Bath VA Medical Center

PURPOSE: This review presents the state of swallowing rehabilitation science as it relates to evidence for neural plastic changes in the brain. The case is made for essential collaboration between clinical and basic scientists to expand the positive influences of dysphagia rehabilitation in synergy with growth in technology and knowledge. The intent is to stimulate thought and propose potential research directions. METHOD: A working group of experts in swallowing and dysphagia reviews 10 principles of neural plasticity and integrates these advancing neural plastic concepts with swallowing and clinical dysphagia literature for translation into treatment paradigms. In this context, dysphagia refers to disordered swallowing associated with central and peripheral sensorimotor deficits associated with stroke, neurodegenerative disease, tumors of the head and neck, infection, or trauma. RESULTS AND CONCLUSIONS: The optimal treatment parameters emerging from increased understanding of neural plastic principles and concepts will contribute to evidence-based practice. Integrating these principles will improve dysphagia rehabilitation directions, strategies, and outcomes. A strategic plan is discussed, including several experimental paradigms for the translation of these principles and concepts of neural plasticity into the clinical science of rehabilitation for oropharyngeal swallowing disorders, ultimately providing the evidence to substantiate their translation into clinical practice.

Few studies have measured combat exposure during deployment to a war zone. Valid, reliable, and specific measurement is needed to broaden existing knowledge of combat experiences to accurately answer clinically important questions regarding postcombat treatment and recovery, particularly with the recognition of new kinds of combat and resulting psychological sequelae. The Combat Experiences Scale (CES) is a 33-item measure that assesses deployment-related experiences. The psychometrics of this measure, however, were undefined before this study. The purpose of this study was to examine aspects of internal and external validity of the CES. Data were collected as part of a study of 500 veterans of the conflicts in Iraq and Afghanistan across five Veterans Affairs medical centers in Upstate New York. An exploratory factor analysis suggested that three factors represented the scale well: Exposure to Combat Environment, Physical Engagement, and Proximity to Serious Injury and Death. The CES scores showed adequate internal consistency, and evidence for convergent validity and discriminant validity was also found. This study underscores the importance of casting a wide net with regard to the assessment of deployment-related experiences and provides evidence that probable post-traumatic stress disorder, depression, and anxiety are highly correlated with all forms of deploymentrelated experiences.

One hundred thirty-seven V.A. patients were randomized to one of three treatment groups to evaluate the efficacy of biphasic calcium phosphate (BCP) ceramic in the treatment of periodontal osseous defects. This material was tested against both autogenous bone implant and open flap curettage procedures. Baseline probing attachment level, Navy plaque index, and gingival index were recorded for all patients. These parameters were monitored for 3 years. At the end of this period, 101 patients had completed the study. Although the plaque and gingival indices steadily increased with time, there were no statistically significant differences among the treatment groups. Patients in the ceramic group had a gain in attachment level of 1.0 mm; those in the curettage group, 0.9 mm; and 0.4 mm for those in the bone implant group. Although the BCP patients had a greater gain, the difference was not statistically significant. In this veteran population, not only did BCP patients fail to outperform those in the control groups, all three treatment groups were similarly ineffective.

The literature regarding age differences in life satisfaction, locus of control and self-concept reveal seriously conflicting results while that on the relationships among these dependent measures has largely supported Erikson's proposals regarding the psychosocial crisis of ego integrity versus despair. A total of ninety-nine V. A. Domiciliary residents, with thirty-three in each of three age groups (50-59, 60-69 and 70+), completed measures of life satisfaction, locus of control and self-concept. Multivariate analysis of covariance demonstrated a significant age difference with the older veterans, who were less well educated and institutionalized longer, more positive on the composite of the three measures. Univariate analysis, however, resulted in significant age differences in self-concept and life satisfaction but not in locus of control. Based upon these findings and the relationships among the dependent variables, the older veterans appear to have resolved the ego integrity versus despair crisis more adequately in spite of having lived for a longer period of time in what has often been viewed as a sterile, blunting environment. Perhaps, contrary to popular assumptions, an institution may provide an environment that facilitates and nourishes the self-esteem and satisfaction of elderly residents.

Erikson's theory regarding the existence of an Ego Integrity versus Despair crisis in old age was tested using an interview derived from Whitbourne and Weinstock's application of Marcia's status construct to the ego integrity crisis. Four integrity statuses were defined: integrity achieving, dissonant (in crisis), foreclosed (avoiding crisis), and despairing. These statuses were reliably (80%) identified among forty elderly community-dwelling men and women through the forty-five-minute semistructured interview. Moreover, predicted differences among the four statuses were observed on questionnaire measures assessing reminiscing activity, death attitudes and preparation, psychological well-being, and questionnaire scales of Stages 6 through 8 of Erikson's theory. The pattern of differences suggested that integrity achieving and foreclosed samples differed mainly regarding their degree of introspection regarding the past, but that both appeared to have a high degree of psychological well-being. Dissonant individuals appeared to be unhappy and stressed, but this was seen as a temporary state in contrast to the more chronic nature of the despairing's low sense of psychological well-being. The validity of the integrity status construct and the interview designed to measure it have, therefore, been supported, and provide the basis for suggested refinements within Erikson's description of the Ego Integrity versus Despair stage.

OBJECTIVE: To describe changes in post-deployment objective and subjective cognitive performance in combat Veterans over 18 months, relative to traumatic brain injury (TBI) status and psychological distress. METHOD: This prospective cohort study examined 500 Veterans from Upstate New York at four time points, six months apart. TBI status was determined by a structured clinical interview. Neuropsychological instruments focused on attention, memory, and executive functions. Subjective cognitive complaints were assessed with the Neurobehavioral Symptom Inventory (NSI). A psychological distress composite included measures of post-traumatic stress disorder (PTSD), depression, and generalized anxiety. RESULTS: Forty-four percent of the sample was found to have sustained military-related TBI, 97% of which were classified as mild (mTBI), with a mean time since injury of 41 months. Veterans with TBI endorsed moderate cognitive symptoms on the NSI. In contrast to these subjective complaints, mean cognitive test performance was within normal limits at each time point in all domains, regardless of TBI status. Multilevel models examined effects of TBI status, time, and psychological distress. Psychological distress was a strong predictor of all cognitive domains, especially the subjective domain. Substantial proportions of both TBI+ and TBI- groups remained in the clinically significant range at the initial and final assessment for all three distress measures, but the TBI+ group had higher proportions of clinically significant cases. CONCLUSIONS: Objective cognitive performance was generally within normal limits for Veterans with mTBI across all assessments. Psychological distress was elevated and significantly related to both objective and subjective cognitive performance.

The existence of a system of quarterly ratings by nurses of psychiatric patients' behavior made possible a relatively objective evaluation of the effects of the introduction of an operant conditioning program on one ward. The 66 patients in the study were rated 6 mo. prior to, immediately prior to, and 3, 6, and 9 mo. subsequent to the introduction of the new treatment regimen. Whereas the behavior on 24 rated items was stable during the period preceding the new treatment, statistically significant changes occurred on 14 behavior items during the treatment period. Worsening of a group of symptoms during the early months of treatment followed by subsequent improvement seems explainable as an aggravation of chronic schizophrenics by a change of their life style. The important finding was that after 9 mo. of operant conditioning techniques, even hard-core psychotic symptoms yielded to this form of behavior modification.

BACKGROUND: We assessed the implementation of telehealth-supported stewardship activities in acute-care units and long-term care (LTC) units in Veterans' Administration medical centers (VAMCs). DESIGN: Before-and-after, quasi-experimental implementation effectiveness study with a baseline period (2019-2020) and an intervention period (2021). SETTING: The study was conducted in 3 VAMCs without onsite infectious disease (ID) support. PARTICIPANTS: The study included inpatient providers at participating sites who prescribe antibiotics. INTERVENTION: During 2021, an ID physician met virtually 3 times per week with the stewardship pharmacist at each participating VAMC to review patients on antibiotics in acute-care units and LTC units. Real-time feedback on prescribing antibiotics was given to providers. Additional implementation strategies included stakeholder engagement, education, and quality monitoring. METHODS: The reach-effectiveness-adoption-implementation-maintenance (RE-AIM) framework was used for program evaluation. The primary outcome of effectiveness was antibiotic days of therapy (DOT) per 1,000 days present aggregated across all 3 sites. An interrupted time-series analysis was performed to compare this rate during the intervention and baseline periods. Electronic surveys, periodic reflections, and semistructured interviews were used to assess other RE-AIM outcomes. RESULTS: = .22); thereafter DOT remained stable in both settings. Providers generally appreciated feedback and collaborative discussions. CONCLUSIONS: The implementation of our telehealth program was associated with reductions in antibiotic use in the LTC units but not in the smaller acute-care units. Overall, providers perceived the intervention as acceptable. Wider implementation of telehealth-supported stewardship activities may achieve reductions in antibiotic use.

OBJECTIVES: Mental health professionals working in integrated, interdisciplinary primary or geriatric care settings may have limited training for this growing model of care. Peer mentorship is one avenue of professional development support. We describe the development and evaluation of a peer mentorship program for mental health professionals working within Veterans Health Administration (VHA) Home Based Primary Care (HBPC) programs. METHODS: Electronic surveys were administered to 57 peer mentorship pairs matched for program participation. The survey examined program utilization characteristics, nature of peer contact, and benefits and challenges reported by participants. RESULTS: Overall, mentor and mentee respondents (N = 58) cited numerous benefits of engaging in the program. Mentees reported their peer mentorship relationships provided acceptance, support, encouragement and positive role modeling. CONCLUSIONS: Findings suggest peer mentoring can be an important professional resource to offer mental health professionals new to working in integrated, geriatric care settings. CLINICAL IMPLICATIONS: Mental health professionals new to working in geriatric and/or integrated care settings may have limited training to meet specialized needs of patients, families, and interdisciplinary care teams. Peer mentorship following formal academic training may be an important option for professional development, supporting enhanced competence and, ultimately, improved patient care and team functioning.

Traumatic brain injury (TBI) in Iraq and Afghanistan war veterans is frequently associated with a variety of complaints, including cognitive problems and posttraumatic stress disorder. In this study, the authors explored the predictive impact of premilitary cognitive abilities on postdeployment cognitive functioning, as mitigated by posttraumatic stress symptoms in a sample of veterans with and without history of TBI. Measures included clinical interview, neuropsychological tests, the PTSD Checklist-Military Version, and the Armed Services Vocational Aptitude Battery. In contrast to history of TBI, premilitary abilities and posttraumatic stress symptoms emerged as significant predictors of postdeployment cognitive deficits.

This study was designed to obtain information potentially of value in understanding an modifying the impact of the social environment of the perceived quality of like among institutionalized aged persons. It was hypothesized that Person-Environment (P-E) congruence, as assessed by the Environmental Perception, Preference and Importance Scale (EPPIS), would be related to (1) sex integration/segregation makeup of the health related facility (HRF) living units, and (2) quantity of social interaction between staff and residents. Analysis of sex by unit sex-type interaction for 60 residents' Person-Environment (P-E) congruence scores revealed that elderly females on sex-integrated units reported a higher level of P-E congruence than those residing on female-only units; males on sex-integrated units, in contrast, reported a poorer level of P-E congruence than males on sex -segregated units. Furthermore, behavioral observations of staff-resident verbal interactions confirmed the hypothesis that residents living on units with high staff-resident interaction perceived the environments more congruent with their preferences than residents on units low in verbal interaction. The observed relationships between the P-E congruence measure, resident-staff interaction, and unit sex-type were taken as further support for the relevance and value of the EPPIS measure as a tool for assessing and improving the institutional milieu.

While important positive effects on the psychological and physical well-being of the elderly often result from increased perceived and actual personal control, the literature also reflects many inconsistent findings. The lack of consensus on aging and the psychology of control has been variously attributed to differences in methodology, measurement devices, theoretical assumptions and the impact of moderator variables. To help bring order to this area the present study evaluated the Latitude of Choice model to determine whether Latitude of Choice scores differ across living arrangements, gender or age. Analysis of covariance tests, controlling for measures of education, perceived health and economic satisfaction, yielded significant main effects but no significant interactions. Partial correlations between Latitude of Choice and measures of psychological well-being, for the total sample and each of the main effect samples, were all significant. These findings provide substantive support for the theoretical approach that underlies Latitude of Choice as a measure of personal control of everyday activities and the potential value of personal control as a moderator of well-being in different environments.

ABSTRACT In the Person-Environment (P-E) Congruence model, psychological well-being is proposed to be a function of the degree of fit between the perceived environment and the important needs of the individual; and, that in more restricted environments, the relationship is stronger. The present study examined, cross-sectionally and longitudinally, the Congruence levels and well-being of elderly veterans ( N = 165) in four microenvironments within a single instutition. Congruence was assessed using the multidimensional Environmental Perception, Preference and Importance Scale (EPPIS). Well-being was measured using the PGC Moral Scale, the Life Satisfaction Index A and a semantic differential self-concept scale. There were significant microenvironment differences on three of the 15 EPPIS dimensions; the P-E Congruence scores were predictive of well-being; and, the specific dimensions predictive of well-being varied across microenvironments, criterion of well-being and time. The data reinforces the notion that treatment programs must be individualized and that the P-E model, operationalized in the EPPIS, may serve as a viable clinical tool.

Research stemming from disengagement and activity theory has recently focused on individual differences in establishing and maintaining interpersonal relationships. A specific intervening variable which has been hypothesized to be related to social activity level is interpersonal cognitive problem solving skills (ICPS). The present study identified two groups of elderly veterans on the basis of their ICPS skills. Those who generated a high number of solutions to interpersonal problems reported significantly more time spent in social and isolated goal-directed tasks than the group generating fewer solutions when age, educational level, and length of institutionalization had been covaried. The results suggest the potential usefulness of the ICPS approach as a means of identifying socially active individuals and as an intervention or training technique for less able institutionalized residents.

Abstract Background Remote Infectious Disease (ID) physicians can provide stewardship support through telehealth. Using the RE-AIM framework, we assessed the implementation of telehealth-supported prospective-audit-and-feedback (tele-PAF) across 3 rural Veterans Administration medical centers (VAMC). Methods All 3 invited sites agreed to participate and lacked ID support for stewardship at baseline. During 2021, an ID physician met virtually 3 times/week with the stewardship pharmacist champion at each participating VAMC to review patients on antibiotics in acute-care (mean daily census 3/site) and nursing-homes (NHs; mean census 71/site); real-time feedback on antibiotic use was given to clinicians. The primary outcome of effectiveness was monthly antibiotic days of therapy (DOT) per 1,000 days-present aggregated across all sites; the secondary outcome was days of antibiotic spectrum coverage (DASC) per 1,000 days-present. An interrupted time-series analysis was performed to asses these outcomes during the 1-year intervention period vs. the 2-year prior baseline. Semi-structured interviews with 20 clinicians and pharmacists were conducted to assess implementation. Results RE-AIM elements are summarized in Table 1. Tele-PAF reviewed 502 unique patients and made 681 recommendations to 23 clinicians; 77% of recommendations were accepted. The most common recommendations were to stop antibiotics (28%) and change duration (20%). After the start of tele-PAF, antibiotic DOT and DASC immediately decreased in acute-care (-20%, p=0.01; -22%, p< 0.01) and NHs (-28%, p=0.03; -37%, p< 0.01). Both metrics began to rise again in acute-care (DOT: +2.5%/month, p=0.02; DASC: +2.7%/month, p=0.02) but were stable in NHs (Figure 1). Clinicians generally appreciated feedback, found it compatible with their workflow and responded favorably to collaborative discussions. Barriers included difficulty establishing rapport with some providers. Conclusion The implementation of tele-PAF was associated with sustained reductions in antibiotic use across 3 NHs but not in the studied small acute-care units. Overall, clinicians perceived the intervention as acceptable and appropriate. Wider implementation of telehealth-supported stewardship activities may achieve reductions in antibiotic use. Disclosures Daniel J. Livorsi, MD, Merck & Co.: Grant/Research Support.

I worked in a long-term care, for-profit nursing home in New Jersey when I was 14 years old (having lied about my age) and saw some sad things done to residents. Forty years later, I'm the restorative nurse at a long-term care facility in New York. I started the restorative nursing program three years ago, and some of our residents have excelled beyond our initial expectations. We have done exceptionally well in helping residents who haven't done so in a while to walk, and in anticipating a decline in their health, which has prevented falls and accidents as well as helped them to maintain functional levels. Yet I still have to check that the nursing staff is doing enough for each resident—and doing it correctly. This article has reminded me to be an advocate for my patients. I hope it's read by caregivers at all levels. Richard Rygiel, RN Bath, NY

Three hypotheses derived partly from Thibaut and Kelley's theory of interpersonal relations received some support using veterans from six VA domiciliaries as Ss. The low compliance Ss differed from the high and/or medium compliant ones in that they were younger, had been in the institution for a shorter time period, had longer service records, showed less motivational distortion or anxiety to do well on tests, were less insecure, but more distrustful and suspecting; they found the general community life more desirable and felt more frequently that they had given up freedom by coming to the domiciliary.

We sincerely thank Heaton et al. 1 for their many positive comments regarding our recent publication 2. While much effort was made to recruit from the ‘finding things easier’ cohort of the quantitative arm 3, they simply did not come forward to be interviewed. We agree that this could have introduced bias in the qualitative section but we highlighted our 10:2 ratio of ‘finding things harder’ and ‘finding things easier’ groups in the paper so that readers were aware. It is also important to emphasise that, as we wrote in our methods section, participants’ scores were not examined before interview so the data collection process could be as open and unbiased as possible. When we conducted our reflexive thematic analysis, we found data pertaining to positive themes from participants in the ‘finding things harder’ group (e.g. the privilege of seeing and enabling what were termed ‘miracles’) and data pertaining to negative themes from the participants in the ‘finding things easier group’ (e.g. the need to be in two places in once, such as on the rota while simultaneously revising). The narrative might be weighted towards the ‘finding things harder’ group in terms of those people we were able to interview. However, because we could estimate how prevalent the issues of stress/depression/burnout were using quantitative methods in the whole population 3, the fact that the qualitative data under-represented the ‘finding things easier’ group should not bias the results of the study as a whole. We do agree it is reasonable to observe that we were not able to drill down in as much detail in the ‘finding things easier’ group. We also agree wholeheartedly that much more needs to be known about the internal and external factors that enable those who are finding the job easier than others in order to experience a more positive working life. We note the highly proactive nature of many Trusts and the Royal College of Anaesthetists 4 with regard to improving trainee job stressors.