In 2011, the National Institute of Nursing Research (NINR) celebrated a quarter century of advancements in nursing science that made an extraordinary impact on the health of our nation. The report, Bringing Science to Life: NINR Strategic Plan (NINR, 2011), describes breakthrough research that has vastly improved health outcomes for the most vulnerable patient populations. Research in Gerontological Nursing has made a commitment to publicizing the outstanding work of gerontological nurse scientists in an annual State of the Science Commentary. In this inaugural commentary, we build on the NINR report by reflecting on critical scientific advances currently being made in the area of nonpharmacological interventions for the nursing care of older adults. Effective nonpharmacological nursing interventions are especially appropriate for older adults because of the low cost and low risk of associated side effects. Nonpharmacological interventions can be considered alone or as a first step in the management of a variety of problems and should be continued as they are augmented by appropriate pharmacological, surgical, or other types of complementary interventions. This focus is timely in light of the recent Centers for Medicare & Medicaid Services initiative aimed at improving behavioral health and reducing unnecessary antipsychotic drug use in nursing. This focus is also directly responsive to Americans’ need for safe, accessible, high-quality, and affordable care.
In this commentary, we limited our review to published literature in 2011–2012 and chose a few examples of non-system interventions (i.e., those implemented in the context of direct, hands-on care). In our search strategy, we selected areas of intervention science that enjoy a strong basis, built over many years of investigation. These interventions include those that relieve pain, improve physical function, reduce behaviors associated with cognitive impairment, promote sleep, and enhance end-of-life care. We also highlight examples of research currently being conducted, offering exciting and innovative solutions to costly clinical problems. Finally, we outline priorities for future research and address our capacity as nurse scientists to advance the science of nursing care.
Nursing research has long focused on implementing behavioral interventions to manage pain in older adults. During the past year, some interesting approaches have been used that can guide clinical nursing as well as inform future research.
Probably one of the most exciting and challenging areas of pain management research is the use of exercise as an intervention to decrease pain. Within the prevailing approach, health care providers assume pain is an indication that one should not move or engage in any kind of activity and instead rest the area experiencing pain. Two studies tested the effects of exercise on pain management among older adults and demonstrated the benefits of exercise on reducing pain (Park, McCaffrey, Dunn, & Goodman, 2011; Tse, Wan, & Ho, 2011). In the Tse et al. (2011) study, the investigators recruited 73 cognitively intact nursing home residents and tested the effectiveness of an 8-week program using a pretest-posttest design. The weekly 1-hour program, provided by a physiotherapist and nurse, involved 15 minutes of warm-up exercises, followed by muscle strengthening, stretching, balance, towel dance, acupressure, and massage. Specific exercises to help relieve pain in certain areas were given on an individual basis, and participants were provided with a pamphlet containing pictures of the exercises to do on their own. On completion of the program, participants experienced significant reduction in pain intensity. While pilot in nature, this study supports important information on the possible benefits of exercise as a low-cost intervention for pain.
The second study by Park et al. (2011) used a quasi-experimental design and compared three interventions: chair yoga, Reiki (i.e., palm healing or hands-on healing), and education. Participants were 29 community-dwelling older adults, and study duration was 8 weeks. Chair yoga participants completed a 45-minute yoga intervention twice per week. The Reiki intervention group completed a 30-minute individual session conducted by certified Reiki instructors once per week. The education group was exposed to a group educational session for 1.5 hours every other week. The four educational sessions focused on discussions about the impact of osteoarthritis, the disadvantages of medication use, and options for alternative and/or complementary treatments. After the intervention, the chair yoga group achieved a significant decrease in pain compared with the other two groups. As with the Tse et al. (2011) study, this work is preliminary, and continued research is needed. However, both studies add to what is known about management of pain using behavioral interventions and provide exciting options for clinical work and research.
During the past 15 years, nursing research has addressed behavioral interventions to optimize function and physical activity among older adults. For example, several nurse researchers are using Function-Focused Care approaches to optimize both function and physical activity across all levels of care (Boltz, Resnick, Capezuti, Shabbat, & Secic, 2011; Resnick, Galik, Enders, et al., 2011; Resnick, Galik, Gruber-Baldini, & Zimmerman, 2011). Function-Focused Care is a philosophy of care that concentrates on evaluating older adults’ underlying capability with regard to function and physical activity and helping them optimize and maintain their abilities and increase time spent in physical activity. While initially developed and implemented for older adults in nursing home settings, the 2011 studies have focused on testing and disseminating Function-Focused Care approaches in acute care (Boltz et al., 2011; Resnick, Galik, Enders, et al., 2011), assisted living (Resnick, Galik, Gruber-Baldini, et al., 2011), and home settings (Pretzer-Aboff, Galik, & Resnick, 2011). Across all settings, results of this work have consistently shown that Function-Focused Care increases time spent in physical activity and improves function.
Other nursing-led studies to increase physical activity and improve function have been conducted with older adults with osteoarthritis (Park, et al., 2011; Schlenk, Lias, Sereika, Dunbar-Jacob, & Kwoh, 2011). Schlenk et al. (2011) tested the Staying Active with Arthritis (STAR) intervention in a volunteer sample of 26 older adults recruited from rheumatology practices. The intervention combined physical therapy and nurse-led education and resulted in increased (a) performance of lower extremity exercise, (b) overall amount and intensity of exercise, (c) number of minutes walked per week, (d) distance walked during 6 minutes, and (e) functional performance, such as getting up from a chair.
Behaviors Associated with Cognitive Impairment
Behavioral symptoms affect up to 90% of people with dementia (Lyketsos et al., 2001). When behaviors interfere with care, such as bathing or oral hygiene, they place the resident at risk for more serious health problems. For example, suboptimal oral hygiene is among the most common risk factors for aspiration pneumonia (Quagliarello et al., 2005). Pharmacological treatments have not demonstrated strong efficacy in the management of behavioral symptoms and may have serious adverse effects in frail older nursing home residents.
An important factor in the development of interventions for behavioral symptoms is identifying and targeting the precipitating cause of the behavior, for example, pain that is not well treated. Nurse scientists have made advances in this area. Kovach et al. (2006) demonstrated that the Serial Trial Intervention (STI), a five-step process of assessment, evaluation, and intervention using both nonpharmacological and analgesic treatments reduced discomfort and behavioral symptoms in nursing home residents with dementia. Kovach is now part of a team that is testing the STI in a Dutch population, and measures of depression and quality of life are being added as additional outcomes of the intervention (Pieper et al., 2011). The researchers are also investigating possible responder differences caused by apolipoprotein E-4 status.
A number of prior studies have supported the use of leisure activities as a method for reducing boredom and subsequent behaviors. Recently, Kolanowski, Litaker, Buettner, Moeller, and Costa (2011) reported on a clinical trial in which they found that tailoring activities to residents’ personality and interests resulted in increased engagement, alertness, and attention during the activity itself compared with non-tailored activities. Extended benefits were also seen for self-reported mood, anxiety, and passivity at 1 week post intervention. This research yielded information about the activity components that produced the most effective results, allowing greater precision when selecting specific activities for people with dementia.
Behaviors can interfere with care, contribute to poor health outcomes, and pose a risk of injury to caregivers and care recipients alike. In a recent pilot study, Jablonski et al. (2011) used threat-reduction techniques combined with best oral care hygiene practices to improve oral health indicators and reduce care-resistive behaviors during mouth care in people with moderate- to late-stage dementia. They found that their intervention significantly improved nurse-sensitive oral health outcomes and care-resistive behaviors compared with usual care. Jablonski’s team is now testing this intervention in a large clinical trial.
Sleep architecture is altered by aging, cognitive impairments, and disease. Medications are often prescribed for sleep disturbances, but in older adults they carry the risk for falls and cognitive disruptions, such as daytime sleepiness. Richards et al. (2011) reported on a randomized controlled trial of nursing home and assisted living residents in which they tested the effectiveness of three interventions: high-intensity physical resistance strength training combined with walking (E), social activities (SA), or a combination of both (ESA), versus usual care on total nocturnal sleep time using polysomnography. Participants in the ESA group had a significant increase in total nocturnal sleep time and greater sleep efficiency and non-rapid eye movement sleep compared with the usual care group.
Beginning evidence supports that sleep disturbances, such as obstructive sleep apnea (OSA), which occurs in 60% of older adults with mild cognitive impairment (MCI) and dementia, might precipitate nighttime wandering and accelerate cognitive decline in people with dementia (Cooke et al., 2009). OSA is effectively treated with continuous positive airway pressure (CPAP), but treatment non-adherence is high. Nurse researchers are at the forefront of designing psychosocial interventions that help patients adhere to CPAP treatment in an effort to improve sleep quality and slow cognitive decline (Sawyer et al., 2011). Currently, Richards is conducting a 6-month double-blind randomized pilot clinical trial to compare the effects of active CPAP versus sham CPAP on cognitive and everyday function in 110 older adults with MCI and OSA.
The NINR is the lead institute at the National Institutes of Health for end-of-life care. Nurse scientists in this field are testing biobehavioral interventions for palliative care and symptom management across the life span. This past year, Hickman et al. (2011) reported on their study that evaluated the Physician Orders for Life-Sustaining Treatment (POLST) program and actual treatments provided to nursing home residents of 90 nursing facilities in Oregon, Wisconsin, and West Virginia. Retrospective chart data indicated that, with the exception of feeding tubes and antibiotic agent use, residents who had POLST forms in place had their preferences honored 94% of the time (Hickman et al., 2011).
The Future of Gerontological Nursing Research
As we look toward the future of research in nonpharmacological interventions in gerontological nursing care, possibilities exist for enriching our science through capitalizing on social strategies, as well as scientific developments in other fields. For example, older American women are the fastest-growing group on Facebook®, Twitter®, and My Space® (Madden & Zickuhr, 2011). We have vivid examples of how social networking can turn a concern into a worldwide crusade; for example, the school bus monitor who was bullied by school children and who is now receiving contributions from around the world. This has created a paradigm shift in how people obtain information and has opened up exciting possibilities for creating behavior change among even the oldest-old individuals. We need to increase our knowledge base about how social media can be used creatively and strategically to promote healthy behaviors among older adults or to change unhealthy behaviors and promote adoption of nonpharmacological interventions that have evidence of efficacy.
As the science of genomics and epigenetics develops, gerontological nursing research can increase understanding of how existing or new behavioral interventions can be targeted and individualized based on genetics. Great potential exists for gerontological nurse scientists to hypothesize, develop, and test genotype-directed biobehavioral interventions. For example, nurse scientists might predict differential responses to dietary or exercise interventions based on genotype and provide better understanding of the interaction between genes and the environment as we move toward personalized geriatric nursing.
Geriatric nurse scientists must also become more involved in comparative effectiveness research and implementation science. We need to better understand what works for which patients under what circumstances. We also need to compare the effectiveness of various behavioral interventions. For example, do yoga and acupuncture work better than traditional exercise or water aerobics in decreasing knee pain from osteoarthritis? We must also develop our knowledge about how we can motivate practitioners to routinely implement nonpharmacological interventions that have been shown to be effective by building on the area of implementation science. Finally, in order for nonpharmacological interventions to be supported through payment policies, we must better understand their cost and cost effectiveness.
The examples from this literature review highlight nurse scientists’ impressive work to develop a wealth of knowledge about the efficacy of nonpharmacological interventions. The challenge of the next generation of geriatric nurse scientists is to not only continue to develop basic knowledge about the effectiveness of additional interventions, but also to expand the knowledge base about how to (a) individualize these interventions for their maximum treatment effect; (b) target interventions to those most likely to benefit due to genetics and environment; (c) design interventions that are culturally appropriate, accessible, and effective in diverse older adults; and (d) promote the use of effective interventions throughout the health care system so they make a significant difference in the health and quality of life of older adults.
- Boltz, M., Resnick, B., Capezuti, E., Shabbat, N. & Secic, M. (2011). Function-focused care and changes in physical function in Chinese American and non-Chinese American hospitalized older adults. Rehabilitation Nursing, 36, 233–240. doi:10.1002/j.2048-7940.2011.tb00088.x [CrossRef]
- Cooke, J.R., Ayalon, L., Palmer, B.W., Loredo, J.S., Corey-Bloom, J., Natarajan, L. & Ancoli-Israel, S. (2009). Sustained use of CPAP slows deterioration of cognition, sleep, and mood in patients with Alzheimer’s disease and obstructive sleep apnea: A preliminary study. Journal of Clinical Sleep Medicine, 5, 305–309.
- Hickman, S.E., Nelson, C.A., Moss, A.H., Tolle, S.W., Perrin, N.A. & Hammes, B.J. (2011). The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form. Journal of the American Geriatrics Society, 59, 2091–2099. doi:10.1111/j.1532-5415.2011.03656.x [CrossRef]
- Jablonski, R.A., Therrien, B., Mahoney, E.K., Kolanowski, A., Gabello, M. & Brock, A. (2011). An intervention to reduce care-resistant behavior in persons with dementia during oral hygiene: A pilot study. Special Care in Dentistry, 31(3), 77–87. doi:10.1111/j.1754-4505.2011.00190.x [CrossRef]
- Kolanowski, A., Litaker, M., Buettner, L., Moeller, J. & Costa, P.T. Jr.. (2011). A randomized clinical trial of theory-based activities for the behavioral symptoms of dementia in nursing home residents. Journal of the American Geriatrics Society, 59, 1032–1041. doi:10.1111/j.1532-5415.2011.03449.x [CrossRef]
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- Madden, M. & Zickuhr, K. (2011). Report: Social networking. Retrieved from the Pew Internet & American Life Project website: http://pewinternet.org/Reports/2011/Social-Networking-Sites.aspx
- National Institute of Nursing Research. (2011). Bringing science to life: NINR strategic plan (NIH Publication No. 11-7783). Retrieved from http://www.ninr.nih.gov/NR/rdonlyres/8BE21801-0C52-44C2-9EEA-142483657FB1/0/NINR_StratPlan_F2_508.pdf
- Park, J., McCaffrey, R., Dunn, D. & Goodman, R. (2011). Managing osteoarthritis: Comparisons of chair yoga, Reiki, and education (pilot study). Holistic Nursing Practice, 25, 316–326.
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