Summary of factors contributing to falls in older adults and nursing implications.

Falls are a common cause of serious injury and injury-related death in the older adult population, and may be associated with multiple risks such as age, history of falls, impaired mobility, balance and gait problems, and medications. Sensory and environmental factors as well as the fear of falling may also increase the risk of falls. The purpose of this article is to review current best practice on screening fall risks and fear of falling, fall prevention strategies, and fall prevention resources to assist gerontological nurses in reducing falls by their older adult clients.

GWAS of 972 autologous stem cell recipients with multiple myeloma identifies 11 genetic variants associated with chemotherapy-induced oral mucositis.

PURPOSE: High-dose chemotherapy and autologous stem cell transplant (ASCT) to treat multiple myeloma (MM) and other cancers carries the risk of oral mucositis (OM) with sequelae including impaired nutritional and fluid intake, pain, and infectious complications. As a result of these problems, cancer treatment may have to be interrupted or delayed. In this study, we looked beyond OM's known risk factors of renal function and melphalan dose with a genome-wide association study (GWAS) to evaluate whether genetic variants in conjunction with clinical risk factors influence predisposition for OM. METHODS: Genotyping was performed using Illumina HumanOmni1-Quad v1.0 BeadChip and further assessed for data quality. We tested 892,589 germline single-nucleotide polymorphisms (SNPs) for association with OM among 972 Caucasian patients treated with high-dose melphalan and ASCT in Total Therapy clinical trials (TT2, TT3, TT4) for newly diagnosed MM. Statistical analyses included t tests, stepwise regression modeling, and logistic regression modeling to find baseline clinical factors and genotypes associated with OM. RESULTS: We found that 353 (36.3 %) patients had grades 2-4 OM. Type of treatment protocol, baseline estimated glomerular filtration rate, and melphalan dose along with baseline serum albumin and female gender predicted 43.6 % of grades 2-4 OM cases. Eleven SNPs located in or near matrix metalloproteinase 13, JPH3, DHRS7C, CEP192, CPEB1/LINC00692, FBN2, ALDH1A1, and DMRTA1/FLJ35282 were associated with grades 2-4 OM. The addition of these SNPs increased sensitivity in detecting grades 2-4 OM cases to 52 %. CONCLUSIONS: These SNPs may be important for their roles in inflammatory pathways, epithelial healing, and chemotherapy detoxification.

Review of current conceptual models and frameworks to guide transitions of care in older adults.

Older adults are at high risk for gaps in care as they move between health care providers and settings during the course of illness, such as following hospital discharge. These gaps in care may result in unnecessary re-hospitalization and even death. Nurses can assist older adults to achieve successful transitions of care by taking a systematic approach and individualizing care to meet patient and family health literacy, cognitive, and sensory needs. This article reviews trends in transitions of care, models, partnerships, and health literacy. Models described include the Transitional Care Model, Care Transitions Program, Project BOOST (Better Outcomes for Older adults through Safe Transitions), Project RED (Re-engineered Discharge), Chronic Care Model, and INTERACT(II) (Interventions to Reduce Acute Care Transfers). Approaches to transitions of care are discussed, and resources for geriatric nurses are provided.

Sleep measured by polysomnography in patients receiving high-dose chemotherapy for multiple myeloma prior to stem cell transplantation.

PURPOSE/OBJECTIVES: To describe the objective sleep of patients receiving chemotherapy for multiple myeloma (MM) prior to stem cell transplantation. DESIGN: A descriptive study with repeated measures. SETTING: An international referral center in an urban area of the southern United States. SAMPLE: A convenience sample of a subset of 12 patients with MM, recruited from a randomized, controlled trial. METHODS: Objective sleep was assessed using two nights of polysomnography, one obtained before and one after a second cycle of high-dose chemotherapy prior to stem cell transplantation. Demographic and clinical data were obtained through a retrospective chart review. MAIN RESEARCH VARIABLES: Objective sleep including sleep characteristics, sleep-related respiratory events, and periodic limb movements (PLMs) of sleep. FINDINGS: Sleep was characterized by a relatively short sleep time, excessive time spent awake after the onset of sleep, and poor sleep efficiency (objective sleep quality). Patients spent more than the expected percent of time in non-rapid eye movement sleep and less in rapid eye movement sleep. Arterial oxyhemoglobin saturation nadirs reflected episodes of low arterial oxygen saturation. PLMs during sleep were in the mildly elevated range. CONCLUSIONS: Findings suggest that patients had poor sleep efficiency (objective sleep quality) and were slightly better sleepers after receiving a second cycle of high-dose chemotherapy. A number of patients also demonstrated obstructive sleep apnea and frequent PLMs. IMPLICATIONS FOR NURSING: Findings support the need for additional investigation of sleep in patients with MM, particularly poor sleep efficiency and PLMs. Improving sleep may improve quality of life by decreasing associated symptoms such as pain, fatigue, and depression. KNOWLEDGE TRANSLATION: Oncology nurses should consider assessing patients with MM for insomnia symptoms, excessive daytime sleepiness, obstructive sleep apnea, and a history of jerking or kicking their legs when asleep. Those symptoms may suggest the need for additional investigation of a possible sleep disorder, which may negatively influence mood and function.

Effects of exercise on fatigue, sleep, and performance: a randomized trial.

PURPOSE/OBJECTIVES: To compare usual care with a home-based individualized exercise program (HBIEP) in patients receiving intensive treatment for multiple myeloma (MM)and epoetin alfa therapy. DESIGN: Randomized trial with repeated measures of two groups (one experimental and one control) and an approximate 15-week experimental period. SETTING: Outpatient setting of the Myeloma Institute for Research and Therapy at the Rockfellow Cancer Center at the University of Arkansas for Medical Sciences. SAMPLE: 187 patients with newly diagnosed MM enrolled in a separate study evaluating effectiveness of the Total Therapy regimen, with or without thalidomide. METHODS: Measurements included the Profile of Mood States fatigue scale, Functional Assessment of Cancer Therapy-Fatigue, ActiGraph® recordings, 6-Minute Walk Test, and hemoglobin levels at baseline and before and after stem cell collection. Descriptive statistics were used to compare demographics and treatment effects, and repeated measures analysis of variance was used to determine effects of HBIEP. MAIN RESEARCH VARIABLES: Fatigue, nighttime sleep, performance (aerobic capacity) as dependent or outcome measures, and HBIEP combining strength building and aerobic exercise as the independent variable. FINDINGS: Both groups were equivalent for age, gender, race, receipt of thalidomide, hemoglobin levels, and type of treatment regimen for MM. No statistically significant differences existed among the experimental and control groups for fatigue, sleep, or performance (aerobic capacity). Statistically significant differences (p < 0.05) were found in each of the study outcomes for all patients as treatment progressed and patients experienced more fatigue and poorer nighttime sleep and performance (aerobic capacity). CONCLUSIONS: The effect of exercise seemed to be minimal on decreasing fatigue, improving sleep, and improving performance (aerobic capacity). IMPLICATIONS FOR NURSING: Exercise is safe and has physiologic benefits for patients undergoing MM treatment; exercise combined with epoetin alfa helped alleviate anemia.

Subjective sleep quality, objective sleep characteristics, insomnia symptom severity, and daytime sleepiness in women aged 50 and older with nonmetastatic breast cancer.

PURPOSE/OBJECTIVES: To examine subjective sleep quality in women aged 50 and older as predicted by cancer status, age, number of comorbidities, and symptoms of depressed mood; and to describe objective sleep characteristics, insomnia symptom severity, and daytime sleepiness. DESIGN: Descriptive. SETTING: Urban university and private oncology clinics in the southern United States. SAMPLE: 32 women with and 35 without nonmetastatic breast cancer, aged 50-90 years (X=64.9, SD=4.67). METHODS: Two telephone interviews, the Pittsburgh Sleep Quality Index, Profile of Mood States, three days of home actigraphy, Insomnia Severity Index, Epworth Sleepiness Scale, and medical records review. MAIN RESEARCH VARIABLES: Subjective quality of sleep; secondary objectives were sleep characteristics, insomnia symptoms, and daytime sleepiness. FINDINGS: Poor subjective sleep quality was predicted by depressed mood (p<0.00005). All mean objective sleep characteristics were similar for the breast cancer and comparison groups. Nocturnal awakenings were excessive (9.2 versus 7.3). Mean sleep onset latency was longer for the breast cancer group than for the comparison group (34.8 versus 15.6 minutes). Mean insomnia severity scores for the breast cancer group indicated subthreshold insomnia symptoms, and no clinically significant insomnia for the comparison group (8.9 versus 6.4). Mean daytime sleepiness scores were normal for both groups (7 versus 6). CONCLUSIONS: Subjective sleep quality was predicted by depressed mood only. Sleep in the breast cancer group was characterized by poor sleep quality, frequent nocturnal awakenings, and insomnia symptoms. IMPLICATIONS FOR NURSING: Screening and monitoring in women aged 50 and older with breast cancer may help promote early sleep intervention; however, additional collaborative research regarding the underlying causes of sleep disruption is needed.

Fatigue, sleep, pain, mood, and performance status in patients with multiple myeloma.

BACKGROUND: Cancer-related fatigue and insomnia are common distressing symptoms and may affect mood and performance status. OBJECTIVE: The objective of this study was to describe fatigue, sleep, pain, mood, and performance status and the relationships among these variables in 187 patients with newly diagnosed multiple myeloma (MM) and conduct an analysis using the correlates of fatigue. METHODS: Data were from baseline measures from the study, using the Profile of Mood States and the Functional Assessment of Cancer Therapy-Fatigue to assess fatigue, the actigraph to measure sleep, the Wong/Baker Faces Pain Rating Scale to assess pain, the Profile of Mood States to assess mood, and the 6-minute walk test along with a back/leg/chest dynamometer to test muscle strength to assess performance status. Data analysis consisted of descriptive statistics, Pearson and Spearman ρ correlations, and multiple regression analysis using fatigue as the dependent variable. All P values were 2-sided, and P<.05 was considered significant. RESULTS: Patients with newly diagnosed MM presented with fatigue, pain, sleep and mood disturbances, and diminished functional performance. The regression model, which included all of these variables along with age, sex, and stage of disease, was statistically significant with a large measure of effect. Mood was a significant individual contributor to the model. CONCLUSIONS: Among patients with MM, fatigue, pain, sleep, mood, and functional performance are interrelated. IMPLICATIONS FOR PRACTICE: Interventions are needed to decrease fatigue and pain and to improve sleep, mood, and functional performance.

Sleep across chemotherapy treatment: a growing concern for women older than 50 with breast cancer.

PURPOSE/OBJECTIVES: To conduct a metasynthesis of human sleep studies that included women aged 50 years and older with breast cancer across chemotherapy treatment. DATA SOURCES: English publications were searched with the terms sleep and breast cancer via Ovid, PubMed, and EBSCO-host databases. Human studies that used sleep-specific instruments published from January 1974-May 2009 were included. Intervention studies also were included if they provided baseline sleep data. Studies that used quality-of-life or symptom instruments or in which patients were prescreened for insomnia were not included. DATA SYNTHESIS: 382 publications were found; 17 met inclusion criteria, and 3 additional studies were located from the literature on fatigue. Two articles reported on the same study, so a total of 19 studies were included in the review. In women with nonmetastatic breast cancer, subjective and objective sleep quality appear to be poor and nocturnal awakenings frequent across chemotherapy treatment. Daytime sleepiness increases in the active phase of chemotherapy, and insomnia symptoms are common before and following chemotherapy treatment. In women with recurrent or metastatic breast cancer, difficulty falling asleep, nocturnal awakenings, difficulty awakening, and daytime sleepiness are problematic at different points in chemotherapy treatment. CONCLUSIONS: Sleep for women, including those older than 50 years, appears to be impaired across chemotherapy treatment, although replication of findings is very limited. IMPLICATIONS FOR NURSING: Future research should investigate sleep in specific age and minority groups, include daytime sleep and sleepiness, and use standard sleep nomenclature and objective measures.

Initial report of a family registry of multiple myeloma.

About 20,000 Americans are diagnosed with multiple myeloma (MM) each year, and more than 10,000 die of MM in the United States annually. The etiology of MM remains unknown, although genetic and environmental factors have been implicated. Patients (n = 68) from the Myeloma Institute for Research and Therapy at the University of Arkansas for Medical Sciences and their family members with MM or a related malignancy were interviewed for environmental factors associated with MM and for family history data to complete pedigrees. In collaboration with Dr Henry Lynch at Creighton University, pedigrees of at least 3 generations were analyzed. Eighteen families (27%) have a putative autosomal dominant mode of genetic transmission of MM. Furthermore, the pedigrees indicate that pancreatic cancer, malignant melanoma, breast cancer, and lymphoma may be part of a myeloma syndrome. Environmental factors associated with MM present in this patient population were being born and raised in a rural area, raising cattle or cotton, and exposure to pesticides, insecticides, or herbicides. This work will be part of the efforts to create an international consortium to study familial MM. Research in the area of molecular epidemiology is needed to discover the genetic and environmental determinants of this disease.

Dietary soy intake and breast cancer risk.

PURPOSE/OBJECTIVES: To conduct a metasynthesis of the literature on human studies of the relationship between dietary soy intake and breast cancer risk. DATA SOURCES: Publications in English reporting human studies were searched with the terms soy and breast cancer, using Ovid, PubMed, and EBSCO databases. Only human studies investigating the relationship of soy intake to breast cancer development in women published from January 1997 through June 2008 were included in the review. DATA SYNTHESIS: A total of 364 publications were located; 18 of the studies met the inclusion criteria and 18 additional studies were located through other publications identified in the search. Because four articles reported on the same two studies, a total of 34 studies were included in the review. CONCLUSIONS: The naturally occurring dietary intake of soy food or its components appears safe for women without breast cancer; however, the safety of high supplements of soy or its components is less certain. IMPLICATIONS FOR NURSING: Nurses should become more knowledgeable about soy foods and supplements and include soy intake in dietary assessments. Nurses caring for women at high risk for or with a history of breast cancer should confer with dietitians on current practice recommendations. Women with health issues should avoid initiating high intake of soy dietary supplements until the possible effects are better understood.

Periodic leg movements predict total sleep time in persons with cognitive impairment and sleep disturbance.

STUDY OBJECTIVE: To determine if periodic leg movements predict total sleep time at night in elders with cognitive impairment and sleep disturbance. DESIGN: Descriptive cross-sectional secondary analysis using data from an observational study and baseline data from a randomized, controlled clinical trial. SETTINGS: Private homes, nursing homes, and assisted living facilities. PARTICIPANTS: One hundred and two persons with a mean age of 81.8 years, cognitive impairment, and sleep disturbance. INTERVENTION: N/A. MEASUREMENTS AND RESULTS: We measured sleep variables using 1 night of attended polysomnography in each participant's usual sleep setting. We assessed 10 characteristics associated with sleep disturbance (periodic leg movement index, time in bed, apnea-hypopnea index, oxygen saturation nadir, age, sex, living arrangement, cognitive status, painful conditions, and depression) with multiple linear regression analyses to determine the predictors of total sleep time. Of the 102 participants, 56.9% were men, and 64.7% lived in nursing homes or assisted living facilities. Their mean Mini-Mental State Examination score was 17.3. In addition, 21.6% had 1 or more painful conditions, and 45.1% were diagnosed with depression. Participants' mean periodic leg movement index was 17.3 with 34 (33.3%) having a periodic leg movement index greater than 15. Time in bed at night exceeded 8 hours, yet participants averaged only 5.5 hours of sleep. They had a mean apnea-hypopnea index of 18.3, with a mean oxygen saturation nadir of 86.4%. Periodic leg movement index, time in bed, and age explained 43.6% of the variance in total sleep time. CONCLUSIONS: Frequent periodic leg movements, less time in bed, and older age are associated with less sleep at night in this population.

Obtaining family histories from patients with cancer.

Information obtained from family history data can provide valuable insight into the biologic and environmental etiologies of an individual's personal and family history of disease. The purpose of this article is to provide a brief introduction to cancer genetics and discuss ways to obtain accurate family histories in a time-efficient manner to identify families with a hereditary cancer syndrome. The focus is on gathering family history information, which should be a standard component of the initial intake for any patient and updated regularly to keep the information current.

Tailored biobehavioral interventions: a literature review and synthesis.

This article presents a metasynthesis of the literature from 1996 through 2005 on randomized clinical or controlled trials comparing effects of tailored interventions to those of control conditions or other interventions. A search was conducted for publications written in English using the terms "patient-centered interventions," "tailored interventions," and "individualized interventions," using Ovid and Elton B. Stephens Company (EBSCO) Host databases. A total of 245 publications were located after deleting duplicates. An additional six studies were identified from two syntheses of intervention research. A total of 63 studies met the inclusion criteria, and 49 of these reported that tailored interventions were superior to control conditions for one or more of the main outcomes. The evidence strongly supports the efficacy of tailored behavioral interventions and provides beginning support for the efficacy of tailored psychosocial and biological interventions.

Research testing of tailored interventions.

The purpose of this article is to offer rationale to support the argument for research testing of tailored interventions. The individualization of nursing interventions is used as a basis for discussion of the emergent need to test tailored interventions at the research rather than practice level. Both justification of efficacy and feasibility support the research testing of tailored interventions, in support of an evolving nursing process. In order to retain its patient-centered focus and yet meet scientific standards for practice, nursing must evaluate the individualization of care through more theory-based and systematic research processes. The testing of tailored interventions at the research level would provide a means to achieve these ends.