"Being careful": How much caution is enough? The relational context of fear of older adult falling in older adult-family caregiver dyads.

Family caregivers play an important role in coping with older adult falls; however, their perspectives on fear of older adult falling are lacking from the falls prevention literature. A mixed-method design (N=25 dyads) with interview and survey data examined linguistic characteristics and coping strategies used by older adult and family caregiver dyads to manage fear of older adult falling. Fear of older adult falling consisted of both affective (e.g., worry) and cognitive (e.g., cautious) properties. Family caregivers more frequently used affective words and first-person plural pronouns ("we" language) when talking about fear of older adult falling, while older adults more frequently used cognitive and first-and-second person singular pronouns ("I", "you"). The concept of "being careful" was shared within dyads. However, dyad partners differed in their perspectives of what constituted "being careful" and the possibilities of future falling. Findings suggest that the need for family-centered interventions to prevent falls are needed.

Is fall self-efficacy an independent predictor of recurrent fall events in older adults? Evidence from a 1-year prospective study.

Falls, which are prevalent among older adults, may not only cause severe physical injuries, but also lead to low fall self-efficacy (FSE). Low FSE is associated with restricted activity, which putatively increases risk of future falls. However, emerging studies have failed to confirm this association. Furthermore, the interplay between age, gender, and fall history with falls has not been adequately addressed in adults aged 70 years or older. The aims of this secondary analysis were to: (1) prospectively explore the association of FSE and fall events considering age, gender, and fall history, and (2) examine the characteristics of fall events and fall-related outcomes. Forty-seven community-dwelling adults over 70 years of age were followed for about 12 months. During the follow-up, 22 participants with low FSE experienced 119 fall events whereas 25 participants with high FSE reported 106 fall events. Among fallers, 72.3% (n = 34) experienced recurrent fall events. About 15.0% (n = 34) of 225 fall events resulted in injuries and 4.0% of injuries required medical care. FSE was a statistically significant predictor of future fall events (incident rate ratio = 0.96, p = .013) regardless of age, gender, and fall history. Participants with low FSE were more likely than those with high FSE to fall more frequently without noticeable prodromal symptoms and apparent reasons. These findings suggest that FSE is an important protective factor against future fall events. However, interpretation of these results requires caution given the small sample size and effect size.

Fear of older adult falling questionnaire for caregivers (FOAFQ-CG): Evidence from content validity and item-response theory graded-response modelling.

AIMS: (1) Determine the content validity of the Fear of Older Adult Falling Questionnaire-Caregivers using a panel of gerontological experts and a target sample of family caregivers (Stage 1) and (2) Examine the response patterns of the Fear of Older Adult Falling Questionnaire-Caregivers and compare it with older adult version of Fear of Falling Questionnaire Revised using graded-response modelling (Stage 2). DESIGN: Cross-sectional mixed-method design. METHODS: Five content experts and 10 family caregivers were involved in the Stage 1 study and 53 family caregiver-older adult dyads (N = 106) were included in the Stage 2 study. The content-validity index and graded-response modelling were used to analyse data. RESULTS: Among experts, the Fear of Older Adult Falling Questionnaire-Caregivers content-validity index for relevancy, importance, and clarity of individual items and total scale ranged from 0.60-1.00 and from 0.77-0.87, respectively. Among family caregivers, the ratings of the item and scale level content-validity index for relevancy, importance, and clarity ranged from 0.90-1.00 and from 0.95-0.97, respectively. Combining feedback from both groups, we revised one item. Subsequently, the graded-response modelling revealed that a 1-factor, 3-item version of the Fear of Older Adult Falling Questionnaire-Caregivers had acceptable psychometric properties. CONCLUSIONS: The brief 3-item version of the Fear of Older Adult Falling Questionnaire-Caregivers is promising for assessing caregivers' fear of their older adult care recipient falling. IMPACT: A significant concern for family caregivers is fearing that older adult care recipients will fall, but a lack of validated measures limits the study of this phenomena. A 3-item version of the Fear of Older Adult Falling Questionnaire-Caregivers has the potential to identify family caregivers with high fear of older adult falling so that fall risk can be appropriately assessed and addressed.

The mediating role of power distance and face-saving on nurses' fear of medication error reporting: A cross-sectional survey.

BACKGROUND: The fear of social and professional consequences is a significant barrier to medication error reporting among nurses. Although some studies have identified cultural factors as playing a significant role in medication error reporting, little is known about the mechanisms by which these cultural characteristics influence the relationship between patient safety emphasis and the fear of medication error reporting. OBJECTIVES: (1) Identify nurses' perceptions of patient safety emphasis, face-saving, power distance, and fear of medication error reporting; and (2) explore face-saving and power distance as the underlying mechanisms for cultural factors in the relationship between nurses' perceptions of safety emphasis and the fear of medication error reporting. DESIGN: A cross-sectional, descriptive, and correlational design. SETTINGS: Three tertiary teaching hospitals located in China, including one children's hospital and two adult hospitals. PARTICIPANTS: We recruited a total of 569 female registered nurses with at least one year of work experience. Most of the participants (73.8%) were junior nurses with mid-associate or associate degrees (55.4%). METHODS: Participants completed four questionnaires, including Safety Emphasis subscales from the Safety Climate Scale, Face-Saving Scale, the Index of Hierarchy of Authority, and the Nurses' Fear of Medication Error Reporting. RESULTS: The average scores of safety emphasis, face-saving, power distance, and the fear of medication error reporting were 20.27 (SD=2.36), 14.63 (SD=3.57), 17.36 (SD=3.49), and 18.92 (SD=4.20), respectively. There were no demographic characteristics associated with these variables, except education (B=-0.16, p = 0.013) and work experience (B=-0.14, p = 0.019), which were related to power distance. Face-saving and power distance were significant mediators that explained the effect of safety emphasis on nurses' fear of medication error reporting. The overall indirect effect for both mediators was statistically significant (ß=-0.27, p<0.05). When we compared the specific mediators' indirect effects, face-saving was a more powerful mediator than power distance (ß=-0.24 vs. ß=-0.04). These mediation effects remained after we adjusted for the effects of education and work experience on power distance. CONCLUSIONS: When nurses have a common cultural background, they tend to perceive similar barriers to medication error reporting. For this study, face-saving and power distance are the two most important cultural factors because they significantly influence the relationship between safety emphasis and the fear of medication error reporting among Chinese nurses. It may not be possible to develop a work culture that minimizes fears of medication error reporting without first addressing face-saving needs and power differences.

Predicting Pressure Injury in Critical Care Patients: A Machine-Learning Model.

BACKGROUND: Hospital-acquired pressure injuries are a serious problem among critical care patients. Some can be prevented by using measures such as specialty beds, which are not feasible for every patient because of costs. However, decisions about which patient would benefit most from a specialty bed are difficult because results of existing tools to determine risk for pressure injury indicate that most critical care patients are at high risk. OBJECTIVE: To develop a model for predicting development of pressure injuries among surgical critical care patients. METHODS: Data from electronic health records were divided into training (67%) and testing (33%) data sets, and a model was developed by using a random forest algorithm via the R package "randomforest." RESULTS: Among a sample of 6376 patients, hospital-acquired pressure injuries of stage 1 or greater (outcome variable 1) developed in 516 patients (8.1%) and injuries of stage 2 or greater (outcome variable 2) developed in 257 (4.0%). Random forest models were developed to predict stage 1 and greater and stage 2 and greater injuries by using the testing set to evaluate classifier performance. The area under the receiver operating characteristic curve for both models was 0.79. CONCLUSION: This machine-learning approach differs from other available models because it does not require clinicians to input information into a tool (eg, the Braden Scale). Rather, it uses information readily available in electronic health records. Next steps include testing in an independent sample and then calibration to optimize specificity.

Individual versus interprofessional team performance in formulating care transition plans: A randomised study of trainees from five professional groups.

Health professions trainees' performance in teams is rarely evaluated, but increasingly important as the healthcare delivery systems in which they will practice move towards team-based care. Effective management of care transitions is an important aspect of interprofessional teamwork. This mixed-methods study used a crossover design to randomise health professions trainees to work as individuals and as teams to formulate written care transition plans. Experienced external raters assessed the quality of the written care transition plans as well as both the quality of team process and overall team performance. Written care transition plan quality did not vary between individuals and teams (21.8 vs. 24.4, respectively, p = 0.42). The quality of team process did not correlate with the quality of the team-generated written care transition plans (r = -0.172, p = 0.659). However, there was a significant correlation between the quality of team process and overall team performance (r = 0.692, p = 0.039). Teams with highly engaged recorders, performing an internal team debrief, had higher-quality care transition plans. These results suggest that high-quality interprofessional care transition plans may require advance instruction as well as teamwork in finalising the plan.

Midrange Braden Subscale Scores Are Associated With Increased Risk for Pressure Injury Development Among Critical Care Patients.

PURPOSE: The purpose of the current study was to examine the relationship between pressure injury development and the Braden Scale for Pressure Sore Risk subscale scores in a surgical intensive care unit (ICU) population and to ascertain whether the risk represented by the subscale scores is different between older and younger patients. DESIGN: Retrospective review of electronic medical records. SUBJECTS AND SETTING: The sample comprised patients admitted to the ICU at an academic medical center in the Western United States (Utah) and Level 1 trauma center between January 1, 2008 and May 1, 2013. Analysis is based on data from 6377 patients. METHODS: Retrospective chart review was used to determine Braden Scale total and subscale scores, age, and incidence of pressure injury development. We used survival analysis to determine the hazards of developing a pressure injury associated with each subscale of the Braden Scale, with the lowest-risk category as a reference. In addition, we used time-dependent Cox regression with natural cubic splines to model the interaction between age and Braden Scale scores and subscale scores in pressure injury risk. RESULTS: Of the 6377 ICU patients, 214 (4%) developed a pressure injury (stages 2-4, deep tissue injury, or unstageable) and 516 (8%) developed a hospital-acquired pressure injury of any stage. With the exception of the friction and shear subscales, regardless of age, individuals with scores in the intermediate-risk levels had the highest likelihood of developing pressure injury. CONCLUSION: The relationship between age, Braden Scale subscale scores, and pressure injury development varied among subscales. Maximal preventive efforts should be extended to include individuals with intermediate Braden Scale subscale scores, and age should be considered along with the subscale scores as a factor in care planning.

Eccentric versus traditional resistance exercise for older adult fallers in the community: a randomized trial within a multi-component fall reduction program.

BACKGROUND: Addressing muscle deficits within a multi-component exercise fall reduction program is a priority, especially for the highest risk older adults, i.e., those who have fallen previously. Eccentric resistance exercise with its high-force producing potential, at a low energetic cost, may be ideally-suited to address muscle impairments in this population. The purpose of this study was to compare the effects of resistance exercise via negative, eccentrically-induced, work (RENEW) versus traditional (TRAD) resistance exercise on mobility, balance confidence, muscle power and cross sectional area, as well as the number of days high fall risk older adults survived without a fall event over a 1 year period. METHODS: Randomized, two group, four time point (over 1 year) clinical trial testing RENEW versus TRAD as part of a 3 month multi-component exercise fall reduction program (MCEFRP). Primary outcomes of mobility, balance confidence, muscle power output and cross sectional area were analyzed using mixed effects modeling. The secondary outcomes of days to fall and days to near-fall were analyzed using survival analysis. RESULTS: The MCEFRP did have an effect on fall risk factors considered reversible with exercise interventions though there was no differential effect of RENEW versus TRAD (p = 0.896) on mobility, balance confidence, muscle power and cross sectional area. There were also no group differences in the number of days survived without a fall (p = 0.565) or near-fall (p = 0.678). Despite 100% of participants having at least one fall in the year prior to the MCEFRP, however, after 3 months of exercise and 9 months of follow-up <50% had experienced a fall or near fall. CONCLUSIONS: There were no differential effects of RENEW or TRAD as components of a MCEFRP on the primary or secondary outcomes. The two modes of resistance exercise had identical effects on fall risk and fall-free survival. TRIAL REGISTRATION: NCT01080196 ; March 2, 2010 (retrospectively registered).

Risk factors for pressure injuries among critical care patients: A systematic review.

OBJECTIVE: To identify risk factors independently predictive of pressure injury (also known as pressure ulcer) development among critical-care patients. DESIGN: We undertook a systematic review of primary research based on standardized criteria set forth by the Institute of Medicine. DATA SOURCES: We searched the following databases: CINAHL (EBSCOhost), the Cochrane Library (Wilson), Dissertations & Theses Global (ProQuest), PubMed (National Library of Medicine), and Scopus. There was no language restriction. METHOD: A research librarian coordinated the search strategy. Articles that potentially met inclusion criteria were screened by two investigators. Among the articles that met selection criteria, one investigator extracted data and a second investigator reviewed the data for accuracy. Based on a literature search, we developed a tool for assessing study quality using a combination of currently available tools and expert input. We used the method developed by Coleman et al. in 2014 to generate evidence tables and a summary narrative synthesis by domain and subdomain. RESULTS: Of 1753 abstracts reviewed, 158 were identified as potentially eligible and 18 fulfilled eligibility criteria. Five studies were classified as high quality, two were moderate quality, nine were low quality, and two were of very low quality. Age, mobility/activity, perfusion, and vasopressor infusion emerged as important risk factors for pressure injury development, whereas results for risk categories that are theoretically important, including nutrition, and skin/pressure injury status, were mixed. Methodological limitations across studies limited the generalizability of the results, and future research is needed, particularly to evaluate risk conferred by altered nutrition and skin/pressure injury status, and to further elucidate the effects of perfusion-related variables. CONCLUSIONS: Results underscore the importance of avoiding overinterpretation of a single study, and the importance of taking study quality into consideration when reviewing risk factors. Maximal pressure injury prevention efforts are particularly important among critical-care patients who are older, have altered mobility, experience poor perfusion, or who are receiving a vasopressor infusion.

Factors that influence physical function and emotional well-being among Medicare-Medicaid enrollees.

Dually enrolled Medicare-Medicaid older adults are a vulnerable population. We tested House's Conceptual Framework for Understanding Social Inequalities in Health and Aging in Medicare-Medicaid enrollees by examining the extent to which disparities indicators, which included race, age, gender, neighborhood poverty, education, income, exercise (e.g., walking), and physical activity (e.g., housework) influence physical function and emotional well-being. This secondary analysis included 337 Black (31%) and White (69%) older Medicare-Medicaid enrollees. Using path analysis, we determined that race, neighborhood poverty, education, and income did not influence physical function or emotional well-being. However, physical activity (e.g., housework) was associated with an increased self-report of physical function and emotional well-being of ß = .23, p < .001; ß = .17, p < .01, respectively. Future studies of factors that influence physical function and emotional well-being in this population should take into account health status indicators such as allostatic load, comorbidity, and perceived racism/discrimination.

Association of Transcobalamin II (TCN2) and Transcobalamin II-Receptor (TCblR) Genetic Variations With Cobalamin Deficiency Parameters in Elderly Women.

Cobalamin (vitamin B12) deficiency is a subtle progressive clinical disorder, affecting nearly 1 in 5 individuals > 60 years old. This deficiency is produced by age-related decreases in nutrient absorption, medications that interfere with vitamin B12 absorption, and other comorbidities. Clinical heterogeneity confounds symptom detection for elderly adults, as deficiency sequelae range from mild fatigue and weakness to debilitating megaloblastic anemia and permanent neuropathic injury. A better understanding of genetic factors that contribute to cobalamin deficiency in the elderly would allow for targeted nursing care and preventive interventions. We tested for associations of common variants in genes involved in cobalamin transport and homeostasis with metabolic indicators of cobalamin deficiency (homocysteine and methylmalonic acid) as well as hematologic, neurologic, and functional performance features of cobalamin deficiency in 789 participants of the Women's Health and Aging Studies. Although not significant when corrected for multiple testing, eight single nucleotide polymorphisms (SNPs) in two genes, transcobalamin II (TCN2) and the transcobalamin II-receptor (TCblR), were found to influence several clinical traits of cobalamin deficiency. The three most significant findings were the identified associations involving missense coding SNPs, namely, TCblR G220R (rs2336573) with serum cobalamin, TCN2 S348F (rs9621049) with homocysteine, and TCN2 P259R (rs1801198) with red blood cell mean corpuscular volume. These SNPs may modify the phenotype in older adults who are more likely to develop symptoms of vitamin B12 malabsorption.

Packaging interventions to increase medication adherence: systematic review and meta-analysis.

OBJECTIVE: Inadequate medication adherence is a widespread problem that contributes to increased chronic disease complications and health care expenditures. Packaging interventions using pill boxes and blister packs have been widely recommended to address the medication adherence issue. This meta-analysis review determined the overall effect of packaging interventions on medication adherence and health outcomes. In addition, we tested whether effects vary depending on intervention, sample, and design characteristics. RESEARCH DESIGN AND METHODS: Extensive literature search strategies included examination of 13 computerized databases and 19 research registries, hand searches of 57 journals, and author and ancestry searches. Eligible studies included either pill boxes or blister packaging interventions to increase medication adherence. Primary study characteristics and outcomes were reliably coded. Random-effects analyses were used to calculate overall effect sizes and conduct moderator analyses. RESULTS: Data were synthesized across 22,858 subjects from 52 reports. The overall mean weighted standardized difference effect size for two-group comparisons was 0.593 (favoring treatment over control), which is consistent with the mean of 71% adherence for treatment subjects compared to 63% among control subjects. We found using moderator analyses that interventions were most effective when they used blister packs and were delivered in pharmacies, while interventions were less effective when studies included older subjects and those with cognitive impairment. Methodological moderator analyses revealed significantly larger effect sizes in studies reporting continuous data outcomes instead of dichotomous results and in studies using pharmacy refill medication adherence measures compared with studies with self-report measures. CONCLUSIONS: Overall, meta-analysis findings support the use of packaging interventions to effectively increase medication adherence. Limitations of the study include the exclusion of packaging interventions other than pill boxes and blister packs, evidence of publication bias, and primary study sparse reporting of health outcomes and potentially interesting moderating variables such as the number of prescribed medications.

Managerial span of control: a pilot study comparing departmental complexity and number of direct reports.

Nurse managers play pivotal roles in hospitals. However, restructuring has resulted in nurse managers having wider span of control and reduced visibility. The purpose of this pilot study was to compare two methods of measuring span of control: departmental complexity and number of direct reports. Forty-one nurse managers across nine hospitals completed The Ottawa Hospital Clinical Manager Span of Control Tool (TOH-SOC) and a demographic survey. A moderate positive relationship between number of direct reports and departmental complexity score was identified (r=.49, p=<.01). Intensive care departments were more likely to be classified differently, using departmental complexity compared to number of direct reports (54%). TOH-SOC is a reliable instrument (Cronbach's alpha = .838). Using departmental complexity rather than direct reports may more accurately reflect the full scope of nurse managers' responsibility.

Predictors of quality in rural nursing homes using standard and novel methods.

We examined the effect of market and organizational characteristics on nursing home quality as measured by deficiencies (number and weighted) on states in a rural region of the United States. Rural nursing homes in five Mountain West states (N = 161) were sampled from the Online Survey Certification and Reporting system between January 1, 2004 and June 15, 2005. State comparisons indicated that rural nursing homes in Nevada had a higher number of deficiencies and weighted deficiency score as compared with Utah, Colorado, Wyoming, and Idaho. Using regression analyses, we found that a higher percentage of licensed practical nurses in the staffing mix were predictive of a greater number of deficiencies. Nursing homes with more beds or higher Medicaid occupancy had higher weighted deficiency scores. Although rural Mountain West nursing homes average a similar number of deficiencies as nursing homes nationwide, these nursing homes had a greater number of serious deficiencies and higher weighted deficiency scores, suggesting greater actual harm to resident health and safety.

Medication reconciliation: A qualitative analysis of clinicians' perceptions.

BACKGROUND: Medication reconciliation has been at the forefront of national patient safety efforts for nearly a decade, yet health care institutions remain challenged with implementation. OBJECTIVES: The objective of this article was to report an analysis of a qualitative study of the experiences of physicians, nurses, and pharmacists with medication management practices, specifically focusing on the practice of medication reconciliation. METHODS: This study used focus groups in a qualitative approach to explore participant perceptions about interprofessional communication and adverse drug events. Three focus groups were conducted at each of 3 Veterans Administration hospitals, 1 each for physicians (13), nurses (19), and pharmacists (16). The analysis for this article focused on specific discussions about medication reconciliation. RESULTS: Two primary thematic questions emerged from the discussion about medication reconciliation: What does medication reconciliation really mean? Who is actually responsible for the process? Participants from each profession had differing perspectives about the purpose and processes of medication reconciliation. Perceived responsibilities appeared to be influenced by their distinct views regarding the meaning and purpose of medication reconciliation. The pharmacist role emerged as a critical role to assure medication safety. CONCLUSIONS: Translating the intent of medication reconciliation into effective practice requires acknowledgment of the involved professionals' diverse perspectives on the independent, joint, and overlapping functions of medication management as well as recognizing the limitations of technology.

Psychotropic-related hip fractures: meta-analysis of first-generation and second-generation antidepressant and antipsychotic drugs.

BACKGROUND: In 2007, more than 18,000 adults aged 65 or older died from injuries related to falls, with up to 30% experiencing severe injuries such as hip fracture or head trauma. The economic impact of falls and fractures among older people is substantial, with direct economic consequences totaling $19 billion in 2000. OBJECTIVE: To evaluate the association between antipsychotic and antidepressant agents and the risk of hip fracture in older adults, across multiple studies. METHODS: An English-language PubMed/MEDLINE search for studies from January 1966 to January 2011 was conducted, using key words including aged, hip fracture, fractures, antidepressive agents, and antipsychotic agents, as well as individual drug names. Criteria for study inclusion were mean subject age greater than or equal to 65 years, adjusted for age and sex, hip fracture-specific results provided, data specific to a drug class, subclass, or single agents, and cohort or case-controlled study design. Two authors reviewed all studies for inclusion/exclusion. A random effects model was used to calculate summary odds ratios. RESULTS: A total of 166 studies were identified in the initial search. Ten antipsychotic-related and 14 antidepressant-related studies, representing more than 70,000 hip fracture cases and approximately 270,000 subjects from 4 continents, met the inclusion criteria. Summary odds ratios (95% CI) were first-generation (conventional) antipsychotics 1.68 (1.43 to 1.99), second-generation (atypical) antipsychotics 1.30 (1.14 to 1.49), first-generation (tricyclic) antidepressants 1.71 (1.43 to 2.04), and second-generation (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and unique agents such as bupropion, mirtazapine, and trazodone) antidepressants 1.94 (1.37 to 2.76). Clear evidence of heterogeneity was noted among all antidepressant study analyses (I(2) > 87%; Q statistic p < 0.05). CONCLUSIONS: All drug classes studied-first- and second-generation antipsychotics and antidepressants-were associated with an increased risk of hip fracture in predominantly older adult populations.

Medication reconciliation in nursing homes: thematic differences between RN and LPN staff.

The purpose of this qualitative descriptive study was to describe medication reconciliation practices in nursing homes with a specific focus on nursing staff involvement in the process. The study was conducted in eight Midwestern nursing homes and included 46 onsite observations of resident transfers to the nursing home. Informal interviews of nursing staff performing medication reconciliation were conducted during each observation. Findings suggest nursing home nursing staff, including both RN and licensed practical nurse (LPN) staff, were primarily responsible for performing medication reconciliation; however, these staff often varied in how they processed resident transfer information to identify medication order discrepancies. Patterns of differences were found related to their perceptions about medication reconciliation, as well as their actions when performing the process. RN staff were more often focused on resident safety and putting the "big picture" together, whereas LPN staff were more often focused on the administrative assignment and "completing the task."

Symptom trajectories during chemotherapy in outpatients with lung cancer colorectal cancer, or lymphoma.

PURPOSE: Pain, depression, distress, fatigue, and sleep disturbance are common symptoms in oncology patients, but little data are available that examine the trajectories of these symptoms during chemotherapy (CTX). The purposes of this study were to examine the trajectories of these symptoms during the first six cycles of CTX and to determine whether individual characteristics predicted the trajectories of these symptoms. METHODS: Oncology outpatients (n = 118) with newly diagnosed lung cancer, colorectal cancer, or lymphoma rated symptoms using an electronic patient care monitor system. Pain, fatigue, and sleep disturbance were rated on 0-10 numeric rating scales; depression and distress were evaluated using scales converted to normalized T scores. Latent growth curve analyses (LGCA) examined for intra- and inter-individual differences in the trajectories of these five symptoms during the six cycles of CTX. RESULTS: Symptoms were present at the initiation of CTX (p < 0.0001) for all symptoms (p < 0.05). Distress (p = 0.03) and pain (p = 0.02) intensity decreased significantly over the six cycles of CTX. Advanced disease and a higher number of comorbidities predicted higher fatigue at baseline (p = 0.02 and 0.01 respectively). A diagnosis of lung cancer predicted an increasing intensity of fatigue during CTX (p = 0.04). Concurrent radiation therapy predicted more intense pain over time (p = 0.03). CONCLUSIONS: While symptom trajectories were highly variable in patients undergoing initial CTX, the majority of the symptom intensity scores decreased over time. However, patients with lung cancer, those with a higher number of comorbidities, and those with advanced disease experienced more intense fatigue and sleep disturbance over time.