Sarah H. Kagan

Traumatic Brain Injury in Older Adults: Epidemiology, Outcomes, and Future Implications

Traumatic brain injury (TBI) is a significant problem in older adults. In persons aged 65 and older, TBI is responsible for more than 80,000 emergency department visits each year; three‐quarters of these visits result in hospitalization as a result of the injury. Adults aged 75 and older have the highest rates of TBI‐related hospitalization and death. Falls are the leading cause of TBI for older adults (51%), and motor vehicle traffic crashes are second (9%). Older age is known to negatively influence outcome after TBI. Although geriatric and neurotrauma investigators have identified the prognostic significance of preadmission functional ability, comorbidities, sex, and other factors such as cerebral perfusion pressure on recovery after illness or injury, these variables remain understudied in older adults with TBI. In the absence of good clinical data, predicting outcomes and providing care in the older adult population with TBI remains problematic. To address this significant public health issue, a refocusing of research efforts on this population is justified to prevent TBI in the older adult and to discern unique care requirements to facilitate best patient outcomes.

Risk factors for pressure ulcers among elderly hip fracture patients

The purpose of this study was to estimate the incidence of hospital‐acquired pressure ulcers among elderly patients hospitalized for hip fracture surgery and to identify extrinsic factors that are associated with increased risk. We conducted a secondary analysis of data abstracted from medical records at 20 hospitals in Pennsylvania, Texas, New Jersey, and Virginia. Participants were patients aged 60 years and older admitted with hip fracture to the study hospitals between 1983 and 1993. The incidence of hospital‐acquired pressure ulcers was 8.8% (95% confidence interval 8.2%−9.4%). After adjusting for confounding variables, longer wait before surgery, intensive care unit stay, longer surgical procedure, and general anesthesia were significantly associated with higher pressure ulcer risk. Extrinsic factors may be important markers for high pressure ulcer risk in hospitalized hip fracture patients. Although it is not possible to eliminate factors such as requiring an intensive care unit stay or having a long surgical procedure, it may be possible to develop interventions that minimize pressure ulcer risk in patients who experience these factors. (WOUND REP REG 2003;11:96–103)

Patient Communication Following Head and Neck Cancer Surgery: A Pilot Study Using Electronic Speech-Generating Devices

PURPOSE/OBJECTIVES To describe the communication of patients who received electronic speech-generating devices (SGDs) following surgical procedures for head or neck cancer. DESIGN Exploratory, complementary mixed methods. SETTING Otolaryngology surgical inpatient unit of an urban teaching hospital. SAMPLE 10 purposively selected patients with a mean age of 57.1 years (SD = 12.8 years) and moderately severe illness (Acute Physiology and Chronic Health Evaluation III score mean = 27.1 + 13.2) who had SGDs in their hospital rooms for 9.1 + 6.2 days. METHODS Observation, interviews, questionnaires, and clinical record review. MAIN RESEARCH VARIABLES Communication methods, communication content, SGD use, communication quality (i.e., ease and user satisfaction), barriers to SGD use, and patient clinical characteristics. FINDINGS SGDs were used in message construction in 8 (17%) out of 48 total observed communication events. Writing (31%) and nonverbal communication (46%) were the most frequently observed primary methods of communication used by patients with head and neck cancer postoperatively. Five patients demonstrated occasional SGD use with or without cuing, and one used the SGD as the dominant communication method. Ease of Communication Scale scores showed only slightly less difficulty with communication when compared to a historic control group. Patients initiated communications more often when SGDs were used in message construction. Poor device positioning, staff unfamiliarity with SGDs, and patient preference and ability for writing were barriers to SGD use. CONCLUSIONS Although writing and making gestures were the most common communication methods, SGDs were used successfully by selected patients and may be particularly beneficial for constructing complex messages during conversation. IMPLICATIONS FOR NURSING SGDs may be an appropriate assistive communication strategy for postoperative patients with head and neck cancer. Nurses can facilitate effective patient communication with SGDs by cuing patients on device options and positioning SGDs within easy reach.

Ageism in Cancer Care

OBJECTIVE To provide an overview of ageism, a review of its influence in cancer, and to outline implications for nursing and interdisciplinary practice. DATA SOURCES Research articles, research and clinical reviews, theoretical works, and clinical expertise. CONCLUSION Ageism may be negative, self-stereotyping, positive, or beneficent. Ageism in cancer care results in age-based disparities in screening and detection, where older adults may have some advantage over younger adults as they have more frequent health care encounters through clinical trials enrollment and treatment. IMPLICATIONS FOR NURSING PRACTICE Nurses are well-positioned to identify ageism, to confront and correct it in clinical practice, and to conduct investigations and create curricula that combat ageism and redress age-based disparities.

Communication Needs, Methods, and Perceived Voice Quality Head and Neck Surgery: A Literature Review

Patients with head and neck cancer experience complex and frustrating communication problems after surgery, yet patient communication during the in hospital postoperative period has received relatively little attention in clinical and research literature. A computerized and hand search of the medical (MEDLINE, Cancerlit), psychological (health and psychosocial instruments), and nursing (CINAHL) literature (1968 to April 2002) produced 10 published studies and 1 clinical case report specifically addressing the communication needs, methods, or perceived voice quality of patients with head and neck cancer during the postoperative period ([.lessequal]12 months after surgery). This review presents a summary and critique of research and related literature on in-hospital postoperative communication with adult patients who have head and neck cancer. Three major themes are addressed: (1) information needs, (2) communication methods and perceived voice quality and (3) quality-of-life perceptions related to communication, disfigurement, and socialization. This review shows that the communication needs, communication methods, and perception of voice quality among patients with head and neck cancer have been ignored during the in-hospital period. Clinical issues and technological advancements in augmentative and alternative communication applicable to the in-hospital period are discussed, and research implications are presented.

Use of photographs for the identification of pressure ulcers in elderly hospitalized patients: validity and reliability

To evaluate the ability of research nurses to identify pressure ulcers, the authors assembled digital photographs of the skin of 160 consenting elderly patients (80% African American, 63% women). The series included 39 photos of pressure ulcers, 109 of normal skin, and 12 of other skin conditions, determined by consensus by two experts (D.J.M. and S.H.K.). Photos were packaged electronically into eight blocks of 20, with pressure ulcer prevalence ranging from 20% to 30% per block. The eight blocks were duplicated to create two sets of 160 photos each. Each of six raters (experienced clinical research nurses), working independently, evaluated the 320 photos as if each photo depicted a different patient. For analysis, the ratings were collapsed into binary determinations (any pressure ulcer vs. none). The overall sensitivity and specificity of the ratings were 0.97 (95% confidence interval: 0.94, 0.98) and 0.81 (95% confidence interval: 0.77, 0.86), respectively. Rater‐specific prevalence (range: 31.8–47.5%) exceeded the true prevalence (24.4%). Inter‐ and intrarater reliability coefficients were 0.69 and 0.84, respectively. Trained research nurses can accurately classify pressure ulcers from photographs, even when patients are largely non‐White and the photographs depict pressure ulcers spanning all pressure ulcer stages.

Gero-oncology nursing research

PURPOSE/OBJECTIVES To analyze the development of gero-oncology research through a critical review of nursing and other relevant research as well as the present state of practice. DATA SOURCES Journal articles, book chapters, and personal experience. DATA SYNTHESIS Cancer in older adults is viewed through two investigative perspectives. The assumptions, questions, theoretical frames, and research design that follow from these investigative perspectives do not adequately meet the need to examine the interplay of responses to aging, cancer, and nursing practice. The mismatch of need, knowledge, and resources marks older adults with cancer as a special population in need of far more sophisticated research. With the synthesis of a new perspective, gero-oncology nursing research becomes age focused, more precisely shaping theoretical, methodologic, and analytic approaches. CONCLUSIONS Uniform attachment of chronologic age or other simple age-related variables to investigations, which is the primary consideration of age-related research, is irrelevant for older adults who are diagnosed with, treated for, live with, survive, and die from cancer. Shaping the next phase of gero-oncology research with a focus on age precisely integrates theoretical, methodologic, and analytic approaches through language specific to older adults and cancer. IMPLICATIONS FOR NURSING Shifting perspectives in gero-oncology nursing research will better inform future practice.

ADHERENCE AND ORAL AGENTS WITH OLDER PATIENTS

OBJECTIVE Oral antineoplastic agents offer multiple advantages in cancer therapies. Thus, understanding issues of adherence to these agents for older adults becomes critical to successful comprehensive care of the older cancer patient. DATA SOURCES This analysis of adherence to oral agents among older cancer patients draws on interdisciplinary geriatric and oncologic research reports and clinical reviews. CONCLUSION Older adults are at increased risk for poor adherence to oral agents. Barriers to adherence are diverse. Problems emerge from age-related physical changes, comorbid conditions, polypharmacy, and drug interactions. Psychosocial barriers include limited insurance coverage and transportation problems to social isolation and inadequate social support. IMPLICATION FOR NURSING PRACTICE Nurses should lead interdisciplinary, individualized plans of care to mitigate barriers and support adherence to cancer therapy.

Impact of age on clinical care pathway length of stay after complex head and neck resection

This article investigates the effect of patient age on postoperative pathway length of stay (LOS) for head and neck surgery. Aggregate clinical results for 43 patients, enrolled in the CCP from June 1996–July 1997, are described. Patient age, comorbid status, and postoperative complications are analyzed with respect to impact on LOS.

Backside first in head and neck surgery?: Preventing pressure ulcers in extended length surgeries

The operating room (OR) presents a high‐risk environment for pressure injury. We designed a project to improve performance in the prevention of intraoperative pressure ulcers in extended length head and neck surgeries for malignancies (ELS) using a fluid mattress (RIK®) intraoperatively.