Nurses helping nurses. Development of internal specialists in long-term care

The prevalence of psychiatric disorders and behavioral disturbances among nursing home residents, combined with observed deficits in geriatric mental health/illness expertise among LTC staff, supports the need for creative approaches to improve the knowledge, understanding, and management of such problems among LTC providers. The train-the-trainer model described in this article proved to be a viable method to providing geriatric mental health consultation and training that targets both improved quality of life for residents and quality of work life for the staff in charge of residents' care. More collaborative efforts among nursing specialists, subspecialists, and generalists are needed to empower those who work in LTC to utilize strengths and abilities inherent to their positions. Nursing homes nurses, who are all too familiar with the problems and challenges of their patient population, may act not only as mental health trainers but also as resource persons, role models, liaisons with geropsychiatric specialists, and leaders in the application of geropsychiatric care principles to residents within their facility, thus promoting improved resident and staff care alike.     

Multiple perceptions of discharge planning in one urban hospital

Since the advent of diagnosis-related groups (DRGs), advocacy groups have claimed that although hospital discharge planners perceive the discharge planning process as helpful, elderly patients and their families do not. This article explores how the discharge planning process was perceived by 40 discharge planners and 40 family caregivers. Planners greatly overrated caregiver influence and the amount adequacy of information shared about posthospital health care, choice of discharge to home or nursing home, and time to decide. Caregivers perceived that nursing homes were forced on patients by social workers and physicians. DRGs, physicians, and hospital administrators appeared to pressure social workers to coerce mentally competent patients into nursing homes. Excessive concern by hospital staff about patient safety after discharge may override patients' rights to autonomy and self-determination, violating the NASW Code of Ethics. Implications for practice, policy, and future research are discussed.     

The psychologist as a consultant in a nursing home: Effect on staff morale and turnover.

Many elderly patients have been transferred from long-term psychiatric hospitals to nursing homes, where knowledge of psychological aspects of patient care is generally poor and where emotional and behavioral disorders are poorly tolerated by staff. One solution to this problem is for psychologists to provide in-service training to nursing-home staff in the psychological aspects of patient care, but this approach ignores such problems as poor staff morale and high staff turnover. A 188-bed skilled nursing home was selected for a 12-wk consultation program based on a mental health and organizational development approach. Turnover rates fell from 73.4%, during the quarter prior to consultation, to 27.8%, during the period of consultation, and averaged 33.6% for the next 3 quarters. Staff morale also improved. Results indicate that before training nursing-home staff in the psychological aspects of geriatric care, problems such as high staff turnover and poor morale should be resolved. (39 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The physician decision-making process in transferring nursing home patients to the hospital

BACKGROUND: Each year more than 25% of nursing home patients are transferred to the emergency department or hospital for evaluation and treatment of infection. These transfers may have an adverse impact on the quality and cost of patient care. This study examined physician assessment and management of acute infections in the nursing home. METHODS: A cross-sectional study was conducted of all acute urinary tract infections and lower respiratory tract infections occurring from February through June 1991 in eight randomly selected urban nursing homes. The numbers of transfers to the emergency department of hospital were recorded along with identification of the clinical, psychosocial, and institutional factors that influenced the physician's decision to transfer. RESULTS: Three hundred fifty-nine patients had 258 urinary tract infections and 219 respiratory tract infections. Eighty-one (17%) of these events resulted in transfer to a hospital for evaluation (16/81) and/or admission (65/81). Less than one third (30.4%) of the events caused the patient to be examined in the nursing home by a physician before the decision to transfer to the hospital. The mean time between the staff notification of an acute event and physician response by telephone was 5.12 hours. Independent mobility (P < or = .05), a transfer to the hospital during the previous 6 months (P < or = .01), and fewer nursing home laboratory tests and treatments (P < or = .01) were all associated with hospital transfer. CONCLUSIONS: In this sample of acutely ill nursing home patients, physicians collected limited clinical data before the decision to transfer. Although some transfers may be appropriate, a reduction in the transfer rate may reduce health care costs and limit the risk of iatrogenesis, thus improving the outcome of acute illnesses occurring in the nursing home.     

Psychiatric disturbances of aged patients in skilled nursing homes

The authors found that 85% of 74 patients supported by Medicaid in two skilled nursing facilities had significant psychiatric disorders in addition to serious multiple medical illnesses. Almost two-thirds of the psychiatric disturbances had not been diagnosed. Although staff were more concerned with the psychosocial than the physical aspects of patients' problems in more than half of the cases, they often had difficulty recognizing the legitimacy of psychological complaints and relating to patients with psychological disturbances. Staff were not clear about the orders for psychotropic medications that were prescribed for more than half of the patients. The authors point out that more psychiatric consultation is needed to ensure appropriate and effective care for psychiatric patients in such facilities.     

Risperidone as an adjunct to clozapine therapy in chronic schizophrenics

BACKGROUND: Some treatment-resistant schizophrenic patients improve enough to remain out of the hospital but continue to have significant positive or negative symptoms. METHOD: The goal of this study was to assess the safety and potential efficacy of risperidone as an adjunct for schizophrenic patients treated with clozapine. In an open 4-week trial involving 12 DSM-III-R-diagnosed patients, the addition of risperidone to clozapine was well tolerated and did not affect serum clozapine concentrations significantly. RESULTS: Total Brief Psychiatric Rating Scale (BPRS) scores and subscales measuring positive symptoms, negative symptoms, and depressive symptoms were significantly reduced from baseline. Ten of 12 participants had a 20% or greater reduction in the total BPRS score. CONCLUSION: In this open trial, the addition of risperidone to clozapine was well tolerated and produced significant reduction of symptoms, suggesting that this may be a useful clinical approach. Because this was an open trial, the improvement we observed must be replicated in a controlled trial.     

Risperidone in children and adolescents with pervasive developmental disorder: pilot trial and follow-up

Dopamine receptor antagonists, particularly haloperidol, have been the most effective medications in currently available double-blind placebo-controlled studies for treating the disruptive behaviors often associated with pervasive developmental disorder (PDD). The rationale for trying risperidone in this population includes its dopamine-blocking activity; its seemingly lower incidence of tardive dyskinesia when compared to standard neuroleptics; the possibility that risperidone may ameliorate the social withdrawal of PDD, as it does the negative symptoms in schizophrenia; and substantial effects on serotonergic neurotransmission, which has been shown to be dysregulated in some patients with PDD. This study was an open-label pilot trial of risperidone in 6 subjects (aged 7-14 years, mean = 10.7) who met DSM-III-R criteria for a PDD diagnosis. The mean optimal dose was 2.7 mg daily (range 1-6). Mean duration of risperidone administration was 5.2 months (range 1-8). Despite the small sample size, risperidone treatment appeared to be associated with significant improvements in ratings of angry affect (p = 0.04) and lability of affect (p = 0.03) and with a trend (p = 0.10) toward a reduction of mean hyperactivity scores. Clinical Global Improvement scale ratings were statistically significant (p < 0.001). Increased sociability was reported in 3 subjects by their parents and family following the study. Three patients continued on risperidone for over 2 years, and none showed any loss of its apparent therapeutic effects. Weight gain was observed in 5 of 6 patients, with a median increase of 5.4 kg (12 lbs) in 7 weeks. Other side effects included transient sedation, increased salivation, and stereotypies. One child showed a worsening of pre-existing tic and phobic symptoms after 5 months of successful monotherapy. No loss of therapeutic effect was noted in the 3 subjects who remained on risperidone for over 2 years, but 1 patient developed hepatotoxicity and another developed withdrawal dyskinesia, similar to her prior experience with haloperidol. Overall, 5 of the 6 patients derived significant clinical benefits from risperidone. Pharmacologic alternatives for treating behavioral symptoms in PDD are need, and risperidone may be a promising possibility.     

Use of electrophoretic karyotyping and DNA-DNA hybridization in yeast identification

The behavioral disturbances of 16 nursing home patients with a history of sundowning behaviour and dementia were treated with light therapy instead of psychopharmacological medication. After the withdrawal of the before established medication a very individual, heterogenous deterioration of the symptoms was noted. A significant improvement of the behaviour was not found by light therapy in any patient. The problems in practical handling and possible consequences of further investigation are discussed.     

Behavior and affect in Alzheimer's disease

The behavioral symptoms associated with AD are a critical aspect of the disease. They provide an additional avenue not only for understanding AD but for implementing interventions. The nature of behavioral disorders in AD is complicated by a number of factors that interact and contribute to the development of problematic behavior. It is difficult to determine whether the behavior is the result of neurodegeneration, cognitive dysfunction, previous experiences, current stressors, independently coexisting psychopathology, or a combination of these factors. In any case, behavioral disturbances need to be more clearly defined and objectively measured. To understand and treat behavioral disturbances in AD, all biopsy-chosocial factors must be examined simultaneously. Currently, there is little that can be done to treat the cognitive components of AD. Consequently, our most successful and beneficial interventions may focus on the remediable behavioral manifestations of the disease. The most valuable treatment approach for patients with AD and their caregivers interweaves medications, psychosocial services, environmental strategies, and caregiver education.     

Effects of kappa-opioid receptor stimulation in the heart and the involvement of protein kinase C

Agitation in the elderly, manifested by verbal and physical aggression, frequently results in increased morbidity and mortality for nursing home residents and reduced morale for the family and nursing home staff. It is also responsible for increased costs associated with caring for these residents. Pharmacologic interventions are often used but are frequently ineffective and associated with significant adverse effects. Few controlled studies of drug treatment are available, but divalproex sodium and carbamazepine are effective and well tolerated by this population. Divalproex sodium has advantages of fewer adverse side effects and drug-drug interactions.     

Primary structure of apolipophorin-III from the greater wax moth, Galleria mellonella

BACKGROUND: Neurobiological research has implicated the dopamine and serotonin systems in the pathogenesis of autism. Open-label reports suggest that the serotonin2A-dopamine D2 antagonist risperidone may be safe and effective in reducing the interfering symptoms of patients with autism. METHODS: Thirty-one adults (age [mean+/-SD], 28.1+/-7.3 years) with autistic disorder (n=17) or pervasive developmental disorder not otherwise specified (n=14) participated in a 12-week double-blind, placebo-controlled trial of risperidone. Patients treated with placebo subsequently received a 12-week open-label trial of risperidone. RESULTS: For persons completing the study, 8 (57%) of 14 patients treated with risperidone were categorized as responders (daily dose [mean+/-SD], 2.9+/-1.4 mg) compared with none of 16 in the placebo group (P<.002). Risperidone was superior to placebo in reducing repetitive behavior (P<.001), aggression (P<.001), anxiety or nervousness (P<.02), depression (P<.03), irritability (P<.01), and the overall behavioral symptoms of autism (P<.02). Objective, measurable change in social behavior and language did not occur. Nine (60%) of 15 patients who received treatment with open-label risperidone following the double-blind placebo phase responded. Other than mild, transient sedation, risperidone was well tolerated, with no evidence of extrapyramidal effects, cardiac events, or seizures. CONCLUSION: Risperidone is more effective than placebo in the short-term treatment of symptoms of autism in adults.     

Sensitivity S of film-screen systems and mode of operation of different automatic exposure systems in general practice conditions. II: Automatic exposure systems

Antipsychotic agents, such as clozapine and risperidone, have been reported to be beneficial in the treatment of some bipolar patients. Many bipolar patients experience 'breakthrough episodes' of mood disorder, with mania or depression recurring despite adequate ongoing levels of one or more mood-stabilizing medications. There are no controlled studies of breakthrough episodes, and there is little open experience to guide clinicians in pharmacotherapy of breakthrough episodes. This report describes the outcome of adjunctive risperidone treatment in breakthrough episodes of bipolar disorder. We assessed the outcome of openly adding risperidone to the medication regimen of 12 outpatients with bipolar disorder, type I, who suffered breakthrough episodes despite adequate maintenance medication (lithium, valproate, or carbamazepine, or a combination of these). Prospective ratings were made at each clinical visit using the Clinical Global Impressions and Global Assessment of Functioning scales. Patients received risperidone for a mean of 6.0 months (23.96 weeks, range 0.5-72 weeks) at a mean dose of 2.75 mg/day (range 1-4.5 mg/day). Four patients discontinued medication (two because of lack of efficacy at weeks 6 and 64, and two because of adverse events at weeks 0.5 and 23). Among the remaining eight patients, four experienced a 10-25 point improvement in Global Assessment of Functioning scores and were rated much better on the Clinical Global Impression-Improvement scale. Although one patient suffered a major depressive recurrence (at week 22), no patient experienced worsening of mania. This small open series suggests a subgroup of bipolar patients with breakthrough episodes may benefit from treatment with risperidone.     

Recent advances in the pharmacotherapy of schizophrenia

The limitations of standard antipsychotics have spurred a search for novel agents that are effective against both positive and negative symptoms of schizophrenia but do not produce the extrapyramidal side effects frequently associated with the older medications. Such agents might more effectively prevent relapse, because of enhanced efficacy for the full spectrum of schizophrenic symptoms and improved tolerability--and hence greater medication compliance. Findings concerning the new antipsychotics currently available, clozapine and risperidone, are reviewed, and clozapine's usefulness as a first-line treatment is evaluated. Although serious side effects and the need for weekly blood monitoring may limit clozapine's use as a first-line treatment, risperidone appears promising in this role. Preclinical and clinical studies of new antipsychotic medications recently submitted for approval (olanzapine and sertindole) or in phase III development (quetiapine and ziprasidone) are also reviewed. The findings are encouraging, and researchers hope that some of these new agents may prove valuable as first-line treatments for schizophrenia. Pharmacoeconomic studies comparing clozapine and risperidone to the standard neuroleptics indicate that these newer drugs appear likely to lower the overall cost of treatment for schizophrenia, primarily by reducing rates of relapse and rehospitalization.     

Care of persons with AIDS in the nursing home

BACKGROUND: AIDS is becoming a chronic illness for some patients whose significant accumulated functional impairments may limit community-based care. Nursing homes can provide an appropriate level of care, although reported experience caring for persons with AIDS in this setting is limited. METHODS: A retrospective case-series review was conducted in a 242-bed community teaching nursing home to describe the initial 26-month experience in providing care for patients with AIDS requiring nursing home admission. RESULTS: A total of 42 admissions by 32 patients with AIDS (mean age = 33.5 years, 81% male) involved a shorter length of stay (mean 63.1 days) and higher numbers of medications (mean = 11.2), facility charges (mean $11,971/admission, $189/day), and greater clinical management complexity than usual nursing home patients. Thirteen patients were discharged, seven for rehospitalization and six into community settings, although ultimately 29 of the 32 patients died in the facility. CONCLUSIONS: AIDS care in the nursing home presents significant, distinct challenges in complex management and terminal care prioritization.     

Diabetic nephropathy

Diabetic nephropathy accounts for almost a third of all causes of ESRD. Microalbuminuria screening among diabetics can offer early detection of incipient nephropathy. Aggressive treatment with ACE inhibitors may delay the onset of overt renal failure or delay its progression. Furthermore, intensive control of blood glucose has also been proven to prevent the microvascular complications of diabetes and should be pursued in both IDDM and NIDDM. The high association of diabetes mellitus with hypertension presents another problem to the clinician. It is necessary to control blood pressure to prevent further progression of renal failure. The choice of antihypertensive medications, however, becomes a therapeutic dilemma because of the metabolic and lipid disturbances that some drugs can cause. ACE inhibitors, CCBs, alpha-agonists, and low-dose diuretics, alone or in combination, may be tried to normalize blood pressures. Although beta-blockers are widely used and effective in nondiabetics, these agents should be considered the drugs of last resort because of their adverse effects, which are particularly troublesome for diabetics. Moderate protein restriction should also be advocated as a helpful adjunct to therapy.     

Respiratory depression associated with patient-controlled analgesia: a review of eight cases

Patient-controlled iv delivery of opioids for postoperative pain management is a popular alternative to the traditional im route of administration. However, occasional patients receiving opioids in this manner develop severe respiratory depression. The purpose of this paper is to determine the incidence of, and factors contributing to, the development of this complication. To do this, the Office of Medical Quality Improvement retrospectively searched for reports of respiratory depression in a database compiled from the charts of approximately 1600 patients who had received PCA at the University of Alberta Hospitals in 1992. Eight cases of serious respiratory depression were detected. Factors associated with the occurrence of respiratory depression included the concurrent use of a background infusion, advanced age, concomitant administration of sedative/hypnotic medications, and pre-existing sleep apnoea syndrome. No cases were attributed to operator error or equipment malfunction. In conclusion, the risk of respiratory depression with patient-controlled opioid administration is similar to that observed when opioids are delivered by the traditional im or spinal routes. The safe and effective use of patient-controlled analgesia depends upon knowledgeable medical and nursing staff, clearly defined nursing policy and procedures, and frequent patient follow-up.     

Observed sleep/wakefulness and severity of dementia in an Alzheimer's disease special care unit

BACKGROUND: This study tested the hypothesis that behaviorally defined sleep disturbance among residents in a Special Care Unit (SCU) for Alzheimer's disease (AD) was related to the severity of their dementia. Previously, sleep laboratory studies have reported such relationships when sleep has been recorded polysomnographically over several nights. Observational studies of sleep have not shown such relationships, presumably because of the impression involved in determining sleep/wake state behaviorally. METHODS: Nightly sleep data based on observations made every two hours by nursing staff for a period of 13 to 18 months were examined for 47 AD residents with a mean age of 80.7 +/- 6.5 years. Level of dementia and functional capacity were assessed with the Mattis Dementia Rating Scale (DRS) and the Katz Activities of Daily Living Scale (ADL). RESULTS: Data indicated that these SCU residents experienced a moderately disturbed night of sleep an average of 24% +/- 10% of their nights in the facility and a severely disturbed night of sleep on 7% +/- 6% of those nights. More profound dementia was associated with more sleep disturbance; however, incapacity in ADLs, age, gender, and psychoactive medications were unrelated to such disturbances. CONCLUSIONS: The results indicate that patterns of relationships noted between laboratory-based measures of sleep and variables such as severity of dementia can be detected using behavioral observations of sleep, provided that the number of nights of observation are sufficiently large to offset the measurement error involved in their use.     

Human circular colonic smooth muscle cells possess active somatostatin receptors

High-dose chemotherapy with autologous and allogeneic blood stem cell transplantation has become a standard therapy for hematological malignancies and solid tumors. To ensure quality of treatment and adherence to internationally approved protocols, the use of computer systems has been introduced in some oncology centers. Most software packages cannot be used automatically by other institutions because of different treatment strategies and medications. To overcome this problem, we designed a software system based on an Oracle database, which allows the user to develop his own therapy blocks and assemble them to generate specific therapy plans. The system supports the daily work of the physicians by suggesting medications based on changes in the vital parameters or the clinical chemistry. Parameters can be given upper and lower limits whose surpassing leads to treatment suggestions by the system. All quantitative variables may be depicted in a graphical way. The system is connected to external laboratory devices. Export of data to international registries is possible. Until now, 43 patients have been transplanted with the help of this system. There is a high degree of acceptance among the nursing staff and the physicians. The system can be transferred to other centers, if the local hardware and network capacities meet the minimal requirements.     

Neuroleptic use and behavioral disturbance in nursing homes: a 1-year study

This article discusses a longitudinal study of change in disruptive behaviors among nursing home residents treated with neuroleptics compared with those not treated with neuroleptics. Observations were made of 201 participants on admission to and after 1 year in eight skilled nursing facilities. Nine disruptive behaviors were measured using the Psychogeriatric Dependency Rating Scale with nursing assistants. Neuroleptic use was documented from medication records. Odds ratios are reported for the association of behavior at baseline and use of neuroleptics on nine problem behaviors. For those who received neuroleptics during the year, there was greater change in both developing and resolving disruptive behaviors than for those not receiving neuroleptics. For both groups, restless or pacing behavior and belligerent behavior manifested by refusing instructions changed the most, both in developing and in apparently resolving. Our results show that change in disruptive behaviors occurs among nursing home residents regardless of neuroleptic use, but it occurs more frequently among those who receive neuroleptic medication. Knowledge of which disruptive behaviors are most likely to resolve or develop is important in training nursing home staff to cope with the behaviors as well as in planning interventions that may modify such behaviors.