Sleep quality prediction in caregivers using physiological signals.

Most caregivers of people with dementia (CPWD) experience a high degree of stress due to the demands of providing care, especially when addressing unpredictable behavioral and psychological symptoms of dementia. Such challenging responsibilities make caregivers susceptible to poor sleep quality with detrimental effects on their overall health. Hence, monitoring caregivers' sleep quality can provide important CPWD stress assessment. Most current sleep studies are based on polysomnography, which is expensive and potentially disrupts the caregiving routine. To address these issues, we propose a clinical decision support system to predict sleep quality based on trends of physiological signals in the deep sleep stage. This system utilizes four raw physiological signals using a wearable device (E4 wristband): heart rate variability, electrodermal activity, body movement, and skin temperature. To evaluate the performance of the proposed method, analyses were conducted on a two-week period of sleep monitored on eight CPWD. The best performance is achieved using the random forest classifier with an accuracy of 75% for sleep quality, and 73% for restfulness, respectively. We found that the most important features to detect these measures are sleep efficiency (ratio of amount of time asleep to the amount of time in bed) and skin temperature. The results from our sleep analysis system demonstrate the capability of using wearable sensors to measure sleep quality and restfulness in CPWD.

An Exploratory Analysis of Potential New Biomarkers of Cognitive Function.

We examined the relationship between serially measured, novel serum biomarkers and a measure of cognitive functioning in older adults. We assayed stored serum samples from two Fels Longitudinal Study visits in N = 100 adult participants (visit 1 ages 59.3 ± 8.5 years; 53% female), and Montreal Cognitive Assessment (MoCA) scores also assessed at the second visit. Assays included acylcarnitines, amino acids, and 2-hydroxybutyric acid (b-HBA). Cross-sectional correlations between acylcarnitines and amino acids and MoCA were identified. Serial change in short-chain acylcarnitines and visit 2 MoCA were also correlated. Participants with MoCA scores <26 were more likely to have an increase in short-chain acylcarnitines between visits 1 and 2 [adjusted odds ratio (OR) = 5.24; 95% confidence interval (CI) 1.07-25.9]. b-HBA was also correlated with acylcarnitines. Several cross-sectional and serial associations between novel serum biomarkers and cognitive functioning were identified. b-HBA may also be a cost-effective marker of dysregulation associated with cognitive decline.

Validating a Commercial Device for Continuous Activity Measurement in the Older Adult Population for Dementia Management.

With the introduction of the large number of fitness devices on the market, there are numerous possibilities for their use in managing chronic diseases in older adults. For example, monitoring people with dementia using commercially available devices that measure heart rate, breathing rate, lung volume, step count, and activity level could be used to predict episodic behavioral and psychological symptoms before they become distressing or disruptive. However, since these devices are designed primarily for fitness assessment, validation of the sensors in a controlled environment with the target cohort population is needed. In this study, we present validation results using a commercial fitness tracker, the Hexoskin sensor vest, with thirty-one participants aged 65 and older. Estimated physiological measures investigated in this study are heart rate, breathing rate, lung volume, step count, and activity level of the participants. Findings indicate that while the processed step count, heart rate, and breathing rate show strong correlations to the clinically accepted gold standard values, lung volume and activity level do not. This indicates the need to proceed cautiously when making clinical decisions using such sensors, and suggests that users should focus on the three strongly correlated parameters for further analysis, at least in the older population. The use of physiological measurement devices such as the Hexoskin may eventually become a non-intrusive way to continuously assess physiological measures in older adults with dementia who are at risk for distressing behavioral and psychological symptoms.

Palliative and end-of-life care training during the surgical clerkship.

BACKGROUND: In 2000, the Liaison Committee on Medical Education required that all medical schools provide experiential training in end-of-life care. To adhere to this mandate and advance the professional development of medical students, experiential training in communication skills at the end-of-life was introduced into the third-year surgical clerkship curriculum at Wright State University Boonshoft School of Medicine. MATERIALS AND METHODS: In the 2007-08 academic year, 97 third-year medical students completed six standardized end-of-life care patient scenarios commonly encountered during the third-year surgical clerkship. Goals and objectives were outlined for each scenario, and attending surgeons graded student performances and provided formative feedback. RESULTS: All 97 students, 57.7% female and average age 25.6 ± 2.04 y, had passing scores on the scenarios: (1) Adult Hospice, (2) Pediatric Hospice, (3) Do Not Resuscitate, (4) Dyspnea Management/Informed Consent, (5) Treatment Goals and Prognosis, and (6) Family Conference. Scenario scores did not differ by gender or age, but students completing the clerkship in the first half of the year scored higher on total score for the six scenarios (92.8% ± 4.8% versus 90.5% ± 5.0%, P = 0.024). CONCLUSIONS: Early training in end-of-life communication is feasible during the surgical clerkship in the third-year of medical school. Of all the scenarios, "Conducting a Family Conference" proved to be the most challenging.

Individualized behavior management program for Alzheimer's/dementia residents using behavior-based ergonomic therapies.

Person-centered, nonpharmacological interventions for managing Alzheimer's/dementia-related behavioral disturbances have received significant attention. However, such interventions are quite often of a single type limiting their benefits. We develop a comprehensive nonpharmacological intervention, the Behavior-Based Ergonomic Therapy (BBET), which consists of multiple therapies. This low-cost, 24/7 program uses learning, personality, and behavioral profiles and cognitive function of each resident to develop a set of individualized therapies. These therapies are made available through an accessible resource library of music and video items, games and puzzles, and memory props to provide comfort or stimulation depending on an individual resident's assessment. The quantitative and qualitative benefits of the BBET were evaluated at the dementia care unit in a not-for-profit continuing care retirement community in west central Ohio. The 6-month pilot study reduced falls by 32.5% and markedly reduced agitation through increased resident engagement.

Reflections on the under-researched topic of grief in persons with dementia: a report from a symposium on grief and dementia.

This article describes a symposium about the clinical challenges of providing care to persons with dementia and their families. The plenary session addressed the bereavement process in the general older adult population, neurocognitive processes that alter the grief process in persons with dementia, and therapeutic approaches to support grieving persons in different stages of dementia. Participants from diverse health care disciplines met in small groups to identify (1) current responses to persons with dementia and their families who experience a loss; (2) barriers to providing effective responses; and (3) possible interventions to improve care. Two general types of interventions emerged: practical/agency support and spiritual/affective engagement.

Evaluation of academic detailing for primary care physician dementia education.

The objective of this evaluation study was to assess the effect of academic detailing (AcD) as a strategy to increase early detection of dementia in primary care practice and to improve support and management of Alzheimer's disease and other dementia disorders by increasing communication and referrals to local community agencies. As designed for dementia education, AcD consisted of 15-minute educational sessions delivered in primary care practice offices. Twenty-nine visits were conducted by trained teams comprised of a physician and representatives of the Alzheimer's Association (AA) and Area Agency on Aging (AAA). A key outcome of the visits was increased knowledge of the specific programs and services available. In all, 77.4% rated the visit very effective, and follow-up evaluation suggests visits led to an increase in referral to these agencies (55%) and potentially enhanced early detection of dementia by physicians as measured by 35% making changes in the way they identify at-risk patients.

Clinical practice guidelines, process improvement teams, and performance on a quality indicator for urinary incontinence: a pilot study.

BACKGROUND: Previous work by the AMDA Foundation Long-Term Care (AMDA-F LTC) Research Network suggests that urinary incontinence (UI), while prevalent, is not a high priority in the nursing facility (NF) and that barriers to better continence care are discipline-specific. Other studies report that interventions for UI in the NF often are not individualized or are poorly implemented. Implementation of processes of care may be more dependent on facility characteristics than on the attitudes, knowledge, and skill of individual health care workers. We tested the hypothesis that better facility performance on a quality indicator (QI) for continence care (toileting) is associated with a more systematic approach to continence care. METHODS: This is a descriptive study of a cohort of 34 for-profit NFs in the AMDA-F LTC Research Network. Facilities were categorized as either good performers or poor performers based on percentile ranking during a 1-year period on the quality indicator for toileting. Good performers and poor performers were compared based on a number of characteristics. RESULTS: There were no significant differences between good performers (17 facilities) and poor performers (17 facilities) with respect to occupancy, turnover, performance on other QIs, and cost of continence products. The prevalence of pharmacotherapy for UI was between 7% and 8%, which is consistent with other reports and did not differ between good performers and poor performers. However, good performers were more likely to report the presence of a process improvement team (PIT) for UI (53% versus 18%, P = .03) and more likely to report using a clinical practice guideline (CPG) for UI along with a UI PIT (47% versus 6%, P = .007). CONCLUSIONS: Facilities that are good performers on the quality indicator for toileting are more likely to report the presence of a process-improvement team for urinary incontinence. Better performance is even more strongly associated with both the presence of a process improvement team and reported use of a clinical practice guideline for urinary incontinence.

Understanding clinical dehydration and its treatment.

Dehydration in clinical practice, as opposed to a physiological definition, refers to the loss of body water, with or without salt, at a rate greater than the body can replace it. We argue that the clinical definition for dehydration, ie, loss of total body water, addresses the medical needs of the patient most effectively. There are 2 types of dehydration, namely water loss dehydration (hyperosmolar, due either to increased sodium or glucose) and salt and water loss dehydration (hyponatremia). The diagnosis requires an appraisal of the patient and laboratory testing, clinical assessment, and knowledge of the patient's history. Long-term care facilities are reluctant to have practitioners make a diagnosis, in part because dehydration is a sentinel event thought to reflect poor care. Facilities should have an interdisciplinary educational focus on the prevention of dehydration in view of the poor outcomes associated with its development. We also argue that dehydration is rarely due to neglect from formal or informal caregivers, but rather results from a combination of physiological and disease processes. With the availability of recombinant hyaluronidase, subcutaneous infusion of fluids (hypodermoclysis) provides a better opportunity to treat mild to moderate dehydration in the nursing home and at home.

Urinary incontinence: a neglected geriatric syndrome in nursing facilities.

PURPOSE: Urinary incontinence (UI) is common but inadequately assessed and treated in nursing facility (NF) residents. The purpose of this study is two-fold: (1) to determine perceptions about the importance of UI and its management in the NF setting compared with other geriatric syndromes and (2) to compare barriers to UI care as perceived by physicians, geriatric nurse practitioners (GNPs), directors of nursing and other nurses in administrative positions (DONs), and nursing assistants (NAs). METHODS: Computer-based surveys of physicians and DONs and a hard copy survey of NAs at their national meetings; an online survey of GNPs. RESULTS: Responses included 395 physicians (31% response rate), 152 DONs (34%), 118 GNPs (23%), and 277 NAs (60%). Physicians, GNPs, and DONs evaluated and managed UI significantly less often than 5 other geriatric syndromes (behavioral symptoms of dementia, falls, unintended weight loss, pain, and delirium). In contrast, NAs were more likely to be involved in UI care than in care provided for residents with any of the other 5 syndromes. All 4 groups agreed that UI has less effect on clinical outcomes than the other 5 syndromes. However, DONs rated UI first with respect to cost of care; NAs third behind falls and pain; and physicians and GNPs rated UI fourth behind falls, behavioral symptoms, and delirium. With respect to quality of life effects, physicians and GNPs rated UI fifth and fourth respectively and DONs fourth. In contrast, NAs rated UI second only to pain with respect to its effect on quality of life. Perceived barriers differ among the 4 groups with physicians relatively more concerned that drug treatment alone is ineffective (P = .002); GNPs relatively more concerned with lack of effective nondrug interventions (P = .001); and DONs relatively more concerned about sufficient time to assess and manage UI (P = .001). NA respondents rated concern about anticholinergic drug effects lower than did respondents in the other 3 groups (P = .001). CONCLUSION: Physicians, GNPs, and DONs are more likely to be involved in evaluating and managing behavioral symptoms of dementia, pain, falls, delirium, and unintended weight loss than UI in the NF setting. This leaves NAs as first-line managers for a condition that they perceive to have an important impact on quality of life. Perceived barriers to improving UI care differ among the 4 groups suggesting that approaches to overcoming the barriers should be multi-faceted.

Nursing staff beliefs and expectations about continence care in nursing homes.

OBJECTIVE: The purpose of this qualitative study was to consider the current beliefs of nursing assistants and directors of nursing about management of urinary incontinence (UI) among the residents in nursing homes. DESIGN: This was a qualitative study using purposive sampling and a focus group methodology. SETTING AND SUBJECTS: Three focus groups including 38 participants were held in 2 different regions. Two of the focus groups comprised nursing assistants and 1 comprised directors of nursing. METHOD: The focus groups were facilitated by 2 different advanced practice nurses (BR and LJK), and 2 similar interview guides were used: 1 for the nursing assistants and 1 for the nurses. The interviews were tape recorded and transcribed verbatim; data were analyzed via content analysis. RESULTS: Ten themes were identified from the data; 3 focused on resident factors that influence UI, 4 related to staff and family contributors to UI, and 3 focused on recommendations to improve UI management in the nursing home setting. CONCLUSIONS: The findings from this study can be used to guide interventions to decrease or eliminate barriers to continence care and thereby facilitate the implementation of clinical practice guidelines and evidence-based interventions to improve urinary continence among nursing home residents.

Differences in diabetes management of nursing home patients based on functional and cognitive status.

OBJECTIVES: To describe practice patterns regarding diabetes management among nursing home (NH) physicians and to identify variation in this practice based on patient characteristics. DESIGN: Mailed survey. PARTICIPANTS: Nursing home physicians from the American Medical Directors Association (AMDA) Foundation Long-Term Care Research Network (n = 142), as well as other members of AMDA who were Certified Medical Directors (CMD) (n = 68) and members who were not CMD certified (n = 45). Response rates to the survey were 51%, 33%, and 23%, respectively. MEASUREMENTS: Physician and facility characteristics were queried. Responses to 12 items pertaining to diabetes management and 5 items pertaining to use of specific oral diabetes medications were evaluated in the context of 3 different patient profiles that reflected different combinations of functional and cognitive impairment. Responses were based on the physicians' perception of how they manage diabetes under these specified patient profiles. RESULTS: Responses from members of the Research Network indicated highly significant variability (P < .01) between the 3 patient profiles for all of the 12 management items. Ordering a special diet, monitoring lipid panel, and ordering routine ophthalmology was less likely for the patient profile with both functional and cognitive impairment (P < .01). These differences among the patient profiles for these 3 interventions were present in the responses from all 3 categories of physicians (Research Network, CMD, and non-CMD members of AMDA). There was no statistically significant variability among the 3 patient profiles for any of the 3 physician groups regarding the likelihood of using of any of the 5 classes of oral diabetic medications. Non-CMD physicians were more likely to have less NH experience; otherwise, there were no differences among the 3 physician groups. CONCLUSIONS: Nursing home physicians appear to alter the approach to diabetes management based on the functional and/or cognitive status of the patient. This was particularly true for those physicians who were members of the AMDA Foundation Research Network. These findings have implications for initiatives designed to guide clinical practice as well as efforts by regulatory bodies to evaluate appropriate care. Further research is needed to measure the actual impact of different approaches to diabetes management on relevant outcomes in this population.

Approaches to the office care of the older adult and the specter of dementia.

The influx of older patients into the office-based primary care setting is a demographic reality for most practices. A shift from the disease-driven model of care delivery to one that focuses on function and quality of life should occur if primary care clinicians are to provide appropriate services to their aging patients, especially as those patients reach a state of vulnerability as defined in the ACOVE studies. Incremental functional assessment may be a first step in making the shift and probably can be implemented in most office-based practices. The specter of dementia, however, is beginning to materialize and affect the approach to addressing the needs of older adults and the expected outcomes of care.

Depression in the older adult.

Older adults who visit the primary care physician's office often exhibit depressive symptoms. The challenge for the physician and other office staff is to determine what these symptoms mean: Loneliness? Fear? Grief? A consequence of a coexisting medical condition? A DSM depressive disorder? Or something else? Addressing ambiguous symptoms that may represent a depressive disorder may be difficult in the busy office setting. The findings of one recent study suggest that it is not lack of knowledge that impedes the recognition of depression but rather the conditions under which clinical decision making occurs. The process of ruling out medical diagnoses and opening the door to consider a mental health diagnosis can be time-consuming and circuitous, especially if the clinician is not already familiar with the patient or if the clinician who is familiar with the patient perceives insufficient time to deal with the issues raised by opening the door. The fundamental challenge for the primary care clinician as aging baby boomers inundate the health care system is to restructure office practice to recognize, assess, and manage geriatric syndromes including depression. The underlying principle for successful restructuring is acknowledging that these syndromes have multiple causes requiring multifaceted interventions. Operationally, doing simple things consistently and well may have significant impact. By consistently recognizing biologic and psychosocial risk factors for depression, by taking a careful history (including the two-question screen), and by conducting a thorough physical examination, the office-based clinician will generally have a strong clinical hunch about the presence or absence of a depressive disorder and any comorbid medical and neuropsychiatric conditions. Armed with this information, additional laboratory and brain imaging studies and subsequent management strategies are straightforward.

The effects of preexisting depression on cerebrovascular health outcomes in geriatric continuing care.

BACKGROUND: Previous studies have investigated depression as the cause and outcome of vascular deficit in elderly persons. METHODS: The authors wanted to determine whether baseline depression is predictive of subsequent cardiovascular events in very elderly persons residing in a continuing care retirement community (n = 181). RESULTS: Controlling for demographic factors, both depression and the number of cardiovascular risk factors (CVRFs) at baseline were strongly predictive of stroke, whereas only CVRFs strongly predicted myocardial infarctions. Depression accounted for 12% of the variance in stroke incidence, beyond the contribution of CVRFs. Path analysis indicated that depression was also a partial moderator of the effect of CVRFs. CONCLUSIONS: In support of the vascular depression hypothesis, the study findings indicate that, for the oldest old, depression may be a strong predictor of future stroke. The presence of depression in elderly patients should alert physicians to carefully investigate other stroke risk factors and to integrate depression into an overall intervention regimen for reducing patients' risks for stroke.

Do not hospitalize orders in nursing homes: a pilot study.

OBJECTIVES: To determine (1) the point prevalence of do not hospitalize (DNH) policies in nursing facilities directed by members of the American Medical Directors Association (AMDA) Foundation Long-term Care Research Network, (2) the frequency with which physicians are writing DNH orders, and (3) respondent perceptions about the appropriateness of the number of DNH orders as too few or too many and reasons for such perceptions. DESIGN: Online survey of members of the AMDA Foundation Long-term Care Research Network. SETTING: Nursing facilities. PARTICIPANTS: All members of the AMDA Foundation Long-term Research Network on July 1, 2003 were eligible for participation (N = 293). INTERVENTION: None. MEASUREMENTS: Demographic information regarding census, region, setting, governance, presence of teaching and/or hospice affiliation, prevalence of DNH orders, and qualitative information regarding the use of DNH orders in each facility. RESULTS: The response rate was 32% (n = 95). DNH policies were in place for 62% of facilities and the prevalence of DNH orders ranged from 12% to 23% when facilities were stratified by size. Percentage of residents with documented DNH orders ranged from 0% to 99% at individual facilities. No significant differences were found although trends were noted as follows: chain facilities had fewer DNH policies (RR = 0.8; 95% CI = 0.6-1.1) whereas rural facilities (RR = 1.1, 95% CI = 0.8-1.5) and those associated with a teaching institution (RR = 1.1, 95% CI = 0.8-1.5) were more likely to have a DNH policy. Of respondents, 80% indicated that physicians in their facilities were writing DNH orders but 77% believed that the number of DNH orders was too few. Respondents cited overly optimistic prognosis and lack of knowledge about DNH orders as barriers to writing more DNH orders. CONCLUSION: The prevalence of DNH orders in this investigation is higher than previous estimates from national data samples. Most facilities had a DNH policy and although respondents indicated that physicians do write DNH orders, they believed that DNH orders were not utilized frequently enough. There is a large variation in prevalence of DNH orders across the facilities included in this survey. Barriers to use, as perceived by medical directors, included unrealistic expectations by family, fear of litigation, and staff discomfort with managing residents who experience clinical decline. Nevertheless, DNH orders are used extensively in some facilities associated with members of the AMDA Foundation Long-term Care Research Network.