Doctor of Philosophy

dissertationThis randomized controlled trial evaluated the efficacy of complicated grief group therapy (CGGT) in the treatment of older adults meeting clinical criteria for complicated grief, as compared to a sample of older adults receiving modified grief support grouptreatment as usual (TAU). The CGGT intervention was an adaptation of complicated grief therapy administered as group therapy. A total of 39 participants were randomly assigned to conditions. Twenty-six participants completed the 16 week intervention; CGGT n = 12, TAU n = 14. Primary outcome measures included the Prolonged Grief Disorder Scale (PG-13), the Brief Grief Questionnaire (BGQ), and the Clinical Global Impressions Scale (CGI). Participants who received CGGT demonstrated higher treatment response than participants receiving TAU. While participants in both groups showed improvement in measures of complicated grief, participants in the CGGT group realized significantly greater improvement. More importantly, when complicated grief was measured on PG-13, nearly half of CGGT participants realized clinically significant improvement. On the BGQ , all 12 of the CGGT completers had scores upon follow-up that, had they scored at that level at pretest, would have disqualified them for study enrollment. This high level of clinical significance suggests that those in the CGGT group were effectively treated for complicated grief. This study offers evidence that CGGT holds promise for treatment of complicated grief in older adults and merits further inquiry in other populations

Practical recommendations for treatment of hypertension in older patients

Philip A Kithas, Mark A SupianoGeriatric Research, Education, and Clinical Center, George E Wahlen Department of Veterans Affairs Medical Center and Department of Internal Medicine, Division of Geriatrics, University of Utah School of Medicine, Salt Lake City, Utah, USABackground: By the year 2030 the percent of the population over the age of 65 years is projected to range from 3.7% (in sub-Saharan Africa) to almost 22% (in Europe). Accompanying this unprecedented growth will be a significant increase in many of the disease processes or “comorbidities” associated with aging, not the least of which is hypertension. Global health care resources and economies in general will be stressed to breaking point if this condition is not dealt with in an aggressive and timely manner because the consequences of untreated hypertension such as stroke, myocardial infarction, and dementia are exceedingly costly in the long term.Methods: To help focus attention on the worldwide epidemic of hypertension, the current literature and guidelines were reviewed, along with information on the various classes of medications indicated in the treatment of hypertension in the elderly. Results: Recent, large, randomized trials indicate that hypertension in the elderly can and should be treated to lower the incidence of stroke, myocardial infarction, and chronic kidney disease. Although thiazide-type diuretics are the recommended first-line agents in most cases of uncomplicated hypertension, multiple drug classes have been shown to be useful. In addition, and where feasible, a multidisciplinary team approach has demonstrated the most durable results.Conclusion: Thiazide diuretics should be the first-line agents in uncomplicated, isolated systolic hypertension. Starting at low doses and proceeding in a gradual manner, these agents have proven efficacy in decreasing the risk of stroke and cardiovascular events. It is now recommended that these agents be used in low-dose combinations with other antihypertensive drug classes in patients who do not achieve target blood pressure (<140/90 mmHg).Keywords: isolated systolic hypertension, pulse pressure, ambulatory blood pressure monitorin

Serial Changes in Norepinephrine Kinetics Associated With Feeding Dogs a High-Fat Diet

J Clin Hypertens (Greenwich). 2010;12:117–124. © 2009 Wiley Periodicals, Inc. The role of increased sympathetic nervous system (SNS) activity in the pathogenesis of obesity hypertension and insulin resistance is controversial. Eight dogs were instrumented and fed a high-fat diet (HFD) for 6 weeks. Dogs were evaluated for changes in weight, blood pressure, insulin resistance, and norepinephrine (NE) kinetics using a two-compartment model. The HFD resulted in weight gain, hypertension, and insulin resistance. During the 6 weeks of the HFD, although plasma NE concentration trended toward increasing ( P =.09), SNS, assessed by NE kinetic studies, significantly increased ( P =.009). Within 1 week of starting the HFD, NE release into the extravascular compartment (NE 2 ) increased from 3.44±0.59 μg/mL to 4.87±0.80 μg/mL ( P <.01) and this increase was maintained over the next 5 weeks of the HFD (NE 2 at week 6 was 4.66±0.97 μg/mL). In addition to the increased NE 2 there was also a significant increase in NE clearance ( P =.04). There were significant correlations between the increase in NE 2 and both the development of insulin resistance and hypertension. This study supports the hypothesis that activation of the SNS plays a pivotal role in the metabolic and hemodynamic changes that occur with weight gain induced by HFD.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78633/1/j.1751-7176.2009.00230.x.pd

Sensitization of human α 1 ‐ and α 2 ‐adrenergic venous responses by guanadrel sulfate

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/109986/1/cptclpt1990190.pd

Age wave is here : the aging of the baby boomers November 2010

ManuscriptPaul C. Light (1998) wrote one of the first books to examine the complexities of the baby boom generation and their future implications and impact. The book titled, "Baby Boomers", investigated what unified and what divided the generation and reflected on the potential for "golden days" (would it be the 1990s?). Since one now has the luxury of looking back over the 90s and the first decade of the new century to see if those years were indeed the "golden years" for boomers, one will have to give credit to Light (1988) for raising the consciousness of how the cohort would have to eventually confront the challenges of an aging society due to the demographic transition of boomers entering the "retirement years." What is also interesting is that Light (1988) elevated the year 2016 - when the boomers reach the age of 70 - as having the most significance in terms of social, political, economic and cultural impact

A Vertically Integrated Geriatric Curriculum Improves Medical Student Knowledge and Clinical Skills

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/65145/1/j.1532-5415.2007.01309.x.pd

Effectiveness of Writing Groups in Nursing Homes

We examine the effect of participation in an 8-week writing group in six nursing homes. Pretest and posttest assessments of cognitive and affective functional status were administered to 62 participants and 54 control subjects. We asked writing-group participants about previous writing experience and perceived ability to convey feelings, ideas, life experiences, and memories to others. Weekly assessments were conducted on eight group process measures. Findings suggest that participation in writing groups may reduce depression, particularly among residents with higher cognitive ability and greater depression. Significantly more participants than control subjects report an ability to relate feelings and ideas to other residents and staff. Improvement in group process measures is greatest for cognitively impaired participants and those with high physical function scores. There is considerable improve ment in residents for whom writing-group participation frequently is considered inappropriate: those without writing experience, the depressed, and the cognitively impaired.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/67030/2/10.1177_073346488900800308.pd

Does Increased Arterial Stiffness Increase the Risk for Postural Hypotension?

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/75516/1/j.1076-7460.2005.04503.x.pd

It’s All about the Nurse Aides

Context: Collaboration between the certified nurse aide (CNA) and licensed nurse (LN) is crucial for the provision of safe, personalized, quality care in the nursing home. This study explored the lived work experience of collaboration in caregiving pairs that identified one another as successful care partners in the delivery of high-quality resident care. Objective: This research explored the CNA and LN experience of mutual support in four nursing homes in the Western United States with a particular focus on varied approaches of LN support for CNAs. Methods: Using a purposive sampling design, we surveyed 12 LN and 12 CNA participants individually and as part of an LN/CNA caregiving pair. Semi-structured interviews were recorded, transcribed verbatim, loaded into NVivo software, and coded for meaning. Findings: LN participants described feeling most supported by CNAs who do their job well. LN and CNA participants described ways LNs in the sample provide holistic support to their CNA coworkers—a phenomenon we coinedundergirding: listen and respond, show respect, help with resident care and answer call lights, educate and explain, provide feedback and encouragement, adjust and divide workloads, protect the CNA, support physical needs, and provide emotional support. Undergirding promotes work success for the CNA and the LN. Most importantly, participants described how undergirding facilitates high-quality resident care. Limitations: This study was designed to identify and explore optimal collaboration as it is possible in the current nursing home setting. It was not intended to represent all LN/CNA caregiving pairs. Implications: These findings may be helpful for educators and administrators, but perhaps they are most important for policymakers. More effective support for CNAs is needed if we hope to decrease turnover, improve retention, and elevate nursing home residents’ quality of care

Low blood pressure and adverse outcomes in acute stroke HeadPoST study explanations

Objective: As uncertainties exist over underlying causes, we aimed to define the characteristics and prognostic significance of low blood pressure (BP) early after the onset of acute stroke. Methods: Post hoc analyzes of the international Head Positioning in acute Stroke Trial (HeadPoST), a pragmatic cluster-crossover randomized trial of lying flat versus sitting up in stroke patients from nine countries during 2015–2016. Associations of baseline BP and death or dependency [modified Rankin scale (mRS) scores 3–6] and serious adverse events (SAEs) at 90 days were assessed in generalized linear mixed models with adjustment for multiple confounders. SBP and DBP was analysed as continuous measures fitted with a cubic spline, and as categorical measures with low (<10th percentile) and high (≥140 and ≥90 mmHg, respectively) levels compared with a normal range (≥10th percentile; 120–139 and 70–89 mmHg, respectively). Results: Among 11 083 patients (mean age 68 years, 39.9% women) with baseline BP values, 7.2 and 11.7% had low SBP (<120 mmHg) and DBP (<70 mmHg), respectively. Patients with low SBP were more likely to have preexisting cardiac and ischemic stroke and functional impairment, and to present earlier with more severe neurological impairment than other patients. Nonlinear ‘J-shaped’ relationships of BP and poor outcome were apparent: compared with normal SBP, those with low SBP had worse functional outcome (adjusted odds ratio 1.27, 95% confidence interval 1.02–1.58) and more SAEs, particularly cardiac events, with adjustment for potential confounders to minimize reverse causation. The findings were consistent for DBP and were stronger for ischemic rather than hemorrhagic stroke. Conclusion: The prognostic significance of low BP on poor outcomes in acute stroke was not explained by reverse causality from preexisting cardiovascular disease, and propensity towards greater neurological deficits and cardiac events. These findings provide support for the hypothesis that low BP exacerbates cardiac and cerebral ischemia in acute ischemic stroke