Effect of a Statewide Fall Prevention Program on Incidence of Femoral Fractures in Residents of Long-Term Care Facilities

OBJECTIVES: To evaluate the effect of a statewide dissemination of a modified evidence-based fall prevention program on incidence of femoral fractures in nursing homes.
DESIGN: Observational study of a staged implementation of a successful fall prevention program.
SETTING: One thousand three hundred fifty-nine nursing homes in two federal states in the south of Germany.
PARTICIPANTS: Nine thousand seventy-seven residents in the intervention homes and 43,583 residents in control homes from the same and a different federal state.
INTERVENTION: Staff education on fall prevention, advice on environmental adaptations, and progressive strength and balance training over at least 1 year.
MEASUREMENTS: Incident femoral fractures.
RESULTS: One thousand five hundred eighteen femoral fractures occurred in the total study population during the intervention period. The crude incidence rate of femoral fractures was 39.5/1,000 person-years in residents from the intervention homes and 40.9 and 39.7/1,000 person-years in residents from two sets of control homes. In a multivariate model, there was no evidence of an effect of the fall prevention program on incidence of femoral fracture when compared with control homes from the same federal state (adjusted hazard ratio (AHR)=0.96, 95% confidence interval (CI)=0.83–1.11) or from a different federal state (AHR=1.00, 95% CI=0.86–1.16).
CONCLUSION: The statewide dissemination of a multifactorial fall prevention program did not appear to reduce the burden of femoral fractures in residents of nursing homes.     

Osteoporosis Risk in Frail Older Adults in Assisted Living

OBJECTIVES: To compare osteoporosis risk in residents of assisted living (AL) with that of age- and sex-matched community-dwelling adults.
DESIGN: Cross-sectional.
SETTING: Community and AL facilities in Connecticut.
PARTICIPANTS: One hundred seven individuals (77 control, 37 AL).
ASSESSMENTS: Fracture and osteoporosis evaluation history, qualitative heel ultrasound (QUS), 25-hydroxyvitamin D (25OHD), parathyroid hormone (PTH), and physical function measures, including walking speed, chair rise time, 6-minute walk, Berg Balance Scale, Get Up and Go, and handgrip strength.
RESULTS: Participants' mean age was 82.7±5.7. There were no group differences in reported fracture, diagnosis of osteoporosis, or previous bone mineral density (BMD) assessment. QUS T-scores were −1.0±1.5 for community living and −1.9±1.3 for AL ( P =.002), 25OHD levels were 113.0±40.1 nnmol/L for community living and 81.8±36.9 for AL ( P <.001), and PTH levels were 50.8±29.8 pg/mL for community living and 58.8±32.8 pg/mL for AL ( P =.22). Physical performance was more impaired in AL ( P <.05), except for single leg stance ( P =.16). In linear regression analysis, age, sex, and site of residence were significant predictors of heel T-score, explaining 53.7% of the variance.
CONCLUSION: Residents of AL did not report less fracture or osteoporosis than those from the community, but risk factors measured directly were significantly different, including lower BMD and 25OHD and more impairment in measures of physical function. These data suggest that residents of AL are at greater risk for osteoporotic fracture and that measures to diminish risk (optimizing vitamin D status, implementing fall prevention strategies, incorporating exercise to improve physical performance) should be considered and studied for benefit.     

Efficacy of a geriatrics team intervention for residents in dementia-specific assisted living facilities: effect on unanticipated transitions

OBJECTIVES: To determine whether a multidisciplinary team intervention minimizes unanticipated transitions from assisted living for persons with dementia.
DESIGN: Randomized trial.
SETTING: Two dementia-specific assisted living facilities in Connecticut owned and managed by the same corporation.
PARTICIPANTS: One hundred older adults with dementia who relocated to assisted living.
INTERVENTION: Four systematic multidisciplinary assessments by a geriatrician, geriatrics advanced practice nurse, physical therapist, dietitian, and social worker during the first 9 months of relocation to assisted living.
MEASUREMENTS: Permanent relocation to a nursing facility, emergency department (ED) visits, hospitalization, and death.
RESULTS: Fifty-five residents experienced any unanticipated transition out of assisted living, on average 84 ± 74 days after relocation; falls were the primary reason for transition. The intervention reduced the risk of any unanticipated transitions (13%), permanent relocation to a nursing facility (11%), ED visits (12%), hospitalization (45%), and death (63%), but the results did not meet statistical significance. In secondary analysis, more men experienced any unanticipated transition ( P <.001), hospitalization ( P <.001), or death ( P <.001) than women.
CONCLUSION: Although an untargeted multidisciplinary intervention did not significantly reduce the risk of transitions for individuals with dementia relocating to assisted living in this small sample, trends for decreasing hospitalization and death were found. The data further suggest that those at risk for falls and men may benefit from targeted clinical interventions to prevent unanticipated transitions, especially during the first 3 months after relocation.     

An Evaluation of an Adapted U.S. Model of Pharmaceutical Care to Improve Psychoactive Prescribing for Nursing Home Residents in Northern Ireland (Fleetwood Northern Ireland Study)

OBJECTIVES: To test the effect of an adapted U.S. model of pharmaceutical care on prescribing of inappropriate psychoactive (anxiolytic, hypnotic, and antipsychotic) medications and falls in nursing homes for older people in Northern Ireland (NI).
DESIGN: Cluster randomized controlled trial.
SETTING: Nursing homes randomized to intervention (receipt of the adapted model of care; n=11) or control (usual care continued; n=11).
PARTICIPANTS: Residents aged 65 and older who provided informed consent (N=334; 173 intervention, 161 control).
INTERVENTION: Specially trained pharmacists visited intervention homes monthly for 12 months and reviewed residents' clinical and prescribing information, applied an algorithm that guided them in assessing the appropriateness of psychoactive medication, and worked with prescribers (general practitioners) to improve the prescribing of these drugs. The control homes received usual care.
MEASUREMENTS: The primary end point was the proportion of residents prescribed one or more inappropriate psychoactive medicine according to standardized protocols; falls were evaluated using routinely collected falls data mandated by the regulatory body for nursing homes in NI.
RESULTS: The proportion of residents taking inappropriate psychoactive medications at 12 months in the intervention homes (25/128, 19.5%) was much lower than in the control homes (62/124, 50.0%) (odds ratio=0.26, 95% confidence interval=0.14–0.49) after adjustment for clustering within homes. No differences were observed at 12 months in the falls rate between the intervention and control groups.
CONCLUSION: Marked reductions in inappropriate psychoactive medication prescribing in residents resulted from pharmacist review of targeted medications, but there was no effect on falls.     

A Cluster-Randomized Trial of an Educational Intervention to Reduce the Use of Physical Restraints with Psychogeriatric Nursing Home Residents

OBJECTIVES: To investigate the effects of an educational intervention on the use of physical restraints with psychogeriatric nursing home residents.
DESIGN: Cluster-randomized trial.
SETTING: Fifteen psychogeriatric nursing home wards in the Netherlands.
PARTICIPANTS: In total, 432 psychogeriatric nursing home residents from 15 psychogeriatric nursing home wards in seven nursing homes were selected for participation; 404 consented, and 371 of these were available at baseline. Two hundred forty-one from 14 wards had complete data and were included in the data analyses.
INTERVENTION: The nursing home wards were assigned at random to educational intervention or control status. The educational intervention consisted of an educational program for nursing staff combined with consultation with a nurse specialist (registered nurse (RN) level).
MEASUREMENTS: Data were collected at baseline and 1, 4, and 8 months postintervention. At each measurement, the use of physical restraints was measured using observations of blinded, trained observers on four separate occasions over a 24-hour period. Other resident characteristics, such as cognitive status, were determined using the Minimum Data Set.
RESULTS: Logistic and linear regression analyses showed no treatment effect on restraint status, restraint intensity, or multiple restraint use in any of the three postintervention measurements. Furthermore, only small changes occurred in the types of restraints used with residents in the experimental group.
CONCLUSION: An educational program for nursing staff combined with consultation with a nurse specialist (RN level) had no effect on the use of physical restraints with psychogeriatric nursing home residents. In addition to restraint education and consultation, new measures to reduce the use of physical restraints with psychogeriatric nursing home residents should be developed.     

Effect of Influenza Vaccination of Nursing Home Staff on Mortality of Residents: A Cluster-Randomized Trial

OBJECTIVES: To evaluate the effect of staff influenza vaccination on all-cause mortality in nursing home residents.
DESIGN: Pair-matched cluster-randomized trial.
SETTING: Forty nursing homes matched for size, staff vaccination coverage during the previous season, and resident disability index.
PARTICIPANTS: All persons aged 60 and older residing in the nursing homes.
INTERVENTION: Influenza vaccine was administered to volunteer staff after a face-to-face interview. No intervention took place in control nursing homes.
MEASUREMENTS: The primary endpoint was total mortality rate in residents from 2 weeks before to 2 weeks after the influenza epidemic in the community. Secondary endpoints were rates of hospitalization and influenza-like illness (ILI) in residents and sick leave from work in staff.
RESULTS: Staff influenza vaccination rates were 69.9% in the vaccination arm versus 31.8% in the control arm. Primary unadjusted analysis did not show significantly lower mortality in residents in the vaccination arm (odds ratio=0.86, P =.08), although multivariate-adjusted analysis showed 20% lower mortality ( P =.02), and a strong correlation was observed between staff vaccination coverage and all-cause mortality in residents (correlation coefficient=−0.42, P =.007). In the vaccination arm, significantly lower resident hospitalization rates were not observed, but ILI in residents was 31% lower ( P =.007), and sick leave from work in staff was 42% lower ( P =.03).
CONCLUSION: These results support influenza vaccination of staff caring for institutionalized elderly people.     

Randomized, placebo-controlled trial of the cognitive effect, safety, and tolerability of oral extended-release oxybutynin in cognitively impaired nursing home residents with urge urinary incontinence

OBJECTIVES: Determine the cognitive effect, safety, and tolerability of oral extended-release oxybutynin in cognitively impaired older nursing home residents with urge urinary incontinence.
DESIGN: Randomized, double-blinded, placebo-controlled trial.
SETTING: Twelve skilled nursing homes.
PARTICIPANTS: Fifty women aged 65 and older with urge incontinence and cognitive impairment.
INTERVENTION: Four-week treatment with once-daily oral extended-release oxybutynin 5 mg or placebo.
MEASUREMENTS: Withdrawal rates and delirium or change in cognition from baseline at 1, 3, 7, 14, 21, and 28 days after starting treatment using the Confusion Assessment Method (CAM), Mini-Mental State Examination (MMSE), and Severe Impairment Battery (SIB). The Brief Agitation Rating Scale, adverse events, falls incidence, and serum anticholinergic activity change with treatment were also assessed.
RESULTS: Participants' mean age ±standard deviation was 88.6±6.2, and MMSE baseline score was 14.5±4.3. Ninety-six percent of subjects receiving oxybutynin (n=26) and 92% receiving placebo (n=24) completed treatment ( P =.50). The differences in mean change in CAM score from baseline to all time points were equivalent between the oxybutynin and placebo groups. Delirium did not occur in either group. One participant receiving oxybutynin was withdrawn because of urinary retention, which resolved without treatment. Mild adverse events occurred in 38.5% of participants receiving oxybutynin and 37.5% receiving placebo ( P =.94).
CONCLUSION: Short-term treatment using oral extended-release oxybutynin 5 mg once daily was safe and well tolerated, with no delirium, in older female nursing home participants with mild to severe dementia. Future research should investigate different dosages and long-term treatment.     

Impact of low cost strength training of dorsi- and plantar flexors on balance and functional mobility in institutionalized elderly people

Aim:   To evaluate the effects of a low cost strength training program of the dorsi- and ankle plantar flexors on muscle strength, balance and functional mobility, in elderly institutionalized subjects; and to determine the association between strength gain and balance and/or functional mobility gain.
Methods:   Forty-eight volunteers were recruited and equally divided into two groups: intervention (aged 78.44 ± 3.84 years) and control (aged 79.78 ± 3.90 years). Both groups were tested at baseline and outcome for ankle dorsi- and plantar flexors muscle strength, balance and functional mobility. The intervention group participated in a 6-week program, three-sessions-per-week, of resisted ankle dorsi- and plantar flexion exercises using elastic bands.
Results:   In the intervention group, maximal isometric dorsi- (from 8.4 ± 0.45 to 12.6 ± 0.95 kg; P  ≤ 0.001) and plantar flexors strength (from 13.0 ± 0.85 to 17.5 ± 0.93 kg; P  ≤ 0.001), balance (from 14.6 ± 0.54 to 22.3 ± 1.81 cm; P  ≤ 0.001) and functional mobility (from 18.4 ± 0.51 to 11.0 ± 0.66 s; P  ≤ 0.001) increased significantly after the 6-week strength training program. In the control group, no significant differences were detected. In the intervention group, a significant correlation between plantar flexor strength gain and balance gain was found ( r  = 0.826; P  = 0.01).
Conclusion:   The proposed low cost strength training of dorsi- and plantar flexors improved strength, balance and functional mobility in institutionalized elderly people; moreover, the improvement in plantar flexor strength was associated with the improvement in balance.     

Pilot Testing of Intervention Protocols to Prevent Pneumonia in Nursing Home Residents

OBJECTIVES: To test intervention protocols for feasibility, staff adherence, and effectiveness in reducing pneumonia risk factors (impaired oral hygiene, swallowing difficulty) in nursing home residents.
DESIGN: Prospective study.
SETTING: Two nursing homes.
PARTICIPANTS: Fifty-two nursing home residents.
INTERVENTION: Thirty residents with impaired oral hygiene were randomly assigned to manual oral brushing plus 0.12% chlorhexidine oral rinse at different frequencies daily. Twenty-two residents with swallowing difficulty were randomly assigned to upright feeding positioning, teaching swallowing techniques, or manual oral brushing. All protocols were administered over 3 months.
MEASUREMENTS: Feasibility was assessed monthly and defined as high if the protocol took less than 10 minutes to administer. Adherence was assessed weekly and defined as high if full staff adherence was demonstrated in more than 75% of assessments. Effectiveness for improved oral hygiene (reduction in oral plaque score) and swallowing (reduction in cough during swallowing) was compared at baseline and 3 months.
RESULTS: Daily manual oral brushing plus 0.12% chlorhexidine rinse demonstrated high feasibility, high staff adherence, and effectiveness in improving oral hygiene ( P <.001 vs baseline); this combination administered twice per day showed the highest plaque score reduction. Daily manual oral brushing and upright feeding positioning demonstrated high feasibility, high staff adherence, and effectiveness in improving swallowing.
CONCLUSION: Manual oral brushing, 0.12% chlorhexidine oral rinse, and upright feeding positioning demonstrated high feasibility, high staff adherence, and effectiveness in pneumonia risk factor reduction. A protocol combining these components warrants testing for its ability to reduce pneumonia in nursing home residents.     

Nursing Time Devoted to Medication Administration in Long-Term Care: Clinical, Safety, and Resource Implications

OBJECTIVES: To quantify the time required for nurses to complete the medication administration process in long-term care (LTC).
DESIGN: Time-motion methods were used to time all steps in the medication administration process.
SETTING: LTC units that differed according to case mix (physical support, behavioral care, dementia care, and continuing care) in a single facility in Ontario, Canada.
PARTICIPANTS: Regular and temporary nurses who agreed to be observed.
MEASUREMENTS: Seven predefined steps, interruptions, and total time required for the medication administration process were timed using a personal digital assistant.
RESULTS: One hundred forty-one medication rounds were observed. Total time estimates were standardized to 20 beds to facilitate comparisons. For a single medication administration process, the average total time was 62.0±4.9 minutes per 20 residents on physical support units, 84.0±4.5 minutes per 20 residents on behavioral care units, and 70.0±4.9 minutes per 20 residents on dementia care units. Regular nurses took an average of 68.0±4.9 minutes per 20 residents to complete the medication administration process, and temporary nurses took an average of 90.0±5.4 minutes per 20 residents. On continuing care units, which are organized differently because of the greater severity of residents' needs, the medication administration process took 9.6±3.2 minutes per resident. Interruptions occurred in 79% of observations and accounted for 11.5% of the medication administration process.
CONCLUSION: Time requirements for the medication administration process are substantial in LTC and are compounded when nurses are unfamiliar with residents. Interruptions are a major problem, potentially affecting the efficiency, quality, and safety of this process.     

Organizational characteristics and restraint use for hospitalized nursing home residents

OBJECTIVES: To examine the effect of organizational characteristics on physical restraint use for hospitalized nursing home residents.
DESIGN: Secondary analysis of data obtained between 1994 to 1997 in a prospective phase lag design experiment using an advanced practice nurse (APN) intervention aimed at reducing physical restraint for a group of hospitalized nursing home residents.
SETTING: Eleven medical and surgical units in one 600-bed teaching hospital.
PARTICIPANTS: One hundred seventy-four nursing home residents aged 61 to 100, hospitalized for a total of 1,085 days.
MEASUREMENTS: Physical restraint use, APN intervention, age, perceived fall risk, behavioral phenomena, perceived treatment interference, mental state, severity of illness, day of week, patient–registered nurse (RN) ratio, patient–total nursing staff ratio, and skill mix.
RESULTS: Controlling for the APN intervention, age, and patient behavioral characteristics (all of which increased the likelihood of restraint use), weekend days as an organizational characteristic significantly increased the odds of restraint (weekend day and patient–RN ratio on physical restraint use: odds ratio (OR) = 1.92, 95% confidence interval (CI) = 1.38–2.68, P < .001; weekend day and patient–total staff ratio on physical restraint use: OR = 1.91, 95% CI = 1.37–2.66, P < .001; weekend day and skill mix on physical restraint use: OR = 1.91, 95% CI = 1.37–2.67, P < .001).
CONCLUSION: Key findings suggest that organization of hospital care on weekends and patient characteristics that affect communication ability, such as severely impaired mental state, English as a second language, sedation, and sensory-perceptual losses, may be overlooked variables in restraint use.     

Residual urine as a risk factor for lower urinary tract infection: a 1-year follow-up study in nursing homes

OBJECTIVES: To determine whether postvoid urine is a risk factor for the development of lower urinary tract infections (UTIs) in nursing home residents.
DESIGN: Prospective surveillance with a follow-up period of 1 year.
SETTING: Six Norwegian nursing homes.
PARTICIPANTS: One hundred fifty nursing home residents.
METHODS: Postvoid residual (PVR) urine volumes were measured using a portable ultrasound. UTIs were registered prospectively for 1 year.
RESULTS: Ninety-eight residents (65.3%) had a PVR less than 100 mL, and 52 (34.7%) had a PVR of 100 mL or greater. During the follow-up period, 51 residents (34.0%) developed one or more UTIs. The prevalence of UTI in women was higher than in men (40.4% vs 19.6%; P =.02). There was no significant difference in mean PVR between residents who did and did not develop a UTI (79 vs 97 mL, P =.26). PVR of 100 mL or greater was not associated with greater risk of developing a UTI ( P =.59).
CONCLUSION: High PVR is common in nursing home residents. No association between PVR and UTI was found.     

Prevention of falls in nursing homes: subgroup analyses of a randomized fall prevention trial

OBJECTIVES: To evaluate the effectiveness of a multifactorial fall prevention program in prespecified subgroups of nursing home residents.
DESIGN: Secondary analysis of a cluster-randomized, controlled trial.
SETTING: Six nursing homes in Germany.
PARTICIPANTS: Seven hundred twenty-five long-stay residents; median age 86; 80% female.
INTERVENTION: Staff and resident education on fall prevention, advice on environmental adaptations, recommendation to wear hip protectors, and progressive balance and resistance training.
MEASUREMENTS: Time to first fall and the number of falls. Falls were assessed during the 12-month intervention period. Univariate regression analyses were performed, including a confirmatory test of interaction.
RESULTS: The intervention was more effective in people with cognitive impairment (hazard ratio (HR)=0.49, 95% confidence interval (CI)=0.35–0.69) than in those who were cognitively intact (HR=0.91, 95% CI=0.68–1.22), in people with a prior history of falls (HR=0.47, 95% CI=0.33–0.67) than in those with no prior fall history (HR=0.77, 95% CI=0.58–1.01), in people with urinary incontinence (HR=0.59, 95% CI=0.45–0.77) than in those with no urinary incontinence (HR=0.98, 95% CI=0.68–1.42), and in people with no mood problems (incidence rate ratio (IRR)=0.41, 95% CI=0.27–0.61) than in those with mood problems (IRR=0.74, 95% CI=0.51–1.09).
CONCLUSION: The effectiveness of a multifactorial fall prevention program differed between subgroups of nursing home residents. Cognitive impairment, a history of falls, urinary incontinence, and depressed mood were important in determining response.     

Effects of a Restraint Minimization Program on Staff Knowledge, Attitudes, and Practice: A Cluster Randomized Trial

OBJECTIVES: To evaluate the effects of a restraint minimization education program on staff knowledge and attitudes and use of physical restraints.
DESIGN: Cluster-randomized controlled trial with nursing units as the basis for randomization.
SETTING: Forty group dwelling units for people with dementia.
PARTICIPANTS: At baseline, there were 184 staff and 191 residents in the intervention group and 162 staff and 162 residents in the control group. At the 6-month follow-up, there were 156 staff and 185 residents (36 newly admitted) in the intervention group and 133 staff and 165 residents (26 newly admitted) in the control group.
INTERVENTION: A 6-month education program for all nursing staff.
MEASUREMENTS: Staff knowledge and attitudes and physical restraint use were measured before and after the education program.
RESULTS: In the intervention group, staff knowledge about and attitudes toward restraint use changed, and the overall use of physical restraints decreased. A comparison including only residents present during the whole study period showed that the level of use was similar between the groups at baseline, whereas it was significantly lower in the intervention group at follow-up. Adjusted analyses showed that the odds of being restrained at follow-up were lower in the intervention group than in the control group. There was no significant change in the number of falls or use of psychoactive medication.
CONCLUSION: The results indicate that staff education can increase knowledge, change attitudes, and reduce the use of physical restraints without any change in the incidence of falls or use of psychoactive drugs.     

Prevalence of Methicillin-Resistant Staphylococcus aureus Colonization in Residents and Staff in Nursing Homes in Northern Ireland

OBJECTIVES: To determine the prevalence of, and factors associated with, methicillin-resistant Staphylococcus aureus (MRSA) colonization in residents and staff in nursing homes in one geographically defined health administration area of Northern Ireland.
DESIGN: Point prevalence study.
SETTING: Nursing homes.
PARTICIPANTS: Residents and staff in nursing homes.
MEASUREMENTS: Nasal swabs were taken from all consenting residents and staff. If relevant, residents also provided urine samples, and swabs were taken from wounds and indwelling devices.
RESULTS: A total of 1,111 residents (66% of all residents) and 553 staff (86% of available staff) in 45 nursing homes participated. The combined prevalence rate of MRSA in the resident population was 23.3% (95% confidence interval (CI)=18.8–27.7%) and 7.5% in staff (95% CI=5.1–9.9%). Residents who lived in nursing homes that were part of a chain were more likely to be colonized with MRSA (odds ratio (OR)=1.91, 95% CI=1.21–3.02) than those living in independently owned facilities. Residents were also more likely to be colonized if they lived in homes in which more than 12.5% of all screened healthcare staff (care assistants and nurses) were colonized with MRSA (OR=2.46, 95% CI=1.41–4.29) or if they lived in homes in which more than 15% of care assistants were colonized with MRSA (OR=2.64, 95% CI=1.58–4.42).
CONCLUSION: The findings suggest that there is substantial colonization of MRSA in nursing home residents and staff in this one administrative health area. Implementation of infection control strategies should be given high priority in nursing homes.     

Functional Trajectories in Older Persons Admitted to a Nursing Home with Disability After an Acute Hospitalization

OBJECTIVES: To characterize the functional trajectories of older persons admitted to a nursing home with disability after an acute hospitalization.
DESIGN: Prospective cohort study of 754 community-living persons aged 70 and older who were initially nondisabled in four essential activities of daily living (ADLs).
SETTING: Greater New Haven, Connecticut.
PARTICIPANTS: The analytical sample included 296 participants who were newly admitted to a nursing home with disability after an acute hospitalization.
MEASUREMENTS: Information on nursing home admissions, hospitalizations, and disability in essential ADLs was ascertained during monthly telephone interviews for up to 9 years. Disability was defined as the need for personal assistance in bathing, dressing, walking inside one's home, or transferring from a chair.
RESULTS: The median time to the first nursing home admission with disability after an acute hospitalization was 46 months (interquartile range 27.5–75.5), and the mean number±standard deviation of ADLs that participants were disabled in upon admission was 3.0±1.2. In the month preceding hospitalization, 189 (63.9%) participants had no disability. The most common functional trajectory was discharged home with disability (46.3%), followed by continuous disability in the nursing home (27.4%), discharged home without disability (21.6%), and noncontinuous disability in the nursing home (4.4%). Only 96 (32.4%) participants returned home at (or above) their premorbid level of function.
CONCLUSION: The functional trajectories of older persons admitted to a nursing home with disability after an acute hospitalization are generally poor. Additional research is needed to identify the factors responsible for these poor outcomes.     

Outcomes of infection in nursing home residents with and without early hospital transfer

Objectives: To compare outcomes of infection in nursing home residents with and without early hospital transfer.
Design: Observational cohort study.
Setting: Fifty-nine nursing homes in Maryland.
Participants: Two thousand one hundred fifty-three individuals admitted to nursing homes between 1992 and 1995.
Measurements: Incident infection was recorded when a new infectious diagnosis was documented in the medical record or nonprophylactic antibiotic therapy was prescribed. Early hospital transfer was defined as transfer to the emergency department or admission to the hospital within 3 days of infection onset. Infection, resident, and facility characteristics were entered into a multivariate model to create a propensity score for early hospital transfer. Association between early hospital transfer and outcomes of infection, namely pressure ulcers and death between Days 4 and 34 after infection onset, were examined, controlling for propensity score.
Results: Four thousand nine hundred ninety infections occurred in 1,301 residents. Genitourinary (28%), skin (19%), upper respiratory (13%), and lower respiratory (12%) were the most common types. Three hundred seventy-five episodes in which residents survived 3 days (7.6%) resulted in early hospital transfer. In multivariate regression, individuals with early hospital transfer had higher mortality (odds ratio (OR) 1.44, 95% confidence interval (CI)=1.04–1.99) and, in 1-month survivors, a greater occurrence of pressure ulcers (OR 1.61, 95% CI=1.17–2.20) than those without, after adjusting for propensity score.
Conclusion: Using observational data and propensity score methods, outcomes were worse in nursing home residents transferred to the hospital within 3 days of infection onset than in those who remained in the nursing home.     

Comparison of effect of aerobic cycle training and progressive resistance training on walking ability after stroke: a randomized sham exercise-controlled study

OBJECTIVES: To determine whether changes in strength or cardiorespiratory fitness after exercise training improve walking ability in individuals who have had a stroke.
DESIGN: A sham exercise-controlled, randomized two-by-two factorial design, in which the two factors investigated were cycle training (AEROBIC) and resistance training (STRENGTH).
SETTING: University exercise laboratory.
PARTICIPANTS: Fifty-two individuals with a history of stroke (aged 63±9; time since stroke, 57±54 months).
INTERVENTION: Participants undertook 30 exercise sessions over 10 to 12 weeks. Depending on group allocation, individuals underwent aerobic cycling plus sham progressive resistance training (PRT) (n=13), sham cycling plus PRT (n=13), aerobic cycling plus PRT (n=14), or sham cycling plus sham PRT (n=12).
MEASUREMENTS: Primary outcomes were 6-minute walk distance, habitual and fast gait velocities, and stair climbing power. Secondary outcomes included measures of cardiorespiratory fitness; muscle strength, power, and endurance; and psychosocial attributes.
RESULTS: Neither AEROBIC nor STRENGTH improved walking distance or gait velocity significantly more than sham exercise, although STRENGTH significantly improved participants' stair climbing power by 17% ( P =.009), as well as their muscle strength, power, and endurance; cycling peak power output; and self-efficacy. Conversely, AEROBIC improved indicators of cardiorespiratory fitness only. Cycling plus PRT produced larger effects than either single modality for mobility and impairment outcomes.
CONCLUSION: Single-modality exercises targeted at existing impairments do not optimally address the functional deficits of walking but do ameliorate the underlying impairments. The underlying cardiovascular and musculoskeletal impairments are significantly modifiable years after stroke with targeted robust exercise.     

The effect of Evercare on hospital use

Objectives: To examine the use of hospital and related medical care services of a novel managed care program using nurse practitioners (NPs) and directed specifically at long-stay nursing home residents.
Design: Quasi-experimental posttest design with two control groups to minimize selection bias.
Setting: Nursing homes.
Participants: Evercare enrollees in five sites were compared with two sets of controls: nursing home residents in the same nursing homes who did not enroll in Evercare (control-in) and residents of nursing homes that did not participate in Evercare (control-out).
Measurements: Utilization data from Medicare and United Healthcare (the parent corporation for Evercare) were obtained for slightly more than 2 years. Patterns of use were assessed by calculating the monthly use rate for each group and aggregating to form annual rates. Usages addressed included hospital admissions and days, emergency room visits, therapy services, mental health services, and podiatry. Adjustments were made to correct for age, race, and sex. Because the groups differed in terms of the rate of cognitive impairment, the analysis was stratified on this variable.
Results: The incidence of hospitalizations was twice as high in control residents as in Evercare residents (4.63 and 4.67 per 100 enrollees per month vs 2.43 in the 15 months after census, P <.001). This difference corresponded to Evercare's use of intensive service days. The same pattern held for preventable hospitalizations (0.80 and 0.86 vs 0.28, P <.001). The pattern held when residents were stratified by cognitive status. On average, using a NP is estimated to save about $103,000 a year in hospital costs per NP.
Conclusion: The use of active primary care provided by NPs may have prevented the occurrence of some hospitalizable events, but its major effect was allowing cases to be managed more cost-effectively.     

Effectiveness of falls clinics: an evaluation of outcomes and client adherence to recommended interventions

OBJECTIVES: To evaluate outcomes associated with falls clinic programs.
DESIGN: Longitudinal.
SETTING: Thirteen outpatient falls clinics in Victoria, Australia.
PARTICIPANTS: Four hundred fifty-four people referred for clinic assessment (mean age±standard deviation 77.9±8.8; 73% female).
INTERVENTION: After assessment, multifactorial interventions were organized to address identified risk factors.
MEASUREMENTS: A Minimum Data Set was developed and used across all clinics to derive common data on falls, falls injuries, and secondary measures associated with falls risk, including balance, falls efficacy, gait, leg strength, function, and activity. All measures were repeated 6 months later.
RESULTS: Clients had a high risk of falls, with 78% having had falls in the preceding 6 months (63% multiple fallers, 10% experiencing fractures from the falls). An average of 7.6±2.8 falls risk factors were identified per client. The clinic team organized an average of 5.7±2.3 new or additional interventions per client. Sixty-one percent of eligible clients returned for the 6-month assessment. At this time, there was more than a 50% reduction in falls, multiple falls, and fall injuries ( P ≤.004) and small but significant improvements evident on secondary measures of balance, leg strength, gait speed, and confidence outcomes ( P <.006). Average adherence to recommendations was 74.3%. Factors associated with higher adherence included being male, younger than 65, living with others, and having a caregiver ( P <.05).
CONCLUSION: This large multicenter study identified high falls risk of older people referred to falls clinics, the multifactorial nature of their presenting problems and provides preliminary evidence of positive outcomes after falls clinic management.