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Biomedical subjects

J G Ouslander

Publications and source records attributed to J G Ouslander.

At least 55 records · Page 3Linked to original sources
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.

Activities of Daily Living↗
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.

Activities of Daily Living↗
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.

Fecal Incontinence↗
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↗
PubMed1995

Does physical activity improve sleep in impaired nursing home residents?

OBJECTIVES: To determine if two physical activity programs of varying intensity would result in improved sleep among incontinent and physically restrained nursing home residents. DESIGN: Controlled trials of two physical activity programs. SETTING: Seven community nursing homes in the Los Angeles area. PARTICIPANTS: Residents were included if they had urinary incontinence or were physically restrained. Sixty-five subjects were studied. Mean age was 84.8 years, 85% were female, mean length of residency in the nursing home was 19.9 months, and mean Mean Mini-Mental State Exam score was 13.1. INTERVENTION: The first physical activity program involved sit-to-stand repetitions and/or transferring and walking or wheelchair propulsion. These activities were performed every 2 hours during the daytime, 5 days per week for 9 weeks. The second, less frequent physical activity program involved rowing in a wheelchair-accessible rowing machine plus walking or wheelchair propulsion once per day three times per week for 9 weeks. MEASUREMENTS: The physical function measures reported here include mobility endurance (maximum time walking or wheeling) and physical activity as measured by motion sensors (Caltrac). Nighttime sleep was estimated by wrist activity monitors. Nighttime sleep measures included total time asleep, percent sleep, average duration of sleep, and peak duration of sleep. Daytime sleep was measured by timed behavioral observations of sleep versus wakefulness performed every 15 minutes during the day. RESULTS: Nighttime sleep was markedly disrupted in both groups at baseline. Across all subjects at baseline, the average total sleep time was 6.2 hours and the percent sleep was 72.0%, but the average duration of sleep episodes was only 21.2 minutes and the peak duration of sleep episode averaged only 83.8 minutes. During the daytime, subjects were observed asleep during 14.5% of observations. Although there was improvement in mobility endurance in the intervention subjects compared with controls (MANOVA F = 4.36, P = .042), there were no differences in the night and day sleep measures at follow-up testing. Even among a subgroup of intervention subjects who showed a 30% or greater improvement in mobility endurance, sleep did not improve at follow-up compared with baseline. CONCLUSION: This study supports our previous findings of marked sleep disruption in impaired nursing home residents. In addition, despite documented improvements in physical function with activity, we did not find improvements in sleep in the intervention versus control groups. These results suggest that increasing daytime physical activity alone is not adequate to improve sleep in impaired NH residents. Future efforts to improve sleep in this population should take into account the multifactorial nature of sleep disruption, including individual health problems that effect sleep and the disruptive nature of the nighttime NH environment.

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PubMed1995

A cost and value analysis of two interventions with incontinent nursing home residents.

OBJECTIVE: More than half of nursing home residents suffer from urinary incontinence. These residents typically have long stays and, because of comorbid cognitive and physical impairments, have little hope of living again in a noninstitutional environment The value of interventions to change functional status of this chronically institutionalized population is often questioned. This paper explores this value issue in the context of two incontinence management interventions that have been shown to improve functional status: (1) Functional Incidental Training (FIT), and (2) Prompted Voiding (PV). The relative value of the different interventions for the nursing home population was estimated using paired preferences. DESIGN: The cost of two interventions (FIT and PV) that target incontinent nursing home residents was related to the value of these interventions as perceived by consumers of nursing home services. Both interventions decrease incontinence frequency, and one intervention also improves mobility endurance. PARTICIPANTS: Ninety incontinent nursing home residents received the intervention; 37 older nondemented board and care residents and 31 family members of the nursing home residents provided estimates of the intervention's value. MEASUREMENT: The staff-time allocations involved in implementing both interventions were documented in more than 85 resident care episodes. These time data were converted to labor cost based on the cost of nursing aides who would actually implement the intervention. The value of each intervention was assessed by asking consumers to make choices between the intervention and its associated outcomes (such as increased dryness) and other nursing home services of known cost (e.g., moving to a private room). RESULTS: Both interventions had labor costs that were greater than "usual care" costs. The additional cost was estimated to be $4.31 per resident per day for PV and $6.42 per resident per day for FIT if these programs were implemented from 7 AM to 7 AM. Consumer preference data indicated that consumers preferred the FIT and PV outcomes to more expensive alternative services, calculated to cost $10.00 per day, often marketed to consumers, CONCLUSION: Consumers may prefer the FIT and PV interventions relative to the typical services often marketed to the nursing home consumer. The analysis completed in this paper suggests that both interventions have value for frail residents likely to live out their lives in a nursing home.

Activities of Daily Living↗
PubMed1995

Accuracy of rapid urine screening tests among incontinent nursing home residents with asymptomatic bacteriuria.

OBJECTIVE: To determine the accuracy of rapid urine screening tests in detecting bacteriuria among incontinent nursing home residents. SETTING: Six nursing homes. PARTICIPANTS: 214 chronically incontinent, but otherwise asymptomatic, nursing home residents who were enrolled in a clinical intervention trial for urinary incontinence. MEASUREMENTS: 684 urine specimens were collected, the majority (76%) by a clean catch technique and the remainder by in-and-out catheterization. Each specimen underwent dipstick testing for nitrite and leukocyte esterase, a rapid, enzyme-based screening test for bacteriuria, and a quantitative urine culture using standard laboratory techniques. RESULTS: No one screening test or combination of tests had adequate sensitivity and specificity for clinical purposes. However, using all three tests, the sensitivity increases to 97% in females and 92% in males when any one of the tests is positive, and the specificity increases to 95% in females and 97% in males when all three tests are negative. Among nursing home residents suspected of having a symptomatic urinary tract infection, the prevalence of bacteriuria is probably higher than in our study population (e.g., 60-70%, compared with 32%). At these prevalence rates, the positive predictive value of any of the three tests being positive is 93% and higher, and the negative predictive value of all three tests being negative is 80 to 90%. CONCLUSIONS: Our data must be interpreted cautiously because of the specimen collection methods, the definitions we used, and the fact that we studied a population who did not have symptoms of an acute urinary tract infection. In addition, we did not examine the absolute accuracy of the screening tests, but their accuracy as a clinician might use them in a nursing home. Despite these caveats, our data suggest that a combination of these screening tests could be useful in the initial assessment of nursing home residents for bacteriuria, and result in considerable cost savings. Studies are needed to replicate our findings among nursing home residents with symptomatic urinary tract infections.

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PubMed1995

Does oxybutynin add to the effectiveness of prompted voiding for urinary incontinence among nursing home residents? A placebo-controlled trial.

OBJECTIVE: To determine if oxybutynin, a bladder relaxant medication, adds to the effectiveness of prompted voiding (PV) in the management of urinary incontinence among nursing home residents. DESIGN: Randomized, placebo-controlled, double-blinded, dose-adjusted, crossover trial of oxybutynin added along with PV. SETTING: Seven nursing homes in Los Angeles County, California. PARTICIPANTS: Seventy-five nursing home residents with predominantly urge incontinence, whose incontinence did not respond well to a trial of PV. MAIN OUTCOME MEASURES: The frequency of incontinence, measured as the percentage of hourly (7 AM to 7 PM) physical checks over a 3-day period at which the resident was found wet. RESULTS: Sixty-three (84%) of the residents completed the study. Among those completing the trial, the percent of checks wet went from 26.5% to 23.7% on placebo to 20.2% on active drug. These changes were statistically significant but not clinically meaningful. A clinically significant decrease in the frequency of incontinence, which we defined as a relative reduction in the percent of checks wet of > 33%, occurred in 20 subjects (32%) while on active drug and in 12 subjects (19%) while on placebo (P = .48 by chi-square). Twenty-five subjects (40%) met our "continence criteria" of an average of one or less wet per day while on active drug, and 11 subjects (18%) achieved this goal on placebo (P = .005 by chi-square). CONCLUSION: Oxybutynin does not add to the clinical effectiveness of PV in the majority of nursing home residents with urge type urinary incontinence. Selected residents may, however, become more responsive to PV while on oxybutynin. Our data are consistent with other studies of bladder relaxant medications in functionally impaired populations. New drugs and/or other interventions are needed for the large number of incontinent nursing home residents who do not respond well to PV.

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PubMed1995

Urine specimen collection from incontinent female nursing home residents.

OBJECTIVE: To determine if a clean catch technique can accurately diagnose bacteriuria among incontinent female nursing home residents. DESIGN: Cultures and dipstick screening test results from paired urine specimens, one collected by a clean catch technique and the other collected by sterile in-and-out catheterization, were compared. PARTICIPANTS: A total of 101 incontinent female nursing home residents who were being assessed for participation in a larger clinical intervention trial for incontinence. MEASUREMENTS: Each urine was tested by a dipstick method for leukocyte esterase and nitrite and sent to a bioclinical laboratory for quantitative culture. RESULTS: Positive and negative culture results matched in 92 of the 101 paired specimens. Using the catheter specimen as a gold standard, the clean catch had a sensitivity of 90%, specificity of 92%, positive predictive value of 81%, and a negative predictive value of 95%. In a population with symptoms suggestive of infection, among whom the prevalence of bacteriuria would likely be higher than in the asymptomatic residents we studied (e.g., 60% vs 30%), the positive predictive value would increase to 95%, but the negative predictive value would decrease to 86%. The concordance of the results of the urine screening tests was not as good, except for the detection of a positive leukocyte esterase test and a negative nitrite test. CONCLUSION: Incontinent female nursing home residents do not necessarily have to be catheterized in order to obtain an accurate quantitative urine culture. Our results using a careful clean catch technique are comparable to those previously reported using urine obtained from a urine-soiled diaper as well as those using a condom catheter technique in men.

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PubMed1994

Physician evaluation and management of nursing home residents.

The diverse goals of nursing home care, the heterogeneity of nursing home residents, and the varied circumstances under which physicians care for them make their evaluation and care complex and challenging. When evaluating and caring for nursing home residents, physicians must address many issues besides treatment of multiple chronic diseases (including impairments in cognitive and physical functioning, sensory deficits, depression, and behavioral disorders associated with dementia) and concerns of family members. The physician should be integrated with an interdisciplinary team composed of nurses, rehabilitation therapists, social workers, and others. Recently implemented federal rules for nursing home care, which include the Minimum Data Set and Resident Assessment Protocols, provide a useful framework for interdisciplinary assessment and care planning and should improve the care nursing home residents receive. Better data are needed on the most cost-effective strategies for evaluating and caring for nursing home residents. Reimbursement for physician services, availability of nurse practitioners and physician assistants, and overall quality of nursing home care must be improved so physicians can better achieve the recommendations outlined.

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PubMed1994

How informed can consent be? New light on comprehension among elderly people making decisions about enteral tube feeding.

Elderly people in long-term care facilities do not understand much about various medical procedures, including enteral feeding. After presentation of empirically precise information about enteral tube feeding, residents in both long-term care and community-dwelling groups showed significant improvement in their understanding. The community-dwelling group showed even greater improvement. For both, comprehension was negatively related to age and depression scores, but positively related to IQ, reading comprehension, social support, and mental status. The MMSE proved the best predictor of comprehension. Implications of the results are discussed.

Advance Directives↗