Influence of Nutritional Status on a Family-Centered Care Intervention for Older Adults with Cognitive Impairment following Hip-Fracture Surgery: Secondary Data Analysis of a Randomized Controlled Trial.

OBJECTIVES: In Taiwan, older adults with cognitive impairment who undergo hip-fracture surgery are routinely cared for by family members. This study aimed to determine if nutritional status influenced the effects of a family-centered intervention for older adults with cognitive impairment recovering from hip-fracture surgery. DESIGN: Secondary data analysis of data from a randomized controlled trial was conducted to examine the influences of nutritional status 1 month after hospital discharge on the effects of a family-centered care intervention model, which was designed for older adults with hip fracture and cognitive impairment. Outcomes were compared among participants according to nutrition status (well-nourished/poorly-nourished) and treatment approach (control/intervention). SETTING: The original study was conducted at a 3000-bed medical center from July 2015 to October 2019. PARTICIPANTS: Participants were older adults with cognitive impairment who had undergone hip-fracture surgery. Participants were assessed as poorly-nourished or well-nourished with the Mini-Nutritional Assessment (MNA) 1-month post-discharge and were then randomly assigned to either the intervention group or control group. INTERVENTION: A family-centered intervention model for family caregivers of older adults with cognitive impairment recovering from hip-fracture surgery was implemented. The intervention was delivered by geriatric nurses, which included instructions for family caregivers in overseeing exercises for strengthening the hip, understanding dietary requirements, and managing behavioral problems associated with cognitive impairment. MEASUREMENTS: Outcome measures included activities of daily living (ADLs), instrumental ADLs, hip range of motion, hip muscle strength, depression, measured with the Geriatric Depressive Scale, and physical and mental health related quality of life, measured with the Short Form Survey (SF-36), Taiwanese version. Participants were assessed at 1-, 3-, 6-, and 12-months post-discharge. RESULTS: Most of the 134 participants were assessed as poorly nourished (n = 122); 57 were the control group and 65 received the intervention. For the well-nourished participants (n = 12), four were in the intervention group and eight were controls. There were no significant differences in any outcome variables for poorly nourished participants who received the intervention compared with controls. For the sample of well-nourished participants, those who received the intervention performed significantly better in outcomes of IADLs (b = 1.74, p < .05), hip muscle strength (b = 9.64, p < .01), and physical health related quality of life (b = 10.47, p < .01). CONCLUSION: The family-centered care intervention was only effective for older adults with cognitive impairment recovering from hip-fracture surgery who were well-nourished at 1 month following hospital discharge, but not for those at risk of malnutrition. Interventions should focus on enhancing nutritional status following hip surgery which could allow the family-centered in-home intervention to be beneficial for more older adults with cognitive impairment recovering from hip-fracture surgery.

Trajectories of Nutritional Status and Cognitive Impairment among Older Taiwanese with Hip Fracture.

OBJECTIVE: This paper describes the trajectories of nutritional status and cognitive impairment and their correlation among older Taiwanese over 1 year after hip-fracture surgery. DESIGN: Secondary analysis of data from a clinical trial evaluating the effects of three types of post-discharge care for 292 older hip-fracture patients (age >60 years). MEASUREMENTS: Nutritional status was assessed by the Mini Nutritional Assessment before and 1, 3, 6, 12 months after hospital discharge. Cognitive function was measured by the Mini-Mental State Examination before surgery, at hospital discharge, 6 and 12 months after discharge. Trajectories of nutritional status and cognitive impairment were depicted by latent class growth modeling, whereas linkages between nutritional-status and cognitive-impairment trajectories were assessed by multinomial logistic regression. RESULTS: Nutritional status in general improved significantly, particularly during the first 3 months after discharge. We identified three trajectories of nutritional status: malnourished (15.4%), at risk for malnutrition (38.9%), and well-nourished (45.7%). In contrast, cognitive changes followed four largely linear but distinct trajectories: moderately impaired (12.2%), mildly impaired (27.8%), borderline impaired (21.8%), and cognitively intact (38.2%). Trajectories of nutritional status were significantly associated with cognitive-function trajectories. For instance, relative to malnourished patients, well-nourished patients were 95% less likely (OR=0.05, CI =0.01-0.24) to be moderately cognitively impaired. CONCLUSION: A good nutritional-status trajectory after hip fracture was associated with better cognitive function. To treat and care for elderly hip-fractured patients, specific interventions need to target those who are malnourished or at risk of malnutrition to decrease their risk for cognitive impairment.

Severity of depression risk predicts health outcomes and recovery following surgery for hip-fractured elders.

UNLABELLED: This study examined how depression risk interfaces with health outcomes of hip-fractured patients during the first year after hospital discharge. Physical function recovery and health outcome trajectories were much poorer for hip-fractured elders with persistent depression risk than for those with transitory and no risk for depression. INTRODUCTION: This study examined how depression risk interfaces with the trajectories of physical activities and health-related quality of life (HRQoL) among hip-fractured elderly patients during the first 12 months after hospital discharge. METHODS: Based on 12-month scores for the Chinese version of Geriatric Depression Scale, patients over age 60 years (N = 147) were classified as (a) at persistent risk for depression, (b) at transitory risk for depression, and (c) at no risk for depression. Outcomes were measured by the Chinese Barthel Index and Medical Outcomes Study Short Form, Taiwan version, and analyzed by the generalized estimating equations approach. RESULTS: Patients who were at persistent risk for depression (n = 46, 31.3%) had much less chance of recovering activities of daily living (OR = 0.16, CI = 0.06-0.42) and walking ability (OR = 0.09, CI = 0.04-0.21) than patients at no risk for depression (n = 36, 24.5%). The trajectories of SF-36 scores for the physical and mental health summary scales were significantly different among the three depression groups; those "at persistent risk for depression" were the poorest and those "at no risk for depression" were the best. CONCLUSION: These results may provide a reference for developing timely assessments and interventions for hip-fractured elders at risk of depression.

Emotional support levels can predict physical functioning and health related quality of life among elderly Taiwanese with hip fractures.

INTRODUCTION: There has been increasing interest in the role emotional support plays on recovery and the perceptions of health. However, the vast majority of studies have been based on data from Western nations. Little is known about hip-fractured elders in Asian countries. This study has examined the influences of emotional support on functional recovery, and health-related quality of life (HRQoL) among elderly patients in Taiwan. METHODS: Data were gathered from 126 hip fractured elders, in a teaching hospital in northern Taiwan. Eleven items from the Medical Outcome Study (MOS) Social Support Survey were administered, in order to measure emotional support at 1 month after discharge. The Chinese Barthel Index (CBI), Lawton and Brody's instrumental activities of daily living (IADL) scale, and MOS Short Form-36 Taiwan version were administered at the end of months 1, 3, and 6 after discharge. RESULTS: After controlling for covariates, greater levels of emotional support predicted a better recovery of the activities of daily living (ADL) (beta=0.23, P=0.04) and IADL (beta=0.03, P=0.03), and better HRQoL in seven of eight dimensions (P ranged from <0.0001 to 0.04), except social function, emotional role , and physical role during the first 6 months after hospital discharge. CONCLUSIONS: Emotional support can have a significant impact on the recovery of self- care ability, and different aspects of HRQoL during the first 6 months after discharge for hip fractured elders in Taiwan. Clinical implications were made, on the basis of these findings.

[Indicators of quality of care in nursing homes from the perspective of elderly residents].

The purpose of this study was to explore the indicators of quality of care in nursing homes from the perspective of residents. A qualitative research method with in-depth interviews and participant observation was used to collect the data. Sample consisted of 10 residents from three accredited nursing homes in Keelung, Chia-I, and Kaohsiung. The study found 7 groups of indicators of quality of care for nursing homes including indicators of environment, nursing professional competence, quality assurance, basic human rights, direct care attitude, social interaction, and needs satisfaction. Findings of this study may sensitize long-term care professionals to the needs of nursing home residents. These findings can also provide a basis for setting indicators for nursing home quality evaluation and for further improvement of the life quality of nursing home residents.

Factor structure and explanatory variables of the Mini-Mental State Examination (MMSE) for elderly persons in Taiwan.

BACKGROUND AND PURPOSE: The Mini-Mental State Examination (MMSE) is commonly used in studies and clinical assessment of cognitive functioning. The purpose of this study was to examine the factor structure and variables explaining the scores of the MMSE in elderly persons in Taiwan, in order to provide a reference for instrument selection and data collection for clinicians and researchers. METHODS: Secondary data from an epidemiologic study that included 1,442 randomly selected subjects aged 64 to 98 with an average age of 72.6 years were used. Males comprised 57.1% of the sample, and females 42.9%. Exploratory and confirmatory factor analysis and covariance structure modeling were used to analyze the data. RESULTS: In the cross validation of the covariance structure modeling, 50.1% of the variance in simple processing, 86.9% in complex processing, and 66.9% in memory/attention were explained. Better education background predicted better score in complex processing ability (path coefficient = .860). Greater independence in self-care ability predicted better scores in simple processing (path coefficient = -.716) and memory/attention (path coefficient = -.811). CONCLUSION: The results of this study indicate that items in the MMSE measuring complex processing ability including writing, reading and obeying, and copy design are seriously biased by educational background, and that the remaining items are better indicators of the subject's cognitive functioning for elderly persons in Taiwan. In our model, self-care ability was strongly related to cognitive functioning as measured by the MMSE, especially for items in the factors of simple processing (registration, naming, repetition, and commanding) and attention/memory (orientation to place and time, attention, and recall).

[Changes in discharge needs and satisfaction of family caregivers of frail elders during the discharge transition].

This longitudinal study was designed to explore the discharge needs and needs satisfaction of frail elders' family caregivers during the discharge transition. A total of 131 pairs of frail elders and their family caregivers from neuro-medical wards in a teaching hospital in northern Taiwan were interviewed using a structured questionnaire. Descriptive statistics, paired t-test, and repeated measure ANOVA were used to analyze the data. The results showed that: (1) The total needs and specific needs were higher before discharge than one week and one month after discharge. The rank order of the discharge needs, from high to low, was health care information services, health care services, emotional support services, and manpower support services. (2) The needs satisfaction at one week after discharge was the same as at one month after discharge. The rank order of needs satisfaction, from high to low, was health care services, health care information services, manpower support services, and emotional support services. The findings of this study suggest that during the discharge transition before discharge is the time of most needs and is an important time for developing nursing interventions. The "caregiver discharge needs and satisfaction assessment tool" can be used in clinical for practice assessment of the discharge needs and needs satisfaction of frail elders' family caregivers during the dis-charge transition.

The needs of family caregivers of frail elders during the transition from hospital to home: a Taiwanese sample.

The needs of family caregivers of frail elders during the transition from hospital to home: a Taiwanese sample This study explored the needs of family caregivers during the transition from hospital to home. Data from 37 face-to-face interviews with 16 caregivers before discharge and at 2 weeks and 1 month after discharge were subjected to constant comparative analysis. Findings revealed changes in family caregivers' needs during the discharge transition. While preparing to take caregiving responsibility, caregivers reported a need for various types of information. After the discharge, but before home caregiving settled into a pattern, they needed help with caregiving practices. After reaching a pattern for providing family care, caregivers frequently reported needs for continuous emotional support. These findings provide a basis for transitional care services such as discharge planning and home health care services.

Development and testing of the Family Caregiving Factors Inventory (FCFI) for home health assessment in Taiwan.

This paper describes the development and psychometric testing of the Family Caregiving Factors Inventory (FCFI). Data were collected from 97 caregivers of frail elders in Taiwan to examine the validity and reliability of the four FCFI scales: caregiving resources, caregiver self-expectations, caregiving task difficulty, and knowledge of the care receiver. Acceptable test-retest and internal consistency reliabilities were found, though inter-rater reliability was unsatisfactory for caregiving task difficulty and knowledge of the care receiver scales. Testing of hypothesized relationships between the FCFI and related variables supported the construct validity of the FCFI. Confirmatory factor analysis with good overall model fits also supported the construct validity of the FCFI scales. In its present form, the FCFI can facilitate home health assessment and problem identification for families with frail elders. Studies with larger samples are needed to further verify the measurement models.

Patterns of caregiving when family caregivers face competing needs.

'Finding a balance point' is a process used by caregivers to achieve or preserve equilibrium in caregiving while facing competing needs. This paper describes different patterns of 'finding a balance point'. Interviews with 15 family caregivers receiving home nursing services and 14 family caregivers of hospitalized and discharged frail elders were analysed using constant comparison. Sources of competing needs and the strategies used to find a balance point were identified by participants. Findings suggest that caregivers in a stable situation maintain a balance point, caregivers experiencing major family change try to regain a balance point, and caregivers experiencing the transition from hospital to home work at establishing a balance point. These findings can sensitize nurses to family caregivers' needs and conditions.

Role tuning between caregiver and care receiver during discharge transition: an illustration of role function mode in Roy's adaptation theory.

The purpose of this study was to develop a conceptual framework to explain the interaction between the caregiver and the care receiver during the discharge transition. Data from face-to-face interviews with 12 care receivers and 16 caregivers were subjected to constant comparative analysis. Findings revealed that role tuning was the process used by caregivers and care receivers to achieve a harmonious pattern of caregiving and care receiving during the transition from hospital to home. This empirical finding can illustrate the concept of role function mode in the Roy adaptation theory and sensitize healthcare providers to the needs of the families during the discharge transition.

Development and testing of the Family Caregiving Consequences Inventory for home nursing assessment in Taiwan.

This paper describes the development and psychometric testing of the Family Caregiving Consequences Inventory (FCCI). Data were collected from a convenience sample of 97 families in Taiwan to examine the validity and reliability of the three FCCI scales: frail elder outcomes, caregiver outcomes and family outcomes. Acceptable test-retest and internal consistency reliabilities were found, though inter-rater reliability was unsatisfactory. Criterion-related validity was demonstrated by congruence with home nursing specialists' assessment of family caregiving outcomes. Confirmatory factor analysis with a good overall model fit supported the construct validity of FCCI. However, a poor fit of the internal measurement structure was found for the frail elder outcomes scale and the family outcome scale. Studies with larger samples are needed to further verify the measurement models used here. Nevertheless, in its current form, the FCCI can be used to increase the sensitivity of home care nurses to family caregiving situations and provide an instrument for studies of family caregiving in Taiwan and other countries with similar home care needs.

A survey of home nursing services in Taiwan.

This study investigated the current situation of home nursing services in Taiwan. A total of 93 home nursing agencies (response rate of 75%) responded to a mail survey. The majority of the agencies (63%) had been established within the last 3 years before the survey, were hospital-based (90%), and had less than 60 (89.3%) average total number of visits per month per nurse. Most of the home care nurses had taken home care nursing training courses and had at least 2 years of clinical experience. Half of the agencies provided care for patients on a respirator, and 28% provided in-home hospice care. Almost a third of the agencies performed poorly in the areas of supply management, supervision of home visits, and quality monitoring and improvement mechanisms. Several suggestions for the development of home nursing services in Taiwan are made.

Finding a balance point: a process central to understanding family caregiving in Taiwanese families.

The grounded theory method was used to explore the psychosocial process of family caregiving to frail elders in Taiwan. Interview and observation data from 15 family caregivers were analyzed using constant comparative analysis. Caregivers used the process of finding a balance point to achieve or preserve equilibrium between and within caregiving and family life. Caregivers who did better in finding a balance point provided better quality care to frail elders. Caregivers who were good at finding a balance point anticipated competing needs, conceptualized multiple strategies to meet the needs, and predicted accurately the consequences of the strategies. They described a wide variety of balancing strategies.

[Community-based integrated home care model for the demented patients and their families].

The purposes of this research project were to establish an integrated home care model and understand the influence of an integrated home care model on demented elders and their families. The changes in cognitive function and self-care ability of demented elders were also explored longitudinally. The disciplines involved in the integrated home care model included doctors, home care nurses and social workers. The integrated home care model was developed according to the functions and roles of different disciplines in their actual working process. Services provided included home nursing care, telephone consultation and a support group. Home care nurses played the role of case manager in this model. Twenty-five families participated in this study. Among them, 22 received home care service, and 20 of them participated in a caregiver support group. The cognitive function of the demented elders did not significantly decrease over the 6-month period. Among their self-care ability, grooming and eating dependency were found significantly increased during this period. Overall, 81% families reported that home nursing care services could help them to develop care skills, care knowledge and provided emotional support. However, the caregiver burden did not significantly decrease after the home nursing care services. Seventy percent of caregivers reported that telephone consultation could support them emotionally and provided them with information concerning care. Over half of the caregivers reported that in getting related information and receiving emotional support was helpful. This integrated model developed from this research project can be adapted and used in networking home care agencies, the community and health care resources. The small and convenient sample was one of the limitations of this study. The insignificance of some of the findings might be due to the short time period (6 months) and some effects of the model might appear later than 6 months. For further research, larger and random samples and a longer period of follow-up with more health disciplines involved were suggested.

Caregiving experiences of family caregivers of elderly persons with dementia in northern Taiwan.

This is part of the follow-up to of a large epidemiological study on the prevalence of dementia. Twenty-nine caregivers of demented elderly persons identified from previous study were further studied in the second phase in order to understand the caregiving experiences. In home, one-time, face-to-face interviews were used to collect data. Qualitative data derived from open-ended questions were transcribed verbatim and the content analyzed by the researchers for major themes. Difficult tasks most frequently reported by caregivers were difficulties in helping with activities of daily living, managing incontinence, and handling patient's health problems. Patient's memory and behavioral problems most frequently causing difficulties in care were suspicion/accusation, forgetfulness, and wandering. Strategies which were most often used by caregivers to handle specific difficult tasks were environmental management and doing/fixing for the elderly subject; to handle patient's memory/behavioral problems were convincing them and going along with them. In overall caregiving strategies, care arrangement was most often used by caregivers. The findings of this study can sensitize the health providers to a wide variety of difficulties and problems caregivers of patients with dementia encounter. Health providers might be also more aware of the different strategies caregivers use in handling these difficulties and problems. Efforts can be put into helping families use more effective strategies when handling the behavioral problems and caregiving difficulties.