The minimum data set depression quality indicator: does it reflect differences in care processes?

PURPOSE: The objective of this work was to determine if nursing homes that score differently on prevalence of depression, according to the Minimum Data Set (MDS) quality indicator, also provide different processes of care related to depression. DESIGN AND METHODS: A cross-sectional study with 396 long-term residents in 14 skilled nursing facilities was conducted: 10 homes in the lower (25th percentile: low prevalence 0-2%) quartile and 4 homes in the upper (75th percentile: high prevalence 12-14%) quartile on the MDS depression quality indicator. Ten care processes related to depression were defined and operationalized into clinical indicators. Measurement of nursing home staff implementation of each care process and the assessment of depressive symptoms were conducted by trained research staff during 3 consecutive 12-hr days (7 a.m. to 7 p.m.), which included resident interviews (Geriatric Depression Scale), direct observations, and medical record review using standardized protocols. RESULTS: The prevalence of depressive symptoms according to independent assessments was significantly higher than prevalence based on the MDS quality indicator and comparable between homes reporting low versus high rates of depression (46% and 41%, respectively). Documentation of depressive symptoms was significantly more common in homes reporting a high prevalence rate; however, documentation of symptoms on the MDS did not result in better treatment or management of depression according to any care-process measure. Psychosocial prevention and intervention efforts, such as resident participation in organized social group activities, were not widely used within either group of homes. IMPLICATIONS: The MDS depression quality indicator underestimates the prevalence of depressive symptoms in all homes but, in particular, among those reporting low or nonexistent rates. The indicator may be more reflective of measurement processes related to detection of symptoms than of prevention, intervention, or management of depression outcomes. A depression quality indicator should not be eliminated from MDS reports because of the importance and prevalence of the condition. However, efforts to improve nursing home staff detection of depressive symptoms should be initiated prior to the use of any MDS-based depression indicator for improvement purposes. Homes that report a low prevalence of depression according to the nationally publicized MDS quality indicator should not be regarded as providing better care.

A randomized trial of a combined physical activity and environmental intervention in nursing home residents: do sleep and agitation improve?

OBJECTIVES: The purpose of this study was to test whether an intervention combining increased daytime physical activity with improvement in the nighttime environment improves sleep and decreases agitation in nursing home residents. DESIGN: A randomized trial. SETTING: One community nursing home in the Los Angeles, California area. PARTICIPANTS: Twenty-nine incontinent residents (mean age 88.3 years, 90% female). INTERVENTION: Subjects were randomized to receive either (1) an intervention combining increased daytime physical activity (14 weeks in duration) plus a nighttime program (5 nights in duration) to decrease noise and sleep-disruptive nursing care practices (intervention group), or (2) the nighttime program alone (control group). MEASUREMENTS: Daytime physical activity monitors and structured physical function assessments; nighttime wrist activity monitors to estimate nighttime sleep; and timed daytime behavioral observations of sleep versus wakefulness, either in or out of bed, and agitation. RESULTS: Physical function measures did not change significantly (MANOVA for repeated measures, group by time effect). Wrist actigraphy estimation of nighttime percent sleep (time asleep over time monitored in bed at night) increased in intervention subjects from 51.7% at baseline to 62.5% at follow-up compared with 67.0% at baseline to 66.3% at follow-up in controls (MANOVA, group by time, F = 4.42, P = .045, df = 27). At follow-up, intervention subjects averaged a 32% decrease in the percent of daytime observations in bed compared with baseline, with essentially no change in controls (MANOVA, group by time, F = 5.31, P = .029, df = 27). Seven of 15 intervention subjects had a decrease in observed agitation at follow-up, compared with baseline, versus only 1 of 14 controls with a decrease in observed agitation. CONCLUSIONS: This study provides preliminary evidence that an intervention combining increased physical activity with improvement in the nighttime nursing home environment improves sleep and decreases agitation in nursing home residents.

The nursing home at night: effects of an intervention on noise, light, and sleep.

OBJECTIVES: The sleep of nursing home residents is fragmented by frequent awakening episodes associated, at least in part, with environmental variables, including noise and light changes. The purpose of this study was to improve sleep by reducing the frequency of nighttime noise and light changes. PARTICIPANTS AND SETTING: Two hundred sixty-seven incontinent nursing home residents in eight nursing homes. DESIGN: A randomized control group design with a delayed intervention for the control group. MEASUREMENTS: Bedside noise and light monitors recorded the number of 2-minute intervals at night with peak sounds recorded above 50 dBs and the number of light changes of at least 10 lux between adjacent 2-minute intervals. Daytime behavioral observations measured sleep and in-bed time during the day, and wrist activity was used to estimate sleep at night. Awakening events associated with the environmental variables were derived from the wrist activity data. INTERVENTION: A behavioral intervention implemented between 7:00 p.m. and 6:00 a.m. that involved feedback to nursing home staff about noise levels and implementation by research staff of procedures to both abate noise (e.g., turn off unwatched television sets) and to individualize nighttime incontinence care routines to be less disruptive to sleep. RESULTS: Noise was reduced significantly, from an average of 83 intervals per night with peak noises recorded above 50 dBs to an average of 58 intervals per night in the group that received the initial intervention, whereas noise in the control group showed no change (MANOVA group x time P < .001). All 10-dB categories of noise from 50 to 90+ dBs were reduced, and light changes were reduced from an average of four per night per resident to two per night (P < .001). Despite these significant changes in the environmental variables, there was a significant differential improvement in the intervention group on only two night sleep measures: awakening associated with a combination of noise plus light (P < .001) and awakening associated with light (P < .001). However, there was a significant correlation between change in noise and change in percent sleep from baseline to intervention (r = -.29, P < .05), suggesting that the intervention did not reduce noise to low enough levels to produce a significant improvement in sleep. The intervention effects on all environmental variables were replicated in the delayed intervention group, who again showed significant improvement on the same sleep measures. Observations of day sleep and in-bed time did not change over the phases of the trial for either group. CONCLUSION: The significant reductions in noise and light events resulting from the intervention did not lead to significant improvements in the day sleep and most night sleep measures. An intervention that combines both behavioral and environmental strategies and that addresses daytime behavioral factors associated with poor sleep (e.g., excessive time in bed) would potentially be more effective in improving the night sleep and quality of life of nursing home residents.

Sleep hygiene in physically dependent nursing home residents: behavioral and environmental intervention implications.

The purpose of this report is to summarize data from a sample of 230 residents in eight nursing homes (NHs) that are relevant to the development of environmental and behavioral interventions for sleep. Four conclusions can be drawn: (1) there is strong evidence that the nighttime sleep of these residents was adversely affected by environmental noise and light; (2) residents appear to spend substantial time in bed and sleeping during the day; (3) there are significant differences between some homes in the amount of time that residents spend in bed and sleeping during the day, as well as the frequency of nighttime awakenings associated with environmental events; and (4) residents' preference and nighttime noise source data suggest that a multifaceted intervention to improve sleep hygiene could successfully implemented in the NH setting. An intervention addressing these issues may result in improved sleep and overall well-being for a substantial portion of the NH population.

Individualizing nighttime incontinence care in nursing home residents.

BACKGROUND: Urinary incontinence is a common problem among nursing home (NH) residents and can be successfully treated with prompted voiding during daytime hours. A previous study of incontinent NH residents demonstrated that noise from the staff and other residents and light and noise from staff-initiated incontinence care routines were associated with waking episodes. Nighttime incontinence care should be individualized to minimize sleep disruption while considering moisture exposure that could affect skin health. Although descriptive studies have been published, there are no published intervention studies describing attempts to improve nighttime environmental factors in NHs. OBJECTIVE: To individualize nighttime incontinence care while minimizing sleep disruption among NH residents. METHOD: Subjects were assigned to a 2- or 4-hour incontinence care schedule based on each resident's risk of skin problems using objective data of spontaneous body movements at night and skin health during baseline, and the research staff provided incontinence care if residents were found awake. RESULTS: Awakenings due to light and sound associated with incontinence care were significantly reduced during the intervention phases (p < .001), and there were no adverse changes in skin health or on most risk factors associated with skin (e.g., exposure to moisture, body turns). CONCLUSIONS: Incorporating this intervention component into more comprehensive efforts to improve sleep and evaluating the long-term effects of the intervention on skin health are recommended.

Nighttime urinary incontinence and sleep disruption among nursing home residents.

OBJECTIVE: To examine the relationship of urinary incontinence episodes to sleep disruption in a sample of nursing home residents. DESIGN: Descriptive, case series. SETTING: Three community nursing homes. PARTICIPANTS: Seventy-three incontinent residents of three nursing homes participating in a trial of a behavioral intervention for nighttime urinary incontinence. MEASUREMENTS: Data were collected during a baseline and repeat baseline period about 2 months later in nursing homes serving as controls for the intervention homes. Incontinence episodes were identified by incontinence pads, which were wired to detect wetness of 10 mL or more. Sleep was monitored by wireless wrist actigraphs. Noise and light changes were monitored by bedside recording devices. MAIN RESULTS: Recordings covered 403 nights, during which 1715 awakenings from 10 consecutive minutes of sleep were detected as were 1168 incontinent episodes. Only 4% of the awakenings were associated with an incontinence episode, and only 23% of the incontinence episodes occurred during periods of at least 10 consecutive minutes of sleep. Of the latter episodes, only 12% appeared to awaken the resident. CONCLUSIONS: Our data raise questions about the relevance of incontinence episodes to sleep disruption among chronically incontinent nursing home residents. Our findings must be interpreted cautiously because of limitations in the technologies and definitions we used to identify sleep, awakenings, and incontinence episodes. Although logistically and technically difficult to perform, studies using polysomnographic recordings of sleep are needed to examine further these important associations.

Skin disorders and moisture in incontinent nursing home residents: intervention implications.

OBJECTIVE: To provide data needed to design an intervention trial to prevent or treat skin disorders in a high risk, incontinent nursing home population. DESIGN: The incidence and prevalence of nine common skin disorders were measured prospectively over a 60-day period using trained observers. Urinary and fecal incontinence frequency were measured over 24 hours, and mobility was measured with subjects both in and out of bed. Direct measures of skin moisture were taken with an impedance device in the presence and absence of urinary incontinence. Multiple regression analyses were used to relate the incontinence and mobility variables to the presence and development of skin disorders. SETTING: Four nursing homes. PARTICIPANTS: One hundred incontinent nursing home residents. MAIN OUTCOME MEASURES: Prospective measures of nine common skin disorders and skin moisture in four perineal regions under continent and incontinent conditions. RESULTS: All subjects had at least one skin condition identified during the 60-day data collection period. The most commonly observed skin condition was blanchable erythema, which occurred in 94% of the subjects, predominantly in the front and back regions that were closest to the urethra and rectum. Twenty-one percent of residents developed either a Stage 1 (nonblanchable erythema) or 2 pressure ulcer. All skin conditions were transient when measured every 3 weeks with the exception of blanchable erythema, which showed stability. Stage 3 or greater pressure ulcers and edema were not observed, and interrater reliability for the measure of papules was poor. Measures of urinary and fecal incontinence severity were correlated with blanchable erythema severity, and blanchable erythema and low bed mobility were predictive of pressure ulcer severity. Blanchable erythema severity was also predictive of Stage 1 and 2 pressure ulcers. Skin moisture levels in the back perineal farthest from the rectum (peripheral) were affected most by urinary incontinence. CONCLUSION: A trial to detect a 50% preventive effect on Stage 1 and 2 pressure ulcers would require that 167 subjects be monitored for 60 days. The transient nature of the skin effects require that skin be monitored at least once a week. Because blanchable erythema is so prevalent and appears to be associated with more severe skin conditions, it would make an excellent marker for beginning to assess the potential preventive effects of various interventions on the incidence of pressure ulcers and other related skin disorders in incontinent patients. It is likely that the back area peripheral to the urethra and rectum would experience the greatest benefit from an intervention trial to reduce moisture caused by incontinence.

Does physical activity improve sleep in impaired nursing home residents?

OBJECTIVES: To determine if two physical activity programs of varying intensity would result in improved sleep among incontinent and physically restrained nursing home residents. DESIGN: Controlled trials of two physical activity programs. SETTING: Seven community nursing homes in the Los Angeles area. PARTICIPANTS: Residents were included if they had urinary incontinence or were physically restrained. Sixty-five subjects were studied. Mean age was 84.8 years, 85% were female, mean length of residency in the nursing home was 19.9 months, and mean Mean Mini-Mental State Exam score was 13.1. INTERVENTION: The first physical activity program involved sit-to-stand repetitions and/or transferring and walking or wheelchair propulsion. These activities were performed every 2 hours during the daytime, 5 days per week for 9 weeks. The second, less frequent physical activity program involved rowing in a wheelchair-accessible rowing machine plus walking or wheelchair propulsion once per day three times per week for 9 weeks. MEASUREMENTS: The physical function measures reported here include mobility endurance (maximum time walking or wheeling) and physical activity as measured by motion sensors (Caltrac). Nighttime sleep was estimated by wrist activity monitors. Nighttime sleep measures included total time asleep, percent sleep, average duration of sleep, and peak duration of sleep. Daytime sleep was measured by timed behavioral observations of sleep versus wakefulness performed every 15 minutes during the day. RESULTS: Nighttime sleep was markedly disrupted in both groups at baseline. Across all subjects at baseline, the average total sleep time was 6.2 hours and the percent sleep was 72.0%, but the average duration of sleep episodes was only 21.2 minutes and the peak duration of sleep episode averaged only 83.8 minutes. During the daytime, subjects were observed asleep during 14.5% of observations. Although there was improvement in mobility endurance in the intervention subjects compared with controls (MANOVA F = 4.36, P = .042), there were no differences in the night and day sleep measures at follow-up testing. Even among a subgroup of intervention subjects who showed a 30% or greater improvement in mobility endurance, sleep did not improve at follow-up compared with baseline. CONCLUSION: This study supports our previous findings of marked sleep disruption in impaired nursing home residents. In addition, despite documented improvements in physical function with activity, we did not find improvements in sleep in the intervention versus control groups. These results suggest that increasing daytime physical activity alone is not adequate to improve sleep in impaired NH residents. Future efforts to improve sleep in this population should take into account the multifactorial nature of sleep disruption, including individual health problems that effect sleep and the disruptive nature of the nighttime NH environment.