News and recent findings to keep the gerontological nurse up-to-date
EXERCISE BENEFITS ARTHRITIC PATIENTS
Research papers delivered at the Pan-American Congress of Rheumatology suggest that carefully designed exercises can benefit patients with certain types of arthritis without doing harm.
Some studies have shown that runners, tennis players, bowlers, and others who put little-used muscles to work may be paving the way for osteoarthritis. However, these new reports indicate that supervised exercise actually can help alleviate the discomfort of some types of joint disease.
One researcher found that female arthritis patients could be helped by exercise sessions as short as 15 minutes. Women with moderate rheumatoid arthritis, a disease in which joint membranes are inflamed, were assigned to three supervised exercise plans using stationary bicycles. The length of exercise time varied from 15 to 35 minutes per session with three sessions each week over a 12- week period. Improvement in aerobic capacity, exercise tolerance, and functional status was recorded in all the groups. Self-assessment tests showed that participants also ïelt less fatigue and were better able to participate in household and social activities.
A supervised cardiovascular fitness training program conducted on patients with fibromyositis - a chronic muscular pain syndrome - found marked improvements in comparison to patients who did only flexibility exercises.
LOCAL INJECTIONS HELP NONJOINT PAIN
Patients with osteoarthritis often suffer pain in areas other than the joints. Recent studies at the Southern Illinois University School of Medicine indicate that injections of local anesthetics into these nonjoint areas may ease this pain.
In a study group of patients with osteoarthritis of the knee, 38% had significant extra-articular pain responsive to ìocaì injection therapy. Among those with pain confined primarily to the knee, however, many responded to injections of intra-articular corticosteroid drugs. The high frequency of nonjoint pain in osteoarthritis may account for conflicting data in the efficacy of intra-articular corticosteroids. If the intra-articular treatments are ineffective, extraarticular injection therapy may be indicated.
CENTER ASSISTS LTC PROVIDERS
The Long-Term Care Assessment Training Center at Cornell University Medicai Center provides consultation, assistance, and training to public and private institutions, agencies, and organizations administering long-term care programs. Integral to the Center's available services is the Long-Term Care Information System (LTCIS) Assessment Process, which aids in decision making about an individual's care and streamlines care management.
Through the assessment process, the patient receives appropriate care and services when needed. The provider can track all care provided, evaluate its effect, monitor treatment and therapy, and validate the continuing need for services. Health care providers, regulators, and fiscal intermediaries can make long-range decisions about necessary services and their reimbursement, coordinate programs, and maintain desirable quality standards without additional cost. Anyone can learn to use the assessment process after a brief training session offered by the Center.
The assessment process encourages the interaction and participation of all members of the health care team - physician, nurse, therapist, nursing aide, social worker, the patient, the family - in obtaining and using core information about the patient. Use of the assessment process can be initiated at any point in the care of the individual: referral, care planning, progress evaluation, level of care determinations, pharmacy review, utilization review, and other decision times.
The hong-Term Care Assessment Training Center welcomes inquiries from any who would like to know more about how the assessment process may aid their program operations and how to receive training in its use. For more information contact: Program Coordinator, Long-Term Care Assessment Training Center, Cornell University Medical Center, Department of Public Health, 421 East 70th Street, New York, NY 10021. 212/472-4423.
DIAGNOSTIC DIFFICULTIES IN DEPRESSION/ ANXIETY
Papers presented at the American Psychiatric Association's 135th annual meeting dealt with the diagnosis and treatment of anxiety and depression among the elderly. Topics included the differentiation of depression from other affective syndromes and the effects that polypharmacopia and the normal aging process may have in the treatment of physical and emotional disorders in the elderly.
Depression in the aged is frequently more difficult to diagnose, more chronic, more severe, and more treatment-resistant than in younger patients. One researcher noted that it is important to distinguish between dementia and depression in the elderly. Difficulties arise since both conditions have similar symptoms: memory loss, inability to concentrate, and diminished interest in the environment. In patients with "pseudodementia of depression" such deficits are reversible.
Another diagnostic difficulty was noted in the treatment of anxiety in the elderly. It is important to distinguish between anxieties that represent extensions of earlier neurotic syndromes and those that have arisen recently. The elderly with neuroses have a higher mortality rate than the non-neurotic. Furthermore, the onset of neurosis late in life may be associated with a serious or life-threatening occult physical illness, particularly in men.
Physical problems associated with anxiety in the elderly include mild dementia, hyperthyroidism, idiopathic hypoglycemia, and adverse reactions to medications such as antiparkinsonian drugs or antidepressants. Erratic use of sleeping pills or intolerance to caffeine also may produce anxiety in the older person.
Anxiety also may coexist with depression in the elderly. Such endogenous depression may not be severe or may be masked by anxiety or phobias. The risk of suicide in the elderly is very real - 25% of all suicides in the U.S. are comitted by people over the age of 65. The diagnosis of depression preempts that of anxiety. In case of doubt, the patient should be diagnosed and treated for depression, with additional symptomatic treatment for any severe anxiety.
Reactive or neurotic depressions also are seen often in the older patient and may be mixed with reactive anxiety symptoms. The distinction between these two conditions is less important than between endogenous depression and anxiety because there is less risk of suicide.
Other difficulties in diagnosis may be created by a common practice among the elderly - polypharmacopia. Many drugs, including over-the-counter preparations, can produce symptoms of anxiety and depression. One investigator suggested that a careful inventory of the medicine cabinet be kept.
Care also must be taken in the use of medication in the treatment of the elderly with affective disorders. While available drugs for anxiety and depression may prove safe and effective in younger individuals, these same medications may at times aggravate the emotional states of the aged. Often, smaller doses are in order.
Before prescribing a drug, a physician must assess its possible effect on any organic disease the patient may have and its interaction with other medications the patient may be taking. Other factors that may influence the efficacy of drug therapy are gender, cigarette smoking, and alcohol consumption. Other difficulties with drug therapy occur in patients with diseases of the cardiovascularsystem and thyroid. Such diseases can render standard antidepressant medication (tri-tetracyclics, monamine oxidase inhibitors, and lithium salts) dangerous or ineffective in the depressed older patient.
Anxiety and agitation are sometimes prominent symptoms of both dementia and depression, which often create diagnostic confusion. The elderly patient should receive a thorough physical examination, including laboratory tests. A careful history must be obtained. Before drug treatment begins, organicity drug reactions and nondrug toxicity must either be ruled out or taken into account.
SUCRALFATE REDUCES ULCER RECURRENCE
Sucralfate was found beneficial in reducing the recurrence of duodenal ulcers by German and Austrian investigators in 12 medical centers. Results of the study that evaluated 251 patients with healed peptic ulcer were reported during the first Plenary Session of the American Gastroenterological Association.
The randomized, double-blind, placebo-controlled study was designed to determine if normal rates of ulcer recurrence could be altered through prophylactic treatment with sucralfate, a complex of sulfated sucrose and aluminum hydroxide.
The 251 patients were assigned randomly either to the treatment group receiving sucralfate or to the control group receiving placebo. Of the patient population, 174 had duodenal ulcers (DU) and 77 had gastric ulcers (GU). At the end of the study, a total of 181 patients remained available for evaluation: 126 DU patients (66 on sucralfate/ 60 on placebo), and 55 GU patients (30 on sucralfate/25 on placebo.)
The diagnosis of healed peptic ulcer was based on patient history and on endoscopic evaluation prior to entering the study. Endoscopy was repeated at the end of the study - or earlier if patients presented with ulcer-like symptoms. The treatment group received 1 g of sucralfate twice daily, which is one half of the recommended adult oral dosage for acute duodenal ulcer. The control group received a lookalike placebo twice daily.
Antacid tablets were allowed during the study. Among concomitant medications used were steroids, antiarthritics, tranquilizers, diuretics, beta blockers, bronchodilators, and cardiac agents.
Among the duodenal ulcer patients there was a 21% recurrence rate in the treatment group, compared with a 50% rate in the placebo group. The gastric ulcer patients did less well on the prophylactic dosage. Their recurrence rate was 37%. Both treatments were well tolerated.
Based on the results of the study, it was concluded that sucralfate significantly reduces the recurrence rate for duodenal ulcers and appears to be advantageous for the longterm prophylactic treatment of patients with duodenal ulcers.
Sucralfate has been available in Germany since 1980 and in the United States since November 1981. The drug currently is indicated in both nations for the short-term treatment of duodenal ulcer.
LVN APPRENTICES GRADUATE
Twenty-three Alameda County nurses have been graduated recently from the first licensed vocational nursing (LVN) apprenticeship program in California.
The program was initiated in 1980, when a consortium of convalescent hospitals in Alameda County joined with a local chapter of the Service Employees International Union (SEIU) to form the first nursing apprenticeship committee in the state. The program allows current employees to remain on the job, building the nursing skills they already have, while taking appropriate coursework and clinical training necessary to prepare them for licensure. The program utilizes funds from the California Worksite Education and Training Act (CWETA) to assist employers with added costs incurred during the worksite training.
March 1982 statistics show that 1,000 health care apprentices are participating in over 125 worksite training programs throughout California. There are 621 apprentices registered in LVN and RN programs at 170 hospitals and 178 psychiatric technician apprentices registered at six California state hospitals. Of the first registered nurse apprentices to graduate, 88% have successfully passed their licensing board examinations.
Other health care apprenticeship programs include dental, biomedical equipment, emergency medical, and x-ray technician.
ANA NATIONAL AWARDS GIVEN
Ten registered nurses and a U.S. senator have received the American Nurses' Association 1982 national awards, which were presented during the ANA 53rd Biennial Convention in Washington, D.C., in June.
The ANA Honorary Membership Award went to Maura C. Carroll, MA, RN, FAAN, and Dolores E. Little, MN, RN, FAAN, for "outstanding leadership, participation in and contributions to the purpose of the ANA." Carroll, associate dean for continuing education in nursing at the University of California in San Francisco, has worked on the ANA's Commission of Nursing Education, Committee to Study the Roles and Functions of Various Levels of the Organization, and Executive Committee of the Division on Medical-Surgical Nursing Practice. Little, a professor of nursing at the University of Washington in Seattle, is a member of the ANA Council of Nurse Researchers and has helped found the Nurses' Coalition for Action in Politics (N-CAP) and Politically United Nurses for Consumer Health (PUNCH). She is author of the film script of "Mrs. Reynolds Needs a Nurse" and co-author of Nursing Care Planning.
Senator Daniel K. Inouye and Margretta Styles, EdD, RN, FAAN, received the Honorary Recognition Award for "distinguished service to the nursing profession. . .whose contributions are of national or international significance to nursing. Inouye has sponsored legislation amending the Social Security Act to allow Medicare and Medicaid reimbursement for gerontological and psychiatric nursing services providing payment under government employee health plans for nursing services, increasing coverage of services provided by certified nurse-midwives, and reimbursing nurse-midwives under the Civilian Health and Medical Program of the Uniformed Services. Styles, professor and dean of the School of Nursing at the University of California in San Francisco, has worked to establish many networks of communication among nurse educators and has been a consultant on nursing issues both nationally and internationally. She also is associate director of nursing services, University of California, San Francisco, Hospitals and Clinics.
Ann Wolbert Burgess, DNSc, RN, FAAN, associate director of nursing research for the Department of Health and Hospitals in Boston, received the Honorary Nursing Practice Award. Burgess has worked extensively with victims of violence - rape, incest, child abuse, child pornography, and child prostitution - as a counselor, educator, and advocate. She coauthored The Victim of Rape and Rape Crisis and Recovery.
The Shirley Titus Award for "efforts to improve the economic and general welfare of registered nurses" was given to Irene C. Agnos, MA, RN, and Mary Ellen Patton, RN. Agnos, director of government relations for the California Nurses' Association, helped defeat the Service Employees International Union's attempt to decertify CNA as the collective bargaining agent for San Francisco area nurses. Salaries for registered nurses have increased from $2, 100 to $2,700 per month, relative to shift and tenure, under her direction. Patton, executive director of District 3, Ohio Nurses' Association, and staff nurse in the Youngstown Hospital Association Emergency Department, helped form the first collective bargaining unit for registered nurses in Ohio and has served as president and member on all committees of this organization. She was an advocate of the ANA economic and general welfare program during her tenure on the board of directors and helped organize the Council of Local Unit Members.
Lillian Holland Harvey, EdD, RN, dean emeritus of Tuskegee Institute School of Nursing in Alabama, was presented with the Mary Mahoney Award for her efforts to improve the professional status of black registered nurses. Harvey established the first baccalaureate program in nursing in Alabama and helped establish the first six master's degree programs in the South, as well as maintaining a preparation program at the institute for black nurses who wanted to enter the military. She has been a member of the Nursing Advisory Committee of the American Red Cross, the Kellogg Foundation, the National League for Nursing board of directors, the American Journal of Nursing board of directors, and the President's Commission on the Status of Women - Committee on Education.
The Pearl Mclver Public Health Award recipient was Sarah Ellen Archer, DrPH, RN, FAAN, associate professor of community health nursing and administration at the University of California, San Francisco. She has practiced and consulted in public health nursing in such diverse places as Jordan, West Virginia, and Australia and is cofounder, trustee, and secretarytreasurer of Nursing Dynamics Corporation, which provides health care services to the elderly. She has published several books and is active in both national and international nursing and health organizations.
Kathryn E. Barnard, PhD, RN, FAAN, has received the Jessie M. Scott Award for her work as a researcher in infant and child assessment. A professor of nursing at the University of Washington, Seattle, Barnard developed the Nursing Child Assessment Satellite Training Program to communicate her research findings in evaluating children according to physical health, motor and mental development, perinatal risk factors, and environment. She formerly worked extensively with mentally handicapped children and is author or coauthor of over 40 books relating to child assessment, intervention, and prediction.
The ANA Distinguished Staff Service Award was presented to Margaret F. Carroll, deputy to the ANA executive director, for her "outstanding contributions to the association" over the past Sl years. Joining the association in 1951 as assistant executive secretary, Carroll moved on to staff the Committee on Legislation, and then to her current position. During those years she also worked as a staff nurse, private duty nurse, and superintendant at the Kennecott Copper Corporation; staff nurse for the Nevada State Department of Health; and executive secretary for the Nevada State Board of Nurse Examiners.
HHS APPOINTS NEW DEPUTY DIRECTOR
The U.S. Department of Health and Human Services recently appointed Gretchen A. Osgood Deputy Director of the Division of Nursing. The Division is the principal focus for nursing in the federal government and supports nursing education and research for improved nursing practice. It is part of the Bureau of Health Professions of the Health Resources Administration, a component of the Public Health Service, U.S. Department of Health and Human Services.
Mrs. Osgood was associate director of the division for the past eight years and, before that, assistant director for six years. She has been with the division since September 1962 when she was assigned as a nurse consultant, first with the Research and Resources Branch and later with the Institutional Nursing Branch.
Before entering Federal service, Mrs. Osgood was associate director of nursing, Clinic Nursing Services of the University of Illinois Research and Educational Hospitals in Chicago from 1952 to 1961. She taught public health nursing at the Boston University School of Nursing and served as a staff nurse with the Nashoba Associated Boards of Health in Ayer, Massachusetts and with the Boston Visiting Nurses Association.