June 20, 2017
Journal of Gerontological Nursing
Volume 43 · Issue 4
Table of Contents
Person-Centered Technology for Older Adults
Nikki L. Hill, PhD, RN
Approximately 5 years ago, I first considered adapting memory compensation strategies for older adults (typically taught in-person with hard copy materials) to a mobile application (app) format. The overwhelming response I received when pitching the idea to peers was, “A 75-year-old isn't going to use a memory app!” And, in some cases, my critics were right. But the most important thing I learned through the development and testing process was that being truly person-centered in planning and implementing a technology-based intervention is critical: if you are not targeting an outcome that is meaningful to your patient, uptake will not happen or will not be sustained, regardless of how impressive your interface….
This is an exciting time of technology innovation that shows no signs of slowing. Wearable camera systems for family caregivers of individuals with dementia, mobile apps to promote reminiscence, and information visualization to improve engagement in the advance directives processare some of the recent examples highlighted in the Journal of Gerontological Nursing. There are so many opportunities for nurses to make a positive impact on the lives of older adults and their families through technology. Our team embraces the following tenets for a person-centered approach to technology for older adults: (a) involve older adults in development and testing; (b) consider individual needs, preferences, and characteristics; (c) focus on outcomes that are personally relevant to each older adult; (d) customize technology for each individual's identified goal(s); and (e) recognize that technology adoption is a process with a moving target. As nurses and patient advocates, we keep the person/patient at the center of what we do, and this makes us critical partners in advancing gerontological nursing through technology development and implementation.
New iStand Walking Cane With SmartWalk Technology™ Aids Joint Relief in Older Adults With Alzheimer's Disease...
WhatBox, Inc., announced its newest product, the iStand Walking Cane with SmartWalk Technology™. The iStand Walking Cane features a unique, scientific design to optimize comfort and aid in joint relief, and is equipped with Fall Detection Alerts, Global Positioning System location, and Alzheimer'sAlert's™
A new study in JAMA Psychiatry is the first to show the multiplying effects of delirium and dementia in hospitalized older adults.
Researchers examined three European populations in Finland, Cambridge, and the United Kingdom, and examined brain specimens in 987 older adults. Each individual's memory, thinking, and experience of delirium had been recorded over 10 years toward the end of his/her life. When these were linked with pathology abnormalities due to Alzheimer's disease and other dementias, those with delirium and dementia changes had the most severe change in memory.
Further research is needed to understand exactly how delirium interacts with dementia and how this could be blocked.
Older adults with arthritis must keep moving to be functionally independent. However, in an examination of a goal that is daunting for most of this aging population, a new Northwestern Medicine study found that performing even one third of the recommended activity is beneficial.
Using sophisticated movement-monitoring accelerometers, researchers measured the physical activity of 1,600 adults from the nationwide research study, Osteoarthritis Initiative, who had pain, aching, or stiffness in their hips, knees, or feet. Federal guidelines suggest achieving 150 minutes of moderate activity in sessions lasting at least 10 minutes to promote good cardiovascular health, but the researchers focused on simply keeping this population functioning over 2 years.
Approximately one third of participants improved or had high function after 2 years, but those who achieved a minimum of 45 minutes of moderate activity (e.g., brisk walking) per week were 80% more likely to improve or sustain high future function over 2 years compared with those doing less. This finding was true for both men and women.
A new study by researchers at the University of Missouri School of Social Work says that more attention to how advance directives are used in nursing homes may reduce unnecessary care and save health care costs, all while respecting residents' wishes.
Researchers analyzed more than 1,800 medical records from St. Louis area nursing homes. Fifty percent of the records contained an advance directive; however, in many cases the forms were difficult to find in the charts due to inconsistent record keeping. The researchers recommend that providers include a designated section in medical files for advance directives and that they reinforce with staff the importance of checking advance directives.
Promising, early studies of deep brain stimulation (DBS) for the treatment of Alzheimer's disease have paved a path for future clinical trials, but there are unique ethical challenges with this vulnerable population regarding decision making and post-study treatment access that must be addressed, according to a new study the Journal of Alzheimer's Disease.
Approved for the treatment of movement and neuropsychiatric disorders, such as Parkinson's disease, DBS is an invasive, surgical procedure involving the implantation of a microstimulator that sends electrical impulses to specific targets in the brain. Driven by the urgent need for effective therapies and the success of recent studies, DBS has now emerged as a possible treatment for Alzheimer's disease. However, researchers note three ethical issues that should be addressed.
Ensuring trial participants possess adequate decision-making capacity is important because they have cognitive deficits that may reasonably limit that capacity and thereby compromise informed consent. DBS for trials must have a robust mechanism for detecting loss of decision-making capacity and protecting the interest of patients during the trial.
Therapeutic misconception is another concern. Patients with Alzheimer's disease may agree to DBS as a last resort. Such desperation may alter their perception that the primary goal of the study is for health benefits and not knowledge about the efficacy of the device. Left unchecked, it could distort patients' understanding of the risks and benefits of DBS.
Another question to be asked at the end of a trial is whether patients who have benefited from the device should continue to receive treatment. This question is particularly salient considering the high cost of DBS and the fact that the device may be with the patient for many years after the trial ends. Denying patients access to the only intervention known to alleviate their symptoms is tantamount to violating the sacrosanct principle of “do no harm.”
Once post-trial access is accepted by a research team, the challenge is financial responsibility. Patients, together with sponsors, investigators, health care systems, insurance, governments, and non-profit organizations must partner to share responsibility and negotiate continued access arrangements prior to study enrollment.
Nurse practitioners (NPs) are increasingly providing house calls for frail, older adults, eclipsing any other specialties in number of home visits in 2013, new research reveals. However, regulations are hindering the profession's growth in many states even as demand increases for in-home care.
In 2013, NPs provided more than 1.13 million home visits, surpassing the 1.08 million made by internal medicine physicians, which is the reverse of 2012, when internal medicine physicians made 1.08 million visits and NPs made <925 o:p="" visits.="">925>
Researchers reviewed Medicare data to learn how many house calls were made in 2012 and 2013, who made them, and where they took place. They found that the total number of home visits made by all specialties grew from 4.9 million to approximately 5.2 million. NPs provided care over the largest geographic area, and most who made >1,000 house calls in 2013 were in the eastern half of the United States, with the strongest concentration in the Northeast. Nursing home residents were more likely to receive house calls than those who were homebound.
Researchers recommend that states re-examine their regulations, and that nursing schools offer training programs in home-based primary and palliative care.
Nursing Home Medication Reconciliation: A Quality Improvement Initiative
Monica Tong; et al..
The current quality improvement initiative evaluated the medication reconciliation process within select nursing homes in Washington, DC. The identification of common types of medication discrepancies through monthly retrospective chart reviews of newly admitted patients in two different nursing homes were described. The use of high-risk medications, namely antidiabetic, anticoagulant, and opioid agents, was also recorded. A standardized spreadsheet tool based on multiple medication reconciliation implementation tool kits was created to record the information. The five most common medication discrepancies were incorrect indication (21%), no monitoring parameters (17%), medication name omitted (11%), incorrect dose (10%), and incorrect frequency (8%). Antidiabetic agents in both sites were the most used high-risk medication. This initiative highlights that medication discrepancies on admission are common in nursing homes and may be clinically impactful. More attention needs to be given to work flow processes to improve medication reconciliation considering the increased risk for adverse drug events and hospitalizations. [Journal of Gerontological Nursing and Mental Health Services, 43(4), 9–14.]
TECHNOLOGY INNOVATIONS SUPPLEMENTAL DATA
Nurse, Patient, and Care Partner Perceptions of a Personalized Safety Plan Screensaver
Megan Duckworth; et al
A patient safety plan dashboard was developed that captures disparate data from the electronic health record that is then displayed as a personalized bedside screensaver. The dashboard aligns all care team members, including patients and families, in the safety plan. The screensaver content includes icons that pertain to common geriatric syndromes. In two phases, interviews were conducted with nurses, nursing assistants, patients, and informal caregivers in a large, tertiary care center. End user perceptions of the content and interface of the personalized safety plan screensavers were identified and strategies to overcome the barriers to use for future iterations were defined. Many themes were identified, ranging from appreciation of the clinical decision support provided by the screensavers to the value of the safety-centric content. Differences emerged stemming from each group of end users' role on the care team. All feedback will inform requirements for improvements to the personalized safety plan screensaver. [Journal of Gerontological Nursing, 43(4), 15–22.]
Comparison of Oral Assessment Results Between Non-Oral and Oral Feeding Patients: A Preliminary Study
Tomohisa Ohno, et al.
In the current study, evaluation and comparison of oral status was performed to confirm the necessity of oral care for non-oral feeding patients. The study involved patients consulting an attending physician in one hospital's Department of Dentistry for oral care. Based on the feeding method, participants were divided into two groups: (a) non-oral (n = 66) and (b) oral (n = 66) feeding. Characteristics and Oral Assessment Guide scores were compared between groups. The non-oral feeding group had significantly worse scores than the oral feeding group. The non-oral feeding group also showed significantly lower voice-, swallowing-, saliva-, and tongue-related scores. The poor oral status of non-oral feeding patients was clarified. The results suggest the importance of oral care for non-oral feeding patients. [Journal of Gerontological Nursing, 43(4), 23–28.]
Is it My Job? The Role of RNs in the Assessment and Identification of Delirium in Hospitalized Older Adults: An Exploratory Qualitative Study
Miriam Anne Coyle, et al
Delirium is characterized by acute and fluctuating cognitive decline, which is often missed in older adults who are assumed to be experiencing age-related changes or dementia. Delirium affects up to 50% of hospitalized older adults. The aim of the current study was to (a) explore current practices of RNs in assessing and identifying delirium in hospitalized older adults and (b) inform new educational initiatives. Qualitative methods were adopted using eight semi-structured group interviews with 24 RNs. Thematic analysis revealed a dichotomy in practice where RNs described delirium assessment and identification as (a) It's Not My Job, (b) It is My Job, and (c) It's Complex. The imperative to improve delirium assessment and identification to create safer and more caring health care environments means the current findings provide important evidence to build into practice and education strategies. The current authors have developed engaging educational interventions and begun implementation at the study site to develop delirium assessment and identification capacity, which moves clinicians beyond awareness and aims at practice adherence or the consistent application of evidence-based delirium assessment. [Journal of Gerontological Nursing, 43(4), 29–37.]
CNE Quiz: Is it My Job? The Role of RNs in the Assessment and Identification of Delirium in Hospitalized Older Adults: An Exploratory Qualitative Study
Long-Term Adherence and Effectiveness of a Multicomponent Intervention for Community-Dwelling Overweight Thai Older Adults with Knee Osteoarthritis: 1-Year Follow Up
Suparb Aree-Ue, et al
Being overweight is a major risk factor for developing knee osteoarthritis (OA). The purpose of the current study was to: (a) determine participant adherence to a quadriceps exercise and weight management program after completion of the intervention; and (b) examine whether a quadriceps exercise and weight management program can reduce knee pain and improve knee function and weight loss in 40 community-dwelling overweight Thai older adults with knee OA at 6- and 12-month follow up. Twenty-nine (76.3%) participants completed at least 75% of the program. Two (5%) participants did not complete the program. In the intervention group, significant improvement was noted in knee range of motion at 6 and 12 months compared with baseline, and a significant reduction was noted in knee pain, time spent in the Timed Up and Go test, and body weight compared with baseline. These study variables, except for body weight, between the intervention group and control group were significantly different. This study highlights the benefit of long-term adherence to the multicomponent intervention for community-dwelling overweight Thai older adults with knee OA. [Journal of Gerontological Nursing, 43(4), 40–48.]
Clinical Nursing Leadership Education in Long-Term Care: Intervention Design and Evaluation
Valerie Fiset, RN, MScN; et al
The main objective of the current case study was to investigate the perceived leadership learning needs and feasibility of delivering leadership education to registered staff involved in direct care in long-term care (LTC) homes. The study was conducted in Ontario, Canada, and participants included RNs, registered practical nurses, and nursing administrators. Phase 1 bilingual web-based survey and bilingual focus group needs assessment data supported a preference for external training along with in-house mentoring to support sustainability. An intervention designed using insights gained from Phase 1 data was delivered via a 2-day, in-person workshop. Phases 2 and 3 evaluation survey data identified aspects of leadership training for LTC that require ongoing refinement. Findings suggest that communication skills and managing day-to-day nursing demands in the context of regulatory frameworks were areas of particular interest for leadership training in the LTC setting. [Journal of Gerontological Nursing, 43(4), 49–56.]
Volume 43 · Issue 5
Table of Contents
Network for Investigation of Delirium Across the U.S. (NIDUS): Advancing the Field of Delirium with a New Interdisciplinary Research Network
Donna M. Fick, et al
Delirium, a manifestation of brain organ dysfunction, presents acutely with impaired attention and disorganized thinking, and imposes a high degree of caregiver burden. Delirium can occur at any age, but occurs more often in older adults due to their increased vulnerability, affecting more than 2.6 million individuals in the United States each year (i.e., more than 5 individuals every minute. Typically following acute illness, hospitalization, or surgery, delirium often leads to loss of independence, cognitive decline, and increased morbidity and mortality. Moreover, delirium is associated with excess health care costs of >$164 billion per year Delirium can be difficult to detect and manage and is receiving increased attention in the medical literature
Many factors, including cognitive impairment, infection, dehydration, and psychoactive medications, are predictive of delirium. In most cases, delirium is multifactorial, which makes finding effective approaches for prevention and treatment highly challenging, and research studies methodologically complex. Importantly, delirium can be prevented with a multidimensional clinical strategy. Despite its importance, delirium is not well understood and vastly under recognized. Fundamental advances in diagnosis and treatment of delirium are lagging. The pathophysiology of delirium remains poorly understood, and there are no biomarkers to serve as diagnostic indicators or therapeutic targets. Although the number of measures for screening and diagnosis of delirium has increased in the past decade, the proportion of patients with unrecognized delirium remains high.
Patients treated with AC-1204 did not demonstrate a statistically significant difference at 26 weeks compared with patients treated with placebo, as measured by the Alzheimer's disease Assessment Scale-Cognitive Subscale test. In the study, AC-1204 was shown to be safe and demonstrated high levels of tolerability with the most prevalent adverse event being only mild, transient gastrointestinal disturbance. A detailed pharmacokinetic analysis has shown that the modified AC-1204 formulation used in the study resulted in lower drug plasma levels than prior formulations. This suboptimal exposure contributed to the lack of efficacy observed in the trial.
“I'm Still Here”: Personhood and the Early-Onset Dementia Experience
Mariko L. Sakamoto, et al
Early-onset dementia (EOD) occurs before age 65. The current study examined the lived experience from the point of view of four adults younger than 65 with dementia, particularly how they perceive their personhood. Using interpretative phenomenological analysis as the research approach, findings revealed that the EOD experience can be incorporated into six themes: (a) A Personal Journey, (b) Navigating the System, (c) The Stigma of Dementia, (d) Connecting to the World, (e) A Story Worth Telling, and (f) I'm Still Here. Participants' stories, as presented via these six thematic threads, reveal that individuals with EOD can have a strong sense of personhood. Findings are discussed and situated within the current EOD body of knowledge, and new knowledge is presented. Implications for practice and recommendations for future research are discussed. [Journal of Gerontological Nursing, 43 (5), 12–17.]
Enhancing Care for Hospitalized Patients With Parkinson's Disease: Development of a Formal Educational Program for Nursing Staff
Mary C. DiBartolo, PhD, RN-BC, CNE
Although not generally a primary admission diagnosis, Parkinson's disease (PD) can be a significant comorbidity during hospitalization. Hospitalized individuals with PD can experience a variety of complications, such as confusion, pneumonia, and urinary infections. More than 20% of patients experience deterioration in symptoms and hospital stays are extended by an average of 4 days. Late, omitted, or inappropriate medications are frequent culprits leading to serious consequences, including falls and aspiration. To address an identified gap in staff knowledge about PD, a formal educational program was developed to review its etiology, symptoms, treatments, and unique considerations in care and medication administration. This 2-hour intervention comprises a knowledge pre-test, PowerPoint® presentation, two concise handouts for reference, discussion of an unfolding case study, and review of the Aware in Care kit. Nurses can play a key role in educating staff to reduce avoidable hospital-related complications and enhance outcomes for this vulnerable group. [Journal of Gerontological Nursing, 43(5), 18–22.]
CNE ARTICLE SUPPLEMENTAL DATA
Creating a Dedicated Education Unit in Long-Term Care
Jodie R. Fox, MSN, RN-BC
CNE Quiz: Creating a Dedicated Education Unit in Long-Term Care
FEATURE ARTICLE SUPPLEMENTAL DATA
Enhancing the ADMIT Me Tool for Care Transitions for Individuals With Alzheimer's Disease
Janet R. Moore, et al
One of the goals of the National Plan to Address Alzheimer's Disease is to ensure safe care transitions. To facilitate safe and effective transitions from home to hospital, the ADMIT (Alzheimer's, Dementia, Memory Impaired Transitions) Me tool was developed and three focus groups were conducted with caregivers (n = 6), emergency department nurses (n = 6), and first responders (n = 14) to determine its usefulness and applicability to practice. Feedback was used to enhance the tool to reflect their needs. Each group expressed that the tool would help promote safety in care transitions. Using ADMIT Me, nurses can practice with clear communication and collaboration in care transitions, and provide patient-centered care based on the behaviors and unique needs of the individual with dementia. [Journal of Gerontological Nursing, 43(5), 32–38.]
Multi-Component Interventions and Cognitive Health: A Scoping Review
Melissa M. Fessel, et al
Single-component interventions for modifiable risk factors to improve cognitive function in older adults have limited impacts. Multi-component interventions may be more effective. The current review describes randomized trials of multi-component interventions, and reports the state of the evidence to protect the cognitive health and reduce the risk of cognitive decline among middle-aged and older adults. Two hundred seventy-nine studies were found through electronic databases, 30 full-text reviews were completed, and six studies were identified for final selection. Findings suggest that a multi-component approach is promising compared to single-component interventions. Most multi-component intervention studies found improvement in at least one domain of cognitive function. However, the quality of multi-component studies was largely fair or poor primarily due to small samples and short trial durations. There is a need for more rigorous studies of multi-component interventions and to refine the knowledge on the specific interventions that optimize prevention domains. [Journal of Gerontological Nursing, 43(5), 39–48.]
Slow Medicine: The Barrier on the Bridge
Charles G. Kerrigan Jr.
I never gave much thought to end-of-life (EOL) care until a junior level course in geriatrics in my baccalaureate nursing program introduced me to disparities in the health care system at EOL. My dissatisfaction with the American cultural perspective on EOL care has made me reflect on what needs to change and how. I became convinced that there must be a more holistic, natural way to approach death and dying. My interest in this paradigm shift has led me to uncover a smoother path known as “slow medicine.”
Slow medicine is a holistic approach to EOL care that capitalizes on quality of life and preparation for the end. It focuses on patients more than the illness and encourages providers to closely examine the most appropriate EOL care for each patient. At the core of slow medicine is the desire to balance what is beneficial to the patient and what is necessary for treatment. Slow medicine is a concept that is undervalued in the current health care system.
Who We Are, What We Believe: Getting to Geriatrics With a Capital “G” at #AGS17
Ellen Flaherty, PhD, APRN, AGSF
For a gerontological nurse or other geriatrics professional, that is a question likely to produce one of two responses: some will wonder why we need saving and others will accept the question as it stands—looking instead for an answer to make it go away!