The Functional Pain Scale: reliability, validity, and responsiveness in an elderly population.

OBJECTIVES: Because of difficulty experienced in assessing pain in frail older patients and the lack of pain assessment tools with standardization in the elderly, the Functional Pain Scale (FPS), an instrument incorporating both subjective and objective components to assess pain, was developed and evaluated. DESIGN, SETTING, PARTICIPANTS, AND MEASURES: One hundred subjects more than 65 years old participated in the validity, reliability, and responsiveness (the clinical sensitivity of the instrument to change) testing of the Functional Pain Scale. Subjects were recruited from a geriatrics inpatient setting, a geriatrics outpatient setting, and a local hospice (residing in their homes). Ninety-four of the subjects completed all phases of testing. Reliability was tested using a test-retest format and a correlation matrix. Criterion-related validity was established as compared with the Visual Analog Scale (VAS), the Present Pain Intensity (PPI), the McGill Short Form Questionnaire (MPQ-SF), and the Numeric Pain Scale (NPS) instruments. Responsiveness for the FPS, the VAS, the PPI, the MPQ-SF, and the NPS instruments was determined using five previously described techniques: effect size, standardized response means, relative efficiency, direct comparison of t test scores, and direct comparison of P values. A cumulative index was developed to rank each scale. Cumulative responsiveness index scores were based on individual scale performance for each separate responsiveness test. The lowest score in the cumulative responsiveness index indicated the most responsive scale. RESULTS: Interrater reliability for instruments tested exceeded 0.95 for all instruments tested. Validity testing showed high correlations as well (r = 0.62, r = 0.85, r = 0.80, r = 0.90 for the VAS, the PPI, the MPQ-SF, and the NPS respectively). Responsiveness evaluated overall by the responsiveness index was best for the Functional Pain Scale (7) followed by the Visual Analog Scale (12), the Present Pain Intensity (13), the McGill Pain Questionnaire-Short Form (19), and the Numerical Pain Questionnaire (24). CONCLUSIONS: The Functional Pain Scale was determined to be reliable, valid, and responsive. The responsiveness of the Functional Pain Scale was superior to the other instruments tested. The Functional Pain Scale is an acceptable instrument for assessing pain in older adults and may reflect changes in pain better than other instruments tested. Further testing in other populations is warranted.

The Frail Elderly Functional Assessment questionnaire: its responsiveness and validity in alternative settings.

OBJECTIVE: To test the Frail Elderly Functional Assessment (FEFA) questionnaire for responsiveness (sensitivity to change) to low-level functional tasks in a frail elderly cohort and to evaluate its validity over the telephone or when administered to a caregiver proxy. SUBJECTS: Fifty-eight elderly patients from three urban inpatient rehabilitation settings and an outpatient geriatrics center. METHODS: A prospective, clinical, comparative trial. The FEFA questionnaire was administered serially. For validity, subjects were observed performing the tasks on the questionnaire within 24 hours of each interview. For responsiveness, repeat measures were performed within a 1- to 2-week period. Validity and sensitivity to change (responsiveness) of the questionnaire were determined by correlating patient responses to direct observations by rehabilitation staff. Responsiveness was also determined based on the Guyatt technique that divides clinically significant change by the normal variance, sigma/(2x [mean squared error])1/2, as well as by measures of effect size, standardized response means, and relative efficiency tests for responsiveness. To evaluate FEFA validity in alternative settings, kappa statistic and regression analyses were used based on the previously validated interviewer-administered format. RESULTS: Responsiveness was excellent with effect size (.35), standardized response means (.48), and relative efficiency (2.67) tests as well as Guyatt (1.26). There was 83% agreement when compared with FEFA task performance. Regression between change in FEFA score versus performance testing was significant (r2 = .33; p = .01). ANOVA was significant at a p = .03 for FEFA scores at first measure in rehabilitation compared to second. Correlation for caregiver proxy administration was .92 (p< or =.0001) and for telephone administration was .99 (p<.0001). CONCLUSIONS: The FEFA questionnaire, previously demonstrated to be reliable and valid, is sensitive to functional change (responsive) in frail elderly people. It is also valid when administered by phone or to a caregiver proxy.

The impact of a geriatrics evaluation and management unit compared to standard care in a community teaching hospital.

A prospective, controlled trial was initiated to determine whether an acute inpatient geriatrics unit located in a community-based teaching hospital provides better care for frail elderly patients at less cost than conventional medical-surgical units.

Hepatitis B virus vaccination for older adults.

OBJECTIVE: To compare in adults more than 50 years old the tolerability and immunogenicity of vaccination with recombinant hepatitis B surface antigen (HBs) compared with vaccination with recombinant hepatitis B protein PreS2 + S, and to investigate the safety and immunogenicity of a fourth vaccine dose in poor and non-responders. DESIGN: Randomized, double-blind prospective study. SETTING: General clinical research center for outpatient evaluation and vaccination. SUBJECTS: Adults older than age 50 who were in general good health and with no known risk factors for acquiring or serologic evidence of hepatitis B virus infection. INTERVENTION: Subjects were randomized to receive 10 mcg HBs (Recombivax, Merck, Sharp and Dohme), 12 mcg PreS2 + S, or 24 mcg PreS2 + S vaccine at 0, 1, and 6 months. Poor and non-responders (anti-Hbs < 10 mIU/mL at month 9 and/or 12) were encouraged to receive a fourth vaccine injection. MEASUREMENTS: Diary records of temperature and local and systemic reactions following each vaccination were maintained by all subjects. Anti-HBs levels were measured by radioimmunoassay before the first injection, at 1, 2, 3, 6, 7, 9, and 12 months after for all subjects, and 1 month after the fourth injection for the group of poor and non-responders. MAIN RESULTS: Twenty men and nine women (mean age +/- SD, 66 +/- 8.0 years) were enrolled. Ten subjects received HBs vaccine, nine received 12 mcg PreS2 + S vaccine, and 10 received 24 mcg PreS2 + S vaccine. One subject in the HBs group dropped out, and data were analyzed for the remaining 28 subjects. There were no differences in rates of side effects reported by each of the three groups. Overall, minor local adverse reactions occurred in 12 (40%) after at least one of the first three vaccinations. Systemic side effects occurred in five (17%) after the first vaccination, in one after the second, but in none after the third. The 24-mcg PreS2 + S vaccine was not more immunogenic than the HBs vaccine, and the 12-mcg PreS2 + S vaccine was judged inadequate. Nineteen of 22 (86%) poor and non-responders received a fourth vaccination. Minor local adverse reactions were reported by six (32%), and none reported a systemic side effect. For the 12 subjects receiving a fourth injection of HBs or 24 mcg PreS2 + S vaccine, the proportion of responders 1 month following the fourth injection was greater than for 1 month following the third injection (11 of 12 [92%] versus 12 of 19 [63%], respectively, P < .05). CONCLUSION: For adults more than 50 years of age who have low anti-HBs levels after three vaccine injections, a fourth injection is well tolerated and results in improved immunogenic response.

The effects of changing prompted voiding schedules in the treatment of incontinence in nursing home residents.

OBJECTIVE: To determine the effects of different prompted voiding schedules on urinary incontinence on a continence unit (CU) and the maintenance of benefits on normal nursing units. DESIGN: Multiphase study with both intra- and inter-subject comparisons. PARTICIPANTS: Subjects were 41 consenting incontinent nursing home residents. Based on clinical criteria, subjects were assigned to one of four treatment groups that varied as to the schedule of prompted voiding received. MEASUREMENT: The study used chart review, Katz ADL, and MMSE. Urologic status, self-initiated toileting, urine volumes voided, and incontinence assessed by pad/pants checks were measured by research nurses. Baseline pad check data were collected on residents' normal nursing units. Residents were transferred to the CU where baseline measurement was repeated, and the effects of different prompted voiding schedules were then assessed. Indigenous staff were trained to use prompted voiding, and nurse supervisors were instructed in special procedures for enhancing maintenance of the intervention. Residents were returned to their normal units and the maintenance of improvements in continence status was assessed at 2 weeks and 3 months post-CU discharge. RESULTS: One of the four groups showed significant improvement on the CU in response to the 2-hour schedule; two groups improved on the less intensive 3-hour schedule (P < 0.05). Two groups maintained this improvement on their normal nursing units (P < 0.05); one group showed a non-significant trend toward improvement. Self-initiated toileting decreased (P < 0.05) and volume voids in an appropriate receptacle increased (P < 0.05) during training. CONCLUSIONS: Prompted voiding is an effective treatment for urinary incontinence, and a less intensive 3-hour schedule may be superior to the standard 2-hour schedule for some residents. These improvements in dryness can be maintained by normal nursing home staff if formal staff management procedures are utilized by nurse supervisors.

Urinary incontinence: an augmented prompted void approach.

Continence improves from 44.7% dryness at baseline to 54.7% at the end of treatment, an improvement of 22%, or about one incontinent episode per day. Urinary incontinence is improved in cognitively impaired residents by augmenting the prompted voiding procedure with a bellpad. Bladder behavior changes with behavioral treatment strategies, because the volume voided into an appropriate receptacle increased an average of 26 mL per 2 hours. Reimbursement policies should not exclude treatment of the severely cognitively impaired nor the immobile in nursing homes.

Cost-effectiveness of treating incontinence in severely mobility-impaired long term care residents.

Severely mobility-impaired residents in long term care facilities are usually incontinent. The incontinence and immobility predispose this group to decubitus ulcers and urinary tract infections that have been described as adding to the "consequence costs of incontinence" of $80 million per year. In this quasi-experimental study of ten subjects, a mechanical lift (Clinilift) was used with a two-hour schedule to improve incontinence. Subjects showed improvement in not only dryness but also volume of urine voided and the frequency of decubitus ulcers and UTIs. Because this incontinence treatment is labor intensive, the costs of treating incontinence increased by $2.90 over the cost of providing incontinent care. When the costs of decubitus ulcers and urinary tract infections are considered, however, the treatment savings were $13.38 per patient per day.

A descriptive analysis of nursing staff behaviors in a teaching nursing home: differences among NAs, LPNs, and RNs.

Various staff behaviors in a nursing home were sampled seven times a day, 5 days a week over 37 months and were coded separately for LPNs, RNs, and NAs. The behavior most frequently observed was patient care, which occurred during 56.9% of the samples. We observed staff interacting with patients during 10.7% and with other staff during 19.5% of the samples. The LPNs displayed significantly more patient care behaviors and NAs significantly more nonwork behaviors than other nursing staff. RNs displayed the least nonwork behavior. We conclude that nursing staff devote most of their time to patient needs and relatively little time to nonproductive activities.

A staff management system for maintaining improvements in continence with elderly nursing home residents.

We developed a staff management system for maintaining treatment gains achieved on a specialized continence unit located in a geriatric nursing home. Geriatric assistants learned to use a prompted voiding procedure to maintain improved dryness for 4 elderly residents. The staff management system included self-monitoring and recording of prompted voiding activities and supervisory monitoring and feedback based on group performance of these activities. Results show that the system was effective in maintaining prompted voiding activities with corresponding maintenance of improved patient continence. However, a gradual decline in staff performance was noted 4 to 5 months after the initiation of the system. During a subsequent phase of the study, provision of individual feedback restored staff performance to previous levels. Results are discussed in relation to the practicality of prompted voiding interventions in nursing home environments and the applicability of staff management systems in this setting.

Nursing management of urinary incontinence in geriatric inpatients.

The management and treatment of incontinence represent two interrelated areas--providing enough providers of care and describing the types of management and treatment options available to the incontinent patient. This article has stressed that adequate staffing underlies any successful program of continence management and treatment. In addition, many options for the management and treatment of incontinence in the elderly have been presented. Of importance are the specific nursing implications that will make many continence protocols successful. These guidelines can provide the basis for planning patient care through the nursing process. This article has also addressed management and treatment strategies for incontinence that not only improve incontinence in patients but may cure it. These include behavioral management strategies which nurses should be encouraged to use in treating incontinent patients in the community. These same behavioral management strategies are being studied in inpatient settings, and the results indicate that nurses in inpatient settings and long-term care facilities should implement behavioral treatment programs for incontinent patients.

Transiently reduced activity of carbamyl phosphate synthetase and ornithine transcarbamylase in liver of children with Reye's syndrome.

Since Reye's syndrome is associated with hyperammonemia, we measured the urea-cycle enzymes in hepatic tissue of 13 patients. Expressed as nanomoles of citrulline per milligram of hepatic protein per minute, mean activity of carbamyl phosphate synthetase (6.27 +/- 2.45 S.D.) and ornithine transcarbamylase (136.19 +/- 41.83) in Reye's syndrome was reduced significantly (P less than 0.005) when compared with that of 25 "normal" controls (11.54 +/- 4.24 and 307.49 +/- 94.15, respectively). Activity was maximally reduced during the first days of clinical symptoms; it returned toward normal during the following week regardless of whether the disease ended in death or recovery. The activity of the two enzymes was normal in patients with salicylate intoxication or heritable argininosuccinic acid synthetase deficiency. The apparent Km of hepatic ornithine transcarbamylase for ornithine was in the normal range in patients with Reye's syndrome (mean 0.24 mM). These observations indicate that Reye's syndrome is associated with acquired and transient dysfunction of hepatic mitochondrial urea-cycle enzymes.