined the prevalence of written cardiopulmonary resuscitation policies in North Carolina nursing homes and evaluated their content according to predetermined criteria. Questionnaires were mailed to 236 state-registered facilities. Two hundred nine nursing homes (88.5%) responded to the questionnaire; 83% reported having a written policy, and half (86 nursing homes) provided copies. Nine of ten nursing homes reported that cardiopulmonary resuscitation was performed at their institution, and a similar number (92%) permitted physician orders restricting cardiopulmonary resuscitation. Written policies were systematically compared with 10 model criteria. Policy content varied substantially. More than half of the policies contained provisions for authorization, informed consent, documentation, competency, review, and applicability of do not resuscitate orders. Less than half contained criteria for autonomy, treatment alternatives, dignity and quality of care, and patient identification. Nursing homes that had written policies were newer, larger, and for-profit; had a greater proportion of skilled nursing care beds; and were more likely to have both Medicare and Medicaid certification. The variations in these policies place nursing home residents at risk for having important personal rights limited or ignored. Inclusion of these 10 policy criteria in a comprehensive cardiopulmonary resuscitation policy would represent an important step toward enhancing the quality of decision making by nursing home residents.

Caregiver time use: an outcome measure in clinical trial research on Alzheimer's disease.

OBJECTIVE: To assess whether unpaid caregiver time and paid professional time increase as cognitive impairment associated with Alzheimer's disease increases and to evaluate the utility of caregiver time as an additional outcome measure in clinical trial research of Alzheimer's disease. METHODS: This was a 24-week, double-blind, multicenter, parallel-group, placebo-controlled study conducted at 17 clinical outpatient sites by Hoechst-Roussel Pharmaceuticals Inc. A total of 449 patients older than 40 years with probable Alzheimer's disease of mild to moderate severity (criteria of the National Institute for Neurological and Communicative Disorders and Stroke--Alzheimer's Disease and Related Disorders Association) entered the study, and 284 completed both baseline and week 24 data collection. A total of 160 caregivers completed time allocation surveys at baseline and at 24 weeks. Patients with Alzheimer's disease received 150 mg/day and 225 mg/day Velnacrine maleate (parallel-group treatment) and placebo. Cognitive function was measured with use of cognitive and noncognitive subscales of the Alzheimer's Disease Assessment Scale (ADAS). Unpaid caregiver and paid professional time use were measured with use of the Caregiver Activities Time Survey (CATS). RESULTS: Unpaid caregiver time per day increased significantly with cognitive impairment at baseline as measured by the ADAS cognitive and noncognitive components. Velnacrine therapy significantly improved cognitive function relative to placebo, and this was associated with decreased unpaid caregiving time at trend levels. Specifically, caregivers of patients in the high-dose velnacrine group (225 mg/day) experienced a partial release from their time involvements, especially in the area of patient supervision, by an average of 3.3 hours per day. CONCLUSIONS: To our knowledge, this study represents the first time that the ADAS has been linked to a caregiver outcome. Results suggest that unpaid caregiver time allocation is sensitive to changes in cognitive function and therefore may be useful as an additional outcome measure in clinical trials of pharmaceutical interventions for Alzheimer's disease.

Linking combat and physical health: the legacy of World War II in men's lives.

OBJECTIVE: This longitudinal study investigated the health effects of experiences during World War II among veterans by examining how well-being changed across the postwar years and varied by prewar individual attributes. METHOD: The subjects were men from the Stanford-Terman data archives who served in World War II and were born before 1925 (N = 328). Of these veterans, 236 were known to have been overseas during the war, and 64 had remained in the United States; 204 of the men who had been sent overseas experienced combat. Life history records were used to construct measures that described physical and emotional health over a range of time points and intervals in the postwar years. RESULTS: Exposure to combat predicted that a subject would experience physical decline or death during the postwar interval from 1945 to 1960, after the effects of self-reported physical health in 1945 and birth cohort were controlled. Rank and theater of engagement, however, were of little consequence, either additively or in interaction with combat. Self-worth before the war did not moderate the risk of physical decline or death that was associated with combat. CONCLUSIONS: Combat in World War II predicted that in the 15 years after the war, a subject would experience physical decline or death. There was no evidence that the effect of combat was more pronounced among men of different ranks, theaters of engagement, or levels of self-worth in 1940.

A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity.

Inappropriate medication prescribing is an important problem in the elderly, but is difficult to measure. As part of a randomized controlled trial to evaluate the effectiveness of a pharmacist intervention among elderly veterans using many medications, we developed the Medication Appropriateness Index (MAI), which uses implicit criteria to measure elements of appropriate prescribing. This paper describes the development and validation of a weighting scheme used to produce a single summated MAI score per medication. Using this weighting scheme, two clinical pharmacists rated 105 medications prescribed to 10 elderly veterans from a general medicine clinic. The summated score demonstrated acceptable reliability (intraclass correlation co-efficient = 0.74). In addition, the summated MAI adequately reflected the putative heterogeneity in prescribing appropriateness among 1644 medications prescribed to 208 elderly veterans in the same general medicine clinic. These data support the content validity of the summated MAI. The MAI appears to be a relatively reliable, valid measure of prescribing appropriateness and may be useful for research studies, quality improvement programs, and patient care.

Psychotropic drug use among caregivers of patients with dementia.

The majority of research on "caregiver burden" focuses on mental health consequences. These stresses are associated with psychotropic drug use among some caregivers. The purposes of this paper are to identify the correlates of psychotropic drug use among caregivers of demented older adults and to determine whether or not certain types of psychotropics (ie, antianxiety, antidepressant, and sedative/hypnotic agents) have common or unique correlates. The prevalence of psychotropic drug use among caregivers in the sample (n = 510) is substantially higher than previously reported prevalence rates in the general population and among community-dwelling elderly. Using logistic regression techniques, caregiver characteristics (eg, gender, health, relationship to the patient) rather than severity of the patient's condition emerge as predictors of antianxiety, antidepressant, and sedative/hypnotic use. The caregiver's perception of how well he or she is supported in the caregiving role emerges as an important correlate of psychotropic drug use in general and especially of antidepressant consumption. Results suggest that caregivers are a high-risk group for the development of emotional symptoms such as nervousness, exhaustion, decreased appetite, and difficulty sleeping, symptoms that may or may not constitute a psychiatric disorder. Characteristics of the caregiver, especially aspects of the support system, should be important considerations in decisions to prescribe psychotropic drugs.

Preparing for the end of life: preferences of patients, families, physicians, and other care providers.

To examine patients', families', and health care providers' preferences regarding preparation for the end of life, attributes of preparation were generated in qualitative focus group discussions and subsequently tested for generalizability in a quantitative national survey. Respondents from all groups showed consensus on the importance of naming someone to make decisions, knowing what to expect about one's physical condition, having financial affairs in order, having treatment preferences in writing, and knowing that one's physician is comfortable talking about death and dying. Patients were more likely than physicians to want to plan funerals and know the timing of death and less likely than all other groups to want to discuss personal fears. Participants in care of dying patients agree overwhelmingly with the importance of preparation. However, significant barriers to preparation impede it from being a common part of clinical encounters. Further research and training are needed to ensure that the desire for greater preparation is translated into improved action toward preparation in medical practice.

When war comes to men's lives: life-course patterns in family, work, and health.

Men generally come to military service at a time of youth. However, the Second World War expanded the period of service eligibility from age 18 to the late 30s. Each year of delay in entry promised a smaller return from military service (economic and job benefits) and a greater risk of life disruption and related costs. Using longitudinal data from the Stanford-Terman sample, the authors examine whether social disruptions resulting from late service entry increased the risk of adverse change in adult health. Apart from preservice factors, the authors found that the late-mobilized men were at greatest risk of negative trajectories on physical health. Work-life disadvantages account in part for this health effect. Pathways that link stress and physical decline are discussed in relation to social disruption.

Dementia and cancer: a comparison of spouse caregivers.

Can prominent themes that have emerged in dementia caregiving research be extrapolated to caregivers of persons with other chronic illnesses such as cancer? To answer this question, the present study compared 272 spouse caregivers of dementia sufferers with 30 spouse caregivers of cancer victims on multiple indicators of well-being. Group contrasts using MANOVA revealed that dementia caregivers were more adversely affected by their role than cancer caregivers. Illness duration and caregivers' employment status did not help to explain this difference, yet caregiver age was a robust covariate. Specifically, younger spouse caregivers were significantly more compromised than older spouse providers.

Resident smoking in long-term care facilities--policies and ethics.

OBJECTIVE: To characterize smoking behavior, facility policies related smoking, and administrators' views of smoking-related problems in Veterans Affairs nursing home care units nationwide. METHODS: An anonymous mail survey of long-term care facilities was administered to 106 nursing home supervisors at VA Medical Centers with nursing home care units. The response rate was 82%. RESULTS: Administrators from 106 VA nursing home units reported smoking rates ranging from 5% to 80% of long-term care residents, with an average of 22%. Half of the nursing homes had indoor smoking areas. Frequent complaints from nonsmokers about passive smoke exposure were reported in 23% of the nursing homes. The nursing administrators reported that patient safety was their greatest concern. Seventy- eight percent ranked health effects to the smokers themselves a "major concern," while 70% put health effects to exposed nonsmokers in that category. Smoking in the nursing home was described as a "right" by 59% of respondents and a "privilege" by 67%. Some individuals reported that smoking was both a right and a privilege. CONCLUSION: Smoking is relatively common among VA long-term care patients. The promotion of personal autonomy and individual resident rights stressed in the Omnibus Budget Reconciliation Act of 1987 may conflict with administrative concerns about the safety of nursing home smokers and those around them.

Informal costs of dementia care: estimates from the National Longitudinal Caregiver Study.

OBJECTIVES: The purpose of the study was to examine on a national level the informal costs of caring for elderly community-dwelling male veterans with dementia by female caregivers and the relationships between informal costs and disease severity, and between informal costs and dementia problem behaviors. METHODS: Female primary caregivers were drawn from the first wave (N = 2043) of the National Longitudinal Caregiver Study, a survey of informal caregivers of elderly male veterans diagnosed with probable Alzheimer's disease or vascular dementia. Cost measures include the following four items: value of caregiving time, caregiver's lost income, out-of-pocket expenditures for formal caregiving services, and caregiver's excess health costs. Disease severity was indexed by the number of impairments in activities of daily living. Patient's problem behaviors were measured using the Behavior Rating Scale-Dementia. RESULTS: The annual cost of providing informal care to elderly community-dwelling veterans with dementia was estimated to be $18,385 per patient in 1998. The larger components of this cost are caregiving time ($6,295) and caregiver's lost earnings ($10,709). All aspects of costs increase with disease severity and problem behavior. Most of this cost increase derives from the increased caregiving time required for the provision of physical care. DISCUSSION: This study provides a comprehensive estimate of the excess costs that result from providing informal dementia care in the community. Unlike previous studies, our estimates excluded costs that caregivers would have incurred if they had not been caregivers. Therefore, results reported here reflect only costs due to informal dementia care.

Worklives and longevity: insights from a life course perspective.

Recent research on work stress has focused heavily on how the demands and rewards of single jobs influence health or mortality, but has left the implications of broader patterns of worklives largely uninvestigated. Life history data from the Stanford-Terman study is used in this research to explore patterns of career mobility among middle-class men and the implications of these patterns for their longevity. While relatively few men in this study experienced a period in which they moved through a series of unrelated jobs, those who did had a higher mortality risk. Similarly, men who progressed early in their careers but then remained stable in later periods tended to be at a greater risk than those who progressed in both time periods. Health and lifestyle measures were also significant predictors of mortality risk, but did not account for the observed impact of worklife patterns on mortality. We discuss the implications of these findings for understanding the work-health relationship.

Wartime losses and social bonding: influences across 40 years in men's lives.

By 1990 over half of all American men entering the retirement years will be veterans with a life history shaped by participation in the Armed Forces. This investigation traces the burden of war mortality and social bonding across the life span of 149 veterans of World War II and the Korean conflict. These veterans come from longitudinal samples at the Institute of Human Development, University of California, Berkeley. Data were also obtained from the record of a Marine unit that served on Iwo Jima. The study is organized around two lines of inquiry. The first examines the relationship between combat and social ties, with emphasis on exposure to combat deaths, the loss of comrades/friends, and postwar stress reactions. The second concerns the healing potential of social ties with service friends and spouses in later life. According to the analysis, heavy combat veterans are more likely than other veterans to have enduring ties from the service. But combat experience alone does not explain these ties; it is war trauma and especially the loss of significant others during war, both comrades and friends, that intensify and maintain postwar relationships. Painful memories of war and stress symptoms in later life are likely to weaken through exposure to a supportive community of service mates and spouses, an effect that suggests the healing potential of periodic reunions of the primary military unit and marital sharing.

A comparison of educational methods to enhance nursing performance in pain assessment.

The purpose of this study was to identify an effective method of teaching nurses to assess and document pain severity using a numerical rating scale prior to narcotic administration. Nurses received a combination of educational methods. Although overall nurse performance using the pain scale was low, nurses receiving video were significantly more likely to use the scale, a finding that remained significant after controlling for nurses' education and years of experience, and for patient age and acuity.

The effect of spousal caregiving and bereavement on depressive symptoms.

The objective of the study was to determine whether spousal caregiving and bereavement increases caregiver depressive symptoms. We followed 1,967 community-dwelling elderly couples from the 1993 Health and Retirement Study (HRS) until 2002 (five bi-annual surveys) or death. Depressive symptoms were measured by the Center for Epidemiological Studies-Depression (CESD) scale. Adjusted depressive symptoms were higher for females for three of the four caregiving arrangements tested (as were unadjusted baseline levels). Depressive symptoms were lowest when neither spouse received caregiving (adjusted CESD of 2.97 for males; 3.44 for females, p<0.001). They were highest when females provided care to their husband with assistance from another caregiver, (4.01) compared to (3.37; p<0.001) when males so cared for their wife. A gender by caregiving arrangements interaction was not significant (p=0.13), showing no differential effect of caregiving on CESD by gender. Depressive symptoms peaked for bereaved spouses within three months of spousal death (4.67; p<0.001) but declined steadily to 2.75 (p<0.001) more than 15 months after death. Depressive symptoms initially increased for the community spouse after institutionalization of the care recipient, but later declined. We conclude that caregiving increases depressive symptoms in the caregiver, but does not have a differential effect by gender. Increases in depressive symptoms following bereavement are short-term.

Caregiver needs and patterns of social support.

Levels of caregiver need were used to predict four patterns of continuity and change in social support over a one-year interval among 376 adults caring for a family member with Alzheimer's disease. Canonical correlation analysis was used to identify predictors of each support pattern from selected caregiver characteristics and needs (i.e., demographics, financial resources, physical and mental health, social and recreational activities, and aspects of the caregiving situation). Three significant canonical variates emerged for each type of support, instrumental and perceived adequacy of support, correctly classifying more than half of the caregiver sample. Results suggest that caregiver need does not necessarily elicit support. Needs do, however, predict several patterns of social support, the most common of which is characterized by stability (high or low support). Depending on type of support (instrumental or perceived adequacy), different configurations of predictors emerge.

Elderly confidants in geriatric assessment.

This study focuses on patterns of consensus between linked samples (focal person and confidant; total n = 124) for the purpose of explaining divergent reports and of assessing this design's utility in geriatric case assessment. Correlations, difference scores and group contrasts suggest that elderly informants who are also confidants can describe most internal states of their partners as these states are self-reported. Partners differed however, on ratings of self-esteem; confidant scores were significantly higher than self-ratings. Under certain conditions self-other discrepancy also occurs on spouse ratings of functional health: in early stages of decline and in marriages judged by clinicians to be of poor quality. This pattern is absent in pairs with women friends. The findings suggest that losses and age-related limitations have the potential to erode the self-esteem of older people and that linked samples would strengthen the process of functional assessment by bringing special information to the clinician.

Patients with cancer and their spouse caregivers. Perceptions of the illness experience.

This study focuses on patterns of response between patients with cancer and their spouse caregivers to examine the reliability of spouse informants in research and clinical settings. Thirty dyads (patient with cancer-spouse caregiver couples; total n = 60) were interviewed concurrently in their homes concerning patient functioning, psychologic distress, physical symptoms, caregiver perceptions of patient functioning, and marriage quality. Couples had been married an average of 32 years. Patients had either the lung or colon as their primary cancer site, and one third had metastasis. Correlations between 14 variable pairs and cross-tabulation of scale scores suggest that spouse caregivers agree with patients on objective measures with observable referents (e.g., ability to dress independently). Partners disagree on subjective aspects of patient functioning (e.g., depression, fear of future, and confidence in treatment) and marriage quality. Almost without exception, caregivers viewed patients' functioning more negatively than patients described themselves. Patients, however, viewed marital quality more negatively than did caregivers. It was concluded that caregivers can serve as proxies for patients with cancer in research and clinical settings when objective data are sought. Data from both spouses are needed, however, to complete the picture of subjective illness experiences in patients with cancer, including perceptions of pain and disease symptoms.

Combat experience and emotional health: impairment and resilience in later life.

War's influence on emotional health includes potential psychological gains as well as losses. In a sample of 149 veterans from longitudinal samples at the Institute of Human Development, University of California, Berkeley, this study explores two questions on the legacy of combat in World War II and the Korean conflict. The first concerns the subjective experience or meanings of combat that veterans hold in later life, with particular attention to how such accounts are linked to the severity of combat and postwar adaptations. The second question links these accounts to the psychosocial functioning of veterans before the war and in later life using reports from veterans and their spouses and Q-sort ratings in adolescence and at age 40. Findings center on veterans of heavy combat. Compared to the noncombatants and light combat veterans, these men were at greater risk of emotional and behavioral problems in the postwar years. In mid-life, they hold mixed memories of painful losses and life benefits associated with military experience. Clinical ratings show that heavy combat veterans became more resilient and less helpless over time when compared to other men. As in the case of life events generally, short- and long-term effects may impair and enhance personal growth.