Jan-06

Providing Nutrition Supplements to Institutionalized Seniors with Probable Alzheimer’s Disease Is Least Beneficial to Those with Low Body Weight Status
Karen W. H. Young, MSc, Carol E. Greenwood, PhD, Robert van Reekum, MD, and Malcolm A. Binns, MSc

Objectives: To examine whether providing a midmorning nutrition supplement increases habitual energy intake in seniors with probable Alzheimer’s disease (AD) and to investigate the effects of body weight status and cognitive and behavioral function on the response to the intervention.

Design: Randomized, crossover, nonblinded clinical trial.

Setting: A fully accredited geriatric teaching facility affiliated with the University of Toronto’s Medical School with a home for the aged.

Participants: Thirty-four institutionalized seniors with probable AD who ate independently.

Intervention: Nutrition supplements were provided between breakfast and lunch for 21 consecutive days and compared with 21 consecutive days of habitual intake.

Measurements: Investigator-weighed food intake, body weight, cognitive function (Severe Impairment Battery and Global Deterioration Scale), behavioral disturbances (Neuropsychiatric InventoryNursing Home Version), and behavioral function (London Psychogeriatric Rating Scale).

Results: Relative to habitual intake, group mean analyses showed increased 24-hour energy, protein, and carbohydrate intake during the supplement phase, but five of 31 subjects who finished all study phases completely compensated for the energy provided by the supplement by reducing lunch intake, and 24-hour energy intake was enhanced in only 21 of 31 subjects. Compensation at lunch was more likely in subjects with lower body mass indices, increased aberrant motor behavior, poorer attention, and increased mental disorganization/confusion.

Conclusion: Nutrition supplements were least likely to enhance habitual energy intake in subjects who would normally be targeted for nutrition intervention—those with low body weight status. Those likely to benefit include those with higher body mass indices, less aberrant motor problems, less mental disorganization, and increased attention. J Am Geriatr Soc 2004;52(8): 1305-1312.
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Behavioral Symptoms in Residential Care/Assisted Living Facilities: Prevalence, Risk Factors, and Medication Management
Ann L. Gruber-Baldini, PhD, Malaz Boustani, MD, MPH, Philip D. Sloane, MD, MPH, and Sheryl Zimmerman, PhD

Objectives: To examine the prevalence, correlates, and medication management of behavioral symptoms in elderly people living in residential care/assisted living (RC/AL) facilities.

Design: Cross-sectional study.

Setting: A stratified random sample of 193 RC/AL facilities in four states (Florida, Maryland, New Jersey, North Carolina).

Participants: A total of 2,078 RC/AL residents aged 65 and older.

Measurements: Behavioral symptoms were classified using a modified version of the Cohen-Mansfield Agitation Inventory. Additional items on resistance to care were also examined.

Results: Approximately one-third (34%) of RC/AL residents exhibited one or more behavioral symptoms at least once a week. Thirteen percent exhibited aggressive behavioral symptoms, 20% demonstrated physically nonaggressive behavioral symptoms, 22% expressed verbal behavioral symptoms, and 13% resisted taking medications or activities of daily living care. Behavioral symptoms were associated with the presence of depression, psychosis, dementia, cognitive impairment, and functional dependency, and these relationships persisted across subtypes of behavioral symptoms. Overall, behavioral symptoms were more prevalent in smaller facilities. More than 50% of RC/AL residents were taking a psychotropic medication, and two-thirds had some mental health problem indicator (dementia, depression, psychosis, or other psychiatric illness).

Conclusion: Integrating mental health services within the process of care in RC/AL is needed to manage and accommodate the high prevalence of behavioral symptoms in this evolving long-term setting. J Am Geriatr Soc 2004;52(10): 1610-1617.
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Risk Factors for Deep Vein Thrombosis in Inpatients Aged 65 and Older: A Case-Control Multicenter Study
Sébastien Weill-Engerer, MD, Sylvie Meaume, MD, Amina Lahlou, MD, François Piette, MD, Olivier Saint-Jean, MD, Annick Sachet, MD, Jean-Yves Beinis, MD, Claude Gallinari, MD, Anne-Sophie Grancher, MD, Jean-Pierre Vincent, MD, Henri Naga, MD, Joel Belmin, MD, Rosella Salvatore, MD, Marie Kazes, MD, Eric Pautas, MD, André Boiffin, MD, Jean-Bernard Piera, MD, Monique Duviquet, MD, David Knafo, MD, Andrée Piau, MD, Dragoslav Miric, MD, Alain Jean, MD, Valérie Bellamy, MD, Olivier Tissandier, MD, and Alain-Ferdinand Le Blanche, MD, PhD

Objectives: To identify independent risk factors of symptomatic deep vein thrombosis (DVT) in geriatric inpatients and to define high-risk patients likely to benefit from preventive treatment.

Design: Hospital-based case-control multicenter study with prospective data collection.

Setting: Geriatric university hospitals with long-, intermediate-, and short-term care facilities.

Participants: All patients aged 65 and older in 19 geriatric departments were submitted to clinical surveillance over a 16-month period.

Measurements: Twenty-three potential risk factors of phlebitis were screened for. Comparison using logistic regression of 310 consecutive patients with symptomatic DVT versus 310 randomly selected controls was performed. The risk for symptomatic DVT in geriatrics was then scored from the clinical risk factors identified using multivariate analysis. This score is defined by the sum of the odds ratio (OR) of each risk factor present.

Results: Six factors were identified as independently related to the development of DVT: restriction of mobility (from OR=1.73, limited mobility without immobilization, to OR=5.64, bedridden during <15 days), aged 75 and older (OR=1.5/10 years), history of DVT or pulmonary embolism (OR=3.38), acute heart failure (OR=2.52), chronic edema of the lower limbs (OR=2.51), and paresis or paralysis of a lower limb (OR=2.06). The defined score of 8 or higher corresponded to an 88.7% probability of having symptomatic DVT.

Conclusion: Treatments to prevent symptomatic DVT in hospitalized elderly should be evaluated on patients with these factors. J Am Geriatr Soc 2004;52(8):1299-1304.
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The Maryland Assisted Living Study: Prevalence, Recognition, and Treatment of Dementia and Other Psychiatric Disorders in the Assisted Living Population of Central Maryland
Adam Rosenblatt, MD, Quincy M. Samus, MS, Cynthia D. Steele, RN, MPH, Alva S. Baker, MD, Michael G. Harper, MD, Jason Brandt, PhD, Peter V. Rabins, MD, and Constantine G. Lyketsos, MD, MHS

Objectives: To obtain a direct estimate of the prevalence of dementia and other psychiatric disorders in residents of assisted living (AL) in Central Maryland, and their rates of recognition and treatment.

Design: Comprehensive review of history and cognitive and neuropsychiatric evaluations using widely accepted instruments in a randomized cohort of AL residents, stratified by facility size. An expert multidisciplinary consensus panel determined diagnoses and appropriateness of treatment.

Setting: Twenty-two (10 large and 12 small) randomly selected AL facilities in the city of Baltimore and seven Maryland counties.

Participants: One hundred ninety-eight volunteers who were residents of AL, 75% were aged 80 and older, and 78% were female. Potential participants were randomly chosen by room number. There was a 67% participation rate.

Measurements: Overall rate of dementia, noncognitive active psychiatric disorders, and recognition and adequate treatment of dementia and psychiatric disorders, as determined by consensus panel.

Results: Two-thirds (67.7%) of participants had dementia diagnosable according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (81% small facilities and 63% large). Family or caregivers recognized 78% to 80% of dementias. Seventy-three percent of dementias were adequately evaluated, and 52% were adequately treated. Of the 26.3% of participants who had an active noncognitive psychiatric disorder, 58% to 61% were recognized and 52% adequately treated.

Conclusion: Dementia and psychiatric disorders are common in AL and have suboptimal rates of recognition and treatment. This may contribute to morbidity and interfere with the ability of residents to age in place. J Am Geriatr Soc 2004;52 (10):1618-1625.
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Nursing Home Characteristics and Potentially Preventable Hospitalizations of Long-Stay Residents
Orna Intrator, PhD, Jacqueline Zinn, Ph, and Vincent Mor, PhD

Objectives: To examine the association between having a nurse practitioner/physician assistant (NP/PA) on staff, other nursing home (NH) characteristics, and the rate of potentially preventable/avoidable hospitalizations of long-stay residents, as defined using a list of ambulatory caresensitive (ACS) diagnoses.

Design: Cross-sectional prospective study using Minimum Data Set (MDS) assessments, Centers for Medicare and Medicaid Services inpatient claims and eligibility records, On-line Survey Certification Automated Records, (OSCAR) and Area Resource File (ARP).

Setting: Freestanding urban NHs in Maine, Kansas, New York, and South Dakota.

Participants: Residents of 663 facilities with a quarterly or annual MDS assessment in the 2nd quarter of 1997, who had a prior MDS assessment at least 160 days before, and who were not health maintenance organization members throughout 1997 (N=54,631).

Measurements: A 180-day multinomial outcome was defined as having any hospitalization with primary ACS diagnosis, otherwise having been hospitalized, otherwise died, and otherwise remained in the facility.

Results: Multilevel models show that facilities with NP/PAs were associated with lower hospitalization rates for ACS conditions (adjusted odds ratio (AOR)=0.83), but not with other hospitalizations. Facilities with more physicians were associated with higher ACS hospitalizations (ACS, AOR=1.14, and non-ACS, AOR=1.10). Facilities providing intravenous therapy, and those that operate a nurses’ aide training program were associated with fewer hospitalizations of both types.

Conclusion: Employment of NP/PAs in NHs, the provision of intravenous therapy, and the operation of certified nurse assistant training programs appear to reduce ACS hospitalizations, and may be feasible cost-saving policy interventions. J Am Geriatr Soc 2004;52(10):1730-1736.
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Ameliorating Pain in Nursing Homes: A Collaborative Quality-Improvement Project
Rosa R. Baier, MPH, David R. Gifford, MD, MPH, Gail Patry, RN, Sara M. Banks, MPH, PhD, Therese Rochon, RNP, MSN, MA, Debra DeSilva, BA, and Joan M. Teno, MD, MS

Objectives: To evaluate a multifaceted intervention to improve pain-management processes of care and outcomes in nursing homes.

Design: Quasi-experimental, pretest/posttest.

Setting: Nursing homes in Rhode Island.

Participants: Twenty-one facilities.

Intervention: This project used a multifaceted collaborative intervention involving audit and feedback of pain management, education, training, coaching using rapid-cycle quality-improvement techniques, and inter-nursing home collaboration.

Measurements: Pain-management processes of care and outcomes, measured using chart review and the Minimum Data Set.

Results: Of 21 facilities, 17 completed the project. Postintervention, nursing homes increased the use of appropriate pain assessments (3.9% vs 43.8%, P<.001), pain intensity scales (15.6% vs 73.9%, P<.001), and nonpharmacological treatments (40.5% vs 81.9%, P<.001). Prescriptions of World Health Organization Step II or Step III pain medications for residents with daily moderate or severe pain showed trends towards improvement (40.8% vs 50.6%, P=.057), but prescription of any pain medication (93.3% vs 94.6%, P=.710), change in pain medication (29.0% vs 30.1%, P=.386), and prescription of pain medications on a regularly scheduled basis (67.9% vs 69.5%, P=.370) did not. There was a 41.1% reduction in prevalence of pain (12.2% vs 7.2%, P=.032) between the pre- and postintervention time periods in the nursing homes that completed the project, whereas all the other facilities in Rhode Island (n=72) had only a 12.1% reduction (12.7% vs 11.2%, P=.286) during the same period.

Conclusion: A multifaceted intervention improved pain-management process and outcome measures in nursing homes. J Am Geriatr Soc 2004;52(12):1988-1995.