Biomedical subjects

A Lynn Snow

Publications and source records attributed to A Lynn Snow.

13 recordsLinked to original sources

PubMed2006

Assessment and treatment of persistent pain in persons with cognitive and communicative impairment.

Pain management is a challenge when working with persons who have cognitive impairment that affects their ability to understand and communicate. This article focuses on pain assessment and treatment in persons who have dementia, but the challenges and principles are relevant to the spectrum of cognitive impairment. Fundamental principles guiding pain assessment and treatment in this population are (1) that behavioral disturbance is the result of an unmet need that causes discomfort, (2) that the behavioral disturbances that result from the unmet need of uncontrolled pain may be identical to those caused by other unmet needs (e.g., thirst, needing to toilet, understimulation, overstimulation, depression, psychosis, uncomfortable clothing), and therefore (3) that any pain treatment protocol for this population must target discomfort behaviors in general and then attempt to determine their causes. Pain assessment and treatment approaches based on these principles are outlined, and then two cases are presented to illustrate the application of these approaches.

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PubMed2005

Prevalence of dementia among Veterans Affairs medical care system users.

OBJECTIVES: In an aging population, the number of veterans diagnosed with dementia is likely to increase. Knowledge of existing dementia prevalence will be beneficial in planning for future patient care needs. Our objectives were to assess the prevalence of the dementia diagnosis among those treated at Veterans Affairs (VA) medical centers and determine how it varies across race and Veterans Integrated Service Network (VISN). MATERIALS AND METHODS: Data were collected on all veterans seen within the VA medical system from 1997 through the first half of 2001. Only veterans aged 65 and over were included in the study. Veterans were included if they had one of the following dementia ICD-9 codes: 290.XX, 291.2, 294.XX, 331.XX, 046.1, or 046.3. RESULTS: The overall prevalence of dementia was 7.3%. The prevalence of dementia was similar among white patients and patients of other races, except African-American patients, in whom it was 50% higher. Across VISNs, the prevalence of dementia ranged from 5.8 to 9.4%. Alzheimer's disease was the most frequently diagnosed type of dementia within the VA, and inpatient service utilization and outpatient psychiatry visits by individuals with dementia were high relative to other VA patients. DISCUSSION: The overall prevalence identified is consistent with that reported in the literature, as is the elevated prevalence in African-Americans versus whites. The data on prevalence by VISN may identify regional variation in either the types of dementia present or the diagnostic criteria used. The dementia diagnosis is clearly associated with substantial service use.

Age Factors↗

PubMed2005

Factors affecting deficit awareness in persons with dementia.

OBJECTIVE: This study examined factors affecting deficit awareness (DA) and the effects of diagnostic status (dementia and depression), measurement method and DA dimension on these relationships. METHODS: One hundred and twenty-one participants (66 persons with dementia and 55 persons without dementia, matched for depression diagnosis) were enrolled, each with a family informant. Participant DA (clinician and informant rated), cognitive impairment, physical illness, functional disability and caregiver burden were assessed. RESULTS: Factors affecting DA included presence of dementia, presence of depression, cognitive impairment, caregiver burden, and functional disability. The relationship between these factors and DA varied by DA dimension. CONCLUSIONS: DA measurement method was an important moderating variable; clinicians may be better at evaluating cognitive DA whereas informants may be better at evaluating functional and emotional/behavioral DA.

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PubMed2005

Self-reported awareness of performance in dementia.

The purpose of this study was to test the theory that patients with dementia do not update their self-perceptions based on actual performance. This experiment compared differences between post-task perceptions of performance and actual performance in persons with dementia and normal controls on seven cognitive tasks. Participants included 35 volunteers (12 with dementia and 23 without) from the Houston Veterans Affairs nursing home and geropsychiatric inpatient unit and outpatient clinics and from the Baylor College of Medicine's Alzheimer's Disease Center. Measurements included 7 subtests of the Alzheimer Disease Assessment Scale-Cognitive Subscale and standardized interview questions assessing perceived performance on each of these subtests. Participants with dementia had similar perceptions of performance to normal controls yet evidenced much worse performance on all seven cognitive screening tasks. Thirty-one percent of normal controls over-estimated their performance, compared to 64% of those with mild-moderate dementia and 93% with moderate-severe dementia. Our study supports the theory that demented individuals do not update their self-perceptions of performance. However, a large portion of normal controls was also inaccurate evaluating their own performances. Thus, post-diction measures provide useful insight into the mechanisms of self-awareness but may not be appropriate assessment tools to identify clinically significant impaired self-awareness.

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PubMed2005

Proxies and other external raters: methodological considerations.

OBJECTIVE: The purpose of this paper is to introduce researchers to the measurement and subsequent analysis considerations involved when using externally rated data. We will define and describe two categories of externally rated data, recommend methodological approaches for analyzing and interpreting data in these two categories, and explore factors affecting agreement between self-rated and externally rated reports. We conclude with a discussion of needs for future research. DATA SOURCES/STUDY SETTING: Data sources for this paper are previous published studies and reviews comparing self-rated with externally rated data. STUDY DESIGN/DATA COLLECTION/EXTRACTION METHODS: This is a psychometric conceptual paper. PRINCIPAL FINDINGS: We define two types of externally rated data: proxy data and other-rated data. Proxy data refer to those collected from someone who speaks for a patient who cannot, will not, or is unavailable to speak for him or herself, whereas we use the term other-rater data to refer to situations in which the researcher collects ratings from a person other than the patient to gain multiple perspectives on the assessed construct. These two types of data differ in the way the measurement model is defined, the definition of the gold standard against which the measurements are validated, the analysis strategies appropriately used, and how the analyses are interpreted. There are many factors affecting the discrepancies between self- and external ratings, including characteristics of the patient, the proxy, and of the rated construct. Several psychological theories can be helpful in predicting such discrepancies. CONCLUSIONS: Externally rated data have an important place in health services research, but use of such data requires careful consideration of the nature of the data and how it will be analyzed and interpreted.

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PubMed2005

Accuracy of self-reported depression in persons with dementia.

OBJECTIVES: To investigate the reliability and validity of self-reported depression in demented elderly patients. DESIGN: This is the first study to combine the use of multiple depression criteria with dementia and depression control groups. SETTING: Houston Veterans Affairs nursing home and geropsychiatric inpatient unit and outpatient clinic, Baylor College of Medicine's Alzheimer's Disease Research Center. PARTICIPANTS: The total sample included 121 volunteer participants, their informants, and their clinicians, forming four diagnostic groups (27 controls, 37 dementia only, 28 depression only, 29 dementia and depression). MEASUREMENTS: Scales assessing depression, deficit awareness, physical illness, functional disability, caregiver burden, and severity of cognitive impairment were used. RESULTS: Analyses of variance using informant- and clinician-rated depression categories found main effects on patient-reported depression scores for deficit awareness and depression diagnosis but not for dementia diagnosis. Chi-square analyses revealed that demented and depressed patients underreported depression at similarly high rates compared with clinician and informant reports. Regression analyses revealed that deficit awareness accounted for significant variance in self-reported depression accuracy, whereas clinician- or informant-rated depression, severity of cognitive impairment, physical disability, functional status, and caregiver burden were not significant. CONCLUSION: The results of this investigation suggest that the presence of dementia per se does not predict inaccurate depression self-reports. Deficit awareness, which covaries with dementia, appears to account for the majority of the variance in self-report accuracy. These findings were stable across informant- and clinician-rated depression criteria and multiple analyses.

Activities of Daily Living↗

PubMed2005

Comorbid psychosocial symptoms and quality of life in patients with dementia.

OBJECTIVE: The authors examined the association between treatable comorbid psychosocial symptoms and quality of life (QOL) in patients with dementia. In an effort to develop a more comprehensive understanding of this relationship, this study included both patient reports of their QOL and caregiver reports of patient QOL. METHODS: Eighty-nine dyads, consisting of a community-residing veteran with dementia and his family caregiver, were interviewed once to determine the correlation between patient QOL and depression, functional disability, pain, and agitation. RESULTS: Higher patient-rated QOL was significantly associated with lower patient depression. Higher caregiver-rated patient QOL was associated with lower caregiver depression and higher patient functional status. Agitation was not related to patient-rated or caregiver-rated patient QOL. CONCLUSIONS: Authors discuss the psychometric and conceptual implications of possible differences between self- and other-ratings of QOL, and treatment implications for caregiver-education interventions.

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PubMed2005

Treatable comorbid conditions and use of VA health care services among patients with dementia.

OBJECTIVE: Although dementia is a progressive degenerative disease, treatable comorbid symptoms, such as pain, aggression, depression, and psychosis, occur among more than 60 percent of patients with dementia. Compared with age-matched controls, patients with dementia use 70 percent more health services and account for 50 percent more managed care costs. This prospective study examined the longitudinal relationship between use of health care services and treatable comorbid conditions among patients with dementia. METHODS: Ninety-nine patient-caregiver dyads from the Michael E. DeBakey Veterans Affairs (VA) Medical Center in Houston, Texas, completed a one-time interview. Patients' VA records were reviewed one year later to examine the relationships between the study variables and three types of service use: inpatient medical stays, outpatient medical visits, and outpatient psychiatric visits. RESULTS: Pain was positively associated with all types of service use. Depression was associated with outpatient psychiatric visits. Psychosis and aggression were not significantly associated with future use of health care services. CONCLUSIONS: The results of this study confirm previous findings that pain and depression are associated with increased use of health care services. Although the other treatable comorbid symptoms, with the exception of pain, are associated with increased service use, their impact varies depending on the type of services provided. Interventions to improve the assessment and treatment of comorbid symptoms, especially pain, among patients with dementia may reduce service needs and thus reduce medical care costs.

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PubMed2004

NOPPAIN: a nursing assistant-administered pain assessment instrument for use in dementia.

The Non-Communicative Patient's Pain Assessment Instrument (NOPPAIN) is a nursing assistant-administered instrument for assessing pain behaviors in patients with dementia. This study investigated the validity of the NOPPAIN. Twenty-one nursing assistants (NAs) with no prior training in using the NOPPAIN watched six videos, each portraying a bed-bound patient with severe dementia receiving personal care from a nursing assistant and responding with a different level of pain intensity. The NAs completed a NOPPAIN rating for each video. The NAs were also presented with each possible pair of videos and asked to identify the video showing the most pain. Results indicated the NAs were quite accurate in their ratings of the videos, providing excellent preliminary evidence on the use of the NOPPAIN for detecting pain in nursing home patients with dementia.

Adult↗

PubMed2004

A conceptual model of pain assessment for noncommunicative persons with dementia.

PURPOSE: Our objectives are to present a conceptual model of the pain assessment process in persons with dementia and discuss methods for validating our model within this population. DESIGN AND METHODS: This conceptual work is based on an integrative review and current pain theory, pain assessment research in demented and nondemented populations, and research on the science of self-report. RESULTS: We present a multidimensional model of pain assessment that emphasizes the role of the external rater. Our model posits that a nociceptive stimulus leads to pain sensation, followed by pain perception, followed by the exhibition of external signs of pain by the patient, followed by an external rater's observation and interpretation of those external signs. Further, the model specifies the effects of nociceptive stimulus factors on pain sensation; patient-specific factors on pain perception; method-specific factors on external sign observation; and rater-specific factors on external sign interpretation. IMPLICATIONS: Pain assessment in persons with dementia must go beyond a unidimensional model of pain assessment. This multidimensional model also directly addresses the challenges of using external ratings to assess pain in persons with dementia. Finally, we present clinical recommendations for applying the model to pain assessment endeavors and research recommendations for evaluating models of pain in this population.

Dementia↗

PubMed2003

Health care utilization in dementia patients with psychiatric comorbidity.

PURPOSE: The purpose of this research was to determine if differences in service use exist between dementia patients with and without psychiatric comorbidity. DESIGN AND METHODS: A retrospective cohort study was conducted on all Veterans Affairs (VA) beneficiaries seen at the Houston Veterans Affairs Medical Center with a VA Outpatient Clinic File diagnosis of dementia in 1997. The primary dependent measure was amount of Houston VA health service use from study entry until the end of fiscal year 1999 or until death. RESULTS: Of the 864 dementia patients in the identified cohort, two thirds had a comorbid psychiatric diagnosis. Examination of 2-year health service use revealed that, after adjusting for demographic and medical comorbidity differences, dementia patients with psychiatric comorbidity had increased medical and psychiatric inpatient days of care and more psychiatric outpatient visits compared with patients without psychiatric comorbidity. IMPLICATIONS: Further understanding of the current health service use of dementia patients with psychiatric comorbidity may help to establish a framework for considering change in the current system of care. A coordinated system of care with interdisciplinary teamwork may provide both cost-effective and optimal treatment for dementia patients.

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PubMedDate not supplied

Dementia Deficits Scale. Rating self-awareness of deficits.

Impaired deficit awareness is important to detect because of its clinical implications; for example, patients with impaired awareness are more likely to engage in potentially dangerous activities, such as operating the stove. This study evaluated the reliability and validity of the Dementia Deficits Scale (DDS), a new multidimensional instrument for the assessment of self-awareness of cognitive, emotional, and functional deficits associated with dementia. Three parallel forms of the DDS were independently completed by the patient, clinician, and informant. The DDS yields two measures of deficit awareness: the discrepancy between clinician and patient assessments of the patient's deficits, and the discrepancy between informant and patient assessments. The DDS demonstrated adequate reliability and good divergent and convergent validity. Clinician and informant reports each added unique information, highlighting the importance of including both perspectives in the awareness assessment process. The DDS is recommended as a reliable and valid tool for the clinical and empirical assessment of deficit awareness in patients with dementia.

Activities of Daily Living↗

PubMedDate not supplied

The Alzheimer's Disease Assessment Scale-Cognitive subscale: normative data for older adult controls.

The Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-cog) is commonly used to assess cognitive dysfunction in individuals with Alzheimer disease and other dementias. The purpose of this study was to provide normative scores for the ADAS-cog 11 individual items and total score, as well for delayed recall errors, using normal, elderly volunteers. The ADAS-cog was administered to 124, non-cognitively impaired volunteers ages 55 to 89, with 10 to 21 years of education. The mean total ADAS-cog score was five. The ADAS-cog error score was not associated with education in this highly educated group, and was positively correlated (P < 0.001) with the age of the participant. Age stratified ADAS-cog normative data are reported for the ADAS-cog total and the delayed recall error score.

Age Factors↗