Care dependency of nursing home patients with dementia: assessment from European perspective

In an international, study psychometric properties of the Care Dependency Scale (in Dutch shortened as: ZAS) were examined by analysing data gathered in nursing homes in Germany, Finland, Italy, The Netherlands, Norway and Wales (UK). For that purpose, from these countries a convenience sample was developed consisting of 832 patients with dementia. The English, Finnish, German, Italian and Norwegian research instruments were translations of the original Dutch ZAS. Psychometric evaluations of the ZAS were carried out for each country separately as well as for the countries combined. High alpha coefficients between 0.93 and 0.97 were calculated. Subsequent interrater and test-retest reliability revealed moderate to substantial kappa values. Factor analysis resulted in a one-factor solution. One of the main outcomes of the cross-cultural comparison was that the findings in the six countries show more similarities than differences, so that the scale can be used appropriately in nursing home practice and for international comparison of care dependency.     

Calidad asistencial en centros gerontológicos

Geriatric centers provide long-term care to elderly individuals with physical and/or psychological dependency, comorbidity and social problems.Care planning in these centers should focus on residents and their safety. An adequate number of qualified and committed professionals are the cornerstone of the structure of a high-quality care system. Care should be monitored and continuously evaluated with implementation of innovative actions for improvement. Improvement in the quality of the care provided should increase residents’ quality of life.     

影响住院患者护理需求的因素分析

目的:既往研究表明不同住院患者人群的护理需求不同,很少有研究对住院患者护理需求的影响因素进行分析。因此,本研究旨在调查影响患者护理需求的因素,为临床全面、个体化的患者护理提供参考依据。方法:采用《住院病人护理需求调查表》对2011年10月至2011年12月在北京中医药大学东方医院的住院患者进行问卷调查,回收结果后进行数据回归统计分析。结果:经济收入高的患者对"尽快解除痛苦"、"病房安静整洁"、"宗教信仰不受干扰"的需求高;年龄大的患者对"协助拍背、咳痰"和"护士注意到病床、轮椅、推车等的安全"的需求高;文化程度高的患者对"宗教信仰不受干扰"需求高。脑力劳动患者对"护士重视并帮助减轻疼痛"和"医务人员耐心解释欠费"的需求要高于体力劳动患者;住院天数短的患者对"了解安全事项"需求高;住院时间长的患者对"护士经常巡视病房"、"了解病情及有关疾病"和"了解检查意义和结果 "的需求高。结论:经济状况、年龄、文化程度、职业性质、住院天数对患者的护理需求有一定影响。今后在为患者提供护理计划时,需要综合考虑患者的状况。     

Residential care for elderly people: a decade of change.

OBJECTIVE--To determine the changes between 1979 and 1990 in demography and dependency levels in elderly people in residential care. DESIGN--Censuses of those aged 65 years and over in any type of residential care at midnight on 11 December 1979 and 27 November 1990. SETTING--Leicestershire District Health Authority (population 865,133, 1991 census), coterminous with county and social services boundaries. MAIN OUTCOME MEASURES--Age, sex, length of stay, and dependency levels (measured by activities of daily living). RESULTS--In 1990 (1979), 6079 (4678) elderly people were enumerated in 241 (133) establishments, a 30% increase in the numbers of elderly people in residential care and an 82% increase in the number of establishments between 1979 and 1990. Dependency levels rose between 1979 and 1990 in all but the geriatric sector, the greatest increases being found in private residential homes where the largest percentage increase in the number of residents had occurred. CONCLUSIONS--Dependency levels in residential care have risen substantially, particularly in the private sector, even beyond levels expected from the greater numbers of elderly people. With the impending move to community care, dependency levels are likely to rise further, and more appropriate staff training and medical input to homes will become necessary.     

Oral hygiene of elderly people in long-term care institutions--a cross-sectional study

Objective: The aim of this cross‐sectional study was to assess the level of oral hygiene in elderly people living in long‐term care institutions and to investigate the relationship between institutional and individual characteristics, and the observed oral cleanliness. Materials and methods: Clinical outcome variables, denture plaque and dental plaque were gathered from 359 older people (14%) living in 19 nursing homes. Additional data were collected by a questionnaire filled out by all health care workers employed in the nursing homes. Results: Only 128 (36%) residents had teeth present in one or both dental arches. About half of the residents (47%) wore complete dentures. The mean dental plaque score was 2.17 (maximum possible score = 3) and the mean denture plaque score was 2.13 (maximum possible score = 4). Significantly more plaque was observed on the mucosal surface of the denture with a mean plaque score of 2.33 vs. 1.93 on the buccal surface (p < 0.001). In the multiple analyses only the degree of dependency on an individual level was found to be significantly correlated with the outcome dental plaque (odds ratio: 3.09) and only the management of the institution with denture plaque (odds ratio: 0.43). Conclusion: Oral hygiene was poor, both for dentures and remaining teeth in residents in long‐term care institutions and only the degree of dependency of the residents and the management of the institutions was associated with the presence of dental plaque and denture plaque respectively.     

Oral hygiene care status of elderly with dementia and in residential aged care facilities

doi: 10.1111/j.1741‐2358.2011.00472.x
Oral hygiene care status of elderly with dementia and in residential aged care facilities Objective: To explore the effectiveness of oral hygiene care on plaque and gingival status of residents with dementia. Background: Oral hygiene and oral hygiene care has been reported to be poor among the institutionalised elderly with dementia. The severity of oral diseases has been shown to increase with the severity of physical and cognitive impairment related with dementia. Little research has been carried out on plaque and gingival status of elderly with dementia and the impact of disability related with dementia on oral health in residential aged care facilities (RACF). Materials and methods: A cross‐sectional study of 205 elderly residing in RACF in Perth. Results: Forty‐one percent of the residents in RACF had dementia. Sixty percent of the residents with dementia and 75% of the residents with an Activities of Daily Living Oral Health score of D were assisted with oral care. Mean plaques scores and extent of gingival inflammation were higher for residents in the DD and D subgroups and resident with dementia. Residents assisted with brushing had higher mean plaque score and more moderate gingival inflammation. Conclusion: Oral hygiene care status in residents with dementia was poor despite the fact that oral care assistance was being provided.     

Nursing dependency in registered nursing homes and long term care geriatric wards in Edinburgh.

There has been growing interest and public investment in registered nursing homes, apparently based on the assumption that these homes are the private equivalent of hospital long term care. We have tested this hypothesis in a survey comparing 400 patients in 18 registered nursing homes with 217 patients in 11 geriatric long term care wards in Edinburgh. The nursing home patients formed a distinct and separate group: 362 (92%) were women, 392 (98%) were single or widowed, and 358 (90%) were self financing, whereas in the geriatric long term care group 148 (68%) were women and 35 (16%) were still married. Patients in nursing homes were also far less dependent than those in geriatric long term care wards (p less than 0.005). This study suggests that there may be large differences between the patients in these two types of institution, particularly with regard to nursing dependency. This finding has important implications in the future planning of long term places for the dependent elderly.     

Factors Associated with Nursing Home Placement of All Patients Admitted for Inpatient Rehabilitation in Singapore Community Hospitals from 1996 to 2005: A Disease Stratified Analysis

Objectives

To (1) identify social and rehabilitation predictors of nursing home placement, (2) investigate the association between effectiveness and efficiency in rehabilitation and nursing home placement of patients admitted for inpatient rehabilitation from 1996 to 2005 by disease in Singapore.

Design

National data were retrospectively extracted from medical records of community hospital.

Data Sources

There were 12,506 first admissions for rehabilitation in four community hospitals. Of which, 8,594 (90.3%) patients were discharged home and 924 (9.7%) patients were discharged to a nursing home. Other discharge destinations such as sheltered home (n = 37), other community hospital (n = 31), death in community hospital (n = 12), acute hospital (n = 1,182) and discharge against doctor’s advice (n = 24) were excluded.

Outcome Measure

Nursing home placement.

Results

Those who were discharged to nursing home had 33% lower median rehabilitation effectiveness and 29% lower median rehabilitation efficiency compared to those who were discharged to nursing homes. Patients discharged to nursing homes were significantly older (mean age: 77 vs. 73 years), had lower mean Bathel Index scores (40 vs. 48), a longer median length of stay (40 vs. 33 days) and a longer time to rehabilitation (19 vs. 15 days), had a higher proportion without a caregiver (28 vs. 7%), being single (21 vs. 7%) and had dementia (23 vs. 10%). Patients admitted for lower limb amputation or falls had an increased odds of being discharged to a nursing home by 175% (p<0.001) and 65% (p = 0.043) respectively compared to stroke patients.

Conclusions

In our study, the odds of nursing home placement was found to be increased in Chinese, males, single or widowed or separated/divorced, patients in high subsidy wards for hospital care, patients with dementia, without caregivers, lower functional scores at admission, lower rehabilitation effectiveness or efficiency at discharge and primary diagnosis groups such as fractures, lower limb amputation and falls in comparison to strokes.     

Cognitive and behavioural impairment among elderly people in institutions providing different levels of care.

OBJECTIVE: To compare the prevalence and degree of cognitive and behavioural impairment in elderly patients in institutions providing different levels of care. DESIGN: Prevalence study. SETTING: A nursing home, a home for the aged and psychogeriatric wards in a provincial psychiatric hospital. PATIENTS: Only subjects 65 years of age or older were eligible for inclusion. A random sample was selected comprising 25% of the residents in the nursing home and the home for the aged; of the 119 asked to participate 95 agreed (44 in the nursing home and 51 in the home for the aged). All 50 on the psychogeriatric wards agreed to participate. MAIN OUTCOME MEASURES: The Mini-Mental State Examination (MMSE) and the Kingston Dementia Rating Scale (KDRS). RESULTS: An MMSE score of less than 24 (cognitive impairment) was given to 37 (84%) of the residents in the nursing home, 43 (84%) of those in the home for the aged and 48 (96%) of the patients in the psychiatric hospital; the corresponding numbers for a KDRS score of more than 0 (cognitive impairment) were 41 (93%), 48 (94%) and 50 (100%). The seven patients receiving the highest level of care at the home for the aged (special care) had more behavioural problems than those in the psychiatric hospital did (p less than 0.001). CONCLUSIONS: Cognitive and behavioural impairment was widespread in the three institutions regardless of the level of care. When planning services and allocating resources government funding agencies should consider the degree and prevalence of such impairment among elderly people in institutions.     

A Systematic Review of Interventions to Change Staff Care Practices in Order to Improve Resident Outcomes in Nursing Homes

Background

We systematically reviewed interventions that attempted to change staff practice to improve long-term care resident outcomes.

Methods

Studies met criteria if they used a control group, included 6 or more nursing home units and quantitatively assessed staff behavior or resident outcomes. Intervention components were coded as including education material, training, audit and feedback, monitoring, champions, team meetings, policy or procedures and organizational restructure.

Results

Sixty-three unique studies were broadly grouped according to clinical domain—oral health (3 studies), hygiene and infection control (3 studies), nutrition (2 studies), nursing home acquired pneumonia (2 studies), depression (2 studies) appropriate prescribing (7 studies), reduction of physical restraints (3 studies), management of behavioral and psychological symptoms of dementia (6 studies), falls reduction and prevention (11 studies), quality improvement (9 studies), philosophy of care (10 studies) and other (5 studies). No single intervention component, combination of, or increased number of components was associated with greater likelihood of positive outcomes. Studies with positive outcomes for residents also tended to change staff behavior, however changing staff behavior did not necessarily improve resident outcomes. Studies targeting specific care tasks (e.g. oral care, physical restraints) were more likely to produce positive outcomes than those requiring global practice changes (e.g. care philosophy). Studies using intervention theories were more likely to be successful. Program logic was rarely articulated, so it was often unclear whether there was a coherent connection between the intervention components and measured outcomes. Many studies reported barriers relating to staff (e.g. turnover, high workload, attitudes) or organizational factors (e.g. funding, resources, logistics).

Conclusion

Changing staff practice in nursing homes is possible but complex. Interventionists should consider barriers and feasibility of program components to impact on each intended outcome.     

The association between circadian rest-activity patterns and the behavioral and psychological symptoms depending on the cognitive status in Japanese nursing-home residents

ABSTRACT

Background: Limited information is available on the relationship between sleep disturbances during nighttime and the behavioral and psychological symptoms of dementia in older nursing-home residents. However, a few reports on the association between the circadian rest-activity rhythm and the behavioral and psychological symptoms of dementia in older residents have been published. The main objective of the present study was to examine the association among the circadian rest-activity rhythm, behavioral and psychological symptoms, and the cognitive function status among older individuals living in facilities. Method: The investigation was conducted from September 2017 to February 2018, and participants were recruited from five nursing homes in Akita prefecture, Japan, after obtaining patient agreement to participate in the study. To measure nonparametric circadian rest-activity parameters such as interdaily stability, intradaily variability, relative amplitude, mean of the least active 5-h period, and mean of the most active 10-h period, Actigraph devices were worn on the participants’ nondominant wrists continuously for seven days. The score or classification of the cognitive status and the severity of the behavioral and psychological symptoms of dementia (BPSD) were assessed using the clinical dementia rating (CDR) and the dementia behavior disturbance scale (DBD), respectively. The binomial logistic regression model was applied to clarify which kinds of circadian rest-activity parameters predicted the cognitive status in nursing home residents as well as the BPSD outcome. A multi-level model was also used to examine the association between the nonparametric rest-activity parameters and the BPSD outcome explained by the cognitive status among older individuals in facilities. Results: Seventy-seven participants (49 residents with dementia, and 28 residents without dementia) were included in this study. According to the binomial logistic regression analysis after adjusting for covariates, the classification of the cognitive status for older residents was associated with the DBD score (odds ratio, 1.22; 95% confidence interval [CI], 1.08, 1.38; p < 0.001), the IS (odds ratio, 0.01; 95% CI, 0.00, 1.00; p = 0.05) and the L5 (odds ratio, 0.99; 95% CI, 0.99, 1.00; p = 0.05). The results of a multi-level model also indicated that the IV at individual-level was significantly associated with the DBD score for nursing home residents, with the CDR score at cluster-level as an explanatory variable. As well, a significant association between the RA at individual level and the DBD score was observed in a multi-level model explained by the CDR score at cluster-level. Conclusion: Of these models, the multi-level model provided grounds for our proposal that the fragmentation or the amplitude of rest-activity parameters might be associated with the outcome of BPSD, considering the cognitive status of older individuals in different facilities. The findings offer practical insight into the prevention of BPSD and the improvement of rest-activity rhythms in rehabilitative care in nursing homes.     

Advances in the Conceptualization and Measurement of Health Care Empowerment: Development and Validation of the Health Care Empowerment Inventory

The Health Care Empowerment Model offers direction for the investigation of patient-controlled engagement and involvement in health care. At the core of the model is the construct of Health Care Empowerment (HCE), for which there exist no validated measures. A set of 27 candidate self-report survey items was constructed to capture five hypothesized inter-related facets of HCE (informed, engaged, committed, collaborative, and tolerant of uncertainty). The full item set was administered to 644 HIV-infected persons enrolled in three ongoing research studies. Exploratory and confirmatory factor analyses resulted in a two factor solution comprising four items each on two subscales: (1) HCE: Informed, Committed, Collaborative, and Engaged HCE ICCE) and (2) HCE Tolerance of Uncertainty (HCE TU). Subscale scores were evaluated for relationships with relevant constructs measured in the three studies, including depression, provider relationships, medication adherence, and HIV-1 viral load. Findings suggest the utility of this 8-item Health Care Empowerment Inventory (HCEI) in efforts to measure, understand, and track changes in the ways in which individuals engage in health care.     

Oral health promotion among older persons and their care providers in a nursing home facility

Objectives: To assess oral health status and oral health‐related quality of life (OHRQoL) of residents in an extended care facility and to assess the care providers’ oral health attitudes and knowledge. Methods: Participants included 137 residents (58.1% female, age range 32–94 years, 91% African–American) and 22 care providers. Residents received an oral examination and completed the Oral Health Impact Profile (OHIP‐14), an OHRQoL questionnaire. Care providers completed an oral health knowledge (OHK) questionnaire before and after the on‐site geriatric oral health education and training programme. Results: Oral examinations showed that 58% of the residents had extensive oral health needs. On the OHIP‐14, the mean severity was 9.2 (SD = 12.0), extent (number of items rated as ‘fairly often’ or ‘often’) was 1.2 (SD = 2.6) and prevalence (participants rating at least one item at least ‘fairly often’) was 37.8%. Most prevalent negative impact items were about ‘oral pain’, ‘appearance’ and ‘self‐consciousness’. Regarding OHK, caregivers’ knowledge improved following instruction from 65% correct on the pre‐test to 90% correct on the post‐test (p < 0.05). Subsequent to the eight in‐service workshops, providers reported that physical limitations, fear of getting bitten and time constraints were barriers to providing oral hygiene to their residents. Conclusion: Examination data showed a high level of dental needs among the majority of residents, accompanied by significantly reduced OHRQoL. Although care providers’ OHK improved following the geriatric service programme, they reported specific barriers regarding their provision of oral hygiene care to the residents.     

De Richtlijn Mondzorg voor zorgafhankelijke cliënten in verpleeghuizen, 2007: bittere noodzaak!

The oral health status of residents in Dutch nursing homes is rather poor, especially of those depending on caregivers for their oral health care. Moreover, when care dependency is rising, the provision of good oral health care becomes more difficult. With more elderly people still having (parts of) their natural teeth, the need for good oral health care is increasing even more. Therefore a specific guideline was developed. The ultimate aim of the guideline "Oral health care for dependent residents in long term care facilities" is to improve the oral health of nursing home residents. Oral health care needs to be incorporated in daily nursing home care routine and in the integral care plan of every resident. Attention is given to the importance of an adequate implementation of this guideline as well as to the necessity of research evaluating the effects of it's implementation.     

The Economics of Dementia-Care Mapping in Nursing Homes: A Cluster-Randomised Controlled Trial

Background

Dementia-care mapping (DCM) is a cyclic intervention aiming at reducing neuropsychiatric symptoms in people with dementia in nursing homes. Alongside an 18-month cluster-randomized controlled trial in which we studied the effectiveness of DCM on residents and staff outcomes, we investigated differences in costs of care between DCM and usual care in nursing homes.

Methods

Dementia special care units were randomly assigned to DCM or usual care. Nurses from the intervention care homes received DCM training, a DCM organizational briefing day and conducted the 4-months DCM-intervention twice during the study. A single DCM cycle consists of observation, feedback to the staff, and action plans for the residents. We measured costs related to health care consumption, falls and psychotropic drug use at the resident level and absenteeism at the staff level. Data were extracted from resident files and the nursing home records. Prizes were determined using the Dutch manual of health care cost and the cost prices delivered by a pharmacy and a nursing home. Total costs were evaluated by means of linear mixed-effect models for longitudinal data, with the unit as a random effect to correct for dependencies within units.

Results

34 units from 11 nursing homes, including 318 residents and 376 nursing staff members participated in the cost analyses. Analyses showed no difference in total costs. However certain changes within costs could be noticed. The intervention group showed lower costs associated with outpatient hospital appointments over time (p = 0^.05) than the control group. In both groups, the number of falls, costs associated with the elderly-care physician and nurse practitioner increased equally during the study (p<0^.02).

Conclusions

DCM is a cost-neutral intervention. It effectively reduces outpatient hospital appointments compared to usual care. Other considerations than costs, such as nursing homes’ preferences, may determine whether they adopt the DCM method.

Trial Registration

Dutch Trials Registry NTR2314     

An Approach to Patient Care Classification

Employing the principles of progressive patient care and using data obtained from charts, nurses and resident physicians, 265 patients on the wards of a teaching hospital were classified into one of six optimal levels of care by the resident physicians and also by an outside observer. It was assumed that facilities for the three alternatives to general hospital care, i.e. long-term hospital care, nursing care and sheltered care, were available in the community. It was also assumed that socio-economic factors presented no barrier to hospital discharge.The outside observer allocated 96 patients, approximately one-third, to the alternative facilities outside the general hospital. Those factors found to have statistically significant effects on assigned levels of care were the diagnoses, length of stay, region of residence, bed status, extent of nursing care, hospital service and discharge status. The residents allocated 60 patients, approximately one-fifth, to alternative facilities.The extent of agreement between the residents and the outside observer reached 81% for those to alternate versus general hospital care.This method could be used by nurses and residents to screen out those most suitable for care in alternate facilities.     

现代医学模式对发展整体护理的要求

探讨现代医学模式的转变以及整体护理的发展与现代医学模式的内在联系。     

Psychometric evaluation of the Orofacial Pain Scale for Non‐Verbal Individuals as a screening tool for orofacial pain in people with dementia

Objective

The aim of this study was to describe the psychometric evaluation of the Orofacial Pain Scale for Non‐Verbal Individuals (OPS‐NVI) as a screening tool for orofacial pain in people with dementia.

Background

The OPS‐NVI has recently been developed and needs psychometric evaluation for clinical use in people with dementia. The pain self‐report is imperative as a reference standard and can be provided by people with mild‐to‐moderate cognitive impairment.

Methods

The presence of orofacial pain during rest, drinking, chewing and oral hygiene care was observed in people with mild cognitive impairment (MCI) and dementia using the OPS‐NVI. Participants who were considered to present a reliable self‐report were asked about pain presence, and in all participants, the oral health was examined by a dentist for the presence of potential painful conditions. After item‐reduction, inter‐rater reliability and criterion validity were determined.

Results

The presence of orofacial pain in this population was low (0%‐10%), resulting in an average Positive Agreement of 0%‐100%, an average Negative Agreement of 77%‐100%, a sensitivity of 0%‐100% and a specificity of 66%‐100% for the individual items of the OPS‐NVI. At the same time, the presence of oral problems, such as ulcers, tooth root remnants and caries was high (64.5%).

Conclusion

The orofacial pain presence in this MCI and dementia population was low, resulting in low scores for average Positive Agreement and sensitivity and high scores for average Negative Agreement and specificity. Therefore, the OPS‐NVI in its current form cannot be recommended as a screening tool for orofacial pain in people with MCI and dementia. However, the inter‐rater reliability and criterion validity of the individual items in this study provide more insight for the further adjustment of the OPS‐NVI for diagnostic use. Notably, oral health problems were frequently present, although no pain was reported or observed, indicating that oral health problems cannot be used as a new reference standard for orofacial pain, and a regular oral examination by care providers and oral hygiene care professionals remains indispensable.