The cultural constructs of cancer-related fatigue among American Indian cancer survivors.

PURPOSE: Cancer-related fatigue (CRF) is a common symptom experienced by cancer survivors. Persistent fatigue can last years after cancer treatment. CRF's origin is unknown, and there are no validated treatments. Cultural constructs (definitions, meaning, and explanations) may vary the presentation and treatment choices related to fatigue. Identifying and categorizing CRF terms and experiences among racial, ethnic, and non-English speaking groups may provide a fuller understanding of CRF to guide tailoring of interventions. We report on the cultural constructs of CRF as reported by American Indian cancer survivors. METHODS: A study of Southwest American Indians collected qualitative data on cancer survivors' experiences of fatigue. Focus groups (n = 132) at urban clinics and rural reservation sites in the Southwest collected qualitative data on cancer survivor experiences with fatigue. The sessions were audiotaped and transcribed verbatim. During analysis, common themes were coded and formed into categories following Grounded Theory analytical procedures. Relationships between categories were examined. RESULTS: CRF was described by survivors as an entity that comes into the brain, "drains life" from the body, and creates long-lasting suffering, pain, and stigma. We review the cultural constructs of fatigue and CRF's relationship to "being out of balance." CONCLUSIONS: There is a need for culturally appropriate education concerning fatigue, techniques for reducing fatigue, and support for American Indian cancer survivors and other vulnerable populations.

Recognition and treatment of postmenopausal osteoporosis.

Osteoporosis is a common but often silent condition among older adults. The characteristic pathological changes associated with osteoporosis may go unnoticed until a fracture occurs or a bone density test is performed. Although osteoporosis occurs in men and among premenopausal women, it is most prevalent among postmenopausal women who are the focus of this article. Within the subpopulation of postmenopausal women, there are major differences in risk status, disease severity, and response to treatment. Two individual examples are presented to highlight these differences and to illustrate appropriate assessment and treatment strategies in each scenario. In addition, general nonpharmacological recommendations for postmenopausal women across risk status and disease severity are presented.

Clinical and transitional care: considerations to optimize functional recovery following hip fracture.

Between 30% and 40% of community-dwelling older adults in the United States fall at least once each year, and approximately 10% of these falls are associated with a major injury such as a hip fracture. Return to maximum level of functional status following surgery requires individualized rehabilitation programs and may involve multiple care transitions. Using an individual example, this article provides context for meeting rehabilitation goals during transitional care following hip fractures. Understanding recommended clinical management strategies during the acute perioperative period and the rationale for postsurgical rehabilitation decisions based on clinical assessment, program eligibility, and Medicare coverage will allow all health professionals to provide optimal guidance and maximize functional recovery for older adults with hip fractures.

Clinical considerations for care of older adult cancer survivors.

The number of cancer survivors has been steadily increasing due in part to the aging population and advancements in cancer care and treatment. Of the current 13.7 million cancer survivors in the United States, most are 65 or older. Aging changes and the presence of comorbidities add complexity to the care of cancer survivors. In addition. common long-term cancer-related symptoms and late effects of cancer treatments provide challenges to nurses and other health professionals caring for older cancer survivors. Transition from oncology care to primary or shared care requires understanding of detailed information about the specific cancer diagnosis, treatments received, and recommendations for follow-up care to prevent recurrence, recognize treatment-associated health effects, and understand strategies for health promotion. Nurses in all practice areas will care for cancer survivors and must be prepared to deliver safe and effective care.

Progressive supranuclear palsy.

Progressive supranuclear palsy (PSP) is the second-most-common parkinsonian neurodegenerative disorder following Parkinson's disease. Although PSP was first identified clinically more than 40 years ago, it remains poorly recognized and underdiagnosed. Using an individual example, this article describes the epidemiology, neuropathology, clinical course, supportive management strategies, and resources for patients with PSP and their families.

Work-related injury and the older adult.

Many older adults are working beyond what was considered a "normal" retirement age in past generations. If work-related injury occurs, older adults may have increased vulnerabilities due to age and comorbid conditions not shared by their younger working peers. This article presents an individual example in which these vulnerabilities are explored, and unique processes within the work environment are noted. Awareness of the risks to older workers will aid clinicians in any setting to maximize prevention and management of co-morbidities that improve health status, function, and employment performance for older workers.

Lumbar spinal stenosis. Clinical considerations for older adults.

Lumbar spinal stenosis (LSS) is becoming more frequent as the population ages and is now the most common spinal diagnosis for individuals older than 65. Because LSS is a common source of pain and disability among older adults, understanding the pathophysiology, clinical presentation, and clinical management of this condition is important. An individual example is used to highlight classic signs and symptoms. Nursing strategies for LSS-associated pain and symptom management to improve physical function and quality of life are discussed.

Primary open-angle glaucoma: clinical update.

Glaucoma is an optic neuropathy that is usually associated with an elevated intraocular pressure. Primary open-angle glaucoma (POAG) is the most common type of glaucoma and is progressive and bilateral but typically asymmetric in patients. Studies have shown that reducing intraocular pressure reduces the risk of vision loss. In the United States, medical intervention by means of prescription eye drops is the initial line of treatment. Nurses play an important role in educating individuals, particularly older adults, about the importance of routine eye care to earlier diagnose, treat, and adequately manage eye diseases such as POAG.

CPR decision making and older adults: clinical implications.

Originally developed in 1960 as an emergency intervention for individuals who unexpectedly went into cardiac arrest, cardiopulmonary resuscitation (CPR) is now in widespread use. With broader use of CPR over the past several decades, some limitations and unintended consequences of the procedure have been identified. In addition, accumulated data have demonstrated low probabilities of survival and uneven success rates of CPR for certain subgroups. Despite advances in the understanding of CPR outcomes, the general public and many health professionals significantly overestimate the benefits and underestimate any negative consequences. As a result, CPR decision making is often based on incomplete or inaccurate information. This article discusses the "rest of the story" about CPR, namely the existing evidence about CPR survival and potential complications of CPR. The article also highlights how nurses can help promote informed decision making about CPR to older adults and their families.

Functional implications of vitamin B(12) deficiency.

Vitamin B(12) deficiency is a common but underrecognized problem in older adults. Historically, B(12) deficiency was diagnosed once a severe pernicious anemia developed. Scientific developments have led to a new understanding of a broader spectrum of B(12) deficiency and identification of a milder form of deficiency associated with food/vitamin B(12) malabsorption. Using an individual example, this article describes the functional impact of vitamin B(12) deficiency and highlights modern approaches to diagnosis and treatment.

Herpes zoster in older adults.

Herpes zoster (HZ) is a common condition among older adults, manifested by pain and the classic presentation of a unilateral rash that follows a dermatomal distribution and does not cross the midline of the body. It is caused by reactivation of the virus that caused chickenpox during an earlier infection. In many cases, acute HZ is followed by a severe and disabling complication known as postherpetic neuralgia (PHN), characterized by pain that persists for months or even years after the HZ rash heals. Using an individual example, this article provides information on the clinical manifestations, evidence-based treatment recommendations for, and prevention of HZ and PHN through use of the zoster vaccine Zostavax, licensed in the United States in 2006.

Why not just ask the resident?

This research evaluated a draft preference assessment tool (draft-PAT) designed to replace the current Customary Routine section of the Minimum Data Set (MDS) for nursing homes. The draft-PAT was tested with a sample of nursing home residents to evaluate survey-level administration time and noncompletion rates, as well as item-level nonresponse rates, response distributions, and test-retest reliability. Modifications to the draft-PAT were then retested with a subsample of residents. Completion times were brief (generally less than 10 minutes), and only a small percentage of residents were unable to complete the interview. Item-level nonresponse rates were low for the draft-PAT (0% to 8%) and even lower during retesting for items advanced to the national field trial (0% to 4%). Item response distributions indicated reasonable use of all options across both testing occasions, and item-level test-retest reliability was high. This study found that nursing home residents can reliably report their preferences. Eighteen items from the modified draft-PAT were advanced to the national field trial of the MDS 3.0. Inclusion of the PAT in the MDS revision underscores increased emphasis on including residents' voice in the assessment process.

The relationship of reported pain severity to perceived effect on function of nursing home residents.

BACKGROUND: We examined whether questions addressing the effect of pain on day-to-day function add unique information to the standardized verbal descriptor scale for pain severity in nursing homes (NHs). METHODS: Interviews were conducted with 123 residents in two Veterans Affairs NHs. All participants were asked about pain presence. Residents reporting pain were asked about severity of worst pain (mild, moderate, severe, very severe/horrible), degree of bother (not at all, a little, a moderate amount, a great deal), and the effect of pain on daily function (whether pain made it hard to "sleep," "get out of bed," or "spend time with other people" and whether activities were limited because of pain). RESULTS: Fifty-one percent of participants reported pain. The correlation between pain severity report and overall count of activity interference was significant (Spearman's rho=.449, p=.001). In general, for each activity, the proportion reporting interference increased as severity increased. Fischer's exact test showed significant association only for "hard to get out of bed" (p=.0175) and "hard to sleep" (p=.0211). As expected, residents reporting "mild" pain reported less activity interference than those reporting "very severe" pain. The association between pain and activity interference was more variable and less predictable among residents with "moderate" or "severe" pain. CONCLUSION: Questions addressing the effect of pain on day-to-day functions are an important addition to standardized pain assessments, particularly for persons who report intermediate levels of pain severity because the perceived effect on daily function may vary most among individuals at these levels.

What the resident meant to say: use of cognitive interviewing techniques to develop questionnaires for nursing home residents.

PURPOSE: Emphasis on consumer-centered care for frail and institutionalized older adults has increased the development and adaptation of surveys for this population. Conventional methods used to pretest survey items fail to investigate underlying sources of measurement error. However, the use of the cognitive interview (CI), a method for studying how respondents answer survey items, is not well established or documented in this population. This study demonstrates how CIs can be used to improve questionnaires intended for nursing home residents. DESIGN AND METHODS: CIs were conducted with 29 nursing home residents in order to identify potential problems with prospective survey items. We used scripted probes to standardize the interviews and adapted the Question Appraisal System to enumerate and classify the problems discovered. RESULTS: We fielded between one and five versions of each item in an iterative process that identified 61 item-specific problems. Additionally, residents' cognitive responses suggested that some screened their answers on the basis of perceived physical and environmental limitations, and some had difficulty answering items about preferences that fluctuate day to day. These findings led us to modify the items and response set to simplify the respondents' cognitive task. IMPLICATIONS: This study illustrates how CI techniques can be used to understand residents' comprehension of and response to survey items.

A standardized quality assessment system to evaluate pain detection and management in the nursing home.

CONTEXT: Assessment and management of pain for nursing home residents is frequently reported to be inadequate, yet few studies have used objective criteria to measure the quality of care related to pain. OBJECTIVE: Field test a standardized resident interview and medical record review protocol to assess and score quality indicators relevant to pain. DESIGN: Descriptive. SETTING: Thirty nursing homes (NHs). PARTICIPANTS: Seven hundred ninety-four residents met overall eligibility criteria. Quality indicators were scored for those residents who met specific eligibility requirements for each pain indicator. MEASUREMENTS: Medical record reviews were completed for 542 participants, and data were used to score 12 indicators related to pain assessment, management, and response to treatment. A seven-item pain interview was attempted with all 794 participants and completed with 478 participants who were rated by NH staff as cognitively aware. RESULTS: Quality indicators could be reliably scored. Physicians scored low on assessment of pain, performing targeted history and physical examinations, documenting risk factors for use of analgesics, and documenting response to treatment. Forty-eight percent of participants (227/478) reported symptoms of chronic pain during the interview, and 81% of this group reported a preference for a pain medication. However, nearly half had no physician assessment of pain in the past year and only 42% were receiving pain medication. Licensed nurse assessments of pain were documented weekly; but, more than 50% of those reporting symptoms of chronic pain on interview had nurse pain scores of 0 for 4 consecutive weeks prior to interview. CONCLUSIONS: Infrequent or incomplete physician pain assessment and treatment and inaccurate documentation by licensed nurses limits evaluation of pain care quality based on medical record review alone. A brief resident interview identified participants reporting symptoms of chronic pain not documented in the medical record and those with a preference for medication. Initial targeting of residents with self-reported pain maximizes the efficiency of the standardized scoring system described in this study. Focusing on explicit process measures clearly identifies areas for improvement and represents an important step in assessing the quality of pain care in the NH.

A Perfect Storm: Care Transitions for Vulnerable Older Adults Discharged Home From the Emergency Department Without a Hospital Admission.

PURPOSE OF THE STUDY: The purpose of the study was to describe, from the perspectives of emergency department (ED) providers, factors that influence quality and safety of transitions home from the ED for vulnerable older adults. DESIGN AND METHODS: A grounded theory approach was used to analyze data from 9 focus groups conducted with ED staff that included representatives from nursing, medicine, pharmacy, social work, and respiratory therapy. RESULTS: From the perspectives of these care providers, 5 antecedent concepts contribute to the perceived quality and safety of transitions from the ED to home. These 5 concepts include the nature of geriatric presentations, provider knowledge, consumer knowledge, the ED resource base, and health care system fractures. Co-occurrence and interaction among the 5 identified antecedents set up conditions for what one focus group participant described as a perfect storm. IMPLICATIONS: Older adults discharged home from the ED without a hospital admission are an increasingly important but understudied group within the transitional care literature. Although they share some similarities with those undergoing different health transitions, their unique needs and the specific characteristics of ED care require a novel approach. The model that emerged in this study provides direction for understanding the complex and interrelated aspects of their transitional care needs.

A standardized quality assessment system to evaluate pain detection and management in the nursing home.

CONTEXT: Assessment and management of pain for nursing home residents is frequently reported to be inadequate, yet few studies have used objective criteria to measure the quality of care related to pain. OBJECTIVE: Field test a standardized resident interview and medical record review protocol to assess and score quality indicators relevant to pain. DESIGN: Descriptive. SETTING: Thirty nursing homes (NHs). PARTICIPANTS: Seven hundred ninety-four residents met overall eligibility criteria. Quality indicators were scored for those residents who met specific eligibility requirements for each pain indicator. MEASUREMENTS: Medical record reviews were completed for 542 participants, and data were used to score 12 indicators related to pain assessment, management, and response to treatment. A seven-item pain interview was attempted with all 794 participants and completed with 478 participants who were rated by NH staff as cognitively aware. RESULTS: Quality indicators could be reliably scored. Physicians scored low on assessment of pain, performing targeted history and physical examinations, documenting risk factors for use of analgesics, and documenting response to treatment. Forty-eight percent of participants (227/478) reported symptoms of chronic pain during the interview, and 81% of this group reported a preference for a pain medication. However, nearly half had no physician assessment of pain in the past year and only 42% were receiving pain medication. Licensed nurse assessments of pain were documented weekly; but, more than 50% of those reporting symptoms of chronic pain on interview had nurse pain scores of 0 for 4 consecutive weeks prior to interview. CONCLUSIONS: Infrequent or incomplete physician pain assessment and treatment and inaccurate documentation by licensed nurses limits evaluation of pain care quality based on medical record review alone. A brief resident interview identified participants reporting symptoms of chronic pain not documented in the medical record and those with a preference for medication. Initial targeting of residents with self-reported pain maximizes the efficiency of the standardized scoring system described in this study. Focusing on explicit process measures clearly identifies areas for improvement and represents an important step in assessing the quality of pain care in the NH.

A Practice Improvement Education Program Using a Mentored Approach to Improve Nursing Facility Depression Care-Preliminary Data.

Depression is common in nursing facility residents. Depression data obtained using the Minimum Data Set (MDS) 3.0 offer opportunities for improving diagnostic accuracy and care quality. How best to integrate MDS 3.0 and other data into quality improvement (QI) activity is untested. The objective was to increase nursing home (NH) capability in using QI processes and to improve depression assessment and management through focused mentorship and team building. This was a 6-month intervention with five components: facilitated collection of MDS 3.0 nine-item Patient Health Questionnaire (PHQ-9) and medication data for diagnostic interpretation; education and modeling on QI approaches, team building, and nonpharmacological depression care; mentored team meetings; educational webinars; and technical assistance. PHQ-9 and medication data were collected at baseline and 6 and 9 months. Progress was measured using team participation measures, attitude and care process self-appraisal, mentor assessments, and resident depression outcomes. Five NHs established interprofessional teams that included nursing (44.1%), social work (20.6%), physicians (8.8%), and other disciplines (26.5%). Members participated in 61% of eight offered educational meetings (three onsite mentored team meetings and five webinars). Competency self-ratings improved on four depression care measures (P = .05 to <.001). Mentors observed improvement in team process and enthusiasm during team meetings. For 336 residents with PHQ-9 and medication data, depression scores did not change while medication use declined, from 37.2% of residents at baseline to 31.0% at 9 months (P < .001). This structured mentoring program improved care processes, achieved medication reductions, and was well received. Application to other NH-prevalent syndromes is possible.

Using the minimum data set to select nursing home residents for interview about pain.

OBJECTIVES: To determine how many nursing home residents can provide stable responses to a simple pain interview and whether a Minimum Data Set (MDS) cognitive performance measure can be used to identify these residents. DESIGN: Cross-sectional descriptive study. SETTING: Thirty-three community-based nursing homes. PARTICIPANTS: Eight hundred ninety-five nursing home residents. MEASUREMENTS: Resident completion rate, stability, and interrater reliability of a four-item interview derived from the Geriatric Pain Measure were calculated. Demographic data and MDS items concerning pain and memory were obtained from medical records. RESULTS: Overall, 835 residents were able to answer all four interview questions. At the lowest MDS recall score of 0, 52.7% of residents were able to complete all questions. All residents able to respond to the interview achieved high stability (kappa=0.633, P<.001). Overall, 62.8% of residents with daily pain or activity-limiting pain on interview did not have daily or moderate to severe pain recorded on the MDS. Residents who had lower MDS recall scores were significantly less likely (P=.004) to be appropriately identified on the MDS. CONCLUSION: Residents with a low MDS recall score were significantly less likely to be noted on the MDS as having serious pain despite being able to complete a simple yes/no interview about pain in a stable fashion. Nursing staff should attempt to ask all residents direct questions about pain. Surveyors may restrict direct questioning to those residents with an MDS recall score of 1 or higher if time is an important consideration. Adjustment for MDS-derived prevalence of pain based on residents' cognitive status is questionable.