The effect of urinary incontinence on quality of life in older nursing home residents

OBJECTIVES: To determine whether nursing home residents with urinary incontinence (UI) have worse quality of life (QoL) than continent residents, whether the relationship between UI and QoL differs across strata of cognitive and functional impairment, and whether change in continence status is associated with change in QoL. DESIGN: Retrospective cohort study using a Minimum Data Set (MDS) database to determine cross-sectional and longitudinal (6 month) associations between UI and QoL. SETTING: All Medicare- or Medicaid-licensed nursing homes in Kansas, Maine, Mississippi, New York, and South Dakota during 1994 to 1996. PARTICIPANTS: All residents aged 65 and older, excluding persons unable to void or with potentially unstable continence or QoL status (recent nursing home admission, coexistent delirium, large change in functional status, comatose, near death). MEASUREMENTS: UI was defined as consistent leakage at least twice weekly over 3 months and continence as consistent dryness over 3 months. QoL was measured using the validated MDS-derived Social Engagement Scale. RESULTS: Of 133,111 eligible residents, 90,538 had consistent continence status, 58,850 (65%) of whom were incontinent. UI was significantly associated with worse QoL in residents with moderate cognitive and functional impairment. New or worsening UI over 6 months was associated with worse QoL (odds ratio = 1.46, 95% confidence interval = 1.36-1.57) and was second only to cognitive decline and functional decline in predicting worse QoL. CONCLUSION: This is the first study to quantitatively demonstrate that prevalent and new or worsening UI decreases QoL even in frail, functionally and cognitively impaired nursing home residents. These results provide a crucial incentive to improve continence care and quality in nursing homes and a rationale for targeting interventions to those residents most likely to benefit.     

Wanderers with cognitive impairment in Department of Veterans Affairs nursing home care units

OBJECTIVES: To explore the extent of and factors associated with male nursing home residents who wander. DESIGN: Cross-sectional design with secondary data analyses. SETTING: One hundred thirty-four nursing home facilities operated by the Department of Veterans Affairs. PARTICIPANTS: Fifteen thousand ninety-two nursing home residents with moderate or severe cognitive impairment admitted over a 4-year period. MEASUREMENTS: Selected variables from the Minimum Data Set included ratings recorded at residents' admission to the nursing home (cognitive impairment, mood, behavior problems, activities of daily living, and wandering). RESULTS: In this sample of residents with moderate or severe cognitive impairment, the proportion of wanderers was found to be 21%. Wanderers were more likely to exhibit severe (vs moderate) cognitive impairment, socially inappropriate behavior, resistance to care, use of antipsychotic medication, independence in locomotion or ambulation, and dependence in activities of daily living related to basic hygiene. A sizable proportion of wanderers were found to be wheelchair users (25%) or were wanderers with dual dementia and psychiatric diagnoses (23%), characteristics that are not well documented in the literature. CONCLUSION: These results support previous clinical understanding of wanderers to be those who are more likely to exhibit more-severe cognitive impairment. Based on a statistical model with variables generated from prior research findings, classification as a wanderer was found to be associated with other disruptive activity such as socially inappropriate behavior and resisting care. Two understudied populations of wanderers were documented: wheelchair wanderers and those with comorbid dementia and psychiatric diagnoses. Future longitudinal studies should examine predictors of wandering behavior, and further research should explore the understudied subpopulations of wheelchair and dual-diagnosis wanderers who emerged in this study.     

The identification of residents capable of accurately describing daily care: implications for evaluating nursing home care quality

PURPOSE: The goal of this study was to develop a method of identifying incontinent nursing home (NH) residents capable of providing accurate interview information about daily NH care. DESIGN AND METHODS: In 177 incontinent NH residents from four facilities, selected Minimum Data Set (MDS) ratings were compared with two standardized, performance-based, cognitive screening instruments to predict which residents could accurately answer questions concerning receipt of daily incontinence and mobility care practices. RESULTS: MDS ratings of activity of daily living performance and cognition significantly predicted residents' ability to accurately describe daily care practices. Performance-based measures of cognitive functioning did not outperform the MDS ratings. Selecting residents who scored two or more on four orientation items composing the MDS Recall subscale identified residents capable of accurately describing daily care practices with a sensitivity of 64% and a specificity of 75%. IMPLICATIONS: The MDS-based criteria identified are a promising, objective method for selecting incontinent NH residents for interview to verify the occurrence of specific daily care practices.     

Pain in U.S. nursing homes: validating a pain scale for the minimum data set

PURPOSE: The aim of this study was to validate a pain scale for the Minimum Data Set (MDS) assessment instrument and examine prevalence of pain in major nursing home subpopulations, including type of admission and cognitive status. DESIGN AND METHODS: This study considered validation of the MDS pain items and derivation of scale performed against the Visual Analogue Scale (VAS), using Automatic Interaction Detection. The derivation data describe 95 postacute care nursing home patients who are able to communicate. The scale is then used in retrospective analysis of 34,675 Michigan nursing home residents. RESULTS: A four-group scale was highly predictive of VAS pain scores (variance explanation 56%) and therefore quite valid in detecting pain. In the prevalence sample, only 47% of postacute patients compared to 63% of postadmission patients reported no pain, and these percentages rose with increasing cognitive impairment. IMPLICATIONS: Pain is prevalent in nursing home residents, especially in those with cognitive dysfunction, and often untreated.     

Decision-making capacity to execute a health care proxy: development and testing of guidelines

OBJECTIVE: To evaluate the reliability and validity of guidelines to determine the capacity of nursing home residents to execute a health care proxy (HCP). DESIGN: A cross-sectional study. SETTING: A 750-bed not-for-profit nursing home located in New York City. PARTICIPANTS: A random sample of 200 nursing home residents: average age, 87; 99% white; 83% female; average length of stay, 3.05 years; mean Mini-Mental State Exam (MMSE) score, 15.9. MEASUREMENTS: Demographic characteristics (Minimum Data Set (MDS)); function and cognitive status (Institutional Comprehensive Assessment and Referral Evaluation (INCARE)); Reisberg Dementia Staging; MMSE; Minimum Data Set-Cognitive Performance Scale (MDS-COGS)); an investigator-developed measure of a nursing home resident's capacity to execute a health care proxy (Health Care Proxy (HCP) Guidelines.) RESULTS: The internal consistency of the decision-making scales in the HCP Guidelines, paraphrased recall and recognition, reached acceptable levels, alphas of .85 and .73, respectively. Interrater reliability estimates were .92 and .94, respectively, for the recall and recognition scales; test-retest reliability estimates were .83 and .90. The discriminant validity of these scales is promising. For example, the MMSE correlation was .51 with the Recall scale and .57 with the Recognition scale. Of residents with severe cognitive impairment (MMSE < 10), 71% completed 50% or more of the scaled items in the HCP guidelines and 95% consistently named a proxy. CONCLUSIONS: Seventy-three percent of testable residents, approximately three-quarters of whom were cognitively impaired, evidenced sufficient capacity to execute an HCP. Of residents with severe cognitive impairment, the HCP guidelines are potentially useful in identifying those with the capacity to execute a HCP. The guidelines are more predictive than the MMSE in identifying residents able to execute a HCP.     

Ability of surrogates to represent satisfaction of nursing home residents with quality of care.

OBJECTIVE: To measure the ability of surrogates to accurately represent nursing home residents' satisfaction with the nursing home care. DESIGN: Comparison by correlation analysis of questionnaire answers by nursing-home residents and their designated surrogates. SETTING: Four non-profit community nursing homes. PARTICIPANTS: One-hundred fifty-two resident-surrogate pairs were included, based on the following criteria: (1) the resident was able to respond to questions verbally and in English, had cognitive abilities sufficient to understand the questions, and had a responsible party who had a telephone number in the medical record; (2) both the resident and the surrogate agreed to be interviewed. OUTCOME MEASURES: A 26-item instrument (21 specific and 5 global items) was developed to measure surrogates' perceptions of residents' satisfaction with the quality of the physician services, nursing care, and the nursing home environment. The instrument was scored on a 4-point Likert scale in which higher scores indicated greater satisfaction and paralleled a similar instrument designed for nursing home residents. Correlation of residents' with surrogates' scores on the satisfaction instruments was examined. RESULTS: The mean score for most items was greater than 3.0, indicating overall satisfaction with the care. Correlations between surrogates and residents on specific items ranged from 0.1 to 0.55. Correlations were highest for global items and items addressing satisfaction with the environment. CONCLUSION: We conclude that nursing home residents' surrogates cannot accurately express the residents' satisfaction with all areas of nursing home care and that their evaluations should not be taken in lieu of the residents' opinions.     

Effects of cognitive performance on change in physical function in long-stay nursing home residents

BACKGROUND: Determining the nature and rate of change in physical function among long-stay nursing home (NH) residents classified by cognitive performance is needed to inform judgments about prognosis and design of clinical trials to minimize functional decline. METHODS: The study consisted of a longitudinal analysis using random coefficients models of 71,388 noncomatose residents aged 65 and older admitted in one of five states participating in the Health Care Financing Administration-sponsored National Case Mix and Quality Demonstration Project who stayed in the nursing home 1 year or longer. Linear effects of cognitive impairment on admission and over time on the trajectory of dependence in activities of daily living (ADLs) were estimated, adjusting for demographic status upon admission. Interaction terms were used to determine if subgroups of residents at the same cognitive level were at risk for a steeper than average rate of decline. Measures were derived from the NH Minimum Data Set (MDS+) ratings of each domain. Cognition was measured using the MDS-Cognitive Performance Scale. Physical function was determined by summing ADL dependence ratings of bathing, dressing, grooming, toileting, and eating (range 0 to 20). Demographics included age, gender, race, and marital status. RESULTS: On average, ADL dependence worsened 0.84 points per year among these long-stay residents. Only cognition and marital status had clinically significant effects on ADL dependence. Married residents exhibited more ADL dependence than unmarried residents. Severity of cognitive impairment on admission and over time influenced severity of ADL dependence but not rate of decline. No interaction terms were clinically significant. CONCLUSIONS: Clinicians seeking to identify factors that accelerate ADL decline in long-stay NH residents must examine explanatory variables other than cognitive impairment and demographics.     

Atypical presentation of scabies among nursing home residents.

BACKGROUND: Scabies epidemics are not uncommon in nursing homes. Effective treatment is enhanced by prompt clinical diagnosis and early intervention. The clinical presentation of scabies may vary in older, immunocompromised or cognitively impaired persons. METHODS: We performed a retrospective study of all residents diagnosed with scabies in a multilevel long-term care geriatric facility. The duration of the outbreak was from May to September 2000. RESULTS: Fifteen residents contracted scabies during the outbreak. All affected residents had predominantly truncal lesions. Twelve residents had diffuse erythematous, papulosquamous lesions. Pruritus occurred in only 5 residents. Three residents with severe dementia and notably impaired functional status failed to respond to Permethrin cream (5%). All 3 residents responded to treatment with oral Ivermectin. CONCLUSION: Older nursing home residents with scabies may present with atypical skin lesions. Residents with cognitive impairment and restricted mobility may be treatment resistant. The diagnosis of scabies should be considered in any nursing home resident with an unexplained generalized rash. Residents with dementia and severe functional impairment that fail to respond to Permethrin cream (5%) may benefit from treatment with oral Ivermectin.     

Agitated Behavior and Cognitive Functioning in Nursing Home Residents

Agitation is a significant problem for nursing home residents, their families, and their caretakers. Previous literature suggests that agitation is related to dementia and cognitive deterioration in the elderly, but no empirical studies support this relationship. This study tests the relationship between level of cognitive functioning and the nature and level of agitation in nursing home residents. Nurses rated one hundred sixty-five nursing home residents on cognitive functioning and agitation. Results indicate that agitation is prevalent among all types of nursing home residents and that cognitively impaired residents exhibit more agitation than cognitively intact residents. The highest levels of agitation appear to be exhibited by those with moderate levels of cognitive impairment. Manifestations of agitation differ between cognitively intact and cognitively impaired residents: agitated behaviors of cognitively intact residents resemble coping mechanisms, while cognitively impaired residents manifest a wide range of inappropriate behaviors.     

Health status and assessed need for a cohort of older people admitted to nursing and residential homes

OBJECTIVE: to investigate dependency and health status of a cohort of older people admitted for long term nursing or residential care and to compare these findings with assessments conducted by social services departments prior to placement. DESIGN: retrospective cohort study. SETTING: residential, nursing and dual registered homes within Nottingham Health Authority boundaries. SUBJECTS: 205 residents placed over 3 months. MAIN OUTCOME MEASURES: levels of disability, cognitive impairment and behavioural disturbance identified by assessment before and after admission. RESULTS: cognitive impairment and physical disability were significantly higher in nursing homes, although a third of residents in residential care had substantial physical disability. In nursing homes, a quarter of residents had low dependency needs but these had greater cognitive impairment than those in residential homes with the same level of dependency. Most residents had some degree of behavioural disturbance (particularly in nursing homes) and more severe disturbance was associated with greater cognitive impairment and more depressed mood, but not physical disability. A moderate level of agreement was found between preadmission and follow-up assessments of health status. CONCLUSIONS: a case-mix which includes higher dependency residents in residential homes and lower dependency residents in nursing homes is likely to reflect changes in the health status of residents following placement but also suggests that a range of placement criteria were used together, rather than individual indicators of need. Although pre-placement measures of disability and dependency were supported by follow-up assessments, it is essential that the needs of residents in long-term care are adequately monitored and managed, in particular those in residential care with higher dependency needs.     

Risk of behavior problems among nursing home residents in the United States

This study identified personal risk factors associated with behavior problems among nursing home residents using data based on a national survey of nursing home residents. Data are based on the Institutional Population Component of the 1987 National Medical Expenditure Survey and include nursing home residents living in licensed facilities on January 1, 1987. Multiple regression analyses were conducted to examine characteristics of residents that place them at risk of behavior problems. Independent variables include physical functioning, sensory impairment, cognitive impairment, psychiatric diagnoses, and demographics. Eleven behavior problems grouped into four categories based on factor analysis serve as dependent variables: wandering/safety, aggressive behaviors, collecting behaviors, and delusions/hallucinations. Risk factors emerging as predictors included sex (male), cognitive impairment, ADL dependency, incontinence, psychiatric history, receptive communication, walking, and difficulty seeing. Risk factors differ by type of behavior problem. Results suggest a multiple etiology in which biological, psychological, and sociocultural factors all play a role in generating behavior problems in the long-term care setting.     

Ratings of activities of daily living in nursing home residents: comparison of self- and proxy ratings with actual performance and the impact of cognitive status

This study was conducted to examine differences between self- and proxy ratings of activities in daily living (ADL) in nursing home residents and to compare them with actual performance. An impact of cognitive status on these ratings was also determined. Data were obtained from 164 dyads of nursing home residents (self-ratings) and their professional care providers (proxy ratings). Statistical procedures included t tests, intraclass correlations, Pearson’s correlations, analysis of variance (ANOVA) and ROC curves. Paired t test provided evidence that residents in general overestimated their abilities for all ADLs (p < .01 in all cases), but a substantial subset of 54 residents, with mean MMSE of 18, agreed with their care providers. The mean MMSE score of those who overestimated their abilities was 13 (N = 57). The ANOVA revealed that greater rating differences were associated with more severe cognitive impairment (MMSE, F = 9.93, p < .001). Proxy ratings of walking were not significantly different from actual performances (p = .145), while self-ratings overestimated it (p < .001). Although residents in general overestimated their ADL abilities and results of comparison with actual performance indicated that proxies may be closer to the actual status in this population, a considerable number of those with milder cognitive impairment were able to assess their ADLs with reasonable accuracy.     

Depression among institutionalized aged: assessment and prevalence estimation

Aged nursing home and congregate apartment residents were screened for symptoms of depression and cognitive impairment. Of 708 survey respondents, 12.4% met DSM-IIIR criteria (33) for major depression; about half this group also displayed significant cognitive deficits. Another 30.5% of the total sample reported less severe but nonetheless marked depressive symptoms. Such "minor" depressive syndromes were much more common among congregate housing than nursing home residents. Possible major depression was more prevalent among newly admitted residents of both housing components. Comparison of cognitively impaired vs intact respondents revealed that the two groups' self-reports of depression were equally internally consistent, and bore equivalent correlations with observer ratings made by interviewers and direct care staff. Checks of medical records of a group of survey nonrespondents (n = 203) indicated that, excepting the extremely demented, the active sample of 708 accurately represents institution residents as a whole. Finally, comparison with clinical diagnoses made by facility psychology and psychiatry department staff indicated good concurrent validity of research screening measures and methods.     

Another look at aggregate changes in severe cognitive impairment: further investigation into the cumulative effects of three survey design issues

OBJECTIVES: This study explored whether previously reported declines in severe cognitive impairment were robust to cumulative effects of potentially confounding survey design issues. METHODS: Using the 1993 Asset and Health Dynamics of the Oldest Old study (n = 7,443) and 1998 Health and Retirement Survey (HRS; n = 7,624) the proportion of persons ages 70 and older with severe cognitive impairment was calculated under various assumptions about item nonresponse, differential loss to follow-up, and the size and composition of the nursing home population. Impairment was measured for self-respondents using a modified version of the Telephone Interview Cognitive Screen; for proxy respondents ratings of memory and judgment were used. Chi-square tests were adjusted to account for complex survey designs. RESULTS: Ignoring loss to follow-up, excluding nursing home residents, and assigning a low score to those refusing subscales yielded a statistically significant decline in severe cognitive impairment from 5.8% in 1993 to 3.8% in 1998, or an average annual decline of 6.9%. When cumulative effects of survey design issues were considered and design effects incorporated into statistical tests, statistically significant declines persisted, albeit at a reduced average annual rate, ranging from 2.5% to 6.9% per year. DISCUSSION: Previously reported improvements in severe cognitive impairment appear to be robust to a variety of specifications. Replication with future waves of the HRS and other data is warranted.     

Rural-urban differences in medical care for nursing home residents with severe dementia at the end of life

OBJECTIVES: To identify factors associated with the use of selected medical services near the end of life in cognitively impaired residents of rural and urban nursing homes. DESIGN: Retrospective cohort study using Centers for Medicare and Medicaid Services administrative data for 1998 through 2002. SETTING: Minnesota and Texas nursing homes. PARTICIPANTS: Nursing home residents aged 65 and older with severe cognitive impairment who subsequently died during 2000/01. MEASUREMENTS: Minimum Data Set and Medicare Provider Analysis and Review, Hospice, and Denominator files were used to identify subjects and to assess medical service use. U.S. Department of Agriculture metro-nonmetro continuum county codes defined rural (codes 6-9) and urban (codes 0-2) nursing homes. Nursing home residents with hospice or health maintenance organization benefits were excluded. Use of hospital services at the end of life was adjusted for use of corresponding services before the last year of life. Outcome variables were feeding tube use, any hospitalization, more than 10 days of hospitalization, and intensive care unit (ICU) admission. RESULTS: The population included 3,710 subjects (1,886 rural, 1,824 urban). In multivariable logistic regression analyses (all P<.05), feeding tube use was more common in urban nursing home residents, whereas rural nursing home residents were at greater risk for hospitalization. CONCLUSION: Rural residence was also associated with lower risk of more than 10 days of hospitalization and ICU admission. Nonwhite race and stroke were associated with higher use of all services. Rural nursing home residence is associated with lower likelihood of use of the most-intensive medical services at the end of life.     

Pain in cognitively impaired nursing home residents: how well are physicians diagnosing it?

OBJECTIVES: This study examined the reliability and validity of geriatricians' assessments of pain in cognitively impaired nursing home residents. DESIGN: Cross-sectional analysis.SETTING: A large suburban nursing home. PARTICIPANTS: Seventy-nine nursing home residents participated in the study. Of these, 31 had mild/moderate cognitive impairment (average Mini-Mental State Examination (MMSE) = 16.04) and 48 were severely cognitively impaired (average MMSE = 1.91). More than 80% of the participants were female, and the average age was 87. MEASUREMENTS: Two geriatricians from outside the nursing home examined laboratory results, performed a physical examination, and completed a detailed assessment of pain. The personal geriatricians of 42 of the participants also completed the same assessment. RESULTS: Intergeriatrician agreement rates were statistically significant and moderate in magnitude. When examined by subgroup, the correlations were significant only for those with mild/moderate impairment. Some of the geriatricians' ratings of pain correlated significantly with residents' self-reports. All relationships were weaker in the severely cognitively impaired group. Ratings of greater pain were significantly correlated with higher cognitive functioning. CONCLUSIONS: The results validate geriatricians' evaluations of pain during a medical examination for moderately impaired persons and question their ability to evaluate pain in the severely cognitively impaired. There is a need for increased awareness of pain in this population and a need for improved methodologies to identify it.     

Tracking the Cognition of Nursing Home Residents

Although estimates place the prevalence of dementia in nursing home residents at approximately 50%, the longitudinal course of cognition and cognitive impairment in nursing home residents are not well understood. Using data from 33 long-term care residents, patterns of performance on the Mini-Mental State Examination across multiple quarterly administrations were examined. Results show that four distinct patterns were evident: declining, stable, improving, and inconsistent performance. Although a number of residents exhibited declines in performance across multiple administrations, the performance of the majority of residents either remained stable or improved. Few clinical correlates of patterns of performance were observed in this cohort. These results have implications for providers working in nursing homes and raise important questions for future research.