Accuracy of caregivers' recollections of caregiving hassles.

Despite their common use in clinical settings, caregivers' recollections of the hassles they face in caregiving have not been examined in previous research. Ninety-seven spousal caregivers of persons with dementia were assessed for 6 consecutive months concerning caregiving hassles and numerous other issues. A multi-pass rank order assessment identified the most stressful event in caregiving over each month-long interval. Each month via telephone interview, caregivers' recollections of the most stressful event in the previous month were assessed; no retrieval cues were provided. Of a total of 582 retrieval events examined, 378 (65%) were correct, 84 (14%) were incorrect, and 120 (21%) were not remembered. These data indicate that a majority of caregivers are capable of accurate recollection of caregiving hassles after a delay of one month following very careful ranking procedures, but also that individual differences in accuracy are present.

The meaning of older adults' health appraisals: congruence with health status and determinant of mortality.

This study explored open-ended responses regarding attributions underlying health appraisals made by older adults, resulting in five categories (physical health, attitudinal/behavioral, externally focused, health transcendence, nonreflective). The older the respondents, the less likely they were to focus on physical aspects of their health. Health optimists were the most likely to make attitudinal/behavioral or health transcendent attributions, while poor-health realists were most likely to mention physical health aspects and least likely to make attitudinal or behavioral attributions. While poor-health realists were at the highest risk of dying within a three-year period, health optimists were significantly less likely to die than poor-health realists, in spite of sharing similar health status. Respondents who were unable to identify underlying attributions were significantly more likely to die than were those identifying any other attribution. In conclusion, health attributions provide unique insight into the complex relationship between older adults' health appraisals, health status, and mortality.

Predictors of attitudes toward three target groups of elderly persons: the well, the physically ill, and patients with Alzheimer's disease.

This research compared attitudes of 143 nursing home employees toward three hypothetical target groups of older adults: well elderly persons, physically ill elderly persons, and elderly persons with Alzheimer's disease. Staff provided successively less positive evaluations of physically ill elderly persons and elderly persons with Alzheimer's disease compared to well elderly persons. Age, education, and contact with grandparents differentially predicted positive evaluations toward well and physically ill older adults. Self-efficacy was a significant predictor of positive evaluations across all target groups. Findings suggest that interventions designed to increase staff members' feelings of self-efficacy may lead to more positive evaluations of elderly clients and, ultimately, improved quality of care.

Influence of altered body weight on energy expenditure.

Long-term metabolic studies indicate that over-feeding underfeeding to gain and lose body weight produce consistent increases and decreases in energy expenditure. These changes occur in both lean and obese subjects and cause deviations from the normal relationship between energy expenditure and metabolic body size. The low energy expenditure/metabolic body size in the reduced obese may contribute to the difficulty in maintaining the reduced body weight.

Metabolic responses of the critically ill patient.

The care of the critically ill patient has become the point of convergence for substrate and energy metabolism, vital organ support, and cell biology. This article includes a brief review of normal metabolism and its endocrine regulation. The metabolic response to injury is reviewed with special attention to insulin resistance. The metabolic response to infection is considered in the light of rapidly emerging information on inflammatory mediators. Finally, brief attention is given to microcirculation and pericellular fluid as sites of metabolic regulation that have the potential for contributing to each of the three converging disciplines.

Hydrolysis of mixed lipid emulsions containing medium-chain and long-chain triacylglycerol with lipoprotein lipase in plasma-like medium.

We explored the effects of plasma-like conditions on hydrolysis of medium-chain triglyceride (MCT) and long-chain triglyceride (LCT) emulsions at different mixing ratios and the effect of the physical method of mixing on lipoprotein lipase hydrolysis of mixed emulsions in vitro. Mixed emulsions with two different mixing ratios, 50% MCTs with 50% LCTs and 70% MCTs with 30% LCTs by weight, were studied. Emulsions containing both MCT and LCT oils blended in the same emulsion particle were compared with mixtures of separate pure MCT emulsion particles and pure LCT particles. MCT hydrolysis was always greater than LCT hydrolysis. In a plasma-free tris(hydroxymethyl)aminomethane-albumin buffer at pH 8.5, the physical method of mixing had substantial effects on hydrolysis; blended emulsions of MCTs and LCTs were hydrolyzed better than separate mixes of pure MCT and pure LCT particles, ie, more total free fatty acids were released. In plasma-free systems, there were no differences in rates of hydrolysis of LCTs or MCTs (as individual triglycerides) between the two different mixing ratios of 50:50 and 70:30. However, the presence of plasma markedly diminished the differences in hydrolysis between blended vs separately mixed emulsions at pH 7.4. Also, in plasma-like incubation buffer, the rates of hydrolysis of MCTs and LCTs in emulsions with 50:50 or 70:30 MCT to LCT ratios reflected the respective amounts of MCT and LCTs in the emulsions.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of respiratory inductive plethysmography in the measurement of breathing pattern and PEEP-induced changes in lung volume.

STUDY OBJECTIVE: To assess the accuracy of the respiratory inductive plethysmography in the measurement of PEEP-induced changes in end-expiratory lung volume during mechanical ventilation and its accuracy and stability in the measurement of ventilation during controlled mechanical ventilation and spontaneous breathing. DESIGN: An open comparison between two methods using a criterion standard. Either a pneumotachometer (mechanically ventilated patients) or a spirometer (spontaneously breathing subjects) was used as the reference method. SETTING: Tertiary care center; a multidisciplinary intensive care unit and a metabolic research unit. PATIENTS: Six mechanically ventilated, paralyzed postoperative open heart surgery patients, six spontaneously breathing COPD patients, and eight healthy volunteers. INTERVENTIONS: Stepwise increases and reductions of PEEP from zero to 12 cm H2O during controlled mechanical ventilation; repeated validation of the calibration of the respiratory inductive plethysmography (RIP) in both mechanically ventilated and spontaneously breathing subjects. MEASUREMENTS AND RESULTS: The baseline drift of the RIP in vitro was 10 ml/150 min and in a ventilated model it was 20 ml/150 min. In mechanically ventilated patients, the mean error of the calibration after 150 min was within +/- 5 percent. Change in end-expiratory lung volume (EELV) during the stepwise increase of PEEP up to 12 cm H2O was 849 +/- 136 ml with the RIP and 809 +/- 125 ml with the pneumotachometer (PT), and during the stepwise reduction of PEEP it was 845 +/- 124 ml and 922 +/- 122, respectively (not significant [NS]. The mean difference between methods in the measurement of change in EELV was -6.6 +/- 3.5 percent during increasing and 6.6 +/- 6.7 percent during decreasing PEEP (NS). Both in mechanically ventilated and spontaneously breathing subjects, the difference between methods was significant for VT and VT/TI. The difference in VT was -2.2 +/- 0.2 percent during mechanical ventilation, -1.1 +/- 0.5 percent in spontaneously breathing COPD patients, and 2.9 +/- 0.4 percent in healthy volunteers (NS between groups). CONCLUSIONS: The RIP is sufficiently accurate for the measurement of PEEP-induced changes in EELV during controlled mechanical ventilation. The accuracy of tidal volume measurement is similar during mechanical ventilation and spontaneous breathing. The calibration of the RIP is stable enough for bedside monitoring of changes in lung volumes.

Sources of stress for family caregivers of institutionalized dementia patients.

Although many caregivers place their relative in a nursing home in an attempt to reduce their own burden, caregiving stress often continues after institutionalization. This research examined sources of stress for 66 caregivers who cared for their impaired relative at home and later placed that individual in a nursing home. We hypothesized that although these caregivers no longer had primary responsibility for direct care, they would continue to experience distress because of the stressors associated with the nursing home. Results ran counter to our expectations. Although many caregivers reported stressors related to nursing home care, stressors stemming from the patient's Alzheimer's disease (AD) symptoms accounted for more variance in caregivers' levels of anxiety and depression, and in the quality of their interpersonal relations. Even though caregivers were assisted in their caregiving responsibilities by the nursing home staff, their relative's AD symptoms continued to prompt distress.

Stressors and well-being among caregivers to older adults with dementia: the in-home versus nursing home experience.

We examined differences in stressors and well-being for caregivers who care for a relative with dementia at home and those who had placed their relative in a nursing home. The groups did not differ in depression or somatic complaints, but nursing home caregivers had fewer social and interpersonal disruptions. Controlling for caregiving problems, nursing home caregivers reported more stressors due to ADL (activities of daily living) assistance, their relatives' behavioral and cognitive functioning, and lack of caregiving support from family and friends.

Resting energy expenditure in injured, septic, and malnourished adult patients on intravenous diets.

Energy expenditures of 237 adult patients and 37 normal subjects receiving all nutrition intravenously were analysed retrospectively. Patients were classified as nutritionally depleted (67), post-operative (96), injured (43), or septic/depleted (31). Groups were further divided into those receiving either: (1) only 5% dextrose (D5W); (2) hypocaloric regimens including glucose and amino-acids; and (3) eucaloric or hypercaloric total parenteral nutrition (TPN) which also included fat. Resting energy expenditures (REE) of normal subjects on D5W were only 85% of predicted basal values based on either the Aub-Du Bois or Harris-Benedict equations. During D5W infusions, increases for the patient groups, above these values for normal subjects, varied depending on whether they were based on absolute values or ratios to predicted values. They were: (1) 1-11% for depleted; 1-21% for post-operative; 28-30% for injured; and 18-30% for septic/depleted patients. The average increase in REE with TPN was 10%. Variability within the patient groups was high, reducing the utility of these values as a basis for estimating energy requirements of patients needing artificial nutrition. Coefficients of variation averaged 15% across patient groups when the data were expressed in kJ/kg, and were reduced only slightly, to 12%, when data were expressed as ratios to predicted values. Thus, 1 3 of the patients would differ by more than 12% from mean values, and 1 out of 20 by more than 24%. Properly performed measurements of individual energy expenditure are therefore superior to values predicted from equations or average values previously obtained from patient groups and should be used wherever possible, particularly in the very sick.

The impact of family interactions on recovery from stroke: help or hindrance?

The family networks of 47 geriatric stroke patients were examined for social supports and social problems as they related to well-being after hospital discharge. Structured interviews assessed positive and negative family interactions and patients' independence in activities of daily living (ADL), time use, personal adjustment, and cognitive functioning. After controlling for patients' medical status at hospital discharge, social supports were not associated with any of the outcomes examined. Social problems explained additional variance in personal adjustment and ADL independence.

Effects of glucose on nitrogen balance during high nitrogen intake in malnourished patients.

1. The effects of increasing glucose intake on nitrogen balance, energy expenditure and fuel utilization were measured in 12 malnourished adult patients receiving parenteral nutrition with constant, very high nitrogen intake (500 mg of N/kg), high (105 kJ/kg) or low (30 kJ/kg) glucose intake and constant fat intake (7 kJ/kg). Each patient received each diet for 8-day periods in random order. 2. Energy balance and nitrogen balance were determined daily. Blood samples, taken at admission, during 5% (w/v) dextrose (D-glucose) infusion and at the end of days 7 and 8 of each diet, were analysed for urea, glucose, lactate, triacylglycerols, fatty acids, glycerol, 3-hydroxybutyrate, insulin and glucagon. 3. The effect of increasing glucose intake was to increase nitrogen balance by 0.60 +/- 0.25 (SEM) mg/kJ. At zero energy balance, nitrogen balance was 48 mg day-1 kg-1. This confirms findings of previous studies: that the effects of glucose on nitrogen balance are greater at high than at low nitrogen intakes, and that, in malnourished patients, unlike in normal adults, markedly positive nitrogen balance can be achieved at zero or negative energy balances. 4. Changes in nitrogen balance were due almost entirely to changes in urea excretion. 5. The high nitrogen intake markedly increased plasma insulin and glucagon concentrations and reduced glycerol, fatty acid and 3-hydroxybutyrate concentrations, independent of any glucose effect. Glucagon concentrations were significantly decreased by added glucose intake, an effect not previously seen at low nitrogen intakes. At this high nitrogen intake, the effects of added glucose appear to be mediated by both insulin and glucagon.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of glucose on fuel utilization and glycerol turnover in normal and injured man.

Rates of fat mobilization (glycerol turnover), and fuel utilization and energy expenditure (indirect calorimetry) were measured in normal subjects and injured or septic patients maintained on high or low iv intakes of glucose as their sole nutrient source during 3-day periods. Regimens were given consecutively to each subject in random order. Concentrations of glucose, glycerol, fatty acids, 3-hydroxybutyrate, urea, insulin, and glucagon were determined in plasma, and of epinephrine and norepinephrine in urine. In normal subjects, there was no increase in energy expenditure with increasing glucose, although estimated costs of glucose storage as glycogen or fat could account for an increase of 4%. Thus, storage costs of glucose do not necessarily constitute an obligatory increase in energy expenditure. Rates of glycerol turnover and fat oxidation, and plasma glycerol concentrations were lower with the high than the low rate of glucose infusion, and lower than values reported by others during fasting or glucose infusion. Rates of fat oxidation were higher and glucose oxidation lower in patients than in controls, even though insulin concentrations were more than twice as high in patients. This confirms previous studies comparing injured and septic patients to depleted patients or historical controls. Triglyceride cycle activity was higher in the injured and septic patients than in normal subjects, and could account for from 6% to 15% of the increase in energy expenditure, in agreement with reports for burn patients.