How Tailoring Led to Variation in Care Issues, Dosage, and Outcomes: Part 1: Secondary Analysis of the PREP Trial for Frail Older Adults and Family Caregivers.

In family caregiving interventions for adults with health problems, tailoring has become the norm. Studies that evaluate tailored interventions, however, have rarely included intentional variation in dosage or explored the dosage-outcome association. In this Part 1 secondary analysis, we examine dosage and outcomes in intervention families (N = 116) who participated in the Oregon Health & Science University/Kaiser Permanente Northwest Region Family Care Study. The Family Care Study was a randomized controlled trial to evaluate the preparedness, skill, enrichment, and predictability (PREP) intervention with caregiving families of frail older adults referred for skilled home health. Tailoring of PREP began with assessment by the PREP nurse. Families then identified and selected care-related issues to work on with their PREP nurse; family needs and preferences guided the number and timing of nurse visits and calls. Families selected a median of 3 (range = 0 to 10) care-related issues in five categories: direct care (chosen by 57% of families), transitions (40%), caregiver strain and health (40%), arranging care (33%), and enrichment (22%). The number of issues strongly predicted number of PREP nurse visits and calls, whereas nurse visits in turn predicted caregivers' reports of improved family care and usefulness of home health assistance, highlighting the importance of visits for achieving outcomes. [Research in Gerontological Nursing, 16(2), 57-70.].

How Concurrent Services Obscured Detection of Intervention Benefits: Part 2: Secondary Analysis of the PREP Trial for Frail Older Adults and Family Caregivers.

Family caregivers frequently use health and social services to support their caregiving. In evaluating care-giving interventions, however, researchers rarely examine the influences of such concurrent services on intervention effectiveness. In this Part 2 secondary analysis of data from the Oregon Health & Science University/Kaiser Permanente Northwest Region Family Care Study, we examined the moderating influences of concurrent services on intervention effectiveness. The Family Care Study was a randomized controlled trial to evaluate the preparedness, skill, enrichment, and predictability (PREP) intervention with caregivers of frail older adults referred for skilled home health. Compared with control caregivers receiving usual home health care (n = 103), PREP intervention caregivers (n = 104) reported greater improvements in family care (effect size, d = 0.58). We conducted follow-up analyses to determine whether PREP was differentially effective depending on whether dyads received concurrent Social Health Maintenance Organization (SHMO) services, concurrent hospice services, or neither. In the 55% of dyads not receiving SHMO or hospice, we found that PREP's effects were large compared to usual care (d = 1.16, p < 0.001). PREP's effects were not significant for dyads receiving concurrent SHMO or hospice services. Results highlight the strong benefits of hospice for control dyads, but reveal difficulties in evaluating intervention effectiveness when dyads receive concurrent services. [Research in Gerontological Nursing, 16(2), 71-83.].

Multisite Randomized Controlled Trial to Compare Two Methods of Tinnitus Intervention to Two Control Conditions.

OBJECTIVES: In this four-site clinical trial, we evaluated whether tinnitus masking (TM) and tinnitus retraining therapy (TRT) decreased tinnitus severity more than the two control groups: an attention-control group that received tinnitus educational counseling (and hearing aids if needed; TED), and a 6-month-wait-list control (WLC) group. The authors hypothesized that, over the first 6 months of treatment, TM and TRT would decrease tinnitus severity in Veterans relative to TED and WLC, and that TED would decrease tinnitus severity relative to WLC. The authors also hypothesized that, over 18 months of treatment, TM and TRT would decrease tinnitus severity relative to TED. Treatment effectiveness was hypothesized not to be different across the four sites. DESIGN: Across four Veterans affairs medical center sites, N = 148 qualifying Veterans who experienced sufficiently bothersome tinnitus were randomized into one of the four groups. The 115 Veterans assigned to TM (n = 42), TRT (n = 34), and TED (n = 39) were considered immediate-treatment subjects; they received comparable time and attention from audiologists. The 33 Veterans assigned to WLC were, after 6 months, randomized to receive delayed treatment in TM, TRT, or TED. Assessment of outcomes took place using the Tinnitus Handicap Inventory (THI) at 0, 3, 6, 12, and 18 months. RESULTS: Results of a repeated measures analysis of variance using an intention-to-treat approach showed that the tinnitus severity of Veterans receiving TM, TRT, and TED significantly decreased (p < 0.05) relative to Veterans in the WLC group at 3 months (effect sizes = 0.44, 0.52, and 0.27, respectively) and at 6 months (effect sizes = 0.52, 0.56, and 0.40, respectively). Analyses comparing effectiveness of TM, TRT, and TED over 18 months revealed that the three conditions were not significantly different, but that tinnitus severity in the combined groups significantly decreased (p < 0.01) from baseline to 3 months (5.6 THI points) and from 3 to 6 months (3.7 THI points). With respect to clinically significant change, about half of Veterans who received TM (55%), TRT (59%), or TED (46%) showed strong or modest improvement on the THI by 18 months. Without treatment, the WLC group did not show significant change. Treatment effectiveness did not differ by study site. CONCLUSIONS: Audiologists who provided interventions to Veterans with bothersome tinnitus in the regular clinic setting were able to significantly reduce tinnitus severity over 18 months using TM, TRT, and TED approaches. These results suggest that TM, TRT, and TED, when implemented as in this trial, will provide effectiveness that is relatively similar by 6 months and beyond.

Blind insertion of feeding tubes in intensive care units: a national survey.

BACKGROUND: Although most critically ill patients experience at least 1 blind insertion of a feeding tube during their stay in an intensive care unit, little is known about the types of health care personnel who perform these insertions or about methods used to determine proper positioning of the tubes. OBJECTIVES: To describe results from a national survey of critical care nurses about feeding tube practices in their adult intensive care units. The questions asked included who performs blind insertions of feeding tubes and what methods are used to determine if the tubes are properly positioned. METHODS: Data were collected from members of the American Association of Critical-Care Nurses via pencil-and-paper and online surveys. Results from both forms were combined for data analysis and were compared with practice recommendations of national-level organizations. RESULTS: A total of 2298 responses were obtained. Physicians perform more blind insertions of styleted feeding tubes than do nurses; in contrast, nurses place more nonstyleted tubes. Radiographic confirmation of correct position is mandated more often for blindly inserted styleted tubes (92.3%) than for nonstyleted tubes (57.5%). The 3 most commonly used bedside methods to determine tube location are auscultation for air injected via the tube, appearance of feeding tube aspirate, and observation for indications of respiratory distress. CONCLUSIONS: Recommendations from multiple national-level organizations to obtain radiographic confirmation that each blindly inserted feeding tube is correctly positioned before the first use of the tube are not adequately implemented. Auscultation is widely used despite recommendations to the contrary.

Monitoring for intolerance to gastric tube feedings: a national survey.

BACKGROUND: Confusion about how to assess for intolerance to feedings often results in unnecessary feeding interruptions. OBJECTIVES: To report findings from a national survey of methods used by critical care nurses to assess tolerance to gastric tube feedings and to discuss the findings in light of current enteral nutrition guidelines. METHODS: A paper-and-pencil survey was mailed to 1909 members of the American Association of Critical-Care Nurses. In addition, the same survey was posted online in a newsletter circulated to association members. Results from both surveys were pooled for data analysis. RESULTS: A total of 2298 responses were obtained; most respondents reported using a combination of methods to assess tolerance to gastric tube feedings (listening for bowel sounds, measuring gastric residual volumes, observing for abdominal distention/discomfort and for nausea and vomiting). More than 97% of the nurses reported measuring gastric residual volumes; the most frequently cited threshold levels for interrupting feedings were 200 mL and 250 mL. About 25% of the nurses reported interrupting feedings for gastric residual volumes of 150 mL or less; only 12.6% of the respondents reported allowing gastric residual volumes of up to 500 mL before interrupting feedings. CONCLUSIONS: Practice among the 2298 critical care nurses varied widely. Many of the survey respondents are practicing in ways that can unnecessarily diminish the delivery of calories to patients. Protocols based on current enteral nutrition guidelines must be developed and implemented in practice settings.

The tinnitus functional index: development of a new clinical measure for chronic, intrusive tinnitus.

OBJECTIVES: Chronic subjective tinnitus is a prevalent condition that causes significant distress to millions of Americans. Effective tinnitus treatments are urgently needed, but evaluating them is hampered by the lack of standardized measures that are validated for both intake assessment and evaluation of treatment outcomes. This work was designed to develop a new self-report questionnaire, the Tinnitus Functional Index (TFI), that would have documented validity both for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus (responsiveness) and that would provide comprehensive coverage of multiple tinnitus severity domains. DESIGN: To use preexisting knowledge concerning tinnitus-related problems, an Item Selection Panel (17 expert judges) surveyed the content (175 items) of nine widely used tinnitus questionnaires. From those items, the Panel identified 13 separate domains of tinnitus distress and selected 70 items most likely to be responsive to treatment effects. Eliminating redundant items while retaining good content validity and adding new items to achieve the recommended minimum of 3 to 4 items per domain yielded 43 items, which were then used for constructing TFI Prototype 1.Prototype 1 was tested at five clinics. The 326 participants included consecutive patients receiving tinnitus treatment who provided informed consent-constituting a convenience sample. Construct validity of Prototype 1 as an outcome measure was evaluated by measuring responsiveness of the overall scale and its individual items at 3 and 6 mo follow-up with 65 and 42 participants, respectively. Using a predetermined list of criteria, the 30 best-functioning items were selected for constructing TFI Prototype 2.Prototype 2 was tested at four clinics with 347 participants, including 155 and 86 who provided 3 and 6 mo follow-up data, respectively. Analyses were the same as for Prototype 1. Results were used to select the 25 best-functioning items for the final TFI. RESULTS: Both prototypes and the final TFI displayed strong measurement properties, with few missing data, high validity for scaling of tinnitus severity, and good reliability. All TFI versions exhibited the same eight factors characterizing tinnitus severity and negative impact. Responsiveness, evaluated by computing effect sizes for responses at follow-up, was satisfactory in all TFI versions.In the final TFI, Cronbach's alpha was 0.97 and test-retest reliability 0.78. Convergent validity (r = 0.86 with Tinnitus Handicap Inventory [THI]; r = 0.75 with Visual Analog Scale [VAS]) and discriminant validity (r = 0.56 with Beck Depression Inventory-Primary Care [BDI-PC]) were good. The final TFI was successful at detecting improvement from the initial clinic visit to 3 mo with moderate to large effect sizes and from initial to 6 mo with large effect sizes. Effect sizes for the TFI were generally larger than those obtained for the VAS and THI. After careful evaluation, a 13-point reduction was considered a preliminary criterion for meaningful reduction in TFI outcome scores. CONCLUSIONS: The TFI should be useful in both clinical and research settings because of its responsiveness to treatment-related change, validity for scaling the overall severity of tinnitus, and comprehensive coverage of multiple domains of tinnitus severity.

Relationship between feeding tube site and respiratory outcomes.

BACKGROUND: It is unclear if placing feeding tubes postpylorically to prevent respiratory complications is worth the extra effort. This study sought to determine the extent to which aspiration and pneumonia are associated with feeding site (controlling for the effects of severity of illness, degree of head-of-bed elevation, level of sedation, and use of gastric suction). METHODS: A retrospective analysis was performed on a large data set gathered prospectively to evaluate aspiration in critically ill, mechanically ventilated patients. Feeding site was designated by attending physicians and confirmed by radiography. Each patient participated in the study for 3 consecutive days, with pneumonia assessed by the simplified Clinical Pulmonary Infection Score on the fourth day. Tracheal secretions were assayed for pepsin in a research laboratory; the presence of pepsin served as a proxy for aspiration. A total of 428 patients were included in the regression analyses performed to address the research objectives. RESULTS: As compared with the stomach, the percentage of aspiration was 11.6% lower when feeding tubes were in the first portion of the duodenum, 13.2% lower when in the second/third portions of the duodenum, and 18.0% lower when in the fourth portion of the duodenum and beyond (all significant at P < .001). Pneumonia occurred less often when feedings were introduced at or beyond the second portion of the duodenum (P = .020). CONCLUSIONS: The findings support feeding critically ill patients with numerous risk factors for aspiration in the mid-duodenum and beyond to reduce the risk of aspiration and associated pneumonia.

Does age make a difference in caregiver strain? Comparison of young versus older caregivers in early-stage Parkinson's disease.

Family care research has identified negative outcomes of providing care to a spouse with Parkinson's disease (PD), such as declining physical and mental health. Research has also identified protective variables that decrease negative outcomes such as high mutuality and rewards of meaning. It is important for clinicians to identify "at risk" family caregivers and provide earlier interventions. Despite the importance of age and developmental stage there is a paucity of research comparing young versus older spouse caregivers. This study compared the difference in negative aspects of strain and modulators of strain in young and older PD spouse caregivers. A series of hierarchical multiple regressions were used to examine the contribution of age on both positive and negative aspects of the care situation for 65 (37 young, 28 old) PD spouse caregivers. Negative variables included 3 dimensions of strain; strain from lack of personal resources, strain from worry, and global strain. Positive or protective variables included mutuality, preparedness, and rewards of meaning. Even in early stage disease before significant care is required, young spouses (40-55) were found to be at greater risk for negative consequences of the care situation reporting significantly more strain from lack of personal resources, and lower levels of mutuality and rewards of meaning than older (greater than 70) spouses. As expected, young spouses were more likely to be working, caring for children in the home, and in better physical health than older spouses. Clinicians are well-situated to identify the unique needs of young spouses and intervene early in the caregiving trajectory. These findings provide ideas for targeted interventions. Future larger studies that compare young and older spouses should include later stage disease to more fully understand the developmental differences raised by the present findings.

Effectiveness of an aspiration risk-reduction protocol.

BACKGROUND: Aspiration of gastric contents is a serious problem in critically ill, mechanically ventilated patients receiving tube feedings. OBJECTIVES: The purpose of this study was to evaluate the effectiveness of a three-pronged intervention to reduce aspiration risk in a group of critically ill, mechanically ventilated patients receiving tube feedings. METHODS: A two-group quasi-experimental design was used to compare outcomes of a usual care group (December 2002-September 2004) with those of an Aspiration Risk-Reduction Protocol (ARRP) group (January 2007-April 2008). The incidence of aspiration and pneumonia was compared between the usual care group (n = 329) and the ARRP group (n = 145). The ARRP had three components: maintaining head-of-bed elevation at 30 degrees or higher, unless contraindicated; inserting feeding tubes into distal small bowel, when indicated; and using an algorithmic approach for high gastric residual volumes. RESULTS: Two of the three ARRP components were implemented successfully. Almost 90% of the ARRP group had mean head-of-bed elevations of 30 degrees or higher as compared to 38% in the usual care group. Almost three fourths of the ARRP group had feeding tubes placed in the small bowel as compared with less than 50% in the usual care group. Only three patients met the criteria for the high gastric residual volume algorithm. Aspiration was much lower in the ARRP group than that in the usual care group (39% vs. 88%, respectively). Similarly, pneumonia was much lower in the ARRP group than that in the usual care group (19% vs. 48%, respectively). DISCUSSION: Findings from this study suggest that a combination of a head-of-bed position elevated to at least 30 degrees and use of a small-bowel feeding site can reduce the incidence of aspiration and aspiration-related pneumonia dramatically in critically ill, tube-fed patients.

Optimism, pessimism, mutuality, and gender: predicting 10-year role strain in Parkinson's disease spouses.

PURPOSE: There is wide variability in how spouses providing care respond to their care situations. Few studies focus on the roles of both intra- and interpersonal factors in long-term spousal care, particularly in the context of Parkinson's disease (PD). The current study uses longitudinal data over a 10-year period to examine the roles of optimism, pessimism, mutuality, and spouse gender in predicting role strain in PD spouses. DESIGN AND METHODS: A longitudinal design was used to study 255 spouses of persons with PD over a 10-year period, with data points at baseline (Year 0), Year 2, and Year 10. A series of multilevel models were used to examine four role strain variables -- global strain, strain from worry, strain from feelings of being manipulated, and strain from increased tension. RESULTS: Female spouse gender predicted both higher Year 10 role strain and faster increases in role strain over the 10-year period. In addition, high mutuality and optimism and low pessimism at baseline played important protective roles against increased role strain at Year 10. IMPLICATIONS: This study focused on early-stage spousal care in a primarily physical disability context. Findings suggest that gender differences place wives at greater risk for negative outcomes, even in the absence of dementia. Additionally, clinicians have opportunities to target interventions early in the care trajectory based on intra- and interpersonal risk factors.

Development of the Ways Of Helping Questionnaire: a measure of preferred coping strategies for older African American cancer survivors.

Although researchers have identified beneficial coping strategies for cancer patients, existing coping measures do not capture the preferred coping strategies of older African American cancer survivors. A new measure, the Ways of Helping Questionnaire (WHQ), was evaluated with 385 African American cancer survivors. Validity evidence from factor analysis resulted in 10 WHQ subscales (Others There for Me, Physical and Treatment Care Needs, Help from God, Church Family Support, Helping Others, Being Strong for Others, Encouraging My Healthy Behaviors, Others Distract Me, Learning about Cancer, and Distracting Myself). Reliability evidence was generally strong. Evidence regarding hypothesized relationships with measures of well-being and another coping measure was mixed. The WHQ's content coverage makes it especially relevant for older African American cancer survivors.

Tinnitus outcomes assessment.

Over the past two decades, recognition has grown that measures for evaluating treatment outcomes must be designed specifically to have high responsiveness. With that in mind, four major types of tinnitus measures are reviewed, including psychoacoustic measures, self-report questionnaires concerning functional effects of tinnitus, various rating scales, and global outcome measures. Nine commonly used tinnitus questionnaires, developed in the period 1980-2000, are reviewed. Because of many similarities between tinnitus and pain, comparisons between pain and tinnitus measures are discussed, and recommendations that have been made for developing a core set of measures to evaluate treatment-related changes in pain are presented as providing a fruitful path for developing a core set of measures for tinnitus. Finally, the importance of having both immediately obtainable outcome measures (psychoacoustic, rating scales, or single global measures) and longer term measures (questionnaires covering the negative effects of tinnitus) is emphasized for further work in tinnitus outcomes assessment.

Do motor and nonmotor symptoms in PD patients predict caregiver strain and depression?

Our objective was to understand the impact of motor and nonmotor symptoms of patients with early and middle stage Parkinson's disease (PD) on their spouses' caregiver strain and depression. A sample of 219 spouse caregivers of PD patients participating in a clinical trial was evaluated for six dimensions of caregiver strain and depression using the Family Care Inventory. Motor and nonmotor (i.e., psychological) clinical symptoms collected from PD patients as part of the clinical trial protocol were used as predictors. Seven hierarchical regression analyses were used to determine the contribution of the motor and nonmotor clinical symptoms in explaining variation in each of the seven caregiver-dependent variables. Clinical symptoms explained 9-16% of the variance in caregiver strain and 10% of depression. Motor symptoms explained 0-6% of the variance and nonmotor psychological symptoms explained 7-13% of the variance in caregiver strain. Comparing our findings with literature that is deemed clinically relevant for patient symptoms that predict caregiver strain, we concluded that PD patient symptoms are important predictors of caregiver strain and depression. Patient nonmotor psychological symptoms have a much greater impact on caregiver strain and depression than patient motor symptoms.

Effects of caregiving demand, mutuality, and preparedness on family caregiver outcomes during cancer treatment.

PURPOSE/OBJECTIVES: To test a model of family caregiving derived from the interactionist approach to role theory that hypothesized that three caregiving role implementation variables (caregiving demand, mutuality between caregivers and patients, and preparedness for caregiving) would predict multiple caregiving-specific and generic outcomes with different patterns of association across outcomes. DESIGN: Descriptive, correlational. SETTING: Surgical, radiation, and medical oncology settings. SAMPLE: 87 family caregivers of adults receiving treatment for solid tumors or lymphoma. METHODS: Caregivers completed the Demand and Difficulty subscales of the Caregiving Burden Scale; the Mutuality, Preparedness, and Global Strain scales of the Family Care Inventory; and the 30-item short form of the Profile of Mood States. Data were analyzed with simultaneous multiple regression. MAIN RESEARCH VARIABLES: Caregiving demand, mutuality, preparedness, caregiving difficulty, global caregiver strain, tension, depression, anger, fatigue, vigor, confusion, and total mood disturbance. FINDINGS: The model explained statistically significant proportions of variance in each outcome, with different patterns of association across outcomes. Demand was associated most strongly with caregiving difficulty and global strain. Mutuality was associated most strongly with caregiver anger. Unexpectedly, preparedness was associated more strongly with mood disturbance outcomes than with the caregiving-specific variables of difficulty and strain. CONCLUSIONS: Further research should explore models that address implementation of the caregiving role to better elucidate how family caregivers learn and carry out the important role. IMPLICATIONS FOR NURSING: Clinical assessment should include caregiving demand, the quality of the relationship between caregiver and patient, and preparedness for caregiving. Interventions could be tailored to meet caregiver needs in each area.

The Spanish Version of the Mutuality Scale: evidence for the cultural equivalence of mutuality in Mexican American families.

Mutuality, the positive quality of the relationship between the family caregiver and care receiver, is an important variable in family care for frail older adults. It has been shown to be associated with lower levels of caregiver strain and higher levels of caregiving rewards. However, the concept and measure of mutuality were developed with non-Hispanic White samples. The purpose of this article is to describe the development of an instrument-the Spanish Version of the Mutuality Scale. We determined for Mexican American families: (a) the functional equivalence of mutuality, (b) a comparative descriptive framework for mutuality, and (c) the language equivalence of the Mutuality Scale and the Spanish Version of the Mutuality Scale. Evaluating mutuality levels for Mexican American older adults and caregivers, especially in view of their strong cultural norm of familism, is essential.

Mutuality and preparedness moderate the effects of caregiving demand on cancer family caregiver outcomes.

BACKGROUND: Family caregiving researchers have explored the moderating or stress-buffering effects of variables such as coping and social support. However, the quality of the family caregiver-patient relationship and preparedness for caregiving have received little attention as potential moderators. OBJECTIVE: To explore whether relationship quality and preparedness moderate the effects of caregiving demand on caregiver outcomes during cancer treatment. METHODS: Eighty-seven family caregivers of patients receiving treatment for cancer completed the Demand and Difficulty subscales of the Caregiving Burden Scale, Mutuality and Preparedness Scales of the Family Care Inventory, and the short form of the Profile of Mood States. Using hierarchical multiple regression analyses, caregiving difficulty and total mood disturbance were regressed on two- and three-way interaction terms for demand, mutuality, and preparedness, controlling for caregiver age and gender, and the simple effect of each independent variable. RESULTS: Negligible effects for two-way interactions were found. However, the three-way interaction between demand, mutuality, and preparedness explained statistically significant variance in both perceived difficulty of caregiving and total mood disturbance. High mutuality in combination with high preparedness protected caregivers from adverse outcomes when demand was high. When either mutuality or preparedness was low, caregivers were at greater risk for negative outcomes when demand was high, but not when demand was low. When both mutuality and preparedness were low, caregivers were at risk for mood disturbance even when demand was low. DISCUSSION: Analysis of three-way interactions provided new theoretical insights into the protective effects of mutuality and preparedness and demonstrated conditions under which caregivers are at increased risk for negative outcomes.

The enduring and contextual effects of physical health and depression on care-dyad mutuality.

Mutuality is a protective factor in family care situations, but little is known about changes in care-dyad mutuality. In this study, we examined mutuality in 103 care dyads over 20 months, and the enduring and contextual impact of older adult and family caregiver health on changes in mutuality. Care dyads consisted of frail older adults and their family caregiver. Older adults reported higher levels of mutuality than family caregivers, but their mutuality declined significantly faster over time. Although changes in physical health were more important than mean health for both older adults and family caregivers, mean depression was more important than changes in depression for older adults. This study shows the importance of examining time-varying covariates in the care dyad.

Assisting cognitively impaired nursing home residents with bathing: effects of two bathing interventions on caregiving.

PURPOSE: When cognitively impaired nursing home residents exhibit agitated and aggressive behaviors during bathing, nursing home caregivers are in a unique position to improve residents' experience. This report addresses whether certified nursing assistants (CNAs) who received training in a person-centered approach with showering and with the towel bath showed improved caregiving behaviors (gentleness and verbal support) and experienced greater preparedness (confidence and ease) and less distress (hassles) when assisting residents with bathing. DESIGN AND METHODS: We used a crossover design and randomized 15 nursing homes into two treatment groups and a control group of 5 facilities each. In one treatment group, CNAs received person-centered training, first with showering for 6 weeks (Time 1) and then with the towel bath for 6 weeks (Time 2). We reversed the treatment order in the other treatment group. Control group CNAs used usual showering procedures without person-centered training. We collected observational and self-report data at baseline and at the end of Time 1 and Time 2 on five caregiving outcomes. We analyzed data from 37 CNAs assisting 69 residents by using 3x2 repeated measures analyses of variance to compare the three groups on change from baseline. RESULTS: Compared with the control group, treatment groups significantly improved in the use of gentleness and verbal support and in the perception of ease. IMPLICATIONS: A person-centered approach with showering and with the towel bath improved not only how care is given to residents who become agitated and aggressive during bathing but also how CNAs perceive their experience when bathing these residents.

How frail elders evaluate their caregiver's role enactment: a scale to measure affection, skill, and attentiveness.

In this validity study, using factor analysis, the authors identified three dimensions (affection, skill, and attentiveness) of the Care Receiver View of Caregiver Role Enactment Scale, a self-report measure designed to elicit an elderly care receiver's evaluation of how well their family member carried out the role of caregiver. The scale is a revision of the Satisfaction With Caregiving Scale. This study was a secondary analysis of data from PREP: Family-based Care for Frail Older Persons. Care receiver mutuality was the variable most highly correlated with caregiver role enactment. Other variables related to good quality care were higher care receiver positive affect, better caregiver physical health, and lower caregiver role strain; husband caregivers were rated as giving poorer quality care.

Outcomes of clinical trial: tinnitus masking versus tinnitus retraining therapy.

A controlled clinical study was conducted to evaluate prospectively the clinical efficacy of tinnitus masking (TM) and tinnitus retraining therapy (TRT) in military veterans having clinically significant tinnitus. Qualifying patients were placed into the two groups in an alternating manner (to avoid selection bias), and treatment was administered at 0, 3, 6, 12, and 18 months. Outcomes of treatment were evaluated using three self-administered tinnitus questionnaires (Tinnitus Handicap Inventory, Tinnitus Handicap Questionnaire, Tinnitus Severity Index) and the verbally administered TRT interview forms. Findings are presented from the three written questionnaires, and from two of the interview questions (percentage time aware of, and annoyed by, tinnitus). Outcomes were analyzed on an intent-to-treat basis, using a multilevel modeling approach. Of the 123 patients enrolled, 118 were included in the analysis. Both groups showed significant declines (improvements) on these measures, with the TRT decline being significantly greater than for TM. The greater declines in TRT compared to TM occurred most strongly in patients who began treatment with a "very big" tinnitus problem. When patients began treatment with a "moderate" tinnitus problem, the benefits of TRT compared to TM were more modest.