Evaluation of an intensive case management program for short-term nursing home residents

This study examines the impact of intensive case management services on nursing home length of stay and use of community-based resources for short-term nursing home residents. The findings did not reveal statistically significant effects, indicating that the outcomes of the services provided by the nursing home social workers and the intensive case managers were essentially the same. Discussion focuses on additional variables, such as rural/urban location and social service/nursing home staff relationships that may impact on the effects of case management on the discharge process.     

The nursing home comprehensive eye examination

BACKGROUND: There is significant need for optometric care in long-term care facilities which can be expected to increase in the next decade. METHODS: The previous ophthalmic and medical literature was reviewed and the practical aspects of providing eye care in a nursing home were analyzed. RESULTS: Comprehensive nursing home care requires the integration of portable ophthalmic equipment, a modification of standard testing procedures, clear and concise documentation, and close communication with other health care providers on the nursing home clinical staff. CONCLUSION: Optometrists must consider the incorporation of nursing home care into their clinical practice, while recognizing the unique aspects of providing eye care within a long-term care facility.     

Regulation of aquaporin-2 gene transcription by GATA-3. off

Many nursing home residents are candidates for antipsychotic pharmacotherapy for dementia-related behavioral disturbances that include physical agitation and aggression, verbal outbursts, anxiety, and depression. These patients are often resistant to or intolerant of standard neuroleptics and are usually receiving multiple medications for concurrent psychiatric or medical conditions. New medications must be carefully considered because they may interact with concurrent medications or aggravate concurrent medical problems. Low doses of risperidone may be better tolerated in the elderly because the drug poses little risk of extrapyramidal side effects or blood disorders. One hundred and nine patients with dementia-related behavioral disturbances were studied in 9 nursing homes; most initially received 0.25 to 0.5 mg of risperidone twice daily. Their behavior was recorded for up to 6 months on questionnaires completed by a nursing staff member at each home. Risperidone was well tolerated overall and nursing staff viewed it as helpful in 38 of 100 patients, moderately helpful in 26, slightly helpful in 17, and not helpful in 19.     

Etiology of dependence in older nursing home residents during morning care: The role of staff behavior.

In an observational-operant design study with 17 staff members and 36 elderly nursing home residents, sequential observations of resident–staff interactions were recorded daily during morning care over a 23-day period. Results suggest that independent behavior in self-maintenance care is not maintained by staff behavior but perhaps by intrinsic reinforcers or reinforcing agents other than staff, whereas dependent behavior is directly maintained by staff reinforcement. (16 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Smoking in nursing homes: conflicts and challenges

Nursing home social workers were surveyed to determine nursing home smoking policies and the effect these policies may have on resident and staff interaction. Data analyses suggest that in the past five years there has been a trend toward facilities becoming smoke-free. Facilities that permit smoking face greater conflicts between residents and staff. Social workers are expected to be resident advocates as well as mediators in such areas of conflict. This difficult position is further complicated by the social workers' personal views regarding smoking and "guest" standing in medical settings.     

Neuroleptic use and behavioral disturbance in nursing homes: a 1-year study

This article discusses a longitudinal study of change in disruptive behaviors among nursing home residents treated with neuroleptics compared with those not treated with neuroleptics. Observations were made of 201 participants on admission to and after 1 year in eight skilled nursing facilities. Nine disruptive behaviors were measured using the Psychogeriatric Dependency Rating Scale with nursing assistants. Neuroleptic use was documented from medication records. Odds ratios are reported for the association of behavior at baseline and use of neuroleptics on nine problem behaviors. For those who received neuroleptics during the year, there was greater change in both developing and resolving disruptive behaviors than for those not receiving neuroleptics. For both groups, restless or pacing behavior and belligerent behavior manifested by refusing instructions changed the most, both in developing and in apparently resolving. Our results show that change in disruptive behaviors occurs among nursing home residents regardless of neuroleptic use, but it occurs more frequently among those who receive neuroleptic medication. Knowledge of which disruptive behaviors are most likely to resolve or develop is important in training nursing home staff to cope with the behaviors as well as in planning interventions that may modify such behaviors.     

Staff–patient relationships in nursing homes: Sources of conflict and rehabilitation potential.

Discusses research indicating that staff–patient interactions often function to encourage dependency among nursing home residents. Hypotheses are developed as to why staff members tend to elicit dependency; these include the operation of culturally and cognitively based stereotypes about the aged, adherence to the medical model, institutional constraints on nursing homes, and burnout. Additional evidence shows that continued dependency and passivity are detrimental to the health of patients and that interventions aimed at decreasing dependency reduce the likelihood of disease and death. Methods of instructing staff members in specific skills for encouraging independent and active engagement by residents are suggested. Possible changes in institutional policies within nursing homes, such as rewarding staff according to residents' outcomes and implementing tactics to prevent burnout among staff members, are also discussed. (54 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Swallowing problems in the nursing home: a novel training response

Various studies suggest that between 50% and 75% of nursing home residents have some difficulty in swallowing. Some of these residents are assessed and treated by speech pathologists, but many are managed by nursing staff without specialist input. A training program called Swallowing ... on a Plate (SOAP) has been developed by the Centre for Education and Research on Ageing and the Inner West Geriatrics and Rehabilitation Service to help address swallowing-related problems in local nursing homes (Inner West of Sydney, Australia). The training program teaches nursing staff how to identify, assess, and manage swallowing problems, including making appropriate referrals. Several new instruments were developed specifically for this program including two assessment checklists, a set of management guidelines, and a swallowing care plan. Evaluation of the program--including 3 months follow-up--showed it to be highly successful. A stand-alone training resource has been produced for wide distribution to help staff implement the program as a permanent aspect of their nursing care. This paper describes the development, content, presentation, resource, and evaluation of the above program.     

Diminished hyperaemic response of the hepatic artery to portal venous occlusion (the buffer response) in Asian hybrid minipigs: a comparison of the response to that observed in dogs

This study is part of a larger study of the effect of integrity-promoting care in a Swedish nursing home ward. Compared with assessments on a control ward, improvements were found in the patients' behaviour and in the quality of care after a three-month intervention period. This paper reports on parts of a questionnaire survey on the nursing staff's opinions of their working conditions and demented patients. Most staff members on both the intervention ward and the control ward found their jobs meaningful, engaging and stimulating, but they also felt that they had a heavy work-load. Most of the staff members experienced mental strain because of the patients' disturbed behaviour. Many did not think that the care on their ward would have been good enough for their own close relatives, if they had been suffering from dementia. Only slight changes were found in the staff members opinions after the intervention.     

Group and single-subject evaluation of a programme to promote self-care in elderly nursing home residents

Residents and staff of a nursing home in a metropolitan area were randomly assigned to three conditions to: (a) test whether staff's use of operant behavioural management strategies (Condition 1) would cause a greater increase in residents' self-care behaviour than staff's use of mutual goal setting (Condition 2) or routine nursing care (Condition 3), and (b) examine how useful group scores were, compared to individual scores, in determining change in individual residents' behaviour due to treatment. In-service training was provided to staff in Conditions 1 and 2 but not in Condition 3. Over a period of 22 weeks, nursing staff encouraged subjects to perform targeted self-care tasks independently. Data analysis indicated significantly greater change in self-care behaviours for subjects in Condition 1 than for subjects in Conditions 2 and 3. However, visual inspection of data for each case revealed that individual scores were more useful than averages and differences between groups for determining the effectiveness of the clinical interventions.     

Effects of kappa-opioid receptor stimulation in the heart and the involvement of protein kinase C

Agitation in the elderly, manifested by verbal and physical aggression, frequently results in increased morbidity and mortality for nursing home residents and reduced morale for the family and nursing home staff. It is also responsible for increased costs associated with caring for these residents. Pharmacologic interventions are often used but are frequently ineffective and associated with significant adverse effects. Few controlled studies of drug treatment are available, but divalproex sodium and carbamazepine are effective and well tolerated by this population. Divalproex sodium has advantages of fewer adverse side effects and drug-drug interactions.     

Tube feeding preferences among nursing home residents

OBJECTIVE: To determine the preferences of nursing home residents regarding the use of tube feedings and to characterize the clinical, functional, and psychosocial factors that are associated with preferences. DESIGN: In-person survey. SETTING: Forty-nine randomly selected nursing homes. PATIENTS/PARTICIPANTS: Three hundred seventy-nine randomly selected, decisionally capable, nursing home residents. MAIN RESULTS: Thirty-three percent of participants would prefer tube feedings if no longer able to eat because of permanent brain damage. Factors positively associated with preferences for tube feedings include male gender. African-American race, never having discussed treatment preferences with family members or health care providers, never having signed an advance directive, and believing that tube feeding preferences will be respected by the nursing home staff. Twenty-five percent of the participants changed from preferring tube feedings to not preferring tube feedings on learning that physical restraints are sometimes applied during the tube feeding process. CONCLUSIONS: Demographic and social factors are associated with preferences for tube feedings. The provision of information about the potential use of physical restraint altered a proportion of nursing home residents' treatment preferences.     

An evaluation of a family visit education program

OBJECTIVES: This study was designed to examine the impact of the Family Visit Education Program (FVEP) on family members, nursing staff, and nursing home residents with dementia. DESIGN: The study employed a 2 x 3 single-blind, randomized control group design with two study conditions, FVEP or usual care (UC), and three times of measurement, baseline, 3-months, and 6-months. SETTING: The study was conducted in five skilled-care nursing homes that ranged in size from 120 to 300 beds. PARTICIPANTS: Sixty-six residents with dementia and their primary visitor were randomly assigned to FVEP (n = 32) or UC (n = 34). MEASUREMENTS: Residents were assessed for (1) psychosocial functioning, (2) depression, (3) agitated behavior, and (4) degree of positive social interaction. Nursing staff were assessed for changes in the time and methods used to manage problem behaviors. Visitors were assessed for (1) dementia management skills, (2) extent of perceived caregiving hassles, and (3) visit satisfaction. RESULTS: FVEP was effective for reducing residents' problem behaviors and for decreasing their symptoms of depression and irritability. It was also effective for improving the way family members and other visitors communicated with residents, but, with the exception of reducing the use of mechanical restraints, it was not effective in changing nurses' management of residents' behavior problems. CONCLUSIONS: It is possible to educate family members to communicate and interact more effectively with nursing home residents with dementia. This has beneficial effects on residents but not on nursing staff's management of problem behaviors.     

The physician decision-making process in transferring nursing home patients to the hospital

BACKGROUND: Each year more than 25% of nursing home patients are transferred to the emergency department or hospital for evaluation and treatment of infection. These transfers may have an adverse impact on the quality and cost of patient care. This study examined physician assessment and management of acute infections in the nursing home. METHODS: A cross-sectional study was conducted of all acute urinary tract infections and lower respiratory tract infections occurring from February through June 1991 in eight randomly selected urban nursing homes. The numbers of transfers to the emergency department of hospital were recorded along with identification of the clinical, psychosocial, and institutional factors that influenced the physician's decision to transfer. RESULTS: Three hundred fifty-nine patients had 258 urinary tract infections and 219 respiratory tract infections. Eighty-one (17%) of these events resulted in transfer to a hospital for evaluation (16/81) and/or admission (65/81). Less than one third (30.4%) of the events caused the patient to be examined in the nursing home by a physician before the decision to transfer to the hospital. The mean time between the staff notification of an acute event and physician response by telephone was 5.12 hours. Independent mobility (P < or = .05), a transfer to the hospital during the previous 6 months (P < or = .01), and fewer nursing home laboratory tests and treatments (P < or = .01) were all associated with hospital transfer. CONCLUSIONS: In this sample of acutely ill nursing home patients, physicians collected limited clinical data before the decision to transfer. Although some transfers may be appropriate, a reduction in the transfer rate may reduce health care costs and limit the risk of iatrogenesis, thus improving the outcome of acute illnesses occurring in the nursing home.     

Underutilization of lipid-lowering drugs in older persons with prior myocardial infarction and a serum low-density lipoprotein cholesterol > 125 mg/dl

OBJECTIVE: To investigate the prevalence of aspirin use in older patients with prior myocardial infarction at the time of admission to a nursing home. DESIGN: In a prospective study, the prevalence of aspirin use in 350 consecutive older patients with documented Q-wave myocardial infarction and no contraindications to aspirin use was investigated in patients aged 60 years or older at the time of admission to a nursing home. SETTING: A large, long-term, healthcare facility. PATIENTS: The patients included 231 women and 119 men, mean age 81 +/- 8 years (range 60 to 100). MEASUREMENTS AND MAIN RESULTS: Of the 350 patients with documented Q-wave myocardial infarction and no contraindications to aspirin therapy, 60 patients (17%) were receiving aspirin at the time of admission to the nursing home. CONCLUSION: There is a marked underutilization of aspirin in the treatment of older patients with documented prior myocardial infarction at the time of admission to a nursing home.     

Turnover among nursing home staff. A review

Turnover is especially critical in nursing homes: continuity of care and personal relationships between care-givers and residents are important determinants of quality of care. Additionally, for the cognitively impaired nursing home resident, constant change of staff is bound to aggravate disorientation. Research demonstrates links between turnover and employment/employee characteristics and employment availability.     

Suicidality in nursing home residents: Part I. Prevalence, risk factors, methods, assessment, and management.

Professional psychologists often work in nursing home settings. As the number of older adults in nursing homes increases, the number of psychologists providing care to this population will likely increase as well. Even though literature has suggested that nursing home residents have a high rate of mental disorders, the literature investigating suicidality in this population is scarce. Our discussion includes two articles. This article (Part 1) summarizes types of suicidal behavior, prevalence, risk factors, methods, screening/assessment, and management issues. The second article (Part 2) describes indirect self-destructive behavior, ethical concerns, involving staff and family members, Medicare information, public policy, and suggestions for training/continuing education offerings. Because few psychologists receive training in geropsychology, this information can help clinicians who serve nursing home residents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)