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UCLA Older Americans Independence Center (Pepper Center)
INTERVENTION STUDY Feeding
Assistance in Nursing Homes: Staffing and Outcomes Malnutrition is a major problem among nursing home (NH) residents, with high prevalence and substantial health and financial consequences. An important contributor to malnutrition in the NH is inadequate staff to provide feeding assistance. This intervention study will refine a method for optimizing NH staff efficiency in providing feeding assistance to residents and then test the efficacy of this model in a randomized clinical trial with quality of life and health outcomes. This study will address this problem in two major phases. In the first phase, the efficacy and costs of providing feeding assistance to residents will be evaluated using a randomized controlled design to define the NH staff resources necessary to provide efficacious assistance. Using these results, computerized staffing simulation models will project the minimum number of nursing staff necessary to provide feeding assistance to residents for a range of environmental and resident acuity levels that characterize different homes. This phase is sufficiently powered to address the important issues of: (1) how NHs should allocate staff so as to provide feeding assistance to residents who need it; and (2) to document the effects of such assistance on food intake. However, Phase 1 is not designed to identify health or quality-of-life outcomes that may be associated with improved feeding assistance and food intake. Therefore, in the second phase, residents in two different nursing homes who are found to increase their intake with the feeding assistance intervention will be randomized into either an immediate or delayed treatment group. Research staff will maintain the efficacious feeding assistance protocols with the intervention group to detect intervention effects on body weight, quality of life, functional status, and biomedical markers of undernutrition.
INTERVENTION DEVELOPMENT STUDIES Multidimensional
Intervention for Vision-Impaired Elders (2001-2004) Visual impairment is very common in older persons and is associated with decreased vision-specific and overall functioning. Two of the most common causes of visual impairment, uncorrected refractive error and cataracts, are reversible, while the others such as glaucoma and age-related macular degeneration are not. No matter whether visual impairment is irreversible or reversible, visual functioning may improve with increased lighting and the use of low vision aids. This Intervention Development Study (IDS) is designed to conduct a small randomized clinical trial of providing eyeglasses on visual functioning in older persons and to gather preliminary information to support an application for a Randomized Clinical Trial (RCT) to determine whether visual and overall functioning of older persons can be enhanced through a multi-dimensional intervention that corrects reversible causes of visual impairment, improves lighting in the home environment, and provides access to low vision aids. The IDS will provide critical information about the feasibility, recruitment rates, expected effect sizes, and costs that would be associated with a RCT.
It is recognized that older African Americans with diabetes experience substantially worse process and outcomes of care. To address this problem, the goal of this Intervention Development Study (IDS) is to develop and evaluate an age-appropriate intervention designed to improve diabetes self-care practices by enhancing the self-efficacy, empowerment, and diabetes-specific knowledge among African Americans over the age of 65 years. Specific aims of the project are: 1) to develop an intervention to prevent functional decline by improving self-efficacy and self-management skills among older African Americans with diabetes; 2) to test the effect of this empowerment intervention that focuses on increasing self-efficacy, knowledge about diabetes care, and self-care skills among older African Americans with diabetes on glycemic control, lipid levels, blood pressure, weight, diabetes-related symptoms, quality of life and costs of care; 3) to describe the relationship between improving patient knowledge of needed diabetes care on receipt of indicators of good process of care such as dilated eye examinations, foot examinations, glycosylated hemoglobin and lipid testing; and 4) to describe the relationship between any intervention-driven changes in physiologic health (glycemic control, weight and symptoms) and changes in multidimensional functional status.
Age-related osteoporosis is characterized by decreased osteoblast number and bone forming activity, and increased bone marrow adipocyte content. This suggests a shift in bone marrow mesenchymal stem cell (MSC) differentiation pathways, with increased adipocyte and decreased osteoblast production. This study will look at the hypothesis that Lipid Oxidation Products (LOPs) contribute to age-related osteoporotic bone loss by decreasing bone cell growth factor production and/or responsiveness, and enhancing adipogenic differentiation of bone marrow stem cells at the expense of osteoblast production. It is anticipated that these studies will identify new targets for interventions to prevent and treat age-related osteoporosis Using Information Technology to Improve Care of Vulnerable Veterans Background: Prior work using Assessing Care of Vulnerable Elders (ACOVE) quality indicators has established that the care elders receive falls short of expected standards and that the care of “geriatric” conditions, such as falls and incontinence—high-risk conditions that may affect the independence of patients—is worse than care of medical conditions such as coronary artery disease. Objective: To establish the feasibility of developing usable and useful computerized templates for VA primary care clinicians. Design, Setting, Subjects:Phase 1—3 structured interviews with VA computer experts and development of prototype templates; Phase 2—10 cognitive interviews with clinicians; Phase 3—randomize 16 clinicians to computerized template versus usual care. Interventions:Phase 1 and 2—interviews, Phase 3—exposure to computerized template versus blank progress note in a laboratory setting using standardized actor-patients, but actual clinicians. Main Outcome Measures: Usefulness and usability of computerized templates for incontinence and fall, changes in ACOVE processes of care measures for incontinence and falls. Conclusion: Templates may improve the processes of care for vulnerable patients. The feasibility of developing a computerized template that primary care clinicians view as usable and useful and that are capable of improving processes of care is unknown. This pilot will test the feasibility of these computerized templates and support a proposal to VA Health Services Research and Development for an evaluation of a full-scale intervention in the VA.
Alzheimer’s disease (AD) is a progressive neurodegenerative disorder characterized by two pathological hallmarks: amyloid plaques composed of aggregated b -amyloid (A b ) protein and neurofibrillary tangles formed by hyperphosphorylated tau. Extensive epidemiological and case control studies to investigate the pathogenesis of AD have revealed that Type II diabetes mellitus is a potent risk factor for developing AD independent of its risk for vascular dementia. Type II diabetes mellitus, the more prevalent form of diabetes which accounts for 90% of cases, is caused by a loss of insulin sensitivity and reduced insulin secretion and, as a result, characterized by hyperglycemia and overweight. The association between AD and diabetes prompted us to investigate insulin-induced signaling cascades in neurons. Our preliminary data have demonstrated that insulin signaling, through the PI3 kinase-Akt signaling cascade, leads to increased expression of insulin degrading enzyme (IDE), which has been shown to be a key enzyme responsible for degradation of A b . Moreover, activated Akt is also an upstream kinase that phosphorylates and inactivates GSK3 b , a kinase responsible for phosphorylation of tau. Insulin signaling and Akt phosphorylation, therefore, may alleviate the accumulation of hyperphosphorylated tau as well as reducing the pathological presence of A b . In addition, insulin signaling leads to activation of p21-activated kinase (PAK), which maintains a dendritic spine actin-binding protein, drebrin (that is lost in AD) and facilitates its association with actin and synaptic/neuritic function. Insulin, however, is a competitive substrate with A b for available IDE, which prompted us to investigate whether a small molecule mimetic of insulin lacking adverse pro-mitogenic activity, demethylasterriquinone B1 (DAQ B1), could be used as an effective insulin alternative to activate the neuroprotective signaling pathway. DAQ B1 has been demonstrated to be an orally active insulin mimetic reducing glucose levels. Two specific aims are proposed here to investigate the therapeutic potential of DAQ B1 in AD-related pathology both in vitro and in vivo. The first specific aim will determine the signaling pathway induced by DAQ B1 in vitro. Hippocampal primary rat neurons and the N2A neuronal cell line will be used to determine DAQ B1-induced IDE expression and resultant A b levels in extracellular medium, Akt, GSK3 b and tau phosphorylation, in addition to drebrin-actin association and neurite morphology. The second specific aim will determine the DAQ B1 effect in vivo in tangle-vulnerable 3xTg-AD triple transgenic mice with similar end points. Pain is often undetected among nursing home (NH) residents and particularly among residents with cognitive impairment. A brief, standardized Pain Detection Interview has been shown to elicit reliable responses from NH residents with and without cognitive impairment when conducted by research staff. The purpose of this controlled intervention pilot study is to improve both pain detection and “as needed” pain medication administration by licensed nurses through an integrated training and management (ITM) model. The ITM model consists of three primary components: (1) licensed nurse training in the administration of the Pain Detection Interview to be used as part of weekly assessments of pain as a 5 th vital sign; (2) licensed nurse training in the use of a standardized report form to communicate the results of pain assessments to residents’ primary care physician, when appropriate; and, (3) brief, weekly, feedback sessions with licensed nurses about pain detection, the delivery of “as needed” pain medications, and physician communication that are based on independent quality monitoring data collected by research staff. Specifically research staff will conduct independent interviews with residents using the Pain Detection Interview and review relevant medical record data (medication passes, licensed nurse and physician notes) weekly. The ITM model will be implemented with licensed nurses on one NH floor and compared to a standard training model that includes two 30-minute training sessions on a control floor. We hypothesize an increase in the proportion of residents detected with pain and treated with “as needed” pain medications on the intervention floor relative to the control floor. If this pilot study is effective, the intervention can be evaluated in a larger controlled trial; and, more importantly, the ITM model can be evaluated in other care areas, such as depression screening, as a method for translating care process improvements into NH practice. The purpose of this pilot study is to characterize the epidemiology of family conferences in geriatric inpatient medical care. Family conferences in health care settings are meetings that may include patients, family members and health care providers from several disciplines to discuss the condition and care of a patient. They are common clinical interventions particularly in the setting of life-threatening illness and end-of-life care. Conferences provide settings for discussing treatment options and reaching consensus, problem solving, and addressing patient and family concerns. They are a context in which a coordinated approach by an interdisciplinary team – recognized as essential to geriatric care -- may be implemented. However, because of a dearth of research on family conferences, little is known about the structure of conferences, clinician participation, and what elements contribute to effective family conferences. This project is a quantitative study of family conferences taking place with patients 65 years and older in Medicine and Critical Care units of UCLA Medical Center and/or Santa Monica/UCLA Hospital. The project goals are to determine prevalence of family conference use, to describe structural characteristics of these conferences (e.g. length, location, participants), to describe the roles of professionals from multiple disciplines in conferences, and to compare perceptions of multiple health care providers, family members and patients about the purpose and success of conferences. Brief daily surveys will be used to collect data from physicians, nurses and social workers about family conferences that took place the previous day. In addition, patients and family members will be interviewed about their perceptions of conference purpose and success. The target sample size will be 200 family conferences. Understanding this clinical intervention will inform interdisciplinary practice and provide a basis for evaluation and improvement of this aspect of care for geriatric patients.
CAREER DEVELOPMENT AWARDS Tara Gruenewald, PhD (2005-2006) – (310) 825-8253 Title of Research: Social Environment Effects on Functional Ability and Health Status in Older Adults The quantity and quality of individuals’ social relationships have been shown to be important predictors of morbidity and mortality in a number of epidemiological and health investigations. However, interventions to enhance levels of social integration have thus far yielded disappointing results, suggesting that we have yet to identify critical elements of the social environment that affect health and functioning. This research project is designed to investigate one hypothesized feature of the social environment that has not been a focus of much research attention to date – namely, the degree to which one’s social relationships generate feelings of being needed, valued, and useful to others and the relation of these feelings to health and well-being. Such feelings are thought to be a benefit of social relationships and an important human need, but these feelings have not been a primary focus of research on social relationships and health. The primary objective of the proposed research during is to examine the relationship between feeling useful/valued and trajectories of positive functioning and health status, measured as cognitive and physical functioning, disease morbidity, and mortality, in two large cohorts of middle-aged and older adults. A secondary objective is to identify the psychosocial, behavioral, and physiological pathways that may underlie relationships between feeling useful/valued and cognitive and physical functioning and health status. A third objective is to identify aspects of social environment, as well as behavioral, health status, and demographic predictors of feeling useful and valued. The ultimate objective of the proposed research is to identify factors that promote feelings of usefulness and value within individuals’ social networks and to better understand the pathways through which these feelings promote positive functioning and better health outcomes with the goal of informing interventions to improve the lives of older adults.
Geoffrey Joyce, PhD(2003-2006) - (310) 393-0411, x6779 Title of Research: The Costs of Chronic Health Conditions over the Course of Treatment Despite considerable research on the costs of treating an episode of care, there is little information on how treatment costs vary over the course of an illness and how stage-specific costs interact with age, mortality and other patient characteristics. For example, what are the costs to Medicare and Medicare beneficiaries of adult-onset diabetes or lung cancer? How do costs vary by age or stage at diagnosis? What are the lifetime treatment costs associated with selected chronic conditions and do high medical expenditures persist in the years after initial diagnosis? The proposed study will extend prior work by examining medical expenditures over the course of an illness for a range of costly and prevalent chronic conditions affecting older Americans. Using a unique dataset that links 8 years of expenditure data from the Medicare Current Beneficiary Survey (MCBS, 1992-1999) to individual Medicare claims for up to 9 years (1991-1999), we will estimate total treatment costs and Medicare expenditures during incident, maintenance, and terminal stages of illness. Documenting the patterns of treatment costs after diagnosis is useful for providing adequate insurance coverage, comparing the financial impact of alternative therapies, evaluating the long-term cost implications of screening and prevention programs and risk-adjusting payments to health plans. Kathrin Maedler, PhD (2005-2006) – ( 310) 794-7675 Title of Research: Effect of aging on β-cell apoptosis: importance in the progression of diabetes Objectives and Hypotheses: Type 2 diabetes especially occurs in older people with an inherited predisposition. Therefore, we suggest that with increasing age, β-cells become more sensitive to environmental factors, but the mechanism is not known. The overall objective of this project is to investigate the sensitivity of human β-cells to the onset of type 2 diabetes at an older age. It is hypothesized that:
Specific Aims: I) to study the sensitivity of human islets to apoptosis with increasing age and its mechanisms. II) to analyze changes in β-cell proliferation with increasing age and its mechanisms. III) to measure insulin secretion from the cultured islets and analyze changes in islet’s secretory function with increasing age and its mechanisms. Title of Research: Changing caregiving practices to improve nursing home resident sleep: intervention development Sleep disturbance is common in NH residents, results from treatable and modifiable factors, and is associated with cognitive impairment, poor health, reduced quality of life and increased mortality. Pharmacological treatment of sleep disturbance has significant risks in NH residents due to the potential adverse effects of sleep medications. Improving NH residents’ sleep with nonpharmacological strategies has been the focus of considerable research and shows some promise. Prior studies, however, are typically limited in that: 1) interventions target individual residents, ignoring sleep-disruptive environmental factors, and/or 2) environmental interventions are carried out by trained research personnel rather than NH staff thereby limiting generalizability to community NHs. The goal of the proposed qualitative research and pilot study is to develop an intervention that can be implemented within community NHs. To inform intervention development, qualitative data from focus groups with certified nurse’s aides (CNAs) and interviews with supervisory staff will be conducted in 4 community NHs to: 1) provide understanding of factors that would motivate nightshift staff to create a sleep-conducive environment, 2) assess the feasibility of changing sleep-disruptive caregiving behaviors and 3) identify barriers to implementing and maintaining such changes. This qualitative data and the prior experience of Dr. Martin and her mentors will be utilized to develop an intervention with NH staff to improve sleep-related caregiving practices. The intervention will be based upon a well-studied psychological model of behavior change, which suggests feedback from individuals targeted for behavior change should inform intervention design and implementation. The intervention will then be pilot tested in a community NH. This proposal will provide needed background information to develop a nursing staff intervention protocol and obtain funding to empirically test the intervention in community NHs. Title of Research: Signaling Cascades and Functional Significance of Demthylasterriquinone B1 in Primary Neurons and Alzheimer’s Disease Animal Models The overall objective of this study is to determine the effect of enhanced insulin signaling on AD pathology and the potential therapeutic effect of a small molecule insulin mimetic, DAQ B1, in AD animal models. The major hypothesis of this proposal is that DAQ B1 induces neuroprotective signaling cascades and targets AD pathology. Specifically, DAQ B1 is hypothesized to induce Akt activation and IDE upregulation, GSK3 b inactivation and reduced tau phosphorylation, and PAK activation and enhanced drebrin-actin interaction. Our extensive body of preliminary data supports each step of the cascades induced by insulin. DAQ B1 is also hypothesized to reduce plaques and tangles and alleviate AD synaptic pathology in triple transgenic 3xTg-AD mice and have a therapeutic effect on diabetic animals raised on high fat diet which develop insulin resistance and AD pathology. As a functional consequence of improved insulin signaling and reduced AD pathology, DAQ B1 is hypothesized to improve cognition/ memory in the diabetic animals. |
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Last Updated: March 3, 2006 |
