Randomized controlled trial of a positive emotion regulation intervention to reduce stress in family caregivers of individuals with Alzheimer's disease: protocol and design for the LEAF 2.0 study

BACKGROUND

Caring for a loved one with Alzheimer's disease can be stressful, resulting in poorer emotional and physical health among family caregivers. Although supportive resources for caregivers are available, distance, caregiver health, and the daily demands of caregiving are barriers to access. Based on research demonstrating the importance of positive emotions in coping with stress, our previous trial showed that dementia caregivers who participated in facilitated, web-based delivery of a positive emotion regulation intervention called LEAF (Life Enhancing Activities for Family caregivers) experienced increased positive emotion and decreased depression and anxiety. Building on this evidence, the LEAF 2.0 study aims to test whether web-based, self-guided delivery can confer similar benefits for caregivers of individuals with Alzheimer's disease.

METHODS

This paper presents the design and methods for LEAF 2.0, a 3-arm web-based randomized controlled trial (N = 500) in which family caregivers of patients with Alzheimer's disease (AD) are randomized to (1) the LEAF intervention facilitated remotely via the web (N = 200), (2) the LEAF intervention self-guided online (N = 200), or (3) an emotion reporting control (N = 100), which then crosses over to the intervention after approximately 6 months, half to the facilitated arm and half to the self-guided arm. We aim to (1) compare the effect of the facilitated and self-guided LEAF positive emotion interventions to an emotion reporting control condition on AD caregiver well-being (positive emotion, depression, anxiety, and perceived stress) and secondary outcomes (caregiving burden, caregiving self-efficacy, positive aspects of caregiving, quality of care, and AD patient quality of life); (2) assess whether effects are mediated by improvements in positive emotion or other aspects of caregiver well-being; and (3) test whether caregiver age or gender or the care recipient's dementia severity moderates the effects of the intervention.

DISCUSSION

If demonstrated to be effective, LEAF can be widely disseminated and ultimately have a significant impact on the stress experienced by AD caregivers and the well-being of people living with Alzheimer's disease.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03610698.

A - 55 Boosting Positive Emotion in Caregivers: Moderators of a Positive Psychological Intervention

OBJECTIVE

There are numerous negative health effects associated with dementia caregiving, including increased stress and depression. Positive emotion interventions could improve health and psychological outcomes for caregivers. The present study was a secondary analysis of data from the Life Enhancing Activities for Family Caregivers (LEAF) trial (R01NR014435). LEAF is an evidence-based intervention designed to increase positive emotion in caregivers.

METHOD

Using multiple linear regression, data from the LEAF trial (n = 170 community-dwelling caregivers) were examined to identify which caregiver characteristics moderated LEAF outcomes (positive emotion, negative emotion, positive aspects of caregiving) over time.

RESULTS

Length of time caregiving significantly moderated the effect of positive emotion from baseline to post-intervention, such that longer-term caregivers in the LEAF intervention group experienced greater increases in positive emotion compared to longer-term caregivers in the emotion-reporting waitlist control group (B = 0.119, t = 2.1, p < 0.05). Moreover, gender moderated positive emotion, such that males in the intervention group and females in the waitlist control group experienced greater increases in positive emotion over time than males in the waitlist control group and females in the intervention group, respectively (R2 = 0.06, F[3, 139] = [2.75], p = <0.05). No other effects were found. Results suggest that length of time caregiving and gender play an important role in the extent to which dementia caregivers benefit from positive emotion interventions.

CONCLUSIONS

This study assists in identifying caregivers for whom positive emotion interventions work best, suggests ways that the intervention should be tailored to match caregiver characteristics, and targets outcomes most impacted according to caregivers' individual differences.

The estimated effect of reducing the maternal smoking rate on neonatal intensive care unit costs in Victorian public hospitals

This analysis estimates the expected number of Victorian public hospital neonatal intensive care unit cot-days that could be saved annually by reducing the maternal smoking rate. Approximately 106 cot-days could be saved if the maternal smoking rate was reduced from 8.4% to 6.4% (estimated annual cost saving of A$276 000).

Disinfection of human cardiac valve allografts in tissue banking: systematic review report

Cardiovascular allografts are usually disinfected using antibiotics, but protocols vary significantly between tissue banks. It is likely that different disinfection protocols will not have the same level of efficacy; they may also have varying effects on the structural integrity of the tissue, which could lead to significant differences in terms of clinical outcome in recipients. Ideally, a disinfection protocol should achieve the greatest bioburden reduction with the lowest possible impact on tissue integrity. We conducted a systematic review of methods applied to disinfect cardiovascular tissues. The use of multiple broad spectrum antibiotics in conjunction with an antifungal agent resulted in the greatest reduction in bioburden. Antibiotic incubation periods were limited to less than 24 h, and most protocols incubated tissues at 4 °C, however one study demonstrated a greater reduction of microbial load at 37 °C. None of the reviewed studies looked at the impact of these disinfection protocols on the risk of infection or any other clinical outcome in recipients.

The Impact of a Videogame-Based Pilot Physical Activity Program in Older Adults with Schizophrenia on Subjectively and Objectively Measured Physical Activity

OBJECTIVES

The purpose of this report is to describe the impact of a videogame-based pilot physical activity program using the Kinect for Xbox 360 game system (Microsoft, Redmond, WA, USA) on physical activity in older adults with schizophrenia.

METHODS

In this one group pre-test, post-test pilot study, 20 participants played an active videogame for 30 min, once a week for 6 weeks. Physical activity was measured by self-report with the Yale Physical Activity Survey and objectively with the Sensewear Pro armband at enrollment and at the end of the 6-week program.

RESULTS

There was a significant increase in frequency of self-reported vigorous physical activity. We did not detect a statistically significant difference in objectively measured physical activity although increase in number of steps and sedentary activity were in the desired direction.

CONCLUSION

These results suggest participants' perception of physical activity intensity differs from the intensity objectively captured with a valid and reliable physical activity monitor.

Comprehensive evidence-based program teaching self-management of auditory hallucinations on inpatient psychiatric units

Patients hearing command hallucinations to harm whose only self-management strategies are to obey these commands, can represent serious safety concerns on inpatient psychiatric units. A comprehensive evidence-based program teaching self-management of auditory hallucinations on inpatient psychiatric units is described that includes five components: suggestions for staff education; patient self-assessment tools; an interview guide and safety protocol; a course to teach strategies for managing distressing voices and commands to harm; suggestions to improve staff communication; and a plan to extend the program from inpatient care settings into the community by sharing materials with community case managers and caregivers when patients are discharged.

Adult day health center participation and health-related quality of life

PURPOSE

The purpose of this study was to assess the association between Adult Day Health Center (ADHC) participation and health-related quality of life.

DESIGN AND METHODS

Case-controlled prospective study utilizing the Medical Outcomes Survey Form 36 (SF-36) to compare newly enrolled participants from 16 ADHC programs with comparable community-dwelling older adults who did not attend an ADHC. Assessments were conducted at study enrollment, 6 and 12 months.

RESULTS

ADHC participants (n = 57) and comparison group subjects (n = 67) were similar at baseline in age, ethnic diversity, medical conditions, depression, cognition, immigration history, education, income, and marital status. Significantly more comparison group subjects lived alone (p = .002). One year after enrollment, the SF-36 domains role physical and role emotional improved significantly. Adjusted role physical scores for ADHC participants improved (23 vs. 36) but declined for the comparison group (38 vs. 26, time by group interaction p = .01), and role emotional scores improved for ADHC participants (62 vs.70) but declined for the comparison group (65 vs. 48, time by group interaction p = .02). Secondary analyses revealed that changes in daily physical functioning, depressed affect, or cognitive functioning did not explain the improvements found in role physical and role emotional scores for ADHC participants. No significant differences in trends for the 2 groups occurred for the SF-36 domains physical functioning, social functioning, and mental health.

IMPLICATIONS

ADHC participation may enhance older adults' quality of life. Quality of life may be a key measure to inform care planning, program improvement, and policy development of ADHC.

Reaching across the pond: a global exchange between health systems

AIM

This article describes a unique programme begun in 2001 through a partnership between the historic St Bartholomew's Hospital and the London National Health Service Trust, in London, England and Valley Health in Winchester, Virginia, USA. Dubbed the RN International Exchange Program, selected registered nurses have the opportunity to experience first-hand healthcare delivery in another country and participate in a creative way of expanding knowledge about nursing.

BACKGROUND

Professional nurses are persistent in seeking new ways to enhance nursing practice and improve patient care. This happens in several ways, including academic study, research, continuing education and dialogue with other healthcare professionals. One method to advance nursing practice is through the sharing of knowledge between nurses, both at home and across the globe.

CONCLUSION

Participating nurses see this type of global educational opportunity as a once-in-a-lifetime experience that could never be duplicated in the traditional classroom setting.

Behavioral Management of Command Hallucinations to Harm in Schizophrenia

The study objective was to evaluate changes in prevalence of command hallucinations to harm self or others, characteristics and intensity of auditory hallucinations, and levels of anxiety and depression after attendance at a 10-session course teaching behavioral strategies for managing persistent auditory hallucinations to adult outpatients with schizophrenia. Prevalence of command hallucinations to harm self or others was measured at baseline, end of course, and 1-year post-course. Pre-course scores on the Characteristics of Auditory Hallucinations Questionnaire, Unpleasant Voices Scale, tension-anxiety subscale of Profile of Mood States, and Beck Depression Inventory-II were compared with scores immediately post-course and 1 year later. The prevalence rate of command hallucinations to harm self of 44% at baseline decreased to 24% immediately after attending the 10-session course and remained at 24% 1-year post-course. The prevalence rate for command hallucinations to harm others of 21% at baseline decreased to 16% at end of course and 17% 1-year post-course. People who attended the course perceived it as helpful, and improvement was seen in all seven characteristics of auditory hallucinations, intensity of auditory hallucinations, and anxiety and depression immediately after the course and 1-year post-course.

Potential Mechanisms for Chemotherapy-Induced Impairments in Cognitive Function

PURPOSE/OBJECTIVES

To review the domains of cognitive function and their corresponding neuroanatomic structures as well as present current evidence for neurotoxicity associated with specific chemotherapeutic agents and potential mechanisms for chemotherapy-induced cognitive impairments.

DATA SOURCES

Published research articles, review articles, and textbooks.

DATA SYNTHESIS

Chemotherapy does not appear to cross the blood-brain barrier when given in standard doses; however, many chemotherapy drugs have the potential to cause cognitive impairments through more than one mechanism. In addition, patient factors may be protective or place individuals at higher risk for cognitive impairments.

CONCLUSIONS

Although evidence of chemotherapy-induced impairments in cognitive function exists, no clinical studies have attempted to elucidate the mechanisms for chemotherapy-induced impairments in cognitive function. In addition, further studies are needed to determine predictive factors, potential biomarkers, and relevant assessment parameters.

IMPLICATIONS FOR NURSING

The ability to identify high-risk patients has important implications for practice in regard to informed consent, patient education about the effects of treatment, and preventive strategies.

Chemotherapy-Induced Cognitive Impairment in Women With Breast Cancer: A Critique of the Literature

PURPOSE/OBJECTIVES

To review and critique the studies that have investigated chemotherapy-induced impairments in cognitive function in women with breast cancer.

DATA SOURCES

Published research articles and textbooks.

DATA SYNTHESIS

Although studies of breast cancer survivors have found chemotherapy-induced impairments in multiple domains of cognitive function, they are beset with conceptual and methodologic problems. Findings regarding cognitive deficits in women with breast cancer who currently are receiving chemotherapy are even less clear.

CONCLUSIONS

Although data from published studies suggest that chemotherapy-induced impairments in cognitive function do occur in some women with breast cancer, differences in time since treatment, chemotherapy regimen, menopausal status, and neuropsychological tests used limit comparisons among the various studies. Further studies need to be done before definitive conclusions can be made.

IMPLICATIONS FOR NURSING

The potential for chemotherapy-induced impairments in cognitive function may influence patients' ability to give informed consent, identify treatment toxicities, learn self-care measures, and perform self-care behaviors.

A metaanalysis of studies of the effects of cancer chemotherapy on various domains of cognitive function

BACKGROUND

Little is known about the effects of chemotherapy on cognitive function. The purposes of this metaanalysis were to estimate the effect sizes for the effect of chemotherapy on each domain of cognitive function and to differentiate effect sizes by each method of comparison of effects (i.e., normative data, control group, or baseline data).

METHODS

Sixteen studies that evaluated cognitive function in chemotherapy patients were included in the study. DSTAT metaanalysis software was used to calculate an effect size and confidence intervals for each neuropsychologic test. Tests were assigned to a specific cognitive domain, and an average effect size was determined for each domain.

RESULTS

Only one domain of cognitive function (i.e., visual memory) had significant chemotherapy-induced impairment across all comparison types. However, when the neuropsychologic test scores of chemotherapy patients were compared with normative data, significant effect sizes were found for four domains of cognitive function (i.e., executive function, information processing speed, verbal memory, visual memory). In addition, significant, albeit small, effect sizes were found for language and verbal memory when chemotherapy patients' test scores were compared with test scores of healthy matched controls. All significant averaged effect sizes were in the negative direction, indicating that mean scores on neuropsychologic tests for patients who had received chemotherapy were on average lower than comparison scores.

CONCLUSION

Data from this metaanalysis supported the hypothesis that chemotherapy can have a negative impact on cognitive function. However, most deficits in this study ranged from small to moderate and were nonsignificant.

The relationship between smoking history and current functioning in disabled community-living older adults

PURPOSE

This study was conducted to determine characteristics associated with continued cigarette use in frail older adults and to examine how smoking history relates to current psychiatric, cognitive, and occupational functioning.

METHODS

Archival records were gathered for 1,064 patients (69% women) who entered On Lok SeniorHealth Services between January 1996 and December 2000. Participants were interviewed on program entry and assessed for smoking history, depressive symptoms, affective disorders, cognitive functioning, alcohol use, and physical functioning (activities of daily living [ADLs] and instrumental ADLs). Cross-sectional analyses were conducted to examine functioning at enrollment relative to smoking history.

RESULTS

Smoking history was related to age at program entry, with current smokers entering On Lok at an earlier age than former or never smokers. Current smokers were more likely to be male, to be of Caucasian or African American descent, to consume alcohol on a regular basis, and to be more independent on ADLs. Specifically, they were more independent on tasks related to their capacity to procure cigarettes or continue smoking, including shopping, using transportation, managing money, dressing themselves, and walking. Smoking history was related to depression, with symptoms lower for current and former smokers.

CONCLUSIONS

Current smokers present for services at an earlier age and have higher levels of independence on ADLs instrumental to nicotine use. Data indicate characteristics associated with continued smoking and provide a foundation for targeting older individuals for cessation efforts.

Long-Term Effects of Teaching Behavioral Strategies for Managing Persistent Auditory Hallucinations in Schizophrenia

1. Attendance at a 10-week class designed to teach behavioral management strategies to people with schizophrenia was effective in reducing some of the negative characteristics of auditory hallucinations for 12 months and in reducing anxiety for 9 months after completion of the class. 2. The sustained improvement experienced by class participants was characterized by their voices being less frequent and more mumbled and the participants feeling more in control, less distractible, and less anxious. 3. Participants recommended that other mental health consumers take similar classes to learn how to better manage their voices. 4. Monthly support groups may help participants maintain gains lost during the follow-up period.

Symptom Management of Auditory Hallucinations in Schizophrenia Results of 1-Year Follow up

1. The majority of participants reported that they were still using behavioral strategies to manage their auditory hallucinations throughout the 12-month follow-up period and that they had experienced a decrease in symptom severity. 2. The answers to managing the symptom of auditory hallucinations are as individual as the symptom itself. All of the behavioral management strategies worked for at least one participant, but no strategy worked for everyone. 3. Practicing strategies in a group and at home seemed to promote long-term use of the behavioral strategies.

Drowning deaths in people with epilepsy

OBJECTIVE

To determine the demographic characteristics and risk factors associated with death from drowning among people with epilepsy.

DESIGN

Retrospective review of medical examiner's investigations into deaths from drowning from Jan. 1, 1981, to Dec. 31, 1990.

SETTING

Alberta.

MEASURES

Personal data, medical history, circumstances surrounding the death, autopsy findings and results of postmortem toxicologic analyses.

RESULTS

Of 482 deaths from drowning in Alberta during the study period, 25 (5%) were considered by the medical examiner's office to be directly related to seizures. Fifteen (60%) of the 25 deaths occurred while the person was taking a bath, unsupervised. Only one person (4%) died while taking a shower. The remaining deaths occurred on a river or lake (16%), in a private pool (8%), in a public pool (8%) and in a jacuzzi (4%). Two people fell out of moving boats while having a seizure; neither had been wearing a personal flotation device. Nineteen (83%) of 23 people who had been receiving anticonvulsant drug therapy had undetectable or subtherapeutic levels of one or more of the drugs at autopsy. Ethanol was not a factor in any of the deaths.

CONCLUSIONS

Seizure-related drownings represent a small but potentially preventable proportion of all drownings. Enhanced seizure control and compliance with anticonvulsant drug therapy may prevent some of these deaths. In addition, all people with epilepsy, regardless of the level of control of their condition, should be encouraged to take showers while sitting instead of baths. The presence of people in the same house who are not directly supervising the person in the bathroom does not protect against drowning. Personal flotation devices should be worn at all times during boating activities.

Urinary retention in hospitalized elderly women

Unrecognized urinary retention may be a factor in the development of recurrent urinary tract infections, urinary incontinence, bladder dysfunction, and upper urinary tract disease. Because urinary retention is often asymptomatic in elderly women, with amounts of up to 1,500 mL retained in the bladder often causing little or no discomfort, nurses need to have a high index of suspicion about its occurrence. A post-void residual is the best way of determining the presence of urinary retention. The goal of treatment for urinary retention is bladder decompression via catheterization followed by voiding trials and determination of residual volumes.

Strategic imperatives for managing materiel into the next century

The next century of opportunity is less than a decade away. Materiel management must involve itself in the strategic changes occurring within the health care industry and its respective institutions. Those materiel managers who are aggressively ensuring that their operations are supported by a well-developed and well-orchestrated operational infrastructure are now well positioned to address the future challenges of this decade. Unfortunately, many other materiel managers are focusing their attention and efforts solely on the management of materiel for which they currently have control. Materiel managers must develop an acute awareness of the support needs of their respective organizations. Those who are not apprehensive about venturing from the traditional materiel management world will be exposed to incredible educational opportunities and will receive responsibilities of unparalleled organizational importance.

Unexpected death as a result of infective endocarditis

Thirteen cases of infective endocarditis (IE) diagnosed for the first time at autopsy or, in those patients with a previous diagnosis of IE, not thought to be active at the time of death, are presented. Of the six patients who died within 24 h of the onset of symptoms, two died of obstruction of a valve orifice, two died of sepsis, one died of sepsis and alcoholic cardiomyopathy, and one died of a coronary artery embolus. Of the five patients with symptoms lasting more than 24 h, three died of sepsis and congestive heart failure. One died from sepsis alone and one died from congestive heart failure (CHF). In two patients whose duration of symptoms is unknown, one died of sepsis and CHF, and in the other the mechanism of death is unknown. Predisposing factors present in 11 of 13 patients included alcoholism (three), intravenous (IV) drug abuse (three), prosthetic valves (three), aortic stenosis (two), past rheumatic fever (one), and nonstenotic congenitally bicuspid valves (two). The reasons for no antemortem diagnosis were a missed or incorrect clinical diagnosis in three patients seen by a physician shortly before death, no signs or symptoms or found dead (four), non-specific signs and symptoms (three), refusal of medical treatment (one), and a solitary lifestyle (one); there was insufficient information about one patient. Individuals with needle tracks, generalized petechiae. Osler's nodes, splinter hemorrhages, intravenous catheters, pacemaker wires, and infected aortic-valve (A-V) shunts are at risk of IE. Blood and the vegetations should be cultured. The attending physician should be notified of the diagnosis in such cases.

Determination of sulfide in brain tissue by gas dialysis/ion chromatography: postmortem studies and two case reports

An analytical method for the determination of sulfide in human and rat brain is described. It utilizes a continuous flow gas dialysis pretreatment and quantitation by ion chromatography with electrochemical detection. Rat brain sulfide levels were reliably measured after fatal intoxication by intraperitoneal injection of NaHS. By expeditious analysis of samples it was possible to demonstrate the presence of endogenous levels of sulfide in both rat and human brain as well as to measure elevated brain levels of sulfide after intoxication. In postmortem rat brain tissue, elevated sulfide levels could still be reliably demonstrated 96 h after death if the bodies had been refrigerated at 4 degrees C. Two case studies of human hydrogen sulfide inhalation fatalities are presented. The described method was able to measure significantly elevated sulfide levels in both cases.

Traumatic basal subarachnoid hemorrhage. Report of six cases and review of the literature

Basal subarachnoid hemorrhage due to rupture of normal extra- and intracranial arteries, in association with minor trauma to the face and neck and alcohol intoxication, has been well described but often goes unrecognized at autopsy. This results in the incorrect classification of the manner of death as natural. Six cases of subarachnoid hemorrhage due to mild-to-moderate blows to the head or neck are presented. All were men in the age range 28-61 years (mean, 38.8 years). Four had blood alcohol levels of 0.09-0.28 g % at autopsy, and five of six were comatose or dead within 30 min of the initiating trauma. Traumatic ruptures of otherwise normal extra- and intracranial arteries were identified in four cases. The site of rupture was not found in one case, and the final case had rupture of a fibrotic intracranial vertebral artery. Multiple sites of incomplete and complete rupture were found in four cases. Postmortem angiography was used in one case to demonstrate the site of rupture prior to removal of the brain. Postmortem angiography and careful gross and histologic examination of extra- and intracranial cerebral arteries is recommended in all cases of basal subarachnoid hemorrhage where minor trauma to the head or neck has occurred prior to collapse or death, especially if the decedent was intoxicated at the time of the trauma.