Cytosolic proteins of 21-23 kDa are methylated by kidney cortex membrane-associated C-terminal carboxyl methyltransferases

The nursing home plays an increasing role as domicile in the last period of life. The following investigation is an assessment of the mortality after entering a nursing home, and an analysis of the mental and physical condition of the residents with the goal of being able to differentiate at admission to a nursing home between short-term and long-term "survivors". Of 317 nursing home residents, the initial physical examination upon admission was investigated retrospectively. The nursing home residents were divided into six groups according to their survival time: survival-time up to 1 week, > 1 week to 1 month, > 1 month to 6 month, > 6 month to 1 year, > 1 year to 5 years, and > 5 years. The mean age of the group studied at admission was 80 years; 75% of the residents were transferred from a hospital. On the average, six diseases or chronic disabilities per patient were diagnosed upon admission to the nursing home. The mean survival time was 2.7 years. The initial phase after admission was the most critical period with a high mortality in the first six months (41% of all nursing home residents); of these, 81% had died already within the first month. The assessment criteria, i. e., the level of communicative abilities, orientation, mobility, and urinary/fecal continence, were found to bear a close relation to survival time. Thus, an important prognostic role as "survival predictors" can be ascribed to these factors.(ABSTRACT TRUNCATED AT 250 WORDS)     

Association of elevated alpha 1-antichymotrypsin with cognitive impairment in a prospective study of the very old

OBJECTIVE: The authors investigated the relationships between concentrations of two acute-phase proteins, alpha 1-antichymotrypsin (ACT) and alpha 2-macroglobulin (MAC), and cognitive impairment in the very old. METHOD: Concentrations of ACT and MAC were determined in a prospective study using sera from medically stable elderly nursing home residents. Cognitive impairment was assessed with the Mini-Mental State. RESULTS: Concentrations of ACT were associated with greater cognitive impairment, as reflected by lower Mini-Mental State scores. This relationship did not exist for MAC. CONCLUSIONS: These data extend previous reports that patients with Alzheimer's disease have greater concentrations of ACT in their blood by demonstrating in a diagnostically diverse nursing home population a relationship between serum ACT and mental status. Elevated serum ACT in patients with compromised mental status may reflect a cerebral acute-phase response.     

Loneliness and nursing home admission among rural older adults

In this study, the authors tested the relation between loneliness and subsequent admission to a nursing home over a 4-year time period in a sample of approximately 3,000 rural older Iowans. Higher levels of loneliness were found to increase the likelihood of nursing home admission and to decrease the time until nursing home admission. The influence of extremely high loneliness on nursing home admission remained statistically significant after controlling for other variables, such as age, education, income, mental status, physical health, morale, and social contact, that were also predictive of nursing home admission. Several mechanisms are proposed to explain the link between extreme loneliness and nursing home admission. These include loneliness as a precipitant of declines in mental and physical health and nursing home placement as a strategy to gain social contact with others. Implications for preventative interventions are discussed.     

Risk factors for a medically inappropriate admission to a Department of Internal Medicine

OBJECTIVE: To identify patient- and admission-related risk factors for a medically inappropriate admission to a department of internal medicine. METHODS: Cross-sectional study of a systematic sample of 500 admissions to the department of internal medicine of an urban teaching hospital. The appropriateness of each admission and reasons for inappropriate admissions were assessed using the Appropriateness Evaluation Protocol. Risk factors included the time (day of week and holidays) and manner (through emergency department or direct admission) of admission, patient age and sex, health status of patient and spouse, living arrangements, formal home care services, and informal support from family or friends. RESULTS: Overall, 76 (15.2%) hospital admissions were rated as medically inappropriate by the Appropriateness Evaluation Protocol. In multivariate analysis, the likelihood of an inappropriate admission was increased by better physical functioning of the patient (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1-2.1 [for 1 SD in Physical Functioning scores]), lower mental health status of the patient's spouse (OR, 2.6; 95% CI, 1.3-5.6), receipt of informal help from family or friends (OR, 3.3; 95% CI, 1.5-7.2), and hospitalization by one's physician (OR, 3.6; 95% CI, 1.7-7.5). Receiving formal adult home care was not associated with inappropriateness of hospitalization. CONCLUSIONS: Inappropriate admissions to internal medicine wards are determined by a mix of factors, including the patient's health and social environment. In addition, the private practitioners' discretionary ability to hospitalize their patients directly may also favor medically inappropriate admissions.     

Randomised trial of impact of model of integrated care and case management for older people living in the community

OBJECTIVE: To evaluate the impact of a programme of integrated social and medical care among frail elderly people living in the community. DESIGN: Randomised study with 1 year follow up. SETTING: Town in northern Italy (Rovereto). SUBJECTS: 200 older people already receiving conventional community care services. INTERVENTION: Random allocation to an intervention group receiving integrated social and medical care and case management or to a control group receiving conventional care. MAIN OUTCOME MEASURES: Admission to an institution, use and costs of health services, variations in functional status. RESULTS: Survival analysis showed that admission to hospital or nursing home in the intervention group occurred later and was less common than in controls (hazard ratio 0.69; 95% confidence interval 0.53 to 0.91). Health services were used to the same extent, but control subjects received more frequent home visits by general practitioners. In the intervention group the estimated financial savings were in the order of 1125 ($1800) per year of follow up. The intervention group had improved physical function (activities of daily living score improved by 5.1% v 13.0% loss in controls; P<0.001). Decline of cognitive status (measured by the short portable mental status questionnaire) was also reduced (3.8% v 9.4%; P<0.05). CONCLUSION: Integrated social and medical care with case management programmes may provide a cost effective approach to reduce admission to institutions and functional decline in older people living in the community.     

Melatonin and biological rhythms

The purpose of this study was to examine the influence of cognitive function and other biopsychosocial factors on test-retest agreement, four-week variability, and intensity of self-reported pain using the verbal 0 to 10 scale and a pain thermometer in 115 nursing home residents over four weeks. Pain was assessed twice on three days during week 1, and once each during weeks 2, 3 and 4. A forward stepwise regression procedure was used to examine the influence of biopsychosocial parameters (age, race, gender, educational status, marital status, comorbidity, cognitive function, depression, social support, physical function and self-rated health) on pain intensity, test-retest agreement and variability. There was a quadratic association between cognitive function and test-retest agreement with the 0-10 scale; residents with Folstein scores of 22-26 were more likely to show disagreement (50% of 34) than residents with scores < 22 or > 26 (7% of 71). Higher Folstein scores were also associated with greater pain intensity for both pain scales (p < 0.001). Baseline pain intensity was significantly related to pain variability (0-10 scale only). The clinician should be cognizant of these relationships when interpreting verbalizations of pain in long-term care facilities.     

Psychiatric assessments of nursing home residents under OBRA-87: should PASARR be reformed? Pre-Admission Screening and Annual Review

OBJECTIVE: As part of nursing home practice reforms, OBRA-87 mandates formal psychiatric assessments (PASARR) of nursing home residents suspected of having mental disorders, a responsibility it delegates individually to states. We describe the initial year of implementation of the PASARR process in King County, Washington, and characterize the mental disorders and mental health services needs of nursing home residents referred for psychiatric screening. DESIGN: Cross-sectional study. SETTING: The 54 Medicare-certified King County nursing homes (total beds = 7013). PARTICIPANTS: All patients referred for psychiatric evaluation under PASARR (n = 510). MEASUREMENTS: A systematic, multidimensional evaluation including a semistructured psychiatric diagnostic examination, validated measures of cognitive dysfunction, depression, and global psychopathology, functional variables relevant to need for nursing home care, and selected mental health services indicators. RESULTS: Fewer than 10% of all nursing home residents were referred for psychiatric evaluation. A primary mental illness, evenly divided between psychoses and mood disorders, was found in 60% of the sample, and a psychiatric disorder associated with dementia or mental retardation was found in 25%. Six percent had complex neuropsychiatric features defying classification, and 4% had no mental disorder. Other disorders, such as substance abuse, were rare. Cognitive impairment and global psychopathology were prevalent in all diagnostic groups, and depressive symptoms were common even in patients without affective diagnoses. Eighty-eight percent of the sample were appropriately placed, based on their needs for daily care. Fifty-five percent had unmet mental health services needs. CONCLUSIONS: The PASARR referral process detected a group of seriously mentally ill, functionally disabled patients, most of whom required the level of care that nursing homes provide. Depressed and psychiatrically impaired dementia patients were underrepresented in the referral pool as measured against widely accepted prevalence figures for mental disorders in nursing home populations. The PASARR process as currently configured appears to be most efficient in identifying schizophrenic patients, who represent a small minority of nursing home residents, and the skewed sample it generates fails to provide an adequate basis for estimating overall mental health services needed in nursing homes. The PASARR process should be altered to improve referral rates for depressed and behaviorally disturbed dementia patients.     

Linking level of care to level of need: Assessing the need for mental health care for nursing home residents.

What are the mental health status and active treatment needs of nursing home residents? A stratified random sample of 828 residents in 25 facilities serving Medicaid recipients was assessed for levels of physical and psychosocial functioning. Although 91.2% had sufficiently high levels of medical and physical care needs to justify nursing home placement, 79.6% also had moderate to intense needs for mental health care. Older residents, relative to their younger counterparts, had more intense medical and mental health care needs. It was also found that psychiatric diagnosis was a poor indicator of mental health service needs, particularly among elderly individuals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Maintaining ambulation in the frail nursing home resident: a nursing administered walking program

This article describes a walking program that was implemented at a 550-bed long-term care facility. The program was developed in order to promote functional mobility in the frail nursing home population. The aim of the program is to establish a nursing procedure that focuses on the individual resident's need to walk, and to improve or maintain the ambulatory status of the frail elderly. Twenty nursing home residents from the first three units on which the program was implemented were evaluated before and after the implementation of the program. The data show that the participants improved their ambulatory status after participating in the walking program. This improvement was accompanied by a decrease in the proportion of residents falling.     

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)     

Multilevel modeling of self-esteem change during acute inpatient stroke rehabilitation.

Objective: To explore self-esteem change during inpatient stroke rehabilitation and moderators of change. Research Method: One hundred twenty survivors of stroke serially completed the State Self-Esteem Scale (SSES) during inpatient rehabilitation, as well as measures of mood and perceived recovery as potential moderators of change. Age, gender, prior stroke, prestroke depression, stroke laterality, and admission Functional Independence Measure (FIM) self-care, mobility, and cognitive scores were also included as moderators. Results: Multilevel modeling of the repeated administrations of the SSES indicated that self-esteem significantly improved during rehabilitation. Female gender, left hemisphere stroke, prior stroke, and lower admission FIM cognitive scores were associated with lower self-esteem ratings at admission, but only age and admission FIM self-care and mobility scores were associated with self-esteem change. Older individuals showed less self-esteem improvement than younger individuals, and higher self-care and mobility scores at admission were associated with greater self-esteem improvement. While mood change significantly covaried with self-esteem, the rate of mood change did not appear to influence rate of self-esteem change. Greater improvement in self-esteem over time was related to lower levels of perceived recovery, but this was likely because of the relationship between perceived recovery and self-esteem at rehabilitation admission. Implications: These results suggest that self-esteem improves during inpatient rehabilitation, and this change may be partially dependent on functional status. Implications for facilitating self-esteem change by the clinician are discussed, as well as future research directions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A conceptual model for the mobility patterns of nursing home admissions

This article draws from the literature in long-term care, demography, and geography to develop an initial conceptual framework to explain variations in the patterns of nursing home moves. The conceptual framework is bolstered by preliminary data from state censuses of nursing homes that asked about the origins of current nursing home residents. The data suggest that a relatively high proportion of nursing home residents move to a different county in the process of admission to a nursing home. The research and applied implications of the framework are discussed.     

Effect of the National Resident Assessment Instrument on selected health conditions and problems

OBJECTIVE: To evaluate the effect of the implementation of the National Resident Assessment Instrument (RAI) system on selected conditions representing outcomes for nursing home residents. DESIGN: Quasi-experimental, pre-/post-design, with assessments at baseline and 6-month follow-up. SAMPLE: Two thousand one hundred twenty-eight residents from 268 nursing homes in 10 states before RAI implementation, and 2,088 from 254 of the same nursing homes after implementation. MEASURES: From the full RAI Minimum Data Set, measures of dehydration, falls, decubitus, vision problems, stasis ulcer, pain, dental status (poor teeth), and malnutrition were examined at baseline and 6 months later. Poor nutrition was evaluated using a body mass index score below 20 and vision using a 4-level scale; other conditions were represented by their presence or absence. Decline and improvement were computed as the changes in level between baseline and follow-up, limiting the sample to those who could manifest each such change. MAIN RESULTS: Of eight health conditions representing poorer health status, dehydration and stasis ulcer had significantly lower prevalence after the implementation of the RAI (1993) compared with 1990. At the same time, there was an increase in the prevalence of daily pain. Fewer residents declined over 6 months in nutrition and vision after implementation. Although for these two conditions there were also significantly reduced rates of improvement, the net was an overall reduction in the 6-month rate of decline for all residents. Pain also demonstrated a decline in the postimplementation rate of improvement. The combined eight conditions showed reductions in the rates of both decline and improvement. CONCLUSIONS: Several outcomes for nursing home residents improved after implementation of the RAI. Of the four conditions for which there are significant declines in prevalence or outcome changes, three are specifically addressed in the care planning guidelines incorporated the RAI system (all except stasis ulcer, although there is a RAP for decubitus ulcer). Pain, the only other condition with a significant result --an increase in baseline prevalence--also has no RAP. Although the changes might be ascribed otherwise, they support the premise that the RAI has directly contributed to improved outcomes for nursing home residents.     

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     

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)     

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.     

Evaluation of a nurse-led continence service in the south-west of Glasgow, Scotland

This paper reports the results of a pilot study of a nurse-led continence promotion service in both the community and a local nursing home. Telephone and written referrals were made to the service from 28 primary care teams in Glasgow, Scotland. In the nursing home all patients were assessed and an appropriate management plan implemented. A full assessment was carried out in all community patients, including an appraisal of contributory factors, urinalysis and diaries of food and drink intake. A management plan suited to the patient was then implemented. Patients' levels of incontinence in both arms of the study were assessed objectively using the Lagro-Janssen method. The cost incurred in both arms of the study were measured. There was a 69% improvement in the level of incontinence in the community group compared with 30% in the residents wing and 13% in the hospital wing. The savings in the nursing home amounted to Pounds 4152 in the residents' wing and Pounds 1959 in the hospital wing. In summary, a nurse dedicated to urinary incontinence in the community allows improved management, a greater level of awareness and results in resource savings, whilst increasing patient accessibility to a service.     

Bronchoscopic, photodynamic, and laser diagnosis and therapy of lung neoplasms

To determine predictors of death, nursing home placement and hospital admission, a prospective study was carried out in a university-affiliated geriatric hospital and a general practice. One hundred and thirty-five patients consecutively admitted from home to the geriatric hospital and discharged home again (site 1), and 144 patients, aged 70 years and over, of a general practice (site 2) were recruited for a comprehensive geriatric assessment program. At baseline, none was completely dependent on others, or severely demented. At follow-up after 18 months, 46 subjects (17%) had died, 20 subjects (7%) had been institutionalized, and 79 had been admitted to hospital (28%) in the interim. Univariate analysis demonstrated a significant association between Barthel Activities of Daily Living (ADL), Lawton-Brody Instrumental Activities of Daily Living (IADL), Mini-Mental State Examination (MMSE), Balance and Gait Evaluation, Timed "Up and Go", Timed Test of Money Counting. Grip-Strength and Williams Board Test, and death as well as nursing home placement. Barthel-ADL were significantly correlated with hospital admission. In a logistic regression analysis, Barthel-ADL were independent predictors for death; Barthel-ADL, Timed "Up and Go", Timed Test of Money Counting, and Williams Board Test were independent predictors for nursing home placement. No independent predictor was found for hospital admission. It is concluded that self-report and performance-based measures of functional capabilities are useful instruments to identify patients at risk for nursing home placement and death. Factors contributing to hospital admissions are other than those measured by the applied tests.     

The relationship between loneliness, social support, and decline in cognitive function in the hospitalized elderly

To determine the effects of preexisting levels of loneliness and social support on cognitive decline during hospitalization, 145 elderly subjects 65 to 92 years old without impaired cognition were tested for levels of loneliness, social support, and cognitive status on admission to an acute care hospital. Five days later, cognitive status was again measured in the remaining 86 patients. Loneliness was found to be inversely related to cognitive status on admission. In those with high loneliness scores on admission, cognitive status had improved significantly 5 days later. High social support was correlated with high cognitive status on admission and significant cognitive decline during hospitalization.