Development of a test of physical performance for the nursing home setting

Zoledronic acid and bone health in older adults with cognitive impairment

Fracture prevention in cognitively impaired individuals is lacking. This work highlights the benefits of zoledronic acid on bone health in cognitively impaired older adults. Demonstrating benefits of therapy may increase treatment uptake and reduce fracture risk in this group.

INTRODUCTION

Osteoporosis has detrimental consequences for frail older adults. The effects on those with both osteoporosis and cognitive impairment are compounded due to increased risk of falls and changes in mobility, both of which can lead to fracture. However, there are limited data on treatment benefits for osteoporotic individuals with cognitive impairment.

METHODS

This post hoc, secondary analysis of data from a randomized, double-blind, placebo-controlled clinical trial of single-dose zoledronic acid included 179 women age ≥ 65 years residing in assisted living facilities or nursing homes, 43 of whom had mild to severe cognitive impairment. We assessed bone mineral density (BMD) of the total hip, femoral neck, and lumbar spine by dual-energy x-ray absorptiometry and serum bone turnover markers (C-terminal telopeptide of type I collagen and procollagen type I N propeptide) at 6 and 12 months.

RESULTS

In participants with cognitive impairment, those who received zoledronic acid had 4.3% greater BMD at the total hip (p=.005) and 5.3% greater BMD at the femoral neck (p<.001) after 12 months compared to those in the placebo group. Bone turnover markers demonstrated significant decreases at 6 months in those with cognitive impairment who received active treatment compared to the placebo group. Improvements in bone health measures with zoledronic acid were similar to those seen in participants without cognitive impairment.

CONCLUSION

Zoledronic acid improves bone health in frail older women with cognitive impairment similar to those without impairment. Further studies are warranted to assess the benefit for fracture reduction in this undertreated population.

Early changes in bone turnover predict longer-term changes in bone mineral density but not trabecular bone score in frail older women

Clinicians and patients want to know if therapy is working early in their course of treatment. We found that early changes in bone turnover markers at 6 months were associated with long-term changes in bone mineral density but not trabecular bone score at 12 and 24 months.

PURPOSE

We sought to examine the association between shorter-term changes in markers of bone turnover and longer-term changes in bone mineral density (BMD) and microstructure in a cohort of frail elderly women with multiple comorbid conditions including osteoporosis.

METHODS

We performed a secondary analysis of a 2-year zoledronic acid trial for osteoporosis in 155 women residents of long-term care communities (mean age 86.9 years). We examined the association of the 6-month change in serum C-terminal crosslinking telopeptide of type I collagen (CTX) and serum intact procollagen type I N propeptide (PINP) with the 12- and 24-month changes in BMD at the spine and hip and the trabecular bone score (TBS), an indirect measure of bone microstructure.

RESULTS

For every 0.2-ng/ml 6-month CTX decrease, the corresponding increase in spine BMD at 12 and 24 months was 0.2% (p = 0.7210) and 1.1% (p = 0.0396), respectively; total hip BMD 1.1% (p = 0.0279) and 0.9% (p = 0.0716); and femoral neck BMD 1.7% (p = 0.0079) and 0.9% (p = 0.1698). Similarly, for every 20-ng/ml 6-month PINP decrease, the corresponding increase in spine BMD at 12 and 24 months was 0.9% (p = 0.0286) and 1.4% (p = 0.0012), respectively; total hip BMD 1.4% (p = 0.0005) and 1.4% (p = 0.0006); and femoral neck BMD 2.3% (p < 0.0001) and 2.0% (p < 0.0001). Bone marker changes were not consistently associated with TBS changes.

CONCLUSION

Shorter-term 6-month changes in bone turnover markers are associated with the long-term changes in BMD over 1-2 years in the spine and hip but not with TBS.

Evaluating Mobility in Advanced Dementia: A Scoping Review and Feasibility Analysis

BACKGROUND AND OBJECTIVES

Mobility decline is a symptom of advanced dementia that affects function, safety, caregiving, and quality of life. Monitoring mobility status is essential for initiating timely and targeted interventions aimed at preventing excess disability in people with dementia (PWD). The physical, cognitive, and behavioral symptoms of dementia however, present unique challenges for mobility assessment. The goals of this review were to (a) identify and describe measures of mobility used for PWD and (b) assess measures' feasibility for use in people with advanced dementia; a group whose degree of cognitive impairment results in severe functional deficits.

RESEARCH DESIGN AND METHODS

Electronic searches of Medline, Embase, CINAHL, and PsychInfo databases were conducted using keywords related to dementia, mobility, measurement, and validation. Descriptive characteristics were extracted and measures coded for mobility components. Tools were also evaluated for feasibility of use in advanced dementia and those deemed feasible, screened for psychometric strength.

RESULTS

Thirty-eight measures were included and 68% of these tools were performance-based. Elements of mobility evaluated were walking (53% of measures), postural transitions (42%), standing (40%), mobility-related behavioral/psychological symptoms (24%), transfers (10%), bed mobility (5%), and wheeled mobility (3%). 36% of studies included people with advanced dementia. Only 18% of tools received high scores for feasibility.

DISCUSSION AND IMPLICATIONS

Existing measures provide only partial information regarding mobility and few target elements that become relevant as dementia progresses. Most measures are not feasible for people with advanced dementia, and the psychometric evaluation of these measures is limited. Further research is needed to develop a comprehensive, dementia-specific, mobility assessment tool.

Fear of falling in sensory impaired nursing home residents

Objectives: Fear of falling (FOF) causes excess disability in nursing home (NH) residents and is associated with vision and hearing impairment. We explored factors associated with FOF in 225 NH residents with vision, hearing or dual sensory impairment.Methods: We explored age, gender, cognition, depression, social engagement, illness burden, falls, physical function, mobility, falls self-efficacy and outcome expectancy as predictors of FOF using univariate logistic regression modeling, followed by multivariate analysis by group (visual, hearing, dual, total sample).Results: Fifty-one percent of residents had FOF. Residents who had FOF reported better cognition, lower falls self-efficacy, and higher outcome expectancy in the total sample and in most impairment groups. Falls outcome expectancy predictedFOF in the total sample and in the visual and hearing sensory impairment groups.Conclusion: When addressing FOF in NH residents it is important to address sensory status along with fears about falling to promote function.

Time Effects on Physical Performance in Older Adults in Nursing Home: A Narrative Review

OBJECTIVES

To gather available evidence about overtime changes on physical performance in institutionalized elderly.

DESIGN, SETTING AND PARTICIPANTS

An electronic search was performed on PubMed database on May 2018. We selected articles reporting the evolution of physical performance in older adults living in care institutions. We looked for data from observational longitudinal studies; data from clinical trials were extracted only for subjects who did not receive exercise intervention. All types of performance-based tests, for upper- and/or lower-body, were scrutinized.

RESULTS

Seventeen studies were reviewed; mean age varied from 78.3 to 88 years old. Fourteen studies were randomized controlled trials (RCTs), other three studies were non-randomized trials and a longitudinal observational study. Different tests assessing physical performance were examined: upper limb strength and lower limb strength, static balance, dynamic balance and mobility showed a tendency to decline over time. On average hand grip strength decreased by 2.2% per month, chair stand test by 3.5%, Berg balance scale by 2%, timed up-and-go test by 2.8%, gait speed by 2.1% and short physical performance battery by 2.8%. A minority of studies have shown an improvement in lower limb muscle strength, endurance and gait speed: in these studies, participants did not attend any kind of physical training but took part to social activities or cognitive interventions.

CONCLUSION

This review shows how physical performance decreases over time in nursing home residents and quantifies their decline. However, in active controls, there was an improvement in some physical performance measures, which indicates that intervention other than exercise might prevent some loss in physical performance.

The Nursing Home Physical Performance Test: A Secondary Data Analysis of Women in Long-Term Care Using Item Response Theory

Background and Objectives

The Nursing Home Physical Performance Test (NHPPT) was developed to measure function among nursing home residents using sit-to-stand, scooping applesauce, face washing, dialing phone, putting on sweater, and ambulating tasks. Using item response theory, we explore its measurement characteristics at item level and opportunities for improvements.

Research Design and Methods

We used data from long-term care women. We fitted a graded response model, estimated parameters, and constructed probability and information curves. We identified items to be targeted toward lower and higher functioning persons to increase the range of abilities to which the instrument is applicable. We revised the scoring by making sit-to-stand and sweater items harder and dialing phone easier. We examined changes to concurrent validity with activities of daily living (ADL), frailty, and cognitive function.

Results

Participants were 86 years old, had more than three comorbidities, and a NHPPT of 19.4. All items had high discrimination and were targeted toward the lower middle range of performance continuum. After revision, sit-to-stand and sweater items demonstrated greater discrimination among the higher functioning and/or greater spread of thresholds for response categories. The overall test showed discrimination over a wider range of individuals. Concurrent validity correlation improved from 0.60 to 0.68 for instrumental ADL and explained variability (R2) from 22% to 36% for frailty.

Discussion and Implications

NHPPT has good measurement characteristics at the item level. NHPPT can be improved, implemented in computerized adaptive testing, and combined with self-report for greater utility, but a definitive study is needed.

Ratings of activities of daily living in nursing home residents: comparison of self- and proxy ratings with actual performance and the impact of cognitive status

This study was conducted to examine differences between self- and proxy ratings of activities in daily living (ADL) in nursing home residents and to compare them with actual performance. An impact of cognitive status on these ratings was also determined. Data were obtained from 164 dyads of nursing home residents (self-ratings) and their professional care providers (proxy ratings). Statistical procedures included t tests, intraclass correlations, Pearson's correlations, analysis of variance (ANOVA) and ROC curves. Paired t test provided evidence that residents in general overestimated their abilities for all ADLs (p < .01 in all cases), but a substantial subset of 54 residents, with mean MMSE of 18, agreed with their care providers. The mean MMSE score of those who overestimated their abilities was 13 (N = 57). The ANOVA revealed that greater rating differences were associated with more severe cognitive impairment (MMSE, F = 9.93, p < .001). Proxy ratings of walking were not significantly different from actual performances (p = .145), while self-ratings overestimated it (p < .001). Although residents in general overestimated their ADL abilities and results of comparison with actual performance indicated that proxies may be closer to the actual status in this population, a considerable number of those with milder cognitive impairment were able to assess their ADLs with reasonable accuracy.

The Physical and Cognitive Performance Test for Residents in Assisted Living Facilities

OBJECTIVES

To develop and evaluate the psychometric properties of a new performance-based instrument (Physical and Cognitive Performance Test for Assisted Living Facilities (PCPT ALF)) designed to assess the physical and cognitive skills associated with performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

DESIGN

There were three stages in this study: development of instrument items and validity testing, a feasibility pilot study, and a cross-sectional trial to establish construct and criterion validity and reliability.

SETTING

One 116-bed assisted living facility (ALF).

PARTICIPANTS

After a pilot test with 10 residents, a cross-sectional trial was conducted with 55 additional residents.

MEASUREMENTS

The Barthel Index and Functional Independence Measure were used to estimate criterion validity. Construct validity was examined using exploratory factor analyses (EFAs).

RESULTS

Disattenuated correlations between the PCPT ALF and other tools were all greater than 0.72, supporting criterion validity. Internal consistency (physical ability, α = 0.95; cognitive support, α = 0.92) and 1-week test-retest reliability (PCPT ALF, P = .93) were high, as was interrater reliability (IRR) (physical ability, 0.99; cognitive support, 1.00). In two EFAs, a one-factor solution accounted for 64.1% of the variance for the physical ability subscale and 63.5% of the variance for the cognitive support subscale.

CONCLUSION

The findings provide early evidence of the PCPT ALF's validity and reliability. If confirmed, this study's findings may be used in future work to assess the success of interventions to prevent or slow decline in the skills associated with ADL and IADL performance in ALFs.

Vitamin D deficiency is associated with functional decline and falls in frail elderly women despite supplementation

We examined the impact of daily supplementation on vitamin D deficiency, function, and falls in female long-term care residents. Initial vitamin D deficiency was associated with greater functional decline and increased fall risk despite guideline-recommended supplementation, highlighting the importance of preventing vitamin D deficiency in frail elderly.

INTRODUCTION

Institute of Medicine (IOM) guidelines recommend 800 IU vitamin D daily for older adults and maintaining serum 25-hydroxyvitamin D [25(OH) D] above 20 ng/ml for optimal skeletal health. The adequacy of IOM guidelines for sustaining function and reducing falls in frail elderly is unknown.

METHODS

Female long-term care residents aged ≥65 enrolled in an osteoporosis clinical trial were included in this analysis (n = 137). Participants were classified based on baseline 25(OH) D levels as deficient (<20 ng/ml, n = 26), insufficient (20-30 ng/ml, n = 40), or sufficient (>30 ng/ml, n = 71). Deficient women were provided initial vitamin D repletion (50,000 IU D₃ weekly for 8 weeks). All were supplemented with 800 IU vitamin D₃ daily for 24 months. Annual functional assessments included Activities of Daily Living (ADLs), Instrumental ADL (IADL), physical performance test (PPT), gait speed, cognition (SPMSQ), and mental health (PHQ-9). We used linear mixed models for analysis of functional measures and logistic regression for falls.

RESULTS

Daily supplementation maintained 25(OH) D levels above 20 ng/ml in 95% of participants. All groups demonstrated functional decline. Women initially deficient had a greater decline in physical function at 12 (IADL -2.0 ± 0.4, PPT -3.1 ± 0.7, both p < 0.01) and 24 months (IADL -2.5 ± 0.6, ADL -2.5 ± 0.6, both p < 0.01), a larger increase in cognitive deficits at 12 months (1.7 ± 0.4: p = 0.01) and more fallers (88.5%, p = 0.04) compared to those sufficient at baseline, despite supplementation to sufficient levels.

CONCLUSIONS

IOM guidelines may not be adequate for frail elderly. Further study of optimal 25(OH) D levels for maintaining function and preventing falls is needed.

Efficacy and safety of single-dose zoledronic acid for osteoporosis in frail elderly women: a randomized clinical trial

IMPORTANCE

Eighty-five percent of institutionalized elderly people have osteoporosis and bone fracture rates 8 to 9 times higher than rates observed among community-dwelling elderly people. Nevertheless, most of these persons are left untreated and are excluded from pivotal osteoporosis trials.

OBJECTIVE

To determine the efficacy and safety of zoledronic acid to treat osteoporosis in frail elderly women in long-term care facilities.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a 2-year, randomized, placebo-controlled, double-blinded study from December 2007 through March 2012. Included were 181 women 65 or older with osteoporosis, including those with cognitive impairment, immobility, and multimorbidity, who were living in nursing homes and assisted-living facilities.

INTERVENTIONS

One 5-mg dose of zoledronic acid or placebo intravenously and daily calcium and vitamin D supplementation.

MAIN OUTCOMES AND MEASURES

Hip and spine bone mineral density (BMD) at 12 and 24 months and adverse events.

RESULTS

There were no baseline differences in mean (SE) age (85.4 [0.6] years), BMD, or functional or cognitive status, but the treatment group included more participants with frailty, falls history, diabetes, and anticonvulsant medication use. Values for BMD were available for 87% of participants at 12 months and 73% at 24 months. Mean (SE) BMD changes were greater in the treatment group: 3.2 (0.7) and 3.9 (0.7) percentage-point differences in the total hip at 12 and 24 months, respectively (P < .01 for both comparisons), and 1.8 (0.7) and 3.6 (0.7) percentage-point differences at the spine (P < .01); adjusted analyses were similar. The treatment and placebo groups' fracture rates were 20% and 16%, respectively (OR, 1.30; 95% CI, 0.61-2.78); mortality rates were 16% and 13% (OR, 1.24; 95% CI, 0.54-2.86). Groups did not differ in the proportion of single fallers (28% vs 24%; OR, 1.24; 95% CI, 0.64-2.42; P = .52), but more participants in the treatment group had multiple falls (49% vs 35%; OR, 1.83; 95% CI, 1.01-3.33; P = .047); however, this difference was no longer significant when adjusted for baseline frailty.

CONCLUSIONS AND RELEVANCE

In this group of frail elderly women with osteoporosis, 1 dose of zoledronic acid improved BMD over 2 years. The clinical importance of nonsignificant increases in fracture and mortality rates in the treatment group needs further study. Since it is not known whether such therapy reduces the risk of fracture in this cohort, any change in nursing home practice must await results of larger trials powered to assess fracture rates.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00558012.

Relative and absolute reliability of functional performance measures for adults with dementia living in residential aged care

BACKGROUND

This pilot investigation aimed to assess the relative and absolute test-retest reliability of commonly used functional performance measures in older adults with dementia residing in residential aged care facilities.

METHODS

A total of 12 participants were tested on the Short Physical Performance Battery (SPPB), the Balance Outcome Measure for Elder Rehab (BOOMER), hand grip strength, anthropometric measures and Bio-electric Impedance Analysis (BIA). This study utilized a seven-day test-retest evaluation. Intra-class Correlation Coefficients (ICC) were used to assess relative reliability, Typical Error of Measurement (TEM) was used to assess the absolute reliability, and Bland-Altman plots were used to assess group and individual levels of agreement.

RESULTS

With the exception of Standing Balance (ICC = 0.49), 2.4-m walk (ICC = 0.68), functional reach (ICC = 0.38), and static timed standing (ICC = 0.47), all measures demonstrated acceptable (>0.71) ICCs. However, only the anthropometric measures demonstrated acceptable levels of absolute reliability (>10% TEM). Bland-Altman analysis showed non-significant (p > 0.05) mean differences, and eight out of the 17 measures showing wide Limits of Agreement (LoA).

CONCLUSIONS

Current measures of functional performance are demonstrably inappropriate for use with a population of older adults with dementia. Authors suggest aligning current measurement strategies with Item Response Theory as a way forward.

Gait speed in ambulant older people in long term care: a systematic review and meta-analysis

BACKGROUND

Gait speed, recently proposed as the sixth vital sign of geriatric assessment, is a strong predictor of adverse outcomes. Walking faster than 1.0 m/s is associated with better survival in community-dwelling older adults, and a recent meta-analysis of older adults in clinical settings estimated usual gait speed to be 0.58 m/s. Here, we aimed to review gait speed values for long term care residents.

METHODS

Relevant databases were systematically searched for original research studies published prior to December 2012. Inclusion criteria were participants living in long term care, mean age >70 years, and gait speed measured over a short distance. Meta-analysis determined gait speed data adjusting for covariates including age, sex, and cognition.

RESULTS

Final data included 2888 participants from 34 studies. The percentage of residents ineligible because of inability to mobilize was stated in only 1 study. Of the 34 studies, 22 reported cognitive status using the Mini-Mental State Examination. Usual pace and maximal pace gait speeds were determined separately using a random effects model. No association between gait speed and covariates was found. Usual pace gait speed was 0.475 m/s (95% confidence interval 0.396-0.554) and maximal pace was 0.672 m/s (95% confidence interval 0.532-0.811).

CONCLUSIONS

In ambulant older people in long term care, gait speed is slow but remains functional. However, since many residents are likely to have been ineligible to participate in assessments, these results cannot be generalized to the long term care population as a whole.

Enhanced medical rehabilitation increases therapy intensity and engagement and improves functional outcomes in postacute rehabilitation of older adults: a randomized-controlled trial

OBJECTIVES

For millions of disabled older adults each year, postacute care in skilled nursing facilities is a brief window of opportunity to regain enough function to return home and live independently. Too often this goal is not achieved, possibly because of therapy that is inadequately intense or engaging. This study tested Enhanced Medical Rehabilitation, an intervention designed to increase patient engagement in, and intensity of, daily physical and occupational therapy sessions in postacute-care rehabilitation.

DESIGN

Randomized controlled trial of Enhanced Medical Rehabilitation versus standard-of-care rehabilitation.

SETTING

Postacute care unit of a skilled nursing facility in St Louis, MO.

PARTICIPANTS

Twenty-six older adults admitted from a hospital for postacute rehabilitation.

INTERVENTION

Based on models of motivation and behavior change, Enhanced Medical Rehabilitation is a set of behavioral skills for physical and occupational therapists that increase patient engagement and intensity, with the goal of improving functional outcome, through (1) a patient-directed, interactive approach, (2) increased rehabilitation intensity, and (3) frequent feedback to patients on their effort and progress.

MEASUREMENTS

Therapy intensity: assessment of patient active time in therapy sessions. Therapy engagement: Rehabilitation Participation Scale. Functional and performance outcomes: Barthel Index, gait speed, and 6-minute walk.

RESULTS

Participants randomized to Enhanced Medical Rehabilitation had higher intensity therapy and were more engaged in their rehabilitation sessions; they had more improvement in gait speed (improving from 0.08 to 0.38 m/s versus 0.08 to 0.22 in standard of care, P = .003) and 6-minute walk (from 73 to 266 feet versus 40 to 94 feet in standard of care, P = .026), with a trend for better improvement of Barthel Index (+43 points versus 26 points in standard of care, P = .087), compared with participants randomized to standard-of-care rehabilitation.

CONCLUSION

Higher intensity and patient engagement in the postacute rehabilitation setting is achievable, with resultant better functional outcomes for older adults. Findings should be confirmed in a larger randomized controlled trial.

Exercise and social activity improve everyday function in long-term care residents

OBJECTIVES

This study examined the effects of high-intensity resistance strength training and walking (E), individualized social activity (SA), and resistance training and walking combined with social activity (ESA) on everyday function in long-term care (LTC) residents and explored the relationship between change in everyday function and change in sleep.

DESIGN

The study used data from The Effect of Activities and Exercise on Sleep, a randomized controlled trial.

SETTING

Residential LTC facilities.

PARTICIPANTS

A total of 119 participants who had measures of everyday function and sleep at baseline and postintervention.

INTERVENTIONS

The E group exercised 5 days a week. The SA group was involved in social activities 5 days a week. The ESA group received both E and SA interventions. The usual care (UC) control group participated in usual activities.

MEASUREMENTS

Everyday function was measured by the Nursing Home Physical Performance Test. Nighttime sleep was measured by attended polysomnography.

RESULTS

The UC and SA groups showed a decline in everyday function, whereas the E and ESA groups showed improvement. There were statistically significant differences between the groups, with pairwise comparisons showing significant improvements in the ESA group over the SA group (95% confidence interval, -3.94 to -0.97) and the UC group (95% confidence interval, -3.69 to -0.64). No relationship was found between change in everyday function and change in sleep.

CONCLUSION

Seven weeks of high-intensity resistance strength training and walking, combined with individualized social activities (ESA), improved everyday function among LTC residents, independent of change in sleep.

Patient-reported physical activity questionnaires: a systematic review of content and format

Background

Many patients with chronic illness are limited in their physical activities. This systematic review evaluates the content and format of patient-reported outcome (PRO) questionnaires that measure physical activity in elderly and chronically ill populations.

Methods

Questionnaires were identified by a systematic literature search of electronic databases (Medline, Embase, PsychINFO & CINAHL), hand searches (reference sections and PROQOLID database) and expert input. A qualitative analysis was conducted to assess the content and format of the questionnaires and a Venn diagram was produced to illustrate this. Each stage of the review process was conducted by at least two independent reviewers.

Results

104 questionnaires fulfilled our criteria. From these, 182 physical activity domains and 1965 items were extracted. Initial qualitative analysis of the domains found 11 categories. Further synthesis of the domains found 4 broad categories: 'physical activity related to general activities and mobility', 'physical activity related to activities of daily living', 'physical activity related to work, social or leisure time activities', and '(disease-specific) symptoms related to physical activity'. The Venn diagram showed that no questionnaires covered all 4 categories and that the '(disease-specific) symptoms related to physical activity' category was often not combined with the other categories.

Conclusions

A large number of questionnaires with a broad range of physical activity content were identified. Although the content could be broadly organised, there was no consensus on the content and format of physical activity PRO questionnaires in elderly and chronically ill populations. Nevertheless, this systematic review will help investigators to select a physical activity PRO questionnaire that best serves their research question and context.

Disaster strikes! Long-term care resident outcomes following a natural disaster

This report describes the outcomes of 17 long-term care residents who were participating in a nursing intervention study. The residents were evacuated for 5 days due to a severe summer storm that caused widespread power outages. These residents were seen the day of the storm and three times per week for 2 weeks following their return to the nursing home. More than half of the participants had significant changes in their NEECHAM Confusion Scale scores (n = 11) and modified Confusion Assessment Method scores (n = 9) scores, suggesting the onset of delirium. Two participants were hospitalized within the 2 weeks of the evacuation. One participant died unexpectedly. This report provides a rare look into the negative effects of a short-term evacuation due to a natural disaster.

Psychometric properties of the PAT: an assessment tool for ADL performance of older people living in residential homes

BACKGROUND

As the world population ages, the number of people with diminished performance on the Activities of Daily Living (ADL) increases. A reliable and valid measure needs to be developed to determine the effects of interventions focused at increasing self-care abilities. We developed the Performance ADL Test (PAT) for this purpose.

OBJECTIVE

The aim of this study was to investigate the reliability and validity of the PAT in older people living in residential homes.

METHODS

The PAT contains 16 test items, covering the entire range of Basic ADL and Instrumental ADL performance in elderly people. For this assessment, 40 older people (mean age of 85 ± 7.5 years) participated. All 40 subjects lived in residential institutions in the Netherlands, were able to walk at least 10 m, could understand instructions spoken in Dutch, and had no cognitive impairment. During the first test session, subjects completed the PAT, the Groningen Activity Restriction Scale (GARS), and performance-based physical fitness tests. Two weeks later, subjects were retested on the PAT.

RESULTS

Factor analysis revealed three subscales: Organization of Performance, Gross Motor Function, and Fine Motor Function. Internal consistency (Cronbach's α) of all scales and subscales ranged from 0.731 to 0.881. Test-retest reliability (intraclass correlation) ranged from 0.316 to 0.950. Paired sample t-tests revealed no significant differences between subject performance obtained during the two test periods. Pearson's correlations between the PAT and the GARS ranged from 0.490 to 0.831, and between the PAT and the fitness tests from 0.317 to 0.781.

CONCLUSION

Although the number of participants was limited (n = 40), the PAT seems to be a useful instrument for assessing ADL performance in older people living in residential homes. In general, internal consistency, test-retest reliability, and validity were satisfactory.

A "Wii" bit of fun: the effects of adding Nintendo Wii(®) Bowling to a standard exercise regimen for residents of long-term care with upper extremity dysfunction

The aims of this randomized, single-blind crossover trial were to investigate the effect of adding a simulated bowling video game via the Nintendo Wii(®) gaming system to the standard exercise regimen of cognitively intact residents of long-term care (LTC) with upper extremity dysfunction and to identify individual characteristics that might predict improvement. Residents (n=34) were recruited through two LTC facilities in southwestern Ontario and were randomized into a standard exercise (SG) or standard exercise plus Wii bowling (Wii) arm. After 4 weeks of intervention, the groups were crossed over to the opposite arm. Outcomes included measures of pain intensity and bothersomeness, physical activity enjoyment, and a six-item measure of functional capacity designed specifically for residents of LTC. Results suggest that subjects improved on all outcomes from pre- to postintervention but that only enjoyment of activity showed a significant difference between the SG and Wii groups. Effect sizes (Cohen's d) ranged from small (0.30 for bothersomeness) to large (1.77 for functional capacity). Responders, defined as those subjects who reported any degree of improvement following the Wii intervention, were less likely to complain of stiffness or shoulder symptoms and were more likely to complain of hand symptoms than non-responders. Limitations in interpretation and recommendations for future research are presented.

Medical conditions of nursing home admissions

Background

As long-term nursing home care is likely to increase with the aging of the population, identifying chronic medical conditions is of particular interest. Although need factors have a strong impact on nursing home (NH) admission, the diseases causing these functional disabilities are lacking or unclear in the residents' file. We investigated the medical reason (primary diagnosis) of a nursing home admission with respect to the underlying disease.

Methods

This study is based on two independent, descriptive and comparative studies in Belgium and was conducted at two time points (1993 and 2005) to explore the evolution over twelve years. Data from the subjects were extracted from the resident's file; additional information was requested from the general practitioner, nursing home physician or the head nurse in a face-to-face interview. In 1993 we examined 1332 residents from 19 institutions, and in 2005 691 residents from 7 institutions. The diseases at the time of admission were mapped by means of the International Classification of Diseases - 9th edition (ICD-9). Longitudinal changes were assessed and compared by a chi-square test.

Results

The main chronic medical conditions associated with NH admission were dementia and stroke. Mental disorders represent 48% of all admissions, somatic disorders 43% and social/emotional problems 8%. Of the somatic disorders most frequently are mentioned diseases of the circulatory system (35%) [2/3 sequels of stroke and 1/5 heart failure], followed by diseases of the nervous system (15%) [mainly Parkinson's disease] and the musculoskeletal system (14%) [mainly osteoarthritis]. The most striking evolution from 1993 to 2005 consisted in complicated diabetes mellitus (from 4.3 to 11.4%; p < 0.0001) especially with amputations and blindness. Symptoms (functional limitations without specific disease) like dizziness, impaired vision and frailty are of relevance as an indicator of admission.

Conclusion

Diseases like stroke, diabetes and mobility problems are only important for institutionalisation if they cause functional disability. Diabetes related complications as cause of admission increased almost three-fold between 1993 and 2005.

Relationships among disordered sleep and cognitive and functional status in nursing home residents

This descriptive study examined relationships among disordered sleep and cognitive and functional status in nursing home residents (N = 90). Baseline data were used from a randomized controlled clinical trial that took place in three nursing homes. The sample included individuals age 55 and older with disordered sleep and cognitive impairment. We measured nighttime sleep with attended polysomnography and cognitive status with the Mini-Mental State Examination and assessed two indicators of functional status: level of assistance required and gait speed. Decreased total sleep time (TST), fewer respiratory awakenings, and higher oxygen saturation (SaO(2)) nadir were associated with better cognitive and functional status. After controlling for the effect of cognitive status, the association between decreased TST and better gait speed remained significant. Although correlation does not establish causation, these findings suggest that interventions to decrease nighttime respiratory awakenings and maintain SaO(2) have the potential to support cognitive and functional status in nursing home residents.

Standardization of the continuing care activity measure: a multicenter study to assess reliability, validity, and ability to measure change

BACKGROUND

There is a lack of standardized mobility measures specific to the long-term care (LTC) population. Therefore, the Continuing Care Activity Measure (CCAM) was developed.

OBJECTIVE

This study determined levels of reliability, validity for clinical utilization, and sensitivity to change of this measure.

DESIGN

This was a prospective longitudinal cohort study among elderly people with primarily physical or medical impairments who were residing in LTC institutions that provide nursing home and more-complex care, with access to physical therapy services.

METHOD

The CCAM, the Clinical Outcome Variables Scale (COVS), the Social Engagement Scale (SES) of the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0 instrument, and the Resource Utilization Groups, version 3, (RUG-III) were administered by clinical and research physical therapists, with timing dictated by the study purpose.

RESULTS

The participants were 136 residents of LTC institutions and 21 physical therapists. The CCAM interrater reliability (intraclass correlation coefficient [ICC]) was .97 (95% confidence interval=.91-1.00), and test-retest reliability (ICC) over a period of 1 week was .99 (95% confidence interval=.93-1.00). Over 6 months, the absolute change in total score was 5.88 for the CCAM and 4.26 for the COVS; the CCAM was 28% more responsive across all participants (n=105) and 68% more responsive for those scoring in the lower half (n=49). The minimal detectable difference of the CCAM was 8.6 across all participants. The CCAM correlated with the COVS, nursing care hours inferred from the RUG-III, and the SES.

LIMITATIONS

Some participants were lost to follow-up.

CONCLUSIONS

The CCAM is a reliable and valid tool to measure gross motor function and physical mobility for elderly people in LTC institutions. It discriminates among functional levels, measures individual functional change, and can contribute to clinical decision making.

Functional status assessment for community long-term care: preliminary observations

The Community Long-Term Care (CLTC) program in South Carolina offers services to nursing home eligible persons that allow them to remain at home and receive help with activities of daily living. Variation in the ways potential clients are evaluated often produces inconsistent eligibility determinations. We developed a simple, objective assessment tool to complement CLTC evaluations. A conceptual framework, based on Nagi's model of disablement, was tested on community-dwelling healthy older adults and CLTC clients. Three simple physiologic tasks assessing mobility, functional leg strength, and manual dexterity discriminated between community-dwelling older adults and CLTC clients, classifying them with 80% to 90% accuracy.

Brief assessment of motor function: content validity and reliability of the fine motor scale

PURPOSE

The Brief Assessment of Motor Function Fine Motor Scale (FMS) allows rapid assessment, independent of age. This study was done to establish content validity of the FMS and to demonstrate FMS reliability.

METHODS

A standard questionnaire ("Disagree" to "Agree," 1-4) was emailed to 28 expert panel members. Ten children with diagnoses including Proteus, Sheldon-Freeman, Smith-Lemli-Opitz, and Smith-Magenis syndromes were videotaped for reliability trials.

RESULTS

Expert panel members agreed that all 28 items should be included (means, 3.43-3.89); were functionally relevant (means, 2.93-3.82), were clearly worded (means, 2.71-3.61), and were easily discriminated (means, 3.32-4.0). Kappa values for interrater and intrarater reliability were 0.978 and 0.993, respectively.

CONCLUSIONS

Feedback from an expert Panel supported content validity of the Brief Assessment of Motor Function FMS. Kappa values for interrater and intrarater reliability suggest this is a reliable instrument for rapid, objective fine motor assessment.

Validity and normative data for thirty-second chair stand test in elderly community-dwelling Hong Kong Chinese

It is important to establish valid field measures of lower body strength in the elderly, and to provide representative normative values that are culturally specific in order to help health professionals in the risk assessment of this group. A sample of 1,038 elderly Hong Kong Chinese undertook a 30-sec chair stand test (30CST), with a subsample of 143 completing isometric measures of maximal hip flexion and knee extension, plus a habitual physical activity questionnaire. The 30CST was significantly, yet only weakly, correlated with the isometric strength measures (r approximately 0.3-0.4), but accurately discriminated between levels of habitual physical activity and across ages in decades. The normative values generated provide useful data for health screening in this elderly Hong Kong population, but do not compare well with their healthier US counterparts.

Effect of family style mealtimes on quality of life, physical performance, and body weight of nursing home residents: cluster randomised controlled trial

OBJECTIVE

To assess the effect of family style mealtimes on quality of life, physical performance, and body weight of nursing home residents without dementia.

DESIGN

Cluster randomised trial.

SETTING

Five Dutch nursing homes.

PARTICIPANTS

178 residents (mean age 77 years). Two wards in each home were randomised to intervention (95 participants) or control groups (83).

INTERVENTION

During six months the intervention group took their meals family style and the control group received the usual individual pre-plated service.

MAIN OUTCOME MEASURES

Quality of life (perceived safety; autonomy; and sensory, physical, and psychosocial functioning), gross and fine motor function, and body weight.

RESULTS

The difference in change between the groups was significant for overall quality of life (6.1 units, 95% confidence interval 2.1 to 10.3), fine motor function (1.8 units, 0.6 to 3.0), and body weight (1.5 kg, 0.6 to 2.4).

CONCLUSION

Family style mealtimes maintain quality of life, physical performance, and body weight of nursing home residents without dementia.

TRIAL REGISTRATION

Clinical trials NCT00114582.

Validity of the minimum data set in identifying urinary tract infections in residents of long-term care facilities

OBJECTIVES

To determine the validity of the Minimum Data Set (MDS) to detect cases of urinary tract infection (UTI) that meet specific evidence-based criteria.

DESIGN

Prospective surveillance.

SETTING

Sixteen long-term care facilities (LTCFs) in Idaho.

PARTICIPANTS

Residents of participating LTCFs for whom an MDS form was completed.

MEASUREMENTS

Prospective surveillance of all types of infection, including UTI, and data collection on clinical manifestation, microbiology, and treatment; MDS data on identification of UTI.

RESULTS

A stratified analysis demonstrated that the validity of MDS was 14% when using the evidence-based criteria for UTIs as the criterion standard. The estimated sensitivity and specificity of MDS entries were 57.9% and 86.5%, respectively. The estimated positive and negative predictive values for the study population were 13.9% and 98.2%, respectively.

CONCLUSION

MDS has the potential to be an important measure of quality in the long-term care setting. When used to detect residents with UTIs, it appears to greatly overestimate the number of cases while adequately screening out residents without UTIs. These problems may be overcome by providing more-explicit definitions for UTIs to be used by providers when completing MDS information on individual residents.

Performance improvement in the long-term-care setting: building on the foundation of infection control

Infection control programs were among the first organized efforts to improve the quality of healthcare delivered to patients and are an excellent model for the development of other healthcare performance improvement activities. Whether labeled as infection control, quality improvement, or patient safety, performance improvement initiatives share similar methods and principles. The quality of care in long-term-care facilities (LTCFs) has been scrutinized for years and has received renewed attention with the recent initiation of public reporting of quality measures by Medicare. This article reviews the principles of performance improvement, discusses the importance of employing evidence-based interventions, and emphasizes the value of local performance improvement in LTCFs. Residents of LTCFs remain at high risk for the development of nosocomial infections, and among performance improvement initiatives, infection control is recommended as a high priority for all LTCFs. Fortunately, infection control contains the essential elements for performance improvement, and a successful infection control program can provide the foundation for expanding performance improvement throughout the LTCF. There is still much that needs to be done to determine the best clinical practices for LTCFs, and this should remain a priority for future research. Furthermore, efforts should continue to apply these principles at the local level to ensure that all residents of LTCFs receive the best care possible.

Outcome Evaluation of the Canadian Centre for Activity and Aging’s Home Support Exercise Program for Frail Older Adults

The Home Support Exercise Program (HSEP) targets frail older adults. After a 4-hr training workshop, home-support workers (HSWs) encourage clients to do a simple, progressive set of 10 exercises during regular visits. Exercise compliance and functional performance were examined in 60 clients who received the HSEP, compared with 38 clients whose HSWs had not received HSEP training. Both groups were primarily female, average age 82, and many of them used walking aids. The 40 HSEP clients who continued with the program over 4 months showed good compliance and significant improvement on several indicators: timed up-and-go, sit-to-stand, 6-min walk, balance confidence, and well-being. Conversely, the comparison group declined on several measures. The findings support the effectiveness of the HSEP, as well as the importance of regular and ongoing support from HSWs for this population.