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We applied machine learning algorithms to examine the relationship between demographics and outcomes of the social work services used by Hispanic family caregivers of persons with dementia recruited for a clinical trial in New York City. The social work service needs were largely concentrated on instrumental support to gain access to the healthcare system rather than other concrete services (e.g., housing or food programs) or to address psychological needs among the caregivers with relatively higher income. A finding from the machine learning approach was that among those who receive medical-related social work services, frequent users (≥ 10 times) with high family friend support(>4) were more likely than frequent users without such support to have their issues resolved (Accuracy: 81.9%, AUC: 0.82, F-measure: 0.86 by J48). Even though half of the participants received social work services multiple times, the needs of the caregivers remained unmet unless they sought social work services frequently (more than ten times). [ABSTRACT FROM AUTHOR]

The current study translated the Resources for Enhancing Alzheimer's Caregiver Health: Offering Useful Treatments (REACH OUT), a skills-building stress and burden intervention, for the primary care setting and pilot the resulting intervention. The 16-week intervention consisted of a combination of clinic-based group and one-on-one sessions offered within a medical home, geriatrics clinic. A quasi-experimental pre- and post-test study design without a control group tested the resulting intervention. Semi-structured qualitative exit interviews evaluated program satisfaction. Twenty-five caregivers participated in one of four intervention groups; 21 caregivers completed the intervention (attended at least five of six group sessions). Caregiver burden on standardized assessments was significantly reduced between pre- and post-intervention, specifically for physical/emotional strain and caregiving uncertainty. Significant reductions were found in the frequency of reported disruptive behaviors; increased caregiver confidence in handling behavior problem frequency, depressive symptoms, disruptive behaviors, and memory-related problems; and decreased bother with respect to behavioral problem frequency and care recipient depression. Program satisfaction was high. This work suggests that the REACH OUT program can be successfully modified for use within a primary-care medical home setting. [ABSTRACT FROM AUTHOR]

Objectives: To compare the effectiveness of 2 caregiver interventions with known efficacy: the Resources for Enhancing Caregiver Health‐Offering Useful Treatment (REACH‐OUT) and the New York University Caregiver Intervention (NYUCI). Design: 1:1 randomized pragmatic trial. Setting: New York City. Participants: Informal Hispanic caregivers of persons with dementia (N=221; mean age 58.2, 82.8% female, 63.3% adult children, 31.7% spouses). Intervention: Participants were randomized to 6 months of NYUCI (n=110) or REACH‐OUT (n=111), balanced on characteristics at baseline. All participants were referred for social supportive services. Measurements: The primary outcomes were changes between baseline and 6 months in depressive symptoms, measured using the Geriatric Depression Scale (GDS), and caregiver burden, measured using the Zarit Caregiver Burden Scale (ZCBS). Results: There were no differences in outcomes between NYUCI and REACH‐OUT. Both interventions showed a reduction in burden (REACH‐OUT: 5.2 points, 95% confidence interval (CI)=2.2–8.1, p<.001; NYUCI: 4.6‐points, 95% CI=1.7–7.5, p=.002). There were no significant changes on the GDS. Effects for the ZCBS were significant only for spouses and older caregivers. Conclusion: Although there were no significant intervention group differences, both interventions resulted in significantly reduced burden for Hispanic caregivers at 6 months, particularly for spouses and older caregivers. [ABSTRACT FROM AUTHOR]

Objectives: Little is known about the patterns of psychotropic medication use in community-dwelling minority persons with dementia (PWD). The purpose of this study was to investigate racial/ethnic differences in psychotropic medication use across a diverse population of community-dwelling PWD and to examine the extent to which caregiver characteristics influence this use. Method: Data were drawn from the baseline assessment of the Resources for Enhancing Alzheimer's Caregiver Health II trial. Generalized linear models were used to identify racial/ethnic differences in psychotropic medication use. Akaike Information Criterion (AIC) model selection was used to evaluate possible explanations for observed differences across racial/ethnic group. Results: Differences in anxiolytic and antipsychotic medication use were observed across racial/ethnic groups; however, race/ethnicity alone was not sufficient to explain those differences. Perceptions of caregiving and caregiver socioeconomic status were important predictors of anxiolytic use while PWD characteristics, including cognitive impairment, functional impairment, problem behavior frequency, pain, relationship to the caregiver, sex, and age were important for antipsychotic use. Conclusion: Racial/ethnic differences in psychotropic medication use among community-dwelling PWD cannot be explained by race/ethnicity alone. The importance of caregiver characteristics in predicting anxiolytic medication use suggest that interventions aimed at caregivers may hold promise as an effective alternative to pharmacotherapy. [ABSTRACT FROM AUTHOR]

Objectives:The current practice of prescribing psychotropic medication for the management of dementia-related behavioral disturbances is under substantial debate. Using Pearlin's stress process model as theoretical underpinning, the aim of this investigation is to identify caregiver and care recipient characteristics as predictors of anxiolytic, antipsychotic, and antidepressant use among community-dwelling dementia patients. We hypothesized that caregiving burden and patient characteristics, particularly behavior disturbances and pain, would be positively associated with psychotropic medication use. Methods:Data for this exploratory, cross-sectional study were drawn from the baseline assessment of the Resources for Enhancing Alzheimer's Caregiver Health II trial. Only participants with full baseline information were examined (N= 598). Caregiver characteristics, such as confidence managing problematic behaviors, and care recipient characteristics including pain, problem behaviors, cognitive impairment, and functional impairment, were examined in relation to care recipient psychotropic medication use. Results:Contrary to our hypothesis, behavioral disturbances and burden associated with these disturbances were not significantly associated with psychotropic use. Rather, caregiver characteristics such as race and overall vigilance, and care recipient characteristics such as cognitive status, functional status, and pain were significantly associated with the use of psychotropic medication. Findings differed by class of medication. Conclusion:These exploratory findings suggest the utility of a holistic approach to understanding the factors associated with pharmacotherapy among community-dwelling elders with dementia. Significant associations between caregiver characteristics and care recipient psychotropic medication use suggest that educating caregivers in non-pharmacologic strategies hold promise for a more balanced biopsychosocial approach to maintaining dementia patients in the community. [ABSTRACT FROM AUTHOR]

Introduction: The prevalence of dementia is increasing without a known cure, resulting in an increasing number of informal caregivers. Caring for a person with dementia results in increased stress and depressive symptoms. There are several behavioural interventions designed to alleviate stress and depressive symptoms in caregivers of persons with dementia with evidence of efficacy. Two of the best-known interventions are the New York University Caregiver Intervention (NYUCI) and the Resources for Enhancing Alzheimer's Caregivers Health (REACH). The effectiveness of the NYUCI and REACH has never been compared. There is also a paucity of data on which interventions are more effective in Hispanics in New York City. Thus, we proposed the Northern Manhattan Hispanic Caregiver intervention Effectiveness Study (NHiCE), a pragmatic clinical trial designed to compare the effectiveness of adaptations of the NYUCI and the REACH in informal Hispanic caregivers of persons with dementia in New York City. Methods and analysis: NHiCE is a 6-month randomised controlled trial comparing the effectiveness of adaptations of the NYUCI and REACH among 200 Hispanic informal adult caregivers of persons with dementia. The planned number of sessions of the NYUCI and REACH are similar. The primary outcome measures are changes from baseline to 6 months in the Zarit Caregiver Burden Scale and Geriatric Depression Scale. Our primary approach to analyses will be intent-to-treat. The primary analyses will use mixed random effects models, and a full information maximum likelihood approach, with sensitivity analyses using generalised estimating equation. Ethics and dissemination: NHiCE is approved by the Institutional Review Board of Columbia University Medical Center (protocol AAAM5150). A Data Safety Monitoring Board monitors the progress of the study. Dissemination will include reports of the characteristics of the study participants, as well as a report of the results of the clinical trial. [ABSTRACT FROM AUTHOR]

Purpose of the Study: To describe the experience of recruiting, training, and retaining retired senior volunteers (RSVs) as interventionists delivering a successful reminiscence and creative activity intervention to community-dwelling palliative care patients and their caregivers. Design and Methods: A community-based participatory research framework involved Senior Corps RSV programs. Recruitment meetings and feedback groups yielded interested volunteers, who were trained in a 4-hr session using role plays and real-time feedback. Qualitative descriptive analysis identified themes arising from: (a) recruitment/feedback groups with potential RSV interventionists; and (b) individual interviews with RSVs who delivered the intervention. Results: Themes identified within recruitment/feedback groups include questions about intervention process, concerns about patient health, positive perceptions of the intervention, and potential characteristics of successful interventionists. Twelve RSVs achieved 89.8% performance criterion in treatment delivery. Six volunteers worked with at least one family and 100% chose to work with additional families. Salient themes identified from exit interviews included positive and negative aspects of the experience, process recommendations, reactions to the Interventionist Manual, feelings arising during work with patient/caregiver participants, and personal reflections. Volunteers reported a strong desire to recommend the intervention to others as a meaningful volunteer opportunity. Implications: RSVs reported having a positive impact on palliative care dyads and experiencing personal benefit via increased meaning in life. Two issues require further research attention: (a) further translation of this cost-effective mode of treatment delivery for palliative dyads and (b) further characterization of successful RSVs and the long-term impact on their own physical, cognitive, and emotional functioning. [ABSTRACT FROM AUTHOR]

Purpose: Literature on institutionalization of patients with dementia has not considered the role of caregivers’ quality of care, which encompasses caregivers’ exemplary care (EC) behaviors and caregivers’ potentially harmful behaviors (PHBs) toward care recipients. This study sought to understand the role of quality of care in mediating between caregiving stressors and caregiver desire to institutionalize (DTI) a patient with dementia. Design and Methods: A sample of 612 family caregivers from diverse racial/ethnic backgrounds was drawn from the baseline data of the Resources for Enhancing Alzheimer’s Caregiver Heath (REACH II) project. Multiple mediator models were run using Preacher and Hayes asymptotic and resampling strategies to assess direct and indirect effects of caregiver stressors (daily care bother, behavioral bother, and burden) on caregiver desire to institutionalize a patient with dementia. Results: Overall, PHB was positively related to caregiver desire to institutionalize their care recipients. Specifically, PHB was found to mediate the relationship between caregiving stressors and DTI in the Caucasian and Latino groups, whereas only the mediation effect of EC was significant in the African American group. Implications: Caregivers’ perceptions of quality of care helped explain their desire to institutionalize their care recipients with dementia. Including assessment of EC and PHB in clinical and social service settings is recommended for all ethnic groups. Interventions should facilitate EC behaviors among African American caregivers and address concerns of PHBs in Caucasian and Latino caregivers. [ABSTRACT FROM PUBLISHER]

Purpose: Exemplary care (EC) is a new construct encompassing care behaviors that warrants further study within stress process models of dementia caregiving. Previous research has examined EC within the context of cognitively intact older adult care recipients (CRs) and their caregivers (CGs). This study sought to expand our knowledge of quality of care by investigating EC within a diverse sample of dementia CGs. Design and Methods: We examined the relation between CG subjective appraisal (daily care bother, burden, and behavioral bother), EC, and CG emotional outcomes (depression and positive aspects of caregiving [PAC]). Specifically, EC was examined as a possible mediator of the effects of CG subjective appraisals on emotional outcomes. Using a bootstrapping method and an SPSS macro developed by Preacher and Hayes (2008 Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models), we tested the indirect effect of EC on the relation between CG subjective appraisals and CG emotional outcomes. Results: Overall, EC partially mediates the relation between the subjective appraisal variables (daily care bother, burden, and behavioral bother) and PAC. Results for depression were similar except that EC did not mediate the relation between burden and depression. This pattern of results varied by race/ethnicity. Implications: Overall, CGs’ perception of providing EC to individuals with dementia partially explains the relation between subjective appraisal and symptoms of depression and PAC. Results of this study suggest that interventions may benefit from training CGs to engage in EC to improve their emotional outcomes and quality of care. [ABSTRACT FROM PUBLISHER]

Objectives: The objectives of this study were to assess the dimensionality and reliability of a frequently used scale for predicting the desire to institutionalize among White, African American, and Hispanic caregivers of persons with dementia. Method: Exploratory factor analysis (EFA) and reliability analyses were performed on a slightly modified version of Morycz’s (1985) Desire to Institutionalize (DTI) scale separately for each racial group using data from the Resources for Enhancing Alzheimer’s Caregiver Health (REACH) II study (Belle et al., 2006). Results: The EFA revealed a one-factor structure that was equivalent across all racial groups. The scale demonstrated moderate reliability with KR-20 alpha of .694 for Whites, .742 for African Americans, and .767 for Hispanics. Discussion: Findings suggest that Morycz’s DTI scale is a consistently reliable measure for assessing the desire to institutionalize across White, African American, and Hispanic dementia caregivers. [ABSTRACT FROM PUBLISHER]

This study explores whether religiosity explains racial differences in caregiving burden for a rural sample of dementia family caregivers. Data are from a probability sample of 74 non-Hispanic White and 67 African American dementia caregivers in rural Alabama. SPSS macros for estimating indirect effects in multiple mediator models are used to test the mediation effects of religiosity. White caregivers report higher burden, are less likely to use religious coping, and less likely to engage in organized religion than do African American caregivers. Church attendance is found to significantly (B = -.57, p < .05) mediate the racial differences on caregiving burden (R² = .07). Religious involvement in general, and church attendance in particular, seem to provide both spiritual and social psychological benefits to dementia caregivers. Thus, supplementing formal services with the services provided by religious organizations may be important in rural areas where formal resources are scarce. [ABSTRACT FROM AUTHOR]

Objective: We examined predictors of staff-reported need-driven behaviors and resistiveness to care in nursing home residents with dementia and predictors of certified nursing assistant (CNA) burden related to both constructs. Background and proximal factors from the need-driven dementia-compromised behavior model [Algase, D.L., Beck, C., Kolanowski, A., Whall, A., Berent, S., Richards, K., et al. (1996). Need-driven dementia-compromised behavior: An alternative view of disruptive behavior. American Journal of Alzheimer's Disease, 5, 10-19] were examined as potential predictors of need-driven behaviors (NDBs) and resistiveness to care and CNA burden. Method: We used secondary data analysis of prospective data from 10 nursing homes in Birmingham, Alabama. One-hundred and sixty-one residents (83.43 ± 8.56 years) with mini mental state examination (MMSE) score = 6.41 (± 6.66) were assessed via chart review, resident surveys, and surveys of CNAs. Results: Multiple regression models revealed that cognitive functioning, activities of daily living functioning, race, gender, and CNA-reported weekly resident pain intensity were associated with resident NDBs. Regression models also revealed that weekly pain intensity and medical comorbidity were associated with CNA burden associated with the resident NDBs. However, we were unable to explain a significant amount of variance in the resistiveness to care or CNA burden associated with resistiveness to care. Discussion: Results underscore the role of pain in both resident NDBs and associated CNA burden. Future research should focus on predictors of resident resistiveness to care and the relation of pain assessment and management practices to CNA burden. Moreover, interventions to improve resident care should seek to include CNAs in institutional pain assessment and management processes. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine the relationships between changes from baseline to post-Resources for Enhancing Alzheimer's Caregiver Health (REACH) intervention in caregiver (CG) self-reported health, burden, and bother. DESIGN: Randomized, multisite clinical trial. SETTING: CG and care recipient (CR) homes in five U.S. cities. PARTICIPANTS: Four hundred ninety-five dementia CG and CR dyads (169 Hispanic, 160 white, and 166 African American) receiving intervention and their controls. INTERVENTION: CGs were assigned to the REACH intervention or a no-treatment control group. Intervention subjects received individual risk profiles and the REACH intervention through nine in-home and three telephone sessions over 6 months. Control subjects received two brief “check-in” telephone calls during this 6-month period. MEASUREMENTS: The primary outcome was change in CG health status from baseline to after the intervention. Secondary outcomes were CG burden and bother after the intervention. RESULTS: After the intervention, CGs reported better self-rated health, sleep quality, physical health, and emotional health, which was related to less burden and bother with their caregiving role than for CGs not receiving the intervention. Changes in depression appeared to mediate these relationships. Several racial and ethnic group differences existed in physical and emotional health, as well as in total frustration with caregiving, emotional burden, and CG-rated bother with CR's activities of daily living and instrumental activities of daily living at baseline and at follow-up, although differences between baseline and posttest did not vary according to race. CONCLUSION: A structured, multicomponent skills training intervention that targeted CG self-care behaviors as one of five target areas, improved self-reported health status, and decreased burden and bother in racially and ethnically diverse CGs of people with dementia. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To develop and validate a brief screening measure for use in research, healthcare, and community settings to systematically assess well-being and identify needed areas of support for caregivers of patients with dementia. DESIGN: This study used data from Resources for Enhancing Alzheimer's Caregiver Health (REACH II), a multisite randomized clinical trial of a behavioral intervention designed to improve the quality of life of caregivers in multiple domains. SETTING: REACH II. PARTICIPANTS: Two hundred twelve Hispanic, 211 black, and 219 white family caregivers providing in-home care to patients with dementia. MEASUREMENT: Based on conceptual and psychometric analyses, a 16-item measure was developed that assesses six domains linked to caregiver risk and amenable to intervention: depression, burden, self-care and health behaviors, social support, safety, and patient problem behaviors. The reliability and validity of the instrument was evaluated with 642 dementia caregiver dyads from the REACH II program. RESULTS: The measure was found to have acceptable internal consistency for a multidimensional scale and similar measurement properties for each of the racial and ethnic groups. Concurrent validity was also demonstrated for the measure. CONCLUSION: The REACH Risk Appraisal Measure developed in this study shows promise as an assessment tool that can be used in research, clinical, and community settings to guide, prioritize, and target needed areas of support for caregivers of patients with dementia. [ABSTRACT FROM AUTHOR]

Purpose: The primary aim of this study was to test the stress process model (SPM; Pearlin, Mullan, Semple, & Skaff, 1990) in a racially diverse sample of Alzheimer's caregivers (CGs) using structural equation modeling (SEM) and regression techniques. A secondary aim was to examine race or ethnicity as a moderator of the relation between latent constructs (e.g., subjective stressors and role strain) in the SPM. Sompile: Participants included White or Caucasian (n = 212), Black or African American (n =201), and Hispanic or Latino (n = 196) Alzheimer's CGs from the Resources for Enhancing Alzheimer's Caregiver Health (REACH) II clinical trial. Results: SEM revealed that the Pearlin model obtains a satisfactory fit across race or ethnicity in the REACH II data, despite significant racial differences in each of the latent constructs. Race or ethnicity moderated the impact of resources on intrapsychic strain, such that CGs reported similar intrapsychic strain across race at lower levels of resources, but White or Caucasian CGs reported more intrapsychic strain than Black or African American or Hispanic or Latino CGs when resources are higher. Implications: Strengths and weaknesses for each race or ethnicity vary considerably, suggesting that interventions must target different aspects of the stress process to provide optimal benefit for individuals of different cultural or ethnic backgrounds. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to translate the evidence-based Resources for Enhancing Alzheimer's Caregiver Health (REACH) II intervention for use in 4 Area Agencies on Aging (AAAs). A secondary aim was to examine possible moderators of treatment outcome. Design and Methods: We used a quasi-experimental pre-post treatment design with no control group. A partnership was formed between the Alabama Department of Senior Services and the University of Alabama. The partnership trimmed the REACH II intervention used in the clinical trial for feasible use in a social service agency. The condensed REACH intervention, termed REACH OUT, was delivered to 272 dementia caregivers during 4 home visits and 3 phone calls for a period of 4 months. The assessment examined pre-post treatment effects on a number of outcomes, including care recipient risk, mood, memory, and behavior problems; caregiver stress and emotional well-being; caregiver health; and program satisfaction. All aspects of the program except for training, periodic consultation, and data analysis were controlled by the AAA staff. Results: Analyses were conducted on the 236 dyads that completed at least 3 of the 4 planned sessions. Significant positive pre-post effects were found on caregiver subjective burden, social support, caregiver frustration, depression, caregiver health, care recipient behavior problems and mood, and 2 of 4 care recipient risk behaviors. Site of intervention and certain participant characteristics (e.g., caregiver relationship) moderated several pre-post differences. A caregiver survey and interventionist focus group reported high acceptability of the program Implications: This project suggests that the REACH II intervention can be modified for feasible and effective use in AAAs. The next step is to integrate the intervention into usual service delivery to achieve sustainability. [ABSTRACT FROM AUTHOR]

Objective: This study explored how male and female family caregivers of Alzheimer's disease (AD) patients differ in their use of formal services and informal support and how religiousness may affect such differences. Methods: Data were from a sample of 720 family caregivers of AD patients who participated in the Resources for Enhancing Alzheimer's Caregiver Heath (REACH I) study sites in Birmingham, Boston, Memphis, and Philadelphia. Results: Female caregivers were less likely to use in-home services than males (M = 0.83 vs. M = 1.06, p < .01) but reported more use of transportation services (21.6% vs. 12.7%, p < .01) and more use of informal support (M = 13.9 vs. M = 10.7, p < .01). Mediation tests suggested that three measures of religiousness helped explain the relationship between gender and use of formal services and informal support. Discussion: These findings highlight the necessity to assess AD caregivers' religiousness to better understand their circumstances. [ABSTRACT FROM AUTHOR]

We examined the efficacy of an innovative family-based intervention designed to decrease caregiving stress and increase family communication among individuals with chronic, life-limiting illnesses and their family caregivers in a randomized, contact control group design. The intervention group received three home visits in which the interventionist actively worked with the family to construct a personal Legacy, usually a scrapbook with photographs or audiotaped stories. Control group families received three supportive telephone calls. Of the 42 families that entered the project, 31 families completed follow-up assessments within 9 to 10 weeks (14 control; 17 intervention; 72% African American) for a retention rate of 74%. Intervention caregivers showed reduced caregiving stress in comparison with control group caregivers, who showed increases in stress. Intervention patients reported decreased breathing difficulty and increased religious meaning. Caregivers and patients reported greater social interaction on the part of the patient. All participants in the intervention group initiated a Legacy activity and reported that Legacy improved family communication. Legacy interventions hold promise and are simple to implement. [ABSTRACT FROM AUTHOR]

Although proxy reports of activities of daily living (ADLs) are commonly used, especially when the care recipient has dementia, how well these caregiver reports correspond to professionals' ratings is not always clear. In this study, dementia caregivers completed an orally administered version of the Self-Care subscale of the Functional Independence Measure (FIM). ADL interactions were videotaped in the home, and independent raters assigned a FIM score to these interactions. An occupational therapist later viewed the videotaped ADLs and assigned FIM scores to those interactions. These three sets of scores were then compared. All possible correlations were significant (n = 21; p ≤.005; rs = .620 to .933; Mdn = .862), and there were no significant differences among ratings obtained from the different sources. These results support earlier conclusions regarding the validity and clinical utility of caregiver proxy ratings of functional ability in elders with dementia. [ABSTRACT FROM AUTHOR]

Purpose: Agitation frequently accompanies cognitive decline among nursing home residents. This study used cross-sectional and longitudinal (up to 18 months) methods to examine agitation among profoundly and moderately impaired residents using both staff report and direct observation methods. Design and Methods: The study included participants (N = 78) from a larger study who completed either 12 or 18 months of data collection. There were four measurement points, each separated by 6-month intervals. We recorded agitation using two measures: (a) the computer-assisted behavioral observation system (CABOS) and (b) the staff-completed Nursing Home Behavior Problem Scale. We used 'ongitudinal hierarchical linear modeling to capture the dynamic nature of behavior change as a function of individual resident characteristics and time. Results: The profoundly cognitively impaired residents (M Mini-Mental State Examination [MMSE] score = 1.7) displayed more agitation than the moderately impaired group (M MMSE score = 15.4) at Epoch 1 (cross-sectional analyses). Longitudinal analysis found a significant linear and quadratic trend only with the profoundly impaired residents using the CABOS. These residents showed slight improvements in agitation up to 12 months, with agitation increasing significantly from 12 to 18 months. Implications: With nursing homes receiving an increasing number of profoundly cognitively impaired residents, these results have potential cost and policy implications. Measuring agitation over time by using both staff report and observation measures presents various problems, and we present an alternative measure that may help to avoid these difficulties. [ABSTRACT FROM AUTHOR]

This study explored differences and similarities in the experiences of African American and White family caregivers of dementia patients living in rural Alabama. This cross sectional survey used a caregiving stress model to investigate the interrelationships between caregiving burden, mediators, and outcomes. Random-digit-dialing telephone interviews were used to obtain data on a probability sample of 74 non-Hispanic WhiTe and 67 African American caregivers. White caregivers were more likely to be married and older, used acceptance and humor as coping styles, and had fewer financial problems. African American caregivers gave more hours of care, used religion and denial as coping styles, and were less burdened. The authors have developed a methodology for obtaining a representative sample of African American and White rural caregivers. Further investigations are needed of the interactions between urban/rural location and ethnic/racial backgrounds of dementia caregivers for heuristic and applied reasons. [ABSTRACT FROM AUTHOR]

Rural dwelling elders who experience mental health problems often have difficulty finding help since rural communities often lack adequate mental health service providers. This paper reports on the initial phase of a 5-year, interdisciplinary clinical research study that is testing the effectiveness of providing a home delivered, therapeutic psychosocial intervention, aimed at improving the emotional well-being and the quality of life of medically frail elders who live in rural communities. In the early phases of this study, the clinical research team encountered a number of interesting and often unanticipated challenges as it attempted to recruit study participants and provide services to them. In this article, we examine these challenges and share what we have learned so far about providing mental health services to elderly persons living in rural environments. [ABSTRACT FROM AUTHOR]

Background: Caring for a family member with dementia is extremely stressful, contributes to psychiatric and physical illness among caregivers, and increases the risk for caregiver death. Finding better ways to support family caregivers is a major public health challenge.Objective: To test the effects of a structured multicomponent intervention on quality of life and clinical depression in caregivers and on rates of institutional placement of care recipients in 3 diverse racial or ethnic groups.Design: Randomized, controlled trial.Setting: In-home caregivers in 5 U.S. cities.Participants: 212 Hispanic or Latino, 219 white or Caucasian, and 211 black or African-American caregivers and their care recipients with Alzheimer disease or related disorders.Intervention: Caregivers within each racial or ethnic group were randomly assigned to an intervention or to a control group. The intervention addressed caregiver depression, burden, self-care, and social support and care recipient problem behaviors through 12 in-home and telephone sessions over 6 months. Caregivers in the control group received 2 brief "check-in" telephone calls during the 6-month intervention.Measurements: The primary outcome was a quality-of-life indicator comprising measures of 6-month caregiver depression, burden, self-care, and social support and care recipient problem behaviors. Secondary outcomes were caregiver clinical depression and institutional placement of the care recipient at 6 months.Results: Hispanic or Latino and white or Caucasian caregivers in the intervention group experienced significantly greater improvement in quality of life than those in the control group (P < 0.001 and P = 0.037, respectively). Black or African-American spouse caregivers also improved significantly more (P = 0.003). Prevalence of clinical depression was lower among caregivers in the intervention group (12.6% vs. 22.7%; P = 0.001). There were no statistically significant differences in institutionalization at 6 months.Limitations: The study used only a single 6-month follow-up assessment, combined heterogeneous cultures and ethnicities into a single group, and excluded some ethnic groups.Conclusions: A structured multicomponent intervention adapted to individual risk profiles can increase the quality of life of ethnically diverse dementia caregivers. ClinicalTrials.gov identifier: NCT00177489. [ABSTRACT FROM AUTHOR]

Background: Caring for a family member with dementia is extremely stressful, contributes to psychiatric and physical illness among caregivers, and increases the risk for caregiver death. Finding better ways to support family caregivers is a major public health challenge. Objective: To test the effects of a structured multicomponent intervention on quality of life and clinical depression in caregivers and on rates of institutional placement of care recipients in 3 diverse racial or ethnic groups. Design: Randomized, controlled trial. Setting: In-home caregivers in 5 U.S. cities. Participants: 212 Hispanic or Latino, 219 white or Caucasian, and 211 black or African-American caregivers and their care recipients with Alzheimer disease or related disorders. Intervention: Caregivers within each racial or ethnic group were randomly assigned to an intervention or to a control group. The intervention addressed caregiver depression, burden, self-care, and social support and care recipient problem behaviors through 12 in-home and telephone sessions over 6 months. Caregivers in the control group received 2 brief "check-in" telephone calls during the 6-month intervention. Measurements: The primary outcome was a quality-of-life indicator comprising measures of 6-month caregiver depression, burden, self-care, and social support and care recipient problem behaviors. Secondary outcomes were caregiver clinical depression and institutional placement of the care recipient at 6 months. Results: Hispanic or Latino and white or Caucasian caregivers in the intervention group experienced significantly greater improvement in quality of life than those in the control group (P < 0.001 and P = 0.037, respectively). Black or African-American spouse caregivers also improved significantly more (P = 0.003). Prevalence of clinical depression was lower among caregivers in the intervention group (12.6% vs. 22.7%; P = 0.001). There were no statistically significant differences in institutionalization at 6 months. Limitations: The study used only a single 6-month follow-up assessment, combined heterogeneous cultures and ethnicities into a single group, and excluded some ethnic groups. Conclusions: A structured multicomponent intervention adapted to individual risk profiles can increase the quality of life of ethnically diverse dementia caregivers. [ABSTRACT FROM AUTHOR]

Background Psychosocial and behavioral interventions trials targeting a broad range of complex social and behavioral problems such as smoking, obesity and family caregiving have proliferated in the past 30 years. At the same time the use of Data and Safety Monitoring Boards (DSMBs) to monitor the progress and quality of intervention trials and the safety of study participants has increased substantially. Most of the existing literature and guidelines for safety monitoring and reporting of adverse events focuses on medical interventions. Consequently, there is little guidance for investigators conducting social and behavior trials. Purpose This paper summarizes how issues associated with safety monitoring and adverse event reporting were handled in the Resources for Enhancing Alzheimer's Caregiver Health (REACH II) program, a multi-site randomized clinical trial, funded by the National Institutes on Aging (NIA) and the National Institutes of Nursing Research (NINR), that tested the efficacy of a multicomponent social/behavioral intervention for caregivers of persons with Alzheimer's disease. Methods A task force was formed to define adverse events for the trial and protocols for reporting and resolving events that occurred. The task force conducted a review of existing polices and protocols for data and safety monitoring and adverse event reporting and identified potential risks particular to the study population. An informal survey regarding data and safety monitoring procedures with investigators on psychosocial intervention trials was also conducted. Results Two categories of events were defined for both caregivers and patients; adverse events and safety alerts. A distinction was also made between events detected at baseline assessment and those detected post-randomization. Standardized protocols were also developed for the reporting and resolution of events that occurred and training of study personnel. Results from the informal survey indicated wide variability in practices for data safety and monitoring across psychosocial intervention trials. Conclusions Overall, the REACH II experience demonstrates that existing guidelines regarding safety monitoring and adverse event reporting pose unique challenges for social/behavioral intervention trials. Challenges encountered in the REACH II program included defining and classifying adverse events, defining "resolution" of adverse events and attributing causes for events that occurred. These challenges are highlighted and recommendations for addressing them in future studies are discussed. [ABSTRACT FROM AUTHOR]

Purpose: We developed and evaluated an explicit procedure for obtaining self-report pain data from nursing home residents across a broad range of cognitive status, and we evaluated the consistency, stability, and concurrent validity of resident responses. Design and Methods: Using a modification of the Geriatric Pain Measure (GPM-M2), we interviewed 61 residents from two nursing homes (Mini-Mental State Examination score, M = 15 ± 7) once a week for 4 consecutive weeks. We collected additional data by means of chart review, cognitive status assessments, and surveys of certified nursing assistants. We used descriptive and correlational analyses to address our primary aims. Results: Eighty-nine percent of residents completed all four scheduled interviews. Cognitive status was not significantly correlated with number of nonresponses and prompts for yes-no questions, but it was significantly correlated with nonresponses and prompts for Likert-scale questions (r = -.48, p < .001 and r = -.59, p < .001, respectively). Completion time for the 17-item pain measure (M = 13 min) was not predicted by cognitive status. Residents' scores on the GPM-M2 were significantly correlated with number of chronic pain-associated diagnoses, r = .37, p < .01, and internal consistency was excellent, = 0.87 - 0.91. Residents' GPM-M2 scores were stable over time, r = .74-.80, p < .0001, for all comparisons. Implications: Using explicit protocols and reporting procedural data allows researchers and clinicians to better understand and apply results of self-report studies with cognitively impaired elders. Results suggest that many nursing home residents can provide consistent and reliable self-report pain data, given appropriate time and assistance. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to examine group differences in verbal agitation, verbal interaction, bed restraint, pain, analgesic and neuroleptic medication use, and medical comorbidity among agitated nursing home residents who died during a 6-month clinical trial compared with residents of the same gender and similar initial cognitive status who did not die during the trial. Design and Methods: We conducted a two-group secondary data analysis of prospective observational data from 10 nursing homes in Birmingham, Alabama. By means of chart review, resident assessments, surveys of certified nursing assistants, and direct observation of residents' daily behaviors and environment, 32 residents (87.34 ± 7.29 years) with a Mini-Mental State Examination (MMSE) score = 4.31 (±5.54) who died were compared with 32 residents (84 ± 6.96 years) with a mean MMSE score = 4.28 (±5.49) who did not die during the clinical trial. Results: Residents who died displayed more verbal agitation, less time in verbal interaction with staff, and almost twice as much time restrained in bed during observation time in comparison with residents who did not die during the clinical trial. However, groups did not differ significantly in severity of comorbid illness, functional status, number of painful diagnoses, certified nursing assistants reports of residents' pain, or opioid or nonopioid analgesic prescription or dosage. Surviving residents were more likely to receive neuroleptic medication than residents who died. Implications: Results suggest that agitated nursing home residents may exhibit a heightened level of verbal agitation, decreased verbal interaction with staff, and increased bed restraint up to 3 months prior to death. Prospective observational studies are needed to identify markers for imminent mortality among nursing home residents. [ABSTRACT FROM AUTHOR]

Objective: To evaluate psychometric properties and response patterns of the Caregiver Assessment of Function and Upset (CAFU), a 15-item multidimensional measure of dependence in dementia patients and caregiver reaction. Method: 640 families were administered the CAFU (53% White, 43% African American, and 4% mixed race and ethnicity). We created a random split of the sample and conducted exploratory factor analyses on Sample 1 and confirmatory factor analyses on Sample 2. Convergent and discriminant validity were evaluated using Spearman rank correlation coefficients. Results: A two-factor structure for functional items was derived, and excellent factorial validity was obtained. Convergent and discriminant validity were obtained for function and upset measures. Differential response patterns for dependence and caregiver upset were found for caregiver race, relationship, and care recipient gender but not for caregiver gender. Discussion: The CAFU is easily administered, reliable, and valid for evaluating appraisals of dependencies and upsetting care areas. [ABSTRACT FROM AUTHOR]

Objectives: Recruitment is often the most challenging aspect of research with older persons. Social marketing--applying marketing techniques to influence the behavior of target audiences to improve their welfare--can help researchers identify factors that influence recruitment. Methods: Illustrations of social marketing principles are provided from the Resources for Enhancing Alzheimer's Caregiver Health project, a national Alzheimer's caregivers study that targeted ethnic and racial minorities. Results: Social marketing principles--the six Ps of participants, product, price, place, promotion, and partners--provide a theoretical framework for organizing and planning recruitment activities, including developing varying strategies to define the target audience (participants), develop the intervention (product), manage time and trouble (price), target the audience, improve accessibility (place), promote the study, and develop and work with partners. Discussion: Strategies to enhance recruitment are often undertaken without a comprehensive plan. A social marketing plan provides a framework to map out the steps in recruitment that will be needed and to plan for allocations of time, staff, and resources. [ABSTRACT FROM AUTHOR]

We examined differences in positive aspects of caregiving (PAC) among 275 African American and 343 Caucasian caregivers of individuals with Alzheimer's disease from the National Institutes of Health Resources for Enhancing Alzheimer's Care Health (REACH) study sites in Birmingham, Memphis, and Philadelphia. African Americans reported higher scores on PAC than did Caucasians. African Americans' higher religiosity partially mediated the relationship between race and PAC. Additional variables that contributed to their higher PAC scores were African Americans' lower anxiety, lower feelings of bother by the care recipient's behavior, and lower socioeconomic status. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to compare a variety of resident and staff outcomes across two types of staffing patterns, permanent and rotating assignment, and work shift. Although studies have examined these staffing patterns as part of multicomponent intervention packages, few studies have examined the isolated effects of staffing pattern by using an experimental design. Design and Methods: A between-groups comparison design was used to compare residents and certified nursing assistants (CNAs) from four nursing homes; two self-identified as using permanent assignment (PA) staffing and two as using rotating assignment (RA) staffing. Measures yielded data on verbal interaction among residents and staff, resident disruptive behavior, and specific aspects of resident-staff behavior during care routines. Other assessments included resident personal appearance and hygiene, expressed affect, and CNAs' job satisfaction, burnout, absenteeism, and turnover rates. A treatment fidelity check was conducted to confirm PA and RA staffing patterns. Results: Staffing patterns were significantly different between self-identified PA and RA nursing homes. Residents in PA nursing homes and on morning shifts received significantly higher ratings of personal appearance and hygiene. Rates of expressed sadness and interest among residents differed by staffing patterns and shift. However, these differences do not appear to be clinically significant. Although absenteeism was higher in PA nursing homes, these CNAs reported greater job satisfaction than CNAs from RA nursing homes. As expected, evening shifts across nursing homes had significantly higher turnover rates and significantly more resident disruptive behavior. Implications: Quality-of-care outcomes were similar among the two types of nursing homes, despite significantly different staffing patterns. Though staff permanency rates in PA nursing homes (50%) were twice that of RA nursing homes (26%), more research is needed to determine feasibility of higher rates of staff permanency (i.e., > 50%) and effects on resident and CNA outcomes. [ABSTRACT FROM AUTHOR]

This study is a critical analysis of the components of a communication skills training program designed to increase the quantity and quality of nursing aides' (N = 126) verbal interactions with residents with dementia (N = 125) during care routines. Training included a didactic in-service, one-on-one, criterion-based training during care interactions, the use of memory books, and a staff management system. Results indicated that this communication skills program significantly improved nursing aides' effective skills (p > .001), effective instructions (p > .01) and manner of communication during care interactions with residents. One-on-one performance training and feedback was required to master and maintain skill use 3 months beyond program termination. [ABSTRACT FROM AUTHOR]

Presents a study that examined the impact of psychological interventions on White and Afro-American family caregivers of individuals with dementia. Care recipient (CR) problem behaviors; Caregiver (CG) social support and activity; Effects of the relationship between CG and CR.

Provides an overview of the Resources for Enhancing Alzheimer's Caregiver Health (REACH) research program sponsored by the U.S. National Institute on Aging and the U.S. National Institute on Nursing Research. Primary purpose of REACH; REACH interventions by site; Descriptive profile of the caregivers participating in the interventions at REACH intervention sites.

Presents information on a study which identified correlates of advance care planning in nursing homes in the U.S. Assessment of resident capacity; Relation of study variables with advance directive possession; Statistical analysis.

OBJECTIVES: To examine correlates of analgesic medication prescription and administration in communicative, cognitively impaired nursing home residents. Residents' behaviors were assessed using computer-assisted real-time observations as potential adjunctive indicators of pain. DESIGN: Cross-sectional study over a 4-week period. SETTING: Five nursing homes in the greater Birmingham, Alabama, area. PARTICIPANTS: Ninety-two residents (mean age ± standard deviation = 83.86 ± 8.55) with a mean Mini-Mental State Examination (MMSE) score of 13.81 ± 6.34. MEASUREMENTS: Data were obtained via chart review, resident assessments, questionnaire completion by certified nursing assistants familiar with residents' care, and direct observation of residents' daily behaviors. RESULTS: Receipt of analgesic medication was related to self-report of pain (F 2,89 = 9.89, P = .0001), MMSE (F 2,88 = 3.98, P = .022), and time spent inactive (F 2,89 = 3.04, P = .053). Residents who received analgesic medication reported greater intensity of pain than other residents. Residents who received analgesics had higher MMSE scores than those who did not receive analgesics. Residents who received analgesics spent less time being inactive than those not prescribed analgesics. Receipt of higher dosage of opioid analgesic medication was associated with more time spent with others in verbal interaction (r = .22, P = .03). CONCLUSION: This study refines the methodology of measuring analgesic medication dosage and its effect on resident behavior. Analgesic prescription and administration patterns are related to time residents spend being inactive. Results suggest that opioid analgesics may hold particular promise in alleviating pain, as indicated by resident behaviors. [ABSTRACT FROM AUTHOR]

Agitation in nursing home residents presents a serious challenge to caregivers and may place residents at risk for harm. Understanding the etiology of agitation can assist clinicians in developing nonpharmacologic interventions for preventing and treating this problem. The purpose of this study was to examine independent and common predictors of resident agitation with structural equation modeling. Agitation was measured with both a standardized staff report rating scale and direct behavioral observation. No indirect or mediating effects were found. Cognitive impairment, vision and hearing impairment, and gender were found to be independent predictors of agitation as measured by direct behavioral observation. Only cognitive impairment was found to be predictive of agitation as measured by the standardized staff report scale. An unexpected finding was that vision impairment appeared to exert a protective effect for agitation in these severely cognitively impaired residents. The clinical implications of these findings are discussed as well as the relative merits of the two methods of measuring agitation. [ABSTRACT FROM AUTHOR]

Computer-assisted behavioral observation data were collected from 66 nursing home residents while they received assistance during personal care routines from a certified nursing assistant (CNA). Data were collected both before and after a comprehensive behavior-managemenl and communication-skills training program was delivered to the nursing staff. A total of 30 residents showed 6 or more episodes of disruptive vocalization or other forms of agitation during baseline observations, and timed-event sequential analysis methods were used to test whether certain CNA behaviors either elicited or prevented onsets of agitation in these 30 residents. Simple verbal prompts used by CNAs during personal care routines before staff training were found to elicit agitation onset (p = .03), whereas positive statements to the resident were found to reduce the likelihood of agitation onset (p = .02). In a previous analysis of the effects of staff training, we found that rates of resident agitation were significantly lower after training compared with baseline and that CNAs increased their rates of positive statements to residents. In the present study, timed-event sequential analyses indicated that the verbal prompts used by CNAs during personal care routines were no longer associated with an increased rate of resident agitation after staff training among the 20 residents who showed 6 or more episodes of agitation both before and after staff training. These findings suggest that the staff training program improved the quality of CNA verbal prompts. The sequential analysis of observational data provides an important method for studying interpersonal interactions, including those of nursing home residents and the nursing staff who care for them. [ABSTRACT FROM AUTHOR]

Presents information on a study which examined the efficacy of a comprehensive behavior management skills training program for improving certified nursing assistants' skill performance in the nursing home. Design and methods; Results and discussion; Implications.

Objective: To determine if caregivers of dementia patients can validly report (a) the level of patient activities of daily living (ADL) dependence and (b) the amount of time they spend providing ADL assistance. Design: Seven ADLs were assessed through caregiver report using the Functional Independence Measure (FIM) and then videotaped. Videotapes were coded using a computer-assisted data collection system that documented the nature and duration of caregiver assistance provided during ADLs. Setting: The study took place in the homes of the caregiver-patient dyads. Subjects: Twenty-one people with dementia and their primary caregivers participated in the study. Main outcome measures: Data analysis examined (a) the degree to which caregiver-reported FIM scores corresponded to FIM scores derived from the observational data and (b) the extent to which caregivers' estimates of ADL assistance time corresponded to the assistance time observed during ADL interactions. Results: For all ADLs, caregiver-reported FIM scores were correlated significantly with observation-derived FIM scores (r[sub s] values ranged from 0.620 to 0.909), and means were similar. Assistance durations were also significantly correlated for some ADLs, but means were significantly different, indicating poor correspondence. Conclusions: Although caregivers of dementia patients can describe the nature of their ADL assistance with reasonable accuracy, they consistently overestimate their ADL assistance time, suggesting that caregive reports of ADL assistance duration be used with caution. Additionally, the degree to which the assistance provided corresponds to the assistance actually needed needs to be addressed in future studies. [ABSTRACT FROM AUTHOR]

Investigates the association between certified nursing assistant on pain in Birmingham, Alabama. Medication used in cognitive impaired nursing home resident; Assessment by three-mile proxy pain questionnaires; Reliability of coefficients for test-retest items.

The effects of a 12-week intervention on a patient-focused skills training group and a caregiver-focused skills training group were compared with those on a control group that received comparable attention, but no training. Intervention effects were monitored at the completion of the treatment phase and at 3- and 6-months postintervention. Treatment implementation was documented in a comprehensive fashion to ensure replicability. Both training groups acquired skills that enabled them to improve targeted behaviors (patient problem behaviors and caregiver mood, respectively). Weaker effects were found for more distal outcomes, such as depression, perceived stress, caregiver strain, and self-efficacy. [ABSTRACT FROM AUTHOR]

The effect of memory aids on conversations between nursing aides and residents with dementia during 5-minute conversations was examined. Nursing home units in seven nursing homes were randomly assigned to treatment and control conditions. Residents in the treatment condition were given 12-page memory books consisting of autobiographical, daily schedule, and problem resolution information. Their assigned nursing aides were trained to use the memory books during care interactions and throughout the day. The duration and quality of verbal interactions between dyads of a resident and their nursing aide during 5-minute conversations were measured pre-and post-treatment using computer-assisted observational techniques and verbatim transcriptions of videotaped conversations (N = 66; 33 treatment dyads and 33 control dyads). The results revealed improvements on a variety of quantitative conversational measures (e.g., duration of speaking time, frequency of utterances) between treatment and control conditions as a function of memory book use. Similarly, the quality of conversations, as measured by the frequency of discourse characteristics (e.g., facilitative behaviors), improved as a function of memory book use for treatment dyads. Nursing aides' judgment of residents' depressive symptoms improved with memory aid use, suggesting changes in resident quality of life as a result of an AAC technique that enhanced information sharing and social closeness. [ABSTRACT FROM AUTHOR]

Deals with a study which discussed the importance of assessing and reporting treatment implementations in dementia caregiver research. Fundamental aspects on intervention application; Multiple threats to consistency of inducing treatment delivery; Strategies in inducing and assessing treatment delivery.

Presents information on a study which examined the effects of communication skills training and the use of memory books by certified nursing assistants (CNA) on verbal interactions between CNA and nursing home residents during care routines. Functions of memory books; Intervention conditions; Methodology; Results and discussion.

In this preliminary, intrasubject study (N = 8), we examined the effects of communication skills training and the use of memory books by Nursing Assistants (NAs) on the social ecology of a nursing home. Through inservice and on-the-job training, NAs were taught to use communication skills and memory books during their interactions with residents with mild to moderate cognitive impairment (Mini Mental Status Examination, M = 16.25), but relatively intact communication abilities. An abbreviated staff motivational system called Behavioral Supervision (Burgio and Burgio, 1990. Int. J. Aging Hum. Deve. 30: 287–302.) was attempted to encourage performance of these skills on the nursing units. Results showed that, regardless of sporadic implementation of the intervention by nursing staff, the intervention improved communication between staff and residents during care routines, increased the amount of time other residents and visitors spent talking with target residents, and increased the rate of positive statements made by the target residents and others in their immediate environment. Results are discussed in terms of limitations of the staff motivational system and modifications made to the system in a larger ongoing intervention trial. [ABSTRACT FROM AUTHOR]

This study used computer-assisted real-time data collection procedures to study temporal patterns of disruptive vocalization (DV) in demented nursing home residents. Residents (N = 68) were observed from 8 a.m. to 8 p.m. and total mean duration of DV within hourly blocks was calculated. Analysis of the temporal distribution of DV exhibited by the group of 68 residents indicated a significant cubic trend. Exploratory cluster analysis uncovered three distinct temporal patterns of DV; although two of the patterns are generally supportive of sundowning. Cluster 1 showed a relatively constant pattern of low rate DV. Clusters 2 and 3 showed cyclic trends. Peaks in DV were observed during noontime and in the evening for Cluster 2. Cluster 3 showed peaks in DV in the early morning hours and late afternoon. MANOVA was employed to examine any differences among clusters in age, cognitive status, and ADL status. Univariate analyses indicated that cognitive status was the only factor that differed significantly among clusters, with members of Cluster 1 (constant low rate DV) manifesting higher cognitive status scores than Clusters 2 and 3. A step-wise discriminant function analysis also showed cognitive status to be the only statistically significant predictor of cluster membership. The authors' note that the scientific literature on agitation is fraught with contradictory findings and assert that inconsistencies may be due to differences across studies in problem definition, method of measurement, and sample size. The results are discussed in relation to these methodological issues and clinical implications of the findings. Copyright © 2001 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]