Statewide survey to compare services provided for residents with dementia in special care units and non-special-care units.

To protect the consumer, consistency is needed in what one can expect when a long-term care facility (LTCF) advertises having an Alzheimer's special care unit (SCU). Arkansas recently passed disclosure legislation, which has led to the development of criteria for licensure of SCUs. This study compared the extent to which Arkansas LTCFs, with and without SCUs, met these criteria. We conducted a statewide survey of 238 LTCFs prior to the enforcement of these regulations and will conduct the same survey following their enforcement. Of the 147 (62 percent) facilities responding, 24 (16 percent) had a SCU. None of the LTCFs with SCUs met all the state criteria. The number and quality of services provided in SCUs and non-SCUs were similar.

A comparison study of multiple measures of adherence to HIV protease inhibitors.

BACKGROUND: Poor adherence to HIV protease inhibitors may compromise the effectiveness of treatment. Few studies have compared methods for measuring adherence or have related adherence measures to a clinical outcome. OBJECTIVE: To examine the relationship among a composite score of adherence, the three primary measures of adherence, and HIV virologic response. DESIGN: Longitudinal cohort study. SETTING: Public HIV clinic. PATIENTS: 108 HIV-infected adults receiving protease inhibitors or non-nucleoside reverse transcriptase inhibitors who were monitored for 666 monthly intervals. MEASUREMENTS: Medication Event Monitoring System (MEMS), pill count, and interview combined into a composite adherence score (CAS), and HIV viral load. RESULTS: Mean antiretroviral adherence differed by adherence measure (MEMS, 0.63; pill count, 0.83; interview, 0.93; and CAS, 0.76). Composite adherence score decreased significantly over time. Composite adherence score, MEMS values, pill values, and interview values were statistically significantly associated with achievement of an undetectable viral load within 6 months of initiating therapy. Composite adherence score showed the strongest predictive relationship (odds ratios for a 10% increase in adherence for CAS, MEMS, pill count, and interview, respectively, were 1.26 [95% CI, 1.16 to 1.37], 1.13 [CI, 1.06 to 1.21], 1.10 [CI, 1.02 to 1.19], and 1.35 [CI, 0.94 to 1.94]). CONCLUSIONS: Different measures applied to the same patient suggest different levels of adherence. Adherence may be underestimated by MEMS and overestimated by pill count and interview. A summary measure combining several measures is more strongly related to a clinical response, but more practical measurement methods are needed for clinical use.

Rural-urban differences in service use for memory-related problems in older adults.

The reduced availability of providers and travel difficulties in rural areas may thwart older rural adults from getting the care they need for memory-related problems. The purpose of this study was to determine whether rural-urban differences exist in the probability of any service use of primary care physicians and mental health specialists in a full sample of older adults and in a subset of impaired respondents. In the full sample, rural respondents were 0.66 times as likely (p = .06) to have used primary care physicians for memory-related problems compared with urban respondents. In the subgroup, rural individuals were 0.26 times as likely (p = .02). In both groups, there were no rural-urban differences in the probability of mental health specialty use for memory-related problems. Further investigations are necessary to determine the causes.

The effect of individualized activities on the sleep of nursing home residents who are cognitively impaired: a pilot study.

This pilot study investigated a program of individualized activities designed to enhance nocturnal sleep in five cognitively impaired veterans residing in a dementia care unit. Actigraphy documented 24-hour sleep-wake patterns of the residents for 3 days. Those meeting the criteria for inclusion then participated in an Individualized Activity Intervention timed to occur during peak napping times for 14 days. During the 10th, 12th, and 14th days of intervention, actigraphy provided a repeat measure of sleep-wake patterns. The results indicated an increase in nocturnal sleep with increased efficiency, as well as a decrease in daytime napping. This pilot study encourages further investigation of this potential method for enhancing nocturnal sleep in cognitively impaired elderly adults.

Infectious diseases in sports.

Participation in sports in on the increase; this article addresses the intersection of sports and infectious diseases. Some infections occur with increased incidence in sports; others have an increased impact in that setting. Addressed in this article are issues of diagnosis, prevention, and management of many of these infections. Included are skin/soft tissue infections, infections related to water exposure, viral infections, infections related to blood exposure, and vaccinations.

Psychosocial and behavioral interventions for Alzheimer's disease patients and their families.

In the absence of definitive treatments for Alzheimer's disease and related dementias, researchers in a variety of disciplines are developing psychosocial and behavioral intervention strategies to help patients and caregivers better manage and cope with the troublesome symptoms common in these conditions. These strategies include cognitive interventions, functional performance interventions, environmental interventions, integration of self interventions, and pleasure-inducing interventions. Although more research is needed to further develop these strategies and establish their best use, psychosocial and behavioral interventions hold great promise for improving the quality of life and well-being of dementia patients and their family caregivers.

The prospective effect of access to medical care on health-related quality-of-life outcomes in patients with symptomatic HIV disease.

OBJECTIVES: This study examined the prospective effect of reported access to medical care on health-related quality-of-life outcomes in patients with symptomatic human immunodeficiency virus (HIV) disease. METHODS: A cohort study was designed with interviews at baseline, follow-up interviews at 3 months after baseline, mortality follow-up through 6 months after baseline, and medical record reviews for selected baseline clinical data. Participants were HIV-infected patients who were receiving ambulatory and/or hospital care at one county-run municipal and one Veterans Administration hospital in metropolitan Los Angeles and were interviewed about access to medical care (using a reliable 9-item scale assessing affordability, availability, and convenience of medical care). Access to care reported by this sample was compared with that of 2,471 patients with other chronic diseases from the Medical Outcomes Study. The main outcome measures were composite scores for physical and mental health-related quality of life 3 months after baseline, derived from a validated 56-item instrument, scored from 0 to 100, and controlling for baseline health-related quality of life. RESULTS: Overall reported access to medical care in this sample was significantly poorer than that for patients with other chronic diseases (means scores were 63 and 73, respectively). The sample was categorized into tertiles of initial physical and mental health-related quality of life and into groups with initial high versus low access to care. Among those in the middle tertile of physical health-related quality of life at baseline, those with high access improved in physical health scores by 10.2 points relative to those with low access. Those in the low and middle tertiles of initial mental health improved in mental health to a significantly greater extent for those with high versus low access. There were nonsignificant trends toward similar effects for most other subgroups. The effects of access on health-related quality-of-life outcomes were generally robust in multivariate regression analyses that included CD4, hemoglobin, albumin, insurance status, and sociodemographic characteristics. CONCLUSIONS: Access to care at baseline predicted better physical and mental health outcomes at 3 months for those in the middle tertile of physical health and for those in the bottom and middle tertiles of mental health at baseline. Increasing access to care for poor public hospital patients with HIV infection may help to improve health-related quality-of-life outcomes among selected persons with advanced disease.

A multidisciplinary team approach to managing Alzheimer's disease.

Patients with Alzheimer's disease experience a range of symptoms that may overwhelm the patients, their families, and the people responsible for their care. With today's drive to reduce health care costs, any plan for managing these patients must produce maximum effectiveness at the lowest possible cost. A multidisciplinary team potentially offers both effective and efficient dementia care by eliminating duplicative or ineffective services and maintaining the optimum health of the patient and family.

Constitutional symptoms and health-related quality of life in patients with symptomatic HIV disease.

PURPOSE: To assess the severity of constitutional symptoms in persons with human immunodeficiency virus (HIV) infection, and their relationship to health-related quality of life (HRQOL). PATIENTS AND METHODS: Two hundred five HIV-infected patients (93% male, 26% African American, 28% Latino, 39% white, 7% other ethnicity) with diarrhea, fever, or weight loss were studied at a county hospital and a Veterans Administration hospital in southern California. Consenting subjects were administered a battery that included 11 scales measuring various aspects of health-related quality of life and detailed questions about six constitutional symptoms or symptom complexes (myalgias, exhaustion, anorexia/nausea/vomiting, night sweats, fever, and weight loss) as well as about other manifestations of HIV disease. RESULTS: Constitutional symptoms except weight loss were all strongly related to all measures of quality of life. On 0 (worst) to 100 (best) point scales, mean scores ranged from 34 (for individuals having all five symptoms other than weight loss) to 78 (for those with none) for physical function, 43 to 79 for emotional well-being, and 36 to 73 for social function. Adjustment for helper T-lymphocyte counts, duration of illness, and demographic characteristics did not diminish these associations. CONCLUSION: The presence, number, and severity of constitutional symptoms in HIV disease is strongly related to health-related quality of life in symptomatic HIV-infected individuals. Identifying and treating these very common symptoms has the potential to improve quality of life in these patients.

The effect of exercise training on aerobic fitness, immune indices, and quality of life in HIV+ patients.

PURPOSE: Thirty four HIV+ patients participated in a 6-wk aerobic exercise training program to determine whether exercise improved aerobic fitness, immune indices, and quality of life. METHODS: Subjects were assigned to three groups: control (no regular aerobic exercise), moderate exercise, and heavy exercise training. At study entry and exit (in each subject) we evaluated aerobic function with a symptom limited cardiopulmonary exercise test, immune indices with CD4 counts and Candida skin tests, viral replication with plasma HIV RNA measurements, and quality of life with a HIV+ population validated questionnaire. RESULTS: Aerobic fitness increased significantly in both exercise groups relative to the control group; immune indices changed very little among all three groups; however, the Candida skin tests (mm2) increased significantly in the moderate group; viral replication was essentially unchanged in all three groups; quality of life (QOL) markers improved in both exercising groups but not the control group. There were no opportunistic infections during the study. CONCLUSIONS: Exercise training resulted in a substantial improvement in aerobic function while immune indices were essentially unchanged. Quality of life markers improved significantly with exercise. Exercise training is safe and effective in this patient group and should be promoted for HIV+ patients.

Assessing functioning and self-care abilities in Alzheimer disease research.

Functional performance is a critical outcome to examine in dementia. The authors review some of the limitations of current research on functional performance and identify a conceptual framework for outcomes research. When considering conceptual frameworks to apply to functional assessment for outcomes research, five broad issues emerge: variability in definitions, an assumed equality between functional performance and capacity, measurement of global task abilities but not abilities for task components, lack of a contextual perspective, and use of a physical disability framework that excludes cognitive disability. When selecting assessment methods, researchers also must consider the implications of informant-based instruments and performance-based instruments. The authors also discuss a conceptual framework for evaluating current functional performance assessment instruments.

"I can do it!" Dressing: promoting independence through individualized strategies.

Caregivers contribute to loss of functional performance and dependency in cognitively impaired persons when they "do for," that is, dress the person instead of supporting independence in dressing. Persons with dementia have functional reserves that can be activated when caregivers use levels of assistance, standard, and problem-oriented strategies to support the person's cognitive and physical deficits. Use of these strategies requires less than one minute of additional caregiver time and leads to positive outcomes for the person and the caregiver.

Brain lesions in patients with AIDS: H-1 MR spectroscopy.

PURPOSE: To evaluate the role of proton (hydrogen-1) magnetic resonance (MR) spectroscopy in the differential diagnosis of focal brain lesions in patients with acquired immunodeficiency syndrome (AIDS). MATERIALS AND METHODS: Twenty-six men with 35 AIDS-related brain lesions underwent MR imaging and localized H-1 MR spectroscopy. Lesions consisted of 11 toxoplasmic abscesses, 12 progressive multifocal leukoencephalopathic lesions, eight lymphomas, and four cryptococcomas. Metabolite peak areas in the lesions were compared with those in the contralateral hemisphere in each patient. RESULTS: H-1 MR spectroscopic findings showed significantly different biochemical profiles for each diagnostic group (P = .0001) with regard to N-acetyl compounds, total creatine pool, choline-containing compounds, myoinositol, and lactate. H-1 MR spectroscopy alone helped correctly diagnose 94% (84% with jackknifed classification) of the brain lesions, without overlap between toxoplasmosis and lymphoma. CONCLUSION: H-1 MR spectroscopy is a sensitive and potentially specific noninvasive adjunctive method for differential diagnosis of focal brain lesions in AIDS.

Validation of a new measure of diarrhea.

Adequate measures of diarrheal disease are important to assess severity for clinical use and outcomes research. We developed a questionnaire to assess diarrhea severity and complications, and administered it to 205 HIV positive patients with diarrhea, fever, or weight loss. Noteworthy variations in stool form were reported by individuals and across subjects. Self-reported diarrhea correlated with the occurrence of any stool pictured without form. However, verbal descriptors "loose" and "semiformed" had little value in assessment of diarrheal disease. Both verbal and pictorial stool descriptors correlated well with diarrhea complications (pain, urgency, tenesmus, incontinence, and nocturnal diarrhea). By factor analysis, discomfort and nondiscomfort diarrhea complications loaded on different factors, consistent with clinical experience that discomfort is a distinct problem in diarrheal disease. In summary we have developed an instrument to precisely characterize diarrhea severity that correlates well with clinically important events such as incontinence and abdominal pain.

Interventions for treating disruptive behavior in demented elderly people.

Studies aimed at explaining and decreasing disruptive behaviors need to be designed within conceptual frameworks. A number of researchers provide examples of such efforts. Meddaugh is examining the theory of reactance, Matteson et al are examining Piagetian concepts (personal communication, 1992), and Hurley is examining the concept of resistance. Such efforts will serve to enlighten our understanding of the dynamics of disruptive behavior and eventually may result in a common multicausal conceptualization of its cause. Additional study of the cause of disruptive behaviors also is needed. Currently the explanations for disruptive behaviors involve a variety of conceptual frameworks with little consistency among studies. Furthermore, many studies designed to decrease these behaviors do not clearly base their interventions on conceptual explanations for the behaviors. Studies aimed at explaining and decreasing disruptive behaviors need to be designed within conceptual frameworks. A number of researchers provide examples of such efforts. Meddaugh is examining the theory of reactance, Matteson et al are examining Piagetian concepts (personal communication, 1992), and Hurley is examining the concept of resistance. Such efforts will serve to enlighten our understanding of the dynamics of disruptive behavior and eventually may result in a common multicausal conceptualization of its cause. This developing conceptualization of causes needs to encompass biologic as well as psychosocial explanations. A number of researchers are conducting studies that will contribute to the understanding of the role of biologic factors. Examples of such efforts include Kolanowski's and Satlin et al's work on the effects of artificial lighting on disruptive behavior and Meddaugh's study of the role of exercise. As interventions are designed for decreasing disruptive behaviors, systems of care that use these interventions need to be evaluated for their cost effectiveness and their impact on quality of life.

Cognitive impairment in the elderly.

This article reviews research related to assessment and interventions for cognitive impairment conducted by nurses as principal and coinvestigators. It focuses on the broad areas of delirium and dementia, which are divided into assessment and intervention-related research. The intervention research begins with descriptive studies and has subdivisions for primary and secondary symptoms. Ideas for future research follow.

Beyond the Role of ExtenderIndependent and Interdependent Contributions of Nursing to Geriatric Rehabilitation.

Too often, the role of nursing in geriatric neurorehabilitation is defined in terms of extending the care of other disciplines and assuring continuity of selected aspects of care over 24 hours. This article argues that nursing has made significant clinical and scientific progress in contributing, independently and interdependently, to quality rehabilitation care for older adults; and that the role of nursing clearly exceeds the realm of mere extension and continuity of care. Reviewed are nursing's innovations in the areas of promoting comprehensive assessment; fostering functional independence, self-care, and self-care agency; enhancing communication; encouraging family involvement; improving cognitive status; and assuring quality physical care. We conclude with a discussion of the relationship of nursing to other disciplines, and how nursing's contributions can be optimized within the broader context of multidisciplinary geriatric rehabilitation.