Predictors of functional ability in geriatric rehabilitation patients

Function-Focused Goal Attainment and Discharge Outcomes in Hospitalized Persons With Dementia

Hospitalized persons with dementia are at higher risk for functional decline and cognitive loss related to delirium. Family-centered, function-focused care (Fam-FFC) engages the family care partner in education and active participation in function-focused goal setting, implementation, and evaluation to support delirium prevention and abatement and return to baseline physical function. The purpose of the current study was to examine the association of function-focused goal attainment with two discharge outcomes, return to baseline physical function and delirium severity at discharge, in hospitalized persons with dementia. In the ongoing Fam-FFC clinical trial, the majority of goals (N = 433) developed by 134 care partner/patient dyads and nurses address mobility, cognitive stimulation, and self-care. Regression techniques demonstrated that goal attainment was significantly associated with return to baseline function (B = 0.826, Wald = 4.17 [1], p = 0.041) and lower delirium severity at discharge (B = 0.175, t = 2.239, p = 0.027). Results support the contribution of family engagement in promoting functional recovery of hospitalized persons with dementia. [Journal of Gerontological Nursing, 47(9), 13-20.].

Racial differences in physical activity in nursing home residents with cognitive impairment

BACKGROUND

Nursing home (NH) residents with moderate-to-severe cognitive impairment experience mostly sedentary lifestyles.

AIM

Previous research has examined racial differences in physical activity (PA) levels in community-dwelling older adults but not in NH residents with cognitive impairment, and the current study aimed to examine these differences.

METHODS

This was a secondary data analysis of baseline data from the Function and Behavior Focused Care Intervention (FBFC) study. The sample included 247 cognitively impaired residents from 12 NHs who wore an ActiGraph to measure PA.

RESULTS

The residents' mean age was 82.6 (SD = 10.1) and had an average MMSE score of 7.8 (SD = 5.0). The sample (N = 247) was 41% African American and 59% White. African American and White residents engaged in only 50.6 and 46.2 min of light- and 1.5 and 1.1 min of moderate-level PA, respectively. Based on a multivariate analysis of covariance (MANCOVA), there was not a statistically significant difference between African American and White residents on combined dependent PA measures [F (8, 237) = 1.067, p = .387, Wilks' Λ = 0.962]. There was a trend that direct care providers subjectively reported that White residents engaged in more PA than their African American counterparts [F(8, 237) = 2.741, p = .09].

CONCLUSIONS

These findings are not consistent with prior research. However, these findings indicate severely low levels of PA in NH residents, regardless of racial group. Future research should prioritize PA interventions that make accommodations for all NH residents, and especially consider their underlying physical comorbidities and cognitive function.

Physical Activity in Hospitalized Persons With Dementia: Feasibility and Validity of the MotionWatch 8

Persons with dementia are at high risk for hospital-acquired disability, associated with low physical activity during hospitalizations. To determine the effectiveness of efforts to increase physical activity, a valid and reliable measurement approach is required. Data from an ongoing cluster randomized clinical trial examined the feasibility and validity of the MotionWatch 8 (MW8) triaxial actigraphy device. The sample included 321 participants of which 259 (81%) were willing to wear the MW8 for 24 hr. Regression analysis revealed that time in low activity, β = 0.17, t(255) = 2.9, p = .004, and time in moderate activity, β = 0.14, t(255) = 2.4, p = .017, measured by the MW8, were associated with participants' physical function. Engagement in moderate physical activity was associated with return to baseline function at discharge (Wald χ2 = 4.10, df = 1, p = .043). The study provides preliminary support for the feasibility and validity of the MW8 in hospitalized persons with dementia.

Pain Incidence, Treatment, and Associated Symptoms in Hospitalized Persons with Dementia

BACKGROUND

Moderate to severe pain has been frequently reported in hospitalized older adults. Pain in hospitalized persons with dementia within the context of other common symptoms, functional decline, delirium, and behavioral and psychological symptoms of dementia (BPSD), has received little attention.

AIMS

Describe the incidence of pain, the pharmacologic management of pain, and the association of pain with physical function, delirium, and BPSD in hospitalized persons with dementia.

DESIGN

Descriptive, cross-sectional study.

SETTING

Six medical units in three hospitals.

PARTICIPANTS

Baseline data from 299 hospitalized persons with dementia enrolled in the Family-centered Function-focused Care (Fam-FFC) cluster randomized trial.

METHODS

Descriptive analyses of pain used the Pain Assessment in Advanced Dementia (PAINAD) scale and the use of medication for pain management. Linear regression analyses tested relationships between pain and:1) physical function (Barthel Index), 2) delirium severity (Confusion Assessment Method Severity Short Form) and 3) BPSD severity (Neuropsychiatric Inventory- Questionnaire).

RESULTS

The majority of the sample was female (61.9%), non-Hispanic (98%), and Black (53.2%), with a mean age of 81.58 (SD=8.54).Of the 299 patients, 166 (56%) received pain medication. Of the 108 individuals who demonstrated pain, 40% (n=43) did not receive pain medication. When controlling for age, gender, cognition, and comorbidities, pain was significantly associated with function, delirium severity, and BPSD severity.

CONCLUSIONS

Results suggest that pain may be undertreated in hospitalized persons with dementia, and should be considered upon admission to optimize function, decrease delirium, and prevent or decrease BPSD.

A Cluster Randomized Controlled Trial Testing the Impact of Function and Behavior Focused Care for Nursing Home Residents With Dementia

OBJECTIVE

The purpose of this study was to test the effectiveness of the Function and Behavior Focused Care for the Cognitively Impaired (FBFC-CI) intervention on function, physical activity, and behavioral symptoms among nursing home residents with dementia, and to explore the adoption of the intervention at the facility level.

DESIGN

This study was a clustered, randomized controlled trial with a repeated measures design that was implemented in 12 nursing homes randomized to either treatment (FBFC-CI) or educational control [Function and Behavior Focused Care Education (FBFC-ED)].

SETTING AND PARTICIPANTS

Twelve nursing homes (6 treatment and 6 control) and 336 residents (173 treatment and 163 control) with moderate to severe cognitive impairment.

MEASURES

Outcomes included functional ability (Barthel Index), physical activity (actigraphy and survey), behavioral symptoms (Resistiveness to Care Scale, Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia), and psychotropic medication use.

RESULTS

The participants were 82.6 (SD = 10.1) years of age, mostly female, and were moderate to severely cognitively impaired (Mini-Mental State Exam of 7.8, SD = 5.1). There was a significantly greater increase in time spent in total activity (P = .004), moderate activity (P = .012), light activity (P = .002), and a decrease in resistiveness to care (P = .004) in the treatment versus control group at 4 months. There was no change in mood, agitation, and the use of psychotropic medications. There was some evidence of adoption of the intervention at treatment sites.

CONCLUSIONS AND IMPLICATIONS

This study provides some support for the use of the FBFC-CI Intervention to increase time spent in physical activity and decrease resistive behaviors during care commonly noted among nursing home residents with moderate to severe cognitive impairment.

Disparities in Physical and Psychological Symptoms in Hospitalized African American and White Persons with Dementia

Objectives: This study examined differences in physical function, delirium, depressive symptoms, and behavioral and psychological symptoms of dementia (BPSD) in hospitalized African American and white older adults with dementia. Methods: This secondary data analysis using baseline data from an ongoing trial testing family-centered function-focused care included African American (n = 159) and white persons (n =135) with dementia. Results: A multivariate analysis of covariance showed that controlling for relevant demographic and health characteristics, African Americans with dementia had lower physical function, more delirium, and more depressive symptoms upon admission than white participants. There were no significant differences in BPSD between African American and white persons. Discussion: To our knowledge, this is the first study to examine racial differences in admission symptoms of hospitalized persons with dementia. While the findings are preliminary, they can be used to inform the design of future research, including identifying the causes of disparities.

Reducing disability via a family centered intervention for acutely ill persons with Alzheimer's disease and related dementias: protocol of a cluster-randomized controlled trial (Fam-FFC study)

Background

Hospitalized older persons with Alzheimer’s disease and related dementias are at greater risk for functional decline and increased care dependency after discharge due to a combination of intrinsic factors, environmental, policy, and care practices that restrict physical and cognitive activity, lack of family involvement and limited staff knowledge of dementia care. We have developed a theory-based intervention, Family centered Function-focused Care, that incorporates an educational empowerment model for family caregivers (FCGs) provided within a social-ecological framework to promote specialized care to patients with dementia during hospitalization and the 60-day post-acute period. Primary aims are to test the efficacy of the intervention in improving physical and cognitive recovery in hospitalized persons living with Alzheimer’s disease and related dementias (ADRD) and improving FCG preparedness and experiences.

Method

We will implement Family centered Function-focused Care in a cluster-randomized trial of 438 patient/FCG dyads in six hospital units randomized within three hospitals. We hypothesize that patients who receive the intervention will demonstrate better physical function, less delirium occurrence and severity, neuropsychiatric symptoms, and depression compared to those in the control condition (Education-only). We also hypothesize that FCGs enrolled in Family centered Function-focused Care will experience increased preparedness for caregiving, and less strain, burden, and desire to institutionalize, as compared to FCGs the control group. We will also examine the costs and relative cost savings associated with the intervention and will evaluate the cultural appropriateness of Family centered Function-focused Care for families from diverse backgrounds.

Discussion

Our theory-based intervention makes use of real-world applicable approaches in a novel and innovative way to change the paradigm of how we currently look at acute care and post-acute transitions in persons with ADRD.

Trial registration

ClinicalTrials.gov, ID: NCT03046121. Registered on 8 February 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2875-1) contains supplementary material, which is available to authorized users.

Pre-admission functional decline in hospitalized persons with dementia: The influence of family caregiver factors

Older adults with dementia are more likely than those who do not have dementia to be hospitalized. Admission functional (ADL) performance is a salient factor predicting functional performance in older adults at discharge. The days preceding hospitalization are often associated with functional loss related to the acute illness. An understanding of functional changes during this transition will inform interventions to prevent functional decline. This secondary analysis examined data from a study that evaluated a family educational empowerment model and included 136 dyads (persons with dementia and their family caregiver). AMOS structural equation modeling examined the effects of family caregiver factors upon change in patient ADL performance (Barthel Index) from baseline (two week prior to hospitalization) to the time of admission, controlling for patient characteristics. Eighty-two percent of the patients had decline prior to admission. Baseline function, depression, and dementia severity, as well as Family caregiver strain, were significantly associated with change in pre-admission ADL performance and explained 40% of the variance. There was a good fit of the model to the data (Χ²⁼12.9, p=0.305, CFI=0.97, TLI=0.90, RMSEA=0.05). Findings suggest the need for a function-focused approach when admitting patients with dementia to the hospital. FCG strain prior to hospitalization may be a factor impacting trajectory of functional changes in older person with dementia, especially in those with advanced dementia. FCG strain is an important assessment parameter in the risk assessment for functional decline, to be considered when engaging the FCG in the plan for functional recovery.

Function Focused Care for Assisted Living Residents With Dementia

PURPOSE OF THE STUDY

Assisted living (AL) residents with dementia require assistance with activities of daily living, encounter limited opportunities to engage in physical activity, and often exhibit challenging behavioral symptoms. The Function Focused Care Intervention for the Cognitively Impaired (FFC-CI) teaches and motivates direct care workers (DCWs) to engage residents with dementia in activities that optimize function and activity while minimizing behavioral symptoms. The purpose of this study was to test the impact of FFC-CI on function, physical activity, behavior, and falls.

DESIGN AND METHODS

A cluster-randomized trial included 96 residents with dementia and 76 DCWs from 4 ALs. Generalized estimating equations were used to evaluate outcomes at 3 and 6 months.

RESULTS

There were no treatment by time differences with regard to resident behavior, mood, counts of physical activity based on actigraphy, falls, and function. There were significant increases in physical activity based on kilocalories burned (p = .001), time spent in physical activity based on survey results (p = .001), and time spent in repetitive behaviors, such as wandering (p = .01) among the control group over time. There were no treatment by time differences with regard to DCW beliefs, knowledge, or performance of FFC, except for less decline in job satisfaction among the treatment group (p = .002). Treatment fidelity with regard to delivery and receipt were poor due to high staff attrition in the treatment group (46% vs. 16%) and limited site support.

IMPLICATIONS

The findings from this study can be used to adapt future FFC intervention studies to improve treatment fidelity and optimize intervention efficacy.

Evaluation of a pet-assisted living intervention for improving functional status in assisted living residents with mild to moderate cognitive impairment: a pilot study

BACKGROUND

In older adults with cognitive impairment (CI), decreased functional status and increased behavioral symptoms require relocation from assisted living (AL) to nursing homes. Studies support positive effects of pets on health/function.

PURPOSE

Evaluate the effectiveness of the Pet AL (PAL) intervention to support physical, behavioral, and emotional function in AL residents with CI.

METHODS

Cognitively impaired AL residents randomized to 60-90 minute sessions [PAL (n = 22) or reminiscing (n = 18)] twice/week for 12 weeks. PAL interventionist encourages residents to perform skills with the visiting dog; reminiscing interventionist encourages residents to reminisce. Monthly assessment of physical (energy expenditure, activities of daily living), emotional (depression, apathy), and behavioral (agitation) function.

RESULTS

In linear mixed models, physical activity depressive symptoms improved more with PAL.

CONCLUSION

Evidence supports that the PAL program helps preserve/enhance function of AL residents with CI. Additional study is required to evaluate the duration and predictors of effectiveness of the PAL intervention.

Optimizing function and physical activity among nursing home residents with dementia: testing the impact of function-focused care

PURPOSE OF THE STUDY

The purpose of this study was to test the impact of Function-Focused Care for the Cognitively Impaired Intervention on nursing home residents with dementia and the nursing assistants who care for them.

DESIGN AND METHODS

This was a cluster-randomized controlled trial using repeated measures. A total of 103 cognitively impaired residents and 77 nursing assistants were recruited from four nursing homes. For residents, outcome measures included function, physical activity (survey and actigraphy), mood, behavior, and adverse events (falls and hospitalization). Main outcome measures for nursing assistants included knowledge, beliefs, and performance of function focused care.

RESULTS

There were significant improvements in the amount and intensity of physical activity (by survey and actigraphy) and physical function in the treatment group. In addition, there was a significant decrease in the number of residents who fell during the treatment period with those in the treatment sites having fewer falls (28% vs. 50% in the control group). Nursing assistants were also observed to be providing a greater percentage of function focused care during resident care interactions in the treatment group at 6 months following the completion of baseline measures.

IMPLICATIONS

This study provides some evidence that nursing home residents with severe cognitive impairment can safely and successfully be engaged in physical and functional activities.

Psychotropic medication use and association with physical and psychosocial outcomes in nursing home residents

Psychotropic medications are commonly prescribed for older adults living in long-term care settings. Use of these medications has been associated with negative functional outcomes. The purpose of this study was to describe the prevalence of psychotropic medication use among nursing home residents, and to explore the relationship of psychotropic medication use on physical and psychosocial outcomes. A secondary data analysis was done using baseline measures from the Res-Care Intervention Study. The sample included 419 residents from 12 nursing homes. There were 288 participants (69%) who were prescribed at least one psychotropic medication, with 81 participants (19%) receiving antipsychotics, 248 (59%) receiving antidepressants, 50 (12%) receiving anxiolytics and 37 (9%) receiving sedative/hypnotics. Controlling for gender, age and cognition, physical outcomes were significantly lower in residents receiving psychotropic medications (F= 3.2, P= 0.01) compared to those not receiving psychotropic medications. Psychosocial outcomes were significantly lower in those residents receiving psychotropic mediations (F= 2.0, P= 0.04). The findings from this study provide additional support for the prevalence of psychotropic medication use among nursing home residents and suggest that residents receiving psychotropic medications may be less likely to engage in functional activities and experience decreased quality of life.

Activity restriction vs. self-direction: hospitalised older adults' response to fear of falling

BACKGROUND

Functional decline is a common complication in hospitalised older adults, associated with low mobility and physical activity. Fear of falling may contribute to limited mobility and physical activity, and loss of physical function. An understanding of this relationship, as well as contributing factors, may inform the development of safe, function-promoting interventions.

AIM

To describe fear of falling in hospitalised older adults and its relationship with patient characteristics and physical function and explore patient views of associated factors.

DESIGN

combined quantitative and qualitative approach using chart extraction, observation and interviews of older adults.

METHODS

(i) correlations and analysis of variance methods; (ii) content and thematic analysis; and (iii) evaluation of convergence, complementarity and dissonance of quantitative and qualitative data.

RESULTS

Depressed older persons were more likely to describe fear of falling (r = 0.47, P = 0.002). Fear of falling was associated with the loss of physical function from admission to discharge (F = 7.6, P = 0.009). The participant response to fear of falling was activity restriction vs. self-direction. Participants described the following factors, organised by social-ecological framework, to be considered when developing alternatives to activity restriction: intrapersonal, interpersonal, environmental and policy.

CONCLUSION

Fear of falling plays a significant role in restricting physical activity and function. A multifactorial approach may provide a viable alternative to activity restriction, by facilitating self-direction and functional recovery.

IMPLICATIONS FOR PRACTICE

Interventions to prevent falls and activities to promote functional mobility are ideally developed in tandem, with attention paid to the physical and social environment. Preventing hospital-acquired disability may require a shift in organisational values around safety, from a soley protective approach to one that reflects an enabling philosophy emphasising independence and self-direction. Such a paradigm shift would demonstrate a valuing not only of the absence of falls but also the preservation and restoration of function.

The decisional balance sheet to promote healthy behavior among ethnically diverse older adults

OBJECTIVE

The rising health care costs and increasing older adult population in the United States make preventive medicine for this age group especially crucial. Regular physical activity and fruit and vegetable consumption may prevent or delay the onset of many chronic conditions that are common among older adults. The decisional balance sheet is a promotional tool targeting the perceived pros and cons of behavior adoption. The current study tested the efficiency and effectiveness of a single-day decisional balance sheet program, targeting increased physical activity and fruit and vegetable intake among older adults.

DESIGN AND SAMPLE

Participating adults (N = 21, age = 72.2) who represented a diverse population in Hawaii (Japanese = 5, Filipino = 4, Caucasian = 4, Native American = 1, Native Hawaiian = 1, Hispanic = 1, and Others = 5) were recruited from housing communities and randomized to a decisional balance sheet program adapted for physical activity or fruit and vegetable consumption.

MEASURES

Physical activity was assessed using the International Physical Activity Questionnaire (IPAQ) short form, and daily fruit and vegetable intake with the National Health and Nutrition Examination Survey single item instrument. Baseline and follow-up data were collected.

RESULTS

Both programs were implemented efficiently, and participants in both groups improved their daily physical activity. The decisional balance sheet for fruit and vegetable consumption appeared less effective.

CONCLUSIONS

Specific suggestions for similar programs are reported.

Does cognitive impairment affect rehabilitation outcome?

OBJECTIVES

To assess how cognitive impairment affects rehabilitation outcomes and to determine whether individual benefit regardless of cognition.

DESIGN

Prospective open observational study.

SETTING

Two rehabilitation wards admitting older adults after admissions with medical or surgical problems.

PARTICIPANTS

Two hundred forty-one individuals admitted to two rehabilitation wards, 144 female, mean age 84.4 ± 7.3 (range: 59-103).

MEASUREMENTS

The Mini-Mental State Examination (MMSE) was administered, and participants were categorized into four groups: cognitively intact (MMSE score: 27-30), mildly impaired (MMSE score: 21-26), moderately impaired (MMSE score: 11-20), and severely impaired (MMSE score: 0-10). Barthel activity of daily living score was calculated on admission, at 2 and 6 weeks (if appropriate), and at discharge to assess level of independence and improvement or deterioration in function. Information relating to mortality, discharge destination, and length of stay was also collected.

RESULTS

After adjusting for comorbidities and age, all four groups showed improvement in Barthel score from admission to discharge. This improvement was highly significant (P = .005) in participants with normal cognition and mild to moderate impairment. Severely impaired participants also made significant improvement (P = .01). Length of stay was significantly longer for participants with lower cognitive scores. Discharge of 50% of participants occurred by 26, 28, 38, and 47 days for Groups 1 to 4, respectively (P = .001). Higher rates of institutionalization and mortality (P = .02) were associated with lower MMSE score.

CONCLUSION

All participants improved functionally regardless of cognition. Likelihood of institutionalization, mortality, length of stay, and adverse incidents was higher with lower MMSE scores.

Social support for exercise by experts in older women post-hip fracture

Using the data of the Baltimore Hip Study 5 (a home-based exercise intervention), this study examined how social support for exercise by experts (SSE-E) affected the self-efficacy, outcome expectations, and exercise behavior among older women following a hip fracture. The total sample included 164 females aged 65 years (M = 81.0; SD = 6.9) who had surgical repair of a nonpathologic hip fracture. Model testing showed a direct relationship between SSE-E and outcome expectations for exercise. There was, however, no direct or indirect relationship between SSE-E and self-efficacy or exercise behavior. The positive effect of SSE-E on the outcome expectations for exercise in older women recovering from a hip fracture provides an opportunity for health care providers in improving physical activity in this population.

Do cognitively impaired patients benefit from rehabilitation?

Rehabilitation in broad terms is a process aimed at restoring a person's functional capacity particularly in relation to activities of daily living. Studies have shown that hospitalization of older patients is a major risk factor for an often irreversible decline in function, and that functional decline from baseline occurs as early as day two of admission. Rehabilitation is therefore often required for older patients following an admission to an acute hospital. Older patients admitted for rehabilitation are more likely to be functionally impaired and are more medically complex than younger patients.

The Reliability and Validity of the Physical Activity Survey in Long-Term Care

The purpose of this study was to develop and test a measure of physical activity for residents in long-term-care facilities, the Physical Activity Survey in Long-Term Care (PAS-LTC). Sixty-six activities are included in the PAS-LTC: routine physical activity, personal-care activities, structured exercise, recreational activities, caretaking activities, and repetitive activities. The study included 13 residents in a long-term-care facility, most of whom were women (62%), with an average age of 84 years (± 6.0) and an average Mini Mental State Examination score of 6 (± 6.9). There was evidence of interrater reliability of the PAS-LTC with intraclass correlations of .83-.94. There was some evidence of validity of the measure with statistically significant correlations between PAS-LTC recorded during the evening and night shifts and the number of counts of activity per the ActiGraph (r= .60 andr= .57, respectively,p< .05) and the calories estimated (r= .58 andr= .60, respectively,p< .05). The PAS-LTC completed during the day shift and total activity based on the PAS-LTC showed nonsignificant correlations of .40 or greater with the ActiGraph activity counts and calories.

Hip fracture and its consequences: differences between men and women

This article describes the state of knowledge regarding gender differences with respect to hip fracture and its subsequent outcomes. Most of the work to date investigating hip fracture patients has been done with women, yet some evidence from a few studies with a significant number of male hip fracture patients and from nonfracture samples suggests that women and men may be different at the time of fracture and will have a different course of recovery.

Pilot Testing of the Restorative Care Intervention: Impact on Residents

The purpose of this pilot study was to test the feasibility and effectiveness of a two-tiered motivational intervention, the Res-Care Intervention, on nursing home residents. Twenty-one residents consented to participate in the study. The residents were 88.3 (+/- 4.9) years of age, had lived in the facility 1.6 (+/- 3.4) years, were women (93%), White (93%), and unmarried (85%). Although there were some positiv trends, there was not a statistically significant difference in any of the resident outcomes following implementation of the Res-Care Intervention. The findings have been used to revise the Res-Care Intervention to include additional education needs for the nursing assistants, revisions in the motivational intervention for the nursing assistants and nurses, clarification of documentation and motivational techniques to improve documentation, and implementation of a more comprehensive treatment fidelity plan.

Factors affecting outpatient rehabilitation outcomes in elders

PURPOSE

To identify factors affecting outpatient rehabilitation outcomes in elders.

DESIGN

A retrospective cohort design was used to explore factors affecting outpatient rehabilitation outcomes in elders.

METHODS

Analyses of health records from a nurse-managed comprehensive outpatient rehabilitation facility were conducted. Data pertinent to the study were abstracted from 201 health records, including scores from three standard instruments: the Functional Independence Measure, the Mini-Mental State Examination, and the Geriatric Depression Scale, to construct study variables. Multivariate and stepwise regression analyses were performed.

FINDINGS

Cognitive impairment was associated with lower admission and discharge function, but not with rehabilitation outcomes (functional gain, rehabilitation efficiency, days of service, and discharge location). Age > or = 80 years, admission function, and the interaction of age > or = 80 years and admission function affected functional gain and rehabilitation efficiency. Older age, being Black, and having more medical comorbidities were associated with days of service. None of these factors contributed to discharge location.

CONCLUSIONS

Cognitive impairment was not associated with outpatient rehabilitation outcomes. Rather, age > or = 80 years and function when admitted affected functional gain and rehabilitation efficiency in elders who participated in outpatient rehabilitation services.

Functional Outcomes for Older Adults with Cognitive Impairment in a Comprehensive Outpatient Rehabilitation Facility

The purpose of the study was to examine functional outcomes of a nurse-managed, community-based Comprehensive Outpatient Rehabilitation Facility (CORF) for frail older adults and to compare the outcomes between two groups: older adults with cognitive impairment and those with intact cognition. A retrospective cohort design using healthcare record abstraction was used for the study. Two hundred and one older adults who were admitted to the CORF from the end of 1997 to early 1999 were included in the study. Data were abstracted from healthcare records, including clinician-generated Mini-Mental State Examination, Geriatric Depression Scale, and Functional Independence Measure scores from the healthcare records and investigator-constructed measures of functional gain, rehabilitation efficiency, days of service, and discharge location. Multivariate regression analyses were performed to compare rehabilitation outcomes between the two groups. Regardless of cognitive status, all subjects improved significantly in their levels of functional dependence through participating in this outpatient rehabilitation program (P<.001). Subjects with cognitive impairment exhibited more functional dependence at baseline and discharge than did their cognitively intact counterparts. Nevertheless, there was no difference between the two groups in functional gain (P=.63), rehabilitation efficiency (P=.66), days of service (P=.83), or discharge location (P=.69). Therefore, despite their greater degree of functional dependence on admission, older adults with cognitive impairment benefited from this CORF without requiring more days of service and should thus be referred for rehabilitation services.

Adult failure to thrive in the older rehabilitation patient

Increasing numbers of older adults require rehabilitation therapy upon discharge from a hospital. This pilot study tested a tool developed to assess failure to thrive syndrome (FTT) in patients admitted to a long-term rehabilitation unit (N = 34), examined the association among commonly recognized FTT factors (persistent, unexpected impairment in physical function, cognitive impairment, and poor nutrition and mood state), and investigated relationships between FTT factors and discharge disposition. Patients with a high level of physical function differed from those with a low level of function in terms of age, mood state, and discharge disposition. Patients discharged home differed from patients who were unable to return home in mood state, physical function score, and admission serum albumin. Suggestions for practice and further research are offered.

Validation of the 'Vienna List' as a proxy measure of quality of life for geriatric rehabilitation patients

The reason for the study was to investigate the discriminative, content- and criterion-related validity of the 'Vienna List', a newly developed proxy-rating measurement for quality of life in very old and severely demented persons. The total population of patients of a geriatric rehabilitation clinic of one year (from November 2001 to October 2002; n = 687) was evaluated at admission and discharge by means of this proxy rating method together with the mini mental state examination, the timed up and go test, the Tinetti measure, the Barthel Index, and the Katz activities of daily living list. Differences, mainly on factors communication, mobility, aggression, and negative affect, appeared between seven diagnostic groups as well between several care-related categories and destination after discharge. The five factors of the measurement explained a significant amount of variance with a high specificity and more than 50% of the Barthel Index scores. The 'Vienna List', originally developed for the assessment of quality of life in severely demented patients, proved to be a useful, differentiating, less time-consuming and practical tool for the documentation of the outcome of geriatric inpatient rehabilitation, as well.

Geriatric rehabilitation nursing: Developing a model

In this paper, we describe a geriatric rehabilitation nursing model developed on the basis of the nursing and rehabilitation literature. That literature comprised some 120 articles addressing the rehabilitation of elderly patients and the work done by nurses in that process, various philosophical questions and the results of geriatric rehabilitation. One-third of these articles has been evaluated on the strength of the articles' evidence, and these are discussed in this paper. The findings show that the main factors in geriatric rehabilitation nursing are the patient with health or functional problems and the nurse with professional values, knowledge and skills. The patient is part of a family and the nurse works as part of a multidisciplinary team. In the geriatric rehabilitation process, the patient and the nurse work in close interaction. The aims of rehabilitation depend upon the patient's commitment to the objective and upon the nurse's commitment to help the patient achieve that objective. A health orientation, goal-oriented work, nursing decision-making and a rehabilitative approach to work are all central to this effort. Work is organized in multidisciplinary teams where nurses have equal responsibilities with other professional staff. Testing and development of the model is ongoing.

RCT of a theory-based intervention promoting healthy eating and physical activity amongst out-patients older than 65 years

A randomised controlled trial was used to evaluate a theory-based health promotion intervention. The intervention, a healthy living booklet, was designed to promote healthy eating and physical activity amongst people aged over 65 years attending hospital out-patient clinics. The booklet employed persuasive arguments targeting the most proximal cognitive antecedents of behaviour specified by the theory of planned behaviour, as well as goal setting prompts. Participants (N = 252, average age=82) were randomly allocated to a control (patient satisfaction questionnaire) or intervention (healthy living booklet) group. Cognitions and behaviour were measured pre-intervention and at a two week follow up. The intervention group made significantly higher gains in perceived behavioural control, intention and behaviour for both target behaviours, suggesting that the intervention was successful. Sixty three of those invited to set goals to eat more healthily (e.g., "to eat five portions of fruit and vegetables a day") did so, and 67% of those who set such goals reported 100% success in acting on them. By contrast, only 34% of intervention participants set an activity goal (e.g., "a five minute walk everyday"), and only 51% reported 100% success in enacting these goals. Results suggest that the observed behavioural effects of the healthy eating booklet could be attributed to goal setting as well as changes in perceived behavioural control and intention.

Predicting post-surgical cognitive disturbance in older Taiwanese patients

The purpose of this study was to test a theoretical model to understand the influences of six predicting variables in post-surgical cognitive disturbance in older Taiwanese patients after elective surgery. The data were collected in a medical center in Taipei, Taiwan. Ninety-three patients were included in the final analysis. The findings showed that cognitive function at admission (beta=0.50, p<0.001), physical function at admission (beta=-0.34, p<0.001), and physiological stability (beta=-0.21, p<0.01) had direct effects on post-surgical cognitive disturbance. Physical function and cognitive function at admission also affected post-surgical cognitive disturbance indirectly through physiological stability. These variables accounted for 67% of the total variance of post-surgical cognitive disturbance. The findings from this study suggest that a careful and systematic assessment of the patient's condition at the time of admission is important. It is necessary to monitor and correct these variables at admission or before surgery to prevent or reduce the impact of post-operative delirium. It is also necessary to monitor these variables during the hospital stay to help nurses to distinguish the etiology of delirium. In each case, knowing when confusion is more likely to occur can assist in focusing more appropriate and effective efforts at detection, thereby reducing the consequences associated with confusion.

Incorporating outcomes research into clinical practice: the four-step approach

Outcomes research is designed to develop new and generalizable knowledge about care delivery, interventions, and patient outcomes. Advanced practice nurses are asked not only to participate in outcomes research but also to develop and maintain outcomes research projects and databases and to demonstrate the effectiveness of their own care practices through outcomes research. A four-step approach is described as an easy way in which to help advanced practice nurses engage in outcomes research at any site and with any patient population. The four steps are: Step I: identify and describe current practice in nursing-medical care and its outcome(s); Step II: data collection; Step III: data analysis; and Step IV: praxis: putting the research into practice. Participating in outcomes research will allow advanced practice nurses to improve healthcare services and to secure the role of advanced practice nurses in the changing healthcare arena.

A study of functional status among elders at two academic nursing centers

Using the Older Americans Resources and Services (OARS) tool, this study examined quality of life related to functional status in 68 elderly clients at two community-based nurse-managed centers (NMCs) in California. Undergraduate and graduate nursing students administered the OARS to three cohort groups. Data from the tool were used to assess functional independence among these clients and organize and evaluate the quality of nursing care delivered at the centers. The study provides the basis for evidence-based nursing care that integrates research strategies and the nursing process.

Functional performance and exercise of older adults in long-term care settings

Performing functional activities and exercising are important for older adults living in long-term care settings. Participation in these activities not only improves and maintains function in older adults but also can improve physical and emotional health and quality of life. The purpose of this study was to explore the variables that influence functional performance and exercise activity in a group of nursing home residents. Participants included 59 residents in a long-term care facility. The mean age of participants was 88 +/- 6.9, and the majority were women (76%), White (97%), and unmarried (76%). Residents participated in a single face-to-face interview. Chart reviews for demographic and health information also were performed. Based on stepwise multiple regression analyses, upper and lower extremity contractures and cognitive status were the only variables that significantly influenced functional performance and accounted for 49% of the variance in function. Self-efficacy and outcome expectations were the only variables to significantly influence exercise behavior and accounted for 57% of the variance in this behavior. These findings can be used to help develop and implement effective restorative nursing care programs in long-term care settings.

Efficacy beliefs in geriatric rehabilitation

Motivation is an important variable in older adults' ability to recover from any disabling event. The theory of self-efficacy states that efficacy beliefs affect behavior, motivational level, thought patterns, and emotional reactions in response to any situation. This study explored the impact of efficacy beliefs on older adults in a rehabilitation program and tested interventions to strengthen efficacy beliefs related to participation in rehabilitation and functional performance. An experimental pretest-posttest design was used. Participants were randomly assigned to: the usual care control group or the treatment group. The study was completed on an inpatient geriatric rehabilitation unit. The sample consisted of 77 participants, 55 women and 22 men with a mean age of 78 +/- 7.2. Individuals in the treatment group received three efficacy enhancing interventions: role modeling, verbal persuasion, and physiological feedback. Baseline data were collected within 48 hours of admission and included four investigator-developed efficacy measures: Functional Inventory Measure, Participation Index, Numeric Rating Scale for pain, amount of analgesic used for pain, and Health Status. With the exception of Health Status, these measures were again completed within 48 hours of discharge. Admission performance was the only statistically significant predictor of efficacy beliefs. All efficacy beliefs increased over time and were significantly correlated with performance behaviors and length of stay. The treatment group had stronger efficacy beliefs regarding participation, higher participation at discharge, and less pain than the control group. Efficacy beliefs, both self-efficacy and outcome expectations, are related to participation, functional performance, and length of stay. Interventions to strengthen these beliefs improved participation in rehabilitation and decreased pain. Consideration of motivation can facilitate rehabilitation and help older adults obtain and maintain their highest functional level.