Exploring the use of the Interpersonal Needs Questionnaire to examine suicidal thoughts and behaviors among Post-9/11 U.S. Combat Veterans: An integrative review

This integrative review expands on the work of Kramer et al. (2020), by reviewing studies that utilized the Interpersonal Needs Questionnaire (INQ) to examine the interpersonal constructs (thwarted belongingness and perceived burdensomeness) of the Interpersonal Theory of Suicide (ITS) to understand suicidal thoughts and behaviors among service members and Veterans with combat experience. Very few studies (n = 9) in the literature were identified, however important relationships were revealed between combat exposure/experiences, thwarted belongingness, perceived burdensomeness, and suicidal thoughts and behaviors among military samples. Studies also reported risk factors for high levels of thwarted belongingness or perceived burdensomeness in military samples, such as moral injuries, betrayal, and aggression. This review highlights the utility of the INQ to measure ITS constructs among Post-9/11 U.S. Combat Veterans.

The Purple Heart and suicide risk in Post-9/11 U.S. Army Combat Veterans with a traumatic brain injury: A mixed methods study

Active service members and Veterans with a combat-related traumatic brain injury (TBI) are four times more likely to attempt suicide than those without a TBI. TBIs are the signature injuries of the Post-9/11 conflicts and Combat Veterans (i.e., current and former service members who deployed in support of a combat mission) with these injuries are entitled to receive the Purple Heart medal. However, potentially tens of thousands of Combat Veterans did not receive, or were denied the Purple Heart during the first decade of the Global War on Terrorism because a TBI was not documented during the deployment. To our knowledge, this is the first study to explore the meaning of the Purple Heart and examine the impact of the Purple Heart on Army Combat Veterans with a combat-related TBI. Findings from this mixed methods study revealed that not receiving the Purple Heart is associated with increased suicide risk and lower quality of life after a brain injury. Additionally, thwarted belongingness, perceived burdensomeness, and perceived military institutional betrayal are associated with increased suicide risk in Army Combat Veterans with a TBI. This mixed methods study provides important insights into how Army culture is perceived and the power of the Purple Heart among this high-risk group of Combat Veterans.

Problem-solving therapy reduces subjective burden levels in caregivers of family members with mild cognitive impairment or early-stage dementia: Secondary analysis of a randomized clinical trial

OBJECTIVES

Interventions addressing burden have limited impact among long-term family caregivers. We examined whether problem-solving therapy (PST) would reduce burden levels of caregivers of individuals diagnosed with mild cognitive impairment (MCI) or early-stage dementia (AD).

METHODS

Caregivers (N = 73) randomly received PST or nutritional training (NT). Burden measures were assessed over 1-year post-intervention.

RESULTS

Relative to NT, caregivers receiving PST endorsed improved perceived burden levels over time, regardless of the type of caregiver. Distress over the care recipient's dementia-related behaviors remained low over time among MCI caregivers receiving PST, while these burden levels among MCI caregivers receiving NT rose over time. AD caregivers receiving PST endorsed reductions in these burden levels over time, while AD caregivers in the NT group endorsed higher burden levels over time.

CONCLUSION

PST, taught early in the caregiving trajectory, improves subjective burden levels among caregivers of family members with relatively mild cognitive deficits.

Design and Implementation of an Intervention Development Study: Retaining Cognition While Avoiding Late-Life Depression (ReCALL)

OBJECTIVE

To discuss the design, rationale, and implementation of an intervention development study addressing indicated and selective prevention of depression and anxiety in individuals 60 years and older with mild cognitive impairment (MCI) and in their caregivers.

METHODS

In Phase I, now completed, we developed and standardized problem-solving therapy (PST) and the combined PST + moderate-intensity physical exercise (PE) intervention to be administered to participants with MCI and their caregivers together, dyadically, with both participants working with the same interventionist in the same therapy sessions. In Phase II we have been testing the interventions against enhanced usual care (EUC) and have addressed challenges to recruitment. Randomization was to one of three cells: PST + PE, PST, or EUC.

RESULTS

Although we set out to intervene dyadically, many individuals with MCI lived alone or did not have a support person who could participate in the study with them. Consequently, we modified the study to include MCI participants with and without support persons. Ninety-four participants were enrolled: 20 with MCI together with their support persons (N = 20 dyads) and 54 MCI participants without accompanying support persons. Most participants have been satisfied with the usefulness of the interventions in managing stress and cognitive problems.

CONCLUSION

PST and moderate-intensity PE are acceptable interventions for depression and anxiety prevention in older adults with MCI and their available caregivers.

The Role of the Nurse Practitioner and Asymptomatic Urinary Treatments

Asymptomatic urinary tract infections (aUTIs) are common among older adults in long-term care facilities (LTCFs) and studies have shown that they are inappropriately treated with antibiotics. We retrospectively characterized treatment strategies among 89 cases of aUTIs before and after a long-term facility hired a full-time nurse practitioner (NP). We found that residents with aUTIs were prescribed significantly more supportive treatment strategies after hiring an NP. However, there was no significant drop in the rate of inappropriate antibiotic treatments for aUTIs after hiring an NP.

Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: a randomized controlled trial

OBJECTIVE

Interventions directed at the mental health of family dementia caregivers may have limited impact when focused on caregivers who have provided care for years and report high burden levels. We sought to evaluate the mental health effects of problem-solving therapy (PST), designed for caregivers of individuals with a recent diagnosis of Mild Cognitive Impairment (MCI) or early dementia.

METHOD

Seventy-three (43 MCI and 30 early dementia) family caregivers were randomly assigned to receive PST or a comparison condition (nutritional education). Depression, anxiety, and problem-solving orientation were assessed at baseline and at 1, 3, 6, and 12 months post intervention.

RESULTS

In general, the PST caregiver intervention was feasible and acceptable to family caregivers of older adults with a new cognitive diagnosis. Relative to nutritional education, PST led to significantly reduced depression symptoms, particularly among early dementia caregivers. PST also lowered caregivers' anxiety levels, and led to lessening of negative problem orientation.

DISCUSSION

Enhanced problem-solving skills, learned early after a loved one's cognitive diagnosis (especially dementia), results in positive mental health outcomes among new family caregivers.

Attribution of mild cognitive impairment etiology in patients and their care partners

OBJECTIVE

This study examined the attribution of mild cognitive impairment (MCI) etiology assigned by individuals with MCI and their care partners, and the extent to which the dyads agreed on the attribution of MCI etiology.

METHODS

We conducted secondary analyses of cross-sectional data from a cohort of individuals with MCI (n = 60) and their care partners (n = 60). The mean age of the individuals with MCI was 71.0 ± 9.4 years and of care partners 64.2 ± 11.0 years. The primary outcome was attribution assigned to memory deficits on the Illness Perception Questionnaire. We categorized the attribution of MCI etiology as either potentially controllable or uncontrollable factors. We described the distribution of MCI etiology with descriptive and contingency tables. We determined the odds of a patient or care partner choosing one type of MCI etiology over another.

RESULTS

Although individuals with MCI and their care partners most frequently attributed MCI to uncontrollable factors (81.7% and 61.0%, respectively), care partners were 28.41 (95% CI, 1.26 to 645.48) times more likely to attribute MCI etiology to potentially controllable factors than individuals with MCI. No significant associations between demographic factors and attribution of MCI etiology were found for the individuals with MCI or the care partners.

CONCLUSION

Findings demonstrated that members of the dyad attributed MCI etiology to different causes. Attributions of MCI etiology should be explored by professionals to clarify misconceptions and potentially improve subsequent voluntary actions intended to assist oneself or others.

Association between anticipatory grief and problem solving among family caregivers of persons with cognitive impairment

OBJECTIVE

Measure perceived involvement in medical decision making and determine if anticipatory grief is associated with problem solving among family caregivers of older adults with cognitive impairment.

METHOD

Retrospective analysis of baseline data from a caregiver intervention (n = 73). Multivariable regression models testing the association between caregivers' anticipatory grief, measured by the Anticipatory Grief Scale (AGS), with problem-solving abilities, measured by the social problem solving inventory-revised: short form (SPSI-R: S).

RESULTS

47/73 (64%) of caregivers reported involvement in medical decision making. Mean AGS was 70.1 (± 14.8) and mean SPSI-R: S was 107.2 (± 11.6). Higher AGS scores were associated with lower positive problem orientation (p = .041) and higher negative problem orientation scores (p = .001) but not other components of problem solving-rational problem solving, avoidance style, and impulsivity/carelessness style.

DISCUSSION

Higher anticipatory grief among family caregivers impaired problem solving, which could have negative consequences for their medical decision making responsibilities.

Incidence and predictors of advance care planning among persons with cognitive impairment

OBJECTIVE

Persons with mild cognitive impairment (MCI) and Alzheimer disease (AD) are at heightened risk for future decisional incapacity. We sought to characterize advance care planning (ACP) rates over time in individuals who had no advance directives (living will or durable power of attorney) in place when they initially presented for a cognitive evaluation.

DESIGN

Retrospective analysis of data that had been prospectively collected.

SETTING

Alzheimer's Disease Research Center memory disorders clinic.

PARTICIPANTS

Persons (N = 127) with a diagnosis of MCI or early AD (n = 72) or moderate to severe AD (n = 55) and no advance directives upon initial presentation for a cognitive evaluation.

MEASUREMENTS

Extraction of responses to items pertaining to ACP assessed during annual semistructured interviews.

RESULTS

By 5 years of follow-up, 39% of the sample had initiated ACP, with little difference by baseline diagnosis. Younger subjects (younger than 65 years) were significantly more likely to initiate advance directives (43%) than older subjects (37%). This age effect was more pronounced in men than in women as well as in married subjects, those with a family history of dementia, those with no depressive disorder, and subjects with moderate to severe AD (versus those with MCI or early AD) at baseline.

CONCLUSION

Only a minority of subjects initiated ACP. The findings suggest the need for interventions aimed at enhancing ACP completion rates, particularly among older adults with cognitive impairment, since these individuals may have a time-limited opportunity to plan for future medical, financial, and other major life decisions.

Development and use of a tool to guide junior faculty in their progression toward promotion and tenure

Junior faculty have multiple roles and need to participate in a variety of activities that increase their likelihood of achieving promotion and tenure. Yet, these faculty often struggle when deciding how and when to expend effort along their career trajectory. In response to the need for structured guidance when setting priorities and making decisions about time management, faculty from a school of nursing at a research university have developed and begun to use a faculty progression tool. Introduced during orientation, this tool helps junior faculty weigh the relative importance of engaging in specific activities by offering a time frame and suggestions for prioritizing and pacing efforts to accomplish critical milestones. Although primarily aimed at tenure stream faculty in a research-intensive environment, this faculty progression tool serves as a model that may be modified for environments with less focus on research. Likewise, it may provide a foundation for development of a similar tool for nontenure stream faculty.

Diagnostic labels, stigma, and participation in research related to dementia and mild cognitive impairment

Health care professionals use diagnostic labels to classify individuals for both treatment and research purposes. Despite their clear benefits, diagnostic labels also serve as cues that activate stigma and stereotypes. Stigma associated with the diagnostic labels of dementia and mild cognitive impairment (MCI) can have a significant and negative impact on interpersonal relationships, interactions with the health care community, attitudes about service utilization, and participation in clinical research. The impact of stigma also extends to the family caregivers of individuals bearing such labels. In this article, we use examples from our investigations of individuals with dementia or MCI and their family caregivers to examine the impact of labeling and stigma on clinical research participation. We also discuss how stigma can affect numerous aspects of the nursing research process. Strategies are presented for addressing stigma-related barriers to participation in clinical research on dementia and MCI.

Frequency and correlates of advance planning among cognitively impaired older adults

OBJECTIVE

To examine the prevalence and sociodemographic correlates of written advance planning among patients with or at risk for dementia-imposed decisional incapacity.

DESIGN

Retrospective, cross-sectional.

SETTING

University-based memory disorders clinic.

PARTICIPANTS

Persons with a consensus-based diagnosis of mild cognitive impairment (N = 112), probable or possible Alzheimer disease (AD; N = 549), and nondemented comparison subjects (N = 84).

INTERVENTION

N/A.

MEASUREMENTS

Semistructured interviews to assess durable power of attorney (DPOA) and living will (LW) status upon initial presentation for a dementia evaluation.

RESULTS

Sixty-five percent of participants had a DPOA and 56% had a LW. Planning rates did not vary by diagnosis. European Americans (adjusted odds ratio = 4.75; 95% CI, 2.40-9.38), older adults (adjusted odds ratio = 1.05; 95% CI, 1.03-1.07) and college graduates (adjusted odds ratio = 2.06; 95% CI, 1.33-3.20) were most likely to have a DPOA. Findings were similar for LW rates.

CONCLUSIONS

Although a majority of persons with and at risk for the sustained and progressive decisional incapacity of AD are formally planning for the future, a substantial minority are not.

Marital quality in the context of mild cognitive impairment

Profound behavioral changes in persons with dementia often negatively affect the quality of marital relationships. Yet, little is known about the extent to which the marital relationship may be affected when the care recipient has milder degrees of cognitive impairment. This study characterizes marital quality among 27 adults who live with a spouse with mild cognitive impairment (MCI). This study demonstrates that at mild levels of cognitive impairment, specific behaviors in the affected person are distressing and may degrade the quality of the marital relationship. These results have implications for clinical practice and the delivery of health care and social services to these families. It is important to develop interventions to address the needs of these individuals and their caregivers. Results of this study suggest the need for mental health interventions designed to preserve the quality of these marital relationships.

Evaluation of the Iowa pain thermometer and other selected pain intensity scales in younger and older adult cohorts using controlled clinical pain: a preliminary study

OBJECTIVE

To evaluate the sensitivity and utility of the Iowa Pain Thermometer (IPT) and other selected pain intensity scales in younger and older adults using a controlled clinical pain condition.

DESIGN

A quasi-experimental study with 61 younger (age 21-55 years) and 36 older (age 65-87 years) adults experiencing arthritic pain at two rheumatology clinics. Before and after joint injection, patients reported current pain intensity with the following scales: IPT, Numeric Rating Scale (NRS), Verbal Numeric Rating Scale (VNS), Faces Pain Scale (FPS), and Visual Analog Scale (VAS).

RESULTS

The IPT demonstrated the lowest failure rate of all pain intensity scales evaluated. Other scale failure rates were relatively low except for the VNS and the VAS. No significant difference was noted in scale failure by age, gender or education level, but cognitive impairment was significantly related to failure on the VAS and the NRS. All five pain scales were sensitive in detecting changes in pain intensity pre and post joint injection. All correlations between the scales were strong and significant; however, the intercorrelations for the older cohort were weaker. The scale most preferred in both cohorts of patients was the IPT, followed by the FPS.

CONCLUSIONS

Based on sensitivity to change, lower failure rates, higher preference evaluations, and little appreciable affects associated with cognitive impairment, the IPT was judged to be the best choice for assessing pain intensity for both age cohorts and warrants further study.

A support group intervention for children bereaved by parental suicide

TOPIC

Bereavement is considered by many to be among the most stressful of life events, and it becomes particularly distressing when it concerns the suicide death of a parent. Such an event is especially traumatic for children.

PURPOSE AND SOURCES

The purpose of this paper is to present a case for support group interventions designed specifically for child survivors of parental suicide. The authors provide a theoretical framework for supportive group interventions with these children and describe the structure of an 8-week bereavement support group for this special population of suicide survivors.

CONCLUSIONS

A case is made for designing and implementing group interventions to meet the mental health needs of this important group of individuals.

Effective communication with bereaved child survivors of suicide

TOPIC

While bereavement is considered by many to be among the most stressful life events, it becomes even more distressing when it is related to the suicide of a loved one. Further, the death of a parent is traumatic for anyone, but it may be especially intensified for young children. This points to a strong need for the recognition and treatment of psychiatric and social problems associated with childhood bereavement.

PURPOSE AND SOURCES

The purpose of this paper is to review the literature and present a synopsis of the psychosocial outcomes of childhood suicide survivor bereavement and outline communication issues that emerge when talking with young suicide survivors.

CONCLUSIONS

A case is made to develop and test interventions designed to meet the mental health needs of this important group of individuals.

Suicide in older adults: nursing assessment of suicide risk

A fundamental objective of the National Strategy for Suicide Prevention is the prevention of suicide in older adults, especially elderly males, because these individuals are at higher risk for suicide than any other age group. Furthermore, they are the fastest growing segment of the population. The suicide rates for older Caucasian men are particularly high. Because nurses play an important role in the identification of persons at risk for suicide, it is important that they be cognizant of the complex risk factors involved in late life suicide. Toward that end, we review the prevalence of suicidal behaviors in older adults and discuss risk factors that contribute to completed suicide in these individuals. Lastly, we discuss the role of nurses in the identification of older adults at risk for suicidal behavior so that life-saving treatment measures can be implemented.

Recommendations for Building Geropsychiatric Nursing Science: A Commentary

Setting a robust research agenda for geropsychiatric nursing science will encompass both short-term methodologic goals and longer term funding, knowledge development, and dissemination goals. This article identifies immediate needs in the areas of multidisciplinary training, collaborative research models, and selection of research designs appropriate to the types of studies that are the particular province of geropsychiatric nursing scientists, for example, prevention, translational, and effectiveness evaluation of different interventions for aging populations. Longer term goals include nurturance of productive research mentor-mentee relationships within the specialty and development of innovative means for disseminating the yield of nursing research.

Suicide Assessment in Hospital Emergency Departments: Implications for Patient Satisfaction and Compliance

Suicide is a complex, multidimensional event with a host of contributing factors. Suicidal emergencies are among other behavioral and psychiatric emergencies that provide the basis for emergency department visits. Therefore, emergency departments are ideal clinical environments for the assessment of suicidal patients. A case example from an emergency department visit is provided as a basis of discussion as we describe subpopulations at high risk for suicide and review critical assessment parameters for the recognition and treatment of suicidal patients. Lastly, factors associated with patient satisfaction and treatment compliance are addressed to promote positive health outcomes among suicidal patients.

Caregiving burden and psychiatric morbidity in spouses of persons with mild cognitive impairment

BACKGROUND

While the deleterious psychosocial and mental health effects of dementia caregiving are firmly established, very little is known about the burdens or psychiatric outcomes of providing care to a spouse with less severe cognitive impairment, such as mild cognitive impairment (MCI). We characterized the nature and level of caregiver burden and psychiatric morbidity in spouses of persons diagnosed with MCI.

METHODS

Interview assessments were completed on a cohort of 27 spouses of persons with a recent diagnosis of MCI. Patient medical records were reviewed to collect information regarding the MCI patient's medical history.

RESULTS

Respondents endorsed elevated levels of both task-related responsibilities and subjective caregiver burden. Depression and anxiety symptom levels also showed some elevations. Measures of caregiver burden were significantly associated with depression and anxiety levels. In particular, even after controlling for demographic risk factors for distress, nursing task burden was correlated with elevated depressive symptoms, and greater lifestyle constraints were correlated with higher anxiety levels.

CONCLUSIONS

Although caregiver burden and psychiatric morbidity levels were lower than those typically observed in family dementia caregiving samples, our findings suggest that MCI caregivers have already begun to experience distress in association with elevated caregiving burden. These individuals may be ideal targets for selective preventive interventions to maximize their psychological well-being as caregiving burdens related to their spouses' cognitive impairment increase.

The use of narrative data to inform the psychotherapeutic group process with suicide survivors

While bereavement is considered by many to be among one of the most stressful life events, it becomes even more distressing when it is related to the suicide of a loved one. A synopsis of psychosocial outcomes of suicide survivor bereavement is presented along with an overview of group interventions designed to help these survivors cope with their grief. The structure of an ongoing eight-week bereavement support group is described to lay a foundation for the application of narrative theory within the group process. Using narrative theory and structural analysis, the discourse of group members is presented and various themes are discussed in an effort to contribute to the task of developing effective psychotherapeutic group interventions for survivors of suicide.

Client narratives: a theoretical perspective

The role of subjective client narratives in health care represents a clinical and therapeutic tool, useful in complementing objective, scientific data. Of particular interest to mental health practitioners is the role narratives play as a therapeutic tool to guide clinical practice. This paper lays a foundation for understanding the importance of narrative in the psychotherapeutic process. It provides a brief overview of narrative theory and methods of structural analysis in order to provide a theoretical approach that can be utilized by nurses to address clients' needs.

A pilot study of immune and mood outcomes of a community-based intervention for dementia caregivers: the PLST intervention

Providing care to a family member with dementia is conceptualized as a chronic stressor with adverse psychological and physical effects. The purpose of this pilot study was to evaluate mood and immune outcomes of caregivers exposed to a community-based psychoeducational nursing intervention based on the progressively lowered stress threshold (PLST) model. The PLST intervention is designed to strengthen the psychological resources of dementia caregivers by teaching methods of preventing and/or managing behavioral problems exhibited by the person with dementia. Mood and immune outcomes were compared between caregivers randomly assigned to receive either the PLST or a comparison intervention. Results of this pilot study suggest that caregivers who received the PLST intervention showed significantly stronger T-cell proliferative responses to both PHA and ConA, indicating an improvement in T-cell immune function immediately after the in-home intervention (T2) and again after 6 months of telephone support for application of the PLST model (T3). Findings do not support the hypothesis that the PLST intervention had a significant effect on total mood disturbance or natural killer cell cytotoxicity over the course of the study.

Assessment and measurement of pain in older adults

Although the empiric base is still limited when providing clear directions for pain assessment and management in older adults, it is possible to identify recommendations for guiding practice based on consensus and a developing scientific base to support best practice activities. A brief overview of the epidemiology and consequences of pain is offered, followed by a summary of issues and approaches relevant to pain assessment in older adults. Cohort-specific recommendations for comprehensive pain assessment and measurement based on current evidence are then addressed, including strategies for assessment of pain in cognitively impaired older adults.

The Evolution of Nursing Research

THE RESEARCH CULTURE in nursing has evolved in the last 150 years, beginning with Nightingale's work in the mid-1850s and culminating in the creation of the National Institute of Nursing Research (NINR) at the National Institues of Health (NIH). This article highlights nursing's efforts to facilitate the growth of the research culture by developing theory, establishing the importance of a research-based practice, advancing education, and providing avenues for dissemination of research. Similarities with the chiropractic profession are discussed, along with a commentary by Cheryl Hawk, D.C, Ph.D.

The biological basis of behavioral symptoms in dementia

This article describes the pathophysiology of dementia and differentiates between cognitive and noncognitive symptoms that characterize this devastating illness. Relationships between brain anatomic and neurochemical systems and behavioral symptoms of dementia are discussed. An overview of the etiologies and neuro-pathologies of dementia are presented as they relate to impairments in memory and intellectual abilities, personality changes, and behavioral symptoms. Recent genetic and molecular discoveries that have advanced our understanding of this complex spectrum of disorders and their treatment(s) are also highlighted.

Life stress, mood disturbance, and elevated interleukin-6 in healthy older women

BACKGROUND

Although adverse effects of severe chronic stress on immunocompetence and physical well-being in older adults have been reported, the immune response to less severe life stress among healthy older adults, particularly among women, is not well understood. Interleukin-6 (IL-6) has been considered a good overall indicator of immune functioning in older adults because of its contribution to the pathogenesis of several age-related conditions such as osteoporosis. Regulation of IL-6 is impaired in elderly adults, and levels of IL-6 increase with stress and depression. This research cross-sectionally examined levels of IL-6 in three groups of healthy older women with varying levels of life stress and mood disturbance and a healthy group of young women.

METHODS

Subjects included 18 caregivers of Alzheimer's patients, 17 older women assessed one month before relocation of their residence, 15 nonmoving and noncaregiving older women, and 20 younger women. Subjects completed the Profile of Mood States (POMS) and had early morning blood draws.

RESULTS

Alzheimer's caregivers reported significantly greater distress than women of all other groups. IL-6 levels in caregivers were significantly higher than those of all other women. The older women had significantly higher IL-6 than young controls, but there were no significant differences in IL-6 between movers and older controls. Among all women, greater depression and distress were related to higher levels of IL-6.

CONCLUSIONS

These findings suggest that in older women, chronic stressors are associated with significant elevations in IL-6 over and above the elevations associated with normal aging, but that moderate stressors may not be related to appreciable elevations in IL-6.

The effects of attrition on implementing and evaluating a mental health continuing education program for nursing personnel in long-term care facilities

BACKGROUND

The effects of attrition on a continuing education program for nursing personnel within long-term care facilities are described.

METHODS

Allowing flexible participation can enhance the impact of a continuing education program designed for paraprofessional staff. Increasing the number of nursing staff who experience only a portion of the training has implications for the instructional design and the evaluation. Recommendations to improve accommodation of staff and enhance dissemination of training are offered as well as appropriate evaluation techniques.

CONCLUSION

Self-contained short units of instruction allow those with minimal time to benefit from the training. Effective evaluation requires special sampling and measurement strategies. Cross-sectional methods make good use of training resources but usually yield measurable changes only in lower-level program objectives.

Elder Mistreatment Among Rural Family Caregivers of Persons With Alzheimer's Disease and Related Disorders

This article presents four case studies of elder abuse from the files of a multisite training project designed to teach rural caregivers of persons with Alzheimer's disease and related disorders how to better manage behavioral problems associated with dementia. The cases are used to illustrate characteristics of victims, perpetrators, and family systems that are vulnerable to abuse. The examples presented reflect a variety of factors associated with abuse in caregiving situations, including denial and maladaptive personality characteristics in the caregiver, and anxiety and lack of knowledge. The role of health care professionals and researchers who uncover abuse or neglect situations is also discussed.

A Comparison of the Effectiveness of Differing Types and Difficulty of Music Activities in Programming for Older Adults with Alzheimer's Disease and Related Disorders

The purpose of this study was to compare the effectiveness of three different types of music activities (movement, rhythm, and singing) presented at two levels of difficulty (high demand and low demand) for persons at three stages of cognitive functioning (high, medium, and low) as a result of Alzheimer's disease and related disorders (ADRD). Trained observers, using a time sampiing tool, documented the quality of participation of 51 persons with ADRD during 12 weeks of music therapy group sessions in 5 different treatment settings. Quality of participation was documented using the following five categories: high response, low response, passive Involvement, passive disruption, and active disruption. Participants at all three stages of cognitive functioning showed a significantly greater amount of high response during movement activities than during singing activities. A significantly greater amount of passivity occurred during singing activities than during movement activities. Participants were more purposefully involved in rhythm and singing activities when those activities were presented at lower levels of demand. Disruptive behaviors occurred less than 10% of the time but were more frequently observed among those persons in the group with the most cognitive dysfunction.

Geropsychiatric nursing consultation as an adjunct to training in long-term care facilities: the indirect approach

Creative, collaborative approaches between sub-specialties in nursing are needed to improve the quality of care and, hence, the quality of life for mentally ill and behaviorally impaired older adults living in long-term care (LTC) facilities. Results of a consultation survey collected as part of a larger geriatric mental health training project, and described in this article, support the position that consultee-centered geropsychiatric nursing consultation services are an important adjunct to training. However, this indirect approach to service enhancement may not be well understood and, as a result, not well utilized by LTC nurses. Methods to facilitate understanding and utilization of "indirect" mental health assistance to LTC residents and staff are explored within the context of building productive liaisons among nurses.

Standardized care plan. Managing Alzheimer's patients at home

1. Family-provided care of members with Alzheimer's disease and related disorders (ADRD) is complicated by the presence of secondary behavioral symptoms, such as agitation, that lead to caregiver depression, burden, and breakdown. 2. Caregiver education to manage secondary symptoms in ADRD can be simplified by using a theoretical framework of person-environment fit, providing a selection of interventions to modify the environment to reduce demand on the dwindling resources of the demented person. 3. The Progressively Lowered Stress Threshold (PLST) model identifies six areas of stress for persons with ADRD fatigue, change of caregiver, environment or routine, demands to achieve beyond capability, multiple and competing stimuli, affective response to perceived losses, and physical stressors.

Geropsychiatric nursing consultation: a valuable resource in rural long-term care

Psychiatric and geropsychiatric nurse specialists have the potential to positively influence the day-to-day care provided in rural nursing homes by acting as teachers, resource persons, facilitators, and role models to long-term care (LTC) personnel. The combined approach of training LTC nurses to train their own staff while supporting the application of learning with consultee-focused nursing consultation proved to be an effective and time-efficient method of improving the geropsychiatric nursing care provided in rural nursing homes.

Evaluation of a geriatric mental health training program for nursing personnel in rural long-term care facilities

Although mental illness among elderly living in nursing homes is a substantial and growing concern, the behavioral problems associated with mental illness or threats to mental health are not well understood, tolerated, or effectively managed by nursing home staff. As a result, resident care and quality of life, and staff morale often suffer. The need for geriatric mental health training in long-term care settings has become increasingly apparent. Psychiatric/mental health nurses are in an advantageous position to address this current need and future challenge through the development, implementation, and evaluation of geriatric mental health education and training programs in long-term care settings. This article describes one such innovative training effort, designed to improve the quality of psychosocial care provided by nursing personnel in rural long-term care settings, and highlights evaluation outcomes related to participant satisfaction, staff knowledge, and attitudes.

An administrator's dilemma: keeping the innovative mental health and aging programs alive after the grant funds end

Too often innovative and successful mental health and aging programs terminate when external funding sources end. This article describes one such project that has survived and even flourished well beyond the grant period. The original program is set forth, and changes in both the type of services offered and in the clientele are reviewed. The rationale for deviations from the original model are highlighted. Expansion, contraction and reexpansion of the range of services offered, as well as factors that impeded and enhanced program survival, are noted. The critical role of administrative leadership, vision and support for geropsychiatric services and staff is emphasized.