Journal of American Geriatrics Society

Huizing, Anna R.; Hamers, Jan P. H.; Gulpers, Math J. M.; Berger, Martijn P. F.

doi: 10.1111/j.1532-5415.2009.02309.xpmid: 19558484

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

Givens, Jane L.; Kiely, Dan K.; Carey, Kristen; Mitchell, Susan L.

doi: 10.1111/j.1532-5415.2009.02304.xpmid: 19486200

OBJECTIVES: To describe the medical decisions confronting healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia and to identify factors associated with greater decision‐making satisfaction. DESIGN: Prospective cohort study. SETTING: Twenty‐two Boston‐area NHs. PARTICIPANTS: Three hundred twenty‐three NH residents with advanced dementia and their HCPs. MEASUREMENTS: Decisions made by HCPs over 18 months were ascertained quarterly. After making a decision, HCPs completed the Decision Satisfaction Inventory (DSI) (range 0–100). Independent variables included HCP and resident sociodemographic characteristics, health status, and advance care planning. Multivariable linear regression identified factors associated with higher DSI scores (greater satisfaction). RESULTS: Of 323 HCPs, 123 (38.1%) recalled making at least one medical decision; 232 decisions were made, concerning feeding problems (27.2%), infections (20.7%), pain (12.9%), dyspnea (8.2%), behavior problems (6.9%), hospitalizations (3.9%), cancer (3.0%), and other complications (17.2%). Mean DSI score±standard deviation was 78.4±19.5, indicating high overall satisfaction. NH provider involvement in shared decision‐making was the area of least satisfaction. In adjusted analysis, greater decision‐making satisfaction was associated with the resident living on a special care dementia unit (P=.002), greater resident comfort (P=.004), and the HCP not being the resident's child (P=.02). CONCLUSION: HCPs of NH patients with advanced dementia can most commonly expect to encounter medical decisions relating to feeding problems, infections, and pain. Inadequate support from NH providers is the greatest source of HCP dissatisfaction with decision‐making. Greater resident comfort and care in a special care dementia unit are potentially modifiable factors associated with greater decision‐making satisfaction.

Resnick, Barbara; Gruber‐Baldini, Ann L.; Zimmerman, Sheryl; Galik, Elizabeth; Pretzer‐Aboff, Ingrid; Russ, Karin; Hebel, J. Richard

doi: 10.1111/j.1532-5415.2009.02327.xpmid: 19570158

OBJECTIVES: To test the effectiveness of a restorative care (Res‐Care) intervention on function, muscle strength, contractures, and quality of life of nursing home residents, with secondary aims focused on strengthening self‐efficacy and outcome expectations. DESIGN: A randomized controlled repeated‐measure design was used, and generalized estimating equations were used to evaluate status at baseline and 4 and 12 months after initiation of the Res‐Care intervention. SETTING: Twelve nursing homes in Maryland. PARTICIPANTS: Four hundred eighty‐seven residents consented and were eligible: 256 from treatment sites and 231 from control sites. The majority were female (389, 80.1%) and white (325, 66.8%); 85 (17.4%) were married and the remaining widowed, single, or divorced/separated. Mean age was 83.8 ± 8.2, and mean Mini‐Mental State Examination score was 20.4 ± 5.3. INTERVENTION: Res‐Care was a two‐tiered self‐efficacy‐based intervention focused on motivating nursing assistants and residents to engage in functional and physical activities. MEASUREMENTS: Barthel Index, Tinetti Gait and Balance, grip strength, Dementia Quality‐of‐Life Scale, self‐efficacy, and Outcome Expectations Scales for Function. RESULTS: Significant treatment‐by‐time interactions (P<.05) were found for the Tinetti Mobility Score and its gait and balance subscores and for walking, bathing, and stair climbing. CONCLUSION: The findings provide some evidence for the utility and safety of a Res‐Care intervention in terms of improving function in NH residents.

Morey, Miriam C.; Peterson, Matthew J.; Pieper, Carl F.; Sloane, Richard; Crowley, Gail M.; Cowper, Patricia A.; McConnell, Eleanor S.; Bosworth, Hayden B.; Ekelund, Carola C.; Pearson, Megan P.

doi: 10.1111/j.1532-5415.2009.02301.x

Gorecki, Claudia; Brown, Julia M.; Nelson, E. Andrea; Briggs, Michelle; Schoonhoven, Lisette; Dealey, Carol; Defloor, Tom; Nixon, Jane; Nixon, Jane

doi: 10.1111/j.1532-5415.2009.02307.xpmid: 19486198

OBJECTIVES: To identify the impact of pressure ulcers (PUs) and PU interventions on health‐related quality of life (HRQL). DESIGN: Systematic review and metasynthesis of primary research reporting the impact of PU and PU interventions on HRQL according to direct patient reports. Quality assessment criteria were developed and applied. Data extraction identified findings in the form of direct quotes from patients or questionnaire items and domain results. Combined synthesis of qualitative and quantitative research was performed using content analysis to generate categories and themes from findings. Thirteen electronic databases were searched, and hand searching, cross‐referencing, contact with experts, and an online search was undertaken. No language restrictions were applied. SETTING: Adults with PUs in acute, community, and long‐term care settings across Europe, the United States, Asia, and Australia. PARTICIPANTS: Thirty‐one studies including 2,463 participants with PUs were included in the review. Ages ranged from 17 to 96. RESULTS: The review included 10 qualitative and 21 quantitative studies; 293 findings, 46 categories, and 11 themes emerged. The 11 HRQL themes were physical impact, social impact, psychological effect, PU symptoms, general health, and other impacts of PUs: healthcare professional–client relationships, need for versus effect of interventions, impact on others, financial impact, perceived etiology, and need for knowledge. CONCLUSION: There is evidence that PUs and PU interventions have a significant impact on HRQL and cause substantial burden to patients.

Caterino, Jeffrey M.; Kulchycki, Lara K.; Fischer, Christopher M.; Wolfe, Richard E.; Shapiro, Nathan I.

doi: 10.1111/j.1532-5415.2009.02320.xpmid: 19558478

OBJECTIVES: To identify independent risk factors for death in elderly emergency department (ED) patients admitted for infection and to derive and validate a mortality‐prediction rule for such patients. DESIGN: Prospective cohort study. SETTING: Tertiary hospital ED with 55,000 annual visits. PARTICIPANTS: ED patients aged 65 and older admitted for infection between December 2003 and September 2004 in the derivation cohort and October 2005 and October 2006 in the validation cohort. MEASUREMENTS: Primary outcome: 28‐day in‐hospital mortality. Data were extracted from charts, and multivariate logistic regression were performed to identify independent mortality predictors. A prediction model was constructed and then validated in a second cohort. RESULTS: Nine hundred thirty‐five patients were included in the derivation cohort and 2,015 in the validation cohort. Mortality was 6% in the derivation cohort and 7% in the validation cohort. In the derivation cohort, logistic regression revealed five independent mortality predictors: respiratory compromise (respiratory rate >20 breaths per minute or hypoxemia) (odds ratio (OR)=4.0, 95% confidence interval (CI)=1.7–9.4), tachycardia (heart rate ≥120 betas per minute; OR=3.2, 95% CI=1.6–6.3), cardiovascular failure (systolic blood pressure <90 mmHg despite fluid challenge or lactate ≥4.0; OR=9.0, 95% CI=4.7–17), preexisting terminal illness (OR=5.7, 95% CI=2.2–15), and platelet count less than 150,000/mm3 (OR=2.7, 95% CI=1.3–5.6). Mortality increased with the number of factors: 0.51% for no factors, 3.1% for one factor, 14% for two factors, 47% for three or more risk factors. The c‐statistic was 0.87 for the derivation model and 0.74 for the validation model. Almost 80% of patients in both cohorts were in low‐risk groups (0 or 1 factor). CONCLUSION: A rule derived from five readily available variables predicts mortality in infected elderly ED patients and allows identification of a large low‐risk subgroup.

Wiglesworth, Aileen; Austin, Raciela; Corona, Maria; Schneider, Diana; Liao, Solomon; Gibbs, Lisa; Mosqueda, Laura

doi: 10.1111/j.1532-5415.2009.02330.xpmid: 19558476

OBJECTIVES: To describe bruising as a marker of physical elder abuse. DESIGN: Consenting older adults were examined to document location and size of bruises and assess whether they were inflicted during physical abuse. An expert panel confirmed physical abuse. Findings were compared with results of an earlier study of accidental bruising in older adults. SETTING: Residences of participants. PARTICIPANTS: Sixty‐seven adults aged 65 and older reported to Adult Protective Services (APS) for suspected physical elder abuse. MEASUREMENTS: Age, sex, ethnicity, race, functional status, medical conditions, cognitive status, history of falls, bruise size and location, recall of cause, and responses to Revised Conflicts Tactics Scale and Elder Abuse Inventory. RESULTS: Seventy‐two percent (n=48) of older adults who had been physically abused within 30 days before examination had bruises. The physically abused older adults had significantly larger bruises; more of them knew the cause of their bruises (43 (89.6%) vs 16 (23.5%) of the comparison group); and they were significantly more likely to have bruises on the face, lateral aspect of the right arm and the posterior torso (including back, chest, lumbar, and gluteal regions) than older adults from an earlier study who had not been abused (n=68). CONCLUSION: Bruises that occur as a result of physical elder mistreatment are often large (>5 cm) and on the face, lateral right arm, or posterior torso. Older adults with bruises should be asked about the cause of the bruises to help ascertain whether physical abuse occurred.

Nahin, Richard L.; Pecha, Monica; Welmerink, Diana B.; Sink, Kaycee; DeKosky, Steven T.; Fitzpatrick, Annette L.; Fitzpatrick, Annette L.

doi: 10.1111/j.1532-5415.2009.02329.xpmid: 19515113

OBJECTIVES: To analyze baseline data on concomitant use of prescription drugs and dietary supplements in elderly people from the Ginkgo Evaluation of Memory (GEM) Study, in which information was collected on all drugs and supplements used by participant. DESIGN: Cross‐sectional correlation analysis. SETTING: GEM Study sites in California, Maryland, North Carolina, and Pennsylvania. PARTICIPANTS: Three thousand seventy ambulatory individuals aged 75 and older enrolled between September 2000 and June 2002. MEASUREMENTS: Use of prescription drugs and dietary supplements identified through bottles brought to the clinic. RESULTS: Almost three‐quarters (74.2%) of the cohort combined use of at least one prescription drug and one dietary supplement, with 32.5% using three or more prescription drugs and three or more supplements. The 15 most‐prevalent prescription drugs exhibited substantial concomitant use with dietary supplements, ranging from 77.6% for diuretics to 93.6% for estrogen preparations. Although supplements were taken concomitantly with all classes of prescription drugs, the use of supplements was more likely in individuals using nonsteroidal anti‐inflammatory drugs, thyroid drugs, and estrogens. The use of drugs for diabetes mellitus was negatively associated with the use of supplements, with most of this attributed to low use in those taking multivitamins, glucosamine and chondroitin, and echinacea. CONCLUSION: There is substantial concomitant use of prescription drugs and dietary supplements in elderly people. Further investigations are needed to define the clinical importance of this concomitant use, especially in elderly patients who consume multiple prescription drugs or have experienced an adverse event secondary to their prescription medications.

Avlund, Kirsten; Schultz‐Larsen, Kirsten; Krustrup, Ulla; Christiansen, Niels; Holm‐Pedersen, Poul

doi: 10.1111/j.1532-5415.2009.02328.xpmid: 19558477

OBJECTIVES: To analyze whether inflammatory processes in the periodontium in early old age are related to subsequent mortality during 21 years of follow‐up in a nondisabled 70‐year‐old population. SETTING: Community‐based population in Copenhagen. DESIGN: The study was based on the Glostrup Aging Study of the 1914 population, with baseline in 1984 when the participants were 70 years old and follow‐up 21 years later. PARTICIPANTS: Three hundred thirty‐five dentate men and women participated in the clinical oral health examination. MEASUREMENTS: Severe periodontal inflammation was measured for all teeth present as the number of teeth with inflammation and periodontal pockets 6 mm deep or more. Mortality data were obtained from the Danish Death Register at 21‐year follow‐up. The Cox proportional hazards regression model was used. Covariates were measured at baseline and included number of teeth, caries, sex, education, income, hypertension, diabetes mellitus, osteoarthritis, arteriostenosis, myocardial infarction, comorbidity, fatigue, and ability to brush teeth. RESULTS: The analyses showed that severe periodontal inflammation in at least three teeth at age 70 was marginally related to mortality during 21‐year follow‐up (crude hazard ratio (HR)=1.17, 95% confidence interval (CI)=0.91–1.78). The estimate increased slightly when adjusted for sex, income, fatigue, and smoking (adjusted HR=1.37, 95% CI=0.97–1.92). The estimates were attenuated when adjusted for the specific diseases, especially arteriostenosis and osteoarthritis. CONCLUSION: Inflammation in the periodontium in early old age tends to be associated with mortality in older age.

Hu, Donglei; Pawlikowska, Ludmila; Kanaya, Alka; Hsueh, Wen‐Chi; Colbert, Lisa; Newman, Anne B.; Satterfield, Suzanne; Rosen, Clifford; Cummings, Steven R.; Harris, Tamara B.; Ziv, Elad; Ziv, Elad