Effect of home-based light treatment on persons with dementia and their caregivers.

Sleep disorders are problematic for persons with dementia and their family caregivers. This randomized controlled trial with crossover evaluated the effects of an innovative blue-white light therapy on 17 pairs of home-dwelling persons with dementia and their caregivers. Subjects with dementia received blue-white light and control ('red-yellow' light) for six weeks separated by a four-week washout. Neither actigraphic nor most self-reported sleep measures significantly differed for subjects with dementia. For caregivers, both sleep and role strain improved. No evidence of retinal light toxicity was observed. Six weeks of modest doses of blue-white light appear to improve sleep in caregivers but not in persons with dementia. Greater or prolonged circadian stimulation may be needed to determine if light is an effective treatment for persons with dementia.

Dizziness: state of the science.

Dizziness is prevalent in all adult populations, causing considerable morbidity and utilization of health services. In the community, the prevalence of dizziness ranges from 1.8% in young adults to more than 30% in the elderly. In the primary care setting, dizziness increases in frequency as a presenting complaint; as many as 7% of elderly patients present with this symptom. Classification of dizziness by subtype (vertigo, presyncope, disequilibrium, and other) assists in the differential diagnosis. Various disease entities may cause dizziness, and the reported frequency of specific diagnoses varies widely, depending on setting, patient age, and investigator bias. Life-threatening illnesses are rare in patients with dizziness, but many have serious functional impairment. Dizziness can be difficult to diagnose, particularly in elderly persons, in whom it often represents dysfunction in more than one body system. Given the relatively underdeveloped state of the empirical literature on dizziness, investigators would benefit from use of consistent criteria to describe dizziness symptoms and establish diagnoses. Investigation of the effects of testing and treatment should focus on diagnoses that are life threatening or lead to significant morbidity. In the elderly, a function-oriented approach should be studied and compared with current diagnosis-focused strategies. Alternative therapies for chronic and recurrent dizziness also merit investigation.

Low bone mineral density and risk of fracture in white female nursing home residents.

CONTEXT: Low bone mineral density (BMD) is a strong risk factor for fracture in community-dwelling white women, but the relationship in white female nursing home residents, for whom fracture rates are highest, is less clear. OBJECTIVE: To assess the relative contribution of low BMD to fracture risk in nursing home residents. DESIGN: Prospective cohort study with baseline data collected April 1995 to June 1997, with 18 months of follow-up. SETTING: Forty-seven randomly selected nursing homes in Maryland. PATIENTS: A total of 1427 white female nursing home residents aged 65 years or older. MAIN OUTCOME MEASURE: Documented osteoporotic fracture occurring during follow-up as a function of baseline BMD measurements higher vs lower than the median, and after controlling for demographic, functional, cognitive, psychosocial, and medical factors. RESULTS: A total of 223 osteoporotic fractures occurred among 180 women. Low BMD and transfer independence were significant independent risk factors for fracture in this nursing home sample (P<.001) and the 2 factors acted synergistically (P =.06) to further increase fracture risk. Compared with women whose BMD was higher than the median (0. 296 g/cm(2)), those whose BMD was lower than the median had an unadjusted hazard ratio for risk of fracture of 2.1 (95% confidence interval [CI], 1.5-2.8); women who were independent in transfer had a hazard ratio of 1.6 (95% CI, 1.2-2.2) compared with women dependent in transfer. Among residents independent in transfer, those with BMD below the median had a more than 3-fold increase in fracture risk compared with those with higher BMD (unadjusted hazard ratio, 3.1; 95% CI, 2.2-4.4). Among residents dependent in transfer, those with BMD below the median had a 60% increase in fracture risk (unadjusted hazard ratio, 1.6; 95% CI, 1.1-2.3). Adjustment for covariates did not alter the BMD-fracture relationship. CONCLUSIONS: Our data indicate that low BMD and independence in transfer are significant predictors of osteoporotic fracture in white female nursing home residents. JAMA. 2000;284:972-977

Specialized dementia programs in residential care settings.

The authors conducted a telephone survey in 7 states to determine the prevalence of residential care specialized dementia programs (RC-SDPs) and to identify a sample of homes (n = 56) for more detailed study. The 56 homes were site visited, and data were gathered on facility administration, therapeutic environment, and characteristics of 259 randomly selected residents. Comparison data from 138 nursing home Special Care Units (NH-SCUs) and 1,340 of their residents were obtained from 4 studies conducted in the same 7 states. RC-SDPs were smaller, provided a more homelike environment, and had a higher proportion of residents paying privately, compared with NH-SCUs. Mean levels of cognitive and physical impairment among residents were higher in NH-SCUs; prevalences of psychotropic medication use and problem behaviors were similar. Among RC facilities, small homes were more homelike, provided fewer structured activities, and charged less than larger facilities. RC-SDPs include 5 types: small, independently operated homes; multiple small homes with joint administration; larger, all-dementia facilities; SDPs operated within larger, exclusively RC facilities; and RC-SDPs in multilevel facilities.

Use of physical restraints and psychotropic medications in Alzheimer special care units in nursing homes.

OBJECTIVES: This study analyzed the use of mechanical restraints and psychotropic medication in Alzheimer special care units (SCUs) in nursing homes. METHODS: We analyzed 1993 data for more than 71,000 nursing home residents in 4 states, including more than 1,100 residents in 48 SCUs. The dependent variable in multinomial logistic regression was use of physical restraints or psychotropic medication. Models contained covariates representing facility and resident characteristics, and multivariate matching strategies were used to protect against selection bias. RESULTS: Residents in SCUs did not differ from similar residents in traditional units in their likelihood of being physically restrained. Residents in SCUs were more likely to receive psychotropic medication. CONCLUSIONS: With regard to the measures used in this research, the findings indicate that residents in the SCUs in the 4 study states did not receive quality of care superior to that provided to similar residents in traditional units. In fact, the results related to drug use raise the question of whether some may have received poorer care.

The prevalence of osteoporosis in nursing home residents.

This study describes the prevalence of osteoporosis in a statewide sample of nursing home residents. Composite forearm bone mineral density (BMD) (including the distal radius and the distal ulna) of 1475 residents aged 65 years and older from 34 randomly selected, stratified nursing homes was assessed. BMD was expressed with reference to World Health Organization diagnostic criteria. Trends with age, gender and race were consistent with other populations. However, prevalence estimates were higher than community-based age-specific rates. The prevalence of osteoporosis for white female residents increased from 63.5% for women aged 65-74 years to 85.8% for women over 85 years of age. Only 3% had composite forearm BMD within 1 standard deviation of the young adult mean. The significance of the high prevalence of low BMD in nursing home residents is the increased fracture risk it may confer. In community cohorts of white women, the risk of hip fracture increases approximately 50% for every 1 standard deviation decrease in bone mass. However, the degree to which BMD contributes to fracture risk in this population has not been well established.

Severe disruptive vocalizers.

OBJECTIVES: To describe the most severe disruptive vocalizers in nursing facilities, in regard to their clinical and behavioral characteristics, staff responses, and treatments used, and to report on their prognosis over 6 months. DESIGN: A longitudinal cohort study. SETTING: One hundred seven skilled nursing facilities. PARTICIPANTS: The 203 residents who were among the two most disruptive vocalizers in their respective facilities and who vocalized at least 2 hours a day. MEASUREMENTS: Telephone interviews of licensed nursing staff who cared for the subjects, conducted at baseline, 2, 4, and 6 months. Data gathered included subject demographics, physical function, diagnoses, medication and restraint use, behavioral problems, vocalization characteristics, treatments used, and status at follow-up. RESULTS: Subjects tended to have dementia, to be dependent in most activities of daily living, to have multiple medical problems, to be physically restrained (48%), and to be taking psychotropic medication (76%). Nearly all (95%) were audible at least 50 feet away, with loudness associated with more severe cognitive impairment (OR 4.90, P = .001). When subjects who primarily made nonverbal noises ("screamers") were compared with those whose predominant expressions were words ("talkers"), hearing impairment, severe cognitive impairment, and greater dependency in activities of daily living characterized the screamers. Staff reported trying a variety of treatments with all subjects, often with little success. Two months after enrollment, 66% of surviving subjects vocalized fewer hours than at baseline, and 45% were rated as improved. Independent predictors of improvement included greater ADL independence, hearing and vision problems, shorter length of stay, urinary incontinence, and use of a treatment other than one-on-one interventions. Nearly one-quarter of subjects (23.4%) died within 6 months. Baseline factors associated independently with a higher probability of death included age, use of activity intervention, physical abusiveness, and absence of wandering. CONCLUSION: Severe disruptive vocalization is associated with severe cognitive and physical impairment and with a high probability of mortality within 6 months. Subcategorization of severe vocalizers by vocalization type or other associated factors may be useful for prognostic and treatment purposes.

Advances in the treatment of Alzheimer's disease.

Management of the most common type of dementia--Alzheimer's disease--is becoming increasingly sophisticated. Differentiation of Alzheimer's disease from vascular dementia has become therapeutically important, since the choice of treatments depends on the diagnosis. Two cholinesterase inhibitors, donepezil and tacrine, are labeled for use in patients with Alzheimer's disease. Other therapies, such as estrogen, nonsteroidal anti-inflammatory drugs and vitamin E, are sometimes used and show promise in delaying the progression of this dementia. Behavior problems, which often accompany the disease, can be managed using environmental modification, alterations in caregiving and medication. In the terminal phase of the illness, quality care involves implementing advance directives, communicating with the family, individualizing care and attending to patient comfort.

Environmental correlates of resident agitation in Alzheimer's disease special care units.

OBJECTIVE: To determine the point prevalence of agitated behaviors in a representative sample of Alzheimer's disease Special Care Units, and to determine the extent to which agitation is associated with aspects of the treatment environment. DESIGN: A cross-sectional study in which nonparticipant observers recorded 3723 observations of resident behaviors in 53 Alzheimer's disease Special Care Units. Observational data were gathered on the physical environment and staff treatment in these settings, and resident characteristics were extracted from a data base developed in the study states by the Health Care Financing Agency. Analyses studied the association between aspects of the staff and physical environment and resident agitation levels, controlling for resident cognitive and functional status. SETTING: Special Care Units in nursing homes in Kansas, Maine, Mississippi, and South Dakota. PARTICIPANTS: All residents and staff of the participating units. MAIN OUTCOME MEASURES: Eight specific agitated behaviors and two indexes of resident agitation were measured by direct observation by research assistants on three to four data collection walk-throughs in each of the study facilities. RESULTS: The most common agitated behaviors noted were repetitive mannerisms (4.5% of resident observations) and non-loud verbal excess (3.8%). Wandering, which frequently reflects agitation, was noted in 6.5% of resident observations. The proportion of residents exhibiting an agitated behavior varied from none in some units to 38% in one unit. Independent correlates of low unit agitation levels included favorable scores on measures of the physical environment and of staff treatment activities, low rates of physical restraint use, a high proportion of residents in bed during the day, small unit size, low levels of resident functional dependency, and fewer numbers of comorbid conditions. CONCLUSIONS: While the prevalence of agitation tends to increase as Alzheimer's disease progresses, modifiable treatment factors appear to have a strong influence on the prevalence of agitation. Both physical design and staff treatment appear to influence agitation rates, as do some measures consistent with a low stimulus approach to Alzheimer's care.

Effects of residence in Alzheimer disease special care units on functional outcomes.

CONTEXT: Alzheimer disease special care units (SCUs) in nursing homes are increasingly prevalent, but little is known about their effects on residents' outcomes. OBJECTIVE: To analyze the effect of SCU residence on the rates at which residents decline in functional status. DESIGN: A cohort of nursing home residents assessed at multiple points during about 1 year. Facility staff completed all assessments using the Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS). SETTING: Medicare- or Medicaid-certified nursing facilities. PATIENTS OR OTHER PARTICIPANTS: All nursing home residents in 1993 and early 1994 in Kansas, Maine, Mississippi, and South Dakota. Serial MDS assessments of 77337 residents in more than 800 facilities, including 1228 residents in 48 facilities with SCUs. MAIN OUTCOME MEASURES: Decline in locomotion, transferring, toileting, eating, dressing, and a summary activities of daily living index; decline in urinary and bowel continence; and significant weight loss. RESULTS: No statistically significant difference was observed in the speed of decline for residents in SCUs and traditional units in any of the 9 outcomes. Residents were matched on a variety of characteristics, and subgroup analyses were performed. In none did we observe a pattern of better outcomes among SCU residents. CONCLUSIONS: Although SCUs may have provided unmeasured benefits to families and residents, it does not appear that those benefits included any slowing in the rates of functional decline experienced by individuals with dementia.

Management of the patient with disruptive vocalization.

Disruptive vocalization (DV) is a common problem in the management of cognitively and physically impaired older people. This article reports the results of a consensus meeting convened to provide guidelines for clinicians and recommendations for researchers in this difficult and little-studied behavioral problem. DV arises largely in people with cognitive impairment and generally reflects an underlying need or discomfort. A variety of factors can precipitate and aggravate DV; the key to management is appropriate identification of all possible factors and development of an individualized treatment plan.

Evaluation and management of dizziness in the older patient.

The increased prevalence of dizziness with advancing age is the result of specific disease processes superimposed on normal aging physiology. The first step in evaluating dizziness in older persons is a careful clinical history, focusing on the type, temporal pattern, onset, associated symptoms, and the patient's overall physical health. Common dizziness problems in this age group are postural dizziness without postural hypotension, positional vertigo, cerebrovascular disease, a variety of acute and recurrent labyrinthine problems, neck problems, physical deconditioning, and medications. Often, multiple problems coexist, and secondary psychologic disability results. Treatment should aim at identifying and managing remediable problems.

Bathing persons with dementia.

In the care of persons with Alzheimer's disease and related disorders, bathing frequently poses a formidable challenge for caregivers. This article reports the results of a consensus conference on techniques to reduce disruptive behaviors during bathing, and to make the process less stressful for persons with dementia.

Nursing home survey deficiencies for physical restraint use.

New federal regulations, implemented in 1990, severely restrict the use of physical restraints in nursing homes nationwide. This study evaluated the impact of these regulations on North Carolina nursing homes during 1991. An average of 32.6% of facility residents were restrained during that year, and 29.2% of facilities were cited for violation of the restraint regulations. Annual health department surveys of a sample of 195 North Carolina nursing homes were analyzed. The facility proportion of restrained residents was modeled using estimated weighted least-squares regression. A probit model was used to predict if the facility received a deficiency for restraint use. Facility-level factors associated with overall restraint use were the ratio of licensed vocational nurse/nursing assistant staff to residents in the facility, and the overall facility disability level. Factors associated with the receipt of a restraint violation were facility size, direct costs per patient day, the proportion of restrained patients, use of bladder training in less than 3% of residents, and the proportion of residents with organic brain syndrome; variables that were of borderline significance included proprietary affiliation, the proportion of intubated residents, the facility disability level, and the proportion of residents on psychotropic medication. These findings indicate that, despite implementation of these regulations, nearly one third of North Carolina nursing home residents remained physically restrained. The characteristics associated with restraint use and with restraints violations can be used to identify facilities most likely to benefit from assistance and education in reducing physical restraints.

Validation of the Minimum Data Set Cognitive Performance Scale: agreement with the Mini-Mental State Examination.

BACKGROUND: Almost all nursing homes in the United States are required by the 1987 Omnibus Budget Reconciliation Act to assess each resident's functional, medical, psychosocial, and cognitive status using a standard instrument known as the Minimum Data Set (MDS). We report a validation study to show that the MDS Cognitive Performance Scale (CPS), a cognitive measure generated from 5 MDS items (comatose status, decision making, short-term memory, making self understood, and eating) can be used to detect cognitive impairment as defined by the Mini-Mental State Examination (MMSE). METHODS: Two hundred subjects were randomly recruited from 8 nursing home facilities in North Carolina. Two medical students administered the MMSE, while a geriatric research nurse was responsible for collecting MDS cognitive items, which included the 5 items required for generating CPS scores. Cognitive impairment was defined by MMSE scores adjusted for education. Agreement between the CPS and the MMSE in identifying cognitively impaired subjects was then evaluated. RESULTS: The CPS showed substantial agreement with the MMSE in the identification of cognitive impairment; the sensitivity was .94 (95% confidence interval [CI]: .90, .98), the specificity was .94 (95% CI: .87, .96), and the diagnostic accuracy as measured by the area under the receiver operating characteristics (ROC) curve was .96 (95% CI: .88, 1.0). CONCLUSIONS: The MDS Cognitive Performance Scale, when performed by a trained research nurse using recommended protocols, provides a valid measure of cognitive status in nursing home residents.

Predictors of fear of falling in dizzy and nondizzy elderly.

Fear of falling may constitute an independent risk factor for disability, leading older people to unnecessarily restrict their activity. Sixty older adults with chronic dizziness and 66 healthy controls were studied to help clarify the interrelationships among demographic factors, psychological status, physical health, and fear of falling. Chronic dizziness was strongly associated with fear of falling; among dizzy patients, nearly half (47%) expressed fear of falling, in comparison with 3% of controls. In participants with dizziness, 3 factors predicted fear of falling: an activity of daily living score, the revised Symptom Checklist 90 Depression (Derogatis, 1983) score, and stability when standing with feet together. These results support the concept that fear of falling is multiply determined and that psychological factors play a major role in influencing the symptoms and responses in many older patients with dizziness.

Evaluating Alzheimer's special care units: reviewing the evidence and identifying potential sources of study bias.

Special Care Units (SCUs) for Alzheimer's disease have been proliferating in long-term care, but their effectiveness remains unproven. This review summarizes the published studies, presents and discusses the many potential sources of bias that pose special problems for SCU research, and proposes strategies for conducting and interpreting future outcome studies in this difficult research setting.