Srijana Shrestha

Managing pain to prevent aggression in people with dementia: a nonpharmacologic intervention.

Aggression is a common form of behavioral disturbance in dementia. Strategies to prevent and treat aggressive behavior are underdeveloped. However, recent work points to several modifiable risk factors that may be targets for intervention. Pain management is an evidence-based, feasible, but potentially underused, strategy that may be incorporated with other behavioral interventions to prevent aggression. In this article, we review areas of overlap in interventions for pain and for behavioral disturbances and describe an intervention concept that may hold promise for older adults with dementia who are at risk of developing aggressive behavior.

Calmer Life: A Culturally Tailored Intervention for Anxiety in Underserved Older Adults

OBJECTIVES To evaluate the feasibility of the Calmer Life and Enhanced Community Care interventions delivered by community and expert providers and test their preliminary effectiveness on worry, generalized anxiety disorder (GAD) severity, anxiety, depression, sleep, health-related quality of life, and satisfaction. DESIGN Small randomized trial, with measurements at baseline and 3 months. SETTING Underserved, low-income, mostly minority communities in Houston, TX. PARTICIPANTS Forty underserved adults 50 years and older, with significant worry and principal or coprincipal GAD or anxiety disorder not otherwise specified. INTERVENTION Combination of person-centered, flexible skills training to reduce worry; resource counseling to target unmet basic needs; and facilitation of communication with primary care providers developed through a community-academic partnership with social service and faith-based organizations. Religion/spirituality may be incorporated. MEASUREMENTS PRIMARY OUTCOMES worry (Penn State Worry Questionnaire-Abbreviated), GAD severity (GAD-7), anxiety (Geriatric Anxiety Inventory-Short Form). SECONDARY OUTCOMES depression (Patient Health Questionnaire-8 and Geriatric Depression Scale-Short Form), sleep (Insomnia Severity Index), health-related quality of life (12-item Medical Outcomes Study Short Form), satisfaction (Client Satisfaction Questionnaire and exit interviews). RESULTS Provider training was valid; mean ratings for community providers were well above average, with none less than adequate. Reach was excellent. Participants receiving the Calmer Life intervention had greater improvement in GAD severity and depression than those receiving Enhanced Community Care. Satisfaction with both treatments was equivalent. CONCLUSIONS A larger comparative-effectiveness trial needs to examine outcomes following the Calmer Life intervention relative to standard community-based care and to evaluate more fully issues of implementation potential.

Establishing community partnerships to support late-life anxiety research: Lessons learned from the calmer life project

Objectives: This article outlines the development of the Calmer Life project, a partnership established between researchers and faith-based and social service organizations to examine the effectiveness of cognitive behavioral therapy (CBT) incorporating religious/spiritual components for older African Americans in low-income communities. Method: The program was designed to bypass several barriers to delivery of CBT within the specified community; it allows multimodal delivery (in person or by telephone) that occurs outside traditional mental health settings through faith-based organizations and neighborhood community centers. It includes religion/spirituality as an element, dependent upon the preference of the participant, and is modular, so that people can select the skills they wish to learn. Established relationships within the community were built upon, and initial meetings were held in community settings, allowing feedback from community organizations. Results: This ongoing program is functioning successfully and has strengthened relationships with community partners and facilitated increased availability of education and services in the community. The lessons learned in establishing these partnerships are outlined. Conclusions: The growth of effectiveness research for late-life anxiety treatments in underserved minority populations requires development of functional partnerships between academic institutions and community stakeholders, along with treatment modifications to effectively address barriers faced by these consumers. The Calmer Life project may serve as a model.

Innovations in research for treatment of late-life anxiety

Objectives: While psychosocial interventions for late-life anxiety show positive outcomes, treatment effects are not as robust as in younger adults. To date, the reach of research has been limited to academic and primary care settings, with homogeneous samples. This review examines recently funded and ongoing late-life anxiety research that uses innovative approaches to reach unique patient populations and tailor treatment content and delivery options to meet the unique needs of older adults. Method: A systematic search was conducted using electronic databases of funded clinical trials to identify ongoing psychosocial intervention studies targeting older adults with anxiety. The principal investigators (PIs) of the studies were contacted for study details and preliminary data, if available. In some cases, the PIs of identified studies acted as referral sources in identifying additional studies. Results: Eleven studies met inclusion criteria and represented three areas of innovation: new patient groups, novel treatment procedures, and new treatment-delivery options. Studies and their associated theoretical bases are discussed, along with preliminary results reported in published papers or conference presentations. Conclusion: Psychosocial intervention trials currently in progress represent promising new strategies to facilitate engagement and improve outcomes among unique subsets of older adults with anxiety. Continued investigation of evidence-based treatments for geriatric anxiety will allow greater understanding of how best to tailor the interventions to fit the needs of older adults.

The Rey 15-Item Memory Test and Spanish-Speaking Older Adults

The Rey 15-Item Memory Test (Rey-15) is a standard instrument frequently employed to assess suspect effort/motivation in English-speaking populations. The objective of the current study was to examine the influence of socio-demographic variables on this measure and provide normative data for use with Spanish speakers. The performance of 130 primarily Spanish-speaking, cognitively intact, older adults (ages 50–69) on six Rey-15 scoring systems and six embedded measures of suboptimal performance was examined. Approximately 8% of the sample scored below the recommended cut-off of 9 on the Rey-15. The lowest recall score of 6 was also the minimum score obtained on the recognition trial. Additionally, scores on the alternative Rey-15 scoring methods and the embedded measures of suboptimal performance were lower in comparison to the normative data presently utilized with English speakers, yet comparable across the examined measures. Basic mental status and education level were significant predictors of Rey-15 performance; however, results indicate that these variables may share a close relationship with socio-demographic characteristics such as acculturation level and years of U.S. residency. Preliminary normative data on the Rey-15 for primarily Spanish-speaking older adults, stratified by education, is provided in conjunction with a recommendation for the use of the recognition trial when interpreting results.

Telephone-Delivered Cognitive-Behavioral Therapy for Older, Rural Veterans with Depression and Anxiety in Home-Based Primary Care

ABSTRACT Objectives: Rural, homebound older adults are at increased risk for anxiety and depression and have limited access to mental health services. These individuals face many barriers to receiving evidence-based mental health treatment and would benefit from interventions that increase access to and efficiency of care. The aim of this study was to evaluate use of a telephone-delivered, modular, cognitive behavioral therapy (CBT) intervention for both late-life depression and anxiety delivered to rural, homebound Veterans. Methods: Three cases are presented to illustrate the flexible adaptation of the intervention for use among older Veterans enrolled in home-based primary care, with varying symptom presentations and functional limitations. The Veterans received 7 to 9 sessions of the CBT intervention, with ordering of skill modules based on symptom presentation and determined collaboratively between patient and therapist. Results: The three Veterans showed improvement in depression and/or anxiety symptoms following treatment and provided positive feedback regarding their experiences in this program. Conclusions: These results suggest that telephone-delivered CBT is acceptable to older adults and can be tailored to individual patient needs. Clinical Implications: Clinicians should consider telephone-delivered CBT as an alternate mode of therapy to increase access to mental health care for rural, homebound individuals with depression and anxiety.

Santa Clara Strength of Religious Faith Questionnaire: psychometric analysis in older adults.

Objectives: To assist researchers and clinicians considering using the Santa Clara Strength of Religious Faith Questionnaire (SCSRFQ) with older-adult samples, the current study analyzed the psychometrics of SCSRFQ scores in two older-adult samples. Method: Adults of age 55 or older who had formerly participated in studies of cognitive-behavioral therapy for anxiety and/or depression were recruited to complete questionnaires. In Study 1 (N = 66), the authors assessed the relations between the SCSRFQ and other measures of religiousness/spirituality, mental health, and demographic variables, using bivariate correlations and nonparametric tests. In Study 2 (N = 223), the authors also conducted confirmatory and exploratory factor analyses of the SCSRFQ, as well as an item response theory analysis. Results: The SCSRFQ was moderately to highly positively correlated with all measures of religiousness/spirituality. Relations with mental health were weak and differed across samples. Ethnic minorities scored higher than White participants on the SCSRFQ, but only in Study 2. Factor analyses showed that a single-factor model fit the SCSRFQ best. According to item response theory analysis, SCSRFQ items discriminated well between participants with low-to-moderate levels of the construct but provided little information at higher levels. Conclusion: Although the SCSRFQ scores had adequate psychometric characteristics, the measures usefulness may be limited in samples of older adults.

Calmer Life: A Hybrid Effectiveness-implementation Trial for Late-life Anxiety Conducted in Low-income, Mental Health-underserved Communities

Objective: Anxiety is common among older adults and is associated with multiple negative outcomes. Late-life anxiety is usually unrecognized by providers and undertreated, although evidence supports the effectiveness of psychosocial treatment. Access to mental health care is especially poor among African American seniors. New treatment models are needed to expand the reach of mental health care to minority elders. Methods: Our article outlines a study designed to test the effectiveness and implementation potential of Calmer Life (CL), a community-based, person-centered, flexible and culturally tailored intervention for late-life anxiety and worry, offered in low-income, mental health-underserved and predominantly African American communities. CL is skills-based, but also includes resource counseling and an option to integrate religion/spirituality. The study population includes individuals 50 years of age and older who are experiencing high levels of worry. The program was developed in the context of a community-academic partnership with organizations that provide services for seniors in underserved communities, and it trains nontraditional community providers to deliver the intervention. Results: Study progress to date, challenges, and lessons learned are discussed. Data collection is ongoing, and study findings will be available in late 2017. Conclusions: CL will offer valuable information to help expand the reach of anxiety treatment among minority seniors living in underserved neighborhoods.

Predictors of Outcomes for Older Adults Participating in Calmer Life, a Culturally Tailored Intervention for Anxiety

ABSTRACT Objective: Determine predictors of reduced worry and anxiety for older adults participating in the pilot phase of Calmer Life, a modular, personalized cognitive-behavioral treatment for worry. Methods: Underserved adults (N = 54) over age 50 participated. Therapists were either experts (Ph.D. or Master’s) or nonexpert providers (case managers, community health workers, and bachelor’s level). Participants completed the Penn State Worry Questionnaire—Abbreviated (PSWQ-A) and the Geriatric Anxiety Inventory—Short Form (GAI-SF) before treatment and at 3 months. Results: Demographic and clinical variables were individually entered into separate regression equations, controlling for pretreatment scores, to determine their associations with post-treatment 1) PSWQ-A and 2) GAI-SF scores. Only younger age and African American race were significant (p < .05) univariate predictors of higher post-treatment PSWQ-A scores. African American race was also a significant predictor of higher post-treatment GAI-SF scores. Conclusions: African American participants had higher post-treatment PSWQ-A and GAI-SF scores than White and Hispanic participants. Younger age was also associated with more severe PSWQ-A post-treatment scores. Clinical Implications: Younger participants may experience additional stressors (e.g., caregiving, working) compared with older participants. Smaller decreases in anxiety in African Americans point to the need for continued focus and additional modification of interventions.

Cultural and Contextual Analysis of Quality of Life Among Older Nepali Women

The quality-of-life construct can be used to assess how well an individual’s needs are met or being met by the society. However, in the dominant narratives of quality of life in old age, exploration of the impact of cultural differences on how older adults define and assess their quality of life has been limited. Moreover, the examination of heterogeneity within one culture and its influence on quality of life has been largely ignored. The present study compares the quality of life as defined by two samples of Nepali elderly women, those who live with their families and those who live in an old-age home, and presents data on factors associated with quality of life in the two samples. The results show that social and cultural norms, informed by religious principles that prescribe familial elder care, impact how quality of life is described by both groups of women.