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Background Falls are a widespread and persistent problem for community-dwelling older adults. Use of fall prevention guidelines in the primary care setting has been suboptimal. Interoperable computerized clinical decision support systems have the potential to increase engagement with fall risk management at scale. To support fall risk management across organizations, our team developed the ASPIRE tool for use in differing primary care clinics using interoperable standards. Objectives Usability testing of ASPIRE was conducted to measure ease of access, overall usability, learnability, and acceptability prior to pilot . Methods Participants were recruited using purposive sampling from two sites with different electronic health records and different clinical organizations. Formative testing rooted in user-centered design was followed by summative testing using a simulation approach. During summative testing participants used ASPIRE across two clinical scenarios and were randomized to determine which scenario they saw first. Single Ease Question and System Usability Scale were used in addition to analysis of recorded sessions in NVivo. Results All 14 participants rated the usability of ASPIRE as above average based on usability benchmarks for the System Usability Scale metric. Time on task decreased significantly between the first and second scenarios indicating good learnability. However, acceptability data were more mixed with some recommendations being consistently accepted while others were adopted less frequently. Conclusion This study described the usability testing of the ASPIRE system within two different organizations using different electronic health records. Overall, the system was rated well, and further pilot testing should be done to validate that these positive results translate into clinical practice. Due to its interoperable design, ASPIRE could be integrated into diverse organizations allowing a tailored implementation without the need to build a new system for each organization. This distinction makes ASPIRE well positioned to impact the challenge of falls at scale.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. This new group of articles provides practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses.

Editor's note: This article is by 22 nursing gerontology experts who are all advocates of nursing home reform. They are listed at the end of this article.

Background The profession of nursing has been on the front line of pain assessment and management in older adults for several decades. Self-report has traditionally been the most reliable pain assessment method, and it remains a priority best practice in identifying the presence and intensity of pain. Although advances in technology, biomarkers, and facial cue recognition now complement self-report, it is still important to maximize self-report of pain and to gather understanding of the total pain experience directly from patients. Practices in pain assessment in older adults have evolved over the past 25 years, and current research and quality improvement studies seek not only to detect the presence of pain, but also to determine the best protocol for assessment and most important pain characteristics to assess. Increasing data are now supporting two emerging practices: (1) consistently assessing the impact of pain on function, and (2) measuring pain during movement-based activities rather than at rest. Objective The purpose of this article is thus to discuss the shifting paradigm for movement-based pain assessment in older adults, as well as the practice, policy, and regulatory drivers that support this practice change.

Vitamin C, well-established in immune function and a key factor in epigenetic inflammatory modifications, is only obtained through consistent dietary intake. Identifying individuals at risk for Vitamin C insufficiency may guide prevention and treatment, however, national surveillance has not been evaluated in the United States since 2006. A descriptive, cross-sectional secondary analysis was performed utilizing data from the 2003–2006 National Health and Nutrition Examination Surveys (NHANES) assessing non-institutionalized adults. Five categories of plasma Vitamin C were delineated: deficiency (&lt, 11 μmol/L), hypovitaminosis (11–23 μmol/L), inadequate (23–49 μmol/L), adequate (50–69 μmol/L), and saturating (≥70 μmol/L). Results indicated 41.8% of the population possessed insufficient levels (deficiency, hypovitaminosis, and inadequate) of Vitamin C. Males, adults aged 20–59, Black and Mexican Americans, smokers, individuals with increased BMI, middle and high poverty to income ratio and food insecurity were significantly associated with insufficient Vitamin C plasma levels. Plasma Vitamin C levels reveal a large proportion of the population still at risk for inflammatory driven disease with little to no symptoms of Vitamin C hypovitaminosis. Recognition and regulation of the health impact of Vitamin C support the goal of Nutrition and Healthy Eating as part of the Healthy People 2030.

Background: Implementation of evidence-based performance metrics drive standardized care and improve patient outcomes. Limited performance metrics have been developed for implementation in the aneurysmal subarachnoid hemorrhage (aSAH) population. Timely aneurysm repair following an aSAH is associated with rebleeding prevention and mortality. The purpose of this study was to evaluate time to aneurysm repair as a candidate performance metric by testing a model that includes hospital and patient characteristics as predictors of time to aneurysm repair and mortality, with time to aneurysm repair as a potential influence on these relationships in aSAH. Methods: A retrospective, cross-sectional analysis of patient discharge data from 2014 in the state of Florida was conducted. Data were derived from The Agency for Healthcare Research and Quality, HealthCare Utilization Project, State Inpatient Dataset, and the American Hospital Association Annual Survey. Patients with a primary ICD-9 diagnosis of aSAH and principle procedure of clipping or coiling were included (n=387). The study outcome was in-hospital mortality. Independent variables were level of stroke center, age, race, sex, and type of aneurysm repair. Hierarchical logistic regression was used to estimate the probability of in-hospital death. Results: Patients who underwent endovascular repair of an aneurysm were more likely to be treated in p =0.01). Patients treated at a comprehensive stroke center (CSC) had a 72% reduction in odds of death compared to those treated at primary stroke centers (OR =0.28, CI = 0.10-0.77, p =0.01), controlling for disease severity and comorbidity. Time to aneurysm repair was not significantly associated with mortality and did not influence the relationship between hospital and patient characteristics and mortality. Conclusions: Treatment at a certified CSC was the only significant predictor of surviving aSAH. Time to aneurysm repair did not influence the relationship between hospital and patient characteristics associated with mortality. Further research is needed to identify appropriate measures and to define what should be tracked for performance in the aSAH population.

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) is a medical emergency that requires rapid identification and focused assessment early to ensure the best possible outcomes. The purpose of this study is to evaluate the associations between system and patient factors and emergency department (ED) length of stay and in-hospital mortality in patients given a diagnosis of ICH. METHODS: A sample of 3108 ICH patients was selected from a statewide administrative database for cross-sectional retrospective analysis. System characteristic (hospital stroke certification), patient characteristics (age, sex, and race), and covariate conditions (stroke severity and comorbidities) were analyzed using descriptive statistics and hierarchical logistic regression models to address the study questions. RESULTS: The mean ED length of stay is 2.9 ± 3 hours (range, 0-42 hours) before admission to an inpatient unit. Inpatient mortality is 14.9%. Stroke center certification (P.000) and stroke severity (P ≤ .000) are significant predictors of ED length of stay, whereas age (P.000), stroke severity (P.000), comorbidities (P = .047), and ED length of stay (P = .04) are significant predictors of in-hospital mortality. Most notably, an ED length of stay of 3 hours or longer has a 37% increase in the odds of in-hospital mortality. CONCLUSION: Our findings support age, stroke severity, and ED length of stay as predictors of in-hospital mortality for ICH patients. The importance of timely admission to an inpatient unit is emphasized. Optimal systems of care and expedited inpatient admission are vital to reduce morbidity and mortality for ICH stroke patients.

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) is a medical emergency that requires rapid identification and focused assessment early to ensure the best possible outcomes. The purpose of this study is to evaluate the associations between system and patient factors and emergency department (ED) length of stay and in-hospital mortality in patients given a diagnosis of ICH. METHODS: A sample of 3108 ICH patients was selected from a statewide administrative database for cross-sectional retrospective analysis. System characteristic (hospital stroke certification), patient characteristics (age, sex, and race), and covariate conditions (stroke severity and comorbidities) were analyzed using descriptive statistics and hierarchical logistic regression models to address the study questions. RESULTS: The mean ED length of stay is 2.9 ± 3 hours (range, 0-42 hours) before admission to an inpatient unit. Inpatient mortality is 14.9%. Stroke center certification (P < .000) and stroke severity (P ≤ .000) are significant predictors of ED length of stay, whereas age (P < .000), stroke severity (P < .000), comorbidities (P = .047), and ED length of stay (P = .04) are significant predictors of in-hospital mortality. Most notably, an ED length of stay of 3 hours or longer has a 37% increase in the odds of in-hospital mortality. CONCLUSION: Our findings support age, stroke severity, and ED length of stay as predictors of in-hospital mortality for ICH patients. The importance of timely admission to an inpatient unit is emphasized. Optimal systems of care and expedited inpatient admission are vital to reduce morbidity and mortality for ICH stroke patients.

Objectives: Given prevalence differences of mild cognitive impairment (MCI) among Black and white older adults, this study aimed to examine whether overall vascular risk factor (VRF) burden and individual VRF associations with amnestic (aMCI) and nonamnestic (naMCI) MCI status varied by Black/white race. Methods: Participants included 2755 older adults without dementia from the ACTIVE study. Comprehensive neuropsychological criteria were used to classify cognitively normal, aMCI, and naMCI. VRFs were primarily defined using subjective report and medication data. Multinomial logistic regression was run predicting MCI subtype. Results: Greater overall VRF burden, high cholesterol, and obesity evinced greater odds of naMCI in Black participants than whites. Across participants, diabetes and hypertension were associated with increased odds of aMCI and naMCI, respectively. Discussion: Results may reflect known systemic inequities on dimensions of social determinants of health for Black older adults. Continued efforts toward examining underlying mechanisms contributing to these findings are critical.

Pain is a common problem for many older adults. Estimates are that more than 50% of older adults experience pain on a regular basis. We provide an overview of pain, including definitions, types of pain, and pain theories and their evolution over time. The study of pain and aging is relatively new, and a history of this area of clinical and research attention is reviewed. We discuss the epidemiology of pain in older adults, age-changes in pain, factors that contribute to pain, and consequences of pain in this population. Pain management requires systematic assessment and effective pain treatment. Strategies for measuring pain are described, including an overview of pain assessment in people with dementia, an area in which substantial advancements have been made. Pain treatment is optimized when a combination of pharmacological and nonpharmacological strategies are used; an overview of pain treatment options is presented.

Purpose Effective pain management for patients undergoing orthopedic surgery, using pharmacological and nonpharmacological strategies, is essential. This pilot study evaluated music as an adjuvant therapy with prescribed analgesics to reduce acute pain and analgesic use among patients undergoing arthroplasty surgery. Design Prospective randomized controlled trial of 50 participants scheduled for arthroplasty surgery at a large university-affiliated hospital. Methods Participants were randomly assigned to treatment (music and analgesic medication; n = 25) or control (analgesic medication only; n = 25) groups. The intervention consisted of listening to self-selected music for 30 minutes, three times per day postoperatively in hospital and for 2 days postdischarge at home. Participants rated pain intensity and distress before and after music listening (treatment group) or meals (control group). Analgesic medication use was assessed via medical records in hospital and self-report logs postdischarge. Results Forty-seven participants completed the study. Participants who listened to music after surgery reported significantly lower pain intensity and distress in hospital and postdischarge at home. There were no statistically significant differences in analgesic medication use after surgery between groups. Conclusions Study findings provide further evidence for the effectiveness of music listening, combined with analgesics, for reducing postsurgical pain, and extend the literature by examining music listening postdischarge. Music listening is an effective adjuvant pain management strategy. It is easy to administer, accessible, and affordable. Patient education is needed to encourage patients to continue to use music to reduce pain at home during the postoperative recovery period.

Although undisputed for its anti-inflammatory and immune system boosting properties, vitamin C remains an inconsistently investigated nutrient in the United States. However, subclinical inadequacies may partly explain increased inflammation and decreased immune function within the population. This secondary analysis cross-sectional study used the 2003–2006 NHANES surveys to identify more clearly the association between plasma vitamin C and clinical biomarkers of acute and chronic inflammation C-reactive protein (CRP) and red cell distribution width (RDW). From plasma vitamin C levels separated into five defined categories (deficiency, hypovitaminosis, inadequate, adequate, and saturating), ANOVA tests identified significant differences in means in all insufficient vitamin C categories (deficiency, hypovitaminosis, and inadequate) and both CRP and RDW in 7607 study participants. There were also statistically significant differences in means between sufficient plasma vitamin C levels (adequate and saturating categories) and CRP. Significant differences were not identified between adequate and saturating plasma vitamin C levels and RDW. Although inadequate levels of vitamin C may not exhibit overt signs or symptoms of deficiency, differences in mean levels identified between inflammatory biomarkers suggest a closer examination of those considered at risk for inflammatory-driven diseases. Likewise, the subclinical levels of inflammation presented in this study provide evidence to support ranges for further clinical inflammation surveillance.

Using resting state functional magnetic resonance imaging (RS-fMRI), we explored: 1) pre- to post-operative changes in functional connectivity in default mode, salience, and central executive networks after total knee arthroplasty (TKA) with general anesthesia, and 2) the contribution of cognitive/brain reserve metrics these resting state functional declines. Individuals age 60 and older electing unilateral total knee arthroplasty (TKA; n = 48) and non-surgery peers with osteoarthritis (n = 45) completed baseline cognitive testing and baseline and post-surgery (post-baseline, 48-h post-surgery) brain MRI. We acquired cognitive and brain estimates for premorbid (vocabulary, reading, education, intracranial volume) and current (working memory, processing speed, declarative memory, ventricular volume) reserve. Functional network analyses corrected for pain severity and pain medication. The surgery group declined in every functional network of interest (p

Objectives Analyzing medication data for research purposes is complex, and methods are rarely described in the literature. Our objective was to describe methods of quantifying opioid and nonopioid analgesics and to compare the utility of five different analgesic coding methods when analyzing relationships between pain, analgesic use, and clinical outcomes. In this study, we used physical function as the outcome variable for its clinical relevance and its relationship to pain in older adults. Design Secondary analyses of baseline cross-sectional data from the Advanced Cognitive Training Interventions for Vital Elders (ACTIVE) study. Setting Community settings in six regions of the United States. Subjects A total of 2,802 community-residing adults older than age 65 years. Methods A medication audit was conducted. Analgesics were coded as any pain medication, counts (total analgesics, number of opioids and nonopioids), equianalgesics (oral morphine equivalents, oral acetaminophen equivalents), and dose categories. Adjuvant medications used to treat pain (e.g., tricyclic antidepressants and anticonvulsants) and low-dose aspirin typically used for cardiovascular conditions were excluded from these analyses. To examine the utility of these various approaches, a series of hierarchical regression models were conducted with pain and analgesics as predictors and physical functioning as the dependent variable. Results Eighty-one point nine percent of participants reported experiencing recent pain, but 26% reported analgesic use. Nonopioids were the most common drug class used. Models revealed that pain was significantly associated with worse physical function (β = -0.45, P = 0.001), after controlling for demographic and analgesic variables. Two basic drug coding methods (e.g., any pain medication, number of pain medications) were equivalent in their explanatory power (β = -0.12, P = 0.001) and were slightly stronger predictors of function than the more complex coding procedures. Conclusions Analgesic medications are important variables to consider in community-based studies of older adults. We illustrate several methods of quantifying analgesic medications for research purposes. In this community-based sample, we found no advantage of complex equianalgesic coding methods over simple counts in predicting physical functioning. The results may differ depending on the research question or clinical outcome studied. Thus, methods of analyzing analgesic drug data warrant further research.

Pain is a common experience for many older adults. Significant efforts have been undertaken to address and improve the assessment of pain in older adults over the past 2 decades. There have been many empirical studies and several expert panel statements to guide health care providers in the best practices for assessing pain in this population. This article provides a conceptual model that summarizes causes and consequences of pain and highlights the relationship between acute and persistent pain. Recommendations for pain assessment tools, including those developed for use in cognitively impaired elders, are presented.

Background Approximately 1.6 million Americans were diagnosed with cancer in 2014. To combat their disease, many individuals received either curative or palliative treatments that produced undesired symptoms. These symptoms, which often cause significant distress for individuals coping with cancer, may share biologic underpinnings such as epigenetic changes and immune dysregulation. Alterations in the normal flora of the gut may also influence cancer symptoms. Objective The aim of this review is to describe the emerging role for the gut microbiome in cancer research, especially the potential relationship between the gut microbiome and cancer symptoms. Methods Extant literature was reviewed and synthesized. Results The majority of studies linking the gut microbiota and cancer are animal models and focus on the relationship between dysbiosis and colorectal cancer. Emerging evidence supports that the "gut-brain" connection is a plausible mechanism for "psychoneurological" cancer symptoms such as depression, pain, and fatigue. Conclusions There is compelling evidence that the gut microbiota affects cancer via several mechanisms, including microbial diversity and number, metabolism, and/or immune initiation. However, more research is necessary to elucidate these mechanisms, particularly among a variety of cancers and cancer-related symptoms. Implications for practice A better understanding of the role of the gut microbiota in cancer symptoms may lead to the development of targeted individualized interventions affecting the gut microbiota that prevent or ameliorate dysbiosis, thereby reducing symptoms. These interventions may emphasize self-care management strategies essential for wellness, such as diet, nutrition, and stress reduction.

Many nurses report a lack of confidence providing care for patients facing a life-threatening illness. Palliative care leaders have devised primary palliative nursing care competencies (CARES [Competencies And Recommendations for Educating undergraduate nursing Students]) that all students should achieve. In this study, nursing students participated in an innovative palliative care immersion experience, the Comfort Shawl Project. We performed a reliable content analysis of their narrative reflections. The goal was to evaluate whether reflections on their interactions with patients/families were consistent with CARES competencies. Nine female students wrote reflections after gifting each of the 234 comfort shawls to patients. Four CARES-related categories were analyzed: Individual Values and Diversity, Compassionate Communication, Fostering Quality of Life, and Self-Insight and Emotion. Reflections were highly representative (41%) of recognizing Individual Values and Diversity, representing sensitivity for patients’ unique differences in values, an integral component of palliative care. The Comfort Shawl Project shows promise as an experiential immersion for introducing nursing students to CARES competencies.

Although there is a wealth of literature addressing effective pharmacological interventions for individuals receiving palliative care, less attention has been devoted to behavioural management of common physical and psychological symptoms seen in individuals with serious illness. Behavioural methods of symptom management are promising as adjuvant and stand-alone treatment options, and this chapter highlights these methods, what symptoms they may effectively treat, and the evidence supporting their use in individuals receiving palliative care. Specific treatment methods addressed include acupuncture, aromatherapy, massage, therapeutic touch, environmental control, Snoezelen, music therapy, art therapy, animal assisted therapy, guided imagery, hypnosis, meditation, relaxation, tai chi, yoga, qigong, cognitive behavioural therapy, acceptance and commitment therapy, self-transcendence, and spiritual/religious interventions. The chapter concludes with a case summary to highlight potential clinical implications of these methods. Overall, behavioural methods are important tools for practitioners to consider in striving for the most holistic, effective management of physical and psychological symptoms in individuals facing serious illness.

Background: The nursing role includes providing compassionate care at the end of life, yet many nurses feel unprepared to provide such care. We describe nursing students' reactions during participation in an experiential immersion in palliative care in which they interacted with seriously ill patients through gifting handmade shawls. Method: After gifting, students wrote three words that best described the feeling in the room. Responses were content-analyzed to assess the frequency of specific concepts produced in the Three Words task. Gifting Reflection narratives were used to characterize the content–analysis categories. Results: Nursing students' most common responses were reflected in the categories Comfort and Kindness, and Thankfulness and Appreciation. Students also reported Sorrow and Need, but positive themes of Happiness and Delight, and Calm and Reflective were equally as prevalent. Conclusion: Experiential learning that focuses on psychosocial learning can result in nurses having positive, meaningful experiences in caring for seriously ill patients. [ J Nurs Educ . 2018;57(11):675–679.]

Diagnostic imaging of disease severity has been found thus far to be a relatively modest predictor of knee osteoarthritis (OA) pain and disability, suggesting that other factors likely contribute to clinical symptoms in this condition. Recent evidence suggests that sensitization of the peripheral and central pathways that process nociceptive information (i.e., pain sensitization) is an important contributor to knee OA clinical symptoms. Furthermore, low levels of vitamin D have been found to be associated with the presence of pain sensitization, as well as the overall experience of clinical pain severity in knee OA. African–Americans with knee OA may be at increased risk for poor clinical outcomes given evidence of lower vitamin D levels as well as greater pain sensitization compared with non-Hispanic whites. Whether vitamin D supplementation is effective for alleviating knee OA clinical symptoms is an important topic to be addressed in future research with racially diverse samples that include sufficient numbers of African–Americans.

Summary Purpose The purpose of this study was to investigate if pain mediates or moderates the relationship between cognitive impairment and aggressive behaviors in nursing home residents with dementia based on the Need-driven Dementia-compromised Behavior model. Methods This was a secondary analysis of the Minimum Data Set assessment data on long-term care from the state of Florida during calendar year 2009. The data used in this study was the first comprehensive assessment data from residents with dementia ( N = 56,577) in Medicare-certified or Medicaid-certified nursing homes. Path analysis using a series of hierarchical regression analyses and two-way analysis of variance was used to evaluate the mediating and moderating effect of pain on the relationship between the level of cognitive impairment and aggression. Results Results indicated that pain did not mediate the relationship between cognition and aggressive behaviors, but there was evidence of a significant moderating effect of pain only for residents with severe cognitive impairment. Only among the residents with severe cognitive impairment, those with pain had significantly more frequent aggressive behaviors than those without pain. Conclusion A change in the frequency of aggressive behaviors in severely cognitively impaired residents should signal the possibility that the person is experiencing pain. Accurate but simple pain assessment in this population including these behavioral changes should be developed further, and pain should be well controlled to reduce these problematic behaviors.

Reduced cognitive skills have been observed in adults with chronic pain. The purpose of this study was to explore the relationship between pain and cognition in adults utilizing a large national sample. This was a cross-sectional study employing the 2015 wave of the Behavioral Risk Factor Surveillance System (BRFSS). A total of 134,058 adults had complete data on the variables of interest for this study. Half of the sample (50%; n = 66,479) reported having joint symptoms or arthritis that was physically limiting and 16% (n = 21,976) reported having difficulty concentrating, remembering, or making decisions. Twelve percent (n = 16,537) of this sample reported having both physically limiting pain and difficulty concentrating and remembering. Chi-square analyses reveal a statistically significant association between pain and cognition in this sample [X2(1, N= 134,058) = 6925.5, p

To enhance the learner's competence by providing research about pressure ulcer-related pain in nursing home residents with cognitive impairment.This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.After participating in this educational activity, the participant should be better able to:1. Explain this study's methodology and tools.2. Predict levels of pressure ulcer pain in a nursing home population with dementia.The objective of this study was to examine how pain is reported in cognitively impaired nursing home residents with pressure ulcers using the Minimum Data Set 2.0 data set. The study design was cross-sectional, comparative stratified by 3 levels of cognitive impairment and 4 stages of PrUs.There were 56,577 participants in the study.

In the acute care setting, pain, agitation, and delirium (PAD) often occur as interrelated parts of a syndrome rather than as separate entities. Because the three facets of PAD may be similar in presentation, it is often difficult for clinicians to recognize the syndrome and to assess and treat it. The challenge is particularly great in older patients, who are more likely than their younger counterparts to have such comorbid conditions as dementia, which may impair the ability to report pain, or age-related physiologic changes that may affect the metabolism and clearance of certain medications. This article provides an overview of each aspect of PAD, discusses clinical considerations related to the assessment and treatment of the syndrome in older adults receiving acute care, and illustrates the application of published PAD guidelines through the use of a hypothetical patient scenario.

Low circulating serum levels of 25-hydroxyvitamin D (referred to hereafter as vitamin D) have been correlated with many health conditions, including chronic pain. Recent clinical practice guidelines define vitamin D levels20 ng/ml as deficient and levels of 21-29 ng/ml as insufficient. Vitamin D insufficiency, including the most severe levels of deficiency, is more prevalent in black Americans. Ethnic and race group differences have been reported in both clinical and experimental pain, with black Americans reporting increased pain. The purpose of this study was to examine whether variations in vitamin D levels contribute to race differences in knee osteoarthritis pain.The sample consisted of 94 participants (74% women), including 45 blacks and 49 whites with symptomatic knee osteoarthritis. Their average age was 55.8 years (range 45-71 years). Participants completed a questionnaire on knee osteoarthritis symptoms and underwent quantitative sensory testing, including measures of sensitivity to heat-induced and mechanically induced pain.Blacks had significantly lower levels of vitamin D compared to whites, demonstrated greater clinical pain, and showed greater sensitivity to heat-induced and mechanically induced pain. Low levels of vitamin D predicted increased experimental pain sensitivity, but did not predict self-reported clinical pain. Group differences in vitamin D levels significantly predicted group differences in heat pain and pressure pain thresholds at the index knee and ipsilateral forearm.These data demonstrate that race differences in experimental pain are mediated by differences in the vitamin D level. Vitamin D deficiency may be a risk factor for increased knee osteoarthritis pain in black Americans.

OBJECTIVES: To investigate the relationship between self-report and behavioral indicators of pain in cognitively impaired and intact older adults. DESIGN: Quasi-experimental, correlational study of older adults. SETTING: Data were collected from residents of nursing homes, assisted living, and retirement apartments in north-central Florida. PARTICIPANTS: One hundred twenty-six adults, mean age 83; 64 cognitively intact, 62 cognitively impaired. MEASUREMENTS: Pain interviews (pain presence, intensity, locations, duration), pain behavior measure, Mini-Mental State Examination, analgesic medications, and demographic characteristics. Participants completed an activity-based protocol to induce pain. RESULTS: Eighty-six percent self-reported regular pain. Controlling for analgesics, cognitively impaired participants reported less pain than cognitively intact participants after movement but not at rest. Behavioral pain indicators did not differ between cognitively intact and impaired participants. Total number of pain behaviors was significantly related to self-reported pain intensity (β=0.40, P=.000) in cognitively intact elderly people. CONCLUSION: Cognitively impaired elderly people self-report less pain than cognitively intact elderly people, independent of analgesics, but only when assessed after movement. Behavioral pain indicators do not differ between the groups. The relationship between self-report and pain behaviors supports the validity of behavioral assessments in this population. These findings support the use of multidimensional pain assessment in persons with dementia.

To determine the relationship between clinical variables (demographics, cognitive testing, comorbidities, and medications) and failing a standardized road test in older adults.Analysis of on-the road studies performed in optimal weather conditions, between January 1, 2005, and May 1, 2007. The standardized testing was held at the National Older Driver Research and Training Center (NODRTC), Florida, and included 127 adults aged 65 and older with current driver licenses, recruited by advertisement from the Gainesville, Florida, community. Measurements consist of demographics, self-reported medications and medical conditions, cognitive testing including Trail Making Part B, global rating score (pass/fail), and driver maneuver score (0-273, with 273 indicating perfect driving or zero errors).A total of 127 older adults completed the protocol. Mean age was 74.8 years (SD = 6.3); 46.5% females. Mean time for Trail Making Part B was 114.3 seconds (SD of 83). Among the 127 drivers, the mean Sum of Maneuvers Score was 238.9 (SD of 25.0) and 24 (19%) failed the driver test. Odds ratio estimates for failing the test included advanced age (6.7, 95% CI 2.2 to 19.8), presence of a neurological disease (2.8, 95% CI 1.2 to 6.5), and prolonged time to complete the Trail Making Part B cognitive test (2.5, 95% CI 1.0 to 5.9). Conversely, odds ratio estimates lowering the risk of failure included taking a non-diabetic hormonal medications (e.g., thyroid and estrogen drugs; 0.3, 95% CI .09 to 0.7) and having a musculoskeletal diagnosis (0.3, 95% CI .1 to 0.7).To our knowledge, this is the first study to examine the medical predictors of failing a standardized road test. Advanced age and prolonged time on Trail Making Part B were the two major predictors of test failure and a lower Sum of Maneuvers Score. Our study also found that having a neurological diagnosis (primarily cerebrovascular and Parkinson's disease) predicted test failure. Medications from neurological class also predicted a lower Sum of Maneuvers Score. Further study needs to be done to explain the apparent protective effect of musculoskeletal conditions and hormonal medications.

Pain in older adults is very often undertreated, and it may be especially so in older adults with severe dementia. Changes in a patient's ability to communicate verbally present special challenges in treating pain, and unrelieved pain can have serious consequences, including declines in physical function and diminished appetite. The Pain Assessment in Advanced Dementia (PAINAD) scale has been designed to assess pain in this population by looking at five specific indicators: breathing, vocalization, facial expression, body language, and consolability. A trained nurse or other health care worker can use the scale in less than five minutes of observation. For an online video showing nurses using the PAINAD scale and other pain-assessment tools, go to http://links.lww.com/A251.

Mild Cognitive Impairment (MCI), a relatively new descriptive category, is believed to represent a stage between normal aging and early dementia. Nurse practitioners, who provide care for older adults across a variety of settings, are in a key position to detect early cognitive changes. The purpose of this study is to describe one approach to identifying MCI using a variety of measures and a consensus conference with neuropsychologists. The study was conducted in a sample of 130 elderly participants (X̅ age= 82.5 yrs; 81% female) residing in nursing homes, assisted living facilities, and senior housing. A team of clinicians (neuropsychologists and nurses) reviewed cognitive, mental health, and demographic data in consensus conference and classified study participants into one of three groups: cognitively intact (50.8%), amnestic MCI (19.2%), or probable dementia (30%). Discriminant function analysis (DFA) was used to independently classify individuals into cognitive status groups based on test scores alone, and to compare quantitatively-determined groups with consensus conference evaluations. The results indicate that the DFA correctly classified 95% of the participants. Further, results revealed a pattern in which persons with amnestic MCI have subtle memory impairments (similar to persons with dementia) but that more general cognitive functioning remains high (similar to intact persons). Nurse practitioners’ heightened awareness of subtle distinctions in the dimensions of cognitive status associated with MCI can enhance their practice and assist them in making more informed referrals for dementia evaluations.

The prevalence of knee osteoarthritis (OA) is increasing with the aging population and is exacerbated by the growing numbers of obese older adults. Low levels of vitamin D, measured by serum 25-hydroxyvitamin D (25(OH)D), in older adults and obese individuals are correlated with several negative health conditions, including chronic pain. This cross-sectional study sought to examine the interactive influence of 25(OH)D levels and obesity on knee OA pain and functional performance measures.The sample consisted of 256 (63% female) racially diverse (55% black/African Americans) middle-aged and older adults (mean age 56.8 y). Blood was collected for analysis of 25(OH)D by high-performance liquid chromatography. Participants provided self-report regarding knee OA pain and underwent a lower extremity functional performance test.Results demonstrated that obesity was associated with lower levels of 25(OH)D. Participants with adequate 25(OH)D levels reported significantly less knee OA pain compared with participants with deficient or insufficient levels, regardless of obesity status. Furthermore, there was a significant interaction between obesity and 25(OH)D levels for lower extremity functional performance, such that obese individuals with adequate 25(OH)D levels demonstrated better performance than those obese participants with deficient or insufficient 25(OH)D levels.The mechanisms by which adequate 25(OH)D levels are associated with pain severity and improved function have not been completely elucidated. It may be that the pleiotropic role of biologically active 25(OH)D influences pain and pain processing through peripheral and central mechanisms. Alternatively, higher levels of pain may lead to reduced outdoor activity, which may contribute to both obesity and decreased vitamin D. Thus, investigating vitamin D status in obese and nonobese individuals with knee OA warrants further study.

The Revised Observed Tasks of Daily Living (OTDL-R), a performance-based test of everyday problem solving, was administered to a sample of community-dwelling older adults. The OTDLR included nine tasks, representing medication use, telephone use, and financial management. The OTDL-R had a desirable range of difficulty and satisfactory internal consistency and showed a relatively invariant pattern of relations between measured tasks and the underlying latent dimensions they represent across White and non-White subsamples. The OTDL-R also correlated significantly with age, education, self-rated health, a paper-and-pencil measure of everyday problem solving, and measures of basic cognitive functioning. Thus, the OTDL-R is a reliable and valid objective measure of everyday problem solving that has great practical utility for assessing performance in diverse populations.

Pain is a significant problem for older adults, and it has the potential to negatively impact their independence, functioning, and quality of life. In order for pain to be managed effectively, it first must be assessed carefully and systematically. Pain assessment in patients with dementia should start with self-report of pain, but must incorporate assessment of nonverbal pain behaviors. Pain treatment in older adults should be tailored to the individual. Pain medications can be used safely in elders, and they may be more effective when combined with nonpharmacological treatment. Despite the preponderance of research on pain, relatively few investigations have focused on pain in older adults in general, and on persons with dementia specifically. Better strategies for assessing pain, using observational methods, are the cornerstone of effective pain management in persons with dementia. Practitioners must be knowledgeable about pain treatment, and use both pharmacological and nonpharmacological strategies to relieve pain. Moreover, clinicians must be aware of the barriers to effective pain management and work to overcome them. In so doing, they may make significant contributions to managing pain in patients with dementia, and in improving the quality of life of this vulnerable population of elders.

Chronic pain is a significant problem among older adults. Undertreated or poorly managed pain can affect the physical, psychological, social, emotional, and spiritual well-being of older people. Several researchers have found that individuals turn to a wide array of cognitive and behavioral coping strategies when experiencing high levels of chronic pain. In addition, there is a growing body of evidence that supports an association between health outcomes and the use of religious coping to manage pain. Thus, the purpose of this descriptive, cross-sectional study was to explore the use of religious and nonreligious coping in older people who were experiencing chronic pain. Specific aims were to (a) describe the chronic pain experiences of older people; (b) examine the frequency and type of religious and nonreligious coping strategies used by older people to manage chronic pain; and (c) determine if there were differences in the use of religious and nonreligious coping across gender and race. Mean age of this convenience sample of 200 community-dwelling adults was 76.36 years (SD = 6.55). On average, study participants reported that their pain was of moderate intensity. Lower extremities were the most frequently reported painful body locations. Findings from this study support prior research that suggests older people report using a repertoire of pharmacologic and nonpharmacologic strategies to manage chronic pain. Older women and older people of minority racial background reported using religious coping strategies to manage their pain more often than did older Caucasian men. Older women also reported using diversion and exercise significantly more often than did older men.

Pain is a common experience for many elderly adults that has negative consequences for their health, functioning, and quality of life. Effective pain management requires thorough assessment, appropriate intervention, and systematic reassessment. This article will discuss strategies for assessing and measuring pain in elderly adults, as well as barriers to effective pain assessment. Pain treatment strategies, including both pharmacological and non-pharmacological approaches will also be covered and special considerations for administering medications to elderly adults will be highlighted.

This study examines the relationships between health-related quality of life and activity engagement among residents in two continuing care retirement communities (CCRCs). Prior research indicates that involvement in activity is an important correlate of healthy aging among other community-dwelling elders, and this finding is expected to hold in CCRCs. Time spent engaged in discretionary activities, specifically active, passive, and outside retirement community activities are expected to be associated with better health-related quality of life across multiple dimensions. Data were collected from 167 independent living and assisted living residents in two CCRCs in a large Midwestern metropolitan area. Activity engagement was measured via a self-report questionnaire. Health-related quality of life was measured using the Medical Outcomes Study Short-Form Health Survey (SF-36), which generates eight health subscales (e.g., physical functioning, social functioning, pain). Based on ordinary least squares regression models, the results indicate that discretionary activities, in particular more active types of activity, are positively associated with higher healthrelated quality of life. These findings have implications for health and activity promotion in CCRCs.

Physical pain is a significant problem for many older adults, and as many as 83% of nursing home residents reportedly have pain. Unrelieved pain has consequences for elderly individuals' physical and mental health, rehabilitation, and quality of life. Evidence suggests, however, that pain is underdetected and poorly managed among older adults. This may be due, in part, to lack of congruence between patients' and caregivers' perceptions of pain. Thus, the purpose of this study was to investigate: the prevalence, location, and intensity of residents' self-rated and nursing assistants' (NA) rated pain; the congruence between residents' and NAs' ratings of pain; and resident-based and NA-based correlates of congruent and incongruent pain ratings. Participants in this study were 45 nursing home resident-NA dyads. The results indicated 49% of residents stated they experienced pain in the past week, but NAs reported that 36% of residents experienced pain during the same time interval. There was no significant association between residents' self-ratings and NAs' ratings of pain. Of the 45 paired ratings, residents and NAs were congruent in 37.7% of cases and incongruent in 62.2% of cases. Incongruent ratings included both underdetection (37.8%) and overreporting (24.4%) by the NAs. Only residents' self-rated affect (e.g., depression, well-being) was significantly associated with whether their pain was congruently assessed, underdetected, or overreported. Depression was highest in those for whom pain was not perceived by the NAs and well-being was highest in those residents who denied pain but for whom NAs reported pain. Caregiver characteristics (e.g., age, education, work experience) were not significantly associated with pain congruence outcomes. These findings illustrate the complexities of assessing pain in older adults, and the need to include nursing assistants (NAs) in educational programs focusing on managing pain in elderly nursing home residents.

The purpose of this paper is to predict health care utilization in the very old from a combination of individual-based factors such as physical and mental health, health attitudes and beliefs, sociodemographic characteristics, and life circumstances. This study was conducted within the context of the Berlin Aging Study (BASE). Higher use of medications was most strongly predicted by more medical diagnoses, better cognitive status, and health attitudes. Physician contact was only weakly predicted by physical health variables, hypochondriasis, and living alone. In contrast, living alone was the greatest predictor of the utilization of increased levels of caregiving services, while having children nearby served as a protective factor against the need for more formal caregiving services. These results show that utilization of health care depends on interaction between physical and mental health, attitudinal, and social factors.

Background Analgesic trials have been advocated as a means to reduce pain in persons with dementia (PWDs), but few systematic studies have been reported. Objectives The aims of this study were to assess the feasibility of conducting a repeated-measures study of pain in PWDs and to investigate the effect of the scheduled dosing of acetaminophen in reducing observable pain behaviors in community-dwelling PWDs. Methods A within-subjects ABAB withdrawal design was utilized in this pilot study, with data collected daily for 24 days. Two baseline (nontreatment) phases were alternated with two treatment phases to examine the effects of scheduled extended-release acetaminophen (1.3 g every 8 hr) in reducing pain-related behaviors. The sample consisted of 3 participants (2 women; mean age = 85 years; mean Mini-Mental State Examination score = 11.7) with osteoarthritis. Pain behaviors were measured during a daily, videotaped activity-based protocol designed to elicit pain. Results The results indicate that it is possible to conduct this type of intensive, daily pain investigation in community-dwelling older adults with moderate to severe dementia. Behavioral indicators of pain varied daily and in response to treatment. During treatment phases, pain behaviors decreased in both frequency and duration relative to the control and baseline phases and increased when treatment was withdrawn. Discussion Acetaminophen use reduced pain behaviors associated with musculoskeletal pain in this sample of PWDs. This provides preliminary evidence that acetaminophen is an effective pain reliever for this population. In addition, the study supports the use of a within-subjects design to examine daily variability in pain behaviors and to demonstrate treatment effects in PWDs.