Kathleen C. Buckwalter

Comorbidity of depression with other medical diseases in the elderly.

A major factor in the context of evaluating depression in the elderly is the role of medical problems. With aging there is a rapid increase in the prevalence of a number of medical disorders, including cancer, heart disease, Parkinsons disease, Alzheimers disease, stroke, and arthritis. In this article, we hope to bring clarity to the definition of comorbidity and then discuss a number of medical disorders as they relate to depression. We evaluate medical comorbidity as a risk factor for depression as well as the converse, that is, depression as a risk factor for medical illness. Most of the disorders that we focus on occur in the elderly, with the exception of HIV infection. This review focuses exclusively on unipolar disorder. The review summarizes the current state of the art and also makes recommendations for future directions.

Comorbidity of late life depression: an opportunity for research on mechanisms and treatment.

Late life depression principally affects individuals with other medical and psychosocial problems, including cognitive dysfunction, disability, medical illnesses, and social isolation. The clinical associations of late life depression have guided the development of hypotheses on mechanisms predisposing, initiating, and perpetuating specific mood syndromes. Comorbidity studies have demonstrated a relationship between frontostriatal impairment and late life depression. Further research has the potential to identify dysfunctions of specific frontostriatal systems critical for antidepressant response and to lead to novel pharmacological treatments and targeted psychosocial interventions. The reciprocal interactions of depression with disability, medical illnesses, treatment adherence, and other psychosocial factors complicate the care of depressed older adults. Growing knowledge of the clinical complexity introduced by the comorbidity of late life depression can guide the development of comprehensive treatment models. Targeting the interacting clinical characteristics associated with poor outcomes has the potential to interrupt the spiral of deterioration of depressed elderly patients. Treatment models can be most effective if they focus on amelioration of depressive symptoms, but also on treatment adherence, prevention of relapse and recurrence, reduction of medical burden and disability, and improvement of the quality of life of patients and their families.

Infusing research into practice to promote quality care

This article describes the Iowa Model of Research in Practice, a heuristic model used at the University of Iowa Hospitals and Clinics for infusing research into practice to improve the quality of care. The components of the model are presented with examples. The impact of the model on patient, staff, and fiscal outcomes is delineated.

The Experience of Caring for a Family Member with Alzheimer’s Disease

The purpose of this phenomenological study was to describe the experience of caring for a family member with Alzheimer’s disease or related disorder (ADRD) living at home among a diverse sample of 103 family caregivers. The study involved secondary analysis of in-depth transcribed interview data using van Kaam’s rigorous four phase, 12-step psychophenomenological method. A total of 2,115 descriptive expressions were categorized into 38 preliminary structural elements. Eight essential structural elements emerged from an analysis of the preliminary structural elements. The eight elements were then synthesized to form the following synthetic structural definition: Caring for a family member living at home with ADRD was experienced as “being immersed in caregiving; enduring stress and frustration; suffering through the losses; integrating ADRD into our lives and preserving integrity; gathering support; moving with continuous change; and finding meaning and joy.”

Impact of a psychoeducational intervention on caregiver response to behavioral problems.

BackgroundEighty percent of persons with Alzheimer’s disease and related disorders are cared for by family members who often lack adequate support and training for this all-consuming job. ObjectiveTo evaluate the efficacy of a longitudinal, multisite, community-based intervention designed to teach home caregivers to manage behavioral problems in persons with Alzheimer’s disease. MethodsUsable data were analyzed from 237 caregiver/care recipient dyads (n = 132 Experimental;n = 105 Comparison). The experimental group received a psychoeducational nursing intervention that was conceptually grounded in the Progressively Lowered Stress Threshold model (Hall & Buckwalter, 1987). The comparison group received routine information and referrals for case management, community-based services, and support groups. Although a variety of psychosocial outcomes were compared between caregivers in the two groups, this article focuses on frequency and response to behavioral problems and functional decline. ResultsThe Progressively Lowered Stress Threshold intervention had a statistically significant effect on spousal response to memory/behavioral problems (p < .01) for all caregivers and on response to activities of daily living problems (p < .01) for spousal caregivers. In addition, nonspouses in the experimental group reported a reduction in the frequency of memory/behavioral problems (p < .01). No intervention effect on reports of activities of daily living frequencies was found for either spouses or nonspouses. ConclusionsThis Progressively Lowered Stress Threshold-based intervention had a positive impact on both the frequency of and response to problem behaviors among spousal caregivers.

History, Development, and Future of the Progressively Lowered Stress Threshold: A Conceptual Model for Dementia Care

Behavioral symptoms associated with dementia are a major concern for the person who experiences them and for caregivers who supervise, support, and assist them. The knowledge and skill of formal and informal caregivers affects the quality of care they can provide and their ability to cope with the challenges of caregiving. Nurses are in an excellent position to provide training to empower caregivers with the knowledge and skills necessary to reduce and better manage behaviors. This article reviews advances in geriatric nursing theory, practice, and research based on the Progressively Lowered Stress Threshold (PLST) model that are designed to promote more adaptive and functional behavior in older adults with advancing dementia. For more than 17 years, the model has been used to train caregivers in homes, adult day programs, nursing homes, and acute care hospitals and has served as the theoretical basis for in‐home and institutional studies. Care planning principles and key elements of interventions that flow from the model are set forth, and outcomes from numerous research projects using the PLST model are presented.

Predictors of Use of Services Among Dementia Caregivers

Caregivers of persons with dementia do not use community resources until late in the disease process, despite the fact that judicious use of community resources can delay nursing home admission. Data from the National Caregiver Training Project, based on Hall and Buckwalter’s (1987) progressively lowered stress threshold (PLST) model, were used to examine variables related to use of community resources. Spouse and adult child caregivers were divided into two groups based on amount of community resources used per week. Within this geographically diverse sample of caregivers, 64% did not use professional services, 79% did not use respite services, and 65% did not use other services. Being a spouse decreased the odds that the caregiver would use community resources. Resource use was also related to the care recipient’s problems with activities of daily living and the increase in frequency of memory and behavioral problems.

Prayer and religious coping for caregivers of persons with Alzheimer's disease and related disorders.

This study examined the use of prayer and religious coping among caregivers of persons with Alzheimers disease (AD) and related disorders. A repeated measures correlational design was used, combined with data from a larger, experimental study (NIH, R01-NR-3434). This expansion study and secondary analysis added two instruments, the Springfield Religiosity Schedule (SRS)1 and the Jalowiec Coping Scale (JCS)2 to the original study, as well as structured interviews to determine the role of prayer and religious coping in the caregiving stress and coping process. A modification of Lazarus and Folkmans3 Stress and Coping model was used that included religious variables. Results showed that caregivers (N = 64) used prayer and religious coping frequently, that they perceived prayer and trusting in God as effective coping mechanisms, and that internal religious activities helped them get through the caregiving situation. Clinical implications are discussed.

Written and Computerized Care Plans

The purpose of this study was to determine how use of a standardized nomenclature for nursing diagnosis and intervention statements on the computerized nursing care plan in a long-term care (LTC) facility would affect patient outcomes, as well as organizational processes and outcomes. An experimental design was used to compare the effects of two methods of documentation: Computer care plan and paper care plan. Twenty participants (10 in each group) were randomly assigned to either group. No statistically significant differences were found by group for demographic data. Repeated measures ANOVA was computed for each of the study variables with type of care plan, written or computerized, as the independent variable. There were no statistically significant differences between participants, group (care plan), within subjects (across time), or interaction (group and time) effects for the dependent variables: Level of care, activities of daily living, perception of pain, cognitive abilities, number of medications, number of bowel medications, number of constipation episodes, weight, percent of meals eaten, and incidence of alteration in skin integrity. There were significantly more nursing interventions and activities on the computerized care plan, although this care plan took longer to develop at each of the three time periods. Results from this study suggest that use of a computerized plan of care increases the number of documented nursing activities and interventions, but further research is warranted to determine if this potential advantage can be translated into improved patient and organizational outcomes in the long-term care setting.

Catastrophic reactions and other behaviors of Alzheimer's residents: Special unit compared with traditional units

Using a quasi-experimental pretest/posttest design, the effects of a Special Care Unit (SCU) on the incidence of catastrophic reactions and other behaviors of nursing home residents with Alzheimers disease (AD) were examined. Findings indicate significantly fewer catastrophic reactions and other selected behavior changes occurred during the posttest period for subjects in the experimental group compared with the subjects in the control group. Implications for psychiatric consultation/liaison nurses (PCLNs) working with this vulnerable population are discussed.