Evaluation of the Montessori-Inspired Lifestyle® as the Foundation of Care in Assisted Living Memory Care.

The Montessori-Inspired Lifestyle® (MIL) was implemented as the foundation of care in several assisted living memory care (ALMC) neighborhoods to enhance meaningful social roles, engagement, and focus on residents' remaining capabilities. The purpose of this quality improvement project was to evaluate the outcomes regarding resident levels of engagement and prescribed antipsychotic medications before and after MIL implementation. A total of 85 residents were observed for 10-minute periods seven times during 1 day to ascertain the level of engagement during meals and planned and unplanned activities. Positive engagement minutes increased after MIL implementation for activities and meals. Outcomes of this project support the MIL as a foundation of care for ALMC residents and have raised the awareness for addressing diverse cognitive abilities. The need for reoccurring training for the sustainability of this model of care was recognized. [Journal of Gerontological Nursing, 46(5), 40-46.].

Hydration Management.

Optimal hydration is essential to health, yet many common health problems of older adults are exacerbated by suboptimal hydration, including falls, adverse medication events, and urinary tract infections to name a few. Understanding dehydration in older adults is difficult, and causes for inadequate intake are multifocal. The current article provides important care guidelines on assessing risk and providing essential interventions to prevent dehydration. [Journal of Gerontological Nursing, 46(2), 19-30.].

Hydration Status of Assisted Living Memory Care Residents.

Water intake and hydration status of assisted living memory care (ALMC) residents were evaluated. Thirty-two residents (eight men; mean age 86.5 years; Global Deterioration Scale [GDS] 3 to 7) from four ALMC units participated. Ingested food and fluid amount, type, and time, and ingestion behaviors were observed from 7:00 a.m. to 7:00 p.m. Related factors were obtained from chart review/participant survey. Mean fluid intake was 1,160.16 mL; mean water intake from food and fluid was 56.55% (SD = 23.4%) of recommended water intake (RWI). Only one participant met 100% RWI. Using osmolality laboratory results (available for 21 participants), five participants were hydrated, whereas eight (38.1%) participants were in impending dehydration and dehydration categories, respectively. Fluid intake, GDS, and level of assistance during meals predicted RWI. Water intake of ALMC residents is inadequate, placing them at risk for dehydration, and justifies development and implementation of care standards for increasing water intake. [Journal of Gerontological Nursing, 45(4), 21-29.].

Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people.

BACKGROUND: There is evidence that water-loss dehydration is common in older people and associated with many causes of morbidity and mortality. However, it is unclear what clinical symptoms, signs and tests may be used to identify early dehydration in older people, so that support can be mobilised to improve hydration before health and well-being are compromised. OBJECTIVES: To determine the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs and tests to be used as screening tests for detecting water-loss dehydration in older people by systematically reviewing studies that have measured a reference standard and at least one index test in people aged 65 years and over. Water-loss dehydration was defined primarily as including everyone with either impending or current water-loss dehydration (including all those with serum osmolality ≥ 295 mOsm/kg as being dehydrated). SEARCH METHODS: Structured search strategies were developed for MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL, LILACS, DARE and HTA databases (The Cochrane Library), and the International Clinical Trials Registry Platform (ICTRP). Reference lists of included studies and identified relevant reviews were checked. Authors of included studies were contacted for details of further studies. SELECTION CRITERIA: Titles and abstracts were scanned and all potentially relevant studies obtained in full text. Inclusion of full text studies was assessed independently in duplicate, and disagreements resolved by a third author. We wrote to authors of all studies that appeared to have collected data on at least one reference standard and at least one index test, and in at least 10 people aged ≥ 65 years, even where no comparative analysis has been published, requesting original dataset so we could create 2 x 2 tables. DATA COLLECTION AND ANALYSIS: Diagnostic accuracy of each test was assessed against the best available reference standard for water-loss dehydration (serum or plasma osmolality cut-off ≥ 295 mOsm/kg, serum osmolarity or weight change) within each study. For each index test study data were presented in forest plots of sensitivity and specificity. The primary target condition was water-loss dehydration (including either impending or current water-loss dehydration). Secondary target conditions were intended as current (> 300 mOsm/kg) and impending (295 to 300 mOsm/kg) water-loss dehydration, but restricted to current dehydration in the final review.We conducted bivariate random-effects meta-analyses (Stata/IC, StataCorp) for index tests where there were at least four studies and study datasets could be pooled to construct sensitivity and specificity summary estimates. We assigned the same approach for index tests with continuous outcome data for each of three pre-specified cut-off points investigated.Pre-set minimum sensitivity of a useful test was 60%, minimum specificity 75%. As pre-specifying three cut-offs for each continuous test may have led to missing a cut-off with useful sensitivity and specificity, we conducted post-hoc exploratory analyses to create receiver operating characteristic (ROC) curves where there appeared some possibility of a useful cut-off missed by the original three. These analyses enabled assessment of which tests may be worth assessing in further research. A further exploratory analysis assessed the value of combining the best two index tests where each had some individual predictive ability. MAIN RESULTS: There were few published studies of the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs or tests to be used as screening tests for detecting water-loss dehydration in older people. Therefore, to complete this review we sought, analysed and included raw datasets that included a reference standard and an index test in people aged ≥ 65 years.We included three studies with published diagnostic accuracy data and a further 21 studies provided datasets that we analysed. We assessed 67 tests (at three cut-offs for each continuous outcome) for diagnostic accuracy of water-loss dehydration (primary target condition) and of current dehydration (secondary target condition).Only three tests showed any ability to diagnose water-loss dehydration (including both impending and current water-loss dehydration) as stand-alone tests: expressing fatigue (sensitivity 0.71 (95% CI 0.29 to 0.96), specificity 0.75 (95% CI 0.63 to 0.85), in one study with 71 participants, but two additional studies had lower sensitivity); missing drinks between meals (sensitivity 1.00 (95% CI 0.59 to 1.00), specificity 0.77 (95% CI 0.64 to 0.86), in one study with 71 participants) and BIA resistance at 50 kHz (sensitivities 1.00 (95% CI 0.48 to 1.00) and 0.71 (95% CI 0.44 to 0.90) and specificities of 1.00 (95% CI 0.69 to 1.00) and 0.80 (95% CI 0.28 to 0.99) in 15 and 22 people respectively for two studies, but with sensitivities of 0.54 (95% CI 0.25 to 0.81) and 0.69 (95% CI 0.56 to 0.79) and specificities of 0.50 (95% CI 0.16 to 0.84) and 0.19 (95% CI 0.17 to 0.21) in 21 and 1947 people respectively in two other studies). In post-hoc ROC plots drinks intake, urine osmolality and axillial moisture also showed limited diagnostic accuracy. No test was consistently useful in more than one study.Combining two tests so that an individual both missed some drinks between meals and expressed fatigue was sensitive at 0.71 (95% CI 0.29 to 0.96) and specific at 0.92 (95% CI 0.83 to 0.97).There was sufficient evidence to suggest that several stand-alone tests often used to assess dehydration in older people (including fluid intake, urine specific gravity, urine colour, urine volume, heart rate, dry mouth, feeling thirsty and BIA assessment of intracellular water or extracellular water) are not useful, and should not be relied on individually as ways of assessing presence or absence of dehydration in older people.No tests were found consistently useful in diagnosing current water-loss dehydration. AUTHORS' CONCLUSIONS: There is limited evidence of the diagnostic utility of any individual clinical symptom, sign or test or combination of tests to indicate water-loss dehydration in older people. Individual tests should not be used in this population to indicate dehydration; they miss a high proportion of people with dehydration, and wrongly label those who are adequately hydrated.Promising tests identified by this review need to be further assessed, as do new methods in development. Combining several tests may improve diagnostic accuracy.

Implementation of a self-care of heart failure program among home-based clients.

Heart failure is the most common admission in hospitals among Medicare recipients aged 65 years or older. Self-care management of heart failure has been reported to decrease heart failure hospital admission rates. The purpose of this evidence-based practice project was to examine how a self-care of heart failure program (Heart Failure Self-care to Success) impacts hospital admissions and patient perceptions of self-care management. Heart Failure Self-care to Success (HF S2S) was successfully implemented with 18 participants by nurse practitioners in a house call practice. Six months following implementation of the self-care of heart failure program no heart failure admissions occurred among participants and a significant increase in their self-care of heart failure behaviors (p < .01) was reported by participants. Nurse practitioners using HF S2S can decrease health care costs and improve self-care behaviors in the older, homebound heart failure patient. Further testing of HF S2S is recommended in different practice settings, sample populations, and geographic locations.

Feasibility and Acceptability Testing of Evidence-Based Hydration Strategies for Residential Care.

The current study examined stakeholder perspectives on the perceived effectiveness, feasibility, and acceptability of 20 evidence-based strategies appropriate for residential care via an online survey (N = 162). Most participants worked in long-term care (83%), were direct care providers (62%), worked in food/nutrition roles (55%), and identified as female (94%). Strategies that were rated as effective, feasible, and likely to be used in the future were social drinking events, increased drink options at meals, and pre-thickened drinks. Participants also listed their top strategies for inclusion in a multicomponent intervention. Responses to open-ended questions provided insight on implementation, compliance, and budget constraints. Participant perspectives provide insight into developing a multicomponent intervention. Strategies prioritized for such an intervention include: staff education, social drinking opportunities, drinks trolley, volunteer support, improved beverage availability, hydration reminders, offering preferred beverages, and prompting residents to drink using various cues. [Research in Gerontological Nursing, 15(1), 27-38.].

Qualitative analysis of a virtual research meeting summarises expert-based strategies to promote hydration in residential care during COVID-19 and beyond.

OBJECTIVES: Poor fluid intake is a complex and long-standing issue in residential care, further exacerbated by COVID-19 infection control procedures. There is no consensus on how best to prevent dehydration in residents who vary in their primary reasons for insufficient fluid intake for a variety of reasons. The objectives of this research were to determine expert and provider perspectives on: (1) how COVID-19 procedures impacted hydration in residential care and potential solutions to mitigate these challenges and (2) strategies that could target five types of residents based on an oral hydration typology focused on root causes of low fluid intake. DESIGN: Qualitative study based on virtual group discussion. The discussion was audiorecorded with supplementary field notes. Qualitative content analysis was completed. SETTING: Residential care. PARTICIPANTS: 27 invited researcher and provider experts. RESULTS: Challenges that have potentially impacted hydration of residents because of COVID-19 procedures were categorised as resident (eg, apathy), staff (eg, new staff) and home-related (eg, physical distancing in dining rooms). Potential solutions were offered, such as fun opportunities (eg, popsicle) for distanced interactions; training new staff on how to approach specific residents and encourage drinking; and automatically providing water at meals. Several strategies were mapped to the typology of five types of residents with low intake (eg, sipper) and categorised as: supplies (eg, vessels with graduated markings), timing (eg, identify best time of day for drinking), facility context (eg, identify preferred beverages), socialisation (eg, promote drinking as a social activity) and education (eg, educate cognitively well on water consumption goals). CONCLUSIONS: COVID-19 has necessitated new procedures and routines in residential care, some of which can be optimised to promote hydration. A variety of strategies to meet the hydration needs of different subgroups of residents can be compiled into multicomponent interventions for future research.

Feasibility and Usability of Salivary Alpha-Amylase to Measure Stress Among Individuals With Dementia.

Salivary alpha-amylase (sAA) is a noninvasive biomarker of the sympathetic-adrenal-medullary system and reflects stress. The purpose of the current study was to determine the feasibility and meaningfulness of the use of sAA levels for assisted living memory care (ALMC) residents. Participants were 10 ALMC and eight independent/assisted living (I/AL) residents. Saliva samples were collected eight times for each participant over a 12-hour period using a tongue swab collection technique with immediate sAA point-of-care analysis. Linear mixed effect modeling and case study analysis were conducted. Levels of sAA varied over a 12-hour period for each participant and between participants. Group membership (i.e., ALMC and I/AL) explained 9.3% of the variation of sAA throughout the day, whereas interpersonal differences explained 56.3%. Feasibility of saliva collection technique and measurement of sAA among an ALMC population was supported. Participants serving as their own controls when testing effects of interventions on sAA levels is warranted. [Research in Gerontological Nursing, 13(3), 120-124.].

Progress and Changes in Gerontological Nursing Research in the Midwest: A Review.

Gerontological nursing has a rich research history. The current article reports trends in gerontological nursing research found through review of abstracts of presentations at the Midwest Nursing Research Society annual conference at 10-year increments over the 40-year existence of the organization. Researchers studied a wide range of topics, from quality of life to use of technology, with a variety of older adult populations represented. Designs, theoretical frameworks, and other methods mirrored trends in nursing research from 1977 to 2017. Gerontological nursing researchers had a strong and sustained presence in the Midwest, as evidenced by these abstracts. [Res Gerontol Nurs. 2018; 11(5):231-237.].

Patient functional status changes during hospitalization: impact on early discharge planning.

PURPOSE/OBJECTIVES: The purpose of this study was to inform the discharge planning process by determining differences in functional status from admission to discharge of adults hospitalized for either medical or surgical reasons. DESIGN: The study design was a secondary analysis of data originally collected for a discharge planning study. SAMPLE/SETTING: The primary study included 304 adult patients hospitalized at 2 hospitals in a large midwestern healthcare delivery system. Functional status data on both admission and discharge recorded in the database of participants from the primary study were used. METHODS: The Rankin Disability Scale was used to rate the participant functional status at admission and discharge in the primary study. Differences in admission to discharge Rankin Disability Scale scores overall and between groups (medical and surgical) were compared using the chi test. The absolute changes between admission and discharge score levels on the Rankin Disability Scale were computed using the Kruskal-Wallis test. FINDINGS: A statistically significant difference between the admission and discharge scores was found overall, although the clinical significance of the difference is questionable. No significant differences between medical and surgical participant scores (admission to discharge) were found. CONCLUSIONS: For the majority of the general population of hospitalized adults, functional status may change very little, if at all, from admission to discharge. IMPLICATIONS FOR PRACTICE: Initiating a discharge plan based on a patient's admission functional assessment appears to be reasonable for the majority of hospitalized adult patients.

Establishing a Collaboration Contract to Facilitate Team Performance.

Effective collaboration is essential for team projects whether related to research, evidence-based practice, or quality improvement efforts and is especially relevant to the doctor of nursing practice (DNP)-prepared nurse (American Association of Colleges of Nursing [AACN], 2006). High-quality projects are accomplished through planning and organization and cannot be left to chance (Yonge, Skillen, & Henderson, 1996). A collaboration contract negates the "left to chance" philosophy by promoting clarity of roles, responsibilities, and team processes. Seven "Cs" of collaboration (contribution, communication, commitment, compatibility, consensus, credit, and cohesion) provide a guiding format for essential components of a contract (Govoni & Pierce, 1997; Lancaster, 1985). This article describes these components and the process for establishing a collaboration contract. An example of a contract is provided that can serve as a template for team projects. Approaches to adapting the contract for use with teams of varied composition are shared. A collaborative contract, along with professional conduct standards, supports achievement of the team goal.

Implementation of a baby doll therapy protocol for people with dementia: Innovative practice.

Dementia is exhibited by both emotional and physical states such as agitation. Chemical restraints, often used for agitated behaviors, are not always effective and produce untoward effects. Baby doll therapy is a nonpharmacologic therapy that can affect agitated behavior in dementia patients, yet a protocol for the therapy did not exist. An implementation protocol for doll therapy for those with dementia was developed and implemented with 16 residents in a dementia care center. Outcomes were measurements of the impact of the dolls on six areas of the resident's behavior and their reactions to the doll. Participants had an increase in level of happiness, activity/liveliness, interaction with staff and others, and ease of giving care. There was also a reduction in the level of anxiety. The increase in happiness was a statistically significant outcome. Baby doll therapy is an effective nonpharmacological approach for improving the well-being of patients with moderate to severe dementia.

Implementation of an epilepsy self-management protocol.

It is essential that patients with epilepsy receive educational information about their disease and its management, but there is dissatisfaction with the education received. The purposes of this evidence-based project were to examine the current knowledge level and disease management behaviors of patients with epilepsy in an outpatient clinic and to measure the effectiveness of implementing a self-management protocol using the Epilepsy Self-Management Scale (ESMS). Pender's health promotion model and Rogers' diffusion of innovation theory were used to guide the development and completion of this project. An evidence-based epilepsy self-management protocol was developed and implemented at an outpatient neurology clinic by an interprofessional clinic team that consisted of (a) evaluation of self-management behaviors (ESMS), (b) individual education using the ESMS and developed resources, (c) follow-up telephone call, and (d) measurement of outcomes of the self-management protocol (patient self-management [ESMS] and process). Twenty patients participated in all or portions of the protocol. Scores on the ESMS increased from preimplementation to postimplementation of the protocol (t = -2.67). Seizure management and information management were identified as the most difficult self-management areas. Recommended changes in protocol implementation include adding information about safety measures such as medical alert bracelets and driving to the educational packets. Follow-up telephone calls were discontinued because of difficulties reaching patients. The results of this study suggest that the ESMS is an acceptable tool for evaluating patients' self-management behaviors. Epilepsy self-management protocols need to include both verbal and written educational materials. Educating patients with epilepsy about positive self-management behaviors may lead to better health outcomes.

A longitudinal study of the health status of a community of religious sisters: addressing the advantages, challenges, and limitations.

Longitudinal studies are recognized as contributing to understanding the complexity of aging and generating insights that cannot be gained using other research methods. However, conducting longitudinal studies is recognized as challenging, especially among older adults. The purpose of the current review is to describe how the authors addressed the limitations and challenges of longitudinal studies in a study of the health status of a community of religious sisters. Methods of this specific longitudinal study are presented to provide background to the discussion. Challenges, limitations, and advantages of the current longitudinal study are organized into three categories (i.e., sample, method, and data analysis) that have been addressed in the literature as contributing to the fidelity of longitudinal studies. The unique characteristics of the current study sample, particularly their access to health care, creates a comparison group for the study of older women in general.

Effect of a long-term care geriatrics rotation on physician assistant students' knowledge and attitudes towards the elderly.

Physician assistants (PAs) have the opportunity to contribute to the high demand of providing health care to the growing older adult population. It is essential they have the knowledge to meet this need. The purpose of this study was to determine the difference in knowledge of and attitudes towards the elderly among a group of PA students before and after a required four-week geriatric rotation. PA students' knowledge of geriatrics was significantly improved following the long-term care rotation. Attitude did not change following the rotation but reflected a positive attitude at baseline. It is recommended that PA programs incorporate a rotation in geriatrics/long-term care to help increase PA students' geriatrics-specific knowledge and to better prepare them to provide care to their elderly patients.

Designing a protocol to reduce catheter-associated urinary tract infections among hospitalized patients.

Hospital-acquired urinary tract infections comprise 40% of hospital-acquired infections with over 80% of these hospital-acquired urinary tract infections associated with the use of urinary catheters. The process that was used to establish a new hospital protocol using the "IAIMS" (identifying, assessing, implementing, modifying/maintaining, spread/surveillance) model to reduce the incidence of catheter-associated urinary tract infections is described. The example is intended to serve as a framework for the development of protocols to address other hospital-acquired infections.

Comparison of four standards for determining adequate water intake of nursing home residents.

Adequate hydration for nursing home residents is problematic. The purpose of this study was to compare four standards used to determine a recommended water intake among nursing home residents. Inconsistencies in the amount of water intake recommended based on the standards compared were identified. The standard based on height and weight provides the most individualized recommendation. An individualized recommendation would facilitate goal setting for the care plan of each older person and assist in the prevention of dehydration. It is essential that a cost-effective and clinically feasible approach to determine adequate water intake be determined for this population to prevent the adverse outcomes associated with dehydration.