Supporting the Health and Well-Being of Caregivers of Persons with Pain Strategies to address stress and improve self-care.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. This new group of articles provides practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses. Cite this article as: Tonkikh, O., et al. Supporting the Health and Well-Being of Caregivers of Persons with Pain. Am J Nurs 2023; 123 (6): 55-61.

Supporting the Health and Well-Being of Caregivers of Persons with Pain.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. This new group of articles provides practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses.

Needs of persons living with ALS at home and their family caregivers: A scoping review.

INTRODUCTION/AIMS: Most persons with amyotrophic lateral sclerosis (ALS) live at home with support of family caregivers, with escalating complexity of care over the trajectory of the disease requiring resources and support to mitigate negative physical, social, and emotional outcomes. METHODS: This scoping review identifies the home health/home care needs of persons with ALS and their caregivers as a basis for creating a home health medical standard. We used the PRISMA Extension for Scoping Reviews (PRISMA-ScR) to examine studies describing home care needs published between 2011 and 2021. RESULTS: Our search yielded 481 articles, of which 44 were included with a total of 3592 (9-273) participants. Most studies used a cross-sectional design and 20 (45%) were rated as high quality. We grouped the needs identified as emotional/psychological, assistive devices and technology, information and education, and human resources and professional services. Most studies demonstrated persistent unmet needs and that available interventions were helpful while needs generally were not met proactively, despite the predictable trajectory. DISCUSSION: This review describes biopsychosocial and equipment interventions over the trajectory of ALS with implications for anticipatory planning by clinicians, as well as policy for coverage of necessary services and supports. Interdisciplinary expert teams could develop consensus around needs across the trajectory and recommended services and supports. To make knowledge more accessible, encourage availability of services, and clarify the need for coverage of services, we aim to develop an expert consensus-based ALS home health medical standard guidance document in collaboration with the American Association of Neuromuscular and Electrodiagnostic Medicine.

Implementation of a Statewide Web-Based Caregiver Resource Information System (CareNav): Mixed Methods Study.

BACKGROUND: With the aging population, family caregivers provide increasingly complex and intense care for older adults and persons with disabilities. There is growing interest in developing community-based services to support family caregivers. Caregiving occurs around the clock, and caregivers face challenges in accessing community-based services at convenient times owing to the demands of care. Web-based resources hold promise for accessible real-time support. CareNav (TM), a caregiver resource information system, is a web-based platform designed to support real-time universal caregiver assessment, a record of client encounters, development of a care plan, tailored information and resource content, access to web-based caregiver resources, the capacity to track service authorization and contracts, and secure communications. The assessment includes needs and health conditions of both the care recipient and caregiver; current resources; and priorities for support, information, and referral. In 2019, the California Department of Health Care Services funded the 11 nonprofit California Caregiver Resource Centers (CRCs) to expand and improve family caregiver services and enhance CRC information technology services. Deployment of a statewide information system offered a unique opportunity to examine structures and processes facilitating implementation, providing feedback to the sites as well as lessons learned for similar projects in the future. OBJECTIVE: The aim of this paper was to describe the statewide implementation of the comprehensive CareNav system using the Consolidated Framework for Implementation Research as an organizing structure for synthesizing the evaluation. METHODS: This mixed methods study used two major approaches to evaluate the implementation process: a survey of all staff who completed training (n=82) and in-depth qualitative interviews with 11 CRC teams and 3 key informants (n=35). We initially analyzed interview transcripts using qualitative descriptive methods and then identified subthemes and relationships among ideas, mapping the findings to the Consolidated Framework for Implementation Research. RESULTS: We present findings on the outer setting, inner setting, characteristics of the intervention, characteristics of the staff, and the implementation process. The critical elements for success were leadership, communication, harmonization of processes across sites, and motivation to serve clients in more accessible and convenient ways. CONCLUSIONS: These findings have implications for technology deployment in diverse community-based agencies that aspire to enhance web-based services.

The role of nurse staffing in the performance of function-preserving processes during acute hospitalization: A cross-sectional study.

BACKGROUND: Performance of function-preserving hospitalization processes related to patient mobility, use of continence aids and food intake is significantly associated with outcomes in older adults. Nurses are the front-line personnel responsible for promoting performance of such processes. The degree to which nurse staffing is related to this performance is unclear. OBJECTIVE: To identify nurse-staffing characteristics and nursing-related care needs associated with older patients' mobility, continence care and food intake during acute hospitalization. DESIGN: Cross-sectional study using survey data from the Hospitalization Process Effects on Functional Outcomes and Recovery (HoPE-FOR) cohort study combined with day-level administrative nurse staffing data and clinical day-level aggregated data for all patients hospitalized during the HoPE-FOR study period. SETTING: Internal medicine units in two medical centers in Israel. PARTICIPANTS: Eight hundred seventy-three older adults. METHODS: Mobility, continence care and food intake were assessed within 2 days of admission using validated questionnaires. Nurse-to-patient ratios and nursing-skill mix (i.e. registered nurses (RNs), nurse aides, nurses with advanced clinical training and RNs with an academic degree) were assessed using administrative data. Decision trees were developed for mobility, continence care and food intake, applying classification and regression-tree analysis. RESULTS: The mobility decision tree identified three characteristics subdividing patients into six nodes: pre-admission functioning, pre-admission activity level and percentage of nurses with advanced training. The percentage of nurses with advanced training classified low-functioning patients into those walking in corridors versus walking or sitting only inside the room. The continence-care classification decision tree identified two characteristics that subdivided the patients into four nodes: pre-admission functioning and bladder control. Nurse-to-patient-ratio variables and patients' nursing-related care needs did not contribute to this classification. The food-intake decision tree identified four characteristics-pre-admission functioning, gender, percentage of nurses with advanced training and percentage of nurse aides-subdividing patients into eight nodes. Low-functioning patients exposed to a higher percentage of nurses with advanced training had food-intake scores 14% higher than patients exposed to a lower percentage of nurses with advanced training. Independent men exposed to a higher percentage of nurse aides had a 14% higher habitual daily in-hospital food-intake score than independent men exposed to a lower percentage of nurse aides. CONCLUSIONS: A higher percentage of nurses with post-graduate education is associated with better performance of mobility and food intake of hospitalized older adults. To maintain the potential benefits of highly trained staff, education levels should be considered in scheduling and assignment decision-making processes in internal medicine units. Tweetable abstract: A higher percentage of nurses with post-graduate education is associated with better mobility and food intake of hospitalized older adults.

Association between continuity of nursing care and older adults' hospitalization outcomes: A retrospective observational study.

AIM: To assess the relationship between continuity in nursing assignment in older adults' acute hospitalization and patient experience and functional decline. BACKGROUND: In-hospital functional decline affects up to 40% of hospitalized older adults. Nurses are responsible for performing functioning-preserving interventions. Whether continuity of nursing care contributes to patients' functional outcomes is unclear. METHOD: A retrospective observational study of 609 patients aged ≥70 admitted to internal medicine units. Patients were surveyed on their functional (cognitive and physical) status and satisfaction with the hospital care experience. Dispersion and sequence of nursing assignment were measured by the Continuity of Care Index and Sequential Continuity Index. Multivariate logistic regressions were modelled for each continuity score and outcome. RESULTS: Achieving 25% of the maximum Continuity of Care Index was associated with lower odds of cognitive decline (OR = 0.64, 95% CI = 0.43-0.94) and higher odds of satisfaction (OR = 1.52, 95% CI = 1.06-2.17). Achieving 25% of the maximum Sequential Continuity Index was associated only with higher odds of satisfaction (OR = 1.43, 95% CI = 1.01-2.02). Continuity scores were not associated with physical functioning decline. CONCLUSION: Continuity in nursing assignment is related to a positive patient experience and cognitive functioning of hospitalized older adults. IMPLICATIONS FOR NURSING MANAGEMENT: Continuity should be prioritized in scheduling and assignment algorithms.

Food intake assessment in acutely ill older internal medicine patients.

AIM: Poor food intake is a major concern among hospitalized older adults. This study investigated the frequency and optimal timing of in-hospital food intake assessment in terms of its ability to predict hospitalization functional outcomes. METHODS: Secondary analysis of a cohort study of 699 older adults (age ≥70 years) admitted to internal medicine wards for non-disabling conditions was carried out. Daily food intake was assessed using self-reported estimation of portions consumed at each meal and calculated according to the caloric composition of the meals. Nutritional status on admission, baseline and discharge activities of daily living, and cognitive status were assessed using validated questionnaires. Repeated measures analysis of variance (n = 263) and multiple logistic regression models (n = 475) for predicting activities of daily living and cognitive decline were used to establish required frequency and optimal timing of food-intake monitoring. RESULTS: Mean daily intake significantly increased from the first 48 h from admission (0.51 ± 0.30) to the second and third assessments (0.62 ± 0.30 and 0.63 ± 0.30, respectively). Eating half or less of the served meals both within the first 48 h of admission and after 48 h was associated with higher odds of cognitive decline (OR 1.93, 95% CI 1.27-2.94; OR 1.62, 95% CI 1.04-2.51, respectively). Low intake after 48 h of admission was associated with higher odds of activities of daily living decline (OR 1.66, 95% CI 1.03-2.67). CONCLUSIONS: Food intake increases from the first 48 h of admission onwards and becomes more consistent 3 days after admission. The associations between low food intake at various time points and worse functional outcomes show the importance of routine food intake monitoring for at least 3 days. Geriatr Gerontol Int 2019; 19: 890-895.

Informal support for older adults is negatively associated with walking and eating during hospitalization.

Processes related to daily care of older adults during hospitalization, such as mobility and nutrition, have long-term consequences for their health and functioning. Although instrumental support provided by family members during hospitalization is highly prevalent, its relationship to older adults' actual walking and eating is unknown. Data on walking level (walking outside vs. inside the room) and nutritional intake were collected from 493 independent older adults admitted to internal medicine wards through up to three daily interviews using validated questionnaires. Informal support with walking and eating was assessed with the modified Informal Caregiving for Hospitalized Older Adults scale. Multivariate regression showed that informal support with walking and eating was associated with greater likelihood of walking inside the room and with lower nutritional intake. This association between informal support and less walking and eating call for routine functional assessments and tailored counseling of informal caregivers to meet older patients' support needs.

[FUNCTIONAL TRAJECTORIES BEFORE, DURING AND AFTER ACUTE HOSPITALIZATION OF OLDER ADULTS IN INTERNAL MEDICINE WARDS].

INTRODUCTION: Hospital-associated functional decline (HAFD) is recognized as a leading cause of adverse hospitalization outcomes, such as prolonged hospitalization, falls, readmission, and mortality. Since most patients hospitalized in internal medicine wards are older-adults, HAFD presents a major challenge to internal medicine. OBJECTIVES: Describe functional trajectories of older-adults (aged ≥70 years) before, during and after acute hospitalization in internal-medicine units. METHODS: A prospective cohort study was conducted of 741 older-adults, hospitalized in two tertiary hospitals in Israel during the period 2009-2011. Basic functional status two weeks before admission, on-admission, at-discharge and one-month post-discharge was assessed using the modified Barthel Index (BI). Eight trajectories were identified. RESULTS: Two-thirds of the participants were completely or almost independent at the pre-morbid period. About a half of the older-adults were hospitalized with pre-admission functional decline, a quarter deteriorated or died during hospitalization, and one-third improved during hospitalization. Most of the older-adults who were stable in functioning at the pre-admission period (57.1%) remained stable during and post-hospitalization; however, about a third of them did not return to their pre-morbid functioning levels. Approximately half of those with pre-morbid functional decline experienced additional deterioration of at least 5 points on the BI scale. Pre-morbid instrumental functional status, comorbidity and depressive symptoms have been found to distinguish older adults with similar pre-admission and in-hospital functional trends. DISCUSSION: Eight functional trajectories describe the hospitalization period of older-adults in internal-medicine units. On-admission personal characteristics may be used to identify older-adults who are at risk of unwarranted hospitalization outcomes and thus allow intervention in the hospital-community interface.

Functional status before and during acute hospitalization and readmission risk identification.

BACKGROUND: Recent efforts to prevent readmissions are increasingly focusing on early identification of high-risk patients. OBJECTIVE: To test whether information on functioning during hospitalization contributes to the ability to accurately identify older adults at high risk of readmission beyond their baseline risk. DESIGN: Prospective cohort study. SETTING: Internal medicine wards at 2 medical centers. PATIENTS: Five hundred fifty-nine community-dwelling older adults (aged ≥70 years) discharged to their homes. MEASUREMENTS: Data on unplanned 30-day readmissions were retrieved from electronic health records. Data on at-admission activities of daily living (ADL) and in-hospital ADL decline were collected using validated questionnaires. Multivariate logistic regression was used to model the association between functioning and readmission controlling for known risk factors. RESULTS: Higher in-hospital ADL decline was significantly associated with readmission (odds ratio for each 10-point decrease in ADL = 1.32, 95% confidence interval = 1.02-1.72) but did not contribute to the overall discrimination of the model, as compared with the at-admission data (C statistic = 0.81 for each model). Identifying high-risk (10th highest percentile) patients by the at-admission model did not detect 7/55 (12.7%) of patients who would have been categorized as high risk if risk identification was postponed to the discharge date and included data on in-hospital ADL decline. CONCLUSIONS: The study highlights the ability to identify patients at high risk for readmission already early in the index hospitalization using data on functioning, nutrition, chronic morbidity, and prior hospitalizations. Nonetheless, at-discharge functional assessment can detect additional patients whose readmission risk changes during the index hospitalization. Journal of Hospital Medicine 2016;11:636-641. © 2016 Society of Hospital Medicine.

Even a small change can make a big difference: the case of in-hospital cognitive decline and new IADL dependency.

BACKGROUND: post-hospitalisation functional decline is a widely described phenomenon, yet factors related to new disability in instrumental activities of daily living (IADL) in previously independently functioning older adults are rarely studied. OBJECTIVE: to test whether change in cognitive status from admission to discharge during short-term acute-care hospitalisation is associated with the incidence of medium-term post-hospitalisation IADL dependency. DESIGN: prospective cohort study. SETTING: internal medicine wards in two Israeli medical centres. SUBJECTS: two hundred and seventy-two hospitalised older adults (≥70) who were independent in self-care and mobility activities at admission, at discharge and 1 month after discharge, and who were independent in IADL pre-admission. METHODS: cognitive status was evaluated at admission and at discharge using Pfeiffer's Short Portable Mental Status Questionnaire (SPMSQ). One-month post-discharge, IADL was assessed using Lawton and Brody's scale by telephone. RESULTS: incidence of IADL dependency was 74/272 (27.2%). Controlling for length of stay, co-morbidities, re-hospitalisation and age, a one-unit decrease in SPMSQ score during hospital stay was associated with 1.57 higher odds (95% CI, 1.14-2.15) of post-hospitalisation new IADL dependency. The odds of new IADL dependency were also significantly higher in participants who were rehospitalised within the previous month (odds ratio = 2.65; 95% CI, 1.25-5.62). CONCLUSIONS: decline in SPMSQ score during acute hospitalisation has a detrimental effect on functional decline after acute hospitalisation, defined by incidence IADL dependency. This finding emphasises the need to identify cognitive decline during hospitalisation to allow timely intervention to prevent post-discharge functional decline in this population.

Anxiety symptoms during hospitalization of elderly are associated with increased risk of post-discharge falls.

BACKGROUND: The aim of this study was to test the association between anxiety at the time of hospitalization and falls occurring within one month of discharge, and to offer potential mechanisms for this association. METHODS: One-month, prospective cohort study of 556 older adults in two medical centers in Israel. Anxiety and functional decline were assessed during hospitalization and falls were assessed one month post-discharge. RESULTS: A total of 72 (12.9%) participants reported at least one fall during the 30-day post-discharge period. Controlling for demographics, functional decline and pre-morbid functional status, the odds of falls between discharge, and 1-month follow-up were almost twice as high among patients with anxiety symptoms (OR = 1.89, 95% CI: 1.04-3.48) compared with those who screened negative for anxiety. After accounting for in-hospital functional decline, the relationship between anxiety symptoms and falls decreased by 11% (from OR = 2.13 to 1.89), indicating that the relationship between anxiety and falls was partially mediated by functional decline during hospitalization. CONCLUSIONS: Anxiety at time of hospitalization is associated with falls 30-days post-discharge, controlling for several well-known confounders. This relationship is partially mediated by functional decline. Identifying patients with anxiety for inclusion in targeted rehabilitation interventions may be an important component of fall prevention strategies.

Hospital-associated functional decline: the role of hospitalization processes beyond individual risk factors.

OBJECTIVES: To investigate the combined contribution of processes of hospitalization and preadmission individual risk factors in explaining functional decline at discharge and at 1-month follow-up in older adults with nondisabling conditions. DESIGN: Prospective cohort study. SETTING: Internal medicine wards in two Israeli medical centers. PARTICIPANTS: Six hundred eighty-four individuals aged 70 and older admitted for a nondisabling problem. MEASUREMENTS: Functional decline was measured according to change in modified Barthel Index from premorbid to discharge and from premorbid to 1 month after discharge. In-hospital mobility, continence care, sleep medication consumption, satisfaction with hospital environment, and nutrition intake were assessed using previously tested self-report instruments. RESULTS: Two hundred eighty-two participants (41.2%) reported functional decline at discharge and 317 (46.3%) at 1 month after discharge. Path analysis indicated that in-hospital mobility (standardized maximum likelihood estimate (SMLE) = -0.48, P < .001), continence care (SMLE = -0.12, P < .001), and length of stay (LOS) (SMLE = 0.06, P < .001) were directly related to functional decline at discharge and, together with personal risk factors, explained 64% of variance. In-hospital mobility, continence care, and LOS were indirectly related to functional decline at 1 month after discharge through functional decline at discharge (SMLE = 0.45, P < .001). Nutrition consumption (SMLE = -0.07, P < .001) was significantly related to functional decline at 1 month after discharge, explaining, together with other risk factors, 32% of variance. CONCLUSION: In-hospital low mobility, suboptimal continence care, and poor nutrition account for immediate and 1-month posthospitalization functional decline. These are potentially modifiable hospitalization risk factors for which practice and policy should be targeted in efforts to curb the posthospitalization functional decline trajectory.