Feasibility of a Multi-Component Strengths-Building Intervention for Caregivers of Persons With Heart Failure.

Caregivers of persons with heart failure (HF) navigate complex care plans, yet support strategies often focus solely on meeting the needs of patients. We conducted a randomized waitlist control trial (N = 38) to test the feasibility and gauge initial effect size of the Caregiver Support intervention on quality of life, caregiver burden, and self-efficacy among HF caregivers. The intervention includes up to five remote, nurse-facilitated sessions. Components address: holistic caregiver assessment, life purpose, action planning, resources, and future planning. Caregivers were 93.3% female, 60% White, and 63.3% spouses. Average age was 59.4. Participants who completed the intervention reported high satisfaction and acceptability of activities. Between-group effect sizes at 16 and 32 weeks suggest improvement in quality of life (mental health) (.88; 1.08), caregiver burden (.31; .37), and self-efficacy (.63; .74). Caregivers found Caregiver Support acceptable and feasible. Findings contribute evidence that this intervention can enhance caregiver outcomes. Clinicaltrials.gov Identifier NCT04090749.

The effects of vitamin D supplementation on types of falls.

BACKGROUND/OBJECTIVES: To assess whether vitamin D supplementation prevents specific fall subtypes and sequelae (e.g., fracture). DESIGN: Secondary analyses of STURDY (Study to Understand Fall Reduction and Vitamin D in You)-a response-adaptive, randomized clinical trial. SETTING: Two community-based research units. PARTICIPANTS: Six hundred and eighty-eight participants ≥70 years old with elevated fall risk and baseline serum 25-hydroxyvitamin D levels of 10-29 ng/ml. INTERVENTION: 200 IU/day (control), 1000 IU/day, 2000 IU/day, or 4000 IU/day of vitamin D3. MEASUREMENTS: Outcomes included repeat falls and falls that were consequential, were injurious, resulted in emergency care, resulted in fracture, and occurred either indoors or outdoors. RESULTS: After adjustment for multiple comparisons, the risk of fall-related fracture was greater in the pooled higher doses (≥1000 IU/day) group compared with the control (hazard ratio [HR] = 2.66; 95% confidence interval [CI]:1.18-6.00). Although not statistically significant after multiple comparisons adjustment, time to first outdoor fall appeared to differ between the four dose groups (unadjusted p for overall difference = 0.013; adjusted p = 0.222), with risk of a first-time outdoor fall 39% lower in the 1000 IU/day group (HR = 0.61; 95% CI: 0.38-0.97; unadjusted p = 0.036; adjusted p = 0.222) and 40% lower in the 2000 IU/day group (HR = 0.60; 95%CI 0.38-0.97; p = 0.037; adjusted p = 0.222), each versus control. CONCLUSION: Vitamin D supplementation doses ≥1000 IU/day might have differential effects on fall risk based on fall location and fracture risk, with the most robust finding that vitamin D doses between 1000 and 4000 IU/day might increase the risk of first time falls with fractures. Replication is warranted, given the possibility of type 1 error.

The Effects of Four Doses of Vitamin D Supplements on Falls in Older Adults : A Response-Adaptive, Randomized Clinical Trial.

BACKGROUND: Vitamin D supplementation may prevent falls in older persons, but evidence is inconsistent, possibly because of dosage differences. OBJECTIVE: To compare the effects of 4 doses of vitamin D3 supplements on falls. DESIGN: 2-stage Bayesian, response-adaptive, randomized trial. (ClinicalTrials.gov: NCT02166333). SETTING: 2 community-based research units. PARTICIPANTS: 688 participants, aged 70 years and older, with elevated fall risk and a serum 25-hydroxyvitamin D [25-(OH)D] level of 25 to 72.5 nmol/L. INTERVENTION: 200 (control), 1000, 2000, or 4000 IU of vitamin D3 per day. During the dose-finding stage, participants were randomly assigned to 1 of the 4 vitamin D3 doses, and the best noncontrol dose for preventing falls was determined. After dose finding, participants previously assigned to receive noncontrol doses received the best dose, and new enrollees were randomly assigned to receive 200 IU/d or the best dose. MEASUREMENTS: Time to first fall or death over 2 years (primary outcome). RESULTS: During the dose-finding stage, the primary outcome rates were higher for the 2000- and 4000-IU/d doses than for the 1000-IU/d dose, which was selected as the best dose (posterior probability of being best, 0.90). In the confirmatory stage, event rates were not significantly different between participants with experience receiving the best dose (events and observation time limited to the period they were receiving 1000 IU/d; n = 308) and those randomly assigned to receive 200 IU/d (n = 339) (hazard ratio [HR], 0.94 [95% CI, 0.76 to 1.15]; P = 0.54). Analysis of falls with adverse outcomes suggested greater risk in the experience-with-best-dose group versus the 200-IU/d group (serious fall: HR, 1.87 [CI, 1.03 to 3.41]; fall with hospitalization: HR, 2.48 [CI, 1.13 to 5.46]). LIMITATIONS: The control group received 200 IU of vitamin D3 per day, not a placebo. Dose finding ended before the prespecified thresholds for dose suspension and dose selection were reached. CONCLUSION: In older persons with elevated fall risk and low serum 25-(OH)D levels, vitamin D3 supplementation at doses of 1000 IU/d or higher did not prevent falls compared with 200 IU/d. Several analyses raised safety concerns about vitamin D3 doses of 1000 IU/d or higher. PRIMARY FUNDING SOURCE: National Institute on Aging.

Rationale and design of the Study To Understand Fall Reduction and Vitamin D in You (STURDY): A randomized clinical trial of Vitamin D supplement doses for the prevention of falls in older adults.

Prior evidence suggests that vitamin D supplementation may reduce fall risk, but existing data are inconsistent and insufficient to guide policy. We designed a two-stage Bayesian response-adaptive dose-finding and seamless confirmatory randomized trial of vitamin D supplementation to prevent falls. Up to 1200 community-dwelling persons, aged ≥70 years, of predominantly white and African-American race, with serum 25(OH)D concentrations of 10-29 ng/mL and at elevated fall risk, will be randomized to one of four vitamin D3 (cholecalciferol) supplement doses: 200 (control), 1000, 2000, or 4000 IU/day and treated for up to 2 years. Stage 1 is designed to identify the best of the non-control doses for fall prevention. If a best dose is selected, Stage 2 will start seamlessly, with enrollees assigned to control or the best dose in Stage 1 continuing on that dose unchanged, enrollees assigned to the two non-control, non-best doses in Stage 1 switched to the best dose, and new enrollees randomly assigned 1:1 to control or the best dose. In Stage 2, we will compare the control dose group to the best dose group to potentially confirm the efficacy of that dose for fall prevention. The primary outcome measure in both stages is time to first fall or death, whichever comes first. Falls are ascertained from calendars, scheduled interviews, or interim self-reports. Secondary outcome measures include time to each component of the composite primary outcome and gait speed. Additional outcomes include the Short Physical Performance Battery score, physical activity level (assessed by accelerometry), and frailty score. CLINICAL TRIAL REGISTRATION: NCT02166333.

Ensuring safe and optimal medication use in older community residents: Collaboration between a nurse and a pharmacist.

The purpose of this retrospective review is to describe 1) a nurse-pharmacist collaboration within a home based nurse-occupational therapist-handyman program called CAPABLE and 2) potential medication problems and 3) information communicated to participants and prescribers about those problems. A chart review was performed for each participant that one CAPABLE nurse referred to the pharmacists. We identified recommendations provided by pharmacists, synthesized common questions posed to the pharmacists' and developed exemplar cases of participant encounters. Fifty-nine participants were reviewed. The median number of total medications was 11 (IQR 9-14.5). Participants were most commonly taking antihypertensives (93%), statins (66%), and supplements/vitamins (61%). Pharmacists provided 83 unique recommendations for the 59 participants. The recommendations from the pharmacist were communicated for 49 of the 59 participants (83%), by the nurse. The nurse-pharmacist collaboration identified medication-related problems and solutions aimed at improving the quality of life for home-dwelling seniors with functional limitations.

Development of an Exergame for Urban-dwelling Older Adults With Functional Limitations: Results and Lessons Learned.

BACKGROUND: Falls at home are common and potentially fatal for disabled older adults. To address this problem, we created an academic-community partnership involving disabled, urban-dwelling older adults and their families, the housing authority, a Tai Chi master, and a university. OBJECTIVES: We conducted a pilot to assess safety, acceptability, and feasibility of a Wii-based exergame designed to increase disabled older adults' strength and balance. METHODS: A working prototype was developed and evaluated. Then, we piloted a refined version with 19 disabled urban-dwelling older adults. RESULTS: The program was enjoyable, feasible, and acceptable. Participants described multiple functional improvements. Of the 16 who completed at least three gaming sessions, average balance score increased 25% and gait speed increased 19%. CONCLUSIONS: This pilot showed promising results for improving strength and balance in the home setting, and yielded valuable lessons about health technology development with community partners.

Examining mindfulness-based stress reduction: perceptions from minority older adults residing in a low-income housing facility.

BACKGROUND: Mindfulness-based stress reduction (MBSR) programs are becoming increasingly common, but have not been studied in low income minority older populations. We sought to understand which parts of MBSR were most important to practicing MBSR members of this population, and to understand whether they apply their training to daily challenges. METHODS: We conducted three focus groups with 13 current members of an MBSR program. Participants were African American women over the age of 60 in a low-income housing residence. We tape recorded each session and subsequently used inductive content analysis to identify primary themes. RESULTS AND DISCUSSION: Analysis of the focus group responses revealed three primary themes stress management, applying mindfulness, and the social support of the group meditation. The stressors they cited using MBSR with included growing older with physical pain, medical tests, financial strain, and having grandchildren with significant mental, physical, financial or legal hardships. We found that participants particularly used their MBSR training for coping with medical procedures, and managing both depression and anger. CONCLUSION: A reflective stationary intervention delivered in-residence could be an ideal mechanism to decrease stress in low-income older adult's lives and improve their health.

Facilitating resilience using a society-to-cells framework: a theory of nursing essentials applied to research and practice.

The resilience potential of each human being is an essential focus of nursing care and research. An honored nursing tradition is viewing each patient in the context of family and culture and recognizing how these factors affect a patient's health and ability to be resilient. We present a society-to-cells nursing theory that formalizes and extends this holistic view of patients by delineating factors that contribute to resilience potential based on the society, community, and family environment in which people live, as well as individual variables that influence psychological, physiological, and cellular coping abilities. We also summarize how this perspective is essential to optimize patient care and to inform future nursing research.

Biological underpinnings of health alterations in women with PTSD: a sex disparity.

Women develop posttraumatic stress disorder (PTSD) at twice the rate of men, even though fewer women than men experience traumatic events over their lifetimes. Current studies of individuals with PTSD provide evidence of alterations in the neuroendocrine system that involve levels and activity of cortisol and DHEA and changes in immune function that predispose these individuals toward an innate (Th1) immune response. Yet few studies have addressed the possible role of these biologic alterations in women's increased vulnerability to developing PTSD. In addition, current studies are limited in their ability to link biologic alterations to the observed fourfold increase in medical conditions in women with PTSD as compared to women without PTSD. And finally, few studies have addressed the biologic impact of co-occurring major depressive disorder (MDD) in individuals with PTSD. This critical review provides an update on neuroendocrine and immune perturbations associated with PTSD with and without co-occurring MDD to suggest links to health and possible mechanisms underlying the observed sex disparity in the development of PTSD.