Aging Individuals With Down Syndrome and Dementia as Teachers: Learnings from Staffin a Developmental Disability Program in Long-Term Care.

Older adults with Down syndrome (DS) and dementia are an emerging sub-population. With much longer life spans than decades ago, issues have arisen as to where these aging adults will live and how nurses and other staff in facilities can provide effective care to these individuals. The current article presents a research study that examined the learnings of nurses and staff members working within a western Canadian program for older adults with DS and dementia. These learnings include: the importance of learning from each other; importance of collaboration; how individuals with developmental disabilities communicate; older adults with DS and dementia differ from older adults with dementia; and residents' impact on staff. [Journal of Gerontological Nursing, 45(5), 17-22.].

What Do Family Members Really Want When Older Adults Transition to a Nursing Home?

The purpose of the current study was to explore family members' perceptions of supports received during the transition experience of their older adult family member into a nursing home. In this exploratory, descriptive, qualitative study, interviews were conducted with six family members during the initial 6-month period following admission of the older adult family members. One overarching theme was found: importance of recognizing and supporting the personhood of older adult family members. Implications for how older adults' personhood can be supported are described. [Journal of Gerontological Nursing, 43(11), 9-14.].

Light therapy for improving cognition, activities of daily living, sleep, challenging behaviour, and psychiatric disturbances in dementia.

BACKGROUND: Rest-activity and sleep-wake cycles are controlled by the endogenous circadian rhythm generated by the suprachiasmatic nuclei (SCN) of the hypothalamus. Degenerative changes in the SCN appear to be a biological basis for circadian disturbances in people with dementia, and might be reversed by stimulation of the SCN by light. OBJECTIVES: The review examines the effectiveness of light therapy in improving cognition, activities of daily living (ADLs), sleep, challenging behaviour, and psychiatric symptoms associated with dementia. SEARCH METHODS: ALOIS, the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched on 20 January 2014 using the terms: "bright light*", "light box*", "light visor*", "dawn-dusk*", phototherapy, "photo therapy", "light therapy" "light treatment", light* . The CDCIG Specialized Register contains records from all major healthcare databases (The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many trials databases and grey literature sources. SELECTION CRITERIA: All relevant, randomized controlled trials were included in which light therapy, at any intensity and duration, was compared with a control group for the effect of improving cognition, ADLs, sleep, challenging behaviour, and psychiatric symptoms associated with dementia (as well as institutionalization rates or cost of care). Included were people with dementia of any type and degree of severity. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the retrieved articles for relevance, and four review authors independently assessed the selected studies for risk of bias and extracted the data. Statistically significant differences in outcomes between the treatment and control groups at the end of treatment and follow-up were examined. Each study was summarized using a measure of effect (for example mean difference). MAIN RESULTS: Eleven trials (13 articles) met the inclusion criteria. However, three of the studies could not be included in the analyses either because the reported data could not be used in the meta-analysis or we were unable to retrieve the required data from the authors.This updated review found no effect of light therapy on cognitive function, sleep, challenging behaviour (for example agitation), or psychiatric symptoms associated with dementia. Reduction in the development of ADL limitations was reported in one study, at three of five time points, and light therapy was found to have an effect after six weeks and two years but not after one year. AUTHORS' CONCLUSIONS: There is insufficient evidence to justify the use of bright light therapy in dementia. Further research should concentrate on replicating the suggested effect on ADLs, and establishing the biological mechanism for how light therapy improves these important outcomes.

Socioeconomic disparities in home health care service access and utilization: a scoping review.

UNLABELLED: Home health care services are expanding at a rapid pace in order to meet the needs of the growing population of older adults and those with chronic illnesses. Because of current restrictions on home health care as an insured service in some countries, individuals may be required to pay for some or all of their home care services out of pocket. These payments may potentially limit access to needed home care services for persons in the lowest socioeconomic strata. Previous research demonstrates a clear socioeconomic gradient in access to acute and primary care services, where those most in need of services are the most disadvantaged and under-serviced. There has been little attention paid thus far, however, to the way in which socioeconomic status may affect the receipt of home health care services. OBJECTIVE: To determine what is known from existing literature about socioeconomic disparities in home health care access and utilization. DESIGN: A scoping review was used to map the extent and nature of the literature in this area. DATA SOURCES: A search of the databases CINAHL, Medline, SocIndex and Sociological Abstracts as well as Dissertations International. REVIEW METHODS: A total of 206 potentially relevant articles were published between 2000 and April 2011. Two reviewers independently reviewed the articles, leaving 15 research articles to be included in the scoping review. RESULTS: The majority of articles reported secondary analyses of administrative datasets related to utilization of home health care. Several studies examined access and utilization using qualitative approaches. The distinction between professional and supportive home care services was not always clear in the articles. Individual and composite measures of socioeconomic status were reported, with the most frequently used indicator being income. Several studies used more complex composite ecological indicators of socieconomic status. There was general agreement that utilization of home health services favored persons with greater economic disadvantage. Education, rurality and race were less frequently reported. CONCLUSIONS: In contrast to well-documented socioeconomic gradient seen with primary and acute care services, we found general agreement that persons of lower socioeconomic status are favored and not disadvantaged in terms of home health care services.

Formal care providers' perceptions of home- and community-based services: informing dementia care quality.

Little attention has been given to the perceptions of formal care providers on the nature and quality of home- and community-based dementia care. The purpose of this descriptive interpretive research was to explore formal care providers' perceptions of their experiences with Canadian home- and community-based dementia care. Participants within three personal interviews and six focus groups (n = 41) included nurses, social workers, therapists, home care aides, and Alzheimer Society personnel (front line/management) in rural and urban areas of Saskatchewan (n = 16), Manitoba (n = 20), and Ontario (n = 8). Two overarching thematic categories, Service Availability and Service Acceptability, emerged from the data analysis. Subthemes of availability were identified as: (a) challenges of service availability, including service wait lists, lack of home care provider training, lack of community-based dementia care infrastructure, and sociocultural and geographic barriers to accessing dementia services; and (b) essential facilitators of availability, including service infrastructure, service bridging, and agency partnerships to form coordinated care systems. Subthemes of acceptability were revealed as: (a) essential components of dementia care, including provision of comprehensive personal care and the use of dementia care professional practice knowledge within a home care setting; and (b) service challenges, including inadequate service time for the physical care and socioemotional support of the client and family caregiver, caregiver and formal provider difficulty with navigation of a fragmented care system, lack of system coordination, and financial costs of services. Essential, integrated dementia care could be established by listening to the "voices of formal care providers," thereby decreasing dementia care costs and increasing the quality of life for those with dementia, and their family caregivers.

Availability and acceptability of Canadian home and community-based services: perspectives of family caregivers of persons with dementia.

Thirty-five percent of Canadians over the age of 85 have dementia, and up to 90% of their home care is provided by family and friends. The purpose of this study was to explore the use and satisfaction with home and community-based services for persons with dementia from the perspectives of family caregivers. The study was conducted using an interpretive, descriptive, qualitative approach. Six focus groups (N = 36) and three personal interviews were conducted with rural and urban caregivers in Ontario, Manitoba, and Saskatchewan, Canada. Using Lubrosky's (1994) thematic analysis, the overarching themes identified were availability and acceptability of services. The findings suggest a need for an integrated continuing care model that includes the person living with dementia and their family caregivers as partners in care, addresses all of the determinants of health, and embraces sensitivity, diversity, flexibility, and supportive services to enhance the availability and acceptability of Canadian home and community-based services.

Gender differences in use and availability of home and community-based services for people with dementia.

The purpose was to examine the use and availability of home and community-based services by men and women with dementia using data from the 2003 Canadian Community Health Survey. Variables of interest were based on the Andersen and Newman model and included predisposing, enabling, need, and use of health service variables, perceived unmet health and home care needs, and availability of home and community-based health services. Women reported better health and received more supportive care yet had more unmet home care needs than men.Thus, the caregivers of men with dementia (often their wives) were particularly vulnerable to negative outcomes, as their care recipients had poorer health yet received fewer services. These gender differences should be considered when policies and programs are developed, the needs of care recipients and caregivers are assessed, and services are provided.

Rural residence and prescription medication use by community-dwelling older adults: a review of the literature.

CONTEXT: Due to various barriers to health care access in the rural setting, there is concern that rural older adults might have lower access to prescribed medications than their urban counterparts. PURPOSE: To review published research reports to determine prevalence and mean medication use in rural, noninstitutionalized older adults and assess whether rural-urban differences exist. METHODS: PubMed, Ageline, Cinahl, PsycInfo, International Pharmaceutical Abstracts, Agricola, and Institute for Scientific Information Web of Science - Social Science Index were searched. English-language articles through May 2005 involving a sample of rural, noninstitutionalized older adults and analyses of overall medication prevalence and/or intensity were included. Review articles, conference abstracts, dissertations, books, and articles targeting nonprescription or specific therapeutic categories were excluded. A total of 206 citations were identified and 26 met the inclusion criteria. FINDINGS: Reported prevalence of prescription medication use by rural older adults varied between 62% and 96%, with 2-6 prescriptions per person. Multivariate analyses results were equally inconsistent. Controlling for insurance, most US studies suggest there is no rural-urban difference in access to prescribed medications. However, this finding may not be generalizable across all regions in the United States or other countries. CONCLUSIONS: Geographic location may not be as important a variable for medication usage as for other health services utilization.

Helping faculty enhance scholarship.

Nurse educators face a myriad of challenges (e.g., changing student populations, increased demand for the use of technology, faculty shortages, and facilitating the development of self-confidence and competence in students) as they endeavor to enhance scholarship and quality in nursing education. Scholarship encompasses four separate but integrated elements (i.e., discovery, integration, application, and teaching) that need to be instilled in nursing students to prepare them for diverse roles in the profession of nursing. Implications for nurse educators relate to creating curricula that support scholarship, technological and interprofessional opportunities, and strategies for socializing students into scholarship.

Smoke-free policies in the psychiatric population on the ward and beyond: a discussion paper.

Healthcare facilities from a number of countries have or are in the process of implementing smoke-free policies as part of their public health agenda and tobacco control strategy. Their main intent is to prevent the harmful effects of environmental tobacco smoke on employees and patients. However, these protection policies are often implemented before taking into account the specific needs of patients in psychiatric facilities and are clouded by a lack of knowledge, myths and misconceptions held by a variety of stakeholders. Consequently, the implementation of smoke-free policies tends to result in unintended and unfavourable consequences for this aggregate. Patients are forced to abstain from tobacco use during their hospitalization but have few options to address their dependence upon discharge. The development and implementation of such policies should not occur in isolation. It requires thoughtful consideration of the needs of the affected population. Recommendations are presented on the role of nurses in lobbying for policy changes. As well as strategies for policy makers and administrators that should accompany such a policy in psychiatry.

Therapeutic touch and agitation in individuals with Alzheimer's disease.

Limited effective strategies exist to alleviate or treat disruptive behaviors in people with Alzheimer's disease. Fifty-one residents of a long-term care facility with Alzheimer's disease were randomly assigned to one of three intervention groups. A multiple time series, blinded, experimental design was used to compare the effectiveness of therapeutic touch, simulated therapeutic touch, and usual care on disruptive behavior. Three forms of disruptive behavior comprised the dependent variables: physical aggression, physical nonaggression, and verbal agitation. Physical nonaggressive behaviors decreased significantly in those residents who received therapeutic touch compared with those who received the simulated version and the usual care. No significant differences in physically aggressive and verbally agitated behaviors were observed across the three study groups. The study provided preliminary evidence for the potential for therapeutic touch in dealing with agitated behaviors by people with dementia. Researchers and practitioners must consider a broad array of strategies to deal with these behaviors.

Diagnosis and management of geriatric insomnia: a guide for nurse practitioners.

PURPOSE: To discuss the assessment, diagnosis, and management of geriatric insomnia, a challenging clinical condition of older adults frequently seen by primary care providers. DATA SOURCES: Extensive literature review of the published research articles and textbooks. CONCLUSIONS: Complaints of insomnia among older adults are frequently ignored, considered a part of the normal aging process or viewed as a difficult to treat condition. Geriatric insomnia remains a challenge for primary care providers because of the lack of evidence-based clinical guidelines and limited treatment options available. Effective management of this condition is necessary for improved quality of life, which is a primary issue for the elderly and their families. Therefore, geriatric insomnia warrants thorough attention from the nurse practitioners (NPs) who provide care for older adults. IMPLICATIONS FOR PRACTICE: Undiagnosed or under treated insomnia can cause increased risk for falls, motor vehicle accidents, depression, and shorter survival. Insomniacs double their risk for cardiovascular disease, stroke, cancer, and suicide compared to their counterparts. Insomnia is also associated with increased healthcare utilization and institutionalization. NPs could play a central role in reducing the negative consequences of insomnia through a systematic approach for diagnosis, evaluation, and management.

Giving voice to informal caregivers of older adults.

This study focused on the experiences of informal caregivers of older adults and explored whether employment, use of home-care services, or other factors influence the health of caregivers and their ability to manage their caregiving and other responsibilities. Focus groups conducted with 26 caregivers and personal interviews with 4 caregivers identified 12 themes under 5 conceptual areas: caregiver health, relationships, independence, employment, and use of home-care services. The findings reveal that caregiving coupled with other responsibilities can have serious health effects. Participants spoke of the tenuous balance of decision-making control between caregiver and care recipient. Many caregivers expressed a desire to be included as part of the formal health-care team. Implications for nursing are discussed.

Palliative sedation: nurses' perceptions.

Patients with advanced illnesses suffer from a myriad of distressing symptoms. Palliative care aims to alleviate the distress caused by such symptoms. In extreme circumstances palliative sedation may be implemented to manage symptom distress that is not responsive to standard treatment modalities. Nurses are involved in the care of patients receiving palliative sedation as well as their families. To date, however, little research has been conducted examining the nurses' experiences with, and perceptions about the use of palliative sedation in end-of-life care. In order to redress this gap in the literature a descriptive-exploratory study guided by the theory of symbolic interactionism was conducted. Face-to-face interviews were conducted with 10 nurses working on an adult in-patient palliative care unit within a long-term care facility in Canada. The major theme emerging from content analysis of interview transcripts was that of 'Working your way through the quagmire'. The metaphor of the quagmire captured the difficult and complex issues nurses grappled with in instances where palliative sedation was used, and integrates the major categories into the key analytic model emerging from this study.

Cognitively impaired older adults: risk profiles for institutionalization.

BACKGROUND: This study focused on the identification of risk profiles for institutionalization among older adults diagnosed with cognitive impairment-not dementia or dementia in 1991/92 and subsequent institutionalization in the following 5-year period. METHODS: Data were from a sample of 123 individuals aged 65+ and their unpaid caregivers in Manitoba, Canada. Cluster analysis was conducted using baseline characteristics of age, cognition, disruptive behaviors, ADLs/IADLs, use of formal in-home services, and level of caregiver burden. RESULTS: Three distinct groups emerged (high risk [n = 12], medium risk [n = 40], and low risk [n = 71]). The high-risk group had the poorest cognitive scores, were the most likely to exhibit disruptive behaviors, were the most likely to need assistance with ADLs and IADLs, and had the highest level of burden among their caregivers. Follow-up of the groups validated the risk profiles; 75% of the high-risk group were institutionalized within the next 5 years, compared to 45% of the medium-risk group and 21% of the low-risk group. DISCUSSION: The risk profiles highlight the diversity among individuals with cognitive impairment and the opportunity for differential targeting of services for the distinct needs of each group.

Perceptions of a senior citizens' Wellness Center. The community's voice.

Health promotion encompasses an important role in the nursing care of all individuals across the life span. The literature indicates senior citizens tend to be the age group most actively involved in health promotion activities. Not only do senior citizens, as an age group, participate more frequently in health promotion activities, but also they tend to seek out health promotion opportunities. A center for community residing senior citizens, funded by the provincial health department for 4 years, was initiated to promote health and wellness among the senior citizens and to delay the onset of disability. To evaluate the outcomes of the Wellness Center, the qualitative methodology of this study used the focus group approach. The participants in the focus groups comprised health professionals and community groups with some involvement with the Wellness Center. In their discussions, participants identified the Center as providing health promotion services different from those currently existing in the health care system. The participants agreed the Center was essential to promote healthy lifestyles for senior citizens.

Advance directives and community-dwelling older adults.

Advance directives (ADs) are documents that allow competent individuals to set forth their medical treatment wishes and/or to name a proxy in the event that they lose the capacity to communicate these decisions in the future. Despite the benefits of and support for such documents, very few people have completed an AD. This posttest-only experimental study examined whether an individualized intervention given to half of the older adults who attended an educational session increased the discussion and/or completion of ADs. Of the 74 participants, 25.7% (n = 19) completed an AD. There were no significant differences between control and intervention groups on the discussion and/or completion of ADs. Multivariate analysis indicated that perceived barriers were significantly associated with the discussion and completion of ADs. Content analysis revealed that major barriers to discussion and completion include procrastination and a reluctance to think about deteriorating health status and/or death.