Geriatrics Nursing (March-April) 2005 Geriatric Nursing, Volume 26, Number 2 65 GERIATRICGERIATRIC NURSING Vol. 26, No. 2 • March/April 2005 69 FROM THE EDITOR Losing and Retrieving Priscilla Ebersole 70 NEWSVIEW 73 CALENDAR DRUG CONSULT 74 Dementia Treatment Update Marti D. Buffum and John C. Buffum NUTRITION AND WELL-BEING 79 Relationship of Dementia and Body Weight Peggy K. Yen HOME HEALTH CARE 81 Dementia: Complex Care Needing Ongoing Assessment Tina M. Marrelli BOOK REVIEWS 83 Marianne LaPorte Matzo NGNA SECTION 86 NGNA News Robin E. Remsburg and Neva L. Crogan 89 Incorporating Medication Regimen Reviews Into the Interdisciplinary Care Planning Process Judy Binch, Ron Beamon, Stephanie Clontz, Patti Goodwin, Heather Hartwig, Ratna Kolhatkar, Mike List, and Shirley S. Travis Although many long-term care providers may view medication utilization reviews negatively, this article describes an innova- tive approach that includes medication reg- imen review in the larger context of resi- dent care planning. NCGNP SECTION 94 Pharmacology Update Ann Schmidt Luggen 95 Research Review Ann Schmidt Luggen 95 GNP Care Guidelines Ann Schmidt Luggen READER SERVICES 67 Information for Authors 68 Information for Readers DEPARTMENTS 66 Geriatric Nursing, Volume 26, Number 2 National Gerontological Nursing Associuation National conference of Gerontological nurse Practitioners Geriatric Nursing (ISSN 0197-4572) is published bimonthly by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710. Months of issue are February, April, June, August, October, and December. Business and Editorial Offices: 170 S Independence Mall West, Suite 300 E, Philadelphia, PA 19106- 3399. Accounting and Circulation Offices: 6277 Sea Harbor Drive, Orlando, FL 32887-4800. Periodicals postage paid at Orlando, FL 32862, and additional mailing offices. POSTMASTER: Send address changes to Geriatric Nursing. Elsevier Periodicals Customer Service, 6277 Sea Harbor Drive, Orlando, FL 32887-4800. Visit our Web site at www.mosby.com/gerinurs. Official Publication of 98Development of Nurse Competencies to Improve Dementia Care Christine L. Williams, Kathryn Hyer, Annette Kelly, Sue Leger-Krall, and Ruth M. Tappen As the number of elders needing dementia care increases, the demand for skilled care providers will require new competency-based curriculum to meet the demand for training. 106 Falls Associated with Dementia: How Can You Tell? Deanna Gray Miceli Post-fall assessment of an individual with dementia differs from the standard post- fall assessment of an older adult without dementia. Early detection of fall events is crucial, but is especially important in the individual with dementia. 111 Imposed Versus Involved: Different Strategies to Effect Driving Cessation in Cognitively Impaired Older Adults Kathleen Jett, Ruth M. Tappen, and Monica Rosselli Giving up driving can be a particularly difficult issue for the cognitively impaired driver. The skilled nurse knows when and where involved versus imposed cessation is appropriate. 117 Subcortical Vascular Dementia Donna Fladd Vascular dementia is the second most prevalent type of dementia in the United States today. Its presentation is subtle and can be mistaken for depression. This article provides a comprehensive review of subcortical vascular dementia to assist the nurse with differential diagnosis. 122 The Frail Elderly Community- Based Case Management Project Cheryl Duke As the frail elderly population continues to increase, health care providers will be challenged to develop new models of care delivery for this unique population. This project demonstrates successful outcomes from one such model. FEATURE ARTICLES EDITOR Priscilla R. Ebersole, PhD, RN, FAAN 2790 Rollingwood Dr. San Bruno, CA 94066 Fax: (650) 952-3155 E-mail: ebersole@sfsu.edu MANAGING EDITOR Leslie J. Flatt ISSUE MANAGER Amy M. Clark JOURNAL COMPOSITION DESIGNER Penny Dietrich RESEARCH BRIEFS Marti D. Buffum, DNSc, APRN, BC, CS Graham McDougall, PhD, CS, RN, FAAN COLUMNISTS Tina M. Marrelli, MSN, MA, RN Marti D. Buffum, DNSc, APRN, BC, CS John C. Buffum, PharmD, BCPP Peggy K. Yen, RD, LD, MPH BOOK REVIEW EDITOR Marianne LaPorte Matzo, PhD, APRN, BC, GNP, FAAN BOARD MEMBERS Mathy Mezey, PhD, RN, FAAN, FGSA Barbara Schrupp, RN, BSN, CDONA/LTC Joyce Springate, EdD, RN, MSc, BN NATIONAL GERONTOLOGICAL NURSING ASSOCIATION Bronwynne C. Evans, PhD, RN, CNS Susan J. Loeb, PhD, RN Jacquelyn M. Sullivan, MSN, GNP NATIONAL CONFERENCE OF GERIATRIC NURSING Geriatric Nursing, Volume 26, Number 2 67 GERONTOLOGICAL NURSE PRACTITIONERS Ann Schmidt Luggen, PhD, GNP Barbara Resnick, PhD, CRNP, FAAN, FAANP mailto:ebersole@sfsu.edu 68 Geriatric Nursing, Volume 26, Number 2 Communication Communications regarding original articles and editorial man- agement should be addressed to Priscilla R. Ebersole, PhD, RN, FAAN, Editor, Geriatric Nursing, 2790 Rollingwood Dr., San Bruno, CA 94066; ebersole@sfsu.edu. Abbreviated instructions for authors appear in each issue. The full instructions for authors appear annual- ly in the July/August issue of the journal. CUSTOMER SERVICE (orders, claims, online, change of address): Elsevier Periodicals Customer Service, 6277 Sea Harbor Drive, Orlando, FL 32887-4800. Tel: (800) 654-2452 (U.S. and Canada); (407) 345-4000 (outside U.S. and Canada). Fax: (800) 225-6030 (U.S. and Canada); (407) 363-9661 (outside U.S. and Canada). E-mail: elspcs@elsevier.com. Address changes must be submitted four weeks in advance. YEARLY SUBSCRIPTION RATES: United States and possessions: Individual $57.00; Institution $121.00; Student/Resident: $29.00. All other countries (prices include airspeed delivery): Individual $93.00; Institution $158.00; Student/Resident $47.00. Single issues $27.00. To receive student/resident rate, orders must be accompanied by name of affiliated institution, date of term and the signature of program/ residency coordinator on institution letterhead. Orders will be billed at the individual rate until proof of status is received. Current prices are in effect for back volumes and back issues. Further information on this journal is available from the Publisher or from this journal’s Web site (http://www.mosby.com/gerinurs). Information on other Elsevier products is available through Elsevier’s Web site (http://www.elsevier.com). Advertising information. Advertising orders and inquiries can be sent to: USA, Canada, and South America, M. J. Mrvica Associ- ates, 2 West Taunton Ave., Berlin, NJ 08009; (856) 768-9360; fax (856) 753-0064. Classified advertising orders and inquiries can be sent to Alexandra Leonardo, Elsevier Inc., 360 Park Avenue South, New York, NY 10010; (212) 633-3649; fax (212) 633-3820. Europe and the rest of the world, Julie Toop; phone +44 (0) 1865 843016; fax +44 (0) 1865 843976; E-mail: media@elsevier.com. Author Inquiries. For inquiries relating to the submission of arti- cles (including electronic submission where available), please visit Elsevier’s Author Gateway at http://authors.elsevier.com. The Author Gateway also provides the facility to track accepted articles and set up e-mail alerts to inform you of when an article’s status has changed, as well as detailed artwork guidelines, copyright informa- tion, frequently asked questions, and more. Please see Information for Authors for individual journal. Contact details for questions aris- ing after acceptance of an article, especially those relating to proofs, are provided after registration of an article for publication. Reprints. For queries about author offprints, e-mail authorsup- port@elsevier.com. To order 100 or more reprints for educational, commercial, or promotional use, contact the Commercial Reprints Department, Elsevier Inc., 360 Park Avenue South, New York, NY 10010-1710. Fax: (212) 462-1935; e-mail reprints@elsevier.com. Reprints of single articles available online may be obtained by pur- chasing Pay-Per-View access for $30 per article on the journal Web site, www.mosby.com/gerinurs. Copyright © 2005 Mosby, Inc. All rights reserved. This journal and the individual contributions contained in it are pro- tected under copyright by Mosby, Inc., and the following terms and conditions apply to their use: Photocopying Single photocopies of single articles may be made for personal use as allowed by national copyright laws. Permission of the Publisher and payment of a fee is required for all other photocopying, includ- ing multiple or systematic copying, copying for advertising or pro- motional purposes, resale, and all forms of document delivery. Special rates are available for educational institutions that wish to make photocopies for non-profit educational classroom use. Permissions may be sought directly from Elsevier's Rights Department in Philadelphia, PA, USA: phone (215) 238-7869, fax (215) 238-2239, e- mail healthpermissions@elsevier.com. Requests may also be completed online via the Elsevier homepage www.elsevier.com/locate/permissions. In the USA, users may clear permissions and make payments through the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA; phone: (978) 750-8400, fax: (978) 750-4744, and in the UK through the Copyright Licensing Agency Rapid Clearance Service (CLARCS), 90 Tottenham Court Road, London W1P 0LP, UK; phone: (+44) 20 7631 5555; fax: (+44) 20 7631 5500. Other countries may have a local reprographic rights agency for payments. Derivative Works Subscribers may reproduce tables of contents or prepare lists of arti- cles including abstracts for internal circulation within their institu- tions. Permission of the Publisher is required for resale or distribu- tion outside the institution. Permission of the Publisher is required for all other derivative works, including compilations and translations. Electronic Storage or Usage Permission of the Publisher is required to store or use electronically any material contained in this journal, including any article or part of an article. Except as outlined above, no part of this publication may be repro- duced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or oth- erwise, without prior written permission of the Publisher. Address permissions requests to: Elsevier Rights Department, at the fax and e-mail addresses noted above. Notice No responsibility is assumed by the Publisher for any injury and/or dam- age to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions or ideas contained in the material herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. Although all advertising material is expected to conform to ethical (medical) standards, inclusion in this publication does not constitute a guarantee or endorsement of the quality or value of such product or of the claims made of it by its manufacturer. Indexed or abstracted in Cumulative Index to Nursing & Allied Health Literature (CINAHL), Current Advances in Ecological Sciences, Current Literature on Aging, Hospital Literature Index, International Nursing Index, International Pharmaceuti- cal Abstracts, Nutrition Research Newsletter, and Psychological Abstracts. Microform edition available from ProQuest Information and Learning, 300 N. Zeeb Rd., Ann Arbor, MI 48106-1346. INFORMATION FOR READERS GERIATRIC NURSING mailto:ebersole@sfsu.edu mailto:healthpermissions@elsevier.com http://www.elsevier.com/locate/permissions mailto:elspcs@elsevier.com http://www.mosby.com/gerinurs http://www.elsevier.com mailto:media@elsevier.com http://authors.elsevier.com mailto:authorsupport@elsevier.com mailto:authorsupport@elsevier.com mailto:reprints@elsevier.com http://www.mosby.com/gerinurs Geriatric Nursing, Volume 26, Number 2 69 When I was young I didn’t dream there would be a day when the tip of one finger could control a vast amount of information. Yesterday I deleted 72 e-mail messages by selecting all messages rather than just junk. Later in the day, I retrieved a history of dementia with a few finger taps on google.com (search: History of Dementia, www.sciencedirect.com/science). But how did I recover from that earlier blunder? I have a backup system—our wonderful man- aging editor, Leslie Flatt, who receives almost everything that is of importance to GN. What possible relevance does this have to dementia? A great deal. First, and most important in my mind, is for- getfulness panic. “Oh, dear! What have I lost?” Age-associated memory impairment (AAMI) exists and is normal for most people after age 80, although some 40-year-old gerontologists may quibble about this. The average (as if there is such a person) older person will forget details that are unimportant—and maybe a few important ones—and often will not regis- ter automatic actions or insignificant events that occur each day, such as, “Did I take my eyedrops this morning?” or “Where did I put my glasses?” Adaptive mechanisms have also developed automatically for most of these people, however. Ordinarily, elders develop backup systems that work beautifully for them. The vial of eyedrops is placed different- ly in the medicine cabinet after the morning dose than before. Several pairs of glasses are placed at strategic points. Everything that is important is written down. Grandchildren can be tapped for their more exacting, although often misinterpreted, memory of whatever happened last week. When one walks down- stairs and forgets why, one simply turns around and goes back up; exercise is a won- derful mental and physical restorative. The fear of dementia is overactive, and many elders live in dread of developing Alzheimer’s disease or a related disorder. Each little lapse of memory triggers an anxi- ety reaction that blocks clear thought. The fear of an irreversible dementia is serious because if we lose our memory, we lose our personhood. We “lose it.” We lose “I.” My 4-year-old granddaughter often wants to talk about when she was a baby. Initially, I thought her focus on that was a trifle unusual, but now I see it as filling in the amnesia of babyhood. She wants to know who she was and what she did, and especially how “adorable” she was. So yesterday we retrieved a dozen or so photos of her babyhood and talked about each one of them—why, when, and where they were taken, and so forth. These ideas can just as easily be trans- ferred to working with an elder who has mild to moderate dementia; maybe even beyond that. Whatever threads of memory may be awakened will make life a little bit more worth living, and even if none are stirred, the special attention will feel good. So who has time to do that? Visual images, foods, objects, fragrances, memorable music—all can be tools of stimu- lation, used carefully to avoid overload and to enrich daily existence. How about assign- ing group leadership to select aides? When dealing with individuals in the home, nurses are detectives, seeking small clues in the environment that may activate thought- provoking comments to an elder or a family member. Irreversible dementias, particularly Alzheimer’s disease, have been the subject of a great deal of geriatric research. Nurses and family members are the people who must deal with the manifestations on a daily basis. We are pivotal in identifying the reality of loss, preventing unnecessary loss, and acti- vating methods of personhood retrieval. We are the “backup system.” 0197-4572/$ - see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2005.01.007 FROM THE EDITOR Losing and Retrieving GERIATRIC NURSING Priscilla Ebersole, PhD, RN, FAAN http://www.sciencedirect.com/science http://google.com NEWSVIEW 70 Geriatric Nursing, Volume 26, Number 2 Report on Pharmacological Treatment of Dementia The Agency for Healthcare Research and Quality (AHRQ) recently released the summary of a new report, Pharmacological Treatment of Dementia. The report presents evidence that drug therapy for dementia can improve symp- toms and outcomes, including global assess- ment, cognition, behavior, mood, and quality of life. Some deficiencies in the research were noted such as insufficient evidence of the effects of drug treatment on delaying the onset or progression of dementia and the lack of drug-to-drug comparison studies. A print copy of the summary and report are available by sending an e-mail to ahrqpubs@ahrq.gov. Diabetes and Dementia Diabetes can accelerate dementia, which in itself hinders the ability to manage one’s blood sugar. Early detection and treatment of dia- betes could help stall the effects of cognitive decline, including Alzheimer’s disease, accord- ing to a recent article posted at the SAGE Crossroads Web site. The full article is available at www.sagecrossroads.net/public/news/show_ article.cfm?articleID=93 Link Between Inappropriate Medications and Elevated Death Rates in Nursing Home Patients According to a study recently reported in the January 10, 2005, issue of the Archives of Internal Medicine, elderly nursing home resi- dents given potentially inappropriate drugs intermittently over a 3-month period had an almost 90% greater likelihood of dying during the last month of that period than similar resi- dents not administered possibly inappropriate medications. The study, conducted by re- searchers at the federal government’s Agency for Healthcare Research and Quality (AHRQ), is the first known analysis in the United States of the effects of potentially inappropriate medica- tion prescribing in nursing homes based on nationally representative survey data. The most common drugs involved were propoxyphene (narcotic painkiller), amitriptyline (antidepres- sant), diphenhydramine and cyproheptadine (antihistamines with strong anticholinergic effects); hyroxyzine (antianxiety drug), oxybu- tynin (bladder muscle relaxant), ranitidine (antacid), and iron supplements. For a pdf file of the article or for questions, contact Bob Isquith at bisquith@ahrq.gov or call (301 427- 1539. Forum Develops Initiatives to Further Patient Safety The nation’s first Chief Nursing Officer (CNO) Patient Safety Leadership Forum was recently held in San Diego, California. Nationally recognized experts gathered in Indianapolis to emphasize the leadership role nurses must play in making patient safety a pri- ority within the health care system. The forum highlighted a series of Institute of Medicine reports on patient safety and best practices for how nurses can improve safety within their individual hospitals and through implementa- tion of practices developed by organizations such as the Joint Commission on American Healthcare Organizations and the Food and Drug Administration. An executive summary of the CNO Patient Safety Leadership Forum is posted at www.alarismed.com or www.clarian.org. Quality-of-Life Measures in Clinical Research and Medical Care The National Institutes of Health (NIH) Roadmap Initiative recently awarded a 5-year grant to David Cella, PhD, director of the Evanston Northwestern Healthcare Center on Outcomes Research and Education (CORE). The project for which the grant was received— “Patient-Reported Outcome Measurement Information System (PROMIS)”—has the potential to improve patient care because it will develop standardized outcome measures across a wide range of chronic diseases for use in clinical research as well as in medical prac- tice. The NIH Roadmap for Medical Research is a series of far-reaching initiatives designed to transform the nation’s medical research capa- NEWSVIEW mailto:ahrqpubs@ahrq.gov mailto:bisquith@ahrq.gov http://www.sagecrossroads.net/public/news/show_article.cfm?articleID=93 http://www.sagecrossroads.net/public/news/show_article.cfm?articleID=93 http://www.alarismed.com http://www.clarian.org Geriatric Nursing, Volume 26, Number 2 71 bilities and speed the movement of scientific discoveries from the bench to the bedside. Additional information about the program can be found at http://nihroadmap.nih.gov. New Master’s Program in Geriatric Nursing Dominican University of California has recently been awarded a large grant from the Gordon and Betty Moore Foundation to provide startup funds for the new Master of Science in nursing (MSN) program that will train students to become nurse educators with a specialty in geriatric nursing. The Geriatric Clinical Nurse Specialist/Nurse Educator program, scheduled to start in the fall of 2005, will be the only one like it in the San Francisco Bay area. The pro- gram is aimed at working clinical nurses and offers a flexible meeting schedule of alternative weekends for 5 semesters. For more informa- tion on the program, contact the school at www.dominican.edu. Simulation Technology and Nursing Education Quality The American Association of Colleges of Nursing (AACN) has recently received new funding to investigate the use of simulation technology to assess the competency of gradu- ating nurses and to enhance education quality. Funding provided by the Helene Fuld Health Trust will be used to study and validate a simu- lation-based training and assessment tool adapted specifically for nursing by Simulis, a leading developer of simulation-based learning systems. AACN and Simulis will initiate the pilot program with a variety of institutions offering baccalaureate nursing programs in the second quarter of 2005. The project will begin by testing an already-developed Pain Manage- ment module. Simulis has also recently part- nered with Sigma Theta Tau International, the Honor Society of Nursing, to build evidence- based Clinical Reasoning Systems for nursing education and skills assessment. American Retirement Corporation Joins NADONA/LTC NADONA/LTC (The National Association of Directors of Nursing Administration in Long Term Care) recently announced that American Retirement Corporation, comprising 66 proper- ties offering independent living, assisted living facilities, and therapy services to residents, has made 25 of its directors of nursing NADONA members. “It’s our people that make the differ- ence,” says Elizabeth Barlow, RN, National Director for Quality Improvement for American Retirement Corporation. NADONA/LTC mem- bership for our directors of nursing gives them the educational resources they need and the ongoing support they deserve to make that essential difference in the lives and care of our residents.” For more information on NADONA/LTC’s Assisted Living Programs, con- tact Gary Warden (gary@nadona.org) or Jamey Schleue (jamey@nadona.org). Congratulations 2005 Christiane Reimann Prize Awarded: The International Council of Nurses (ICN) recently announced that Dr. Margretta Madden Styles, a nurse scholar recognized globally as an international leader in nursing education, regulation, and credentialing, has been awarded the 2005 Christiane Reimann Prize for her international achievements and contributions to the nursing profession. The prize is awarded every 4 years and will be pre- sented to Dr. Madden Styles during the opening ceremony of the ICN’s 23rd Quadrennial Congress slated for Taiwan in May 2005. Cherokee Inspired Comfort Award: Lynda Chever, an LPN specializing in geriatric medicine who has devoted her life to the care of elderly Catholic priests and nuns residing at the Mohun Health Care Center in Columbus, Ohio, was recently selected as one of the 15 national winners of the 2004 Cherokee Inspired Comfort Award. Nearly 1,700 nominations were submit- ted from which the 15 winners were selected. This award, a national health care recognition program, raises awareness of the vital profes- sion of nursing by highlight the best of the best in health care. RESOURCES Dementia and Alzheimer’s Resources • The Alzheimer’s Association, 225 North Michigan Avenue, Suite 1700, Chicago, IL 60601; phone: (800) 272-3900; Web site: www.alzheimers.org • Alzheimer’s Disease Education and referral (ADEAR) Center, P.O. Box 8250, http://nihroadmap.nih.gov mailto:gary@nadona.org mailto:jamey@nadona.org http://www.dominican.edu http://www.alzheimers.org Geriatric Nursing, Volume 26, Number 2 72 Silver Spring, MD 20907; phone: (800) 438- 4380; Web site: www.alz.org • Alzheimer’s Caregivers Support Online, phone: (866) 260-2466; Web site: www. alzonline.net • Alzheimer’s Foundation of American, 322 8th Avenue, 6th Floor, New York, NY 10001; phone: (866) 232-8484; Web site: www.alzfdn.org • The National Women’s Health Informa- tion Center: frequently asked questions about dementia. Available at: www.nlm. nih.gov/medlineplus/dementia.html Guide for the Aging Driver A new guide and online video for families worried about an aging parent’s ability to drive safely are available at www.thehartford.com/ talkwitholderdrivers or by writing to The Hartford, We Need to Talk, 200 Executive Blvd., Southington, CT 06489. The guide offers practi- cal information on helping elders know when it is time to limit or give up driving altogether. Alzheimer’s Speaker’s Kit Available The Alzheimer’s Disease Education and Re- ferral Center (ADEAR) has developed a Speaker’s Kit to help volunteers, health educators, and other community speakers disseminate basic informa- tion about Alzheimer’s disease, diagnosis, treat- ment, and current and future research directions. The kit contains a PowerPoint slideshow and booklet based on the ADEAR Center’s booklet— “Unraveling the Mystery of Alzheimer’s Disease.” For more information, go to the organization’s Web site: www.alzheimers.org/unraveling/ speak_kit.html. Internet Resource Health Politics with Dr. Mike Magee is an expertly researched and informative online commentary from Dr. Magee, a senior fellow in the humanities to the World Medical Associa- tion and director of the Pfizer Medical Humanities Initiative. The program topics change weekly, but an archive of articles is available and offers many items of potential interest to geriatric nurses, such as commen- taries on driving fatalities in the elderly, osteo- porosis, hidden costs of caring for an Alzheimer’s patient, and so on. Take a look at this free resource at www.HealthPolitics.com. Patient Safety E-Newsletter Available The Agency for Healthcare Research and Quality (AHRQ) has launched the AHRQ Patient Safety E-Newsletter. This new online resource will ensure that subscribers receive important patient safety news and information as quickly as possible. To subscribe to this free service, send an e-mail to listserv@list. ahrq.gov; in the subject line, type: Subscribe. For questions, e-mail Salina Prasad in AHRQ’s public affairs office at sprasad@ahrq.gov. GeroNurseOnline Program Geriatric nursing resources are at your fin- gertips with the new GeroNurseOnline program made possible through the Nurse Competence in Aging initiative. You can access “Try This” tips from the Hartford Institute at the new Web site (www.GeroNurseOnline.org) by clicking on “Resources.” New issues of the “Try This” series on Dementia include “Therapeutic Activity Kits,” “Recognition of Dementia in Hospitalized Older Adults,” and “Wandering in the Hospitalized Older Adult.” 0197-4572/$ - see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2005.01.015 http://www.alz.org http://www.alzonline.net http://www.alzonline.net http://www.alzfdn.org http://www.nlm.nih.gov/medlineplus/dementia.html http://www.nlm.nih.gov/medlineplus/dementia.html http://www.HealthPolitics.com http://www.thehartford.com/talkwitholderdrivers http://www.thehartford.com/talkwitholderdrivers mailto:listserv@list.ahrq.gov mailto:listserv@list.ahrq.gov mailto:sprasad@ahrq.gov http://www.GeroNurseOnline.org http://www.alzheimers.org/unraveling/speak_kit.html http://www.alzheimers.org/unraveling/speak_kit.html Geriatric Nursing, Volume 26, Number 2 73 CALENDAR MAY 19–20 Alzheimer’s Disease: Update on Research, Treat- ment and Care, San Diego, California. Contact: (858) 622-5850 or e-mail: jcollier@ucsd.edu. 20 10th Annual VAMC San Francisco Nursing Research Conference: Improving Practice Through Research, San Francisco VA Medical Center, San Francisco, California. Contact: Alicia. Levin@med.va.gov, phone: (415) 221-4810 ext. 4901; or Mimi.Haberfelde@med.va.gov, phone: (415) 221- 4810, ext. 4679. 21–27 International Council of Nurses (ICN) 23rd Quadrennial Conference, Nursing on the Move: Knowledge, Innovation and Vitality, Taipei, Taiwan. Contact the council’s Web site for further information: www.icn.ch/congresss2005.htm. 25–28 13th National Conference on Gerontological Nursing, of the Canadian Gerontological Nursing Association: “Gerontological Nursing: The Future’s So Bright!” Halifax, Nova Scotia. To register online or for additional information, visit the Web site: www.cgna.net/home.htm. JUNE 9-10 Pain Management and End-of-Life Care: A Comprehensive Approach to Patient Care, Fairmont Hotel, San Francisco, California. Con- ference sponsored by the University of California, San Francisco, Schools of Medicine, Nursing and Pharmacy. Contact: (415) 476-4251 or info@ocme. ucsf.edu. You can also visit the UCSF Office of Continuing Medical Education’s Web site at www.cme.ucsf.edu. 18-21 International Conference on Prevention of Dementia, Washington, DC. Contact: www.alz.org, e-mail to prevention@alz.org, or phone (800) 272- 3900. Inquiries to the Alzheimer’s Association, 225 N. Michigan Avenue, Suite 1700, Chicago, IL 60601. 21-25 Case Management Society of America’s 2005 Annual Conference, Gaylord Palms Resort and Convention Center, Kissimmee–St. Cloud, Florida. Contact: www.cmsa.org/conference or phone (501) 225-2229, ext. 10. 20-22 Dementia: Molecules to Management, Brisbane, Queensland, Australia. Contact: Australian Society for Geriatric Medicine, c/o Organisers Australia, P.O. Box 1237, Milton, Queensland 4064, Australia; phone: (+61) 7-3371-0333; e-mail: asgm@orgaus.com.,au or their Web site at www.asgm.org.au. 25-29 18th Annual NADONA Conference, New Orleans Marriott, Louisiana. Contact (800) 222-0539 or email to: info@nadona.org. JULY 16th International Nursing Research Con- gress: Renewing Nursing Through Scholarship, Hilton Waikoloa Village, Hawaii. Contact: www. nursingsociety.org or e-mail to research@stti. iupui.edu. 26-29 13th Annual Dementia Care Conference, Hyatt Regency Chicago Hotel, Chicago, Illinois. Contact: Alzheimer’s Association, 225 N. Michigan Avenue, Suite 1700, Chicago, IL 60601; phone: (800) 272-3900; Web site www.alz.org/careconference. NOVEMBER 12-16 Sigma Theta Tau International 38th Biennial Convention, Indianapolis, Indiana. Contact: www. nursingsociety.org or e-mail Indy05@stti.iupui.edu. 0197-4572/$ - see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2005.01.016 mailto:jcollier@ucsd.edu mailto:Alicia.Levin@med.va.gov mailto:Alicia.Levin@med.va.gov mailto:Mimi.Haberfelde@med.va.gov mailto:prevention@alz.org http://www.cmsa.org/conference mailto:asgm@orgaus.com.au http://www.asgm.org.au mailto:info@nadona.org http://www.icn.ch/congresss2005.htm http://www.cgna.net/home.htm http://www.nursingsociety.org http://www.nursingsociety.org mailto:research@stti.iupui.edu mailto:research@stti.iupui.edu http://www.alz.org/careconference mailto:info@ocme.ucsf.edu mailto:info@ocme.ucsf.edu http://www.cme.ucsf.edu http://www.alz.org http://www.nursingsociety.org http://www.nursingsociety.org mailto:Indy05@stti.iupui.edu 74 Geriatric Nursing, Volume 26, Number 2 DRUG CONSULT Alzheimer’s disease, the most common form of dementia, is a progressive and fatal neurode- generative disorder that affects about 4.5 mil- lion persons in the United States. The disease affects about 30% of people older than 80 years, and the risk increases with age over 60 years. The fastest-growing segment of the population is over age 85. Indeed, dementia is estimated to affect 13.2 million persons by 2050.1 Pro- gressive memory loss and functional decline that characterize dementia pose extensive bur- den on families and health care resources. With no known cure, much research has been direct- ed to treatment. This column presents an update on the newest medications for Alz- heimer’s disease (AD). Emphases are on preventing onset, halting progression, and promoting improvement in cognition in patients with dementia. Prevention research has been focusing on vaccine develop- ment for promoting antibodies against amyloid. To date, pharmacologic treatments that have been tested for the above mentioned emphases include selegiline, piracetam, vitamin E, ginkgo biloba, anti-inflammatory agents,2-4 and hor- mone replacement therapy. According to the Cochrane Database of Systematic Reviews, these have not demonstrated efficacy for Alzheimer’s disease.5,6 Clinical trials are inves- tigating benefits of statins and entirely new medications that may offer neuroprotection.7-9 Medications for slowing progression and pro- moting improvement have pharmacologic actions that either inhibit cholinesterase or regulate glutamate; other drugs are used to manage behaviors such as depression, agita- tion, or anxiety. Drugs that have demonstrated benefit in reducing signs of AD are compared in Table 1. The first cholinesterase inhibitor, tacrine (Cognex®), has been associated with hepato- toxicity and is seldom used. Hence, it is not included in the table. Antipsychotics, anxiolyt- ics, and antidepressants that may be used to manage symptoms common to dementia are not included in the table. The cholinesterase inhibitors differ in their pharmacokinetic properties. Both donepezil and galantamine are metabolized through hepatic cytochrome P450 enzymes (CYP450) involving the CYP2D6 and CYP3A4 pathways. Rivastigmine is metabolized by hydrolysis (not through CYP450), thereby greatly minimizing the drug interactions that exist with the other medications. Donepezil has a long half-life, administered once daily. Memantine, with pharmacologic actions dif- ferent from cholinesterase inhibitors, undergoes little metabolism, excreted nearly unchanged in the urine; no drug interactions are identified. Deciding Which Drug to Select The selection of the best medication for indi- vidual patients requires consideration of the type and severity of dementia, potential for drug interactions, side effects, and comorbidi- ties. All of these drugs are approved for AD at stages described in Table 1. Drug interactions are presented in Table 2. Because AD is more prevalent than vascular or Lewy body dementia, most medications have been tested for efficacy in AD. Up to 70% of dementias are of the Alzheimer’s type, and the medications are more effective in AD than in those dementias. Vascular dementia affects 1% to 20% of people over 65 years and is secondary to vascular injury to the brain; dementia symp- toms are related to size and location of cere- brovascular lesions. Interventions usually focus on controlling cardiovascular risks.12 One study with memantine revealed significant improve- ment in cognitive function and behavioral DEMENTIA TREATMENT UPDATE Marti D. Buffum, DNSc, APRN, BC, CS, and John C. Buffum, PharmD, BCPP Disclosure of potential conflict of interest—M. D. Buffum owns shares of Pfizer. J. C. Buffum owns shares of Neuro- biological Technologies, Inc. Geriatric Nursing, Volume 26, Number 2 75 symptoms in mild to moderate vascular demen- tia.13 The multifactorial and heterogeneous nature of vascular dementia poses challenges to conducting drug trials, which is the reason no recommendations are made.14 Mixed dementia refers to a combination of both AD and vascu- lar pathology, and research offers no informa- tion about successful treatment.12 The following questions address issues that may be informative for nurses working with patients and their families. 1. Should the Drugs Be Stopped and Switched? Will This Improve the Effect? Whereas some authors report that deteriora- tion occurs if the drugs are stopped,15 others report that discontinuing for short periods did not result in irreversible worsening.16,17 Nonetheless, if there is need to stop, the time should be minimal and the medication restarted as soon as possible to prevent possible deterio- ration. Reasons to switch medications might be, for example, cases in which once-daily dosing is easier to accomplish than twice daily dosing or when drug interactions might occur. Titration should always be considered when restarting the medication; as with all geriatric dosing, the rule is to “start low and go slow.” 2. Will Early Initiation Result in Long- Term Benefits? Clinical trials suggest that starting treatment early will prevent early decline. It is unknown whether decline prevention occurs if medica- tions are taken when the Mini-Mental State (MMSE) score is close to normal, between 27 and 30. The cholinesterase inhibitors are approved for mild to moderate dementia. However, the cholinesterase inhibitors have only been stud- ied in patients with a MMSE score of between 10 and 26. As of November 2004, the Food and Drug Administration (FDA) has accepted Forest Laboratories’ filing of the supplemental New Drug Application for expansion of memantine’s indication to include mild Alzheimer’s disease.18 This means the FDA will consider approval of memantine for mild AD in the near future. In 1 published abstract, a study of 403 patients with mild to moderate probable AD (MMSE 10–22) were randomly assigned to memantine or place- bo; those receiving memantine demonstrated significant cognitive and global function improvements.19 Furthermore, a review of 4 clinical trials validates safety and effectiveness of memantine across all AD stages of severity.20 Still, it is unknown how early in the disease treatment could be beneficial. 3. Can Medications Be Combined? When patients are stabilized on cholin- esterase inhibitors and suffering from moderate Table 1. Drugs That Reduce Symptoms of Dementia6,7 Stage of Absorption Dementia (AD) Dose Daily Affected Name (Generic/Trade) Mechanism of Action (FDA Indications) mg/day Doses by Food Donepezil/Aricept® Cholinesterase inhibitor Mild to moderate 5–10 1 No Rivastigmine/Exelon® Cholinesterase inhibitor Mild to moderate 3–12 2 Yes Galantamine/Reminyl® Cholinesterase inhibitor Mild to moderate 8–24 2 Yes Memantine/Namenda® N-methyl-D-aspartate (NMDA)-receptor antagonist Moderate to severe* 5–20 2 No *Data have been submitted to the Food and Drug Administration supporting memantine efficacy also in mild dementia. Geriatric Nursing, Volume 26, Number 2 76 to severe dementia, adding memantine may show some slowing of decline in cognition, activities of daily living, global outcome, and behavior.15 Combining memantine with a cholinesterase inhibitor in mild AD is a promis- ing focus for research. More than 1 concurrent cholinesterase inhibitor is not advised.21,22 4. What Are Possible Side Effects? Side effects of cholinesterase inhibitors include nausea, vomiting, diarrhea, and anorex- ia with weight loss. These are more frequent at dose escalation than during maintenance, and dose titration should be done slowly, some- times over 4 weeks.22 Dosage change may be needed at any point. Administering medications with food may decrease gastrointestinal side effects. Adverse events reported with the cholin- esterase inhibitors include insomnia, abnormal dreams, incontinence, muscle cramps, brady- cardia, syncope, and fatigue. Caution is advised in using the cholinesterase inhibitors in patients Table 2. Drug Interactions10,11 Name (Generic/Trade) Drug Interactions Rivastigmine/Exelon® Increased oral clearance (decreases level of rivastigmine): cigarette smoking Donepezil/Aricept®; Inhibited metabolism of drug (raising drug levels): Galantamine/Reminyl® CYP2D6 inhibitors (amiodarone, amitriptyline, cimetidine, delavirdine, fluoxetine, paroxetine, propafenone, quinidine, ritonavir) CYP34A inhibitors (ketaconazole, quinidine, paroxetine, clarithromycin, erythromycin, fluvoxamine, itraconazole, nefazodone, ritonavir) May cause bradycardia: diltiazem, verapamil, pindolol, digoxin, amiodarone Increased risk of central nervous system adverse events: ethanol Reduces levels of other drugs (antagonist): anticholinergics Synergistic with other drugs: succinylcholine, bethanechol Increased risk for gastrointestinal bleeding or ulcer with concomitant use of NSAIDS Increased metabolism (decreasing drug levels): rifampin, rifabutin, barbiturates, phenytoin, cigarette smoking, St. John’s wort Memantine/Namenda® Decreased renal elimination (increasing levels): drugs that alkalinize the urine (carbonic anhydrase inhibitors, sodium bicarbonate) Reduces levels of other drugs: hydrochlorothiazide NSAIDS = nonsteroidal anti-inflammatory drugs. Geriatric Nursing, Volume 26, Number 2 77 with bradycardia, sick-sinus syndrome, active peptic ulcer disease, severe asthma or chronic obstructive pulmonary disease, urinary ob- struction, or seizure disorders.21,22 Side effects and adverse effects of meman- tine include dizziness, headache, confusion, and constipation.13,10,21 Caution is indicated with memantine in patients with renal impair- ment.10,21 How the Drugs are Evaluated The goals of therapy are to improve ability or prevent decline in cognition and function in patients with dementia while minimizing side effects. Package inserts have reported magni- tudes of improvement based on percentages of patients achieving 4- to 7-point improvements on 1 cognitive test (Alzheimer’s Disease Assessment Scale–Cognitive Subscale [ADAS- Cog]); these improvements are equivalent to disease reversal of 6 months to 1 year, respec- tively, depending on sensitivity of the tests used to evaluate cognition, function, and behavior.22 Not everyone shows improvement. Research shows no consistent efficacy differences among the anticholinergic medications.16,22 At maintenance doses, patients on trials lasting between 13 and 30 weeks showed significant improvements in cognition when taking any of the 3 cholinesterase inhibitors—donepezil, rivastigmine, and galantamine.22 Applying Research Findings to Practice: Considerations Research issues need consideration before applying findings to practice. Symptoms of dementing conditions are devastating for the individual and the family. All involved persons have an urgent desire to prevent deterioration, and they are desperate to try new medications. Nurses play a vital role in instilling hope through accurate education about safe and effective treatments. Newest findings in the media throughout December 2004 reveal the dangers of anti- inflammatory medications as causing myocar- dial infarctions. The dangers for gastrointesti- nal bleeding and prevention of healing of existing ulcers prompt extreme caution. Certainly families need awareness about these dangers before embarking on an unsupervised trial of nonsteroidal anti-inflammatory drugs. Patients and their families as well as providers can easily be confused by media reports. For example, they may be confused about the risk-benefit of the cholinesterase inhibitors. Of note is that a recent meta-analysis (a powerful statistical technique that incorpo- rates outcomes of different studies and emerges with strong conclusive evidence) of 16 trials concludes that there is a modest but sig- nificant therapeutic effect of the cholinesterase inhibitors versus placebo along with modest but significantly higher rates of adverse events and discontinuation.23 Should this evidence prompt usage? Mixed-sample populations, sampling, and funding mechanisms need consideration. The similarity among the cholinesterase inhibitors enables generalization from the use of donepezil to the other drugs in this category. A recent large study (N = 565 persons) with donepezil in the United Kingdom, reported slight improvements in function and no delay in institutionalization or prevention of decline over 2 and 3 years; the investigators questioned the value of these medications.16 One research consideration is that the study was with com- munity residents and included patients with Alzheimer’s disease with and without vascular dementia. Because treatment for vascular dementia is problematic, poor responses could skew the results. Community residents with mild dementia and multiple comorbidities are more likely to be representative of real patients in clinical practice than selected patients for clinical trials of drug studies; cognitive and behavioral improvements may be harder to detect in community-based samples. Finally, this study was funded by the British govern- ment, the primary health care provider in Great Britain. The cost–benefit analysis prompts thought about the economic value of providing medication when improvement and time to institutionalization are no different from place- bo. Other studies are often funded by the drug industry, and the commercial motives may bias reporting of effectiveness. This cost-benefit study is more current than the above-mentioned meta-analysis. Which should be believed? Caution should be taken when interpreting research and attempting to generalize findings to all individuals. Bias exists because persons selected to participate in clinical trials are 78 Geriatric Nursing, Volume 26, Number 2 known to differ from unselected populations of AD patients. For example, patients who partici- pate in research tend to be better educated, wealthier, and younger than patients not enrolled in trials; they also tend to be Caucasian, receiving care in an academic envi- ronment, and encouraged to stay the study duration.22 To minimize side effects and create more homogeneous samples, patients with comorbid conditions are often excluded from drug studies; thus, healthier people are studied. Additionally, participants may concurrently be taking other remedies for decreasing AD effects. Of note is that baseline medication use in a study combining memantine and donepezil, patients were taking tocopherol (vitamin E; 59%–64%), ginkgo biloba (12%–15%), and calci- um (10%–12%);15 efficacy of these medications is not known and could influence findings when mixed within studies. In sum, medication regi- mens need to be customized for each individual in the context of their health and environment. References 1. Hebert LE, Scherr PA, Bienias JL, et al. Alzheimer dis- ease in the U.S. population: prevalence estimates using the 2000 Census. Arch Neurol 2003;60:1119-22. 2. Etminan M, Gill S, Samii A. Effect of non-steroidal anti-inflammatory drugs on risk of Alzheimer’s dis- ease: systematic review and meta-analysis of observa- tional studies. BMJ 2003;327:1-5. 3. Martyn C. Anti-inflammatory drugs and Alzheimer’s disease. Evidence implying a protective effect is as yet tentative. BMJ 2003;327:353-4. 4. Gasparini L, Ongini E, Wenk G. Non-steroidal anti- inflammatory drugs (NSAIDs) in Alzheimer’s disease: old and new mechanisms of action. J Neurochem 2004;91:521-36. 5. Evans JG, Wilcock G, Birks J. Evidence-based phar- macotherapy of Alzheimer’s disease. Int J Neuro- psychopharmacol 2004;7:351-69. 6. The Cochrane Database of Systematic Reviews. The Cochrane Library Web site: http://www.cochrane.org. Accessed December 15, 2004. 7. Cummings JL. Alzheimer’s disease. N Engl J Med 2004;351:56-67. 8. Drugs and therapies. Alzheimer’s Association Web site: http://www.alzforum.org/dis/tre/drt/default.asp. Accessed December 17, 2004. 9. Drugs in clinical trials. Alzheimer’s Association Web site: http://www.alzforum.org/dis/tre/drc/. Accessed December 17, 2004. 10. Forest Laboratories. Package insert. Namenda® (memantine hydrochloride). 2003. 11. Novartis Pharmaceuticals. Package insert. Exelon® (rivastigmine tartrate). 2004. 12. Areosa Sastre A, McShane R, Sherriff F. Memantine for dementia. The Cochrane Database of Systematic Reviews 2004;4:CD003154.pub2. DOI: 10.1002/ 14651858.CD 003154.pub2. 13. Orgogozo J, Rigaud A, Stoffler A, et al. Efficacy and safety of memantine in patients with mild to moderate vascular dementia. Stroke 2002;33:1834-9. 14. Pantoni L. Treatment of vascular dementia: Evidence from trials with non-cholinergic drugs. J Neurol Sci 2004;226:67-70. 15. Tariot PN, Farlow MR, Grossberg GT, et al. Meman- tine Study Group. Memantine treatment in patients with moderate to severe Alzheimer disease already receiving donepezil. A randomized controlled trial. JAMA 2004;291:317-24. 16. AD2000 Collaborative Group. Long-term donepezil treatment in 565 patients with Alzheimer’s disease (AD2000): randomized double-blind trial. Lancet 2004;363:2105-15. 17. Schneider LS. Commentary. AD2000: donepezil in Alzheimer’s disease. Lancet 2004;363:2100-1. 18. Forest Laboratories. FDA accepts supplemental New Drug Application filing to expand Namenda’s® indica- tion to include treatment of mild Alzheimer’s disease. Press release, November 15, 2004. http://www.frx.com. Accessed January 1, 2005. 19. Pomara N, Peskind ER, Potkin SG, et al. Memantine monotherapy is effective and safe for the treatment of mild to moderate Alzheimer’s disease: A random- ized controlled trial [abstract 01-05-04]. Presented at the 9th International Conference on Alzheimer’s Disease and Related Disorders, Philadelphia, July 2004. 20. Tariot PN, Doody R, Peskind E, et al. Memantine treatment for mild to severe Alzheimer’s disease: Clinical trials summary [abstract P1-021]. Poster pre- sented at the 9th International Conference on Alz- heimer’s Disease and Related Disorders, Philadelphia, July 2004. 21. Semla TP, Beizer JL, Higbee MD. Geriatric dosage handbook. 10th ed. Hudson, OH: Lexi-Comp; 2005. 22. Cummings JL. Use of cholinesterase inhibitors in clin- ical practice. Evidence-based recommendations. Am J Geriatr Psychiatry 2003;11:131-45. 23. Lanctôt KL, Herrmann N, Yau KK, et al. Efficacy and safety of cholinesterase inhibitors in Alzheimer’s dis- ease: a meta-analysis. CMAJ 2003;169:557-64. MARTI BUFFUM, DNSc, APRN, BC, CS, is associate chief, Nursing Service for Research, Veterans Affairs Medical Center, San Francisco, and associ- ate clinical professor, University of California School of Nursing, San Francisco; JOHN C. BUF- FUM, PharmD, BCPP, is associate clinical profes- sor, University of California School of Pharmacy, San Francisco, California. 0197-4572/$ - see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2004.01.003 http://www.cochrane.org http://www.alzforum.org/dis/tre/drt/default.asp http://www.alzforum.org/dis/tre/drc/ http://www.frx.com NUTRITION AND WELL-BEING RELATIONSHIP OF DEMENTIA AND BODY WEIGHT Peggy K. Yen, RD, LD, MPH Peggy K. Yen The number of people with dementia will increase by an estimated 400% between 2000 and 2050. Obesity and weight loss are related to dementia in what seem to be contradictory ways. Weight monitoring has always been essential to the care of older adults, but it may become an important tool for dementia preven- tion and treatment in the future. Obesity Women obese at age 70 showed an increased risk of developing Alzheimer’s disease in their 80s, according to a Swedish study. There was no significant relationship between weight and cognitive function among the men studied. Other research assessed the calorie and fat intake of older adults with and without the Apo E4 allele. Apolipoprotein E is a protein involved in transporting cholesterol in the blood. People with the Apo E4 allele are more likely to devel- op Alzheimer’s disease. The combination of genetic predisposition and higher intake of fat and calories doubled the risk of developing symptoms of dementia. This study did not report the weight status of the participants whose weight may have varied according to their fat and calorie intake. Weight Loss Other studies show a relationship between weight loss and dementia. In free-living older men and women followed for a period of 20 years, the group that eventually developed Alzheimer’s disease showed a significant decrease in weight over time. There was no sig- nificant weight loss in the men and women whose cognition was unimpaired. Researchers concluded that the weight loss was not a con- sequence of the dementia but an indicator of mild to moderate dementia.1 Men in the Honolulu-Asia Aging Study lost weight in the 6 years before developing demen- tia, more weight than those who did not devel- op this condition. The weight loss seemed to coincide with a period of mild cognitive impair- ment preceding their dementia diagnosis. These men were followed for 32 years and received several careful assessments of mental status. Most of the men were in the normal weight range at the beginning of the study.2 Dementia and the wandering associated with it are often considered to be a cause of weight loss in older adults with Alzheimer’s disease, not the result. With further research on the tim- ing of weight loss in relation to diagnosis, health care professionals may be able to antici- pate dementia diagnosis and intervene. Weight loss in older adults already diagnosed with Alzheimer’s disease is an indicator of a negative prognosis and greater mortality. The Physician’s Guide to Nutrition in Chronic Disease Management for Older Adults from the Nutrition Screening Initiative describes weight loss as an early symptom of dementia. Mechanism for the Weight Loss Effect on Dementia Weight loss may contribute to cognitive impairment. Atrophy in certain lobes of the brain correlates with lower body weight. High levels of the hormone cortisol resulting from weight loss may be one reason. The complicat- ed relationship between hormones such as cor- tisol and leptin, an appetite-suppressing hor- mone, and free radicals that result from metabolism of food may also explain some of the effects of weight loss on brain function. Excess production of free radicals may also partially explain the relationship between dementia and high fat and calorie intakes. Importance of Monitoring Weight The Minimum Data Set describes as signifi- cant weight loss of 5% or more in 30 days or 10% in 180 days. Weight loss can predict mortality in elderly people. Nursing home staff should mon- Geriatric Nursing, Volume 26, Number 2 79 80 Geriatric Nursing, Volume 26, Number 2 itor weight changes of elderly residents, even though interpretation of weight changes can be complicated. Measuring weight regularly using a systematic method such as a bed, bath, or standing scale promotes accuracy. Policies and procedures developed to help nursing home staff with weight status monitoring are avail- able at the following Web site: http://www.fiu. edu/%7Enutreldr/LTC_Institute/materials/LTC_ Products2.htm. Additional materials at this site include instruc- tions for accurate weighing, evaluating weight change, and a weight record sample form. Regular weight monitoring combined with mental status assessments can help nursing home staff identify elders at risk for dementia. Drug therapies that slow the progress of dementia can then be instituted and families, and caregivers can adapt living arrangements to prepare for its effects. Nursing home staff con- sistently overestimate the nutritional intake of residents. Weight is a more reliable indicator of calorie intake. Intentional Weight Loss Many elders are at risk for or have chronic diseases that are made worse by overweight and obesity. Carefully monitored, gradual weight loss to control blood sugar or blood pressure is not likely to increase the risk for dementia. In fact, type 2 diabetes and cardio- vascular disease increase the risk of developing the vascular type of dementia. Physical Activity Higher levels of physical activities such as walking are associated with better maintenance of cognitive function and less cognitive decline in women in the Nurses Health Study. Men in the Honolulu-Asia Aging Study who walked more had a reduced risk of developing demen- tia. None of these studies related physical activ- ity to weight, but it is likely that the weight loss of early dementia is not related to intentional increases in physical activity. References 1. Barrett-Conner E, Edelstein SL, Corey-Bloom J, Wiederholt WC. Weight loss precedes dementia in community-dwelling older adults. J Am Geriatr Soc 1996;44:1147-52. 2. Stewart R, Masaki K, Qian-Li Xue, et al. A 32- year prospective study of change in body weight and incident dementia. Arch Neurol 2005;62:55- 60. PEGGY K. YEN, RD, LD, MPH, is a public health nutri- tion consultant in Baltimore, Maryland. 0197-4572/$ - see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2005.01.009 http://www.fiu.edu/%7Enutreldr/LTC_Institute/materials/LTC_Products2.htm http://www.fiu.edu/%7Enutreldr/LTC_Institute/materials/LTC_Products2.htm http://www.fiu.edu/%7Enutreldr/LTC_Institute/materials/LTC_Products2.htm HOME HEALTH CARE Tina M. Marrelli, MSN, MA, RN Home Health Care Editor Author’s Note: The following patient sce- nario highlights the multiple and complex problems that caregivers and families face as they seek to provide the best, safest care for patients and to identify the best setting for that care. The patient scenario is followed by a listing of resources available to assist nurses and family caregivers in this quest. Mr. Davis is a 76-year-old man living in his own home in a suburban neighborhood. He has been a widower for approximately 6 years, and a home care agency was contacted to provide an assessment because the family is increasing- ly uneasy with his continuing to live alone. The family reports that he still dresses himself and drives but that he is increasingly forgetful and that “they are worried.” When asked for an example about his forgetfulness, the daughter stated, “We turned off the stove so it could not be used, but he is unaware of that and fre- quently calls the appliance store to turn it back on. Now we are worried that he is going to buy a new stove.” The daughter goes on to explain Mr. Davis has 7 adult children, all within a 10- mile area, and they take turns coming over in the mornings and cooking breakfast and then leave him food for lunch and dinner. The daugh- ter also notes that Mr. Davis has lost weight over the past few months. She emphasizes that he will not leave his home, and when they have broached the subject of moving out of the home, perhaps to an assisted living center, he angrily orders them out of the house. In addi- tion, they express concern over his driving and shopping habits; he has spent thousands of dol- lars in the last months on new TVs and other electronic equipment. She explains that although he has the money, they are worried about his driving and believe he may be experi- encing some personality changes. He was recently involved in a fender-bender when he backed into another car and then physically threatened the other driver, a young man. Fortunately, the young driver called the police on his cell and sat in the car until they arrived. The daughter was later contacted and told that her father should no longer be driving. A court date has been set for the accident, and the daughter is aware that she has to make some changes. Until that time, she wants the home care program to provide an aide as much as pos- sible. The problem is that as soon as the agency identifies an aide for the assignment and takes the aide out to meet Mr. Davis, he “fires” the per- son and will not let him or her back into his home. Finally, he fell the week before (reported- ly while trying to get under the stove to identify why it would not turn on) and now has a cast on his right foot. The nurse case manager refers the family to their doctor, who recommends a geria- trician as a starting point for a safety plan. The daughter and her siblings are now considering whether Mr. Davis should live with them or if they can alternate caring for him in his own home. Months later, the daughter calls the agency to say that their father has been evaluat- ed and diagnosed with dementia and she was told that it might be Alzheimer’s disease (AD). Patients like Mr. Davis have a plethora of problems that all affect safety—his own and that of others. Unfortunately, these patients are increasing as the population ages. In fact, the estimates of how many people with AD drive are staggering and frightening. AD is the most common cause of dementia among people aged 65 and older. Regardless of the diagnosis patients with these problems need assistance primarily related to safety and personal care. The following are resources to help ensure that the elderly with dementia or AD are prop- erly cared for in the home for as long as safely possible. Alzheimer’s Disease Centers: The National Institute on Aging (NIA) funds 29 Alzheimer’s Disease Centers (ADCs) across the country and many of them also have satellite offices in Geriatric Nursing, Volume 26, Number 2 81 DEMENTIA: COMPLEX CARE NEEDING ONGOING ASSESSMENT 82 Geriatric Nursing, Volume 26, Number 2 underserved and rural communities. Many of the centers are located at large university hos- pitals, including Stanford, Duke, Case Western Reserve, Mayo Clinic, and Johns Hopkins. For patients and families, they provide diagnoses and management, information about the dis- ease, resources and services, volunteer oppor- tunities related to drug trials, support groups, and other programs. For the current listing of ADCs, visit www.alzheimers.org. Alzheimer’s Association: This national association provides education and information about the disease. It can be reached through its Web site: www.alz.org. Alzheimer’s Disease Education and Referral (ADEAR) Center: The ADEAR cen- ter is a part of the National Institutes on Aging (NIA) and provides publications and informa- tion about AD, including booklets on caregiving and other resources. There are also phone lines staffed by information specialists to provide referral and other information. NIA can be con- tacted by calling (800) 438-4380 or by visiting its Web site: www.alzheimers.org. National Institute on Aging: The NIA offers a 60-page book titled Alzheimer’s Disease: Unraveling the Mystery. This book introduces the concept of Alzheimer’s and has a practical definition: Dementia is the loss of memory, reason, judgment, and language to such as extent that it interferes with a person’s daily life and activities. It is not a disease itself, but a group of symptoms that often accompa- nies a disease or condition.” The book is in color and explains the brain, factors related to AD, and support for families and other care- givers. The book also offers a glossary of brain and other terms as well as a CD with a brief ani- mation explaining Alzheimer’s and text and PDF files of the book. The book can be ordered by calling ADEAR (800) 438-4380. Caregiver Guide: Tips for Caregivers of People with Alzheimer’s Disease. The NIA offers this 23-page guide free to caregivers and others. Topics addressed include communica- tion, bathing, dressing, eating, activities, exer- cise, incontinence, sleep problems, hallucina- tions and delusions, wandering, home safety, driving, visiting the doctor, choosing a nursing home, and more. Call the Alzheimer’s Disease Education and Referral at (800) 438-4380 to order. Eldercare Locator: The Eldercare Locator is a national directory assistance program that helps patients and caregivers locate local serv- ices. It is funded by the U.S. Administration on Aging (www.aoa.gov). To contact Eldercare Locator for services, call (800) 677-1116. Hartford Foundation Institute for Geriatric Nursing: The institute offers many helpful and practical resources. “Try This” is a publication of the Hartford Institute and is a series of assessment tools that focus on issues specific to older adults. All of the tools are con- sidered best practices and include, for example, “Katz Index of Independence in ADLs,” “The Mini-Mental State Examination,” “Fall Risk Assessment,” “Confusion Assessment Method,” “Caregiver Strain Index,” and “Assessing Pain in Persons with Dementia,” among others. These can be viewed on the institute’s Web site: www.hartfordign.org. The 36-Hour Day: A Family Guide to Caring for Persons with Alzheimer Disease, Related Dementing Illnesses, and Memory Loss in Later Life by Nancy Mace is a book that all caregivers and family members should read. It provides insight into the patient with AD and the care needed. Amazon.com or local bookstores offer this text. TINA M. MARRELLI, MSN, MA, RN, is the Home Health Care section editor for Geriatric Nursing. 0197-4572/$ - see front matter © 2005 Elsevier Inc. All rights reserved.. doi:10.1016/j.gerinurse.2004.01.010 http://www.alzheimers.org http://www.alz.org http://www.aoa.gov http://www.alzheimers.org http://www.hartfordign.org http://Amazon.com BOOK REVIEWS Marianne LaPorte Matzo, PhD, APRN, BC, GNP, FAAN Book Review Editor Making the Moments Count: Leisure Activi- ties for Caregivi Joanne Ardolf D 1997, Johns Ho pages, paperbac Alzheimer’s: The Helen D. Davies 1998, Elder Boo paperback, $10. Candle and Dark Alzheimer’s Dise Joseph Rogers 1998, Bonus B $13.95. Caregiver’s Repr Survival When Y You Love Avrene L. Bran 1997, Impact, 1 Be Prepared: The and Practical Gu Challenging Con David S. Landa 1998, St. Mart $29.95. Gerontological patients but frequ of these patients heath care needs patients are depen nonprofessional c mated 7 million u givers in the Unite es must have kn caregiver to prov person with chro viding the caregiv survive the work roles for the geria geriatric nurse to reading books abo This month’s re caregivers and cov caregiving as well for the caregivers disease. Geriatric nurses need to be familiar Geriatric Nursing, Volume 26, Number 2 83 ng Relationships ecker pkins University Press, 192 k, $14.95. Answers You Need , Michael P. Jensen ks, Forest Knolls, 138 pages, 95. ness: Current Research in ase ooks, 166 pages, paperback, ieve: A Guide to Emotional ou’re Caring for Someone dt 06 pages, paperback, $11.95. Complete Financial, Legal, ide for Living with a Life- dition y in’s, 447 pages, hardcover, nurses work not only with ently also with the caregivers . The mental and physical of many of these geriatric dent on the care provided by aregivers. There are an esti- npaid nonprofessional care- d States. Gerontological nurs- owledge of the role of the ide better care for the older nic disease or illness. Pro- er with support and ways to of caregiving are important tric nurse. One way for the learn about caregiving is by ut caregiving. viewed books are written for er a variety of key aspects of as providing specific support of persons with Alzheimer’s with these types of books and the information contained in them; they may want to recom- mend some of these books to caregivers or use them as teaching guides when working with caregivers of all kinds—family, friends, and vol- unteers. Geriatric nurses may also want to rec- ommend these books to local public or medical libraries. A certified therapeutic recreation specialist wrote Making the Moments Count: Leisure Activities for Caregiving Relationships. Leisure is frequently thought of as something you do if you have completed all your tasks and then have some left-over time. Joanne Ardolf Decker debunks this theory of leisure. She describes to the reader how to bring leisure into all activities using small true-to-life scenarios. She provides strategies that can bring the care- giver and patient closer together. An extensive checklist of leisure favorites when completed will provide the caregiver with ideas of what leisure activities are enjoyed and can still be done by the patient. Activities for ambulatory, limited mobility, and bed-bound patients are described. Chapters are divided into areas of activity called THE P.I.E.S.S. system: Physical activity: using simple natural body movements with daily activities, rather than a strenuous exercise program. Examples: have the bed-bound patient squeeze stuffed animals; have the ambulatory patient help set the table. Intellectual activity: keeping the mind active through recall, reminiscence, decision making, following directions, and stimulation of senses. Example: use maps to reminisce about previous vacations and trips. Emotional and Expressive activity: expres- sion of moods through humor, self-esteem build- ing, creativity and self-expression. Example: caring for a pet, collecting comics, keeping a journal, engaging in hobbies. Social activity: connections with other people and with plants, pets, and the community. Example: celebrate holidays, plan trips, and maintain association with clubs. Spiritual activity: being in touch with one’s Higher Power, life and death, motivation, and 84 Geriatric Nursing, Volume 26, Number 2 inspiration. Example: attend church, watch or listen to religious TV shows or radio programs, prayer. This author does not forget the leisure needs of the caregiver and stresses the importance of caregivers taking time for leisure activities of their own to stay refreshed to continue to pro- vide care. Eighty-eight fun, free things to do are provided for the caregiver. Some of these activ- ities include learning to play the harmonica, making cookies, telling jokes, praying, and throwing away clutter. A list of resources for special needs is found at the back of the book. This is an easy book to read. It is full of won- derful ideas and can be useful for the geriatric nurse and caregiver. Keep this book handy and share its information with caregivers. Alzheimer’s: The Answers You Need is writ- ten by a caregiver of an Alzheimer’s patient and by the co-director of the Stanford/Veterans Administration Alzheimer’s Center. This is a short and quick-read book. It is written in ques- tion-and-answer format with each question list- ed at the top of a page. It is directed at the per- son with early-stage Alzheimer’s and their caregivers. There are questions about sex, driv- ing, stigma, durable power of attorney, finances, work, changes within the family and marriage, treatments, vitamins, and other issues. This book can be read from cover to cover or just skimmed, reading only selected parts. Helen D. Davies and Michael P. Jensen provide caregivers with a quick and easy-to- read book on a difficult topic. Geriatric nurses may find this book useful and share it with patients with early-stage Alzheimer’s and their caregivers. Candle and Darkness: Current Research in Alzheimer’s Disease is written by a scientist devoted to studies of aging and Alzheimer’s dis- ease. It is a short and quick-read book. Joseph Rogers describes what Alzheimer’s is, what treatments are available, and what research is being done. It gives hope that research will find a cure for this disease one day. He discusses who is at risk for Alzheimer’s and what happens to the person and the brain of someone with this disease. Technical chapters on apolipopro- tein E, amyloid B peptide, and neurofibrillary tangles may be of interest to some caregivers but may be too advanced for others. In the back of the book, the reader is provided with a list of additional reading material, both technical and nontechnical in nature. The author also lists the names and places of locations of current Alzheimer’s research. This book helps make a difficult disease understandable for geriatric nurses and caregivers of Alzheimer’s disease. Caregiver’s Reprieve: A Guide to Emotional Survival When You’re Caring for Someone You Love is written by a clinical psychologist. In addition, this short, quick-read book provides information about the stressors and emotional aspects of caregiving. Avrene L. Brandt uses stories to demonstrate the role of the caregiver. Caregivers reading this may identify with some of the stories. Caregivers are told that their feel- ings are normal. She describes the psychologi- cal defenses that caregivers use to survive: denial, isolation, rationalization, and displace- ment. This book looks at caregivers who are family members—parents, spouses, and chil- dren—and looks at how family relationships are changed when one takes on the role of caregiver. Examples of emotional aspects of caregiving: fear, denial, anxiety, frustration, resentment, anger, guilt, isolation, depression, and grief are identified. Developing coping tools such as physical exercise, relaxation tech- niques, time away, humor, and support systems are addressed. A list of personal and social sup- port resources is provided for the caregiver. Caregivers are given guidelines for coping with emotions in a simple format. Gerontological nurses should read this book because it gives insight into the life of a caregiver; caregivers of all types can benefit from reading this book. Be Prepared: The Complete Financial, Legal, and Practical Guide for Living with a Life- Challenging Condition is written by a practic- ing attorney who heads an information resource firm dedicated to advising people with life-challenging conditions. This is a large book and not necessarily meant to be read from cover to cover. David S. Landay has given care- givers an excellent reference book. It contains 38 chapters in 8 parts dealing with what the title indicates. The detailed table of contents and index make it easy for the reader to find a sub- ject of interest. There are introductions to all chapters and simple, practical tips are provided in each chapter. Part 1 consists of on chapter, an overview of the entire book, and the reader is encouraged to Geriatric Nursing, Volume 26, Number 2 85 read this chapter to better understand the vol- ume’s contents. Part 2 reviews the building blocks for successful living. Attitudes, coping, relaxation, employment benefits, social securi- ty, credit status, health, financial information, employment, and net worth are some of the topics discussed. Part 3 reviews topics about income, including disability, hiring, rehiring, confidentiality, advancement, leave of absence, health insurance protection, making your job work better for you, the ideal job, job inter- views, disability income, worker’s compensa- tion, unemployment insurance, retirement plan- ning, and investments. Part 4 contains information about protection against increased expenses. Included are dis- cussions on health insurance, Medicare, Medicaid, government programs, property and casualty insurance, financial management and taxes. Part 5 details new uses of assets. Subject matter includes life insurance as a liquid asset, conversion of retirement assets to income, and rethinking credit, real property, and other assets. Part 6 deals with health matters such as finding a doctor, drugs and treatments, nutri- tion and exercise, home, assisted living, nursing homes, hospitals, hospice, and bodily changes. Part 7 describes estate planning, advanced directives, health care power of attorney, wills, taxes, and funeral arrangements. Part 8 talks about the importance of support groups, describes who is on a support team, and addresses travel and a few other topics such as student loans, pets, and disabled parking. This book is an excellent resource for anyone who is or may become a caregiver for a person with a chronic disease or illness. It should be required reading for all gerontological nurses. CAROL HRICZ TOWNSEND, MSN, GNP, CS, is a geri- atric nurse practitioner at the Geriatric Primary Care Clinic, Gainesville VA, Gainesville, Florida. 0197-4572/$ - see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2005.01.006 86 Geriatric Nursing, Volume 26, Number 2 GERIATRIC NURSING Official Section of the National Gerontological Nursing Association NGNA NEWS Robin E. Remsburg, PHD, APRN, BC, FNGNA, and Neva L. Crogan, PhD, APRN, BC, FNGNA, Section Editors NGNA: WHAT’S IT ALL ABOUT? The mission of the National Gerontological Nursing Association (NGNA) is to promote gerontological nursing in order to influence the clinical care of older adults. The goals of NGNA are to: 1. Provide a forum in which gerontological nursing issues are identified and explored 2. Promote the specialty of gerontological nursing 3. Conduct educational programs 4. Promote research in gerontological nursing 5. Support the professional development of nurses whose practice includes older adults 6. Engage in programs designed to demon- strate innovative techniques and approaches in gerontological health care to better meet the needs of America’s aging population 7. Advocate for legislation which enhances the care of older adults and the role of gerontological nursing in the care of older adults 8. Provide grants to conduct activities which further the goals and purposes of NGNA 9. Disseminate information related to geron- tological nursing Then NGNA Board of Directors, in conjunc- tion with its committees, task forces, appointed representatives, and NGNA Fellows, are dedi- cated to carrying out the mission and goals of the Association. Members are encouraged to participate through committee and task-force activities, running for a position of leadership at the local chapter or national level, and recruit- ing new members to NGNA. Some highlights of 2004 NGNA activities include the following: • Chartering 3 new NGNA chapters • Initiating plans for redesign of the Web site • Collaborating with the Canadian Geronto- logical Nursing Association to write a joint position statement • Reviewing and revising important organiza- tional documents such as the policy and procedure manual, strategic plan, and awards and scholarship applications • The Clinical Practice Committee published 4 Innovations in Clinical Practice (ICP) papers and identified topics for ICPs in 2005 • The Convention Planning Committee plan- ned an exciting and lively 2004 Convention in Las Vegas • The Research Committee reviewed poster abstracts for the convention and selected the Judith V. Braun Research and Innova- tions in Practice Award recipients • The Education Committee completed a member needs assessment process and planned the Certification Preparation Review course that was presented at the 2004 Convention • The Nominating Committee recruited mem- bers for the 2004 Elections; the member- ship elected a new treasurer, 2 directors-at- large, a president-elect, and 3 Nominating Committee members • The Board initiated many e-mail communi- cations to notify members of important and late-breaking information • NGNA collaborated with the Cancer Care Network • Members represented NGNA at numerous national meetings including the Nursing Organizations Alliance, Nurse Competence in Aging Program, Senior Clinicians Task Force, Centers for Medicare and Medicaid Services (CMS) Staffing and Quality Partners Projects A Few Words About the 2004 Convention Kudos to the NGNA Planning Committee for the work that contributed to the very successful 2004 Convention, Gerontological Nursing: Aging Is a Work of Art, at the Stardust Hotel in Las Vegas, Nevada. Examples of comments from convention participants include the following: Geriatric Nursing, Volume 26, Number 2 87 “I learned a lot, but most importantly there was great networking. I always knew special people took care of our seniors.” “So inspiring! Excellent topics/speakers, valuable to my practice.” “This was one of the best conferences that I have attended. It was so very well organized. Staff was extremely helpful and pleasant— very professional. The food was superb! Thank you! Presenters were outstanding! Informa- tion was current and accurate. I am so proud to be a gerontological nurse!” “The speakers were all dynamic and inter- esting. The Planning Committee did a fantas- tic job.” “The convention was outstanding in every aspect! Great quality of presentations, quality of the hotel, and quality of the food.” “Poster presentations were some of the best I have ever seen! Excellent!” “Excellent conference. My first one!” “I’m looking forward to next year in Myrtle Beach.” “Gala outstanding!” 20th Anniversary Convention in 2005 The 2005 Planning Committee is hard at work preparing for the 20th Anniversary NGNA Convention, October 21–23, 2005, in Myrtle Beach, South Carolina. The theme is Geronto- logical Nursing: Looking Toward the Horizon! Mark your calendars and make plans to join your peers in the anniversary celebra- tion of NGNA’s dedication to the clinical care of older adults across diverse care settings. For more information, visit the NGNA Web site at www.ngna.org. 2005 Call for Poster Abstracts The Call for Posters for the 2005 NGNA Annual Convention, October 20–23, 2005, Myrtle Beach, South Carolina, is available on the NGNA Web site (www.ngna.org) or by con- tacting the NGNA National Office at (800) 723- 0560. Abstracts selected for presentation at the annual meeting will be featured in the 2006 January/February issue of GN. 2005 Opportunities for Leadership— A Call for Nominations The NGNA Nominating Committee is seeking candidates for the office of vice president, sec- retary, directors-at-large, and Nominating Com- mittee members (2). The National Office must receive nominations no later than April 30, 2005, for consideration by the Nominating Com- mittee. All current members of NGNA are eligi- ble to be nominated. Self-nominations are also encouraged. Nomination does not guarantee that a person’s name will appear on the final slate. Complete instructions and nominations can be obtained from the National Office at (800) 723-0560 or by visiting the NGNA web page at www.ngna.org. NGNA Recognition and Scholarship Opportunities—A Call for Nominations Excellence in Gerontological Nursing Awards The Excellence in Gerontological Nursing Awards were established to recognize excel- lence in individuals who provide direct care to older adults. Four awards honor a recipient in each of the following categories: registered nurse, advanced practice nurse, licensed practi- cal nurse, and a certified nursing assistant; the honorees will have consistently provided out- standing care to older adults and been inspira- tional role models and mentors to other health care workers. Mary Opal Wolanin Scholarship Program NGNA currently offers 2 scholarships in memory of Mary Opal Wolanin. The Board of Directors recently removed the requirement that applicants must be members of NGNA; a 1- year membership in NGNA will now be given along with the award. Graduate—A nursing student with a major in gerontology or geriatric nursing enrolled in a nationally accredited nursing program and car- rying a minimum of 6 credits. Applicants must submit proof of U.S. citizenship. A $1,500 schol- arship will be awarded at the annual conven- tion. Undergraduate—Eligible applicants include full-time or part-time nursing students in a http://www.ngna.org http://www.ngna.org http://www.ngna.org 88 Geriatric Nursing, Volume 26, Number 2 nationally accredited U.S. school of nursing. Applicants must have an intent to work in a gerontology or geriatric setting after gradua- tion. A $1,500 scholarship will be awarded at the annual convention. Distinguished Service Award The Distinguished Service Award, established in 1999 by the NGNA Board of Directors, is pre- sented to a NGNA member in recognition of outstanding leadership, participation, and con- tributions toward achieving NGNA goals. Cindy Shemansky Travel Scholarship The National Gerontological Nursing Associ- ation Travel Scholarship was established to pro- vide assistance to NGNA members who wish to attend the annual convention but who need financial assistance with travel expenses. Each Scholarship is a $1,000 cash award that can be used for registration fees, lodging, and other travel costs. Individuals who have been mem- bers of NGNA for at least 1 year are eligible for the Scholarship. Members of the Board of Directors are not eligible for the Scholarship. NGNA Photo Contest Each year NGNA holds a photo contest to identify pictures that promote and highlight positive aspects the older adult population. The NGNA photo contest is open to NGNA mem- bers and NGNA Chapters. The contest winner receives a complimentary registration to NGNA’s 2005 convention. 2004-2005 Board of Directors The members of the Board of Directors for 2004-2005 are as follows: President: Cindy Shemansky, MEd, RN,C, LNHA, FNGNA Vice President: Neva L. Crogan, PhD, APRN, BC, FNGNA President Elect: Robin E. Remsburg, PhD, APRN, BC, FNGNA Secretary: Victoria Schirm, PhD, RN, CS Treasurer: Amy Cotton, MS,CS,FNP Director: Barbara McCabe, PhD, APRN, BC, FNGNA Director: Anita Siccardi, EdD, APRN, BC Director: JaNellyn Hannah, BSN, RN,BC, PHN, CDE Director: Martha Sparks, PhD, RN, GCNS The NGNA Board of Directors would like to extend thanks to outgoing Board members Shirley Travis and Kay Cresci for their hard work and dedication to the organization. Kay and Shirley were presented plaques in recognition of their service at the 2004 NGNA convention. News From the Chapters Three new Chapters were chartered in 2004: the Southwest Texas Chapter, Atlanta Area Chapter, and North Carolina Piedmont Regional Chapter. The NGNA Chapter Committee is available to assist NGNA members start a chap- ter. If you are interested in starting an NGNA chapter, contact Barbara Broxson at the National Office, (800) 723-0560. Call for NGNA Section Manuscripts Calling all NGNA members! We are seeking manuscripts for the NGNA section of Geriatric Nursing. We would like to showcase NGNA members’ research studies, clinical projects, and innovative clinical practices. In particular, we are interested in evidenced-based care, translating research into practice, use of new technologies or new applications for established technologies, end-of-life care, effective ways to reduce nursing errors, cost-effective care, inno- vative staffing strategies, and new care models. Manuscripts that address health care issues for older adults in any setting where gerontological nurses practice (e.g., long-term, acute, ambula- tory, and home care) are highly desired. Manuscripts may focus on administration, edu- cation, research, clinical practice, community service, or health policy implications. The NGNA section provides members an opportunity to share their expertise and experi- ence with fellow gerontology nurses. Query let- ters are welcome (but not necessary). For in- structions on manuscript preparation see “Author Guidelines” at www.mosby.com/gerinurs. Send all correspondence and manuscripts to the National Office: NGNA, 7794 Grow Drive, Pensacola, FL 32514; fax: (850) 484-8762; e-mail: ngna@puetzamc.com. 0197-4572/$ - see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2005.01.008 http://www.mosby.com/gerinurs mailto:ngna@puetzamc.com Geriatric Nursing, Volume 26, Number 2 89 Although many long-term care providers regard medication utilization reviews in terms of regulatory mandates, survey defi- ciencies, practice intrusion, and policy viola- tions, not all consider these activities in such negative terms. This article describes the approach used by a large interdiscipli- nary team at a private continuing-care retirement community (CCRC) in North Carolina that includes medication regimen review in the larger context of resident care planning. (Geriatr Nurs 2005;26:89-93) O ne recent national study reported that nursing home residents received an average of 6.7 routine prescription med- ications and 2.7 prn (as needed) medications per day in 2000.1 Because the rate of medication error increases with the number of medications given, and elders in long-term care are among the highest users of potentially lethal drug com- binations, few people question the importance of drug utilization reviews in these settings.2-5 For those long-term care facilities that receive Medicare and Medicaid reimbursement, the Centers for Medicaid and Medicare Services (CMS) exert a powerful influence on drug uti- lization patterns through a vast array of policy mandates and state surveyor procedures.6 Even with this mandated oversight by many individu- als at many levels of review, polypharmacy, medication error, and adverse drug reactions with resulting hospitalization and death are long-standing and persistent medication-related problems for vulnerable older adults who reside in long-term care facilities.2,7-9 Our purpose is to describe the care planning practices at a private-pay continuing-care retire- ment community (CCRC) in the southeastern United States where drug utilization reviews are a routine part of interdisciplinary team meetings for residents in both assisted living and nursing home care. The mission statement of this organ- ization specifically addresses the need to attend to the physical, emotional, intellectual, social, and spiritual needs of the residents. This mis- sion translates into 3 primary themes for med- ication administration practices: 1) drug utiliza- tion review is just “good practice,” 2) measuring therapeutic outcomes in long-term care requires a holistic mind-set that considers all aspects of a resident’s care and his or her response to treat- ment, and 3) concerns about intrusion or med- dling in someone else’s professional practice domain are counterproductive to cohesive team management of the residents’ needs. We also discuss 3 common barriers to creating interdis- ciplinary teams and conclude with suggestions for improving the practice of medication utiliza- tion review in environments where cohesive interdisciplinary teams do not exist. Interdisciplinary Teaming and Effective Medication Regimen Reviews In this large CCRC, the monthly team meet- ings are regularly attended by the medical director, nursing administrator, nursing team leaders, dietitian, social services coordinator, activities coordinator, and the consulting phar- macist. This interdisciplinary team cares for residents on nursing home units, a memory impaired unit, and an assisted living unit. Just Good Practice Mandates, regulations, and the threat of defi- ciencies may lead a team to address medication Incorporating Medication Regimen Reviews Into the Interdisciplinary Care Planning Process Judy Binch, RN, Ron Beamon, MD, Stephanie Clontz, BSW, Patti Goodwin, RN, BSN, Heather Hartwig, CTRS, Ratna Kolhatkar, RD, Mike List, RPh, Pharm D, and Shirley S. Travis, PhD, APRN, FAAN 90 Geriatric Nursing, Volume 26, Number 2 utilization issues, but they will not necessarily make the team focus on what constitutes good practice and good resident care. There are many ways to organize a discussion about a res- ident’s care that enable teams to focus on what is working and what is not. In our team meet- ings, the medical director serves as chair. Before the meeting, the director of health serv- ices (a nurse), the nurse manager, or the head nurse of the nursing home unit provides the chairperson with a verbal summary of the rele- vant issues for each resident on the list for dis- cussion. Residents may also be added at the last minute when new problems emerge over night. All residents’ charts are transported to the con- ference room the morning of the meeting and are readily available if needed. The presentation of a resident to the team by the medical director usually begins with a state- ment of the problem, need, or concern that has been identified from regular resident assess- ments, family members, or the resident. The staff member who is closest to the issue (nurse, social worker, dietician, etc.) follows the intro- duction with details for the team discussion. Others on the team are then invited to add information, ask questions, or propose solu- tions and changes to the plan of care. Medication-related issues regularly include discussions about benefits and potential adverse effects of adding or eliminating a med- ication from the resident’s current medication profile, the resident’s response to previous tri- als of a medication under consideration, any known idiosyncratic responses to medications, past adverse drug events, and cost comparisons of medications. A secondary gain of these dis- cussions is ongoing educational opportunities for the team to learn about geropharmacology, pharmacokinetics, and pharmacodynamics. A standing rule is that no questions are off limits. Although much of the information offered for discussion about medication regimens comes from the medical director and consulting phar- macist, the other members of the team are also important resources. The dietician, for example, is a trusted and valued source of information about potential drug-food interactions, weight loss and weight gain issues, and general nutrition considerations and pharmacotherapy. The nurs- ing members of the team regularly provide expert insight into the trials and tribulations of administering medications to frail older adult populations and the needs of individual resi- dents. For example, swallowing multiple pills and capsules is a common problem in long-term care settings. Problem solving includes discus- sions about mixing medications with different foods and food textures, alternative routes of administration, dosing and administration schedules, and changing a medication to one that is more palatable to the resident. Ultimately, the team arrives at the medication regimen that is most suited to the needs of the individual res- ident to achieve the desired outcomes. These sessions tend to be lively, dynamic, and high- energy exercises in problem solving and clinical decision making with input from the entire team. Outcomes in the Context of Holistic Care Providing care for frail residents in long-term care settings is extraordinarily complex. By the time an individual reaches his or her eighth decade, alterations in physiologic functioning, mentation, affect, and social relationships cre- ate challenges for even the most astute clini- cian. Treating a single symptom without con- sidering the effects on the whole person simply does not work. Considering the whole person is a 2-fold process. First, there are the clinical signs and symptoms of well-being that staff members mon- itor when medication changes occur. Routinely, time is given in team meetings to review any changes in a resident’s sleep patterns, food intake, activity level, mobility, behavior, and affect that might be related to the medication regimen. Input from the nursing staff on all 3 shifts is essential for this discussion. Second, knowledge of the resident’s lifelong behaviors and preferences—determined from input of fam- ily members and significant others—provides an understanding of traits, behaviors, and prefer- ences that could affect a resident’s responses to medications. Consultations with family mem- bers by members of the nursing and social work staff are a regular part of preparing for a team meeting. When changes in medications need to be made, the principle “start low, go slow” is rou- tinely followed. Consequently, it may take 2 or more team meetings before a satisfactory out- come in the resident’s condition is achieved. Geriatric Nursing, Volume 26, Number 2 91 Turf Issues and Effective Interdisciplinary Teams As others have noted, medication utilization reviews work best when integrated into the activities of a facility’s interdisciplinary team.6 Interdisciplinary teams, by definition, are expected to have highly visible lines of commu- nication among team members to facilitate team assignments, share information, and eval- uate the team’s progress toward achieving patient care goals. One of the most striking characteristics of these teams is the purposeful blurring of disciplinary boundaries so that the team members can focus on total resident care rather than separating the resident’s needs into disciplinary compartments.10-11 Barriers to Interdisciplinary Teaming in Long-Term Care In our collective experiences, there are 3 major problems listed (Table 1) that staff mem- bers in long-term care facilities can face when they attempt to implement successful interdis- ciplinary teams: overcoming familiar and static routines, dealing with scheduling difficulties and time constraints, and the lack of good team models or prior interdisciplinary experiences. Overcoming Routines Regulatory oversight in long-term care set- tings is often noted to create a burdensome sys- tem of reports for the documentation of patient care.3 If the primary foci of the team’s efforts are on charting procedures and getting the paper- work done, team cohesion and the importance of improving patient care can be affected. Staff members have to believe that the results of working as a team are worth the effort it takes to change from solitary or discipline-specific care planning to interdisciplinary teamwork. Time Constraints Historically, teams often have little time to schedule meetings when the entire team can meet to discuss residents’ needs and progress toward therapeutic goals. Consequently, many nurses may have experienced fragmented dis- cussions, incomplete information about the res- ident, and unsatisfying action plans. Unless a strong organizational commitment to interdisci- plinary teaming exists and an effective team leader emerges to keep the work on track, most efforts at interdisciplinary teaming will not suc- ceed.12,13 Given the holistic care mission of the CCRC, the opening message of our team meet- ings is always the same: 1) the work before the members requires a group effort and 2) the best solutions will come from the team’s collective wisdom. Therefore, everyone is expected to attend the meeting and to participate in the work of the team. The group convenes at the same time (7:30 a.m.) on the same Wednesday of each month. Table 1. Barriers to Effective Interdisciplinary Teaming in Long-Term Care I. Familiar or static routines resistant to change • Regulatory mandates • Preference for discipline-specific practice • Blurred focus on improving resident care II. Time constraints • Scheduling difficulties for the team members • Lack of organizational commitment to team meetings • Low expectations for attending meetings • Lack of good team models or prior interdis- ciplinary experiences • Few interdisciplinary opportunities during formal educational experiences • Low trust and/or respect among potential team members • Prior negative experiences with disciplinary turf battles III. Lack of an effective organizational leader to create an interdisciplinary team 92 Geriatric Nursing, Volume 26, Number 2 Coffee and a light breakfast are served for those in attendance. The relaxed meeting atmosphere and spirit of collegiality give members the free- dom to move around during the meeting without disturbing others or disrupting the discussion. All members view interdisciplinary meetings as stimulating and satisfying opportunities to engage in high-quality care planning activities. Good Interdisciplinary Models Most health care professionals have never had experience with or instruction about how to work in an interdisciplinary environ- ment.12,14,15 There are pitfalls in the process. For example, the spirit of interdisciplinary work can easily break down into professional turf wars and resentment when others make sug- gestions about elements of practice that histor- ically belong to a given discipline. In the case of medication utilization review, consulting pharmacists and physicians often find themselves trying to negotiate the meaning of interdisciplinary work and collaboration.6 Similarly, nurses may feel out of the input and decision-making loop that exists between the pharmacist and the physician. In our experience, fully integrating the consulting pharmacist into the team provides this team member with knowl- edge of the residents, opportunities to interact with the nursing staff on a personal basis, and a synergistic working relationship with the med- ical director and the nursing staff during team meetings. It is common in meetings for the nurs- es, the dietician, or the medical director to ask the consulting pharmacist for his opinion. Ideally, health and human service profession- als will increasingly be exposed to interdiscipli- nary models of care while they are in training.12 For those professionals already in practice, modeling the collaborative practices of others will have to suffice. In our work, the develop- ment of the team was not driven by preexisting experiences with interdisciplinary teaming models or preconceptions about how the model should work. Rather, the spirit of teamwork was first embraced by the medical director and the director of health services. The trust and enthusiasm that other team members observed in the relationship between these 2 organiza- tional leaders gave them confidence to partici- pate in team meetings. Because the facility’s medical director chairs the committee, he has to be sensitive to tradi- tional power hierarchies in health care settings and ensure that everyone on the team has a chance to participate in discussions. Paying close attention to body language and inviting individual team members to comment, who may otherwise be hesitant to participate, are important functions for a physician who chairs an interdisciplinary team meeting. By design, the director of health services for the organiza- tion, who is a nurse, takes a leadership role only when an administrative decision needs to be made. This approach avoids the model in which an agency administrator and the medical direc- tor have discussions and make decisions that are void of team input. When team members understand that their expertise counts in care planning decisions and that they are expected The CCRC interdisciplinary team at work. Geriatric Nursing, Volume 26, Number 2 93 to participate in care planning decisions, an enthusiastic and cohesive team will develop. Conclusion Many nursing facilities complete medication utilization reviews because they are required to do so. What may be lacking is a more dynamic and comprehensive review process for total resident care. Organizations that desire a more effective process would do well to follow 5 sim- ple suggestions. • First, choose an effective team leader or coleaders to maximize team involvement in resident care discussions. • Second, place medication utilization review in the large context of exemplary resident care. • Third, expect all staff members to prepare for team meetings and to participate fully in the discussions. • Fourth, help team members learn to trust and respect each other and to see team meetings as opportunities for ongoing edu- cation and professional development. Our team has had the advantage of a stable membership for a number of years. How- ever, each time a new member is added, an assimilation process must occur to main- tain team trust and respect. • Finally, do not allow a mandated activity to become so rote that the value and intent of the activity are lost in the process. Currently, many facilities are looking for ways to improve medication management and to reduce error and adverse events.16 As we described in this article, at least some of this change will come from the commitment of the interdisciplinary team members to go beyond minimum performance standards and to redis- cover the excitement that comes from knowing that they are creating “best practices” within their own organization. Moreover, teams that work in high collaborative cultures are widely known to produce superior clinical outcomes of care.17 References 1. Tobias DE, Sey M. General and psychotherapeutic medication use in 328 nursing facilities: A year 2000 national survey. Consult Pharm 2001;16:54-64. 2. Gurwitz JH, Field TS, Avorn J, et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med 2000;109:87-94. 3. Harjivan C, Lyles A. Improved medication use in long- term care: Building on the consulting pharmacist’s drug regimen review. Am J Manag Care 2002;8:318-26. 4. Kubacka RT. A primer on drug utilization review. J Am Pharm Assoc 1996;NS36:257-79. 5. Mendelson D, Ramchand R, Abramson R, et al. Pre- scription drugs in nursing homes: Managing costs and quality in a complex environment (Issue Brief No. 784). Washington, DC: National Health Policy Forum; 2002. 6. MacLean DS. Drug regimen review: Bane or boon? Caring Ages 2002;3:8, 17. 7. Dyer CC, Oles KS, Davis SW. The role of the pharma- cist in a geriatric nursing home: A literature review. Drug Intell Clin Pharm 1984;18:428-33. 8. Hanlon JT, Shimp LA, Semla TP. Recent advances in geriatrics: Drug-related problems in the elderly. Ann Pharmacother 2000;34:360-5. 9. Strandberg LR, Dawson GW, Mathieson D, et al. Effect of comprehensive pharmaceutical services on drug use in long-term care facilities. Am J Hosp Pharm 1980;37:92-4. 10. Robertson D. The roles of health care teams in care of the elderly. Fam Med 1992;24:136-41. 11. Tuchman LI. The team and models of teaming. In: Rosin P, Whitehead A, Tuchman LI, Jesien GS, Begun AL, Irwin L, editors. Partnerships in family-centered care. Baltimore: Paul Brookes; 1996. p. 119-43. 12. Travis SS, Duer B. Interdisciplinary management of the older adult with cancer. In: Luggen A, Meiner S, edi- tors. Handbook for care of the older adult with cancer. Philadelphia: Oncology Nursing Press; 2000. p. 25-34. 13. Travis SS, Larsen, P. Palliation and end of life care across health care settings. In: Matzo M, Sherman S., editors. Gerontological palliative care nursing. St. Louis: Mosby; 2004. p. 66-81. 14. Clark PG. Values in health care professional socializa- tion: Implications for geriatric education in interdisci- plinary teamwork. Gerontologist 1997;37:441-51. 15. Larson EL. New rules for the game: interdisciplinary education for health professionals. Nurs Outlook 1995;43:180-5. 16. Cafiero AC. Reducing medication errors in a long- term care setting. Ann Long-Term Care 2003;11:29-35. 17. Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA 2004;291:1246-51. JUDY BINCH, RN, is now retired but served as director of health services; RON BEAMON, MD, is medical director; STEPHANIE CLONTZ, BSW, is a health center BSW; PATTI GOODWIN, RN, BSN, is nurse manager; HEATHER HARTWIG, CTRS, is health center therapeutic recreations coordinator; RATNA KOLHATKAR, RD, is dietitian; MIKE LIST, RPh, Pharm D, is consulting pharmacist—all at the Pines at Davidson in Davidson, North Carolina; SHIRLEY S. TRAVIS, PhD, APRN, FAAN, is dean, College of Nursing and Health Science, George Mason University, Fairfax, Virginia. 0197-4572/$ - see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2005.01.002 94 Geriatric Nursing, Volume 26, Number 2 GERIATRIC NURSING NATIONAL CONFERENCE OF GERONTOLOGICAL NURSE PRACTITIONERS PHARMACOLOGY UPDATE: DEMENTIA Ann Schmidt Luggen, PhD, GNP The Food and Drug Administration (FDA) has approved 5 prescription drugs for the treatment of Alzheimer’s disease (AD). Four of these are cholinesterase inhibitors and are usually used for the treatment of mild to moderate AD. The fifth drug (memantine) is an NMDA (N-methyl D- aspartate) antagonist and is usually used to treat moderate to severe AD. No study has been pub- lished that directly compares these drugs to one another; however, the National Institute on Aging (NIA) has published a summary that provides information in a table format for easy review of information about all 5 of these drugs. This infor- mation is provided in the following table, although 1 drug has been omitted (tacrine or Cognex®) because it is no longer marketed by the manufacturer. Drug/Action Type and Treatment Recommended Dose Interactions Aricept® (donepezil) A cholinesterase 5 mg qd; increase to None observed in lab Prevents breakdown inhibitor used to treat 10 mg qd after 4–6 studies; NSAIDs should of acetylcholine in mild to moderate AD weeks if well tolerated be used with caution the brain with donepezil* Exelon® (rivastigmine) A cholinesterase 1.5 mg bid; total of 3 None observed in lab Prevents breakdown inhibitor used to treat mg/day; increase by 3 studies; NSAIDs should of acetylcholine and mild to moderate AD mg/day every 2 weeks be used with caution butyrlcholine in the to 6 mg bid (12 mg/day) rivastigmine brain† if well tolerated Reminyl® (galantamine) A cholinesterase 4 mg bid (8 mg/day); NSAIDs should be used Prevents breakdown of inhibitor used to treat increase by 8 mg/day with caution with acetylcholine and stimu- mild to moderate AD in 4 weeks to 8 mg galantamine; drugs lates nicotinic receptors bid (16 mg qd) if well with anticholinergic to release more acetyl- tolerated; increase to properties, especially choline in the brain 12 mg bid (24 mg/day) antidepressants such if well tolerated as paroxetine, fluoxetine, fluoxamine, and amitripty- line cause retention of galantamine, which may cause problems Namenda® (memantine) NMDA antagonist 5 mg qd; increase to 5 Other NMDA antagonists Blocks toxic effects used to treat moderate mg bid (10 mg/day) such as amantadine, dex- associated with excess to severe AD after 1 week if well tromethorphan, and keta- glutamate and regulates tolerated; continue to mine have not been fully glutamate activation increase weekly up to investigated with meman- 20 mg/day in divided tine and should be used doses (bid) if well with caution with this drug tolerated Definitions of acronyms: AD, Alzheimer’s disease; bid, twice daily; NMDA, N-methyl D-aspartate; NSAIDs, nonsteroidal anti-inflam- matory drugs; qd, daily. *Increased risk of stomach ulcers when used with cholinesterase inhibitors. Prolonged use of NSAIDs (non-steroidal anti-flammato- ry drugs) such as aspirin or ibuprofen can cause ulcers even when used alone. †Butyrlcholine is a chemical in the brain that is similar to acetylcholine. 0197-4572/$ - see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2005.01.012 The information in this column has been obtained from the National Institutes of Health, National Institute of Aging, January 16, 2005. The Web site is available at: www.alzheimers.org/pubs/medications/htm. The information contained in the table is a brief summary and should not be assumed to be complete but should provide minimal guidance to practitioners. The drugs listed are used to delay or prevent increasing symptomatology in those with AD. They help for a limited time and may control some of the behavioral symp- toms of AD. Researchers do not completely understand how cholinesterase inhibitors work to treat AD, although it is known that they prevent breakdown of acetylcholine, which is important for memory and cogni- tive function. In advancing AD, less acetylcholine is produced, thus the limited use of these drugs. NMDA antagonists are used to delay progression of symptoms (for example, loss of self-toileting) of moderate to severe AD. This drug regulates glutamate which causes cell death in excessive amounts. The two kinds of drugs can be used together at the moderate stage of AD because they work differently. http://www.alzheimers.org/pubs/medications/htm 95 GERONTOLOGIC NURSE PRACTITIONER CARE GUIDELINES: DEMENTIA BEHAVIORS: RECOGNITION AND MANAGEMENT Ann Schmidt Luggen, PhD, GNP CAUSES OF DEMENTIA There are many causes of dementia.1 The best known, Alzheimer’s disease (AD), is also the most common, accounting for at least 50% to 60% of dementias. Dementia with Lewy bodies (DLB) is the second most common cause of bly making up 20% to 30% of dementia is thought to be the mon cause of dementia, ac- to 20% of cases. An elder may one type of dementia at the ever, and because subcortical ia (SVD) is caused by chronic e common in elders—hyperten- s—it is likely to occur in com- er forms. The least common of re the frontal temporal lobe s). Pick’s disease is the most e rarer types. Others include ssive supranuclear palsy, corti- ration, parkinsonism linked to , and neurofibrillary tangle lassification of FTDs is ongo- entia, of less concern today, is by syphilis, a disease that is on in the United States.3 Other used by vitamin B-12 deficien- sm, and alcoholism to name a ately 60 causes of dementia.1 oblems are reversible. OF DEMENTIAS ill know that AD and vascular e differentiated by their pres- slow and insidious; vascular “stepping stone” advancement progression of multiple small compares the most common veral variables. OMMON TO DEMENTIAS thing to remember is that like s are in the eye of the beholder. disturbing to the person with be very disturbing to family caretakers in a long-term care ehaviors may be disturbing to Geriatric Nursing, Volume 26, Number 2 dementia, proba cases. Vascular third most com counting for 10% have more than same time, how vascular dement problems that ar sion and diabete bination with oth the dementias a dementias (FTD common of thes FTDP-17, progre cobasilar degene chromosome 17 dementia.2 The c ing. Another dem dementia caused the rise again dementias are ca cy, hypothyroidi few of approxim Some of these pr RECOGNITION Most readers w dementias can b entation. AD is dementia has a caused by the strokes. Table 1 dementias on se BEHAVIORS C One important beauty, behavior What may not be dementia may members or the setting. Certain b 96 Geriatric Nursing, Volume 26, Number 2 the patient, however, yet not always discernible to others. Pain can be a common precipitant of disturbing behaviors and is difficult for the patient and staff if not managed. The most disturbing behaviors in the home are suicide threats, agitation, insomnia, rest- lessness with wandering, and incontinence behaviors. In the nursing home, agitation, screaming, and combativeness are disturbing behaviors because they upset other residents as well as the staff. Inappropriate sexual behav- iors can be distressing to other residents and visitors as well. CAUSES OF BEHAVIORS Gerontological nurse practitioners know well that the most common causes of behavior changes are urinary tract infections (UTI) and respiratory infections. A high index of suspi- cion is essential in any setting if there is an abrupt change in behavior. Infection may pre- cipitate a fall, cause pain, or cause metabolic changes if eating and drinking are slowed; hypoxia may occur with pneumonia and increase confusion. A new drug may cause a change in behavior, especially if it is an anti- cholinergic drug such as Benadryl®. Some changes in behaviors with dementia are actually delirium. Hypoglycemia, encephalitis, medications, hypoxia, and intracranial bleed may be manageable. It is important to work up the UTI or respiratory infection immediately to begin the search for other problems in the event that these are not the source of behavior change. Depression can also be confused with demen- tia. Like dementia, the onset is usually slow and insidious. It commonly occurs in those with dementia, especially dementia with Lewy bod- ies. It is common to miss this diagnosis. In an elder with dementia, the loss of a roommate or lack of family attention in the nursing facility can precipitate or aggravate an already present depression. MANAGEMENT OF BEHAVIORS Environmental manipulation is an excellent start for management of disturbing behaviors. Strict routines in the daily schedule are relaxing to the anxious or restless elder. Toileting every 2 hours is helpful for the elder who is beginning to become incontinent. Nightlights are often mentioned as helpful tools. I find that even in early dementia or for those in a new environ- ment, nightlights are confusing, changing the environment so that it is unrecognizable. Usual Table 1. Differentiating Dementias1-3 Type Age at Onset/Sex Prognosis Symptomatology Alzheimer’s 65+, greatest in 80+, 8–10 years median, Gradual memory loss, change in Disease most common in range 3–20 personality, loss of language skills, women disorientation, impaired judgment Dementia with 60-80, most common 6+ years Rigidity, visual hallucinations, slowed Lewy bodies in men movements, fluctuation in cognition Vascular 70s, most common Depends on control Amnesia, aphasia, apraxia, depres- in men of causative factors: sion, socially inappropriate behaviors, hypertension, loss of visual field, seizures, paralysis diabetes, lipids Other < 65 5–7 years (Pick’s) Disinhibition, poor insight, apathy, (Pick’s) verbal aggression, hygiene neglect, perseveration,* (Pick’s) Neurosyphilis, memory loss, hallucinations, loss of language skills *Perseveration = repetitive thoughts. Geriatric Nursing, Volume 26, Number 2 97 lighting, at least in the hallway, is more useful for those who have insomnia, or in those for whom day becomes night and night becomes day, which commonly occurs in DLB. Separating residents in the nursing home can be helpful if some are particularly disruptive (e.g., residents who scream, rummage through other residents’ rooms and drawers, climb into others’ beds, etc.). These behaviors are disturb- ing and cause stress to many residents with dementia. Methods to decrease environmental stress are helpful. Maintaining a safe environment is difficult in the home and is one reason many elders are moved to the nursing home. In this instance, the nursing facility can generally provide a safe environment. A rule is that the best quality of life for an elder is the least restrictive environ- ment, and this can be provided in a nursing facility.4 Conducting an environmental assessment of stressful stimuli is a good practice in any set- ting. Auditory, visual, tactile, and multiple com- peting stimuli are unmanageable for elders with dementia.1 TVs that are on all day can precipi- tate hallucinations in those vulnerable to this problem, for example, the elder with DLB. The elder cannot distinguish reality from TV drama. Conversations should not be complex because they will not be understood. Open-ended ques- tions (e.g., “Why?”) are useless. “What would you like to wear today?” will go unanswered. A better choice is, “Would you like to wear a blue shirt? Here, this is a blue shirt.” Too often med- ical management is seen as the answer for nurs- ing facility staff and managers. MEDICAL MANAGEMENT OF BEHAVIORS A number of helpful drugs are available now that are effective in slowing the progression of dementia and reversing behaviors disturbing to the elder. Cholinesterase inhibitors approved by the Food and Drug Administration (FDA), including Aricept®, Exelon®, and Reminyl®, are used extensively today. Cognex or tacrine is no longer on the market but was the first drug on the market for treatment of AD. A number of drugs can be useful to treat psy- chosis and agitation that can be problematic in moderate to severe dementia. Risperidone is an atypical antipsychotic that has been studied extensively. The atypical antipsychotics have fewer extrapyramidal effects compared with the older antipsychotics of 10 to 20 years ago. Other medications for this purpose include olanzapine, quietapine, and aripiprazole, and others. These drugs have not been found to be superior to other agents in treating elders with dementia; however, they are safer, more easily tolerated, and have fewer side effects.5 Clozapine is another drug in this class, but it has major side effects and is not recommended for patients with dementia. References 1. Stanley M, Blair K, Beare PG. Dementia in older adults. In: Gerontological nursing. 3rd ed. Philadelphia: FA Davis; 2005. p. 355-68. 2. Alzheimer’s Disease Education and Referral Center (ADEAR). Frontotemporal dementia: growing interest in a rare dementia. Connections 2002;9(4):1-20. 3. Aung M, Benias P, Edwards B, Wolf-Klein G. Dementia, possibly caused by syphilis in elderly patients. Long- Term Care Interface 2004;5(7):53-5. 4. Fiore P. Management of behaviors in seniors with dementia. Presented at the 16th Annual Conference of Kentucky Nurse Practitioners/Nurse Midwives, Louisville, Kentucky, April 24, 2004. 5. CME Consultants. Special report: Update in the treat- ment of psychosis in the elderly. Available at www.CMEZone.com. Accessed November, 2004. ANN SCHMIDT LUGGEN, PhD, GNP, is a professor at Northern Kentucky University in Highland Heights, and a geriatric nurse practitioner at Evercare. She serves as NCGNP section editor for Geriatric Nursing. 0197-4572/$ - see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2005.01.011 http://www.CMEZone.com 98 Geriatric Nursing, Volume 26, Number 2 The rapid increase in the number of elders who need dementia care and the critical need for skilled care providers prompted Florida legislators to enact legislation to im- prove the care of these residents. One com- ponent of the new legislation mandated dementia training for long-term care staff and led to the development of dementia care competencies that would guide a com- petency-based curriculum to meet the demand for training. The competencies, methods used for development, and infor- mation regarding how to access these newly developed resources are described in this article. (Geriatr Nurs 2005;26:98-105) D emographics related to the care of resi- dents in long-term care (LTC) are pro- viding the impetus to improve care in nursing homes for residents with dementia. At least 60% of all nursing home residents have some form of dementia,1 and that number will continue to grow.2 Consistent with this trend, the state of Florida legislature enacted major reforms in 2001 through Senate Bill 1202. The legislation established new nurse staffing lev- els, dementia training for staff, and tort reform.3 Specifically, the legislature mandated that all nursing home staff members who have direct contact with residents receive 1 hour of required dementia care education and further, that clinical staff with direct patient contact receive 3 additional hours of dementia training (SB 1202, page 62, section 26). The state of Florida allocated responsibility for the implementation of this new law to 2 state agencies—the Department of Elder Affairs (DOEA) to “prescribe training standards” by establishing a program to approve curriculum and certification of Alzheimer’s trainers and the Agency for Health Care Administration (AHCA) to monitor if nursing home staff received the required dementia training as proscribed by law. New rules, based on the language of SB1202, were promulgated by the DOEA, including a set of recommendations called “Training Guidelines for the Special Care of Nursing Home Residents with Alzheimer’s Disease or Related Disorders (ADRD).” These rules required 1 hour of content to include an understanding of ADRD, charac- teristics of ADRD, and communicating with res- idents with ADRD, as well as 3 additional hours of content for direct-care staff to include infor- mation on behavior management, assistance with activities of daily living, activities for resi- dents, stress management for the caregiver, fam- ily issues, resident environment, and ethical issues (Florida Administrative Code 58A-4.001. F.A.C.). The state of Florida had a unique resource to help develop new materials to meet the training requirements. In 2000, recognizing the increas- ing number of elders in Florida and the need to educate health care providers about how to care for them, the state funded the Teaching Nursing Home (TNH) to “formulate, implement, advocate, and disseminate best practices.” Florida House Bill 1971 charged AHCA with the establishment of a Teaching Nursing Home Pilot Project “to improve and expand capacity of Florida’s healthcare system to respond to the medical, psychological, and social needs of the increasing population of frail older citizens. In 2001, as the TNH was establishing its structure and products, the Advisory Committee chose to develop a model curriculum to meet the new dementia training requirements. The TNH Steering Committee convened a statewide Advisory Committee of Dementia Care Ex- perts,2 who were given the charge for curricu- lum development. The Advisory Committee of Dementia Care Experts included representa- tives from AHCA, DOEA, the Alzheimer’s Association, Florida Association of Homes for the Aging (FAHA), Florida Health Care Associ- ation (FHCA), and the Department of Veteran’s Affairs (DVA), as well as from Florida’s leading universities and professional organizations. The committee’s responsibility was to create a model for development, dissemination, evalua- tion, and validation of the dementia training materials. Christine L. Williams, DNSc, RN, BC, Kathryn Hyer, PhD, MPP, Annette Kelly, PhD, ARNP, Sue Leger-Krall, ARNP, PhD, and Ruth M. Tappen, EdD, RN, FAAN Development of Nurse Competencies to Improve Dementia Care Geriatric Nursing, Volume 26, Number 2 99 Two realities shaped the decision to focus the educational development efforts toward LPNs. In 2002 and 2003, LPNs averaged 0.9 hours of care per resident day in comparison to 0.6 hours of care from RN staff in Florida long-term care facilities.4 LPNs are the largest group of licensed caregivers, and they provide the major- ity of licensed nursing care to long-term care residents. Furthermore, at the same time the Advisory Committee was deciding about the audience for the curriculum, the Florida Board of Nursing approved a rule change to expand LPNs’ role to include direct supervision of long- term care paraprofessional staff if the LPN took an additional 30 hours of supervisory training. Thus, LPNs’ role of caring for residents with dementia evolved to include supervision and mentoring of the most numerous nursing home workers, certified nursing assistants (CNAs), who were responsible for the day-to-day care of dementia residents. The Advisory Committee also realized that the LPN focus would be opti- mal for future repeated efforts; professional materials could be edited for the RN audience and simplified for CNAs. Recognizing that a competency-based curricu- lum is more likely to improve care outcomes,5 the TNH Advisory Committee, composed of nursing educators and experts in dementia care, met to develop dementia education competen- cies. This initial process of competency develop- ment was considered crucial; it drove the con- tent development and is the focus of this article. Development of Competencies Ballantyne and colleagues6 stressed the need for the development of competency criteria that could ensure effective care provided by nurses working with the older adults. Zhang7 defined nursing competencies as “sets of knowledge, skills, traits, motives and attitudes that are required for effective performance in a wide range of nursing activities” (p. 469). To begin the process of developing competencies, a literature search was conducted. Results indicated that although significant progress has been made toward the development of “best practices” for care of the older adult, little published material was available directed specifically toward LPN practice in LTC and the person with dementia.8 Competency-based education focuses on per- formance of measurable outcomes; the value of this approach is that one can measure outcomes by assessing differences in quality of care per- formed by the care provider. In an attempt to implement the state mandate and improve care delivery in LTC, the task force focused on the development of competencies that would pro- vide desired outcomes for the curriculum. A review of LPN curricula, National League for Nursing (NLN) publications, and Florida scope of practice for LPNs was completed, providing necessary direction to identify the appropriate level of knowledge, skills, and attitudes. The task force identified a comprehensive level of dementia knowledge necessary to pro- vide high-quality care. Members further delin- eated which of these content areas were basic to dementia care delivery and necessary to include in the initial hour of training and which would be included in the additional 3 hours of training mandated for direct care staff. Advanced competencies, such as identification and treatment of pain in dementia and end-of- life care, were identified but could not be included in the initial state-mandated training because of time constraints. It was decided that content with this focus could be developed at a later date, building on the basic knowledge mandated in the 4 training hours. Another dilemma was how to integrate the state-mandated areas with the outcome compe- tencies defined by the group and considered crucial to quality care. For example, the group had identified competencies related to the importance of the LTC environment well beyond the training guidelines promulgated by DOEA. The group recognized the importance of quality of life for persons with dementia as well as ethical content and chose to include these additional competencies. Negotiations involved a year-long process of competency develop- ment, presentation and feedback from an advi- sory committee, and development and contin- ued refinement of content modules. Taylor9 identified 4 broad areas of nursing competencies—interpersonal, intellectual, tech- nical, and moral—and stated that nurses often emphasized technical and intellectual compe- tencies to the exclusion of interpersonal and moral competencies. The task force group con- curred that it was important to include moral and interpersonal competencies, especially con- sidering the care required for the vulnerable population experiencing dementia in nursing homes. The task force evaluated the competen- cies needed for dementia-specific care in long- term care, with a broad focus of including the 100 Geriatric Nursing, Volume 26, Number 2 intellectual skills required in the state man- date and the additional moral and interper- sonal skills the group considered important to quality of care. For example, one of the state- mandated content areas was “managing prob- lem behaviors.” Members of the task force decided to shift the focus to person-centered care that involved responding to the needs of the resident rather than focusing on the prob- lem for the staff. This philosophy is consistent with the national Alzheimer’s Association approach to care.10 Taylor9 defined the compe- tencies as abilities in a variety of domains (see Table 1). Table 1. Domains for Nursing Competencies Interpersonal Establishing and maintaining caring relationships Intellectual Reasoning to achieve valued goals Technical Manipulating equipment skillfully Moral Living is consistent with one’s personal moral code and role responsibilities Table 2. Nursing and Dementia Competencies Dementia-Specific Competencies: Phase 1 Training Nursing Competencies Competency 1.1 Understands the characteristics of dementia and Intellectual, interpersonal the special needs of the person with dementia Competency 1.2 Adapts communication to cognitive/emotional Interpersonal needs of the person with dementia Competency 2.1 Demonstrates a working knowledge of dementia Intellectual Competency 2.2 Recognizes, prevents, and manages distress Interpersonal, moral behaviors including agitation, pacing, exit-seeking, combativeness, withdrawal, and repetitive vocalizations Competency 2.3 Understands special needs of family and friends of Interpersonal, intellectual persons with dementia Competency 2.4 Promotes independence in activities of daily living Intellectual, interpersonal Competency 2.5 Promotes an optimal environment that will support Intellectual, interpersonal resident autonomy and enhance capabilities Competency 2.6 Recognizes ethical issues that arise in dementia care Moral, intellectual and incorporates these into care approaches Note: These categories (excluding the technical category) provided a framework from which to organize the competencies that were developed (see Table 1). Geriatric Nursing, Volume 26, Number 2 101 Table 3. Competencies Phase 1. 1 Hour of Training Competency 1: Understands the characteristics of a dementing illness and the special needs of the person with dementia Knowledge, skills, attitudes: • Defines dementia as decreasing brain function including memory problems, loss of some thinking and communication skills, and changes in personality • Contrasts dementia with cognitive changes of normal aging and delirium • Describes the early, middle, and late phases of dementia • Recognizes and incorporates into the dementia care plan that quality of life is a realistic goal • Interprets individual responses, mood, and other feedback as meaningful • Seeks to create a homelike and comfortable environment • Seeks a wide range of resources, such as community volunteers in daily care, whenever possible • Uses individual’s preferences and social history in daily practice Competency 2: Adapts communication to cognitive/emotional needs of the person with dementia Knowledge, skills, attitudes: • Explains changes in communication skills that occur during progression of dementia • Describes the relationship between communication and distress behaviors • Demonstrates strategies for effective verbal and nonverbal communication • Uses touch to gain person’s attention • Uses simple sentences • Presents 1 idea at a time • Asks 1 question at a time • Avoids negatively worded statements • Breaks down tasks • Gives simple choices • Identifies nonverbal expressions of physical discomfort and pain • Demonstrates communication skills and strategies for managing disruptive, aggressive, or other problem behavior • Listens and responds to emotional message • Uses verbal redirection • Uses written and visual cues • Allows time to respond • Avoids asking “why,” arguing, correcting misinformation, confrontation • Avoids raising voice • Avoids sarcasm with person with dementia • Demonstrates desired action • Reacts appropriately to negative communication by individual with dementia • Avoids responding to negative language by individual with dementia • Uses redirection • Reinforces (own) positive (caregiver) self-image using techniques such as positive self-talk • Discusses cultural differences in individuals with dementia and how to appropriately adapt com- munication strategies • Includes emotion-focused communication strategies in interactions with individuals • Gives recognition • Expresses positive regard • Uses verbal encouragers • Explores incomplete expressions of ideas Table 3. Competencies (continued) • Adopts an attitude of respect for individuality and dignity of the person with dementia • Uses individual’s name in communication • Approaches individual in a calm, unhurried manner • Avoids confrontation and arguments in communication Phase 2: 2–4 Hours of Training Competency 1: Demonstrates a working knowledge of dementia Knowledge, skills, attitudes: • Lists several diseases or conditions that may cause dementia • Identifies polypharmacy, depression, and other conditions that may result in symptoms of dementia • Describes how the disease progresses, as well as its symptoms, behaviors, and challenges associ- ated with each stage. • Discusses current research findings, including the research on cause, prevention, cure, and the recommended diagnostic process Competency 2: Recognizes, prevents, and manages distress behaviors including agitation, pacing, exit-seeking, combativeness, withdrawal, and repetitive vocalizations Knowledge, skills, attitudes: • Recognizes antecedents and consequences for distress behaviors • Monitors, documents, and reports to team the time, place, and circumstances accompanying dis- tress behaviors • Looks for patterns that reveal potential causes (correlates vs. triggers) of distress • Monitors, documents, and reports to team staff responses to residents’ distress behaviors and resi- dents’ responses to consequences • In collaboration with interdisciplinary team and family, plans prevention or modification strategies and addresses residents’ needs • Under the direction of a registered nurse, teaches and supervises nursing assistants regarding their responses to dementia-related behaviors • Assists in the design and implementation of care plan • Cooperates in modification of care plan • Teaches and supervises nursing assistants in reporting behaviors • Under the direction of a registered nurse, teaches and implements recommended staff stress- relieving strategies such as social support • Promotes quality of life and mental health consistent with resident’s individual history and prefer- ences through: - pet therapy - music therapy - structured activities - family photos and/or tape recordings - physical exercise • Describes the risks associated with wandering, pacing, and exit-seeking • Identifies and addresses mental health issues appropriately • Identifies and reports symptoms of psychological distress, acute confusion, or depression • Describes the effects of pain, illness, limited mobility, and sensory loss on behavior • Discusses the use, effects, side effects, and undesirable effects of medications used in memory loss • Discusses the use, effects, side effects, and undesirable effects of medications used to manage symptoms of dementia • Understands the use and misuse of restraints 102 Geriatric Nursing, Volume 26, Number 2 Geriatric Nursing, Volume 26, Number 2 103 Table 3. Competencies (continued) Competency 3: Understands special needs of family and friends of persons with dementia Knowledge, skills, attitudes: • Discusses the psychological needs and stress of family members including - stages of grief, anger, concern, and guilt - cultural differences in expressions of grief, anger, concern, guilt - how to respond to family expression of these needs and stresses • Identifies and reports family member needs, problems, and concerns to the team • Plans with team strategies to address family issues and includes family input • Supervises nursing assistants regarding their responses to families’ concerns • Includes family members in planning care and devising strategies as a means to provide quality care • Incorporates resident’s philosophy and values in an individualized care plan Competency 4: Promote independence in activities of daily living Knowledge, skills, attitudes: • Incorporates an approach to remaining capabilities and capitalizes on individual’s potential for rehabilitation • Breaks tasks down to manageable components • Promotes independence in activities of daily living • Looks for appropriate process as outcome in chosen activities rather than successful product • Encourages direct care staff in “doing with” rather than “doing for” approach to activities of daily living • Allows for personal choices and preferences using past history and other family information Competency 5: Promotes an optimal environment Knowledge, skills, attitudes: • Maintains safety and security of residents • Monitors environmental stimuli • Provides information as to date, day, season, and weather • Ensures needed auditory and visual aids and mobility and memory aids • Increases lighting to prevent shadows • Identifies and responds to individual’s feelings and fosters their expression • Reduces isolation through group activities, through family, friend, and community visits, and intergenerational experiences • In collaboration with other departments and consultants, promotes physical, social, and mental health • Avoids overhead paging • Promotes social interaction among individuals with dementia as well as staff members • Uses simple designs and colors • Avoids mirrors in hallways or common rooms • Provides sheltered freedom • Initiates appropriate conversation to maintain abilities • Provides opportunity for productivity • Decreases background noise (e.g., TV, radio) • While maintaining resident confidentiality, posts signs as reminders; puts labels on family photos, uses other written cues • Promotes constancy and predictability through a consistent and individualized routine, familiar care- givers, and appropriate activities Dementia-specific competencies were priori- tized for each phase of state-mandated training. Phase 1 (1 hour of training) included an overview of dementia and communication issues. Phase 2 included more detailed content on dementia and its treatment, related behav- ioral changes, the role of the family, and ethical issues. Time constraints of the state-mandated training necessitated creating advanced compe- tencies for other content that the task force considered important but could not be included in either phase 1 or phase 2 (see Table 2). The task force constructed a draft of the LPN competencies, as well as a diagram depicting the progression from core to advanced competen- cies within a novice-to-expert framework. The draft was distributed to the Advisory Committee members for review and in a face-to-face meet- ing; each competency was discussed along with questions and comments from LPNs at the TNH who reviewed earlier drafts. Suggestions from the wider group were incorporated, and consen- sus was reached. The revised document was dis- tributed by e-mail for comments and revisions. At the end of 2001, the final version was ready to be used for the development of the curriculum. Although core competencies will change as knowledge and skills in dementia care advance, the list in Table 3 represents the current con- sensus of the TNH Steering Committee. The proposed phases of training for LPN competen- cies is organized to reflect training that might occur in 1- and 3-hour sessions in compliance with the dementia training mandate of SB1202. With the projected increases in the number of elders with dementia in nursing homes and the rapidly growing dementia population in the LTC system in Florida, it was imperative to ensure that Florida’s nursing home care providers were prepared to care for these residents. The Florida legislature signed into law SB 1202 in 2001 to begin the process of improving demen- tia care.3 Legislation passed in 2002 requires the same 4-hour mandatory dementia training for hospice and adult day care personnel and rec- ognizes the pressing need to train all staff who work with community living elders to be com- petent in dementia care. Table 3. Competencies (continued) Competency 6: Recognizes ethical issues that arise in dementia care and incorporates these into care approaches Knowledge, skills, and attitudes: • Articulates an awareness of issues such as privacy, honesty, and autonomy in the daily care of persons with dementia • Identifies common ethical conflicts that may arise when caring for residents with dementia • Discusses ethical decision-making process using problem-based learning • Recognizes variability in family and cultures in making ethical decisions • Identifies the resources available for resolving ethical dilemmas Advanced Competencies • To prevent excess disability, incorporates an approach to support remaining capabilities and capi- talizes on potential for rehabilitation • Identifies physical discomfort, pain, fatigue, dehydration, hunger • Identifies verbal and nonverbal pain and discomfort, reports changes in cognitive function, antici- pates individual’s needs to prevent pain, fatigue, dehydration, and hunger and assists with plan to address same • Understands the end-of-life issues facing residents, staff, families, and guardians related to dementing illness • Explains the complex and terminal nature of providing care for persons with advanced, progres- sive dementia • Incorporates palliative care principles into planning, supervision, and delivery of care • Discusses the concept and implementation of an Advance Directive 104 Geriatric Nursing, Volume 26, Number 2 Geriatric Nursing, Volume 26, Number 2 105 The competencies for dementia care and the curriculum based on those competencies are cur- rently available through the TNH online educa- tional site GeriU (www.GeriU.org). GeriU is the first online geriatric university dedicated specifi- cally to the provision of accurate and timely information on the care of older patients for health care providers. Although these education- al resources were developed with State of Florida funding for Florida nurses, by accessing this Web site, any health care provider can use the demen- tia education learning modules without cost. The learning modules are available from the “Public Content” link at the GeriU Web site. From there, the learner will be directed to a link to Florida’s Teaching Nursing Home Program. The instruc- tional activities titled “Nursing Home Alzheimer’s Disease and Related Disorders Training for LPNs” include learning modules divided into 2 sections representing basic and more advanced training. The basic modules (“Understanding Dementia” and “Communication”) provide an overview of dementia, quality of life, person-cen- tered care, types of communication, and accom- modations to improve communication with cog- nitively impaired residents. There are 5 modules that make up the second phase of the program (“Distress Behavior,” “Loved Ones,” “Activities of Daily Living,” “Environment,” and “Ethics”). Each module begins with a set of objectives, followed by learning activities, practice exercises, and resources for further information. Modules are presented as computer-based interactive learning that can be completed independently. A complete description of the training materi- als and the curriculum is beyond the scope of this article; it will be the subject of a forthcoming paper.11 The results of a preliminary evaluation of the program are reported elsewhere.12 With its high concentration of older residents, Florida is positioned to develop models of care and educa- tion for long-term care providers. This article has described the process we used to develop not only the most comprehensive competencies to guide staff training but also the need to establish buy-in from all of the constituents who provide and would benefit from this training. References 1. Fries BE, Schroll M, Hawes C, et al. Approaching cross-national comparisons of nursing home resi- dents. Age Ageing 1997;26:13-8. 2. Hebert LE, Scherr PA, Bienias JL, et al. Alzheimer disease in the U.S. population: prevalence estimates using the 2000 Census. Arch Neurol 2003;60:1119–22. 3. Polivka L, Salmon JR, Hyer K, et al. The nursing home problem in Florida. Gerontologist 2003;43(Special Issue II):7-18. 4. Harrington C, Carrillo H, Crawford CS. Nursing facili- ties, staffing, residents, and facility deficiencies, 1997 through 2003. Table 31, “Average RN, LPN/LVN, & assistant hours per resident day in all certified nursing facilities in the US.” p. 74. San Francisco: Department of Social and Behavioral Sciences, University of California San Francisco; August 2004. 5. Ozcan YA, Shukla RK. The effect of a competency- based targeted staff development program on nursing productivity. J Nurs Staff Dev 1993;9(2):78-84. 6. Ballantyne A, Cheek J, O’Brien B, et al. Nursing com- petencies: ground work in aged and extended care. Int J Nurs Pract 1998;4:156-65. 7. Zhang Z, Luk W, Arthur D, et al. Nursing competen- cies: personal characteristics contributing to effective nursing performance. J Adv Nurs 2001;33:467-74. 8. Regenstreif DI, Brittis S, Fagin CM, et al. Strategies to advance geriatric nursing: the John A. Hartford Founda- tion initiatives. J Am Geriatr Soc 2003;51:1479-83. 9. Taylor C. Rethinking nursing’s basic competencies. J Nurs Care Quality 1995;9(4):1-13. 10. Fazio S, Semen D, Stansell J. Rethinking Alzheimer’s care. Baltimore: Health Professions Press; 1999. 11. Mintzer MJ, Hyer K, Williams C, et al. Statewide devel- opment of a curriculum for LPNs caring for residents with dementia in long-term care [working paper]. 2005. 12. Ruiz J, Mintzer MJ, Hyer K, et al. The educational impact of a computer-based training tutorial on dementia in long term care for licensed practical nurs- ing students. Accepted for publication. Gerontol Geriatr Educ 2005. CHRISTINE L. WILLIAMS, DNSc, RN, BC, is associate pro- fessor, University of Miami School of Nursing, Coral Gables. KATHRYN HYER, PhD, MPP, is associate professor, School of Aging Studies, College of Arts and Sciences, University of South Florida, Tampa. ANNETTE KELLY, PhD, ARNP, is assistant professor of Nursing, Florida Southern College, Lakeland, and executive director, Alzheimer’s Association (Central and North Florida). SUE LEGER-KRALL, ARNP, PhD, is director of research and community clinical servic- es, River Garden Hebrew Home/Wolfson Health and Aging Center, Jacksonville. RUTH M. TAPPEN, EdD, RN, FAAN, is professor and eminent scholar, College of Nursing, Florida Atlantic University, Boca Raton. ACKNOWLEDGMENT The authors acknowledge the Stein Gerontological Institute and the work of the members of the Teaching Nursing Home Steering Committee and Advisory Committee. With their countless hours of discussion, sug- gestions, and critique, it was possible to arrive at compe- tencies that reflect the viewpoints of multiple stakeholders within the Florida long-term care system. This work was supported by the Agency for Health Care Administration, State of Florida. 0197-4572/$ - see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2005.01.005 http://www.GeriU.org In any practice setting, professional nurses must be skilled to assess and manage med- ical problems rapidly. Post-fall assessment among those with dementia is a daunting task. Emergent medical problems after a fall are difficult to detect among those with dementia, because impaired communica- tion portrays a false reality that the older adult is uninjured. Furthermore, early detec- tion of potential post-fall injuries may not occur within a health care system that relies on verbal communication and eyewitness accounts as the main source of fall occur- rence information. Professional nurses must turn to other means of fall detection. One such strategy relies on observable changes in function and behavior, such as a recent decline in mobility, change in gait, level of consciousness, neurological func- tion or vital signs. Those most susceptible exhibit prior observable signs of visual-spa- tial impairment such as impaired clock drawing, gait apraxia, and inability to nego- tiate their environment without falling. (Geriatr Nurs 2005;26:106-10) P erhaps the most difficult assessment of any condition comes when an older adult client cannot vividly recall an event, or circumstances surrounding that event, for which an evaluation is requested or sought. When the event in question is a fall, the difficul- ties are no less complex. If a fall happens to occur within the confines of a long-term care facility, clinicians search for validation that the fall occurred by questioning staff members and families. If no eyewitness accounts are avail- able and others deny the occurrence, clinicians may still wonder, did the fall actually happen? Although there is no “absolute,” evidence-based technique to answer this question, there are a handful of valuable clinical findings that indi- cate a recent fall occurrence among older adults with dementia. Early detection of any fall is crucial to treat underlying predisposing fac- tors such as orthostatic hypotension or infec- tion and to assess for injury. When a fall is sus- pected in a person with dementia (and impaired communication), time is of the essence because it may be unclear when the fall actually occurred. Post-fall assessment of an individual with dementia differs from the standard post-fall assessment of an older adult without dementia. The difference lies in recognizing some of the latent or subclinical findings such as behavioral or functional changes indicative of injury. Following a stepwise approach that considers all of the past static characteristics (Table 1) of the older adult coupled with evaluation of current or dynamic characteristics (Table 2) are integral components of the post-fall assessment. Many of the past static characteristics are well known to the clinician from the medical record and review of fall risk assessment tools. None, however, are more important than current or dynamic events revealed on an immediately performed compre- hensive post-fall assessment. Because falling may be unobserved, and the resident may be unaware that it took place, assessment must be thorough and interventions should always con- sider patient safety first. Consider this scenario of an ambulatory older adult with advanced dementia who resided in a long-term care unit. Mrs. S, aged 82 years, was admitted to a long-term care facility because of con- tinued wandering and getting lost at home. She was diagnosed with moderate stage Alzheimer’s disease and demon- strated a need for complete assistance in activities of daily living. She was apha- sic with both expressive and receptive inabilities to communicate, but would roam the long-term care unit for hours on end. After dressing in the morning, she would ambulate back and forth on the unit, stopping to stare at the room num- bers. When approached by name, she con- tinued to walk uninterrupted. Mrs. S had Deanna Gray Miceli, DNSc, APRN, FAANP Falls Associated With Dementia: How Can You Tell? 106 Geriatric Nursing, Volume 26, Number 2 Geriatric Nursing, Volume 26, Number 2 107 no other medical problems and took no medications. One day, staff reported the resident as having upper respiratory symptoms of nasal congestion and poor oral intake that resulted in bed rest. Once recovered, the staff noted her balance to be “off” as she leaned to the right and dragged her leg. No adverse events were reported. Closer physical examination revealed a large ecchymosis of the right hip and pelvis with exquisite pain to range of motion. An x-ray was ordered of the right hip showing a recent intertro- chanteric fracture. A bone mineral den- sitometry showed no osteoporosis. The likely etiology of the fracture was pre- sumed to be a fall because review of the progress notes showed that while she was in bed, there were several attempts to get out of bed, and on one occasion, she was found sitting on the floor, voicing no complaints. Case Analysis The onset of an acute medical event as mild as an upper respiratory infection can change baseline patterns of mobility for a resident with advanced dementia. Nasal congestion may cause lightheadedness and generalized fatigue exacerbated by restlessness. In this case sce- nario, the resident’s baseline motor function, chronic restlessness, was operative, raising the likelihood of a bed fall. Also, evidence of mod- erate dementia and impaired communication precluded a reliable history, therefore symp- toms may never be elicited. Rather, more reli- able indicators of a fall might be clinical obser- vation of a change in behavior or function such as limping with ambulation. The Clinical Relevance Of A Diagnosis Of Dementia Dementia is a serious, often insidious disease that destroys the white matter substrate of the brain, eventually affecting all aspects of higher cognitive function including mobility. The destruction of white matter involves irre- versible neuronal damage. The location of the destruction is important in terms of areas of cortical involvement, but a diagnosis of Table 1. Important Static Characteristics of the Older Adult With a Presumed Fall History Dementia* Parkinson’s disease* Subdural hematoma Head trauma/traumatic brain injury Hip fracture Osteoporosis Gait or balance impairment* Visual impairment* Hearing loss Orthostatic hypotension* Delirium* Medications Vasodilators Neuroleptics Agents that lower blood pressure Narcotic analgesia Diuretics Behavior associated with dementia Wandering and elopement Agitation and restlessness Visual hallucination Motor or gait apraxia *Items found on fall risk assessment tools. Table 2. Important Dynamic Characteristics of an Older Adult With a Presumed Fall Assess for acute changes in Vital signs Level of consciousness Neurological system—gait or balance instability Skin integrity—skin tear, hematoma, bruises Musculoskeletal system—sprain, strain, fracture 108 Geriatric Nursing, Volume 26, Number 2 Alzheimer’s disease typically causes global deterioration highlighted by neurofibrial tan- gles and plaques.1,2 One of the most obvious signs of dementia is impaired communication, with both expressive and receptive loss. However, it should be kept in mind that impaired commu- nication, the end product of neuronal dam- age, is only one of the many changes. Others include loss of visuospatial skill. If the area of destruction involves the basal ganglia, signs of Parkinsonism—such as shuffling with walking, balance instability, and truncal rigid- ity—can be evidenced. These changes supple- ment the chronic disorientation, confusion, and memory loss of dementia. Illnesses such as Alzheimer’s disease often result in frequent falling because of visuospatial impairment and motor apraxia. (Apraxia is loss of a learned skill such as walking, dressing, and bathing.) The baseline cognitive screen using the Folstein Mini-Mental State Examination (MMSE) can provide invaluable information about the resident’s overall cognitive capabili- ties and executive function noting specific areas of impairment. In particular, the clock- drawing component of the MMSE has been shown in research to contribute to the diagno- sis of dementia.3 The MMSE identifies disorien- tation, visuospatial impairment, loss of recall, as well as impaired communication and lan- guage abilities. Research centered on clock- drawing skills has found correlations between dementia and impairment in visuospatial abili- ties, as evidenced by impaired clock drawing.4 In this study, the severity of dementia was found to be a good predictor of the deficit in visuo-constructive performance. In one recent study, the clock-drawing test was a valid screening method for mild cognitive impair- ment.5 When correlated with neuroanatomy by magnetic resonance imaging, it was found that interruptions in large cortical-subcortical neu- ral networks underlie impairment in the clock- drawing test.6 Given the significance of a diagnosis of dementia, the index of suspicion for a fall among older adults with dementia should be considered high. Valuable components of any post-fall assessment when a diagnosis of dementia is present would include interviews of the resident, his or her roommate, or staff; review and observation of baseline function and behavior; and observation for pertinent changes in the resident’s condition. Interview The Resident There is always the possibility that questions of falling will trigger a memory of a recent or distant fall. Care must be taken in the inter- pretation of this information because the resi- dent may be recalling a fall from long ago, and in the absence of a witness, there is no reliable means to determine the accuracy of this description. Further probing about where the fall occurred and associated circumstance may reveal the exact time of its occurrence. Typical statements from residents with demen- tia who fall include both “I don’t know” responses and “I don’t remember falling.” Sometimes having the resident tell his or her story of a recent fall is helpful. This can be noted in the medical record, and should a fall reoccur, another story can be elicited and compared with the previous one. Table 3. Tips to Possible Dementia- Related Causes of a Fall Clinical Tips Clinical progression of white matter dis- ease/dementia Impairments in clock drawing (refer to diagnostic criteria) Unexplained falls despite comprehensive evaluation Motor or gait apraxia Sitting down when there is no furniture or object present to sit on With intact vision, walking into objects, furniture, or persons Apraxia with walking aids—inability to utilize an aide despite prior knowledge or teaching Geriatric Nursing, Volume 26, Number 2 109 Interview Potential Witnesses— Roomate, Staff, And Family Should a fall occur in the resident’s room or hallway, it is likely to have been observed by someone such as the housekeeper or a room- mate or a staff member. Important information includes the nature of the fall in terms of whether the fall was broken by, for example, a slide to the floor, and whether the person land- ed on a hard surface or experienced a head injury. Family members may have received a call by telephone from the resident stating that they fell earlier in the day. These sources of information need further follow-up. Review Baseline Behavior And Function (Static Events) The baseline data obtained from the compre- hensive health history and reflected on the Minimum Data Set (MDS) provides for a tem- plate of information about overall baseline function, past medical history, and medications. This information forms static characteristics about the resident. Key areas to review on the MDS include notation of gait or balance impair- ment and behavioral manifestations such as chronic restlessness, aimless ambulation, or wandering. Although not on the MDS, residents with dementia should be observed for walking into objects such as furniture or into other peo- ple, which suggests visuospatial or judgment impairment. Other observations include the inability to judge space relationships, evi- denced by attempts to sit down when a seat or chair is not present. Other observations include the resident’s ambulation pattern. Does the res- ident take large bounding steps or appear to step over objects on the floor that are not pres- ent? These findings may signal visuospatial impairment or visual misperceptions such as hallucinations, especially when the older adult’s vision remains intact. Observe Resident Function And Behavior For Change (Current-Dynamic Events) Despite an inability to communicate verbally, many nonverbal cues can give light to an impending medical problem. Failure to eat or drink as before is often a general marker of an imminent underlying problem. Any holding of a body part may be a sign that the resident is experiencing pain at that site. Examples include when a resident holds his or her lower back (indicating backache) or the jaw (indicat- ing toothache). Inability to walk, stand, or transfer may indicate an underling muscu- loskeletal problem, not solely a cognitive dete- rioration reflective of dementia. Changes in behavior such as a new onset or intensification of an existing behavior, such as agitation or restlessness can signal the post-fall effects associated with trauma. All of these changes are significant and require additional assess- ment. Assess For Pertinent Signs Or Symptoms (Current-Dynamic Events) Vital signs provide for important informa- tion about overall physiology and homeosta- sis. Residents who have fallen and fractured a rib may present with guarding of respiration and shallow breathing. Sudden drops in blood pressure or hypotension can be observed in crush injuries or systemic results of a lower extremity fracture. Any acute change in level of alertness that progressively deteriorates is a medical emergency. Often, regular vital signs and neurological checks (typically up to 72 hours post-fall or more) can detect these events. Observation of the integument can point to skin tears, new and old bruises, and the potential for underlying muscular strain or fracture. Signs of head trauma may be as vague as a mild headache of new onset, changes in vital signs, or neurological decline. Nurse’s Observation And Perception Of The Resident The nurses’ perception that a fall event poten- tially occurred is as valuable as any other infor- mation. Daily observations of the resident allow for the nurse to accrue information incremen- tally about changes in function. Gradual deteri- oration, for instance, can be surmised when the nurse reflects back on previous types of func- tion or behavior. Knowledge gained assists in an overall real-time perception of the resident’s current status. When these observations yield a high degree of suspicion for a fall, it is vital not only to evaluate the resident thoroughly, but also to consider interventions that will promote patient safety. Injury prevention strategies that are initiated for protective reasons range from 110 Geriatric Nursing, Volume 26, Number 2 padded and elevated side rails to use of hip pro- tectors, low-rise beds, or bed alarms. Great variability exists in the type of intervention cho- sen; selection is typically based on the specific needs of the resident and facility resources. Conclusion Overall, the post-fall assessment of the older adult with dementia and impaired executive function translates to greater use of the nurse’s observation of the resident for subtle or dramat- ic changes in function and behavior. The vital signs, assessment of integument, cardiovascular, respiratory, and neurological systems remain unchanged as the standard components of a post-fall assessment. The MMSE and its clock- drawing components have special value in iden- tifying visuospatial impairment along with loss of higher cortical function that may explain why the fall occurred in the first place. If the workup of the fall etiology is uneventful, the clinician should consider assessment using the clock- drawing test and MMSE to identify root causes associated with visuospatial impairment that may be the underlying diagnosis of dementia. References 1. Roman G. Diagnosis of vascular dementia and Alz- heimer’s disease. Int J Clin Pract Suppl 2001 (May); 120:9-13. 2. Estol CJ. Dementia: clinic and diagnosis. Vertex 2001; 12(46):292-302. 3. Cosentino S, Jefferson A, Chute DL, et al. Clock draw- ing errors in dementia: neuropsychological and neu- roanatomical considerations. Cognitive Behavioral Neurology 2004, Jun 17(2):74-84. 4. Elzen H, Schmidt I, Bouma A. The diagnostic value of drawing a clock in geriatrics. Tijdschr Gerontology Geriatric 2004; June 35(3):107-13. 5. Kalman J, Magloczky E, Janka Z. 1995. Disturbed visuo-spatical orientation in the early states of Alzheimer’s Disease. Arch Geronoltogical Geriatric 1995, 21(1):27-34. 6. Yammamoto S, Mogi N, Umegaki H, et al. The clock drawing test as a valid screening method for mild cog- nitive impairment. Dementia Geriatrics Cognitive Disorders 2004; 18(2):172-9. DEANNA GRAY MICELI, DNSc, APRN, FAANP, is a board certified Gerontological Nurse Practitioner with expertise in falls. She is a post-doctoral scholar (2002-2004) of the John A. Hartford Foundation Building Academic Geriatric Nursing Capacity Program at the University of Pennsylvania-School of Nursing, adjunct assistant pro- fessor, University of Pennsylvania and nurse practition- er/falls consultant, the New Jersey Department of Health and Human Services, Trenton, New Jersey. 0197-4572/$ - see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2005.01.014 In the lives of persons with cognitive impair- ments, a time comes when it is necessary to give up driving. This may be a particularly difficult issue for the driver, his or her fami- ly members, and their health care profes- sionals. In this study, the phenomenon of unsafe driving by cognitively impaired older adults and the process of affecting driving cessation, was explored through guided interviews with 216 persons throughout the state of Florida. Participants included pro- fessionals working in the aging network, mobility counselors, safety officers, individ- uals with a mild degree of cognitive impair- ment and their family members. The strate- gies employed to influence or effect cessation could be categorized as those that involved the individual affected and those that were imposed on the individual. Conditions that appeared to influence whether driving cessation would occur were observed. There were distinct pros and cons to each strategy. In this article, specific information is provided to guide nurses working with cognitively impaired people who have become unsafe drivers. It is expected that driving cessation can be voluntarily effected in many cases but may have to be imposed in others. The skilled nurse will know when and which type of recommendation is appropriate. (Geriatr Nurs 2005;26:111-16) T he acquisition of a driver’s license is a critical developmental task associated with achieving adulthood in the United States. It symbolizes independence and confers a certain social status on the driver and owner of a vehicle. The ability to drive permits indi- viduals not only to meet basic needs more easi- ly in most locales (for shopping, seeking health care, and travel to places of employment) but also permits connection with the community by facilitating attendance at religious, social, sporting, or entertainment events, and visiting with friends and family, thus preventing social isolation.1-3 As a result, having to relinquish one’s driver license often causes much distress to the older driver and, consequently, to his or her family as well.4-6 On the other hand, 7,269 people aged 65 and older died from motor vehicle crashes in a sin- gle year. Older drivers are more likely to die as the result of injuries associated with a motor vehicle accident. When calculated on the basis of estimated annual travel, the fatality rate for drivers aged 85 and over is 9 times greater than the rate for drivers aged 25 through 69 years.7 Based on current rates, the numbers of traffic fatalities involving older drivers will more than triple by 2030.1,8 Many older people continue to drive even though they may not be able to do so safely.5 A substantial proportion of their driving problems are associated with the disease processes that increase with advancing age and diminish the skills needed to drive. For example, older per- sons are more likely to be taking medications, many of which can affect driving ability.2 Of particular concern are changes involving visual, perceptual, cognitive, and motor skills.9,10 Although individuals with mild dementia actually have fewer accidents per year than young people (16–24 years), as dementia pro- gresses, it becomes an important risk factor for motor vehicle accidents.11 Cognitive changes, especially visuospatial, agnosic, apraxic, and attention deficits, have been implicated in unsafe driving.12 Some individuals with demen- tia appear to either lack insight or deny any decline in driving competence, often deciding to stop driving only after one or more accidents have occurred.13 Freund and Szinovacz5 found that more than half of those with mild cognitive Kathleen Jett, PhD, APRN, GNP, BC, Ruth M. Tappen, EdD, RN, FAAN, and Monica Rosselli, PhD Imposed Versus Involved: Different Strategies to Effect Driving Cessation in Cognitively Impaired Older Adults Geriatric Nursing, Volume 26, Number 2 111 112 Geriatric Nursing, Volume 26, Number 2 impairment continue to drive. Almost 20% of the men and 6% of the women with severe impairment continued to drive long distances. Not surprisingly, the lack of an alternative driv- er was found to be a significant factor in the continuation of driving for both men and women. Those who do not drive or who must stop driving have to depend on public trans- portation, walking, the favors of friends or rela- tives, or hiring someone to drive them. These alternatives are often inadequate, increasing reluctance to cease driving.6 Although the effects of driving cessation and some of the salient factors (e.g., gender, driving partner, metropolitan residence) that influence driving cessation have been explored, the process of arriving at that outcome has not been articulat- ed. The purpose of this study was to identify and describe the strategies health and social service professionals, paraprofessionals, older persons and their families find to be effective and ineffec- tive in bringing about driving cessation. METHODS Participants We recruited 216 persons from across the state of Florida to participate in a guided interview related to driving cessation in older adults with cognitive problems (Table 1). Participants were selected on the basis of their personal or profes- sional experience dealing with this issue. They included professionals working in memory dis- order clinics, Alzheimer’s Association chapter staff, mobility counselors, safety officers, older drivers, and laypersons who attended support groups for people with a mild degree of cognitive impairment and their family members. Data Analysis Participant responses were hand written dur- ing the interviews and later transcribed. The data were subjected to concurrent analysis using a grounded theory strategy.14 As themes emerged in the early stages of data collection, they were discussed with later participants and among the investigators to refine and revise the thematic structure. When saturation was reached, the investiga- tors separately read and reread the transcripts, and then came together to compare and recon- cile the thematic structures identified. The results were further refined, and the themes were again reviewed for coherence and consis- tency. Finally, the themes were reviewed with selected key informants for purposes of estab- lishing validity of the findings. RESULTS The phenomena under study were those of unsafe driving and driving cessation related to cognitive impairment. The themes identified relat- ed to the context of unsafe driving, the interven- ing conditions that affected cessation and action and intervention strategies employed to effectu- ate cessation of unsafe driving. The analysis has implications for counseling cognitively impaired persons regarding driving cessation. Interestingly, there was considerable concordance in the responses of the participants from various groups, that is, individuals with mild cognitive impairment and their family members vis-à-vis professionals. Where substantive differences arose, these are noted and the reasons discussed. Unsafe Driving Potentially unsafe driving was observed by the participants in the presence of topographic agnosia, apraxia, or attention deficits (Table 2). Impaired drivers got lost coming or going to familiar places (topographic agnosia), had impaired ability to use car equipment correctly Table 1. Types and Gender of Respondents (N = 216) Category of Respondent Men Women Older drivers 15 25 Family members 42 59 Paraprofessionals/ 12 51 professionals in aging Persons who are both family 4 9 members and work in the field of aging Total 73 144 Participant age ranged from ~35 to 97 years. Geriatric Nursing, Volume 26, Number 2 113 (apraxia), and had decreased awareness of other cars, pedestrians, and so on (attention deficits). People spoke of such things as the failure to identify the brake and gas pedals cor- rectly, crossing lines of traffic without realizing it, and driving with the car door open. Unsafe driving was described as occurring most often under certain conditions (Table 3). It was reported that people with cognitive impairment would often continue to drive if one or more of the following were present: the indi- vidual had a strong desire or need to drive, the individual had access to a car, the lack of an alternate driver, and alternative transportation that was not available, difficult to use, or of unacceptable nature (e.g., rowdy adolescents encountered on public buses). Driving was also particularly likely to occur in the company of a “copilot,” or someone avail- able in the car who could direct, instruct, and supervise. A number of the women interviewed preferred to act as a copilot to their impaired husbands rather than to assume the responsi- bility of driving. Intervening Conditions Intervening conditions are those factors believed to influence the continuance of unsafe driving or the cessation of driving. The condi- tions reported included the visibility of the driv- ing deficits; available economic resources; the relationship the driver had with family mem- bers, health care providers, and law enforce- ment personnel; and the meaning the driver attached to his or her vehicle and driving. The visibility of specific driving impairments was a particularly important intervening condi- tion. For example, a daughter reported that she had not known her father was having difficul- ties until she visited him and was a passenger in the car. Her father asked her which pedal was for gas. Stunned, she refused to stay in the car if he continued to drive. In another case, a son never knew his father was a dangerous driver because he automatically assumed the role of the driver during his visits and thus his father’s deficits remained invisible. Actions and Intervention Strategies Two different—and in many respects con- flicting—strategies to achieving driving cessa- tion were espoused by the respondents (Table 4). An involved strategy is based on open com- munication and inclusion of the cognitively impaired person in the decision to stop driving. An imposed strategy, in contrast, uses direct action to prevent the cognitively impaired per- son from driving without discussion or partici- pation in making the decision. Few, if any, cog- nitively impaired respondents supported the imposed strategy, whereas a significant minori- ty of family members and professionals did, providing examples and arguments in favor of its efficacy and, at times, necessity. Involved Strategy. An involved strategy is based on the principle that the cognitively impaired person is an adult who has the right to be included in decisions affecting his or her life. It is further argued that the person who under- stands the reasons for stopping will, in most cases, agree that it is necessary to stop driving. Table 2. Conditions Indicating High Risk for Unsafe Driving (Relating to Cognition) • Topographic agnosia (e.g., getting lost going to or from common places) • Apraxia (e.g., loss of ability to use care equipment correctly such as key, brake pedal, etc.) • Attention deficits (e.g., decreased aware- ness of other cars, pedestrians, stationary objects or condition of the car) Table 3. Conditions That Increase the Likelihood of Unsafe Driving • Desire to drive • Need to drive (no alternatives available or acceptable) • Access to a vehicle • Willing copilot 114 Geriatric Nursing, Volume 26, Number 2 Combining suggestions from a variety of respondents, including people with a mild degree of cognitive impairment, the involved strategy would begin with discussion of the eventual need to stop driving, preferably long before it becomes a critical safety issue. Any dis- cussion of driving errors should be specific, not global. “You went through that stop sign” is con- sidered preferable to “You never pay attention to what you are doing.” A calm, empathetic shar- ing of views is thought to be more likely to occur under this scenario than if the subject is brought up during an argument or when an accident or near accident has occurred. Acknowledging the losses incurred when one stops driving is con- sidered important. Equally important is the cre- ation of a realistic, affordable, and acceptable plan for alternative transportation. A number of respondents raised an interest- ing point about convincing the cognitively impaired person that it has become dangerous to drive. Danger to oneself, many reported, is not persuasive to a cognitively impaired older adult. Danger to others, especially a beloved grandchild, neighbor’s child or even a pet, was reported to be far more persuasive. A somewhat different but nevertheless involved tactic is to point out the legal and eco- nomic ramifications of having an accident, par- ticularly after the person has been advised to stop or had the driver’s license revoked. The dan- ger of losing one’s savings in the resulting law- suit can be persuasive to some. Others may be persuaded by an analysis of the cost of owning, maintaining, and insuring a car compared with paying someone to drive or using a taxi service. The involved strategy is time-consuming, and its effectiveness is uncertain, particularly with more advanced impairment. On the other hand, it helps to maintain relationships and demon- strates respect for the individual with cognitive limitations. Imposed. Use of the imposed strategy is based on several arguments. The first is that cogni- tively impaired persons are either unwilling or unable to make a wise decision, so the family member or professional must do it for them. The second major argument is that the safety of the cognitively impaired driver and anyone in the vicinity of this driver is in jeopardy and that safety considerations supercede any other considerations. The third is that this strategy works. One or more respondents mentioned a num- ber of strategies that fall within the imposed category: • Keep the car out of sight and put the keys in a new place where they are not easily found. • Tell a “therapeutic fib” that the car won’t work, the keys are lost, or the insurance was cancelled. • Disable the car or put an antitheft device on the steering wheel to lock it. Table 4. Action Strategies Used to Bring about Driving Cessation Action Strategies Imposed Type Involved Type Report person to division of motor vehicles for All family members and individual meet, discuss possible license suspension the situation, and come to a mutual agreement of the problem Use of deception or threats such as false keys, Dialogue is ongoing from the earliest signs of disabling the car, saying car was stolen cognitive impairment of the eventuality of the need to stop driving Attempts to order or control such as provider Arrangements are made for alternative trans- writing a prescription, commands from portation plans that are available when needed children to stop driving and acceptable to the individual Geriatric Nursing, Volume 26, Number 2 115 • Sell the car or give it away. • Report the person to the Division of Motor Vehicles pursuant to having that license revoked. (It was noted that this is not as cer- tain a solution as it would first appear because some people drive without a license.) On one hand, the imposed strategy includes a number of strategies that may be highly effec- tive and quick to accomplish. On the other hand, imposed strategies may be considered dehumanizing and have the potential to under- mine trust and damage the relationship between the cognitively impaired person, his or her family, and professionals involved in caring for the impaired person. Health care providers who use the imposed strategy may be “fired” by the patient, and family members may be the tar- get of much displeasure if not anger, but driving cessation is usually achieved. DISCUSSION The participants in this study described spe- cific safety concerns regarding people who have cognitive impairment continuing to drive. These areas of concern were consistent with the liter- ature: getting lost coming or going to familiar places, inability to use car equipment correctly, and decreased awareness of other cars, pedes- trians, and so on. Once these factors become apparent, intervention was deemed necessary. Many cognitively impaired adults voluntarily stop driving when the potential dangers become apparent to them (Table 5). Some are frightened by an incident that occurred while driving; others are happy to have someone else Table 5. Factors That Positively Influence the Success of Driving Cessation Counseling Interventions • Visibility of the impaired driving skills • The occurrence of recent accidents or “near misses” • Positive relationships with family member and health care provider • Individual is female • There are acceptable options for trans- portation alternatives Table 6. Sources of Information About Driving Testing Locations • Local department of motor vehicles • State department of transportation • Area agencies on aging • Senior help lines • National Safety Council • National Highway Transportation Safety Administration (www.nhtsa.dot.gov) • Health care facilities with outpatient occu- pational therapy services Most driving testing is for persons with physical challenges. It is important that this testing is specifically designed for persons with cognitive limitations. Table 7. Factors to Consider in the Development of an Alternative Transportation Plan • Specific information about transportation needs (e.g. distance, frequency of reoccur- ring needs such as trips to church) • Specific costs of current transportation (e.g., insurance, gas, maintenance, pay- ments) • Meaning that independent transportation and vehicle(s) holds for driver • Pros and cons of each form of alternative transportation available and suitability for the persons with a cognitive impairment • Level of cognitive impairment http://www.nhtsa.dot.gov 116 Geriatric Nursing, Volume 26, Number 2 drive. In either instance, they stop with little or no argument. Naturally, these individuals are less likely to come to the attention of profes- sionals than are those who resist. Among people reluctant to give up driving, driving cessation is more problematic. Because dementia affects the quality of decision making, multiple judgment issues arise. Dementia patients may have reduced insight about their own capabilities and try to do things that they are not capable of doing,15 including driving. Professional intervention, through counseling the driver and significant others, may be neces- sary. Counseling can prepare family members for the expected course of disease and increase the caregivers’ ability to cope.16 The reality of the unsafe driving must be made visible to both the driver and the family. This may occur through simple observation or through driver testing, preferably testing that is specific to persons with cognitive impairment (Table 6). Once unsafe driving is made apparent, health care professionals and others in the aging net- work have a responsibility to provide the cogni- tively impaired person and his or her family with a range of options and informed strategies for effecting cessation. Measures to influence the context of driving and the intervening condi- tions—for example, reducing the need for driving and developing reasonable and acceptable alter- natives to driving (Table 7)—may be fruitful. Involving the impaired driver in the process from the beginning would be the preferred strategy from a humanistic point of view, but the potential necessity of the imposed strategy is recognized. As the number of older persons and, therefore, older drivers with cognitive impairment increases, so does the need to implement an effective yet car- ing strategy to bring about driving cessation. This article presents information that should be of use to nurses dealing with driving cessation for a per- son with cognitive impairment. By incorporating the information presented, the intervention may be affirming whenever possible but may become directive when necessary. Further research is needed to test the effectiveness of these interven- tions on drivers with cognitive impairment. References 1. Burkhardt J, Berger A, Creedon M, et al. Mobility and independence: changes for older drivers. Developed under cooperative agreement with US Department of Health and Human Services. 1998. Available at the Administration of Aging Web site: www.aoa.dhhs.gov. Accessed March 4, 2005. 2. Carr D. The older adult driver. Am Fam Physician 2000;61:141-6, 148. 3. Johnson E. Transportation mobility and older drivers. J Gerontol Nurs 2003;29:34-41. 4. Foley D, Masaki K, Ross W, et al. Driving cessation in older men with incident dementia. J Am Geriatr Soc 2000;48:928-30. 5. Freund B, Szinovacz M. Effects of cognition on driv- ing involvement among the oldest old: variations be gender and alternative transportation opportunities. Gerontologist 2002;42:621-33. 6. Taylor B, Tripodes S. The effects of driving cessation on the elderly with dementia and their caregivers. Accident Anal Prev 2001;33:519-28. 7. Family and friends concerned about an older driver; final report. DOT 809-307. August 2001. Available at: www.NHTSA.DOT.gov/people/injury/OLDDRIVE/ FAMILYNFRIENDS/faf_INDEX.htm. Accessed March 4, 2005. 8. Carr D, Duchek J, Morris J. Characteristics of motor vehicle crashes of drivers with dementia of the Alzheimer’s type. J Am Geriatr Soc 2000;48:18-22. 9. Ham R. Sloane P, Warshaw G. Primary care geriatrics: a case based approach. 4th ed. St. Louis, MO: Mosby; 2002. 10. Messinger-Rapport B, Rader E. High risk on the high- way: how to identify and treat the impaired older driv- er. Geriatrics 2000;55:32-45. 11. Drachman DA, Swearer JM. Driving and Alzheimer’s disease: the risk of crashes. Neurology 1993;43:2448-56. 12. Rees J, Bayer A, Phillips G. Assessment and management of the demented driver. J Ment Health 1995;4:165-75. 13. Kapust LR, Weintraub S. To drive or not to drive: Pre- liminary results from the road testing of patients with dementia. J Geriatr Psychiatry Neurol 1992;5:210-16. 14. Strauss A, Corbin J. The basics of qualitative research. Newbury Park: Sage; 1998. 15. Mendez MF, Cummings JL. Dementia: a clinical approach. Philadelphia: Butterworth Heinemann; 2003. 16. Brodaty H, McGilchrist D, Harris L, et al. Time until institutionalization and death in patients with demen- tia: role of caregiver training and risk factors. Arch Neurol 1993;50:643-50. KATHLEEN JETT, PhD, APRN, GNP, BC, is assistant pro- fessor and RUTH M. TAPPEN, EdD, RN, FAAN, is a Christine E. Lynn Eminent Scholar and professor, both at Florida Atlantic University, Christine E. Lynn College of Nursing; MONICA ROSSELLI, PhD, is associate professor, Department of Psychology, Florida Atlantic University, College of Science, Boca Raton, Florida. ACKNOWLEDGMENT Supported by a grant from the Florida Department of Transportation, grant CP-02-04-11 Driving Cessation: Counseling the Cognitively Impaired Older Driver and Family. Principal investigator: Sidney Breman; project Director: Ruth M. Tappen, EdD, RN, FAAN. 0197-4572/$ - see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2005.01.004 http://www.NHTSA.DOT.gov/people/injury/OLDDRIVE/FAMILYNFRIENDS/faf_INDEX.htm http://www.NHTSA.DOT.gov/people/injury/OLDDRIVE/FAMILYNFRIENDS/faf_INDEX.htm http://www.aoa.dhhs.gov Vascular dementia is the second most prevalent type of dementia in the United States today. This article includes a review of its pathophysiology, which involves the damage of small vessels in the brain, an abundance of which are in the subcortical region, thus creating a subcategory called when the risk factors are managed.3 This article reviews the physiology of the brain, outlines the pathophysiology of SVD, compares Alzheimer’s dementia (AD) with SVD, and differentiates SVD from depression. Finally, evidenced-based interventions are discussed. Background an interactive mass of neurons formation from within and y, processing this information, responses back through our ctions. Damage to brain tissue ugh a variety of mechanisms, entia and estimated to cost the illion annually.4 Dementia is mings2 as impairment “in 3 out domains”: personality, memory, kills, language, and cognition, problem solving and mathemat- s. Of those people over age 65 severe dementia, and 10% have te dementia.5,6 gy in tissues become damaged and sets in is through atherosclero- ning and hardening of the arter- risk factors that accelerate ath- the arterioles are hypertension etes mellitus (DM).3 Within the r lumen arterioles lack the elas- larger arteries possess, making ceptible to damage by athero- e vessel walls thicken and stiff- radually narrows and the vessel lly creating 2 conditions: hypo- clusion.3 Hypoperfusion slowly nd nutrients to brain tissue. enly halts the blood supply to a ion of tissue. Both result in tissue. brain where arterioles are most n the subcortical region, at the connects to the frontal lobe. Donna Fladd, NPP, RN Subcortical Vascular Dementia 2 117 subcortical vascular dementia (SVD). Vari- ous diseases, such as diabetes and high blood pressure, predispose the individual to damage to these small vessels. The symp- toms of SVD are included as a review and helpful outline to differentiate SVD from Alzheimer’s dementia and depression. Additionally, evidence-based interventions are reviewed. Nurses play a unique role in preventing and minimizing this dementia, which afflicts such a large percentage of our elderly population. (Geriatr Nurs 2005;26:117- 21) W hen an elderly patient presents to a visiting home nurse, psychiatric nurse, or a nurse working in a medical clinic, it is important to recognize that there may be other health problems that mimic depressive- like symptoms. One of these conditions is sub- cortical vascular dementia (SVD). Vascular dementia is the second most prevalent demen- tia in the United States.1-3 In the early stages, the presentation is subtle and can be mistaken for depression. Oftentimes, months and even years go by with the patient trying expensive but ineffective treatment, which is frustrating to all involved. As nurses, we are patient advo- cates when we have a good knowledge base. With this base internalized, we can critically analyze the data, determine whether interven- tions are working, and provide feedback to the primary care provider. Nurse practitioners can determine whether there is a need for further diagnostic workup to rule out underlying med- ical conditions, such as SVD, and adjust the course of treatment accordingly. Cognitive decline from SVD can be slowed and stabilized The brain is conducting in around the bod and relaying thoughts and a can occur thro resulting in dem nation $30 b defined by Cum of 5 behavioral visual-spatial s which includes ical calculation years, 5% have mild to modera Pathophysiolo One way bra that dementia sis—the thicke ies. The 2 main erosclerosis of (HTN) and diab brain the smalle ticity that the them more sus sclerosis. As th en, the lumen g twists, eventua perfusion or oc cuts oxygen a Occlusion sudd particular reg ischemic brain Areas in the abundant are i point where it Geriatric Nursing, Volume 26, Number 118 Geriatric Nursing, Volume 26, Number 2 Therefore, vascular damage most likely occurs in the subcortical-frontal lobe areas of the brain.1,3 With enough damage, dementia emerges with behavioral changes that correlate to the region of the brain where there is ischemia. With subcortical vascular dementia, changes may be sudden or gradual and then progress in a stepwise manner.1 Although nor- mal intelligence is maintained, behavioral changes may be seen, including a change in or impairment of a person’s sense of social judg- ment, speech and language patterns, and prob- lem-solving ability.7 Motor slowing, blunting of emotion, and lack of initiation are or can also be seen because the motor circuit is damaged between the basal ganglion and frontal cor- tex.7,8 These changes give the person the appearance of being depressed. Populations in which subcortical vascular dementia is seen with the most frequency are in those where hypertension and diabetes mellitus are more prevalent. These populations include African Americans and Japanese Americans.3 Identifying SVD “The main feature [that differentiates] sub- cortical dementia . . . from other dementias is psychomotor slowness.”7 Straub and Black7 note that a quick clinical test developed by Power and colleagues9 assesses cognitive slow- ing by asking the patient to write the alphabet in uppercase letters. The normal range in this timed test is less than 21 seconds. Longer then 21 seconds indicates cognitive slowing,9 as in a patient with SVD. Further diagnostic workups can then be justified to determine the appropri- ate diagnoses and treatment. Various workup interventions and blood tests can be gathered to rule out other illnesses and support dementia diagnoses. Magnetic res- onance imaging (MRI) is the most definitive diagnostic tool.3 A retinal examination can also reveal arteriole damage. Observation of arteri- ole damage could be the wake-up call to reeval- uated diabetes and hypertension management. Chui3 noted that a benefit of knowing whether there is hypoperfusion of the brain tissue is to manage the blood pressure accordingly, that is, not to bring it too low so as to exacerbate ischemia through hypoperfusion. Chui3 sug- gested systolic blood pressure remain in the range of 135 to 150 mm Hg. Another important factor to consider with an accurate diagnosis of SVD is that whereas AD is progressive, SVD can be slowed and stabilized by managing risk factors. Differentiating SVD from AD Alzheimer’s dementia (AD) is the most com- mon type of dementia in the United States, affecting 2–4 million people.10 AD is a progres- sive degeneration of the cerebral cortex neu- rons, where memories are stored. The cortex is also where the ability to learn new things, abstract thinking, and visual-spatial under- standing takes place. With progressive cortex deterioration, knowledge of the most basic skills ebbs, resulting in progressive amnesia, loss of meaning in speech, impairment in visu- ally understanding the world, and an inability to think abstractly.11 Refer to Table 1 for a sum- mary of the presentation of SVD and AD and applied mental status examination techniques that the clinician can perform to assess various cognitive functions. In many cases, AD and SVD occur simultaneously. Differentiating SVD from Depression When it comes to assessing whether an eld- erly patient has depression or dementia, sever- al considerations need to be addressed, sum- marized from Straub and Black.7 First, a history must be obtained by interviewing the patient and those people who know the person best. Determining whether there is a history of depression or psychiatric problems, including alcohol or drug abuse, is helpful. Second, it is important to find out the onset and course of cognitive decline. With dementia there is usual- ly a long delay between the onset of symptoms and seeking help. Suspect depression if the onset of cognitive decline is sudden and if social stresses precipitate decline in function- ing. Next, evaluate whether the cognitive exam results are consistent and valid. The depressed elderly patient may provide inconsistent results because his or her cooperation and concentration may wax and wane. Anything that requires mental energy will be difficult for the depressed patient. On the other hand, the person with dementia will present as willing to attempt the cognitive examination. The depressed patient may also complain about poor cognitive decline, whereas the person with dementia is unaware of cognitive changes. Sometimes the evening hours worsen dementia Geriatric Nursing, Volume 26, Number 2 119 symptoms and will have no effect on the per- son with depression. Refer to Table 2 for a summary of the differences between depres- sion and dementia. If health care providers determine that depression is present, treat- ment should proceed and improvement should be expected. Evidence-Based Interventions Evidence-based intervention (EBI) is a term used to classify the type of research that sup- ports interventions used in the medical commu- nity. The type of research is divided into 3 class- es. Class I describes research evidence from 1 or more well-designed, randomized, controlled Table 1. Comparing and Contrasting AD to SVD Using the Mental Status Exam Mental Status Alzheimer’s Subcortical Vascular Exam Test Dementia Dementia Motor speed Observe gait Spastic hyperreflexia Small steps Attention Rule out delirium test with digit Normal Normal repetition test Psychomotor Writing the alphabet in upper case Normal Slowed speed letters (normal < 21 seconds) Memory Test memory with register and recall Amnesia Patchy retrieval defects Speech Observation Aphasic, empty with Dysarthric loss of meaning Visual-spatial Request a cube drawing from an Poor Occasional defects example Executive Multitask questions, math calculations, Dysfunction with poor Poor functioning and proverb interpretation insight Adapted from Lauterbach.12 For more information on the Mental Status Examination, please refer to Straub and Black.7 Table 2. Differentiating Between Dementia and Depression Depression Dementia Inconsistent presentation Usually an unchanging presentation Complains of loss of cognitive functioning Few complaints of any changes in cognition Gives little effort on examination items Struggles with tasks Adapted from Straub and Black.7 120 Geriatric Nursing, Volume 26, Number 2 clinical trials. Class II provides evidence based on 1 or more well-designed clinical studies from case–control, cohort, and other less controlled studies. Class III describes evidence provided by expert opinion, nonrandomized historical controls or 1 or more case reports. Primary prevention, the most effective means to prevent or reduce SVD, is demonstrated by several Class I studies that show, that manage- ment of hypertension (HTN) improves cogni- tive functioning and prevents dementia.13-16 Other noted studies include the use of antiplatelet medication as prevention of vascu- lar damage.17 Secondary prevention describes treatments to prevent the recurrence of a vascular accident or minimize further cognitive decline. Class I stud- ies include the management of HTN as well as antiplatelet medications.17 Other Class I studies with rivastigmine tartrate and galantamine hydrobromide18,19 show enhancing cholinergic functioning improves cognitive functioning or slows cognitive decline in people with vascular dementia. Additional Class I studies of donepezil hydrochloride showed cognitive improvement over placebo in people with vascular demen- tia.20–22 Finally, tertiary care or treating the symp- toms as best as possible, includes several studies in progress that include research on acetyl- cholinesterase inhibitors and ginkgo biloba.12 Nursing Management An important aspect of nursing management of SVD is to facilitate prevention of HTN and DM. Paramount to prevention includes, but is not limited to, a good diet, at least 8 hours of sleep, and regular exercise. Health care providers who list these recommendations without inquiring about a patient’s lifestyle are not really providing information or education. As nurses, we are in a position to ask questions pertaining to lifestyle and listen to the patient who may describe barriers to basic health main- tenance. Poverty, limited support systems, stressful life styles, and drug or alcohol abuse are but a few unhealthy situations and behav- iors that predispose a person to chronic health problems, including HTN and DM. Once a barri- er is identified, the nurse should be ready to provide appropriate information and encour- agement, supporting the patient to make changes. When HTN and DM are diagnosed, the nurse may be the primary health care provider who runs educational groups, is asked medica- tion questions, and follows up with patients regarding lab results. Summary This article presents a comprehensive review of SVD and offers a clear outline to assist nurs- es in differentiating among patients with SVD and those with AD or depression. Research- based interventions are included to support nurses in providing effective patient and family education and treatment to prevent or minimize SVD by managing HTN and DM. Conclusion Knowledge of the various types of dementias becomes poignant when caring for patients who struggle to accomplish seemingly simple activities. This underscores the importance of primary prevention through education and reg- ular health checks for diabetes and hyperten- sion. As nurses, we are the main providers of such multifaceted care and can provide educa- tion and support for management of DM and HTN. The long-term consequences are too criti- cal to ignore. Tools for early detection of vessel damage are sorely lacking, and more research in this area is needed. Perhaps in the future, MRI dementia screening will become as routine as mammograms and prostate screening. Tools designed to collect information to assess changes in a patient should also include ques- tions for significant others. Likewise, further research is needed to determine whether poor glycemic control of DM contributes to the pre- vention of cognitive decline. References 1. Cummings JL. Vascular subcortical dementias: clinical aspects. Dementia 1994;5:177-80. 2. Cummings JL. Neuropsychiatric aspects of Alzheimer’s disease and other dementing illnesses. In: Yudofsky SC, Hales RH, editors. Synopsis of neuropsychiatry. Washington, DC: American Psychiatric Press; 1994. p. 469-82. 3. Chui H. Dementia due to subcortical ischemic vascu- lar disease. Clin Cornerstone 2001;3:40-51. 4. Hays JW, Ernst RL. The economic costs of Alzheimer’s disease. Am J Public Health 1987;77:1169-75. 5. Ineichen B. Measuring the rising tide: how many dementia cases will there be in 2001? Br J Psychiatry 1987;150:193-200. 6. Jorm AF, Korten AE, Henderson AS. The prevalence of dementia: a quantitative integration of the litera- ture. Acta Psychiatr Scand 1987;76:465-79. Geriatric Nursing, Volume 26, Number 2 121 7. Straub RL, Black FW. The mental status examination in neurology. 4th ed. Philadelphia: FA Davis; 2000. 8. Levy ML, Cummings JL. Parkinson’s disease. In: Lauterbach EC, editor. Psychiatric management in neurological disease. Washington DC: American Psychiatric Press; 2000. p. 41-70. 9. Power C, Selnes OA, Grim JA, et al. HIV dementia scale: a rapid screening test. J Acquir Immune Defic Syndr Hum Retrovirol 1995;8:273-8. 10. Katzman R. Alzheimer’s disease. New Engl J Med 1986;314:964-73. 11. Keltner NL, Folks DG. Psychotropic drugs. 3rd ed. St. Louis, MO: Mosby; 2001. 12. Lauterbach EC. Psychiatric management principles in neurological disease. In: Lauterbach EC, editor. Psychiatric management in neurological disease. Washington, DC: American Psychiatric Press; 2000. p. 1-40. 13. Elias MF, D’Agostino RB, Elias PK, et al. Neuropsychological test performance, cognitive func- tioning, blood pressure, and age: the Framingham Heart Study. Exp Aging Res 1995;21:369-91. 14. Launer LJ, Masaki K, Petrovitch H, Foley D, Havik RJ. The association between midlife blood pressure levels and late-life cognitive function. The Honolulu-Asia Aging Study. JAMA 1995;274:1846-51. 15. Knopman D, Boland LL, Mosley T, et al. for the Atherosclerosis Risk in Communities (ARIC) Study Investigators. Cardiovascular risk factors and cogni- tive decline in middle-aged adults. Neurology 2001;6:42-8. 16. Forette F, Seux ML, Staessen JA, et al. The prevention of dementia in randomised double-blind placebo-con- trolled Systolic Hypertensive in Europe (Syst-Eur) trial. Lancet 1998;352:1347-51. 17. Meyer JS, Rogers RL, McClintic K, et al. Randomized clinical trial of the daily aspirin therapy in multi- infarct dementia. A pilot study. J Am Geriatr Soc 1989;37:549-55. 18. Moretti R, Torre P, Antonello RM, et al. Rivastigmine in subcortical vascular dementia: A randomized, con- trolled, open 12-month study in 208 patients. Am J Alzheimers Dis Other Demen 2003;18:265-72. 19. Erkinjuntti T, Kurz A, Gauthier S, et al. Efficacy of galantamine in probable vascular dementia and Alzheimer’s disease combined with cerebrovascular disease: a randomized trial. Lancet 2002;359:1283-90. 20. Wilkinson D, Doody R, Helme R, et al. Donepezil 308 Study Group. Donepezil in vascular dementia: a ran- domized, placebo-controlled study. Neurology 2003;61:479-86. 21. Black S, Roman GC, Geldmacher DS, et al. Donepezil 307 Vascular Dementia Study Group. Efficacy and tol- erability of donepezil in vascular dementia: positive results of a 24-week, multicenter, international, ran- domized, placebo-controlled clinical trial. Stroke 200;34:2323-30. 22. Perdomo C, Pratt R. Donepezil provides significant benefits in patients with vascular dementia [abstract]. J Neuropsych Clin Neurosci 2003;15:271-2. DONNA FLADD, NPP, RN, is a nurse practitioner and clinical nurse specialist in adult psychiatric nursing in upstate New York for Finger Lake Health Care and at the John D. Kelly Behavioral Health outpatient psychiatric clinic in Penn Yan, New York. 0197-4572/$ - see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2005.01.001 Nationally, the older population is expected to double in numbers through the year 2030. Health care providers are challenged to develop new models of care delivery for this unique population. Described in this article is one project that demonstrates suc- cessful outcomes for a community in east- ern North Carolina. The model implement- ed community-based geriatric case management for frail elderly citizens resid- ing in a private home or in an assisted living facility. Conventional hands-on delivery was combined with the distance-based conven- ience of telehealth. The outcomes prove this model to be cost-effective while improving quality of life for enrollees. (Geriatr Nurs 2005;26:122-7) A s the U.S. geriatric population continues to grow, utilization of health care resources will also continue at its increased rate among this population, com- pared with other age groups. This is particular- ly true for the frail elderly, aged 85 and older, which is the fastest-growing segment of the eld- erly population.1 In North Carolina, the number of people aged 65 and older is expected to increase by more than 50% from 2000 and 2030,2 which implies a demand on the health care sys- tem consistent with national projections. As of 2000, Pitt County’s elderly population had approximately 13,000 senior citizens, and pro- jections are that this will increase to 26,000 by 2025.3 Because of these projections, new mod- els of care must be undertaken to determine models for cost-effective delivery of care for this unique population while ensuring that the quality of care is not sacrificed. Program Overview In June 2000, Pitt County Memorial Hospital the PCMH and BSOM Geriatric Clinic provided in-kind support. The purpose of the study was to investigate the effects of community-based case management for frail elderly residents of Pitt County and what effect this would have on health care utilization among this population group. This new health care initiative had never been attempted in eastern North Carolina. The clinical staff consisted of 2 nurse case man- agers (NCM) and 1 social-work case manager (SWCM). One of the NCMs was an advanced practice nurse and was board certified as a gerontological nurse; and the other was BSN- prepared with extensive rehab and community health experience. The SWCM was masters-pre- pared and a licensed counselor. The program service provided a combination of traditional hands-on care by nurse and social-work case managers, as well as the technology of dis- tance-based health care utilized through a tele- health unit. This unit is approximately the size of a breadbox and allows regular physical assessments in the convenience of one’s home by providing two-way audio and visual inter- face, allowing the nurse to complete a compre- hensive physical assessment. It was proposed that this part of the case management model would allow earlier identification of health- related problems, an overall decrease in frag- mentation of health care delivery, and reduc- tion of health care costs for this population. Program Development And Goals A steering committee was formed that includ- ed medical staff from the BSOM Geriatric Clinic, PCMH staff, executive directors from local assisted living facilities, representatives from the local council on aging (regional ombudsman of the MidEast Commission on Aging), legislative representatives, the Pitt County Department of Social Services, and the Cheryl Duke, RN, MSN, FNP, APRN-BC The Frail Elderly Community– Based Case Management Project 122 Geriatric Nursing, Volume 26, Number 2 (PCMH) and the Brody School of Medicine (BSOM) at East Carolina University Geriatric Clinic joined efforts to execute a 3-year study. The Duke Endowment funded the project, and Eastern Area Health Education Center (AHEC). Through a collaborative effort, the following goals were created for the program: • Establishment of a community-based med- Geriatric Nursing, Volume 26, Number 2 123 ical case management program for resi- dents with symptoms of frailty • Evaluation of home telehealth technology and outcomes in a population-based appli- cation • Reduction of emergent visits to the hospital and physician’s office related to chronic disease as well as other health issues and a decrease in hospital admissions • Increased understanding and acceptance of end-of-life options • Establishment of a community-based edu- cational program for assisted living resi- dents, caregivers, and staff to learn about aging issues and prevention of frailty and other debilitating diseases and syndromes. The Steering Committee met on a quarterly basis throughout the 3-year grant period to pro- vide program oversight and assist with ongoing program development and evaluation. Enrollment Methodology And Data Collection After approval from the hospital internal review board was obtained, enrollment method- ology consisted of obtaining signed informed consent from the patient or his or her legal rep- resentative for case management services and telehealth services, as well as a consent waiver and release for images when pictures were obtained for educational use at various local and national presentations. To obtain objective base- line data, the nurse and social-work case man- agers developed comprehensive discipline-spe- cific assessment forms, which were administered to all enrollees.4–8 The enrollment data also included administration of the Folstein Mini- Mental State Exam (MMSE) and the Modified Geriatric Depression Scale (MDGS), which were administered at time of enrollment and annually thereafter.6,9 A health care satisfaction survey was developed by one of the nurse case man- agers and administered at the time of enrollment and the completion of the project. Those enrolled into the program were aged 65 or older, resided in a private home or in 1 of 3 local assisted living communities in Pitt County, and received their health care at the BSOM Geriatric Clinic. The enrollees were identified by their primary care physician as those who would benefit from intense monitoring of chron- ic illnesses that could not be done through regu- lar clinic visits. On average, the enrollees had 12 chronic diseases and took 15 daily medications. The number enrolled totaled 107. During the week, whenever a case manager had contact with a patient, whether face-to- face, in a telehealth assessment, or by phone call, data were documented into a paperless electronic database, developed by a hospital data analyst. This comprehensive relational database was used to document, trend, and report clinical, social, and behavioral changes. Cumulative data were compiled throughout the grant period to track outcomes. Information such as type of visit, length of visit, cumulative number of visits, as well as all general and clin- ical information was collected in this database. Other capabilities, such as when the next assessment was scheduled, could be stored and retrieved. The same clinical data was also com- municated, in a “cut and paste” fashion to the physicians in real time using an electronic med- ical record, called Logician, which is used by all staff members at the BSOM clinics. This time- effective communication allowed faster treat- ment for exacerbations of disease states, quick- er turnaround time on prescription refills, and kept the physician informed on a patients’ over- all status between regular clinic visits. Program Components Depending on individual needs, interventions consisted of case management of medical and social conditions, telemedicine assessments for medically compromised patients, and utiliza- tion of hospice and promotion for acceptance of end-of-life decision making. On a monthly basis, the nurse case managers also provided education about specific health care issues for assisted living staff members and residents and their family members.10–13 Assisted living facili- ties in North Carolina are required to provide continuing education for staff on an annual basis. The nurse case managers were able to help meet this need by facilitating monthly staff inservices on various subjects that could posi- tively impact the needs of the residents (Table 1). Weekly patient care conferences were con- ducted at the geriatric clinic; the case man- agers, geriatricians, geriatric fellows, pharmacy and medical students, and the geriatric clinic support staff attended these. Through a collab- orative effort between the primary care physi- cians, geriatric clinic and assisted living com- munity staff, and nurse and social-work case 124 Geriatric Nursing, Volume 26, Number 2 managers, this unique health care delivery model was successfully executed over a 3-year grant period. An overview of services provided by the model is as follows: • Case management of medical and social conditions • Telehealth assessments for medically com- promised patients • Hospice use and acceptance for end-of-life care needs • Education for the patient or resident, staff of the assisted living communities, and fam- ily members or primary caregivers about specific care needs and concerns Outcomes Because of the outcomes of this project, Geriatric Case Management is now a permanent outreach community service for Pitt County geriatric residents provided by Pitt County Memorial Hospital. These services are now completely funded by PCMH with 2 full-time nurse case managers at no cost to the client. It has been found to be financially worthwhile for PCMH to provide this service for community- dwelling seniors. It also provides a needed serv- ice to an identified elderly population known to be at risk for fragmented, costly health care. The total number of case-managed days was compared with the number of days before case management enrollment. This was done so that those who died or moved away could still be included in the outcomes data. The project demonstrated positive outcomes in all areas that were studied. The figures provide pre- and postenrollment cumulative outcomes, including emergency department visits (Figure 1), emer- gency department costs (Figure 2), hospital admissions (Figure 3), hospital admission costs (Figure 4), and total number of hospital days (Figure 5). It should also be noted that the aver- age MMSE score declined over time, indicating a progressive deterioration of mental function- ing, but the MGDS scores demonstrated an improved perception on quality of life. Lessons Learned During the execution of the grant, we discov- ered that telehealth was not always “user friendly” for people who had middle-stage Alzheimer’s disease. At times, it caused unnec- essary frustration or agitation for the enrollee who had difficulty learning a new task, such as how to navigate correctly with the telehealth machine itself. Training was provided to the assisted living staff, and when needed, they would assist those residents with functional limitations. After discussion with the case man- agers, facility staff, and Dr. Kenneth Steinweg, the program medical director, it was decided not to implement telehealth as an assessment modality for those enrolled with moderate to severe Alzheimer’s-type dementia.10 Face-to- face assessments were provided for these indi- viduals, which proved to be the most appropri- ate assessment standard.8 One ideal example that demonstrates the pos- itive effects of telehealth was with a legally blind resident with stage IV heart failure. She was able to memorize by touch and sound which button to press while being assessed by the NCMs and commented that telehealth was “better than indoor plumbing.” Through the use of this technology, this resident was able to Table 1. Examples of Education Sessions Provided to Assisted Living Staff, Residents, and Family Members Fall prevention and gait instability Dementia, depression, and delirium Stroke prevention Osteoporosis Skin care and pressure sore prevention Nutrition and hydration End-of-life issues Pneumonia and influenza prevention Diabetes Polypharmacy Constipation Dental care Geriatric Nursing, Volume 26, Number 2 125 reduce significantly her trips to the emergency department because of frequent heart failure exacerbations. In this particular case, the patient used telehealth 2 to 3 times a week. The NCMs were able to perform a comprehensive cardiovascular assessment, including ausculta- tion of heart and lung sounds, obtain blood pressure and weight measures, and inspect lower extremities for degree of edema.5,13 The NCMs were also able to review with the patient and staff what the patient’s recent diet consist- ed of and provide guidance on strategies for reducing dietary sodium. Depending on these assessment findings and contact with the physician through the Logician database, the NCMs would make a subsequent face-to-face visit to administer intravenous Lasix when nec- essary. This intense monitoring prevented mul- tiple trips to the emergency department through early intervention and symptom man- agement. Data from this project have been shared on the national level with the American Geriatrics Society and the National Gerontological Nursing Associations, and the project was nominated for the Judith Braun Clinical Research Award, as well as the local level for the East Carolina University School of Nursing and Pitt County Memorial Hospital’s Collaborative Research Day, an annual event. Other benefits included monitoring the enrollees in their own environment and learn- ing individual idiosyncrasies. The case man- agers were also able to complement the knowl- Figure 1. Emergency Department Visits Figure 2. Emergency Department Costs 126 Geriatric Nursing, Volume 26, Number 2 Figure 5. Hospital length of stay (LOS) Figure 4. Hospital Costs Figure 3. Hospital Admissions Geriatric Nursing, Volume 26, Number 2 127 edge base of the geriatric clinic staff by sharing significant information with them that is typi- cally not discovered in the clinic setting. Over time, the staff at the assisted living facilities and the NCMs developed a close working relation- ship, and when a question arose or a change in a resident’s status was discovered, many times it was the nurse case manager the staff would call first. This allowed quick assessment of the situation and frequently prevented a trip to the clinic or hospital. Outcomes One Year After The Grant Data from June 2002 to July 2003 demon- strate continued benefit in reducing hospital cost, length of stay, number of hospitalizations and trips for emergency care. The role of the NCMs has changed. Both NCM positions are now filled by BSN-prepared nurses. One of the NCMs has been in her role since the implemen- tation of the grant and focuses completely on community-based needs, utilizing the model developed during the grant period. The other NCM has an inpatient focus and makes contact with every inpatient admitted, aged 85 and older, and makes a phone follow-up after dis- charge to determine whether medical needs are being met. Interestingly, the makeup of those case managed have changed since the grant ended. Of those 48 individuals case managed during that first year following the grant, 33 are those who reside in a private home. During the grant period, the majority of the case-managed population resided in an assisted living facility. The change in population makeup may be an effect of staff education, which resulted in a greater knowledge base for the particular needs of this unique population. This occurred due to regular contact with the NCMs, attending edu- cation sessions, assisting with telehealth assessments, and learning which findings indi- cated a problem.7,9 They became more alert to significant changes and knew when to notify the health care provider before an exacerbation of a chronic illness occurred. Overall, the out- comes are as follows: • 13% decrease in hospital admissions • 38% decrease in emergency room visits • 22% decrease in length of stay • 73% decrease in total hospital cost The Frail Elderly Community–Based Case Management Project is a successful example of what can happen when a community pulls together various experts and resources for the benefit of the local geriatric population. With adequate funding, this model can and should be proactively duplicated by other communities. References 1. Hobbs FB. The elderly population. U.S. Census Bureau, Population Division and Housing and Household Economic Statistics Division. 2001. Available: http://www.census.gov/population/www/ pop-profile/elderpop.html. Accessed March 23, 2004. 2. North Carolina State Demographics. http:// demog.state.nc.us/. Accessed March 25, 2004. 3. North Carolina Division on Aging. The baby boomers approach retirement. The Growth of the Older Population in NC Counties, 1996 to 2020 (prepared May 1998). http://ssw.unc.edu/cares/ boomproc/copo9620.htm. Accessed March 25, 2004. 4. Abrams W, Beers M, Berkow R, eds. The Merck manu- al of geriatrics. Rahway, NJ: Merck Laboratories; 1995. 5. Chenitz WC, Stone JT, Salisbury L. Clinical geronto- logical nursing—A guide to advanced practice. Philadelphia: W.B. Saunders; 1991. 6. Hazzard W, Blass J, Ettinger W, et al. Principles of geriatric medicine & gerontology. New York: McGraw- Hill; 1999. 7. Gershman K, McCullough, D. The little black book of geriatrics. Cambridge: Blackwell Science; 1998. 8. Lueckenotte A. Gerontologic nursing. St Louis: Mosby; 2000. 9. Ham R, Sloane P. Primary care geriatrics—a case based approach. St. Louis: Mosby; 1997. 10. Hamdy R, Turnbull JE, Lancaster M. Alzheimer’s dis- ease—a handbook for caregivers. St. Louis: Mosby; 1998. 11. Mace N, Rabins P. The 36-hour day: A family guide to caring for persons with Alzheimer’s disease, related dementing illnesses, and memory loss in later life. Baltimore: John Hopkins University Press; 1999. 12. Miller C. Nursing care of older adults—theory and practice. Philadelphia: Lippincott; 1999. 13. Sodeman W. Instructions for geriatric patients. Philadelphia: W.B. Saunders; 1999. CHERYL DUKE, RN, MSN, FNP, APRN-BC, is a nurse practitioner with the Patient Care Services Administra- tion of Pitt County Memorial Hospital in Greenville, North Carolina. ACKNOWLEDGMENT This project was funded through a grant from the Duke Endowment, and in-kind support was provided from Pitt County Memorial Hospital and Brody School of Medicine Division of Geriatrics at East Carolina University. The Duke Endowment provided $680,609 over a 3-year period to support the development and implementation of this project. 0197-4572/$ - see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2005.03.003 http://www.census.gov/population/www/pop-profile/elderpop.html http://www.census.gov/population/www/pop-profile/elderpop.html http://demog.state.nc.us/ http://demog.state.nc.us/ http://ssw.unc.edu/cares/boomproc/copo9620.htm http://ssw.unc.edu/cares/boomproc/copo9620.htm 74-78.pdf DEMENTIA TREATMENT UPDATE Deciding Which Drug to Select How the Drugs are Evaluated Applying Research Findings to Practice: Considerations References 79-80.pdf RELATIONSHIP OF DEMENTIA AND BODY WEIGHT Obesity Weight Loss Mechanism for the Weight Loss Effect on Dementia Importance of Monitoring Weight Intentional Weight Loss Physical Activity References 81-82.pdf DEMENTIA: COMPLEX CARE NEEDING ONGOING ASSESSMENT 89-93.pdf Incorporating Medication Regimen Reviews Into the Interdisciplinary Care Planning Process Interdisciplinary Teaming and Effective Medication Regimen Reviews Just Good Practice Outcomes in the Context of Holistic Care Turf Issues and Effective Interdisciplinary Teams Barriers to Interdisciplinary Teaming in Long-Term Care Overcoming Routines Time Constraints Good Interdisciplinary Models Conclusion References 94.pdf PHARMACOLOGY UPDATE: DEMENTIA 95-97.pdf GERONTOLOGIC NURSE PRACTITIONER CARE GUIDELINES: DEMENTIA BEHAVIORS: RECOGNITION AND MANAGEMENT CAUSES OF DEMENTIA RECOGNITION OF DEMENTIAS BEHAVIORS COMMON TO DEMENTIAS CAUSES OF BEHAVIORS MANAGEMENT OF BEHAVIORS MEDICAL MANAGEMENT OF BEHAVIORS References 98-105.pdf Development of Nurse Competencies to Improve Dementia Care Development of Competencies References 106-110.pdf Falls Associated With Dementia: How Can You Tell? Case Analysis The Clinical Relevance Of A Diagnosis Of Dementia Interview The Resident Interview Potential Witnesses-Roomate, Staff, And Family Review Baseline Behavior And Function (Static Events) Observe Resident Function And Behavior For Change (Current-Dynamic Events) Assess For Pertinent Signs Or Symptoms (Current-Dynamic Events) Nurse's Observation And Perception Of The Resident Conclusion References 111-116.pdf Imposed Versus Involved: Different Strategies to Effect Driving Cessation in Cognitively Impaired Older Adults METHODS Participants Data Analysis RESULTS Unsafe Driving Intervening Conditions Actions and Intervention Strategies Involved Strategy Imposed DISCUSSION References 117-121.pdf Subcortical Vascular Dementia Background Pathophysiology Identifying SVD Differentiating SVD from AD Differentiating SVD from Depression Evidence-Based Interventions Nursing Management Summary Conclusion References 122-127.pdf The Frail Elderly Community-Based Case Management Project Program Overview Program Development And Goals Enrollment Methodology And Data Collection Program Components Outcomes Lessons Learned Outcomes One Year After The Grant References