Kari M. Koerner

Recruitment of Older Adults: Success May Be in the Details

PURPOSE Describe recruitment strategies used in a randomized clinical trial of a behavioral prospective memory intervention to improve medication adherence for older adults taking antihypertensive medication. RESULTS Recruitment strategies represent 4 themes: accessing an appropriate population, communication and trust-building, providing comfort and security, and expressing gratitude. Recruitment activities resulted in 276 participants with a mean age of 76.32 years, and study enrollment included 207 women, 69 men, and 54 persons representing ethnic minorities. Recruitment success was linked to cultivating relationships with community-based organizations, face-to-face contact with potential study participants, and providing service (e.g., blood pressure checks) as an access point to eligible participants. Seventy-two percent of potential participants who completed a follow-up call and met eligibility criteria were enrolled in the study. The attrition rate was 14.34%. IMPLICATIONS The projected increase in the number of older adults intensifies the need to study interventions that improve health outcomes. The challenge is to recruit sufficient numbers of participants who are also representative of older adults to test these interventions. Failing to recruit a sufficient and representative sample can compromise statistical power and the generalizability of study findings.

Multifaceted Prospective Memory Intervention to Improve Medication Adherence

To test whether a multifaceted prospective memory intervention improved adherence to antihypertensive medications and to assess whether executive function and working memory processes moderated the intervention effects.

Neurocognitive predictors of academic outcomes among childhood leukemia survivors

Background: Acute lymphoblastic leukemia is the most common pediatric cancer, and survival approaches 90%. Acute lymphoblastic leukemia survivors are more likely than healthy peers or siblings to experience academic underachievement, yet little is known about neurocognitive predictors of academic outcomes. Objectives: Objectives were to compare neurocognitive abilities to age-adjusted standardized norms, examine change over time in neurocognitive abilities, and establish neurocognitive predictors of academic outcomes. Methods: Seventy-one children were followed over the course of therapy. Cognitive abilities were assessed during induction when the child was in remission (baseline) and annually for 3 years (years 1, 2, and 3). Reading and mathematics abilities were assessed at year 3. Results: Fine motor dexterity was significantly below age-adjusted norms at all data points but showed improvement over time. Baseline visual-motor integration was within the reference range but significantly declined by year 3, and mean scores at years 2 and 3 were significantly below age-adjusted norms. Verbal short-term memory was significantly below age-adjusted norms at all assessments. Visual-motor integration predicted reading and mathematics abilities. Verbal short-term memory predicted reading abilities, and visual short-term memory predicted mathematics abilities. Conclusions: Central nervous system–directed therapy is associated with specific neurocognitive problems. Visual-spatial skills and verbal and visual short-term memory predict academic outcomes. Implications for Practice: Early assessment of visual-spatial perception and short-term memory can identify children at risk of academic problems. Children who are at risk of academic problems could benefit from a school-based individual educational program and/or educational intervention.

Differences in Transitional Care Provided to Mexican American and Non-Hispanic White Older Adults.

Background:Transitional care, assisting patients to move safely through multiple health care settings, may be insufficient for older Hispanic patients. Purpose: Describe home health care services referral rates for Hispanic and non-Hispanic White (NHW) patients and factors that influence case managers’ (CMs’) discharge planning processes. Design: Organized by the Ethno-Cultural Gerontological Nursing Model, health records were reviewed (n = 33,597 cases) and supplemented with qualitative description (n = 8 CMs). Findings: Controlling for gender, insurance type, age, and hospital length of stay, NHW older adults received more home health care services referrals (odds ratio = 1.23). Insurance coverage was the most frequent determinant of CMs’ post–hospital care choices, rather than patients’ being Hispanic. NHW older adults were more likely to have insurance than Hispanic older adults. Implications: Insurance coverage being CMs’ primary consideration in determining patients’ dispositions is a form of systems-level discrimination for Hispanic vulnerable groups, which combined with other hospital-level constraints, should be addressed with policy-level interventions.

Defining older adults’ perceived causes of hypertension in the Brief Illness Perception Questionnaire

Objectives: This study sought to make the Brief Illness Perception Questionnaire (BIPQ) to be more informative about illness representation among older adults with hypertension. The authors developed categories for coding the open-ended question regarding cause of illness in the BIPQ – a pervasive quantitative measure for illness representation. Methods: Using inductive thematic analysis, the authors described categories which emerged from analysing the open-ended question of the BIPQ applied to patients with hypertension. Then using deductive thematic analysis, we applied known categories in the literature to causes for hypertension elicited by the BIPQ. Our categories are: behavioural, natural, physical, psychosocial, supernatural, and other. Results: We established inter-coder reliability by applying the coding scheme to a sample of suburban central Illinois (n=197) and urban Tucson, Arizona (n=299) older adults with hypertension (initial kappa=0.61, revised kappa after decision rules=0.987). To demonstrate the utility of the coding scheme we found that both Illinois and Arizona nonwhite patients differ from white patients in how they understand the cause of their hypertension. Conclusion: A more complete illness representation can now be quantified and statistically analysed through the BIPQ using the categories we revised for cause of hypertension. Assessment of causal beliefs through the BIPQ and the authors’ coding scheme may enable tailored and efficient patient education, resulting in more effective provider–patient relationships.

Increase in oxidative stress as measured by cerebrospinal fluid lipid peroxidation during treatment for childhood acute lymphoblastic leukemia

Five-year survival from childhood acute lymphoblastic leukemia (ALL) approaches 90%, but 40% of survivors experience central nervous system (CNS) treatment–related cognitive problems. Despite considerable evidence for cognitive problems, less is known about mechanisms of neurological injury. Our purpose was to investigate oxidative stress, measured by lipid peroxidation, as a mechanism of CNS treatment–related neurological injury. The sample included 55 children (mean age at diagnosis=6.84 y, SD=3.40) who received intrathecal and intravenous chemotherapy for CNS-directed treatment according to Children’s Oncology Group protocols. Glycerophospholipids were extracted from cerebrospinal fluid samples obtained at diagnosis and during intrathecal chemotherapy administration. Unoxidized and oxidized phosphatidylcholine (PC) and phosphatidylinositol (PI) were measured by normal phase high-performance liquid chromatography with diode array detection, and analyzed with a general linear model for repeated measures analysis of variance. Compared with the diagnostic cerebrospinal fluid sample, unoxidized and oxidized PC and PI increased significantly across treatment phases. Amount of intravenous methotrexate received was significantly correlated with oxidized PI, and age at time of ALL diagnosis was significantly associated with oxidized PC. These findings support our hypothesis that oxidative stress is a mechanism of neurological injury associated with CNS-directed treatment for ALL.

Declines noted in cognitive processes and association with achievement among children with leukemia

PURPOSE/OBJECTIVES To assess change in specific cognitive processes during treatment with chemotherapy only among children with acute lymphoblastic leukemia (ALL). 
. DESIGN A prospective, repeated measures design.
. SETTING Pediatric oncology treatment centers at Banner-University Medical Center Tucson/Banner Childrens-Diamond Medical Center (University of Arizona) and Texas Childrens Cancer and Hematology centers (Baylor College of Medicine) in Houston. 
. SAMPLE 71 children with ALL, with a mean age of 6.18 years at the time of diagnosis. 
. METHODS Using mixed-effects latent growth curve modeling with time since diagnosis as a fixed effect, age-adjusted standardized measures of working memory, processing speed, executive function, and attention were obtained and repeated about one and two years later. A subsample was tested for academic achievement at the end of treatment.
. MAIN RESEARCH VARIABLES Verbal working memory, visual spatial memory, processing speed, academic achievement, age, and gender. 
. FINDINGS A significant main effect was observed for age at diagnosis on decline in verbal working memory during treatment. Planned contrasts revealed greater decline among children who were diagnosed when aged younger than five years compared to those diagnosed when aged five years or older. Decline in verbal working memory and achievement in letter-word identification and calculation skills were associated, and decline in spatial memory was associated with calculation. A main effect of gender was observed on processing speed, with female patients showing greater decline than male patients. 
. CONCLUSIONS Findings from this study may guide the timing of interventions that could improve school achievement among survivors. 
. IMPLICATIONS FOR NURSING Children undergoing treatment for ALL may experience issues with verbal working memory and increased difficulty in school. Nurses are in a position to refer parents and children to school resources for additional academic support.

Influence of Nitrosative Stress on Fatigue During Childhood Leukemia Treatment

The focus on a cure for childhood leukemia over the last three decades has resulted in survival rates of more than 80%. However, efforts to manage leukemia-treatment symptoms have not kept pace with new therapies. Symptom toxicity during treatment can result in complications, treatment delays, and therapy dose reductions. Compromise in therapy can negatively influence the quality of life and, even more notably, jeopardize chances for long-term survival. This study examined biologic mechanisms that influence fatigue caused by increased reactive oxidative species (ROS) or actual failure of the antioxidant defense system due to genetic variation by investigating reactive nitrosative species, a “downstream” consequence of ROS. The specific aims of this study were to characterize the trajectory of nitrosative stress during acute lymphoblastic leukemia treatment and evaluate the influence of nitrosative stress on fatigue. A repeated measures design was used to evaluate the fatigue experienced by 186 children and adolescents, 3–18 years of age, with a diagnosis of leukemia during the most intense phase of treatment. An established biomarker of nitrosative stress, protein 3-nitrotyrosine (3NT) residues in the cerebral spinal fluid, was evaluated at diagnosis, postinduction, and consolidation phases of treatment. Higher fatigue was associated with higher 3NT levels at the beginning of treatment. Two distinct groups of children experienced either consistently high or consistently low 3NT levels across the treatment trajectory, from diagnosis to 12 months postinduction. Findings from this study support continued exploration into the phenotypic biochemical mechanisms that influence a reactive response to childhood cancer treatment.

Changes in Oxidant Defense, Apoptosis, and Cognitive Abilities During Treatment for Childhood Leukemia

Aggressive central nervous system (CNS)-directed treatment for acute lymphoblastic leukemia (ALL), the most prevalent cancer among children and adolescents, prevents metastasis of leukemia cells into the brain. Up to 60% of survivors experience cognitive problems, but knowledge about risk factors for and mechanisms of neurologic injury is lacking. Objectives of the present study were to (1) quantify changes in oxidant defense and apoptosis over the course of ALL therapy and (2) elucidate risk factors for long-term cognitive problems. The sample included 71 children with ALL. Cerebrospinal fluid (CSF) samples were collected at diagnosis and during intrathecal chemotherapy administration. Oxidant defense was measured by reduced glutathione (GSH), oxidized glutathione (GSSG), and the ratio of GSH:GSSG. Apoptosis was measured by activity of several cysteine-dependent aspartate-specific protease (abbreviated as caspase) enzymes that initiate (caspases 8 and 9) or execute (caspases 3/7) apoptosis. Cognitive abilities were assessed by standardized measures of short-term memory, visual-motor integration, and attention 3 years after ALL diagnosis. GSH and GSSG concentration increased significantly during ALL therapy, and a low GSH:GSSG ratio was indicative of an oxidized extracellular environment. Caspase enzyme activity increased significantly, and caspases 3/7 activity was significantly and negatively associated with performance on measures of cognitive abilities. Younger age at time of ALL diagnosis was associated with some measures of attention. Efflux of glutathione into CSF maintains oxidant defense by scavenging free radicals and other reactive oxygen species and is an early event in apoptosis. These mechanisms may be involved in neurologic injury associated with CNS-directed treatment and subsequent cognitive problems.

Understanding the Medication Adherence Strategies of Older Adults with Hypertension

Many older adults are living with at least one chronic disease and must adhere to prescribed medication to mitigate and control its impact. Hypertension is one chronic disease that affects a significant portion of the world’s population, especially older adults, and is responsible for a high number of annual deaths. It is asymptomatic, meaning that there are no perceptible symptoms and, as such, older adults may struggle with adhering to their prescribed antihypertensive medications. How one internalizes the disease may influence the degree of success in managing the condition. The current study analyzed archival data from a multifaceted prospective memory intervention for older adults with hypertension who were nonadherent to their medication. We coded their responses to self-management interview questions to identify the common themes regarding the knowledge and sense of control the older adults held relevant to managing their illness. Participants’ responses revealed how they internalized hypertension and their medication, as well as the strategies and goals they reportedly used to manage the illness. The association strategy was found to be the most commonly used within participants’ routines. In addition, many participants expressed a general lack of knowledge about the disease or their medication, and their goals regarding hypertension management were general and inexplicit (e.g., “to reduce their blood pressure). This information informs the design of more effective and longer-lasting interventions geared toward significantly improving the medication adherence of older adults diagnosed with hypertension.