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.     

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.     

Cognitive impairment. Can it predict the course of hospitalized patients?

All patients admitted to three medical services at the New York Hospital during a one-month period were screened with Folstein's Mini-Mental State Examination. The prevalence of cognitive impairment was 19.8% (23 of 116). Cognitively "impaired" patients, ie, those with a Folstein score less than 24, were older, sicker, and less physiologically stable than the cognitively "intact." The in-hospital mortality (17 versus 5%) and morbidity (39 versus 18%) rates were higher for the cognitively "impaired" patients; these differences could be explained by the greater severity of illness, instability, and comorbidity found in these patients. Cognitively "impaired" patients were particularly susceptible to respiratory complications. Cognitively "impaired" patients had longer lengths of hospital stay, spent more time in hospital awaiting placement, and were more likely to be discharged to a nursing home or require home assistance than their cognitively "intact" counterparts. Three-month mortality rates were also higher for the cognitively "impaired" patients (30 versus 15%). These findings suggest that cognitive impairment on admission may be regarded as a marker for patients with poorer prognoses.     

Pain Assessment in Persons with Dementia: Relationship Between Self-Report and Behavioral Observation

OBJECTIVES: To investigate the relationship between self-report and behavioral indicators of pain in cognitively impaired and intact older adults.
DESIGN: Quasi-experimental, correlational study of older adults.
SETTING: Data were collected from residents of nursing homes, assisted living, and retirement apartments in north-central Florida.
PARTICIPANTS: One hundred twenty-six adults, mean age 83; 64 cognitively intact, 62 cognitively impaired.
MEASUREMENTS: Pain interviews (pain presence, intensity, locations, duration), pain behavior measure, Mini-Mental State Examination, analgesic medications, and demographic characteristics. Participants completed an activity-based protocol to induce pain.
RESULTS: Eighty-six percent self-reported regular pain. Controlling for analgesics, cognitively impaired participants reported less pain than cognitively intact participants after movement but not at rest. Behavioral pain indicators did not differ between cognitively intact and impaired participants. Total number of pain behaviors was significantly related to self-reported pain intensity (β=0.40, P =.000) in cognitively intact elderly people.
CONCLUSION: Cognitively impaired elderly people self-report less pain than cognitively intact elderly people, independent of analgesics, but only when assessed after movement. Behavioral pain indicators do not differ between the groups. The relationship between self-report and pain behaviors supports the validity of behavioral assessments in this population. These findings support the use of multidimensional pain assessment in persons with dementia.     

Do impaired older persons with health care needs occupy U.S. assisted living facilities? An analysis of six national studies

OBJECTIVES: The assisted living facility (ALF) is the fastest-growing noninstitutional long-term care alternative for frail older persons in the United States. This analysis assesses the extent to which older persons with physical and cognitive disabilities and health care needs occupy ALFs in the United States. METHODS: Information on study design and six indicators of the occupancy patterns of older persons in ALFs were abstracted from six national studies. The collected data were based on reports by the administrators of ALFs. RESULTS: The six reviewed studies had several methodologic weaknesses, resulting in different statistical populations of ALFs, samples with very different numerical and attribute properties, and findings based on disparate indicators. The older residents in ALFs were less physically and cognitively impaired than those in nursing homes. ALF facilities were more likely to admit or retain frail older persons when they had relatively minor or less serious physical or cognitive impairment or health care needs. DISCUSSION: ALFs are currently serving older residents who require less nursing care and who are less functionally and cognitively impaired than those found in nursing homes. The more restrictive admitting and discharge criteria of a substantial share of ALFs guarantee their less frail occupant profile. This is, however, an extraordinarily diverse shelter and care alternative, and very frail older persons with serious chronic health problems can be found in ALFs. Average duration of stays may be as long as 3 years. Researchers must conduct more carefully executed studies with replicable methodologies that produce unbiased and generalized findings.     

Hospitalization of nursing home residents with cognitive impairments: the influence of organizational features and state policies

PURPOSE: The purpose of this study was to quantify the effect of specific nursing home features and state Medicaid policies on the risk of hospitalization among cognitively impaired nursing home residents. DESIGN AND METHODS: We used multilevel logistic regression to estimate the odds of hospitalization among long-stay (>90 days) nursing home residents against the odds of remaining in the nursing home over a 5-month period, controlling for covariates at the resident, nursing home, and county level. We stratified analyses by resident diagnosis of dementia. RESULTS: Of 359,474 cognitively impaired residents, 49% had a diagnosis of dementia. Of those, 16% were hospitalized. The probability of hospitalization was negatively associated with the presence of a dementia special care unit (adjusted odds ratio [AOR] = 0.90, 95% confidence interval [CI] = 0.86-0.94) and with a high prevalence of dementia in the nursing home (AOR = 0.96, 95% CI = 0.88-1.03). Higher Medicaid payment rates were associated with reduced likelihood of hospitalization (AOR = 0.95, 95% CI = 0.90-1.00), whereas any bed-hold policy substantially increased that likelihood (AOR = 1.44, 95% CI = 1.12-1.86). We observed similar results for residents without a dementia diagnosis. IMPLICATIONS: Directed management of chronic conditions, as indicated by facilities' investment in special care units, reduces the risk of hospitalization, but the effect of bed-hold policies illustrates how fragmentation in the financing system impedes these efforts.     

Decision making by and for nursing home residents. A legal view

The law is concerned with a panoply of issues affecting the care and lives of nursing home residents. This article has outlined one area, that of decision making, which in many respects is the embodiment of and key to all other fundamental resident rights. The doctrine of informed consent applies with full force in the nursing home, both for mentally competent residents and for cognitively impaired residents for whom decision making rights must be exercised through a proxy. Long-term care institutions and professionals are obligated to insure that decisions made by or for residents are made voluntarily, competently, and knowingly.     

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.     

Symptom experience of dying long-term care residents

OBJECTIVES: To describe the end-of-life symptoms of nursing home (NH) and residential care/assisted living (RC/AL) residents, compare staff and family symptom ratings, and compare how staff assess pain and dyspnea for cognitively impaired and cognitively intact residents.
DESIGN: After-death interviews.
SETTING: Stratified random sample of 230 long-term care facilities in four states.
PARTICIPANTS: Staff (n=674) and family (n=446) caregivers for dying residents.
MEASUREMENTS: Interview items measured frequency and severity of physical symptoms, effectiveness of treatment, recommendations to improve care, and staff report of assessment.
RESULTS: Decedents' median age was 85, 89% were white, and 77% were cognitively impaired. In their last month of life, 47% had pain, 48% dyspnea, 90% problems with cleanliness, and 72% symptoms affecting intake. Problems with cleanliness, intake, and overall symptom burden were worse for decedents in NHs than for those in RC/AL. Treatment for pain and dyspnea was rated very effective for only half of decedents. For a subset of residents with both staff and family interviews (n=331), overall ratings of care were similar, although agreement in paired analyses was modest (kappa=−0.043–0.425). Staff relied on nonverbal expressions to assess dyspnea but not pain. Both groups of caregivers recommended improved application of treatment and increased staffing to improve care.
CONCLUSION: In NHs and RC/AL, dying residents have high rates of physical symptoms and need for more-effective palliation of symptoms near the end of life.     

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.     

Pain in the nursing home.

The treatment of pain in the nursing home setting continues to present several unique and challenging problems. Increasingly, studies are focusing on the large number of elderly with important pain problems in long-term care. The inclusion of pain as an area of clinical focus in the Minimum Data Set has fueled interest in this problem and will provide solid data for future study. Researchers are attempting to establish reliable and valid data using standardized assessment tools previously validated in younger adults and are attempting use of traditional and cutting-edge assessment tools in cognitively impaired patients. Assessment is being linked to innovative interventions in noncommunicative, cognitively impaired residents using primary care nurses who best know these patients to decipher "normal" from "abnormal" behavior. The application of available pharmacologic interventions are more challenging because of the higher incidence of side effects in the elderly; part of this problem is the result of the decreased hepatic metabolism and renal clearance present in older patients. The nursing home environment has limited resources that can create logistical concerns in terms of diagnosis and treatment but also can positively limit overly invasive modalities. This article explores these issues and offers suggestions for the appropriate assessment and management of pain in long-term care residents.     

Value-added outcomes: the use of advanced practice nurses in long-term care facilities

The purpose of this study was to determine the effect on clinical outcomes for newly admitted nursing home residents when advanced practice gerontological nurses (APNs) worked with staff to implement scientifically based protocols for incontinence, pressure ulcers, depression, and aggressive behavior. Use of APNs in this manner differs from the usual way APNs have been used in nursing homes, in which their primary focus has been to augment the physician's role. The APN treatment was randomly assigned to two nursing homes and usual care was assigned to a third. Trajectories from admission to 6 months revealed that residents with APN input into their care (n = 86) experienced significantly greater improvement or less decline in incontinence, pressure ulcers, and aggressive behavior, and they had higher mean composite trajectory scores compared with residents receiving usual care (n = 111). Significantly less deterioration in affect was noted in cognitively impaired residents in the treatment group. Findings suggest that APNs can be effective links between current scientific knowledge about clinical problems and nursing home staff.     

Correlates and management of nonmalignant pain in the nursing home. SAGE Study Group. Systematic Assessment of Geriatric drug use via Epidemiology.

OBJECTIVE: Nonmalignant pain is a common problem among older people. The prevalence of pain in the nursing home is not well studied. We looked at the association between nonmalignant pain, psychological and functional health, and the practice patterns for pain management in the nursing home. DESIGN: A cross-sectional study. SETTING: Nursing Home in four US states. PARTICIPANTS: A total of 49,971 nursing home residents from 1992 to 1995. MEASUREMENTS: We used the SAGE database (Systematic Assessment of Geriatric drug use via Epidemiology), which linked information from the Minimum Data Set and nursing home drug utilization data. The MDS items measured included pain, activities of daily living (ADL) function, mood, and time involved in activities. The use of analgesics, anxiolytics, and antidepressants was also documented. RESULTS: Daily pain was reported in 26% of nursing home residents. The prevalence was lower among men, persons more than age 85, and racial minorities. Persons suffering pain daily were more likely to have severe ADL impairment, odds ratio (OR) (2.47 (95% CI, 2.34-2.60)), more depressive signs and symptoms (OR 1.66 (95% CI, 1.57-1.75)), and less frequent involvement in activities (OR 1.35 (95% CI, 1.29-1.40)). Approximately 25% of persons with daily pain received no analgesics. Residents who were more than 85 years old (OR 1.15 (95% CI 1.02-1.28)), cognitively impaired, (OR 1.44 (95% CI, 1.29-1.61)), of male gender (OR 1.17 (95% CI, 1.06-1.29)), or a racial minority (OR 1.69 (95% CI, 1.40-2.05) and OR 1.56 (95% CI, 0.70-1.04) for blacks and Hispanics, respectively) were at greater risk of not receiving analgesics. Approximately 50% of those in pain used physical and occupational therapies, which was more than two times higher (OR 2.44 (95% CI, 2.34-2.54)), than use for those not in pain. CONCLUSIONS: Daily nonmalignant pain is prevalent among nursing home residents and is often associated with impairments in ADL, mood, and decreased activity involvement. Even when pain was recognized, men, racial minorities, and cognitively impaired residents were at increased risk for undertreatment. More education and research is necessary to improve the recognition and management of pain in the nursing home, remembering that attention should be paid to populations at increased risk for underrecognition and undertreatment.     

Predictors of institutionalization of cognitively impaired elders: family help and the timing of placement

Although predictors of nursing home placement have attracted a good deal of attention in gerontological research, the type and amount of family assistance offered to caregivers prior to institutionalization has not been extensively examined. This study analyzed the impact of family help on the timing of placement among cognitively impaired care recipients. Using longitudinal data from the Adult Day Care Collaborative Study, an event-history analysis was performed to determine the effects of family help after sociodemographic characteristics, caregiving stressors, and indicators of caregiver well-being were taken into account. Results showed that caregivers were far less likely to institutionalize their relatives when family members provided overnight help and assisted with activities of daily living care. These findings suggest that specific types of family help play an important role in delaying nursing home placement among older adults suffering from dementia.     

Pain assessment and management in cognitively impaired nursing home residents: association of certified nursing assistant pain report,Minimum Data Set pain report,and analgesic medication use

OBJECTIVES: The primary purpose of this preliminary study was to investigate the associations between certified nursing assistant (CNA) report of pain, Minimum Data Set (MDS) report of pain, and analgesic medication use in cognitively impaired nursing home residents. DESIGN: Correlational study. SETTING: Three nursing homes in the greater Birmingham, Alabama area. PARTICIPANTS: Fifty-seven cognitively impaired nursing home residents with a mean Mini-Mental State Examination (MMSE) score of 11.1. MEASUREMENTS: Pain was assessed using a three-item proxy pain questionnaire (PPQ), developed by the researchers and administered to the residents' primary CNA. MDS and analgesic medication data corresponding with the time of PPQ data collection were gathered from medical records. Cognitive status was measured with the MMSE. RESULTS: The PPQ elicited substantially higher estimates of pain prevalence than the MDS (48% versus 20%), and the PPQ and the MDS were not well correlated (pain frequency: r=.19, P=.18; pain intensity: r=.22, P=.11). The PPQ was also more strongly associated with analgesic medication use than the MDS. Cognitive status was significantly associated with pain report on the PPQ but not on the MDS. Test-retest reliability coefficients for the three items of the PPQ were excellent, ranging from.84 to.87 (P 相似文献   

Cognitive, affective, and behavioral effects of reminiscence group therapy on demented elderly

Twenty-seven demented elderly nursing home residents were given either reminiscence group therapy or supportive group therapy or were assigned to a no-treatment control group. The self-reported level of depression in participants given reminiscence therapy was positively affected compared to participants in the supportive therapy and control groups, but no significant effects were found for cognitive or behavioral functioning. Results are discussed in terms of the issue of the applicability of reminiscence therapy for cognitively impaired persons, the appropriateness of the measures used in this study to assess depression, cognitive ability and behavioral functioning, and in conjunction with clinical observations made during the process of therapy.     

Outcomes of pain in frail older adults with dementia

OBJECTIVES: To describe the outcomes of pain in cognitively impaired older adults in a Program of All-inclusive Care for older people (PACE) setting and to determine whether pain and psychotropic drug use, behavioral disturbances, hospital, nursing facility, and emergency department use, or mortality increases with the level of pain reported. DESIGN: Retrospective review of an observational cohort of patients with dementia. SETTING: A first-generation PACE program located in Portland, Oregon. Patients with the diagnosis of dementia had been assessed for pain in a prior study. PARTICIPANTS: One hundred fifty-four cognitively impaired subjects. MEASUREMENTS: Standardized pain assessments were administered to cognitively impaired subjects between June and October 1998. After the pain assessment, information about mortality and healthcare use, including use of medication, was collected and analyzed. Subjects who reported moderate to severe pain were compared with demented subjects who reported no or mild pain. RESULTS: There were no differences in patient characteristics (age, sex, functional limitations, disruptive behaviors, and incontinence), medications (pain and psychotropic), use (hospital, nursing home, or emergency department visit), or mortality by level of pain alone or by levels of pain and dementia together. CONCLUSIONS: The study did not demonstrate that a single point-in-time measurement of pain in demented persons was associated with an increased rate of behavioral problems, narcotic use, or hospital or emergency department use over the following year. Prospective studies are needed that measure pain over time to determine more accurately the relationship between pain and negative outcomes in dementia.     

Informal caregiver involvement and illness detection among cognitively impaired nursing home residents

BACKGROUND: The participation of informal caregivers in the care of nursing home (NH) residents has the potential to positively impact care, especially for cognitively impaired residents whose own ability to advocate for their care is often limited. This study examined relationships between the level of informal caregiver involvement (ICI) in the NH and the degree to which residents' common medical conditions were detected by facility staff. METHODS: One hundred pairs of cognitively impaired residents and their primary informal caregivers were enrolled from three facilities in the Baltimore, Maryland area. Data collection involved interviews with informal caregivers and facility staff, as well as a medical evaluation and chart review of residents. A measure of illness detection was created by comparing a medical examination of the resident with chart review information. ICI was measured via staff rating and informal caregiver self-report. RESULTS: Correlations between illness detection and ICI were significant, with r = -.46 (p <.001) and r = -.39 (p <.001), for staff rating and self-reports, respectively. In regression models taking into account resident characteristics (age, race, gender, comorbidities, payment status, duration of stay, and cognitive impairment) and facility differences, higher ICI and being female predicted higher rates of illness detection. CONCLUSIONS: Though the cross-sectional nature of the study prevents the analysis of causal relationships, the involvement level of informal caregivers in the NH care of cognitively impaired residents was statistically related to higher rates of illness detection. Ramifications for the role of informal caregivers in long-term care are discussed.     

Social cognition in nursing home residents with and without cognitive impairment

Dementia affects the specific cognitive abilities underlying social functioning in ways that are just beginning to be understood. This pilot study compared the performances of 15 nursing home residents with cognitive impairment and 25 without cognitive impairment on a broad range of measures of social-cognitive functioning. The cognitively impaired group scored significantly lower than the unimpaired group on tests of face processing, person perception, and social reasoning but not on tests of affect recognition and the representation of social situations. Individuals' deficits in working memory and executive function did not fully account for their impaired performance on tests of social cognition. An improved understanding and assessment of the basic cognitive mechanisms underlying the ability of persons with dementia to interact with others would inform the design of interventions to optimize their social functioning.