Influence of poststroke urinary incontinence on disability: the nursing home setting

OBJECTIVE: To characterize the association of poststroke urinary incontinence with disability progression in nursing home residents. DESIGN: In this prospective cohort study, the Minimum Data Set from the State of New York between 1994 and 1997 was utilized. From a pool of over 240,000 potential subjects, 500 met inclusion/exclusion criteria. Previously continent, first-time stroke survivors were classified as being continent or incontinent immediately after their stroke and were followed for changes in activities of daily living status (disability) at quarterly intervals for a 1 yr. In addition, a post hoc analysis was performed examining changes in activities of daily living status from the prestroke condition and exploring the relationship between poststroke impairments in continence and limitations in mobility. RESULTS: An almost 2-fold difference in level of disability was noted poststroke among those who were incontinent those who were continent (P < 0.001). This difference in disability level remained unchanged for 1 yr. Through the post hoc analysis, it was determined that, although the onset of stroke produced significant elevations in disability for both continent and incontinent stroke survivors (P < 0.001), the presence of an impairment in urinary continence was associated with a significantly greater increase (94% 13%) in disability (P < 0.001). In addition, incontinence occurred more frequently among those who had a loss in mobility function. CONCLUSION: Incontinence is a clinical factor after stroke that is associated with greater disability among nursing home residents. These findings have clinical implications for physiatrists and nursing home clinicians and provide a context in which future disability research can be conducted.     

Impairment,disability, and life satisfaction in Parkinson's disease

Purpose : To determine the correlation of motor and musculoskeletal impairments with disability scores and life satisfaction. Musculoskeletal impairments might be due to the impact of motor impairments, however some cases may have these impairments even before the disease is diagnosed.

Methods : 48 consecutive patients (32 male, 16 female) with Parkinson's disease with a mean age of 65.6, mean age of onset of the disease of 59.8, and Hoehn and Yahr staging system 1-4 participated. Unified Parkinson's disease rating scale, modified Schwab and England activities of daily living scale and life satisfaction index were used. Also New York modified mobility rating scale for c-spine and upper extremities and trunk and lower extremities was performed.

Results : Motor and musculoskeletal impairments were correlated with the disability score. Bradykinesia, and tremor were correlated with upper and lower extremity range of motion limitation, but rigidity was not. Bradykinesia was correlated with life satisfication. Having had the disease longer was related to upper extremity range of motion limitation.

Conclusions : Motor and musculoskeletal impairments are correlated with disability scores. Bradykinesia and musculoskeletal impairments are correlated with life satisfication. Patients with Parkinson's disease might benefit from a rehabilitation programme focusing on motor impairments such as bradykinesia as well as musculoskeletal impairments even in the early stages of the disease.     

The disablement process: factors associated with progression of disability and recovery in French elderly people

PURPOSE: To study the factors associated with progression, recovery and death from different grades of disability in elderly people. METHOD: The sample included 3198 participants of the PAQUID ('Personnes Agées QUID') cohort, aged 65 and over and community-dwellers at baseline. Subjects were re-interviewed 1, 3, 5, 8 and 10 years after baseline. A five-state Markov model was used to estimate transition intensities between four grades of disability and toward death. We used a hierarchic scale of disability, which combines basic and instrumental activities of daily living and mobility. Several explanatory variables were investigated: medical, personal and environmental factors. RESULTS: The factors associated with progression and/or no recovery of disability were cardiovascular diseases, stroke and diabetes, low cognition, visual impairment and dyspnoea (for pathologies and impairments), older age, female gender, low educational level (for risk factors), depression (for intra-individual factor) and being married, recent hospitalization and number of drugs (for extra-individual factors). Older age, male gender, tobacco consumption and living in an urban area were associated with mortality. CONCLUSIONS: These findings confirm the independent contribution of each group of variables in the disablement process and stress their different impact on progression of disability or on recovery from different grades of disability.     

Factors Influencing Long-Term Home Care Utilization by the Older Population: Implications for Targeting

This research was designed to explore factors that affect the choice of long-term care modalities in the older population and to discuss the appropriate target population of home health care services within the entire long-term care system. The study subjects' activities of daily living limitations, cognitive status, and sociodemograhic data at the time of admission were obtained from retrospective chart reviews. The sample included 134 older subjects who were receiving long-term care from a Long-Term Home Health Care Program or a nursing home in New York City. The results indicated that Long-Term Home Health Care Program use by older persons was characterized by a higher rate of being admitted from private homes, less cognitive impairments, less limitations in activities of daily living, and younger age than older patients who were nursing home residents. Consequently, in the choice of different care modalities, health-related factors of the older population were found to be more important predictors than sociodemographic characteristics or support system. The implication to both nurses and researchers is the development of eligibility criteria that captures the unique characteristics of disabled older persons in each of the different long-term care programs to serve them better in a cost-effective manner.     

Rated cognition in nursing home residents with multiple sclerosis: cross-sectional and longitudinal analyses

Purpose.?To examine cognitive change in nursing home residents with multiple sclerosis (MS) over the first year of a nursing home stay and to predict cognition functioning in these residents at admission and the 1-year annual assessment.

Method.?In the first part of this study, the cognitive functioning of nursing home residents with MS (n?=?1890) and without MS (n?=?22,985) were compared. In the second part, demographic and other variables were used to predict cognition at the admission and 1-year annual assessment for MS residents.

Results.?Nursing home residents with MS had better cognitive functioning than residents without MS at admission and 1 year later. Regression analyses demonstrated that higher education and pain predicted higher Minimum Data Set Cognition Scale (MDS-Cog) at admission and at 1 year later, but poorer activities of daily living predicted worse MDS-Cog at admission and 1 year later. For the longitudinal analysis, MDS-Cog at the admission assessment was an independent predictor of MDS-Cog scores at the 1-year annual assessment.

Conclusions.?Nursing home residents with MS have significantly better cognitive functioning than non-MS residents and, over the first year of a nursing home stay, higher education and pain, but lower activities of daily living, predict poorer cognitive functioning.     

The effects of the Green House nursing home model on ADL function trajectory: A retrospective longitudinal study

BackgroundGrowing attention in the past few decades has focused on improving care quality and quality of life for nursing home residents. Many traditional nursing homes have attempted to transform themselves to become more homelike emphasizing individualized care. This trend is referred to as nursing home culture change in the U.S. A promising culture change nursing home model, the Green House nursing home model, has shown positive psychological outcomes. However, little is known about whether the Green House nursing home model has positive effects on physical function compared to traditional nursing homes.ObjectivesTo examine the longitudinal effects of the Green House nursing home model by comparing change patterns of activities of daily living function over time between Green House home residents and traditional nursing home residents.DesignA retrospective longitudinal study.SettingsFour Green House organizations (nine Green House units and four traditional units).ParticipantsA total of 242 residents (93 Green House residents and 149 traditional home residents) who had stayed in the nursing home at least 6 months from admission.MethodsThe outcome was activities of daily living function, and the main independent variable was the facility type in which the resident stayed: a Green House or traditional unit. Age, gender, comorbidity score, cognitive function, and depressive symptoms at baseline were controlled. All of these measures were from a minimum dataset. Growth curve modeling and growth mixture modeling were employed in this study for longitudinal analyses.ResultsThe mean activities of daily living function showed deterioration over time, and the rates of deterioration between Green House and traditional home residents were not different over time. Four different activities of daily living function trajectories were identified for 18 months, but there was no statistical difference in the likelihood of being in one of the four trajectory classes between the two groups.ConclusionsAlthough Green House nursing homes are considered to represent an innovative model changing the nursing home environment into more person-centered, this study did not demonstrate significant differences in activities of daily living function changes for residents in the Green House nursing homes compared to traditional nursing homes. Given that the Green House model continues to evolve as it is being implemented and variations within and across Green House homes are identified, large-scale longitudinal studies are needed to provide further relevant information on the effects of the Green House model.     

The disablement process: Factors associated with progression of disability and recovery in French elderly people

Purpose:?To study the factors associated with progression, recovery and death from different grades of disability in elderly people.

Method:?The sample included 3198 participants of the PAQUID (‘Personnes Agées QUID’) cohort, aged 65 and over and community-dwellers at baseline. Subjects were re-interviewed 1, 3, 5, 8 and 10 years after baseline. A five-state Markov model was used to estimate transition intensities between four grades of disability and toward death. We used a hierarchic scale of disability, which combines basic and instrumental activities of daily living and mobility. Several explanatory variables were investigated: medical, personal and environmental factors.

Results:?The factors associated with progression and/or no recovery of disability were cardiovascular diseases, stroke and diabetes, low cognition, visual impairment and dyspnoea (for pathologies and impairments), older age, female gender, low educational level (for risk factors), depression (for intra-individual factor) and being married, recent hospitalization and number of drugs (for extra-individual factors). Older age, male gender, tobacco consumption and living in an urban area were associated with mortality.

Conclusions:?These findings confirm the independent contribution of each group of variables in the disablement process and stress their different impact on progression of disability or on recovery from different grades of disability.     

Analyses of nursing home residents with cancer at admission

The objective of the study was to profile nursing home residents with cancer at admission to the nursing facility. We used all admission assessments in the Minimum Data Set recorded throughout the United States during 2002 to identify 61,890 residents with cancer, or 11.3% of all admissions. Nursing home residents with cancer were significantly older and more likely to be male than other residents at admission. Large proportions of nursing home residents with cancer were activities of daily living dependent and about 55% used a wheelchair as their primary mode of locomotion. More than 37% of residents with cancer experienced at least moderate daily pain at admission and almost 26% had a diagnosis of depression. At admission, more than half of residents with cancer had an unstable health condition, 21% were judged to be in their final 6 months of life, and 19% received hospice care. More than 40% of residents with cancer had no advance directives recorded at admission. Compared to other residents at admission, larger proportions of residents with cancer require heavy care. Staff at nursing facilities need to address depression, pain management, and the implementation of advance directives to improve the quality of life for residents with cancer.     

Pain and Associated Factors in Nursing Home Residents

BackgroundUnderstanding factors associated with risk of pain allows residents and clinicians to plan care and set priorities, however, factors associated with pain in nursing home residents has not been conclusively studied.AimTo evaluate the association between pain and nursing home (NH) resident demographic and clinical characteristics.DesignRetrospective analysis of Minimum Data Set 3.0 records of nursing home residents residing in 44 Indiana NHs between September 27, 2011 and December 27, 2019 (N = 9,060).ResultsPain prevalence in this sample of NH residents was 23.7%. Of those with pain, 28.0% experienced moderate to severe/frequent pain and 54.6% experienced persistent pain. Risk factors for moderate to severe/frequent pain include female sex; living in a rural setting; intact, mildly, or moderately impaired cognition; arthritis; contracture; anxiety; and depression. In contrast, stroke and Alzheimer's disease and Alzheimer's-disease related dementias (AD/ADRD) were associated with decreased risk of reporting moderate to severe/frequent pain, likely representing both the under-assessment and under-reporting of pain among cognitively impaired NH residents. Risk factors for persistent pain included age <70, Black race, living in a rural location, intact cognition, contracture, and depression.ConclusionsPain remains a pressing problem for NH residents. In this study, we identified demographic and clinical factors associated with moderate to severe frequent pain and persistent pain. Residents with a diagnosis of AD/ADRD were less likely to report pain, likely representing the difficulty of evaluating pain in these residents. It is important to note that those with cognitive impairment may not experience any less pain, but assessment and reporting difficulties may make them appear to have less pain. Knowledge of factors associated with pain for NH residents has the potential for improving the ability to predict, prevent, and provide better pain care in NH residents.     

Nursing home case mix in Wisconsin. Findings and policy implications

Along with many other states, Wisconsin is considering a case mix approach to Medicaid nursing home reimbursement. To support this effort, a nursing home case mix model was developed from a representative sample of 410 Medicaid nursing home residents from 56 facilities in Wisconsin. The model classified residents into mutually exclusive groups that were homogeneous in their use of direct care resources, i.e., minutes of direct care time (weighted for nurse skill level) over a 7-day period. Groups were defined initially by intense, Special, or Routine nursing requirements. Within these nursing requirement categories, subgroups were formed by the presence/absence of behavioral problems and dependency in activities of daily living (ADL). Wisconsin's current Skilled/Intermediate Care (SNF/ICF) classification system was analyzed in light of the case mix model and found to be less effective in distinguishing residents by resource use. The case mix model accounted for 48% of the variance in resource use, whereas the SNF/ICF classification system explained 22%. Comparisons were drawn with nursing home case mix models in New York State (RUG-II) and Minnesota. Despite progress in the study of nursing home case mix and its application to reimbursement reform, methodologic and policy issues remain. These include the differing operational definitions for nursing requirements and ADL dependency, the inconsistency in findings concerning psychobehavioral problems, and the problem of promoting positive health and functional outcomes based on models that may be insensitive to change in resident conditions over time.     

A randomised controlled trial testing the impact of exercise on cognitive symptoms and disability of residents with dementia

A randomized controlled trial was undertaken to measure effects of exercise on: 1) the progression of cognitive symptoms related to dementia using the Clock- Drawing test Shulman et al. 1993); and 2) disability using the Revised Elderly Persons Disabilities Scale (REPDS; Fleming and Bowles 1993). Data was analysed from 75 nursing home residents with dementia who were randomly assigned to one experimental group and two control groups. Group 1 (control) received no intervention, Group 2 (control) received a social visit equivalent in duration and frequency as those undertaking the exercise program in the experimental group, Group 3. A specifically designed, frail aged appropriate, twelve week exercise program was undertaken by the those in the experimental group three times per week, each session lasted for thirty minutes. The findings from: 1) the clock drawing test showed that exercise may slow the rate of progression of the cognitive symptoms related to dementia; and 2) the REPDS showed that exercise slowed and reversed disability in some of the activities of daily living.     

Voluntary upper-extremity movements in patients with unilateral peripheral vestibular hypofunction

BACKGROUND AND PURPOSE: People with peripheral vestibular pathology demonstrate motor impairments when responding and adapting to postural platform perturbations and during performance of sit-to-stand and locomotor tasks. This study investigated the influence of unilateral peripheral vestibular hypofunction on voluntary arm movement. SUBJECTS AND METHODS: Subjects without known neurological impairments and subjects with vestibular impairments performed 3 voluntary arm movements: an overhead reach to a target, a sideward reach to a target, and a forward flexion movement through 90 degrees. Subjects performed these tasks under precued and choice reaction time conditions. During all tasks, body segment motion was measured. Head velocity measurements were calculated for the side task only. RESULTS: Subjects with vestibular loss restricted upper body segment motion within the frontal and transverse planes for the 90-degree and overhead tasks. Average angular head velocity was lower for the group with vestibular hypofunction. Task uncertainty (the introduction of a choice reaction time paradigm) differentially influenced the groups regarding head velocity at target acquisition. DISCUSSION AND CONCLUSION: Individuals with vestibular loss altered their performance of voluntary arm movements. Such alterations may have served to minimize the functional consequences of gaze instability.     

Analyses of nursing home residents in hospice care using the minimum data set

OBJECTIVE: To present comprehensive profiles of residents in hospice care at admission to the nursing home using the Minimum Data Set (MDS). DESIGN AND SETTING: We analysed 40,622 MDS admission assessments for nursing home residents in hospice care. The MDS contains resident-focused data on pain, cognitive patterns, physical function, disease diagnoses, medications, nutrition, and specific treatments received. RESULTS: About four in five recently admitted hospice residents had 'do not resuscitate' orders and only 27% had a living will. Over 70% of recently admitted hospice residents experienced pain, with almost one half experiencing daily pain. Over one half of those hospice residents in pain experienced moderate pain and almost one third experienced horrible or excruciating pain. About 57% of recently admitted hospice patients had cancer, 21 % had congestive heart failure, 20% had emphysema/chronic obstructive pulmonary disease, and 18% had depression. About one in two recently admitted hospice residents exhibited at least moderate impairment in cognitive function. CONCLUSIONS: There is a need to improve pain management, advanced directives, and mental health services for residents dying in nursing homes.     

Usefulness of the nursing home quality measures and quality indicators for assessing skilled nursing facility rehabilitation outcomes

OBJECTIVE: To examine the usefulness of the nursing home quality indicators and nursing home quality measures for differentiating among providers from a rehabilitation outcomes perspective. DESIGN: Retrospective. SETTING: Skilled nursing facilities (SNFs) across the United States. PARTICIPANTS: A total of 211 SNFs. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: All quality indicators, all quality measures except for CWLS01 (residents who lose too much weight), and a set of rehabilitation outcomes including residualized FIM motor gain, the percentage of patients discharged to community, and the percentage of patients reporting "quite a lot" or "completely" prepared to manage their care at discharge from SNF-based rehabilitation. RESULTS: No quality measures correlated with any rehabilitation outcomes. Residualized FIM motor gain did not correlate with any quality indicators or quality measures. Only 1 quality indicator-prevalence of daily use of restraints (QI 22)-correlated with the rehabilitation indicator community discharge percentage. The third rehabilitation indicator, prepared to manage care at discharge, correlated (negatively) only with QI 18 incidence of decrease in range of motion. Among the rehabilitation outcomes, residualized FIM motor gain correlated significantly with both community discharge percentage and prepared to manage care at discharge. CONCLUSIONS: Patients and referrers choosing SNF-based medical rehabilitation need tools that differentiate among prospective providers from a rehabilitation outcomes perspective. Data in this study indicate that nursing home quality indicators and quality measures are inadequate for this purpose.     

Prevalence of sarcopenia and its association with activities of daily living among japanese nursing home residents

Sarcopenia is an important predictor of adverse outcomes in elderly people. Based on a common clinical experience, sarcopenia may be associated with activities of daily living (ADL). To our knowledge, no study has investigated the association between sarcopenia and ADL in nursing home residents requiring long-term care. This cross-sectional study included 250 nursing home residents. Nutritional status, physical function, ADL and cognitive function were assessed using Mini Nutritional Assessment-Short Form (MNA-SF), Short Physical Performance Battery (SPPB), Barthel Index (BI) and Mini-Mental State Examination (MMSE). To examine the factors that may affect self-care capacity, a stepwise multiple linear regression analysis was performed. The prevalence of sarcopenia was 45.2%. Age, MMSE, MNA-SF, SPPB, and grip strength were independently associated with BI. A high prevalence of sarcopenia was observed among nursing home residents in Japan. However, sarcopenia was not associated with ADL.     

Effect of Life Review on Quality of Life For Older Adults Living in Nursing Homes

Aim: To examine the effects of life review on daily activities, social participation, outlook on life, and perceptions of living in a nursing home measured by life satisfaction and quality of life in older adults. Method: The study design was a two-phase quasi-experimental pre-post-tests including development and testing of a life review protocol. Nine residents, age ≥65, participated in a life review group once weekly for 6 weeks. Outcomes were analyzed using the Life Satisfaction Index-Z (LSI-Z) and pre-post surveys. Results: LSI-Z scores improved post-intervention and survey outcomes indicated participation in activities of daily living (ADLs), socialization, outlook on life, and living in a nursing home perceptions improved for all participants. Conclusion: The study demonstrates the effectiveness of a life review protocol to improve ADLs, social participation, and enhancing perceptions of outlook on life and living in a nursing home enhancing QOL and life satisfaction for older adult nursing home residents.     

Natural history of change in physical function among long-stay nursing home residents

BACKGROUND: Few longitudinal studies exist to guide clinicians or administrators on what functional outcomes can be expected among nursing home residents with different levels of cognitive impairment. Extrapolating from cross-sectional studies or from longitudinal studies of community-dwelling residents may provide misleading estimates of prognosis, hindering efforts to target preventive care. OBJECTIVE: To describe patterns of change in physical function on a quarterly basis over 1 year among long-stay nursing home residents grouped according to their level of cognitive impairment on admission. METHOD: Retrospective analysis of activities of daily living dependence ratings were based on quarterly MDS+ assessments from 76,016 long-stay residents admitted to nursing homes during calendar years 1993 through 1996 in five states participating in the National Case Mix and Quality and Demonstration Project. Residents were stratified by level of cognitive impairment on admission using a 7-level Cognitive Performance Scale. The activities of daily living dependence was measured by a 20 point scale. Mean activities of daily living scores on admission to the hospital and at four quarterly intervals following admission were compared across cognitive impairment levels and by state of residence. RESULTS: A change in activities of daily living dependence over 1 year in most groups averaged 1 point or less. Three patterns of activities of daily living dependence were identified consistently across five states. Those with mild cognitive impairment on admission showed an initial reduction in dependence followed by slow increase; those with moderately severe impairment showed slow linear increased dependence; and those with severe cognitive impairment showed an initial improvement in dependence, followed by stability. CONCLUSION: More complex statistical models that take into account comorbid conditions at baseline, in addition to cognitive performance, might identify subgroups of nursing home residents who are at risk for rapid decline. Ways to better characterize declines in function are needed, otherwise relatively large samples will be required for intervention trials.     

Morbus Parkinson,Morbus Alzheimer und onkologische Erkrankungen in der stationären Altenhilfe

Background

Adequate pain management and palliative care structures are of significant importance in residential nursing homes. Whilst professional pain treatment and palliative care measures are frequently implemented for residents with oncological diseases, this is often not the case for residents with neurological disorders. Such a potential undertreatment is even more challenging when the means of interaction and communication with affected persons are aggravated by impairments in cognitive function.

Objective

To examine differences in selected health care service characteristics between nursing home residents with Parkinson’s disease, Alzheimer’s disease and residents diagnosed with cancer.

Material and methods

Secondary data analysis of residents’ survey and medical record data from 13 nursing homes as part of the study “Action Alliance Pain-free City Münster”.

Results

Compared with residents with Parkinson’s disease and cancer, nursing home residents with Alzheimer’s disease exhibited significantly more severe impairment in cognitive function, less additional pain-associated diagnoses, shorter length of stay in nursing homes and more indications of pain.

Conclusion

The generally high level of pain in all observed residents elucidates the principle necessity of adequate pain assessment and an interprofessional pain treatment. Furthermore, there seems to be a still unmet need for specifically adapted pain management strategies especially for the steadily increasing number of people with Parkinson’s disease and Alzheimer’s disease living in nursing homes. This should be a future high priority task for (nursing) practice and research against the background of the vulnerability of nursing home populations.