Publications by authors named "Valerie T Cotter"

23 Publications

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High-fidelity simulation and nurse clinical competence-An integrative review.

J Clin Nurs 2021 Aug 27. Epub 2021 Aug 27.

Johns Hopkins School of Nursing, Baltimore, Maryland, USA.

Aim: The aim of this review was to synthesise current knowledge of high-fidelity simulation practices and its impact on nurse clinical competence in the acute care setting.

Background: There is no consensus or standardisation surrounding best practices for the delivery of high-fidelity simulation in the acute care setting. This is an understudied area.

Design: An integrative review using Johns Hopkins Nursing Evidence-Based Practice Model.

Methods: Medical subject heading terms 'Clinical Competence', AND 'High Fidelity Simulation Training', AND 'Clinical Deterioration' were systematically searched in PubMed, CINAHL and Embase databases for peer-reviewed literature published through September 2020. The current study was evaluated using PRISMA checklist.

Results: Seven studies met the inclusion criteria. Three main concepts were identified: modes of delivery, approach to learner participation and outcome measurement.

Conclusions: This review substantiated the use of high-fidelity simulation to improve acute care nurses' early identification and management of clinical deterioration. Global variations in course design and implementation highlight the need for future approaches to be standardised at the regional level (i.e., country-centric approach) where differing scopes of practice and sociocultural complexities are best contextualised.

Relevance To Clinical Practice: These findings add to the growing body of evidence of simulation science. Important considerations in course planning and design for nursing clinical educators were uncovered. This is especially relevant given the current COVID-19 pandemic and urgent need to train redeployed nurses safely and effectively from other units and specialties to acute care.
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http://dx.doi.org/10.1111/jocn.16028DOI Listing
August 2021

Home/community-based interventions to improve function in persons with mild cognitive impairment/early dementia.

Geriatr Nurs 2021 Jul 16;42(5):1109-1124. Epub 2021 Jul 16.

Johns Hopkins University School of Nursing, 525 N. Wolfe St. Room 422, Baltimore, MD 21205 USA.

Persons with mild cognitive impairment/early dementia have a possible 20-year trajectory of disability and dependence with little information on the effectiveness of interventions to improve function. This review investigates the literature of home/community-based interventions for physical and executive function in persons with mild cognitive impairment/early dementia. A 2007-2020 systematic literature search was conducted through PubMed, CINAHL Plus with Full Text and PsycINFO. Of the 1749 articles retrieved, 18 eligible studies were identified and consisted of three types of interventions: cognitive training-only (n = 7), multicomponent (n = 9), and physical activity-only (n = 2). Results showed that the interventions impacting function in persons with cognitive impairment incorporated a visual/written element, technology-based training, caregiver support, and modified duration/increased frequency of interventions. In studies improving function, participants simulated Instrumental Activities of Daily Living. They addressed cognitive function using both objective and subjective cognitive measures. We found gaps in the literature in incorporating race/ethnicity and appropriate socioeconomic status measures.
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http://dx.doi.org/10.1016/j.gerinurse.2021.06.023DOI Listing
July 2021

Diabetes management among underserved older adults through telemedicine and community health workers.

J Am Assoc Nurse Pract 2021 Apr 7. Epub 2021 Apr 7.

Johns Hopkins School of Nursing (JHSON), Baltimore, Maryland, Rocking Horse Community Health Center (RHCHC), Springfield, Ohio.

Background: Diabetes mellitus (DM) disproportionately affects older adults from marginalized communities. In the United States, the prevalence of DM in ages ≥65 years is twofold higher than the national average for adult populations. Telemedicine and community health workers (CHWs) are emerging diabetes care models but their impact on older adults with limited resources are relatively neglected within the medical literature.

Objectives: The purpose of this systematic review was to explore the impact of telemedicine and CHW interventions for improving A1C levels and self-management behaviors among underserved older adults with DM.

Data Sources: A systematic literature search was performed in PubMed, CINAHL, Embase, and Cochrane databases using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses as a reporting guideline.

Conclusions: Diabetes self-management education (DSME) administered through telemedicine and CHW interventions were effective for improving A1C levels, self-care adherence, and patient and provider satisfaction among adults aged ≥50 years. Common barriers to diabetes care include inadequate resources, lack of transportation, inconsistent means of communications, social isolation, and low motivation. Community health workers and telemedicine were effective in improving disease management and optimizing care coordination within the vulnerable adult populations.

Implications For Practice: Well-coordinated, evidence-based, and population-centered interventions can overcome the unique disparities experienced by underserved older adults with diabetes. Incorporating DSME-guided telemedicine and CHW interventions into primary care can mitigate diabetes-related complications in older populations. The lack of evidence specific to adults aged ≥65 years calls for a universally accepted age range when referring to older adults in future research.
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http://dx.doi.org/10.1097/JXX.0000000000000595DOI Listing
April 2021

Advance Care Planning Shared Decision-Making Tools for Non-Cancer Chronic Serious Illness: A Mixed Method Systematic Review.

Am J Hosp Palliat Care 2021 Feb 15:1049909121995416. Epub 2021 Feb 15.

Johns Hopkins University, School of Nursing, Baltimore, MD, USA.

Context: Shared decision-making tools can facilitate advance care planning and goals of care conversations in non-cancer serious illness. More information on integrating these tools in ambulatory care could better support clinicians and patients/caregivers in these conversations.

Objectives: We evaluated effectiveness and implementation of integrating palliative care shared decision-making tools into ambulatory care for U.S. adults with serious, life-threatening illness and their caregivers.

Data Sources: We searched PubMed, CINAHL, and the Cochrane Central Register of Controlled Trials (2000 - May 2020) for quantitative controlled, qualitative, and mixed-methods studies.

Review Methods: Two reviewers screened articles, abstracted data, and independently assessed risk of bias or study quality. For quantitative trials, we graded strength of evidence for key outcomes: patient/caregiver satisfaction, depression or anxiety, concordance between patient preferences for care and care received, and healthcare utilization, including advance directive documentation.

Results: We included 6 quantitative effectiveness randomized, controlled trials and 5 qualitative implementation studies across primary care and specialty populations. Shared decision-making tools all addressed goals-of-care communication or advance care planning. Palliative care shared decision-making tools may be effective for improving patient satisfaction with communication and advance directive documentation. We were unable to draw conclusions about concordance between preferences and care received. Patients and caregivers preferred advance care planning discussions grounded in patient and caregiver experiences with individualized timing.

Conclusions: For non-cancer serious illness, advance care planning shared decision-making tools may improve several outcomes. Future trials should evaluate concordance with care received and other health care utilization.

Key Message: This mixed-methods review concludes that when integrating palliative care into ambulatory care for serious illness and conditions other than cancer, advance care planning shared decision-making tools may improve patient satisfaction and advance directive documentation.
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http://dx.doi.org/10.1177/1049909121995416DOI Listing
February 2021

Place of Death for Persons With and Without Cognitive Impairment in the United States.

J Am Geriatr Soc 2021 04 20;69(4):924-931. Epub 2021 Jan 20.

Johns Hopkins University School of Nursing, Baltimore, Maryland, USA.

Background/objectives: There is increasing recognition that place of death is an important component of quality of end-of-life care (EOLC) and quality of death. This study examined where older persons with and without cognitive impairment die in the United States, what factors contribute to place of death, and whether place of death influences satisfaction with EOLC.

Design: Cross-sectional secondary data analysis.

Setting: In-person interviews with community-dwelling proxy respondents.

Participants: Data were collected from 1,500 proxies for deceased participants in the National Health and Aging Trends Study (NHATS), a nationally-representative sample of community-dwelling Medicare beneficiaries aged 65 and older.

Measurements: Study variables were obtained from the NHATS "last month of life" interview data. Survey weights were applied to all analyses.

Results: Persons with cognitive impairment (CI) most often died at home, while cognitively healthy persons (CHP) were equally likely to die at home or in a hospital. Persons with CI who utilized the Medicare Hospice Benefit were 14.5 times more likely to die at home than in a hospital, and 3.4 times more likely to die at home than a nursing home. CHP who use this benefit were over six times more likely to die at home than in a hospital, and more than twice as likely to die at home than a nursing home. Place of death for CHP was also associated with age and race. Proxies of persons with CI who died at home rated EOLC as more favorable, while proxies of CHP rated in-home and hospital care equally.

Conclusion: Findings add to the scant literature identifying factors associated with place of death for older adults with and without CI and results suggest that place of death is a quality of care indicator for these populations. These findings may inform EOLC planning and policy-making and facilitate greater well-being at end-of-life.
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http://dx.doi.org/10.1111/jgs.16979DOI Listing
April 2021

Association of Hearing Loss With Neuropsychiatric Symptoms in Older Adults With Cognitive Impairment.

Am J Geriatr Psychiatry 2021 06 14;29(6):544-553. Epub 2020 Oct 14.

Cochlear Center for Hearing and Public Health (ASK, EEGM, FRL, NSR, ESO, CLN), Baltimore, MD; Department of Otolaryngology-Head and Neck Surgery (FRL, CLN), Johns Hopkins University School of Medicine, Baltimore, MD. Electronic address:

Neuropsychiatric symptoms (NPS) in persons with dementia (PWD) are common and can lead to poor outcomes, such as institutionalization and mortality, and may be exacerbated by sensory loss. Hearing loss is also highly prevalent among older adults, including PWD.

Objective: This study investigated the association between hearing loss and NPS among community- dwelling patients from a tertiary memory care center.

Design, Setting, And Participants: Participants of this cross-sectional study were patients followed at the Johns Hopkins Memory and Alzheimer's Treatment Center who underwent audiometric testing during routine clinical practice between October 2014 and January 2017.

Outcome Measurements: Included measures were scores on the Neuropsychiatric Inventory-Questionnaire and the Cornell Scale for Depression in Dementia.

Results: Participants (n = 101) were on average 76 years old, mostly female and white, and had a mean Mini-Mental State Examination score of 23. We observed a positive association between audiometric hearing loss and the number of NPS (b = 0.7 per 10 dB; 95% confidence interval [CI]: 0.2, 1.1; t = 2.86; p = 0.01; df = 85), NPS severity (b = 1.3 per 10 dB; 95% CI: 0.4, 2.5; t = 2.13; p = 0.04; df = 80), and depressive symptom severity (b = 1.5 per 10 dB; 95% CI: 0.4, 2.5; t = 2.83; p = 0.01; df = 89) after adjustment for demographic and clinical characteristics. Additionally, the use of hearing aids was inversely associated with the number of NPS (b = -2.09; 95% CI -3.44, -0.75; t = -3.10; p = 0.003; df = 85), NPS severity (b = -3.82; 95% CI -7.19, -0.45; t = -2.26; p = 0.03; df = 80), and depressive symptom severity (b = -2.94; 95% CI: -5.93, 0.06; t = 1.70; p = 0.05; df = 89).

Conclusion: Among patients at a memory clinic, increasing severity of hearing loss was associated with a greater number of NPS, more severe NPS, and more severe depressive symptoms, while hearing aid use was associated with fewer NPS, lower severity, and less severe depressive symptoms. Identifying and addressing hearing loss may be a promising, low-risk, non-pharmacological intervention in preventing and treating NPS.
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http://dx.doi.org/10.1016/j.jagp.2020.10.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8044263PMC
June 2021

Interdisciplinary or Interprofessional: Why Terminology in Teamwork Matters to Hospice and Palliative Care.

J Palliat Med 2020 09 7;23(9):1157-1158. Epub 2020 Jul 7.

Division of Gerontology and Geriatric Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, USA.

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http://dx.doi.org/10.1089/jpm.2020.0299DOI Listing
September 2020

Integrating Culturally Competent Advance Care Planning for Korean Immigrants: An Integrative Review.

Am J Hosp Palliat Care 2021 Jun 19;38(6):678-687. Epub 2020 Jun 19.

1466Johns Hopkins University School of Nursing, Baltimore, MD, USA.

Aims: This review aims to explore the extant literature on the current utilization of ACP in Kisin order to obtain a comprehensive understanding of their health disparities and to determineevidence-based best practices to integrate culturally-competent ACP for EOL care of KIs.

Design: A systematic integrative review of the literature Data Sources:  Four electronic databases including PubMed, the Cumulative Index of Nursing and Allied Health Literature, the Cochrane Library, and Embase.

Method: The detailed search strategy for databases implicated a combination of MeSHkeywords and associated terms, which can be found in Table A.Results: Three themes emerged in relation to fundamental components in the integration of culturally-competent ACP for EOL of KIs: (1) cultural characteristics of KIs; (2) disparities in ethnic-oriented ACP and EOL care resources in KIs; and (3) KIs' perspectives on ACP.

Conclusion: The findings of this review indicate that culturally-competent ACP resources for KIsare presently quite insufficient. It is determined that much future research is needed on howculturally-competent ACP can best augment the quality of EOL care for KIs, and on howspecific interventions can effectively implement ACP in community settings. Impact: Such ongoing research dedicated to the development of feasible culturally competent practice guidelines is anticipated to markedly reduce health disparities and promote ACP in KIs. The recommendations in this review may support Korean primary HCPs, Korean health care center administrators, Korean health maintenance organizations (HMOs), Korean advance care nurse practitioners in hospice and palliative care, and nurse researchers in their work.
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http://dx.doi.org/10.1177/1049909120933856DOI Listing
June 2021

A Practice Improvement Project to Increase Advance Care Planning in a Dementia Specialty Practice.

Am J Hosp Palliat Care 2019 Sep 4;36(9):831-835. Epub 2019 Apr 4.

3 Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, MD, USA.

This study was conducted to enhance the rate of advance care planning (ACP) conversations and documentation in a dementia specialty practice by increasing physician knowledge, attitudes, and skills. We used a pre- and postintervention paired design for physicians and 2 independent groups for patients. The ACP dementia educational program encompassed 3 objectives: (1) to understand the relevance of ACP to the dementia specialty practice, (2) to provide a framework to discuss ACP with patients and caregivers, and (3) to discuss ways to improve ACP documentation and billing in the electronic medical record. A 10-item survey was utilized pre- and posteducational intervention to assess knowledge, attitudes, and skill. The prevalence of ACP documentation was assessed through chart review 3 months pre- and postintervention. The educational intervention was associated with increased confidence in ability to discuss ACP ( = .033), belief that ACP improves outcomes in dementia ( = .035), knowledge about ACP Medicare billing codes and requirements ( = .002), and belief that they have support from other personnel to implement ACP ( = .017). In 2 independent groups of patients with dementia, documentation rates of an advance directive increased from 13.6% to 19.7% ( = .045) and the Medical Order for Life-Sustaining Treatment (MOLST) increased from 11.0% to 19.0% ( = .006). The MOLST documentation in 2 independent groups of patients with nondementia increased from 7.3% to 10.7% ( = .046). Continuing efforts to initiate educational interventions are warranted to increase the effectiveness ACP documentation and future care of persons with dementia.
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http://dx.doi.org/10.1177/1049909119841544DOI Listing
September 2019

An Interprofessional Education Simulation Workshop: Health Professions Learning Palliative Care Communication.

J Nurs Educ 2018 Aug;57(8):493-497

Background: Patients with life-limiting illnesses need health professionals who can communicate with each other, as well as with patients and family members. Nursing faculty teach these skills in a variety of formats and, increasingly, via simulation experiences.

Method: This pilot study aimed to compare a group of interprofessional health professions students' (N = 73) self-reported level of confidence in communication, explore behavior change and professional identity, and identify areas for future interprofessional education. Students participated in a simulated team meeting with a standardized family member of an older adult patient hospitalized with an acute aspiration pneumonia and a chronic, progressive illness.

Results: Postworkshop, students rated themselves as significantly more confident in interprofessional and palliative care communication (p ⩽ .001) than preworkshop, identified important areas of behavior change and professional identity, and provided faculty with ideas for future simulation workshops.

Conclusion: Additional research is needed regarding longitudinal curricular efforts and direct patient care outcomes. [J Nurs Educ. 2018;57(8):493-497.].
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http://dx.doi.org/10.3928/01484834-20180720-08DOI Listing
August 2018

Influence of hope, social support, and self-esteem in early stage dementia.

Dementia (London) 2018 Feb 22;17(2):214-224. Epub 2017 Nov 22.

The University of Texas at Austin, USA.

Background People in the early stages of dementia adjust to the illness through stages of awareness, coping, and evaluation. Studies have found that hope, social support, and self-esteem facilitate coping, adjustment, and adaptation in chronic illness. Objective The purpose of this descriptive study was to examine the relationships between hope, social support, and self-esteem in individuals with early stage dementia. Methods Data were obtained from 53 individuals with early stage dementia. The scores on the Herth Hope Index, Social Support Questionnaire Short-Form, and the State Self-Esteem Scale were analyzed using linear regression. Results Hope was moderately associated with self-esteem ( r = .49, p < .001). Hope accounted for 25% of the variance in self-esteem and was a key component in predicting self-esteem. No significant relationship was found between social support and self-esteem. Conclusion Findings suggest that hope may be an important factor to help individuals manage potential threats to self-esteem in the experience of early stage dementia. Strategies to inspire hope and then enhance self-esteem are promising for individuals living with early stage dementia.
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http://dx.doi.org/10.1177/1471301217741744DOI Listing
February 2018

Student drug testing in nursing education.

J Prof Nurs 2012 May-Jun;28(3):186-9

University of Pennsylvania School of Nursing, Claire Fagin Hall, Philadelphia, PA 19104, USA.

Nursing faculty and administrators have a responsibility to keep abreast of current research, legal regulations, and professional standards that affect students in the classroom and clinical setting. The purpose of this article is to examine whether empirical research supports the current trend of mandatory drug testing, provide a synopsis of current practice, and discuss the legal and ethical implications for nursing faculty.
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http://dx.doi.org/10.1016/j.profnurs.2011.11.017DOI Listing
September 2012

Clinical evaluation tools for dual track adult and gerontology nurse practitioner students.

J Am Acad Nurse Pract 2009 Dec;21(12):658-62

University of Pennsylvania School of Nursing, ClaiPhiladelphia, Pennsylvania 19104-6076, USA.

Purpose: To describe the development of a dual track offering for the Adult Health and Gerontology Nurse Practitioner (AGNP) Programs at the University of Pennsylvania School of Nursing and share clinical evaluation tools used with nurse practitioner students in this curriculum.

Data Sources: Selected research and clinical articles.

Conclusions: A variety of evaluation approaches are utilized in the AGNP student clinical performance evaluation. These incorporate the extended clinical practicum sequence for the dual track curriculum in addition to each individual program's objectives. Formative and summative evaluations include reflective logs, clinical documentation of patient encounters, preceptor evaluation, and faculty site visits. Self-evaluative skills of the student and quality faculty feedback are two additional integral components that facilitate learning outcomes in the cognitive, psychomotor, and affective learning domains.

Implications For Practice: The summary of evaluation tools presented here is an example of how the AGNP Programs at the University of Pennsylvania School of Nursing effectively measure student progress in a curriculum model for dual track enrollment.
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http://dx.doi.org/10.1111/j.1745-7599.2009.00463.xDOI Listing
December 2009

Self-concept in older adults: an integrative review of empirical literature.

Holist Nurs Pract 2009 Nov-Dec;23(6):335-48

Drexel University College of Nursing and Health Professions, Philadelphia, Pennsylvania 19104, USA.

The aging process leads to normative age-related bodily and functional declines and numerous social changes and life events that potentially threaten the self-concept. Despite these changes, the majority of older adults are able to maintain a positive sense of self and remain resilient. This article presents an integrative review of the empirical literature addressing self-concept in older adults.
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http://dx.doi.org/10.1097/HNP.0b013e3181bf37eaDOI Listing
March 2010

Hope in early-stage dementia: a concept analysis.

Authors:
Valerie T Cotter

Holist Nurs Pract 2009 Sep-Oct;23(5):297-301

Drexel University College of Nursing and Health Professions and University of Pennsylvania School of Nursing, Philadelphia, PA 19104, USA.

Hope is central to the adjustment process in early-stage dementia when trying to maintain a sense of normalcy and developing cognitive, social, and behavioral strategies to improve confidence. Maintaining hope, helping others, and living within a supportive social network can positively influence adaptation to daily living and to the preservation of self-concept. Utilizing Walker and Avant's method of concept analysis, the literature was examined to explore hope in early-stage dementia and to identify the dynamics and components of the hope experience. Gaining an understanding of the concept of hope in early-stage dementia will aid nurses and other healthcare professionals to help people with early-stage dementia and their family caregivers find ways of maintaining hope and strengthening a sense of self.
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http://dx.doi.org/10.1097/HNP.0b013e3181b66d4fDOI Listing
November 2009

Student perceptions of cultural competence content in the curriculum.

J Prof Nurs 2008 May-Jun;24(3):155-60

School of Nursing, University of Pennsylvania, Philadelphia, PA 19104-6096, USA.

The 31-item Blueprint for Integration of Cultural Competence in the Curriculum (BICCC) was used as an organizing framework and an evaluative tool to survey student perceptions of inclusion of cultural-specific content in undergraduate and graduate courses. Quantitative and qualitative data were used to complete this survey, which provided definitive information about the strengths and deficiencies of the curriculum initiative. Findings show that faculty made considerable progress with the curriculum integrative efforts. With responses of sometimes to quite often on the BICCC survey, 90% of the master's, 87% of senior, and 25% of first-semester freshmen participants reported a sufficient level of teaching in response to the survey items on aspects of culture and health. For all cohorts, the survey showed that content related to critique of health disparities research and theoretical formulation about culture, health, and nursing were not sufficiently addressed. Open-ended comments showed that freshmen reported a solid foundation of culturally related courses in arts and humanities courses; seniors disclosed a high level of knowledge about aspects of culture competence; and master's participants had high levels of self-awareness about values, cultural beliefs, and challenges of cross-cultural communication. The BICCC provided substantial information for faculty to address areas of omission, deficiency, and redundancy in the cultural competence education.
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http://dx.doi.org/10.1016/j.profnurs.2008.01.003DOI Listing
August 2008

Cultural competence in the master's curriculum--a course exemplar.

J Prof Nurs 2008 May-Jun;24(3):150-4

University of Pennsylvania, School of Nursing, Philadelphia, PA 19104-6096, USA.

This article focuses on the teaching-learning strategies for integration of cultural competence in the first clinical core course in Primary Care of the Middle Aged and Older Adult, a required course for graduate students enrolled in the Adult Health Nurse Practitioner Program, Gerontology Nurse Practitioner Program, and the Family Health Nurse Practitioner Program at the University of Pennsylvania School of Nursing. Multiple teaching-learning strategies for the first clinical course consisted of preliminary online self-assessment, clinical case scenarios, critique of multicultural clinical vignettes, and cultural assessment of the clinical agency. In the outcomes of these teaching-learning strategies, it was shown, through the use of reflective diaries of nurse practitioner students and course evaluations, that the multiple strategic approaches were effective for cultural competence integration within each of the nurse practitioner programs.
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http://dx.doi.org/10.1016/j.profnurs.2008.01.007DOI Listing
August 2008

Avoiding restraints in patients with dementia: understanding, prevention, and management are the keys.

Am J Nurs 2008 Mar;108(3):40-9; quiz 50

Psychiatric Mental Health Advanced Practice Program, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.

Older adults with dementia are at higher risk than other patients for being placed in restraints, despite numerous negative physical and psychological outcomes associated with their use. Many nurses continue to believe that restraints are necessary to control behavioral symptoms and prevent falls or the disruption of life-sustaining therapies in patients with dementia. Reducing the use of restraints depends on interpreting patient behavior to identify unmet needs; regular assessment for changes in mental or physical status; individualized care focused on communication, consistency, surveillance, and appropriate environments; and a flexible team approach based on dialogue among staff members and respect for patients' needs and rights. For a free online video demonstrating the use of the practice guide, go to: (http://links.lww.com/A231).
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http://dx.doi.org/10.1097/01.NAJ.0000311827.75816.8bDOI Listing
March 2008

The burden of dementia.

Authors:
Valerie T Cotter

Am J Manag Care 2007 Dec;13 Suppl 8:S193-7

School of Nursing, University of Pennsylvania, 420 Guardian Dr, Philadelphia, PA 19104, USA.

Dementia care is a significant and growing healthcare need that will have major economic and medical impact as the prevalence of Alzheimer's disease (AD) and related dementias continues to increase in the United States during the next 50 years. The ability to differentiate the signs and symptoms of the most common dementing illnesses - AD, vascular dementia, frontotemporal dementia, and dementia with Lewy bodies - is essential to dementia care and management. Additionally, dementia patients in longterm care (LTC) facilities are prone to significantly greater risk of negative outcomes compared with nondemented residents as a result of a decline in activities of daily living, physical capacities, and behavioral manifestations. Careful and active assessment of risk factors and their management provides opportunities for improving outcomes. These include behavioral manifestations of pain, wandering, and risks of malnutrition, falls and injuries, and restraint use. Specific nonpharmacologic interventions to promote restraint- and pain-free care in LTC are highlighted.
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December 2007

Avoiding restraints in patients with dementia.

Medsurg Nurs 2006 Oct;15(5):315-6

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October 2006

Alzheimer's disease: issues and challenges in primary care.

Authors:
Valerie T Cotter

Nurs Clin North Am 2006 Mar;41(1):83-93, vi

School of Nursing, 420 Guardian Drive, University of Pennsylvania, Philadelphia, PA 19104, USA.

The challenge in primary care practice is identifying persons with symptoms of Alzheimer's Disease (AD) who often have limited capacity to recognize their own symptoms and attribute cognitive decline to chronic illness or aging. Brief office visit communications without an informant,such as a spouse or adult child rarely uncover mild stage AD. Clinicians in primary care fail to screen older adults for AD on a routine basis be-cause of insufficient time, inadequate reimbursement for services, and uncertainty about the value of an early diagnosis. Although current pharmacologic and behavioral interventions and patient education do not prevent eventual disease progression, they arguably lead to improvements in understanding, self-efficacy, and quality of life for the patient and family.
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http://dx.doi.org/10.1016/j.cnur.2005.09.005DOI Listing
March 2006

Restraint free care in older adults with dementia.

Authors:
Valerie T Cotter

Keio J Med 2005 Jun;54(2):80-4

University of Pennsylvania School of Nursing, Philadelphia, PA, USA.

During the past two decades, significant research and several government and health care quality groups have advised against the use of physical restraints in hospitals and nursing homes, yet older adults are continuing to die, become injured or experience the iatrogenic complications associated with this practice. Deaths are usually caused by asphyxiation, but also occur from strangulation, or cardiac arrest. Older adults with dementia are at high risk for restraint use because of impaired memory, language, judgment and visual perception. In moderate to severe dementia, the risk of falls is greater because of gait apraxia and unsteadiness. Agitation, disorientation, and pacing behaviors from delirium or dementia can precipitate staff to use restraints to prevent harm to the older adult or to others. Physical restraints should be eliminated as an intervention in older adults with dementia because they are also very likely to cause acute functional decline, incontinence, pressure ulcers and regressive behaviors in a short period of time. The purpose of this paper is to disseminate the dangers of this clinical practice and to summarize the latest research in restraint free care and restraint alternatives in the United States.
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http://dx.doi.org/10.2302/kjm.54.80DOI Listing
June 2005

Cognitive function assessment in individuals at risk for Alzheimer's disease.

J Am Acad Nurse Pract 2003 Feb;15(2):79-86

Adult Health & Gerontology Nurse Practitioner Programs, School of Nursing, Alzheimer's Disease Center, University of Pennsylvania, USA.

Purpose: To describe brief assessments of functional performance and cognition to detect Alzheimer's disease (AD) and depression in older adults for the primary care provider.

Data Sources: Review of the literature.

Conclusions: It is important for the clinician to interview both the patient and a knowledgeable informant to assess changes in the patients' functioning in daily life tasks and to administer brief screening tests to detect cognitive impairment and depression in older adults. Several suggested instruments for use in the primary care setting are included.

Implications For Practice: Standardized assessments of functional performance and brief cognitive tests identify individuals with clinically meaningful cognitive impairment and provide baseline measurement against which to compare future assessments.
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http://dx.doi.org/10.1111/j.1745-7599.2003.tb00355.xDOI Listing
February 2003
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