Demented Residents Research Articles

Structural model for the relationships between indoor built environment and behaviors of residents with dementia in care and attention homes

Behavioral symptoms such as distress, sleep disturbance and aberrant mobility are common in all types of dementia. Indoor built environment (IBE) of care and attention (C&A) homes should be optimized for the abilities, health and morale of their elderly residents with dementia, to reduce the likelihood of it inducing in residents problematic behaviors with burdensome symptoms. Therefore, it is necessary to investigate the interactions between the IBE and the behavior of the elderly with dementia. This study aims to establish an integrated IBE-Behavior model to uncover these complicated relationships. The daily activities and engagement of 40 residents with dementia were observed and recorded using dementia care mapping. A questionnaire survey of a total of 96 respondents with mild and moderate dementia was conducted in C&A homes. Multiple research methods were applied to develop the integrated IBE-Behavior model, including factor analysis, reliability test, Pearson correlation, multiple regression analysis and structural equation modeling. The model confirmed the following: 1) surprisingly, both factors of the space management component (i.e., distances and privacy) are found to have no impact on the behavioral symptoms of residents with dementia in C&A homes; 2) three IBE factors belonging to building services components – lighting (E4), lifts (E6) and water supply (E7) – influence demented residents’ negative emotion, positive emotion, sleeping disturbance and limited mobility; 3) loneliness is affected by the supporting facilities factor of furniture (E8). Practical recommendations are made, including: automatic adjustment of lighting, anti-scald devices, seats around small tables or in a sociopetal position, etc.

Impact of an awareness of the doctors treating on the decrease of the prescriptions of antipsychotics in the demented residents in Ehpad.

Despite the context of several national warnings, antipsychotics drugs are commonly used to treat behavioural and psychological symptoms in dementia (BPSD). To observe a decrease of antipsychotic drug prescription, in old NH (nursing homes) residents with dementia, after an awareness of their general practitioner. Observational, prospective, multicenter study. The study population corresponds to NH residents with dementia, and antipsychotic drug consumption, in nursing homes volunteered to participate. Awareness-raising is carried out through information documents. The evaluation criteria is the proportion of residents under antipsychotics after sensitization. out of the 30 nursing homes included, 26.7% of the patients were prescribed at least one antipsychotic and 15% were both demented and under antipsychotics. A total of 317 residents with dementia and antipsychotics were included 15% of the total NH population. Psychotropic drug co-prescriptions was very frequent 43.2% also used benzodiazepines, 37.2% anxiolytics and 33.1% antidepressants. Agitation, aggressiveness, opposition to care and wandering were the most commonly BPSD encountered. After a first sensitization, we obtained a 15.5% decrease of antipsychotic prescriptions. A personalized sensitization towards GP allowed a reduction of antipsychotic drugs prescription in NH residents with dementia and BPSD.

Effect of physical and cognitive function by 6 months exercise intervention for demented residents of special nursing home

Background: It is widely known effects of exercise intervention for patients with dementia.

The Utility of Slums as a Screening Tool Among Nursing Home Residents in Poland: First Results.

Introduction The aging of the world population implies challenges in the area of early diagnosis in geriatric psychiatry as well as in general medical practice. Researchers found that the screening tool developed by Saint Louis University detects early cognitive problems, specifically mild cognitive impairments (MCI), missed by other screening tools. Aims To compare the Polish version of SLUMS as a screening instrument with other screening tests mostly used in Poland such as: MMSE or STMS. Methods The cross-sectional descriptive study was conducted. The total sample included 58 nursing home residents with the mean age of 81.74 (± 8.6). According to CDR 32.8% (n=19) of participants fulfill the criteria of dementia, 27.6% (n=16) of MCI and 39.7% (n=23) were considered as healthy. Results The internal consistencies (Crohnbach's a) of the SLUMS test was 0.7031. The average of total SLUMS score were 23.3 in healthy participants, 19.3 in MCI and 13.1 in demented residents. The statistical analysis illustrated that SLUMS differentiate the dementia residents from those considered as MCI (p=0.01), as well as from healthy participant (p=0.0001). Furthermore, it is also useful in conducting the differential diagnosis between MCI and healthy participants (p=0.017), where MMSE does not offer such a possibility (MCI vs healthy, p=0.51) Conclusions It seems that the SLUMS is not just another screening tool that can complement the range of existing cognitive tests in Polish clinical practice. Preliminary statistical analysis demonstrated its superior capabilities in the screening diagnosis compared to most famous test in Poland, MMSE.

EFFICACY OF SPACED RETRIEVAL ONLY COMPARED TO A COMBINATION OF SPACED RETRIEVAL WITH MONTESSORI-BASED ACTIVITIES IN IMPROVING OVEREATING OF RESIDENTS WITH DEMENTIA

Project Description: The aims of this study were to construct spaced retrieval (SR) only and spaced retrieval combined with Montessori-based activities (SR&M) training programs, and then compare the efficacy of both training programs in reducing overeating behavior for residents with dementia. One hundred thirty-five demented residents with overeating behavior were chosen from six dementia special care units and randomly assigned into an Experimental I (EI) group, an Experimental II (EII) and the control group. Forty-four subjects in the EI group were received SR&M training, forty-eight subjects in the EII group were received SR training only, while 43 subjects in the control group were received routine activities. Data were collected at pre-test, post-test, and at post intervention periods of 1, 3, and 6 months. Data was analyzed and long-term effects were compared using GEE. Research findings revealed both SR only and SR&M training could significantly improve overeating behavior and eating habit change of residents with dementia, and caregivers' distress. Moreover, SR&M training had long-term effects notably in improving in the mechanics, attitude and process of eating meals, in BMI results. Both training programs have effects in improving overeating behaviors. In comparison with SR only, SR&M training has better long-term effects. However, it costs more in training time for caregivers. Thus, managers in institutions should decide which training they prefer based on their manpower and budget.

Effect of electric toothbrush on residents' oral hygiene: a randomized clinical trial in nursing homes

A single-blinded, randomized controlled clinical trial was performed to investigate the effect of electric toothbrushes (ET) compared with manual toothbrushes (MT) on residents in nursing homes and to evaluate the caregiver's opinion on ET. A sample of 180 nursing-home residents were given either a new ET or a new MT. Oral examinations were performed to measure dental hygiene, using the Oral Hygiene Index-Simplified (OHI-S). Both groups received the same instructions for use. After 2 months participants were re-examined. Questionnaires were then sent to their caregivers. Participants' mean age was 86.1 ± 7.7 yr, and the mean number of remaining teeth was 20 ± 5.6. No specific intervention effect was found for ET. Both groups showed identical improvements in the OHI-S, from 1.27 ± 0.63 at baseline (the mean value for all participants) to 1.01 ± 0.53 after 2 months. Of 152 caregivers who responded to the questionnaire, the majority evaluated ET to be beneficial and less time-consuming compared with MT, also for demented residents. In a frail population, no difference is found in the effect of ET compared with MT. However, the ET appears to be a useful aid for residents who receive assistance with dental hygiene.

Validation of a Causal Model of Agitation Among Institutionalized Residents With Dementia in Taiwan

The aim of this study was to test a causal model of the predictors of agitation among 405 nursing home residents in Taiwan with varying degrees of cognitive impairment. Chart review and behavioral observations were used to assess residents' physical and psychosocial condition. The final version of the model had a good fit. Cognitive function and depression had direct effects on agitation, and pain and functional ability had indirect effects on agitation via depression. Additionally, cognitive function and pain influenced functional ability directly, which in turn influenced depression and ultimately influenced agitation. The results suggest that effective management of agitation in demented residents requires identifying the needs underlying the behavior rather than directly treating the behavior itself.

Malnutrition in demented care home residents

Introduction.– People with dementia have been identified to be at high riskofmalnutrition, especially if they reside in carehomes. The aim of this studywas to investigate the prevalence and characteristics ofmalnutrition in demented care homepatients longitudinally. Methods.– This study is part of the annual Dutch National Prevalence Measurement of Care Problems conducted by Maastricht University (LPZ).Onpatient level amongstother, demographicdata, (co)morbidity, care dependency and the prevalence aswell as other relevant indicators of nutritional care are measured. The diagnosis of malnutrition is determined by low BMI, undesired weight loss and low nutritional intake. Results.– Seventy-five thousand three hundred and ninety-nine residents (mean age 84) from 670 care home organizations participated over a period of 4 years. Sixty percent of the residents was care dependent and 32,6% suffered from dementia. When discriminating between demented (D) and non-demented (ND) residents, demented residents were overall significantly more care dependent (D 43,2, ND 85,2) P<0.001) and more often malnourished than non-demented residents (D26,7, ND18.0) P<0.001). Looking to the overall care home population and taking into account several care improvement programmes the prevalence of malnutrition shows a gradual but progressive decline over the years, while the malnutrition prevalence in the demented care home population remains rather stable. Conclusions.– That malnutrition prevalence in the demented care home population, despite increasing nutritional attention in daily practice, remains the same over the years, raises the question whether the phenomenon of Alzheimer cachexia should receive renewed scientific attention.

Who Really Benefits From Decreased Hospitalization?

Who Really Benefits From Decreased Hospitalization?

Prevalence and correlates of potentially undetected dementia among residents of institutional care facilities in Ontario, Canada, 2009–2011

This study aims to determine the prevalence of potentially undetected dementia among institutional care facility residents in Ontario, Canada, and to identify factors associated with undetection. We utilized a population-based secondary data analysis approach, pertaining to data from the Canadian Institute for Health Information's Continuing Care Reporting System, 2009-2011. Potentially undetected dementia was defined as having severely impaired cognitive function and requiring extensive assistance on activity of daily living (ADL) but no records of dementia diagnoses. Cognitive function was measured by the Cognitive Performance Scale (CPS), 0 (intact) to 6 (very severe impairment), and ADL by a hierarchy scale, 0 (independent) to 6 (total dependence). Of the 242,957 residents who had no records of dementia diagnoses, 11.6% (n = 28,078) had a CPS score ≥4 (severe impairment or higher) and ADL score ≥3 (required extensive assistance or more). Data from 11,614 demented residents with corresponding CPS and ADL scores were used for comparison. Residents without dementia diagnosis were younger (77 vs. 84 years), more likely to have never married (20% vs. 6%), and have longer admission (4 vs. 2.8 years). The most significant factors for no diagnoses were never married (adjusted odds ratio = 2.1, 95% confidence interval [CI] = 1.91-2.29), admitted to hospital-based facilities (adjusted odds ratio = 1.58, 95% CI = 1.48-1.69), presence of schizophrenia (adjusted odds ratio = 1.43, 95% CI = 1.22-1.69), depression (adjusted odds ratio = 1.23, 95% CI = 1.16-1.29), and diabetes mellitus (adjusted odds ratio = 1.32, 95% CI = 1.26-1.40). A large number of residents who had poor cognitive function and inadequate ADL ability did not have dementia diagnoses on record. Social and comorbid conditions were contributing factors to potentially undetected dementia.

Postural stability and quality of life after guided and self-training among older adults residing in an institutional setting

PurposeTo evaluate whether rehabilitation of muscle force or balance improves postural stability and quality of life (QoL), and whether self-administered training is comparable with guided training among older adults residing in an institutional setting.Patients and methodsA randomized, prospective intervention study was undertaken among 55 elderly patients. Three intervention groups were evaluated: a muscle force training group; a balance and muscle force training group; and a self-administered training group. Each group underwent 1-hour-long training sessions, twice a week, for 3 months. Postural stability was measured at onset, after 3 months, and after 6 months. Time-domain-dependent body sway variables were calculated. The fall rate was evaluated for 3 years. General health related quality of life (HRQoL) was measured with a 15D instrument. Postural stability was used as a primary outcome, with QoL and falls used as secondary outcomes.ResultsMuscle force trainees were able to undertake training, progressing towards more strenuous exercises. In posturography, the number of spiky oscillations was reduced after training, and stationary fields of torque moments of the ankle increased, providing better postural stability in all groups; in particular, the zero crossing rate of weight signal and the number of low variability episodes in the stabilogram were improved after training. While no difference was found between different training groups in posturography outcomes, a reduction of fall rate was significant in only the guided training groups. A significant part of the variability of the QoL could be explained by the posturography outcome (46%). However, the outcome of training was associated with a reduced QoL.ConclusionEven moderate or severely demented residents could do exercises in five-person groups under the supervision of a physiotherapist. An improvement in postural stability was observed in all training groups, indicating that even self-administered training could be beneficial. Posturography outcome indicated that training alters the postural strategy by reducing the oscillatory fluctuations of body sway signal. However, only guided training tended to reduce falls. Short training intervention programs may decrease QoL by changing the elderly’s daily routine and making it more active and exhausting.

Rates, variability, and associated factors of polypharmacy in nursing home patients

ObjectivesTo determine the rate and variability of polypharmacy in nursing home (NH) residents and investigate its relationship to age, sex, functional status, length of stay, and comorbidities.MethodsWe conducted a cross sectional, multicenter study that included six nursing homes. Demographic, clinical characteristics, Charlson comorbidity index (CCI), the number and classes of chronic medications, rate of polypharmacy >5 drugs (per day) and polypharmacy >7 drugs (per day) were recorded.ResultsNine hundred and ninety-three residents were included; 750 (75.5%) fully dependent residents and 243 (24.5%) mobile demented residents requiring institutional care. The mean age was 85.04±7.55 (65–108) years. The mean rates of polypharmacy >5 drugs and polypharmacy >7 drugs were 42.6% and 18.6%, respectively. Differences in polypharmacy >5 drugs and polypharmacy >7 drugs were observed in NHs 24.7%–56% and 4.9%–30.4%, respectively (P<0.001). Mean number of chronic drugs per resident was 5.14±2.60 from 3.81±2.24 to 5.95±2.73 (P<0.001). No differences in polypharmacy were found between sex and fully dependent versus mobile demented residents. The most common medications taken were for gastrointestinal, neurological, and cardiovascular disorders. Regression analysis revealed four independent variables for polypharmacy >5 drugs: groups aged 75–84 and >85 relative to 65–74, odds ratio (OR) 0.46 (95% confidence interval [CI] 0.27–0.78) P=0.004, OR 0.35 (95% confidence interval 0.19–0.53), respectively, P<0.001; length of stay >2 years, OR 0.51 (95% CI 0.36–0.73) P<0.001; CCI, OR 1.58 (95% CI 1.42–1.75) P<0.001; and feeding tube versus normal feeding, OR 0.27 (95% CI 0.12–0.60) P=0.001.ConclusionRates of polypharmacy in NHs are high with significant variability. Variability rates of polypharmacy, distinct residents’ characteristics, and excessive use of certain drug groups may indicate that a decrease in medication is potentially feasible.

Potential benefits of reducing medication‐related anticholinergic burden for demented older adults: A prospective cohort study

Medication-related anticholinergic burden is a quality indicator for geriatric pharmacotherapy; however, little is known regarding the benefits of reducing anticholinergic burden for demented patients Demented residents in a Veteran Home were enrolled for this study and an educational program was held for primary care physicians providing services at the Veterans Home. Residents were assigned to the intervention group if the primary care team could adhere to the research protocol and the remaining residents were assigned to the reference group receiving conventional care. Anticholinergic burden was estimated by Clinician-Rated Anticholinergic Score (CR-ACHS). Healthcare outcomes; for example, hospitalizations, mortality, cognitive and physical function, were compared between groups. Overall, 53 of the 67 demented residents (mean age 83.4 ± 4.4 years) completed this study. Anticholinergic exposure was found in 38 participants (56.7%) at baseline, in which antipsychotics (n=29, 76.3%) and antidepressants (n=19, 50%) were the most common agents. Compared with participants in the reference group, CR-ACHS was significantly reduced in the intervention group at 12-week follow up (intervention group vs reference group=0.5 ± 1.1 vs 1.1 ± 1.3, P=0.021), whereas the mean Mini-Mental State Examination and Barthel Index were similar between groups. In contrast, no clinical complication was observed regarding medication adjustments during the study period. Anticholinergic burden can be successfully and safely reduced through an educational program for primary care physicians, but the benefit of reducing anticholinergic burden remained unclear within the first 12 weeks. Further investigation is required to evaluate the long-term benefits of reducing anticholinergic burden for demented older adults.

Psychotropic Drug Consumption at Admission and Discharge of Nursing Home Residents

To quantify transitions of residents into or out of nursing homes (NHs) and to describe psychotropic drug prescription at admission and discharge and with regard to dementia diagnosis. A descriptive, cross-sectional, noninterventional study. The setting included 300 NH in France. Participants included 2231 NH residents. Participants reported the number, origin, and destination of residents transiting into or out of the NH in the previous 3 months and provided information on NH characteristics. For eight residents admitted or discharged by the NH, information was collected on medical characteristics, including psychotropic and antidementia drug prescription, and dementia status. The mean number of beds in participating NHs was 85.9 ± 33.2 (mean occupation rate = 96.6%). The mean number of admissions and discharges in the previous 3 months was 13.7 ± 8.5 and 11.2 ± 4.3, respectively. Most admissions (direct admission 3.2 ± 3.3 or readmission 6.4 ± 6.0) and discharges (4.4 ± 6.7) were from and to the hospital. Of the 2231 residents included, 1005 (45.0%) were diagnosed with dementia. At least one psychotropic drug (antidepressant, hypnotic, antipsychotic, or anxiolytic) was prescribed to 70.7% of residents and in particular an antipsychotic to 19.1% of residents. Psychotropic drugs, and in particular antipsychotic drugs, were significantly more prescribed to demented residents than to nondemented residents (76.2% vs 64.3% and 28.0% vs 11.8%, respectively). The extent of prescription (at least one psychotropic drug) was similar in residents admitted to (70.2%) and discharged from (67.5%) the NHs. Antidementia drugs (acetylcholinesterase inhibitors or NMDA receptor antagonists) were prescribed to 53.7% of demented residents. Movement of residents into and out of NHs and especially from and to the hospital is extensive and the prescription rate for psychotropic drugs is very high in this population, especially in residents with dementia. Multiple groups of health care providers should be targeted by educational measures to improve the quality of care for NH residents.

Effects of Depressive Syndromes on the Everyday Competence of Nursing Home Residents with Dementia

Depression in dementia is very common and has significant effects on the functional impairment of nursing-home residents. This study assesses depression, depression diagnosis, cognitive status, status of medication and functional status in 138 residents. Results: (1) 34.1% of the demented residents had a depressive symptomatology. (2) No diagnosis of “depression” was documented for a high percentage of depressed residents. (3) No correlation between depressive symptoms and treatment with antidepressants was present. (4) There was no correlation between the stage of dementia and the rate of depression. (5) There were significant differences in the everyday competence between depressive and nondepressive residents with dementia. The data suggest the need for an adequate diagnosis and treatment of depressive residents with dementia and underlines the need for improvement in care and treatment in primary care and nursing homes.

Patterns of Dementia Treatment Use in Assisted Living Facilities: A Cross-Sectional Study of 1975 Demented Residents

To report the associated factors with the nonuse of cholinesterase-inhibitors and memantine in residents from assisted living (AL) facilities suffering from dementia. A cross-sectional study. The "Réseau de Recherche en Etablissement d'Hébergement pour Personnes Agées" (REHPA) network composed of 236 AL facilities in France. 4896 residents randomly selected by birth date. A structured questionnaire was completed for each resident by the geriatricians of each AL facility. Demographics, medical history (including diagnosis of dementia), drugs (including specific dementia treatments), functional status and behavioral disturbances were collected. Multivariate linear regression analyses were performed. Among the 1975 suffering from dementia, 49.1% were not specifically treated. The independent associated factors to the nonuse of dementia treatment were an institutional length of stay longer than 3 years (OR = 1.62; 95% CI: 1.31-2.02), a transfer from a hospital (OR = 1.68; 95% CI: 1.33-2.11) or another institution (OR = 2.06; 95% CI: 1.45-2.93) before admission, being diagnosed by a specialist other than neurologist (GP: OR = 3.90; 95% CI: 2.58-5.89) (psychiatrist: OR = 1.88; 95% CI: 1.26-2.81) (geriatrician: OR = 1.42; 95% CI:1.08-1.87), a concomitant antipsychotic treatment (OR = 1.44; 95% CI: 1.13-1.82), the absence of behavioral disturbances (OR = 1.51; 95% CI: 1.14-2.01), and a higher degree of disability (OR = 2.16; 95% CI: 1.59-2.92). Nearly half of the dementia-affected residents were not specifically treated. The independent associated factors that have been identified in the study might bring light on the particular issues of dementia treatments in AL facilities.

The introduction of a nursing guideline on depression at psychogeriatric nursing home wards: Effects on Certified Nurse Assistants

Background To improve care for residents with depression in dementia, an evidence based nursing guideline was developed. Using the guideline has already shown positive effects on depression in psychogeriatric nursing home residents. Objective To study the effects of the introduction of the nursing guideline ‘depression in dementia’ on perceived professional autonomy, workload and feelings of powerlessness and confidence in Certified Nurse Assistants. Design A multi-center controlled intervention study with randomization at ward level, using pre-test, post-test and follow-up measurements. Setting 18 psychogeriatric wards in 9 Dutch nursing homes. Participants : 193 Certified Nurse Assistants working on psychogeriatric nursing home wards for at least 20 h per week. Methods An evidence based guideline for nursing teams of psychogeriatric nursing home wards was introduced on nine experimental wards to reduce depression in residents diagnosed with depression in dementia. The guideline introduction consisted of team training and the installation of a promotion group. The nine control wards continued providing usual care. Primary outcomes are: (1) perceived professional autonomy and (2) experienced workload in Certified Nurse Assistants measured with the VBBA subscales ‘autonomy’ and ‘pace and amount of work’. Secondary outcomes are perceived powerlessness and confidence in caring for depressed and demented residents, using two self-developed scales. Results The guideline introduction had a small, significant, positive effect on generally perceived professional autonomy in the Certified Nurse Assistants of the experimental wards. No short-term effects were found on generally experienced workload, or on confidence and powerlessness in caring for depressed residents with dementia. Conclusion The introduction of the nursing guideline ‘depression in dementia’ has small, positive effects on perceived professional autonomy among the Certified Nurse Assistants. Long-term effects on experienced workload should be studied.

Depression in Dutch homes for the elderly: under‐diagnosis in demented residents?

Although community-based studies reported an increased incidence of depression among demented persons compared with non-demented persons, it is not clear whether this relationship also exists among institutionalised elderly persons. The aim of this study was to compare the prevalence of diagnosed depressive disorders and mood symptoms between demented and non-demented residents living in Dutch homes for the elderly. Cross-sectional analysis in 16 homes for the elderly of routine outcome measurements by trained nurse assistants using the Resident Assessment Instrument (RAI) between January 2007 and April 2008. Nurse assistants recorded all known medical diagnoses including dementia and depression, as well as a structured observation of the presence or absence of 11 mood symptoms over the last 3 days. 313 demented and 463 non-demented residents with complete data were included (99% of all residents, mean age 84 years). 24.6% of participants were diagnosed with a depressive disorder, with no statistically significant difference between demented and non-demented persons (p = 0.237). Mood symptoms were more prevalent in demented residents (p < 0.001, OR 2.14, 95%CI 1.56-2.93). Among residents with mood symptoms, demented residents were less likely to be diagnosed with a depressive disorder than non-demented residents (p = 0.039, OR 0.61, 95%CI 0.38-0.98). The prevalence of diagnosed depressive disorders was comparable between demented and non-demented residents. However, demented residents suffered more from mood symptoms and may be at risk of under-diagnosis of depression.

S1211 Dyssynergia, Laxatives and Stool Softeners - Factors That Predispose Demented or Immobile Nursing Home Residents with Impaired Anorectal Function to the Development of Diaper-Dependent Fecal Incontinence

S1211 Dyssynergia, Laxatives and Stool Softeners - Factors That Predispose Demented or Immobile Nursing Home Residents with Impaired Anorectal Function to the Development of Diaper-Dependent Fecal Incontinence

Proxy screening tools improve the recognition of dementia in old-age homes: results of a validation study

Despite the high true prevalence of dementia, demential disorders of residents of old age homes may often be not recognized. There is a need for a standardised tool which includes observations of nursing staff. To describe and validate the Dementia Screening Scale (DSS) for use by nursing staff in old-age homes. All residents of 20 randomly selected old age homes in the city of Mannheim, Germany (n = 1, 922) were rated by nurses using the seven-item proxy dementia rating scale. Based on a subset of residents (n = 598) the DSS was validated against independent diagnostic assessments made by trained psychologists including the Mini-Mental-State-Examination (MMSE), the Dementia Scale of the Brief Assessment Schedule (BAS DEM), and the Washington University Clinical Dementia Rating (CDR). Using the CDR as a gold standard, the DSS correctly classified at a cut-off of 2/3, 85.8% of the mildly, moderately, or severely demented residents. The accuracy of the DSS was only a little worse than that of the MMSE and the BAS DEM. The DSS is well-suited for the recognition of dementia in old age homes. It achieved a better validity than global diagnosis-related staff assessments and compared to performance-based instruments. It is easier to apply, more economic, and associated with a fewer rate of non-response.