Filling the void in geriatric mental health: the Geropsychiatric Nursing Collaborative as a model for change

Mental health for older adults is a looming public health problem. Yet, geriatric mental health specialists are a scarce commodity, and few generalists have had formal education in either geriatrics or mental health. A multilevel collaboration using a diffusion of innovation model served to achieve change nationally in preparing entry-and advanced practice-level nurses to improve the mental health of older Americans. The John A. Hartford Foundation Geropsychiatric Nursing Collaborative at the American Academy of Nursing is the exemplar described here. The Geropsychiatric Nursing Collaborative developed and infused mental health competency enhancements for generalist and specialist nurses; identified and disseminated teaching-learning strategies to convey related key concepts using the POGOe (Portal of Geriatric Online Education) website; raised awareness through multiple presentations and publications; and notified deans of every school of nursing about these new resources. Fully embracing diffusion of innovation principles, the Geropsychiatric Nursing Collaborative is achieving change in this critical area of nursing practice.

Lay health educators translate a weight-loss intervention in senior centers: a randomized controlled trial

BACKGROUND

Older adults have high obesity rates and respond well to evidence-based weight-loss programs, such as the Diabetes Prevention Program (DPP) Lifestyle intervention. The goal of this study was to determine whether a translation of the DPP Lifestyle program delivered by lay health educators and conducted in senior centers is effective in promoting weight loss among older adults.

DESIGN

An RCT with older adults nested within senior centers. Senior centers identified lay health educators to receive training and deliver the intervention program at the senior center. Senior centers were randomized to DPP Lifestyle program or an attention control intervention (cognitive training).

SETTING/PARTICIPANTS

Senior centers (N=15) located throughout Arkansas. Participants (N=228) were obese (BMI=34.5±4.9) older (aged 71.2±6.6 years) adults able to engage in moderate exercise. Follow-up data were collected at 4 months on 93% of the original cohort between February 2009 and July 2010.

INTERVENTIONS

A 12-session translation of the Diabetes Prevention Program Lifestyle behavioral weight-control program delivered in group sessions by trained lay health educators.

MAIN OUTCOME MEASURES

Body weight was assessed by digital scale. Percentage weight loss from baseline and proportion achieving ≥5% and ≥7% weight loss were examined. Analyses were completed in March 2011.

RESULTS

Participants attending senior centers randomized to Lifestyle lost a significantly greater percentage of baseline weight (3.8%, 95% CI=2.9%, 4.6%) than those in the control senior centers (0.2%, 95% CI= -0.6%, -0.9%) after adjusting for baseline BMI and gender (p<0.001). Among participants attending senior centers offering the Lifestyle program, 38% lost ≥5% of baseline weight compared with 5% in the control arm (p<0.001). Similarly, significantly more participants (24%) in Lifestyle senior centers lost ≥7% than did control participants (3%, p=0.001).

CONCLUSIONS

A behavioral lifestyle weight-loss intervention delivered by a lay health educator offers a promising vehicle for translation of evidence-based obesity treatment programs in underserved areas.

TRIAL REGISTRATION

This study is registered at Clinicaltrials.govNCT01377506.

Combining feature selection and integration--a neural model for MT motion selectivity

Background

The computation of pattern motion in visual area MT based on motion input from area V1 has been investigated in many experiments and models attempting to replicate the main mechanisms. Two different core conceptual approaches were developed to explain the findings. In integrationist models the key mechanism to achieve pattern selectivity is the nonlinear integration of V1 motion activity. In contrast, selectionist models focus on the motion computation at positions with 2D features.

Methodology/Principal Findings

Recent experiments revealed that neither of the two concepts alone is sufficient to explain all experimental data and that most of the existing models cannot account for the complex behaviour found. MT pattern selectivity changes over time for stimuli like type II plaids from vector average to the direction computed with an intersection of constraint rule or by feature tracking. Also, the spatial arrangement of the stimulus within the receptive field of a MT cell plays a crucial role. We propose a recurrent neural model showing how feature integration and selection can be combined into one common architecture to explain these findings. The key features of the model are the computation of 1D and 2D motion in model area V1 subpopulations that are integrated in model MT cells using feedforward and feedback processing. Our results are also in line with findings concerning the solution of the aperture problem.

Conclusions/Significance

We propose a new neural model for MT pattern computation and motion disambiguation that is based on a combination of feature selection and integration. The model can explain a range of recent neurophysiological findings including temporally dynamic behaviour.

Victim or initiator? Certified nursing assistants' perceptions of resident characteristics that contribute to resident-to-resident violence in nursing homes

The purpose of this portion of a larger qualitative study was to explore certified nursing assistants' (CNAs) perceptions of the characteristics of both the victims and initiators of resident-to-resident violence (RRV) to identify resident characteristics that influence development of RRV. Findings gained from semi-structured interviews revealed that CNAs perceive initiators of RRV to be "more with it" and to have "strong personalities," a "short fuse," and "life history" that make them prone to inflict harm on other residents. CNAs described victims of RRV using phrases such as, "they don't know," "can't communicate," and "gets around good." The results also revealed that, in some situations, residents who were usually even tempered might strike out with violence if exposed to triggers over time. This study provides the first detailed description of nursing home residents who initiate violence against other residents. Knowledge gained from this study may be useful in generating models of RRV-a precursor to developing interventions for its prevention.

Factors associated with problematic vocalizations in nursing home residents with dementia

PURPOSE OF THE STUDY

Problematic vocalizations (PVs) are the most frequent and persistent disruptive behaviors exhibited by nursing home residents with dementia. Understanding factors associated with these behaviors are important to prevent or reduce them. We used the Need-Driven Dementia-Compromised Behavior model to identify the characteristics of persons with dementia who are likely to display nonaggressive and aggressive PVs and the conditions under which these behaviors are likely to occur and persist.

DESIGN AND METHODS

This multisite descriptive study included 138 residents of 17 nursing homes, and approximately half had a history of PVs. Background data were gathered through interviews, chart reviews, and administration of physical and neuropsychological assessments. Proximal data were obtained from observations and videotapes.

RESULTS

When the 2 subscales of the Verbal Behavior Scale were used as the dependent variables, agreeableness and conscientiousness, positive affect, and discomfort were associated with nonaggressive vocalizations, and general health state (GHS), age, and negative and positive affect were associated with aggressive vocalizations. When the verbally agitated (nonaggressive) section of the Cohen-Mansfield Agitation Inventory was the dependent variable, the background factors of gender, agreeableness, GHS, and age remained predictors, as did the proximal factors of affect and discomfort.

IMPLICATIONS

We identified 5 background factors and 3 proximal factors as risk factors for PVs in persons with dementia, with variation between nonaggressive or aggressive PVs. These data provide direction for caregiving for persons with dementia and design of interventions to prevent or reduce PVs.

Functional characterization of a novel mutation localized in the start codon of the tissue-nonspecific alkaline phosphatase gene

Hypophosphatasia (HPP) is a rare inborn disease caused by different mutations in the tissue-nonspecific alkaline phosphatase (ALPL) gene. Previous studies showed that gene mutations could exhibit a dominant negative effect leading to a mild HPP phenotype in heterozygous carriers. In the present report we describe the clinical and functional studies of a novel mutation localized in the start codon of transcript variant 1 of the ALPL gene from a female adult heterozygous carrier. The mutation results in translation of an N-terminally truncated protein, which might be identical to the deduced protein from ALPL transcript variant 2. When overexpressed in HEK-293 cells it does not exhibit any enzymatic activity and has no significant effect on the wild type ALPL protein. Furthermore it is not attached to the cell membrane. Due to the loss of the signal peptide an intracellular misrouting and a premature degradation is obvious. Hence the new isoform deposited in the database does not produce an active protein as it is the case in the natural mutation of our patient. Since the mutation does not produce a dominant negative protein in heterozygous carriers, the clinical phenotype in our patient and her relatives is very mild with only unspecific myalgia. However the patient developed bone marrow edema of both femoral heads during lactation after delivery of a healthy child, indicating a risk to develop alterations of bone metabolism in challenge situations. Her sister complains of identical symptoms, her father shows distinct symptoms of odonto-hypophosphatasia. The question if or if not carriers of ALPL mutations in general or only with distinct genotypes can be symptomatic in normal life or in challenge situations requires systematic clinical studies.

Multifractal analysis of nonhyperbolic coupled map lattices: application to genomic sequences

Symbolic sequences generated by coupled map lattices (CMLs) can be used to model the chaotic-like structure of genomic sequences. In this study it is shown that diffusively coupled Chebyshev maps of order 4 (corresponding to a shift of four symbols) very closely reproduce the multifractal spectrum D(q) of human genomic sequences for coupling constant α = 0.35 ± 0.01 if q > 0. The presence of rare configurations causes deviations for q < 0, which disappear if the rare event statistics of the CML is modified. Such rare configurations are known to play specific functional roles in genomic sequences serving as promoters or regulatory elements.

Sleep disturbances and nocturnal agitation behaviors in older adults with dementia

STUDY OBJECTIVES

To examine nighttime sleep patterns of persons with dementia showing nocturnal agitation behaviors and to determine whether restless legs syndrome (RLS), periodic limb movements in sleep (PLMS), and obstructive sleep apnea (OSA) are associated with nocturnal agitation behaviors.

DESIGN

Cross-sectional.

SETTING

General community.

PARTICIPANTS

59 participants with geriatrician-diagnosed dementia. Participants ages ranged from 66 to 88 years (mean age 79.1; SD 6.0). Mean Mini Mental State Examination (MMSE) score was 20.1 (SD 6.6). MMSE was used to measure baseline cognitive function and not for the diagnosis of dementia.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Sleep was measured by 2 nights of in-home, attended, portable polysomnography (PSG). Nocturnal agitation was measured over 3 additional nights using the Cohen-Mansfield Agitation Inventory modified for direct observations. Two experts independently and via consensus identified probable RLS. Total sleep time in participants was 5.6 h (SD 1.8 h). Mean periodic limb movements in sleep index (PLMI) was 15.29, and a high percentage (49%) had moderate to severe obstructive sleep apnea. Probable RLS was present in 24% of participants. Those with more severe cognitive impairment had longer sleep latency. Severe cognitive impairment, low apnea hypopnea index (AHI), and probable RLS were associated with nocturnal agitation behaviors (R(2) = 0.35, F(3,55) = 9.40, P < 0.001).

CONCLUSIONS

It appears that probable RLS is associated with nocturnal agitation behaviors in persons with dementia, while OSA and PLMS are not. Further investigation is warranted to determine if treatment of RLS impacts nocturnal agitation behaviors in persons with dementia.

Relationship between system-level characteristics of assisted living facilities and the health and safety of unlicensed staff

This study examined system-level characteristics of assisted living facilities and the association between these characteristics and the health and safety outcomes of unlicensed staff. Forty-two unlicensed direct care workers completed a survey related to system-level stressors and the individual stress responses of staff. Measurement tools included the Work Stressor Inventory (WSI), General Health Questionnaire (GHQ-12), and Maslach Burnout Inventory (MBI). High levels of emotional exhaustion, psychiatric distress, and work-related injuries were reported by unlicensed staff. Providing care to residents with dementia-related behaviors and supporting families were the most frequently reported work stressors. System-level factors were significantly associated with staff role competence, job commitment, and emotional exhaustion. These results support the need for continued exploration, development, and evaluation of strategies to reduce occupational stressors at multiple levels in assisted living facilities.

Relationship between System-Level Characteristics of Assisted Living Facilities and the Health and Safety of Unlicensed Staff

This study examined system-level characteristics of assisted living facilities and the association between these characteristics and the health and safety outcomes of unlicensed staff. Forty-two unlicensed direct care workers completed a survey related to system-level stressors and the individual stress responses of staff. Measurement tools included the Work Stressor Inventory (WSI), General Health Questionnaire (GHQ-12), and Maslach Burnout Inventory (MBI). High levels of emotional exhaustion, psychiatric distress, and work-related injuries were reported by unlicensed staff. Providing care to residents with dementia-related behaviors and supporting families were the most frequently reported work stressors. System-level factors were significantly associated with staff role competence, job commitment, and emotional exhaustion. These results support the need for continued exploration, development, and evaluation of strategies to reduce occupational stressors at multiple levels in assisted living facilities.

Non-verbal cues to osteoarthritic knee and/or hip pain in elders

Behavioral cues are believed to be useful to identify pain among elders who may be experiencing pain but unable to express it. To examine this assumption, we recruited 192 elders who could verbally express pain to determine whether regression models combining behavioral cues (motor and gait patterns) predicted verbal pain reports. In the best model, age (p < .01) and subscales that measured guarding (p < .001) and joint flexion (p < .01) motor patterns were significant predictors of verbal pain reports. The receiver operating characteristic curve indicated that the best cutoff for predictive probability was 40-44%, with a fair to good C statistic of .78 (SD = .04). With a 40% cutoff, sensitivity and specificity were 71.6% and 71.0%, respectively. The investigators concluded that the final model could serve as a building block for the development of a tool using behavioral cues to identify elders' pain.

The effect of tai chi on cognition in elders with cognitive impairment

This one-arm pilot study investigated the effect of tai chi on cognition in elders with cognitive impairment. Although no significant difference existed between pre- and post-test performance on all cognition measures, a dose-response relationship was demonstrated between attendance and some cognition measures.