Observation of dependent and independent behavior in a German old age home: the social environment as an influencing factor

The present study was an attempt to replicate observational data on dependence vs. independence obtained from American nursing home populations. For a period of three weeks naturally occurring interactions between 39 residents of a nursing home and their social partners were observed daily. The results of the replication study support the findings concerning the interaction patterns demonstrated in the American studies. Dependent behavior of residents in the context of self-care is followed most frequently by dependence-supportive behavior of social partners; independent self-care behavior as well as passive and destructively engaged behavior of residents is followed by "no response" of social partners, while constructively engaged behavior sometimes entails engagement-supportive behavior by social partners. As for the frequency distribution of the observed behavior there is both consistency as well as divergence between the American and Berlin data. These differences are partly the result of culturally linked differences in customs and administrative habits developed in the daily routine of an institution.     

Activity Outcomes for Assisted Living Residents Compared to Nursing Home Residents

Abstract

This study examines and compares activity of residents of assisted living settings and nursing home facilities in Oregon over a one-year period (N= 125 residents at baseline). Residents in assisted living tended to report significantly higher activity when compared to nursing home residents over time, but considerable variability in activity also existed across settings. The philosophy governing assisted living in Oregon, with its emphasis on resident independence, privacy, and normal life styles may have enabled residents to maintain more active affiliations, relationships, and interest, thus promoting role continuity.     

Effects of facility characteristics on departures from assisted living: results from a national study

PURPOSE: Assisted living is an increasingly important residential setting for the frail elderly person. How often and why residents leave such facilities are important issues for consumers, for clinicians advising frail patients on their options for living arrangements, and for policymakers. This research investigated the impact of facility and individual characteristics on residents' departures from assisted living. DESIGN AND METHODS: This research is based on data on 1,483 residents in a nationally representative sample of 278 assisted living facilities (ALFs). Analyses of these data from 1998 and 1999 especially focused on those residents who left a study ALF between baseline and follow-up data collection. Multinomial logit models were estimated to investigate the impact of facility and individual factors on residents' status at follow-up. RESULTS: Over three quarters of those leaving their baseline ALF did so because they needed more care. The multivariate analyses indicated that poorer functional status and being married affected residents' relative odds of death before follow-up. Moving to another setting, other than a nursing home, was more likely for residents in for-profit ALFs. Functional status, cognitive status, and the presence of a full-time RN affected residents' odds of moving from an ALF to a nursing home. IMPLICATIONS: Both facility-level and individual-level factors affected residents' relative odds of leaving an ALF. The findings with the most potentially interesting policy implications are those concerning the factors that affected residents' relative likelihoods of entering a nursing home.     

Families filling the gap: comparing family involvement for assisted living and nursing home residents with dementia

PURPOSE: The purpose of this study was to compare the sociodemographics, self-rated health, and involvement levels of family caregivers of residents with dementia in residential care/assisted living (RC/AL) versus nursing home settings. DESIGN AND METHODS: We conducted telephone interviews with the family caregivers most involved with 353 residents of 34 residential care and 10 nursing home facilities. We measured involvement by caregiver self-report of monthly out-of-pocket spending, involvement and burden ratings, and the frequency of engaging in eight specific care activities. Open-ended questions elicited areas in which caregivers preferred different involvement and ways the facility could facilitate involvement. RESULTS: Nursing home caregivers rated their health poorer than RC/AL caregivers, but there were no sociodemographic differences between the two. RC/AL caregivers rated both their perception of involvement and burden higher and engaged more frequently in monitoring the resident's health, well-being, and finances than did nursing home caregivers, although the reported time spent per week on care did not differ. IMPLICATIONS: RC/AL and nursing home caregivers to residents with dementia may tailor their care to fit the needs of the resident and setting. Results are discussed in relation to the Congruence Model of Person-Environment Fit.     

Coordinating services across the continuum of health,housing, and supportive services

This article describes trends in three areas of state long-term care policy for elderly low-income Medicaid beneficiaries--providing home care services to residents in subsidized housing and assisted living; offering nursing home residents opportunities to relocate to community settings; and integrating acute and long-term care services for beneficiaries who are dually eligible for Medicare and Medicaid. The information was obtained from reports and studies on state policy, site visits, and interviews with state officials. Multiple initiatives responding to consumer preferences and fragmentation of the delivery systems were identified. Key components were consumer demand; the availability of nursing facility alternatives; and state priorities for controlling expenditure growth. States use Medicaid to develop broad service menus that include in-home, community, residential, and institutional services. Several states are conducting demonstration programs that improve coordinating or integration of long-term care with the acute care system.     

The effect of long-term care environments on health outcomes

This study contrasts rates of mortality and of relocation to higher levels of care as well as trajectories of cognitive status, functional ability, depression, and subjective health of residents of an assisted living facility with those of a nursing home. Data were collected from medical records and face-to-face interviews with 158 residents at baseline and 4, 8, and 12 months later. All participants lived on a single long-term care campus. Logistic regression revealed that facility was not a significant predictor of mortality or relocations due to declining health. A repeated measures analysis of variance found that outcomes for people living in the two facilities did not change at different rates. These consistent findings suggest that although the assisted living and nursing home environments claim to have different philosophies of care, health outcome patterns for people living in the two environments were similar.     

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.     

Health and functional outcomes and health care utilization of persons with dementia in residential care and assisted living facilities: comparison with nursing homes

PURPOSE: This study compares health and functional outcomes and health care utilization of persons with dementia residing in residential care/assisted living (RC/AL) facilities and nursing homes. DESIGN AND METHODS: The study uses data from a longitudinal cohort study of 1,252 residents with dementia in 106 RC/AL facilities and 40 nursing homes in four states. RESULTS: Rates of mortality; new or worsening morbidity; and change in activities of daily living, cognition, behavioral problems, depressive symptoms, social function, and withdrawal did not differ between the two settings. However, because of death or transfer, only about one half of the persons with mild dementia and one third of those with moderate to severe dementia remained in RC/AL facilities 1 year after enrollment. In addition, hospitalization rates were greater among individuals with mild dementia in RC/AL facilities, largely because of a medically unstable subgroup with high nursing-home-transfer rates. IMPLICATIONS: Many persons with dementia can be served equally well in either setting; however, those with major medical care needs may benefit from nursing home residence.     

Attitudes, stress, and satisfaction of staff who care for residents with dementia

PURPOSE: Considering the increasing proportion of residents in long-term care who have dementia, and the important influence that direct care providers have on resident quality of life, this study explores the dementia-related attitudes of residential care/assisted living (RC/AL) and nursing home staff, as well as their work stress and satisfaction. DESIGN AND METHODS: Data were derived from interviews with 154 direct care providers from 31 RC/AL facilities and 10 nursing homes who participated in the Collaborative Studies of Long-Term Care. RESULTS: Stress was more often reported by care providers who had been working for 1 to 2 years (compared with longer); in addition, those who had been working for 1 to 2 years were more likely to espouse hopeful or person-centered attitudes than those who had been working for a longer period of time. Also, a person-centered attitude related to satisfaction, and perceived competence in providing dementia care was consistently associated with dementia-sensitive attitudes and job satisfaction. IMPLICATIONS: Attending to the welfare and ongoing training of workers who have demonstrated job commitment may lessen their tendency to become jaded over time or seek job opportunities elsewhere. Further, the attitudes the staff hold related to dementia and the training they receive to provide dementia care are important for their own well-being.     

Special care facility compared with traditional environments for dementia care: a longitudinal study of quality of life

OBJECTIVES: To compare the effect of a specialized care facility (SCF) on quality of life (QoL) for residents with middle- to late-stage dementia over a 1-year period with residence in traditional institutional facilities. DESIGN: A prospective, matched-group design with assessments of QoL every 3 months for 1 year. SETTING: Twenty-four long-term care centers and four designated assisted living environments in an urban center in western Canada. PARTICIPANTS: One hundred eighty-five residents with Global Deterioration Scores of 5 or greater were enrolled: 62 in the intervention SCF group and 123 in the traditional institutional facilities groups. INTERVENTION: The SCF is a 60-bed purpose-built facility with 10 people living in six bungalows. The facility followed an ecologic model of care that is responsive to the unique interplay of each person and the environment. This model encompasses a vision of long-term care that is more comfortable, more like home, and offers more choice, meaningful activity, and privacy than traditional settings. MEASUREMENTS: QoL outcomes were assessed using the Brief Cognitive Rating Scale, Functional Assessment Staging, Cohen-Mansfield Agitation Inventory, Pleasant Events Scale-Alzheimer's disease, Multidimensional Observation Scale of Elderly Subjects, and Apparent Affect Rating Scale. RESULTS: The intervening SCF group demonstrated less decline in activities of daily living, more sustained interest in the environment, and less negative affect than residents in the traditional institutional facilities. There were no differences between groups in concentration, memory, orientation, depression, or social withdrawal. CONCLUSION: The present study suggests that QoL for adults with middle- to late-stage dementia is the same or better in a purpose-built and staffed SCF than in traditional institutional settings.     

Strength training, walking, and social activity improve sleep in nursing home and assisted living residents: randomized controlled trial

OBJECTIVES: To compare the effects of physical resistance strength training and walking (E), individualized social activity (SA), and E and SA (ESA) with a usual care control group on total nocturnal sleep time in nursing home and assisted living residents. DESIGN: Pretest–posttest experimental design with assignment to one of four groups for 7 weeks: E (n=55), SA (n=50), ESA (n=41), and usual care control (n=47). SETTING: Ten nursing homes and three assisted living facilities. PARTICIPANTS: One hundred ninety‐three residents were randomly assigned; 165 completed the study. INTERVENTION: The E group participated in high‐intensity physical resistance strength training 3 days a week and on 2 days walked for up to 45 minutes, the SA group received social activity 1 hour daily 5 days a week, the ESA group received both E and SA, and the control group participated in usual activities provided in the homes. MEASUREMENT: Total nocturnal sleep time was measured using 2 nights of polysomnography before and 2 nights of polysomnography after the intervention. Sleep efficiency (SE), non‐rapid eye movement (NREM) sleep, rapid eye movement sleep, and sleep onset latency were also analyzed. RESULTS: Total nocturnal sleep time was significantly greater in the ESA group than in the control group (adjusted means 364.2 minutes vs 328.9 minutes), as was SE and NREM sleep. CONCLUSION: High‐intensity physical resistance strength training and walking combined with social activity significantly improved sleep in nursing home and assisted living residents. The interventions by themselves did not have significant effects on sleep in this population.     

Prevalence of insomnia and its associated factors in elderly long-term care residents

Insomnia is a significant problem that may jeopardize elderly residents' quality of life in long-term care settings. However, there are only a few studies dealing with sleeping disturbances among nursing home residents. The goal of this study was to determine the prevalence of insomnia and its associated factors in nursing home residents. A cross-sectional study (n=2332) was conducted among seniors living in long-term care facilities. The findings indicate that 144 (6.2%) participants had an insomnia disorder according to DSM-IV criteria, 17% displayed at least one symptom of insomnia, and more that half of the subjects were benzodiazepine users. According to multivariate analysis, psychological distress (adjusted odds ratio=1.51) and disruptive behaviors (adjusted odds ratio=2.10) were the only factors associated with an insomnia disorder among this population. In conclusion, insomnia is a fairly important problem, as a symptom or a syndrome, among elderly people and deserves attention from caregivers. Alternative interventions to benzodiazepine drugs, which are suited to long-term care residents while tailored to these specific care settings, should be developed.     

Family caregiver involvement for long-term care residents at the end of life

Objectives. To examine family caregiver involvement for long-term care (LTC) residents during the last month of life. Researchers examined direct (personal care and meals) and indirect (management and monitoring) types of caregiver involvement and the relationship between the type of involvement and predisposing, enabling, and need characteristics. Researchers also examined whether the frequency of involvement changed during the end-of-life (EOL) period. Method. Researchers used an expanded version of Andersen's Behavioral Model to conceptualize predictors of family involvement for 438 residents in 125 residential care/assisted living and nursing home settings. Bivariate and multivariate analyses examined relationships among variables. RESULTS: More than one-half of family caregivers monitored, managed care and assisted with meals, and 40% assisted with personal care tasks. The enabling characteristic of days visited and the need characteristic of caregiver role strain were related to each of the 4 types of involvement. However, the other correlates were distinct to the type of involvement. Discussion. Families are involved in EOL care in LTC settings. Higher role strain is related to more involvement in each of the 4 types of involvement, suggesting that whether involvement is by desire, perceived need, or both, there is cause to more critically examine the family caregiver's desired role and need for support.     

A comparison of three methods of measuring dementia-specific quality of life: perspectives of residents, staff, and observers

PURPOSE: This exploratory study compared three methods of assessing dementia specific quality of life, corresponding to the perspectives of residents, staff members, and trained observers. DESIGN AND METHODS: We collected data on 172 residents with dementia in four special care nursing facilities and three assisted living facilities. Analyses assessed the relationship of each quality-of-life method or perspective to the others and to resident characteristics such as cognitive and functional status. RESULTS: The relationship of staff quality-of-life measures to resident characteristics varied by care setting while no significant relationships were found for resident quality-of-life measures. Staff and observational measures were moderately correlated in both settings. Moderate correlations of resident measures with staff and observational measures were found in the assisted living sample. IMPLICATIONS: Each perspective is relatively independent and somewhat unique. Measures that focus on specific aspects of quality of life may be more appropriate to use with assisted living residents than with residents of special care facilities.     

Consumer satisfaction in long-term care: state initiatives in nursing homes and assisted living facilities

PURPOSE: We report the results of a survey of state initiatives that measure resident satisfaction in nursing homes and assisted living facilities, and we describe several model programs for legislators and public administrators contemplating the initiation of their own state programs. DESIGN AND METHODS: Data on state initiatives and programs were collected during March and April 2000 through a mailed questionnaire and follow-up telephone interviews and were current as of September 2002. RESULTS: Of the 50 states surveyed, 50 responses were received (response rate = 100%); 12 states (24%) reported the use of consumer satisfaction measures, and 7 (Florida, Iowa, Ohio, Oregon, Texas, Vermont, and Wisconsin) reported using resident satisfaction data within their consumer information systems for nursing homes or assisted living facilities. Additionally, 2 states (Iowa and Wisconsin) use resident satisfaction data for facility licensing and recertification. The design of the instruments and collection methods vary in these states, as do the reported response rates, per-resident cost, and the purpose for satisfaction data collection. IMPLICATIONS: State satisfaction efforts are in an early stage of development. Well-produced, easily understandable reports on nursing home and assisted living quality could provide information and guidance for patients and families contemplating the utilization of long-term care services. Dissemination of quality information may also facilitate sustained quality and efficiency improvements in long-term care facilities and thus enhance the quality of care for and quality of life of long-term care residents.     

The effect of a social work intervention to enhance advance care planning documentation in the nursing home

OBJECTIVES: To assess the effect of a multicomponent advance care planning intervention directed at nursing home social workers on identification and documentation of preferences for medical treatments and on patient outcomes. DESIGN: Controlled clinical trial. SETTING: New York City nursing home. PARTICIPANTS: One hundred thirty-nine newly admitted long-term care residents. INTERVENTION: Nursing home social workers were randomized to the intervention or control groups. The intervention consisted of baseline education in advance care planning that incorporated small-group workshops and role play/practice sessions for intervention social workers; structured advance care planning discussions with residents and their proxies at admission, after any change in clinical status, and at yearly intervals; formal structured review of residents' goals of care at preexisting regular team meetings; "flagging" of advance directives on nursing home charts; and feedback to individual healthcare providers of the congruence of care they provided and the preferences specified in the advance care planning process. Control social workers received an educational training session on New York State law regarding advance directives but no additional training or interventions. Subjects were enrolled from January 9, 2001 through May 25, 2003 and followed for 6 months after enrollment. MEASUREMENTS: Nursing home chart documentation of advance directives (healthcare proxies, living wills) and do-not-resuscitate orders; preferences for artificial nutrition and hydration, intravenous antibiotics, and hospitalization; and concordance of treatments received with documented preferences were compared for residents assigned to intervention and control social workers. RESULTS: Intervention residents were significantly more likely than residents in the control group to have their preferences regarding cardiopulmonary resuscitation (40% vs 20%, P=.005), artificial nutrition and hydration (47% vs 9%, P<.01), intravenous antibiotics (44% vs 9%, P<.01), and hospitalization (49% vs 16%, P<.01) documented in the nursing home chart. Control residents were significantly more likely than intervention residents to receive treatments discordant with their prior stated wishes. Two of 49 (5%) intervention residents received a treatment in conflict with their prior stated wishes (one hospitalization, one episode of intravenous antibiotics), compared with 17 of 96 (18%) control patients (P=.04). CONCLUSION: This generalizable intervention directed at nursing home social workers significantly improved the documentation and identification of patients' wishes regarding common life-sustaining treatments and resulted in a higher concordance between patients' prior stated wishes and treatments received.     

Assessing life expectancies of institutionalized older persons in Hong Kong

BACKGROUND: In Hong Kong, it has been projected that, by the year 2010, there will be 0.86 million persons aged 65 or older. The demand for residential care places continues to rise. Information on the survival of older persons will allow better management of care in institutional settings. OBJECTIVE: The Weibull model was developed to predict the 18-month survival of a group of Chinese nursing home residents. METHODS: In this prospective cohort study, 590 older residents from four nursing homes with different levels of care were enrolled. The main outcome measure was survival at 18 months. Information on subject demographics, clinical data and disability levels as measured by the Patient Assessment Instrument (PAI) was collected at baseline. Life expectancies were derived from accelerated failure time models. RESULTS: Independent predictors of decreased survival derived from the Weibull model included increased age, male gender, diagnosis of cancer, presence of malnutrition and functional dependence. Significant interaction was observed between male gender and PAI score. The goodness of fit of the model was satisfactory. CONCLUSIONS: From this study, the model for predicting life expectancy in nursing home residents can assist policy makers in planning long-term care. It can also guide clinicians to make more appropriate management decisions for their older patients.     

Potential cost savings in residential care for Alzheimer's disease patients.

Data from a 1996 cross-sectional study examining the costs of care for Alzheimer's Disease patients are used to estimate the potential cost savings that could result by substituting assisted living for nursing home care for AD residents with health profiles that appear to be manageable within assisted living facilities that specialize in dementia care. Results indicate that up to 13.9% of nursing home costs could be saved, making such a service substitution an attractive alternative in the provision of residential care for certain categories of AD patients.