Kevin’s Comments: Beginning in 2012, the Center for Medicare and Medicaid Services (CMS) plans to introduce the Hospital Readmission and Reduction Program. Hospitals will be penalized if patients are readmitted within 30 days of discharge for certain diagnoses targeted by the Medicare Payment Advisory Commission (such as congestive heart failure and pneumonia). In 2013, the bundled payment pilots will begin. A single payment will be provided for an episode of care—including hospital, physician, and post-acute care. The hope is that such a system will drive better coordination of care, cost efficiencies, and better quality. In post-acute care settings, it will be important for caregivers to have tools to identify and report changes in condition. Timely identification and intervention may reduce unnecessary hospitalizations resulting in significant cost savings and better health outcomes. The INTERACT II tools show promise in achieving these goals, but further studies are needed to confirm these effects.
Strength Training, Walking, and Social Activity Improve Sleep in Nursing Home and Assisted Living Residents: Randomized Controlled Trial. Richards KC, Lambert C, et al: The Journal of the American Geriatrics Society 2011; 59 (February): 214-223
Objectives: To compare the effects of physical resistance strength training and walking (E), individualized social activity (SA), and E and SA (ESA) with a usual care control group on total nocturnal sleep time in nursing home and assisted living residents.
Design: Pretest–posttest experimental design with assignment to one of four groups for 7 weeks: E (n=55), SA (n=50), ESA (n=41), and usual care control (n=47).
Setting: Ten nursing homes and three assisted living facilities.
Participants: One hundred ninety-three residents were randomly assigned; 165 completed the study.
Intervention: The E group participated in high-intensity physical resistance strength training 3 days a week and on 2 days walked for up to 45 minutes, the SA group received social activity 1 hour daily 5 days a week, the ESA group received both E and SA, and the control group participated in usual activities provided in the homes.
Measurement: Total nocturnal sleep time was measured using 2 nights of polysomnography before and 2 nights of polysomnography after the intervention. Sleep efficiency (SE), non-rapid eye movement (NREM) sleep, rapid eye movement sleep, and sleep onset latency were also analyzed.
Results: Total nocturnal sleep time was significantly greater in the ESA group than in the control group (adjusted means 364.2 minutes vs 328.9 minutes), as was SE and NREM sleep.
Conclusion: High-intensity physical resistance strength training and walking combined with social activity significantly improved sleep in nursing home and assisted living residents. The interventions by themselves did not have significant effects on sleep in this population.
Kevin’s Comments: Sleep disturbance is a very common condition in nursing home and assisted living residents. Often drug treatments are used which have a constellation of potentially serious adverse effects including confusion and falls. Nonpharmacologic interventions that favorable affect nocturnal sleep would be welcome. This study showed that strength training and walking combined with social activities improved sleep. These interventions did not have a favorable effect unless give together. Possible explanations for the benefit include increased daytime alertness and reductions in depression and anxiety.
Improvement in Memory with Plasticity-Based Adaptive Cognitive Training: Results of the 3-Month Follow-Up. Zelinski EM, Spina LM, et al: The Journal of the American Geriatrics Society 2011; 59 (February): 258-265
Objectives: To investigate maintenance of training effects of a novel brain plasticity–based computerized cognitive training program in older adults after a 3-month no-contact period.
Design: Multisite, randomized, controlled, double-blind trial with two treatment groups.
Setting: Communities in northern and southern California and Minnesota.
Participants: Four hundred eighty-seven community-dwelling adults aged 65 and older without diagnosis of clinically significant cognitive impairment.
Intervention: Random assignment into a broadly available brain plasticity–based computerized cognitive training program experimental group or a novelty- and intensity-matched cognitive stimulation active control. Assessments at baseline, after training, and at 3 months.
Measurements: The primary outcome was a composite of auditory subtests of the Repeatable Battery for the Assessment of Neuropsychological Status. Secondary measures included trained task performance, standardized neuropsychological assessments of overall memory and attention, and participant-reported outcomes (PROs).
Results: A significant difference in improvement from baseline to 3-month follow-up was seen between the experimental training and control groups on the secondary composite of overall memory and attention, (P=.01, d=0.25), the trained processing-speed measure (P<.001, d=0.80), word list total recall (P=.004, d=0.28), letter–number sequencing (P=.003, d=0.29), and the cognitive subscale of PRO (P=.006, d=0.27). Previously significant improvements became nonsignificant at the 3-month follow-up for the primary outcome, two secondary measures of attention and memory, and several PROs. Narrative memory continued to show no advantage for the experimental group. Effect sizes from baseline to follow-up were generally smaller than effect sizes from baseline to posttraining.
Conclusion: Training effects were maintained but waned over the 3-month no-contact period.
Kevin’s Comments: Many older adults have memory complaints. Consequently, a variety of programs and products have been developed in the hope of stimulating and improving memory. Computer-based cognitive stimulation programs have become quite popular. This study is a follow-up on IMPACT (Improvement in Memory with Adaptive Plasticity-based Cognitive Training) Study which showed that such programs have favorable effects on a number of cognitive domains. However, the current study demonstrates that these training effects waned over time. This seems to confirm the notion that we must continue to "Use it or lose it." Just as the benefits of exercise will only be realized if continued, it appears that cognitive stimulating activities need to be maintained to remain effective.
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