Differential Impact of Index Stroke on Dementia Risk in African-Americans Compared to Whites.

OBJECTIVE: To compare whites and African-Americans in terms of dementia risk following index stroke. METHODS: The data consisted of billing and International Classification of Diseases, Ninth Revision diagnosis codes from the South Carolina Revenue and Fiscal Affairs office on all hospital discharges within the state between 2000 and 2012. The sample consisted of 68,758 individuals with a diagnosis of ischemic stroke prior to 2010 (49,262 white [71.65%] and 19,496 African-Americans [28.35%]). We identified individuals in the dataset who were subsequently diagnosed with any of 5 categories of dementia and evaluated time to dementia diagnosis in Cox Proportional Hazards models. We plotted cumulative hazard curves to illustrate the effect of race on dementia risk after controlling for age, sex, and occurrence of intervening stroke. RESULTS: Age at index stroke was significantly different between the 2 groups, with African-Americans being younger on average (70.0 [SD 12.5] in whites versus 64.5 [SD 14.1] in African-Americans, P < .0001). Adjusted hazard ratios revealed that African-American race increased risk for all 5 categories of dementia following incident stroke, ranging from 1.37 for AD to 1.95 for vascular dementia. Age, female sex, and intervening stroke likewise increased risk for dementia. CONCLUSIONS: African-Americans are at higher risk for dementia than whites within 5 years of ischemic stroke, regardless of dementia subtype. Incident strokes may have a greater likelihood of precipitating dementia in African-Americans due to higher prevalence of nonstroke cerebrovascular disease or other metabolic or vascular factors that contribute to cognitive impairment.

Feasibility, acceptability, and tolerability of RGN107 in the palliative wound care management of chronic wound symptoms.

OBJECTIVE: To assess the feasibility, acceptability and tolerability of RGN107 use, a natural powder blend of Arnica Montana, Calendula Officinalis, Mentha Arvensis and Santalum Album, among hospice patients and their wound caregivers in the palliative wound care management of chronic wound symptoms at end-of-life. METHOD: Data were collected between May 2013 and November 2015. A pilot trial conducted among 50 hospice patients with symptomatic (pain, odour, or exudate) chronic wounds. Caregivers received initial RGN107 protocol training, actively applied the powder to patient wounds for 4-weeks, and completed an 8-week retrospective survey. Feasibility was assessed by measuring process outcomes, including the number and proportion of participants referred, screened eligible, enrolled, withdrawn and successfully completed. Acceptability measures included: a protocol training evaluation, caregiver pre and post self-efficacy ratings, retrospective usability, symptom control management and comparative technique caregiver ratings, and recorded open-ended comments. Tolerability was assessed through a 12-week cumulative review of the study adverse event profile. RESULTS: Feasibility, tolerability and acceptability of use of the RGN107 powder for chronic wounds were established. Recruitment goals were achieved and 92 % of the patients successfully completed the study. 95 % of wound caregivers would recommend the powder for use in this population. CONCLUSION: This study supports the feasibility, acceptability and tolerability of a wound care powder that espouses a multi-symptom palliative comfort care approach for hospice patients with chronic wounds at end-of-life. Further research is needed to establish the efficacy of the powder.

Person-centered Feeding Care: A Protocol to Re-introduce Oral Feeding for Nursing Home Patients with Tube Feeding.

BACKGROUND: Although the literature on nursing home (NH) patients with tube feeding (TF) has focused primarily on the continuation vs. discontinuation of TF, the reassessment of these patients for oral feeding has been understudied. Re-assessing patients for oral feeding may be better received by families and NH staff than approaches focused on stopping TF, and may provide an opportunity to address TF in less cognitively impaired patients as well as those with end-stage conditions. However, the literature contains little guidance on a systematic interdisciplinary team approach to the oral feeding reassessment of patients with TF, who are admitted to NHs. METHODS: This project had two parts that were conducted in one 170-bed intermediate/skilled, Medicare-certified NH in Honolulu, Hawai'i. Part 1 consisted of a retrospective observational study of characteristics of TF patients versus non-tube fed patients at NH admission (2003-2006) and longitudinal follow-up (through death or 6/30/2011) with usual care of the TF patients for outcomes of: feeding and swallowing reassessment, goals of care reassessment, feeding status (TF and/or per oral (PO) feedings), and hospice status. Part 2 involved the development of an interdisciplinary TF reassessment protocol through working group discussions and a pilot test of the protocol on a new set of patients admitted with TF from 2011-2014. RESULTS: Part 1: Of 238 admitted patients, 13.4% (32/238) had TF. Prior stroke and lack of DNR status was associated with increased likelihood of TF. Of the 32 patients with TF at NH admission, 15 could communicate and interact (mild, moderate or no cognitive impairment with prior stroke or pneumonia); while 17 were nonverbal and/or bedbound patients (advanced cognitive impairment or terminal disease). In the more cognitively intact group, 9/15 (60%) were never reassessed for tolerance of oral diets and 10/15 (66.7%) remained with TF without any oral feeding until death. Of the end-stage group, 13/17 (76.5%) did not have goals of care reassessed and remained with TF without oral feeding until death. Part 2: The protocol pilot project included all TF patients admitted to the facility in 2011-2014 (N=33). Of those who were more cognitively intact (n=22), 21/22 (95.5%) had swallowing reassessed, 11/22 (50%) resumed oral feedings but 11 (50%) failed reassessment and continued exclusive TF. Of those with end-stage disease (n=11), 100% had goals of care reassessed and 9 (81.8%) families elected individualized oral feeding (with or without TF). CONCLUSION: Using findings from our retrospective study of usual care, our NH's interdisciplinary team developed and pilot-tested a protocol that successfully reintroduced oral feedings to tube-fed NH patients who previously would not have resumed oral feeding.

Differences in Medical and Life-style Risk Factors for Malnutrition in Limited-Resource Older Adults in a Rural U.S. State: A Descriptive Study.

OBJECTIVES: Medical and life-style factors are associated with malnutrition in older adults. This study assessed the presence of these risk factors in limited-resource, community-dwelling older adults to inform the development of a nutrition education interventions. DESIGN: Quantitative descriptive study. SETTING: A total of 24 randomly selected congregate nutrition sites (where limited-resource older adults can receive one hot meal/day, five days/week) in the rural state of South Carolina, USA. PARTICIPANTS: Data were collected from 477 older adults (of the 407 who reported race, 219 were African American and 171 were White). MEASUREMENTS: Extension Educators who work for the Cooperative Extension Service (a formalized educational outreach system associated with some U.S. universities) read aloud a 27-item instrument designed to assess risk factors for malnutrition. Response frequencies were tabulated and chi-square tests were performed using SAS 9.3. RESULTS: More African Americans reported having a chronic illness or condition (81.2 vs. 68.3%; p=0.003), eating alone (66.2 vs. 53.6%; p=0.012), having a refrigerator that sometimes did not keep food cold (31.8 vs. 8.4%; p<0.0001), and sometimes not having enough money to buy food (38.9 vs. 18.5%; p<0.0001) compared to White older adults. CONCLUSION: Rural older adults who attend congregate nutrition sites, especially African Americans, could be at risk for malnutrition due to health status and food preparation-related factors. Evidence-based, tailored programs are needed to minimize malnutrition among limited-resource older adults living in rural areas in the U.S.

Resistance at mealtimes for persons with dementia.

BACKGROUND: For persons unable to feed themselves, resistance to assistance with meals may result in increased morbidity and premature mortality because of inadequate nutritional intake. Additionally, unwillingness to accept food offered has social and ethical implications in all cultures and may influence caregiving. OBJECTIVE: As part of a larger study, this analysis sought to determine if resistance or willingness to accept assistance at meals by persons with dementia could be predicted by various personal interaction and contextual factors. DESIGN: Resistance was studied in a sample of 53 nursing home residents with late-stage dementia who were assisted at meals by CNAs. Using the EdFED-Q (Edinburgh Feeding Evaluation in Dementia Questionnaire), two groups of individuals who were being fed were identified: those who resisted assistance (n = 23) and those who accepted assistance (n = 30). Proportion of food consumed was determined by percentage of weight decrease in food offered. RESULTS: Differences between the two groups were identified. Although not differing in degree of cognitive impairment as measured by the MMSE or Body Mass Index, significant differences (p < .05) were found in level of functioning as measured by the Global Deterioration Scale, the proportion of food consumed and amount of time taken to assist with the meal. Resistors showed significantly different interaction behaviors in 8 of the 10 on the Interaction Behavior Measure-Modified when correlated with food consumed (r = .49 - .68, p < .02). CONCLUSION: When examining resistance to feeding a variety of factors must be examined, including the quality of the interaction between the caregiver and the person being fed.

Partners for NP education: the 1999 AANP preceptor and faculty survey.

PURPOSE: To increase understanding of national trends in nurse practitioner (NP) clinical education, the Education Committee of the American Academy of Nurse Practitioners (AANP) conducted a survey at the 1999 National AANP Conference in Atlanta. DATA SOURCES: A convenience sample of preceptors (n = 87) and faculty (n = 42) out of the total attendance of 1,744 responded to a written questionnaire. CONCLUSIONS: Preceptor respondents provided data concerning the number of NP students supervised, influence of student supervision on productivity, and availability of incentives for precepting. Faculty reported placement and supervision issues, the extent of precepting in their clinical practice site, and recognition and support for this role. Faculty and preceptors disagreed about the types and number of incentives offered for accepting students as well as the congruence of clinical teaching activities and national teaching guidelines. Precepting did not appear to strongly influence preceptor productivity. External funding did not influence opportunities for clinical education. IMPLICATIONS FOR PRACTICE: In 1998, the graduates of NP programs rose by 15.8% and over half of all nursing students enrolled in graduate nursing programs were seeking a NP education. This increase in students may compromise the ability of schools of nursing to insure quality clinical education of NP students by increasing faculty workload and placing greater demands on expert preceptors in the community. Clinical education is also changing in light of changes in the health care system.

Factors influencing the proportion of food consumed by nursing home residents with dementia.

BACKGROUND: Assessment of and interventions for promoting eating in persons with late-stage dementia have primarily focused on facilitation of safe feeding and methods to promote ingestion of nutrients via several routes. Using Social Exchange Theory, this study examined how the quality of the interaction between care giver and care receiver influenced the proportion of food consumed by persons with late-stage dementia. METHODS: Fifty-three dyads composed of nursing home residents with late-stage dementia and Certified Nursing Assistants (CNAs) were observed during the breakfast meal. The proportion of food consumed by the residents was measured by weight. The study included measures of the quality of interaction between the resident and the CNA (Interaction Behavior Measure-Modified (IBM-M) and the IBM), CNA empathy (Interpersonal Reactivity Index), and CNA power (Control subscale of the FIRO-B). RESULTS: Specific resident behaviors and the CNA's ability to allow another person to control a relationship were most predictive of the variance in the proportion of food consumed (R2 = .41; F(3,49) = 12.54; P < .001). The quality of the resident-CNA interaction accounted for 32% of the variance in the proportion of food consumed. One aspect of power was correlated significantly to the proportion of food consumed whereas CNA empathy was not. CONCLUSIONS: Because eating is the most social of all ADLs and is culturally bound, clinicians need to examine the interactional components of meals within the caregiving dyad when a person with late-stage dementia fails to ingest adequate nutrients.

Nutrition and health status assessment of community-residing elderly in New York City: a pilot study.

Ninety-five percent of persons over the age of 65 years live in the community and benefit from community-based health and nutrition services. The purpose of this project was to evaluate diet, function, and mental health in 40 men and women aged 65 years and older who were residing in a large metropolitan community. Nutritional status was assessed using two 24-hour recalls, 5 days of food records, a food frequency, and anthropometric measurements. Participants responded to standardized activities of daily living and instrumental activities of daily living instruments and an investigator-developed, performance-based appraisal of food preparation and management. Cognition and mood were assessed using the Folstein Mini-Mental Examination and the Yesavage Depression Scale. The nutrient intakes for individuals were compared with the Recommended Dietary Allowances (RDAs) and the Food Guide Pyramid. Mean energy intake was 1,625 kcal (range = 787 to 2,910 kcal); 7 persons consumed more than 2,000 kcal. The mean vitamin and mineral intake for participants met the RDAs except for calcium, vitamin D, zinc, and magnesium intakes. The average percentages of carbohydrate, protein, and fat were 53%, 16%, and 30%, respectively. Nutritional assessments of subjects with and without congregate meals were contrasted. Six of the 13 congregate-meal participants were at nutritional risk, compared with 6 of 27 not receiving congregate meals. The interrelationships of diet, functional status, and mental health factors were examined along with recommendations for future data collection in similar studies.

Assessment and management of eating and feeding difficulties for older people: a NICHE protocol.

Adequate nutritional intake is critical to preserving the health of older people. When an elderly person requires assistance with eating, the most social of all activities of daily living, the assessment of nutritional issues becomes multidimensional and interdisciplinary. Management strategies should involve the professional nurse's attention to dietary needs, as well as the social, cultural, and interactive components of mealtime. Additionally, special strategies need to be developed for people with cognitive and physical disabilities.

Educational assessment and teaching of older clients with pressure ulcers.

The importance of education in preventing and treating patients with pressure ulcers is evident by the inclusion of recommendations for educational objectives in the clinical guidelines by the Agency for Health Care Policy and Research. Both caregiver and client should be assessed for knowledge of pressure ulcers. Physical changes in vision, hearing, and cognition that might affect educating older clients are described. Strategies suitable for teaching older clients about the prevention and treatment of pressure ulcers are given.

Facilitating expert practice in gerontological nursing.

Educators and clinical specialists can collaborate to develop experts in gerontological nursing. The authors use Loevinger's theory of ego development and Benner's model to guide their work. Their teaching strategies are designed to increase self-awareness, add conceptual contexts, broden practice perspectives, and promote professional esteem.