Antidepressant prescribing in nursing homes: is there a place for tricyclics?

OBJECTIVE: To deduce a model describing physicians' choice of antidepressants for treating elderly nursing home patients. METHODS: Subjects were geriatric residents of 137 skilled nursing facilities who regularly received an antidepressant medication for at least one month (n = 3,440, 28% of all residents). Reasons for prescribing antidepressants and physicians' diagnoses of depression and dementia were identified by medical record audit. Residents were grouped by dementia and antidepressant target symptoms (depression, or one or more non-psychiatric symptoms, i.e. insomnia, pain, incontinence, itching). RESULTS: Selective serotonin reuptake inhibitors (SSRIs) were prescribed preferentially over tricyclic antidepressants (TCAs) for treating depression in both demented and non-demented residents, but TCAs were nine times more likely to be prescribed for treating non-psychiatric target symptoms alone. When non-psychiatric target symptoms were present without depression or dementia, both amitriptyline and nortriptyline prescribing was increased, but amitriptyline appeared to be the antidepressant of choice. In all subgroups examined, its use was two to five times more prevalent when such symptoms were present. In patients with dementia, amitriptyline prescribing declined whether or not non-psychiatric target symptoms were present, but nortriptyline prescribing did not; nortriptyline was three times more likely than amitriptyline to be prescribed in the presence of dementia. CONCLUSIONS: Physicians prescribe anticholinergic TCAs principally to treat common non-depressive symptoms in nursing home residents, preferring SSRIs for uncomplicated depression and depression with dementia. They tend to avoid prescribing anticholinergic TCAs other than nortriptyline when they recognize a patient as demented. The data suggest that physicians employ a decision model for antidepressant prescribing that simultaneously recognizes the utility of TCAs in treating non-psychiatric symptoms and the anticholinergic vulnerability of older, especially demented, patients. Whether or not this model leads to optimal patient management requires further study.

Are the salutogenic effects of social supports modified by income? A test of an "added value hypothesis".

Older adults (54 men, 113 women; M age = 69.5 years) were examined to test the hypothesis that social supports would be more salutogenic (health promoting) for persons with lower incomes than for persons with higher incomes. Interactions of income and social supports (mean of 3 emotional scales of the Interpersonal Support Evaluation List) at study entry predicted changes 15-18 months later in a cardiovascular composite (linear combination of high-density lipoproteins-mean arterial pressure; p < .05), and natural killer cell activity (p < .05). For both outcomes, emotional supports were salutogenic for persons with lower incomes (< or =$29,000/year), but not for persons with higher incomes (>$29,000/year). In contrast, interactions of the Tangible Support Scale with income did not occur. Persons with lower incomes may derive benefits from social supports that go beyond tangible assistance.

Sense of coherence buffers relationships of chronic stress with fasting glucose levels.

Sense of coherence (SOC) was examined as a buffer of the relationship of chronic stress with fasting glucose and insulin levels. Spouse caregivers of persons with diagnoses of Alzheimer's disease (AD) (n = 73) were compared to controls [spouses of nondemented persons (n = 69)], group-matched on age/gender. After controlling for anger and coronary heart disease (CHD), interactions of SOC and gender explained variance in glucose (but not insulin) at study entry (T1) and 15-18 months later (T2). However, this occurred only in caregivers. At both times SOC and glucose were negatively related in men caregivers but not in women caregivers or in controls. In caregivers (but not controls), SOC at T1 predicted glucose at T2, independent of gender, anger, and glucose at T1; and hassles at T1 appeared to mediate this relationship. Future research should examine SOC as a buffer of other chronic stressors and metabolic variables.

Lymphocyte proliferation is associated with gender, caregiving, and psychosocial variables in older adults.

We examined lymphocyte responses to mitogens [phytohemagglutinin (PHA), concanavalin A, pokeweed] in spouse caregivers of persons with Alzheimer's disease (n = 82; mean age = 69.4) and noncaregiver spouses (n = 83) group matched on age and gender. Data were collected at study entry (T1) and 15-18 months later (T2). In men (n = 52), a depressed mood factor was negatively related to all mitogen responses at T1 and PHA at T2. Loneliness was the most important variable in the depressed mood factor. No relationships occurred in women (n = 113). At T2 an anger expression factor (anger-out--anger-control) was negatively related to all mitogen responses in caregivers. Anger-out was the most important variable for anger expression. Depressed mood at T1 predicted residualized changes in PHA at T2 in men. In conclusion, men with higher depressed mood and caregivers with higher anger expression may be at risk for lower proliferation responses.

Learning clinical teaching. Is it magic?

Clinical teaching in nursing is a complex phenomenon that lacks a coherent theoretical base and is perplexing to novices, who tend to teach as they were taught. Nursing educators must find strategies to assist novice clinical teachers to learn the practice of clinical teaching. This article reports on the findings of a qualitative study that describes the process of learning clinical teaching through the voices of five novice and five expert clinical teachers. Essential differences between novices and experts are presented, and the challenges of preparing clinical teachers are discussed.

Dealing with the unsafe student in clinical practice.

How do social justice issues affect the clinical evaluation of students? An emotionally charged issue, clinical evaluation can become a mine field when it becomes entangled with issues of social justice. The authors discuss the issues of justice and fairness in relation to situations that arise when a student repeatedly fails to meet minimum expectations for clinical performance. They discuss policies developed to deal with such situations and describe the application of these policies in a case study.

Meeting the challenge of developing courses for distance delivery: two different models for course development.

Nursing education is increasingly challenged to convert traditional course offerings to distance delivery modalities to accommodate practicing RNs who wish to pursue continuing education. There is a lack of understanding regarding the experiences of faculty and staff from other departments within the university in the development of distance education courses. The purpose of this descriptive study was to uncover the experiences of nursing faculty and members of a university support unit involved in interdisciplinary development of distance delivery courses. Interviews were conducted with 11 participants. Two organizational models were identified. Other issues that emerged in the development of distance delivery courses were: faculty ownership of distance courses; workload implications for faculty; clinical practice by distance; and faculty expertise in new technologies. Implications for incorporating the challenges facing nursing faculty in the 21st century in the development of distance delivery courses are discussed.

Stage-specific prevalence of behavioral symptoms in Alzheimer's disease in a multi-ethnic community sample.

The authors extended previous studies of the stage-specific prevalence of behavioral pathology to members of ethnic minority groups. Behavioral symptoms and their relationship to severity of Alzheimer's disease (AD) were examined in 125 heterogeneous minority elderly patients interviewed with a modified CERAD protocol, with behavioral symptoms scored on the caregiver-rated BEHAVE-AD Rating Scale. Behavioral disturbances were extremely common, occurring in 98% of the sample; the most common was activity disturbances (89%), followed by paranoid and delusional ideation (72%), aggressivity (64%), anxieties and phobias (61%), depressive symptoms (50%), sleep disturbances (43%), and hallucinations (34%). As in white patients, overall behavioral symptoms were most frequent among patients with moderate and severe dementia. Preliminary evidence supports the possibility of ethnic differences in behavioral profiles; Blacks showed lower affective, anxiety, and sleep symptoms than Asians and Hispanics, and lower total BEHAVE-AD scores than Hispanics. Inquiry in larger, population-based samples will be needed to determine whether the ethnic differences in behavioral symptoms of AD found here are robust and replicable.

Anthropometric dimensions to predict 1-RM bench press in untrained females.

BACKGROUND: Previous research has indicated a strong relationship between anthropometric dimensions and strength in males. To date, little work has been done to explore this topic in females. The purpose of this study was to determine the relationships between selected anthropometric dimensions and 1-RM bench press in untrained college females. METHODS: Untrained college females (n = 113) were evaluated for 18 measured and seven derived anthropometric variables to predict 1-RM bench press strength. Triplicate measurements were averaged for five skinfolds, five circumferences, and six skeletal widths. Derived measurements included Body Mass Index, percent fat, fat-free mass (FFM), flexed arm cross-sectional area (CSA), shoulder width: hip width ratio, androgyny index, and somatotype. RESULTS: Highest zero-order correlations with bench press were arm CSA (r = 0.45), flexed arm circumference (r = 0.45), mesomorphy (r = 0.44), and forearm circumference (r = 0.42). First-order partial correlations holding constant body mass or FFM generally decreased most correlations with bench press (r < 0.30). Factor loadings were used to produce muscle, length, and fat components which were placed in a multiple regression analysis to predict bench press but resulted in only limited success (R = 0.58, SEE = +/- 5.6 kg). Coefficients of variation (SEE/Mean x 100) for the equations ranged from was 18.9% to 21.0%. CONCLUSIONS: Prediction of bench press strength from anthropometric dimensions does not appear to be practical or accurate in untrained females.

Thyroid hormones: positive relationships with cognition in healthy, euthyroid older men.

BACKGROUND: Although the association of clinical hypothyroidism with cognitive deficits is well known, the cognitive effects of thyroid hormones in euthyroid subjects are less studied and understood. The purpose of this study was to examine thyroid-cognition relationships in healthy, euthyroid older men. METHODS: We examined healthy men (N = 44, mean age = 72), excluding clinically hypothyroid/hyperthyroid or diabetic/hyperglycemic subjects and those with dementia, depression, CNS medications, or recent illness. Plasma samples obtained across a 24-hour period were pooled, then assayed for total thyroxine (TT4), total triiodothyronine (TT3), and T3 resin uptake. Free thyroxine index (FT4I) was calculated. A broad cognitive battery (including the Wechsler Adult Intelligence Scale-Revised [WAIS-R], the Dementia Rating Scale [DRS], and the Rivermead Behavioral Profile [PROFILE]) was administered to all subjects. RESULTS: Regression analyses controlling age and education showed TT4 and FT4I to have significant positive relationships with measures of overall cognition; TT4 accounted for 8% to 12% of the variance in omnibus cognitive measures such as WAIS Performance, WAIS Verbal score, and GLOBAL cognitive scores. CONCLUSIONS: Our findings suggest that within "normal" range of variation in plasma thyroid hormones, TT4 but not T3 positively associates with general cognition in healthy elderly men.

Coronary heart disease moderates the relationship of chronic stress with the metabolic syndrome.

Metabolic syndrome levels (MSLs) were compared in caregivers (CGs) of spouses with Alzheimer's disease who had diagnoses of coronary heart disease (CHD; n = 27) with non CGs with CHD diagnoses (n = 18), and CGs (n = 44) to non CGs (n = 52) free of CHD. MSLs were greater for CGs than non CGs, but only in persons with CHD (CHD, B for CG status = -.41; non CHD, B = .12; p < .05) at study entry (Time 1 = T1) and CHD, B = -.32; non CHD, B = .14; p < .05) 15-18 months later (Time 2 = T2). In the CHD group, MSLs were associated with poorer health habits at T1 (r = .39, p < .01), uplifts (r = -.37, p < .01) at T2, and CG status (p < .05) at T1 and T2. Relationships of CG status and MSLs declined in the presence of poor health habits at T1 and uplifts at T2. Poorer health habits and fewer uplifts may be associated with elevated MSLs in CGs with CHD.

CD4 and CD8 counts are associated with interactions of gender and psychosocial stress.

OBJECTIVE: This study examined relationships of gender, psychosocial stress/distress (caregiving, hassles, depressed mood), and the relative percentage and absolute cell counts of CD4 and CD8 cells in two samples of older adults (mean age = 69.4)--spouse caregivers of persons with Alzheimer's disease (N = 78) and age- and gender-matched spouses of nondemented controls (N = 72). METHODS: Counts and percentages of CD4 and CD8 cells and psychosocial variables were assessed twice (Time 1, Time 2) over a 15- to 18-month period. Several covariates were examined in the analyses, including body mass index (BMI), medication use, alcohol use, exercise, and illness history. RESULTS: Caregiver men had fewer CD4 cell counts at Times 1 and 2 than did control men (p < .05). At Times 1 and 2, both CD8 cell counts and percentages were positively associated with hassles in men (p < .05), but not in women. Although interactions of hassles and gender were present for CD8 percentages at both times, interactions and main effects were not present for CD4 percentages at either time. When the ratio of CD4 to CD8 levels was analyzed, hassles by gender interactions were present at both Times 1 and 2-hassles were negatively associated with the CD4/CD8 ratio in men (p < .05), but unrelated in women. From Time 1 to Time 2, change analyses showed that increases in hassles scores were associated with decreases in CD4 counts (p < .05), whereas increases in Hamilton Depression Scores were related to increases in both CD8 counts and percentages (p < .05). CONCLUSION: Caregiver status, hassles, and depressed mood had cross-sectional and/or longitudinal associations with CD4 and CD8 counts, but such relationships occurred primarily in men. Moreover, absolute cell counts were more related to psychosocial factors than were percentages.

Prevalence and predictors of sexual dysfunction in long-term survivors of marrow transplantation.

PURPOSE: To describe the prevalence of sexual difficulties in men and women after marrow transplantation (MT), and to define medical, demographic, sexual, and psychologic predictors of sexual dysfunction 3 years after MT. PATIENTS AND METHODS: Four hundred seven adult MT patients were assessed pretransplantation. Survivors repeated measures of psychologic and sexual functioning at 1 and 3 years posttransplantation. RESULTS: Data were analyzed from 102 event-free 3-year survivors who defined themselves as sexually active. Men and women did not differ in sexual satisfaction pretransplantation. At 1 and 3 years posttransplantation, women reported significantly more sexual dysfunction than men. Eighty percent of women and 29% of men reported at least one sexual problem by 3 years after MT. No pretransplantation variables were significant predictors of 3-year sexual satisfaction for women. For men, pretransplantation variables of older age, poorer psychologic function, not being married, and lower sexual satisfaction predicted sexual dissatisfaction at 3 years (R2=.28; P < .001). Women who were more dissatisfied 3 years after MT did not receive hormone replacement therapy (HRT) at 1 -year posttransplantation and were less satisfied at 1 year, but not pretransplantation (R2=.35; P < .001). CONCLUSION: Sexual problems are significant in the lives of MT survivors, particularly for women. Although HRT before 1 year posttransplantation improves sexual function, it does not ensure sexual quality of life. Intervention for women is needed to apply hormonal, mechanical, and behavioral methods to prevent sexual difficulties as early after transplantation as possible.

Psychosocial stress moderates the relationship of cancer history with natural killer cell activity.

Data suggest that both cancer history and psychosocial stress may be associated with reductions in natural killer cell activity (NKA). Therefore, we tested whether individual differences in cancer history, chronic/perceived stress, and their interactions would be associated with decreased levels of NKA. We tested these hypotheses in 80 spouse caregivers of victims of Alzheimer's Disease (AD) (persons known to report high levels of psychosocial stress) and in 85 age- and sex-matched spouses of non-demented controls. Participants were assessed at study entry (Time 1) and 15-18 months later (Time 2). Individuals with cancer histories (N = 43) had not been treated with immune altering medications within the last year. At both Times 1 and 2, cross-sectional main effects were weak or absent for cancer history, perceived stress (e.g. high hassles, low uplifts), and caregiver status; however, interactions occurred between cancer history and perceived stress, such that persons with cancer histories and high hassles/low uplifts had the lowest NKA values (p < .05). These results occurred even after controlling for age, gender, beta-blocker use, hormone replacement therapy, alcohol, and exercise. At Time 1, an interaction also occurred between caregiver status and cancer history--caregivers with cancer histories had lower NKA than did controls with cancer histories and caregivers/controls without cancer histories (p < .05). At Time 2, this interaction only showed a trend (p < .08), primarily because caregivers with cancer histories experienced increases in NKA (p < .05) from Time 1 to Time 2, whereas in the other three groups NKA did not change. Importantly, in caregivers with cancer histories, high perceived stress at Time 1 predicted low NKA at Time 2 (p < .05). This research suggests that the combinations of biological vulnerabilities and chronic/perceived stress may have interactive effects resulting in reduced NKA.

Developing the reflective teacher.

The conceptual issues and research findings surrounding the meaning and use of reflection are examined in this paper and serve as a foundation for discussing significant assumptions and beliefs regarding the use of reflection in nursing education. The strengths and limitations of reflection are discussed. The paper links current knowledge about reflection to the development of reflective thinking and its use by nurse educators and suggests strategies to enhance this development.

Juvenile friends, behavior, and immune responses to separation in bonnet macaque infants.

Individual differences in the response to maternal separation in nonhuman primate infants have been attributed to (among other variables) presence or absence of processes that may model social support in humans. Alternative attachments to other members of the social group buffer the infant against a depressive response to maternal separation. This hypothesis was tested in a group of bonnet macaques by manipulating the presence or absence of alternative juvenile attachment figures (friends) during separation. Infants who retained such attachments showed fewer behavioral evidences of depression when separated from their mothers. These infants without friends also showed changes in lymphocyte activation by mitogens or natural cytotoxicity that were not evident in the infants with juvenile friends. Across all separated infants, natural cytotoxicity was positively correlated with juvenile affiliative behavior directed toward the infants during the separation. These results support the hypothesis that social support, available from alternative attachments, can modulate the response to loss, and can account for some of the individual differences seen in these responses.

Psychological distress, caregiving, and metabolic variables.

This study examined relationships between chronic stress and insulin/glucose in two groups of nondiabetics, M age = 69.4: spouse caregivers (CGs) of persons with Alzheimer's disease (n = 73) and age- and gender-matched spouses of nondemented controls (COs) (n = 69). Fasting insulin/glucose and psychological variables were assessed twice (Time 1, Time 2) over a 15-18 month period. CGs had significantly higher insulin levels at Times 1 and 2 than did COs even when obesity, exercise, gender, age, alcoholic drinks, hormone replacement therapy (HRT), lipids, and hypertension (HTN) were considered in the analyses. CGs generally reported significantly more psychological distress (higher burden, depression, hassles, and lower uplifts) than did COs at each time. Differences in psychological distress at Time 1 between CGs and COs did not mediate the insulin difference in the groups at Time 1, but differences in distress at Time 2 between CGs and COs did mediate their difference in insulin at Time 2. Although caregiver status was not associated with glucose at Time 1 or Time 2, psychological distress was positively associated with glucose at Time 2. Moreover, psychological distress at Time 1 was associated with higher glucose at Time 2 after controlling for glucose at Time 1. These data suggest that relationships between psychological and physiological distress exist both cross-sectionally and over time. These results may be important because higher insulin and glucose levels are associated with increased coronary risk and coronary heart disease.

Insulin and glucose: relationships with hassles, anger, and hostility in nondiabetic older adults.

Relationships of psychosocial factors (anger, hostility, hassles, and caregiving) with fasting insulin and glucose levels were examined. Samples included two groups of nondiabetic adults (mean age = 69.4 years): spouse caregivers (CG) of individuals with diagnoses of Alzheimer's disease (AD) (N = 78) and spouses of nondemented controls (CO) (N = 72) matched for age and gender. The groups were assessed twice with a 15-to 18-month hiatus. To obtain more stable assessments, all biopsychosocial measures were averaged over time. Psychosocial factors were associated with insulin and glucose, even after controlling for significant health variables: obesity, lipids, and cardiovascular disease. As hypothesized, CG with high anger-out/hostility (AOHO) had significantly higher glucose levels than all other group combinations. The glucose levels for subjects with high hassles or high AOHO were significantly higher than those for subjects who were low on both of these factors. For insulin, a three-way interaction occurred among AOHO, hassles, and gender-hormone replacement therapy (HRT); in women taking HRT, no relationships occurred between insulin with AOHO and hassles. In women not taking HRT, those with high AOHO and high hassles had significantly higher insulin levels than the other three combinations, whereas in men, those with either high AOHO or high hassles had significantly higher insulin levels than men who were low on both of these factors. Given these results, future research should examine the degree to which interactions between metabolic processes with psychosocial variables, gender, and HRT have long term health consequences in nondiabetics.

Weight changes in caregivers of Alzheimer's care recipients: psychobehavioral predictors.

Relationships of changes in body mass index (BMI) were examined with changes in psychobehavioral variables in spouse caregivers of individuals with Alzheimer's disease (n = 81) and matched spouses of controls (n = 86). Men caregivers had significantly greater BMI and obesity than men controls at both times. Over 15-18 months, women caregivers gained significantly more weight than did women controls. A trend for greater obesity occurred in women caregivers than in women controls at follow-up. Although weight gain was not related to psychobehavioral variables in controls, in men caregivers decreased perceived control and increased fat intake explained significant variance in weight gain. In women caregivers, increased anger control and increased calories explained weight gain. Such caregivers may be at risk for health problems.