Kenneth Hepburn

Dementia family caregiver training : Affecting beliefs about caregiving and caregiver outcomes

OBJECTIVES: Family caregiving is an integral part of the care system for persons with dementing disorders, such as Alzheimers disease. This study tested role‐training intervention as a way to help family caregivers appreciate and assume a more clinical belief set about caregiving and thereby ameliorate the adverse outcomes associated with caregiving.

Internet-Based Program for Dementia Caregivers:

The overall goal of the Internet-Based Savvy Caregiver (IBSC) program was to develop and bring to market an Internet-based psycho-educational program designed to provide dementia caregivers the knowledge, skills, and outlook they need to undertake and succeed in the caregiving role they have assumed. The IBSC program’s concept is based on a face-to-face caregiver-training program and curriculum, the previously validated Savvy Caregiver Program (SCP). The project used an iterative design with expert and consumer input to develop the initial prototype. Forty-seven participants completed the IBSC program and follow-up questionnaire. Results of the formative evaluation showed that participants found the program educational, convenient, useful, and interesting. Participants endorsed feeling more confident in caregiving skills and communication with their family members. The evidence points to the feasibility of an Internet-based program to strengthen family caregivers’ confidence in caring for persons with dementia.

Low serum albumin levels, confusion, and fecal incontinence: are these risk factors for pressure ulcers in mobility-impaired hospitalized adults?

Background: Studies of risk factors for clinically significant pressure ulcers in the hospital have been limited by the small number of study subjects that develop pressure ulcers, resulting in contradictory findings regarding some risk factors. Objective: To determine if three risk factors (low serum albumin level, fecal incontinence, and confusion) were significant risk factors when tested in a large data set. Methods: The study design was a longitudinal cohort study using data collected as a component of a multi-site controlled clinical trial. The data were collected at 47 Veterans Affairs Hospitals. 2,771 subjects that required high levels of nursing care were identified to have mobility impairment. Their medical records were abstracted using a standard form to identify a large number of potential risk factors. The subsequent development of stage 2 or greater pressure ulcers was recorded for a maximum of 14 days after admission. Results: 406 patients (14.7%) subsequently developed at least one stage 2 or greater pressure ulcer over a 2-week period. In a multivariate model, the presence of low albumin levels (odds ratio OR = 1.40) and confusion (OR = 1.45) were both found to be statistically significant risk factors, while fecal incontinence was not. Having a Do Not Resuscitate (DNR) order was also a significant risk factor (OR = 1.55). Two other known risk factors also entered the model: being malnourished (OR = 1.69) and requiring a urinary catheter (OR = 1.55). Conclusions: This study confirmed confusion and low albumin as pressure ulcer risk factors, but not fecal incontinence. A DNR order was found to be a new pressure ulcer risk factor not previously described in the literature.

Clinically significant changes in burden and depression among dementia caregivers following nursing home admission

BackgroundAlthough extensive research exists on informal long-term care, little work has examined the clinical significance of transitions in family caregiving due to a lack of established clinical cut-points on key measures. The objectives of this study were to determine whether clinically significant changes in symptoms of burden and depression occur among caregivers within 12 months of nursing home admission (NHA) of their relatives with dementia, and to identify key predictors of clinically persistent burden and depression in the first year after institutionalization.MethodsSecondary longitudinal analysis of dementia caregivers were recruited from eight catchment areas in the United States with 6- and 12-month post-placement follow-up data. The sample included data on 1,610 dementia caregivers with pre- and six-month post-placement data and 1,116 with pre-placement, six-month, and 12-month post-placement data. Burden was measured with a modified version of the Zarit Burden Inventory. Depressive symptoms were assessed with the Geriatric Depression Scale.ResultsChi-square analyses found significant (P < .05) reductions in the number of caregivers who reported clinically significant burden and depressive symptoms after NHA compared to pre-placement. Logistic regression models revealed that wives and daughters were most likely to experience clinically persistent burden and husbands were most likely to experience clinically significant depression after NHA.ConclusionsIn addition to suggesting that clinically significant decreases in caregiver burden and depression are likely to occur following institutionalization, the results reveal particular subsets of caregivers who are at continued risk of distress. Such findings can facilitate development of screening processes to identify families at-risk following institutionalization.

Post-hospital sub-acute care: an example of a managed care model.

OBJECTIVE: This article describes Transitional Care Centers (TCC), an innovative sub‐acute care program developed by a large managed care organization (HealthPartners in Minnesota) in partnership with five area nursing homes. The purpose of the TCC is to promote continuity of care for frail older members covered under a TEFRA risk contract.

Clinical Care of Persons with Dementia in the Emergency Department: A Review of the Literature and Agenda for Research

The segment of older adults who present to the emergency department (ED) with cognitive impairment ranges from 21% to 40%. Difficulties inherent in the chaotic ED setting combined with dementia may result in a number of unwanted clinical outcomes, but strategies to minimize these outcomes are lacking. A review of the literature was conducted to examine the practices undertaken in the care of persons with dementia (PWD) specific to the ED setting. PubMed and Cumulative Index to Nursing and Allied Health Literature were searched for published articles specific to the care of PWD provided in the ED. All English‐language articles were reviewed; editorials and reflective journals were excluded. Seven articles ultimately met inclusion criteria; all provided Level 7 evidence: narrative review or opinions from authorities. The articles recommended clinical practices that can be categorized into five themes: assessment of cognitive impairment, dementia communication strategies, avoidance of adverse events, alterations to the physical environment, and education of ED staff. Many recommendations are extrapolated from residential care settings. Review results indicate that there is minimal guidance for the care of PWD specific to the ED setting. There are no empirical studies of the care (assessment, interventions) of PWD in the ED. The existing (Level 7) recommendations lack a research base to support their effectiveness or adoption as evidence‐based practice. There is a significant opportunity for research to identify and test ways to meet the needs of PWD in the ED to ensure a safe visit, accurate diagnosis, and prudent transfer to the most appropriate level of care.

Ten years' experience conducting the aging game workshop: Was it worth it?

In the Aging Game, medical students experience simulated physical, sensory, and cognitive deficits that are associated with disability from chronic diseases. Since 1994, the University of Minnesota has presented an innovative version of the Aging Game as part of the curriculum in a required clinical clerkship. The experiences conducting the Aging Game over the past decade were reviewed, focusing on the resources necessary to produce it and on its worth as an educational tool. Because many of the reusable props were obtained free as donations, start‐up material costs were calculated at

The stress of dementia: View from the inside

530. Personnel necessary for each half‐day presentation of the Aging Game included two faculty and a minimum of five nonfaculty serving as facilitators; a staff coordinator was also essential. Quantitative student evaluations (N=673) exhibited mean ratings of 1.41, 1.35, and 1.40 (1=excellent) for overall value, teaching effectiveness, and quality of a postsimulation discussion. Written student comments regarding the strengths of the Aging Game centered on three major themes: mode of learning, especially using role playing and simulating deficits (total of 192 comments); attitudinal change, specifically raising awareness and stimulating reflection on the experiences of disabled older adults (121 comments); and educational value, particularly the Aging Games capacity for creating a memorable impression (56 comments). Despite consuming significant personnel resources, the Minnesota version of the Aging Game is an effective tool for stimulating long‐lasting awareness and understanding of key issues related to aging and geriatrics.

Relationship matters in demantia caregiving

This descriptive exploratory study used thematic analysis to interpret short videotaped speech samples produced by persons with dementia in response to the question, “How have things been going for you lately?” The researchers were able to identify themes in 50 of the 56 interviews with men and women with Mini-Mental State Examination (MMSE) scores that ranged from five to 28. The major themes across all MMSE levels were losses, feelings about losses, and attempts to manage losses. The individuals’ choice of themes as well as their verbal and nonverbal expressions suggested that they were experiencing a significant amount of stress, especially related to their relationships with family and friends.

''Flying by the Seat of Our Pants'': What Dementia Family Caregivers Want in an Advanced Caregiver Training Program

This study examined the relationship between four framing categories of caregiving (Relational, Instrumental, Reactive, Role Acquiring), derived from interviews with spouse caregivers, and scores on standardized measures of responses to and outcomes of caregiving. Participants were 132 spouses recruited into a larger intervention study of family caregivers of communitydwelling persons with dementia. Qualitative data were analyzed using constant comparative method; quantitative data were analyzed using one-way analysis of variance (ANOVA). Findings demonstrated that relational spouses scored better than spouses in the other three categories, indicating greater positive well-being. Relational spouses also scored significantly lower than instrumental and reactive spouses on a composite caregiver distress measure (p = 0.003). These results suggest that interventions may need to be tailored to spouses with different caregiving perspectives.