A Tailored Intervention for PAP Adherence: The SCIP-PA Trial

OBJECTIVE/BACKGROUND

Positive airway pressure (PAP) is highly efficacious treatment but nonadherence is prevalent with little improvement over the last 15 years. Tailored interventions show promise for promoting adherence to other treatments. The study objective was to examine feasibility and acceptability of a tailored intervention to promote PAP adherence.

PARTICIPANTS

The convenience sample met inclusion criteria: newly diagnosed OSA; treatment-naïve; ≥ 18 years.

EXCLUSION CRITERIA

previous obstructive sleep apnea (OSA) diagnosis and treatment; new psychiatric diagnosis; use of oxygen/bilevel PAP; secondary sleep disorder. Adults (n = 118) were randomized to tailored intervention (TI; n = 61) or usual care (UC; n = 57); application of a priori exclusion criteria resulted in 30 participants per assignment who were middle-aged (51.3 ± 11.1 years) adults (70% male) with severe OSA (apnea hypopnea index [AHI], 35.9 ± 25.2).

METHODS

Randomized, double-blind, single-site pilot controlled trial. A multiphased tailored intervention targeting social cognitive perceptions of OSA-PAP treatment was delivered at four intervals. Descriptive analysis, group differences, and self-efficacy change scores by t-test, and thematic analysis of acceptability data are reported.

RESULTS

One-week PAP use among TI was 35 min greater than UC condition (p = 0.20; Cohen's d = 0.336). Treatment use decreased at 1 month and 3 months (NS). Per-protocol delivery of face-to-face intervention delivery was 100% but lower for telephone intervention delivery. Personalized approach was valued by participants.

CONCLUSIONS

A tailored intervention approach is acceptable to participants and feasibly implemented in a clinical sleep center setting. The intervention effect size at 1 week is consistent with other educational PAP adherence interventions but was not sustained; further pilot testing is warranted to address pilot RCT limitations.

Measurement Challenges in Research With Individuals With Cognitive Impairment

This State of the Science Commentary responds to the preliminary recommendation from the National Research Summit on Dementia Care, Services and Supports for Persons with Dementia and Their Caregivers to develop and identify a broad array of outcome measures (objective and subjective) that are meaningful to different stakeholders. Five significant measurement challenges that nurse scientists confront when conducting research with individuals with cognitive impairment are presented: (a) assessment of subjective memory complaints; (b) validity of self-report; (c) ecological validity of cognitive performance measures; (d) use of biomarkers (neuroimaging) for describing the biological dynamics of symptoms; and (e) effect of high variability in measurement on statistical significance. Methods for addressing these challenges are offered. [Res Gerontol Nurs. 2019; 12(1):7-15.].

Advancing Research on Care Needs and Supportive Approaches for Persons With Dementia: Recommendations and Rationale

The first National Research Summit on Care, Services, and Supports for Persons with Dementia and Their Caregivers was held on October 16-17, 2017, at the National Institutes of Health. In this paper, participants from the Summit Session on Research on Care Needs and Supportive Approaches for Persons with Dementia summarize the state of the science, identify gaps in knowledge, and offer recommendations to improve science and practice in long-term care. Recommendations cover 4 areas focused on persons living with dementia: (1) symptoms (behavioral and psychological symptoms of dementia, function, cognition, and sleep); (2) dementia care settings (physical and social environments, home, and residential care); (3) living with dementia (living well with dementia, living alone with dementia, and living with dementia and intellectual and developmental disabilities); and (4) technology as a cross-cutting theme. The participants identify 10 of the most pressing research issues based on the findings from their collective papers. Final Summit recommendations included those presented by session participants and will be used to advise federal agencies and other organizations that fund research.

Incongruence of subjective memory impairment ratings and the experience of memory problems in older adults without dementia: a mixed methods study

OBJECTIVES

The objective of this study was to describe the experiences of older adults living with subjective memory impairment (SMI) and examine the extent to which SMI severity was associated with impact of SMI on daily life.

METHOD

A mixed methods convergent design was utilized. Participants with SMI (n = 19, mean age 80.7 years) were recruited from community settings. Semi-structured interviews were analyzed using thematic analysis; these findings were integrated with descriptive statistics from questionnaire and cognitive status data.

RESULTS

The impact of SMI varied depending on the personal meaning individuals attributed to the experience. Older adults with normal cognition reported episodic memory problem compared to more pervasive problems reported by participants with mild cognitive deficits. The impact of memory problems ranged from frustration/embarrassment to avoidance of social activities, but the degree of emotional impact was not reflected in SMI severity or cognitive status.

CONCLUSION

SMI is common in older adults without dementia but the impact on function and well-being is variable and does not seem to be associated with objective cognition. Future research is needed to validate these associations and to inform the development of SMI measures that accurately reflect older adults' experiences.

Reliability and Validity of the Care Plan Checklist for Evidence of Person-Centered Approaches for Behavioral and Psychological Symptoms Associated With Dementia

PURPOSE

The purpose of this study was to test the reliability and validity of the Care Plan Checklist for Evidence of Person-Centered Approaches for Behavioral and Psychological Symptoms Associated with Dementia (BPSD).

METHODS

This study used baseline data from the first cohort of a larger randomized clinical trial testing the implementation of the Evidence of Integration Triangle for BPSD. Fourteen settings volunteered to participate, 8 from Maryland and 6 from Pennsylvania, and a total of 137 residents were recruited. In addition to completing the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD, assessments of depressive symptoms (Cornell Scale for Depression in Dementia), resistiveness to care (Resistiveness to Care Scale), and agitation (Cohen-Mansfield Agitation Inventory) were also completed on each participant. Reliability was tested based on evidence of internal consistency and inter-rater reliability. Construct validity was tested using a Rasch measurement model to determine item fit and hypothesis testing using bivariate correlations. Item mapping was also performed.

RESULTS

The majority of the sample was female (69%), Caucasian (69%), non-Hispanic (98%), and not married (78%). The mean age of the sample was 82.01 years (standard deviation = 11.44). There was evidence of reliability based on internal consistency with a Cronbach alpha of 0.96 and inter-rater reliability with correlations between 2 evaluators of r = 0.93, P = .001. There was evidence of validity of the scale based on item fit as the infit statistics and outfit statistics were all within the acceptable range with the exception of the outfit statistic for the item focused on sexually inappropriate behaviors. Lastly, there was evidence of significant relationships between the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD and the Cornell Scale for Depression in Dementia (r = 0.38, P < .001) and the Cohen-Mansfield Agitation Inventory (r = 0.44, P < .001). There was not a significant relationship between resistiveness to care and scores on the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD (r = -0.02, P = .86). There were 78 care plans that were so low in evidence of using appropriate interventions that they could not be differentiated.

CONCLUSIONS

There was sufficient evidence for the reliability and validity of the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD. Additional items should be considered to better differentiate those low on the Checklist for Evidence of Person-Centered Approaches for BPSD.

Association between social interaction and affect in nursing home residents with dementia

BACKGROUND

Social interactions that lead to positive affect are fundamental to human well-being. However, individuals with dementia are challenged to achieve positive social interaction. It is unclear how social interactions influence affect in people with dementia. This study examined the association between social interactions and affect in nursing home residents with dementia.

METHODS

This repeated measures study used baseline data from a clinical trial in which 126 residents from 12 nursing homes were enrolled. Participants were video recorded twice daily on five days. Ratings of social interaction and affect were taken from the videotapes using the Interacting with People subscale of the Passivity in Dementia and the Philadelphia Geriatric Center Apparent Affect Rating Scale. Linear mixed models were used for analysis.

RESULTS

Social interaction was significantly related to higher interest and pleasure at within- and between-person levels. Social interaction significantly predicted anxiety and sadness at the between-person level only. Residents with higher cognitive function also displayed greater pleasure. Greater interest and anxiety was evident during the afternoon hours.

CONCLUSIONS

This study supports the impact of social interactions on positive and negative affect. Findings can guide intervention development, aimed at promoting positive social interactions and improving affect for people with dementia.

Reliability and Validity Testing of the Quality of Life in Late-Stage Dementia Scale

BACKGROUND/RATIONALE

This study tested the psychometric properties of the Quality of Life in Late-Stage Dementia (QUALID) Scale using Rasch analysis. The QUALID includes 11 items with a 5-point response scale. Scores range from 11 to 55, and lower scores indicate higher quality of life (QoL).

METHODS

Baseline data from a randomized clinical trial including 137 residents from 14 nursing homes were used. Psychometric testing included item mapping, evaluation of response categories, item reliability, construct validity based on INFIT and OUTFIT statistics, and convergent validity based on correlations between QoL and pain, agitation, depression, and function.

RESULTS

The Cronbach α was .89. All the items except "appears physically uncomfortable" fit the model. There was a significant relationship between QoL and depressive symptoms ( r = .71, P = .001), pain ( r = .26, P = .01), physical function ( r = -.19, P = .03), and agitation ( r = .56, P = .001). The categories were appropriately used. Item mapping suggested a need for easier items.

Testing the evidence integration triangle for implementation of interventions to manage behavioral and psychological symptoms associated with dementia: Protocol for a pragmatic trial

Behavioral and psychological symptoms of dementia (BPSD) include aggression, agitation, resistiveness to care, depression, anxiety, apathy, and hallucinations. BPSD are common in nursing home residents and can be ameliorated using person-centered approaches. Despite regulatory requirements, less than 2% of nursing homes consistently implement person-centered behavioral approaches. In a National Institute of Nursing Research-funded research protocol, we are implementing a pragmatic cluster randomized clinical trial designed to enable staff in nursing homes to reduce BPSD using behavioral approaches while optimizing function, preventing adverse events, and improving quality of life of residents. The implementation is based on use of the Evidence Integration Triangle (EIT), a parsimonious, community-engaged participatory framework that is well suited to the complexity and variability in the nursing home environment. A total of 50 nursing home communities will be randomized to EIT-4-BPSD or education only. Primary Aim 1 is to determine if communities exposed to EIT-4-BPSD demonstrate evidence of implementation evaluated by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) criteria. Primary Aim 2 is to evaluate the feasibility, utility, and cost of the EIT approach in EIT-4-BPSD communities.

Observing wandering-related boundary transgression in people with severe dementia

OBJECTIVES

Wandering-related boundary transgression (BT) in long term care (LTC) frequently manifests as intrusion into another resident's bedroom and is associated with adverse outcomes (loss of privacy, resident-to-resident altercations, and becoming lost). This observational study is the first to empirically describe the characteristics of wandering-related BT in LTC residents with severe dementia.

METHOD

Using real-time observation, seven independently ambulant residents with severe dementia and a positive history of wandering and BT were observed for a minimum of twelve 30 minute periods randomized over two non-consecutive days (n=92 observation periods). Frequency and duration of locomoting/non-locomoting phases and BT (entry into out of bounds/private space), patterns of ambulation (direct, random, pacing, and lapping), and activities observed during BT were measured during observation periods.

RESULTS

Across 431 locomoting phases, 58 (13%) resulted in a BT and the bedroom of another resident was most frequently (86%) involved. BT was statistically associated with random ambulation and peak activity periods, and was observed more often in those with more frequent ambulation. Most BT events were unwitnessed by others and occurred when the participant was alone.

CONCLUSIONS

Describing BT has increased understanding of when, where, and how BT occurs and provides background for future intervention research.

Determinants of behavioral and psychological symptoms of dementia: A scoping review of the evidence

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) are prevalent in people with neurodegenerative diseases.

PURPOSE

In this scoping review the Kales, Gitlin and Lykestos framework is used to answer the question: What high quality evidence exists for the patient, caregiver and environmental determinants of five specific BPSD: aggression, agitation, apathy, depression and psychosis?

METHOD

An a priori review protocol was developed; 692 of 6013 articles retrieved in the search were deemed eligible for review. Gough's Weight of Evidence Framework and the Cochrane Collaboration's tool for assessing risk of bias were used. The findings from 56 high quality/low bias articles are summarized.

DISCUSSION

Each symptom had its own set of determinants, but many were common across several symptoms: neurodegeneration, type of dementia, severity of cognitive impairments, and declining functional abilities, and to a lesser extent, caregiver burden and communication.

CONCLUSION

Research and policy implications are relevant to the National Plan to Address Alzheimer's Disease.

Genetic and environmental factors associated with delirium severity in older adults with dementia

OBJECTIVE

To determine (1) whether delirium severity was associated with Apolipoprotein E (APOE) genotype status and occupational complexity, a measure of cognitive reserve, in individuals with delirium superimposed on dementia; and (2) whether decline in delirium severity was associated with these same factors over a post-acute care (PAC) stay.

METHODS

Control group data (n = 142) from a completed randomized clinical trial were used to address the aims of the study. Delirium severity was calculated by combining items from the Confusion Assessment Method and the Montreal Cognitive Assessment. APOE ε4 carriers versus non-carriers were considered. Occupational complexity, a measure of cognitive reserve, was derived from the Lifetime of Experiences Questionnaire. Covariates examined included age, gender, education, Clinical Dementia Rating Scale, and the Charlson comorbidity score. Data were nested (i.e., days nested within persons) and analyzed using multilevel models.

RESULTS

The presence of an APOE ε4 allele and higher Clinical Dementia Rating Scale were associated with greater delirium severity at baseline. The presence of an APOE ε4 allele was also associated with greater delirium severity averaged across the PAC stay. Occupational complexity was not associated with baseline delirium severity or average daily delirium severity; however, individuals with low occupational complexity showed a significant decreased in delirium severity during the course of their PAC stay.

CONCLUSIONS

Individual differences, including genetic factors and level of cognitive reserve, contribute to the severity of delirium in older adults with dementia. Copyright © 2016 John Wiley & Sons, Ltd.

Effect of Cognitively Stimulating Activities on Symptom Management of Delirium Superimposed on Dementia: A Randomized Controlled Trial

OBJECTIVE

To determine whether cognitively stimulating activities would reduce duration and severity of delirium and improve cognitive and physical function to a greater extent than usual care.

DESIGN

Single-blind randomized clinical trial.

SETTING

Eight post-acute care (PAC) facilities.

PARTICIPANTS

Community-dwelling older adults with dementia and delirium (N = 283).

INTERVENTION

Research staff provided cognitively stimulating activities daily for up to 30 days.

MEASUREMENTS

Primary outcomes were delirium duration (Confusion Assessment Method) and delirium severity (Delirium Rating Scale). Secondary outcomes were cognitive function (Digits Forward, Montreal Cognitive Assessment, CLOX) and physical function (Barthel Index).

RESULTS

Mean percentage of delirium-free days (intervention: 64.8%, 95% confidence interval (CI) = 59.6-70.1; control: 68.7%, 95% CI = 63.9-73.6; P = .37, Wilcoxon rank sum test) and delirium severity (range 0-39: intervention: 10.77, 95% CI = 10.10-11.45; control: 11.15, 95% CI = 10.50-11.80; difference 0.37, 95% CI = 0.56-1.31, P = .43) were similar in both groups. Significant differences for secondary outcomes favoring intervention were found (executive function (range 0-15): intervention: 6.58, 95% CI = 6.12-7.04; control: 5.89, 95% CI = 5.45-6.33; difference -0.69, 95% CI = 1.33 to -0.06, P = .03; constructional praxis (range 0-15): intervention: 8.84, 95% CI = 8.83-9.34; control: 7.53, 95% CI = 7.04-8.01; difference -1.31, 95% CI = 2.01 to -0.61, P < .001). After adjusting for baseline constructional praxis, the group comparison was no longer significant. Average length of stay was shorter in the intervention (36.09 days) than the control (53.13 days) group (standard error = 0.15, P = .01, negative binomial regression).

CONCLUSION

Cognitively stimulating activities did not improve delirium but improved executive function and reduced length of stay. Resolution of delirium may require more-intense nonpharmacological management when the individual has dementia.

Pilot Testing of the EIT-4-BPSD Intervention

Behavioral and psychological symptoms of dementia are common in nursing home residents, and the Centers for Medicare and Medicaid Services now require that nonpharmacological interventions be used as a first-line treatment. Few staff know how to implement these interventions. The purpose of this study was to pilot test an implementation strategy, Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD), which was developed to help staff integrate behavioral interventions into routine care. The EIT-4-BPSD was implemented in 2 nursing homes, and 21 residents were recruited. A research nurse facilitator worked with facility champions and a stakeholder team to implement the 4 steps of EIT-4-BPSD. There was evidence of reach to all staff; effectiveness with improvement in residents' quality of life and a decrease in agitation; adoption based on the environment, policy, and care plan changes; and implementation and plans for maintenance beyond the 6-month intervention period.

The Diagnosis of Delirium Superimposed on Dementia: An Emerging Challenge

Delirium occurring in patients with dementia is referred to as delirium superimposed on dementia (DSD). People who are older with dementia and who are institutionalized are at increased risk of developing delirium when hospitalized. In addition, their prior cognitive impairment makes detecting their delirium a challenge. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision are considered the standard reference for the diagnosis of delirium and include criteria of impairments in cognitive processes such as attention, additional cognitive disturbances, or altered level of arousal. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision does not provide guidance regarding specific tests for assessment of the cognitive process impaired in delirium. Importantly, the assessment or inclusion of preexisting cognitive impairment is also not addressed by these standards. The challenge of DSD gets more complex as types of dementia, particularly dementia with Lewy bodies, which has features of both delirium and dementia, are considered. The objective of this article is to critically review key elements for the diagnosis of DSD, including the challenge of neuropsychological assessment in patients with dementia and the influence of particular tests used to diagnose DSD. To address the challenges of DSD diagnosis, we present a framework for guiding the focus of future research efforts to develop a reliable reference standard to diagnose DSD. A key feature of a reliable reference standard will improve the ability to clinically diagnose DSD in facility-based patients and research studies.

Need-driven dementia-compromised behavior: An alternative view of disruptive behavior

The disruptive behavior of persons with dementia is a problem of considerable clinical interest and growing scientific concern. This paper offers a view of these behaviors as expressions of unmet needs or goals and provides a comprehensive conceptual framework to guide further research and clinical practice. Empiricalfindings and clinical impressions related to wandering, vocalizations and aggression to support and illustrate the framework are presented

"Wish we would have known that!" Communication Breakdown Impedes Person-Centered Care

PURPOSE

To understand how nursing home staff obtain information needed for implementing person-centered care (PCC) to residents with dementia who exhibit behavioral and psychological symptoms of dementia (BPSD), and how they communicate this information to other staff. Barriers to PCC and information exchange were also explored.

DESIGN AND METHODS

Participants were 59 staff from two nursing homes. Focus group methodology captured discussions in eight 1-hr sessions. Sessions were audiotaped and transcribed. Data were analyzed using qualitative content analysis to provide a comprehensive summary of real world context of implementing PCC.

RESULTS

To deliver PCC staff identified a need for access to psychosocial/medical history of the resident and knowledge of strategies families used for managing BPSD in the past. However, resident information is not routinely shared with all staff and written documentation systems for communicating resident-specific information do not support the time-pressured work pattern of certified nursing assistants (CNAs). Word-of-mouth was considered more reliable and expedient than educational sessions. CNAs described themselves as visual learners who prefer educational programs addressing individual resident emergent behaviors and programs that are scheduled at dedicated times.

IMPLICATIONS

To improve PCC the flow of information exchange requires: inclusion of all staff, particularly CNAs; systems of communication that consider the time and resource constraints of nursing homes; development of educational programs for BPSD that are responsive to staff learning styles; administrative investment in nursing leadership to effect these changes; and reimbursement approaches to encourage culture change investments.