Louis D. Burgio - US grants

This application is in response to the NIA SERCA in Behavioral Geriatrics Research. The candidate is a behavioral psychologist who has developed expertise in behavioral treatments for urinary incontinence in nursing homes. Having recently completed a four-year study investigating the use of behavioral treatments for incontinence, the candidate is proposing to develop a practical and comprehensive continence treatment system for use in the nursing home. This system will involve instructing the staff in the use of prompted voiding and checking-changing. Staff will be taught how to bring about initial improvements in incontinence and through the use of formal staff management procedures, they will be taught how to apply behavioral interventions in a consistent manner over a long term. The candidate believes that a true understanding of incontinence and its treatment requires knowledge of both environmental factors and basic physiological processes. Not having been trained in the biochemical sciences, the candidates has proposed a training program in the biomedical aspects of incontinence which includes a combination of coursework, practice, and training experiences with senior personnel in the areas of geriatrics, nursing, urology, and diagnostics.

The major goal of this proposal is to utilize microcomputer technology for real-time recording of behavioral disturbances and environmental events that may be related to these disturbances. Direct observations will be conducted intensively and consecutively in each of four nursing homes, and will be repeated sequentially among the nursing homes over a two year period of time. Standardized assessments of cognitive and ADL status, as well as evaluations on exploratory measures of medication and health status/life events will also be repeated during each observational epoch over two years. There are three specific aims: (1) based on direct observations, we will report the rate of occurrence and duration of physical aggression, verbal disruption, and pacing/restlessness. Rate and duration will be compared with initial measures of cognitive and ADL status, and the exploratory measures. Analysis will be based on a cross-sectional sample of the first complete observational epoch for 136 residents; (2) based on the same cross-sectional data base, we will examine the relationship between environmental factors and behavioral symptomatology through the use of lag sequential analysis. The influence of cognitive, ADL, medication, and health status on these relationships will also be assessed; (3) we will conduct a longitudinal analysis of the rate and duration of individual resident behavioral symptomatology over a maximum of two years. The focus of this analysis will be on the relationship between change in behavior and changes in cognitive and ADL status, and changes on the exploratory measures. Results of this project will be used to develop environmental/behavioral interventions for the behavioral complications of DAT.

The major goal of this study is to utilize a Formal Staff Management (FSM) system for motivating Certified Nursing Aides (CNA) to employ behavior management skills on the nursing units. The FSM system is based on a model proposed by the authors and field tested in their incontinence research. The FSM system contains the following components: (1) the CNAs will use performance checklists, which serve to remind them of the steps involved in appropriate task performance; (2) CNAs will use these checklists to self-monitor their own performance and nurse supervisors will monitor CNA performance on a consistent schedule; (3) nurse supervisors will provide immediate and delayed verbal performance feedback and written feedback to the group and individual CNAs. The FSM system will be compared with Conventional Staff Management (CSM) procedures, and changes in both staff and resident behaviors will be assessed. There are 3 specific aims: Aim 1: after establishing equivalence in behavior management skill acquisition in both groups, we will assess whether there are differences in skill performance on units under CSM and FSM conditions; Aim 2: we will evaluate the effects of CNA behavior management training on various resident behaviors; Aim 3: we will use computer-assisted real-time data collection procedures to analyze the effects of behavior management training on environmental contextual factors surrounding behaviorally disruptive events. We will examine whether type of dementia, cognitive and ADL status, and use of psychotropic medications predict disruptive behaviors or resident responsivity to treatment. We will also investigate whether CNA stress level or social support predicts their ability to acquire or perform behavior management skills. Finally, we will examine the costs of the training/management system related to the gains achieved.

caucasian American; African American; caregivers; training; behavioral /social science research tag;

DESCRIPTION (Adapted from the Investigator's Abstract): The major goal of this revision is to expand our investigation into the relationships among resident personal characteristics, environmental context, and agitation in the nursing home (NH) using a computer-assisted system of real time behavioral observation. However, in response to preliminary findings from our agitation intervention research, we propose to extend our original aims from the context of an intervention trial. Our original study allowed us to develop a real-time observational system that has been used by the applicant in numerous additional studies and has also been adopted by other research teams. The previous application produced a number of intriguing findings regarding agitation, including precise descriptive data and predictors of occurrence, duration and temporal patterns; sequential conditional probabilities of agitation given staff touch and verbal interaction and exploratory structural equation modeling (SEM) relating agitation, cognitive and functional status, and resident gender over time. The proposal for continuation has 3 specific aims: Aim 1: using our system of observation, we will examine the effects of two promising and practical interventions for agitation: environmental white noise and soothing spoken word audiotapes, both delivered to residents via earphones. Intervention groups will be compared to a no treatment control group. An uncomplicated staff management system will be integrated with both intervention protocols to encourage nursing assistants (NAs) compliance with the treatment protocols; Aim 2; we will examine NA compliance with the protocol and resident response to the interventions over a 12 month period; Aim 3: we will continue to examine the relationship among resident personal characteristics, environmental context and agitation both cross-sectionally and longitudinally using SEM. In these analyses, intervention will be considered just one of many variables that can affect agitation over time. We are proposing to expand our investigations by discriminating additional subclassifications of agitation, refining our entry criteria to allow entry of only clinically significant agitated residents, and measuring agitation intensity and resident affect.

DESCRIPTION (provided by applicant): The objective of this proposal is to refine and test a multi-component psychosocial behavioral intervention to reduce burden and depression among family caregivers of persons with Alzheimer?s Disease or related disorders. This competing renewal will build on existing infrastructures and results obtained from its parent multi-site feasibility study, Resources for Enhancing Alzheimer?s Caregiver Health (REACH). REACH, (funded by the National Institute on Aging (NIA) and the National Institute for Nursing Research (NINR) U01-AG13305) explored the effectiveness of different interventions to reduce burden and distress of family caregivers in six participating sites. Detailed analyses of these data suggest specific components of the REACH interventions that may be efficacious in improving caregiver outcomes. The current study integrates identified components from the REACH interventions and tests a single multi-component intervention. This intervention will be evaluated among a sample of geographically and racially/ethnically diverse caregiver populations. The study design is a multi-site, two-group randomized clinical trial. The same two conditions: an in-home multi-component intervention or a standardized information only control condition will be implemented at five sites (Birmingham, Memphis, Miami, Palo Alto, and Philadelphia), with the Coordinating Center in Pittsburgh. Recruitment of 600 (120 per site) caregiver-care recipient dyads will yield 510 completing the protocol (15% attrition expected). Equal numbers of African Americans/Blacks, Hispanics/Latinos, and Caucasian/Whites will be recruited and assigned to each condition at each site. Phase 1 involves a refinement of the intervention and training of the interventionists across sites; in Phase 2, the randomized clinical trial will be conducted. The intervention is designed to enable caregivers to earn and use cognitive and behavioral strategies, to impact both care recipient behaviors (e.g. wandering) and their own behaviors (e.g., managing stress). The intervention will consist of 10 home visits by trained staff plus 5 preplanned contacts with trained staff through innovative technology over a six-month period. The technology will also provide access to formal services, family, and other caregivers. A uniform battery of predictor and outcome measures will be collected at baseline, three and six months. Cost effectiveness and clinical significance of the two conditions will also be evaluated.

DESCRIPTION (provided by applicant): Assessing and managing pain among nursing home residents is often complicated by resident cognitive impairment and the lack of adequate skill training among direct-care staff. Although the gold standard for measuring pain in any population is widely recognized as self-report, most nursing home residents experience some degree of cognitive impairment such that applying this gold standard is problematic. Observational measures of pain are an important corollary to self-report among cognitively impaired nursing home residents and represent the primary means by which the pain of non-communicative residents can be assessed. The proposed feasibility study (R03) will address the lack of adequate skill training among direct care staff by providing a training and communication intervention to Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs). The intervention will include didactic and hands-on training, as well as a staff motivational system to encourage direct-care staff in their efforts to implement the intervention in their day-to-day routine. Treatment implementation measures will also be used to assess the adequacy of training, the degree to which direct-care staff understood the training, and the consistency of intervention use in the everyday environment. The specific aims of this study are as follows: (1) to assess the feasibility and efficacy of a Pain Assessment and Communication Training (PACT) intervention for improving the detection of behavioral pain cues among nursing home residents with varying degrees of cognitive impairment; and (2) to assess the feasibility and efficacy of the PACT intervention for facilitating communication among CNAs and LPNs about resident pain. A secondary aim is to explore the impact of the PACT intervention on analgesic medication use, the most common pain management strategy used in nursing homes. This project attempts to extend Burgio and colleagues' staff training and motivational systems to a new area (pain assessment), using an interdisciplinary team (Drs. Ann Horgas and A. Lynn Snow) with expertise in pain assessment and nursing home research.