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.].

Comparing the Effect of a Moderate Physical Activity Intervention on the Mental Health Outcomes of African American and Caucasian Dementia Family Caregivers: A Secondary Data Analysis.

Increased attention to the effects of the stressful demands of caregiving on the mental health of dementia caregivers has resulted in the development of numerous interventions. The current study is a secondary analysis of a randomized controlled trial that tested a 12-month moderate physical activity intervention with dementia caregivers. Our secondary data analysis examined racial differences in caregiver mental health outcomes including subjective burden, depressive symptoms, and positive affect, as well as differences in physical activity. A total of 211 community-dwelling dementia family caregivers were randomly assigned to a 12-month Enhanced Physical Activity (treatment) Intervention (EPAI) or a Caregiver Skill Building (control) Intervention (CSBI). Of these, 34 African American and 80 Caucasian caregivers completed the study. At baseline, race was associated with subjective burden and positive affect, but not with depressive symptoms. Post intervention (12 months), there were no racial differences in subjective burden or depressive symptoms. However, race was significantly associated with decreased positive affect (p = 0.003) and decreased total minutes of physical activity (p = 0.012). Findings suggest that the mental health needs of African American caregivers warrant additional exploration, where physical activity may be of benefit. These findings provide a cultural perspective to consider during intervention development for future nurse-driven research.

Racial Differences in Program Evaluation of a Lifestyle Physical Activity Randomized Controlled Trial.

The purpose of this study was to compare program evaluation responses between African American and Caucasian caregivers of persons with Alzheimer's disease and related dementias who completed a lifestyle physical activity randomized controlled trial. The aim was to determine if African Americans evaluated the study differently than Caucasians. Family caregivers (N = 211) were randomly assigned to a 12-month physical activity intervention or a control condition. Upon intervention completion (n = 114), caregivers responded to an 11-item questionnaire using Likert-type scale responses and three open-ended questions about the overall intervention quality. Findings indicated that African American caregivers evaluated both conditions more favorably than Caucasian caregivers (p = .02). Content analysis of the narrative responses revealed five major qualitative themes: support, resources, responsibility, adjusting, and time These findings suggest the value of both access to resources, and support for African American caregivers who participate in intervention research.

Impact of an Individualized Physical Activity Intervention on Improving Mental Health Outcomes in Family Caregivers of Persons with Dementia: A Randomized Controlled Trial.

PURPOSE: This study examined secondary benefits of an individualized physical activity intervention on improving dementia family caregivers' subjective burden, depressive symptoms and positive affect. DESIGN AND METHODS: A community-based randomized controlled trial (RCT) was implemented with family caregivers of persons with dementia (N = 211) who received the Enhanced Physical Activity Intervention (EPAI: treatment intervention, n = 106) or the Caregiver Skill Building Intervention (CSBI: control intervention, n = 105). Interventions were delivered over 12 months, including a baseline home visit and regularly spaced telephone calls. Data were collected in person at baseline, 6 and 12-months; and telephonically at 3 and 9-months. The EPAI integrated physical activity and caregiving content while the CSBI focused only on caregiving content. Descriptive, bivariate and intention-to-treat analyses using generalized estimating equations (GEE) were performed to examine secondary benefits of the EPAI on family caregiver burden, depressive symptoms and positive affect. RESULTS: Compared to caregivers in the CSBI group, caregivers in the EPAI significantly increased their overall and total moderate physical activity and showed a positive interaction between the intervention and time for positive affect at both six (p = 0.01) and 12-months (p = 0.03). The EPAI was significantly associated with improving burden at 3 months (p = 0.03) but had no significant effect on depressive symptoms. IMPLICATIONS: Caregiver involvement in an individualized physical activity intervention was associated with increased overall and total moderate physical activity and improved positive affect from baseline to 12 months. Improved positive affect may help caregivers to feel better about themselves and their situation, and better enable them to continue providing care for their family member for a longer time at lower risk to their own mental health.

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.

Demographic and Socioenvironmental Characteristics of Black and White Community-Dwelling Caregivers and Care Recipients' Behavioral and Psychological Symptoms of Dementia.

The purpose of the current study was to compare the association between caregiver background characteristics and care recipients' behavioral and psychological symptoms of dementia (BPSD) in Black and White community-dwelling family caregivers. Using logistic regression models, caregiver/care recipient dyad data from the Aging Demographics and Memory Study were used to describe associations between caregiver background characteristics (i.e., demographic and socioenvironmental variables) and care recipients' BPSD (i.e., hallucinations, delusions, agitation, depression) (N = 755). Results showed that Black caregivers were more likely to be female, younger, an adult child, have less education, and live in the South (p ≤ 0.05); they were less likely to be married. Several caregiver background characteristics were associated with care recipients' depression and agitation, but not with other BPSD. Caregiver background characteristics may play a role in the recognition and reporting of BPSD and should be considered when working with families of individuals with dementia.

A chronic grief intervention for dementia family caregivers in long-term care.

Dementia caregivers do not relinquish their role after placing family members in long-term care and they experience increased chronic grief. The Chronic Grief Management Intervention (CGMI) is a12-week group-based program that uses guided discussion to deliver knowledge of Alzheimer's or a related dementia and teach skills in communication, conflict resolution, and chronic grief management in dementia caregivers who placed their family members in long-term care. Using a quasi-experimental design, 83 caregivers from 15 long-term care facilities received either the CGMI (n = 34) or a comparison condition consisting of two check-in calls (n = 49). In this pilot study, we examined the feasibility of implementing the CGMI and evaluated the effects of the intervention on caregivers' knowledge and skill and their chronic grief and depression. The intervention was feasible and resulted in significant improvement in caregivers' heartfelt sadness and longing at 3 months and a significant drop in their guilt at the 6-month follow-up.

Preliminary study of themes of meaning and psychosocial service use among informal cancer caregivers.

OBJECTIVE: The burden experienced by informal caregivers (ICs) of patients with advanced cancer is well documented. ICs are at risk for anxiety and depression, as well as existential concerns that arise when a loved one is facing a terminal illness. Few psychosocial interventions focus on existential concerns of ICs. However, a growing body of literature indicates that finding meaning in the experience of being an IC for a person with cancer has the potential to buffer against burden. The purpose of this study was to collect preliminary descriptive data regarding caregiver burden, meaning, and psychosocial service use to inform the adaptation of a meaning-centered intervention for ICs. METHOD: Twenty-five caregivers and 32 patients completed brief, anonymous questionnaires that asked about their role as a caregiver or their perception of their loved one as a caregiver, caregiver burden, and psychosocial service use. RESULTS: Caregivers and patients identified anxiety and depression as top correlates of burden experienced by caregivers, whereas guilt, issues with role/sense of identity, and self-care were additional areas of concern. The majority of caregivers were not receiving psychosocial services, although they almost unanimously reported desiring services. A greater proportion of patients than caregivers believed that an intervention designed to enhance meaning would ameliorate burden, but, nevertheless, close to three quarters of caregivers reported interest in participating in such an intervention. SIGNIFICANCE OF RESULTS: These study findings provide further support for, at a minimum, engaging ICs of persons with advanced cancer in interventions that address existential issues, mental health, self-care, and service use. Such interventions are likely to improve the quality of life of both patients with cancer and their ICs.

Recruitment and enrollment of caregivers for a lifestyle physical activity clinical trial.

This article presents the efficacy of the recruitment framework used for a clinical trial with sedentary family caregivers of persons with Alzheimer's disease. An integrated social marketing approach with principles of community-based participatory research provided the theoretical framework for organizing recruitment activities. This multi-pronged approach meant that caregivers were identified from a range of geographic locations and numerous sources including a federally funded Alzheimer's disease center, health care providers, community based and senior organizations, and broad-based media. Study enrollment projections were exceeded by 11% and resulted in enrolling n = 211 caregivers into this clinical trial. We conclude that social marketing and community-based approaches provide a solid foundation for organizing recruitment activities for clinical trials with older adults.

Chronic grief management for dementia caregivers in transition: intervention development and implementation.

Research reveals that Alzheimer's disease (AD) caregivers do not relinquish their role after placing a family member in long-term care. Caregivers report increased emotional upset around the time of placement, with sustained losses over time leading to chronic grief. Chronic grief increases caregivers' risk for depression and suicide. There are no documented interventions designed to decrease caregivers' chronic grief post placement. The Chronic Grief Management Intervention (CGMI) builds on existing evidence to target caregivers' chronic grief in the transition of a family member into long-term care. The intervention is structured into three major components: (a) knowledge, (b) communication and conflict resolution skills, and (c) chronic grief management skills. The 12-week intervention was pilot tested with 34 caregivers for feasibility and preliminary effects on caregiver skill, knowledge, chronic grief, and depression. This article presents a general study description while focusing on the development and implementation of the CGMI.

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.

Relationship between system-level characteristics of assisted living facilities and the health and safety of unlicensed staff.

This study examined system-level characteristics of assisted living facilities and the association between these characteristics and the health and safety outcomes of unlicensed staff. Forty-two unlicensed direct care workers completed a survey related to system-level stressors and the individual stress responses of staff. Measurement tools included the Work Stressor Inventory (WSI), General Health Questionnaire (GHQ-12), and Maslach Burnout Inventory (MBI). High levels of emotional exhaustion, psychiatric distress, and work-related injuries were reported by unlicensed staff. Providing care to residents with dementia-related behaviors and supporting families were the most frequently reported work stressors. System-level factors were significantly associated with staff role competence, job commitment, and emotional exhaustion. These results support the need for continued exploration, development, and evaluation of strategies to reduce occupational stressors at multiple levels in assisted living facilities.

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.

Staff training in assisted living: evaluating treatment fidelity.

OBJECTIVES: To investigate a protocol for identifying and evaluating treatment fidelity in Staff Training in Assisted-living Residences (STAR), a structured but flexible program to train direct care staff to improve care of residents with dementia. DESIGN: Multisite feasibility trial. SETTING: Assisted living facilities (ALFs). PARTICIPANTS: Forty-four direct care staff and 36 leadership staff. INTERVENTION: STAR is a comprehensive, dementia-specific training program to teach direct care staff in ALFs to improve care and reduce affective and behavioral problems in residents with dementia. It is conducted on-site over 2 months through 2 half-day group workshops and four individualized sessions. MEASURES: Treatment fidelity was assessed following the National Institute of Health Behavior Change Consortium model utilizing observations and self-report of trainers, direct care staff, and leadership. RESULTS: Each key area of treatment fidelity was identified, measured, and yielded significant outcomes. For example, significant increases included direct care staff identifying activators, behaviors, and consequences (an essential component of training); understanding basics of dementia care; and applying STAR techniques. CONCLUSIONS: Results support that STAR is ready to be translated and disseminated into practice. Because ALFs will continue to provide care for individuals with dementia, the need for effective, practical, and sustainable staff training programs is clear. STAR offers one such option. It is hoped that this report will encourage others to conduct comprehensive evaluations of the treatment fidelity of their programs and thereby increase the availability of such programs to enhance care.

Content validity and satisfaction with a stroke caregiver intervention program.

BACKGROUND AND PURPOSE: Establishing evidence of content validity and satisfaction is an integral part of intervention research. The purpose of this article is to describe content validity and satisfaction relative to the Telephone Assessment and Skill-Building Kit (TASK), an 8-week follow-up program based on individualized assessment of stroke caregiver needs. DESIGN AND METHODS: The TASK intervention enables caregivers to develop skills based on assessment of their own needs. During the development of the TASK program, 10 experts rated the validity of the TASK intervention components for accuracy, feasibility, acceptability, and problem relevance. After incorporating feedback from the experts, a randomized controlled clinical trial was instituted using a convenience sample of 40 stroke caregivers to determine satisfaction (usefulness, ease of use, and acceptability) with the TASK intervention (n=21) compared with an attention control group (n=19). Data collection occurred between March 2005 and June 2006. Data were analyzed using descriptive statistics, independent sample t tests, and content analysis. FINDINGS: Expert ratings on a 1 to 5 scale, with 5 being strongly agree, provided evidence of content validity (accuracy 4.71, feasibility 4.46, acceptability 4.40, problem relevance 4.67). Caregivers in the TASK group scored significantly higher than the attention control group on all satisfaction measures (usefulness p=.02; ease of use p=.02; acceptability p=.05). Qualitative comments from caregivers provided further evidence of satisfaction. CONCLUSIONS: Evidence of content validity and user satisfaction for the TASK intervention relative to an attention control group was found. CLINICAL RELEVANCE: The TASK program may be a viable telephone-based program that can be implemented by nurses to support family caregivers during the first few months after stroke survivors are discharged home.

Stroke caregiver outcomes from the Telephone Assessment and Skill-Building Kit (TASK).

PURPOSE: Stroke caregivers often express the need for information about stroke and assistance with stroke-related care in the early discharge period. The Telephone Assessment and Skill-Building Kit (TASK) is an 8-week program that addresses caregiver needs. This study explored the efficacy of the TASK program in improving stroke caregiver outcomes. METHOD: Guided by a conceptual model, 6 outcomes (optimism, task difficulty, threat appraisal, depressive symptoms, life changes, general health perceptions) were measured in 40 caregivers randomized to the TASK (n=21) or an attention control group (n=19). Data were analyzed using analysis of covariance (ANCOVA), controlling for baseline scores and minutes spent with the nurse. RESULTS: Significant increases in optimism at 4 weeks, 8 weeks, and 12 weeks were found, with medium effect sizes for the TASK group relative to the control group (p<.05). Significant improvements in task difficulty at 4 weeks, and threat appraisal at both 8 weeks and 12 weeks were also found (p<.05). CONCLUSION: Caregivers receiving the TASK intervention improved in optimism, task difficulty, and threat appraisal. Further testing of an enhanced version of the TASK program is warranted, with attention directed toward more distal stroke caregiver outcomes.

Improving dementia care in assisted living residences: addressing staff reactions to training.

More than 1 million older adults, many with significant cognitive impairment, receive care in assisted living residences (ALRs), and their numbers are increasing. Despite this, ALR staff are often inadequately trained to manage the complex emotional, behavioral, and functional impairments characteristic of these residents. Nurses are in a unique position to improve this situation by training and supervising ALR staff. To facilitate such training, an understanding of staff reactions to receiving training as well as a systematic yet flexible method for training is needed. This article provides information on one such program (STAR-Staff Training in Assisted-living Residences), discusses challenges that arose when offering this program across 3 states in 6 diverse ALRs (rural, urban, for-profit, and not-for-profit sites), and describes how these challenges were addressed. We illustrate how nurses can successfully train ALR staff to improve resident and staff outcomes and offer guidance for those interested in providing such training.

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.