Nursing Home Units Research Articles

Quality of Life of Nursing Home Residents: A Comparative Study of Persons with and Without Dementia in Regular Units, and Persons with Dementia in Different Care Settings

Purpose: To compare the quality of life (QoL) between persons with and without dementia in regular nursing home units, and to compare the QoL between persons with dementia in different care settings. Method: A one-time survey was carried out using the adapted Norwegian version of the dementia specific questionnaire, QoL-AD. Subjects were non-random (convenience) sample. Results: No significant differences in QoL-AD score between residents with and without dementia in regular units (p=0.38), between residents with dementia in different care settings (p=0.27) was found. A significant difference in QoL-AD score between residents with different marital status (p=0.05) were observed. Conclusion: The study identified no significant differences in QoL among people with and without dementia in regular units and between residents with dementia in regular units and special care units. The married residents were significantly lower quality of life than unmarried.

Maximising sensory awareness for patients with dementia

Patients with dementia often exhibit significant mental state disturbances including confusion, agitation and aggression and these may be provoked or exacerbated by many external factors. The research team hypothesised that optimising the sensory awareness of residents to their environment would reduce the number of documented aggressive episodes. During this four-month study the care team documented the number of aggressive episodes in a nursing home unit before, during and after the implementation of the following changes: residents had their hearing aids and glasses checked, cleaned and fitted on a daily basis to maximise the resident's sensory awareness. Living conditions were altered with improved lighting, signing and daily sensory stimulation in line with NICE guideline recommendations. Following the implementation of this intervention, the number of documented aggressive episodes reduced throughout the study period with an overall significant reduction of 25%. The research concluded that simple non-pharmaceutical measures aimed at maximising the ability of residents to sense their environment could indeed reduce aggressive episodes.

Grieving the Loss of a Friend

We belong to what have been called the “helping professions.” I serve on a health care team that delivers palliative care. Palliative care aims to bring comfort and pain relief to a dying person. My work at a Veterans Affairs (VA) hospital has focused on doing psychotherapy with a variety of veterans who are at the end of their lives. The focus of what I do is typically directed to the veteran patient and his or her family. Only rarely do I consider the effect of caring for patients at the end of life on me and other team members. It is commonly observed that interactions with some patients leave a deeper impression than do others. Located at life’s end, the work often ceases when the patient dies. Families grieve the loss of a loved one, but hospital staff members are less often acknowledged in their grief. When I came to the Community Living Center (VA nursing home unit), the director asked me to develop a meeting to respond to the needs of staff who had lost patients. I scheduled a meeting each month for several months; however, few staff members attended. “Self-care” sounded like an important concept, but our health care team seemed to have little time in their days for it. The meetings were discontinued. I forgot about the meetings and continued my work, as staff members and veteran residents came and went. One day, an oncologist asked me to meet with a hospitalized inpatient. Mr A and I met on 8 different occasions over a 4-month period, each time during one of his admissions to the hospital. It would be melodramatic to state that my time with Mr A “changed my life” or changed his. As he negotiated his final life stage, however, he made as much of an impact on me as I may have made on him. When Mr A finally died, he left an empty space in my life, and I will dearly miss him. What follows is the story of those 4 months, which, I am aware, forms a significant part of the process of my grief for his loss.

A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial

BackgroundElder abuse in long-term care has received considerable attention; however, resident-to-resident elder mistreatment (R-REM) has not been well researched. Preliminary findings from studies of R-REM suggest that it is sufficiently widespread to merit concern, and is likely to have serious detrimental outcomes for residents. However, no evidence-based training, intervention and implementation strategies exist that address this issue. ObjectivesThe objective was to evaluate the impact of a newly developed R-REM training intervention for nursing staff on knowledge, recognition and reporting of R-REM. DesignThe design was a prospective cluster randomized trial with randomization at the unit level. MethodsA sample of 1405 residents (685 in the control and 720 in the intervention group) from 47 New York City nursing home units (23 experimental and 24 control) in 5 nursing homes was assessed. Data were collected at three waves: baseline, 6 and 12 months. Staff on the experimental units received the training and implementation protocols, while those on the comparison units did not. Evaluation of outcomes was conducted on an intent-to-treat basis using mixed (random and fixed effects) models for continuous knowledge variables and Poisson regressions for longitudinal count data measuring recognition and reporting. ResultsThere was a significant increase in knowledge post-training, controlling for pre-training levels for the intervention group (p<0.001), significantly increased recognition of R-REM (p<0.001), and longitudinal reporting in the intervention as contrasted with the control group (p=0.0058). ConclusionsA longitudinal evaluation demonstrated that the training intervention was effective in enhancing knowledge, recognition and reporting of R-REM. It is recommended that this training program be implemented in long-term care facilities.

Preparing for the Next Stage

As I have gotten older, my career has taken several twists and turns. Each turn has brought new colleagues and new opportunities to learn. During my “peak” years, I had a 30-hour outpatient practice of adult psychiatry, informed by the cognitive therapy model that I learned from Aaron Beck, MD. When I left Washington, DC, for Charleston, South Carolina, I took an academic job. I taught the cognitive model and supervised psychiatric resident psychotherapy, worked for the first time in an adult primary care clinic, and worked alongside an oncologist, seeing his patients once a week with him. During this 3-year oncology outpatient experience, the value of the cognitive model for helping cancer patients adjust to their disease became apparent. I left the university in 2003. For the next 7 years, I had a small private practice, did some speaking, and worked in an outpatient oncology practice for 18 months. In 2010, I was hired by the Department of Medicine of the Veterans Administration hospital to work part-time on a palliative care geriatric team. I continued my private office time, but at a reduced level. It was at the Veterans Administration hospital, when I applied the cognitive model to newly admitted nursing home veterans, that I found the most use for the concept of life stage. Elderly male patients admitted to a nursing home unit on an “end-of-life contract” often lived longer and did better than expected. There was an often unanticipated need for them to focus on this life stage to determine their plan for it. I worked with several men (and a few female veterans) to help them do this. I did not expect this life stage work, however, to be relevant to my office practice, which represented a more heterogeneous group of patients. Then, one day, an internist colleague referred Mr A to me for cognitive therapy.

Engaging life in two Irish nursing home units for people with dementia: Quantitative comparisons before and after implementing household environments

Objectives: This study compares the Social Engagement and Interactive Occupation of residents with dementia in two Irish nursing homes, before and after conversion to a household model environment. The changes were an open plan design and a functioning unit kitchen, supported by a homemaker role and operational policies which reduced task-based work in favour of person-centred care offering choice. Method: A snapshot observation method was used to obtain quantitative data of resident activity using the Assessment Tool for Occupation and Social Engagement (ATOSE). Residents were assessed for four hours, on seven different weekdays, over a six-week period both pre- and post-renovation. The exception to this was the assessment of the traditional model unit (TMU) for Nursing Home 1 which was reduced to four days due to the early start of the building work. Results: The results were consistent for both nursing homes and data were aggregated. Residents spent more time in the communal living spaces and were more likely to be active and engaged in the household model units (HMUs) compared to the TMUs. Using the independent t-test, these changes were found to be highly significant (p < 0.001). Conclusion: Creating an HMU increased the Interactive Occupation and Social Engagement of residents in the communal areas of the two nursing homes. The physical environment change, in conjunction with supportive staff procedures and organizational initiatives, improved the well-being of residents with dementia. The outcomes must be viewed in context with financial implications.

Inappropriate prescribing for older people admitted to an intermediate-care nursing home unit and hospital wards

Objective. To identify inappropriate prescribing among older patients on admission to and discharge from an intermediate-care nursing home unit and hospital wards, and to compare changes during stay within and between these groups. Design. Observational study. Setting and subjects. Altogether 400 community-dwelling people aged ≥ 70 years, on consecutive emergency admittance to hospital wards of internal medicine and orthopaedic surgery, were randomized to an intermediate-care nursing home unit or hospital wards; 290 (157 at the intermediate-care nursing home unit and 133 in hospital wards) were eligible for this sub-study. Main outcome measures. Prevalence on admission and discharge of potentially inappropriate medications (Norwegian general practice [NORGEP] criteria) and drug–drug interactions; changes during stay. Results. The mean (SD) age was 84.7 (6.2) years; 71% were women. From admission to discharge, the mean numbers of drugs prescribed per person increased from 6.0 (3.3) to 9.3 (3.8), p < 0.01. The prevalence of potentially inappropriate medications increased from 24% to 35%, p < 0.01; concomitant use of ≥ 3 psychotropic/opioid drugs and drug combinations including non-steroid anti-inflammatory drugs (NSAIDs) increased significantly. Serious drug–drug interactions were scarce both on admission and discharge (0.7%). Conclusions. Inappropriate prescribing was prevalent among older people acutely admitted to hospital, and the prevalence was not reduced during stay at an intermediate-care nursing home unit specially designed for these patients.

A Continuing Saga

It is often said that sports imitate life. The College of Charleston (Charleston, South Carolina) men’s basketball team had a good season last year. Unlike their professional counterparts, however, college students graduate, and the Cougars lost 3 highly productive players from last year’s team. With an above-average recruiting class, this season’s team completed its preconference schedule, winning 10 games and losing only 3. Fans expected another outstanding season. Then came an inexplicable loss—the loss of a sterling freshman to injury—and another unexpected defeat. How could they possibly recover? The basketball coach described his preparation for game 17 as a “new beginning.” Fittingly, he started some new players and gave others newfound court time. Would the new combinations work? Last fall, I worked with Mr A, a 60-year-old Vietnam veteran who had suffered a severe abdominal insult and nearly died. By the strength of his will, Mr A summoned the motivation to rehabilitate himself and to reach the point of discharge from a nursing home unit. He had pushed himself to achieve many small gains, which had added up to a reclaimed ability to walk and the hope that he could take care of himself. Leaving the nursing home unit, however, Mr A could not know what lay ahead—only that he had earned a second chance at life, beginning at age 61 years. As happened with the basketball team, the road for Mr A had several unanticipated turns and unplanned-for defeats. It seemed prudent to continue our work together, as Mr A sought to negotiate the world he found outside the confines of a nursing home. We described his task at discharge as a new beginning.

The “End of Life” Stage

One of the more important books that I have read talks about the different segments of one's life.1 The concept of life stage has been useful for treating a variety of people at different times of their lives. When puberty or the calendar ushers in adolescence, a new life stage begins. When schooling ends, when someone is hired to work, when the employed man or woman retires, or when a marriage takes place, a new life stage may begin. When a married couple has a child, a new stage of life often starts, and when the last child leaves home, a married couple may begin a new life stage. Similarly, when serious illness (eg, cancer) brings restrictions, a new life stage can be said to follow. Once defined, I have found it useful to ask the patient to describe how he or she wants to spend this stage. A Veterans Administration colleague recently gave me an article2 to read that calls attention to the “homelessness” that typically results when an older person is admitted to a nursing home. It seems to me that one approach to the institutionalized elderly man or woman at the end of life is to define the problem as the onset of a new life stage and encourage the individual to plan for this time. I have been working on a palliative care team at a local Veterans Affairs hospital now for nearly 2 years. As part of that work, I treat patients who have been admitted to our nursing home unit. Although every case is different, and the problems presented may vary, I utilize the concept of a new life stage with practically every veteran that I treat. The loss of a home is one of many events that challenge the older person's need to have some control over his or her life. The event forces the individual at the end of life to make a plan for this period. In a manner similar to those individuals who are admitted to hospice, some patients who learn to call our nursing home unit their home outlive their commitment. When they leave the place where they expected their life to end, a new life stage can also be said to begin.

Serum carnitine levels and levocarnitine supplementation in institutionalized Huntington’s disease patients

Along with antioxidant properties, carnitine is an important regulator of lipid metabolism in humans. While beneficial effects of carnitine have been demonstrated in animal models of Huntington's disease (HD), metabolism of carnitine has not been studied in humans with this illness. In this retrospective database review from 23 patients admitted to a HD-specialized nursing home unit, we found a relatively high prevalence of hypocarnitinemia (6 cases, 26%). Our review suggests that catabolism and chronic valproate use predisposed our patients to develop hypocarnitinemia. The patients with low serum carnitine levels who received levocarnitine supplementation, during a mean period of 7.3 months, showed improvement in motor, cognitive and behavioral measures. We hypothesize that observed improvement related to the resolution of reversible metabolic encephalopathy and myopathy associated with secondary carnitine deficiency. In conclusion, notwithstanding its limitations, this is the first study to report measurements of carnitine levels in HD patients, revealing relatively high prevalence of hypocarnitinemia in our population. Our findings suggest that HD patients with hypocarnitinemia may benefit from low-dose levocarnitine supplementation. Further studies of carnitine metabolism and supplementation in HD patients are warranted.

Addressing Substance Use Disorders in VA Nursing Homes

Residents of Veterans Affairs nursing homes have high rates of substance use problems. To evaluate relevant treatment resources and practices available to them, we surveyed 48 nursing home units with high substance use disorder prevalence. We summarize survey findings and describe areas of strength and weakness in addressing the needs of residents with substance use disorders. Social workers can make important contributions in key areas identified in the survey, including fostering improved communication and coordination with medical center programs, educating care staff regarding substance use in older persons, and providing discharge planning that takes into account residents' substance use history.

Nijmegen Observer‐Rated Depression scale for detection of depression in nursing home residents

This study aims to test the accuracy of the Nijmegen observer-rated depression (NORD) scale, a new short scale for screening of depression in nursing home (NH) residents with and without dementia. This cross-sectional study with 103 residents with dementia (N = 19 depressed) and 72 residents without dementia (N = 10 depressed) was undertaken in 13 Dutch NH units. An elderly care physician and a psychologist of each unit assessed residents for the presence of clinical depression. Primary professional caregivers administered the NORD scale. Five of the six proposed items showed acceptable performance in screening for depression. Receiver operating characteristic analyses revealed significant areas under the empirical curve (AUC) for the 5-item NORD scale in the total sample (AUC = 0.83, p < 0.001), as well as in residents with dementia (AUC = 0.84, p < 0.001) and without dementia (AUC = 0.84, p < 0.001). The cutoff score of >1 showed the highest sum of sensitivity (100) and specificity (69) in non-dementia and >2 the highest sum of sensitivity (79) and specificity (77) in dementia. The cutoff score of >1 showed the lowest negative likelihood ratio of 0.0 in non-dementia and of 0.2 in dementia. The highest positive likelihood ratios were found for the cutoff of >2 in non-dementia (3.4) and for >4 in dementia (26.5). The 5-item NORD scale showed acceptable accuracy comparable with those of more extensive scales in other studies. It is easy and quick to administer and can be used for screening of depression in NH residents with or without dementia.

Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial

Objective To determine whether a systematic approach to the treatment of pain can reduce agitation in people with moderate to severe dementia living in nursing homes.Design Cluster randomised controlled trial.Setting...

Management of person with dementia with aggressive and violent behaviour: a systematic literature review

Studies indicate that physical and pharmacological restraints are still often in the frontline of aggression management in a large number of nursing homes. In the present literature review the aim was to describe, from a nursing perspective, aggressive and violent behaviour in people with dementia living in nursing home units and to find alternative approaches to the management of dementia related aggression as a substitute to physical and chemical restraints. A systematic literature review in three phases, including a content analysis of 21 articles published between 1999 and August 2009 has been conducted. The results could be summarised in two themes: 'origins that may trigger violence' and 'activities that decrease the amount of violent behaviour'. Together, the themes showed that violence was a phenomenon that could be described as being connected to a premorbid personality and often related to the residents' personal care. It was found that if the origin of violent actions was the residents' pain, it was possible to minimise it through nursing activities. This review also indicated that an organisation in special care units for residents who exhibit aggressive and violent behaviour led to the lesser use of mechanical restraints, but also an increased use of non-mechanical techniques. The optimal management of aggressive and violent actions from residents with dementia living in nursing homes was a person-centred approach to the resident. Qualitative studies focusing on violence were sparsely found, and this underlines the importance of further research in this area to elucidate how violence and aggressiveness is experienced and understood by both staff and patients. To communicate with people with dementia provides a challenge for nurses and other health caregivers. To satisfy the needs of good nursing care, an important aspect is therefore to get knowledge and understanding about aggressive and violent behaviour and its management.

Care providers’ perceptions of the importance of oral care and its performance within everyday caregiving for nursing home residents with dementia

The oral caregiving in nursing homes for persons with dementia often becomes complicated due to the patients' lack of compliance, which in turn can result in giving oral care a low priority in daily care. Furthermore, directives for responsibilities are unclear. The aim of this article was to describe care providers' perception of and reasoning for the oral care for nursing home residents with dementia and to describe registered nurses' reasoning in relation to their responsibility for monitoring oral care interventions within the regular caregiving routines for nursing home residents with dementia. Two sub-studies were carried out; focus group discussions with nine care providers and interviews with four nurses. All participants were staff in nursing home units specialized in dementia. The focus group discussion revealed three themes: Art of caregiving, Barriers and Treatment strategies. Themes related to the nurses' statements about oral hygiene within caregiving were Care, Responsibility for care and Information. Three main findings from the study are discussed: Unclear responsibilities of different staff members related to daily oral care for the nursing home patients; a lack of guidelines and routines for oral hygiene and a lack of guidelines for sharing information between the different professional groups.

Keeping Hope Alive

American society has been through significant changes in our lifetime. Recent events have focused people on the stability of their employment and the continuity of their income flow. When the situation is global and affects many people, multiple others are available to counsel an individual seeking to adapt to change. However, when the change relates to illness in a given person, it is often easier to lose perspective, fail to adapt, and to “give in” to the consequences of the disease. The typical patient one sees while working on a geriatric nursing home unit in a Veterans Administration hospital is elderly, suffers from multiple physical illnesses, and at times is demented as well. There is only the occasional female patient and the infrequent younger person. Mr A was diagnosed with multiple sclerosis in his 20s. The disease was stable with few changes requiring adaptation until 3 years before his admission to our hospital at age 35 years. Prior to that time, he continued to work and live a productive life within his family and community. Then, symptoms and dysfunction had a sudden onset and a rapid progression. The man I met was bedridden, had seriously impaired mobility and speech, and had a horizon that appeared bleak. It would be his task to find a mindset that allowed for hope for the future and to modify his thinking to take into consideration the physical changes brought about by his disease. He would be asked to accomplish this while living alongside a decidedly older (and often unavailable) population of men. There would seem to be an ample agenda for the unit psychiatrist to address.

Return to Life

The inpatient nursing home unit on which I work has 2 designations: long-term care and end-of-life care. Each of 20 patients qualifies for one, but it is rare that a patient's designation changes from one to the other. Each patient has substantial medical reasons to be continuously hospitalized, and many have additional social and family considerations that make it unlikely that they could be managed at home. In addition, the incidence of mental health problems that complicate medical management is high. Some nursing home residents have been staying at our facility for quite a while, while others may reside here only for a short time at the end of their life. For example, Mr A had been a nursing home inpatient for more than a year when a psychiatric referral was made.

Nursing home placements: the benefits and challenges

This article is a follow-up to a brief presentation given to nursing home managers and Thames Valley University faculty of Health and Sciences lecturers on a personal experience of a recent nursing home placement over a duration of 8 weeks. The nursing home placement included rotation between two units, where one was a specialist dementia nursing home unit and the other a nursing home unit consisting of elderly residents with general health needs. This account will incorporate the benefits of the placement, challenges, proposed improvements and an overall summary.

Finding a Way Home

Palliative care is defined as the relief of pain, symptoms, and stress of a serious illness. One of us (J.S.) has had an ongoing medical interest in this area for years. The other (D.S.) was recently hired to work part-time on a geriatric unit of a general hospital, wherein he joined a palliative care team. On this unit, the concept of “life stage” has a particular poignancy. While most of the patients have a variety of serious medical illnesses, many are also older and are often thrust into a new life stage upon admission. Their lives have not always been happy ones, and, too often, there is no caretaker to relieve the burden of constant isolation. Daily existence becomes dominated by staff and other residents, as well as the experiencing of symptoms relevant to their underlying medical circumstances and the treatments aimed at relieving them. There is a need therefore for a medical physician to diagnose and treat patients admitted to a nursing home unit, along with a psychiatrist to provide brief psychotherapy focused on adjustment to this new life stage.

Quality of Drug Prescribing in Elderly People in Nursing Homes and Special Care Units for Dementia

Drug prescribing to the elderly is extensive and often inappropriate. Furthermore, the number of drugs used is the most important risk factor for adverse drug reactions. Despite this, drug prescribing in the elderly in Sweden is high and increasing. In 2003 the Swedish National Board of Health and Welfare launched a set of indicators to evaluate the quality of drug therapy in the elderly. Use of this tool in combination with the Swedish computerized national register covering all persons receiving multi-dose drug dispensing (drugs dispensed in one dose unit bag for each dose occasion) would enable detection of inappropriate drug prescribing and could help reduce the risk of drug-related problems among the elderly. To assess the extent and quality of drug prescribing in younger and older elderly residents receiving multi-dose drug dispensing in ordinary nursing homes (NHs) and special care units for dementia (NHDs), and to evaluate the relationship between the quality of prescribing and the number of prescribers per resident, in a Swedish county. The computerized national pharmacy drug register provided the database and a cross-sectional design was used. Selected drug-specific quality indicators proposed by the Swedish National Board of Health and Welfare in 2003 were used to assess the quality of drug prescribing. This study included 3705 residents. Their mean age was 85 years and 72% were women. The mean number of prescribed drugs was 10.3 per resident. The proportion of residents with prescriptions for psychotropic drugs was 80% in NHs and 85% in NHDs. The prevalence of each drug-specific quality indicator was as follows: long-acting benzodiazepines 16.4% (NHs) versus 11.7% (NHDs), anticholinergic drugs 20.7% versus 18.5%, drug duplication 14.6% versus 13.6%, three or more psychotropic drugs 25.6% versus 35.3%, class C interactions (drug combinations that may require dose adjustment) 41.9% versus 38.7% and class D interactions (drug combinations that should be avoided) 8.1% versus 5.6%. Younger elderly residents (age 65-79 years) had a lower quality of drug prescribing. An increasing number of prescribers per resident was associated with a lower quality of drug therapy. We found a lower quality of drug prescribing, e.g. anticholinergic drugs prescribed to approximately 20% of residents of NHs and NHDs, and a higher rate of psychotropic drug use (>/=80%) compared with previous studies in NHs. Our results also demonstrated a negative correlation between quality of prescribing and number of prescribers per resident.