Hebrew Rehabilitation Center Research Articles

Trauma-Informed Care Takes Center Stage in Ongoing Pandemic

Trauma-Informed Care Takes Center Stage in Ongoing Pandemic

The ACTIVE Study

In response to data indicating that persons over age 65 account for almost half of all days of care in short stay hospitals (Graves & Kozak, 1999), constitute the majority of residents of nursing homes (Strahan, 1997), and account for over 75% of required formal home-based care supports (Levit et al., 1997; Office, 1996), the National Institute on Aging and the National Institute for Nursing Research funded an initiative to test the effectiveness of cognitive interventions in maintaining cognitive health and functional independence in older adults. This initiative was based on evidence that the cognitive performance of older adults can be improved through systematic training focused on cognitive skills (Baltes, Kuhl, Gutzmann, & Sowarka, 1995; Caprio-Prevette & Fry, 1996; Hayslip, Maloy, & Kohl, 1995; Kramer, Larish, & Strayer, 2002; Mohs et al., 1998; Neely & Backman, 1995; Noice, Noice, & Staines, 2004; Oswald, Rupprecht, Gunzelmann, & Tritt, 1996) paired with evidence of the importance of cognitive functioning for performing activities of daily living (Allaire & Marsiske, 1999; Backman & Hill, 1996; Burdick et al., 2005; Cahn-Weiner, Malloy, Boyle, Marran, & Salloway, 2000; Owsley, Sloane, McGwin, & Ball, 2002) and maintaining health related quality of life among older adults (Hultsch, Hammer, & Small, 1993; Swan, Carmelli, & LaRue, 1995; Wolinsky & Johnson, 1991). At that time, essentially no research had been conducted demonstrating training transfer to real-world functional outcomes in later adulthood. The Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) trial addressed this gap. The goal of ACTIVE was to test the effectiveness of three cognitive interventions (memory, reasoning, and visual speed of processing) in maintaining cognitive health and functional independence in older adults. The targeted abilities-- memory, reasoning, and speed of processing—were selected based on evidence that they exhibit relatively early age-related decline, beginning on average in the mid-sixties (Schaie, 1996), that interventions have been shown to be effective in training these abilities (K Ball, 1997; K. Ball & Owsley, 2000; Kliegl, Smith, & Baltes, 1990; Lachman, Weaver, Bandura, Elliott, & Lewkowicz, 1992; McDougal, 1999; Mohs et al., 1998; Oswald et al., 1996; Rasmusson, Rebok, Bylsma, & Brandt, 1999; Rebok & Balcerak, 1989; S. Willis, 1990; S. Willis, Cornelius, Blow, & Baltes, 1983; S. Willis & Nesselroade, 1990; S. Willis & Schaie, 1986, 1994), and that performance on these abilities is associated with performance of cognitively demanding instrumental activities of daily living, critical for independent living (K. Ball & Owsley, 2000; K. Ball, Owsley, Sloane, Roenker, & Bruni, 1993; Diehl, Willis, & Schaie, 1995; S. L. Willis, 1996; S. L. Willis, Jay, Diehl, & Marsiske, 1992). ACTIVE began in September, 1996 at six field centers: the University of Alabama at Birmingham, the Boston Hebrew Rehabilitation Center for Aged (now Hebrew Senior Life), the Indiana University School of Medicine, the Johns Hopkins University, the Pennsylvania State University, and Wayne State University, with a data coordinating center at the New England Research Institutes. The conceptual model that informed the design of ACTIVE (Figure 1) was based on prior evidence showing that cognitive training would be domain specific. That is, each intervention was expected to result in specific improvement on measures of the trained ability relative to the other interventions and control group. For example, training in memory was expected to improve memory function (the proximal outcome) but was not expected to improve reasoning or speed of processing skills. On the other hand, intervention effects were expected to show some level of general transfer to daily function (the primary outcome) based on the critical assumption that declines in cognitive function lead to declines in activities in daily living. In other words, improvement in cognitive ability should result in maintenance of functional independence. In turn, maintained functional independence could result in a positive cascade of effects including improvements in quality of life, mobility, and health service utilization. Figure 1 Hypothesized mode of effects in ACTIVE trial. Influence of intervention on primary and secondary outcomes is mediated through trained abilities. Bold lines represent specific effects of training. Dashed lines represent non-specific effects of training ...

How One Rehab Center Pumped Iron

How One Rehab Center Pumped Iron

Hypertension, Orthostatic Hypotension, and the Risk of Falls in a Community-Dwelling Elderly Population: The Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study

To investigate the relationships between uncontrolled and controlled hypertension, orthostatic hypotension (OH), and falls in participants of the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study (N=722, mean age 78.1). Prospective population-based study. Community. Seven hundred twenty-two adults aged 70 and older living within a 5-mile radius of the study headquarters at Hebrew Rehabilitation Center in Boston. Blood pressure (BP) was measured at baseline in the supine position and after 1 and 3 minutes of standing. Systolic OH (SOH) and diastolic OH at 1 and 3 minutes were defined as a 20-mmHg decline in systolic BP and a 10-mmHg decline in diastolic BP upon standing. Hypertension was defined as BP of 140/90 mmHg or greater or receiving antihypertensive medications (controlled if BP < 140/90 mmHg and uncontrolled if ≥ 140/90 mmHg). Falls data were prospectively collected using monthly calendars. Fallers were defined as those with at least two falls within 1 year of follow-up. OH was highest in participants with uncontrolled hypertension; SOH at 1 minute was 19% in participants with uncontrolled hypertension, 5% in those with controlled hypertension, and 2% in those without hypertension (P ≤ .001)). Participants with SOH at 1 minute and uncontrolled hypertension were at greater risk of falls (hazard ratio=2.5, 95% confidence interval = 1.3-5.0) than those with uncontrolled hypertension without OH. OH by itself was not associated with falls. Older adults with uncontrolled hypertension and SOH at 1 minute are at greater risk for falling within 1 year. Hypertension control, with or without OH, is not associated with greater risk of falls in older community-dwelling adults.

Medical Director of the Year Leads by Example and Design

Medical Director of the Year Leads by Example and Design

Frailty, health-related quality of life and mental well-being in older adults with cardiometabolic risk factors

Frailty is an emergent health-related problem in older adults. The aim of this study was to examine the health-related quality of life (HRQOL) and the effect of frailty in elderly patients with cardiometabolic risk factors. One-hundred and one patients 65 years or older responded to an HRQOL assessment using the World Health Organization Quality of Life (WHOQOL)-26 questionnaire. Frailty was assessed using two indices: the Hebrew Rehabilitation Center for Aged (HRCA) vulnerability index and the Vulnerable Elders Survey (VES) index. In addition, these patients completed self-rating questionnaires assessing mental well-being [the 28-item version of the General Health Questionnaire (GHQ-28)] and depression (Geriatric Depression Scale). Based on the combination of HRCA and VES indices, 24 subjects (23.7%) met the criteria of frail. Persons > or = 75 years old and those with depressive mood or lower creatinine clearance had significantly lower WHOQOL-26 scores than their counterparts. Diabetes and macrovascular complications did not associate with the WHOQOL-26 scores. Compared with non-frail patients, the frail scored lower on the WHOQOL-26 questionnaire after adjusting for age, kidney dysfunction and depressive mood. Frail patients also reported significantly higher the GHQ-28 scores compared with non-frail patients. Frail older adults had a significant lower HRQOL, as well as lower mental well-being, independent of age, diabetes, macrovascular complication, kidney dysfunction and depressed mood.

Want to Promote Long-Term Care? Consider Teaching It

Want to Promote Long-Term Care? Consider Teaching It

Identification of Measurement Differences Between English and Spanish Language Versions of the Mini-Mental State Examination

Knowledge of the extent to which measurement of adult cognitive functioning differs between Spanish and English language administrations of the Mini-Mental State Examination (MMSE) is critical for inclusive, representative, and valid research of older adults in the United States. We sought to demonstrate the use of an item response theory (IRT) based structural equation model, that is, the MIMIC model (multiple indicators, multiple causes), to evaluate MMSE responses for evidence of differential item functioning (DIF) attributable to language of administration. We studied participants in a dementia case registry study (n = 1546), 42% of whom were examined with the Spanish language MMSE. Twelve of 21 items were identified as having significant uniform DIF. The 4 most discrepant included orientation to season, orientation to state, repeat phrase, and follow command. DIF accounted for two-thirds of the observed difference in underlying level of cognitive functioning between Spanish- and English-language administration groups. Failing to account for measurement differences may lead to spurious inferences regarding language group differences in level of underlying level of cognitive functioning. The MIMIC model can be used to detect and adjust for such measurement differences in substantive research.

Research Finds Need for Core Data in Transfers

DALLAS — There is strong agreement on a core set of medical data that should be transferred from the nursing home or assisted-living facility to the hospital, according to preliminary research findings presented recently at the annual symposium of the American Medical Directors Association. Dr. Howard L. Nachamie, a geriatrician at the Hebrew Rehabilitation Center in Boston, and his colleagues conducted a survey of long-term care facility staff members and hospital workers in an effort to identify the information needed when transferring residents from a long-care setting to the hospital. Throughout his training, Dr. Nachamie said he received patients without the proper information, regardless of the setting where he was working. “In addition to this leading to unnecessary tests and risks to the patients, it also was a waste of time for everybody,” he said. There currently is no validated set of medical data needed on any of the stages of the patient transfer, he said. Dr. Nachamie, who began this research while at Brown University in Providence, Rhode Island, initially conducted a pilot survey of front-line providers including geriatricians, geriatric nurse practitioners, geriatric fellows, internal medicine hospitalists, and emergency department physicians. Dr. Nachamie and his colleagues developed a list of the core medical data that should be transferred to the hospital with the patient and asked survey respondents to rate their agreement on each item from “strongly agree” to “strongly disagree.” The pilot survey had about 60 respondents, Dr. Nachamie said. The most popular general items to include in transfer—those that received agreement from more than 90% of respondents—included advance directives, mental status, functional status, allergies, medication list, history of illness leading to transfer, and the active problem list. The researchers used the results of the pilot survey to help revise the transfer criteria before posting it as an online survey to the AMDA Foundation Research Network. The researchers sent out 303 online surveys to the membership list of the AMDA Foundation Research Network, and about 125 members responded. Among that group, the general items that had agreement of more than 90% of respondents included advance directives, mental status, functional status, allergy, medications, laboratory information, radiology, cardiac tests, history of illness leading to transfer, active problem list, and history of surgeries. Overall, 11 of the 14 general domains included in the survey received more than 90% agreement from respondents in the AMDA Foundation Research Network and 23 of the 35 more specific items included in the survey had agreement from more than 90% of respondents. “We got good evidence that we're working toward the right direction in getting the core list that should accompany the patient in transfer,” Dr. Nachamie said. The analysis of the data is ongoing, he said. In the future, Dr. Nachamie said, he would like to continue to test the core set of medical data in a larger sample. Ultimately, researchers will need to review how well physicians and others transfer this critical medical information, Dr. Nachamie added.

Is pulse pressure a predictor of cardiovascular complications in a frail elderly nursing home population?

Previous studies have focused on systolic blood pressure (SBP), diastolic pressure (DBP), and more recently pulse pressure (PP) as risk factors for adverse cardiovascular (CV) endpoints in elderly people. However, the relation between these pressures and CV complications in the frail nursing home population has not been well studied. The aims of this project are to determine the value of PP in predicting CV complications in a nursing home population, and to compare its predictive value with SBP, DBP, and mean arterial pressure (MAP). This study is a retrospective 2-year review of the medical charts of 248 residents of the Hebrew Rehabilitation Center for the Aged, a long-term care facility in Boston, MA, USA. During the review process, data were collected about past medical history and new onset CV events, in addition to blood pressure and medication use. The results showed, with 95% confidence, that within a 2-year period, the odds ratio for the occurrence of the selected CV outcomes (myocardial infarction, congestive heart failure, angina, stroke, renal failure, syncope, death) included 1.0 for PP, SBP, DBP, MAP, and changes in these values. After adjusting for medication use, pulse pressure was still not an independent risk factor for CV complications. PP, SBP, DBP or MAP cannot serve as predictors of CV outcomes in the nursing home population. The presence of multiple medical problems in this frail population may have resulted in CV morbidity and mortality, independent of blood pressure effects.

Quality of life for oncology patients during the terminal period. Validation of the HRCA-QL index.

The evolution of performance status, disability, and quality of life (QL) according to the Hebrew Rehabilitation Center for Aged QL (HRCA-QL) index for cancer patients through their terminal period is described. The assessment of HRCA-QL validity and reliability is also described. A total of 200 cancer patients were followed up from the onset of their "terminal phase" until they died. Information on symptoms, performance, disability and QL were collected by patient's oncologists in hospital and by their family practitioners and community nurses when the patient was at home. Health measures were: the HRCA-QL index, Karnofsky performance status (KPS) and the Independence in Activities of Daily Living (IADL) index. The three indices were acceptable for a fair number of patients at the start of the terminal phase. Almost two-thirds had a KPS > or =60. With respect to the IADL index, the patients were independent in five of the six functions, with 80% having a HRCA-QL equal to or greater than 4. The median duration of the terminal period was 59 days. All three indices declined progressively, with marked deterioration in the last 2 weeks. The HRCA-QL index was highly correlated with KPS and the IADL index, had good internal consistency and showed an acceptable test-retest and inter-rater reliability. The HRCA-QL index was reactive to clinical changes. All three scales confirmed that terminal patients experience a progressive loss of performance, increase in dependence and deterioration of QL as they approach the end of life. Based in these results, we consider the HTCA-QL index valid for use in terminal cancer patients.

Ethics Corner: Cases from the Hebrew Rehabilitation Center for Aged—Friends

Miriam S. is an 85-year-old woman who was admitted to the Hebrew Rehabilitation Center for Aged (HRCA) from her apartment in the community 5 years ago. She was admitted after a visiting social worker observed that Ms. S. had difficulty with personal hygiene and with making her way back to her apartment after performing errands. Ms. S. was born and raised in Boston, completed high school, and worked in a department store until retiring at age 65. She never married. She had one surviving sibling with severe dementia who was a resident of another nursing home. Upon admission to the HRCA, Ms. S. was diagnosed with mild dementia and hypertension. Her niece, who had previously agreed to assume the role of durable power of attorney, refused to be the health care proxy for her aunt, though Ms. S. would have willingly appointed her. Over the next few months, Ms. S.’s social worker at HRCA inquired of the niece on several occasions about becoming her aunt’s health care proxy, and on each occasion the niece declined. One year into her stay at the HRCA, Ms. S. fell and fractured a hip. The medical treatment team found that Ms. S. retained the capacity to make medical decisions, and her hip replacement surgery and recuperation were uneventful. Over the next 2 years, Ms. S.’s treatment team observed slow progression of Ms. S.’s dementia. After Ms. S.’s niece again declined to become the health care proxy, the treatment team referred Ms. S. to the Ethics Committee’s Informal Surrogate for the Unbefriended program. A member of the Ethics Committee was designated as the informal surrogate. She began to meet with Ms. S. on a regular basis and recorded in Ms. S.’s chart details of conversations about advance directives. Five years after her original hip surgery, Ms. S. required surgical revision of the hip. Ms. S’s informal surrogate was included in discussions about the surgery. The orthopedist recognized that Ms. S. had impaired decision-making capacity but felt that she retained the ability to make a valid decision about the procedure. Ms. S. agreed to the surgery and her surrogate believed that her consent was consistent with previously expressed goals for her health care. The surgery proceeded without incident.

Financial Incentives for Placing Feeding Tubes in Nursing Home Residents with Advanced Dementia

Financial Incentives for Placing Feeding Tubes in Nursing Home Residents with Advanced Dementia

Ethics Corner: Cases from the Hebrew Rehabilitation Center for Aged—Truth or Consequences

Charlotte R. is a 91-year-old woman who was admitted to the Hebrew Rehabilitation Center for Aged (HRCA) 2 years ago when, because of moderate dementia, she could no longer live independently. Mrs. R. was born and raised in New York and moved to Boston after she married. She raised a daughter, who eventually moved to the West Coast. Mrs. R. became widowed when she was 75. Several years before her admission to HRCA, she designated a niece who lived in Boston as her health care proxy. Mrs. R. made a smooth transition to HRCA. At the time of the ethics consult, she had developed a close relationship with a gentleman resident at the center and had not inquired about her daughter in approximately 9 months.

Ethics Corner: Cases from the Hebrew Rehabilitation Center for Aged—Truth or Consequences

This article is the fifth of a six-part JAMDA series devoted to medical ethics in the nursing home. In each issue, a case is presented from the Ethics Committee at the Hebrew Rehabilitation Center for Aged (HRCA) in Boston, Massachusetts. Following a description of the case and a discussion of the ethical issues that the case raises, Dr. Steven Levenson will discuss the implications for medical directors.

Ethics Corner: Cases from the Hebrew Rehabilitation Center for Aged???Truth or Consequences

Charlotte R. is a 91-year-old woman who was admitted to the Hebrew Rehabilitation Center for Aged (HRCA) 2 years ago when, because of moderate dementia, she could no longer live independently. Mrs. R. was born and raised in New York and moved to Boston after she married. She raised a daughter, who eventually moved to the West Coast. Mrs. R. became widowed when she was 75. Several years before her admission to HRCA, she designated a niece who lived in Boston as her health care proxy. Mrs. R. made a smooth transition to HRCA. At the time of the ethics consult, she had developed a close relationship with a gentleman resident at the center and had not inquired about her daughter in approximately 9 months.

Ethics Corner: Cases from the Hebrew Rehabilitation Center for Aged—Sex in the Facility

Ethics Corner: Cases from the Hebrew Rehabilitation Center for Aged—Sex in the Facility

Ethics Corner: Cases from the Hebrew Rehabilitation Center for Aged???Sex in the Facility

Ethics Corner: Cases from the Hebrew Rehabilitation Center for Aged???Sex in the Facility

Ethics Corner: Cases from the Hebrew Rehabilitation Center for Aged—Restraint Complaint

This article is the third of a six-part JAMDA series devoted to medical ethics in the nursing home. In each issue, a case is presented from the Ethics Committee at the Hebrew Rehabilitation Center for Aged (HRCA) in Boston, Massachusetts. After a description of the case and a discussion of the ethical issues that the case raises, Dr. Steven Levenson discusses the implications for medical directors.

Ethics Corner: Cases from the Hebrew Rehabilitation Center for Aged???Restraint Complaint

The Ethics Committee was asked to consult on the case of Frederick N., an 81-year-old, Russian-speaking man transferred to the HRCA from another nursing home. Mr. N. had been diagnosed with vascular dementia 6 years before his admission, and the dementia had progressed to the point where Mr. N. was totally dependent on caregivers for personal hygiene and dressing. In addition, Mr. N. received nourishment through a percutaneous endoscopically placed gastrostomy (PEG) tube that had been inserted 5 months before his admission to the HRCA. His other medical problems included a history of pulmonary embolism with subsequent inferior vena cava filter placement, congestive heart failure, right parietal meningioma, gallstone pancreatitis, recurrent urinary tract infections, and recurrent falls.