Pao-Feng Tsai

Analgesic drug prescription and use in cognitively impaired nursing home residents.

BACKGROUND Prior research has documented the high prevalence of pain in elderly adults and the difficulties associated with properly assessing and treating pain in elders with cognitive impairment. OBJECTIVES To investigate the prescription and administration of analgesic medications to treat pain in cognitively impaired nursing home residents. METHOD The current sample consisted of 339 nursing home residents (295 women and 44 men) with a mean age of 87 years (range 66-104). Forty-six percent of the sample had diagnosed cognitive impairment, and 55% had at least one diagnosed painful condition. Data for this correlational study were drawn from four nursing homes in Western Pennsylvania. The Multidimensional Observation Scale for Elderly Subjects was used to assess behavioral indicators of cognitive impairment, and chart review was used to obtain demographic, medication, and diagnostic data. RESULTS The results indicated that cognitively impaired nursing home residents are prescribed and administered significantly less analgesic medication, both in number and in dosage of pain drugs than their more cognitively intact peers. In multiple regression analyses holding the presence of painful conditions constant, more disoriented and withdrawn residents were prescribed significantly less analgesia by physicians; more disoriented, withdrawn, and functionally impaired residents were administered significantly less analgesia by nursing staff. CONCLUSIONS The findings highlight the difficulties of assessing pain in cognitively impaired elders and the lack of knowledge among health care providers about effective pain management.

A Pilot Cluster-Randomized Trial of a 20-Week Tai Chi Program in Elders With Cognitive Impairment and Osteoarthritic Knee: Effects on Pain and Other Health Outcomes

CONTEXT Because Tai Chi (TC) is beneficial to elders without cognitive impairment (CI), it also may benefit elders with CI. But elders with CI have generally been excluded from TC studies because many measurement tools require verbal reports that some elders with CI are unable to provide. OBJECTIVES To test the efficacy of a TC program in improving pain and other health outcomes in community-dwelling elders with knee osteoarthritis (OA) and CI. METHODS This pilot cluster-randomized trial was conducted between January 2008 and June 2010 (ClinicalTrials.gov Identifier: NCT01528566). The TC group attended Sun style TC classes, three sessions a week for 20 weeks; the control group attended classes providing health and cultural information for the same length of time. Measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, physical function and stiffness subscales; the Get Up and Go test; the Sit-to-Stand test; and the Mini-Mental State Examination (MMSE), administered at baseline, every four weeks during the intervention and at the end of the study (post-test). RESULTS Eight sites participated in either the TC group (four sites, 28 participants) or control group (four sites, 27 participants). The WOMAC pain (P = 0.006) and stiffness scores (P = 0.010) differed significantly between the two groups at post-test, whereas differences between the two groups in the WOMAC physical function score (P = 0.071) and the MMSE (P = 0.096) showed borderline significance at the post-test. WOMAC pain (P = 0.001), physical function (P = 0.021), and stiffness (P ≤ 0.001) scores improved significantly more over time in the TC group than in controls. No adverse events were found in either group. CONCLUSION Practicing TC can be efficacious in reducing pain and stiffness in elders with knee OA and CI.

Sleep disturbances and nocturnal agitation behaviors in older adults with dementia.

STUDY OBJECTIVES To examine nighttime sleep patterns of persons with dementia showing nocturnal agitation behaviors and to determine whether restless legs syndrome (RLS), periodic limb movements in sleep (PLMS), and obstructive sleep apnea (OSA) are associated with nocturnal agitation behaviors. DESIGN Cross-sectional. SETTING General community. PARTICIPANTS 59 participants with geriatrician-diagnosed dementia. Participants ages ranged from 66 to 88 years (mean age 79.1; SD 6.0). Mean Mini Mental State Examination (MMSE) score was 20.1 (SD 6.6). MMSE was used to measure baseline cognitive function and not for the diagnosis of dementia. INTERVENTIONS None. MEASUREMENTS AND RESULTS Sleep was measured by 2 nights of in-home, attended, portable polysomnography (PSG). Nocturnal agitation was measured over 3 additional nights using the Cohen-Mansfield Agitation Inventory modified for direct observations. Two experts independently and via consensus identified probable RLS. Total sleep time in participants was 5.6 h (SD 1.8 h). Mean periodic limb movements in sleep index (PLMI) was 15.29, and a high percentage (49%) had moderate to severe obstructive sleep apnea. Probable RLS was present in 24% of participants. Those with more severe cognitive impairment had longer sleep latency. Severe cognitive impairment, low apnea hypopnea index (AHI), and probable RLS were associated with nocturnal agitation behaviors (R(2) = 0.35, F(3,55) = 9.40, P < 0.001). CONCLUSIONS It appears that probable RLS is associated with nocturnal agitation behaviors in persons with dementia, while OSA and PLMS are not. Further investigation is warranted to determine if treatment of RLS impacts nocturnal agitation behaviors in persons with dementia.

Improving the process of pain care in nursing homes: A literature synthesis

Regulatory agencies, researchers, and clinicians have identified improving pain assessment and management in nursing homes as a high priority, but there is no consensus regarding the best strategies to change pain management practices in nursing homes. The goal of this article is to present a synthesis of published literature of process‐level pain management improvement projects in nursing homes and identify and describe the role and necessary skills of various clinicians and nursing leaders in successful interventions. This literature synthesis is limited to research in nursing homes. Reports of research or reports of evaluation of quality improvement programs and descriptions of process interventions that targeted pain assessment and management were reviewed. Studies that focused primarily on the efficacy of pain treatment (e.g., analgesic trials or nonpharmacological therapies) were excluded. Of the original 472 articles, 53 were kept for a full text review. Of these, 10 were included in the final synthesis. Findings from this synthesis suggest that pain management practices may improve with the adoption of systematic implementation models, clinical decision‐making algorithms, an interdisciplinary approach, continuous evaluation of outcomes, and use of on‐site resource consultants. Clinician leaders in nursing homes require adept pain assessment and management skills and working knowledge of organizational change practices, including quality improvement processes, team building, collaborative decision‐making, and assessing and solving system‐level problems.

Challenges in tailored intervention research

Although individuals and nurses value tailored health interventions, incorporating tailored interventions into research is fraught with pitfalls. This manuscript provides guidance on addressing challenges on developing, implementing, and evaluating tailored interventions (TIs). The initial step in designing TIs involves selecting the individual characteristics on which to tailor the intervention. After selecting critical characteristics for tailoring, researchers must decide how to assess these characteristics. Then researchers can use manuals, algorithms, or computer programs to tailor an intervention and maintain treatment fidelity. If desired outcomes are not achieved, focus groups or individual interviews may be conducted to gather information to improve the intervention for specific individuals/groups. Then, incorporating study arms of TIs in intervention studies, investigators may compare TIs with standardized interventions statistically and clinically. We believe TIs may have better outcomes, promote better adherence, and be more cost efficient.

A Middle-Range Theory of Caregiver Stress

The Roy adaptation model is a widely used nursing theory, but only a few studies have used it in the context of caregiving for the chronically ill. Many caregivers with chronically ill relatives suffer from stress and its consequences, and in an aging society, more and more people will be affected by stress. In this article, the author presents a middle-range theory of caregiver stress based on the Roy adaptation model as the first step in understanding the applicability of the Roy adaptation model in the context of stress in caregivers.

The Effect of Tai Chi on Knee Osteoarthritis Pain in Cognitively Impaired Elders: Pilot Study

This article reports a pilot study of the effect of tai chi (TC), a pharmacological adjunct and mild aerobic exercise, on osteoarthritic knee pain in elders with cognitive impairment (CI). The TC program included a warm-up, 12-form Sun-style TC, and a cool-down period, for a total of 20-40 minutes per session, twice a week for 15 weeks. The results showed no significant differences in knee pain after the TC intervention in 7 elders with CI. However, more minutes of TC attendance were related to improved pain scores (Spearmans rho=.78, P < .05). Greater accuracy in TC performance was also correlated with improvements in pain scores (Spearmans rho = .70, P=.08). Of 4 elders who participated in TC practice regularly (more than 20 sessions), 3 showed clinically important improvements, but 3 elders who participated in no sessions or only a few sessions showed no improvement.

Prevention of methylmercury-induced mitochondrial depolarization, glutathione depletion and cell death by 15-deoxy-delta-12,14-prostaglandin J2

Methylmercury (MeHg) is an environmental toxin that causes severe neurological complications in humans and experimental animals. In addition to neurons, glia in the central nervous system are very susceptible to MeHg toxicity. Pretreatment of glia with the prostaglandin derivative, 15-deoxy-delta-12,14-prostaglandin J(2) (15d-PGJ(2)), caused a significant protection against MeHg cytotoxicity. Results with the C6 glioma cells demonstrated that the protection was dependent on the duration of pretreatment, suggesting that time was required for the up-regulation of cellular defenses. Subsequent experiments indicated that 15d-PGJ(2) prevented MeHg induced mitochondrial depolarization. Similar protection against MeHg cytotoxicity was observed in primary cultures of mouse glia. Analysis of cellular glutathione (GSH) levels indicated that 15d-PGJ(2) caused an up-regulation of GSH and prevented MeHg-induced GSH depletion. Buthionine sulfoximine (BSO), a GSH synthesis inhibitor, completely inhibited the GSH induction by 15d-PGJ(2). However, BSO did not prevent the stabilization of mitochondrial potential and only partially prevented the protection caused by 15d-PGJ(2). While induction of heme oxygenase-1 was implicated in the cytoprotection by 15d-PGJ(2) under some experimental conditions, additional experiments indicated that this enzyme was not involved in the cytoprotection observed in this system. Together, these results suggested that while up-regulation of GSH by 15d-PGJ(2) might help cells to defend against MeHg toxicity, there may be other yet unidentified mechanism(s) initiated by 15d-PGJ(2) treatment that contributed to its protection against MeHg cytotoxicity.

IL-6 release from mouse glia caused by MeHg requires cytosolic phospholipase A2 activation

Methylmercury is a potent neurotoxin that causes severe neurological disorders in fetuses and young children. Recent studies indicated that MeHg could alter levels of immune mediators produced by cells of the central nervous system. Results from this study indicated that MeHg could greatly induce IL-6 release from primary mouse glial cultures. This property was not shared by other cytotoxic heavy metals, such as CdCl(2) or HgCl(2). MeHg was known to induce cytosolic phospholipase A(2) (PLA(2)) activation and expression, and this enzyme was required for IL-6 induction in some experimental systems. Further experiments using structurally distinct pharmacological agents were performed to test the hypothesis that MeHg induced PLA(2) activation was necessary for MeHg induced IL-6 release. Results indicated that AACOCF(3) (>or=10 microM), MAFP (>or=0.625 microM) and BEL (>or=0.625 microM) significantly reduced MeHg induced IL-6 release in glia. However, these PLA(2) inhibitors did not block MeHg induced GSH depletion. These results suggested that PLA(2) activation was required for MeHg to induce glial IL-6 release.

Temporal discounting rates and their relation to exercise behavior in older adults.

UNLABELLED As our nations population ages, the rates of chronic illness and disability are expected to increase significantly. Despite the knowledge that exercise may prevent chronic disease and promote health among older adults, many still are inactive. Factors related to exercise behaviors have been explored in recent years. However, temporal discounting is a motivational concept that has not been explored in regard to exercise in older adults. Temporal discounting is a decision making process by which an individual chooses a smaller more immediate reward over a larger delayed reward. The aim of this study was to determine if temporal discounting rates vary between exercising and non-exercising older adults. DESIGN This study used cross-sectional survey of 137 older adults living in the community. Older adults were recruited from 11 rural Arkansas churches. The Kirby delay-discounting Monetary Choice Questionnaire was used to collect discounting rates and then bivariate analysis was performed to compare temporal discounting rate between the exercisers and non-exercisers. Finally, multivariate analysis was used to compare discounting rate controlling for other covariates. RESULTS The results indicated that exercising older adults display lower temporal discounting rates than non-exercising older adults. After controlling for education, exercisers still have lower temporal discounting rates than non-exercisers (p<0.001). CONCLUSIONS AND IMPLICATIONS These findings are important as several chronic health conditions relate to lack of exercise especially in older adults. This research suggests that if we can find appropriate incentives for discounting individuals, some type of immediate reward, then potentially we can design programs to engage and retain older adults in exercise.