Susan K. Frazier

The Efficacy of Acupressure for Symptom Management: A Systematic Review

CONTEXT Acupressure is a noninvasive strategy used to manage various symptoms. OBJECTIVES The purpose of this article was to review randomized controlled trials that investigated the efficacy of acupressure for the management of symptoms. METHODS A literature search was conducted in the Cumulative Index to Nursing and Allied Health Literature, Medline, and PubMed using the key words acupressure, clinical trial, human, and/or randomized. Randomized clinical trials published between January 1, 2000 and January 31, 2010, which used acupressure as the sole intervention for one group, were included when they were written in English and when there were four or more studies of the efficacy of acupressure for that particular symptom. RESULTS Forty-three studies were included in this review. Investigators in 16 of 23 studies concluded acupressure was effective, primarily for the management of nausea and vomiting in patients during pregnancy and during chemotherapy. Investigators in nine of 10 studies concluded that acupressure was effective for pain in patients with dysmenorrhea, during labor and after trauma. Investigators of four studies concluded that acupressure was effective in the management of dyspnea and investigators in six studies concluded that acupressure was effective in improving fatigue and reducing insomnia in a variety of populations. However, evaluation of the randomized controlled trial reports indicated a significant likelihood of bias. CONCLUSION Acupressure may be a useful strategy for the management of multiple symptoms in a variety of patient populations, but rigorous trials are needed. Inclusion of acupressure as an intervention may improve patient outcomes.

Critical care nursing practice regarding patient anxiety assessment and management

Anxiety is common in critically ill patients and can adversely affect recovery if not properly assessed and treated. The objectives of this study were to: (1) identify the clinical indicators that critical care nurses consider to be the defining attributes of anxiety in critically ill patients; and (2) delineate the interventions that critical care nurses use to alleviate anxiety in their patients. A total of 2500 nurses who worked in adult critical care areas were randomly selected from the membership of the American Association of Critical Care Nurses. Nurses selected were mailed a survey designed to determine what they considered to be the important attributes of anxiety in their patients and what interventions they commonly used to manage anxiety. The 593 nurses (31.6% response rate) who responded identified 70 individual anxiety indicators and 61 anxiety management strategies that were categorized into four and three major categories, respectively. The four major anxiety assessment categories were: (1) physical/physiological; (2) behavioral; (3) psychological/cognitive; and (4) social. The three major anxiety management strategies were: (1) care techniques; (2) improving knowledge and communication; and (3) support. Critical care nurses reported numerous and distinctive anxiety indicators and management strategies. Further research is needed to examine exactly how appropriate and effective these assessment indicators and management strategies are.

Symptom clusters in men and women with heart failure and their impact on cardiac event-free survival

Background:Because patients with heart failure (HF) experience multiple symptoms simultaneously, it is necessary to explore symptom clusters rather than individual symptoms to determine their impact on outcomes. Given gender differences in symptom experience, examination of potential gender differences in clusters is reasonable. Objective:The objective of the study was to compare symptom clusters between men and women with HF, differences in patient characteristics among symptom clusters, and the impact of symptom clusters on cardiac event-free survival. Methods:A total of 331 patients with HF recruited from HF clinics were included (35% were female and 62% were of New York Heart Association classes III/IV). Cluster analysis was used to identify symptom clusters between men and women based on ratings of distress related to 7 symptoms. Analysis of variance or &khgr;2 test was used to compare characteristics of patient groups that were divided by the median split of total distress scores of each cluster. Cox proportional hazards regression was used to determine whether total scores of symptom distress in symptom clusters predicted time to first cardiac event. Results:Two identical symptom clusters were identified in men and women: a physical symptom cluster composed of dyspnea, fatigue/increased need to rest, fatigue/low energy, and sleep disturbances and an emotional/cognitive symptom cluster composed of worrying, feeling depressed, and cognitive problems. Patients with higher distress from the physical symptom cluster were primarily females and of New York Heart Association classes III and IV (P < .05). Patients with higher distress from the emotional/cognitive symptom cluster were younger than those with lower distress (P < .05). The total symptom distress score in the emotional/cognitive cluster, but not the physical cluster, was an independent predictor of cardiac event-free survival (hazard ratio, 1.18; 95% confidence interval, 1.03-1.37). Conclusion:Although distress for individual symptoms may differ between men and women, they both experienced identical symptom clusters. Only the emotional/cognitive cluster predicted a higher risk for a cardiac event. These results suggested that interventions should be developed that consider symptom clusters. Targeting patients who have high distress from emotional/cognitive symptoms may be particularly important as they may be most vulnerable for adverse outcomes.

Medication adherence mediates the relationship between marital status and cardiac event-free survival in patients with heart failure

OBJECTIVE Prognosis is worse in unmarried patients compared with married patients with heart failure (HF). The reasons for differences in outcomes are unclear, but variations in medication adherence may play a role, because medication adherence is essential to achieving better outcomes. The study objective was to determine whether medication adherence mediated the relationship between marital status and cardiac event-free survival in patients with HF. METHODS Demographic, clinical, and psychosocial data were collected by questionnaires and medical record review for 136 patients with HF (aged 61 ± 11 years, 70% were male, 60% were in New York Heart Association class III/IV). Medication adherence was monitored objectively for 3 months using the Medication Event Monitoring System. Cardiac event-free survival data were obtained by patient/family interview, hospital database, and death certificate review. A series of regression and Cox survival analyses were performed to determine whether medication adherence mediated the relationship between marital status and event-free survival. RESULTS Cardiac event-free survival was worse in unmarried patients than in married patients. Unmarried patients were more likely to be nonadherent and 2 times more likely to experience an event than married patients (P = .017). Marital status was not a significant predictor of event-free survival after entering medication adherence in the model, demonstrating a mediation effect of adherence on the relationship of marital status to survival. CONCLUSION Medication adherence mediated the relationship between marital status and event-free survival. It is important to design interventions to increase medication adherence that take into account subgroups, such as unmarried patients, who are at higher risk for nonadherence.

Adherence to disease-modifying antirheumatic drugs in patients with rheumatoid arthritis: a narrative review of the literature.

AIM: This paper synthesizes findings from available research about medication adherence to disease-modifying antirheumatic drugs (DMARDs) in the population with rheumatoid arthritis (RA). RESULTS: This review of literature included 35 articles. Medication adherence to DMARDs ranged from 30% to 107%. Adherence rates of more than 100% indicated that patients took more than the prescribed amount of medication. There were no consistent risk factors for nonadherence to DMARD prescriptions identified, but some evidence was provided for self-efficacy, patient–healthcare provider relationships, social support, patient beliefs about medications, and age as factors affecting medication adherence. Support for educational interventions focused on medication adherence was equivocal. CONCLUSION Further research is necessary to develop a comprehensive, theoretically based understanding of medication adherence in RA patients.

Depressive Symptoms and Dietary Adherence in Patients with End-Stage Renal Disease

Depressive symptoms may be associated with fluid and dietary non adherence which could lead to poorer outcomes. The purpose of this study was to examine the relationship between depressive symptoms and fluid and dietary adherence in 100 patients with end-stage renal disease (ESRD) receiving haemodialysis. A descriptive, cross-sectional design with a convenience sample of 100 patients with ESRD receiving maintenance haemodialysis completed instruments that measured self-reported depressive symptoms and perceived fluid and dietary adherence. Demographic and clinical data and objective indicators of fluid and diet adherence were extracted from medical records. As many as two-third of these subjects exhibited depressive symptoms and half were non adherent to fluid and diet prescriptions. After controlling for known covariates, patients determined to have moderate to severe depressive symptoms were more likely to report non adherence to fluid and diet restrictions. Depressive symptoms in patients with ESRD are common and may contribute to dietary and fluid non adherence. Early identification and appropriate interventions may potentially lead to improvement in adherence of these patients.

Daily Variability in Dyspnea, Edema and Body Weight in Heart Failure Patients

Background: Heart failure (HF) and heart failure exacerbations are associated with distressing physical signs and symptoms that include dyspnea, peripheral edema and weight gain. There are no prior investigations that describe the daily fluctuations of these. Purpose: The purpose of this investigation was to characterize daily dyspnea, edema and body weight in patients with HF for 1 month. Methods: This analysis used a descriptive correlational design. Data were collected daily for 30 days from a cohort of heart failure subjects (n = 48). Daily mean values and associations between self-reported dyspnea, edema and body weight were determined. Results: The sample included 48 participants with a mean age of 48 ± 15 years. Slightly more than half were male (54%) and a majority were married (54%). On average, subjects with HF reported moderate daily levels of self-reported dyspnea and perceived edema. The average daily association between self-reported dyspnea and edema was a positive, significant relationship (p < 0.001). There were fewer significant positive associations between self-reported dyspnea and body weight and self-reported edema and body weight. Conclusions: In this cohort, heart failure patients were able to monitor symptoms daily, detect fluctuations and may be able to modify self-care activities and therapeutic regimen based on these ratings.

Depressive Symptoms and Dietary Nonadherence in Patients with End-Stage Renal Disease Receiving Hemodialysis: A Review of Quantitative Evidence

Patients with end-stage renal disease (ESRD) who receive hemodialysis have high rates of psychosocial distress and nonadherence to diet prescription. The purpose of this study was to examine the quantitative research evidence about the effect of depressive symptoms on dietary adherence. A systematic search of the literature using MEDLINE, CINAHL, PubMed, and PsycINFO databases was performed for quantitative research studies. Forty-four studies met inclusion criteria and were included in this review. Nearly all studies supported an association between depressive symptoms and dietary adherence in patients with ESRD. Depressive symptoms were associated with dietary nonadherence in patients with ESRD.

Medication Adherence Is a Mediator of the Relationship between Ethnicity and Event-Free Survival in Patients with Heart Failure

BACKGROUND Rehospitalization rates are higher in African American than Caucasian patients with heart failure (HF). The reasons for the disparity in outcomes between African Americans and Caucasians may relate to differences in medication adherence. To determine whether medication adherence is a mediator of the relationship between ethnicity and event-free survival in patients with HF. METHODS AND RESULTS Medication adherence was monitored longitudinally in 135 HF patients using the Medication Event Monitoring System. Events (emergency department visits for HF exacerbation, HF and cardiac rehospitalization, and all-cause mortality) were obtained by interview and hospital data base review. A series of regression models and survival analyses was conducted to determine whether medication adherence mediated the relationship between ethnicity and event-free survival. Event-free survival was significantly worse in African Americans than Caucasians. Ethnicity was a predictor of medication adherence (P=.011). African Americans were 2.57 times more likely to experience an event than Caucasians (P=.026). Ethnicity was not a predictor of event-free survival after entering medication adherence in the model (P=.06). CONCLUSIONS Medication adherence was a mediator of the relationship between ethnicity and event-free survival in this sample. Interventions designed to reduce barriers to medication adherence may decrease the disparity in outcomes.

The Psychometric Properties of the Brief Symptom Inventory Depression and Anxiety Subscales in Patients With Heart Failure and With or Without Renal Dysfunction

More than 5 million Americans have heart failure (HF); approximately one third have concomitant renal dysfunction. Anxiety and depressive symptoms are the most common psychological responses of these individuals and may influences outcomes; thus a reliable valid instrument to measure these is needed. This article reports a psychometric evaluation of the Brief Symptom Inventory (BSI) depression and anxiety subscales in patients with HF and with or without renal dysfunction, as these scales are commonly used in this population for research studies. This rigorous psychometric analysis used existing data from 590 patients with HF with an average ejection fraction of 35% ± 15% and average age of 63 ± 13 years. Patients were categorized as normal renal function (n = 495) or renal dysfunction (n = 95), and groups were compared and analyzed separately. Cronbachs alpha for the BSI subscales was .82 for those with normal renal function and .88 for those with renal dysfunction. Factor analysis determined that the subscales evaluated one dimension, psychological distress, in both groups. Construct validity was examined using hypothesis testing, and construct validity was supported in patients with HF and with normal renal function by significant associations of the BSI subscales with another measure of depression and a measure of perceived control. Construct validity in patients with HF and renal dysfunction was not strongly supported. Only the BSI depression subscale predicted poorer outcomes in patients with HF and with normal renal function; neither subscale was associated with event-free survival at 12 months in those with renal dysfunction. The BSI anxiety and depression subscales provide reliable and valid data in patients HF and normal renal function. Although reliability is excellent, construct validity was weak in those patients with HF and with concomitant renal dysfunction, which may reduce the validity of those data.