Nancy A. Hodgson

A Biobehavioral Home-Based Intervention and the Well-being of Patients With Dementia and Their Caregivers: The COPE Randomized Trial

CONTEXTnOptimal treatment to postpone functional decline in patients with dementia is not established.nnnOBJECTIVEnTo test a nonpharmacologic intervention realigning environmental demands with patient capabilities.nnnDESIGN, SETTING, AND PARTICIPANTSnProspective 2-group randomized trial (Care of Persons with Dementia in their Environments [COPE]) involving patients with dementia and family caregivers (community-living dyads) recruited from March 2006 through June 2008 in Pennsylvania.nnnINTERVENTIONSnUp to 12 home or telephone contacts over 4 months by health professionals who assessed patient capabilities and deficits; obtained blood and urine samples; and trained families in home safety, simplifying tasks, and stress reduction. Control group caregivers received 3 telephone calls and educational materials.nnnMAIN OUTCOME MEASURESnFunctional dependence, quality of life, frequency of agitated behaviors, and engagement for patients and well-being, confidence using activities, and perceived benefits for caregivers at 4 months.nnnRESULTSnOf 284 dyads screened, 270 (95%) were eligible and 237 (88%) randomized. Data were collected from 209 dyads (88%) at 4 months and 173 (73%) at 9 months. At 4 months, compared with controls, COPE patients had less functional dependence (adjusted mean difference, 0.24; 95% CI, 0.03-0.44; P = .02; Cohen d = 0.21) and less dependence in instrumental activities of daily living (adjusted mean difference, 0.32; 95% CI, 0.09-0.55; P = .007; Cohen d = 0.43), measured by a 15-item scale modeled after the Functional Independence Measure; COPE patients also had improved engagement (adjusted mean difference, 0.12; 95% CI, 0.07-0.22; P = .03; Cohen d = 0.26), measured by a 5-item scale. COPE caregivers improved in their well-being (adjusted mean difference in Perceived Change Index, 0.22; 95% CI, 0.08-0.36; P = .002; Cohen d = 0.30) and confidence using activities (adjusted mean difference, 0.81; 95% CI, 0.30-1.32; P = .002; Cohen d = 0.54), measured by a 5-item scale. By 4 months, 64 COPE dyads (62.7%) vs 48 control group dyads (44.9%) eliminated 1 or more caregiver-identified problems (chi(2/1) = 6.72, P = . 01).nnnCONCLUSIONnAmong community-living dyads, a nonpharmacologic biobehavioral environmental intervention compared with control resulted in better outcomes for COPE dyads at 4 months. Although no group differences were observed at 9 months for patients, COPE caregivers perceived greater benefits.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT00259454.

Targeting and managing behavioral symptoms in individuals with dementia: a randomized trial of a nonpharmacological intervention.

OBJECTIVES: To test the effects of an intervention that helps families manage distressing behaviors in family members with dementia.

Long-term effect on mortality of a home intervention that reduces functional difficulties in older adults: results from a randomized trial.

OBJECTIVES: To evaluate the long‐term mortality effect of a home‐based intervention previously shown to reduce functional difficulties and whether survivorship benefits differ according to initial mortality risk level.

The Cost-Effectiveness of a Nonpharmacologic Intervention for Individuals With Dementia and Family Caregivers: The Tailored Activity Program

OBJECTIVESnTo evaluate cost-effectiveness of the Tailored Activity Program (TAP) for individuals with dementia and family caregivers.nnnDESIGNnCost-effectiveness study of a two-group randomized controlled trial involving 60 patients-caregiver dyads randomized to intervention or wait-list control.nnnSETTINGnParticipants homes in Philadelphia region.nnnPARTICIPANTSnCaregivers were aged ≥ 21 years, lived with patients, and provided ≥ 4 hours of daily care. Patients had moderate dementia and behavioral symptomsnnnINTERVENTIONnEight sessions of occupational therapy over 4 months to identify patients preserved capabilities, previous roles, habits and interests, develop customized activities, and train families in their use.nnnMEASUREMENTSnIncremental cost-effectiveness ratios (ICER) expressed as the cost to bring about one additional unit of benefit measured by caregiver hours per day doing things and hours per day being on duty. Decision tree and Monte Carlo analyses tested robustness of the economic models.nnnRESULTSnTotal average intervention cost was

The Clinical Efficacy of Reflexology in Nursing Home Residents with Dementia

941.63 per day. Intervention caregivers saved one extra hour per day doing things at a cost of

Determinants of functional recovery in older adults surgically treated for cancer.

2.37/day and one extra hour per day being on duty at a cost of

Undiagnosed Illness and Neuropsychiatric Behaviors in Community Residing Older Adults With Dementia

1.10/day. Monte Carlo showed that TAP was cost-effective 79.2% of the time for doing things and 79.6% of the time for being on duty. Varying the cost assumptions did not change cost-effectiveness.nnnCONCLUSIONSnFindings suggest that investment in TAP is cost-effective and afforded families an important, limited and highly valued resource, needed time off from caregiving. This nonpharmacologic approach should be considered part of the clinical management of dementia.

Caregiver’s Perceptions of the Relationship of Pain to Behavioral and Psychiatric Symptoms In Older Community Residing Adults with Dementia

OBJECTIVEnThis experimental, repeated-measures, crossover design study with nursing home residents examined the efficacy of reflexology in individuals with mild-to-moderate stage dementia. Specifically, the study tested whether a weekly reflexology intervention contributed to the resident outcomes of reduced physiologic distress, reduced pain, and improved affect.nnnSETTINGnThe study was conducted at a large nursing home in suburban Philadelphia.nnnSAMPLEnThe sample included 21 nursing home residents with mild-to-moderate stage dementia randomly assigned to two groups.nnnINTERVENTIONSnThe first group received 4 weeks of weekly reflexology treatments followed by 4 weeks of a control condition of friendly visits. The second group received 4 weeks of friendly visits followed by 4 weeks of weekly reflexology.nnnOUTCOME MEASURESnThe primary efficacy endpoint was reduction of physiologic distress as measured by salivary alpha-amylase. The secondary outcomes were observed pain (Checklist of Nonverbal Pain Indicators) and observed affect (Apparent Affect Rating Scale).nnnRESULTSnThe findings demonstrate that when receiving the reflexology treatment condition, as compared to the control condition, the residents demonstrated significant reduction in observed pain and salivary alpha-amylase. No adverse events were recorded during the study period.nnnCONCLUSIONSnThis study provides preliminary support for the efficacy of reflexology as a treatment of stress in nursing home residents with mild-to-moderate stage dementia.

Who Should Assess the Needs of and Care for a Dementia Patient's Caregiver?

The purpose of this study was to examine the psychosocial and disease-specific factors that influence functional recovery in older adults newly diagnosed with cancer. Multivariate logistic regression models were estimated using panel data from a sample of community-residing adults older than 65 years surgically treated for lung, prostate, breast, or colorectal cancer (N 172). Data were obtained between 1993 and 1997 during interviews 4 to 6 weeks after cancer surgery for Wave 1 and 14 to 16 weeks after hospital discharge for Wave 2. The outcome measure, functional recovery, was determined by comparing the physical function and physical role subscales of Medical Outcomes Study (MOS) SF-36 over time. Findings showed that prostatectomy patients were more likely to recover by Wave 2 when compared to individuals with lung, colon, or breast resections. Comorbidities and symptom severity were each significantly associated with a decreased probability of recovery. Pain and fatigue were the most common and most severe symptoms reported, regardless of primary site. Psychological well-being was a significant factor influencing functional recovery when age, comorbidities, site of disease, and symptom severity were controlled. The results clearly point to the need for psychological support following cancer surgery.

Application of Productivity Estimates to Psychiatric Nursing Practice

The aim of this retrospective analysis was to examine prevalence of undiagnosed acute illness and characteristics including neuropsychiatric symptoms associated with illness in community residing older adults with Alzheimer disease or related disorders. Subjects included 265 community residing older adults with dementia who participated in 1 of 2 interventions being tested in randomized clinical trials. Measures included a brief nursing assessment and laboratory evaluations including complete blood count, blood chemistry (Chem 7), and thyroid function tests of serum samples and culture and sensitivity tests of urine samples. Undiagnosed illness was identified according to currently published criteria. Neuropsychiatric behaviors were assessed using 21 behaviors derived from standard measures. Thirty-six percent (N=96) of patients had clinical findings indicative of undetected illness. Conditions most prevalent were bacteriuria (15%), followed by hyperglycemia (6%) and anemia (5%). The behavior most often demonstrated among those with detected illness was resisting or refusing care (66% vs. 47% for those without detected illness). Individuals with detected illness had significantly lower functional status scores [3.8 vs. 4.4, t(275)=7.01, P=0.01], lower cognitive status scores [10.5 vs. 14.4, t(275)=12.1, P<0.01], and were more likely to be prescribed psychotropic medications for behavior (41% vs. 26%, &khgr;2=3.67, P<0.05) than those without illness. Findings suggest that challenges of diagnosing acute illness with atypical presentation must be addressed to promote quality of care and the specialized needs for this vulnerable population.