Functional performance of older adults in a long-term care setting

Organizational Capacity Building in Nursing Facilities to Promote Resident Mobility: A Systematic Review

OBJECTIVES

The objective of the present systematic review was to investigate the effects of organizational capacity building interventions on the environment, nursing staff capacity, and mobility of residents in nursing facilities.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Nursing facilities, staff, and residents.

METHODS

We conducted a systematic review according to the methods of the Cochrane Collaboration. The systematic review was prospectively registered in the PROSPERO database of systematic reviews (registration number CRD42020202996). We searched for studies in MEDLINE (via PubMed), CINAHL (via EBSCO), the Physiotherapy Evidence Database (PEDro), and the Cochrane Library (07/20). A narrative synthesis was conducted because of the high heterogeneity of the included studies.

RESULTS

We identified 6747 records and included 14 studies in our review. We clustered the 14 interventions into 3 different categories (environmental modification, nursing staff capacity, and multifactorial interventions). Three studies assessed outcomes at the nursing staff level, and all studies reported outcomes at the resident level. We found highly heterogeneous and inconsistent effects of organizational capacity building on increasing nursing staff capacity and/or resident mobility.

CONCLUSIONS AND IMPLICATIONS

The findings emphasize the need for further research focusing on an international understanding and definition of organizational capacity building. Additionally, research and intervention development for organizational capacity building interventions to promote resident mobility are needed while applying the framework of the Medical Research Council. Furthermore, studies should assess outcomes regarding the environment and nursing staff to better understand if and how environmental structures and nursing staff capacity effect resident mobility.

Reliability and Validity of the Checklist for Function-Focused Care in Service Plans

The purpose of this study was to test the reliability and validity of the Checklist for Function-Focused Care in Service Plans. Function-focused care is a care approach that optimizes function and physical activity during all care interactions. This study used baseline data from the first cohort of the study titled Dissemination and Implementation of Function-Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT). A total of 242 participants were recruited from 26 assisted living facilities. The majority of participants were White, female, and unmarried. There was support for internal consistency with an alpha coefficient of .96, interrater reliability with a correlation of .80, construct validity based on Rasch analysis and INFIT statistics ranging from 0.69 to 1.29, and a significant association with function-focused care activities. Although there is some support for reliability and validity of the measure, modifications are recommended to add more challenging items.

Heightening Person-Centered Care Processes in the Delivery of Nursing Restorative Care

The objective of the current study was to investigate the perspectives of nursing home (NH) providers regarding the requirements to achieve reimbursement for nursing restorative care (NRC) services and propose recommendations to state agencies to assist NH providers to conduct NRC programs that are person-centered and able to achieve full reimbursement. Methods included a survey of NH providers in one state and a stakeholder focus group to discuss survey findings and develop recommendations. Key findings are that NH providers perceive value to residents from the provision of NRC; providers do not associate these benefits with the stringent reimbursement requirements; and NHs often provide NRC that is individualized, based on resident goals and activity tolerance, as well as realistic given competing demands on staff, even when doing so means giving up reimbursement for NRC services. Recommendations include basing reimbursement for NRC on outcomes rather than the process; reconsideration of the frequency and intensity requirements for NRC components; and increased availability of NRC training/education and resources for providers and case-mix reviewers. [Journal of Gerontological Nursing, 45(5), 5-10.].

Testing of the Function Focused Environment Assessment and the Function Focused Policy Assessment in Assisted Living

This study tested two new instruments, the Function Focused Environment Assessment (FF-EA) and the Function Focused Policy Assessment (FF-PA). The measures were developed for clinical evaluation of AL settings to help optimize function and physical activity among residents. A total of 106 AL settings and 242 residents were included. There was evidence of item reliability (0.92) and interrater reliability (kappa=0.40, p=.015; percent agreement 85%) of FF-EA and item reliability (0.89) and interrater reliability (kappa=0.48, p=.001, percent agreement 82%) of the FF-PA, and support for validity of both measures based on INFIT and OUTFIT statistics and hypothesis testing.

Fear of falling in community-dwelling older adults: A cause of falls, a consequence, or both?

Background

Despite the number of studies that have tried to demonstrate that there is an association between previous falls and the fear of falling, the relationship between these two variables remains a matter of controversy.

Objectives

Our objective was to investigate whether the fear of falling is a cause of falls, a consequence, or both in community-dwelling adults aged ≥ 75 years old.

Methods

A descriptive, longitudinal, prospective study was performed. A total of 640 individuals were interviewed between 2009 and 2011. Sociodemographic data, health status, history of falls and fear of falling were assessed at baseline and at 24 months.

Results

The prevalence of falls at baseline was 25% as opposed to 35.2% at 24 months. The prevalence of the fear of falling was 41.5% at baseline. Logistic regression analysis showed a significant association between a history of falls and the fear of falling. Other factors associated with the fear of falling were female gender, comorbidity, depressive symptoms, and disability. In total, 41.7% of the subjects who had reported a fear of falling at baseline had suffered at least one fall 24 months later. Unadjusted Cox regression analysis revealed that the fear of falling was a risk factor for falls. According to the final model adjusted for other covariates, the only reliable predictor was female gender. The Cox model stratified by gender failed to show a crude association between fear of falling and falls.

Conclusion

A previous history of falls in the previous year was a good predictor of the fear of falling; but the fear of falling was a predictor of falls during follow-up only in the unadjusted model, pointing to strong gender turns out as an effect modifier of the association of FOF and subsequent falls. Nursing staff working in elderly care should not only routinely assess patients’ previous history of falls, but also evaluate their fear of falling and its associated factors.

The Role of Caregivers in Physical Activity for Older Adults With Alzheimer's Disease

This study examined the determinants of physical activity (PA) for older adults with Alzheimer's disease (AD) to learn more about how to promote PA in this population. Caregivers of older adults with AD (N = 99) provided information related to care recipient's PA, as well as addressed sociodemographics and perceptions about their care recipient's PA. Gender of care recipient was a significant predictor of PA (β = .80, P < .05); men with AD participated in more PA than women with AD. Also, caregiver's outcome expectation for care recipient's PA also predicted more PA (β = .82, P < .05). Caregiver's perceived benefits of PA (outcome expectation) for their care recipient partially mediated the relationship between self-efficacy for care recipient's PA and the reported levels of PA for the care recipient. This study demonstrated the importance of caregiver perceptions about care recipient's PA.

AGING, DIABETES, AND FALLS

KEY POINTS Falls are a major health issue for older adults, leading to adverse events and even death. Older persons with type 2 diabetes are at increased risk of falling compared to healthy adults of a similar age. Over 400 factors are associated with falls risk, making identification and targeting of key factors to prevent falls problematic. However, the major risk factors include hypertension, diabetes, pain, and polypharmacy. In addition to age and polypharmacy, diabetes-related loss of strength, sensory perception, and balance secondary to peripheral neuropathy along with decline in cognitive function lead to increased risk of falling. Designing specific interventions to target strength and balance training, reducing polypharmacy to improve cognitive function, relaxation of diabetes management to avoid hypoglycemia and hypotension, and relief of pain will produce the greatest benefit for reducing falls in older persons with diabetes. Abbreviation: DPN = diabetic polyneuropathy.

[Quality of life of patients carrying an urinary diversion]

INTRODUCTION

A urinary diversion is more often needed in the context of total cystectomy for bladder cancer. This pathology and this surgical resection alter the quality of life of patients. This article reviews the consequences of urinary diversions on patients' quality of life and ways to minimize them.

MATERIAL AND METHOD

A systematic review of the literature search was performed from the databases Medline (NLM, Pubmed) and Embase, focused on the following keywords: "cystectomy"; "urinary diversion"; "quality of life"; "stoma"; "education". Publications obtained were selected based on methodology, language, date of publication (last 30 years) and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 218 articles. After reading titles and abstracts, 30 were included in the text, based on their relevance.

RESULTS

The informed choice of the urinary diversion contributes to its acceptance by the patient and to improve the urinary-related quality of life. The selection criteria must be analyzed and presented to the patient in a multidisciplinary way, involving surgeon, physician, nurse, physiotherapist and stomaterapist. By means of the care networks, the choice of the patient should not be limited by the experience of the surgical and paramedical team. There is no clear evidence about the superiority of a derivation over others regarding the quality of life of patients.

CONCLUSION

The quality of life of patients carrying an urinary diversion depends less on the type of diversion than on whether the diversion is chosen by the patient himself. Patient information by all stakeholders involved in its communication is therefore essential.

The Interplay of Genetics, Behavior, and Pain with Depressive Symptoms in the Elderly

PURPOSE OF STUDY

About 25% of older adults suffer from depressive symptoms. Commonly studied candidate genes associated with depression include those that influence serotonin (SLC6A4), dopamine (COMT), or neuroplasticity (BDNF, NTRK3). However, the majority of candidate gene studies do not consider the interplay of genetics, demographic, clinical, and behavioral factors and how they jointly contribute to depressive symptoms among older adults. The purpose of this study was to gain a more comprehensive understanding of depressive symptoms among older adults.

DESIGN AND METHODS

In this descriptive study, demographic, behavioral, and clinical characteristics (age, gender, comorbidities, volunteering, physical activity, pain, and fear of falling) were obtained via interview of 114 residents in a continuing care retirement community. Peripheral whole blood was collected for DNA extraction. We examined common single nucleotide polymorphisms (SNPs) in the aforementioned genes using path analyses.

RESULTS

SNPs in the NTRK3 gene, pain, physical activity, and fear of falling were directly associated with depressive symptoms in older adults. Those who had polymorphisms in the NTRK3 gene, pain, fear of falling, and were less physically active were more likely to exhibit depressive symptoms. None of the SNPs in SLC6A4, COMT, or BDNF genes were significantly associated with depressive symptoms.

IMPLICATIONS

Our use of a path analysis to examine a biopsychosocial model of depressive symptoms provided the opportunity to describe a comprehensive clinical picture of older adults at risk for depressive symptoms. Thus, interventions could be implemented to identify older adults at risk for depressive symptoms.

Sensory-motor training targeting motor dysfunction and muscle weakness in long-term care elderly combined with motivational strategies: a single blind randomized controlled study

BACKGROUND

This study evaluated the effects of a combined innovative training regime consisting of stochastic resonance whole-body vibration (SR-WBV) and a dance video game (DVG) on physical performance and muscle strength in long-term-care dwelling elderly.

METHODS

Thirthy long-term-care elderly were randomly allocated to an intervention group (IG; n = 16) receiving combined SR-WBV training and DVG, or a sham group (SG; n = 14). IG performed five sets one minute of SR-WBV, with one minute rest between sets (base frequency 3 Hz up to 6 Hz, Noise 4) during the first five weeks on three days per week. From week five to eight a DVG was added to SR-WBV for IG on three days per week. SG performed a five-set SR-WBV program (1 Hz, Noise 1) lasting five times one minute, with one minute rest in between, three days a week. From week five to eight stepping exercises on a trampoline were added on three days per week.

PRIMARY OUTCOME

Short physical performance battery (SPPB). Secondary outcome: isometric maximal voluntary contraction (IMVC), and sub phases of IMVC (Fsub), isometric rate of force development (IRFD) and sub time phases of IRFD (IRFDsub) were measured at baseline, after four and eight weeks. ANOVA with repeated measures was used for analyses of time and interaction effects and MANOVA determined between group intervention effects.

RESULTS

Between group effects revealed significant effects on the SPPB primary outcome after four weeks F(1, 27) = 6.17; p = 0.02) and after eight weeks F(1,27) = 11.8; p = 0.002). Secondary muscle function related outcome showed significant between group effects in IG on IRFD, Fsub 30 ms, 100 ms, 200 ms and IRFDsub 0-30 ms, 0-50 ms, 0-100 ms and 100-200 ms compared to SG (all p < 0.05).

CONCLUSIONS

Eight weeks SR-WBV and DVG intervention improved lower extremity physical function and muscle strength compared to a sham intervention in long-term-care elderly. SR-WBV and DVG seems to be effective as a training regime for skilling up in long-term-care elderly.

Dissemination and Implementation of Function Focused Care for Assisted Living

Assisted living (AL) settings are residential settings that provide housing and supportive services for older and disabled adults. Although individuals in AL are less functionally impaired than those in nursing home settings, they engage in limited amounts of physical activity and experience more rapid functional decline than their peers in nursing homes. Function Focused Care for Assisted Living (FFC-AL) was developed to prevent decline, improve function, and increase physical activity among residents living in these settings. The purpose of this study was to disseminate and implement the previously established, effective FFC-AL approach to 100 AL settings. Evidence of our ability to successfully disseminate and implement FFC-AL across these settings was established using the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance model. Settings were eligible to participate if they had more than eight beds and identified a nurse (i.e., registered nurse, licensed practical nurse, or direct care worker) champion to facilitate the implementation process. Setting recruitment was done via mailed invitations to 300 eligible ALs and e-mails to relevant AL organizations. Evidence of reach was based on our ability to recruit 99 ALs with adoption of the intervention in 78 (78%). There was a significant improvement in policies supporting function-focused care and in establishing environments that supported function-focused care, and there was evidence of enduring changes in settings indicative of maintenance. We were able to implement all aspects of the intervention although challenges were identified. Future work should focus on using more face-to-face interactions with champions along with identified stakeholders, evaluating characteristics of champions to establish those who are most successful, and recruiting residents to obtain resident-specific outcomes.

Preliminary inconclusive results of a randomised double blinded cross-over pilot trial in long-term-care dwelling elderly assessing the feasibility of stochastic resonance whole-body vibration

Background

This randomised double-blinded controlled cross-over pilot study examined feasibility and preliminary effects of stochastic resonance whole-body vibration training applied in long term care elderly.

Findings

Nine long term care elderly were recruited and randomized to group A (6 Hz, Noise 4 SR-WBV/ Sham) or B (Sham / 1 Hz, Noise 1 SR-WBV). Feasibility outcomes included recruitment rate, attrition, adherence and safety. Physical performance outcomes focused on the Expanded Timed Get Up-and-Go (ETGUG) test, the Short Physical Performance Battery (SPPB), and lower extremity muscle strength.

Of 24 subjects initially approached 9 started and 5 completed the study resulting in 37.5 recruitment, 44.4 attrition and 81.7 % adherence rates. No adverse events were reported. There is more evidence of improved performance levels in the SR-WBV treatment group with significant differences in average change for isometric rate of force development (p = 0.016 left leg; p = 0.028 right leg). No statistical significance was reached for other parameters.

Conclusions

The findings of this study indicate that the used training protocol for long term care elderly is feasible, however, requires more closely monitoring of participants; e.g. needs protocol modifications that target improved compliance with the intervention in this setting. SR-WBV shows beneficial effects on physical performance for those adhering to the intervention.

Trial registration

U.S. National Institutes of Health NCT01543243

Electronic supplementary material

The online version of this article (doi:10.1186/s11556-015-0150-y) contains supplementary material, which is available to authorized users.

The Self-Efficacy for Functional Abilities Scale for older adults in long-term care: two-level exploratory and confirmatory factor analysis

BACKGROUND AND PURPOSE

This study examines the underlying factor structure of the Self-Efficacy for Functional Abilities (SEFA) scale among older adults in long-term care settings.

METHODS

A secondary analysis of SEFA data for 568 residents in 16 long-term care facilities was applied. The sample was randomly split into 2 subsamples. A 2-level exploratory and confirmatory factor analysis adjusting for clustering effect of facilities was used to identify and determine the factor structures respectively.

RESULTS

There were 1- and 2-factor models that were identified. Both models demonstrated acceptably mixed model fit. The 2-factor model had poor discriminant validity with high correlation between factors (r = .92, p < .001). The single-factor model was considered valid with moderate correlation with function (r = .301, p < .001).

CONCLUSIONS

The SEFA scale demonstrated a unidimensional construct among older adults in long-term care settings. Future testing is needed among other older adult populations.

Implementation of an Exercise Program in an Assisted Living Facility

This quality improvement project was designed to implement a sit-to-stand exercise program delivered by nursing assistants in an assisted living facility. The primary outcome was for residents to either improve or maintain function in activities of daily living. The findings of this program have implications for nursing and the role that nursing assistants can play in promoting exercise and thus preventing avoidable decline in institutionalized residents.

The impact of osteoporosis, falls, fear of falling, and efficacy expectations on exercise among community-dwelling older adults

PURPOSE

The purpose of this study was to test a model delineating the factors known to influence fear of falling and exercise behavior among older adults.

DESIGN AND METHODS

This was a secondary data analysis using baseline data from the Bone Health study. A total of 866 individuals from two online communities participated in the study: 161 (18.6%) were from SeniorNet and 683 (78.9%) were from MyHealtheVet. More than half (63%) of the participants were male with a mean age of 62.8 (SD = 8.5) years. The majority was White (89%) and married (53%) and had some college education (87%).

RESULTS

Knowledge about osteoporosis and awareness one has a diagnosis of osteoporosis directly influenced fear of falling, and knowledge of osteoporosis directly and indirectly influenced exercise behavior. A diagnosis of osteoporosis indirectly influenced exercise behavior. Taken together, the hypothesized model explained 13% of the variance in exercise behavior.

IMPLICATIONS

Improving knowledge of osteoporosis and awareness of having a diagnosis of osteoporosis, decreasing fear of falling, and strengthening self-efficacy and outcome expectations for exercise may help improve exercise behavior among older adults.

Participant Variation by Delivery Site Type in an Evidence-Based Physical Activity Program

This study examined participant demographic and physical function characteristics from EnhanceFitness, an evidence-based physical activity program for older adults. The sample consisted of 19,964 older adults. Participant data included self-reported health and demographic variables, and results for three physical function tests: chair stand, arm curls, and timed up-and-go. Linear regression models compared physical function test results among eight program site types. Participants were, on average, 72 years old, predominantly female, and reported having one chronic condition. Residential site participants' physical function test results were significantly poorer on chair stand and timed up-and-go measures at baseline, and timed up-and-go at a four-month follow-up compared with the reference group (senior centers) after controlling for demographic variables and site clustering. Evidence-based health-promotion programs offered in community settings should assess demographic, health, and physical function characteristics to best serve participants' specific needs, and offer classes tailored to participant function and ability while maintaining program fidelity.

Volunteering and depressive symptoms among residents in a continuing care retirement community

This descriptive study examined the relationship between volunteer activities, depressive symptoms, and feelings of usefulness among older adults using path analysis. Survey data was collected via interview from residents of a continuing care retirement community. Neither feelings of usefulness nor volunteering were directly associated with depressive symptoms. Volunteering was directly associated with feelings of usefulness and indirectly associated with depressive symptoms through total physical activity. Age, fear of falling, pain, physical activity, and physical resilience explained 31% of the variance in depressive symptoms. Engaging in volunteer work may be beneficial for increasing feelings of usefulness and indirectly improving depressive symptoms among older adults.

Impact of fear of falling in long term care: an integrative review

Long term care elders with fear of falling may restrict their activity resulting in declines in function and excess disability. To further explore this problem, a review of the literature was conducted. The search yielded 26 studies on the epidemiology of fear of falling in nursing homes and assisted living as well as intervention studies in these settings. Fear of falling is common, affecting more than 50% of long term care elders and is associated with negative outcomes, including falls, functional impairments, depression, and poor quality of life. Longitudinal studies are rare. There were few intervention studies, with most testing exercise programs, including balance training, such as t'ai chi, and little research testing other approaches. Few conclusions can be drawn about interventions, as most sample sizes were small and the interventions and measurement varied widely. Additional research is needed to identify long term care residents most in need of intervention, and the best ways to reduce fear of falling and its consequences.

Activity restriction vs. self-direction: hospitalised older adults' response to fear of falling

BACKGROUND

Functional decline is a common complication in hospitalised older adults, associated with low mobility and physical activity. Fear of falling may contribute to limited mobility and physical activity, and loss of physical function. An understanding of this relationship, as well as contributing factors, may inform the development of safe, function-promoting interventions.

AIM

To describe fear of falling in hospitalised older adults and its relationship with patient characteristics and physical function and explore patient views of associated factors.

DESIGN

combined quantitative and qualitative approach using chart extraction, observation and interviews of older adults.

METHODS

(i) correlations and analysis of variance methods; (ii) content and thematic analysis; and (iii) evaluation of convergence, complementarity and dissonance of quantitative and qualitative data.

RESULTS

Depressed older persons were more likely to describe fear of falling (r = 0.47, P = 0.002). Fear of falling was associated with the loss of physical function from admission to discharge (F = 7.6, P = 0.009). The participant response to fear of falling was activity restriction vs. self-direction. Participants described the following factors, organised by social-ecological framework, to be considered when developing alternatives to activity restriction: intrapersonal, interpersonal, environmental and policy.

CONCLUSION

Fear of falling plays a significant role in restricting physical activity and function. A multifactorial approach may provide a viable alternative to activity restriction, by facilitating self-direction and functional recovery.

IMPLICATIONS FOR PRACTICE

Interventions to prevent falls and activities to promote functional mobility are ideally developed in tandem, with attention paid to the physical and social environment. Preventing hospital-acquired disability may require a shift in organisational values around safety, from a soley protective approach to one that reflects an enabling philosophy emphasising independence and self-direction. Such a paradigm shift would demonstrate a valuing not only of the absence of falls but also the preservation and restoration of function.

A theoretical model of efficacy beliefs, functional status and quality of life for older people during rehabilitation: testing causal relationships

AIMS

Structural equation modelling tested hypothesized causal relationships between age, gender, pain, depression, self-efficacy, outcome expectations, functional status and quality of life in older Australians post-orthopaedics surgery across three stages of their rehabilitation.

BACKGROUND

Self-efficacy is important in forming personal beliefs about capabilities to perform functional activities, which is believed to maintain individual's quality of life. Research examining how efficacy beliefs influence functional status in older people following orthopaedic events is limited.

DESIGN

A descriptive, longitudinal method was used for this study.

METHODS

A convenience sample of 101 older people with orthopaedic surgery to lower extremities was recruited from private rehabilitation units in Brisbane, Australia. Data were collected from September 2008-November 2009. Standardized questionnaires were used to measure efficacy beliefs, functional status, and quality of life.

RESULTS

Structural equation modelling revealed that depression, efficacy beliefs, age, and gender significantly influenced quality of life, as self-efficacy and gender have a direct relationship on functional status. Across three stages in the model, outcome expectation at stage 2 was the most significant predictor of functional recovery after discharge. Older men with higher quality of life at admission was positively related to self-efficacy and negatively associated with depression at stage 2: quality of life influenced outcome expectations and pain positively at stage 3.

CONCLUSION

Rehabilitation programmes play a significant role in assisting older people in resuming functional activities and quality of life following orthopaedic surgery. Enhancing self-efficacy may facilitate older people's participation and adherence to rehabilitation programmes during hospitalization and following discharge.

Factors associated with exercise among older adults in a continuing care retirement community

The objectives of this study were to test a model of the factors that influence exercise activities among a group of older adults living in a continuing care retirement community with a wellness center that features a pool, exercise room, and exercise classes. This was a correlational study using a one-time survey. A total of 163 residents with an average age of 86.6 years (SD = 6.1) participated in the study. Ninety (55%) of the participants exercised regularly (30 minutes daily), 88% of whom used the wellness center. Of all participating residents, 49% reported using the wellness center. Self-efficacy and negative outcome expectations directly related to exercise behavior. Marital status, resilience, health status, pain, and fear of falling were indirectly related to exercise. All of these factors explained 15% of the variance in exercise behavior. These findings support previous work and provide future direction for research regarding interventions to increase exercise among older adults. Further, access to a wellness center providing exercise opportunities may increase adherence to a regular exercise regimen among older adults.

Exploring the Factors That Influence Functional Performance Among Nursing Home Residents

Objective: To promote healthy aging in older nursing home (NH) residents, it is important to identify factors that impact functional performance. Using the Disablement Process Model, it was hypothesized that variables from all levels of the model would significantly impact the ability of a NH resident to get up from a chair. Method: A stepwise multiple logistic regression model was used to test the impact of sociodemographic, physiologic, physical, psychosocial, and environmental factors on chair rise. Results: Analysis indicated that three factors, strength, gait, and self-efficacy, were significantly associated with chair-rise ability and together explained approximately 64% of the variance and successfully classified 88.4% of the chair-rise cases. Discussion: These findings indicate that identifying physical and psychosocial variables early in the disablement process will help health care providers tailor medical and restorative care interventions that may help older adults maintain the ability to chair rise.

Satisfaction with assisted living: the unexplored role of physical activity

In the ongoing Interdisciplinary Nursing Quality Research Initiative Program study, we are testing the impact of Function-Focused Care, which is an approach to care in which we work with assisted living (AL) residents and staff to optimize the functional and physical activities of residents during daily activity. The purpose of this article is to evaluate life satisfaction of AL residents with a focus on the impact of physical activity. In a sample of 171 older adults from 4 ALs, it was found that depression, social support from friends and experts, time in caregiving, and fear of falling all had a significant relationship with life satisfaction in AL. Physical activity was not related to life satisfaction in this study. Ongoing research is necessary to explore whether changing attitudes about physical activity among older adults and increasing social support related to physical activity can improve life satisfaction.

Perceptions and performance of function and physical activity in assisted living communities

OBJECTIVE

The purpose of this study was to describe residents' self-efficacy and outcome expectations with regard to function and physical activity (PA); to measure functional performance and time in PA; to evaluate the fit between the resident and the environment; and to evaluate knowledge, beliefs, and care behaviors of nursing assistants (NAs) in 4 different assisted living (AL) communities.

DESIGN

This was a descriptive study using baseline data from an ongoing intervention study, Testing the Impact of a Function Focused Care Intervention, Res-Care-AL.

SETTING

Four assisted living communities in Maryland.

PARTICIPANTS

A total of 171 residents and 96 NAs consented, passed eligibility, and were included in this study.

MEASUREMENTS

Descriptive data were obtained from NAs and residents. Resident data also included self-efficacy and outcome expectations associated with functional tasks and exercise, social support for exercise, and subjective and objective information about function and physical activity. NA data included self-efficacy and outcome expectations, knowledge, and performance of function-focused care.

RESULTS

Residents were mostly female, white, and widowed; needed some assistance with activities of daily living; and engaged in very little PA based on subjective and objective reports. NAs were mostly female and black, had more than a decade of nursing experience, strong confidence but limited knowledge of function-focused care, and performed this care in 76% of observed care interactions. There were no site-specific differences among NAs with regard to beliefs, knowledge, or performance of function-focused care. There were site-specific differences in residents with regard to self-efficacy for functional ability; functional performance; social supports for exercise from experts; and from family, person-environment fit, and PA based on subjective surveys. There were no differences noted based on actigraphy.

CONCLUSION

Residents in AL communities engage in very limited amounts of PA and staff in these sites could benefit from ongoing education about how to increase PA among residents and help them adhere to current guidelines for PA so as to optimize overall health status.

Nursing home resident outcomes from the Res-Care intervention

OBJECTIVES

To test the effectiveness of a restorative care (Res-Care) intervention on function, muscle strength, contractures, and quality of life of nursing home residents, with secondary aims focused on strengthening self-efficacy and outcome expectations.

DESIGN

A randomized controlled repeated-measure design was used, and generalized estimating equations were used to evaluate status at baseline and 4 and 12 months after initiation of the Res-Care intervention.

SETTING

Twelve nursing homes in Maryland.

PARTICIPANTS

Four hundred eighty-seven residents consented and were eligible: 256 from treatment sites and 231 from control sites. The majority were female (389, 80.1%) and white (325, 66.8%); 85 (17.4%) were married and the remaining widowed, single, or divorced/separated. Mean age was 83.8 +/- 8.2, and mean Mini-Mental State Examination score was 20.4 +/- 5.3.

INTERVENTION

Res-Care was a two-tiered self-efficacy-based intervention focused on motivating nursing assistants and residents to engage in functional and physical activities.

MEASUREMENTS

Barthel Index, Tinetti Gait and Balance, grip strength, Dementia Quality-of-Life Scale, self-efficacy, and Outcome Expectations Scales for Function.

RESULTS

Significant treatment-by-time interactions (P<.05) were found for the Tinetti Mobility Score and its gait and balance subscores and for walking, bathing, and stair climbing.

CONCLUSION

The findings provide some evidence for the utility and safety of a Res-Care intervention in terms of improving function in NH residents.

The Exercise Assessment and Screening for You (EASY) Tool: Application in the Oldest Old Population

The screening tool, the Exercise Assessment and Screening for You (EASY), was developed to call attention to the benefits of exercise and to assist older adults in selecting safe and effective exercise. The purpose of this study is to describe the use of the EASY in an oldest old population, consider the factors associated with EASY scores, and examine the relationship between exercise and adverse events in this population. The sample comprised 163 oldest old adults with an average age of 86.5 (SD = 5.8), the majority of whom were women (73%) and unmarried (64%). The participants responded affirmatively to approximately 2 of the 6 items on the EASY (mean = 1.9, SD = 1.3). Fear of falling, negative outcome expectations, number of comorbidities, age, and pain were all significantly associated with the total score on the EASY and accounted for 24% of the variance. Those who responded affirmatively to at least 1 item on the EASY were more likely to engage in exercise than those who did not (chi-square = 8.0, P = .01). The findings from this study help establish some baseline evidence of the applicability of the EASY when used as a screening tool to help guide oldest old adults prior to starting an exercise program.

Testing the Senior Exercise Self-efficacy Project (SESEP) for use with urban dwelling minority older adults

OBJECTIVES

To test the feasibility and effectiveness of the Senior Exercise Self-efficacy Project (SESEP).

DESIGN

A feasibility study using a randomized control trial.

SAMPLE

The total sample included 166 persons, with a mean age of 73 years (SD=8.2 years), the majority of whom were female (81%), African American (72%), unmarried (86%), had at least a high school education (64%), and were retired (77%). There were 100 participants in the intervention group and 66 in the comparison group.

METHODS

The SESEP was a combined physical activity and efficacy-enhancing intervention for community-dwelling minority older adults. The primary outcomes included self-efficacy, outcome expectations, exercise, and overall physical activity, and the secondary outcomes were mental and physical health-related quality of life, depressive symptoms, pain, fear of falling, mobility, and chair rise time. Data were collected at baseline and following the 12-week intervention.

RESULTS

There were statistically significant improvements in outcome expectations (p=.02), time spent in exercise (p=.04), and depressive symptoms (p=.02). Overall, there was a 77% rate of participation in classes.

CONCLUSION

Although there was good participation in the SESEP among minority older adults, the primary outcomes were only minimally supported and there was even less support for the secondary outcomes.

Barriers and benefits to implementing a restorative care intervention in nursing homes

OBJECTIVES

This study considered the factors that facilitated or prevented nursing assistants (NAs) from engaging in restorative care activities.

DESIGN

This was a qualitative study using a focus group methodology.

SETTING

Study participants were recruited from 6 nursing homes.

PARTICIPANTS

Participants were nursing assistants (NAs) from a study testing the implementation of a restorative care intervention (Res-Care) study. Of the 244 NAs recruited from the 6 treatment sites, 179 were available at 12 months and 93 (52%) participated in the study.

MEASUREMENT

An interview guide was used during each of the focus groups. Data analysis was done using basic content analysis.

RESULTS

Sixty-one codes were identified and reduced to 4 themes: facilitators of restorative care; barriers to restorative care; benefits of restorative care; and sustaining restorative care.

CONCLUSION

The findings provide an important NA perspective with regard to implementation of a restorative philosophy of care and provide recommendations for future work in this area.

Aging, health, and physical activity in Korean Americans

Little is known about the health benefits and the factors that influence physical activity among older adults from ethnically different backgrounds. The aim of this article is to provide a sociocultural context for understanding aging, health, and physical activity among older Korean Americans. Studies that focused on physical activity and exercise among older adults, older Koreans, or older Korean Americans were reviewed. The results of the review were integrated to better understand physical activity in older Korean Americans. Results from varied population-based, cross-sectional, and longitudinal studies that assessed the relationships among aging, health, and physical activity were relatively consistent in their findings. Many correlational studies found a strong, positive relationship between physical activity and health benefits and a moderately positive but sometimes mixed association between physical activity and quality of life among older adults. Additional research is needed to clarify the gap between physical activity and actual and predictive quality of life among older Korean Americans. Also, we need more evidences to show the effects of late-life physical activity or exercise on reducing or minimizing disablement in older Korean Americans.

A structural equation model relating impaired sensorimotor function, fear of falling and gait patterns in older people

Many falls in older people occur while walking, however the mechanisms responsible for gait instability are poorly understood. Therefore, the aim of this study was to develop a plausible model describing the relationships between impaired sensorimotor function, fear of falling and gait patterns in older people. Temporo-spatial gait parameters and acceleration patterns of the head and pelvis were obtained from 100 community-dwelling older people aged between 75 and 93 years while walking on an irregular walkway. A theoretical model was developed to explain the relationships between these variables, assuming that head stability is a primary output of the postural control system when walking. This model was then tested using structural equation modeling, a statistical technique which enables the testing of a set of regression equations simultaneously. The structural equation model indicated that: (i) reduced step length has a significant direct and indirect association with reduced head stability; (ii) impaired sensorimotor function is significantly associated with reduced head stability, but this effect is largely indirect, mediated by reduced step length, and; (iii) fear of falling is significantly associated with reduced step length, but has little direct influence on head stability. These findings provide useful insights into the possible mechanisms underlying gait characteristics and risk of falling in older people. Particularly important is the indication that fear-related step length shortening may be maladaptive.

The effects of in-home rehabilitation on task self-efficacy in mobility-impaired adults: A randomized clinical trial

OBJECTIVES

To examine the effect on mobility self-efficacy of a multifactorial, individualized, occupational/physical therapy (OT/PT) intervention delivered via teletechnology or in-home visits.

DESIGN

Randomized, clinical trial.

SETTING

One Department of Veterans Affairs and one private rehabilitation hospital.

PARTICIPANTS

Sixty-five community-dwelling adults with new mobility devices. Thirty-three were randomized to the control or usual care group (UCG), 32 to the intervention group (IG).

INTERVENTION

Four, once-weekly, 1-hour OT/PT sessions targeting three mobility and three transfer tasks. A therapist delivered the intervention in the traditional home setting (trad group n = 16) or remotely via teletechnology (tele group n = 16).

MEASUREMENTS

Ten-item Likert-scale measure of mobility self-efficacy.

RESULTS

The IG had a statistically significantly greater increase in overall self-efficacy over the study period than the UCG (mean change: IG 8.8, 95% confidence interval (CI) = 3.8-13.7; UCG 1.2, 95% CI = -5.8-8.2). Descriptively, the IG exhibited positive changes in self-efficacy for all tasks and greater positive change than the UCG on all items with the exception of getting in and out of a chair. Comparisons of the two treatment delivery methods showed a medium standardized effect size (SES) in both the tele and trad groups, although it did not reach statistical significance for the tele group (SES: tele = 0.35, 95% CI = -2.5-0.95; trad = 0.54, 95% CI = 0.06-1.14).

CONCLUSION

A multifactorial, individualized, home-based OT/PT intervention can improve self-efficacy in mobility-impaired adults. The trend toward increased self-efficacy irrespective of the mode of rehabilitation delivery suggests that telerehabilitation can be a viable alternative to or can augment traditional in-home therapy.

Pilot Testing of the Restorative Care Intervention: Impact on Residents

The purpose of this pilot study was to test the feasibility and effectiveness of a two-tiered motivational intervention, the Res-Care Intervention, on nursing home residents. Twenty-one residents consented to participate in the study. The residents were 88.3 (+/- 4.9) years of age, had lived in the facility 1.6 (+/- 3.4) years, were women (93%), White (93%), and unmarried (85%). Although there were some positiv trends, there was not a statistically significant difference in any of the resident outcomes following implementation of the Res-Care Intervention. The findings have been used to revise the Res-Care Intervention to include additional education needs for the nursing assistants, revisions in the motivational intervention for the nursing assistants and nurses, clarification of documentation and motivational techniques to improve documentation, and implementation of a more comprehensive treatment fidelity plan.

Measuring the Psychological Outcomes of Falling: A Systematic Review

The objectives were to identify fall-related psychological outcome measures and to undertake a systematic quality assessment of their key measurement properties. A Cochrane review of fall-prevention interventions in older adults was used to identify fall-related psychological measurements. PubMed, CINAHL, and PsycINFO were systematically searched to identify instruments not used in trials and papers reporting the methodological quality of relevant measures. Reference lists of articles were searched for additional literature, and researchers were contacted. Two reviewers undertook quality extraction relating to content, population, reliability, validity, responsiveness, practicality, and feasibility. Twenty-five relevant papers were identified. Twenty-three measures met the inclusion criteria: six single-item questions, Falls Efficacy Scale (FES), revised FES, modified FES, FES-UK, Activities-specific Balance and Confidence Scale (ABC), ABC-UK, Confidence in maintaining Balance Scale, Mobility Efficacy Scale, adapted FES, amended FES, Survey of Activities and Fear of Falling in the Elderly (SAFFE), University of Illinois at Chicago Fear of Falling Measure, Concern about Falling Scale, Falls Handicap Inventory, modified SAFFE, Consequences of Falling Scale, and Concern about the Consequences of Falling Scale. There is limited evidence about the measurement properties of single-item measures. Several multiitem measures obtained acceptable reliability and validity, but there is less evidence regarding responsiveness, practicality, and feasibility. Researchers should select measures based on the constructs they intend to study. Further research is needed to establish and compare the instruments' measurement properties.

Geriatric rehabilitation nursing: Developing a model

In this paper, we describe a geriatric rehabilitation nursing model developed on the basis of the nursing and rehabilitation literature. That literature comprised some 120 articles addressing the rehabilitation of elderly patients and the work done by nurses in that process, various philosophical questions and the results of geriatric rehabilitation. One-third of these articles has been evaluated on the strength of the articles' evidence, and these are discussed in this paper. The findings show that the main factors in geriatric rehabilitation nursing are the patient with health or functional problems and the nurse with professional values, knowledge and skills. The patient is part of a family and the nurse works as part of a multidisciplinary team. In the geriatric rehabilitation process, the patient and the nurse work in close interaction. The aims of rehabilitation depend upon the patient's commitment to the objective and upon the nurse's commitment to help the patient achieve that objective. A health orientation, goal-oriented work, nursing decision-making and a rehabilitative approach to work are all central to this effort. Work is organized in multidisciplinary teams where nurses have equal responsibilities with other professional staff. Testing and development of the model is ongoing.

Functional and self-efficacy changes of patients admitted to a Geriatric Rehabilitation Unit

BACKGROUND

Geriatric Rehabilitation Units (GRUs) have been established to restore functional abilities of older hospitalized patients. Although considerable health care resources have been allocated to these units, few outcome-based research studies have been reported on Canadian GRUs.

AIM

The aim of this paper is to report a study examining the effect of admission to a GRU on changes in patients' functional ability and self-efficacy in performing everyday activities at home.

METHODS

Following Institutional Review Board approval, data were collected from 40 patients age 65-101 years (mean 83.8, sd 6.57) admitted to a 21-bed interdisciplinary GRUs over a 7-month period. All were living independently prior to hospital admission. Data were collected on admission to the unit and on discharge using two instruments: the Functional Independence Measure and Falls Efficacy Scale.

RESULTS

Statistically significant improvements were found in functional ability and self-efficacy following admission to the GRUs.

CONCLUSIONS

Although functional level and feelings of self-efficacy on admission to the unit were at levels which may have prevented participants from returning home, the majority were discharged to the community. Results suggest that admission to a GRU helps prepare patients to return to community living.

Increased physiotherapy in sheltered housing in Sweden: a study of structure and process in elderly care

The effect of increasing the level of physiotherapy services in elderly care was studied using an intervention and a control unit. The units had 20 and 2 hours of physiotherapy services per week, respectively. Physiotherapy and occupational therapy records were reviewed before and during the project. Physiotherapists also kept extended documentation over an 11-month period. Data analyses employed the chi-square test and content analysis. There was a significant increase in the number of patients receiving physiotherapy and occupational therapy within both units. No significant differences between the units were found for the number of patients receiving physiotherapy. The number of patients receiving occupational therapy differed significantly between units before as well as during the intervention. Primarily care assistants and auxiliary nurses initiated contact with the physiotherapists mainly for patient-orientated errands. Fifty per cent of the instructions given by the physiotherapist at the 20-hour unit related to movement-orientated activities of daily living. At the 2-hour unit, the majority of instructions (52%) were programme-orientated.

The impact of alcohol use in community-dwelling older adults

The purpose of this study was to explore the use of alcohol in community-dwelling older adults and to consider differences in physical and mental health, function, cognitive status, and social supports between those who drink minimal (1 to 3 glasses weekly), moderate (4 to 7 glasses weekly), or no alcohol. A total of 3305 older adults with a mean age of 81.6 -/+ 6.0 participated in the study. Twenty-two percent (n = 709) of the participants had 1 to 3 drinks weekly, only 1% (n = 18) reported 4 to 7 drinks weekly, and none of the participants admitted to 8 or more drinks. There was no difference in drinking behavior with regard to age (F = 1.1, p >.05) or social supports (F =.39, p >.05). There was a difference in drinking behavior with regard to physical health (F = 4.9, p <.05), functional status (F = 7.7, p <.05), cognitive status (F = 11.8, p <.05), and mental health (F = 6.9, p <.05). Health care providers should use an individualized approach to alcohol use in older adults and help these individuals establish, as appropriate, safe drinking habits that will augment health and quality of life.

Restorative care nursing activities: pilot testing self-efficacy and outcome expectation measures

Implementing restorative care programs often involves changing the behavior of individuals who work in long-term care settings. The theory of self-efficacy has been used to facilitate such change. The purpose of this study was to test two new measures, the Self-efficacy for Restorative Care Nursing Activities and the Outcome Expectancy for Restorative Care Activities. The study included a sample of 27 nursing assistants; testing was done at baseline and repeated 2 weeks later. Developing reliable and valid measures of self-efficacy and outcome expectations for nursing assistants' performance of restorative care activities is useful to help establish weaknesses in the expectations of nursing assistants and allow for the development and testing of interventions to strengthen self-efficacy and outcome expectations related to restorative care activities and thereby improve adherence among nursing assistants.

Geriatric rehabilitation: the influence of efficacy beliefs and motivation

The theory of self-efficacy is that the more one believes in the efficacy of a specific activity, the more likely (motivated) one is to perform that activity. Most of the research into self-efficacy beliefs among older adults has been quantitative and has consistently supported the influence of those beliefs on behavior. However, it has not been established how efficacy beliefs actually influence motivation in older adults, or what sources of efficacy-enhancing information help strengthen those beliefs. The purpose of this study was to better understand the factors that influence the efficacy beliefs that motivate older adults in a rehabilitation program, and to uncover the relation between efficacy beliefs, motivation, and behavior (i.e., participation in rehabilitation activities). Seventy-seven older adults, 55 women and 22 men, in an inpatient geriatric rehabilitation program were interviewed. Through content analysis, 11 major themes were identified as factors that influence efficacy beliefs and motivate people to participate in rehabilitation: personal expectations, personality, role models, verbal encouragement, progress, past experiences, spirituality, physical sensations, individualized care, social supports, and goals. The findings support the theory of self-efficacy, and are best explained within a social cognitive theory framework.

A prediction model of aerobic exercise in older adults living in a continuing-care retirement community

OBJECTIVES

The purpose of this study was to test a model of exercise behavior in older adults. It was hypothesized that gender, marital status, chronic illness, mental and physical health, self-efficacy and outcome expectations, fear of falling, and past exercise behavior were directly and/or indirectly associated with current exercise behavior.

METHODS

In this descriptive study, interviews were conducted with 201 older adults living in a continuing-care retirement community.

RESULTS

Twelve paths were significant, and the model accounted for 40% of the variance in exercise behavior. Self-efficacy expectations, outcome expectations, and prior exercise were directly associated with current exercise; health status, gender, and marital status were indirectly associated with current exercise behavior through self-efficacy and outcome expectations.

DISCUSSION

Recognizing and treating mental and physical health problems may directly influence self-efficacy and outcome expectations related to exercise. Moreover, interventions that strengthen self-efficacy and outcome expectations related to exercise may improve exercise behavior.