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J G Ouslander

Publications and source records attributed to J G Ouslander.

At least 19 recordsLinked to original sources
PubMed1997

Policy without technology: a barrier to improving nursing home care.

Standards of care are written for nursing homes without a realistic assessment of whether there is an intervention protocol or resources to meet these standards. This situation produces unfair pressures on nursing home providers, who react with paper compliance strategies, and creates a barrier to implementing new interventions that do meet care standards once they are developed. This article explores this barrier and illustrates examples of interventions that have been attempted in nursing homes using a continuous quality improvement model. The development of quality indicators based on assessment data available in all nursing homes is a step toward making the survey process more focused on outcomes rather than on paper compliance. Much more research is needed to design effective clinical interventions and to provide nursing homes with the technologies necessary to target them. Internal nursing home quality assurance programs based on principles of continuous quality improvement, with reinforcement from the external survey process, are suggested as a strategy to maintain clinically effective interventions. Applied research centers based in long-term care facilities should be supported in order to accomplish such research designed to improve the care and quality of life our increasing frail nursing home population.

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PubMed1997

Selecting nursing home residents for satisfaction surveys.

Many cognitively impaired nursing home (NH) residents are excluded from interviews measuring quality of life or care based on the belief that these residents cannot accurately answer questions. These exclusions are based on subjective criteria and ignore individual differences among cognitively impaired NH residents. This study describes a screening rule based on four minimum data set (MDS) indicators that provides an objective method for identifying residents capable of accurate report. Sixty percent of a sample of 83 NH residents who could answer yes or no questions about their care could do so accurately. Eighty-one percent of the sample was correctly classified by the MDS indicators.

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PubMed1997

Aging and the lower urinary tract.

Lower urinary tract symptoms and disorders are prevalent and bothersome in the rapidly growing aging population. Common symptoms include urinary frequency, nocturia, urgency, and incontinence. Among older men, symptoms of voiding difficulty, such as hesitancy, slow stream, and straining, are also common. A variety of aging changes, as well as age-associated disease, predispose older people to the development of lower urinary tract symptoms. Medications used to treat conditions outside the lower urinary tract also can contribute to these symptoms. Physicians and other health professionals should routinely ask specific questions about lower urinary tract symptoms in their older patients and evaluate them thoroughly when they are present.

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PubMed1997

Postmenopausal vaginal atrophy and atrophic vaginitis.

Menopause is associated with a marked reduction in endogenous estrogen production. Lower levels of circulating blood estrogen have various deleterious effects, including those on the lower urinary tract. The vaginal epithelium becomes atrophied and dry, which can cause vaginal discomfort, itching, and dyspareunia. The epithelium may become inflamed and contribute to urinary symptoms, including frequency, urgency, dysuria, and incontinence. Diminished estrogen effects on periurethral tissues can contribute to pelvic laxity and stress incontinence. Changes in vaginal pH and normal flora may predispose older women to urinary tract infection. Although estrogen replacement therapy can result in maturation of the vaginal epithelium, the optimal form of administration and the dosage regimen for improving symptoms and quality of life of the geriatric female population have not been well studied.

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PubMed1997

Skin disorders and moisture in incontinent nursing home residents: intervention implications.

OBJECTIVE: To provide data needed to design an intervention trial to prevent or treat skin disorders in a high risk, incontinent nursing home population. DESIGN: The incidence and prevalence of nine common skin disorders were measured prospectively over a 60-day period using trained observers. Urinary and fecal incontinence frequency were measured over 24 hours, and mobility was measured with subjects both in and out of bed. Direct measures of skin moisture were taken with an impedance device in the presence and absence of urinary incontinence. Multiple regression analyses were used to relate the incontinence and mobility variables to the presence and development of skin disorders. SETTING: Four nursing homes. PARTICIPANTS: One hundred incontinent nursing home residents. MAIN OUTCOME MEASURES: Prospective measures of nine common skin disorders and skin moisture in four perineal regions under continent and incontinent conditions. RESULTS: All subjects had at least one skin condition identified during the 60-day data collection period. The most commonly observed skin condition was blanchable erythema, which occurred in 94% of the subjects, predominantly in the front and back regions that were closest to the urethra and rectum. Twenty-one percent of residents developed either a Stage 1 (nonblanchable erythema) or 2 pressure ulcer. All skin conditions were transient when measured every 3 weeks with the exception of blanchable erythema, which showed stability. Stage 3 or greater pressure ulcers and edema were not observed, and interrater reliability for the measure of papules was poor. Measures of urinary and fecal incontinence severity were correlated with blanchable erythema severity, and blanchable erythema and low bed mobility were predictive of pressure ulcer severity. Blanchable erythema severity was also predictive of Stage 1 and 2 pressure ulcers. Skin moisture levels in the back perineal farthest from the rectum (peripheral) were affected most by urinary incontinence. CONCLUSION: A trial to detect a 50% preventive effect on Stage 1 and 2 pressure ulcers would require that 167 subjects be monitored for 60 days. The transient nature of the skin effects require that skin be monitored at least once a week. Because blanchable erythema is so prevalent and appears to be associated with more severe skin conditions, it would make an excellent marker for beginning to assess the potential preventive effects of various interventions on the incidence of pressure ulcers and other related skin disorders in incontinent patients. It is likely that the back area peripheral to the urethra and rectum would experience the greatest benefit from an intervention trial to reduce moisture caused by incontinence.

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PubMed1996

Perioperative care in the elderly urologic patient.

This article summarizes the preoperative evaluation and postoperative care recommended for elderly patients undergoing urologic procedures. Most of the common issues faced during the perioperative period are discussed, but many other topics require reference to other sources or consultation with specialists. A thorough preoperative evaluation is needed, and meticulous attention to postoperative care is mandatory. The most important common problem is assessment of cardiovascular risk in patients and a general approach is suggested by the authors. Surgical risk in elderly patients is increased, but most of this excess risk is because of associated comorbid conditions. Effective pre- and postoperative assessment and care can minimize this risk and maximize the chances of a successful outcome.

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PubMed1996

Exercise with physically restrained nursing home residents: maximizing benefits of restraint reduction.

OBJECTIVE: To evaluate an exercise protocol designed to improve strength and mobility, and to decrease injury risk factors in physically restrained nursing home residents. DESIGN: A randomized controlled trial. PARTICIPANTS: Ninety-seven residents were randomized into either exercise or control groups. Thirty-five exercise and 37 control group residents completed all post-assessments after a 9-week trial. INTERVENTION: Walking or wheelchair movement training was supplemented by rowing exercise three times per week. Practice in behaviors related to safe movement was provided incidental to the exercise. MEASUREMENT: Endurance, speed, and injury risk measures relevant to walking, wheelchair propulsion, and standing were assessed by standardized protocols. Rowing endurance, rowing range of motion, and handgrip strength measures were collected to assess the effect of the rowing component of the exercise protocol. RESULTS: Fifty-four percent of the subjects who provided consent did not complete the protocol because of health status changes, lack of cooperation, or physical limitations that precluded exercise. The subjects who completed the exercise program showed significant improvement on injury risk and measures related to upper body strength (handgrip strength, rowing endurance, wheelchair endurance, and speed). Measures related to lower body strength did not significantly improve. CONCLUSION: Physically restrained residents are very frail, and it is difficult to implement a long-term exercise program with many residents because of the frailty. However, a substantial proportion of residents did cooperate well with the exercise program and showed improvement on measures correlated with decreased injury risk. The exercise program could be easily modified to include more lower body exercise, and the resultant protocol would be an important adjunct to restraint reduction programs.

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PubMed1996

A walking program for nursing home residents: effects on walk endurance, physical activity, mobility, and quality of life.

OBJECTIVES: To determine the effects of a 12-week walking program on walk endurance capacity, physical activity level, mobility, and quality of life in ambulatory nursing home residents who had been identified as having low physical activity levels and low walk endurance capacities. To determine the effects of 12 versus 22 weeks of walk training on walk endurance capacity, physical activity level, mobility, and quality of life in ambulatory nursing home residents. DESIGN: Experiment 1: Residents of one nursing home campus were assigned to the walking program, and residents of a second campus were assigned to the social visit control group. Outcome measures were taken before and after 12 weeks. Experiment 2: Pretest/posttest with outcome measures taken before and, again, after 12 and 22 weeks of walking. SETTING: Two campuses of the Jewish Homes for the Aging in the Los Angeles area. PARTICIPANTS: Experiment 1: Nineteen of 22 residents in the walking group completed the walking program, and 12 of 15 residents in the control group completed the study. Experiment 2: Thirty of 41 residents (from the two nursing homes) completed the 22-week walking program. INTERVENTION: Experiment 1: The walking program involved each resident walking with research staff at his/her self-selected walking pace, 5 days per week for 12 weeks, for a maximum of 30 minutes per day; while the control group had weekly individual social visits, which lasted 30 minutes, from a research assistant. Experiment 2: All residents, those in both the walking and the control group, were offered the opportunity to complete 22 weeks of walking. MAIN OUTCOME MEASURES: Maximal walk endurance capacity, the resident's maximum walk time performed in a single day of walking (distance and speed also were measured); physical activity level based on time-sampled observations and physical activity monitors; mobility as measured with the Timed-Up-and-Go test, left handgrip strength, and Tinetti's Mobility Assessment; and quality of life as assessed with the Geriatric Depression Scale (a bodily pain scale) and the Dartmouth Primary Care Cooperative Information Project (COOP) physical work chart. RESULTS: Experiment 1: The walking group significantly improved their maximal walk endurance time by 77% and distance by 92%, with no significant change in walk speed; however, the control group showed no significant changes in these variables. There were no significant group by time interactions on measures of physical activity, mobility, and quality of life. Experiment 2: No further significant changes were found from 12 to 22 weeks in walk endurance capacity, physical activity, mobility, or quality of life. CONCLUSION: Twelve weeks of daily walking at a self-selected walking pace by ambulatory nursing home residents produced significant improvements in walk endurance capacity. No other significant changes were noted in physical activity level, mobility, or quality of life in either group after the intervention. Also, there were no side effects, such as increases in falls or cardiovascular complications, due to the walking intervention. Lengthening the walking program to 22 weeks produced no further significant changes in any outcome measures.

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PubMed1996

Pyuria among chronically incontinent but otherwise asymptomatic nursing home residents.

OBJECTIVE: To determine the prevalence of pyuria and its relationship to bacteriuria in a representative sample of chronically incontinent nursing home residents. DESIGN: Prospective, descriptive case series. SETTING: Six nursing homes. PARTICIPANTS: Two hundred fourteen chronically incontinent, but otherwise asymptomatic, nursing home residents who were enrolled in a clinical intervention trial for urinary incontinence. MEASURES: Two hundred fourteen urine specimens were collected by a validated clean catch technique. Each specimen underwent dipstick testing for leukocyte esterase, microscopic urinalysis to determine the number of white blood cells per high power field of centrifuged urine, and quantitative urine culture using standard laboratory techniques. RESULTS: The overall prevalence of pyuria was 45%, as defined by > 10 white blood cells per high field of spun urine, and the overall prevalence of bacteriuria was 43%, as defined by the growth of > 100,000 colony forming units of a urinary pathogen. Fifty-nine percent of the specimens with bacteriuria and 34% of the specimens without bacteriuria had pyuria. Of specimens with pyuria, 56% had bacteriuria, and of specimens without pyuria, 31% had bacteriuria. When any colon change on the leukocyte esterase pad was considered positive, this finding had a sensitivity of 83% and a specificity of 52% for pyuria on microscopic urinalysis. CONCLUSIONS: Pyuria is common among chronically incontinent nursing home residents, both in the presence and absence of bacteriuria. Clinicians must therefore be cautious in interpreting the presence of pyuria to indicate symptomatic infection in this population. Using pyuria to determine the need for antimicrobial treatment could result in unnecessary expense and morbidity as well as contribute to the development of resistant organisms in nursing homes. Research is needed to define pyuria better, to determine its prevalence and relationship to bacteriuria among nursing home residents with symptoms of acute urinary tract infection, and to elucidate the etiology and significance of sterile pyuria in this population.

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PubMed1996

Effects of prompted voiding on fecal continence among nursing home residents.

OBJECTIVE: To determine the effects of prompted voiding on fecal continence in nursing home residents. DESIGN: Prospective, uncontrolled trial of prompted voiding for urinary incontinence. PARTICIPANTS: One hundred sixty-five nursing home residents who completed a 9 to 10-week trial. MEASUREMENTS: Trained research aides performed physical checks for urinary and fecal incontinence hourly from 8 AM to 6 PM for 3 days (total of 33 checks) at baseline, for the last 3 days of a 1-week trial of prompted voiding, and after 9 to 10 weeks of prompted voiding. RESULTS: After 9 to 10 weeks of prompted voiding, there was no significant change in the frequency of incontinent bowel movements per resident (1.1 [95% CI.83, 1.4] to .87 [95% CI.67, 1.1]; P = 0.140). There was a significant increase in the number of continent bowel movements per resident (.17 [95% CI.10, .24] to .62 [95% CI.45, .80]; P = .000). This increase occurred in residents whose urinary incontinence responded well to prompted voiding as well as those whose urinary incontinence did no respond. The percentage of bowel movements that were continent also increased significantly from 18% (95% CI 8,29) at baseline to 45% (95% CI 32,57) after 9 to 10 weeks of intervention (P = .000). In addition to these findings, we noted a marked increase in the total frequency of bowel movements after the first week of prompted voiding. This may have resulted from the relief of fecal impactions caused by the increased toileting, mobility, and fluid intake that occurred with prompted voiding. CONCLUSION: Prompted voiding did not change the frequency of incontinent bowel movements significantly in this sample of nursing home residents. However, the number of continent bowel movements and the percentage of bowel movements that were continent did increase. Our data must be interpreted cautiously because our study was designed primarily as an intervention for urinary, not fecal, incontinence and the design was neither blinded nor controlled. Trials of systematic toileting schedules specifically directed at fecal incontinence, with attention to fecal impaction, diet, fluid intake and laxative use, should be conducted.

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PubMed1995

Does eradicating bacteriuria affect the severity of chronic urinary incontinence in nursing home residents?

OBJECTIVE: To determine the effects of eradicating otherwise asymptomatic bacteriuria on the severity of chronic urinary incontinence among nursing home residents. DESIGN: Residents were categorized as nonbacteriuric or bacteriuric on the basis of urine cultures. Bacteriuric residents were then randomly assigned to immediate and delayed treatment groups. The delayed treatment group was included to control for spontaneous changes in the severity of incontinence. The immediate treatment group received antimicrobial therapy for 7 days; after outcome measures had been repeated, the delayed treatment group was treated. SETTING: 6 community-based nursing homes. PATIENTS: Nursing home residents with chronic urinary incontinence. MEASUREMENTS: The frequency and volume of urinary incontinence were determined by physical checks for wetness by trained research aides hourly between 7 a.m. and 7 p.m. for 3 days in all patient groups (non-bacteriuric, bacteriuric with immediate treatment, and bacteriuric with delayed treatment) at baseline, after the immediate treatment group was treated, and again after the delayed treatment group was treated. RESULTS: 191 residents were enrolled, and 176 completed the study. Bacteriuria was eradicated by antimicrobial therapy in 71 residents (40%), and 17 residents (10%) had bacteriuria before and after therapy. The percentage of hourly checks at which the residents were found wet and other measures of incontinence severity remained essentially the same after bacteriuria was eradicated. In the nonbacteriuric group, the percentage of checks that were wet increased from 29% (95% CI, 26% to 32%) at baseline to 30% (CI, 27% to 34%) on repeated measurement. In the bacteriuric groups, the percentage increased from 34% (CI, 30% to 38%) before treatment to 35% (CI, 31% to 39%) after bacteriuria was eradicated. The presence of pyuria did not affect the results. CONCLUSION: Eradicating bacteriuria has no short-term effects on the severity of chronic urinary incontinence among nursing home residents. Our data support the practice of not treating asymptomatic bacteriuria in this population and validate the recommendations in the Health Care Financing Administration's Resident Assessment Protocol for urinary incontinence.

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PubMed1995

Predictors of successful prompted voiding among incontinent nursing home residents.

OBJECTIVE: To develop a simple, noninvasive assessment strategy that will enable nursing home staff to identify incontinent residents who respond well to prompted voiding. DESIGN: Incontinent nursing home residents underwent an extensive clinical and functional assessment and then 7 days of prompted voiding. Data from the assessment and the first 3 days of prompted voiding were used to predict responsiveness to the intervention. SETTING: Seven nursing homes. PATIENTS: A cohort of 191 incontinent, long-stay nursing home residents who passed a simple behavioral screen (able to state their name or reliably point to one of two named objects). INTERVENTION: Prompted voiding was carried out by trained research nurse's aides from 7 AM to 7 PM for 7 days. The intervention was maintained in responsive residents 5 days per week for an additional 9 weeks. MAIN OUTCOME MEASURES: Physical checks for wetness were done by research staff hourly from 7 AM to 7 PM for 3 days in a baseline condition, during days 5 through 7 of the 7-day prompted voiding intervention, and for 3 days at the end of 9 weeks of prompted voiding in the responsive group. Outcome measures were percentage of checks wet and response to prompted voiding, with "responders" defined as residents with an average of one or fewer wet episode per day on days 5 through 7 of prompted voiding. RESULTS: Seventy-eight (41%) of the residents were responders. Their wet percentage went from 26.7% to 6.4% at the end of 1 week and was maintained at 9.6% after 9 weeks of prompted voiding. The best predictors of responsiveness were the wet percentage and the appropriate toileting percentage during the first 3 days of prompted voiding, the self-care subscale score of the Multidimensional Observational Scale for the Elderly, and the ability to ambulate without human assistance. The best sensitivity and specificity in identifying responders was achieved when either the wet percentage was lower than 20% or the appropriate toileting percentage was higher than 66% during the first 3 days of prompted voiding (sensitivity, 87%; specificity, 69%). Those residents falsely identified as responders by these criteria still had a 46% relative reduction in wetness. CONCLUSIONS: A substantial proportion of nursing home residents respond well to prompted voiding. The most responsive residents can be easily identified using data collected during a 3-day trial of the intervention. The assessment strategy is consistent with federal guidelines and could be used to facilitate quality control by assessing changes in percentage of wetness from the expected norm.

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PubMed1995

Incontinence in the nursing home.

Urinary and fecal incontinence are prevalent, disruptive, and expensive health problems in the nursing home population. Nursing home residents who are incontinent of urine should have a basic diagnostic assessment, including a focused history and bladder record, a targeted physical examination, a urinalysis, and a determination of postvoid residual urine volume done by catheterization or ultrasonography. Potentially reversible conditions, such as fecal impaction and drug side effects, should be identified and treated. Selected residents should have further urodynamic evaluation or other diagnostic tests. Prompted voiding, a simple, noninvasive behavioral intervention, is effective in managing daytime urinary incontinence in one quarter to one third of incontinent nursing home residents. If it is to be effective over a long period of time, this intervention must be targeted to those residents most likely to respond. Selected nursing home residents will benefit from other behavioral interventions, drug therapy, or surgery. Because of the morbidity associated with it, long-term catheterization should only be used for specific indications. Like urinary incontinence, fecal incontinence may be caused by potentially reversible conditions. After such conditions have been excluded, fecal incontinence can generally be managed effectively by avoiding fecal impaction and by using a systematic bowel-training protocol.

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PubMed1995

The use of a computer-based model to implement an incontinence management program.

A computerized total quality management model was used to implement an incontinence system in eight nursing homes. Research staff measured resident wetness for one month, provided training in the implementation of the program in less than five days, and measured resident wetness for six months after implementation. Seven of the eight nursing homes significantly improved resident dryness for a six-month period. However, extensive monitoring of the nursing home computers by modem and telephone feedback from the research staff was necessary to produce successful maintenance.

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PubMed1995

Wheelchairs as mobility restraints: predictors of wheelchair activity in nonambulatory nursing home residents.

OBJECTIVE: The purpose of this paper is to describe factors affecting wheelchair mobility in nonambulatory nursing home (NH) residents. DESIGN: Prospective descriptive study of a convenience sample of nonambulatory NH residents. SETTING: Seven nursing homes. PARTICIPANTS: Sixty-five nonambulatory residents. MEASUREMENTS: One-minute, time-sampled observations of behavior for each resident were made every 15 minutes for 8 to 11 hours across 2 days, noting wheelchair propulsion activity for the dependent variable; independent variables included measures of wheelchair level of assistance, speed, endurance, handgrip strength, and balance. MAIN RESULTS: A stepwise Multiple Regression analysis found wheelchair speed to be the single best predictor of the percentage of time residents were behaviorally observed wheelchair propelling (Multiple r = .45, P < .02). Handgrip strength and wheelchair endurance measures were highly intercorrelated with wheelchair speed. Wheelchairs that were either dysfunctional or inappropriately fitted to the residents' size were a major barrier to wheelchair use, affecting 46% of residents using wheelchairs. CONCLUSION: Improving wheelchair skills with targeted intervention programs, along with making chairs more "user friendly" (e.g., grip extensions on brakes, foot pedals that one can move without bending over), could result in more wheelchair propulsion with resultant improvements in the NH resident's independence, freedom of movement, and quality of life.

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PubMed1995

Functional Incidental Training, mobility performance, and incontinence care with nursing home residents.

OBJECTIVE: To determine if an exercise intervention, Functional Incidental Training (FIT), results in improvements in mobility endurance and physical activity when compared with prompted voiding (PV) among cognitively and mobility impaired nursing home residents. DESIGN: Residents from four nursing homes were randomized into either a PV only (PV) or a PV plus FIT (FIT) intervention group for 8 weeks. Research staff implemented all intervention and measurement protocols. PARTICIPANTS: Seventy-six incontinent nursing home residents completed all phases of the trial. MEASURES: The standing, walking, and wheelchair endurance, physical activity, and frequency of agitation of all residents were assessed before, during, and after the 8-week intervention. RESULTS: The average length of time that subjects could walk or wheel was 2.6 and 4.6 minutes, respectively, at baseline. There was a significant group x time interaction after intervention, with only the FIT group showing improvements in walking, wheelchair, and standing endurance (Manova F = 4.56, 2.62, and 5.98, respectively; P < .05 in all cases). The frequency with which agitation was observed showed a significant drop over time in both groups (F = 14.3, P < .001), with no significant group x time interaction. CONCLUSION: The FIT intervention, which requires 6 minutes more nurses' aide time than does PV, increases both physical activity and mobility endurance in extremely frail and deconditioned nursing home residents. The increased cost of this intervention must be evaluated both in terms of clinical outcomes and by the reality that the target group for this intervention is very frail and will continue to require nursing home care, even assuming an excellent response to the intervention.

Activities of Daily Living↗