Measuring psychological well-being in cognitively impaired persons

An objective measure of psychological well-being (a previously understudied outcome for persons with dementia) was developed and tested as part of a longitudinal study ( n= 96 participant pairs; n= 73 pairs remaining at 18 months). The reliability and validity of the Psychological Well-being in Cognitively Impaired Persons (PWB-CIP) scale was examined as a measure of one dimension of quality of life (QoL) as persons progress in the disease. The original 16-item PWB-CIP Likert-type scale required only five to 10 minutes to complete and was reduced to 11 items following factor analysis. Cronbach's alpha for the total scale was .79 at baseline and .82 at 18 months. Two subscales were identified: positive affect/interaction and negative affect/interaction. One item ('involved in a single activity for > five minutes') loaded on a different subscale at baseline (early disease stages) compared to 18 months (reflecting disease progression). The internal consistency of the two subscales remained acceptable across the two measurement intervals. Controlling for mental status, the PWB-CIP's construct validity was supported through significant relationships with depression, personal characteristics (personality), and the behavioral competence QoL dimensions at baseline and at 18 months. Because both rural (55%) and urban populations were sampled and the PWB-CIP was used across care settings, the findings support the PWB-CIP as a psychometrically sound measure of psychological well-being for diverse populations of persons with dementia.

Predictors of Emotional Distress, General Health, and Caregiving Outcomes in Family Caregivers of Stroke Survivors

Predictors of emotional distress, general health, and stroke-related caregiving outcomes were determined in 104 family caregivers of stroke survivors based on a conceptual model derived from Lazarus' theory of stress and coping. Predictors of emotional distress (R(2) =.48, p <.001) were low caregiver self-esteem, high task difficulty, and high threat appraisal. Predictors of poorer health (R(2) =.25, p <.001) were not living with the patient, low household income, and high threat appraisal. Predictors of poor stroke-related care-giving outcomes (R(2) =.45, p <.001) were emotional distress, low benefit appraisal, high task difficulty, and high threat appraisal. Findings suggest potential areas for multidimensional caregiver interventions.

The effects of perceived stigma on quality of life outcomes in persons with early-stage dementia: Longitudinal findings: Part 2

This article is the second report from a study examining perceived stigma in persons with dementia with findings regarding the association between stigma and quality of life outcomes being reported here. Fifty persons with dementia and 47 family caregivers were sampled, with data being collected at baseline and six, 12, and 18 months. The modified Stigma Impact Scale measured perceived stigma. Quality of life outcomes included: depression, anxiety, behavioral symptoms, personal control, physical health, self-esteem, social support, and activity participation. Linear mixed model or generalized linear mixed model (for depression) analyses revealed that some aspect of perceived stigma was associated with each outcome. Social rejection was associated with anxiety, behavioral symptoms, health, and activity participation. Internalized shame was associated with anxiety, personal control, health, self-esteem, social support understanding and assistance, and activity participation. Finally, social isolation was associated with depression, anxiety, personal control, health, self-esteem, social support understanding, and activity participation. The complexity of relationships between perceived stigma and quality of life outcomes is evident from these findings.

Perceived stigma in persons with early-stage dementia: Longitudinal findings: Part 1

This longitudinal study examined perceived stigma in persons with dementia, with 50 persons with dementia, and 47 corresponding family caregivers. Data were collected at baseline and at 6, 12, and 18 months. Study results are reported in two parts, with findings regarding the stability of perceived stigma, measured using the modified Stigma Impact Scale, and relationship of stigma to person-centered variables being reported here. Findings included stability in perceived stigma, which did not show a downward trend until 18 months. Significant differences at baseline were found only for geographic location (rural vs. urban) with persons living in urban areas having higher levels of Stigma Impact Scale internalized shame compared to rural counterparts. Cognitive functioning was significantly, positively related to the Stigma Impact Scale social rejection and social isolation subscales. Findings support the enduring nature of perceived stigma over the early disease stages and the relationship of perceived stigma to some person-centered characteristics.

Model for the First NIH-funded Center of Excellence in End-of-Life Research

Centers of excellence are widely acknowledged as a mechanism to promote scientific advances in a particular field of science, but until recently there have been no end-of-life or palliative care research centers funded by the National Institutes of Health (NIH). The purpose of this article is to describe aims, framework, and organizational structure of the first NIH-funded Center of Excellence on end-of-life research, the Center for End-of-Life Transition Research (CEoLTR), and the advances in end-of-life research that the CEoLTR will facilitate. The teams of researchers involved in the CEoLTR have grown impressively since it was funded in 2007. Collectively, the teams are on target to accomplish all of the original goals for this five year award.

A combined, multimodal intervention for individuals with dementia

Few studies have tested the effects of nonpharmacological interventions designed for people in early-stage dementia on the family caregiver. This study tested a multimodal intervention (Taiji exercise and support group) for people with dementia, with some treatment group caregivers choosing to co-participate. Control group caregivers participated in educational programs. Outcome measures included role stress (Relatives Stress Scale [RSS]) and quality of the relationship with the person with dementia. Trends toward positive effects for participating caregivers were found for overall role stress and the Personal Distress subscale and quality of the relationship with the person with dementia. In comparing outcomes between the total treatment group and the control group, treatment group caregivers rated one RSS subscale, Negative Feelings toward the Care Recipient, significantly lower (more positive) than control group caregivers. A within-group difference was found for the quality of the relationship for control group caregivers (increased negativity), with no increase in treatment group caregivers. Findings support the potential benefits of the intervention for both participating and nonparticipating caregivers.

The effects of a multimodal intervention on outcomes of persons with early-stage dementia

Theories supporting the existence of a use-dependent neuroplasticity in the older brain were used to guide this pilot study. A repeated-measures randomized design was used to test the effectiveness of a multimodal (Taiji exercises, cognitive-behavioral therapies, support group) intervention on cognitive functioning, physical functioning, and behavioral outcomes in persons with dementia. The treatment group (n = 24 persons with dementia) participated in a 40-week intervention, with outcomes assessed at 20 and 40 weeks to assess optimal treatment length. Control group subjects (n = 19 persons with dementia) received attention-control educational programs. At 20 weeks, differences between groups were found for mental ability and self-esteem, with gains in balance being evident. Also, stability in depression and physical health were evident at 20 and 40 weeks for treatment group subjects. Continued improvement in outcomes was not observed at 40 weeks. However, findings support further testing of the intervention along with potential for achieving positive outcomes in early-stage dementia.

Measuring perceived stigma in persons with progressive neurological disease

The perceived stigma inherent in progressive neurological diseases, such as Alzheimer's dementia (AD) and Parkinson's Disease (PD), has been under-recognized. The purposes of this pilot study were to examine: (1) the psychometric properties of the Stigma Impact (SIS) and Stigma Experience Scales (SES) when used with persons with AD or PD; and (2) differences in perceived stigma by disease diagnosis. The sample included 26 persons with AD and 14 persons with PD. Findings support the reliability of the total SIS scale for both persons with AD or PD. The four SIS subscales had acceptable reliability when used with persons with PD, while two of the four subscales had adequate reliability when used with persons with AD. Internal consistency reliability of the SES was acceptable in PD sample only. Validity of the total SIS scale and the four subscales was supported through significant correlations with mental status (AD sample only), self-esteem, depression, and personal control. Persons with AD scored higher on the SIS internalized shame subscale and lower on personal control compared to persons with PD. Overall, support was found for the SIS as a reliable and valid measure of perceived stigma in persons with AD or PD. The magnitude of perceived stigma in persons with AD is comparable to or greater than other populations of persons with chronic illness, including cancer and PD.

Evidence supporting nutritional interventions for persons in early stage Alzheimer's disease (AD)

The purpose of this paper is to grade research evidence supporting nutritional interventions for persons with early stage dementias and to report the recommendations of a consensus panel. Thirty four studies were reviewed in the areas of dietary restriction, antioxidants, and Mediterranean diet with strong support from epidemiological studies found in all three areas. The body of evidence to support nutritional interventions in the prevention and treatment of AD is growing and has potential as a treatment modality following translational studies.

Measurement and relevance of personality characteristics in persons with dementia: a longitudinal perspective

Studies of personality and outcomes in persons with dementia (PWD) have focused primarily on disease stages or change from premorbid personality following diagnosis. Data from a longitudinal study of 96 caregiver/PWD dyads was used to evaluate psychometric properties of two personality measures: one rated by proxies, the other by PWD. Proxy ratings indicate change in strength of personality traits across disease stages; self-ratings were stable, excepting decreased extroversion. Items detracting from reliability of some subscales reflected disease-related changes in PWD rather than true shifts in personality. Findings support importance of collecting both proxy and self-ratings of personality, examining individual items contributing to low reliability, and evaluating change in personality within the context of expected changes inherent in dementia.

Interventions for persons with irreversible dementia

This chapter provides an overview and critique of the theoretical and research literature by nurse researchers and researchers in other disciplines regarding interventions for persons with dementia (PWD). Reports were included if published in English between 1990 and 2000 and if a descriptive, correlational, longitudinal, or intervention design was used. Case studies and narrative descriptions were not included. No specific age criteria for study participants were applied; however, PWD are generally over age 55. The theoretical literature and various disease stages were reviewed, including clinical and behavioral indicators for disease progression. Using a variety of approaches to survey the extant literature (review of computer databases, contacts with experts in the field, ancestry method, and manual searches of key gerontology journals), over 1,200 citations were initially reviewed, allowing for approximately 375 publications undergoing thorough analysis with 157 research publications being included in this synthesis. Key findings include the identification of well-supported cognitive-behavioral interventions to enhance cognitive functioning and memory, and to relieve depression in the early disease stages; multiple environmental and behavioral approaches for improvement in functioning, maintenance of activities, and alleviation of behavioral symptoms in the middle disease stages; and behavioral, interactive, and staff support and education interventions for adequate nutritional intake, urinary incontinence, and management of problematic vocalizations and other behavioral symptoms in the later disease stages. Recommendations for future studies include the need for development of operational definitions of behavioral symptoms, inclusion of the perspective of PWD, evaluation of long-term outcomes, adequate sample size, community rather than institutional-based studies, and increased intervention testing at various stages of the disease.

Predicting quality of life in caregivers of Alzheimer's patients: the role of support from and involvement with the religious community

Examines the differences in caregivers of Alzheimer's patients and an age-matched comparison group on the variables of religious behavior; support and contact with the religious community; number of friends; quality of life; and well-being, and the relationship among these variables for predictors of the caregivers' quality of life. Findings included lower caregiver well-being, mental health, public religious behavior, satisfaction with church/synagogue support and contact, number of friends, support from and contact with friends, and quality of life indicators compared to comparison group subjects. Concludes that religious well-being and support from friends in the church/synagogue helps to explain a significant amount of the variance in the caregivers' well-being, health perceptions, mental health, and distress within the caregiving role.

Scholarship of practice for a practice profession

At a time of shrinking resources, rapidly changing health care environments, and increased demands for solutions to pressing health issues, concerns regarding the relevance of nursing research for practice are again being raised. After the national debate surrounding definitions of scholarship across disciplines and having established respectability for past and current contributions to knowledge development, nursing may now begin to reconceptualize what constitutes scholarship in a practice profession. This article addresses two central questions related to the scholarship of nursing practice: (1) How is scholarship of practice in a practice of profession defined? and (2) What characteristics differentiate the new conceptualizations of scholarship of practice from traditional research models? The results include a delineation of scholarship of practice and a differentiation of characteristics between scholarship of practice and traditional research approaches. Implications for nursing education are also addressed.

Assessing patients in the early stages of irreversible dementia. The relevance of patient perspectives

1 Individuals with Alzheimer's dementia are able to describe their personal responses to the disease, including how the disease has affected their perceptions of self. 2 Individual-centered variables, other than those related to the disease, are associated with quality of life outcomes in individuals with Alzheimer's dementia, including the individuals' personality, age, and education level. 3 The importance of maintenance of social activities and past pleasant activities is shown by the relationships among these variables and quality of life outcomes in individuals with dementia. 4 The quality of the relationship between caregivers and individuals with dementia, including the role-stress experiences by the caregivers, is moderately to strongly associated with the individuals' level of depression, psychological well-being, and productive behaviors.

Effective caregiving approaches for patients with Alzheimer's disease

To address the need for nonpharmacologic approaches to managing difficult behaviors in patients with dementia, a repeated measures design was used to test the effectiveness of educational and behavioral intervention on behavioral and functional outcomes in home-dwelling patients with dementia and their caregivers' knowledge of dementia. Baseline and 6-month postintervention data were collected for 108 subjects (54 caregiver/patient pairs) following random assignment to an intervention or comparison group. Findings included increases in caregiver knowledge in two treatment groups and patient self-care ability in one treatment group and ratings of the most effective behavioral interventions by caregivers.

Caregiver religiosity and well-being in dealing with Alzheimer's dementia

To examine the relationship among religious participation, stress, and well-being, 84 caregivers of Alzheimer's patients and 81 control subjects completed the Religiosity Scale, Life-3, and Medical Outcomes Study well-being measures. Caregivers only completed the Relative's Stress Scale. No differences were found between groups in religious practices, although caregivers indicated higher levels of clergy-visiting than the others and control subjects indicated a greater met need for contact with the church or synagogue. In contrast, control subjects show higher levels of well-being, social functioning, and mental health than caregivers. In care-givers, significant relationships were found among several religiosity variables, stress, and well-being.

Variables related to caregiver behaviors with cognitively impaired elders in institutional settings

The purpose of this study was to identify variables that might influence the behaviors of institutional caregivers when they interact with institutionalized, cognitively impaired elders. Independent variables included type of care situation, type of institution and nursing unit, and selected characteristics of both the caregiver and elder. The care situation was found to have a significant effect on caregiver behaviors. Caregiver characteristics of knowledge of dementia, experience in working with demented elders, and total years of education were significantly related to several caregiver behaviors. Elder characteristics of years of education, number of diagnoses, time on the nursing unit, age, self-care ability, and extent of dementia were related to several caregiver behaviors. Caregiver behaviors did not vary by the elder's gender.

Expressions of individuality in cognitively impaired elders. Need for individual assessment and care

1. Cognitively impaired elders uniquely express their individuality (expressed selfness) despite the effects of the dementing process. 2. Recognizing and attending to expressed selfness has implications for planning nursing care both to meet specific needs and to support existing characteristics and behaviors. 3. With the multiple losses encountered in dementia, supporting expressed selfness accessible to the individual can enhance the quality of the individual's living experience.

Conceptualizing psychological well-being in cognitively-impaired older persons

This article addresses a neglected area within nursing knowledge development: appropriate conceptual frameworks for guiding care of institutionalized, cognitively-impaired elders. Following a review of possible conceptual frameworks, psychological well-being, as defined by Lawton (1983), is proposed as an appropriate framework for guiding knowledge development and care of this elderly population. Two aspects of psychological well-being, positive and negative affect, may be appropriate indicators of the concept in cognitively-impaired elders. Instruments for measurement of psychological well being are also discussed. The implications of using psychological well-being as a conceptual basis for both research and nursing care are presented.

Caregiver and environmental variables related to difficult behaviors in institutionalized, demented elderly persons

This study describes the relationship between caregiver and elder behavior in institutionalized, cognitively impaired, elderly persons. A repeated-measures design was used to observe interactive behaviors between caregivers and demented elders within three caregiving situations (dressing, toileting, and bathing) and an interpersonal contact in two long-term care facilities. During observations, the caregiver's behaviors were rated using the Interaction Behavior Measure and Health Professional's-Geriatric Patient Behavior Rating scale, whereas the elder's behaviors were rated using a modified version of the Interaction Behavior Measure. The study included 116 subjects (58 elders and 58 caregivers), with each unique caregiver/elder pair being observed in the four situations. All elder behaviors varied according to situation type, with the most difficult elder behaviors occurring during bathing. Ten of the 12 caregiver behaviors included in the analysis varied by situation type. Significant relationships were systematically found between the caregiver's relaxed and smiling behavior and the elder's calm/functional behaviors, r = .42 (dressing) to r = .46 (toileting) for caregiver relaxed behavior and r = .34 (bathing) to r = .58 (dressing) for smiling. The elder's behavior did not vary by type of nursing unit (special dementia unit or general nursing unit), or interruptions to the interaction.

Nursing care of cognitively impaired, institutionalized elderly

Findings indicate the importance of many nursing staff behaviors in relation to the behaviors of demented elderly persons, especially when asking the elder to complete a care task, such as dressing. Nonverbal as well as verbal nursing staff behaviors were related to behaviors of demented elderly persons, especially smiling, eye contact, and manipulating the environment to avoid difficult encounters. The nursing staff's ability to remain relaxed and flexible when assisting with the elder's care was strongly related to the elder's ability to remain flexible, calm, and cooperative during the care procedure. Use of verbal distraction or redirection, praise, and light-hearted, playful approaches were often found to be helpful when the demented elder became upset or paranoid.