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.

Developing rehabilitative behavioral interventions for long-term care: technology transfer, acceptance, and maintenance issues.

Rehabilitative behavioral interventions that are documented in clinical trials to improve nursing home resident outcomes and are recommended by practice guidelines are often not adapted for daily use in nursing homes and other long-term care (LTC) facilities. Failure to evaluate issues other than clinical efficacy when developing interventions contributes to this gap between efficacy and effectiveness in practice. A potential solution is a research model that supplements traditional clinical intervention research with methodology designed specifically to evaluate the ability of LTC facilities to implement the interventions. This paper discusses several critical issues of intervention and implementation that should be addressed, including targeting interventions, advocacy, cost-effectiveness, training, and quality control. We also describe how clinical trials could be designed and staged to increase the probability that effective interventions will be implemented in the day-to-day care of frail older patients in LTC facilities.

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.

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.

Skin disorders and moisture in incontinent nursing home residents: intervention implications.

OBJECTIVE: To provide data needed to design an intervention trial to prevent or treat skin disorders in a high risk, incontinent nursing home population. DESIGN: The incidence and prevalence of nine common skin disorders were measured prospectively over a 60-day period using trained observers. Urinary and fecal incontinence frequency were measured over 24 hours, and mobility was measured with subjects both in and out of bed. Direct measures of skin moisture were taken with an impedance device in the presence and absence of urinary incontinence. Multiple regression analyses were used to relate the incontinence and mobility variables to the presence and development of skin disorders. SETTING: Four nursing homes. PARTICIPANTS: One hundred incontinent nursing home residents. MAIN OUTCOME MEASURES: Prospective measures of nine common skin disorders and skin moisture in four perineal regions under continent and incontinent conditions. RESULTS: All subjects had at least one skin condition identified during the 60-day data collection period. The most commonly observed skin condition was blanchable erythema, which occurred in 94% of the subjects, predominantly in the front and back regions that were closest to the urethra and rectum. Twenty-one percent of residents developed either a Stage 1 (nonblanchable erythema) or 2 pressure ulcer. All skin conditions were transient when measured every 3 weeks with the exception of blanchable erythema, which showed stability. Stage 3 or greater pressure ulcers and edema were not observed, and interrater reliability for the measure of papules was poor. Measures of urinary and fecal incontinence severity were correlated with blanchable erythema severity, and blanchable erythema and low bed mobility were predictive of pressure ulcer severity. Blanchable erythema severity was also predictive of Stage 1 and 2 pressure ulcers. Skin moisture levels in the back perineal farthest from the rectum (peripheral) were affected most by urinary incontinence. CONCLUSION: A trial to detect a 50% preventive effect on Stage 1 and 2 pressure ulcers would require that 167 subjects be monitored for 60 days. The transient nature of the skin effects require that skin be monitored at least once a week. Because blanchable erythema is so prevalent and appears to be associated with more severe skin conditions, it would make an excellent marker for beginning to assess the potential preventive effects of various interventions on the incidence of pressure ulcers and other related skin disorders in incontinent patients. It is likely that the back area peripheral to the urethra and rectum would experience the greatest benefit from an intervention trial to reduce moisture caused by incontinence.

Nighttime urinary incontinence and sleep disruption among nursing home residents.

OBJECTIVE: To examine the relationship of urinary incontinence episodes to sleep disruption in a sample of nursing home residents. DESIGN: Descriptive, case series. SETTING: Three community nursing homes. PARTICIPANTS: Seventy-three incontinent residents of three nursing homes participating in a trial of a behavioral intervention for nighttime urinary incontinence. MEASUREMENTS: Data were collected during a baseline and repeat baseline period about 2 months later in nursing homes serving as controls for the intervention homes. Incontinence episodes were identified by incontinence pads, which were wired to detect wetness of 10 mL or more. Sleep was monitored by wireless wrist actigraphs. Noise and light changes were monitored by bedside recording devices. MAIN RESULTS: Recordings covered 403 nights, during which 1715 awakenings from 10 consecutive minutes of sleep were detected as were 1168 incontinent episodes. Only 4% of the awakenings were associated with an incontinence episode, and only 23% of the incontinence episodes occurred during periods of at least 10 consecutive minutes of sleep. Of the latter episodes, only 12% appeared to awaken the resident. CONCLUSIONS: Our data raise questions about the relevance of incontinence episodes to sleep disruption among chronically incontinent nursing home residents. Our findings must be interpreted cautiously because of limitations in the technologies and definitions we used to identify sleep, awakenings, and incontinence episodes. Although logistically and technically difficult to perform, studies using polysomnographic recordings of sleep are needed to examine further these important associations.

Arginine vasopressin levels in nursing home residents with nighttime urinary incontinence.

OBJECTIVES: To examine the relationship between diurnal urine volume and plasma arginine vasopressin levels (AVP) in nursing home residents with nighttime urinary incontinence and a comparison group of frail but nondemented, continent geriatric board and care residents. DESIGN: Case series. SETTING: Four nursing homes and two board and care facilities. PARTICIPANTS: Sixty-two nursing home residents and 27 board and care residents. MEASUREMENTS: Daytime (7:00 a.m. to 7:00 p.m.) and nighttime (7:00 p.m. to 7:00 a.m.) urine volumes of incontinent nursing home residents were measured over 3 days and 3 nights by reweighing preweighed adults diapers and toileting inserts emptied by research staff for the comparison group. AVP levels were drawn in the early morning (5:00 a.m. to 7:00 a.m.) before subjects arose and in the evening after an hour of lying in bed (8:00 p.m. to 11:00 p.m.), and plasma levels were determined by radioimmunoassay. RESULTS: Half of the nursing home residents and 82% of the comparison group had night/total urine volume ratios > or = 50%. Forty-nine percent of the total of 89 subjects had undetectable morning AVP levels, 61% had undetectable evening AVP levels, and 42% had undetectable AVP levels in both morning and evening. There were no significant differences in AVP levels between those with night/total urine volume ratios > or = 50% and < 50% in either the nursing home or comparison groups though the small number of comparison group subjects with ratios < 50% may have limited our statistical power to detect differences. CONCLUSION: Our data suggest that a substantial proportion of both nursing home residents with nighttime incontinence and frail geriatric patients with a reversal of the normal diurnal pattern of urine excretion have an accompanying deficiency in AVP production and/or secretion. More detailed physiologic studies are needed to understand better the pathophysiology of geriatric nocturia and nighttime incontinence and the role that AVP deficiency may play in these conditions. Until such studies are carried out, we do not recommend the routine use of exogenous AVP for geriatric patients with unexplained nocturnal polyuria.

Approaches to contact investigations in Texas.

Tuberculosis (TB) spreads when family and social contacts breathe the air exhaled by someone with active TB disease. Contact investigation is the most appropriate strategy to interrupt the transmission and subsequent development of TB. One of the problems associated with contact investigations in an area with a very diverse population has been the inability of investigations to adapt their methods of approach to the different circumstances of each person with TB disease. Through interviews and group discussions with public health field workers and local TB program managers across Texas, the authors have been able to gather information on how contact investigation practices can be customized to overcome barriers specific to different populations in the state and generate a productive outcome. Variables such as culture, language, risk factors, and various settings may require a different investigational approach than the standard, traditional approach to contact investigation. It is anticipated that the concept of customizing contact investigations to meet the needs of specific populations and circumstances will become the practice worldwide, and will be a useful tool in the management of contact investigations.

Policy without technology: a barrier to improving nursing home care.

Standards of care are written for nursing homes without a realistic assessment of whether there is an intervention protocol or resources to meet these standards. This situation produces unfair pressures on nursing home providers, who react with paper compliance strategies, and creates a barrier to implementing new interventions that do meet care standards once they are developed. This article explores this barrier and illustrates examples of interventions that have been attempted in nursing homes using a continuous quality improvement model. The development of quality indicators based on assessment data available in all nursing homes is a step toward making the survey process more focused on outcomes rather than on paper compliance. Much more research is needed to design effective clinical interventions and to provide nursing homes with the technologies necessary to target them. Internal nursing home quality assurance programs based on principles of continuous quality improvement, with reinforcement from the external survey process, are suggested as a strategy to maintain clinically effective interventions. Applied research centers based in long-term care facilities should be supported in order to accomplish such research designed to improve the care and quality of life our increasing frail nursing home population.

Ethnography and AIDS: a methodology for identifying culturally relevant risk-reducing behaviors.

As the AIDS pandemic enters its second decade, persons most at risk for developing the disease are low-income African-American women and their children. This group has been extremely difficult to reach with traditional "top-down" risk reduction programs developed by the federal government. The authors describe an ethnographic case study strategy, appropriate for and within the reach of many community-based organizations. This strategy can be used to identify barriers to risk-reducing behaviors; ultimately this strategy can be used to assist organizations to develop culturally relevant intervention programs.

The limits of Medicaid reimbursement incentives. An evaluation of the Florida AIDS Nursing Home Admission Program.

Provider incentive payments in the Medicaid program have been in operation nationally since the early 1980s. Although initially indicating favorable results, recently the ability of such incentives to produce the desired action has been questioned. This study examined the Florida Medicaid AIDS Nursing Home Admission Incentive Program to determine the reasons behind the program's apparent inability to increase Medicaid-covered persons with AIDS (PWAs) admissions to nursing homes. A survey of 308 nursing homes in the 10 Florida counties with the highest cumulative AIDS cases in the state was conducted. The results reveal that (a) the level of incentive reimbursement received, (b) the financial classification of existing (non-AIDS) residents, and (c) the level of technological sophistication of the facility are all significantly related to the number of PWAs admitted. Based on these results, the author discusses implications for the future of Medicaid incentive programs for PWAs.

Assessing employee attitudes in a community-based AIDS service organization.

This study surveyed employees of the Comprehensive AIDS Program of Palm Beach County, Florida, a community-based AIDS service organization, to understand employees' motives for working for the organization and their attitudes toward their jobs, the organization, its clients (persons with AIDS), and governments. The study revealed that the primary reasons employees work for the organization are a desire for personal involvement in the AIDS fight and the personal lifestyle and/or feeling of each employee. These employees were highly motivated, showing some very positive attitudes toward their jobs, organization, and clients. On the other side, these employees reported concern for future funding of their organization and unhappiness with both federal and state governments' role in the fight against AIDS. Based on these findings, the authors discuss implications for the management of AIDS service organizations, the quality of the AIDS service delivery system, and the future development of AIDS service organizations.

AIDS services in Florida: who's doing what, and who's paying for it?

The rapid growth of AIDS in the 1980s was paralleled by a rapid growth in AIDS Service Organizations (ASOs) throughout the United States. This article examines one state, Florida, and the 52 ASOs to determine each ASOs organizational affiliation, major types of service offered, sources of funding, and geographic dispersion in the state. Based on the results of this examination, several research and policy implications are discussed.

First among (UN) equals: assessing hospital performance using data envelopment analysis.

This article explores the use of Data Envelopment Analysis (DEA) as a comparative analytic tool to assess the relative effectiveness of competing hospitals. Building on previous research with DEA in hospital efficiency analysis, the authors extend the earlier technical efficiency-based DEA models to include qualitative outcome measures. Data from hospitals in a regional competitive health care market in South Florida are assessed using this new DEA model.

AIDS and long-term care. An examination of Florida's Medicaid incentive reimbursement program.

People living with HIV/AIDS will have a greater need for long-term care options as the disease develops into a chronic, rather than an acute, condition. Nursing homes, a major component in the long-term care continuum, traditionally have been reluctant to admit PWAs, forcing some states to adopt incentive programs to encourage such admissions. The efficacy of such programs, however, has not been studied. This article will examine Florida's Medicaid AIDS nursing home admission incentive program, focusing on its effect on PWA admission rates in the state.

Comparative performance assessment in managed care: data envelopment analysis for health care managers.

In health care markets increasingly dominated by managed care, health care managers need sophisticated yet understandable comparative performance assessment methods. Ideally, these methods should provide targets for the managers to improve program or organization performance. This article reviews three comparative performance methodologies with a comprehensive explanation of data envelopment analysis (DEA). DEA is a form of linear programming that allows for the inclusion of multiple input and output/outcome performance variables from a virtually unlimited number of organizations, facilitating meaningful health service provider comparative assessments.

Designing an international industrial hygiene database of exposures among workers in the asphalt industry.

OBJECTIVES: The objective of this project was to construct a database of exposure measurements which would be used to retrospectively assess the intensity of various exposures in an epidemiological study of cancer risk among asphalt workers. METHODS: The database was developed as a stand-alone Microsoft Access 2.0 application, which could work in each of the national centres. Exposure data included in the database comprised measurements of exposure levels, plus supplementary information on production characteristics which was analogous to that used to describe companies enrolled in the study. RESULTS AND DISCUSSION: The database has been successfully implemented in eight countries, demonstrating the flexibility and data security features adequate to the task. The database allowed retrieval and consistent coding of 38 data sets of which 34 have never been described in peer-reviewed scientific literature. We were able to collect most of the data intended. As of February 1999 the database consisted of 2007 sets of measurements from persons or locations. The measurements appeared to be free from any obvious bias. CONCLUSIONS: The methodology embodied in the creation of the database can be usefully employed to develop exposure assessment tools in epidemiological studies.

Values of baccalaureate nursing students in secular and religious schools.

This study examined if and how values held by baccalaureate nursing students in secular and religious schools changed during their school experience. The Rokeach Value Survey was used to measure and assess respondents' hierarchical arrangement of two kinds of values, instrumental and terminal. Two-way analysis of variance was done on each value to ascertain difference by class level or school orientation. Significant differences were found for 25 of the 36 values when the students were compared for school orientation, but for only 17 or the 36 values when freshmen and seniors were compared.

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.