Development of the Gerontological Nursing Competency Questionnaire.

AIM: The aim of this study was to develop an instrument to measure competencies of gerontological nursing faculty. BACKGROUND: There is no accepted instrument to assess competencies of gerontological nursing faculty. METHOD: To develop the Gerontological Nursing Competency Questionnaire (GNCQ), we used a modified Delphi technique focused on consensus building among experts from the National Hartford Center for Gerontological Nursing Excellence. The 25-item GNCQ measures confidence in knowledge, confidence in teaching, and interest in further training in gerontological nursing. The instrument was piloted in a large nursing department at a university in southern California. RESULTS: Low faculty competencies in knowledge and teaching and low interest in further training were observed. CONCLUSION: The GNCQ demonstrated initial content validity and an ability to identify key areas of deficiency in knowledge and teaching among nursing faculty. It may be used for improvement initiatives in gerontological nursing programs.

The nursing assistants' communication style and the behavioral symptoms of dementia in Korean-American nursing home residents.

Few studies examined the association between communication style and behavioral symptoms of dementia (BSD). The communication style of Nursing Assistants' (NAs), whose ethnic background is different from the residents, may contribute to BSD. The purpose of this study was to explore the relationship between non-Korean NAs' communication style and BSD in Korean-American (KA) nursing home residents with dementia. Twenty eight NAs and 20 KA residents were recruited from an ethno-specific nursing home. Research assistants observed and recorded NAs' communication style and residents' behavior simultaneously during routine care for 3 days. This study shows a trend that NAs' dementia and culturally appropriate communication style influenced the decreased behavioral symptoms. This finding suggests the need for training for NAs in dementia and culturally appropriate communication.

The development of direct-care staff social interaction coding schemas for nursing home residents with dementia.

Two social interaction coding schemas were developed to measure the dementia competent (DSI) and culturally competent (CSI) social interaction of direct-care staff for persons with dementia in a Korean American nursing home. A pilot study was conducted to assess: feasibility, content validity, inter-rater reliability and the ease of use of both schemas. An expert panel evaluated the content validity of the DSI/CSI. Two research assistants (RAs) simultaneously observed and recorded direct-care staff social interaction encounter during care activities. Twenty-three morning care activities were recorded over a 3-day period. The Index of Content Validity score for the DSI and the CSI was .88 and .80, respectively. Cohen's Kappa ranged from 0.73 to 0.83 for the DSI and 0.69 to 0.82 for the CSI, indicating good to very good inter-rater reliability. RA interviews noted that schemas were easy to use and feasible.

Raising the index of suspicion for elder abuse: cognitive impairment, falls, and injury patterns in the emergency department.

Cognitive impairment limits older adults' abilities to advocate for themselves, thus heightening their risk for abuse. Some older adults with cognitive impairments who seek emergency department (ED) services may present with injuries suspicious of abuse. A portion of these injuries may be erroneously attributed to accidents such as falls. A retrospective analysis of 2 years of ED data using International Classification of Diseases, Ninth Revision (ICD-9) codes was conducted focusing on characteristics of injuries sustained by persons with co-occurring cognitive impairment and fall status. Cognitive impairment was not significantly related to falls (P = .533). Findings suggest that persons with cognitive impairment have unique injury patterns based on fall status, which has implications for elder abuse screening. Injuries for persons with no fall history included injury to the upper limb (P = .004), contusions (P = .012), and open wounds (P = .000). An increased recognition of common injuries in older adults can aid in elder abuse assessment by providing a reference point for uncommon injuries.

Social Isolation and Nursing Leadership in Long-Term Care: Moving Forward After COVID-19.

Nursing leaders have a responsibility to promote and facilitate social engagement and connectedness to mitigate social isolation in long-term care (LTC). The COVID-19 pandemic has emphasized longstanding problems in LTC facilities, such as staff mix, workload, and support. The pandemic has shed light on the severe deleterious effect of social isolation and the critical importance of maintaining social engagement and connectedness, especially in times of crisis or major change. Staff education and ongoing support cannot be overemphasized. Critical nursing leadership and interdisciplinary collaboration engaging all team members are essential in operationalizing nonpharmacological approaches that foster the well-being of residents with dementia.

A Call to the CMS: Mandate Adequate Professional Nurse Staffing in Nursing Homes.

Editor's note: This article is by 22 nursing gerontology experts who are all advocates of nursing home reform. They are listed at the end of this article.

We've got trouble: medications in assisted living.

The rise in assisted living facilities (ALFs), coupled with residents with increasingly complex conditions, leads to unanticipated problems linked to medication management. The purpose of this study was to describe one western state's scope of medication-related problems, the relationship of problems to facility characteristics, and the nature of the problems using state surveyors' reports from routine inspections and complaint investigations. Of the 1,335 ALFs surveyed for 2007-2008, 61.8% received a medication-related citation. Of the 1,558 allegations, 60.3% involved individual residents, with 25.2% of these being medication related. The variability in state regulations obscures an accurate understanding of the problem. Complex medication regimens delivered by unlicensed assistive personnel place residents at risk for negative health consequences. More nursing oversight is critically needed to ensure the health and safety of the new generation of ALF residents.

Taking Another Look: Thoughts on Behavioral Symptoms in Dementia and Their Measurement.

This article proposes taking another look at behavioral symptoms of dementia (BSDs) both from a theoretical perspective that informs research and practice and from a measurement perspective. We discuss why this rethinking of behaviors impacts current models of care and our ability to better detect outcomes from interventions. We propose that BSDs be viewed from a pattern perspective and provide some suggestions for how to identify and measure these patterns that can influence the timing and type of intervention. Evidence suggests that BSDs are complex, sequential, patterned clusters of behavior recurring repeatedly in the same individual and escalate significantly without timely intervention. However, BSDs are frequently viewed as separate behaviors rather than patterns or clusters of behaviors, a view that affects current research questions as well as the choice, timing, and outcomes of interventions. These symptoms cause immense distress to persons with the disease and their caregivers, trigger hospitalizations and nursing home placement, and are associated with increased care costs. Despite their universality and that symptoms manifest across disease etiologies and stages, behaviors tend to be underrecognized, undertreated, and overmanaged by pharmacological treatments that may pose more harm than benefit.

Cortisol and wake time in nursing home residents with behavioral symptoms of dementia.

Alterations in sleep and behavioral symptoms are consistently reported among nursing home residents with dementia. Disregulation in the hypothalamic-pituitary-adrenal axis (HPA), indexed by basal cortisol levels, offers one explanation. The purpose of this study is to examine the relationship between wake time and cortisol slope in residents with behavioral symptoms. The study included 27 residents aged 71 to 84 years with dementia and behavioral symptoms. Using a within-subject longitudinal design, the researchers documented wake time and collected saliva samples for 4 consecutive days upon waking and at 30 min, 6 hr, and 12 hr after waking. Within-person cortisol slopes were categorized into zero-positive and negative slopes. The zero-positives (35%) exhibited an earlier wake time than the negatives (65%). These preliminary results suggest both a relationship between wake time and HPA diurnal profile and an association between the sleep-wake cycle and cortisol secretion among nursing home residents with dementia.

Aging, Genetic Variations, and Ethnopharmacology: Building Cultural Competence Through Awareness of Drug Responses in Ethnic Minority Elders.

Unique drug responses that may result in adverse events are among the ethnocultural differences described by the Agency for Healthcare Research and Quality. These differences, often attributed to a lack of adherence on the part of the older adult, may be linked to genetic variations that influence drug responses in different ethnic groups. The paucity of research coupled with a lack of knowledge among health care providers compound the problem, contributing to further disparities, especially in this era of personalized medicine and pharmacogenomics. This article examines how age-related changes and genetic differences influence variations in drug responses among older adults in unique ethnocultural groups. The article starts with an overview of age-related changes and ethnopharmacology, moves to describing genetic differences that affect drug responses, with a focus on medications commonly prescribed for older adults, and ends with application of these issues to culturally congruent health care.

The effect of therapeutic touch on behavioral symptoms of persons with dementia.

BACKGROUND: Approximately 80% of nursing home residents who suffer from Alzheimer's disease and related dementia develop behavioral symptoms of dementia. Given the deleterious side effects of pharmacologic therapy in this population there is an urgent need for clinical trials of nonpharmacologic interventions. OBJECTIVE: To examine the effect of therapeutic touch on the frequency and intensity of behavioral symptoms of dementia. METHOD: A randomized, double-blind, three-group experimental study: experimental (therapeutic touch), placebo (placebo therapeutic touch), and control (usual care). Fifty-seven residents, aged 67 to 93 years, exhibiting behavioral symptoms of dementia, were randomized to one of the three groups within each of three Special Care Units within three Long-Term Care facilities in a western Canadian province. Behavioral observation was completed every 20 minutes from 8:00AM to 6:00PM for three days pre-intervention and for three days post-intervention by trained observers who were blind to group assignment. The intervention consisted of therapeutic touch given twice daily for 5-7 minutes for three days between 10:00AM and 11:30PM and between 3:00PM and 4:30PM (N = 57). The main outcome variable was overall behavioral symptoms of dementia, consisting of six categories of behaviors: manual manipulation (restlessness), escape restraints, searching and wandering, tapping and banging, pacing and walking, and vocalization. RESULTS: Analysis of variance (ANOVA) (F = 3.331, P = .033) and the Kruskal-Wallis test (chi2 = 6.661, P = .036) indicated a significant difference in overall behavioral symptoms of dementia, manual manipulation and vocalization when the experimental group was compared to the placebo and control groups. The experimental (significant) was more effective in decreasing behavioral symptoms of dementia than usual care, while the placebo group indicated a decreasing trend in behavioral symptoms of dementia compared to usual care. CONCLUSIONS: Therapeutic touch offers a nonpharmacological, clinically relevant modality that could be used to decrease behavioral symptoms of dementia, specifically manual manipulation (restlessness) and vocalization, two prevalent behaviors.

Developing and proposing the ethno-cultural gerontological nursing model.

By 2050, for the first time in U.S. history, almost half of elders will be from ethnic minority groups. To meet the needs of this rapidly diversifying population, nurses need to be able to marry transcultural nursing knowledge with gerontological nursing knowledge. The purpose of this article is to propose a new theoretical model for explaining health outcomes and health responses for older individuals in unique ethno-cultural groups and to discuss implications and applications of the model to transcultural gerontological nursing practice and research. The discussion will include (1) an overview of currently available theoretical knowledge in the area, (2) a description of the theory development process, (3) presentation of the proposed ethno-cultural gerontological nursing theoretical model, and (4) discussion of how this model can enhance nursing's contributions to reducing health disparities. This model is presented not as a finished product but as a basis for future discussion and refinement.

The effect of therapeutic touch on agitated behavior and cortisol in persons with Alzheimer's disease.

Agitated behavior in persons with Alzheimer's disease (AD) presents a challenge to current interventions. Recent developments in neuroendocrinology suggest that changes in the hypothalamic-pituitary-adrenal (HPA) axis alter the responses of persons with AD to stress. Given the deleterious effects of pharmacological interventions in this vulnerable population, it is essential to explore noninvasive treatments for their potential to decrease a hyperresponsiveness to stress and indirectly decrease detrimental cortisol levels. This within-subject, interrupted time-series study was conducted to test the efficacy of therapeutic touch on decreasing the frequency of agitated behavior and salivary and urine cortisol levels in persons with AD. Ten subjects who were 71 to 84 years old and resided in a special care unit were observed every 20 minutes for 10 hours a day, were monitored 24 hours a day for physical activity, and had samples for salivary and urine cortisol taken daily. The study occurred in 4 phases: 1) baseline (4 days), 2) treatment (therapeutic touch for 5 to 7 minutes 2 times a day for 3 days), 3) posttreatment (11 days), and 4) post- "wash-out" (3 days). An analysis of variance for repeated measures indicated a significant decrease in overall agitated behavior and in 2 specific behaviors, vocalization and pacing or walking, during treatment and posttreatment. A decreasing trend over time was notedfor salivary and urine cortisol. Although this study does not provide direct clinical evidence to support dysregulation in the HPA axis, it does suggest that environmental and behavioral interventions such as therapeutic touch have the potential to decrease vocalization and pacing, 2 prevalent behaviors, and may mitigate cortisol levels in persons with AD.

Biobehavioral measures as outcomes: a cautionary tale.

This article discusses the use of biobehavioral measures as outcomes for health care intervention studies. Effect size (ES) values for salivary cortisol and observation-based measures of pain and agitation were examined. Effects pre to post treatment were assessed separately for nursing home residents with and without acute psychotic symptoms. This study revealed large positive effects on both pain and agitation measures in the group with acute psychotic symptoms and small-to-medium positive effects on these same measures in the group without acute psychotic symptoms. In both of these groups, the ES values were not consistently positive on the cortisol measures. Prior to determining whether a measure can be used to estimate minimum clinically important differences, it is essential to consider if the biomarker will be responsive to therapy in the populations and contexts being studied.

To nap or not to nap: excessive daytime napping is associated with elevated evening cortisol in nursing home residents with dementia.

BACKGROUND: Alterations in the sleep-wake cycle, including daytime napping, are consistently reported in persons with dementia (PWD). A dysregulation in the hypothalamic-pituitary-adrenal (HPA) axis, indexed by elevated evening cortisol, may offer one explanation for these alterations. Alternatively, excessive daytime sleeping may alter cortisol rhythm and increase intraindividual variability, potentially contributing to increased environmental reactivity and behavioral symptoms. The purpose of this substudy (N = 12) was to examine the association between daytime napping and basal cortisol diurnal rhythm in nursing home residents with dementia. METHOD: In this within-individual longitudinal design, saliva samples were obtained daily for 5 consecutive days upon waking and 30-45 min, 6 hr, and 12 hr after waking to obtain a cortisol diurnal rhythm. Behavior and sleep-wake state (nap/no nap) were observed and recorded every 20 min for 12 hr per day for 5 days. RESULTS: Participants were categorized as high nappers (HNs) or low nappers (LNs). There was a significant difference in evening cortisol levels (t = -2.38, p = .032) and continence (t = 3.37, p = .007) between groups, with HNs exhibiting higher evening cortisol levels. There were no other significant differences in resident characteristics between the two groups. CONCLUSIONS: These data suggest a link between excessive daytime napping and elevated evening cortisol in PWD consistent with findings in children. Elevated evening cortisol is an indication of a dysregulation in the HPA axis. These preliminary data support a close association between the sleep-wake cycle and HPA-axis regulation in PWD.

Evening cortisol is associated with intra-individual instability in daytime napping in nursing home residents with dementia: an allostatic load perspective.

BACKGROUND: Circadian rhythm disruption, reflected in alterations in sleep-wake activity and daytime napping behavior, is consistently reported in nursing home (NH) residents with dementia. This disruption may be reflected in day-to-day instability. The concept of allostatic load (AL), a measure of cumulative biological burden over a lifetime, may be a helpful model for understanding cortisol diurnal rhythm and daytime napping activity in this population. The purpose of this study was to examine the association between intra-individual daytime napping episodes and basal cortisol diurnal rhythm in NH residents with dementia in the context of AL. METHOD: U sing a within-individual longitudinal design (N = 51), the authors observed and recorded daytime napping activity every 20 min for 10 hr per day across 4 consecutive days. The authors obtained saliva samples 4 times each day (upon participants' waking and within 1 hr, 6 hr, and 12 hr of participants' wake time) for cortisol analysis. RESULTS: The authors categorized participants as high changers (HCs; day-to-day instability in napping activity) or low changers (LCs; day-to-day stability). There were no significant differences in resident characteristics between groups. There was a significant difference between HCs and LCs in napping episodes (F = 4.86, p = .03), with an interaction effect of evening cortisol on napping episodes in the HC group (F = 10.161, p = .001). CONCLUSIONS: NH residents with unstable day-to-day napping episodes are more responsive to alterations in evening cortisol, an index of a dysregulated hypothalamic-pituitary-adrenal (HPA) axis. They may also be more amenable to environmental intervention, an avenue for further research.

Diurnal cortisol and functional outcomes in post-acute rehabilitation patients.

BACKGROUND: Cortisol is a stress-related hormone with a robust circadian rhythm where levels typically peak in the morning hours and decline across the day. Although acute cortisol increases resulting from stressors are adaptive, chronic elevated cortisol levels are associated with poor functioning. Studies have shown age-related changes in cortisol levels. The present study investigated the relationship between salivary diurnal cortisol and functional outcomes among older adults undergoing inpatient post-acute rehabilitation. METHODS: Thirty-two older adults (mean age 78 years; 84% men) in a Veterans Administration inpatient post-acute rehabilitation unit were studied. Functional outcomes were assessed with the motor component of the Functional Independence Measure (mFIM; where mFIM change = discharge - admission score). Saliva samples were collected on 1 day at wake time, 45 minutes later, 11:30 AM, 2 PM, 4:30 PM, and bedtime. We analyzed the relationship between cortisol measures and functional outcomes, demographics, and health measures. RESULTS: The analyses consistently showed that greater functional improvement (mFIM change) from admission to discharge was associated with lower comorbidity scores and higher cortisol levels at 2 PM, 4:30 PM, and bedtime. A morning cortisol rise was also associated with greater mFIM change. CONCLUSIONS: Measurement of cortisol in saliva may be a useful biological marker for identification of patients who are "at risk" of lower benefits from inpatient rehabilitation services and who may require additional assistance or intervention during their post-acute care stay.

Comparison of the effectiveness of two protocols for treating nursing home residents with advanced dementia.

The Serial Trial Intervention (STI) is a decision support tool to address the problem of underassessment and undertreatment of pain and other unmet needs of people with dementia. This study compared the effectiveness of the 5-step and 9-step versions of the STI using a two-group repeated measures quasi-experimental design with randomization of 12 matched nursing homes. The sample consisted of 125 residents with moderate to severe dementia. Both the 5- and 9-step STIs significantly decreased discomfort and agitation from pre- to posttest (effect sizes = 0.45 to 0.90). The 9-step version was more effective for comorbid burden and increased cortisol slope (effect sizes = 0.50 and 0.49). Process variables were all statistically significantly improved using the 9-step STI. Nurse time was not different between the two groups. The clinical decision support rules embedded in the STI, particularly the 9-step version, helped nurses change practice and improved resident outcomes.

Spit: saliva in nursing research, uses and methodological considerations in older adults.

Over the last 10 years, interest in the analysis of saliva as a biomarker for a variety of systemic diseases or for potential disease has soared. There are numerous advantages to using saliva as a biological fluid, particularly for nurse researchers working with vulnerable populations, such as frail older adults. Most notably, it is noninvasive and easier to collect than serum or urine. The authors describe their experiences with the use of saliva in research with older adults that examined (a) osmolality as an indicator of hydration status and (b) cortisol and behavioral symptoms of dementia. In particular, the authors discuss the timing of data collection along with data analysis and interpretation. For example, it is not enough to detect levels or rely solely on summary statistics; rather it is critical to characterize any rhythmicity inherent in the parameter of interest. Not accounting for rhythmicity in the analysis and interpretation of data can limit the interpretation of associations, thus impeding advances related to the contribution that an altered rhythm may make to individual vulnerability.