Family members' preferences for nutrition interventions to improve nursing home residents' oral food and fluid intake

OBJECTIVES

To measure family members' preferences for nutrition interventions to improve the oral food and fluid intake of their relatives in a nursing home.

DESIGN

Cross-sectional descriptive.

SETTING

Three skilled nursing facilities in Southern California.

PARTICIPANTS

One hundred five residents from the three skilled nursing facilities and their respective family members.

MEASUREMENTS

A mailed questionnaire to family members that consisted of 15 forced-choice comparisons between six nutrition interventions. An assessment of oral food and fluid intake during mealtime for 3 days (nine meals) for each participant using direct observations and estimations of percentage consumed (0% to 100%) by trained research staff.

RESULTS

In order of most to least desirable, the family members preferred the following interventions to improve their relative's oral food and fluid intake: (1) improve quality of food; (2) improve quality and quantity of feeding assistance; (3) provide multiple small meals and snacks throughout the day; (4) place resident in preferred dining location; (5) provide an oral liquid nutritional supplement between meals; and (6) provide a medication to stimulate appetite. The average +/- standard deviation total percentage intake for residents whose family members reported that they thought their relative had a problem with their intake was 50%+/- 16%.

CONCLUSIONS

Family members prefer that other nutrition interventions be attempted before the use of oral supplements or pharmacological approaches. Family members perceive a need for interventions when residents consume, on average, only half of the food and fluid items provided during mealtime.

Effects of a controlled exercise trial on pain in nursing home residents

OBJECTIVES

To report preliminary data relevant to the effects of an exercise and toileting intervention on pain among incontinent nursing home (NH) residents.

DESIGN

A randomized controlled intervention trial.

SETTING AND PARTICIPANTS

Fifty-one incontinent residents in one skilled NH.

INTERVENTION

The intervention was implemented by research staff for a total of 4 times a day (every 2 hours), 5 days a week, for 32 weeks. Residents were provided with incontinence care and assistance to either walk or, if nonambulatory, wheel their chairs, and to repeat sit-to-stand movements.

MEASUREMENTS

Pain was measured in two ways at baseline and again at 32 weeks: (1) a count of the number of verbal expressions and pain behaviors during a standardized physical performance assessment; and (2) a modified Geriatric Pain Measure administered in a one-on-one interview format.

RESULTS

There were significant differences between intervention and control groups on all physical performance measures over time, with the intervention group remaining stable and the control group showing a significant decline in sit-to-stand, walking, and wheelchair propulsion endurance. Both groups showed mild to moderate pain at baseline according to each of the two pain measures, while there were no significant changes in pain reports between groups over time based on either measure. There was, however, a trend for pain to increase in the intervention group.

CONCLUSIONS

No significant changes in pain reports were attributable to exercise despite significant improvements in physical performance. In fact, there was a tendency for pain reports to increase with exercise. These preliminary findings suggest that exercise alone may be ineffective for pain management among incontinent NH residents. Care providers should consider that exercise to improve physical function may increase pain symptoms, requiring preemptive analgesia, other pain control strategies, or modified exercise techniques for this frail segment of the NH population.

Quality Assessment in Nursing Homes by Systematic Direct Observation: Feeding Assistance

Background. Direct observation of care is an important data source for nursing home (NH) quality assessment, especially in light of evidence that chart information is inaccurate or incomplete for many daily care areas. The purpose of this study was to describe a standardized feeding assistance observational protocol that is designed for routine use by external (survey teams) and internal (licensed NH staff) quality assurance personnel to (i) maximize the amount of useful information gained from relatively brief observational periods; (ii) provide specific rules of measurement, which allow for replication and valid comparisons between NHs; and (iii) provide specific scoring rules that allow defensible categorical statements to be made about feeding assistance care quality within the NH. Methods. Four feeding assistance care quality indicators (QIs) were defined and operationalized in this study for 302 long-term residents in 10 skilled NHs: (i) Staff ability to accurately identify residents with clinically significant low oral food and fluid intake during mealtime; (ii) Staff ability to provide feeding assistance to at-risk residents during mealtime; (iii) Staff ability to provide feeding assistance to residents identified by the Minimum Data Set as requiring staff assistance to eat; and (iv) Staff ability to provide a verbal prompt to residents who receive physical assistance at mealtimes. Results. There were significant differences between facilities for three of the four QIs. The proportion of participants in each facility where staff "failed" the QIs ranged as follows: (Quality Indicator i) 42% to 91%; (ii) 25% to 73%; (iii) 11% to 82%; and (iv) 0% to 100%. Conclusions. A standardized observational protocol can be used to accurately measure the quality of feeding assistance care in NHs. This protocol is replicable and shows significant differences between facilities with respect to accuracy of oral intake documentation and the adequacy and quality of feeding assistance during mealtimes.

Translating clinical research into practice: a randomized controlled trial of exercise and incontinence care with nursing home residents

OBJECTIVES

To examine clinical outcomes and describe the staffing requirements of an incontinence and exercise intervention.

DESIGN

Randomized controlled trial with blinded assessments of outcomes at three points over 8 months.

SETTING

Four nursing homes.

PARTICIPANTS

Two hundred fifty-six incontinent residents.

INTERVENTION

Research staff provided the intervention, which integrated incontinence care and exercise every 2 hours from 8:00 a.m. to 4:00 p.m. 5 days a week.

MEASUREMENTS

Average and maximum distance walked or wheeled, level of assistance required to stand, maximum pounds lifted by arms, fecal and urinary incontinence frequency, and time required to implement intervention.

RESULTS

Intervention residents maintained or improved performance whereas the control group's performance declined on 14 of 15 outcome measures. Repeated measures analysis of variance group-by-time significance levels ranged from P <.0001 to.05. The mean time required to implement the intervention each time care was provided was 20.7 +/- 7.2 minutes. We estimate that a work assignment of approximately five residents to one aide would be necessary to provide this intervention.

CONCLUSIONS

The incontinence care and exercise intervention resulted in significant improvement for most residents, and most who could be reliably interviewed expressed a preference for such care. Fundamental changes in the staffing of most nursing homes will be necessary to translate efficacious clinical interventions into everyday practice.

A comparison of methods to assess nursing home residents' unmet needs

PURPOSE

This paper compares three interview methodologies to assess nursing home (NH) residents' unmet needs with regard to activity of daily living (ADL) care.

DESIGN AND METHODS

The study was a survey of 70 residents across seven ADL care domains. The three types of interview methods included: (a) direct satisfaction questions about ADL care, (b) questions that compared residents' preferences about ADL care frequency or occurrence to perceptions of the ADL care delivered (discrepancy measure), and (c) open-ended questions that asked what residents wanted changed about ADL care.

RESULTS

Estimates of the proportion of residents with unmet needs were significantly higher with the discrepancy and open-ended measures as compared to the direct satisfaction measures across most ADL care domains (McNemar's Test; p <.05-p <.01).

IMPLICATIONS

The analysis of residents' responses to open-ended questions produced the most useful information for individualizing aspects of technical care and assessing the interpersonal quality of care, whereas the discrepancy questions elicited specific information useful for changing the frequency or occurrence of ADL care. Interview methodologies that directly ask residents questions about satisfaction with ADL care are the least useful for designing improvement interventions.

Accuracy of minimum data set in identifying residents at risk for undernutrition: oral intake and food complaints

OBJECTIVE

to evaluate the accuracy of nursing home (NH) staff in documenting two Minimum Data Set (MDS) items that are used to identify residents at risk for undernutrition, low oral intake and food complaints, using standardized observation and interview assessment protocols implemented by research staff.

DESIGN AND METHODS

MDS information related to low oral intake (item K4c: <75% of most meals) and complaints about the taste of food (item K4a) was compared to independent evaluations of low oral intake and food complaints for a random sample of 75 residents in two proprietary NHs within the same month that a complete MDS assessment was due for each participant. Direct observations were conducted by research staff during nine mealtime periods for 3 consecutive days according to a standardized mealtime observational protocol to estimate low oral intake; and, two one-on-one interviews with residents were conducted on two consecutive days using standardized questions to assess the stability of food complaints.

RESULTS

Research staff documentation based on direct observation and resident interviews showed a significantly larger number of residents being identified as potentially at risk for undernutrition due to low oral intake (73%) and/or stable complaints about the taste of food (32%) as compared with NH staff documentation of MDS items K4c (44%) and K4a (0%), respectively, within the same month. A total of 47% of the participants expressed stable complaints about some aspect of the NH food service (eg, variety, appearance, temperature).

CONCLUSION

The documentation of low oral intake and food complaints on the MDS was inaccurate and resulted in a significant underestimate of residents with either of these risk factors for undernutrition.

Improving food intake in nursing home residents with feeding assistance: a staffing analysis

BACKGROUND

Recommendations have been made to increase the number of nursing home (NH) staff available to provide feeding assistance during mealtime. There are, however, no specific data related to two critical variables necessary to estimate mealtime staffing needs: (1) How many residents are responsive to feeding assistance? (2) How much staff time is required to provide feeding assistance to these residents? The purpose of this study was to collect preliminary data relevant to these two issues.

METHODS

Seventy-four residents in three NHs received a 2-day, or six-meal, trial of one-on-one feeding assistance. Total percentage (0% to 100%) of food and fluid consumed during mealtime was estimated across 3 days during usual NH care and 2 days during the intervention. The amount of time that staff spent providing assistance and type of assistance (i.e., frequency of verbal and physical prompts) was measured under each condition.

RESULTS

One half (50%) of the participants significantly increased their oral food and fluid intake during mealtime. The intervention required significantly more staff time to implement (average of 38 minutes per resident/meal vs 9 minutes rendered by NH staff).

CONCLUSIONS

The time required to implement the feeding assistance intervention greatly exceeded the time the nursing staff spent assisting residents in usual mealtime care conditions. These data suggest that it will almost certainly be necessary to both increase staffing levels and to organize staff better to produce higher quality feeding assistance during mealtimes.

The identification of residents capable of accurately describing daily care: implications for evaluating nursing home care quality

PURPOSE

The goal of this study was to develop a method of identifying incontinent nursing home (NH) residents capable of providing accurate interview information about daily NH care.

DESIGN AND METHODS

In 177 incontinent NH residents from four facilities, selected Minimum Data Set (MDS) ratings were compared with two standardized, performance-based, cognitive screening instruments to predict which residents could accurately answer questions concerning receipt of daily incontinence and mobility care practices.

RESULTS

MDS ratings of activity of daily living performance and cognition significantly predicted residents' ability to accurately describe daily care practices. Performance-based measures of cognitive functioning did not outperform the MDS ratings. Selecting residents who scored two or more on four orientation items composing the MDS Recall subscale identified residents capable of accurately describing daily care practices with a sensitivity of 64% and a specificity of 75%.

IMPLICATIONS

The MDS-based criteria identified are a promising, objective method for selecting incontinent NH residents for interview to verify the occurrence of specific daily care practices.

An intervention to increase fluid intake in nursing home residents: prompting and preference compliance

OBJECTIVE

To evaluate a three-phase, behavioral intervention to improve fluid intake in nursing home (NH) residents.

DESIGN

Controlled clinical intervention trial.

SETTING

Two community NHs.

PARTICIPANTS

Sixty-three incontinent NH residents.

INTERVENTION

Participants were randomized into intervention and control groups. The intervention consisted of three phases for a total of 32 weeks: (1) 16 weeks of four verbal prompts to drink per day, in between meals; (2) 8 weeks of eight verbal prompts per day, in between meals; and (3) 8 weeks of eight verbal prompts per day, in between meals, plus compliance with participant beverage preferences.

MEASUREMENTS

Between-meal fluid intake was measured in ounces by research staff during all three phases of the intervention. Percentage of fluids consumed during meals was also estimated by research staff for a total of nine meals per participant (3 consecutive days) at baseline and at 8 and 32 weeks into the intervention. Serum osmolality, blood urea nitrogen, and creatinine values were obtained for all participants in one of the two sites at the same three time points.

RESULTS

The majority (78%) of participants increased their fluid intake between meals in response to the increase in verbal prompts (phase 1 to 2). A subset of residents (21%), however, only increased their fluid intake in response to beverage preference compliance (phase 3). There was a significant reduction in the proportion of intervention participants who had laboratory values indicative of dehydration compared with the control participants. Cognitive and nutritional status were predictive of residents' responsiveness to the intervention.

CONCLUSIONS

A behavioral intervention that consists of verbal prompts and beverage preference compliance was effective in increasing fluid intake among most of a sample of incontinent NH residents. Verbal prompting alone was effective in improving fluid intake in the more cognitively impaired residents, whereas preference compliance was needed to increase fluid intake among less cognitively impaired NH residents.

Measurement sensitivity and the Minimum Data Set depression quality indicator

PURPOSE

The purpose of this study was to determine the accuracy of the prevalence rating of depression in nursing homes as flagged on the Minimum Data Set (MDS) quality indicator report.

DESIGN AND METHODS

Research Staff measured depression symptoms and compared the results with the prevalence of disturbed mood symptoms documented by nursing home (NH) staff on the MDS in two samples of residents living in different NHs. The homes had been flagged on the nationally mandated MDS quality indicator report as having unusually low (Site 1) or high (Site 2) prevalence rates of depression.

RESULTS

The percentages of residents determined by research staff interview assessments to have probable depression in the two resident samples were not significantly different (49% vs. 55%, respectively) between homes. The staff in the home flagged on the MDS quality indicator report as having a high depression prevalence rate identified significantly more residents who also had scores indicative of probable depression on the resident interviews for follow-up mood assessments than did the home with a low quality indicator prevalence rate (78% vs. 25%, respectively).

IMPLICATIONS

The prevalence of the depression quality indicator may be more reflective of measurement processes than of depression outcomes. Factors that may affect the difference in detection rates are discussed.

Nutritional intake monitoring for nursing home residents: a comparison of staff documentation, direct observation, and photography methods

BACKGROUND

The current approach to assessing nutritional intake requires nursing home (NH) staff to document total percentage of food and fluid consumed at each meal. Because NH staff tend to significantly overestimate total food intake, methods need to be developed to improve the accuracy of food intake measurement.

OBJECTIVE

To compare three methods of assessing the nutritional intake of NH residents.

RESEARCH DESIGN

Validation Study.

SUBJECTS

Fifty-six NH residents in one facility.

MEASURES

Total percentage of food and fluid intake of each resident for each of nine meals, or all three meals for 3 consecutive days, was assessed by: (1) Nursing home staff chart documentation, (2) Research staff documentation according to direct observations, and (3) Research staff documentation according to photographs of residents' trays before and after each meal.

RESULTS

Research staff documentation of total intake and intake of all individual food and fluid items was similar for the direct observation and photography methods. In comparison with these two methods, NH staff documentation reflected a significant overestimate (22%) of residents' total intake levels. In addition, NH staff failed to identify the more than half (53%) of those residents whose intake levels were equal to or below 75% for most meals.

CONCLUSIONS

The photography method of nutritional assessment yielded the same information as direct observations by research staff, and both of these methods showed the intake levels of NH residents to be significantly lower than the intake levels documented by NH staff. The photography method also has several advantages over a documentation system that relies on an observer to be present to record food and fluid intake levels.

Strategies to measure nursing home residents' satisfaction and preferences related to incontinence and mobility care: implications for evaluating intervention effects

This study compared four different interview strategies to measure 111 incontinent nursing home residents' "met need" related to incontinence and mobility care. Strategies were compared on criteria related to ceiling effects and stability. Four methods were used: questions that used the term "satisfaction" and direct questions about preferences that did not use the term "satisfaction" and which could be translated into three indirect measures of met need. To facilitate a comparison among the four methods, a statement of satisfaction was interpreted as met need. All of these measures were then compared to direct observations of care processes. Residents were more stable in their reports indicating that their care needs were met than they were in their reports that their needs were not met. The direct satisfaction questions produced information most characterized by ceiling effects compared to information elicited by the preference questions. Despite high reported rates of met need as assessed by two of the four methods, direct observations revealed low frequencies of care provision.

The nighttime environment and incontinence care practices in nursing homes

OBJECTIVES

To determine the variability in noise, light, and incontinence care practices between nursing homes (NHs) and the association between these factors and residents' nighttime sleep.

DESIGN

Prospective descriptive study of a sample of incontinent NH residents.

SETTING

Ten nursing homes.

SUBJECTS

Two hundred twenty-five incontinent NH residents.

MAIN OUTCOME MEASURES

Measurements of residents' sleep by wrist actigraphs, bed mobility by pressure sensitive Kynar strips, and environmental noise and light changes were recorded by bedside monitors in consecutive 2-minute intervals for two 10-hour nighttime data collection periods (7 PM to 5 AM).

RESULTS

Forty-two percent of waking episodes lasting 4 minutes or longer were associated with noise, light, or incontinence care events. Twenty-two percent of waking episodes of 4 minutes or longer were associated with noise alone, 10% with light or light + noise, and 10% with incontinence care routines. Seventy-six percent of all incontinence care practices resulted in awakenings. There was variability between the 10 NHs, with the percentage of waking episodes associated with environmental events (noise, light, or incontinence care events) ranging from 23.6 to 66.0%.

CONCLUSION

Noise and incidents of incontinence care practices were associated with a substantial amount of sleep disruption in residents in all 10 nursing homes, even though there was variability between homes. Interventions minimizing such environmental events are needed to promote better sleep in incontinent NH residents.

Selection bias in samples of older twins? A comparison between octogenarian twins and singletons in Sweden

Twin studies are a powerful approach for estimating genetic and environmental influences in later life, but the usual requirement that both twins are alive may introduce a selection bias in gerontological studies relative to representative samples of nontwins. In the present study, samples of older twins and nontwins in Sweden were compared across the domains of vitality, well-being, physical and cognitive functioning, and health utilization to evaluate possible selection bias. One member of each twin dyad in the OCTO-Twin Study of intact twin pairs older than age 80 was randomly selected (N = 128) and compared with a population-based sample of nontwins (N = 324) from the OCTO Study. Multiple regressions adjusting for differences in demographic variables showed significant effects for twin status in only 3 of 20 comparisons. The results suggest that twin pairs surviving into very late life are similar to a representative sample of nontwins of the same age in health status and biobehavioral functioning. These findings support the generalizability of twin studies for understanding genetic and environmental influences on aging, health, and behavior.

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.

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.

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.

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.

The upstream sequences of the HSP82 and HSC82 genes of Saccharomyces cerevisiae: regulatory elements and nucleosome positioning motifs

We present the upstream sequences of HSP82 and HSC82, two closely related, but differentially regulated, heat-shock genes of Saccharomyces cerevisiae. Several dozen potential regulatory elements are identified within each upstream region; interestingly, only a few are conserved between the two genes. These include a consensus heat-shock element, an upstream repressor element, and a consensus TATA element. A search for motifs known actively to position nucleosomes in vitro revealed that such sequences are three- to seven-fold enriched within each promoter; a comparable enrichment is seen near the 3' end of each transcription unit. Located approximately 1100 bp upstream of HSC82 is an open reading frame (ORF) of 255 amino acids; approximately 800 bp upstream of HSP82 is an ORF of 132 amino acids. The latter ORF contains several conserved ankyrin motifs and appears to be expressed under normal growth conditions. Finally, we show by clamped homogeneous electric field gel electrophoresis that the two genetic loci map to different chromosomes: HSP82 to chromosome XVI and HSC82 to chromosome XIII. The sequences have been deposited in the GenBank database under Accession Numbers U20323 and U20349.

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.

Safety assessment for the frail elderly: a comparison of restrained and unrestrained nursing home residents

OBJECTIVE

To facilitate clinicians' judgement concerning physical restraint decisions by identifying potentially reversible injury risk factors that differentiate representative samples of restrained and unrestrained nursing home residents.

DESIGN

Comparison of restrained and unrestrained nursing home residents on a safety assessment for the frail elderly (SAFE) protocol.

SETTING

Long-term care facilities in the Greater Los Angeles Area.

PARTICIPANTS

One hundred eight physically restrained and 111 unrestrained nursing home residents.

INTERVENTION

None.

MAIN OUTCOME MEASURES

(1) Internal, Interrater, and test/retest reliability of the overall SAFE protocol and of the four major factors measured by SAFE; (2) The relationship of SAFE scores to expert judgment of resident injury risk; (3) Differences between large samples of restrained and unrestrained residents on specific SAFE score factors.

RESULTS

Two walking, one transition, and one judgment factor are reliably measured by the SAFE protocol. SAFE scores were significantly correlated with expert judgment of risk for injury and showed large differences between restrained and unrestrained residents, even after differences in ambulation ability between the two groups were accounted for.

CONCLUSION

The SAFE is a reliable protocol that measures behavioral factors related to falls and risk for injury among nursing home residents with a broad range of cognitive impairment. Factors that significantly differentiate restrained and unrestrained groups should be targeted for rehabilitation and remediation in physical restraint reduction efforts. Removing or changing restraints for the large sample (50%) of restrained residents who were not ambulatory will not significantly increase their mobility, since the majority of this group could not independently propel their wheelchairs. Increased mobility for the large group of both restrained and unrestrained residents will likely be realized only if restraint reduction programs are combined with interventions to improve both mobility and the specific behavioral performance factors measured by SAFE.

Nighttime sleep and bed mobility among incontinent nursing home residents

OBJECTIVE

To describe sleep and body movement patterns in incontinent nursing home residents for the purpose of determining if the residents require nighttime changing and body repositioning on a 2-hour schedule.

DESIGN

Cross-sectional survey.

SETTING

Four nursing homes.

PARTICIPANTS

118 nursing home residents.

MEASUREMENTS

Over two nights, bedside monitoring equipment recorded wrist activity (as a proxy measure for sleep) and body movements of both the shoulder and hip areas in consecutive 2-minute intervals. Specific outcome measures were: (1) Average duration of a sleep episode, peak duration of a sleep episode, and percent of time in bed asleep. (2) The number of 2-minute intervals in which a large movement (45 degree turn) at the shoulder and hip was noted per hour of recording for each resident. (3) The number of resident-initiated, rather than staff-initiated, large movements at the shoulder and hip that occurred within the same 2-minute intervals.

RESULTS

There was large variability in all sleep measures; however, on average, residents slept 66% of the time they were in bed. The distribution of these measures suggests that sleep was punctuated with frequent nighttime awakenings. Thirty-three percent of the incontinent residents demonstrated very low levels of resident-initiated movement at the shoulder and hip. Sixty-six percent demonstrated at least one large movement at the shoulder and hip per hour during periods of sleep as well as during periods of wake.

CONCLUSION

The majority of incontinent nursing home residents self-initiate sufficiently frequent movements at both the shoulder and hip so as not to be in need of frequent repositioning by nursing staff. Since the sleep of many of these residents is also characterized by frequent awakenings, incontinent nursing home residents may benefit from a schedule of nursing care at night that considers sleep of equal importance to incontinence care and body repositioning.

The nighttime environment, incontinence care, and sleep disruption in nursing homes

OBJECTIVE

To evaluate the association between noise, light, nursing care practices, and nighttime awakenings in incontinent nursing home residents.

DESIGN

Cross-sectional survey.

SETTING

Four long-term care nursing facilities.

PARTICIPANTS

One hundred eighteen incontinent nursing home residents.

MEASUREMENTS

Over two nights, bedside monitoring equipment recorded wrist activity, resident bed movements, and environmental noise and light changes in consecutive 2-minute intervals. Changes in sleep and bed movement were compared with changes in noise and light that occurred within the same or proximal 2-minute intervals. Noise and light changes in combination with large resident movement at the hip and shoulder were interpreted as related to incontinence care based on observational measures. Specific outcome measures were: (1) the number of noise and light changes as well as staff care practices that did not wake the resident during periods of consecutive sleep, ie, sleep lasting a minimum of 10 minutes; (2) the number of noise and light changes as well as staff care practices that occurred immediately before or during the 2-minute intervals during which a resident woke from a period of consecutive sleep; and (3) the number of such staff care practices that were related to incontinence care.

RESULTS

Noise and light changes associated with both general environmental events and more specific nurse care practices were associated with 50% of all waking episodes of 4 minutes or longer and 35% of all waking episodes of 2 minutes or shorter. The major sources of all noise were traced to nursing staff. Eighty-seven percent of all incontinence care practices were associated with episodes of waking.

CONCLUSION

The data reported in this paper document that general environmental noise and incidents of nursing care practices, particularly those related to incontinence care, are responsible for a substantial amount of the sleep fragmentation that is common among nursing home residents.