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.     

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.     

Evaluation of the effective levels of vegetable mixture for the recovery of animals with early or late protein-calorie malnutrition

Essays were gathered from fifty-three elderly nursing home residents about the strongest meaning in their lives. These elderly nursing home residents most often reported the category of family relationships as central, followed by pleasure and then health. A chi-square analysis showed a significant difference between the type of meaning of the elderly nursing home residents and those of younger adults. An additional chi-square analysis found no significant difference between the nursing home residents and a group of golden anniversary couples' meanings. Finally, our results indicate that elderly nursing home residents do not report an absence of meaning in their lives.     

Neoplasm of endolymphatic sac origin: clinical, radiological and pathological features

PURPOSE: Examine antiepileptic drug (AED) use in nursing homes by age, gender, and use of comedication that can interact with AEDs. METHODS: Two point-prevalence evaluations of AED use from computerized medical records of nursing home residents throughout the United States (set 1, 43,757; set 2, 41,386) 65 years and older serviced by PHARMERICA. RESULTS: 10.5% of residents received an AED. Of the age group 65-84 years, 15 % received an AED compared with 6.1% of those 85 years or older (p < 0.001). Gender differences were present; 13.4% of the male residents and 9.4% of the female residents were treated with an AED (p < 0.001). The most frequently prescribed AEDs were phenytoin, carbamazepine, clonazepam, or phenobarbital. The average number of routine medications taken by AED recipients was 5.6, greater than the average of 4.6 for other residents. CONCLUSIONS: AEDs are extensively prescribed for elderly nursing home residents. Men and persons aged 65-85 years were more likely to receive AEDs than were women or those older than 85 years. AED recipients receive more routine medications than do other residents, including co-medications that alter hepatic metabolism and clinical response. The reasons for age and gender differences are unclear and require further study.     

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     

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.     

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.     

A case of recessive X-linked ichthyosis: scale-specific abnormalities of lipid composition may explain the pathogenesis of the skin manifestation

Even though fecal incontinence is a leading cause of nursing home placement, risk factors contributing to its development have not been established. Identification of such factors may lead to prevention of incontinence and reduce the need for nursing home placement. A total of 388 residents of five nursing homes were included. Data regarding mental status, bowel habits, obstetrics history, and the presence, frequency, and severity of fecal incontinence were collected for each participant. Of the 388 nursing home residents, 46% were incontinent of feces. Incontinence was 1.5 times more common in males and in those younger than 65 years of age. In both univariate and multivariate analyses, diarrhea, dementia, restricted mobility, and male gender were independently associated with incontinence. In contrast to previous studies, constipation was not associated with fecal incontinence. If elimination of these risk factors leads to prevention of incontinence in even a few people, some elderly patients may not require institutionalization, which will result in improvement in their quality of life, not to mention a reduction in public health expenditures.     

Nursing home residents functional ability and perceptions of choice

1. Nursing home residents have the right to be involved in decision making relative to their care, which researchers have demonstrated has a positive effect on residents. 2. The authors designed a study to explore discrepancies between residents' perceptions of choice and the amount of choice preferred and their relationship to self-care abilities and functional abilities in nursing home residents. 3. The results indicate that residents desired more choice than they felt they were given, but that this difference was not related to their perceptions of their self-care abilities. As residents' functional abilities increased, actual choice as well as desired choice increased slightly. 4. Nurses should structure the nursing home's approach to residents so that choice is maximized within the constraints of the institution.     

The impact on general practitioners of the changing balance of care for elderly people living in institutions

OBJECTIVES: To describe utilisation of general practitioners by elderly people resident in communal establishments; to examine variations in general practitioner utilisation and estimate the likely impact of the "downsizing" of long stay provision in NHS hospitals. DESIGN: Secondary analyses of the survey of disability among adults in communal establishments conducted by the Office of Population Censuses and Surveys in 1986, and projection to present day. SETTING: Nationally representative sample of communal establishments in Great Britain. SUBJECTS: Disabled residents aged 65 or more without mental handicap. RESULTS: Residents with higher levels of disability, disorders of the digestive system, resident in smaller local authority homes or larger voluntary residential homes were more likely to consult a general practitioner. For those who consulted, higher levels of disability and morbidity and residence in a private nursing home or a larger private residential home were all associated with greater general practitioner utilisation. Overall, when residents' characteristics and size of home was controlled for, residents in nursing homes had greater predicted utilisation than those in residential care homes. People who would previously have been cared for in NHS hospitals and are now cared for in nursing homes have high predicted utilisation due to their greater morbidity and disability. CONCLUSION: The "downsizing" of NHS provision for elderly people has increased demand on general practitioners by 160 whole time equivalents per year in Britain.     

Nursing homes--structure and selected characteristics, 1987 and 1996

This paper briefly describes changes in the nursing home market over a nine-year period, 1987 to 1996. Estimates are based on the "Institutional Population Component" of the 1987 National Medical Expenditure Survey (NMES) and the "Nursing Home Component" of the 1996 Medical Expenditure Panel Survey (MEPS). Both surveys were sponsored by the Agency for Health Care Policy and Research. On January 1, 1996, approximately 1.56 million residents were receiving care in 16,840 nursing homes with 1.76 million beds. This compares to 1.36 million residents in 14,050 nursing homes with 1.48 million beds in 1987, increases of 15, 20 and 19 percent, respectively. The average size of a nursing home remained constant. The occupancy rate decreased from 92 percent in 1987 to 89 percent in 1996, in spite of the growth of the elderly population, both in relative and absolute terms. There was also a significant drop in the supply of nursing home beds relative to the elderly population; this decrease was observed in all four regions of the country, with the greatest drop being in the West. In 1987 only 28 percent of nursing homes were certified by both Medicare and Medicaid (dually certified), while this proportion increased to 73 percent in 1996. Conversely, while only 17 percent of nursing homes were certified by only Medicaid in 1996, a full 50 percent were certified as such in 1987. By far the most common type of nursing home in both 1987 and 1996 was the nursing home with only nursing home beds. Such nursing homes represented 87 percent of the market in 1987 but just 77 percent in 1996. The remaining were either hospital-based or nursing homes with personal care and/or independent living beds in addition to nursing home beds or were part of a continuing care retirement community.     

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.     

Disruptive behavior of elderly residents and the use of nursing methods

This study is the first part of a larger research project concerned with disruptive behaviour and the use of physical restraints on elderly nursing home residents. This paper is focused on the types and prevalence of disruptive behaviour among elderly residents, nurses' experiences and the types of nursing interventions employed. Data was collected from nurses of varying qualifications (n = 173) in seven Swiss nursing homes by using a questionnaire. The most frequent behavioural problems reported by nurses were mobility, incontinence, getting dressed, verbal communication, passivity, withdrawal and continual requests. Nurses found physical aggression, continual shouting and verbal abuse the most difficult to manage with. The results also indicated that experiences varied between nurses. In particular, nursing staff always considered disruptive behaviour more disruptive against other residents rather then against themselves. The most frequently used interventions against disruptive behaviour were considering residents' wants and needs, getting close, adjustment to residents' background and organisation of activities. Physical and chemical restraints were also used.     

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.     

Arginine vasopressin levels in nursing home residents with nighttime urinary incontinence

OBJECTIVES: To examine the relationship between diurnal urine volume and plasma arginine vasopressin levels (AVP) in nursing home residents with nighttime urinary incontinence and a comparison group of frail but nondemented, continent geriatric board and care residents. DESIGN: Case series. SETTING: Four nursing homes and two board and care facilities. PARTICIPANTS: Sixty-two nursing home residents and 27 board and care residents. MEASUREMENTS: Daytime (7:00 a.m. to 7:00 p.m.) and nighttime (7:00 p.m. to 7:00 a.m.) urine volumes of incontinent nursing home residents were measured over 3 days and 3 nights by reweighing preweighed adults diapers and toileting inserts emptied by research staff for the comparison group. AVP levels were drawn in the early morning (5:00 a.m. to 7:00 a.m.) before subjects arose and in the evening after an hour of lying in bed (8:00 p.m. to 11:00 p.m.), and plasma levels were determined by radioimmunoassay. RESULTS: Half of the nursing home residents and 82% of the comparison group had night/total urine volume ratios > or = 50%. Forty-nine percent of the total of 89 subjects had undetectable morning AVP levels, 61% had undetectable evening AVP levels, and 42% had undetectable AVP levels in both morning and evening. There were no significant differences in AVP levels between those with night/total urine volume ratios > or = 50% and < 50% in either the nursing home or comparison groups though the small number of comparison group subjects with ratios < 50% may have limited our statistical power to detect differences. CONCLUSION: Our data suggest that a substantial proportion of both nursing home residents with nighttime incontinence and frail geriatric patients with a reversal of the normal diurnal pattern of urine excretion have an accompanying deficiency in AVP production and/or secretion. More detailed physiologic studies are needed to understand better the pathophysiology of geriatric nocturia and nighttime incontinence and the role that AVP deficiency may play in these conditions. Until such studies are carried out, we do not recommend the routine use of exogenous AVP for geriatric patients with unexplained nocturnal polyuria.     

Special care units for people with Alzheimer's disease. Only for the privileged few?

The number of Special Care Units (SCUs) for people with Alzheimer's disease (AD) in nursing homes have increased dramatically in the past 10 years. Despite the rapid increase in number of SCUs and the concern that most SCUs report higher costs than traditional nursing home units where residents with AD are integrated with cognitively intact residents, the evaluation of costs has been largely unsystematic and noncomparative. Studies are urgently needed to assess comparative costs so that administrators and policy makers can make informed decisions. This article reviews studies that examine the costs of care in SCUs and presents cost-related data comparing the outcomes of care for residents with AD on a SCU and on traditional units in one long-term care setting.     

Validation and application of the pneumonia prognosis index to nursing home residents with pneumonia

OBJECTIVES: To evaluate the predictability of a pneumonia prognosis index in nursing home residents with pneumonia and to use the index to account for acute severity of pneumonia before comparing the short-term outcome of residents with pneumonia treated with intravenous antibiotic therapy in two different settings: an inpatient geriatrics unit and a nursing home DESIGN: A retrospective chart review of 158 episodes of nursing home-acquired pneumonia treated initially with intravenous antibiotics; 100 episodes were treated in an inpatient acute geriatrics service (AGS), and 58 were treated completely in a nursing home (Nursing Home group) SETTING: The AGS is a 20-bed unit within a 400-bed, public, university-affiliated hospital. The Nursing Home group consisted of residents of two nonproprietary nursing homes. PARTICIPANTS: Nursing home residents with radiographically proven pneumonia who had at least one of the following signs/symptoms: cough, fever, purulent sputum, respiratory rate > or = 25 per minute, localized auscultatory findings, or pleuritic pain. MEASUREMENTS: The pneumonia prognosis index was calculated for each resident at the time of diagnosis of pneumonia; the index has been validated as a predictor of hospital outcome in patients with community-acquired pneumonia and is also considered a measure of acute severity of pneumonia. Status (alive or dead) of each resident at 30 days after diagnosis was the major dependent variable RESULTS: Mean (+/-SD) duration of antibiotic therapy for the Nursing Home group (10.7+/-4.5 days) was not significantly different from that of the AGS group (9.6+/-3.4 days; P = .26). The pneumonia prognosis index stratified the 158 episodes of pneumonia into low- and high-risk groups for 30-day mortality; the mortality rates in each risk strata were not significantly different from those reported in the original derivation and validation studies of the index. In addition, the distribution of episodes among the risk strata of the index was not significantly different for the two study groups, which was an indication that the two groups were similar in terms of acute severity of pneumonia. Thirty-day mortality was not significantly different between the two groups: AGS, 21% and Nursing Home, 24.1% (P = .66). CONCLUSION: The pneumonia prognosis index seems to have the same capability for predicting the outcome in nursing home residents with pneumonia as in residents with community-acquired pneumonia. The index is also a measure of acute pneumonia severity. Nursing home residents with pneumonia, even those who are most acutely ill, can be treated successfully with intravenous therapy in the nursing home; their 30-day mortality was no different than that of those with the same acute severity of illness who were admitted to a hospital for treatment.     

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.