Special Care Facility Compared with Traditional Environments for Dementia Care: A Longitudinal Study of Quality of Life

Marlene A. Reimer, RN, PhD, Susan Slaughter, RN, MSc(A), Cam Donaldson, PhD, Gillian Currie, PhD, and Michael Eliasziw, PhD

Objectives: To compare the effect of a specialized care facility (SCF) on quality of life (QoL) for residents with middle- to late-stage dementia over a 1-year period with residence in traditional institutional facilities.

Design: A prospective, matched-group design with assessments of QoL every 3 months for 1 year.

Setting: Twenty-four long-term care centers and four designated assisted living environments in an urban center in western Canada.

Participants: One hundred eighty-five residents with Global Deterioration Scores of 5 or greater were enrolled: 62 in the intervention SCF group and 123 in the traditional institutional facilities groups.

Intervention: The SCF is a 60-bed purpose-built facility with 10 people living in six bungalows. The facility followed an ecologic model of care that is responsive to the unique interplay of each person and the environment. This model encompasses a vision of long-term care that is more comfortable, more like home, and offers more choices, meaningful activity, and privacy than traditional settings.

Measurements: QoL outcomes were assessed using the Brief Cognitive Rating Scale, Functional Assessment Staging, Cohen-Mansfield Agitation Inventory, Pleasant Events Scale—Alzheimer’s disease, Multidimensional Observation Scale of Elderly Subjects, and Apparent Affect Rating Scale.

Results: The intervening SCF group demonstrated less decline in activities of daily living, more sustained interest in the environment, and less negative affect than residents in the traditional institutional facilities. There were no differences between groups in concentration, memory, orientation, depression, or social withdrawal.

Conclusion: The present study suggests that QoL for adults with middle- to late-stage dementia is the same or better in a purpose-built and staffed SCF than in traditional institutional settings. J Am Geriatr Soc 2004;52(7):1085-1092.

Office Evaluation and Treatment of Elderly Patients with Acute Bronchitis

Michael A. Steinman, MD, Angela Sauaia, MD, PhD, Judy H. Maselli, MSPH, Peter M. Houck, MD, and Ralph Gonzales, MD, MSPH

Objectives: To assess the office evaluation of seniors with uncomplicated acute bronchitis and to determine the association between elements of the clinical evaluation and antibiotic prescribing decisions.

Design: Cross-sectional chart review.

Setting: Seventy-seven community-based office practices in the Denver metropolitan area.

Participants: Elderly fee-for-service Medicare patients.

Measurements: Medicare administrative data to identify patients with acute bronchitis; medical record review to confirm the diagnosis and record other clinical data.

Results: Of 198 elderly patients with acute bronchitis, the mean age ± standard deviation was 76 ± 8.6; 53% had at least one comorbid condition. Clinically important vital signs were frequently not recorded; temperature was missing from 34% of charts and pulse from 50% of charts. When recorded, significant vital sign abnormalities were uncommon, with 7% having a temperature of 100°F and 8% having a pulse of 100 beats per minute or greater. However, antibiotics were prescribed to 83% of patients, with more than half of these prescriptions being for extended-spectrum antibiotics. Treatment with antibiotics was more common in men than women (92% vs 78%, P = 0.007) but was not associated with clinical factors including vital sign measurement, vital sign results, chest radiography, patient age, duration of illness, or the presence of comorbidities.

Conclusion: The vast majority of seniors with acute bronchitis are treated with antibiotics, regardless of patient characteristics or the type of evaluation received. Reducing inappropriate antibiotic use in seniors with acute bronchitis may depend on improving the evaluation of these patients and encouraging clinicians to act appropriately on the results. J Am Geriatr Soc 2004;52(6):875-879.

Persistent Nonmalignant Pain and Analgesic Prescribing Patterns in Elderly Nursing Home Residents

Aida B. Won, MD, Kate L. Lapane, PhD, Sue Vallow, RPH, MBA, Jeff Schein, DrPH, MPH, John N. Morris, PhD, and Lewis A. Lipsitz, MD

Objectives: To determine the prevalence of analgesics used, their prescribing patterns, and associations with particular diagnoses and medications in patients with persistent pain.

Design: Cross-sectional study.

Setting: Nursing homes from 10 U.S. states.

Participants: A total of 21,380 nursing home residents aged 65 and older with persistent pain.

Measurements: Minimum Data Set (MDS) assessments on pain, analgesics, cognitive, functional, and emotional status were summarized. Logistic regression models identified diagnoses associated with different analgesic classes.

Results: Persistent pain as determined using the MDS was identified in 49% of residents with an average age of 83; 83% were female. Persistent pain was prevalent in patients with a history of fractures (62.9%) or surgery (63.6%) in the past 6 months. One-quarter received no analgesics. The most common analgesics were acetaminophen (37.2%), propoxyphene (18.2%), hydrocodone (6.8%), and tramadol (5.4%). Only 46.9% of all analgesics were given as standing doses. Acetaminophen was usually prescribed as needed (65.6%), at doses less than 1300 mg per day. Nonsteroidal antiinflammatory drugs (NSAIDs) were prescribed as a standing dose more than 70% of the time, and one-third of NSAIDs were prescribed at high doses.

Conclusion: In nursing home residents, persistent pain is highly prevalent, there is suboptimal compliance with geriatric prescribing recommendations, and acute pain may be an important contributing source of persistent pain. More effective provider education and research is needed to determine whether treatment of acute pain could prevent persistent pain. J Am Geriatr Soc 2004;52(6):867-874.

The Effects of Staffing on In-Bed Times of Nursing Home Residents

Barbara M. Bates-Jensen, PhD, RN, CWOCN, John F. Schnelle, PhD, Cathy A. Alessi, MD, Nahla R. Al-Samarrai, MS, and Lené Levy-Storms, PhD, MPH

Objectives: To examine the effect of staffing level on time observed in bed during the daytime in nursing home (NH) residents.

Design: Descriptive, cross-sectional study.

Setting: Thirty-four southern California NHs.

Participants: A total of 882 NH residents: 837 had hourly observation data, 777 had mealtime observations, 837 completed interviews, and 817 completed a physical performance test.

Measurements: Cross-sectional data collected from participants at each NH site included direct observations (hourly and mealtime), resident interviews, medical record review, and physical performance tests.

Results: In multivariate analyses, staffing level remained the strongest predictor of time observed in bed after controlling for resident functional measures (odds ratio = 4.89; P = 0.042). Residents observed in bed during the daytime in more than 50% of hourly observations were observed also to experience increased daytime sleeping (P < 0.001) and less social engagement (P = 0.026) and consumed less food and fluids during mealtimes than those observed in bed in less than 50% of observations, after adjusting for resident function (P < 0.001).

Conclusion: In this sample of NHs, resident functional measures and NH staffing level predicted observed time in bed according to hourly observations, with staffing level the most powerful predictor. Neither of these predictors justifies the excessive in-bed times observed in this study. Staff care practices relevant to encouraging residents to be out of bed and resident preferences for being in bed should be examined and improved. Practice recommendations regarding in-bed time should be considered, and further research should seek to inform the development of such recommendations. J Am Geriatr Soc 2004;52(6):931-938.