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Levy I, Attias S, Ben-Arye E, Bloch B, Schiff E. Complementary medicine for treatment of agitation and delirium in older persons: a systematic review and narrative synthesis. Int J Geriatr Psychiatry 2017; 32:492-508. [PMID: 28239906 DOI: 10.1002/gps.4685] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/24/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Agitation and delirium frequently occur in cognitively impaired older people. We conducted a systematic review with narrative synthesis of the literature aiming to assess effectiveness of complementary and alternative medicine (CAM) modalities to address these conditions. METHODS Following preliminary search, we included 40 original researches on CAM treatment of delirium and agitation in older persons. Then, the quality of these studies was assessed using the Downs and Black Checklist and Quality Assessment Tool for Studies with Diverse Designs, and the effect sizes were calculated. We subsequently conducted a narrative synthesis of the main findings, including theory development, preliminary synthesis, exploration of relationships within and between studies, and assessment of synthesis robustness. RESULTS Forty articles that met the inclusion criteria were analyzed. Sixteen of these were randomized controlled trials. One article specifically addressed CAM treatment of delirium in patients without dementia, and the remaining 39 articles described treatments of agitated older persons with dementia. Thirty-five of the 40 included studies suggested that the investigated CAM therapies may ameliorate the severity of agitation and delirium. The physiological surrogates of agitation assessed in these studies included cortisol level, chromogranin A level, and heart rate variability. Very few of the studies systematically assessed safety issues, although no major adverse effects were reported. CONCLUSION Overall, the systematic review of the literature suggests that several CAM modalities are potentially beneficial in the treatment of agitation and delirium among older persons. We suggest that promising CAM modalities should be further explored through large-scale randomized controlled trials in different clinical settings. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Ilana Levy
- Internal Medicine B Department, Bnai Zion Medical Center, Haifa, Israel
| | - Samuel Attias
- Complementary Medicine Department, Bnai Zion Medical Center, Haifa, Israel.,School of Public Health, University of Haifa, Haifa, Israel
| | - Eran Ben-Arye
- Integrative Oncology Program, The Oncology Service, Lin Medical Center, Clalit Health Services, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Boaz Bloch
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Psychiatric Department, HaEmek Medical Center, Afula, Israel
| | - Elad Schiff
- Internal Medicine B Department, Bnai Zion Medical Center, Haifa, Israel.,Complementary Medicine Department, Bnai Zion Medical Center, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Williams C, Tappen R, Wiese L, Newman D, Corbett M, Pinos S, Curtis B, Murray B. Stress in Persons with Dementia: Benefits of a Memory Center Day Program. Arch Psychiatr Nurs 2016; 30:531-8. [PMID: 27654233 DOI: 10.1016/j.apnu.2016.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 03/08/2016] [Accepted: 04/27/2016] [Indexed: 10/21/2022]
Abstract
Most persons with dementia are cared for by family members who are so overwhelmed that their mental and physical health declines. Adult day care programs (ADC) are growing in number to meet caregivers' needs for respite but little is known about their effect on enrollee mental health. We examined mental health of enrollees (stress, anxiety, mood, emotions) and arousal (blood pressure and salivary cortisol) from day program enrollment to 3 months following enrollment. Results showed significant decreases in morning cortisol level at 1 and 3 months (p=.047). Perceived stress decreased at 1 and 3 months measured by Perceived Stress Scale (p=.03) and Index of Clinical Stress (p=.01). Results provide support for ADC as a stress-reducing environment for individuals with mild to moderate cognitive impairment. Future studies should be conducted to examine which elements of ADC are beneficial.
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Affiliation(s)
| | - Ruth Tappen
- Florida Atlantic University, Christine E Lynn College of Nursing
| | - Lisa Wiese
- Florida Atlantic University, Christine E Lynn College of Nursing
| | - David Newman
- Florida Atlantic University, Christine E Lynn College of Nursing
| | - Maria Corbett
- Florida Atlantic University, Department of Psychology
| | - Suzanne Pinos
- Florida Atlantic University, Christine E Lynn College of Nursing
| | - Barbara Curtis
- Florida Atlantic University, Christine E Lynn College of Nursing, Louis and Ann Greene Memory and Wellness Center
| | - Belinda Murray
- Florida Atlantic University, Christine E Lynn College of Nursing, Louis and Ann Greene Memory and Wellness Center
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Ewen HH, Chahal JK, Fenster ES. A Portrait of Resilience in Caregiving. Res Gerontol Nurs 2015; 8:29-38. [DOI: 10.3928/19404921-20141111-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 08/29/2014] [Indexed: 11/20/2022]
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Kovach CR, Woods DL, Devine EC, Logan BR, Raff H. Biobehavioral measures as outcomes: a cautionary tale. Res Gerontol Nurs 2013; 7:56-65. [PMID: 24158972 DOI: 10.3928/19404921-20131018-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 10/04/2013] [Indexed: 11/20/2022]
Abstract
This article discusses the use of biobehavioral measures as outcomes for health care intervention studies. Effect size (ES) values for salivary cortisol and observation-based measures of pain and agitation were examined. Effects pre to post treatment were assessed separately for nursing home residents with and without acute psychotic symptoms. This study revealed large positive effects on both pain and agitation measures in the group with acute psychotic symptoms and small-to-medium positive effects on these same measures in the group without acute psychotic symptoms. In both of these groups, the ES values were not consistently positive on the cortisol measures. Prior to determining whether a measure can be used to estimate minimum clinically important differences, it is essential to consider if the biomarker will be responsive to therapy in the populations and contexts being studied.
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Walmsley BD, McCormack L. The dance of communication: retaining family membership despite severe non-speech dementia. DEMENTIA 2013; 13:626-41. [PMID: 24339076 DOI: 10.1177/1471301213480359] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is minimal research investigating non-speech communication as a result of living with severe dementia. This phenomenological study explores retained awareness expressed through non-speech patterns of communication in a family member living with severe dementia. Further, it describes reciprocal efforts used by all family members to engage in alternative patterns of communication. Family interactions were filmed to observe speech and non-speech relational communication. Participants were four family groups each with a family member living with non-speech communication as a result of severe dementia. Overall there were 16 participants. Data were analysed using thematic analysis. One superordinate theme, Dance of Communication, describes the interactive patterns that were observed during family communication. Two subordinate themes emerged: (a) in-step; characterised by communication that indicated harmony, spontaneity and reciprocity, and; (b) out-of-step; characterised by communication that indicated disharmony, syncopation, and vulnerability. This study highlights that retained awareness can exist at levels previously unrecognised in those living with limited or absent speech as a result of severe dementia. A recommendation for the development of a communication program for caregivers of individuals living with dementia is presented.
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Woods DL, Yefimova M. Evening cortisol is associated with intra-individual instability in daytime napping in nursing home residents with dementia: an allostatic load perspective. Biol Res Nurs 2012; 14:387-95. [PMID: 22811289 DOI: 10.1177/1099800412451118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Circadian rhythm disruption, reflected in alterations in sleep-wake activity and daytime napping behavior, is consistently reported in nursing home (NH) residents with dementia. This disruption may be reflected in day-to-day instability. The concept of allostatic load (AL), a measure of cumulative biological burden over a lifetime, may be a helpful model for understanding cortisol diurnal rhythm and daytime napping activity in this population. The purpose of this study was to examine the association between intra-individual daytime napping episodes and basal cortisol diurnal rhythm in NH residents with dementia in the context of AL. METHOD U sing a within-individual longitudinal design (N = 51), the authors observed and recorded daytime napping activity every 20 min for 10 hr per day across 4 consecutive days. The authors obtained saliva samples 4 times each day (upon participants' waking and within 1 hr, 6 hr, and 12 hr of participants' wake time) for cortisol analysis. RESULTS The authors categorized participants as high changers (HCs; day-to-day instability in napping activity) or low changers (LCs; day-to-day stability). There were no significant differences in resident characteristics between groups. There was a significant difference between HCs and LCs in napping episodes (F = 4.86, p = .03), with an interaction effect of evening cortisol on napping episodes in the HC group (F = 10.161, p = .001). CONCLUSIONS NH residents with unstable day-to-day napping episodes are more responsive to alterations in evening cortisol, an index of a dysregulated hypothalamic-pituitary-adrenal (HPA) axis. They may also be more amenable to environmental intervention, an avenue for further research.
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Affiliation(s)
- Diana Lynn Woods
- School of Nursing, University of California, Los Angeles, 90095, USA.
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Fiorentino L, Saxbe D, Alessi CA, Woods DL, Martin JL. Diurnal cortisol and functional outcomes in post-acute rehabilitation patients. J Gerontol A Biol Sci Med Sci 2012; 67:677-82. [PMID: 22219521 DOI: 10.1093/gerona/glr230] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cortisol is a stress-related hormone with a robust circadian rhythm where levels typically peak in the morning hours and decline across the day. Although acute cortisol increases resulting from stressors are adaptive, chronic elevated cortisol levels are associated with poor functioning. Studies have shown age-related changes in cortisol levels. The present study investigated the relationship between salivary diurnal cortisol and functional outcomes among older adults undergoing inpatient post-acute rehabilitation. METHODS Thirty-two older adults (mean age 78 years; 84% men) in a Veterans Administration inpatient post-acute rehabilitation unit were studied. Functional outcomes were assessed with the motor component of the Functional Independence Measure (mFIM; where mFIM change = discharge - admission score). Saliva samples were collected on 1 day at wake time, 45 minutes later, 11:30 AM, 2 PM, 4:30 PM, and bedtime. We analyzed the relationship between cortisol measures and functional outcomes, demographics, and health measures. RESULTS The analyses consistently showed that greater functional improvement (mFIM change) from admission to discharge was associated with lower comorbidity scores and higher cortisol levels at 2 PM, 4:30 PM, and bedtime. A morning cortisol rise was also associated with greater mFIM change. CONCLUSIONS Measurement of cortisol in saliva may be a useful biological marker for identification of patients who are "at risk" of lower benefits from inpatient rehabilitation services and who may require additional assistance or intervention during their post-acute care stay.
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Affiliation(s)
- Lavinia Fiorentino
- Department of Psychiatry, School of Medicine, University of California, San Diego, USA
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Woods DL, Kim H, Yefimova M. To nap or not to nap: excessive daytime napping is associated with elevated evening cortisol in nursing home residents with dementia. Biol Res Nurs 2011; 15:185-90. [PMID: 21998447 DOI: 10.1177/1099800411420861] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Alterations in the sleep-wake cycle, including daytime napping, are consistently reported in persons with dementia (PWD). A dysregulation in the hypothalamic-pituitary-adrenal (HPA) axis, indexed by elevated evening cortisol, may offer one explanation for these alterations. Alternatively, excessive daytime sleeping may alter cortisol rhythm and increase intraindividual variability, potentially contributing to increased environmental reactivity and behavioral symptoms. The purpose of this substudy (N = 12) was to examine the association between daytime napping and basal cortisol diurnal rhythm in nursing home residents with dementia. METHOD In this within-individual longitudinal design, saliva samples were obtained daily for 5 consecutive days upon waking and 30-45 min, 6 hr, and 12 hr after waking to obtain a cortisol diurnal rhythm. Behavior and sleep-wake state (nap/no nap) were observed and recorded every 20 min for 12 hr per day for 5 days. RESULTS Participants were categorized as high nappers (HNs) or low nappers (LNs). There was a significant difference in evening cortisol levels (t = -2.38, p = .032) and continence (t = 3.37, p = .007) between groups, with HNs exhibiting higher evening cortisol levels. There were no other significant differences in resident characteristics between the two groups. CONCLUSIONS These data suggest a link between excessive daytime napping and elevated evening cortisol in PWD consistent with findings in children. Elevated evening cortisol is an indication of a dysregulation in the HPA axis. These preliminary data support a close association between the sleep-wake cycle and HPA-axis regulation in PWD.
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Affiliation(s)
- Diana Lynn Woods
- School of Nursing, University of California-Los Angeles (UCLA), Los Angeles, CA, USA.
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Woods DL, Phillips LR, Martin JL. Biological Basis for Sleep Disturbance and Behavioral Symptoms in Dementia: A Biobehavioral Model. Res Gerontol Nurs 2011; 4:281-93. [DOI: 10.3928/19404921-20110302-01] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Accepted: 10/26/2010] [Indexed: 11/20/2022]
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Woods DL, Mentes JC. Spit: Saliva in Nursing Research, Uses and Methodological Considerations in Older Adults. Biol Res Nurs 2011; 13:320-7. [DOI: 10.1177/1099800411404211] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over the last 10 years, interest in the analysis of saliva as a biomarker for a variety of systemic diseases or for potential disease has soared. There are numerous advantages to using saliva as a biological fluid, particularly for nurse researchers working with vulnerable populations, such as frail older adults. Most notably, it is noninvasive and easier to collect than serum or urine. The authors describe their experiences with the use of saliva in research with older adults that examined (a) osmolality as an indicator of hydration status and (b) cortisol and behavioral symptoms of dementia. In particular, the authors discuss the timing of data collection along with data analysis and interpretation. For example, it is not enough to detect levels or rely solely on summary statistics; rather it is critical to characterize any rhythmicity inherent in the parameter of interest. Not accounting for rhythmicity in the analysis and interpretation of data can limit the interpretation of associations, thus impeding advances related to the contribution that an altered rhythm may make to individual vulnerability.
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Affiliation(s)
- Diana Lynn Woods
- School of Nursing, University of California, Los Angeles, CA, USA,
| | - Janet C. Mentes
- School of Nursing, University of California, Los Angeles, CA, USA
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Hanneman SK, Cox CD, Green KE, Kang DH. Estimating intra- and inter-assay variability in salivary cortisol. Biol Res Nurs 2011; 13:243-50. [PMID: 21498487 DOI: 10.1177/1099800411404061] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Investigators commonly assess intra- and inter-assay coefficients of variation (CVs) to estimate the precision of salivary cortisol enzyme immunoassay (EIA). However, little guidance is available as to which samples to use for CV assessment. The purposes of this methodological study were to compare differences in intra- and inter-assay CVs (a) among controls, standards, and/or unknown samples; and (b) between fresh and previously frozen saliva. A total of 174 duplicates (controls = 58, standards = 48, and unknowns = 68) were tested. The unknowns were from 34 students; all student saliva was assayed as both fresh and frozen samples. All samples were assayed in duplicate, using a commercial salivary cortisol EIA kit, by the same technician with the same equipment. A priori criteria for intra- and inter-assay CV, respectively, were ≤ 4% and ≤ 7%, and a was .05 for CV differences. Mean intra-assay CVs for controls, standards, unknowns, and combined samples were ≤ 2.5%, and mean inter-assay CVs were ≤ 2.8%. Mean intra-assay CVs were 2.2% for fresh saliva and 1.5% for frozen samples. Comparisons showed no significant differences in intra- or inter-assay CV among controls, standards, and/or unknown samples. Inter-assay CV was significantly different between fresh and previously frozen saliva (p = .043), with fresh saliva CV higher than frozen; the difference was not meaningful because all evaluations showed minimal measurement error. In conclusion, results indicate that estimation of precision can be achieved by testing of controls, standards, or unknowns and with either fresh or frozen saliva in this population.
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Affiliation(s)
- Sandra K Hanneman
- Bioscience Laboratory, Center for Nursing Research, School of Nursing, The University of Texas Health Science Center, Houston, TX, USA.
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Woods DL, Kim H, Yefimova M. Morning Cortisol in Relation to Behavioral Symptoms of Nursing Home Residents With Dementia. Biol Res Nurs 2010; 13:196-203. [DOI: 10.1177/1099800410385568] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Behavioral symptoms of dementia (BSD) are a significant challenge for elders, their caregivers, and clinicians, with a prevalence ranging between 66% and 98%. Although several studies have examined BSD type and frequency, few studies have examined a possible neuroendocrine basis of BSD. The purpose of this study was to examine the association between morning cortisol levels and BSD in nursing home (NH) residents. Method: Using a within-subject longitudinal design, saliva was collected four times daily for 5 days to obtain basal cortisol levels from 30 NH residents, aged 80 to 102. Behavior was observed every 20 min for 12 hr/day for 5 days. Mixed-model analysis was used to test the association between morning cortisol (MC) and BSD. To examine the association between MC and BSD across time, participants were divided into low (LM) and high morning (HM) cortisol groups. Results: A significant inverse association between mean overall BSD and morning cortisol (F = 12.71, p = .000) was found. A significant inverse association between low and high morning cortisol and behavior variability across time (F = 15.36. p = .000) was found. The LM group exhibited significantly more behavioral variability across the day than the HM cortisol group. There was a significant group difference between two co-occurring behaviors, vocalization, and restlessness (F = 19.59, p = .000). Conclusion: Although preliminary, these results suggest an association between morning cortisol and BSD. Low morning cortisol, potentially indicating HPA axis dysregulation, may increase vulnerability to BSD.
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Affiliation(s)
| | - Haesook Kim
- School of Nursing, University of California Los Angeles
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Abstract
OBJECTIVE Although awareness has been extensively researched in relation to people with dementia, studies have focussed mainly on people who have dementia of mild to moderate severity. Consequently, relatively little is known about awareness in people with severe dementia, and there is no clear conceptual framework to indicate how this should be understood or investigated. METHOD This review presents a conceptual framework for considering awareness in people with moderate to severe dementia which distinguishes fundamental awareness of sensory and perceptual stimuli and three levels of awareness involving more complex cognitive operations, termed 'on-line monitoring', 'evaluative judgement' and 'meta-representation', and provides an integration of the available evidence regarding each level. RESULTS Findings indicate that sensory and perceptual awareness can be detected even in people with very severe or end-stage dementia, while some aspects of complex awareness may be retained into the severe stages. CONCLUSIONS The environmental context and the nature of caregiving interactions influence the extent to which awareness is expressed. There may be scope for enhancing the expression of some aspects of awareness in people with moderate to severe dementia, but this should only be undertaken where it is likely to improve quality of life. Understanding more about awareness is an important element in the provision of high-quality care for people with moderate to severe dementia.
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Affiliation(s)
- Linda Clare
- School of Psychology, Bangor University, Bangor, Gwynedd LL57 2AS, UK.
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Woods DL, Kovach CR, Raff H, Joosse L, Basmadjian A, Hegadoren KM. Using saliva to measure endogenous cortisol in nursing home residents with advanced dementia. Res Nurs Health 2008; 31:283-94. [DOI: 10.1002/nur.20254] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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