Development and Evaluation of Evidence-Based Nursing Protocol for Extracorporeal Membrane Oxygenation to Critically Ill Patients

Purpose@#This study aimed to develop an evidence-based extracorporeal membrane oxygenation (ECMO) nursing protocol for critically ill patients receiving ECMO treatment by using an adaptation process, and to verify the effects of the protocol. @*Methods@#The protocol was developed according to the adaptation guidelines. A non-randomized controlled trial was conducted to test the protocol’s effects. Data were collected between April 2019 and March 2021. The differences in physiological indicators and complication rates between the two groups were investigated using a chart review to evaluate patient outcomes. The nurses’ outcome variables were evaluated using a questionnaire. @*Results@#First, after reviewing 11 guidelines by appraisal of the guidelines for research and evaluation collaboration II, 5 guidelines with a standardization grade of over 50 points were selected. An ECMO nursing protocol was developed based on these guidelines. Second, there were no statistically significant differences in physiological indicators between the two groups of patients. However, the experimental group showed a statistically significant decrease in the infection rate (p = .026) and pressure injury rates (p = .041). The levels of satisfaction with ECMO nursing care, and empowerment and performance of the nurses who used the ECMO nursing protocol were higher than those of nurses who did not (p < .001). @*Conclusion@#This protocol may help prevent infections and pressure injuries in patients, and improve nurses’ satisfaction and empowerment. The nursing protocol developed for critically ill patients receiving ECMO treatment can be utilized in evidence-based nursing practice.

The mediating effect of the positive psychological capital between self-determination and grit in nursing students / 한국간호교육학회지

Purpose@#This is a study to confirm the mediating effect of positive psychological capital in the relationship between the self-determination and grit of nursing students. @*Methods@#The subjects of the study were 122 university nursing department students in their junior and senior years. The data were collected from December 1 to 23, 2022. The collected data were analyzed by descriptive statistics, an independent t-test, Mann–Whitney U-test, Pearson’s correlation, and a hierarchical multiple regression analysis using IBM SPSS statistics version 26.0. @*Results@#A statistically significant correlation was observed between self-determination, positive psychological capital and grit (p<.001). The positive psychological capital had full mediation effects on the relationship between self-determination and grit. In other words, the higher levels of positive psychological capital were associated with better levels of grit among nursing students. @*Conclusion@#The study showed that positive psychological capital and self-determination have important effects on grit. To enhance the grit of nursing students, it is essential to implement educational programs aimed at improving self-determination and positive psychological capital.

The longitudinal effects of children’s temperament on maternal depression: A hierarchical linear modeling approach / 한국간호교육학회지

Purpose@#This study aimed to identify the longitudinal effects of children’s temperament on maternal depression. @*Methods@#Data from a longitudinal cohort of the Panel Study of Korean Children (PSKC) from 2010 to 2012 were analyzed using hierarchical linear modeling. The survey included 1,721 mother-child dyads. The mothers reported on their children’s temperament and on maternal depression. The children’s temperament was measured by the Emotionality, Activity and Sociability-Temperament Survey for Children-Parental Ratings, while maternal depression was measured by the Kessler 6 Psychological Distress Scale. @*Results@#The results showed that both children’s temperament and maternal depression were relatively stable when the children were between the ages of 2 to 4. The mean maternal depression scores were 11.83 in 2010, 11.88 in 2011, and 11.75 in 2012. There were significant negative correlations between the maternal depression scores and children’s ages, and sociability and activity subdomain scores ranged from r=-.05 to -.11 (p<.05). There was a significant positive correlation between children’s emotionality subdomain scores and maternal depression scores (r=.35, p<.001). Children’s temperament rament (emotionality: β=0.26, activity: β=-0.07, and sociability: β=-0.03) were significant factors in maternal depression. @*Conclusion@#These findings indicate the need for the early assessment of and intervention for children’s temperament and maternal depression. The results of this study will provide basic data for the development of nursing education programs related to early assessment and intervention to improve the health and quality of life of young children and mothers.

Comparison of Bleeding, Hematoma, Pain, and Discomfort After Bone Marrow Examination With or Without Sandbag Compression

Purpose@#A safe and effective hemostatic care is necessary after bone marrow examination to minimize bleeding, pain, and discomfort. However, a standardized hemostatic care protocol following bone marrow examination has not been established. The purpose of this study was to investigate the differences in bleeding, hematoma, pain, and discomfort by the hemostatic method used following bone marrow examination. @*Methods@#This study was carried out with a pre-test/post-test nonequivalent control group design. Sixty-four patients undergoing bone marrow examination at the hemato-oncology ward in a tertiary hospital in South Korea were assigned to an intervention (n = 30) and comparison group (n = 34). The intervention group was treated using a compression dressing alone, while the comparison group received a compression dressing followed by sandbag compression. Both groups received two hours of bedrest. Bleeding, hematoma, pain, and discomfort were measured at one and two hours after the biopsy. @*Results@#No significant differences in the occurrence of bleeding between the groups at one and two hours after bone marrow examination were observed, and no participant developed hematoma. The intervention group had significantly lower pain than the comparison group two hours after the bone marrow examination as well as lower discomfort one hour and two hours after the bone marrow examination (p < .05). @*Conclusion@#Applying only compression dressing after a bone marrow examination is effective in reducing pain and discomfort without measurable differences in bleeding and hematoma, suggesting that compression dressings alone could be effective in lowering pain and discomfort following bone marrow examination.

Comparison of Bleeding, Hematoma, Pain, and Discomfort After Bone Marrow Examination With or Without Sandbag Compression

Purpose@#A safe and effective hemostatic care is necessary after bone marrow examination to minimize bleeding, pain, and discomfort. However, a standardized hemostatic care protocol following bone marrow examination has not been established. The purpose of this study was to investigate the differences in bleeding, hematoma, pain, and discomfort by the hemostatic method used following bone marrow examination. @*Methods@#This study was carried out with a pre-test/post-test nonequivalent control group design. Sixty-four patients undergoing bone marrow examination at the hemato-oncology ward in a tertiary hospital in South Korea were assigned to an intervention (n = 30) and comparison group (n = 34). The intervention group was treated using a compression dressing alone, while the comparison group received a compression dressing followed by sandbag compression. Both groups received two hours of bedrest. Bleeding, hematoma, pain, and discomfort were measured at one and two hours after the biopsy. @*Results@#No significant differences in the occurrence of bleeding between the groups at one and two hours after bone marrow examination were observed, and no participant developed hematoma. The intervention group had significantly lower pain than the comparison group two hours after the bone marrow examination as well as lower discomfort one hour and two hours after the bone marrow examination (p < .05). @*Conclusion@#Applying only compression dressing after a bone marrow examination is effective in reducing pain and discomfort without measurable differences in bleeding and hematoma, suggesting that compression dressings alone could be effective in lowering pain and discomfort following bone marrow examination.

Impact of Resistance Training on Obesity index, Lipid Index, Blood Pressure, Pulse Rate, and Bone Mineral Densitometer in Middle-aged Women: A Meta-analysis of Randomized Controlled Trials / 재활간호학회지

PURPOSE: We reviewed the effects of resistance training on obesity index, lipid index, blood pressure, pulse rate, and bone mineral densitometer in middle-aged women. METHODS: Randomized, controlled trials lasting 12 weeks investigating the effects of resistance training obesity index, lipid index, blood pressure, and bone densitometer in middle-aged women and published in a peer-reviewed journal up to March 2018 were included. Random- and fixed-effects models were used for analyses, with data reported as weighted means and 95% confidence limits. RESULTS: We included 8 randomized, controlled trials, involving 18 study groups and 335 participants. Overall, resistance training induced a significant low-density lipoprotein reduction [−13.44 (95% CI=−26.71~−0.18)]. No significant effect was observed on other blood lipids, obesity index, blood pressure, pulse rate, and bone mineral density. When study groups were divided according to the period of training, resistance training groups for 24 weeks resulted in a significant decrease in systolic blood pressure [−6.19 (95% CI=−10.95~−1.43 mm Hg)]. CONCLUSION: This meta-analysis supports the potential of resistance training to reduce the level of low-density lipoprotein in middle-aged women. Based on these results, we suggest the application of comprehensive management strategies such as aerobic exercise, resistance exercise, behavior control, and dietary management to prevent obesity in middle-aged women.

The Prevalence and Associated Factors of the Metabolic Syndrome in Pre-menopausal Housewives: An Analysis of the 2010~2015 Korean National Health and Nutrition Examination Survey

PURPOSE: The purpose of this study is to estimate the prevalence of the metabolic syndrome in pre-menopausal housewives and to explore controllable and uncontrollable factors regarding metabolic syndrome. METHODS: The study population of this cross-sectional survey was from the Korean Health and Nutrition Examination Survey (KHANES) 2010 through 2015, including the fifth and sixth population-based studies. The criteria for metabolic syndrome include waist circumference, blood pressure, fasting plasma glucose, triglyceride, high-density lipoprotein (HDL) based on Korean Clinical Practice Guideline for Metabolic Syndrome by the Korean Academy of Family Medicine 2015. RESULTS: Among the 2,498 subjects, 247 subjects had metabolic syndrome and the prevalence was estimated to be 9.9%. The number of subjects who met the criterion of HDL was 936 (36.2%), which was the most prevalent among the criteria for metabolic syndrome. Statistically significant (p < .05) factors include age, livinghood benefit group, perceived health status, obesity, family history of DM, sleeping time, awareness of stress,leukocyte, and erythrocyte count. The odds ratio of obesity in the BMI ≥25 group was 12.59 times as high as that of the BMI < 25 group (p < .001) for metabolic syndrome. CONCLUSION: The prevalence of metabolic syndrome in pre-menopausal housewives in the survey was not low, and it is necessary to develop and apply comprehensive health habit management programs to improve controllable factors including exercise and food intake.

The Effects of Mentoring Functions and Job Satisfaction on Turnover Intention according to Nurses' Mentoring Phases / 산업간호학회지

PURPOSE: The purpose of this study was to determine the effect of nurses' mentoring functions and job satisfaction on their turnover intention on the basis of Kram's mentoring phases. METHODS: The participants were 286 nurses who were working at tertiary or general hospitals. Data were collected through surveys conducted between February 1 and 27, 2017, analyzed using independent t-test, one-way ANOVA, Pearson's correlation coefficient, and hierarchical multiple regression with the IBM SPSS 21.0 program. RESULTS: The mean mentoring functions score was 3.64 out of 5 points. Job satisfaction had statistically significant positive correlation with mentoring function (p < .05), while turnover intention showed statistically significant negative correlation with job satisfaction (p < .001). Job satisfaction was the only statistically significant variable affecting turnover intention in all three phases p < .001). CONCLUSION: Nursing organizations may reduce nurses' turnover intention by increasing job satisfaction, which can be improved by developing and applying a differentiated mentoring program according to the nurses' mentoring phases.

Impact of Interpersonal Relationship Ability, Job Stress, and Stress Coping Type on Turnover Intention of Nurses in the Early Stage of their Careers: Focusing on Job Stress / 산업간호학회지

PURPOSE: This study aimed to examine the effects of interpersonal relationship ability, job stress, and stress coping type on the turnover intention of nurses in the early stage of their careers. METHODS: Data were collected from 136 early stage nurses from two general hospitals and one tertiary hospital in Chungbuk province. An early stage nurse was defined as the nurse with a work experience of 3 to 36 months. The collected data were analyzed using independent t-test, one-way ANOVA, Mann-Whitney U test, Person's correlation coefficient, and stepwise multiple regression. RESULTS: It was seen that turnover intention had a negative correlation with interpersonal competency (r=-.20, p=.020) and a positive correlation with job stress (r=.56, p < .001). Job stress due to work over load, inadequate compensation and working environment, interpersonal relationship ability, and length of clinical career were significant factors influencing turnover intention (p < .05). These variables explained for 50.4% of the variance in turnover intention. CONCLUSION: It is necessary to develop an interpersonal relationship ability improvement program to decrease turnover intention among early stage nurses by helping them to successfully adapt to their job. Moreover, it is important to bring about continuous improvements in terms of provision of adequate workload and appropriate rewards, and creation of a suitable work environment to reduce the job stress of early stage nurses.

The Effects of Mentoring Functions and Job Satisfaction on Turnover Intention according to Nurses' Mentoring Phases / 한국직업건강간호학회지

PURPOSE@#The purpose of this study was to determine the effect of nurses' mentoring functions and job satisfaction on their turnover intention on the basis of Kram's mentoring phases.@*METHODS@#The participants were 286 nurses who were working at tertiary or general hospitals. Data were collected through surveys conducted between February 1 and 27, 2017, analyzed using independent t-test, one-way ANOVA, Pearson's correlation coefficient, and hierarchical multiple regression with the IBM SPSS 21.0 program.@*RESULTS@#The mean mentoring functions score was 3.64 out of 5 points. Job satisfaction had statistically significant positive correlation with mentoring function (p < .05), while turnover intention showed statistically significant negative correlation with job satisfaction (p < .001). Job satisfaction was the only statistically significant variable affecting turnover intention in all three phases p < .001).@*CONCLUSION@#Nursing organizations may reduce nurses' turnover intention by increasing job satisfaction, which can be improved by developing and applying a differentiated mentoring program according to the nurses' mentoring phases.

Impact of Interpersonal Relationship Ability, Job Stress, and Stress Coping Type on Turnover Intention of Nurses in the Early Stage of their Careers: Focusing on Job Stress / 한국직업건강간호학회지

PURPOSE@#This study aimed to examine the effects of interpersonal relationship ability, job stress, and stress coping type on the turnover intention of nurses in the early stage of their careers.@*METHODS@#Data were collected from 136 early stage nurses from two general hospitals and one tertiary hospital in Chungbuk province. An early stage nurse was defined as the nurse with a work experience of 3 to 36 months. The collected data were analyzed using independent t-test, one-way ANOVA, Mann-Whitney U test, Person's correlation coefficient, and stepwise multiple regression.@*RESULTS@#It was seen that turnover intention had a negative correlation with interpersonal competency (r=-.20, p=.020) and a positive correlation with job stress (r=.56, p < .001). Job stress due to work over load, inadequate compensation and working environment, interpersonal relationship ability, and length of clinical career were significant factors influencing turnover intention (p < .05). These variables explained for 50.4% of the variance in turnover intention.@*CONCLUSION@#It is necessary to develop an interpersonal relationship ability improvement program to decrease turnover intention among early stage nurses by helping them to successfully adapt to their job. Moreover, it is important to bring about continuous improvements in terms of provision of adequate workload and appropriate rewards, and creation of a suitable work environment to reduce the job stress of early stage nurses.

Influencing Factors on Cardio-cerebrovascular Disease Risk Factors in Young Men: Focusing on Obesity Indices

PURPOSE: The purpose of this study was to investigate influences of drinking, smoking, and obesity indices on cardio-cerebrovascular disease risk factors in Korean young men. METHODS: The subjects were 234 young men, aged 20 to 39 years. Body mass index (BMI), percent body fat (PBF), body fat mass (kg), and waist hip ratio (WHR) were measured as obesity indices. Systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting blood sugar (FBS), total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) were measured as cardio-cerebrovascular disease risk factors. The data were analyzed by t-test, ANOVA, Pearson's correlation coefficient, and multiple regression analysis using SAS 9.4. RESULTS: Statistically significant factors were BMI for SEP; age, degree of drinking, body fat mass for DBP; WHR for TC; WHR and age for TG; age, degree of smoking and PBF for HDL-C; WHR, age and degree of smoking for LDL-C. CONCLUSION: Factors identified in this study need to be considered in cardio-cerebrovascular disease prevention programs for young men.

The Relationship among Practice Environment, Organizational Justice, and Job Satisfaction of Male Nurses / 한국직업건강간호학회지

PURPOSE: This cross-sectional descriptive study was to explore the relationship among practice environment, organizational justice, and job satisfaction of male nurses. METHODS: Subjects were 115 male nurses who were the member of the Korean man nurses association, and they were asked to complete self-administration questionnaires via internet site for this survey which included nurse's practice environment, organizational justice, and job satisfaction. Collected data were analyzed using SPSS/WIN version 21.0 software. RESULTS: The mean scores of the nurse's practice environment, organizational justice, and job satisfaction were 2.9, 3.0, 3.1 out of 5 Likert scale respectively. The job satisfaction was positively correlated with the nurse's practice environment (r=.70, p<.001) and organizational justice (r=.78, p<.001). The job satisfaction was affected by procedure-related justice, interpersonal justice, adequacy of staffing and resources in nursing work environment, compensation justice, and good healthy status. These variables explained 68.6% of male nurse's job satisfaction. CONCLUSION: This finding suggest that suitable organization management for male nurses are necessary through improvement of practice environment and organizational justice in hospital.

The Relations among Attitude, Competency, and Appropriateness of Work on Student Suicide in Health Teachers / 한국간호교육학회지

PURPOSE: The purpose of this study was to identify the relations among appropriateness of work, competency on student suicide and attitude toward suicide in health teachers. METHODS: This study was a cross-sectional descriptive one. The subjects were 193 health teachers. Self-administered questionnaires were used to measure the variables of this study. Descriptive statistics, independent t-test, one way ANOVA, Pearson correlation, and stepwise multiple regression with SAS 9.3 software were used for the data analysis. RESULTS: The attitude score toward suicide ranged from 1.47 to −1.03. The average score of appropriateness of work and competency related to student suicide were 2.34 and 2.81 respectively. Associated factors with competency related to student suicide among health teacher were appropriateness of work related to student suicide, two items of attitude toward suicide(suicide is an acceptable means to end an incurable illness and people who commit suicide are usually mentally ill), education level, education experience on suicide prevention and management, and the adjusted R2 of the regression model was 34.3%. CONCLUSION: Health teachers were not tolerable to student suicide. However, they evaluated themselves as low in the appropriateness and competency to the work on student suicide, especially in screening and counselling of high risk groups. The results of this study suggest that it is necessary to develop education programs about counseling and intervention on student suicide for health teachers.

Influence of Emotional Awareness, Ambivalence over Emotional Expressiveness and Emotional Regulation Style on Nursing Student Adjustment / 한국간호교육학회지

PURPOSE: This study was conducted to identify influence of emotional awareness, ambivalence over emotional expressiveness and emotional regulation style on nursing student adjustment. METHOD: One hundred and sixty nine nursing students completed the questionnaires from May to June, 2013. Data analysis was done using descriptive statistics, independent t-test, ANOVA, Pearson correlation coefficient, and multiple regression with SAS v 9.3. RESULTS: Ambivalence over positive emotional expressiveness, motivation of application for nursing-aptitude, emotional awareness-mood labeling, avoidant/distractive style of emotion regulation, and parents-both alive were identified as factors influencing nursing student adjustment. The model explained 37% of variance in nursing student adjustment. CONCLUSION: The results of this study suggest that programs for promoting mood labeling and reducing ambivalence over positive emotional expressiveness and avoidant/distractive style of emotion regulation are important for college adjustment in nursing students. In addition, aptitude test for nursing applicants can be considered.

Effects of a Fall Prevention Program on Falls in Frail Elders Living at Home in Rural Communities

PURPOSE: This study was conducted to determine the effects of a fall prevention program on falls, physical function, psychological function, and home environmental safety in frail elders living at home in rural communities. METHODS: The design of this study was a nonequivalent control group pre posttest design. The study was conducted from July to November, 2012 with 30 participants in the experimental group and 30 in the control group. Participants were registered at the public health center of E County. The prevention program on falls consisted of laughter therapy, exercise, foot care and education. The program was provided once a week for 8 weeks and each session lasted 80 minutes. RESULTS: The risk score for falls and depression in the experimental group decreased significantly compared with scores for the control group. Compliance with prevention behavior related to falls, knowledge score on falls, safety scores of home environment, physical balance, muscle strength of lower extremities, and self-efficacy for fall prevention significantly increased in the experimental group compared with the control group. CONCLUSION: These results suggest that the prevention program on falls is effective for the prevention of falls in frail elders living at home.

Factors Associated with Senile Macular Degeneration in Elders within Communities

PURPOSE: This study was conducted to examine the degree of senile macular degeneration in elders aged 65 or older and identify factors associated with senile macular degeneration in elders within communities. METHODS: Participants in this cross-sectional descriptive study were 388 elders without cataract, glaucoma, and diabetic retinopathy. Data were collected through face to face interviews using a questionnaire in an urban area from June 2010 to December 2011. To detect senile macular degeneration, the participants' self-tests were carried out with Amsler grid testing. Stepwise multivariate logistic regression was performed to evaluate the effects of health behavior and knowledge about eye health on senile macular degeneration. RESULTS: The proportion of participants with senile macular degeneration was 11.6%. Factors that significantly increased the risk of senile macular degeneration included eye discomfort and history of ophthalmic examination (p<.05). Factors that significantly decreased the risk of senile macular degeneration included regular change of magnifiers, non-use of magnifiers, and knowledge about preventive effects of non-smoking and antioxidant vitamin intake on senile macular degeneration (p<.05). CONCLUSION: This study showed that programs for preventing senile macular degeneration were necessary for elders within communities and the results of this study can be used for developing those programs.

Clinical Nurses' Knowledge and Visual Differentiation Ability in Pressure Ulcer Classification System and Incontinence-associated Dermatitis

PURPOSE: This study was done to compare clinical nurses' knowledge and visual differentiation diagnostic ability for the pressure ulcer classification system (PUCS) and incontinence-associated dermatitis (IAD). METHODS: A convenience sample of 602 nurses took the pressure ulcer classification system and incontinence-associated dermatitis knowledge test (PUCS & IAD KT) and completed the visual differentiation tool (VDT), consisting of 21 photographs with clinical information. RESULTS: The overall mean score for correct answers was 14.5 (+/-3.2) in PUCS & IAD KT and 11.15 (+/-4.9) in PUCS & IAD VDT. Incorrect responses were most common for statements related to stage III, IAD for PUCS & IAD KT, and suspected deep tissue injury (SDTI), unstageable, and stage III for PUCS & IAD VDT. Significant correlations were found between PUCS & IAD KT and VDT (r=.48, p<.001). Factors affecting scores for PUCS & IAD VDT were PUCS & IAD KT, frequency of pressure ulcer, IAD management and participation in wound care education programs. CONCLUSION: Results indicate that nurses have an overall understanding of PUCS & IAD, but low visual differentiation ability regarding stage III, SDTI, and unstageable ulcers. Continuing education is needed to further improve knowledge and visual differentiation ability for PUCS & IAD.

Gender Difference in Risk Factors for Depression in Community-dwelling Elders

PURPOSE: This study was conducted to compare the degree of depression between men and women and to identify factors influencing their depression. METHODS: Participants in this cross-sectional descriptive study were 263 persons over 65 years old (men: 103, women: 160). Data were collected through face to face interviews using questionnaires and were done in two urban areas in 2010. Research instruments utilized in this study were SGDS, MMSE-K, SRH, FILE, sleep pattern scale, family and friend support scale, and social support scale. Multivariate regression analysis was performed to identify factors influencing depression in elders. RESULTS: The proportions of participants with depression were significantly different between men and women (52.4% vs. 67.5%). Regression model for depression in elderly men significantly accounted for 54%; disease stress (32%), economic stress (10%), perceived health status (4%), and family support, educational level, age, and hypertension. Regression model for depression in elderly women significantly accounted for 47%; disease stress (25%), perceived social loneliness (8%), friend support (5%), family stress (4%), and sleep satisfaction, and family support. CONCLUSION: Results demonstrate that depression is an important health problem for elders, and show gender differences for factors influencing depression. These results could be used in the developing depression prevention programs.

The Knowledge, Awareness and Preventive Behaviors of Pneumococcal Vaccination for the Elderly

PURPOSE: The purpose of this study was to ascertain current status of pneumococcal vaccination for the elderly and their knowledge, awareness and preventive behaviors for the vaccination and to verify the relationship between results. METHODS: This cross-sectional study was performed using a questionnaire. Data were collected from 114 elderly people over 65 years at one community center from October to November in 2011. Collected data were analyzed using SPSS. RESULTS: The vaccination rate of the elderly was as low as 19.3%. The most common reason for no vaccination was 'Because I did not know about it' (64.0%), and the intention to vaccination was to ascertain in 77.2%. The scores of knowledge, awareness and preventive behavior for vaccination were 0.31/1, 1.15/3 and 1.48/2, respectively. The knowledge for vaccination was significantly different by gender and education. The awareness of vaccination showed statistically significant difference by religion, perceived health status and experience of vaccination. A positive correlation was observed between both knowledge and awareness and awareness and preventive behavior for vaccination. CONCLUSION: The pneumococcal vaccination rate of the elderly was relatively low. To develop, therefore, the educational program for improving awareness and preventive behavior regarding pneumococcal vaccination of the elderly is necessary.