Shared mechanisms for cognitive impairment and physical frailty: A model for complex systems.

INTRODUCTION: We describe findings from a large study that provide empirical support for the emerging construct of cognitive frailty and put forth a theoretical framework that may advance the future study of complex aging conditions. While cognitive impairment and physical frailty have long been studied as separate constructs, recent studies suggest they share common etiologies. We aimed to create a population predictive model to gain an understanding of the underlying biological mechanisms for the relationship between physical frailty and cognitive impairment. METHODS: Data were obtained from the longitudinal "Invecchaiare in Chianti" (Aging in Chianti, InCHIANTI Study) with a representative sample (n = 1453) of older adults from two small towns in Tuscany, Italy. Our previous work informed the candidate 132 single nucleotide polymorphisms (SNPs) and 155 protein biomarkers we tested in association with clinical outcomes using a tree boosting, machine learning (ML) technique for supervised learning analysis. RESULTS: We developed two highly accurate predictive models, with a Model I area under the curve (AUC) of 0.88 (95% confidence interval [CI] 0.83-0.90) and a Model II AUC of 0.86 (95% CI 0.80-0.90). These models indicate cognitive frailty is driven by dysregulation across multiple cellular processes including genetic alterations, nutrient and lipid metabolism, and elevated levels of circulating pro-inflammatory proteins. DISCUSSION: While our results establish a foundation for understanding the underlying biological mechanisms for the relationship between cognitive decline and physical frailty, further examination of the molecular pathways associated with our predictive biomarkers is warranted. Our framework is in alignment with other proposed biological underpinnings of Alzheimer's disease such as genetic alterations, immune system dysfunction, and neuroinflammation.

Anticholinergic Drug Induced Cognitive and Physical Impairment: Results from the InCHIANTI Study.

BACKGROUND: The aims of this study were to evaluate the relationship between anticholinergic drug burden (ACB) cognitive impairment, physical frailty, and cognitive frailty, and to determine if ACB is predictive of these phenotypes when modeled with biological and genomic biomarkers. METHODS: In a retrospective cohort study, a total of 1,453 adults aged 20-102 years were used to examine ACB as a predictor for cognitive impairment, physical frailty, and cognitive frailty. Anticholinergic burden is examined as a predictor for all phenotypes in a cross-sectional analysis using logistic, ordinal regression models, and Extreme Gradient Boosting for population predictive modeling. RESULTS: A significant association was found between ACB and cognitive decline (p = .02), frailty (p < .001), and cognitive frailty (p < .001). The odds of cognitive impairment increased by 1.21 (95% confidence interval [CI] = 1.06-1.37, p < .001), odds of being frail increased by 1.33 (95% CI = 1.18-1.50, p < .001), and odds of having cognitive frailty increased by 1.36 (95% CI = 1.21-1.54, p < .001). Population modeling results indicated ACB score as one of the stronger predictors for cognitive impairment, physical frailty, and cognitive frailty with area under the curves ranging from 0.81 to 0.88. CONCLUSIONS: Anticholinergic medications are a potentially modifiable risk factor for the prevention of cognitive and physical decline. Identification of reversible causes for cognitive and physical impairment is critical for the aging population. These findings encourage new research that may lead to effective interventions for deprescribing programs for the prevention of cognitive and physical decline in older adults.

Experimental Comparison of Efficacy for Three Handfeeding Techniques in Dementia.

BACKGROUND: Nursing home (NH) residents who require assistance during mealtimes are at risk for malnutrition. Supportive handfeeding is recommended, yet there is limited evidence supporting use of a specific handfeeding technique to increase meal intake. OBJECTIVES: To compare efficacy of three handfeeding techniques for assisting NH residents with dementia with meals: Direct Hand (DH), Over Hand (OH), and Under Hand (UH). DESIGN: A prospective pilot study using a within-subjects experimental Latin square design with randomization to one of three handfeeding technique sequences. SETTING AND PARTICIPANTS: 30 residents living with advanced dementia in 11 U.S. NHs. MEASUREMENTS: Time required for assistance; meal intake (% eaten); and feeding behaviors, measured by the Edinburgh Feeding Evaluation in Dementia (EdFED) scale. INTERVENTION: Research Assistants provided feeding assistance for 18 video-recorded meals per resident (N = 540 meals). Residents were assisted with one designated technique for 6 consecutive meals, changing technique every 2 days. RESULTS: Mean time spent providing meal assistance did not differ significantly between techniques. Mean meal intake was greater for DH (67 ± 15.2%) and UH (65 ± 15.0%) with both significantly greater than OH (60 ± 15.1%). Feeding behaviors were more frequent with OH (8.3 ± 1.8%), relative to DH (8.0 ± 1.8) and UH (7.7 ± 1.8). CONCLUSION: All three techniques are time neutral. UH and DH are viable options to increase meal intake among NH residents with advanced dementia and reduce feeding behaviors relative to OH feeding.

Perceptions of Home Health Nurses Regarding Suffering, Artificial Nutrition, and Hydration in Late-Stage Dementia.

The purpose of this study was to explore perceptions of home healthcare nurses related to suffering, artificial nutrition and hydration in people with late-stage dementia, and if these perceptions influence care to people with dementia and their families. Part of a mixed-methods study, the qualitative portion examined perceptions of home healthcare nurses in a rural area in the southern United States. Seventeen home healthcare nurses participated in this study. Semistructured focus group interview questions were used. Constant comparative analysis was the method used for coding transcripts. Three themes emerged from the analysis: patient/family comfort, futility, and symbols of suffering. Although many of the nurses reported that artificial nutrition and hydration was of comfort to the patient and family because of the potential for "starving," they also felt it prolonged the patient's suffering due to the invasive procedure, need for restraints, and possibility of fluid overload. Several nurses felt that artificial nutrition and hydration gave a sense of false hope to the family that the patient would live longer. The perceptions of these home healthcare nurses influence their care to people with dementia and their families related to artificial nutrition and hydration, possibly based on experience. Their perceptions could influence family decisions regarding treatment options. Further research and education with home healthcare nurses is vital to ensure nurses are appropriately caring for patients with dementia and their families.

Feasibility of a web-based dementia feeding skills training program for nursing home staff.

Nursing home (NH) staff do not receive adequate training for providing feeding assistance to residents with dementia who exhibit aversive feeding behaviors (e.g., clamping mouth shut). The result is often low meal intake for these residents. This feasibility study tested a web-based dementia feeding skills program for staff in two United States NHs. Randomly assigned, the intervention staff received web-based dementia feeding skills training with coaching. Both groups participated in web-based pre-/post-tests assessing staff knowledge and self-efficacy; and meal observations measured NH staff and resident feeding behaviors, time for meal assistance, and meal intake. Aversive feeding behaviors increased in both groups of residents; however, the intervention NH staff increased the amount of time spent providing assistance and meal intake doubled. In the control group, less time was spent providing assistance and meal intake decreased. This study suggests that training staff to use current clinical practice guidelines improves meal intake.

Instrument validation and measurement of home healthcare nurses' knowledge of artificial nutrition and hydration at end of life.

The purpose of this exploratory pilot study was two-fold: (a) to determine the reliability of the instrument to measure nurses' knowledge of artificial nutrition and hydration, and (b) to assess home healthcare nurses' knowledge of artificial nutrition and hydration. A cross-sectional design was used to administer the questionnaire to 91 home healthcare nurses in North Carolina; 33 questionnaires were returned. Results revealed an accurate answer rate of 73% and Cronbach's alpha was 0.71, indicating adequate internal consistency reliability.

Isolation of lesbian, gay, bisexual and transgender youth: a dimensional concept analysis.

AIM: To present the findings of a dimensional analysis of isolation in the context, and from the perspective, of lesbian, gay, bisexual and transgender youth. BACKGROUND: Lesbian, gay, bisexual and transgender youth are often at greater risk for negative health outcomes compared with heterosexual youth. Isolation is one risk factor cited throughout the literature; however, the concept is complicated and has many uses and thus warrants clarification. DESIGN: Concept Analysis. DATA SOURCES: Sources comprise 35 English language research articles retrieved from CINAHL and EBSCOHost (1987-2012). METHODS: A dimensional concept analysis was undertaken to analyse how the concept, isolation, is socially constructed. RESULTS: This dimensional analysis revealed five socially constructed dimensions and four sub-dimensions. These findings indicate that there is substantial variability in the concept of isolation. These differences and variations are most notably observed in the 20 articles (57%) that had more than one dimension. Although some of these articles were explicit with the different meanings and use of the concept, most of the papers had wide variability in the use and meaning of the concept. CONCLUSION: The disproportionately greater physical and mental health disparities between lesbian, gay, bisexual and transgender and heterosexual youth are a signal to conduct more research to clarify the concept of isolation, to develop instrumentation to identify at-risk youth and to explore predictors and consequences of isolation. Nurses and others can lead the way in translating this knowledge into strategies that will improve the health and lives of these young people.

Facilitating ADLs by caregivers of persons with dementia: the C3P model.

The purpose of this paper is to explicate a change model for caregivers of persons with dementia to assist them in facilitating meals in the home, at community-based programs and in institutional settings. Building on a Social Ecological Model, the C3P Model-Change the Person, Change the People, Change the Place offers a clear method to adapt care strategies to foster independence while providing appropriate support as the person with dementia cognitively and functionally declines. Meals are highly embedded within a culture and are ritualized events within a family requiring an individualized approach when modifications are needed.

Factors associated with weight loss, low BMI, and malnutrition among nursing home patients: a systematic review of the literature.

BACKGROUND: Weight loss and poor nutrition are important quality measures in long term care. Long term care professionals need to identify factors associated with weight loss and poor nutrition to target high-risk patients. METHODS: The authors systematically searched Medline and CINAHL databases and included English language studies with more than 100 subjects analyzed, published after January 1, 1990, with data on factors associated with at least one of the following: weight loss, low body mass index (BMI), low Mini-Nutritional Assessment (MNA) score, or other standard measure of malnutrition. Data from all studies were systematically extracted onto a matrix table. The Critical Appraisal Skills Programme (CASP) questions were used to compare the quality of evidence extracted. Data from each article were then sorted and arranged into tables of factors associated with weight loss, low BMI, and malnutrition. RESULTS: Sixteen studies met the inclusion criteria for the review. The factors most consistently associated with weight loss were depression, poor oral intake, swallowing issues, and eating/chewing dependency. Staffing factors were associated with weight loss in most studies. The factors most consistently associated with low BMI included immobility, poor oral intake, chewing problems, dysphagia, female gender, and older age. The factors most consistently associated with poor nutrition included impaired function, dementia, swallowing/chewing difficulties, poor oral intake, and older age. CONCLUSION: Potentially modifiable factors consistently associated with increased likelihood of weight loss, low BMI, or poor nutrition included depression, impaired function, and poor oral intake. Nursing home medical directors may wish to target quality improvement efforts toward patients with these conditions who are at highest risk for weight loss and poor nutrition.

Prevalence and measures of nutritional compromise among nursing home patients: weight loss, low body mass index, malnutrition, and feeding dependency, a systematic review of the literature.

Weight loss and poor nutrition have been important considerations in measuring quality of nursing home care since 1987. Our purpose was to examine, synthesize, and provide a systematic review of the current literature on the prevalence and definitions of nutritional problems in nursing home residents. In the fall of 2011, we performed MEDLINE searches of English-language articles published after January 1, 1990. Articles were systematically selected for inclusion if they presented prevalence data for general nursing home populations on at least one of the following: weight loss, low body mass index, Mini-Nutritional Assessment or other measure of malnutrition, poor oral intake, or dependency for feeding. Data on each study, including study author, year, setting, population, type of study (study design), measures, and results, were systematically extracted onto standard matrix tables by consensus by a team of two fellowship-trained medical school faculty geriatrician clinician-researchers with significant experience in long term care. The MEDLINE search yielded 672 studies plus 229 studies identified through related citations and reference lists. Of the 77 studies included, 11 articles provided prevalence data from the baseline data of an intervention study, and 66 articles provided prevalence data in the context of an observational study of nutrition. There is a wide range of prevalence of low body mass index, poor appetite, malnutrition, and eating disability reported among nursing home residents. Studies demonstrate a lack of standardized definitions and great variability among countries. Of all the measures, the Minimum Data Set (MDS) weight loss definition of ≥5% in 1 month or ≥10% in 6 months had the narrowest range of prevalence rate: 6% to 15%. Weight loss, as measured by the MDS, may be the most easily replicated indicator of nutritional problems in nursing home residents for medical directors to follow for quality-improvement purposes. Additional studies are needed, reporting the prevalence of the MDS weight loss definition among international nursing home residents.

State of the science: alleviating mealtime difficulties in nursing home residents with dementia.

Three million people will reside in nursing homes (NH) in the United States, and over 50% will experience some level of dementia by 2030. People with dementia become increasingly dependent on others to manage mealtime difficulties and oral intake as the disease progresses. The purpose of this review is to explore the state of the science related to assisted hand-feeding of people with dementia in the NH, identify gaps, and inform future policy. The review was conducted in 2010 and identified sources from journal articles, websites, and other related publications. Results are presented around key themes of characteristics, measurements, related factors, and interventions for alleviating mealtime difficulties in people with dementia. Though in the early stages, international and interdisciplinary research interest exists to understand mealtime difficulties and effective intervention strategies. Health care providers must be able to identify problems and intervene appropriately to alleviate mealtime difficulties.

Methodological issues in fall prevention research involving older adults in long-term care facilities.

The purpose of this study was to conduct a systematic review of the current fall prevention literature, examining methodological issues resulting from variations in fall definitions, methods of data collection, and standards for reporting fall rates in studies involving older adults in long-term care settings. This systematic review used the five stages of Whittemore and Knafl's review methodology to extract data from the databases, summarize, and synthesize the findings of the 10 studies included. The Critical Appraisal Skill Program checklist for randomized controlled trials criteria was used to appraise the methodological quality of the studies. Inconsistencies in fall definitions, methods of data collection, and standards for reporting fall rates were apparent across the studies reviewed. Standardized approaches to defining falls, collecting data, and reporting fall rates are necessary to interpret, make comparisons among, and disseminate the findings of studies.

Time travel: the lived experience of providing feeding assistance to a family member with dementia.

A major concern facing family members of people with advanced dementia is deciding how to provide food and water. Nurses play a significant role in supporting mealtimes, yet little is known about the meaning of mealtime for family caregivers of people with dementia. The purpose of this phenomenological study was to explore the experience of providing feeding assistance to a family member with dementia from the perspective of community and nursing home family caregivers. Data were collected through in-depth interviews with 16 family caregivers of individuals with advanced dementia. Analysis revealed that the experience was likened to living in a time warp whereby family caregivers were propelled from pleasant memories of the past, to the stark reality of the present, to a foreboding and uncertain future. Findings can guide nurses to dialogue with family members and to ensure that the full spectrum of mealtime is preserved.

An evolutionary analysis of mealtime difficulties in older adults with dementia.

AIMS AND OBJECTIVES: To use the evolutionary method of concept analysis to identify attributes, antecedents and consequences of mealtime difficulties providing direction for assessment and management in older adults with dementia. BACKGROUND: Mealtimes encompass more than the physical act of feeding a person with dementia. Social and contextual considerations are vital considerations to improving nutritional intake. While feeding difficulties in dementia have been analysed in the literature, this paper proposes a broader scope of mealtime considerations to alleviate nutritional deficiencies often associated with dementia. DESIGN: Evolutionary method of concept analysis. METHODS: In 2008, literature searches using keywords (meal, history, sociology, mealtime, culture, habit, dementia, dementia) were done in CINAHL, Academic Search Premiere, MasterFILE, Americal Life and History, Communication and Mass Media Complete, EJS, Health Source Plus-Academic, PsychARTICLES and PsychINFO, ScienceDirect, Sociological Abstracts and Google. Year limits were from 1988-2008. A total of 659 abstracts were reviewed, Google, books and textbooks with relevant content. RESULTS: Fourty-eight sources were used in the final analysis of mealtime difficulties in older adults with dementia. A model of mealtime difficulties delineates attributes, antecedents and consequences. CONCLUSIONS: Mealtime difficulties in dementia emerged as a concept with supporting evidence-based practice guidelines in 2003. Most research has been conducted in institutional settings, but community research is growing as the shifting demographics of ageing demand attention for this setting. Interventions vary in effectiveness for alleviating sequelae of mealtime difficulties in older adults with dementia. RELEVANCE TO CLINICAL PRACTICE: The conceptual model of mealtime difficulties provides a broader scope of mealtime difficulties in dementia that considers environmental, social, cultural and contextual implications with nutritional intake. The model can be used to guide future research to alleviate mealtime difficulties in older adults with dementia.

Nurses' perspectives on feeding decisions for nursing home residents with advanced dementia.

AIM: To develop a broad understanding of nursing beliefs, knowledge and roles in feeding decisions for nursing home residents with advanced dementia. BACKGROUND: Concern is growing about the common use of feeding tubes in nursing home residents with advanced dementia. Nurses can play an important role in providing information and guiding family members through difficult feeding decisions. Little is known about nurses' perspectives on feeding decisions. DESIGN: Qualitative descriptive. METHODS: In-depth semi-structured interviews of 11 licensed nurses who were experienced in caring for nursing home residents with dementia. RESULTS: Analysis of the interview transcripts revealed three themes: insufficient empirical information, ambiguous role in feeding decisions and uncertainty about moral agency in decisions about the placement of feeding tubes. CONCLUSIONS: Despite views that family members would benefit from guidance in decisions regarding the placement of feeding tubes, nurses were, nevertheless, reluctant to become involved in these difficult decisions. RELEVANCE TO CLINICAL PRACTICE: If nurses are to guide family members in decisions about the use of feeding tubes, they need more education about evidence-based practice as well as support in exercising their nursing responsibilities.

The influence of nursing home culture on the use of feeding tubes.

BACKGROUND: Nationwide, many nursing home (NH) residents with advanced cognitive impairment are tube fed, despite no demonstrable benefits of this intervention in this population. Studies suggest that organizational features of NHs are associated with this practice, but underlying reasons for these associations are poorly understood. METHODS: We conducted a focused ethnographic study of 2 NHs in South Carolina, 1 with a high tube-feeding rate (41.8%) in patients with advanced dementia, and 1 with a low rate (10.7%). Data were collected about physical environment, mealtime and decision-making processes, and explicit and implicit values using 80 hours of direct observation, semistructured interviews with 30 key facility personnel, and abstraction of publicly available material describing the facilities. Data were analyzed using qualitative methods. RESULTS: Striking variations in organizational culture were identified. The low-use NH had a homelike environment centered on food as an important component of daily life, mealtimes staffed with knowledgeable nursing assistants who valued hand feeding, and advance care planning that included family and palliative care options. In contrast, the high-use NH had an institutionlike environment, poorly staffed mealtimes, and staff attitudes favoring feeding tubes to avoid aspiration and to meet perceived regulatory compliance. CONCLUSIONS: The NH culture influences the approach to feeding in advanced cognitive impairment, whether by hand or placement of a feeding tube. Key features of NHs with a low rate of tube-feeding use include a physical environment that promotes the enjoyment of food, administrative support, and empowerment of staff to value hand feeding and shared decision-making processes involving family members.

The Edinburgh Feeding Evaluation in Dementia Scale: determining how much help people with dementia need at mealtime.

OVERVIEW: The Edinburgh Feeding Evaluation in Dementia scale is an 11-item instrument developed to assess eating and feeding problems in people with late-stage dementia. By looking for certain behaviors--spilling food while eating or turning the head when prompted to eat, for example--a nurse can identify a patient's needs and build an effective care plan. The scale takes as little as five minutes to complete. Watch an online video of nurses demonstrating the use of the scale: http://links.lww.com/A281.