Helping Older Residents Remain in Subsidized Housing: Predictive Validity of the Live Well at Home-Rapid Screen (LWAH-RS) in a Real-World Application

Common Bond Communities (CBC) is a nonprofit organization that provides housing for low-income individuals and families. CBC utilized the Live Well at Home-Rapid Screen (LWAH-RS) to identify the risks for nursing home admission or assisted living entry among housing residents aged 60 or above. Drawing data from 842 assessments, we studied how well the LWAH-RS predicted moves to nursing homes or assisted living settings. Cox regression models showed that the LWAH-RS did predict which residents would move to a care setting. Every 1-point higher in the LWAH-RS assessment score was associated with a 38% higher risk of moving to a higher-level care facility due to health issues. Given this demonstrated predictive validity in a real-world setting, we suggest more systematic approaches for housing practitioners to combat low assessment completion rates and unclear protocols for actions based on the scores.

QUALITATIVE FINDINGS AND THEMES IN REIMAGINING LTC: RESULTS ROUND 1 AND 2 OF THE NATIONAL DELPHI STUDY

From Round 1 we developed programmatic building blocks, which we classified as: housing suggestions; services suggestions; housing and/or technology heavy suggestions; policy or regulation suggestions;new philosophical approaches; and long-range social engineering. Besides the quantitatively ratings of the importance of each building block, respondents explained what they liked and disliked about each.. They frequently commented that environments rich in design features, amenities and activities would not be practical for low-income people. Respondents felt that some ideas would not be suitable for people with dementia because they would be insufficiently protected. Principles that seemed to be incompatible could be highly endorses; e.g., the principle that we prioritize people staying in their own homes and a principle that frail elderly persons living along should relocate to group residential settings to avoid social isolation. This paper concludes with a list of areas for further discussion by work groups.

RE-IMAGINING LTC: QUANTITATIVE AND QUALITATIVE RESULTS OF A NATIONAL MODIFIED DELPHI STUDY, IMPLICATIONS AND NEXT STEPS

In 11/2016 Robert and Rosalie Kane began a 3-round Delphi study to re-imagine long-term care (LTC), , which took as a starting premise that LTSS in the United States fails to comport to the values and preferences of consumers. The Delphi study is “modified” from more typical Delphi designs because of 1) a sample sizes over 100, 2) an unusually broad topic--optimal LTC systems if not constrained by existing programs, financial arrangements and regulations; and 3) incorporation of new sample at each round. Round 1 asked respondents to rate and add to a list of values important to LTC< but largely was an open-ended request for respondents’ ideas, Round 2 was fielded in 6/2018 with all data collection completed by 11/2018 (the delay partly due to Robert Kane’s sudden death on March 6, 2017 and also the time needed to analyze, summarize and present the complex and detailed responses to the first round). Round 3, to be fielded in 4/2019., will provide participants with the ratings of values, principles and programmatic building blocks at Round Two, and the open-ended comment of respondents in explanation of their ratings. Each Round is analyzed cross-sectionally and can be considered a separate “virtual town square.” Ellen McCreedy and Rosalie Kane, respectively, present quantitative and qualitative results from the first two rounds. Discussants will each comment briefly from their perspectives as 1) state LTC policy developer,2) LTC university-based researcher; 3) consumer advocate, followed by audience and presenter discussion of the implications of the findings.

What we learned through asking about evidence: A model for interdisciplinary student engagement

Traditional university learning modalities of lectures and examinations do not prepare students fully for the evolving and complex world of gerontology and geriatrics. Students involved in more active, self-directed learning can develop a wider breadth of knowledge and perform better on practical examinations. This article describes the Evidence in Aging (EIA) study as a model of active learning with the aim of preparing students to be effective interdisciplinary researchers, educators, and leaders in aging. We focus particularly on the experiences and reflections of graduate students who collaborated with faculty mentors on study design, data collection, and analysis. Students acquired new methodological skills, gained exposure to diverse disciplines, built interdisciplinary understanding, and cultivated professional development. The EIA study is a model for innovative student engagement and collaboration, interactive learning, and critical scholarly development. Lessons learned can be applied to a range of collaborative research projects in gerontology and geriatrics education.

Effects of Posthospital Informal Care on Nursing Home Discharge

This study examines the effect of family caregiving on the probability that nursing home residents would be discharged to the community. The effect of the number of hours of informal care on the probability of nursing home discharge was estimated using a logistic regression of a 6-week postadmission location (home or institution) on the number of hours of informal care in the first 2 weeks in the nursing home, of caregiver visits, and other patient factors. The odds of being discharged to their home were higher for those who received more care that is informal. Informal care may increase the quality and the amount of care that residents receive, thus, influencing rehabilitation outcomes and returns to home. Caregiving families may advocate for residents and signal to nursing home staff that the resident has a well-functioning support system.

Beyond Burden

This analysis compares the results of an open-ended study on the effects of informal caregiving with data obtained from a separate investigation that used the same sample but employed fixed-item measures of burden. Informal caregivers ( N = 229) were interviewed with both approaches six weeks after the patients (care receivers) were discharged from the hospital. Percentages, t tests, and analyses of variance were used to compare and contrast the data. The analysis found substantial correspondence between the results from the two approaches, especially around the negative effects of caregiving. Less correspondence was found on the positive effects of caregiving, particularly with regard to subjective fixed items.

Long-Term Care Case Managers’ Out-of-Home Placement Decisions

Hierarchical logistic regression was used with the results of a factorial vignette survey of a national sample of case managers for the disabled elderly in Medicaid home- and community-based services waiver programs. The effects of client, case manager, and agency factors on case managers’out-of-home placement decisions in response to hypothetical case studies were estimated. Results show that client preferences, workload, and division of labor affect the probability that a case manager will recommend an out-of-home placement, controlling for client’s physical and cognitive disability and the available resources. Significant variation among individuals was found. Implications of the findings are discussed.

Anatomy of a Choice: Deciding on Assisted Living or Nursing Home Care in Oregon

This study, based on interviews with 1,215 assisted living and nursing home residents and family members in Oregon, compares assisted living residents and their family proxies with their nursing home counterparts regarding preferences for long-term care settings and circumstances and decisions surrounding their move. Analyses showed some differences between reported preferences of assisted living and nursing home groups, with the former placing more emphasis on control over private space and the latter on rehabilitation. There were also many similarities, however, especially in the views of residents themselves rather than those of their family proxies. For example, high value given by both groups to help with care from staff, decisions on how much care, and private rooms indicate policy planners and providers should take into account such preferences and develop a hybrid of positively valued features in both assisted living and nursing homes.

Long-Term Services and Supports for Older Adults: A Review of Home and Community-Based Services Versus Institutional Care

Despite a shift from institutional services toward more home and community-based services (HCBS) for older adults who need long-term services and supports (LTSS), the effects of HCBS have yet to be adequately synthesized in the literature. This review of literature from 1995 to 2012 compares the outcome trajectories of older adults served through HCBS (including assisted living [AL]) and in nursing homes (NHs) for physical function, cognition, mental health, mortality, use of acute care, and associated harms (e.g., accidents, abuse, and neglect) and costs. NH and AL residents did not differ in physical function, cognition, mental health, and mortality outcomes. The differences in harms between HCBS recipients and NH residents were mixed. Evidence was insufficient for cost comparisons. More and better research is needed to draw robust conclusions about how the service setting influences the outcomes and costs of LTSS for older adults. Future research should address the numerous methodological challenges present in this field of research and should emphasize studies evaluating the effectiveness of HCBS.

Re-imagining long-term services and supports: towards livable environments, service capacity, and enhanced community integration, choice, and quality of life for seniors

In the half century since enactment of the 1965 Great Society programs, accomplishments were gradually made to improve access to and quality of long-term services and supports (LTSS), including: mitigation of financial and care abuses in nursing facilities (NFs); substantial rebalancing of LTSS towards consumer-preferred home-and-community-based services (HCBS); increasing flexible consumer-centered HCBS including payment to family caregivers; and more assisted-living and housing options for seniors with heavy care needs. A unified planning and advocacy agenda across age and disability type and greater consumer transparency fueled progress. Nonetheless, LTSS is a broken system; persistent problems interfere with substantial and necessary change. These include; over-emphasis on safety for LTSS consumers; inattention to physical environments in all settings; regulatory and professional rigidity; and poor communication and information. Our recommendations are aimed at builders and designers, LTSS professionals, regulators, and educators/trainers; the last may be crucial in forging new consensus and over-coming entrenched beliefs. Policy recommendations include relatively narrow steps-for example, requiring single occupancy in all NFs and assisted living settings financed with public dollars-to broad reworking of the prerequisites for livable age-friendly (and dementia-friendly) communities and for a capable, flexible LTSS workforce.

Use of mental health care by community-dwelling older adults

OBJECTIVES

To examine relationships between perceived need for care, illness characteristics, attitudes toward care, and probability that older adults will use mental health care (MHC).

DESIGN

Secondary data analysis.

SETTING

The Collaborative Psychiatric Epidemiology Surveys (2001-2003).

PARTICIPANTS

One thousand six hundred eighty-one community-dwelling adults aged 65 and older.

MEASUREMENTS

Self-reported MHC use and perceived need for care in the previous 12 months, previous year and history of mental illness, history of physical illness, attitudes toward care, and sociodemographic characteristics.

RESULTS

Of the entire sample, 6.5% had received some type of MHC in the previous year, although 65.9% of those with major depressive disorder (MDD) and 72.5% with anxiety did not receive MHC. In respondents with previous-year depression or anxiety, use was less likely for those with low World Health Organization Disability Assessment Scale (WHO-DAS) self-care ability. Use was more likely for those with more chronic physical conditions and worse WHO-DAS cognitive capacity. Seventeen percent of those with perceived need for MHC did not receive it. In respondents with perceived need, subthreshold generalized anxiety disorder was associated with lower likelihood of use. Use was more likely for older respondents and those with more household members, at least a high school education, and better self-care ability. Forty-one percent of those who perceived a need for care but did not use it met previous-year diagnostic criteria for anxiety, and 17% met criteria for MDD.

CONCLUSION

Understanding the perceptions that underlie individuals' health care-seeking behavior is an important step toward reducing underuse of MHC by older adults.

Prostate-specific antigen lewels in 1695 men without evidence of prostate cancer: Findings of the American cancer society national prostate cancer detection project

The American Cancer Society National Prostate Cancer Detection Project is a prospective, multidisciplinary, and multicenter trial to assess the potential for early detection of prostate cancer by transrectal ultrasonography (TRUS), digital rectal examination (DRE), and serum prostate-specific antigen assay (PSA). By November 1990, 2805 men between the ages of 55 and 70 years with no known signs or symptoms of prostate cancer were enrolled in the study, which is planned to run for 5 years. Annual TRUS, DRE, and PSA tests were done on these subjects, and biopsies were recommended for suspicious lesions when detected. To study the performance of PSA testing in presumed normal subjects, all men were eliminated who had (1) prostate cancer detected on their initial examinations and proven by biopsy or (2) cancer detected during the year or subsequent examinations. Additionally, all men with TRUS or DRE findings that were interpreted as suspicious for cancer but who are being followed and have not yet had biopsies done were removed from this series. This left a unique, extensively screened group of 1695 men who were free of prostate cancer, as far as could be determined. Analyses of the PSA levels in this large population in the appropriate age range for increasing risk of prostate cancer revealed several important findings. First, there was a direct relationship between serum PSA levels and estimated prostate volume for both the currently available monoclonal and polyclonal PSA assays. Individuals with benign prostatic hyperplasia and larger gland volume have a higher normal limit of PSA than men with normal gland volume. Second, analyses showed no relationship between age and PSA levels or between symptoms of prostatism and PSA levels independent of gland enlargement. It was concluded that volume-adjusted upper limits of normal PSA can be determined for different levels of specificity desired. This information may be applicable to the use of PSA in men not already suspected of having prostate cancer and may increase its effectiveness as a tool for early detection.

Perceived need for mental health care among community-dwelling older adults

Only half of older adults with a mental disorder use mental health services, and little is known about the causes of perceived need for mental health care (MHC). We used logistic regression to examine relationships among depression, anxiety, chronic physical illness, alcohol abuse and/or dependence, sociodemographics, and perceived need among a national sample of community-dwelling individuals 65 years of age and older (the Collaborative Psychiatric Epidemiology Surveys data set). Less than half of respondents with depression or anxiety perceived a need for care. Perceived need was greater for respondents with more symptoms of depression regardless of whether they met diagnostic criteria for a mental illness. History of chronic physical conditions, history of depression or anxiety, and more severe mental illness were associated with greater perceived need for MHC. Future studies of perceived need should account for individual perceptions of mental illness and treatment and the influence of social networks.

We've looked at care from both sides now: the effects of alternative evaluation strategies on study conclusions

This study uses two studies about the role of managed-care programs in serving Medicaid long-term care clients in Florida to illustrate how different research designs can reach divergent conclusions. Two reports from different groups using essentially the same database to assess the impact of managed care on a group of older Medicaid clients served by a Nursing Home Diversion Program reached different conclusions. The report from Florida's Office of Program Policy Analysis and Government Accountability concluded that the Diversion program saved money, whereas the report from the Florida Policy Exchange Center on Aging at the University of South Florida reached basically the opposite conclusion. Both agreed that the capitation rate was too high. How the policy questions are framed and analyzed can affect the conclusions reached. A variety of factors can influence the apparent effects of programmatic interventions. Evaluations must take relevant confounding variables into account.

Assisted living literature through May 2004: taking stock

PURPOSE

This article assesses the state of research on assisted living (AL) from 1989 to May 2004.

DESIGN AND METHODS

We undertook keyword searches for AL research and amplified these with searches of Web sites, conference proceedings, and follow-up inquiries. We annotated and coded the resultant items according to categories reflecting the research methods used and the topics studied. We did additional comparisons for 38 studies with quantitative data that permitted summarizing resident characteristics, settings, and entry and move-out patterns.

RESULTS

The 411 identified items ranged across a large number of topics. Qualitative studies outnumbered quantitative ones, and longitudinal studies were rare. We found little standardization in the way variables were measured, making cross-study comparisons difficult. As AL research has become more common, some items are directed at studying ways to proceed within AL as opposed to globally commenting on the worth of AL as a service sector.

IMPLICATIONS

The research base for AL has grown rapidly but is still underdeveloped. We recommend using more consistent sets of standardized measures in AL studies and reporting analyses based on them. We also recommend fuller reporting of details on sampling, time frames, and measures in AL research.

Effects of Green House nursing homes on residents' families

A longitudinal quasi-experimental study with two comparison groups was conducted to test the effects of a Green House (GH) nursing home program on residents' family members. The GHs are individual residences, each serving 10 elders, where certified nursing assistant (CNA)-level resident assistants form primary relationships with residents and family, family is encouraged to visits, and professionals adapted their roles to support the model. GH family were somewhat less involved in providing assistance to their residents although family contact did not differ among the settings at any time period. GH family were more satisfied with their resident's care and with their own experience as family members, and had no greater family burden. Issues in studying family outcomes are discussed as well as implications for roles of various personnel, including social service and activities staff in a GH model.

Resident Outcomes in Small-House Nursing Homes: A Longitudinal Evaluation of the Initial Green House Program

OBJECTIVES

To determine the effects of a small-house nursing home model, THE GREEN HOUSE (GH), on residents' reported outcomes and quality of care.

DESIGN

Two-year longitudinal quasi-experimental study comparing GH residents with residents at two comparison sites using data collected at baseline and three follow-up intervals.

SETTING

Four 10-person GHs, the sponsoring nursing home for those GHs, and a traditional nursing home with the same owner.

PARTICIPANTS

All residents in the GHs (40 at any time) at baseline and three 6-month follow-up intervals, and 40 randomly selected residents in each of the two comparison groups.

INTERVENTION

The GH alters the physical scale environment (small-scale, private rooms and bathrooms, residential kitchen, dining room, and hearth), the staffing model for professional and certified nursing assistants, and the philosophy of care.

MEASUREMENTS

Scales for 11 domains of resident quality of life, emotional well-being, satisfaction, self-reported health, and functional status were derived from interviews at four points in time. Quality of care was measured using indicators derived from Minimum Data Set assessments.

RESULTS

Controlling for baseline characteristics (age, sex, activities of daily living, date of admission, and proxy interview status), statistically significant differences in self-reported dimensions of quality of life favored the GHs over one or both comparison groups. The quality of care in the GHs at least equaled, and for change in functional status exceeded, the comparison nursing homes.

CONCLUSION

The GH is a promising model to improve quality of life for nursing home residents, with implications for staff development and medical director roles.

Predictors of Institutionalization in Latinos with Dementia

The present study identified predictors of time to institutionalization among elderly Latinos suffering from dementia, and determined how these predictors varied when compared to Caucasians and African-Americans. The sample included 324 Latino, 701 African-American, and 7,100 Caucasian dementia patients and their caregivers recruited from eight catchment regions in the U.S. and were assessed over a 3-year period. Potential predictors considered in the event history analyses included context of care and indicators of care recipient cognitive and functional status, caregiver stress and depression, and caregiving resources. Cox proportional hazards models revealed that various indicators of sociodemographic context, caregiver well-being, and community-based service utilization influenced time to institutionalization among Latinos. Cross-ethnic/racial comparisons also identified statistical variations in site, living arrangement, intensity of informal care provision, caregiver depression, and adult day service use across the Latino, Caucasian, and African-American samples when predicting time to nursing home placement. The findings emphasize the need to explore time to institutionalization across racial and ethnic contexts, and suggest future variables to consider when analyzing nursing home placement in diverse situations.

Resident and Family Perspectives on Assisted Living

This research describes and compares the relative importance residents and family members place on attributes of the environment, the programs, and the policies of assisted living; describes their satisfaction with these features; and identifies factors associated with congruence between residents' and family members' ratings of importance and satisfaction. Both residents and their family members had high importance and satisfaction ratings. Family members gave the assisted living setting lower satisfaction ratings on all features than did residents. Congruence ranged from 34% to 71% for importance items and from 29% to 63% for satisfaction. Female residents, affectionate family relationships, and residing in an AL owned by a chain were positively associated with congruence on importance items, while resident and family education, resident income, and family involvement were negatively associated with congruence on importance items. For congruence on satisfaction items, having an affectionate relationship was positively associated and higher ADL dependency, more family involvement at the facility, and family members who viewed the facility as a safe place were negatively associated with congruence. This study makes a major stride forward because cognitively intact residents' perspectives are compared and contrasted with their own family members' perspectives, thus showing that residents and family members are two distinct groups, each with a unique set of preferences.

Radical Redesign of Nursing Homes: Applying the Green House Concept in Tupelo, Mississippi

PURPOSE

We present the concept of the Green House, articulated by William Thomas as a radically changed, "deinstitutionalized" nursing home well before its first implementation, and we describe and discuss implications from the first Green Houses in Tupelo, Mississippi.

DESIGN AND METHODS

Green Houses are small, self-contained houses for 10 or fewer elders, each with private rooms and full bathrooms and sharing family-style communal space, including hearth, dining area, and full kitchen. Line staff at the level of certified nursing assistants, called Shahbazim, are "universal workers," who cook meals, do laundry, provide personal care, assist with habilitation, and promote the elders' quality of life. Nurses, doctors, and other professionals comprise a visiting clinical support team for the residents and Shahbazim. Multiple Green Houses comprise a nursing home, meeting all nursing facility regulations and working within state-reimbursement levels. In 2003, four Green Houses were built on the campus of a retirement community; in June of that year, 40 residents relocated from the 140-bed nursing home to the Green Houses, including 20 residents previously living in the locked dementia unit.

RESULTS

Experiences to date are positive for residents, family, and staff. The sponsor is converting the entire facility to Green Houses, and other providers around the country plan to implement Green House variants.

IMPLICATIONS

Because nursing home stock is aging, many physical plants are or soon will be slated for major rebuilding, thereby providing sponsors with an opportunity to consider Green Houses. Early experience suggests that Green Houses are feasible and that outcomes are likely to be positive, and it also suggests that there are some potential issues to overcome in such a dramatic reengineering of nursing homes.

Nurse delegation of medication administration for older adults in assisted living

Assisted living (AL) is a relatively new form of long-term care that offers residents personal care services and more independence in a home-like environment. Introduced to the United States in the 1980s, AL is changing the conventional thinking about how to care for frail older adults. One important issue to explore is registered nurse (RN) delegation to unlicensed assistive personnel (UAP), particularly for medication administration. This study provides a national perspective on medication delivery in AL settings from the perspectives of state Board of Nursing (BON) executives. Qualitative interviews using semi-structured interview guides were conducted with BON executives to validate a legal summary of AL regulations and nurse practice acts, and to identify nursing issues pertaining to medication management in AL across the United States. In this study, there was considerable variation across states regarding medication administration and the role of both the RN and the UAP. BON executives displayed a range of knowledge about nursing practice issues in AL, with many reporting low familiarity with this setting. Mechanisms for systematic review of quality of delegation were not in place. Medication administration and nurse delegation were dynamic issues, with practice and policy evolving concurrently. This study highlights the limited articulation of policies between agencies and across states in the important and growing setting of assisted living. Nurses have the opportunity to shape this evolving practice arena and to enhance awareness of the professional and clinical issues inherent in working with UAP in medication delivery.

Predicting nursing facility residents' quality of life using external indicators

PURPOSE

A newly developed brief measure of nursing facility (NF) resident self-reported quality of life (QOL) has been proposed for inclusion in a modified version of the minimum data set (MDS). There is considerable interest in determining whether it is possible to develop indicators of QOL that are more convenient and less expensive than direct, in-person interviews with residents.

DESIGN AND METHODS

QOL interview data from 2,829 residents living in 101 NFs using a 14-item version of a longer instrument were merged with data from the MDS and the Online Survey and Certification Automated Record (OSCAR). Bivariate and multivariate hierarchical linear modeling were used to assess the association of QOL with potential resident and facility level indicators.

RESULTS

Resident and facility level indicators were associated with self-reported QOL in the expected direction. At the individual resident level, QOL is negatively associated with physical function, visual acuity, continence, being bedfast, depression, conflict in relationships, and positively associated with social engagement. At the facility level, QOL is negatively associated with citations for failing to accommodate resident needs or providing a clean, safe environment. The ratio of activities staff to residents is positively associated with QOL. This study did not find an association between QOL and either use of restraints or nurse staff levels. Approximately 9 percent of the total variance in self-reported QOL can be attributed to differences among facilities; 91 percent can be attributed to differences among residents. Resident level indicators explained about 4 percent of the variance attributable to differences among residents, and facility factors explained 49 percent of the variance attributable to differences among NFs. However, the different variables explained only 10 percent of the variance in self-reported QOL.

IMPLICATIONS

A brief self-report measure of NF resident QOL is consistently associated with measures that can be constructed from extant data sources. However, the level of prediction possible from these data sources does not justify reliance on external indicators of resident QOL for policy purposes.

Unmet care needs and key outcomes in dementia

OBJECTIVES

To determine how unmet needs for activity of daily living tasks influenced nursing home placement, death, or loss to follow-up in dementia.

DESIGN

An 18-month longitudinal design, with interviews administered every 6 months.

SETTING

Eight catchment areas in the United States.

PARTICIPANTS

Five thousand eight hundred thirty-one dementia patients and their caregivers were included at baseline.

MEASUREMENTS

Measures of sociodemographic context of care; functional, cognitive, and behavioral status of care recipients; caregiver stress and well-being; and formal and informal resources served as covariates. The independent variables of interest were unweighted unmet care need scores and unmet need scores weighted by importance and severity in a prior sample of older consumers of long-term care. Outcomes included nursing home placement, death, and loss to follow-up.

RESULTS

Cox regression models suggested that greater unmet need was predictive of nursing home placement, death, and loss to follow-up. These results were apparent when the unweighted and the weighted scores for unmet need with activity of daily living dependencies were used.

CONCLUSION

Unmet need may be useful in identifying dementia care recipients at risk for nursing home placement and death. Further study of unmet need is needed to effectively assess and target intervention protocols during the course of dementia.

Assessing and Comparing Physical Environments for Nursing Home Residents: Using New Tools for Greater Research Specificity

PURPOSE

We developed and tested theoretically derived procedures to observe physical environments experienced by nursing home residents at three nested levels: their rooms, the nursing unit, and the overall facility. Illustrating with selected descriptive results, in this article we discuss the development of the approach.

DESIGN AND METHODS

On the basis of published literature, existing instruments, and expert opinion about environmental elements that might affect quality of life, we developed separate observational checklists for the room and bath environment, unit environment, and facility environment. We trained 40 interviewers without specialized design experience to high interrater reliability with the room-level assessment. We used the three checklists to assess 1,988 resident room and bath environments, 131 nursing units, and 40 facilities in five states. From the data elements, we developed quantitative indices to describe the facilities according to environmentally relevant constructs such as function-enhancing features, life-enriching features, resident environmental controls, and personalization.

RESULTS

We reliably gathered data on a large number of environmental items at three environmental levels. Environments varied within and across facilities, and we noted many environmental deficits potentially relevant to resident quality of life.

IMPLICATIONS

This research permits resident-specific data collection on physical environments and resident-level research using hierarchical analysis to examine the effects of specific environmental constellations. We describe practice and research implications for this approach.

Unmet care needs and key outcomes in dementia

OBJECTIVES

To determine how unmet needs for activity of daily living tasks influenced nursing home placement, death, or loss to follow-up in dementia.

DESIGN

An 18-month longitudinal design, with interviews administered every 6 months.

SETTING

Eight catchment areas in the United States.

PARTICIPANTS

Five thousand eight hundred thirty-one dementia patients and their caregivers were included at baseline.

MEASUREMENTS

Measures of sociodemographic context of care; functional, cognitive, and behavioral status of care recipients; caregiver stress and well-being; and formal and informal resources served as covariates. The independent variables of interest were unweighted unmet care need scores and unmet need scores weighted by importance and severity in a prior sample of older consumers of long-term care. Outcomes included nursing home placement, death, and loss to follow-up.

RESULTS

Cox regression models suggested that greater unmet need was predictive of nursing home placement, death, and loss to follow-up. These results were apparent when the unweighted and the weighted scores for unmet need with activity of daily living dependencies were used.

CONCLUSION

Unmet need may be useful in identifying dementia care recipients at risk for nursing home placement and death. Further study of unmet need is needed to effectively assess and target intervention protocols during the course of dementia.

Proxy Sources for Information on Nursing Home Residents' Quality of Life

OBJECTIVES

This study explores how well staff and family proxies' reports on selected quality-of-life (QOL) domains (comfort, dignity, functional competence, privacy, meaningful activity, food enjoyment, relationships, security, and autonomy) correspond to residents' own reports.

METHODS

We compared QOL domain scores for nursing home residents and 1,326 staff proxies and 989 family proxies at the individual and facility level using means, Pearson correlation statistics, and intraclass correlations. Regression models adjusted for residents' age, gender, length of stay, ability to perform activities of daily living, and cognition.

RESULTS

For each domain in more than half the cases, proxy means were within 1 SD of the resident means. Resident and family proxy individual reports for selected domains were correlated at 0.14 to 0.46 (all p <.000). Resident and staff proxy individual reports were correlated at 0.13 to 0.37 (all p <.000). Correlation of mean levels by facility for staff proxies was 0.26 to 0.64 (generally p <.05) and for family proxies 0.13 to 0.61 (p <.01 except for one domain).

DISCUSSION

Although staff and family proxy domain scores are significantly correlated with resident scores, the level of correlation suggests they cannot simply be substituted for resident reports of QOL. Determining how proxy reports can be used for residents who cannot be interviewed at all remains an unresolved challenge.

Early community-based service utilization and its effects on institutionalization in dementia caregiving

PURPOSE

The present study attempts to determine whether utilizing community-based long-term-care services early in the dementia caregiving career delays time to nursing home placement (adjusting for severity of dementia).

DESIGN AND METHODS

With a reliance on data from 4,761 dementia caregivers recruited from eight catchment areas in the United States and followed over a 3-year period, a Cox proportional hazards model was conducted that considered key components of the stress process (e.g., context of care, primary objective and subjective stressors, and resources), duration, and community-based long-term-care use.

RESULTS

An analysis of interaction terms in the Cox regression model found that those individuals who utilized in-home help services earlier in their dementia caregiving careers were more likely to delay institutionalization.

IMPLICATIONS

The findings suggest the practical importance and cost-effectiveness implications of early community-based service use, and they emphasize the role of timing when one is conceptualizing the proliferation of stress in the dementia caregiving career.

Cognitive Impairment and Quality-of-Life

Quality-of-life (QoL) is now recognized as a principal outcome marker for long-term care. However, QoL is difficult to define and measure, especially in residents with dementia. Providers of long-term care services (n = 182) were asked to rate the importance of 19 psychosocial quality-of-life elements for hypothetical residents with physical impairment and for residents with cognitive impairment. Respondents also were asked to rate their ability to influence these elements for each type of resident. Respondents rated the importance of 18 of the 19 elements and their ability to influence 17 of 19 elements lower for residents with cognitive impairment. Of the five types of respondents, certified nursing assistants (CNAs) rated their ability to influence these QoL elements the highest for both types of residents; physicians' ratings were the lowest. Pain management was given high ratings for both importance and ability to influence for both resident types; the lowest ratings were given for elements that pertained to residents' understanding. A strong correlation between ratings for importance and ability to influence was observed. Additional research is needed on the psychosocial aspects of long-term care residents' QoL, especially those with cognitive impairment.

The effects of duration of caregiving on institutionalization

PURPOSE

Our objective in this analysis was to determine how the duration of caregiving interacts with key care demands (i.e., severity of problem behaviors) to influence the institutionalization of individuals suffering from dementia.

METHODS

We utilized multiregional data from 4,761 caregivers of individuals with dementia over a 3-year period. We conducted multinomial logistic and Cox proportional hazards analyses to determine the moderating effects of duration on behavior problems when institutionalization was predicted. Baseline covariates included the context of care, primary objective stressors, primary subjective stressors, resources, and global outcomes.

RESULTS

The Duration of care x Behavior problems interaction term was not significant in the multinomial regression or Cox hazards models. However, main effects models demonstrated that more recent caregivers were more likely to institutionalize individuals with dementia than respondents in different stages of the caregiving career.

IMPLICATIONS

The results emphasize the need to (a) broaden scientific conceptualizations to consider duration of care as integral; (b) refine targeting when interventions are administered early in the dementia caregiving process; and (c) understand patterns of attrition when caregiver adaptation is modeled over time.

The Longitudinal Effects of Early Behavior Problems in the Dementia Caregiving Career

Using multiregional, 3-year data from early career dementia caregivers, this study determines how behavior problems that occur early in the caregiving career influence time to nursing home placement and change in burden and depression over time. A Cox proportional hazards model indicated that caregivers who managed frequent behavior problems earlier are more likely to institutionalize. After controlling for important time-varying covariates in a series of growth-curve models, caregivers who were faced with severe, early behavior problems reported greater increases in burden and depression over the 3-year study period. The findings suggest the need to consider experiences early in the dementia caregiving career when accounting for key longitudinal outcomes and also emphasize the importance of attrition when attempting to model the health implications of informal long-term care over time.

Using Resident Reports of Quality of Life to Distinguish Among Nursing Homes

PURPOSE

We used measures created to assess the quality of life (QOL) of nursing home residents to distinguish among nursing facilities.

DESIGN AND METHODS

We statistically adjusted scores for 10 QOL domains derived from standardized interviews with nursing home residents for age, gender, activities of daily living functioning, cognitive functioning, and length of stay, and then we aggregated them to the facility level. We compared the patterns across a sample of 40 facilities. We correlated facility characteristics with QOL scores.

RESULTS

The pattern of QOL scores for each of the 10 domains was generally consistent within a given facility. Although resident characteristics played a major role in explaining variance, there were significant effects of facilities as well. Some modest relationships were found between facility characteristics such as ownership, percentage of private rooms, and rural-urban location and facility QOL scores. No effect of facility size was detected.

IMPLICATIONS

This article shows that it is possible to differentiate among facilities on the basis of resident self-reported QOL. On the basis of our analysis, we find that a sample of 28 residents per facility is sufficient to generate a reliable QOL score for each of the domains studied.

Addressing the ethical, legal, and social issues raised by voting by persons with dementia

This article addresses an emerging policy problem in the United States participation in the electoral process by citizens with dementia. At present, health care professionals, family caregivers, and long-term care staff lack adequate guidance to decide whether individuals with dementia should be precluded from or assisted in casting a ballot. Voting by persons with dementia raises a series of important questions about the autonomy of individuals with dementia, the integrity of the electoral process, and the prevention of fraud. Three subsidiary issues warrant special attention: development of a method to assess capacity to vote; identification of appropriate kinds of assistance to enable persons with cognitive impairment to vote; and formulation of uniform and workable policies for voting in long-term care settings. In some instances, extrapolation from existing policies and research permits reasonable recommendations to guide policy and practice. However, in other instances, additional research is necessary.

A phylogeny based on three mitochondrial genes supports the division of Schistosoma intercalatum into two separate species

Two recognized strains of Schistosoma intercalatum, one from the Democratic Republic of Congo (DRC), formerly Zaire, and the other from Cameroon, have been investigated using DNA sequences from 3 mitochondrial genes, cytochrome oxidase subunit 1 (cox1), NADH dehydrogenase subunit 6 (nad6) and the small ribosomal RNA gene (rrnS). In addition, partial DNA sequences from the nuclear large subunit ribosomal RNA gene (lsrDNA) were included within the study. Although partial lsrDNA alone reveals little taxonomic information, phylogenetic analysis of the mitochondrial data demonstrates a clear dichotomy between the 2 purported strains and it is proposed that they should be treated as distinct taxa. The 'original' S. intercalatum now falls relatively basal in the S. haematobium group, while the proposed new species is more derived and sister taxon to S. bovis and S. curassoni.

Definition, measurement, and correlates of quality of life in nursing homes: toward a reasonable practice, research, and policy agenda

PURPOSE

This article identifies challenges in defining, measuring, and studying quality of life of nursing home residents.

DESIGN AND METHOD

A theoretical analysis was conducted based on literature and the author's own large-scale studies of quality of life of nursing home residents.

RESULTS

Measuring quality of life is a relatively low priority in nursing homes because of focus on markers of poor quality of care, pervasive sense that nursing homes are powerless to influence quality of life, and impatience with research among those dedicated to culture change. The research argues that the resident voice must be sought in reaching operational definitions for quality of life and as reporters on the quality of their own lives, and that resident burden is a spurious concern that should not deter direct interviews with residents. Five challenges in measuring quality of life were identified: (a) designing questions with appropriate response categories and time frames, (b) developing a sampling strategy, (c) aggregating information at the individual and facility level, (d) validating what are ultimately subjective constructs, and (e) developing an approach using observations and proxies to assess quality of life for approximately the 40% of the residents who will be impossible to interview.

IMPLICATIONS

Although residents' perceived quality of life is partly a product of their health, social supports, and personalities, nursing homes can directly influence quality of life through their policies, practices, and environments, and, indirectly, through their approaches to family and community. A research agenda is needed, which includes both methodological research and studies of the correlates of quality of life.

Caregiving and institutionalization of cognitively impaired older people: utilizing dynamic predictors of change

PURPOSE

The purpose of this study was to identify reliable predictors of nursing home entry over a 3-year period in a sample of 3,944 persons with dementia who resided in a home setting at baseline. Strengths of the analysis include a multiregional recruitment strategy, incorporation of salient caregiver characteristics, and a 3-year prospective design that allows for the modeling of change in important variables (e.g., care recipient functional status or caregiving indicators) when time to institutionalization is predicted.

DESIGN AND METHODS

Data were derived from the control sample of the Medicare Alzheimer's Disease Demonstration Evaluation (MADDE). A Cox proportional hazards model was used to predict time to institutionalization among individuals with dementia (baseline was enrollment into MADDE). Predictors included care recipient demographics, caregiver demographics, and time-varying measurements of care recipient functional status, caregiving indicators, and service utilization. Indicators of change were also incorporated to capitalize on the prospective data available.

RESULTS

Although several results were consistent with prior findings, caregiving indicators (i.e., burden and self-rated health) and community-based service use were significant predictors of earlier placement. Change in caregiver instrumental activities of daily living and care recipient activities of daily living were also related to expedited institutionalization.

IMPLICATIONS

The findings emphasize the importance of incorporating both care recipient and caregiver function and service use patterns when targeting programs designed to prevent or delay institutionalization for people with dementia.

Quality of life measures for nursing home residents

BACKGROUND

Quality of life (QOL) is a goal for nursing home residents, but measures are needed to tap this phenomenon.

METHODS

In-person QOL interviews were attempted for 1988 residents, stratified by cognitive functioning, from 40 nursing homes in five states. Likert-type response options were used with reversion to dichotomous responses when necessary; z-score transformations were used to combine the formats. Tests of internal consistency and confirmatory factor analysis were performed; cluster analysis was used to shorten the scales. Correlations between domain scores were examined, and tests of convergent validity performed. Analyses were repeated for subgroups based on cognitive functioning levels.

RESULTS

Long QOL scales were constructed for 1316 of the 1988 residents, including many with substantial cognitive impairment. Confirmatory factor analysis confirmed 10 QOL domains. Cronbach alphas ranged from.76 to.52. The majority (93%) of the 45 possible interscale correlations among domains were below.l4 and the rest were between.4 and.5. QOL scales were correlated with, but distinct from, residents' emotions ratings and overall satisfaction, and each was correlated with a corresponding summary rating for the domain.

CONCLUSIONS

QOL can be feasibly measured from resident self-report for much of the nursing home population, including cognitively impaired residents. Additional research is suggested on the measures, but the approach has promise for regulation, continuous quality improvement, and public information.

Intraoperative ultrasound of the biliary system: techniques and clinical applications

Intraoperative ultrasonography (IOUS) of the intra- and extrabepatic biliary system is being used with increased frequency in many medical centers. The value of IOUS in facilitating surgery in patients with complicated diseases of the gallbladder or with stones in the bile ducts is well recognized. However, a variety of less common diseases affect the intrahepatic ducts, many of which require sophisticated surgical techniques when resection is being undertaken. In many situations, these operations can be facilitated by the use of IOUS, both for depicting segmental and ductal anatomy, and in guiding resections and anastomoses. This report summarizes the techniques currently used for performing IOUS of the biliary system, and illustrates the spectrum of clinical applications that may require IOUS guidance.

Family care for older adults with disabilities: toward more targeted and interpretable research

Family care of the elderly is key to the long-term care system, and its importance has led to an abundance of research over the past two decades. Several methodological and substantive issues, if addressed, could create even more targeted and interpretable research. The present review critically examines methodological topics (i.e., definitions of family caregiving, measurement of caregiving inputs) and conceptual issues (i.e., family involvement in long-term residential settings, and the care receiver's perspective on care) that have received insufficient attention in the caregiving literature. Throughout this review recommendations are offered to improve these areas and advance the state of the art.

Application of single strand conformational polymorphism (SSCP) analysis with fluorescent primers for differentiation of Schistosoma haematobium group species

To assess the utility of single-stranded conformational polymorphism (SSCP) analysis for the differentiation of schistosomes, using methods adapted for a Perkin Elmer ABI Prism 377 automated sequencer, 3 isolates of Schistosoma haematobium, 2 of S. intercalatum and single isolates of S. curassoni and S. bovis were selected for study. Two fluorescently labelled, double-stranded polymerase chain reaction products, amplified from the mitochondrial cytochrome oxidase subunit 1 (CO1) gene and the nuclear ribosomal second internal transcribed spacer (ITS2), were generated from single male and female worms. Changes in electrophoretic mobility of fragments within an SSCP profile revealed variation at individual, isolate and species levels. The mutational basis between representative SSCP profiles was confirmed by direct sequencing, demonstrating that single point substitutions were detectable. SSCP analysis has considerable potential as an alternative molecular method of identification and characterization of schistosomes. More broadly, fluorescence-based SSCP analysis is applicable to almost any gene target from any species of parasite and is a powerful molecular tool for genetic profiling.