Noticing Acute Changes in Health in Long-Term Care Residents.

PURPOSE: Early signs of acute conditions and increased fall risk often go unrecognized in patients in long-term care facilities. The aim of this study was to examine how healthcare staff identify and act on changes in health status in this patient population. DESIGN: A qualitative study design was used for this study. METHODS: Six focus groups across two Department of Veterans Affairs long-term care facilities were conducted with 26 interdisciplinary healthcare staff members. Using thematic content analysis, the team preliminarily coded based on interview questions, reviewed and discussed emerging themes, and agreed on the resultant coding scheme for each category with additional independent scientist review. RESULTS: Themes included describing and explaining how "normal" or expected behavior is identified by staff, noticing changes in a resident, determining the significance of the change, hypothesizing reasons for an observed change, response to an observed change, and resolution of the clinical change. CONCLUSIONS: Despite limited training in formal assessment methods, long-term care staff have developed methods to conduct ongoing assessments of the residents. This technique, individual phenotyping, often identifies acute changes; however, the lack of formal methods, language, or tools to communicate the changes means that these assessments are not often formalized in a manner that informs the residents' changing care needs. CLINICAL RELEVANCE TO THE PRACTICE OF REHABILITATION NURSING: More formal objective measures of health change are needed to assist long-term care staff in expressing and interpreting the subjective phenotype changes into objective, easily communicated health status changes. This is particularly important for acute health changes and impending falls, both of which are associated with acute hospitalization.

PTSD Avoidance Symptoms Associated With Alcohol Craving in Treatment-Seeking Veteran Population.

Objective: Posttraumatic stress disorder (PTSD) is one of the most frequently treated behavioral health conditions within the Department of Veterans Affairs and often co-occurs with alcohol or substance use. Past research suggests that alcohol and/or substance use may be used to cope with PTSD symptoms but there are inconsistent findings in how specific PTSD symptom clusters are associated with alcohol use disorder (AUD) or substance use disorder (SUD). Evaluating the relationship between PTSD symptom clusters and craving for individual drug of dependence may help explain these ambiguous results. Methods: Veterans (N = 167) recently engaged in mental health residential treatment were recruited to participate in a semi-structured diagnostic interview (Structured Clinical Interview for the DSM-5, Research Version [SCID-5-RV]) to assess for past 12-month history of AUD/SUD. Participants also completed the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) to assess PTSD symptoms. Results: Covarying for severity of alcohol use, avoidance symptoms were significantly associated with alcohol craving for veterans with alcohol as their drug of dependence. Covarying for severity of stimulant use, no PTSD symptom clusters were associated with stimulant craving for veterans with stimulants as their drug of dependence. Conclusions: Veterans with high levels of PTSD avoidance symptoms may experience alcohol craving symptoms because they believe that alcohol use will eliminate or alleviate thoughts, feelings, or external reminders of the trauma. These results have important clinical implications in the treatment of co-occurring PTSD and AUD.

Genetic Variation in PADI6-PADI4 on 1p36.13 Is Associated with Common Forms of Human Generalized Epilepsy.

We performed a genome-wide association study (GWAS) to identify genetic variation associated with common forms of idiopathic generalized epilepsy (GE) and focal epilepsy (FE). Using a cohort of 2220 patients and 14,448 controls, we searched for single nucleotide polymorphisms (SNPs) associated with GE, FE and both forms combined. We did not find any SNPs that reached genome-wide statistical significance (p ≤ 5 × 10-8) when comparing all cases to all controls, and few SNPs of interest comparing FE cases to controls. However, we document multiple linked SNPs in the PADI6-PADI4 genes that reach genome-wide significance and are associated with disease when comparing GE cases alone to controls. PADI genes encode enzymes that deiminate arginine to citrulline in molecular pathways related to epigenetic regulation of histones and autoantibody formation. Although epilepsy genetics and treatment are focused strongly on ion channel and neurotransmitter mechanisms, these results suggest that epigenetic control of gene expression and the formation of autoantibodies may also play roles in epileptogenesis.

Factors Associated With Health Service Use Among Older Adults in a Mobile Veterans Program.

The current retrospective, longitudinal study applied Andersen's Behavioral Model of Health Services Use to examine how demographic characteristics (age), available resources (e.g., a caregiver, the Mobile Veterans Program [MVP]) and health needs (e.g., cognitive and physical functioning, depressive symptoms) affect hospitalization and institutionalization outcomes among older adults using the MVP. Fifty-four Veterans (age 55 to 95) participating in the MVP for up to 2 years were examined using hierarchical linear modeling (HLM) and growth curve model. In the final HLM model, each 1-point increase in depressive symptoms was associated with 76% (p ≤ 0.05) greater risk of institutionalization and 40% (p ≤ 0.01) greater risk of hospitalization. Each 1-point increase in cognitive functioning was associated with 24% (p ≤ 0.05) lower risk of institutionalization. The relationship between caregiver burden and hospitalization was attenuated by frequency of MVP visits. Services focused on reducing depressive symptoms may influence health service use and reduce caregiver burden in this population. [Journal of Gerontological Nursing, 46(5), 15-22.].

Evaluation of Cholesterol as a Biomarker for Suicidality in a Veteran Sample.

A reduction in total cholesterol may alter the microviscosity of the brain-cell-membrane, reducing serotonin receptor exposure. The resulting imbalance between serotonin and dopamine may lead to an increased risk for suicidality. The objective of this research was to evaluate total cholesterol as a biological marker for suicidality in a sample of US military veterans. The study population consisted of veterans who received care at the Coatesville Veterans Affairs Medical Center (VAMC) and were included in the Suicide Prevention Coordinator's database for having suicidal ideation with evidence of escalating intent, a documented suicide attempt, or committed suicide between 2009 and 2015. The veterans' medical data were obtained from the facility's computerized patient record system. The final sample was 188 observations from 128 unique veterans. Veterans with total cholesterol levels below 168 mg/dl appeared to have a higher suicide risk than those with higher levels. The cholesterol levels of veterans reporting suicidal ideation or attempt were significantly lower than the group reporting neither [F(2, 185) = 30.19, p < .001]. When data from multiple visits were available, veterans reporting suicidal ideation or attempt had experienced a significant (20%) decrease in cholesterol levels from an earlier visit in which they did not report suicidality. A latent class analysis revealed that among other differences, suicidal veterans were younger, leaner, and had more anxiety, sleep problems, and higher education than those being seen for an issue unrelated to suicidality. © 2017 Wiley Periodicals, Inc.