Texture-Modified Diet for Improving the Management of Oropharyngeal Dysphagia in Nursing Home Residents: An Expert Review.

OBJECTIVES: This paper provides evidence-based and, when appropriate, expert reviewed recommendations for long-stay residents who are prescribed texture-modified diets (TMDs), with the consideration that these residents are at high risk of worsening oropharyngeal dysphagia (OD), malnutrition, dehydration, aspiration pneumonia, and OD-associated mortality, poorer quality of life and high costs. DESIGN: Nestlé Health Science funded an initial virtual meeting attended by all authors, in which the unmet needs and subsequent recommendations for OD management were discussed. The opinions, results, and recommendations detailed in this paper are those of the authors, and are independent of funding sources. SETTING: OD is common in nursing home (NH) residents, and is defined as the inability to initiate and perform safe swallowing. The long-stay NH resident population has specific characteristics marked by a shorter life expectancy relative to community-dwelling older adults, high prevalence of multimorbidity with a high rate of complications, dementia, frailty, disability, and often polypharmacy. As a result, OD is associated with malnutrition, dehydration, aspiration pneumonia, functional decline, and death. Complications of OD can potentially be prevented with the use of TMDs. RESULTS: This report presents expert opinion and evidence-informed recommendations for best practice on the nutritional management of OD. It aims to highlight the practice gaps between the evidence-based management of OD and real-world patterns, including inadequate dietary provision and insufficient staff training. In addition, the unmet need for OD screening and improvements in therapeutic diets are explored and discussed. CONCLUSION: There is currently limited empirical evidence to guide practice in OD management. Given the complex and heterogeneous population of long-stay NH residents, some 'best practice' approaches and interventions require extensive efficacy testing before further changes in policy can be implemented.

The accuracy of monthly weight assessments in nursing homes: implications for the identification of weight loss.

BACKGROUND: The prevalence of weight loss is a quality indicator for nursing homes (NH), and monthly weight assessments are conducted by NH staff to determine weight loss. METHODS: A longitudinal study was conducted with 90 long-stay residents in four NHs for 12 study months. Monthly weight values documented in the medical record by NH staff were compared to independent weight values collected by research staff using a standardized protocol. Weight loss was defined according to the Minimum Data Set (MDS) criterion: >or= 5% in 30 days or >or= 10% in 180 days. RESULTS: The total frequency of weight loss episodes per person was comparable between NH and research staff weight assessments across the 12 study months. However, monthly weight values recorded by NH staff were consistently higher than values recorded by research staff, which resulted in a higher prevalence of weight loss and earlier identification of weight loss according to research staff weight values using a standardized weighing protocol. CONCLUSIONS: A standardized weighing protocol improved the detection of weight loss among NH residents and should allow for earlier nutrition intervention.

Testing the effect of specific orders to provide oral liquid nutritional supplements to nursing home residents: a quality improvement project.

OBJECTIVES: To improve nursing home (NH) staff delivery of oral liquid nutritional supplements between meals to residents with a history of weight loss. DESIGN: Pre-Post intervention study. SETTING: Two skilled nursing homes. PARTICIPANTS: Eighteen long term care residents. INTERVENTION: At baseline all participants had a non-specific physician's order to receive a nutritional supplement. The intervention consisted of specifying the physician's order as follows: "Give 4 oz high protein supplement at 10 am, 2 pm, and 7 pm". MEASUREMENTS: Research staff conducted direct observations for two days during and between meals for a total of 4 days, or 12 possible observation periods per participant before and one week following the intervention. Research staff documented NH staff delivery of snacks (including high protein supplements) and amount consumed (fluid ounces) for the high protein supplements using a standardized protocol during each observation period. RESULTS: Before the specific order was written participants were offered any type of snack an average of 1.82 times per day and a high protein supplement 0.59 times per day. After the specific order was written participants were offered any type of snack an average of 1.59 times per day and a high protein supplement 0.91 times per day. There were no statistically significant differences in the average number of times snacks or supplements were offered before and after the specific order was written. The proportion of snacks offered that were high protein supplements did increase after the specific order was written (p<0.001). When a high protein supplement was provided, most residents consumed 100% of it. CONCLUSIONS: Oral liquid nutritional supplements were not provided consistent with orders in NH practice. The specificity of the order related to type of supplement and time of delivery did not influence when and how often supplements are provided to residents but it did influence the type of nutritional supplement offered.

The effect of staff care practices on nursing home residents' preferences: implications for individualizing care.

PURPOSE: To examine the effect of staff care practices on nursing home residents' preferences for dining location. METHODS: A cross-sectional study was conducted with 304 long-stay residents in six skilled nursing homes. Research staff conducted direct observations during meals for two days and interviewed residents on the same two days about their preferences for dining location for each scheduled meal (breakfast, lunch and dinner). RESULTS: Staff care practices were significantly related to residents' preferences to eat in the dining room for all meals after adjusting for resident characteristics and nurse aide staffing level. For each unit increase in the proportion of residents taken to the dining room for meals by staff, residents' preferences to eat in the dining room also significantly increased by approximately three to four percent for each mealtime period. DISCUSSION: Staff care practices may influence residents' reported preferences for dining location. Daily care practices may be inappropriately justified by residents' preferences, which are shaped by their nursing home care experience and reduced expectations. In efforts to individualize resident care, nursing home staff should consider the influence of established care practices on residents' reported preferences for daily care.

The effect of dining location on nutritional care quality in nursing homes.

BACKGROUND: Nutritional care quality in nursing homes (NHs) is often characterized by inadequate and poor quality feeding assistance and inaccurate medical record documentation of residents' oral food and fluid intake. OBJECTIVE: To describe the effect of dining location on indicators of nutritional care quality in NH residents. DESIGN AND METHODS: A cross-sectional study in 34 NHs with 761 residents. RESULTS: Nutritional care quality was significantly better according to two of four indicators if a resident ate meals in the dining room compared to their rooms. First, residents who were rated by NH staff as requiring assistance to eat were more likely to receive assistance in the dining room compared to their rooms. Second, NH staff medical record documentation of oral food and fluid consumption was more accurate when residents ate in the dining room. CONCLUSIONS: Residents at risk for unintentional weight loss should eat their meals in a common area, such as the dining room, to promote adequate feeding assistance care provision and accurate medical record documentation of oral food and fluid consumption.

Nutritional intake monitoring for nursing home residents: a comparison of staff documentation, direct observation, and photography methods.

BACKGROUND: The current approach to assessing nutritional intake requires nursing home (NH) staff to document total percentage of food and fluid consumed at each meal. Because NH staff tend to significantly overestimate total food intake, methods need to be developed to improve the accuracy of food intake measurement. OBJECTIVE: To compare three methods of assessing the nutritional intake of NH residents. RESEARCH DESIGN: Validation Study. SUBJECTS: Fifty-six NH residents in one facility. MEASURES: Total percentage of food and fluid intake of each resident for each of nine meals, or all three meals for 3 consecutive days, was assessed by: (1) Nursing home staff chart documentation, (2) Research staff documentation according to direct observations, and (3) Research staff documentation according to photographs of residents' trays before and after each meal. RESULTS: Research staff documentation of total intake and intake of all individual food and fluid items was similar for the direct observation and photography methods. In comparison with these two methods, NH staff documentation reflected a significant overestimate (22%) of residents' total intake levels. In addition, NH staff failed to identify the more than half (53%) of those residents whose intake levels were equal to or below 75% for most meals. CONCLUSIONS: The photography method of nutritional assessment yielded the same information as direct observations by research staff, and both of these methods showed the intake levels of NH residents to be significantly lower than the intake levels documented by NH staff. The photography method also has several advantages over a documentation system that relies on an observer to be present to record food and fluid intake levels.

An intervention to increase fluid intake in nursing home residents: prompting and preference compliance.

OBJECTIVE: To evaluate a three-phase, behavioral intervention to improve fluid intake in nursing home (NH) residents. DESIGN: Controlled clinical intervention trial. SETTING: Two community NHs. PARTICIPANTS: Sixty-three incontinent NH residents. INTERVENTION: Participants were randomized into intervention and control groups. The intervention consisted of three phases for a total of 32 weeks: (1) 16 weeks of four verbal prompts to drink per day, in between meals; (2) 8 weeks of eight verbal prompts per day, in between meals; and (3) 8 weeks of eight verbal prompts per day, in between meals, plus compliance with participant beverage preferences. MEASUREMENTS: Between-meal fluid intake was measured in ounces by research staff during all three phases of the intervention. Percentage of fluids consumed during meals was also estimated by research staff for a total of nine meals per participant (3 consecutive days) at baseline and at 8 and 32 weeks into the intervention. Serum osmolality, blood urea nitrogen, and creatinine values were obtained for all participants in one of the two sites at the same three time points. RESULTS: The majority (78%) of participants increased their fluid intake between meals in response to the increase in verbal prompts (phase 1 to 2). A subset of residents (21%), however, only increased their fluid intake in response to beverage preference compliance (phase 3). There was a significant reduction in the proportion of intervention participants who had laboratory values indicative of dehydration compared with the control participants. Cognitive and nutritional status were predictive of residents' responsiveness to the intervention. CONCLUSIONS: A behavioral intervention that consists of verbal prompts and beverage preference compliance was effective in increasing fluid intake among most of a sample of incontinent NH residents. Verbal prompting alone was effective in improving fluid intake in the more cognitively impaired residents, whereas preference compliance was needed to increase fluid intake among less cognitively impaired NH residents.

Nighttime sleep and bed mobility among incontinent nursing home residents.

OBJECTIVE: To describe sleep and body movement patterns in incontinent nursing home residents for the purpose of determining if the residents require nighttime changing and body repositioning on a 2-hour schedule. DESIGN: Cross-sectional survey. SETTING: Four nursing homes. PARTICIPANTS: 118 nursing home residents. MEASUREMENTS: Over two nights, bedside monitoring equipment recorded wrist activity (as a proxy measure for sleep) and body movements of both the shoulder and hip areas in consecutive 2-minute intervals. Specific outcome measures were: (1) Average duration of a sleep episode, peak duration of a sleep episode, and percent of time in bed asleep. (2) The number of 2-minute intervals in which a large movement (45 degree turn) at the shoulder and hip was noted per hour of recording for each resident. (3) The number of resident-initiated, rather than staff-initiated, large movements at the shoulder and hip that occurred within the same 2-minute intervals. RESULTS: There was large variability in all sleep measures; however, on average, residents slept 66% of the time they were in bed. The distribution of these measures suggests that sleep was punctuated with frequent nighttime awakenings. Thirty-three percent of the incontinent residents demonstrated very low levels of resident-initiated movement at the shoulder and hip. Sixty-six percent demonstrated at least one large movement at the shoulder and hip per hour during periods of sleep as well as during periods of wake. CONCLUSION: The majority of incontinent nursing home residents self-initiate sufficiently frequent movements at both the shoulder and hip so as not to be in need of frequent repositioning by nursing staff. Since the sleep of many of these residents is also characterized by frequent awakenings, incontinent nursing home residents may benefit from a schedule of nursing care at night that considers sleep of equal importance to incontinence care and body repositioning.

The nighttime environment, incontinence care, and sleep disruption in nursing homes.

OBJECTIVE: To evaluate the association between noise, light, nursing care practices, and nighttime awakenings in incontinent nursing home residents. DESIGN: Cross-sectional survey. SETTING: Four long-term care nursing facilities. PARTICIPANTS: One hundred eighteen incontinent nursing home residents. MEASUREMENTS: Over two nights, bedside monitoring equipment recorded wrist activity, resident bed movements, and environmental noise and light changes in consecutive 2-minute intervals. Changes in sleep and bed movement were compared with changes in noise and light that occurred within the same or proximal 2-minute intervals. Noise and light changes in combination with large resident movement at the hip and shoulder were interpreted as related to incontinence care based on observational measures. Specific outcome measures were: (1) the number of noise and light changes as well as staff care practices that did not wake the resident during periods of consecutive sleep, ie, sleep lasting a minimum of 10 minutes; (2) the number of noise and light changes as well as staff care practices that occurred immediately before or during the 2-minute intervals during which a resident woke from a period of consecutive sleep; and (3) the number of such staff care practices that were related to incontinence care. RESULTS: Noise and light changes associated with both general environmental events and more specific nurse care practices were associated with 50% of all waking episodes of 4 minutes or longer and 35% of all waking episodes of 2 minutes or shorter. The major sources of all noise were traced to nursing staff. Eighty-seven percent of all incontinence care practices were associated with episodes of waking. CONCLUSION: The data reported in this paper document that general environmental noise and incidents of nursing care practices, particularly those related to incontinence care, are responsible for a substantial amount of the sleep fragmentation that is common among nursing home residents.

Wheelchairs as mobility restraints: predictors of wheelchair activity in nonambulatory nursing home residents.

OBJECTIVE: The purpose of this paper is to describe factors affecting wheelchair mobility in nonambulatory nursing home (NH) residents. DESIGN: Prospective descriptive study of a convenience sample of nonambulatory NH residents. SETTING: Seven nursing homes. PARTICIPANTS: Sixty-five nonambulatory residents. MEASUREMENTS: One-minute, time-sampled observations of behavior for each resident were made every 15 minutes for 8 to 11 hours across 2 days, noting wheelchair propulsion activity for the dependent variable; independent variables included measures of wheelchair level of assistance, speed, endurance, handgrip strength, and balance. MAIN RESULTS: A stepwise Multiple Regression analysis found wheelchair speed to be the single best predictor of the percentage of time residents were behaviorally observed wheelchair propelling (Multiple r = .45, P < .02). Handgrip strength and wheelchair endurance measures were highly intercorrelated with wheelchair speed. Wheelchairs that were either dysfunctional or inappropriately fitted to the residents' size were a major barrier to wheelchair use, affecting 46% of residents using wheelchairs. CONCLUSION: Improving wheelchair skills with targeted intervention programs, along with making chairs more "user friendly" (e.g., grip extensions on brakes, foot pedals that one can move without bending over), could result in more wheelchair propulsion with resultant improvements in the NH resident's independence, freedom of movement, and quality of life.

Functional Incidental Training, mobility performance, and incontinence care with nursing home residents.

OBJECTIVE: To determine if an exercise intervention, Functional Incidental Training (FIT), results in improvements in mobility endurance and physical activity when compared with prompted voiding (PV) among cognitively and mobility impaired nursing home residents. DESIGN: Residents from four nursing homes were randomized into either a PV only (PV) or a PV plus FIT (FIT) intervention group for 8 weeks. Research staff implemented all intervention and measurement protocols. PARTICIPANTS: Seventy-six incontinent nursing home residents completed all phases of the trial. MEASURES: The standing, walking, and wheelchair endurance, physical activity, and frequency of agitation of all residents were assessed before, during, and after the 8-week intervention. RESULTS: The average length of time that subjects could walk or wheel was 2.6 and 4.6 minutes, respectively, at baseline. There was a significant group x time interaction after intervention, with only the FIT group showing improvements in walking, wheelchair, and standing endurance (Manova F = 4.56, 2.62, and 5.98, respectively; P < .05 in all cases). The frequency with which agitation was observed showed a significant drop over time in both groups (F = 14.3, P < .001), with no significant group x time interaction. CONCLUSION: The FIT intervention, which requires 6 minutes more nurses' aide time than does PV, increases both physical activity and mobility endurance in extremely frail and deconditioned nursing home residents. The increased cost of this intervention must be evaluated both in terms of clinical outcomes and by the reality that the target group for this intervention is very frail and will continue to require nursing home care, even assuming an excellent response to the intervention.

The nighttime environment and incontinence care practices in nursing homes.

OBJECTIVES: To determine the variability in noise, light, and incontinence care practices between nursing homes (NHs) and the association between these factors and residents' nighttime sleep. DESIGN: Prospective descriptive study of a sample of incontinent NH residents. SETTING: Ten nursing homes. SUBJECTS: Two hundred twenty-five incontinent NH residents. MAIN OUTCOME MEASURES: Measurements of residents' sleep by wrist actigraphs, bed mobility by pressure sensitive Kynar strips, and environmental noise and light changes were recorded by bedside monitors in consecutive 2-minute intervals for two 10-hour nighttime data collection periods (7 PM to 5 AM). RESULTS: Forty-two percent of waking episodes lasting 4 minutes or longer were associated with noise, light, or incontinence care events. Twenty-two percent of waking episodes of 4 minutes or longer were associated with noise alone, 10% with light or light + noise, and 10% with incontinence care routines. Seventy-six percent of all incontinence care practices resulted in awakenings. There was variability between the 10 NHs, with the percentage of waking episodes associated with environmental events (noise, light, or incontinence care events) ranging from 23.6 to 66.0%. CONCLUSION: Noise and incidents of incontinence care practices were associated with a substantial amount of sleep disruption in residents in all 10 nursing homes, even though there was variability between homes. Interventions minimizing such environmental events are needed to promote better sleep in incontinent NH residents.

Safety assessment for the frail elderly: a comparison of restrained and unrestrained nursing home residents.

OBJECTIVE: To facilitate clinicians' judgement concerning physical restraint decisions by identifying potentially reversible injury risk factors that differentiate representative samples of restrained and unrestrained nursing home residents. DESIGN: Comparison of restrained and unrestrained nursing home residents on a safety assessment for the frail elderly (SAFE) protocol. SETTING: Long-term care facilities in the Greater Los Angeles Area. PARTICIPANTS: One hundred eight physically restrained and 111 unrestrained nursing home residents. INTERVENTION: None. MAIN OUTCOME MEASURES: (1) Internal, Interrater, and test/retest reliability of the overall SAFE protocol and of the four major factors measured by SAFE; (2) The relationship of SAFE scores to expert judgment of resident injury risk; (3) Differences between large samples of restrained and unrestrained residents on specific SAFE score factors. RESULTS: Two walking, one transition, and one judgment factor are reliably measured by the SAFE protocol. SAFE scores were significantly correlated with expert judgment of risk for injury and showed large differences between restrained and unrestrained residents, even after differences in ambulation ability between the two groups were accounted for. CONCLUSION: The SAFE is a reliable protocol that measures behavioral factors related to falls and risk for injury among nursing home residents with a broad range of cognitive impairment. Factors that significantly differentiate restrained and unrestrained groups should be targeted for rehabilitation and remediation in physical restraint reduction efforts. Removing or changing restraints for the large sample (50%) of restrained residents who were not ambulatory will not significantly increase their mobility, since the majority of this group could not independently propel their wheelchairs. Increased mobility for the large group of both restrained and unrestrained residents will likely be realized only if restraint reduction programs are combined with interventions to improve both mobility and the specific behavioral performance factors measured by SAFE.

Does physical activity improve sleep in impaired nursing home residents?

OBJECTIVES: To determine if two physical activity programs of varying intensity would result in improved sleep among incontinent and physically restrained nursing home residents. DESIGN: Controlled trials of two physical activity programs. SETTING: Seven community nursing homes in the Los Angeles area. PARTICIPANTS: Residents were included if they had urinary incontinence or were physically restrained. Sixty-five subjects were studied. Mean age was 84.8 years, 85% were female, mean length of residency in the nursing home was 19.9 months, and mean Mean Mini-Mental State Exam score was 13.1. INTERVENTION: The first physical activity program involved sit-to-stand repetitions and/or transferring and walking or wheelchair propulsion. These activities were performed every 2 hours during the daytime, 5 days per week for 9 weeks. The second, less frequent physical activity program involved rowing in a wheelchair-accessible rowing machine plus walking or wheelchair propulsion once per day three times per week for 9 weeks. MEASUREMENTS: The physical function measures reported here include mobility endurance (maximum time walking or wheeling) and physical activity as measured by motion sensors (Caltrac). Nighttime sleep was estimated by wrist activity monitors. Nighttime sleep measures included total time asleep, percent sleep, average duration of sleep, and peak duration of sleep. Daytime sleep was measured by timed behavioral observations of sleep versus wakefulness performed every 15 minutes during the day. RESULTS: Nighttime sleep was markedly disrupted in both groups at baseline. Across all subjects at baseline, the average total sleep time was 6.2 hours and the percent sleep was 72.0%, but the average duration of sleep episodes was only 21.2 minutes and the peak duration of sleep episode averaged only 83.8 minutes. During the daytime, subjects were observed asleep during 14.5% of observations. Although there was improvement in mobility endurance in the intervention subjects compared with controls (MANOVA F = 4.36, P = .042), there were no differences in the night and day sleep measures at follow-up testing. Even among a subgroup of intervention subjects who showed a 30% or greater improvement in mobility endurance, sleep did not improve at follow-up compared with baseline. CONCLUSION: This study supports our previous findings of marked sleep disruption in impaired nursing home residents. In addition, despite documented improvements in physical function with activity, we did not find improvements in sleep in the intervention versus control groups. These results suggest that increasing daytime physical activity alone is not adequate to improve sleep in impaired NH residents. Future efforts to improve sleep in this population should take into account the multifactorial nature of sleep disruption, including individual health problems that effect sleep and the disruptive nature of the nighttime NH environment.

Exercise with physically restrained nursing home residents: maximizing benefits of restraint reduction.

OBJECTIVE: To evaluate an exercise protocol designed to improve strength and mobility, and to decrease injury risk factors in physically restrained nursing home residents. DESIGN: A randomized controlled trial. PARTICIPANTS: Ninety-seven residents were randomized into either exercise or control groups. Thirty-five exercise and 37 control group residents completed all post-assessments after a 9-week trial. INTERVENTION: Walking or wheelchair movement training was supplemented by rowing exercise three times per week. Practice in behaviors related to safe movement was provided incidental to the exercise. MEASUREMENT: Endurance, speed, and injury risk measures relevant to walking, wheelchair propulsion, and standing were assessed by standardized protocols. Rowing endurance, rowing range of motion, and handgrip strength measures were collected to assess the effect of the rowing component of the exercise protocol. RESULTS: Fifty-four percent of the subjects who provided consent did not complete the protocol because of health status changes, lack of cooperation, or physical limitations that precluded exercise. The subjects who completed the exercise program showed significant improvement on injury risk and measures related to upper body strength (handgrip strength, rowing endurance, wheelchair endurance, and speed). Measures related to lower body strength did not significantly improve. CONCLUSION: Physically restrained residents are very frail, and it is difficult to implement a long-term exercise program with many residents because of the frailty. However, a substantial proportion of residents did cooperate well with the exercise program and showed improvement on measures correlated with decreased injury risk. The exercise program could be easily modified to include more lower body exercise, and the resultant protocol would be an important adjunct to restraint reduction programs.

Improving food intake in nursing home residents with feeding assistance: a staffing analysis.

BACKGROUND: Recommendations have been made to increase the number of nursing home (NH) staff available to provide feeding assistance during mealtime. There are, however, no specific data related to two critical variables necessary to estimate mealtime staffing needs: (1) How many residents are responsive to feeding assistance? (2) How much staff time is required to provide feeding assistance to these residents? The purpose of this study was to collect preliminary data relevant to these two issues. METHODS: Seventy-four residents in three NHs received a 2-day, or six-meal, trial of one-on-one feeding assistance. Total percentage (0% to 100%) of food and fluid consumed during mealtime was estimated across 3 days during usual NH care and 2 days during the intervention. The amount of time that staff spent providing assistance and type of assistance (i.e., frequency of verbal and physical prompts) was measured under each condition. RESULTS: One half (50%) of the participants significantly increased their oral food and fluid intake during mealtime. The intervention required significantly more staff time to implement (average of 38 minutes per resident/meal vs 9 minutes rendered by NH staff). CONCLUSIONS: The time required to implement the feeding assistance intervention greatly exceeded the time the nursing staff spent assisting residents in usual mealtime care conditions. These data suggest that it will almost certainly be necessary to both increase staffing levels and to organize staff better to produce higher quality feeding assistance during mealtimes.

The identification of residents capable of accurately describing daily care: implications for evaluating nursing home care quality.

PURPOSE: The goal of this study was to develop a method of identifying incontinent nursing home (NH) residents capable of providing accurate interview information about daily NH care. DESIGN AND METHODS: In 177 incontinent NH residents from four facilities, selected Minimum Data Set (MDS) ratings were compared with two standardized, performance-based, cognitive screening instruments to predict which residents could accurately answer questions concerning receipt of daily incontinence and mobility care practices. RESULTS: MDS ratings of activity of daily living performance and cognition significantly predicted residents' ability to accurately describe daily care practices. Performance-based measures of cognitive functioning did not outperform the MDS ratings. Selecting residents who scored two or more on four orientation items composing the MDS Recall subscale identified residents capable of accurately describing daily care practices with a sensitivity of 64% and a specificity of 75%. IMPLICATIONS: The MDS-based criteria identified are a promising, objective method for selecting incontinent NH residents for interview to verify the occurrence of specific daily care practices.

Strategies to measure nursing home residents' satisfaction and preferences related to incontinence and mobility care: implications for evaluating intervention effects.

This study compared four different interview strategies to measure 111 incontinent nursing home residents' "met need" related to incontinence and mobility care. Strategies were compared on criteria related to ceiling effects and stability. Four methods were used: questions that used the term "satisfaction" and direct questions about preferences that did not use the term "satisfaction" and which could be translated into three indirect measures of met need. To facilitate a comparison among the four methods, a statement of satisfaction was interpreted as met need. All of these measures were then compared to direct observations of care processes. Residents were more stable in their reports indicating that their care needs were met than they were in their reports that their needs were not met. The direct satisfaction questions produced information most characterized by ceiling effects compared to information elicited by the preference questions. Despite high reported rates of met need as assessed by two of the four methods, direct observations revealed low frequencies of care provision.

Measurement sensitivity and the Minimum Data Set depression quality indicator.

PURPOSE: The purpose of this study was to determine the accuracy of the prevalence rating of depression in nursing homes as flagged on the Minimum Data Set (MDS) quality indicator report. DESIGN AND METHODS: Research Staff measured depression symptoms and compared the results with the prevalence of disturbed mood symptoms documented by nursing home (NH) staff on the MDS in two samples of residents living in different NHs. The homes had been flagged on the nationally mandated MDS quality indicator report as having unusually low (Site 1) or high (Site 2) prevalence rates of depression. RESULTS: The percentages of residents determined by research staff interview assessments to have probable depression in the two resident samples were not significantly different (49% vs. 55%, respectively) between homes. The staff in the home flagged on the MDS quality indicator report as having a high depression prevalence rate identified significantly more residents who also had scores indicative of probable depression on the resident interviews for follow-up mood assessments than did the home with a low quality indicator prevalence rate (78% vs. 25%, respectively). IMPLICATIONS: The prevalence of the depression quality indicator may be more reflective of measurement processes than of depression outcomes. Factors that may affect the difference in detection rates are discussed.

Risk factors that predict staff failure to release nursing home residents from restraints.

This study identifies resident characteristics related to nursing staff failure to provide consistent release from physical restraints as required by regulation. The lengths of intervals during which residents were restrained were measured and correlated with the staff's perception of degree of care burden and resident behavioural characteristics in order to identify risk factors related to the absence of consistent release. Staff perceptions of residents' verbal aggressiveness (multiple R = -.30, p < .01), physical aggressiveness (multiple R = -.25, p < .03) and unpleasantness (multiple R = -.25, p < .03) are the three characteristics most predictive of the length of time residents continuously remain restrained.