Virginia J. Neelon

the Assessment of Discomfort in Elderly Confused Patients: A Preliminary Study

&NA; With the increasing numbers of older adults in our population, nurses are reexamining all aspects of nursing care in order to best meet the needs of these individuals. Normal age changes, the impact of decades of environmental challenges, successful adaptations, acute illnesses, trauma and chronic illnesses combine to create a challenge for accurate and effective assessment of elderly patients. The nurse finds her assessment skills challenged with increasing frequency by the elderly patient who is also acutely confused and experiencing discomfort. The purpose of this study was to explore the clinical utility, validity and reliability of four different approaches to nursing assessment of discomfort with this particularly vulnerable group of elders.

EVALUATION OF A NON-INVASIVE RESPIRATORY MONITORING SYSTEM FOR SLEEPING SUBJECTS

In a previous paper we introduced a non-invasive respiratory monitoring system (NIRMS) for monitoring respiratory movements during sleep. Unlike standard sleep laboratory methods, the NIRMS can be used in frail older adults to describe breathing patterns during sleep that will mark individuals with declining neurological function. The present study evaluates the use of the NIRMS as a respiratory monitor and identifies variables that can reliably detect changes in breathing patterns and the presence of other body movements. Data were obtained from eleven healthy adults (six women, five men) whose body mass indices ranged from 20 to 47 kg m(-2), and whose baseline respiratory rates ranged from 4 to 19 breaths per minute. We evaluated three variables derived from frequency and amplitude measurements of the NIRMS: (1) the interval between breathing cycles (the interbreath interval or IBI); (2) the period between breathing cycles (the interbreath frequency or IBF); and (3) the amplitude of breath cycles (AMP). The frequency of NIRMS waveform deflections correlated highly with the frequency of visually observed chest movements (r = 0.99). Compared with a subjects baseline, a standard deviation of IBI > 3.0 s consistently identified time segments with three or more apnoeic events. The IBF and AMP differentiated respiratory from other body movements. An IBF > 20 cycles/s or an AMP > 0.4 V identified experimentally introduced body movements much more accurately than wrist accelerometry (NIRMS detected 99% of events, kappa = 0.90; WA detected 50%, kappa = 0.70). These findings support the use of the NIRMS in monitoring changes in breathing patterns during sleep, especially in frail and cognitively impaired subjects.

Quality of Life and Productivity in Nurses Reporting Migraine

A random sample survey was conducted to determine the prevalence of migraine in nurses and to study its effect on quality of life and productivity. Of the 10 000 nurses sampled, 2949 returned the questionnaire for a response rate of 29.5%. The majority (99%) of respondents were employed and worked in hospitals (60%). According to the International Headache Society (IHS) criteria, 17% of the sample (n=495) were classified as having migraine. An additional 25% (n=750) suffered severe headaches but did not meet IHS criteria for migraine, and the remaining 58% (n=1704) were classified as not having either migraine or severe headaches. The migraineurs had significantly reduced work productivity and quality of life compared to both the severe headache and the nonmigraine nonsevere headache groups. This study will increase awareness and sensitivity of the profession to its colleagues who are migraine sufferers.

Delirium in Hospitalized Older Patients With Cancer

PURPOSE/OBJECTIVES To examine key aspects of delirium in a sample of hospitalized older patients with cancer. DESIGN Secondary analysis of data from studies on acute confusion in hospitalized older adults. SETTING Tertiary teaching hospital in the southeastern United States. SAMPLE 76 hospitalized older patients with cancer (mean age = 74.4 years) evenly divided by gender and ethnicity and with multiple cancer diagnoses. METHODS Data were collected during three studies of acute confusion in hospitalized older patients. Delirium was measured with the NEECHAM Confusion Scale on admission, daily during hospitalization, and at discharge. Patient characteristics and clinical risk markers were determined at admission. MAIN RESEARCH VARIABLES Prevalent and incident delirium, etiologic risk patterns, and patient characteristics. FINDINGS Delirium was noted in 43 (57%) patients; 29 (38%) were delirious on admission. Fourteen of 47 (30%) who were not delirious at admission became delirious during hospitalization. Delirium was present in 30 patients (39%) at discharge. Most delirious patients had evidence of multiple (mean = 2.3) etiologic patterns for delirium. CONCLUSIONS Delirium was common in this sample of hospitalized older patients with cancer. Patients with delirium were more severely ill, were more functionally impaired, and exhibited more etiologic patterns than nondelirious patients. IMPLICATIONS FOR NURSING Nurses caring for older patients with cancer should perform systematic and ongoing assessments of cognitive behavioral performance to detect delirium early. The prevention and management of delirium hinge on the identification and treatment of the multiple risk factors and etiologic mechanisms that underlie delirium. The large number of patients discharged while still delirious has significant implications for posthospital care and recovery.

Cerebral Oxygenation in Wake and During Sleep and Its Relationship to Cognitive Function in Community-Dwelling Older Adults Without Sleep Disordered Breathing

BACKGROUND This descriptive cross-sectional study investigated the relationships between cerebral oxygen reserve and cognitive function in community-dwelling older adults. METHODS Participants (72 women and 40 men) underwent standard polysomnography, including regional measures of percent oxyhemoglobin saturation (rcSO(2)) determined by cerebral oximetry. Two variables were used to calculate cerebral oxygen reserve: (a) awake rcSO(2) (mean presleep rcSO(2)) and (b) the change in rcSO(2) from before sleep to the end of the first non-rapid-eye movement cycle. General linear models, adjusted for the effects of education and occupation, tested differences in performance on standard tests of memory, attention, and speed of mental processing. RESULTS Awake rcSO(2) values were normal (60%-79.9%) in 64 participants, marginal (50%-59.9%) in 41, and low (43%-49.9%) in 7. Participants with normal awake levels had higher cognitive function than those with low levels (p < .05). Changes in rcSO(2) were greatest in participants with marginal awake rcSO(2) values; among whom, those who increased rcSO(2) during sleep (n = 17) had better memory function than the 24 who did not (p < .05). CONCLUSIONS Low awake rcSO(2) values mark individuals with low cerebral oxygen reserves and generally lower cognitive function; marginal awake rcSO(2) values that fall during sleep may indicate loss of cerebral oxygen reserve and an increased risk for cognitive decline. Further studies may clarify the significance of and mechanisms underlying individual differences in awake rcSO(2) and the changes that occur in rcSO(2) while asleep.

A new non-invasive approach for monitoring respiratory movements of sleeping subjects

We have developed a minimally intrusive system to monitor respiratory movements of sleeping subjects. This system is based on a pressure transducer which measures the changes in air pressure inside an inflatable mattress on which the subject sleeps. Using a mechanical filter to protect the transducer against the large pressure changes due to sudden movements and subject weight, we can detect the more subtle movements of the subjects chest. This paper discusses the design of the monitoring system, including the design and modelling of the mechanical filter.

Delirium Resolution in Hospitalized Older Patients With Cancer

Delirium is a troubling complication in hospitalized older patients with cancer. Although preventable and potentially reversible, delirium may be prolonged. Persistent delirium at the time of hospital discharge is common and associated with multiple adverse outcomes. We conducted a secondary data analysis to examine delirium resolution in 43 hospitalized older patients with cancer who had prevalent or incident delirium. We describe trajectories of delirium resolution and evaluate differences in patients with and without delirium resolution. Delirium was assessed using the NEECHAM confusion scale. Forty-one of the 43 patients had delirium during hospitalization before discharge; 2 had delirium only at the time of discharge. Although delirium resolved in 13 patients, a significant majority (70%) had delirium at discharge. Patients with delirium resolution were less functionally impaired before hospitalization and exhibited fewer etiologic risk patterns at admission. Mild delirium was more likely to resolve than severe delirium. All patients with chronic cognitive impairment had persistent delirium. Care for hospitalized older patients with cancer should incorporate delirium prevention and intervention strategies. Caregiver education, communication between providers, and follow-up are critical when delirium persists. Additional research focusing on the management and impact of persistent delirium in hospitalized older patients with cancer is needed.

Cerebrovascular disease and patterns of cerebral oxygenation during sleep in elders.

Purpose: The aim of this descriptive exploratory study was to describe patterns of cerebral oxygen reserves during sleep and their association with cerebrovascular risk factors in elders. Method: Participants—115 elders, age 70 + years—were monitored overnight using standard polysomnography. Measures included arterial oxyhemoglobin (SaO2) and regional measures of percentage of cerebral oxyhemoglobin saturation (rcSO2) via cerebral oximetry. Participants were classified based on the magnitude of change in rcSO2 from resting baseline to the end of the first nonrapideye-movement (NREM) period. One-way ANOVA and Chi-square were used to test group differences in SaO2 and the prevalence of cerebrovascular risk factors. Findings: 20 participants (Group 1) experienced an increase in rcSO2 during sleep along with sleeping rcSO2 levels !55%; 95 participants experienced a decline in rcSO2; 72 participants (Group 2) had sleeping rcSO2 levels !55%; and 23 participants had sleeping rcSO2 levels <55% (Group 3). Although all three groups had equivalent declines in SaO2 levels during sleep, Group 3 had more cardiovascular comorbidity than Groups 1 and 2. Conclusions: Although SaO2 levels decline in most people during sleep, compensatory vascular responses to these drops in SaO2 are important for preventing rcSO2 from falling during sleep. Those entering sleep with lower baseline rcSO2 levels and those with greater declines in cerebral oxygenation during sleep may have greater cardiovascular burden and be at greater risk for stroke and other forms of disabling cerebrovascular disease.

Tailoring protocols to successfully recruit and retain older adults in a longitudinal study of sleep and cognition.

Many studies attest to the challenges of recruiting and retaining older adults in longitudinal studies. This article presents the methods used by the Physiological Research to Improve Sleep and Memory project to recruit and retain 115 adults (age 70 and older) in a 2-year study that involved annual administrations of two neurocognitive test batteries and two nights of polysomnography. Strategies built on knowledge obtained from participant informants and the use of tailored, individualized protocols are described. Together, these strategies enabled participants to become vested in the research process and to fully participate in all aspects of the study.

Exploratory analysis of cerebral oxygen reserves during sleep onset in older and younger adults.

OBJECTIVES: To explore differences in cerebral oxygen reserves during sleep in old and young adults.