Cognitive status and behavioral problems in older hospitalized patients

A Non-Pharmacologic Approach to Manage Behaviours in Confused Medically Ill Older Adults in Acute Care

Background

Non-pharmacological interventions are recommended to manage challenging behaviours among cognitively impaired older adults, however few studies have enrolled patients in acute care. This study aimed to determine the feasibility of implementing non-pharmacological interventions to manage behaviours in hospitalized older adults.

Method

A self-identity approach was used to identify potentially engaging activities for 13 older medically ill adults admitted to acute hospital; these activities were trialed for a two-week period. Data were collected on frequency of intervention administration and assistance required, as well as frequency of behaviours and neuroleptic use in the seven days prior to and following the trial of activities.

Results

Per participant, 5–11 interventions were prescribed. Most frequently interventions were tried two or more times (46%); 9% were not tried at all. Staff or family assistance was not required for 27% of activities. The mean number of documented behaviours across participants was 4.8 ± 2.3 in the pre-intervention period and 2.1 ± 1.9 in the post-intervention period. Overall the interventions were feasible and did not result in increasing neuroleptic use

Conclusion

Non-pharmacologic interventions may be feasible to implement in acute care. More research in this area is justified.

Biological sensitivity to context: A test of the hypothesized U-shaped relation between early adversity and stress responsivity

We conducted signal detection analyses to test for curvilinear, U-shaped relations between early experiences of adversity and heightened physiological responses to challenge, as proposed by biological sensitivity to context theory. Based on analysis of an ethnically diverse sample of 338 kindergarten children (4-6 years old) and their families, we identified levels and types of adversity that, singly and interactively, predicted high (top 25%) and low (bottom 25%) rates of stress reactivity. The results offered support for the hypothesized U-shaped curve and conceptually replicated and extended the work of Ellis, Essex, and Boyce (2005). Across both sympathetic and adrenocortical systems, a disproportionate number of children growing up under conditions characterized by either low or high adversity (as indexed by restrictive parenting, family stress, and family economic condition) displayed heightened stress reactivity, compared with peers growing up under conditions of moderate adversity. Finally, as hypothesized by the adaptive calibration model, a disproportionate number of children who experienced exceptionally stressful family conditions displayed blunted cortisol reactivity to stress.

DTI measures identify mild and moderate TBI cases among patients with complex health problems: A receiver operating characteristic analysis of U.S. veterans

Standard MRI methods are often inadequate for identifying mild traumatic brain injury (TBI). Advances in diffusion tensor imaging now provide potential biomarkers of TBI among white matter fascicles (tracts). However, it is still unclear which tracts are most pertinent to TBI diagnosis. This study ranked fiber tracts on their ability to discriminate patients with and without TBI. We acquired diffusion tensor imaging data from military veterans admitted to a polytrauma clinic (Overall n = 109; Age: M = 47.2, SD = 11.3; Male: 88%; TBI: 67%). TBI diagnosis was based on self-report and neurological examination. Fiber tractography analysis produced 20 fiber tracts per patient. Each tract yielded four clinically relevant measures (fractional anisotropy, mean diffusivity, radial diffusivity, and axial diffusivity). We applied receiver operating characteristic (ROC) analyses to identify the most diagnostic tract for each measure. The analyses produced an optimal cutpoint for each tract. We then used kappa coefficients to rate the agreement of each cutpoint with the neurologist's diagnosis. The tract with the highest kappa was most diagnostic. As a check on the ROC results, we performed a stepwise logistic regression on each measure using all 20 tracts as predictors. We also bootstrapped the ROC analyses to compute the 95% confidence intervals for sensitivity, specificity, and the highest kappa coefficients. The ROC analyses identified two fiber tracts as most diagnostic of TBI: the left cingulum (LCG) and the left inferior fronto-occipital fasciculus (LIF). Like ROC, logistic regression identified LCG as most predictive for the FA measure but identified the right anterior thalamic tract (RAT) for the MD, RD, and AD measures. These findings are potentially relevant to the development of TBI biomarkers. Our methods also demonstrate how ROC analysis may be used to identify clinically relevant variables in the TBI population.

Handling clinical comorbidity in randomized clinical trials in psychiatry

The purpose of this paper is to a) outline the importance of including patients with clinical comorbidities in Randomized Clinical Trials (RCTs) of psychiatric treatments; and b) to propose a specific approach for best handling, analyzing and interpreting the data on clinical comorbidities in terms of their impact on treatment outcomes. To do this we first define and describe clinical comorbidity and differentiate it from other forms of comorbidity. We then describe the methodological and analytical problems associated with excluding patients with clinically comorbid conditions from RCTs, including the impact on the outcomes of RCTs in psychiatry and the impact on evidence-based clinical decision-making. We then address the challenges inherent to including patients with clinical comorbidities in RCTs. Finally, we propose a methodological and analytic approach to deal with these issues in RCTs which aims to significantly improve the information yielded from RCTs in psychiatry, and thus improve clinical decision-making.

Caregiver-reported neuropsychiatric symptoms in patients undergoing treatment for head and neck cancer: a pilot study

BACKGROUND

Patients with cancer experience multiple neuropsychiatric symptoms. Whereas individual symptoms have been studied in patients with head and neck cancer, the broader context of neuropsychiatric symptoms needs to be explored.

OBJECTIVE

The aims of this pilot study were to (a) determine the caregiver-reported prevalence and severity of neuropsychiatric symptoms in patients with head and neck cancer, (b) determine the associated level of caregiver distress, and (c) describe the effects of neuropsychiatric symptoms on patients and their caregivers.

METHODS

Twenty-three family caregivers of patients with head and neck cancer completed the Neuropsychiatric Inventory Questionnaire and participated in a semistructured interview.

RESULTS

All caregivers reported that patients experienced at least 1 neuropsychiatric symptom (mean, 7.5; range, 1-12). The most frequently reported symptoms were trouble with appetite and eating (95.7%), altered nighttime behaviors (82.6%), depression/dysphoria (78.3%), decreased alertness (69.6%), inattention (60.9%), apathy/indifference (56.5%), anxiety (56.5%), irritability/lability (52.5%), agitation/aggression (52.2%), and slowed behavior (43.5%). The mean severity rating for 9 symptoms was moderate to severe. Most symptoms caused mild to moderate levels of caregiver distress. Qualitative data indicated that neuropsychiatric symptoms negatively affected patients, their caregivers, and other family members. Patients required more caregiver support resulting in increased caregiver burden and distress.

CONCLUSIONS

Neuropsychiatric symptoms are common and troubling in patients with head and neck cancer during treatment. Further investigation of their effects on patients and family caregivers is needed.

IMPLICATIONS FOR PRACTICE

Clinicians should monitor for and treat neuropsychiatric symptoms throughout treatment and provide caregiver and patient education and support.

Quality of life three years after major lower extremity amputation due to peripheral arterial disease

BACKGROUND AND AIMS

The purpose of this study was to assess the quality of life (QoL) of peripheral arterial disease (PAD) amputees.

PATIENTS AND METHODS

Fifty-nine PAD patients (mean age 75.2, SD 10.7, range 39-96, 47% men) who had undergone their first major lower leg amputation (LEA) on average 2.7 years earlier (in 1998-2002) were interviewed, and 118 age- and gender-matched controls completed a postal questionnaire. Outcomes were assessed with 15D Health-Related QoL instrument, Rand-36 Physical Functioning- and General Health subscales, Geriatric Depression Scale, 6-item Brief Social Support Questionnaire, and Self-reported Life Satisfaction score.

RESULTS

The amputees had more diseases than their controls. HRQoL was lower among amputees than among controls. Half the amputees lived in institutional care, 25% had a Mini-Mental Examination score <18, and 22% had unilateral belowknee amputations only. The amputees had a similar self-assessed sense of their general state of health, life satisfaction and perceived social support as controls. Amputees who were institutionalized and those who did not use prostheses had more symptoms of depression than those who lived at home or used prostheses.

CONCLUSION

Home-dwelling amputees had a relatively good QoL, whereas institutionalization was associated with depressive symptoms. In rehabilitation programs, not only physical disability assessment but also QoL should be considered.

Health and well-being in care staff and their relations to organizational and psychosocial factors, care staff and resident factors in nursing homes

OBJECTIVE

The aim of this study is to investigate the association of psychosocial factors and patient factors with stress in care staff in nursing homes.

METHODS

In this cross-sectional survey, 197 care staff from 13 dementia wards from four nursing homes in the Stavanger region, Norway, participated. Stress in care staff was measured by Perceived Stress Scale, Hopkins Symptom Check List, and subjective health complaints. Agitation in patients was measured with the Cohen-Mansfield Agitation Inventory. Work-related psychosocial factors were measured by General Nordic Questionnaire for Psychosocial and Social Factors at Work (QPSNordic). Data were analyzed using multivariate regression analyses.

RESULTS

Psychosocial factors (QPS Nordic) were significantly associated with all the three outcome measures of stress in care staff, whereas agitation was associated with subjective health complaints only. QPS Nordic subscales significantly associated with stress in care staff were those associated with leadership.

CONCLUSIONS

Psychosocial factors were more important predictors of carer stress than patient-related factors such as dementia severity and agitation. The findings provide key background information in the planning of interventions to improve conditions for care staff and ultimately for nursing home residents.

Predictors of employment and lost hours from work in cancer caregivers

This cross-sectional, descriptive study identified variables associated with caregivers who (1) were employed and (2) reported lost hours from work due to care demands. Family caregivers (N=80) of persons with a primary malignant brain tumor participated in a 45-60 min telephone interview, answering questions regarding the impact of providing care on their emotional health and employment status. Younger caregivers were more likely to be employed. Caregivers were more likely to report lost hours from work when care recipients required assistance with Instrumental Activities of Daily Living (IADLs) and were closer to the time of diagnosis. Data suggest that interventions to assist caregivers in maintaining employment should target caregivers of persons with limitations in physical function and should include strategies to coordinate care to assist with IADLs.

The influence of caregiver mastery on depressive symptoms

PURPOSE

The purpose of this study was to explore how the relationship between care recipients' problem behaviors and caregivers' depressive symptoms varies as a function of caregiver mastery, controlling for the effects of caregiver age, gender, and relationship to the care recipient in caregivers of people with primary malignant brain tumor (PMBT).

DESIGN

A cross-sectional design was used to gather data via telephone interviews from 95 caregivers of people with primary malignant brain tumor, recruited from 2003 to 2004 from a brain tumor treatment center, two national support groups, and a statewide cancer registry.

METHODS

Measures for the study included the Neuropsychiatric Inventory-Questionnaire, Caregiver Mastery, and the Center for Epidemiologic Studies-Depression. A stepwise regression procedure was used to evaluate potential moderating and mediating relationships.

FINDINGS

Data did not indicate that caregiver mastery was a moderating variable. The analysis showed caregiver mastery as a partial mediator, with both a direct effect of care recipients' problem behaviors on caregivers' depressive symptoms and an indirect effect through caregiver mastery. Concerning the indirect effect, care recipients' problem behaviors were related to lower levels of caregiver mastery, which in turn were related to more depressive symptoms in caregivers.

CONCLUSIONS

Findings showed a link between care recipients' problem behaviors and caregivers' depressive symptoms, a relationship that has not been well established in oncology. This association indicates one mechanism through which problem behaviors in the care recipient might lead to caregiver depressive symptoms.