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Browsing by Author "Kunik, Mark E."

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Aggression Prevention Training for Individuals With Dementia and Their Caregivers: A Randomized Controlled Trial
(Elsevier, 2020) Kunik, Mark E.; Stanley, Melinda A.; Shrestha, Srijana; Ramsey, David; Richey, Sheila; Snow, Lynn; Freshour, Jessica; Evans, Tracy; Newmark, Michael; Williams, Susan; Wilson, Nancy; Amspoker, Amber B.; Baylor College of Medicine; University of Alabama Tuscaloosa
Objective: International appeals call for interventions to prevent aggression and other behavioral problems in individuals with dementia (IWD). Aggression Prevention Training (APT), based on intervening in three contributors to development of aggression (IWD pain, IWD depression, and caregiver-IWD relationship problems) aims to reduce incidence of aggression in IWD over 1 year. Design: Randomized, controlled trial. Setting: Three clinics that assess, diagnose, and treat dementia. Participants: Two hundred twenty-eight caregiver-IWD dyads who screened positive for IWD pain, IWD depression, or caregiver-IWD relationship problems randomized to APT or Enhanced Usual Primary Care (EU-PC). Intervention: APT, a skills-based intervention delivered over 3 months to address pain/depression/caregiver-IWD relationship issues. EU-PC included printed material on dementia and community resources; and eight brief, weekly support calls. Measurements: The primary outcome was incidence of aggression over 1 year, determined by the Cohen Mansfield Agitation Inventory-Aggression Subscale. Secondary outcomes included pain, depression, caregiver- IWD relationship, caregiver burden, positive caregiving, behavior problems, and anxiety. Results: Aggression incidence and secondary outcomes did not differ between groups. However, in those screening positive for IWD depression or caregiver-IWD relationship problems, those receiving EU-PC had significant increases in depression and significant decreases in quality of the caregiver-IWD relationship, whereas those receiving APT showed no changes in these outcomes over time. Conclusion: The cost to patients, family, and society of behavioral problems in IWD, along with modest efficacy of most pharmacologic and nonpharmacologic interventions, calls for more study of novel preventive approaches.
A Break-Even Analysis for Dementia Care Collaboration: Partners in Dementia Care
(Springer, 2015) Morgan, Robert O.; Bass, David M.; Judge, Katherine S.; Liu, C. F.; Wilson, Nancy; Snow, A. Lynn; Pirraglia, Paul; Garcia-Maldonado, Maurilio; Raia, Paul; Fouladi, N. N.; Kunik, Mark E.; University of Texas Health Science Center Houston; University of Texas School Public Health; Cleveland State University; US Department of Veterans Affairs; Veterans Health Administration (VHA); Vet Affairs Puget Sound Health Care System; University of Washington; University of Washington Seattle; Baylor College of Medicine; University of Alabama Tuscaloosa; Providence VA Medical Center; Brown University; Alzheimer's Association
Dementia is a costly disease. People with dementia, their families, and their friends are affected on personal, emotional, and financial levels. Prior work has shown that the "Partners in Dementia Care" (PDC) intervention addresses unmet needs and improves psychosocial outcomes and satisfaction with care. We examined whether PDC reduced direct Veterans Health Administration (VHA) health care costs compared with usual care. This study was a cost analysis of the PDC intervention in a 30-month trial involving five VHA medical centers. Study subjects were veterans (N = 434) 50 years of age and older with dementia and their caregivers at two intervention (N = 269) and three comparison sites (N = 165). PDC is a telephone-based care coordination and support service for veterans with dementia and their caregivers, delivered through partnerships between VHA medical centers and local Alzheimer's Association chapters. We tested for differences in total VHA health care costs, including hospital, emergency department, nursing home, outpatient, and pharmacy costs, as well as program costs for intervention participants. Covariates included caregiver reports of veterans' cognitive impairment, behavior problems, and personal care dependencies. We used linear mixed model regression to model change in log total cost post-baseline over a 1-year follow-up period. Intervention participants showed higher VHA costs than usual-care participants both before and after the intervention but did not differ significantly regarding change in log costs from pre- to post-baseline periods. Pre-baseline log cost (p a parts per thousand currency signaEuro parts per thousand 0.001), baseline cognitive impairment (p a parts per thousand currency signaEuro parts per thousand 0.05), number of personal care dependencies (p a parts per thousand currency signaEuro parts per thousand 0.01), and VA service priority (p a parts per thousand currency signaEuro parts per thousand 0.01) all predicted change in log total cost. These analyses show that PDC meets veterans' needs without significantly increasing VHA health care costs. PDC addresses the priority area of care coordination in the National Plan to Address Alzheimer's Disease, offering a low-cost, structured, protocol-driven, evidence-based method for effectively delivering care coordination.
Characteristics of Generalized Anxiety Disorder in Patients With Dementia
(Sage, 2011) Calleo, Jessica S.; Kunik, Mark E.; Reid, Dana; Kraus-Schuman, Cynthia; Paukert, Amber; Regev, Tziona; Wilson, Nancy; Petersen, Nancy J.; Snow, A. Lynn; Stanley, Melinda; Baylor College of Medicine; University of Alabama Tuscaloosa
Background: Overlap of cognitive and anxiety symptoms (i.e., difficulty concentrating, fatigue, restlessness) contributes to inconsistent, complicated assessment of generalized anxiety disorder (GAD) in persons with dementia. Methods: Anxious dementia patients completed a psychiatric interview, the Penn State Worry Questionnaire-Abbreviated, and the Rating for Anxiety in Dementia scale. Analyses to describe the 43 patients with and without GAD included the Wilcoxon Mann-Whitney two-sample test, Fisher's exact test. Predictors of GAD diagnosis were identified using logistic regression. Results: Those with GAD were more likely to be male, have less severe dementia and endorsed more worry, and anxiety compared to patients without GAD. Gender, muscle tension and fatigue differentiated those with GAD from those without GAD. Conclusions: Although this study is limited by a small sample, it describes clinical characteristics of GAD in dementia, highlighting the importance of muscle tension and fatigue in recognizing GAD in persons with dementia.
Concordance of self- and proxy-rated worry and anxiety symptoms in older adults with dementia
(Pergamon, 2013) Bradford, Andrea; Brenes, Gretchen A.; Robinson, Roberta A.; Wilson, Nancy; Snow, A. Lynn; Kunik, Mark E.; Calleo, Jessica; Petersen, Nancy J.; Stanley, Melinda A.; Amspoker, Amber B.; UTMD Anderson Cancer Center; Wake Forest University; Wake Forest Baptist Medical Center; Baylor College of Medicine; University of Alabama Tuscaloosa
We compared the psychometric performance of two validated self-report anxiety symptom measures when rated by people with dementia versus collaterals (as proxies). Forty-one participants with mild-to-moderate dementia and their respective collaterals Completed the Geriatric Anxiety Inventory, the Penn State Worry Questionnaire-Abbreviated, and a structured diagnostic interview. We used descriptive and nonparametric statistics to compare scores according to respondent characteristics. Receiver operating characteristic (ROC) curves were calculated to establish the predictive validity of each instrument by rater type against a clinical diagnosis of an anxiety disorder. Participant and collateral ratings performed comparably for both instruments. However, collaterals tended to give more severe symptom ratings, and the best-performing cut-off scores were higher for collaterals. Our findings suggest that people with mild-to-moderate dementia can give reliable self-reports of anxiety symptoms, with validity comparable to reports obtained from collaterals. Scores obtained from multiple informants should be interpreted in context. (C) 2012 Elsevier Ltd. All rights reserved.
A controlled trial of Partners in Dementia Care: veteran outcomes after six and twelve months
(BMC, 2014) Bass, David M.; Judge, Katherine S.; Snow, A. Lynn; Wilson, Nancy L.; Morgan, Robert O.; Maslow, Katie; Randazzo, Ronda; Moye, Jennifer A.; Odenheimer, Germaine L.; Archambault, Elizabeth; Elbein, Richard; Pirraglia, Paul; Teasdale, Thomas A.; McCarthy, Catherine A.; Looman, Wendy J.; Kunik, Mark E.; Cleveland State University; University of Alabama Tuscaloosa; US Department of Veterans Affairs; Veterans Health Administration (VHA); Baylor College of Medicine; University of Texas Health Science Center Houston; University of Texas School Public Health; National Academies of Sciences, Engineering & Medicine; Alzheimer's Association; Harvard University; VA Boston Healthcare System; University of Oklahoma Health Sciences Center; Providence VA Medical Center; Brown University
Introduction: "Partners in Dementia Care" (PDC) tested the effectiveness of a care-coordination program integrating healthcare and community services and supporting veterans with dementia and their caregivers. Delivered via partnerships between Veterans Affairs medical centers and Alzheimer's Association chapters, PDC targeted both patients and caregivers, distinguishing it from many non-pharmacological interventions. Hypotheses posited PDC would improve five veteran self-reported outcomes: 1) unmet need, 2) embarrassment about memory problems, 3) isolation, 4) relationship strain and 5) depression. Greater impact was expected for more impaired veterans. A unique feature was self-reported research data collected from veterans with dementia. Methods and Findings: Five matched communities were study sites. Two randomly selected sites received PDC for 12 months; comparison sites received usual care. Three structured telephone interviews were completed every 6 months with veterans who could participate. Results: Of 508 consenting veterans, 333 (65.6%) completed baseline interviews. Among those who completed baseline interviews, 263 (79.0%) completed 6-month follow-ups and 194 (58.3%) completed 12-month follow-ups. Regression analyses showed PDC veterans had significantly less adverse outcomes than those receiving usual care, particularly for more impaired veterans after 6 months, including reduced relationship strain (B = -0.09; p = 0.05), depression (B = -0.10; p = 0.03), and unmet need (B = -0.28; p = 0.02; and B = -0.52; p = 0.08). PDC veterans also had less embarrassment about memory problems (B = -0.24; p = 0.08). At 12 months, more impaired veterans had further reductions in unmet need (B = -0.96; p < 0.01) and embarrassment (B = -0.05; p = 0.02). Limitations included use of matched comparison sites rather than within-site randomization and lack of consideration for variation within the PDC group in amounts and types of assistance provided. Conclusions: Partnerships between community and health organizations have the potential to meet the dementia-related needs and improve the psychosocial functioning of persons with dementia.
The Peaceful Mind Manual: A Protocol for Treating Anxiety in Persons With Dementia
(Sage, 2013) Paukert, Amber L.; Kraus-Schuman, Cynthia; Wilson, Nancy; Snow, A. Lynn; Calleo, Jessica; Kunik, Mark E.; Stanley, Melinda A.; Baylor College of Medicine; University of Alabama Tuscaloosa
Anxiety disorders are highly prevalent among individuals with dementia and have a significant negative impact on their lives. Peaceful Mind is a form of cognitive-behavioral therapy for anxiety in persons with dementia. The Peaceful Mind manual was developed, piloted, and modified over 2 years. In an open trial and a small randomized, controlled trial, it decreased anxiety and caregiver distress. The treatment meets the unique needs of individuals with dementia by emphasizing behavioral rather than cognitive interventions, slowing the pace, limiting the material to be learned, increasing repetition and practice, using cues to stimulate memory, including a friend or family member in treatment as a coach, and providing sessions in the home. The manual presented here includes modules that teach specific skills, including awareness, breathing, calming self-statements, increasing activity, and sleep management, as well as general suggestions for treatment delivery.
The Peaceful Mind Program: A Pilot Test of a Cognitive-Behavioral Therapy Based Intervention for Anxious Patients with Dementia
(Elsevier, 2013) Stanley, Melinda A.; Calleo, Jessica; Bush, Amber L.; Wilson, Nancy; Snow, A. Lynn; Kraus-Schuman, Cynthia; Paukert, Amber L.; Petersen, Nancy J.; Brenes, Gretchen A.; Schulz, Paul E.; Williams, Susan P.; Kunik, Mark E.; Baylor College of Medicine; University of Alabama Tuscaloosa; Wake Forest University; University of Texas Health Science Center Houston
Objectives: To assess feasibility and to conduct a preliminary evaluation of outcomes following Peaceful Mind, a cognitive-behavioral therapy-based intervention for anxiety in dementia, relative to usual care. Design: Pilot randomized controlled trial including assessments at baseline and 3 and 6 months. Setting: Houston, TX Participants: Thirty-two outpatients diagnosed with mild (47%) or moderate (53%) dementia receiving care through outpatient clinics at the Veterans Affairs medical center, Baylor College of Medicine, Harris County Hospital District, and community day centers for dementia, and their collaterals, who spent at least 8 hours a week with them. Intervention: Peaceful Mind included up to 12 weekly in-home sessions (mean: 8.7, SD: 2.27) during the initial 3 months and up to eight brief telephone sessions (mean: 5.4, SD: 3.17) during months 3-6, involving self-monitoring for anxiety, deep breathing, and optional skills (coping self-statements, behavioral activation, and sleep management). Patients learned skills, and collaterals served as coaches. In usual care, patients received diagnostic feedback, and providers were informed of inclusion status. Measurements: Neuropsychiatric Inventory-Anxiety subscale, Rating Anxiety in Dementia scale, Penn State Worry Questionnaire-Abbreviated, Geriatric Anxiety Inventory, Geriatric Depression Scale, Quality of Life in Alzheimer disease, Patient Health Questionnaire, and Client Satisfaction Questionnaire. Results: Feasibility was demonstrated with regard to recruitment, attrition, and treatment characteristics. At 3 months, clinicians rated patients receiving Peaceful Mind as less anxious, and patients rated themselves as having higher quality of life; collaterals reported less distress related to loved ones' anxiety. Although significant positive effects were not noted in other outcomes or at 6-month follow-up, the pilot nature of the trial prohibits conclusions about efficacy. Conclusions: Results support that Peaceful Mind is ready for future comparative clinical trials.
Psychometric properties of a structured interview guide for the rating for anxiety in dementia
(Routledge, 2012) Snow, A. Lynn; Huddleston, Cashuna; Robinson, Christina; Kunik, Mark E.; Bush, Amber L.; Wilson, Nancy; Calleo, Jessica; Paukert, Amber; Kraus-Schuman, Cynthia; Petersen, Nancy J.; Stanley, Melinda A.; University of Alabama Tuscaloosa; Baylor College of Medicine; University of Houston
Objectives: The Rating Anxiety in Dementia (RAID; Shankar, K. K., Walker, M., Frost, D., & Orrell, M. W. (1999). The development of a valid and reliable scale for rating anxiety in dementia (RAID). Aging and Mental Health, 3, 39-49.) is a clinical rating scale developed to evaluate anxiety in persons with dementia. This report explores the psychometric properties and clinical utility of a new structured interview format of the RAID (RAID-SI), developed to standardize administration and scoring based on information obtained from the patient, an identified collateral, and rater observation. Method: The RAID-SI was administered by trained master's level raters. Participants were 32 persons with dementia who qualified for an anxiety treatment outcome study. Self-report anxiety, depression, and quality of life measures were administered to both the person with dementia and a collateral. Results: The RAID-SI exhibited adequate internal consistency reliability and inter-rater reliability. There was also some evidence of construct validity as indicated by significant correlations with other measures of patient-reported and collateral-reported anxiety, and non-significant correlations with collateral reports of patient depression and quality of life. Further, RAID-SI scores were significantly higher in persons with an anxiety diagnosis compared to those without an anxiety diagnosis. Conclusion: There is evidence that the RAID-SI exhibits good reliability and validity in older adults with dementia. The advantage of the structured interview format is increased standardization in administration and scoring, which may be particularly important when RAID raters are not experienced clinicians.
Teaching Caregivers of Persons with Dementia to Address Pain
(Elsevier, 2017) Kunik, Mark E.; Snow, A. Lynn; Wilson, Nancy; Amspoker, Amber R.; Sansgiry, Shubhada; Morgan, Robert O.; Ying, Jun; Hersch, Gayle; Stanley, O. T. R. Melinda A.; Baylor College of Medicine; University of Alabama Tuscaloosa; University of Texas Health Science Center Houston; Texas Womans University
Objectives: To compare the efficacy of Preventing Aggression in Veterans with Dementia (PAVeD) with that of usual care in decreasing incidence of aggression (primary outcome) and pain and improving depression, pleasant events, caregiver burden, and patient-caregiver relationship quality (secondary outcomes). Design: Randomized controlled trial with assessments at baseline and 3, 6, 9, and 12 months Setting: Houston, TX. Participants: A total of 203 community-dwelling veterans with pain and dementia and their caregivers. Intervention: PAVeD, 6 to 8 weekly sessions of 45-minute home visits with masters-level clinicians providing instruction to caregivers on recognizing pain, enhancing communication, and making daily activities pleasant and enjoyable, and at least two elective sessions. Measurements: Cohen-Mansfield Agitation Inventory (primary outcome), Philadelphia Geriatric Pain Intensity Scale, Geriatric Depression Scale, Pleasant Events Schedule-AD, Burden Interview, Mutuality Scale (secondary outcomes), Client Satisfaction Questionnaire. Results: There were no significant differences in aggression incidence between intervention and control groups, although the PAVeD group had significantly better mutuality than controls. Conclusions: PAVeD may need to address a broader range and more in-depth coverage of aggression risk factors with person-centered tailoring to target certain types of distress. Interventions to prevent aggression may also need to address medical providers in addition to caregivers.
Validation of a Brief Screen to Identify Persons With Dementia at Risk for Behavioral Problems
(Sage, 2021) Evans, Tracy L.; Kunik, Mark E.; Snow, A. Lynn; Shrestha, Srijana; Richey, Sheila; Ramsey, David J.; Yusuf, Zenab I.; Amspoker, Amber B.; Baylor College of Medicine; University of Alabama Tuscaloosa
Objectives: Clinical assessment of persons with dementia should include potential causes of behavioral problems, including pain, depression, and caregiver-patient relationship quality. Many validated assessment tools are available; however, a brief screening tool is needed, as administering a battery of instruments is impractical in most clinical settings. We evaluated (a) the construct validity of brief screens for pain, depression, and relationship strain by examining their associations with validated measures and medication use and (b) the predictive validity of each screen and the screens as a set by examining their associations with frequency of disruptive behaviors. Methods: Patient-caregiver dyads (n = 228) in Aggression Prevention Training for Caregivers were examined. Results: There was evidence of good construct validity for each screen. The relationship screen and total number of screens endorsed were significantly associated with frequency of disruptive behaviors. Conclusion: The brief screens show potential for use in clinical practice.

Browsing by Author "Kunik, Mark E."

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