01/13/2011
Reviewed, prepared, and submitted by Joseph G. Ouslander, MD, Executive Editor, Journal of the American Geriatrics SocietyTitle:Targeting and Managing Behavioral Symptoms in Individuals with Dementia: A Randomized Trial of a Nonpharmacological InterventionAuthors:
Gitlin LN, Winter L, Dennis MP, et alSummary:
This was a two-group randomized trial designed to test the effects of a home-based intervention that helps families manage distressing behaviors in family members with dementia. Two hundred seventy-two caregivers were randomized, with 106 in the intervention group and 1114 in the control group completing the 6-month data collection time point. The intervention consisted of up to 11 home and telephone contacts over 16 weeks by health professionals who identified potential triggers of patient behaviors, including communication and environmental factors and patient undiagnosed medical conditions (by obtaining blood and urine samples) , and trained caregivers in strategies to modify triggers and reduce their upset. Between 16 and 24 weeks, three telephone contacts reinforced strategy use. At 16 weeks, 67.5% of intervention caregivers reported improvement in targeted problem behavior, compared with 45.8% of caregivers in a no-treatment control group (P=.002), and reduced upset with (P=.03) and enhanced confidence managing (P=.01) the behavior. Additionally, intervention caregivers reported less upset with all problem behaviors (P=.001), less negative communication (P=.02), less burden (P=.05), and better well-being (P=.001) than controls. Fewer intervention caregivers had depressive symptoms (53.0%) than control group caregivers (67.8%, P=.02). Similar caregiver outcomes occurred at 24 weeks. Intervention caregivers perceived more study benefits (P.05), including ability to keep family members home, than controls. Blood and urine samples of intervention patients with dementia showed that 40 (34.1%) had undiagnosed illnesses requiring physician follow-up.Comment:
This is a very important study, because we know that treating caregivers of patients with dementia is just as important as treating the patients. Several studies demonstrate that caregivers are at increased risk for depression and other adverse health consequence. This well conceived and executed randomized trial shows that targeting behaviors upsetting to caregivers and modifying potential triggers improves symptomatology in people with dementia and caregiver well-being and skills. The intervention is consistent with high quality interdisciplinary person-centered care. Future studies should be done to determine the most efficient and effective methods of disseminating this intervention into clinical practice.The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or Journal of the American Geriatrics Society.______________________________________________________________________Title:
Effect of Walking Distance on 8-Year Incident Depressive Symptoms in Elderly Men with and without Chronic Disease: The Honolulu-Asia Aging StudyAuthors:
Smith TL, Masaki KH, Fong K, et al Summary:
This prospective cohort study sought to determine the effect of walking on incident depressive symptoms in elderly Japanese-American men with and without chronic disease aged 71 to 93 at baseline. Physical activity was assessed according to self-reported distance walked per day. Depressive symptoms were measured using an 11-question version of the Centers for Epidemiologic Studies Depression Scale (CES-D 11) at the fourth examination (n=3,196) and at the seventh examination 8 years later (1999/00, n=1,417). Presence of incident depressive symptoms was defined as a CES-D 11 score of 9 or greater or taking antidepressants at Examination 7. Subjects with prevalent depressive symptoms at baseline were excluded. Age-adjusted 8-year incident depressive symptoms were 13.6%, 7.6%, and 8.5% for low (0.25 miles/day), intermediate (0.25–1.5 miles/day), and high (>1.5 miles/day) walking groups at baseline (P=0.008). Multiple logistic regression analyses, adjusted for age, education, marital status, cardiovascular risk factors, prevalent diseases, and functional impairment, showed that those in the intermediate and highest walking groups had significantly lower odds of developing 8-year incident depressive symptoms (odds ratio (OR) = 0.52, 95% confidence interval (CI) = 0.32–0.83, P=.006 and OR=0.61, 95% CI= 0.39–0.97, P=.04, respectively). Analysis found that this association was significant only in participants without chronic diseases (coronary heart disease, cerebrovascular accident, cancer, Parkinson's disease, dementia, or cognitive impairment) at baseline.Comment:
This study reinforces many other studies that demonstrate the benefits of physical activity on future health status. Its strengths include the longitudinal design and the exclusion of participants with depression at baseline (thus avoiding the “chicken and egg” conundrum that arises in cross sectional studies). This research team also carefully examined the impact of several chronic illnesses on the outcome. A weakness of the study is the population (Japanese Americans in Hawaii), thus limiting its generalizability. The results clearly demonstrate that self-reported walking greater than a quarter mile per day among men without depression or several major chronic illnesses at baseline have a significantly lower incidence of depression over 8 years. Given the morbidity, health care expenditures, and suicide risk associated with depression in older men, encouraging physical activity – even a modest amount of daily walking, appears to be a reasonable preventive intervention to discuss with older men in good health.The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or Journal of the American Geriatrics Society.______________________________________________________________________Title:A Controlled Trial of an Intervention to Improve Urinary and Fecal Incontinence and ConstipationAuthors:
Schnelle JF, Leung FW, Rao SC, et alSummary:
This randomized controlled trial evaluated the effects of a multicomponent intervention on fecal incontinence (FI) and urinary incontinence (UI) among 112 residents of six nursing homes (NHs). Intervention subjects were offered toileting assistance, exercise, and choice of food and fluid snacks every 2 hours for 8 hours per day over 3 months. The frequency of UI and FI and rate of appropriate toileting were determined by direct checks from research staff. Anorectal assessments were completed on a subset of 29 residents. The intervention significantly increased physical activity, frequency of toileting, and food and fluid intake. UI improved (P=.049), as did frequency of bowel movements (P.001) and percentage of bowel movements (P.001) in the toilet. The frequency of FI did not change. Eighty-nine percent of subjects who underwent anorectal testing showed a dyssynergic voiding pattern, which could explain the lack of efficacy of this intervention program alone on FI.Comment:
Numerous previous studies have demonstrated the efficacy of toileting on the frequency of UI in NH residents. This is the first controlled trial to specifically address FI and constipation. The multicomponent intervention significantly changed multiple risk factors associated with FI and increased bowel movements without decreasing FI. The dyssynergic voiding pattern and rectal hyposensitivity suggest that future interventions may have to be supplemented with bulking agents (fiber), biofeedback therapy, or both to improve bowel function in the NH population. Biofeedback, which generally requires adequate cognition for learning, practice and incorporation of techniques into daily life, may have limited utility in this population because of the very high prevalence dementia among NH residents with FI. Other considerations include the difficulty encountered in trying to provide NH residents with adequate dietary bulk because of limited fluid intake, and the widespread use of laxatives in what are often erratic patterns in this setting. Nonetheless, this study demonstrates that it is possible to impact bowel habits in NH residents, and when combined with other interventions in properly selected residents could decrease the distressing and potentially serious consequences of constipation and FI in the NH population.The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or Journal of the American Geriatrics Society.
