Caregivers of Alzheimer's patients and factors influencing institutionalization of loved ones: some considerations on existing literature.

BACKGROUND: Informal caring or caregiving is very common in our postindustrial society. Caregiving burden grows with the worsening of cognitive impairment of the patient and is one of the factors influencing institutionalization. Alzheimer's disease (AD) is a type of dementia that is chronic and deteriorative. The symptoms of this neuropsychiatric disorder generally begin to manifest after the age of sixty and currently 8.9 million family caregivers provide assistance to someone with AD or a related dementia. As the patient's condition worsens, it increases the burden on the caregivers, due to the physical, psychological, and emotional stresses that result from caring for the patient. METHODS: A search of the literature was conducted on electronic database: PubMed, Google Scholar, Science direct, CINAHL in a exploratory way. Inclusion criteria were: articles in English and Italian published between 1999-2011 which mentioned Alzheimer's caregivers, burden, stressors, and institutionalization. The exclusion criterion was failure to mention the word "caregivers". About 100 titles were found and 30 articles abstracts with key words in the title were reviewed. Of the 30 articles selected for further review based on the relevance to the study purpose, 17 articles were finally selected for inclusion in this literature review. RESULTS: Results display that caregiver burden is influenced by patient behavioral and cognitive status, hours involved in care, stress, social isolation, gender, relationship to the patient, availability of support resources, and caregiver characteristics. Assessment tools available to assess and recognize risk factors and burden in caregivers are useful both in terms of caregivers health and decision on istitutionalization. CONCLUSION: Literature suggests to provide information for health care providers to reduce burden and support caregiver health and well-being. Assessment tools available to assess and recognize risk factors and burden in caregivers should be used more often to contribute to reducing caregiver stress and the impact of institutionalization.

Immersion research education: students as catalysts in international collaboration research.

BACKGROUND: This paper describes an international nursing and health research immersion program. Minority students from the USA work with an international faculty mentor in teams conducting collaborative research. The Minority Health International Research Training (MHIRT) program students become catalysts in the conduct of cross-cultural research. AIM: To narrow the healthcare gap for disadvantaged families in the USA and partner countries. METHODS: Faculty from the USA, Germany, Italy, Colombia, England, Austria and Thailand formed an international research and education team to explore and compare family health issues, disparities in chronic illness care, social inequities and healthcare solutions. USA students in the MHIRT program complete two introductory courses followed by a 3-month research practicum in a partner country guided by faculty mentors abroad. The overall program development, student study abroad preparation, research project activities, cultural learning, and student and faculty team outcomes are explored. RESULTS: Cross-fertilization of research, cultural awareness and ideas about improving family health occur through education, international exchange and research immersion. Faculty research and international team collaboration provide opportunities for learning about research, health disparities, cultural influences and healthcare systems. The students are catalysts in the research effort, the dissemination of research findings and other educational endeavours. Five steps of the collaborative activities lead to programmatic success. CONCLUSIONS: MHIRT scholars bring creativity, enthusiasm, and gain a genuine desire to conduct health research about families with chronic illness. Their cultural learning stimulates career plans that include international research and attention to vulnerable populations.

Differential access in the receipt of antiretroviral drugs for the treatment of AIDS and its implications for survival.

BACKGROUND: Recently published research based on selected samples of patients treated at human immunodeficiency virus clinics documents that use of more intensive antiretroviral drug therapies is responsible for significant declines in morbidity and mortality in persons living with human immunodeficiency virus or acquired immunodeficiency syndrome (PLWHAs). In this study, we evaluate whether receipt of more recently developed antiretroviral therapies varies by sex and race/ethnicity in a large population-based sample of PLWHAs and whether receipt of such drugs has any impact on survival. METHODS: Analysis of Florida Medicaid eligibility, enrollment, and claims data for PLWHAs for 1993 through 1997. Receipt of 2 nucleoside analogs (TWONUKES) and receipt of 1 protease inhibitor and a nucleoside combination (PI+NUKES) was constructed from claims data. The probability of dying was constructed from eligibility and enrollment data. RESULTS: The probabilities of receiving TWONUKES and PI+NUKES are 0.16 and 0.09, respectively, lower for women relative to men (P<.01 for both). Blacks are more likely to receive TWONUKES than whites, whereas the reverse is true for Hispanics; this probability is almost 0.04 higher for blacks and 0.03 lower for Hispanics relative to whites (P<.01). In contrast, blacks are significantly less likely to receive PI+NUKES (P<.01). Both drug variables have large statistically significant negative effects on the probability of death. The PLWHAs who received PI+NUKES are 60% as likely to die each month (P<.01). Receipt of TWONUKES lowers the relative hazard of death by close to 66% each month (P<.01). Survival varies significantly by sex and race/ethnicity. Controlling for receipt of drug therapy and diagnosed health throughout the period, women are 56% as likely to die as men (P<.01). Hispanics are almost 14% less likely to die each month relative to whites (relative hazard, 0.87), and blacks are 20% more likely to die than whites (relative hazard, 1.21). CONCLUSIONS: States need to investigate why women are less likely to receive antiretroviral drug therapies than men and to consider policies that might foster better access to antiretroviral therapies for women with acquired immunodeficiency syndrome because these efforts might yield even further reductions in mortality in women. Given the large reductions in mortality that accompany receipt of antiretroviral therapies, states need to foster policies that promote widespread use of new drug treatment protocols.

Effects of case management and new drugs on Medicaid AIDS spending.

This study evaluates the effects of Florida's participation in the Medicaid acquired immunodeficiency syndrome (AIDS) home and community-based waiver and the use of recently developed AIDS drugs on spending per Medicaid beneficiary. We find that monthly Medicaid spending for waiver non-participants was significantly higher than was spending for waiver nonparticipants. The major reason for the cost difference is that nonwaiver enrollees incurred significantly higher inpatient costs than did those enrolled in the waiver. Although waiver enrollees had higher drug spending, these represent only a fraction of the higher inpatient costs incurred by nonwaiver enrollees. Thus, it appears that adherence to appropriate medications reduces the need for inpatient care. The case management approach of the AIDS waiver may have similar effects for persons with other chronic diseases.

Cytokines in human breast cancer: IL-1alpha and IL-1beta expression.

We hypothesize that interleukin 1alpha (IL-1alpha) and interleukin 1beta (IL-1beta) are present and tumor cell associated in human breast cancer (HBC) specimens. To test our hypothesis: a) immunologic analysis was performed on HBC histologic sections for IL-1alpha (n=49) and IL-1beta (n=42) distribution; and b) homogenates of HBC tumors were analyzed for levels of IL-1alpha (n=82), IL-1beta (n=101) and interleukin 8 (IL-8) (n=103) expression. Immunohistochemical analysis demonstrated the presence of IL-1alpha and IL-1beta in tumor cells in patients with invasive cancer and ductal carcinoma in situ. Quantitative analysis confirmed the presence and positive correlation of IL-1alpha and IL-1beta to IL-8, a known angiogenic factor, in cancer specimens. These studies demonstrate that tumor-associated IL-1alpha+, IL-1beta are present in the tumor microenvironment and may play a pivotal role in regulating breast tumor growth and metastasis.

Expression of interleukin-8 receptors on tumor cells and vascular endothelial cells in human breast cancer tissue.

UNLABELLED: Recently, we demonstrated the presence of Interleukin-8 (IL-8) in human breast cancer (HBC) tissue. We hypothesize that the IL-8 receptors are present and play a role in tumor cell and vascular endothelial cell (VEC) activation (e.g. proliferation and angiogenesis). MATERIALS AND METHODS: Immunohistochemical analysis for IL-8 receptors (IL-8RA and IL-8RB) was performed on 43 malignant and 8 benign breast tissue samples. RESULTS: Tumor cells expressed IL-8RA and IL-8RB in all of the malignant specimens. Only 50% of the benign ductal epithelial cell (DEC) samples expressed these receptors. The majority of small vessel endothelial cells (SVEC) expressed IL-8RA and IL-8RB, while large vessel endothelial cells (LVEC) showed primarily IL-8RB expression. CONCLUSIONS: Our results demonstrate that tumor and VEC express the IL-8 receptors and likely play a role in regulating tumor and VEC activation which controls proliferation, angiogenesis and metastasis in HBC.

Expenditures on services for persons with acquired immunodeficiency syndrome under a Medicaid home and community-based waiver program. Are selection effects important?

OBJECTIVES: In 1990, the state of Florida implemented an acquired immunodeficiency syndrome (AIDS)-specific Medicaid waiver program to provide home and community-based services to AIDS patients as an alternative to institutional care. The program is available to Medicaid beneficiaries with AIDS who are at risk of institutionalization. This study examines whether the waiver option was effective in reducing Medicaid expenditures per beneficiary during its first 2 years of operation. METHODS: The authors used Medicaid claims data and county information on the availability of health services to model the selection of the waiver option by AIDS patients and then to estimate the effect of the waiver on expenditures controlling for nonrandom program selection. RESULTS: The results indicate that the selection model is highly significant, but that the influence of nonrandom selection on the estimation of the program effects is negligible. More importantly, the regression results indicate that persons with AIDS who use waiver services incur monthly Medicaid expenditures that are on average 22% to 27% lower than otherwise similar nonparticipants. CONCLUSIONS: These results, based on the first 2 years that Project AIDS Care was operational, suggest that home and community-based care for AIDS patients results in lower expenditures per beneficiary.

The influence of illness severity and family resources on maternal uncertainty during critical pediatric hospitalization.

BACKGROUND: Psychological management of parents during a child's critical illness is a challenge to intensive care nurses because of the uncertainty that accompanies hospitalization. OBJECTIVE: To explore the relationship among illness severity, family resources, and maternal uncertainty during the initial stage of a child's hospitalization in a pediatric intensive care unit for a life-threatening illness. METHODS: A convenience sample of 40 mothers rated perceptions of uncertainty (using Mishel's Uncertainty of Illness Scale: Parent Child Form), family cohesion (using Olson's Family Adaptability and Cohesion Evaluation Scale), and social support (using Norbeck's Social Support Questionnaire). Illness severity was estimated with the Pediatric Risk of Mortality Scale. RESULTS: ¿ Results showed a positive association between illness severity and maternal uncertainty and a negative association between family cohesion and maternal uncertainty. Severity of illness contributed less to maternal uncertainty than did family cohesion. CONCLUSIONS: Family relationship are important factors to consider when clinicians estimated the effect on parents of their child's critical illness, particularly when uncertainty over their child's outcome may lead to parental stress that can interfere with coping and child management. (American Journal of Critical Care.)

Children's temperament at 3 months and 6 years old: stability, reliability, and measurement issues.

This study examined the stability of temperament characteristics in children over a 6-year period as well as the reliability of Rothbart's infant and child temperament measures. Thirty-seven mothers rated their firstborns' temperaments using the Infant Behavior Questionnaire (IBQ) at 3 months and the Children's Behavior Questionnaire (CBQ) at 6 years of age. Paired t tests between matched IBQ/CBQ subscales revealed that children were rated significantly higher in all behavioral subscales at 6 years, with the exception of Soothability, which remained stable. Correlations among matched IBQ/CBQ subscales showed significant positive relationships between Soothability and Smiling over the 6-year period. Estimates of internal consistency on three of the six IBQ subscales were lower than Rothbart's reported values, whereas the CBQ values were similar. Findings suggest there was not long-term stability in temperament estimates from early infancy to childhood, except in positive affective response to the environment and rate of recovery from distress and excitement. Measurement issues related to using the IBQ/CBQ, assessing temperament at an early age, maturational effects, and implications for practice are discussed.

Patients with dementia involving families to maximize nursing care.

Incorporating family members in the care of patients with dementia provided pertinent psychosocial data, led to mutual decision-making regarding care, and produced changes in the responses of the residents with dementia, as well as in the family and nursing staff. The experimental group experienced increases in psychosocial nursing diagnoses with planning and interventions to meet the problems, more extensive problem description, and an active focus on interaction and change in the nurse's notes. As a result of collaborative nursing and family involvement, personal articles were brought from home; family collateral visits and interaction increased; families were more involved in the unit, medical center, and support groups; and p.r.n. medication use was decreased. As health-care technology prolongs the life of patients with chronic illness and sequelae such as dementia, nurses will need to continue to include families as collaborators in providing quality care.

The family health system as an emerging paradigmatic view for nursing.

This paper explores the phenomena of family health from a nursing perspective by examining the view of health in the discipline of nursing, and the view of family health in multiple disciplines. A holistic definition of family health for nursing is proposed which includes five realms of family experience which make up the family health system. The proposed classification is offered as a beginning heuristic model to organize knowledge generation for use in the practice of family nursing.

Mental health and the labor force participation of older workers.

Over the past 20 years, while mortality rates have dramatically declined, the prevalence of work-related stress has increased. This phenomenon suggests that the population's physical health has improved, but mental health has deteriorated. Concomitantly, fewer older workers are participating in the labor force. Our paper, using data from the Epidemiologic Catchment Area (ECA) program, assesses whether the decline in numbers of older workers is linked to the increasing prevalence of job-related stress. Our results indicate that symptoms of poor mental health are the most important determinants of work behavior. Surprisingly, economic and demographic characteristics appear to have little impact on an individual's labor force participation status. Further research is needed, however, because the ECA data provides insufficient information to accurately assess the relative importance of both mental health and economic factors on the retirement decision.

Age at marriage in Malaysia: a hazard model of marriage timing.

"This paper estimates a proportional hazards model for the timing of age at marriage of women in Malaysia. We hypothesize that age at marriage responds significantly to differences in male and female occupations, race, and age. We find considerable empirical support for the relevance of economic variables in determining age at marriage as well as evidence of strong differences in marriage patterns across races."

The effect of health programs on breastfeeding and child mortality in Peninsular Malaysia.

PIP: Examining household behavior in Peninsular Malaysia, this study attempts to determine if the availability of certain government health programs significantly alters breastfeeding and if these changes in input prices significantly affect mortality rates and fertility decisions. To explain the interrelationships, an economic model of the demand for infant survival and fertility and the derived demand for breastfeeding is developed. Using household and community level data, the demand equations are then estimated and the results discussed in relation to the predictions of the model and the prospect of additional government inputs. The theoretical model predicts that, if income effects are small: a decline in the price of children (hospital distance) will increase fertility, decrease survival and reduce breastfeeding; a decline in the price of health goods inputs (hospital distance and sanitation) will reduce fertility and increase survival; and a decline in the price of contraceptives (family planning distance) will reduce fertility but increase survival and breastfeeding. The empirical results support some of the model's predictions. In communities with modern sanitation, breastfeeding was shorter on average, as predicted, but differences in mortality were not detected and fertility was actually higher. The latter effect can result from an income effect in the price decline that exceeds the cross substitution effect. Distance to a hospital was positively associated with breastfeeding length. This is expected if the effect of distance on the price of children exceeds the effect of distance on the price of survival. Hospital distance had no impact on either survival or fertility. Distance to a family planning clinic had no effect on breastfeeding or fertility but had a slight positive association with mortality. This positive relationship is expected if fertility and survival are substitutes. Parental schooling and race also are important in determining demand. As economic development proceeds and educational attainment increases, breastfeeding and fertility declined and survival increased. The Chinese, the wealthiest racial group, had lower fertility and mortality and breastfed less than Malays or Indians. The empirical results failed to support the prediction of differences in male and female survival. The results suggest some interesting implications. If breastfeeding has been declining in low income countries such as Malaysia as they develop, the culprit may be the economic development process itself, which increases the value of a woman's time and raises family income. The decline in breastfeeding does not necessarily imply a significant increase in infant mortality if good substitutes for breastfeeding exist. In addition, breastfeeding is highly substitutable with many government programs designed to reduce mortality. In designing policies which will bring about a decline in infant mortality rates, both cross substitution and joint production must be considered. Programs that can be most successful in reducing mortality will be the programs that are the least substitutable with breastfeeding.^ieng

Marriage and labor market discrimination in Japan.

"Many Japanese firms have engaged in the practice of compulsory retirement upon a female employee's marriage. In 1966, this practice was ruled as being contrary to provisions in Japan's Civil Code. [The authors] have specified and estimated a model of the economic determinants of age at marriage in order to analyze the effect that this discrimination has had on nuptiality in Japan. [The] results indicate that on average, after accounting for an upward trend, women who married after the 1966 court decision married about one year younger than women who married before 1966." It is also found that age at marriage is influenced by several socioeconomic variables, including wife's wage and educational level, husband's income and educational level, and wife's family background. Data are from a 1975 survey of women aged 20-59 who were living in the Tokyo metropolitan area.