A pilot randomized trial of two cognitive rehabilitation interventions for mild cognitive impairment: caregiver outcomes.

OBJECTIVE: This study aims to provide effect size estimates of the impact of two cognitive rehabilitation interventions provided to patients with mild cognitive impairment: computerized brain fitness exercise and memory support system on support partners' outcomes of depression, anxiety, quality of life, and partner burden. METHODS: A randomized controlled pilot trial was performed. RESULTS: At 6 months, the partners from both treatment groups showed stable to improved depression scores, while partners in an untreated control group showed worsening depression over 6 months. There were no statistically significant differences on anxiety, quality of life, or burden outcomes in this small pilot trial; however, effect sizes were moderate, suggesting that the sample sizes in this pilot study were not adequate to detect statistical significance. CONCLUSION: Either form of cognitive rehabilitation may help partners' mood, compared with providing no treatment. However, effect size estimates related to other partner outcomes (i.e., burden, quality of life, and anxiety) suggest that follow-up efficacy trials will need sample sizes of at least 30-100 people per group to accurately determine significance. Copyright © 2017 John Wiley & Sons, Ltd.

A patient-centered analysis of enrollment and retention in a randomized behavioral trial of two cognitive rehabilitation interventions for Mild Cognitive Impairment.

BACKGROUND: A major potential barrier for studying behavioral interventions for patients with Mild Cognitive Impairment (MCI) is the willingness and ability of people to enroll in and adhere to behavioral interventions, especially when the intervention involves dyads of patients with MCI and support partners. Details regarding recruitment strategies and processes (such as number of dyads screened) are often missing from reports of behavioral trials. In addition, reports do not detail the reasons a potentially eligible candidate opts out of participation in a research study. OBJECTIVE: To describe the challenges and successes of enrollment and retention in a behavioral trial for persons with MCI and their care partners, and to better understand barriers to participation from the patient's point of view. DESIGN: Multi-site, randomized trial. SETTING: Major medical centers. PARTICIPANTS: Our accrual target for the study was 60 participants. Potential candidates were patients presenting to memory evaluation clinics whose resulting clinical diagnosis was MCI. A total of 200 consecutive potential candidates were approached about participating in the study across the three sites. INTERVENTION: Detailed recruitment and retention data of a randomized trial comparing two behavioral interventions (memory notebook training versus computer training) provided in two separate training time frames (10 days versus 6 weeks). MEASUREMENTS: Structured interview with those declining to participate in the trial. RESULTS: Overall recruitment 37% with a range of 13%-72% across sites. Overall retention 86% with a range of 74%-94% across sites. CONCLUSION: The primary barriers to enrollment from the patient's perspective were distance to the treatment center and competing comprehensive behavioral programming. However, retention data suggest that those dyads who enroll in behavioral programs are highly committed.

Evidence-based practice for the busy nurse practitioner: part four: putting it all together.

PURPOSE: Understanding the critical appraisal process allows nurse practitioners (NPs) to determine a study's reliability, validity, and applicability to their client(s)/families, and to their clinical practice setting. The purpose of this final part of this four-part evidence-based practice (EBP) series is designed to utilize a clinical scenario that will walk the NP through EBP steps 1 through 3 while providing an example of how to critically appraise a randomized control trial. DATA SOURCES: Scientific literature review, gray literature, PubMed and other online literature databases and resources, and online EBP websites. CONCLUSIONS: As healthcare providers, our role is to provide the best possible care we can to our client(s) and their families. One way to do this is through the utilization of the EBP process. When EBP processes are integrated into our clinical practice settings it augments the existing provider-client relationship and shared decision-making process. IMPLICATIONS FOR PRACTICE: It is hoped that this four-part series enhanced NPs' understanding of the EBP processes of developing a clinical inquiry, searching for the best evidence, critically appraising the evidence, and integrating EBP into clinical practice.

Evidence-based practice for the busy nurse practitioner: part three: critical appraisal process.

PURPOSE: Evidence-based practice (EBP) involves integrating research evidence with clinical expertise to answer clinical practice inquiries. The purpose of part 3 of this EBP series is to provide an introductory overview of the critical appraisal process, relevant clinical measurements, and critical thinking skills that can enhance nurse practitioners' (NPs') confidence in the clinical decision-making process. DATA SOURCES: Scientific literature review, gray literature, PubMed and other online literature databases and resources, and online EBP websites. CONCLUSIONS: Critical appraisal skills can assist NPs in interpreting available research, determining its validity reliability, and applicability to their clinical practice. Similarities in the critical appraisal process center around determining a study's reliability, validity, and applicability to the client(s) in question, while the differences exist in the clinical measurements used within specific research designs. IMPLICATIONS FOR PRACTICE: Because medicine is an evolving field, access to knowledge sources that address diagnostic, therapeutic, and prognostic questions is essential for the NP in order to maintain best practice skills. Making EBP user friendly for the practicing NP is paramount for utilization of best evidence.

Evidence-based practice for the busy nurse practitioner: part two: searching for the best evidence to clinical inquiries.

PURPOSE: The purpose of this four-part evidence-based practice (EBP) series is to enhance the nurse practitioner's (NP's) EBP skills by reviewing the process of developing a clinical question, searching for the best evidence, and critically appraising and applying the findings. Part two of the series focuses on how to search the published scientific literature for the most relevant studies that will answer a specific clinical question of importance to the NP. DATA SOURCES: Scientific literature review, gray searching, PubMed and other online literature databases and resources, and online EBP websites. CONCLUSIONS: Technology has allowed multiple healthcare resources to be available at one's fingertips enabling both NPs and their patients to find answers to clinical questions. EBP databases can be categorized as synthesized/filtered, unfiltered, and background information/expert opinion resources. Learning which database can best answer the clinical inquiry can streamline the search process. IMPLICATIONS FOR PRACTICE: For the busy NP, EBP has emerged as an important strategy to maintain valid, accurate, and relevant clinical knowledge. It is expected that this part of the series will enable NPs to identify appropriate databases to answer clinical inquires while refining their search strategy skills, which takes both time and practice.

Evidence-based practice for the busy nurse practitioner: part one: relevance to clinical practice and clinical inquiry process.

PURPOSE: Evidence-based practice (EBP) continues to gain momentum within health care. The purpose of this four-part EBP series is to provide an introductory overview of the EBP process, emphasizing EBP steps one through three, in order to assist nurse practitioners (NPs) in building EBP skills that can be integrated into clinical practice. The relevance of EBP to the NP's clinical practice, an introduction to the EBP process steps, and clinical inquiry process begin the series. DATA SOURCES: Scientific literature review, gray literature, and online evidence-based practice databases and resources. CONCLUSIONS: EBP has become increasingly important to NPs, yet there is evidence suggesting it is not being fully implemented in clinical practice. EBP is one way to keep the busy NP's knowledge up to date, enhance clinical judgment, and augment the existing provider-client decision-making process. IMPLICATIONS FOR PRACTICE: The principles of EBP have become the cornerstone strategy for NPs to translate research findings into clinical practice. Practicing in an ever-changing healthcare environment, NPs have a responsibility to provide their clients with the best available evidence, while incorporating that evidence into the provider-client decision-making process.

Longitudinal modeling of age-related memory decline and the APOE epsilon4 effect.

BACKGROUND: The APOE epsilon4 allele is associated with the risk of late-onset Alzheimer's disease. The age at which memory decline diverges among persons who are homozygous for the APOE epsilon4 allele, those who are heterozygous for the allele, and noncarriers is unknown. METHODS: Using local advertisements, we recruited cognitively normal subjects between the ages of 21 and 97 years, who were grouped according to their APOE epsilon4 status. We then followed the subjects with longitudinal neuropsychological testing. Anyone in whom mild cognitive impairment or dementia developed during follow-up was excluded. We compared the rates of decline in predetermined cognitive measures between carriers and noncarriers of the APOE epsilon4 allele, using a mixed model for longitudinal change with age. RESULTS: We analyzed 815 subjects: 317 APOE epsilon4 carriers (79 who were homozygous for the APOE epsilon4 allele and 238 who were heterozygous) and 498 noncarriers. Carriers, as compared with noncarriers, were generally younger (mean age, 58.0 vs. 61.4 years; P<0.001) and were followed for a longer period (5.3 vs. 4.7 years, P=0.01), with an equivalent duration of formal education (15.4 years) and proportion of women (69%). Longitudinal decline in memory in carriers began before the age of 60 years and showed greater acceleration than in noncarriers (P=0.03), with a possible allele-dose effect (P=0.008). We observed similar although weaker effects on measures of visuospatial awareness and general mental status. CONCLUSIONS: Age-related memory decline in APOE epsilon4 carriers diverges from that of noncarriers before the age of 60 years, despite ongoing normal clinical status.

The patient with Parkinson's disease: part I-treating the motor symptoms; part II-treating the nonmotor symptoms.

PURPOSE: This two-part article provides the nurse practitioner (NP) with information on the developments in the pathophysiology and expanded treatment options in the motor and nonmotor symptoms of Parkinson's disease (PD). The discussion provides treatment strategies that may offer improved ability to manage the disabling symptoms of this neurodegenerative disorder. DATA SOURCES: Review of scientific literature from PubMed search for English language articles on PD from 1998 to 2005 and books or chapters in textbooks published on the disease in the same time frame provided the data source for this article. The content reflects our clinical judgments and experience from clinical practice in the Movement Disorder Clinic at Mayo Clinic Arizona. CONCLUSIONS: The high prevalence of the disease and important advances in its management means that the NP needs to have knowledge of the disorder and the combination of multiple treatment options available for both the motor and the nonmotor symptoms. IMPLICATIONS FOR PRACTICE: PD is a progressive neurodegenerative disease affecting 1% of persons over the age of 60 in the United States. As prevalence increases with age, so does the need for early accurate diagnosis and proper treatment of the PD by the clinician. Advances in the treatment for the motor and nonmotor symptoms of PD provide the clinician with increased options to improve the patient's quality of life.

Dementia and driving: autonomy versus safety.

PURPOSE: This article reviews the effects of various types of dementia on driving skills, the available assessment measures, legal considerations, and the important role played by the nurse practitioner (NP) in the process of recommending driving cessation. It provides strategies and resources that may offer guidance to NPs who are attempting to balance the continued independence of patients with dementia, as represented by driving, with the safety not only of such patients but also of the public at large. DATA SOURCES: A review of the biomedical literature, resources available on the World Wide Web, and illustrative case studies were used. CONCLUSIONS: The diagnosis of dementia alone is often insufficient to determine driver competence because the topographic losses of dementia are complex. Recognizing when cessation should occur is made more difficult because objective assessment tools do not exist to predict impaired driving skills. Recommending driving cessation at the appropriate time can be a challenge for NPs, who must balance such a significant impact on the driver's autonomy with concerns about public safety if the patient continues to drive despite progressive impairment. IMPLICATIONS FOR PRACTICE: The progressive loss of cognitive abilities in dementia presents a series of ongoing challenges for the patient throughout the disease continuum. Unfortunately, the recommendation to stop driving can present one of the more immediate issues confronting the patient, the family, and the healthcare provider. Failure to assess diminished driving skill can lead either to premature or to delayed driving cessation. Either outcome can have adverse effects on the patient, the patient's family, and public safety.

Coccidioidal meningitis presenting as memory loss.

PURPOSE: This case study is designed to help the nurse practitioner recognize atypical symptoms of coccidioidal meningitis, particularly in high-risk groups that require further diagnostic treatment. DATA SOURCES: Selected research, clinical articles, and case studies. CONCLUSIONS: Coccidioidal meningitis is a potentially lethal infection unless recognized and treated. Unlike other infectious meningitides that present with more acute meningeal symptoms, disseminated coccidioidomycosis can present insidiously. When it presents as cognitive dysfunction, it may be mistaken for early dementia and if undiagnosed can result in death. While it is an infectious disease that is endemic to a small number of southwestern states, these areas see a high volume of tourists who can unwittingly become infected. Knowledge of this infectious disease and the many ways it can imitate other diseases is critical to its early recognition and treatment. IMPLICATIONS FOR PRACTICE: Failure to recognize this reemerging, endemic fungal infection in high-risk groups can result in death.