Low serum free thyroxine index in ambulating elderly is due to a resetting of the threshold of thyrotropin feedback suppression.

Subnormal free T4 index (FT4I) values (less than 80) with inappropriately normal serum TSH concentrations that could not be attributed to illness or drugs were found in 2.5% of ambulating elderly clinic patients. Six such individuals (three men and three women, aged 68.8 +/- 4.8 yr) were selected for their persistent thyroid test abnormalities and were sex and age matched to six subjects (67.7 +/- 4.9 yr) with normal FT4I (greater than 90) and TSH levels. The former also had low serum total T4 (TT4) and rT3 (TrT3) concentrations, but total T3 (TT3) and basal TSH values were normal and did not differ between the groups. Responses of ACTH, LH, FSH, TSH, and PRL to stimulation with CRH, GnRH, and TRH showed no differences between the two groups, indicating that the normal TSH concentration, inappropriate for the low FT4I level, is not due to generalized hypothalamic or pituitary dysfunction. Administration of 3 g iopanoic acid (IOP) daily for 3 days produced significant increases in the TT4 and TrT3 concentrations to the same degree in both groups. Also, in both groups the IOP-induced suppression of T4 to T3 conversion in the pituitary gland provoked similar increases in basal TSH (280 +/- 47% and 288 +/- 33%) and TSH secretion in response to TRH (173 +/- 7% and 156 +/- 13%). These results indicate that the low FT4I is not the consequence of reduced pituitary TSH reserve. In addition, evidence for normal thyroid gland reserve and the secretion of TSH of normal biological activity was obtained by comparing the acute iodothyronine responses to TRH-induced TSH release in both groups. It is concluded that the normal serum TSH concentration, inappropriate for the low FT4I value in some elderly subjects, is due to an apparent resetting of the thyroid hormone feedback regulation threshold of TSH secretion. It may, in turn, be the result of enhanced pituitary conversion of T4 to T3 or increased T4 uptake by the thyrotrophs.

Sleep hygiene in physically dependent nursing home residents: behavioral and environmental intervention implications.

The purpose of this report is to summarize data from a sample of 230 residents in eight nursing homes (NHs) that are relevant to the development of environmental and behavioral interventions for sleep. Four conclusions can be drawn: (1) there is strong evidence that the nighttime sleep of these residents was adversely affected by environmental noise and light; (2) residents appear to spend substantial time in bed and sleeping during the day; (3) there are significant differences between some homes in the amount of time that residents spend in bed and sleeping during the day, as well as the frequency of nighttime awakenings associated with environmental events; and (4) residents' preference and nighttime noise source data suggest that a multifaceted intervention to improve sleep hygiene could successfully implemented in the NH setting. An intervention addressing these issues may result in improved sleep and overall well-being for a substantial portion of the NH population.

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.

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.

The nursing home at night: effects of an intervention on noise, light, and sleep.

OBJECTIVES: The sleep of nursing home residents is fragmented by frequent awakening episodes associated, at least in part, with environmental variables, including noise and light changes. The purpose of this study was to improve sleep by reducing the frequency of nighttime noise and light changes. PARTICIPANTS AND SETTING: Two hundred sixty-seven incontinent nursing home residents in eight nursing homes. DESIGN: A randomized control group design with a delayed intervention for the control group. MEASUREMENTS: Bedside noise and light monitors recorded the number of 2-minute intervals at night with peak sounds recorded above 50 dBs and the number of light changes of at least 10 lux between adjacent 2-minute intervals. Daytime behavioral observations measured sleep and in-bed time during the day, and wrist activity was used to estimate sleep at night. Awakening events associated with the environmental variables were derived from the wrist activity data. INTERVENTION: A behavioral intervention implemented between 7:00 p.m. and 6:00 a.m. that involved feedback to nursing home staff about noise levels and implementation by research staff of procedures to both abate noise (e.g., turn off unwatched television sets) and to individualize nighttime incontinence care routines to be less disruptive to sleep. RESULTS: Noise was reduced significantly, from an average of 83 intervals per night with peak noises recorded above 50 dBs to an average of 58 intervals per night in the group that received the initial intervention, whereas noise in the control group showed no change (MANOVA group x time P < .001). All 10-dB categories of noise from 50 to 90+ dBs were reduced, and light changes were reduced from an average of four per night per resident to two per night (P < .001). Despite these significant changes in the environmental variables, there was a significant differential improvement in the intervention group on only two night sleep measures: awakening associated with a combination of noise plus light (P < .001) and awakening associated with light (P < .001). However, there was a significant correlation between change in noise and change in percent sleep from baseline to intervention (r = -.29, P < .05), suggesting that the intervention did not reduce noise to low enough levels to produce a significant improvement in sleep. The intervention effects on all environmental variables were replicated in the delayed intervention group, who again showed significant improvement on the same sleep measures. Observations of day sleep and in-bed time did not change over the phases of the trial for either group. CONCLUSION: The significant reductions in noise and light events resulting from the intervention did not lead to significant improvements in the day sleep and most night sleep measures. An intervention that combines both behavioral and environmental strategies and that addresses daytime behavioral factors associated with poor sleep (e.g., excessive time in bed) would potentially be more effective in improving the night sleep and quality of life of nursing home residents.

A randomized trial of a combined physical activity and environmental intervention in nursing home residents: do sleep and agitation improve?

OBJECTIVES: The purpose of this study was to test whether an intervention combining increased daytime physical activity with improvement in the nighttime environment improves sleep and decreases agitation in nursing home residents. DESIGN: A randomized trial. SETTING: One community nursing home in the Los Angeles, California area. PARTICIPANTS: Twenty-nine incontinent residents (mean age 88.3 years, 90% female). INTERVENTION: Subjects were randomized to receive either (1) an intervention combining increased daytime physical activity (14 weeks in duration) plus a nighttime program (5 nights in duration) to decrease noise and sleep-disruptive nursing care practices (intervention group), or (2) the nighttime program alone (control group). MEASUREMENTS: Daytime physical activity monitors and structured physical function assessments; nighttime wrist activity monitors to estimate nighttime sleep; and timed daytime behavioral observations of sleep versus wakefulness, either in or out of bed, and agitation. RESULTS: Physical function measures did not change significantly (MANOVA for repeated measures, group by time effect). Wrist actigraphy estimation of nighttime percent sleep (time asleep over time monitored in bed at night) increased in intervention subjects from 51.7% at baseline to 62.5% at follow-up compared with 67.0% at baseline to 66.3% at follow-up in controls (MANOVA, group by time, F = 4.42, P = .045, df = 27). At follow-up, intervention subjects averaged a 32% decrease in the percent of daytime observations in bed compared with baseline, with essentially no change in controls (MANOVA, group by time, F = 5.31, P = .029, df = 27). Seven of 15 intervention subjects had a decrease in observed agitation at follow-up, compared with baseline, versus only 1 of 14 controls with a decrease in observed agitation. CONCLUSIONS: This study provides preliminary evidence that an intervention combining increased physical activity with improvement in the nighttime nursing home environment improves sleep and decreases agitation in nursing home residents.

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.

Community physicians' cooperation with a program of in-home comprehensive geriatric assessment.

OBJECTIVES: To study the cooperation of primary care physicians with a community-based prevention and health promotion program for older persons, to study physician factors related to cooperation, and to determine any relationship between physician cooperation and patient adherence to program recommendations and patient satisfaction with health care. DESIGN AND SETTING: A survey administered in subjects' homes and physicians' offices in Santa Monica, California. PARTICIPANTS: Patients (n = 81) were intervention group subjects in a 3-year, randomized, controlled trial of in-home comprehensive geriatric assessment paired with prevention and health promotion. Physicians (n = 50) were selected if they had been contacted at least once by a study nurse practitioner about one of these patients. MEASUREMENTS: Physician cooperation was rated by study nurse practitioners. Physicians were interviewed to identify factors associated with cooperation. Patients' satisfaction with health care and adherence were measured prospectively throughout the 3-year program. MAIN RESULTS: Physicians exhibiting better cooperation had fewer years in practice (P = .03) and were more likely to discuss the program with their patients (P = .005), see benefit for their patients from the program (P = .02), and rate program information as useful (P = .002). Higher physician cooperation did not predict higher patient satisfaction (P = .23) but did predict higher patient adherence to program recommendations (P = .02). CONCLUSIONS: Physicians rated as cooperative were more likely to have a positive appraisal of the program, and their patients had higher adherence to program recommendations. These findings suggest that strategies for increasing primary care physician cooperation might improve effectiveness of similar community-based prevention and health promotion programs.

Effectiveness of preventive in-home geriatric assessment in well functioning, community-dwelling older people: secondary analysis of a randomized trial.

OBJECTIVES: To determine whether preventive in-home comprehensive geriatric assessment (CGA) prevents functional decline in community-dwelling older persons with different baseline functional status: (1) without any basic activities of daily living (BADL) dependency at baseline; and (2) without any instrumental ADL (IADL) and basic ADL dependency at baseline. DESIGN: Subgroup analyses of a 3-year randomized controlled trial. SETTING: The city of Santa Monica, California. PARTICIPANTS: Participants came from the original population (n = 414) of community-living older persons aged 75 years and older who participated in a trial testing the effectiveness of annual preventive in-home CGA. For the first subgroup analysis, we excluded subjects (n = 27) who were dependent in one or more BADL before randomization (final sample size, n = 387); for the second subgroup analysis, we excluded 93 additional subjects who were dependent in one or more IADL before randomization (final sample size, n = 294). INTERVENTION: Annual preventive in-home CGA, with quarterly home visits by gerontologic nurse practitioners, for 3 years. MEASUREMENTS: Functional status data were collected through yearly in-home interviews by independent observers. Subjects were classified as (1) independent in both BADL and IADL, (2) dependent in IADL but independent in BADL, or (3) dependent in both IADL and BADL. RESULTS: In both subgroup analyses, there was no difference in survival between intervention and control subjects. In the subgroup with no BADL impairment at baseline, intervention subjects spent significantly fewer days dependent in both BADL and IADL during each year of the study (5 days vs 14 days, P = .022; 13 vs 33, P = .016; and 19 vs 44, P = .014 for years 1, 2, and 3, respectively) and over all 3 years combined (36 days vs 92 days, P = .016) in bivariate analyses. In multivariate analyses, the intervention reduced time spent in complete (BADL and IADL) dependency (P = .028). In the subgroup of subjects without any IADL or BADL impairment at baseline, no significant differences were apparent in the number of days spent in complete independence and days spent in complete dependency. Intervention group subjects spent more days in partial dependency during Year 1 (24 days vs 9 days, P = .021), but the difference was not significant during Year 2 (47 vs 29, P = .088), Year 3 (49 vs 41, P = .370), and over all 3 years combined (120 vs 79, P = .123) as well as in multivariate analysis (P = .062). CONCLUSION: These findings support the hypothesis that in-home preventive visits delay the onset of disability in people without initial BADL impairment. Further studies in larger samples are needed to determine optimal intervention strategies and effectiveness among well functioning older people.

The association between chronic illness and functional change among participants in a comprehensive geriatric assessment program.

OBJECTIVE: To examine the association between chronic illness and functional status change during a 3-year period in older people enrolled in an in-home comprehensive geriatric assessment (CGA) and preventive care program. DESIGN: Secondary analysis of data from a longitudinal cohort study. SETTING: Santa Monica, California. PARTICIPANTS: Two hundred two community-dwelling older persons (mean age at baseline was 81 years, 70% were women, and 72% reported good health) randomized to the intervention group in a trial of in-home comprehensive geriatric assessment and preventive care. MEASUREMENTS: We studied 13 common chronic illnesses/conditions determined clinically from an annual comprehensive evaluation by gerontologic nurse practitioners (GNPs) in consultation with study geriatricians. These target conditions included hypertension, osteoarthritis, coronary artery disease, obesity, undernutrition, urinary incontinence, sleep disorders, falls, gait/balance disorders, hearing and vision deficits, depression, and unsafe home environment. The dependent variable was functional change as measured by instrumental activities of daily living (IADL) and basic activities of daily living (BADL) assessed at baseline and annually for 3 years by independent research personnel. Potential confounding variables, including comorbid conditions and other subject characteristics, were controlled for in the analyses. RESULTS: Although functional status was similar at baseline, the presence of certain target conditions in this sample was associated significantly with functional decline in IADL and BADL during the 3-year period. Four conditions (gait/balance disorders, depression, unsafe home environment, and coronary artery disease) were associated with significant declines in IADL, and four conditions (gait/balance disorders, depression, hypertension, and urinary incontinence) were associated with significant declines in BADL. Conversely, subjects with obesity had no significant change in IADL or BADL throughout the study period and had less decline in IADL compared with nonobese subjects. CONCLUSIONS: Certain chronic conditions, particularly gait/balance disorders and depression, are associated with significant decline in functional status in older persons who receive CGA. These findings may help identify older persons at risk for greatest functional decline despite participation in CGA and may also suggest the need for more effective intervention strategies in these individuals.

The process of care in preventive in-home comprehensive geriatric assessment.

OBJECTIVES: To describe the process of care of a program of in-home comprehensive geriatric assessment (CGA) and to determine: (1) if there are major findings in all domains of CGA (medical, functional, mental health, and social/ environmental), (2) if there is a continued clinical yield when CGA is repeated annually, and (3) factors that affect patient adherence with recommendations from CGA. DESIGN: Descriptive prospective study of subjects allocated to the intervention group of a 3-year randomized trial of preventive in-home CGA. SETTING: Homes of participants living in an urban setting. PARTICIPANTS: Persons aged 75 years or older and living at home who received the intervention (N = 202 subjects, mean age 80.8 years, 70% female, 95% white, 64% living alone). INTERVENTION: Annual in-home CGA and quarterly home visits by gerontologic nurse practitioners for 3 years. MEASUREMENTS: Detailed data were collected prospectively on clinical problems detected by CGA, and specific recommendations were made for these problems using an instrument developed explicitly for this project to study the CGA process. Subject adherence with these recommendations was also recorded. RESULTS: Major problems were identified in all domains of CGA; the most common problems were medical. In the first year, 76.7% of subjects had at least one major problem identified that was either previously unknown or suboptimally treated. One-third of subjects had additional major problems identified during the second and third years. A constant number of therapeutic and preventive recommendations was made each year (11.5 per subject annually). Subject adherence varied by type of recommendation (ANOVA, F = 108.4, P < .001); adherence was better for referrals to a physician than for referrals to a non-physician professional or community service or for recommendations involving self-care activities (Scheffe's test, P < .001). CONCLUSION: In these community-dwelling older people, there was a continued yield of problems identified and recommendations made when CGA was repeated annually for 3 years, supporting the practice of repeat CGA in older people in the community. Subject adherence with recommendations from CGA varied by type of recommendation, but further work is needed to determine additional factors that affect this adherence and to determine the association between the yield of CGA (i.e., problems identified, recommendations given and adherence with these recommendations) and important clinical outcomes.

Development and testing of a five-item version of the Geriatric Depression Scale.

OBJECTIVE: To develop and test the effectiveness of a 5-item version of the Geriatric Depression Scale (GDS) in screening for depression in a frail community-dwelling older population. DESIGN: A cross-sectional study. SETTING: A geriatric outpatient clinic at the Sepulveda VA Medical Center, Sepulveda, California. PARTICIPANTS: A total of 74 frail outpatients (98.6% male, mean age 74.6) enrolled in an ongoing trial. MEASUREMENTS: Subjects had a comprehensive geriatric assessment that included a structured clinical evaluation for depression with geropsychiatric consultation. A 5-item version of the GDS was created from the 15-item GDS by selecting the items with the highest Pearson chi2 correlation with clinical diagnosis of depression. Sensitivity, specificity, diagnostic accuracy, and positive and negative predictive values were calculated for the 15-item GDS and the new 5-item scale. RESULTS: Subjects had a mean GDS score of 6.2 (range 0-15). Clinical evaluation found that 46% of subjects were depressed. The depressed and not depressed groups were similar with regard to demographics, mental status, educational level, and number of chronic medical conditions. Using clinical evaluation as the gold standard for depression, the 5-item GDS (compared with the 15-item GDS results shown in parentheses) had a sensitivity of .97 (.94), specificity of .85 (.83), positive predictive value of .85 (.82), negative predictive value of .97 (.94), and accuracy of .90 (.88) for predicting depression. Significant agreement was found between depression diagnosis and the 5-item GDS (kappa = 0.81). Multiple other short forms were tested, and are discussed. The mean administration times for the 5- and 15-item GDS were .9 and 2.7 minutes, respectively. CONCLUSIONS: The 5-item GDS was as effective as the 15-item GDS for depression screening in this population, with a marked reduction in administration time. If validated elsewhere, it may prove to be a preferred screening test for depression.

Managing the behavioral problems of dementia in the home.

The majority of persons with dementia are cared for in the home by family and friends. The goals of treatment in this setting are to maximize the quality of life of the demented person and minimize burdens on the caregiver. Behavioral problems are common with dementia and can lead to significant caregiver burden. Behaviors that are most common or most serious to caregivers include behaviors related to memory disturbances, restlessness and agitation, catastrophic reactions, day/night disturbances, delusions, wandering, and physical violence. A general method for clinicians to manage these problems involves the identification of the behavior and its antecedent and consequent events. Stressors that may cause behavioral problems include fatigue, a change of routine, excessive demands, overwhelming stimuli, and acute illness or pain. Caregivers can be taught to identify these stressors in order to prevent or alleviate troublesome behaviors. When behavioral techniques are not successful and the behaviors are particularly dangerous or burdensome, therapy with low doses of high-potency neuroleptics has been suggested. Measures such as these to help caregivers in the management of dementia at home can be instrumental in improving the quality of life for the person with dementia.

Constipation and fecal impaction in the long-term care patient.

Constipation is a significant problem in the long-term care patient. There is a high prevalence of both primary and secondary causes of constipation in this population. Common primary causes include deficient dietary fiber, deficient fluid intake, and immobility. Common secondary causes include carcinoma, constipating medications, and neurologic and endocrine diseases. Moreover, complications of constipation such as fecal impaction, fecal incontinence, stercoral ulceration, and obstruction can be catastrophic in the debilitated elderly patient. Many cases of constipation can be treated by supplementing dietary fiber and fluid intake, with attention to nonmedical forms of intervention. In some patients, therapies such as bulk-forming agents, emollients, and periodic enemas may be necessary. In addition, there are some newer therapies available. Chronic stimulant laxative therapy should be reserved for patients with certain conditions that warrant their use.

A prospective study of acute illness in the nursing home.

Managing acute illness is an important aspect of medical care for nursing home residents, but little data is available on the nature of acute illness in this setting. The aims of this study were to determine the incidence, etiologies, risk factors and outcomes of acute illness in nursing home residents. This was a prospective cohort study of residents at one Veterans Administration nursing home (N = 140). Acute illness episodes were identified prospectively for one year through staff interviews and medical record review. Etiologies of acute illness were determined based on standardized criteria. Subjects were followed for three years to determine hospital utilization, discharge location and survival. There were 113 acute illness episodes identified (0.59 episodes per subject per month). The most common etiologies were pneumonia (33% of episodes), and urinary tract infection (27%). Significant risk factors for acute illness included anemia, dependence in mobility and surveillance time (i.e., duration of time monitored for illness episodes) in the nursing home (model chi 2 27.16, p < 0.001). Subjects who developed acute illness had increased hospital utilization during the first year of follow-up (p = 0.034); they were also less likely to be discharged home by both one year (chi 2 12.37, p < 0.001) and two years of follow-up (chi 2 9.45, p = 0.009). When hospice and respite residents with short stay were excluded, subjects who developed acute illness had lower 3-year survival (Log rank 4.97, p = 0.026), and the rate of acute illness episodes (i.e., number per month monitored) predicted 3-year mortality (Cox proportional hazards, p < 0.001). In conclusion, acute illness is extremely common among nursing home residents, and is most often due to infection. The occurrence of acute illness identifies residents who have increased hospital utilization, are less likely to return home, and have decreased long-term survival.

Individualizing nighttime incontinence care in nursing home residents.

BACKGROUND: Urinary incontinence is a common problem among nursing home (NH) residents and can be successfully treated with prompted voiding during daytime hours. A previous study of incontinent NH residents demonstrated that noise from the staff and other residents and light and noise from staff-initiated incontinence care routines were associated with waking episodes. Nighttime incontinence care should be individualized to minimize sleep disruption while considering moisture exposure that could affect skin health. Although descriptive studies have been published, there are no published intervention studies describing attempts to improve nighttime environmental factors in NHs. OBJECTIVE: To individualize nighttime incontinence care while minimizing sleep disruption among NH residents. METHOD: Subjects were assigned to a 2- or 4-hour incontinence care schedule based on each resident's risk of skin problems using objective data of spontaneous body movements at night and skin health during baseline, and the research staff provided incontinence care if residents were found awake. RESULTS: Awakenings due to light and sound associated with incontinence care were significantly reduced during the intervention phases (p < .001), and there were no adverse changes in skin health or on most risk factors associated with skin (e.g., exposure to moisture, body turns). CONCLUSIONS: Incorporating this intervention component into more comprehensive efforts to improve sleep and evaluating the long-term effects of the intervention on skin health are recommended.

Clarifying confusion: the confusion assessment method. A new method for detection of delirium.

OBJECTIVE: To develop and validate a new standardized confusion assessment method (CAM) that enables nonpsychiatric clinicians to detect delirium quickly in high-risk settings. DESIGN: Prospective validation study. SETTING: Conducted in general medicine wards and in an outpatient geriatric assessment center at Yale University (site 1) and in general medicine wards at the University of Chicago (site 2). PATIENTS: The study included 56 subjects, ranging in age from 65 to 98 years. At site 1, 10 patients with and 20 without delirium participated; at site 2, 16 patients with and 10 without delirium participated. MEASUREMENTS AND MAIN RESULTS: An expert panel developed the CAM through a consensus building process. The CAM instrument, which can be completed in less than 5 minutes, consists of nine operationalized criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). An a priori hypothesis was established for the diagnostic value of four criteria: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness. The CAM algorithm for diagnosis of delirium required the presence of both the first and the second criteria and of either the third or the fourth criterion. At both sites, the diagnoses made by the CAM were concurrently validated against the diagnoses made by psychiatrists. At sites 1 and 2 values for sensitivity were 100% and 94%, respectively; values for specificity were 95% and 90%; values for positive predictive accuracy were 91% and 94%; and values for negative predictive accuracy were 100% and 90%. The CAM algorithm had the highest predictive accuracy for all possible combinations of the nine features of delirium. The CAM was shown to have convergent agreement with four other mental status tests, including the Mini-Mental State Examination. The interobserver reliability of the CAM was high (kappa = 0.81 - 1.0). CONCLUSIONS: The CAM is sensitive, specific, reliable, and easy to use for identification of delirium.