Liza Behrens

Anticholinergic Exposure during Rehabilitation: Cognitive and Physical Function Outcomes in Patients with Delirium Superimposed on Dementia

OBJECTIVES We examined the association between anticholinergic medication exposure and subsequent cognitive and physical function in patients with delirium superimposed on dementia during rehabilitation. We also examined length of stay and discharge disposition by anticholinergic medication exposure. DESIGN In this secondary analysis we used control group data from an ongoing randomized clinical trial. SETTING/PARTICIPANTS Participants with delirium and dementia were enrolled at admission to post-acute care. These 99 participants had a mean age of 86.11 (±6.83) years; 67.6% were women; 98% were Caucasian; and 33% were positive for at least one APOE e4 allele. MEASURES We obtained daily measures of cognitive and physical function using: Digit Span; memory, orientation and attention items from the Montreal Cognitive Assessment; CLOX; the Confusion Assessment Method; and the Barthel Index. Anticholinergic medication exposure was measured weekly using the Anticholinergic Cognitive Burden Scale. RESULTS Using multilevel models for time we found that greater use of clinically relevant anticholinergic medications in the previous week reduced cognitive and physical function, as measured by Digit Span Backwards and the Barthel index, in the current week. There was no effect of anticholinergic medication use on delirium severity, and APOE status did not moderate any outcomes. Greater use of clinically relevant anticholinergic medications was related to longer length of stay but not discharge disposition. CONCLUSIONS For vulnerable older adults, anticholinergic exposure represents a potentially modifiable risk factor for poor attention, working memory, physical function, and greater length of stay during rehabilitation.

When study participants are vulnerable: getting and keeping the right team

Background E-Delphi is a way to access a geographically dispersed group of experts. It is similar to other Delphi methods but conducted online. E-research methodologies, such as the e-Delphi method, have yet to undergo significant critical discussion. Aim To highlight some of the challenges nurse researchers may wish to consider when using e-Delphi in their research. Discussion This paper provides details about the authors approach to conducting an e-Delphi study in which a group of health literacy nurse experts (n=41) used an online survey platform to identify and prioritise essential health literacy competencies for registered nurses. Conclusion This paper advances methodological discourse about e-Delphi by critically assessing an e-Delphi case study. The online survey platform used in this study was advantageous for the researcher and the experts: the experts could participate at any time and place where the internet was available; the researcher could efficiently access a national group of experts, track responses and analyse data in each round. Implications for practice E-Delphi studies create opportunities for nurse researchers to conduct research nationally and internationally. Before conducting an e-Delphi study, researchers should carefully consider the design and methods for collecting data, to avoid challenges that could potentially compromise the quality of the findings. Researchers are encouraged to publish details about their approaches to e-Delphi studies, to advance the state of the science.

Testing the evidence integration triangle for implementation of interventions to manage behavioral and psychological symptoms associated with dementia: Protocol for a pragmatic trial

Behavioral and psychological symptoms of dementia (BPSD) include aggression, agitation, resistiveness to care, depression, anxiety, apathy, and hallucinations. BPSD are common in nursing home residents and can be ameliorated using person-centered approaches. Despite regulatory requirements, less than 2% of nursing homes consistently implement person-centered behavioral approaches. In a National Institute of Nursing Research-funded research protocol, we are implementing a pragmatic cluster randomized clinical trial designed to enable staff in nursing homes to reduce BPSD using behavioral approaches while optimizing function, preventing adverse events, and improving quality of life of residents. The implementation is based on use of the Evidence Integration Triangle (EIT), a parsimonious, community-engaged participatory framework that is well suited to the complexity and variability in the nursing home environment. A total of 50 nursing home communities will be randomized to EIT-4-BPSD or education only. Primary Aim 1 is to determine if communities exposed to EIT-4-BPSD demonstrate evidence of implementation evaluated by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) criteria. Primary Aim 2 is to evaluate the feasibility, utility, and cost of the EIT approach in EIT-4-BPSD communities.

Real-Time Observation of Apathy in Long-Term Care Residents With Dementia: Reliability of the Person–Environment Apathy Rating Scale

Apathy is prevalent in individuals with dementia. Lack of responsiveness to environmental stimulation is a key characteristic of apathy. The Person-Environment Apathy Rating (PEAR) scale consists of environment and apathy subscales, which allow for examination of environmental impact on apathy. The interrater reliability of the PEAR scale was examined via real-time observation. The current study included 45 observations of 15 long-term care residents with dementia. Each participant was observed at three time points for 10 minutes each. Two raters observed the participant and surrounding environment and independently rated the participants apathy and environmental stimulation using the PEAR scale. Weighted Kappa was 0.5 to 0.82 for the PEAR-Environment subscale and 0.5 to 0.8 for the PEAR-Apathy subscale. Overall, with the exception of three items with relatively weak reliability (0.50 to 0.56), the PEAR scale showed moderate to strong interrater reliability (0.63 to 0.82). The results support the use of the PEAR scale to measure environmental stimulation and apathy via real-time observation in long-term care residents with dementia. [Journal of Gerontological Nursing, 44(4), 23-28.].

Reliability and Validity Testing of the Quality of Life in Late-Stage Dementia Scale

Background/rationale: This study tested the psychometric properties of the Quality of Life in Late-Stage Dementia (QUALID) Scale using Rasch analysis. The QUALID includes 11 items with a 5-point response scale. Scores range from 11 to 55, and lower scores indicate higher quality of life (QoL). Methods: Baseline data from a randomized clinical trial including 137 residents from 14 nursing homes were used. Psychometric testing included item mapping, evaluation of response categories, item reliability, construct validity based on INFIT and OUTFIT statistics, and convergent validity based on correlations between QoL and pain, agitation, depression, and function. Results: The Cronbach α was .89. All the items except “appears physically uncomfortable” fit the model. There was a significant relationship between QoL and depressive symptoms (r = .71, P = .001), pain (r = .26, P = .01), physical function (r = −.19, P = .03), and agitation (r = .56, P = .001). The categories were appropriately used. Item mapping suggested a need for easier items.

Assessing apathy in long-term care residents with dementia: Who should be the rater?

Background Apathy is prominent in persons with dementia and apathy assessment is challenging. It remains unclear who should conduct apathy assessments in long-term care settings for residents with moderate to advanced dementia. The Apathy Evaluation Scale (AES) is a widely used instrument and its use for long-term care residents with dementia needs to be further established. This study explored the relationship among apathy assessments conducted by family and clinical caregivers using the original AES (AES-18) and the nursing home version (AES-10). Methods This study used a cross-sectional, descriptive design and enrolled 15 quartets of participants recruited from long-term care settings. Each quartet consisted of one resident with dementia, one family member, one certified nursing assistant, and one licensed practical nurse or activity staff. Family, certified nursing assistants, and licensed practical nurses/activity staff rated the resident’s apathy level on the AES independently. Bivariate Pearson correlation coefficients were used for analysis. Results The results revealed that ratings conducted by certified nursing assistants and licensed practical nurses/activity staff were moderately correlated for the AES-18 and the result approached statistical significance (r = 0.47, p = .08). None of the other AES ratings among family, certified nursing assistants, and licensed practical nurses/activity staff were significantly correlated. Discussion Family and clinical caregivers were incongruent on their AES ratings of apathy. It remains undetermined which rater provides the most valid AES rating for residents with dementia. Findings from this study further highlight challenges in rating apathy in this population. Future research is needed to determine best practices for accurate apathy assessment for residents with dementia in long-term care.