Nursing Leadership and Palliative Care in Long-Term Care for Residents with Advanced Dementia.

Alzheimer disease and related dementias (ADRD) are irreversible, progressive brain disorders. Many people with ADRD experience the final stage of the disease, advanced dementia, in nursing homes (NHs). Although palliative care, including symptom management and emotional support for caregivers, is advocated for those with advanced dementia, many NH residents experience potentially burdensome interventions, such as feeding tubes, hospital transfers, and intensive rehabilitation. Nurses play a critical role in ensuring high-quality palliative care to residents with advanced dementia. The aim of this article is to raise awareness of the palliative care needs of NH residents with advanced dementia.

Functions and Value of Reminiscence for Nursing Home Staff.

The purpose of the current study was to understand (a) the extent to which reminiscence is used among nursing home staff (RNs, licensed practical nurses, and certified nursing assistants), (b) the reasons nursing home staff engage in reminiscence activities with nursing home residents, and (c) the value they attribute to these activities. The degree to which engagement in reminiscence activities by nursing staff contributed to knowledge about residents was also explored. The most frequently used functions of reminiscence, as reported by nursing staff, were to calm anxiety, help residents see meaning in life, and reorient confused residents. Although nursing caregivers (N = 43) found reminiscence activities moderately to very enjoyable (76.5%), less than one half (46.5%) reported engaging in reminiscence activities with residents frequently or very frequently. Nurses who engaged in reminiscence activities more often also reported knowing residents better-a hallmark of high-quality care for residents with dementia. [Journal of Gerontological Nursing, 43(6), 35-43.].

The functions and value of reminiscence for older adults in long-term residential care facilities.

For the many older adults living in long-term care facilities, the ability to connect with others, as well as with one's own personal past, may be of particular value. Reflecting on the past and sharing reminiscences with others serves different psychosocial functions in various settings. This study examined the functions of reminiscence for long-term care residents in the United States (Mage = 86.5) by addressing the self-reported frequency of reminiscence, the counterparties involved, the overall purpose and value of reminiscence, and the relation to residents' mental health and well-being. Results demonstrated that although some functions of reminiscence were comparable to those found in community-dwelling older adults, others were unique to the long-term care setting. Residents were most likely to reminisce alone and they found the experience enjoyable. They reported engaging in and enjoying reminiscence with family more than with fellow residents, and a subset desired increased opportunities to share memories with healthcare providers. Residents with lower morale and more depressive symptoms were more likely to engage in unhealthy styles of reminiscence. These findings suggest that interventions shaping reminiscence encounters may have positive outcomes for long-term care residents.

Validity and reliability of the geriatric sexuality inventory.

Effective health care for older adults requires that providers assess and manage sexual health needs with high priority. This assessment begins with an effective sexuality assessment tool. A two-step, research approach was undertaken to develop and test the Geriatric Sexuality Inventory (GSI). Literature and expert review resulted in a 34-item instrument that was initially completed by 34 older adults ages 60 to 91 (mean age = 75). The testing was repeated in 19 of the original participants. The sample was 75% women, and 88% Caucasian with 9% single, 27% married, 18% divorced, and 46% widowed participants. Internal consistency reliability was run on all 53 responses and revealed adequate reliability (alpha = 0.74). Test-retest analysis also revealed good initial instrument reliability (r = 0.78; p < 0.001). Responses to open-ended questions regarding sexual information and care needs supported evidence gathered from the literature. Initial testing of the GSI revealed content validity and good internal consistency and test-retest reliability.

Pressure ulcers among terminally ill nursing home residents.

The purpose of this prospective, anthropological study was to describe and analyze the experiences and care of terminally ill nursing home residents who were admitted with or acquired pressure ulcers (PUs) after admission. Data were collected in two proprietary nursing homes. Participant observation, in-depth interviews, event analysis, and chart review were used to obtain data. A total of 64 (54.7%) of the 117 terminally ill residents in the study had PUs; 52 (81.3%) of whom died with PUs. The findings disclosed that the absence of family advocacy, inability to speak English, and inadequate staffing and lack of supervision, along with other previously reported risk factors, contributed to the development of PUs. Specifically, inadequate staffing and lack of supervision led to inadequate assistance at mealtime, infrequent repositioning, and inadequate continence care, which in turn led to weight loss, unrelieved pressure on bony prominences, and moist, irritated skin. The outcome was a high rate of residents dying with PUs. Knowledge of and attention to these risk factors can guide nurses in the prevention and management of PUs.

Hospice care in nursing homes: does it contribute to higher quality pain management?

PURPOSE: The purpose of this study was to investigate pain management among 42 hospice and 65 non-hospice residents in two proprietary nursing homes. DESIGN AND METHODS: In this prospective, anthropological, quantitative, and qualitative study, we used participant observation, event analysis, and chart review to obtain data. The Medication Quantification Scale was used in order to account for the prescription and administration of all analgesic medications. RESULTS: Although 72% of residents experienced pain, we found no statistically significant differences in the proportion of hospice versus non-hospice residents (a) who had been prescribed opioids and co-analgesics, and (b) whose medication was administered around the clock or as needed. Limited physician availability, lack of pharmacologic knowledge, and limitations of nursing staff hindered pain management of both groups of residents. IMPLICATIONS: Although hospice care is of some benefit, pain management and high-quality end-of-life care is dependent upon the context in which it is provided. Given that between 1991 and 2001 Medicare expenditures for nursing home-based hospice care increased from dollar 8.6 million to dollar 21.8 million, the effectiveness of hospice-care programs in nursing homes warrants further study.

Length of hospice enrollment and subsequent depression in family caregivers: 13-month follow-up study.

OBJECTIVE: Although more people are using hospice than ever before, the average length of hospice enrollment is decreasing. Little is known about the effect of hospice length of enrollment on surviving family caregivers. The authors examine the association between patient length of hospice enrollment and major depressive disorder (MDD) among the surviving primary family caregivers 13 months after the patient's death. METHODS: The authors conducted a three-year longitudinal study of 175 primary family caregivers of patients with terminal cancer who consecutively enrolled in the participating hospice from October 1999 through September 2001. Interviews were conducted with the primary family caregiver when the patient first enrolled with hospice and again 13 months after the patient's death. The authors used multivariate logistic regression models to estimate caregivers' adjusted risk at 13 months postloss for MDD, assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). RESULTS: The effect of very short hospice length of enrollment (three days or less) compared with longer lengths of enrollment on caregiver MDD 13 months after their loss was nonsignificant in unadjusted analyses. The adjusted risk of MDD was significantly elevated for caregivers of patients who had very short hospice enrollments (adjusted odds ratio: 8.76, 95%confidence interval: 1.09-70.19) only after adjusting for baseline MDD, caregiver gender, caregiver age, kinship relationship to patient, caregiver education, caregiver chronic conditions, and caregiver burden. The adjustment for caregiver burden resulted in the greatest increase in odds ratio for very short hospice length of enrollment on risk of caregiver MDD 13 months after the loss. CONCLUSIONS: This study identifies a potential target group of family caregivers, characterized by hospice length of enrollment and several caregiver features, who might be most in need of mental health interventions.

A model long-term care hospice unit: care, community, and compassion.

The purpose of this study was to investigate the factors that influenced the quality of care of terminally ill nursing home residents on a hospice unit in a city and county long-term care facility. The findings disclosed that the hospice team had created a cultural environment in which care, community, and compassion were the predominant components of their philosophy of palliative care. Communication at all levels-among staff, family, friends, and residents-was found to be a core hospice value, essential to community development. The results of this study illustrate that exemplary palliative care can be provided when an interdisciplinary team is dedicated to creating an environment where the principles of palliative care can be fully implemented. The authors conclude that there is a developing role for geriatric nurses to participate in further defining and providing palliative care for older people in their homes, hospitals, nursing homes, and residential care.

Symptom experience of adult hospitalized medical-surgical patients.

The purpose of this study is to describe the symptom experience of adult patients hospitalized in medical/surgical units, to examine the relationship between demographic characteristics and symptom experience, and to explore the relationship between symptom severity and symptom distress. Utilizing the Memorial Symptom Assessment Scale (MSAS), patients (n=334) were asked to convey the presence or absence of each of 31 symptoms, the severity of the symptoms, and the degree to which the symptoms distressed or bothered them. Higher levels of symptom distress were found in women and in those who were unpartnered. The average number of symptoms reported per patient was 9.31 (SD=5.15), with a mean symptom distress rating of 1.8 (SD=0.84) and a mean symptom severity rating of 1.65 (SD=0.83) on a 1-5 scale. The correlation between reports of symptom severity and symptom distress varied greatly by symptom, ranging from r=0.37 to r=0.82. This is the first study to examine the symptom prevalence, severity, and distress of hospitalized medical/surgical patients. The large sample size allowed for the detection of demographic differences in the reporting of symptom distress, and advances the current knowledge in the area.

Factors that influence end-of-life care in nursing homes: the physical environment, inadequate staffing, and lack of supervision.

PURPOSE: This study investigated the physical environment and organizational factors that influenced the process of providing care to terminally ill nursing home residents. DESIGN AND METHODS: Participant observation, interviews, and event analysis were used to obtain data in two proprietary facilities. RESULTS: The physical environment was not conducive to end-of-life care. The rooms were crowded, there was little privacy, and the facilities were noisy. Inadequate staffing and lack of supervision were among the most significant organizational factors that influenced care. Often, residents did not receive basic care, such as bathing, oral hygiene, adequate food and fluids, and repositioning. A consequence of inadequate staffing was the development of pressure ulcers; 54% of the residents had pressure ulcers; 82% of these residents died with pressure ulcers. IMPLICATIONS: Findings suggest that the nursing home environment in these two facilities, as now structured, is an inappropriate setting for end-of-life care.