Appraisal of the quality of care of older adults with cognitive impairment in the emergency department.

The medical records of 273 patients 75 years and older were reviewed to evaluate quality of emergency department (ED) care through the use of quality indicators. One hundred fifty records contained evidence of an attempt to carry out a cognitive assessment. Documented evidence of cognitive impairment (CI) was reported in 54 cases. Of these patients, 30 had no documented evidence of an acute change in cognitive function from baseline; of 26 patients discharged home with preexisting CI (i.e., no acute change from baseline), 15 had no documented evidence of previous consideration of this issue by a health care provider; and 12 of 21 discharged patients who screened positive for cognitive issues for the first time were not referred for outpatient evaluation. These findings suggest that the majority of older adults in the ED are not receiving a formal cognitive assessment, and more than half with CI do not receive quality of care according to the quality indicators for geriatric emergency care. Recommendations for improvement are discussed.

Longitudinal investigation of wandering behavior in Department of Veterans Affairs nursing home care units.

OBJECTIVES: To explore the extent of and factors associated with male residents who change wandering status post nursing home admission. DESIGN: Longitudinal design with secondary data analyses. Admissions over a 4-year period were examined using repeat assessments with the Minimum Data Set (MDS) to formulate a model understanding the development of wandering behavior. SETTING: One hundred thirty-four Veterans Administration (VA) nursing homes throughout the United States. PARTICIPANTS: Included 6673 residents admitted to VA nursing homes between October 2000 and October 2004. MEASUREMENTS: MDS variables (cognitive impairment, mood, behavior problems, activities of daily living and wandering) included ratings recorded at residents' admission to the nursing home and a minimum of two other time points at quarterly intervals. RESULTS: The majority (86%) of the sample were classified as non-wanderers at admission and most of these (94%) remained non-wanderers until discharge or the end of the study. Fifty-one per cent of the wanderers changed status to non-wanderers with 6% of these residents fluctuating in status more than two times. Admission variables associated with an increased risk of changing status from non-wandering to wandering included older age, greater cognitive impairment, more socially inappropriate behavior, resisting care, easier distractibility, and needing less help with personal hygiene. Requiring assistance with locomotion and having three or more medical comorbidities were associated with a decreased chance of changing from non-wandering to wandering status. CONCLUSION: A resident's change from non-wandering to wandering status may reflect an undetected medical event that affects cognition, but spares mobility.

Are wandering and physically nonaggressive agitation equivalent?

OBJECTIVE: The authors examined equivalence of wandering and physically nonaggressive agitation (PNA) as concepts. DESIGN: A cross-sectional correlational design was used. SETTING: Participants were recruited from 22 nursing homes and 6 assisted living facilities in two states. PARTICIPANTS: Ambulatory residents meeting DSM-IV criteria for dementia (N = 181) were studied. MEASUREMENTS: Video-tapes for up to twelve 20-minute observations per participant were coded for wandering using an empirically derived taxonomy of ambulation patterns. Separate raters coded the same tapes for six PNA behaviors on the agitation behavior mapping instrument. RESULTS: Most participants (73.5%) wandered; all showed PNA behaviors. Factor analyses yielded an one-factor solution for wandering (explained variance = 43.66%) and a two-factor solution for PNA (explained variance = 53.45%). Overall wandering correlated significantly with PNA Factor 1 (df =179, r = 0.68, p <0.001) and Factor 2, but at a lower value (df = 179, r = 0.26, p <0.01). CONCLUSION: Findings depict wandering and PNA as overlapping, but nonequivalent phenomena. Evidence supporting construct validity of wandering was more robust than that for PNA. Results have implications for accuracy in scientific and clinical detection and labeling of wandering and agitation.

Wanderers with cognitive impairment in Department of Veterans Affairs nursing home care units.

OBJECTIVES: To explore the extent of and factors associated with male nursing home residents who wander. DESIGN: Cross-sectional design with secondary data analyses. SETTING: One hundred thirty-four nursing home facilities operated by the Department of Veterans Affairs. PARTICIPANTS: Fifteen thousand ninety-two nursing home residents with moderate or severe cognitive impairment admitted over a 4-year period. MEASUREMENTS: Selected variables from the Minimum Data Set included ratings recorded at residents' admission to the nursing home (cognitive impairment, mood, behavior problems, activities of daily living, and wandering). RESULTS: In this sample of residents with moderate or severe cognitive impairment, the proportion of wanderers was found to be 21%. Wanderers were more likely to exhibit severe (vs moderate) cognitive impairment, socially inappropriate behavior, resistance to care, use of antipsychotic medication, independence in locomotion or ambulation, and dependence in activities of daily living related to basic hygiene. A sizable proportion of wanderers were found to be wheelchair users (25%) or were wanderers with dual dementia and psychiatric diagnoses (23%), characteristics that are not well documented in the literature. CONCLUSION: These results support previous clinical understanding of wanderers to be those who are more likely to exhibit more-severe cognitive impairment. Based on a statistical model with variables generated from prior research findings, classification as a wanderer was found to be associated with other disruptive activity such as socially inappropriate behavior and resisting care. Two understudied populations of wanderers were documented: wheelchair wanderers and those with comorbid dementia and psychiatric diagnoses. Future longitudinal studies should examine predictors of wandering behavior, and further research should explore the understudied subpopulations of wheelchair and dual-diagnosis wanderers who emerged in this study.

Use of a Robotic Seal as a Therapeutic Tool to Improve Dementia Symptoms: A Cluster-Randomized Controlled Trial.

OBJECTIVES: To test the effects of individual, nonfacilitated sessions with PARO (version 9), when compared against a look-alike plush toy and usual care, on the emotional and behavioral symptoms of dementia for people living in long-term care facilities. DESIGN: Parallel, 3-group, cluster-randomized controlled trial conducted between June 14, 2014, and May 16, 2015. SETTING: Twenty-eight long-term care facilities operated by 20 care organizations located in South-East Queensland, Australia. PARTICIPANTS: Four hundred fifteen participants aged ≥60 years, with a documented diagnosis of dementia. INTERVENTION: Stratified by private/not-for-profit status and randomized using a computer-generated sequence, 9 facilities were randomized to the PARO group (individual, nonfacilitated, 15-minute sessions 3 times per week for 10 weeks); 10 to plush toy (same, but given PARO with robotic features disabled); and 9 to usual care. Treatment allocation was masked to assessors. MEASUREMENTS: Primary outcomes were changes in levels of engagement, mood states, and agitation after a 10-week intervention, assessed by coded video observations (baseline, weeks 1, 5, 10, and 15) and Cohen-Mansfield Agitation Inventory-Short Form (baseline, weeks 10 and 15). Analyses followed intention-to-treat, using repeated measures mixed effects models. Australian New Zealand Clinical Trials Registry (ACTRN12614000508673). RESULTS: Video data showed that participants in the PARO group were more verbally [3.61, 95% confidence interval (CI): 6.40-0.81, P = .011] and visually engaged (13.06, 95% CI: 17.05-9.06, P < .0001) than participants in plush toy. Both PARO (-3.09, 95% CI: -0.45 to -5.72, P = .022) and plush toy (-3.58, 95% CI: -1.26 to -5.91, P = .002) had significantly greater reduced neutral affect compared with usual care, whilst PARO was more effective than usual care in improving pleasure (1.12, 95% CI: 1.94-0.29, P = .008). Videos showed that PARO was more effective than usual care in improving agitation (3.33, 95% CI: 5.79-0.86, P = .008). When measured using the CMAI-SF, there was no difference between groups. CONCLUSIONS: Although more effective than usual care in improving mood states and agitation, PARO was only more effective than a plush toy in encouraging engagement.

Characteristics of older people with cognitive impairment attending emergency departments: A descriptive study.

OBJECTIVE: The objective of this paper is to describe the profile of older people with cognitive impairment (CI) presenting to emergency departments (EDs). METHODS: This was a multi-centre (n=8) observational study of a convenience sample of older (≥70y) ED patients (n=579). Participants were prospectively assessed for CI and surveyed for the duration of their ED stay (n=191). A picture of patients' health status and ED responses to care needs was obtained through application of standardised assessment tools. Additionally, observations of care processes in ED were undertaken. Demographic data were collected through both ED's information system and survey. Outcome data were collected 28 days post-ED visit using follow-up telephone interviews. RESULTS: Of 579 older persons, 191 (33%) persons met criteria for CI. The majority of older ED patients with CI in ED lived in the community (157/177, 88.7%), arrived by ambulance (116/172, 67%), were accompanied by a support person (94/149, 63%), were triaged as urgent to semi-urgent (157/191, 82%), and were hospitalised (108/172, 57%). The median ED length of stay was 6h. In ED, 53% of the sample experienced pain (92/173). Older ED patients with CI pose the following characteristics: prior hospital admissions (43/129, 33%), incontinence (61/178, 34%), dependence in activities in daily living (81/190, 43%), issues in nutrition (73/182, 40%), vision and hearing impairment (93% (160/172) and 26% (44/171) respectively). CONCLUSION: Increased understanding of these presenting characteristics and their impacts on patient risk facilitates tailoring the quality of emergency care to better suit the needs and improve outcomes of this increasing ED population.

Structural quality indicators to support quality of care for older people with cognitive impairment in emergency departments.

OBJECTIVES: The purpose of this study was to identify the structural quality of care domains and to establish a set of structural quality indicators (SQIs) for the assessment of care of older people with cognitive impairment in emergency departments (EDs). METHODS: A structured approach to SQI development was undertaken including: 1) a comprehensive search of peer-reviewed and gray literature focusing on identification of evidence-based interventions targeting structure of care of older patients with cognitive impairment and existing SQIs; 2) a consultative process engaging experts in the care of older people and epidemiologic methods (i.e., advisory panel) leading to development of a draft set of SQIs; 3) field testing of drafted SQIs in eight EDs, leading to refinement of the SQI set; and 4) an independent voting process among the panelists for SQI inclusion in a final set, using preestablished inclusion and exclusion criteria. RESULTS: At the conclusion of the process, five SQIs targeting the management of older ED patients with cognitive impairment were developed: 1) the ED has a policy outlining the management of older people with cognitive impairment during the ED episode of care; 2) the ED has a policy outlining issues relevant to carers of older people with cognitive impairment, encompassing the need to include the (family) carer in the ED episode of care; 3) the ED has a policy outlining the assessment and management of behavioral symptoms, with specific reference to older people with cognitive impairment; 4) the ED has a policy outlining delirium prevention strategies, including the assessment of patients' delirium risk factors; and 5) the ED has a policy outlining pain assessment and management for older people with cognitive impairment. CONCLUSIONS: This article presents a set of SQIs for the evaluation of performance in caring for older people with cognitive impairment in EDs.

Process quality indicators targeting cognitive impairment to support quality of care for older people with cognitive impairment in emergency departments.

OBJECTIVES: The objective of this study was to develop process quality indicators (PQIs) to support the improvement of care services for older people with cognitive impairment in emergency departments (ED). METHODS: A structured research approach was taken for the development of PQIs for the care of older people with cognitive impairment in EDs, including combining available evidence with expert opinion (phase 1), a field study (phase 2), and formal voting (phase 3). A systematic review of the literature identified ED processes targeting the specific care needs of older people with cognitive impairment. Existing relevant PQIs were also included. By integrating the scientific evidence and clinical expertise, new PQIs were drafted and, along with the existing PQIs, extensively discussed by an advisory panel. These indicators were field tested in eight hospitals using a cohort of older persons aged 70 years and older. After analysis of the field study data (indicator prevalence, variability across sites), in a second meeting, the advisory panel further defined the PQIs. The advisory panel formally voted for selection of those PQIs that were most appropriate for care evaluation. RESULTS: In addition to seven previously published PQIs relevant to the care of older persons, 15 new indicators were created. These 22 PQIs were then field tested. PQIs designed specifically for the older ED population with cognitive impairment were only scored for patients with identified cognitive impairment. Following formal voting, a total of 11 PQIs were included in the set. These PQIs targeted cognitive screening, delirium screening, delirium risk assessment, evaluation of acute change in mental status, delirium etiology, proxy notification, collateral history, involvement of a nominated support person, pain assessment, postdischarge follow-up, and ED length of stay. CONCLUSIONS: This article presents a set of PQIs for the evaluation of the care for older people with cognitive impairment in EDs. The variation in indicator triggering across different ED sites suggests that there are opportunities for quality improvement in care for this vulnerable group. Applied PQIs will identify an emergency services' implementation of care strategies for cognitively impaired older ED patients. Awareness of the PQI triggers at an ED level enables implementation of targeted interventions to improve any suboptimal processes of care. Further validation and utility of the indicators in a wider population is now indicated.

Biomechanical activity devices to index wandering behavior in dementia.

Valid and reliable measures of wandering are needed to study this troubling behavior. Although researchers have used various perspectives, definitions, and approaches to study wandering, spontaneous ambulation is a key characteristic across all views. Biomechanical activity devices for capturing movement provide one way to index wandering. This study examined four devices with ambulatory nursing home residents with dementia (N = 178) who wore devices simultaneously during four observations. Among the Actillume, StepWatch, Step Sensor, and TriTrac-R3D, the StepWatch yielded data from the highest proportion of observations, explained the most variance (63.9 percent) among all instruments, and was acceptable to nursing staff. Although the Step Sensor was the staff's preferred device, its performance was least acceptable for research purposes. Results support use of the StepWatch in future studies of wandering.

Delirium knowledge and recognition: a randomized controlled trial of a web-based educational intervention for acute care nurses.

Delirium is a significant problem for older hospitalized people and is associated with poor outcomes. It is poorly recognized and evidence suggests that a major reason is lack of education. Nurses, who are educated about delirium, can play a significant role in improving delirium recognition. This study evaluated the impact of a delirium specific educational website. A cluster randomized controlled trial, with a pretest/post-test time series design, was conducted to measure delirium knowledge (DK) and delirium recognition (DR) over three time-points. Statistically significant differences were found between the intervention and non-intervention group. The intervention groups' DK scores were higher and the change over time results were statistically significant [T3 and T1 (t=3.78 p=<0.001) and T2 and T1 baseline (t=5.83 p=<0.001)]. Statistically significant improvements were also seen for DR when comparing T2 and T1 results (t=2.56 p=0.011) between both groups but not for changes in DR scores between T3 and T1 (t=1.80 p=0.074). Participants rated the website highly on the visual, functional and content elements. This study supports the concept that web-based delirium learning is an effective and satisfying method of information delivery for registered nurses. Future research is required to investigate clinical outcomes as a result of this web-based education.

An evidence-based program to improve analgesic practice and pain outcomes in residential aged care facilities.

Pain is common in individuals living in residential aged care facilities (RACFs), and a number of obstacles have been identified as recurring barriers to adequate pain management. To address this, the Australian Pain Society developed 27 recommendations for comprehensive good practice in the identification, assessment, and management of pain. This study reviewed preexisting pain management practice at five Australian RACFs and identified changes needed to implement the recommendations and then implemented an evidence-based program that aimed to facilitate better pain management. The program involved staff training and education and revised in-house pain-management procedures. Reviews occurred before and after the program and included the assessment of 282 residents for analgesic use and pain status. Analgesic use improved after the program (P<.001), with a decrease in residents receiving no analgesics (from 15% to 6%) and an increase in residents receiving around-the-clock plus as-needed analgesics (from 24% to 43%). There were improvements in pain relief for residents with scores indicative of pain, with Abbey pain scale (P=.005), Pain Assessment in Advanced Dementia Scale (P=.001), and Non-communicative Patient's Pain Assessment Instrument scale (P<.001) scores all improving. Although physical function declined as expected, Medical Outcomes Study 36-item Short-Form Survey bodily pain scores also showed improvement (P=.001). Better evidence-based practice and outcomes in RACFs can be achieved with appropriate training and education. Investing resources in the aged care workforce using this program improved analgesic practice and pain relief in participating sites. Further attention to the continued targeted pain management training of aged care staff is likely to improve pain-focused care for residents.

Wandering and the physical environment.

BACKGROUND/RATIONALE: Guided by the need-driven dementia-compromised behavior (NDB) model, this study examined influences of the physical environment on wandering behavior. METHODS: Using a descriptive, cross-sectional design, 122 wanderers from 28 long-term care (LTC) facilities were videotaped 10 to 12 times; data on wandering, light, sound, temperature and humidity levels, location, ambiance, and crowding were obtained. Associations between environmental variables and wandering were evaluated with chi-square and t tests; the model was evaluated using logistic regression. RESULTS: In all, 80% of wandering occurred in the resident's own room, dayrooms, hallways, or dining rooms. When observed in other residents' rooms, hallways, shower/baths, or off-unit locations, wanderers were likely (60%-92% of observations) to wander. The data were a good fit to the model overall (LR [logistic regression] chi(2) (5) = 50.38, P < .0001) and by wandering type. CONCLUSIONS: Location, light, sound, proximity of others, and ambiance are associated with wandering and may serve to inform environmental designs and care practices.

Empirical derivation and validation of a wandering typology.

OBJECTIVES: To develop and validate a wandering typology. DESIGN: Cross-sectional, correlational descriptive design. SETTING: Twenty-two nursing homes and six assisted living facilities. PARTICIPANTS: One hundred forty-two residents with dementia who spoke English, met Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, criteria for dementia, scored less than 24 on the Mini-Mental State Examination (MMSE), were ambulatory (with or without assistive device), and maintained a stable regime of psychotropic medications were studied. MEASUREMENTS: Data on wandering were collected using direct observations, plotted serially according to rate and duration to yield 21 parameters, and reduced through factor analysis to four components: high rate, high duration, low to moderate rate and duration, and time of day. Other measures included the MMSE, Minimum Data Set 2.0 mobility items, Cumulative Illness Rating Scale-Geriatric, and tympanic body temperature readings. RESULTS: Three groups of wanderers were identified through cluster analysis: classic, moderate, and subclinical. MMSE, mobility, and cardiac and upper and lower gastrointestinal problems differed between groups of wanderers and in comparison with nonwanderers. CONCLUSION: Results have implications for improving identification of wanderers and treatment of possible contributing factors.

A framework for managing wandering and preventing elopement.

PURPOSE OF THE STUDY: A framework aids choice of interventions to manage wandering and prevent elopement in consideration of associated risks and mobility needs of wanderers. DESIGN AND METHODS: A literature review, together with research results, published wandering tools, clinical reports, author clinical experience, and consensus-based judgments was used to build a decision-making framework. RESULTS: Referencing a published definition of wandering and originating a clinical description of problematic wandering, authors introduce a framework comprising (1) wandering and related behaviors; (2) goals of wandering-specific care, (3) interpersonally, technologically, and policy-mediated wandering interventions, and (4) estimates of relative frequencies of wandering behaviors, magnitudes of elopement risk, and restrictiveness of strategies. IMPLICATIONS: Safeguarding wanderers from elopement risk is rendered person-centered and humane when goals of care guide intervention choice. Despite limitations, a reasoned, systematized approach to wandering management provides a basis for tailoring a specialized program of care. The need for framework refinement and related research is emphasized.

The concept of vulnerability and the protection of human subjects of research.

This article provides an overview of the concept of vulnerability through the lens of the U.S. federal regulations for the protection of human subjects of research. General issues that emerge for nurse researchers working with regulated vulnerable populations are identified. Points of current controversy in the application of the regulations and current discourse about vulnerable groups are highlighted. Suggestions for negotiating the tension between federally regulated human subject requirements and the realities of research with vulnerable subjects are given. The limitations of the designation of vulnerable as a protection for human subjects will also be discussed.

Initial psychometrics of the ambiance scale: a tool to study person-environment interaction in dementia.

Our purpose was to evaluate the psychometric properties of the Ambiance Scale (AS), a new instrument that assesses the capacity of long-term care environments for generating affective and behavioural responses in people with dementia. Within the context of three parent studies of dementia-related behaviour in long-term care settings, we conducted a cross-sectional correlational study by creating two separate samples of ratings from among all those available. Factor analysis revealed a two-factor structure (engaging, soothing) for the AS. Internal consistency and evaluation of inter- and intra-rater reliability were favourable. A consistent pattern of ratings on the AS and its subscales, moderate subscale correlations, and significant differences between facility types: nursing homes (NH) vs assisted living facilities (ALF) and among selected locations (residents' rooms, dining rooms, halls) within facility types support construct validity of the scale.

A comparison of wandering behavior in nursing homes and assisted living facilities.

Wandering, a challenging behavior associated with dementia, affects many residents of long-term care facilities and can result in elopement, injury, and death. Most studies of wandering have taken place in nursing homes (NH). Expansion of the long-term care sector over the last 2 decades has resulted in a surge in options such as assisted living facilities (ALF). This study compared wandering behavior of residents (N = 108) in 21 long-term care facilities (15 NH, 6 ALF). Staff used the Revised Algase Wandering Scale-Nursing Home Version (RAWS-NH) to quantify wandering. While there were some differences in demographic variables (i.e., race, motor ability) between NH and ALF participants, no significant differences were found in either RAWS-NH overall or any of the 6 subscale scores. This suggests that the expression of wandering is similar in long-term care residents across all dimensions of the RAWS-NH regardless of facility type. Findings are of concern for those involved in the safe management and protection of residents at risk for wandering, particularly in long-term care facilities with underregulated staffing and training requirements.

Comparison of U.S., Canadian, and Australian participants' performance on the Algase Wandering Scale-Version 2 (AWS-V2).

Although wandering in dementia is seen in various cultures, cross-cultural comparisons have not been reported. We examined wandering in residents of long-term care settings (LTCs) in three English-speaking countries (n = 96, America; n = 42, Canada; n = 13, Australia) using the Algase Wandering Scale-Version 2 (AWS-V2). Participants differed by country on age and medical diagnosis. The Americans were significantly older; the Canadians had a greater rate of Alzheimer's disease (AD). In one-way ANOVAs, AWS-V2 ratings from nurse aides revealed significant differences in the AWS-V2 and three subscales (spatial disorientation, attention shifting, eloping behavior), but not for two others (persistent walking, shadowing). Where significant, Canadians had consistently lower ratings than others. Post-hoc analyses by age of participants failed to reveal significant differences. However, participants with AD had significantly lower AWS-V2 scores than those with mixed-type dementia. Lower MMSE score predicted higher AWS-V2, spatial disorientation, and eloping behavior. Post-hoc analyses of respondent characteristics revealed no significant differences on AWS-V2 or subscales by frequency of attending dementia classes and level of experience with dementia. Thus the nature of wandering in these three countries is not substantially different. However, variations in care environments may contribute to differences in attention shifting. Further, limited sample size, particularly among Australians and Canadians, make findings tentative.