A cost and value analysis of two interventions with incontinent nursing home residents

OBJECTIVE: More than half of nursing home residents suffer from urinary incontinence. These residents typically have long stays and, because of comorbid cognitive and physical impairments, have little hope of living again in a noninstitutional environment The value of interventions to change functional status of this chronically institutionalized population is often questioned. This paper explores this value issue in the context of two incontinence management interventions that have been shown to improve functional status: (1) Functional Incidental Training (FIT), and (2) Prompted Voiding (PV). The relative value of the different interventions for the nursing home population was estimated using paired preferences. DESIGN: The cost of two interventions (FIT and PV) that target incontinent nursing home residents was related to the value of these interventions as perceived by consumers of nursing home services. Both interventions decrease incontinence frequency, and one intervention also improves mobility endurance. PARTICIPANTS: Ninety incontinent nursing home residents received the intervention; 37 older nondemented board and care residents and 31 family members of the nursing home residents provided estimates of the intervention's value. MEASUREMENT: The staff-time allocations involved in implementing both interventions were documented in more than 85 resident care episodes. These time data were converted to labor cost based on the cost of nursing aides who would actually implement the intervention. The value of each intervention was assessed by asking consumers to make choices between the intervention and its associated outcomes (such as increased dryness) and other nursing home services of known cost (e.g., moving to a private room). RESULTS: Both interventions had labor costs that were greater than "usual care" costs. The additional cost was estimated to be $4.31 per resident per day for PV and $6.42 per resident per day for FIT if these programs were implemented from 7 AM to 7 AM. Consumer preference data indicated that consumers preferred the FIT and PV outcomes to more expensive alternative services, calculated to cost $10.00 per day, often marketed to consumers, CONCLUSION: Consumers may prefer the FIT and PV interventions relative to the typical services often marketed to the nursing home consumer. The analysis completed in this paper suggests that both interventions have value for frail residents likely to live out their lives in a nursing home.     

Using Margaret A. Newman's theory of health with elderly nursing home residents

TOPIC: The use of Margaret A. Newman's theory by psychiatric nursing students with elderly nursing home residents. SOURCE: The author's work with baccalaureate nursing students. CONCLUSIONS: Nurses who form relationships with elderly nursing home residents can help their clients identify problematic patterns, move to a choice point, then to a higher level of consciousness, resulting in a reduction in problematic patterns of behavior.     

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.     

Psychiatric disorders in Nigerian nursing home residents

BACKGROUND: The prevalence of psychiatric disorders in nursing homes, which has not been studied before in Nigeria, is the subject of this cross-sectional study. METHOD: Psychiatric disorders were assessed in 23 of the 29 residents of the two nursing homes in Lagos and diagnoses based on DSM-III-R criteria (APA, 1987) and AGECAT (Copeland et al., 1986) were made independently. RESULTS: The commonest diagnoses were dementia in 11 out of 23 residents and depression in four residents. Overall prevalence rate of psychiatric disorders was 74%. CONCLUSION: The present prevalence rate of psychiatric disorders is similar to those reported in similar institutions in the industrialized societies. This has implications for the care of the elderly in a non-industrialized society.     

Rosenborg Project: nursing home residents with senile dementia--treatment methods in family therapy

To assess the role of metabolic shifts in pathogenesis of excretory renal dysfunction arising in chronic glomerulonephritis (CGN), two groups of patients were considered. Fourteen patients of group 1 had CGN in a preazotemia stage, thirteen patients of group 2 died of CGN-induced uremia. Cortical nephrobiopsies obtained intravitally (group 1) and renal tissue specimens obtained at autopsies during postmortal hours 0-2 (group 2) were investigated. Apical epithelium of proximal canaliculi in group 1 showed higher levels of acid phosphatase (AP), though much lower of succinate dehydrogenase (SDH) and lactate dehydrogenase (LDH) compared to group 2. In basal proximal nephrothelium of group 1 the activity of LDH and AP was inhibited against these values in group 2. The activity of NADPN2-dehydrogenase, SDH and AP in group 1 surpassed that in group 2 in endothelium of renal cortex peritubular capillaries. These structures LDH and AP proved more active in group 1. The authors observed a series of significant multidirectional correlations between the activity of the enzymes studied and renal excretion. The growing activity of NADN2-dehydrogenase and AP was associated with diminution of electrolyte and water excretion, while enhancing LDH activity exhibited the opposite effect. It is concluded that progression of cortical disorders in the kidneys of CGN patients entails serious metabolic derangement reflected by imbalance in aerobic and anaerobic metabolism. These biochemical shifts result in ambiguous functional sequelae and may contribute both to renal retention of fluid, electrolytes and their excretion. The latter is likely a compensatory mechanism involved in maintenance of water-salt homeostasis in relevant patients.     

Managed primary care of nursing home residents

The mechanisms responsible for immediate adjustments in cardiac output at onset of exercise, in the absence of neural drive, are not well defined in heart transplant (HT) recipients. Seven male HT recipients (mean +/- SD 57 +/- 6 years) and 7 age-matched sedentary normal control subjects (mean age 57 +/- 5 years) performed constant load cycle exercise at 40% of peak power output (Watts). Cardiac output and plasma norepinephrine were determined at rest and every 30 seconds during the first 5 minutes of exercise and at minutes 6, 8, and 10. All subjects were admitted to the General Clinical Research Center for determination of plasma volume. After 3 days of equilibration to a controlled and standardized diet, plasma volume was measured using a modified Evans Blue Dye (T-1824) dilution technique. Heart rate at rest was higher in the HT group (105 +/- 12 vs 74 +/- 6 beats/min), but during submaximum exercise, heart rates in the control group increased more rapidly (p < or = 0.05) and to a greater magnitude (54 +/- 7% vs 17 +/- 4% above rest). Stroke volume at rest was lower in HT recipients (45 +/- 4 vs 68 +/- 9 ml) but was significantly augmented immediately after onset of exercise (30 seconds) and the relative increase was greater than controls at peak exercise (61% vs 38% greater than baseline). Cardiac output at rest was within the normal range in both groups (4.58 +/- 0.27 vs 4.94 +/- 0.40 L/min). Relative increases in cardiac output were similar (p > or = 0.05) for the HT (106 +/- 12%) and control groups (97 +/- 10%). Plasma norepinephrine did not become significantly greater than resting values until approximately 4 minutes after onset of exercise in both groups. Blood volume, normalized for body weight, was 12% greater in the HT group. Thus, HT recipients with expanded blood volume (12%) augment stroke volume immediately after the onset of exercise. Plasma norepinephrine levels contribute negligibly to the rapid adjustment in cardiac output. Rather, we speculate that abrupt on-transit increases in stroke volume are due to augmented venous return, secondary to expanded blood volume.     

Occupationally embedded exercise versus rote exercise: a choice between occupational forms by elderly nursing home residents

The purpose of this study was to to assess the effect on ethanol drinking of ibotenic acid lesions in the medial prefrontal cortex and the ventral striatum of female rats with continuous access to water and a 6% ethanol solution. Ibotenic acid infusions in the prefrontal cortex did not affect ethanol intake at any time, but a significant increase in water intake was observed on the third postoperative week. Ventral striatal lesions significantly increased ethanol intake during the first 2 postoperative weeks. On the third week consumption was not significantly different from vehicle-infused controls. Apparently, then, severe excitoxic injury to the ventral striatum is compatible with normal, or increased, intake of ethanol; in contrast, similar lesions reduce the intake of other drugs of abuse such as psychostimulants and opioids.     

Obtaining a durable power of attorney for health care from nursing home residents

BACKGROUND: A durable power of attorney for health care (DPA) allows a person to appoint a surrogate decision-maker for any future period of mental incapacity. The absence of advance directives can lead to confusion and the expenditure of resources while trying to exert a substituted judgment. METHODS: The Wisconsin DPA was presented with an organized pilot program to 150 residents who had been judged by their social workers to have the capacity to make informed decisions regarding medical care. The reasons residents gave for accepting or rejecting a DPA were analyzed. RESULTS: Seventy-nine percent prepared a DPA. Reasons for signing included allowing the resident to decide who would make medical decisions and assuring that specific wishes would be carried out. Twenty-one percent did not execute a DPA. Reasons were categorized as confusion and misunderstanding regarding the legal system, mistrust, or social isolation. CONCLUSIONS: The high rate (79%) of DPA completion is probably related to individually counseling residents. However, competent residents who despite counseling do not choose to execute a DPA can have detailed advance directives ("living wills") prepared without appointing a decision-maker.     

Assessing life expectancies of older nursing home residents

OBJECTIVE: Care of nursing home (NH) residents is often based on the usual survival of the home's residents. In order to improve our understanding of this population, and, thus, ultimately facilitate individualization of their care, we developed a mathematical model that predicts their survival. SETTING: The Jewish Home and Hospital (JHH), a nursing home. PARTICIPANTS: 1145 older residents who were at the JHH from January 1, 1986, through July 1, 1986. MEASUREMENTS: Information abstracted from medical records and JHH computerized data: clinical, demographic, and dependencies in activities of daily living (ADLs). Main outcome measure: survival from July 1, 1986. DESIGN: Retrospective cohort study via medical chart review. The study period covered admission to JHH through January 17, 1996. Accelerated failure time (AFT) models generated the life expectancy model derived from 50% of the study group and were validated on the remaining sample. We computed predicted AFT and proportional hazards (PH) life expectancies. RESULTS: Significant, independent predictors of decreased survival were male gender, increased age, increase in summary ADL index, and impairment of cardiac, respiratory, neurological, and endocrine/metabolic systems. The interaction between gender and respiratory system impairment was significant. The Spearman correlation coefficients between the observed survivals and those predicted by the Phase I model are 0.49 for Phase I residents and 0.42 for Phase II residents. Our sample life table includes NH residents with different risk profiles and their associated survival estimates as well as interquartile ranges. AFT and PH survivals were similar. CONCLUSION: This first comprehensive model that predicts survival of NH residents can help formulate public health policies and identify appropriate NH residents for clinical trials. The model is a promising step toward improving the health care of NH residents.     

Respiratory viral infections in the elderly in a nursing home

The purpose of this study was to investigate what viruses infiltrate into our nursing home, assess the related clinical symptoms in elderly subjects, and compare the incidence of infections with those in the general community. Between July 1994 and June 1995, 40 elderly persons dwelling in the nursing home were evaluated by clinical observation, serologic analysis, and viral culture of samples to determine the presence of viruses. Enteroviruses and herpes simplex I virus could be isolated from asymptomatic elderly subjects. Individuals with influenza B virus and RSV infections diagnosed by serology did have clinical symptoms. The prevalence of both influenza B virus and enteroviruses was related to that of such viruses in the general community. Our data suggest that respiratory viruses are readily transmitted from the community to nursing home residents.     

Improving dressing behavior in cognitively impaired nursing home residents

Gays and lesbians are becoming increasingly visible to the healthcare professional as a result of the AIDS epidemic and the growing number of lesbian mothers. Ethical practice requires that nurses have an understanding of diverse cultures but focus has historically been on racial and ethnic minorities; little research exists on those with minority sexual or affectional preferences. Heterosexism, the promotion of a heterosexual orientation as the only viable option, has much the same effect as racism. Individuals experience feelings of shame, self-hatred, and lowered self-esteem. The purpose of this article is (1) to present the current state of knowledge regarding individual identity formation and couple development in the gay and lesbian community and (2) to describe the impact of heterosexism. Implications for nursing practice and research will be explored.     

Eating behaviors of nursing home residents who display agitation

To determine if cognitive level and agitation affect eating behavior, 33 females and four males in a 210-bed nursing home were studied. The researcher inconspicuously observed the evening meal for subjects on three occasions. Nearly 80% of the subjects showed a high frequency of agitation and 84% exhibited cognitive impairment. More than one-half were independent in feeding, with caregivers neither touching nor encouraging subjects during more than half of the 110 meals observed. No significant relationships were demonstrated between level of agitation and eating behavior or between cognitive level and eating behavior.     

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.     

Efficacy of elderly and adolescent volunteer counselors in a nursing home setting.

Reliance on the use of volunteers and lay paraprofessionals in human services delivery has increased with the rising demand and shortage of professional providers. We examined the effects of a volunteer training program on depression levels of nursing home residents. The Zung Self-Rating Depression Scale (SDS) was used to identify 60 moderately depressed residents. A total of 20 volunteer counselors (10 elderly, 10 adolescent) were trained in empathic listening, and 20 volunteer counselors (10 elderly, 10 adolescent) were only given information regarding the aging process. Counselors and nursing home residents met twice a week for 5 weeks. Zung SDS posttest results showed that residents who received a volunteer counselor significantly improved (p     

Longitudinal prescribing patterns of psychotropic drugs in nursing home residents.

Changes in the use of psychotropic drugs in a large nursing home were examined both in terms of usage for the total facility and in longitudinal changes within individuals. Data for the nursing home showed a gradual increase in use of antidepressants; a decrease in use of antianxiety medications and of sedative-hypnotics. Changes in the number of residents prescribed antipsychotics were not marked. Data within residents showed a great variability in number of psychotropic drugs used, in number of changes in dosage, and in specific patterns of medication change. The first drug change after admission (excluding day of admission) was more likely to involve initiation rather than discontinuation of psychotropic drugs. The medications studied were used over 4–7 months on the average, covering 20–30% of the resident's nursing home stay. The findings suggest that there is continued monitoring of psychotropic medications in the nursing home. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Validity of the minimum data set for assessing nutritional status in nursing home residents

The Minimum Data Set (MDS), a Health Care Financing Administration (HCFA)-mandated resident assessment system used in community nursing homes, is potentially useful for assessing nutritional status. We compared anthropometric measures of nutritional status available in the MDS [weight and body mass index (BMI)] with other anthropometric and bioelectrical measures of nutritional status, not available on the MDS. We also studied associations of MDS-measured clinical characteristics of nursing home residents with anthropometric and bioelectrical measures of lower and higher nutritional status, defined as measures in the 25th percentile and below, and 75th percentile and above, respectively. Data were from a sample of residents of an academic long-term care facility (n = 186, 75% female, mean age 89.9 +/- 5.6 y). Results were as follows: 1) MDS measures of weight and BMI were significantly correlated with all the anthropometric and bioelectrical measures of nutritional status in women, and most measures in men; 2) some MDS variables, including poor oral intake and advanced cognitive decline, were significantly associated with two or more anthropometric and bioelectrical measures of low nutritional status; and 3) complaints of hunger were significantly associated with two or more anthropometric and bioelectrical measures of high nutritional status. Results suggest that 1) weight and BMI, available in the MDS, are correlated with other measures of nutritional status not available, and 2) MDS clinical variables are associated with measures of low and high nutritional status, and may be useful in identifying patients at nutritional risk.     

Skin disorders and moisture in incontinent nursing home residents: intervention implications

OBJECTIVE: To provide data needed to design an intervention trial to prevent or treat skin disorders in a high risk, incontinent nursing home population. DESIGN: The incidence and prevalence of nine common skin disorders were measured prospectively over a 60-day period using trained observers. Urinary and fecal incontinence frequency were measured over 24 hours, and mobility was measured with subjects both in and out of bed. Direct measures of skin moisture were taken with an impedance device in the presence and absence of urinary incontinence. Multiple regression analyses were used to relate the incontinence and mobility variables to the presence and development of skin disorders. SETTING: Four nursing homes. PARTICIPANTS: One hundred incontinent nursing home residents. MAIN OUTCOME MEASURES: Prospective measures of nine common skin disorders and skin moisture in four perineal regions under continent and incontinent conditions. RESULTS: All subjects had at least one skin condition identified during the 60-day data collection period. The most commonly observed skin condition was blanchable erythema, which occurred in 94% of the subjects, predominantly in the front and back regions that were closest to the urethra and rectum. Twenty-one percent of residents developed either a Stage 1 (nonblanchable erythema) or 2 pressure ulcer. All skin conditions were transient when measured every 3 weeks with the exception of blanchable erythema, which showed stability. Stage 3 or greater pressure ulcers and edema were not observed, and interrater reliability for the measure of papules was poor. Measures of urinary and fecal incontinence severity were correlated with blanchable erythema severity, and blanchable erythema and low bed mobility were predictive of pressure ulcer severity. Blanchable erythema severity was also predictive of Stage 1 and 2 pressure ulcers. Skin moisture levels in the back perineal farthest from the rectum (peripheral) were affected most by urinary incontinence. CONCLUSION: A trial to detect a 50% preventive effect on Stage 1 and 2 pressure ulcers would require that 167 subjects be monitored for 60 days. The transient nature of the skin effects require that skin be monitored at least once a week. Because blanchable erythema is so prevalent and appears to be associated with more severe skin conditions, it would make an excellent marker for beginning to assess the potential preventive effects of various interventions on the incidence of pressure ulcers and other related skin disorders in incontinent patients. It is likely that the back area peripheral to the urethra and rectum would experience the greatest benefit from an intervention trial to reduce moisture caused by incontinence.