Longitudinal Effects of Activities, Social Environment, and Psychotropic Medication Use on Behavioral Symptoms of Individuals With Alzheimer's Disease in Nursing Homes.

A secondary data analysis of 25,560 minutes of structured clinical observations from a longitudinal study examined the impact of time-varying background factors, social environment, and psychotropic medication use on behavioral symptoms of nursing home residents with Alzheimer's disease (AD). Data were collected at baseline (N = 177), 12 months (N = 138), and 24 months (N = 111). Mixed-effects regression modeling showed that at 24 months: (a) higher cognitive and physical function and having a private bedroom/bathroom had the most positive influence on resident positive behaviors; (b) use of antipsychotic medications and solitary activities had the most negative influence on resident positive behaviors; (c) higher cognitive function significantly decreased negative behaviors; and (d) care-related activities and total number of psychotropic medications significantly increased negative behaviors. The current study describes risk factors for behavioral disturbances and the impact of activities, social environment, and psychotropic medications on behavioral outcomes in nursing home residents with AD. [Journal of Psychosocial Nursing and Mental Health Services, 56(11), 18-26.].

Assessing family caregiver skill in managing behavioral symptoms of Alzheimer's disease.

OBJECTIVES: This measurement study operationalized family caregiver skill in managing behavioral symptoms associated with Alzheimer's disease (AD) by testing a Caregiver Assessment of Behavioral Skill-Self-Report (CAB-SR) measure. METHOD: A cross-sectional design was used. Caregivers had a family member with possible/probable AD, resided at home with the care recipient and provided the majority of care (N = 82). The mail-administered assessment included the CAB-SR and other care recipient and caregiver measures. RESULTS: Preliminary CAB-SR reliability and validity were determined using reliability, factor analytic and correlational procedures. CONCLUSION: This measure provides a preliminary assessment of caregiver skill in managing behavioral symptoms of AD and shows promise for use in research and clinical intervention settings.

A lifestyle physical activity intervention for caregivers of persons with Alzheimer's disease.

BACKGROUND: The purpose of this pilot study was to examine the effects of lifestyle physical activity in caregivers (CGs) of persons with Alzheimer's disease. METHODS: Fifteen CGs engaged in lifestyle physical activity during a 6-month, home-based health promotion program. Mean changes in self-reported physical activity were compared using repeated-measures analysis of variance. RESULTS: Fifty percent of CGs increased total self-reported minutes and 42% increased total moderate minutes of physical activity from preintervention to postintervention; however, no CG engaged in vigorous physical activity and there were no significant improvements in self-reported physical activity for the total group. Hot summer weather, heavy non-caregiving responsibilities, heavy caregiving responsibilities, and feelings of anxiety, depressive symptoms, and fatigue were the most frequently identified physical activity barriers. CONCLUSION: Incorporating an individualized, home-based program of lifestyle physical activity appears feasible; however, attention needs to be given in the future to physical activity barriers identified by this select group of CGs.

Use of home-based formal services by adult day care clients with Alzheimer's disease.

OBJECTIVES: To explore the association between adult day care (ADC) attendance and utilization of home-based formal services among people with Alzheimer's Disease (AD). METHODS: Data for this secondary analysis came from a longitudinal parent study of 457 subjects from 16 ADC programs and an Alzheimer's diagnostic center in metropolitan Chicago. We used the method of Generalized Estimating Equations to model the use of home-based formal services over time. RESULTS: Adjusting for relevant covariates, more days of ADC use at each follow-up was associated with decreased use of home-based formal services (coefficient = .25, p< .0001). Older, unmarried caregivers who are children of the care recipients had lower use of home-based services. DISCUSSION: Results suggest that ADC services may substitute for specific types of home-based formal services. The projected increase in AD prevalence over the next several decades warrants a clearer understanding of how people with AD use formal services.

Comparison of self-reported pain and the PAINAD scale in hospitalized cognitively impaired and intact older adults after hip fracture surgery.

PURPOSE: The purpose of this study was a psychometric evaluation of the PAINAD to assess pain in hospitalized cognitively impaired and intact older adults admitted for surgical repair of a hip fracture. METHOD: A descriptive correlational design was used. A convenience sample of older patients hospitalized for surgical repair of a hip fracture was used. Twelve of the patients had cognitive impairment and 13 were cognitively intact. All were assessed for pain using both the self-report numeric rating scale and an observational assessment tool, the PAINAD. FINDINGS: A positive correlation was found between the PAINAD and a self-report pain scale, providing evidence of concurrent validity. PAINAD scores were higher when patients were likely to experience pain than when unlikely, providing evidence of discriminant validity. The results of this study provide evidence supporting the validity and reliability of the PAINAD in the pain assessment of hospitalized post-orthopaedic surgical older adults who are unable or reluctant to self-report pain.

Nursing home placement, day care use, and cognitive decline in Alzheimer's disease.

OBJECTIVE: People with Alzheimer's disease are often placed in a nursing home, sometimes after using adult day care services. How affected persons function during this potentially difficult transition is not well understood. The aim of this study was to examine the associations of day care use and nursing home placement with the rate of cognitive decline in Alzheimer's disease. METHOD: The participants were 432 older persons with Alzheimer's disease who were recruited from health care settings in the Chicago area. At baseline, they lived in the community and were using day care services a mean 1.7 days per week. At 6-month intervals for up to 4 years, they completed nine cognitive tests from which a composite measure of global cognition was derived. RESULTS: On average, cognition declined at a gradually increasing rate during the study period. Nursing home placement was associated with a decrease in the level of cognition and an acceleration in the rate of cognitive decline. Day care use at baseline was not related to cognitive decline in initial analyses, but it interacted with nursing home placement such that higher level of day care use substantially reduced association of placement with accelerated cognitive decline. Education interacted with placement such that more schooling was associated with a greater increase in cognitive decline upon nursing home placement, but prior day care use also attenuated this association. CONCLUSIONS: Nursing home placement is associated with accelerated short-term cognitive decline in Alzheimer's disease. Prior experience in adult day care may lessen this association.

Efficacy of behavioral interventions for dementia caregivers.

Behavioral symptoms of Alzheimer's disease, particularly agitation, appear to be a major contributing factor to the emotional distress exhibited by family caregivers. Psychosocial interventions have been shown to reduce caregiver emotional distress, but few studies have examined the efficacy of these interventions with caregivers exposed to high levels of dementia-related behavioral symptoms. The purpose of this study is to test the efficacy of a caregiver skill building intervention in reducing emotional distress to agitated behaviors of care recipients. This study analyzed data from a subgroup of caregivers who participated in a larger randomized clinical trial (N = 295). Data from 143 caregivers of family members with baseline agitated behaviors indicate that the skill building intervention was more effective than an information and support oriented comparison condition in reducing emotional distress over an 18-month period. These findings indicate that dementia caregivers exposed to agitated behaviors can benefit from psychosocial interventions, particularly those aimed at building behavioral management skills.

Effect of Moderate to Vigorous Physical Activity Intervention on Improving Dementia Family Caregiver Physical Function: A Randomized Controlled Trial.

OBJECTIVE: Alzheimer's disease and related dementias (ADRD) affect more than five million Americans and their family caregivers. Caregiving creates challenges, may contribute to decreased caregiver health and is associated with $9.7 billion of caregiver health care costs. The purpose of this 12 month randomized clinical trial (RCT) was to examine if the Enhancing Physical Activity Intervention (EPAI), a moderate to vigorous physical activity (MVPA) treatment group, versus the Caregiver Skill Building Intervention (CSBI) control, would have greater: (1) MVPA adherence; and (2) physical function. METHODS: Caregivers were randomly assigned to EPAI or CSBI (N=211). MVPA was assessed using a self-report measure; and physical function was objectively assessed using two measures. Intention-to-treat analyses used descriptive, categorical and generalized estimating equations (GEE), with an exchangeable working correlation matrix and a log link, to examine main effects and interactions in change of MVPA and physical function over time. RESULTS: At 12 months, EPAI significantly increased MVPA (p=<0.001) and number of steps (p=< .01); maintained stable caregiving hours and use of formal services; while CSBI increased hours of caregiving (p=<0.001) and used more formal services (p=<0.02). Qualitative physical function data indicated that approximately 50% of caregivers had difficulties completing physical function tests. CONCLUSION: The EPAI had a stronger 12 month effect on caregiver MVPA and physical function, as well as maintaining stability of caregiving hours and formal service use; while CSBI increased caregiving hours and use of formal services. A study limitation included greater EPAI versus CSBI attrition. Future directions are proposed for dementia family caregiver physical activity research.

The effect of adult day care services on time to nursing home placement in older adults with Alzheimer's disease.

PURPOSE: This longitudinal study examined whether the use of adult day care services delayed time to nursing home placement in persons with Alzheimer's disease. DESIGN AND METHODS: Two hundred and eighteen adult day care clients with Alzheimer's disease were recruited from 16 adult day programs in a large metropolitan area. Two hundred and ninety eight persons with Alzheimer's disease but not using adult day care were recruited from a federally funded Alzheimer's diagnostic center and frequency matched to adult day care users on age, gender, race, and level of cognitive impairment. Participants were followed at 3-month intervals for up to 48 months. Cox proportional hazards models were used to examine the effects of adult day care and other fixed and time-varying factors on risk of nursing home placement. RESULTS: Risk of nursing home placement increased significantly with the number of days of adult day care attendance, with this effect being substantially greater for men (hazard ratio or HR = 1.33; confidence interval or CI = 1.18-1.49) than for women (HR = 1.09; CI = 1.00-1.18). Participant disability and hospitalizations and caregiver age and burden were independent predictors, but their inclusion in the model did not alter the risk associated with adult day care. IMPLICATIONS: More severe disease and greater caregiver burden did not explain the increased risk of nursing home placement among adult day care users with Alzheimer's disease. Rather, it appears that other unmeasured factors, such as a proclivity to institutionalize, may account for the association of adult day care to nursing home risk.

Caregiver psychological adjustment and institutionalization of persons with Alzheimer's disease.

UNLABELLED: This prospective study examines the relationship between caregiver psychological adjustment and institutionalization of persons with Alzheimer's disease (AD). METHOD: A 3-year longitudinal study was conducted with a clinic-based cohort of 396 persons with AD and their respective family caregivers. Caregiver adjustment was sequentially measured in 3-month intervals using standard scales of appraisal (perceived burden and satisfaction) and emotion (depressive symptoms and positive affect). RESULTS: In multivariable proportional hazards regression models predicting time to institutionalization controlling for AD severity, hazard ratios were significant for appraisal measures of caregiver adjustment, perceived burden (1.053; 95% confidence interval [CI], 1.014, 1.093), and satisfaction (.929; 95% CI, .883, .977). In contrast, levels of caregivers' positive and negative emotion did not reliably predict institutionalization. DISCUSSION: The findings highlight the importance of caregiver appraisals in decisions to institutionalize persons with a dementia syndrome, but the limited impact of caregiver emotion was unexpected and requires further study.

Attitudes Toward and Experiences in End-of-life Care Education in the Intensive Care Unit: A Survey of Resident Physicians.

INTRODUCTION: Resident physicians provide the most physician care to intensive care unit (ICU) patients. The body of literature about residents' palliative and end-of-life care (PC/EOLC) experiences in the ICU is limited. To our knowledge, this is the first study to assess resident physicians in multiple specialties regarding PC/EOLC in the ICU. METHODS: A Web-based survey was developed and administered to all resident physicians in a single academic institution who had completed at least 1 dedicated ICU rotation. RESULTS: Residents reported moderate comfort in dealing with end-of-life (EOL) issues and felt somewhat prepared to care for critically ill patients at the EOL. Feedback should be provided to residents regarding their PC/EOLC skills, and education should be tailored to residents rotating in the ICU.

Temporal patterns of negative and positive behavior among nursing home residents with Alzheimer's disease.

Although clinical observations suggest a late-day peak in disruptive behavior in persons with dementia, results from studies of temporal patterns of behavior are equivocal. This study used direct observation methods and systematic time sampling to examine temporal patterns of negative and positive behavior in 177 residents of 2 long-term care facilities with clinically diagnosed Alzheimer's disease (AD). The authors found small statistically significant diurnal variation in both negative and positive behavior, characterized by a curvilinear pattern with a single peak. This pattern was unaffected by seasonal differences in length of day, severity of cognitive impairment, level of behavior, or sleep disturbances. Time when behavior peaked differed by type of behavior and by facility, and there was substantial heterogeneity in behavior patterns.

Do behavioral disturbances in persons with Alzheimer's disease predict caregiver depression over time?

Random effects models were used to examine the association between behavioral disturbances in persons with Alzheimer's disease (N = 90) and caregiver depressive symptoms at 2-month intervals over an 18-month period. There was substantial variability in trajectories of change in caregiver depressive symptoms over time but no systematic increase in distress despite increased severity of dementia symptoms. Total behavioral disturbances were associated with higher levels of caregiver depressive symptoms: this effect was primarily attributable to aggressive behaviors. No consistent departure from linearity was evident in the relationship between behavior and depression over time.

Caring for self while caring for others: the two-track life of coping with Alzheimer's disease.

Relationships between depressive symptoms and altered immune function have been documented in the literature; however, the links between depressive symptoms, altered immune function, and changes in physical health are less clear. Although a number of caregiver descriptive studies have examined immunological outcomes, only one intervention study with caregivers of individuals with Alzheimer's disease, known to the authors, has included immunological outcomes. The purpose of this pilot study was to assess the effectiveness of a caregiver skill-building intervention to decrease caregiver depressive symptomatology and care-receiver behavioral symptoms; and to assess the feasibility and stability of the delayed type hypersensitivity (DTH) skin test with this population. Caregiver depressive symptoms decreased, while care-receiver behaviors did not. Findings suggested that the DTH skin test could be successfully administered to caregivers of individuals with Alzheimer's disease and that this skin test had short-term stability. There were no significant relationships between caregiver depressive symptoms and immune function. Study findings suggest that nurses can play a pivotal role in intervening with family caregivers and potentially decreasing their depressive symptoms.

Do Community and Caregiver Factors Influence Hospice Use at the End of Life Among Older Adults With Alzheimer Disease?

Hospice is an underused service among people with Alzheimer disease. This study used the Hospice Use Model to examine community, care recipient, and caregiver characteristics associated with hospice use before death among 145 community-dwelling care recipients with Alzheimer disease and their caregivers. Secondary analysis using logistic regression modeling indicated that older age, male gender, black race, and better functional health of care recipients with Alzheimer disease were associated with a decreased likelihood of using hospice (model χ25 = 23.5, P = .0003). Moreover, care recipients recruited from an Alzheimer clinic were more likely to use hospice than those recruited from adult day-care centers. Caregiver factors were not independent predictors of hospice use. However, there was a significant interaction between hours of care provided each week and recruitment site. Among care recipients from the Alzheimer clinic, the probability of hospice use increased as caregiving intensity increased. This relationship was reversed in care recipients from day-care centers. Results suggest that adult day-care centers need to partner with hospice programs in the community. In conclusion, care recipient and community service factors influence hospice use in individuals with Alzheimer disease.

Role of technology in supporting quality control and treatment fidelity in a family caregiver clinical trial.

This article describes how a family caregiver lifestyle physical activity clinical trial uses research technology to enhance quality control and treatment fidelity. This trial uses a range of Internet, Blaise(®) Windows-based software and Echo Server technologies to support quality control issues, such as data collection, data entry, and study management advocated by the clinical trials literature, and to ensure treatment fidelity concerning intervention implementation (i.e., design, training, delivery, receipt, and enactment) as proposed by the National Institutes of Health Behavior Change Consortium. All research staff are trained to use these technologies. Strengths of this technological approach to support quality control and treatment fidelity include the comprehensive plan, involvement of all staff, and ability to maintain accurate and timely data. Limitations include the upfront time and costs for developing and testing these technological methods, and having support staff readily available to address technological issues if they occur.

Creative partnerships for funding nursing research.

The Small Business Innovation Research (SBIR) program and the Small Business Technology Transfer Research (STTR) program are two federal funding mechanisms that some nurses in academic positions have used to support research and development of innovative nursing products or services. Both the SBIR and STTR mechanisms are excellent sources of funding for nurse researchers who want to capitalize on relationships with small businesses or obtain seed money to fund high-risk projects with potential to attract new venture capital. This article provides an overview of National Institutes of Health (NIH)-funded SBIR and STTR programs and summarizes similarities and differences between the programs. The article also describes unique features of NIH SBIR and STTR funding mechanisms that differentiate them from other R-series funding mechanisms, reviews evaluation criteria for SBIR and STTR projects, and discusses critical partners and resources for proposal development. Finally, the article describes characteristics of successful partnerships and provides examples of SBIR/STTR-funded projects.

Upper and lower extremity motor performance and functional impairment in Alzheimer's disease.

This report examines the relation of upper and lower extremity motor performance to functional impairment among 371 persons with probable Alzheimer's disease (AD). Cognitive and motor performance tests were administered at 6-month intervals for up to 4 years. Motor performance was assessed using 3 lower extremity tests and 2 upper extremity tests. Functional impairment was measured at 3-month intervals using caregiver ratings of impairments in activities of daily living, mobility, and range of motion. Both lower and upper extremity performance were inversely related to functional impairments on all 3 scales (all Ps < .001), after controlling for age, sex, and level of cognitive impairment. This suggests that motor performance contributes to functional impairments in AD, independent of cognitive impairment. It is important to preserve motor performance in individuals with AD because it influences physical function throughout the course of the disease.

Developing a Measurement Strategy for Assessing Family Caregiver Skills: Conceptual Issues.

This report presents a conceptual approach to assessing skills of family caregivers for persons with Alzheimer's disease and recommends next steps for development of this science. Researchers used multiple methods to develop a conceptual strategy for assessing family caregiver skills. Study participants included clinical/outreach staff from an Alzheimer's Disease Center, nursing faculty with expertise in dementia care, and family caregivers. Mixed methods contributed to the conceptual clarification of caregiving skill and to the development of three approaches to assessing caregiver skill: caregiver self report, clinician assessment, and direct observational assessment. Caregiver effectiveness has the potential to affect the process of caregiving and outcomes for the person with dementia and caregiver.