The Effects of Osteoarthritis on Depressive Symptomatology Among Older U.S. Military Veterans.

Osteoarthritis (OA) is a leading cause of disability among older adults. By 2050, approximately 60 million will suffer from arthritis adding up to a total societal cost of $65 billion. Chronic illnesses resulting in pain, and functional decline have been associated with depression in previous studies.A causal model was developed and tested using structural equation modeling that examined depression scores of 503 older (age 50-85), male Veterans with moderate to severe symptomatic OA of the knee\hip.The results of the structural equation modeling produced a final model of depressive symptomatology that fit the data well (Chi square = 12.23, DF = 11, p = .346; TLI = .99; CFI = 1.00; RMSEA = .02).The findings indicate the central role that OA severity (pain, stiffness, and functional difficulties) plays in the mental health of older Veterans in terms of the level of reported depressive symptoms.

Mood outcomes of a behavioral treatment for urinary incontinence in prostate cancer survivors.

PURPOSE: This study aimed to assess whether prostate cancer survivors who received a behavioral intervention to urinary incontinence had experienced a significant mood improvement. METHODS: One hundred fifty-three prostate cancer survivors with persistent incontinence were included in this secondary data analysis. They were randomly assigned to usual care or interventions that provided pelvic floor muscle exercises and self-management skills. All subjects had measures of anxiety, depression, and anger at baseline, 3 months (post-intervention), and 6 months (follow-up). Negative binomial regression analysis was performed to examine the group status, daily leakage frequency at 3 months, and their interactions at 3 months as predictors for mood outcomes at 6 months, controlling for demographic and medical variables. RESULTS: The main effect of daily leakage frequency at 3 months significantly predicted anxiety at 6 months (p < .01). The group main effect on any mood outcomes at 6 months was not statistically significant. The interaction between the group and 3-month leakage had a significant effect on anxiety; intervention subjects achieving a significant leakage reduction at 3 months exhibited significantly less anxiety at 6 months than other subjects (p = .04). Age, employment status, and receiving surgery at baseline were significantly associated with less anxiety, depression, and anger at 6 months. CONCLUSIONS: Reduced urinary incontinence significantly predicted less anxiety, especially among the intervention subjects. The findings suggest a significant association between a behavioral therapy of urinary incontinence and anxiety reduction in prostate cancer survivors.

Impacting the Trajectory of Chronic Kidney Disease With ARPN-Led Renal Teams.

Health care reform demands improvements in population health and the patient experience while reducing costs. This demand is referred to as The Triple Aim of Improvement. A sense of urgency must be created for development of new models of care that impact outcomes earlier in the disease process. One new model of care addressing the triple aim is the Advanced Practice Registered Nurse (APRN)-Led Specialty Care Team. APRN-Led Specialty Care Team members engage patients and implement evidence at a point in the disease trajectory that is most likely to influence population outcomes, resources, and cost. In the pilot described in this article, a nurse practitioner, a registered nurse, a licensed practice nurse, a registered nurse certified diabetes educator, a registered dietitian, and a clinical pharmacist provided care to 20 patients with diabetes and chronic kidney disease, using the chronic disease trajectory model. The team was trained and supported through virtual technology and chronic kidney disease clinical decision-making tools. This APRN-Led Renal Specialty Care Team was embedded into primary care, using group appointments with nephrology support. Lessons learned regarding implementation, with a focus on the role of the nursing executive, are presented along with recommendations for future implementation.

Effects of Patient Centered Interventions on Persistent Urinary Incontinence after Prostate Cancer Treatment: A Randomized, Controlled Trial.

PURPOSE: We examined whether an intervention combining pelvic floor muscle exercise and symptom self-management would improve urinary continence and quality of life in patients with prostate cancer. MATERIALS AND METHODS: In a randomized, controlled, longitudinal clinical trial 279 patients with prostate cancer with persistent urinary incontinence were randomized to 1 of 3 groups, including biofeedback pelvic floor muscle exercise plus a support group, the biofeedback exercise plus telephone contact and usual care without intervention. The biofeedback plus support and plus telephone groups received 1 session of biofeedback assisted exercise and 6 biweekly sessions of problem solving therapy. This delivered symptom management skills through a peer support group or telephone contacts for 3 months. All subjects were assessed in blinded fashion at baseline, and 3 and 6 months for urinary leakage frequency, leakage amount and disease specific quality of life. RESULTS: A total of 244 subjects completed the study. The biofeedback plus support and biofeedback plus telephone groups had a lower frequency of daily urinary leakage than the group with usual care without intervention at 3 months (p=0.019 and p≤0.001, respectively) but not at 6 months. The biofeedback plus support group but not the biofeedback plus telephone group had 13.3 gm lower leakage at 6 months than the usual care group (p=0.003). Overall the biofeedback plus support and plus telephone groups reported less symptom severity (p≤0.001) and fewer incontinence problems (p≤0.01) than the usual care group at 6 months. CONCLUSIONS: Study findings show that pelvic floor muscle exercise practice plus symptom self-management in a peer support setting can significantly improve urinary continence and quality of life in patients with prostate cancer.

Racial Difference in Response to Vitamin D Supplementation.

UNLABELLED: This manuscript is the result of work supported by the use of resources and facilities at the Louis Stokes Cleveland Department of Veterans Affairs Medical Center, specifically, the Geriatric Research Education and Clinical Center (GRECC). BACKGROUND: Deficiency in 25-hydroxyvitamin D (25[OH]D) is common, especially in the elderly and African Americans (AA). While 25(OH) D deficiency is associated with multiple negative health outcomes, current recommendations for supplementation of this deficiency may be insufficient. OBJECTIVE: To determine the prevalence of 25(OH)D deficiency, the extent of vitamin D supplementation, and the effect of supplementation on 25(OH) D levels in an elderly Veteran population. The study also focused specifically on the role of race in the risk for 25(OH)D deficiency and in the response to vitamin D supplementation. METHODS: A retrospective chart review was conducted of information including 25(OH)D serum levels pre and post-supplementation, race, and vitamin D supplementation. Subjects were community-dwelling Veterans (≥60years) followed by a VA geriatric clinic. A total of 234 charts were reviewed (124 Caucasian, 78 AA, 32 other/unknown race). Information collected through the chart review was analyzed by comparing the means of 25(OH)D levels pre and post-supplementation across races and across times. RESULTS: At Baseline 206 subjects (88%) were 25(OH)D deficient (<32ng/ml). While 80.6% of them were supplemented, only 10.24% (17 of 166) achieved normal 25(OH)D serum levels. AAs (n=78) had significantly lower Baseline levels compared to Caucasians (n=124) and differences were consistent across time. Fewer AAs than Caucasians increased to normal (AA:6.3%; Caucasian:12.8%). CONCLUSIONS: Conservative oral vitamin D supplementation is largely ineffective at achieving therapeutic serum levels, especially for AAs. Future research is needed to focus on individualized supplementation strategies and targeted risk factors such as race.

Willingness and access to joint replacement among African American patients with knee osteoarthritis: a randomized, controlled intervention.

OBJECTIVE: African American patients are significantly less likely to undergo knee replacement for the management of knee osteoarthritis (OA). Racial difference in preference (willingness) has emerged as a key factor. This study was undertaken to examine the efficacy of a patient-centered educational intervention on patient willingness and the likelihood of receiving a referral to an orthopedic clinic. METHODS: A total of 639 African American patients with moderate-to-severe knee OA from 3 Veterans Affairs primary care clinics were enrolled in a randomized, controlled trial with a 2 × 2 factorial design. Patients were shown a knee OA decision-aid video with or without brief counseling. The main outcome measures were change in patient willingness and receipt of a referral to an orthopedic clinic. Also assessed were whether patients discussed knee pain with their primary care provider or saw an orthopedic surgeon within 12 months of the intervention. RESULTS: At baseline, 67% of the participants were definitely/probably willing to consider knee replacement, with no difference among the groups. The intervention increased patient willingness (75%) in all groups at 1 month. For those who received the decision aid intervention alone, the gains were sustained for up to 3 months. By 12 months postintervention, patients who received any intervention were more likely to report engaging their provider in a discussion about knee pain (92% versus 85%), to receive a referral to an orthopedic surgeon (18% versus 13%), and for those with a referral, to attend an orthopedic consult (61% versus 50%). CONCLUSION: An educational intervention significantly increased the willingness of African American patients to consider knee replacement. It also improved the likelihood of patient-provider discussion about knee pain and access to surgical evaluation.

Needs assessment survey of healthcare providers' perceptions and practices regarding delirium prevention at a university medical center.

Background: Despite the high prevalence and serious implications of delirium, identification, tracking, and documentation of the condition remain a challenge for the health care team, impeding management of patients. This survey is the first phase of a qualitative study to build a conversational agent-based tool for screening and managing delirium-prone patients. Objectives: To assess healthcare providers' perceptions of delirium management, focusing on patient assessment, therapeutic interventions, and subsequent communication and documentation. Design: An electronic web-based survey was distributed to healthcare providers identified as caring for inpatient acutely ill older adults admitted for medical and orthopedic surgery needs. Respondent contact information was removed to preserve anonymity. Setting: A 1,000 bed university-affiliated teaching hospital in an urban setting. Participants: 23 residents in family practice, 36 residents in internal medicine, and a total of 492 advanced care nurses, nurses, and clinical staff. Approach: The analysis of survey responses provided insight into providers' current experiences with delirium assessment tools including computerized documentation, as well as their perceptions and attitudes toward delirium prevention. Key results: Most respondents (89%) thought delirium could be prevented, and 85% thought targeting delirium risk factors was helpful. Fifty one percent reported patients' loneliness and need for companionship, and 65% believed delirium was linked to higher mortality. Only 14% of respondents thought existing Electronic Health Record (EHR) alerts to identify high-risk delirium patients were useful, and 38% thought current delirium assessment protocols were helpful. In addition, 33% of nurses never received formal delirium prevention training, and 48% indicated that they needed improved systems to assess and manage patients at risk for delirium. Conclusion: A majority of providers affirmed that current delirium protocols are helpful; however, existing screening instruments and methods for documentation are cumbersome, resulting in incomplete or limited documentation of episodes. These barriers lead to an understatement of evidence available for continuous improvement of the patient management process.

Impact of perceived discrimination in healthcare on patient-provider communication.

BACKGROUND: The impact of patients' perceptions of discrimination in healthcare on patient-provider interactions is unknown. OBJECTIVE: To examine association of past perceived discrimination with subsequent patient-provider communication. RESEARCH DESIGN: Observational cross-sectional study. SUBJECTS: African-American (N=100) and white (N=253) patients treated for osteoarthritis by orthopedic surgeons (N=63) in 2 Veterans Affairs facilities. MEASURES: Patients were surveyed about past experiences with racism and classism in healthcare settings before a clinic visit. Visits were audio-recorded and coded for instrumental and affective communication content (biomedical exchange, psychosocial exchange, rapport-building, and patient engagement/activation) and nonverbal affective tone. After the encounter, patients rated visit informativeness, provider warmth/respectfulness, and ease of communicating with the provider. Regression models stratified by patient race assessed the associations of racism and classism with communication outcomes. RESULTS: Perceived racism and classism were reported by more African-American patients than by white patients (racism: 70% vs. 26% and classism: 73% vs. 53%). High levels of perceived racism among African-American patients was associated with less positive nonverbal affect among patients [ß=-0.41, 95% confidence interval (CI)=-0.73 to -0.09] and providers (ß=-0.34, 95% CI=-0.66 to -0.01) and with low patient ratings of provider warmth/respectfulness [odds ratio (OR)=0.19, 95% CI=0.05-0.72] and ease of communication (OR=0.22, 95% CI=0.07-0.67). Any perceived racism among white patients was associated with less psychosocial communication (ß=-4.18, 95% CI=-7.68 to -0.68), and with low patient ratings of visit informativeness (OR=0.40, 95% CI=0.23-0.71) and ease of communication (OR=0.43, 95% CI=0.20-0.89). Perceived classism yielded similar results. CONCLUSIONS: Perceptions of past racism and classism in healthcare settings may negatively impact the affective tone of subsequent patient-provider communication.

The use of multimodal strategies for distance education in the GRECCs.

The Department of Veterans Affairs (VA) has found distance education to be particularly valuable as a means to disseminate information to large numbers of busy learners in geographically diverse settings. Specifically, Geriatric Research, Education and Clinical Centers (GRECCs) of the VA have used various forms of distance learning to provide geriatrics-focused education to diverse health care providers. Such formats allow programs to be available to audiences regardless of distance or time. Although the distance-learning format has clear benefits, there are also some barriers that have hindered its wider adoption, including technical difficulties and ease of use. Organizers of distance education programs are challenged to overcome these barriers to provide a quality learning experience for the audience. The GRECCs will likely continue to be leaders in exploring innovative distance-learning strategies to accomplish their mission of quality geriatric education.

The effect of patient race on total joint replacement recommendations and utilization in the orthopedic setting.

BACKGROUND: The extent to which treatment recommendations in the orthopedic setting contribute to well-established racial disparities in the utilization of total joint replacement (TJR) in the treatment of advanced knee/hip osteoarthritis has not been explored. OBJECTIVE: To examine whether orthopedic surgeons are less likely to recommend TJR to African-American patients compared to white patients with similar clinical indications, and whether there are racial differences in the receipt of TJR within six months of study enrollment. DESIGN: Prospective, observational study. PARTICIPANTS: African-American (AA; n = 120) and white (n = 337) patients seeking treatment for knee or hip osteoarthritis in Veterans Affairs orthopedic clinics. MAIN MEASURES: Patients completed surveys that assessed socio-demographic and clinical variables that could influence osteoarthritis treatment. Orthopedic surgeons' notes were reviewed to determine whether patients had been recommended for TJR and whether they underwent the procedure within 6 months of study enrollment. RESULTS: Rate of TJR recommendation was 19.5%. Odds of receiving a TJR recommendation were lower for AA than white patients of similar age and disease severity (OR = 0.46, 95% CI = 0.26-0.83; P = 0.01). However, this difference was not significant after adjusting for patient preference for TJR (OR = 0.69, 95% CI = 0.36-1.31, P = 0.25). Overall, 10.3% of patients underwent TJR within 6 months. TJR was less likely for AA patients than for white patients of similar age and disease severity (OR = 0.41, 95% CI = 0.16-1.05, P = 0.06), but this difference was reduced after adjusting for whether patients had received a recommendation for the procedure at the index visit (OR = 0.57, 95% CI = 0.21-1.54, P = 0.27). CONCLUSIONS: In this study, race differences in patient preferences for TJR appeared to underlie race differences in TJR recommendations, which led to race differences in utilization of the procedure. Our findings suggest that patient treatment preferences play an important role in racial disparities in TJR utilization in the orthopedic setting.

Assessment and Management of Delirium in Critically Ill Veterans.

BACKGROUND: Delirium is a complex syndrome prevalent in the intensive care unit. It has been associated with significant morbidity including distress, longer hospital stays, prolonged cognitive impairment, and increased mortality. OBJECTIVE: To describe a nurse-led interdisciplinary quality improvement initiative to increase nurses' knowledge of delirium, documentation of delirium assessment, and patient mobility. METHODS: Sixty-seven nurses in medical and surgical intensive care units were required to attend an interactive education program on delirium assessment and management. Scores on tests taken before and after the education program were used to evaluate knowledge. Medical records and bedside rounds were used to validate Confusion Assessment Method for the Intensive Care Unit documentation and interventions. Descriptive statistics were used to describe changes over time. A delirium resource team composed of nurses, physicians, and therapists provided didactic education paired with simulation training and bedside coaching. Mobility screening tests and computer templates guided assessments and interventions. RESULTS: Documentation of the Confusion Assessment Method improved from less than 50% to consistently 99%. Mobilization in the surgical intensive care unit increased from 90% to 98% after intervention. Days of delirium significantly decreased from 51% before intervention to 31% after intervention (χ12=7.01, P = .008). CONCLUSIONS: The success of this quality improvement project to enhance recognition of delirium and increase mobility (critical components of the pain assessment, breathing, sedation choice, delirium, early mobility, and family education bundle) was contingent on nursing leaders hip, interdisciplinary team collaboration, and interactive education.

The relationship of indwelling urinary catheters to death, length of hospital stay, functional decline, and nursing home admission in hospitalized older medical patients.

OBJECTIVES: To determine the association between indwelling urinary catheterization without a specific medical indication and adverse outcomes. DESIGN: Prospective cohort. SETTING: General medical inpatient services at a teaching hospital. PARTICIPANTS: Five hundred thirty-five patients aged 70 and older admitted without a specific medical indication for urinary catheterization. INTERVENTION: Indwelling urinary catheterization within 48 hours of admission. MEASUREMENTS: Death, length of hospital stay, decline in ability to perform activities of daily living (ADLs), and new admission to a nursing home. RESULTS: Indwelling urinary catheters were placed in 76 of the 535 (14%) patients without a specific medical indication. Catheterized patients were more likely to die in the hospital (6.6% vs 1.5% of those not catheterized, P=.006) and within 90 days of hospital discharge (25% vs 10.5%, P<.001); the greater risk of death with catheterization persisted in a propensity-matched analysis (hazard ratio (HR)=2.42, 95% confidence interval (CI)=1.04-5.65). Catheterized patients also had longer lengths of hospital stay (median, 6 days vs 4 days; P=.001); this association persisted in a propensity-matched analysis (HR=1.46, 95% CI=1.03-2.08). Catheterization was not associated (P>.05) with decline in ADL function or with admission to a nursing home. CONCLUSION: In this cohort of older patients, urinary catheterization without a specific medical indication was associated with greater risk of death and longer hospital stay.

Emerging nurse-sensitive outcomes and evidence-based practice in postoperative cardiac patients.

Outcomes continue to be one of the most powerful measures of quality care in all health care settings for all caregivers. Nurse-sensitive outcome measurement is one of the most promising strategies that can enhance patient care and satisfaction of patients, families, and caregivers. The purpose of this article is to assist intensive care unit nurses with identification and implementation of current evidence-based nursing interventions for the critically ill patients undergoing cardiac surgery.

Malnutrition as a Fall Risk Factor.

Examining various aspects of malnutrition in elderly patients may be helpful in determining the risk of falls.

Is a behavioral treatment for urinary incontinence beneficial to prostate cancer survivors as a follow-up care?

PURPOSE: The American Cancer Society (ACS) recommends a follow-up care plan for urinary incontinence of prostate cancer survivors that includes pelvic floor muscle exercise (PFME). We examined potential impacts and access barriers of this recommendation with consideration of patients who normally do not seek such care. METHODS: We compared 267 participants of a clinical trial that tested a PFME-based treatment of urinary incontinence and 69 nonparticipants who declined the trial. All subjects were assessed at baseline, 3, and 6 months on leakage frequency, disease-specific quality of life (QOL), and physical well-being. The nonparticipants were interviewed to examine reasons for intervention refusal. RESULTS: The participating and nonparticipating groups did not differ in most baseline demographics and clinical variables except that the nonparticipants had lower baseline prostate-specific antigen (P ≤ 0.01), lower education levels, and higher likelihood of receiving surgery alone (both P ≤ 0.05). Nonparticipants exhibited significantly more frequent daily leakage, poorer urinary function and bother, and severer urinary problems at 3 and 6 months, as well as worse physical well-being at 6 months, relative to baseline, than the participants. The primary reason for refusal was economical, such as lacking transportation and time for participation. CONCLUSIONS: Urinary function and QOL can worsen without appropriate follow-up care. It is important to make a PFME-based follow-up care program available to all incontinent prostate cancer survivors as recommended by ACS guidelines. IMPLICATIONS FOR CANCER SURVIVORS: Seeking PFME-based treatment is crucial for long-term urinary health outcomes even if present leakage is minor or financial challenge is a concern.

Patterns of Benign Prostatic Hyperplasia Associated Urinary Retention: Indwelling Urinary Catheter Use and Clinical Sequelae.

INTRODUCTION: Current clinical practice guidelines aim to decrease the use of unnecessary indwelling urinary catheters to prevent catheter associated urinary tract infections. Patients with benign prostatic hyperplasia often experience increased post-void residual urine volume and subsequent bladder catheterization to prevent complications such as urinary tract infections or hydronephrosis. However, the management of urinary retention in patients with benign prostatic hyperplasia varies and clinical guidelines are lacking. In this study we gather information on post-void residual urine volume, the use of catheters and associated complications in a sample of older veterans with benign prostatic hyperplasia. METHODS: A retrospective chart review was performed using 660 patients screened for documented post-void residual urine volume greater than 100 cc, age greater than 65 years and the absence of cancer. A final chart review of 136 male veterans was performed for this analysis. RESULTS: A total of 59 (43.4%) indwelling urinary catheters were placed. Catheters were placed in subjects with modest post-void residual urine volumes in the 100 to 150 cc range and in those with a post-void residual urine volume greater than 500 cc. Overall complication rates were low. Among those patients who had a catheter placed 51% reported hematuria, 36% reported pain and only 1 had documented urosepsis. Hydronephrosis occurred in 4 cases, each with a post-void residual urine volume of 301 to 400 cc, and 3 of these individuals had an indwelling urinary catheter placed. In those patients emergency room visits and hospitalizations were more frequently associated with placement of an indwelling urinary catheter. CONCLUSIONS: Larger studies are needed for the development of clinical guidelines on the treatment of patients with benign prostatic hyperplasia and urinary retention.

Simulation Training, Coaching, and Cue Cards Improve Delirium Care.

A quality improvement study supports the use of multimodal education to enhance clinical practice for care of patients with delirium.

Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age.

OBJECTIVES: To describe the changes in activities of daily living (ADL) function occurring before and after hospital admission in older people hospitalized with medical illness and to assess the effect of age on loss of ADL function. DESIGN: Prospective observational study. SETTING: The general medical service of two hospitals. PARTICIPANTS: Two thousand two hundred ninety-three patients aged 70 and older (mean age 80, 64% women, 24% nonwhite). MEASUREMENTS: At the time of hospital admission, patients or their surrogates were interviewed about their independence in five ADLs (bathing, dressing, eating, transferring, and toileting) 2 weeks before admission (baseline) and at admission. Subjects were interviewed about ADL function at discharge. Outcome measures included functional decline between baseline and discharge and functional changes between baseline and admission and between admission and discharge. RESULTS: Thirty-five percent of patients declined in ADL function between baseline and discharge. This included the 23% of patients who declined between baseline and admission and failed to recover to baseline function between admission and discharge and the 12% of patients who did not decline between baseline and admission but declined between hospital admission and discharge. Twenty percent of patients declined between baseline and admission but recovered to baseline function between admission and discharge. The frequency of ADL decline between baseline and discharge varied markedly with age (23%, 28%, 38%, 50%, and 63% in patients aged 70-74, 75-79, 80-84, 85-89, and > or =90, respectively, P <.001). After adjustment for potential confounders, age was not associated with ADL decline before hospitalization (odds ratio (OR) for patients aged > or =90 compared with patients aged 70-74 = 1.26, 95% confidence interval (CI) = 0.88-1.82). In contrast, age was associated with the failure to recover ADL function during hospitalization in patients who declined before admission (OR for patients aged > or =90 compared with patients aged 70-74 = 2.09, 95% CI = 1.20-3.65) and with new losses of ADL function during hospitalization in patients who did not decline before admission (OR for patients aged > or =90 compared with patients aged 70-74 = 3.43, 95% CI = 1.92-6.12). CONCLUSION: Many hospitalized older people are discharged with ADL function that is worse than their baseline function. The oldest patients are at particularly high risk of poor functional outcomes because they are less likely to recover ADL function lost before admission and more likely to develop new functional deficits during hospitalization