Efficacy of Peracetic Acid and Sodium Hypochlorite against SARS-CoV-2 on Contaminated Surfaces

SARS-CoV-2 is primarily a respiratory virus that can potentially be transmitted through fomites. Sodium hypochlorite (NaOCl) and peracetic acid (PAA) are widely used disinfectants on surfaces in diverse settings such as hospitals and food production facilities. The objectives of this study were to investigate the virucidal efficacy of NaOCl and PAA against SARS-CoV-2 using the ASTM standard methods. In the suspension assay, NaOCl and PAA (5, 50, and 200 ppm) were tested against SARS-CoV-2 in the presence/absence of soil load after 1 min of contact time. In the carrier assay, NaOCl and PAA were tested at 200, 400, 600, and 1,000 ppm for 1 min and 200 and 1,000 ppm for 5 and 10 min. Stainless steel (SS) and high-density polyethylene (HDPE) disks were used as carriers. The virus was suspended in soil load and the disinfectants were prepared in 300 ppm of hard water. Virus quantification was done by TCID50 assay using Vero-E6 cell line. NaOCl and PAA were effective (> 3 log reduction in infectious virus) at 50 ppm in the absence of soil load. However, in the presence of soil load, 200 ppm was required for > 3 log reduction in virus infectivity. In contrast, NaOCl and PAA at 200 ppm and with a 1-min contact time were not effective against SARS-CoV-2 on either SS or HDPE surfaces. PAA at 200 ppm for 10 min was effective against SARS-CoV-2 on SS and HDPE surfaces, whereas NaOCl required 1,000 ppm for 10 min to be effective against SARS-CoV-2 on both surfaces. IMPORTANCE In the context of the COVID-19 pandemic, the World Health Organization (WHO) recommended the use of chlorine-based products such as sodium hypochlorite (NaOCl) at 1,000 ppm for a minimum of 1 min to disinfect environmental surfaces. However, this recommendation was not based on validated studies on the actual SARS-CoV-2 itself. In fact, over half of the chemical disinfectants, including many peracetic acid products, listed in EPA List N were approved based on "kills a harder-to-kill pathogen" without further validation on SARS-CoV-2. Research on SARS-CoV-2 is restricted to BSL3 laboratories and the urgency of tackling the pandemic might explain the lack of studies on the actual virus. Our results show that the WHO recommendation of 1 min contact time with 1,000 ppm NaOCl is not effective against SARS-CoV-2 on surfaces. Also, our results indicate that PAA is effective against SARS-CoV-2 on surfaces and can be used as safer and more environmentally friendly alternative to NaOCl at a lower concentration.

Validating the Mental Health Assessment Protocols (MHAPs) in the Resident Assessment Instrument Mental Health (RAI-MH)

For persons with mental illness and addictions, comprehensive assessment of their strengths, preferences and needs is central to person-centred care planning. In this study, the validity of the Mental Health Assessment Protocols (MHAPs) embedded in the Resident Assessment Instrument Mental Health instrument (the mandated assessment system for Ontario adult inpatient psychiatry) is examined, and triggering rates are compared in inpatient and community-based mental health settings. The sample is based on adults admitted to a psychiatric facility (n = 963) and to community mental health programmes (n = 1505) participating in the study. An international panel of mental health experts further evaluated study results. Among the 27 MHAPs, all but one had sensitivity rates above 80%, and the specificity was over 80% for 74% of the MHAPs. The expert panel found that the MHAPs worked well and could be used to support mental health care. The present study found that the MHAPs are valid measures, though more complex triggering algorithms capable of differentiating individuals based on outcomes were suggested to enhance their clinical relevance to care planning. Further, the use of compatible instrumentation in community-based mental health settings was promoted to enhance continuity of care.

A review of evidence on the reliability and validity of Minimum Data Set data

This paper reviews the reliability and validity of the Minimum Data Set (MDS) assessment, which is being used increasingly in Canadian nursing homes and continuing care facilities. The central issues that surround the development and implementation of a standardized assessment such as the MDS are presented, including implications for health care managers in how to approach data quality concerns. With other sectors such as home care and inpatient psychiatry using MDS for national reporting, these issues have importance in and beyond residential care management.

Physical activity in older women: associations with area deprivation and with socioeconomic position over the life course: observations in the British Women's Heart and Health Study

OBJECTIVE

To assess the association between residential area-level deprivation, individual life-course socioeconomic position and adult levels of physical activity in older British women.

METHODS

A cross-sectional study of 4286 British women aged 60-79 years at baseline, who were randomly selected from general practitioner lists in 23 British towns between April 1999 and March 2001 (the British Women's Heart and Health Study).

RESULTS

All three of childhood socioeconomic position, adult socioeconomic position and area of residence (in adulthood) deprivation were independently (of each other and potential confounders) associated with physical activity. There was a cumulative effect of life-course socioeconomic position on physical activity, with the proportion who undertook no moderate or vigorous activity per week increasing linearly with each additional indicator of life-course socioeconomic position (p<0.001 for linear trend).

CONCLUSION

Adverse socioeconomic position across the life-course is associated with an increased cumulative risk of low physical activity in older women. Reducing socioeconomic inequalities across the life course would thus be expected to improve levels of physical activity and the associated health benefits in later life.

Defining a minimum income for healthy living (MIHL): older age, England

BACKGROUND

Worldwide biomedical and social research is providing evidence on the personal requirements for health and well-being. Assessment of the minimum personal costs entailed in meeting these requirements is important for the definition of 'poverty'. Barriers to health must arise if income is below this level. We demonstrate the principle of such assessment for people aged 65 years plus without significant disability living independently in England.

METHODS

Current best evidence on the needs for healthy living was derived for nutrition, physical activity, housing, psychosocial relations/social inclusion, getting about, medical care and hygiene. We used conclusions of expert reviews, published research and where necessary, our judgement. This knowledge was translated into presumptively acceptable ways of living for the specified population. Current corresponding minimal personal costs were assessed from familiar low cost retailers/suppliers or, where unavoidable, from national data on the expenditure of low-income older people.

RESULTS

Minimum income requirements for healthy living, MIHL, for this population in England is 50% greater than the state pension. It is also appreciably greater than the official minimum income safety floor (after means testing), the Pension Credit Guarantee; that will also have to meet any extra costs of disability.

CONCLUSION

Objective evidence-based assessment of MIHL now is practicable but not presently as a basis of health and social policy in the UK or elsewhere apparently. Such assessment could also be an operational criterion of poverty and society's minimum income standards. The results suggest that inadequate income currently could be a barrier to healthy living for older people in England.

Coronary heart disease risk in men and the epidemic of overweight and obesity

OBJECTIVE

To evaluate the contributions of socioeconomic, lifestyle, and body weight factors to predicted risk of coronary heart disease (CHD) in the population and thus provide a focus for policies on prevention.

DESIGN

Prospective study and cross-sectional population health survey.

SUBJECTS

In all, 3090 men in the Framingham study and 2571 men in the 1998 Health Survey for England (HSE) aged 35-74 y with no history of cardiovascular disease participated in the study.

MEASUREMENTS

Data on sex, age, systolic blood pressure and antihypertensive medication, total and high-density lipoprotein cholesterol levels, diabetes, and their association with the incidence of myocardial infarction and fatal CHD in the Framingham study population were used to derive functions for predicting individual 10-y risk of CHD. These functions were applied to the same data on participants in the HSE. High risk was defined as 10-y CHD risk > or = 15%. The proportion of high risk in the English population attributable to each of the risk factors examined was assessed.

RESULTS

In all, 32% of men in England had predicted 10-y CHD risk > or =15%. Such high risk was significantly associated with body mass index (BMI, kg/m2), waist:hip ratio (WHR), smoking, and levels of physical activity, educational attainment, and income (all P < or = 0.007). In this population, 47% of high CHD risk was attributable to excess body weight--BMI > or = 25 kg/m2 and/or WHR > or = 0.95--and 31% to the sum of the four other significant factors: lack of educational qualifications, low income, smoking, and physical inactivity.

CONCLUSION

Overweight and obesity now dominate the standard risk factors of CHD in men and should be the focus of national policies for prevention.

The RAI-PC: an assessment instrument for palliative care in all settings

Large numbers of persons in most types of healthcare settings have palliative care needs that have considerable impact on their quality of life. Therefore, InterRAI, a multinational consortium of researchers, clinicians, and regulators that uses assessment systems to improve the care of elderly and disabled persons, designed a standardized assessment tool, the Resident Assessment Instrument for Palliative Care (RAI-PC). The RAI-PC can be used for both the design of individual care plans and for case mix and outcomes research. Some elements of this instrument are taken from the resident assessment instrument (RAI) mandated for use in all nursing homes in the United States and widely used throughout the world. The RAI-PC can be used alone or in counjunction with the other assessment tools designed by the InterRAI collaboration: the RAI for homecare (RAI-HC), for acute care (RAI-AC), and for mental health care (RAI-MH). The objective of this study was to field test and carry out reliability studies on the RAI-PC. After appropriate approvals were obtained, the RAI-PC instrument was field tested on 151 persons in three countries in more than five types of settings. Data obtained from 144 of these individuals were analyzed for reliability. The reliability of the instrument was very good, with about 50 percent of the questions having kappa values of 0.8 or higher, and the average kappa value for each of the eight domains ranging from 0.76 to 0.95. The 54 men and 95 women had a mean age of 79 years. Thirty-four percent of individuals suffered pain daily. Eighty percent tired easily; 52 percent were breathless on exertion; and 19 to 53 percent had one or more other symptoms, including change in sleep pattern, dry mouth, nausea and vomiting, anorexia, breathlessness at rest, constipation, and diarrhea. The number of symptoms an individual reported increased as the estimated time until death declined. The "clinician friendly" RAI-PC can be used in multiple sites of care to facilitate both care planning and case mix and outcomes research.

Racial and state differences in the designation of advance directives in nursing home residents

OBJECTIVES

To examine racial and state differences in the use of advance directives and surrogate decision-making in a nursing home population.

DESIGN

A retrospective cohort study.

SETTING

Nursing homes in the states of California (CA), Massachusetts (MA), New York (NY), and Ohio (OH).

PARTICIPANTS

Nursing home residents: 130,308 in CA, 59,691 in MA, 112,080 in NY, and 98,954 in OH.

MEASUREMENTS

Minimum Data Set information concerning resident race and whether or not residents have a living will (LW), a do not resuscitate (DNR) order, or a surrogate decision-maker (SDM).

RESULTS

The proportion of LWs, DNR orders, and SDMs varied significantly (P < .0001) by racial categories in each state. In general, whites were distinctly different from other racial categories. Whites were significantly more likely to have a LW (odds ratio (OR) = 1.9 (CA), OR = 2.2 (NY), OR = 4.9 (OH)), a DNR order (OR = 2.4 (CA), OR = 2.4 (MA), OR = 3.3 (NY), OR = 3.2 (OH)), and a SDM (OR = 1.1 (CA), OR = 1.2 (NY), OR = 1.6 (OH)) than were nonwhites, after adjusting for potentially confounding factors. Significant state differences (P < .0001) were observed in LWs, DNR orders, and SDMs and were most pronounced in residents of Ohio, who were significantly more likely to have a LW than were residents in other states (OR = 9.3).

CONCLUSIONS

Various resident characteristics explain some of the racial differences, although whites are still more likely to have a LW, a DNR order, or an SDM independent of various resident characteristics included in the adjusted analyses. This pattern is observed in all states, although the ORs varied by state. Some of these differences may be due to distinct cultural approaches to end-of-life care and lack of knowledge and understanding of advance directives. The distinctly higher rates of LWs among all racial groups in Ohio than in other states suggest that states can potentially increase the use of advance directives through intervention.

ACTIVE: a cognitive intervention trial to promote independence in older adults

The Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) trial is a randomized, controlled, single-masked trial designed to determine whether cognitive training interventions (memory, reasoning, and speed of information processing), which have previously been found to be successful at improving mental abilities under laboratory or small-scale field conditions, can affect cognitively based measures of daily functioning. Enrollment began during 1998; 2-year follow-up will be completed by January 2002. Primary outcomes focus on measures of cognitively demanding everyday functioning, including financial management, food preparation, medication use, and driving. Secondary outcomes include health-related quality of life, mobility, and health-service utilization. Trial participants (n = 2832) are aged 65 and over, and at entry into the trial, did not have significant cognitive, physical, or functional decline. Because of its size and the carefully developed rigor, ACTIVE may serve as a guide for future behavioral medicine trials of this nature.

Deriving a risk-adjustment model for pressure ulcer development using the Minimum Data Set

OBJECTIVE

To use the Minimum Data Set (MDS) to derive a risk-adjustment model for pressure ulcer development that may be used in assessing the quality of nursing home care.

DESIGN

Perspective observational study using MDS data from 1997.

SETTING

A large, for-profit, nursing home chain.

PARTICIPANTS

Our unit of analysis was 39,649 observations made on 14,607 nursing home residents who were without a stage 2 or larger pressure ulcer on an index assessment.

MEASUREMENTS

Pressure ulcer status was determined at an outcome assessment approximately 90 days after an index assessment. Potential predictors of pressure ulcer development were examined for bivariate associations, contributing to the development of a multivariate logistic regression model.

RESULTS

A stage 2 or larger pressure ulcer developed in 2.3% of the observations. Seventeen resident characteristics were found to be associated with pressure ulcer development. These included dependence in mobility and transferring, diabetes mellitus, peripheral vascular disease, urinary incontinence, lower body mass index, and end-stage disease. A risk-adjustment model based on these characteristics was well calibrated and able to discriminate among residents with different levels of risk for ulcer development (model c-statistic = 0.73).

CONCLUSION

A clinically credible risk-adjustment model with good performance properties can be developed using the MDS. This model may be useful in profiling nursing homes on their rate of pressure ulcer development.

Evaluation of a risk-adjustment model for pressure ulcer development using the Minimum Data Set

OBJECTIVE

To validate a previously derived risk-adjustment model for pressure ulcer development in a separate sample of nursing home residents and to determine the extent to which use of this model affects judgments of nursing home performance.

DESIGN

Retrospective observational study using Minimum Data Set (MDS) data from 1998.

SETTING

A large, for-profit, nursing home chain.

PARTICIPANTS

Twenty-nine thousand and forty observations were made on 13,457 nursing home residents who were without a pressure ulcer on an index assessment.

MEASUREMENTS

We used logistic regression in our validation sample to calculate new coefficients for the 17 previously identified predictors of pressure ulcer development. Coefficients from this new sample were compared with those previously derived. Expected rates of pressure ulcer development were determined for 108 nursing homes. Unadjusted and risk-adjusted rates of pressure ulcer development from these homes were also calculated and outlier identification using these two approaches was compared.

RESULTS

Predictors of pressure ulcer development in the derivation sample generally showed similar effects in the validation sample. The model c-statistic was also unchanged at 0.73, but it was not calibrated as well in the validation sample. On applying the model to the nursing homes, expected rates of ulcer development ranged from 1.1% to 3.2% (P <.001). The observed rates ranged from 0% to 12.1% (P <.001). There were 12 outliers using unadjusted rates and 15 using adjusted performance. Ten nursing homes were identified as outliers using both approaches.

CONCLUSIONS

Our MDS risk-adjustment model for pressure ulcer development performed well in this new sample. Nursing homes differ significantly in their expected rates of pressure ulcer development. Outlier identification also differs depending on whether unadjusted or risk-adjusted performance is evaluated.

Pain in U.S. nursing homes: validating a pain scale for the minimum data set

PURPOSE

The aim of this study was to validate a pain scale for the Minimum Data Set (MDS) assessment instrument and examine prevalence of pain in major nursing home subpopulations, including type of admission and cognitive status.

DESIGN AND METHODS

This study considered validation of the MDS pain items and derivation of scale performed against the Visual Analogue Scale (VAS), using Automatic Interaction Detection. The derivation data describe 95 postacute care nursing home patients who are able to communicate. The scale is then used in retrospective analysis of 34,675 Michigan nursing home residents.

RESULTS

A four-group scale was highly predictive of VAS pain scores (variance explanation 56%) and therefore quite valid in detecting pain. In the prevalence sample, only 47% of postacute patients compared to 63% of postadmission patients reported no pain, and these percentages rose with increasing cognitive impairment.

IMPLICATIONS

Pain is prevalent in nursing home residents, especially in those with cognitive dysfunction, and often untreated.

[Integrated health information system based on Resident Assessment Instruments]

The paper explores the meaning of Resident Assessment Instruments. It gives a summary of existing RAI instruments and derived applications. It argues how all of these form the basis for an integrated health information system for "chain care" (home care, home for the elderly care, nursing home care, mental health care and acute care). The primary application of RAI systems is the assessment of client care needs, followed by an analysis of the required and administered care with the objective to make an optimal individual care plan. On the basis of RAI, however, applications have been derived for reimbursement systems, quality improvement programs, accreditation, benchmarking, best practice comparison and care eligibility systems. These applications have become possible by the development on the basis of the Minimum Data Set of RAI of outcome measures (item scores, scales and indices), case-mix classifications and quality indicators. To illustrate the possibilities of outcome measures of RAI we present a table and a figure with data of six Dutch nursing homes which shows how social engagement is related to ADL and cognition. We argue that RAI/MDS assessment instruments comprise an integrated health information system because they have consistent terminology, common core items, and a common conceptual basis in a clinical approach that emphasizes the identification of functional problems.

A minimum income for healthy living

BACKGROUND

Half a century of research has provided consensual evidence of major personal requisites of adult health in nutrition, physical activity and psychosocial relations. Their minimal money costs, together with those of a home and other basic necessities, indicate disposable income that is now essential for health.

METHODS

In a first application we identified such representative minimal costs for healthy, single, working men aged 18-30, in the UK. Costs were derived from ad hoc survey, relevant figures in the national Family Expenditure Survey, and by pragmatic decision for the few minor items where survey data were not available.

RESULTS

Minimum costs were assessed at 131.86 pound sterling per week (UK April 1999 prices). Component costs, especially those of housing (which represents around 40% of this total), depend on region and on several assumptions. By varying these a range of totals from 106.47 pound sterling to 163.86 pound sterling per week was detailed. These figures compare, 1999, with the new UK national minimum wage, after statutory deductions, of pound 105.84 at 18-21 years and 121.12 pound sterling at 22+ years for a 38 hour working week. Corresponding basic social security rates are 40.70 pound sterling to 51.40 pound sterling per week.

INTERPRETATION

Accumulating science means that absolute standards of living, "poverty", minimal official incomes and the like, can now be assessed by objective measurement of the personal capacity to meet the costs of major requisites of healthy living. A realistic assessment of these costs is presented as an impetus to public discussion. It is a historical role of public health as social medicine to lead in public advocacy of such a national agenda.

The protective effect of social engagement on mortality in long-term care

OBJECTIVES

To examine the effect of social engagement (SE) on mortality in long-term care.

DESIGN

A retrospective cohort study.

SETTING

A 725-bed long-term care facility.

PARTICIPANTS

A total of 927 long-term care residents who had SE measurements and did not have a serious communication problem.

MEASUREMENTS

Minimum Data Set information including psychosocial items comprising an internally reliable and valid SE scale, and mortality risk factor measurements. Mortality data during the 1,721-day follow-up period was obtained from facility records.

RESULTS

Life table analyses indicate that higher levels of SE are associated with longer survival (P = .0001). Unadjusted proportional hazards analyses show that residents who did not engage socially were 2.3 times more likely to die during the follow-up period compared with residents who were the most socially engaged. Multivariate adjusted analyses showed the protective effect of SE on mortality remained even after simultaneously adjusting for mortality risk factors. Residents who did not engage socially were 1.4 times as likely to die during the follow-up period compared with residents who were the most socially engaged.

CONCLUSIONS

Increased levels of SE were associated with longer survival independent of mortality risk factors. SE may be a modifiable risk factor for death among long-term care residents. More research is needed to understand psychological factors that may influence residents' desire and ability to engage socially.

Resident characteristics associated with wandering in nursing homes

OBJECTIVES

This retrospective cohort study examined the association between resident characteristics and the development of wandering behavior.

METHODS

Subjects included a total of 8982 residents from the states of Mississippi, Texas, and Vermont who had baseline and 3-month follow-up Minimum Data Set assessments between 1 January 1996 and 31 December 1997.

RESULTS

Residents who had a short-term memory problem (Odds Ratio (OR) = 3.05), had pneumonia (OR = 3.15), asked repetitive questions (OR = 2.19), had a long-term memory problem (OR = 2.06), exhibited dementia (OR = 19.4), constipation (OR = 1.82), expressed sadness or pain (OR = 1.65), and used antipsychotic medication (OR = 1.70), were at an increased risk for developing wandering behavior compared to residents without these characteristics. Residents with functional impairment (OR = 0.28) and women (OR = 0.61) were less likely to develop wandering behavior.

CONCLUSIONS

Results of this study may be useful in constructing causal theories for the development of wandering behavior.

Physical activity and cause-specific mortality in the Whitehall study

A prospective cohort study of London civil servants was used to examine the relation of physical activity to various causes of death. 6,702 men aged 40-64 y who participated in a baseline examination between 1969 and 1970 were followed up for 25 y during which time there were 2859 deaths. The association of two measures of physical activity (leisure time activity and usual walking pace) with cause-specific mortality was examined. Walking pace demonstrated inverse relations with mortality from all-causes, coronary heart disease (CHD), other cardiovascular disease (CVD), all cancers, respiratory disease, colorectal cancer and haematopoietic cancer following adjustment for risk factors which included age, employment grade, smoking, body mass index, and forced expiratory volume (P [trend]<0.05 for all). In analyses restricted to men without disease at entry, walking pace retained inverse associations with all-cause, CHD, other cardiovascular disease, and haematopoietic cancer mortality (P [trend]<0.05 for all). Leisure time activity was also inversely associated with mortality from all-causes, CHD, other CVD, and all-cancers following adjustment for risk factors (P [trend]<0.05 for all). Eliminating deaths in the first 5 and 10 y of follow-up did not greatly alter these associations. It is concluded that physical activity may confer protection against death due to some cancers, in addition to reducing cardiovascular disease risk.

Accelerated dysfunction among the very oldest-old in nursing homes

BACKGROUND

The population aged 65 and older is often analyzed in three categories: young-old (65-74), middle-old (75-84), and oldest-old (> or = 85). This may blind heterogeneity within the oldest category. New, large data sets allow examination of the very oldest-old (e.g., aged > or = 95) and contrasts with those who are younger.

METHODS

We determined the annual change of prevalence of physical and cognitive function, and of disease problems in the old to very oldest-old, using data from existing Resident Assessment Instrument records from nursing homes in seven states during 1992-1994. We used data from 193,467 unique residents aged 80 or older, including 6,556 residents aged 100 or older. We computed the prevalence, by age, of selected conditions: physical and cognitive function, diseases, problem behavior, mood disturbance, restraint use, falls, weight loss, eating less, body mass index, chewing and swallowing problems, incontinence (bowel and bladder), catheter use, and selected diagnoses.

RESULTS

Prevalence of all measures of physical and cognitive dysfunction increased most rapidly with each year of age among the very oldest-old. Most of the slope changes occurred from 95 to 100 years of age. Such changes are less pronounced or not seen in measures of disease prevalence.

CONCLUSIONS

Accelerated change in prevalence of dysfunction seen in the nursing home population may suggest a change in the mechanisms of aging that occur after the mid-nineties. Examination of the very oldest-old may provide new insight into the nature of the aging process.

Integrated health information systems based on the RAI/MDS series of instruments

There is a growing need for an integrated health information system to be used in community, institutional and hospital based settings. For example, changes in the structure, process and venues of service delivery mean that individuals with similar needs may be cared for in a variety of different settings. Moreover, as people make transitions from one sector of the healthcare system to another, there is a need for comparable information to ensure continuity of care and reduced assessment burden. The RAI/MDS series of assessment instruments comprise an integrated health information system because they have consistent terminology, common core items, and a common conceptual basis in a clinical approach that emphasizes the identification of functional problems.

Development of a minimum data set-based depression rating scale for use in nursing homes

BACKGROUND

depression is common but under-diagnosed in nursing-home residents. There is a need for a standardized screening instrument which incorporates daily observations of nursing-home staff.

AIM

to develop and validate a screening instrument for depression using items from the Minimum Data Set of the Resident Assessment Instrument.

METHODS

we conducted semi-structured interviews with 108 residents from two nursing homes to obtain depression ratings using the 17-item Hamilton Depression Rating Scale and the Cornell Scale for Depression in Dementia. Nursing staff completed Minimum Data Set assessments. In a randomly assigned derivation sample (n = 81), we identified Minimum Data Set mood items that were correlated (P < 0.05) with Hamilton and Cornell ratings. These items were factored using an oblique rotation to yield five conceptually distinct factors. Using linear regression, each set of factored items was regressed against Hamilton and Cornell ratings to identify a core set of seven Minimum Data Set mood items which comprise the Minimum Data Set Depression Rating Scale. We then tested the performance of the Minimum Data Set Depression Rating Scale against accepted cut-offs and psychiatric diagnoses.

RESULTS

a cutpoint score of 3 on the Minimum Data Set Depression Rating Scale maximized sensitivity (94% for Hamilton, 78% for Cornell) with minimal loss of specificity (72% for Hamilton, 77% for Cornell) when tested against cut-offs for mild to moderate depression in the derivation sample. Results were similar in the validation sample. When tested against diagnoses of major or non-major depression in a subset of 82 subjects, sensitivity was 91% and specificity was 69%. Performance compared favourably with the 15-item Geriatric Depression Scale.

CONCLUSION

items from the Minimum Data Set can be organized to screen for depression in nursing-home residents. Further testing of the instrument is now needed.

Scaling ADLs within the MDS

BACKGROUND

Dependency in activities of daily living (ADLs) is a reality within nursing homes, and we describe ADL measurement strategies based on items in the Minimum Data Set (MDS) and the creation and distributional properties of three ADL self-performance scales and their relationship to other measures.

METHODS

Information drawn from four data sets for a multistep analysis was guided by four study objectives: (1) to identify the subcomponents of ADLs that are present in the MDS battery; (2) to demonstrate how these items could be aggregated within hierarchical and additive ADL summary scales; (3) to describe the baseline and longitudinal distributional properties of these scales in a large, seven-state MDS database; and (4) to evaluate how these scales relate to two external criteria.

RESULTS

Prevalence and factor structure findings for seven MDS ADL self-performance variables suggest that these items can be placed into early, middle, and late loss ADL components. Two types of summary ADL self-performance measures were created: additive and hierarchical. Distributional properties of these scales are described, as is their relationship to two external ADL criteria that have been reported in prior studies: first as an independent variable predicting staff time involved in resident care; second as a dependent variable in a study of the efficacy of two programs to improve resident functioning.

CONCLUSIONS

The new ADL summary scales, based on readily available MDS data, should prove useful to clinicians, program auditors, and researchers who use the MDS functional self-performance items to determine a resident's ADL status.

Nursing rehabilitation and exercise strategies in the nursing home

BACKGROUND

The purpose of this study was to evaluate how weight training or nursing-based rehabilitative care programs in nursing homes impact on resident performance of Activities of Daily Living (ADL) and objectives tests of physical performance.

METHODS

This study involved a quasi-experimental control, longitudinal comparison of functional status over a 10-month period, where baseline status was adjusted through a weighting procedure based on functional status, cognitive status, and age. All residents from six residential care nursing home facilities were eligible except those with a terminal prognosis, a projected stay of less than 90 days, or with health complications that prohibited contact. Homes were placed into matched triplets based on patient characteristics: two members of each triplet were randomly designated to be experimental sites, the third became the control site. Baseline data were available for 468 subjects, follow-up for 392. ADL self-performance measures derived from the Minimum Data Set, including indicators of early loss ADL, locomotion, and late loss ADL; a number of objective functional tests (including measures of balance, power, and endurance); and mood state as measured by the Geriatric Depression Scale.

RESULTS

Mean ADL values in the two experimental groups declined at a significantly lower rate than did rates for the controls. Functional decline was also lower in more specific measures: locomotion, early loss ADL, and late loss ADL.

CONCLUSIONS

With both interventions, facilities were able to implement a broad-based intervention that resulted in a significant reduction in ADL decline rates. A facility-wide nursing rehabilitation program can play a useful role in reversing functional decline, helping residents to maintain their involvement in a broad spectrum of ADL activities.

Educational attainment, deprivation-affluence and self reported health in Britain: a cross sectional study

STUDY OBJECTIVE

The level of material deprivation or affluence is strongly and independently correlated with all cause mortality at an area level, but educational attainment, after controlling for deprivation-affluence, remains strongly associated with coronary and infant mortality. This study investigated whether these relations hold at an individual level with self reported morbidity.

DESIGN

Analysis of the cross sectional associations of self reported longstanding illness and "not good" or "fairly good" self assessed health with individual educational attainment in seven levels, adjusting for deprivation measures (economic status of head of household, car ownership, housing tenure, overcrowding).

SETTING

The 1993 General Household Survey, a random sample of households in Great Britain.

PARTICIPANTS

11,634 subjects aged 22 to 69.

MAIN RESULTS

After adjusting for household deprivation, lower educational attainment was significantly associated with longstanding illness in men (odds ratio 1.05 per education category, 95% CI 1.02 to 1.08), but not in women (odds ratio 1.01, 95% CI 0.98 to 1.04). The associations with "not good" or "fairly good" self assessed health were stronger and significant in both men and women (men 1.13, 95% CI 1.10 to 1.17; women 1.10, 95% CI 1.07 to 1.14). The findings were little changed by allowing for people in poor health becoming economically inactive.

CONCLUSIONS

The associations of self reported health with deprivation-affluence are stronger than with educational attainment. However, educational attainment is associated with self assessed health in adulthood, independently of deprivation-affluence. Longstanding illness may be associated with educational attainment in men only. Educational attainment may be a marker for childhood socioeconomic circumstances, its association with health may result from occupational characteristics, or education may influence the propensity to follow health education advice.

Nursing home characteristics and the development of pressure sores and disruptive behaviour

OBJECTIVE

To determine how nursing home characteristics affect pressure sores and disruptive behaviour.

METHOD

Residents (n = 5518, aged > or =60 years) were selected from 70 nursing homes in the National Health Care chain. Homes were classified as high- or low-risk based on incidence tertiles of pressure sores or disruptive behaviour (1989-90). Point-prevalence and cumulative incidence of pressure sores and disruptive behaviour were examined along with other functional and service variables.

RESULTS

The overall incidence of pressure sores was 11.4% and the relative risk was 4.3 times greater in high- than low-risk homes; for disruptive behaviour, the incidence was 27% and the relative risk was 7.1 times greater in the high-risk group. At baseline, fewer subjects in homes with a high risk of pressure sores were white or in restraints, but more had received physician visits monthly and had had problems with transfers and eating. High-risk homes also had fewer beds and used less non-licensed nursing staff time. At follow-up (1987-90), 52% of homes in the low-risk group and 35% of those in the high-risk group had maintained their risk status; low-risk homes were more likely to have rehabilitation and maintenance activities. Having multiple clinical risk factors was associated with more pressure sores in high- (but not low-) risk homes, suggesting a care-burden threshold. By logistic regression, the best predictor of pressure sores was a home's prior (1987-88) incidence status. Interestingly, 67% of homes with a high risk of pressure sores were also high-risk for disruptive behaviour, while only 27% of homes with a low risk of pressure sores were high-risk for disruptive behaviour. A threshold effect was also observed between multiple risk factors and behaviour. More homes with a high risk of disruptive behaviour (68%) remained at risk over 4 years, and the best predictor of outcome was a home's previous morbidity level.

CONCLUSION

Nursing-home characteristics may have a greater impact than clinical factors on pressure sores and disruptive behaviour in long-stay, institutionalized elders.

Measurement choices in multi-site studies of outcomes in dementia

This paper summarizes the measurement choices made by selected current or recently completed multi-site projects with a common emphasis on measuring outcomes in dementia. Information on number of items and scoring, reason(s) for selecting the measure, and reliability and validity of the measure (either citations providing this information or a report of pertinent unpublished findings) is presented for eight domains: cognition, behavioral symptoms, physical health status, physical functioning and self-care abilities, quality of life, family/staff caregiver outcomes, service use, and cost. We found considerable reliance on the published literature as a guide to measurement choice, motivated largely by measures' superior psychometric properties, their ubiquity in the literature, and/or their brevity or ease of use. There is still evidence of "starting from scratch" in some domains, however. To the extent that these projects reflect the state of the art in dementia-relevant outcomes research, we conclude that comparison of outcomes across studies will continue to be problematic. However, as long as dissemination of methodological as well as substantive findings continues to characterize outcome studies in dementia, there is hope that a more congruent view of how to assess key outcomes in dementia will emerge.

The potential for using administrative and clinical data to analyze outcomes for the cognitively impaired: an assessment of the minimum data set for nursing homes

Quite frequently, data from administrative or clinical data sets are not considered suitable for research because of concerns about their validity and reliability. The authors discuss the important role that such data sets may play in the future of health care. To provide an indication that all administrative and clinical data bases do not provide inferior data, the authors compare the internal consistency and predictive validity of information from three statewide administrative/clinical databases, focusing on nursing home residents with comparable data from a research database. These databases contain information gathered using the Minimum Data Set (MDS) for Nursing Home Resident Assessment and Care Screening. The two dimensions of status considered in this illustration are cognition and physical function. The results of this comparison indicate that the assessment data in three statewide clinical/administrative databases are as reliable and valid as the data found in the research database. Finally, the authors discuss the precepts one might follow in developing clinical/administrative databases that provide good data. These precepts also can be used as guidelines in the evaluation of the probable usefulness of such databases for assessing outcomes among cognitively impaired nursing home residents.

The effect of specific medical conditions on functional decline

OBJECTIVES

To examine how functional status among older community-dwelling residents differs over time between those with and those without specific medical conditions.

DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 1060 community-dwelling Massachusetts residents aged 65 or older who were not totally functionally dependent at baseline assessment.

MEASUREMENTS

Functional status, five medical conditions (heart problem, arthritis, diabetes, cancer, and stroke), and the total number of these five medical conditions. Assessments were done at baseline and at two annual follow-ups.

RESULTS

Adjusted repeated measures analysis of covariance revealed a time difference (P < .001) for all five medical conditions and group differences for diabetes (P = .006) and stroke (P < .001). Functional abilities declined over time and those with specific medical conditions were more impaired initially, but the rate of decline did not significantly differ from those free of the condition. The presence of each additional medical condition resulted in additional impairment (P < .001), but the rate of decline over time did not differ by number of medical conditions.

CONCLUSIONS

Efforts to reduce or prevent the development of specific medical conditions are essential to maintaining functional independence of older people as well as to reducing use of supportive services and admission rates to nursing homes. Particular attention should be directed toward preventing stroke since its consequences are the most functionally disabling.

Development of the nursing home Resident Assessment Instrument in the USA

BACKGROUND

the nursing home Resident Assessment Instrument (RAI) includes a set of core assessment items, known as the Minimum Data Set (MDS), for assessment and care screening and more detailed Resident Assessment Protocols in 18 areas that represent common problem areas or risk factors for nursing home residents. Its primary use is clinical, to assess residents on admission to the nursing home, at least annually thereafter and on any significant change in status and to develop individualized, restorative plans of care.

AIM

to describe the content and development of the RAI, including US testing for MDS item reliability and validity of the RAI, and the results of a 4-year evaluation of the effects of its clinical use.

CONCLUSIONS

the evaluation found that implementation of the RAI was associated with significant improvements in a variety of measures of process quality, resident functional outcomes and reduced hospitalization. Other uses of the RAI data in the USA-including payment using resident classification systems and, with RAI-based outcome-oriented quality indicators, quality assurance activities-and the status of RAI use in other countries are also summarized.

Low-care cases in long-term care settings: variation among nations

METHOD

residents of long-term care settings without major activity of daily living (ADL) deficits are often referred to as 'low-care cases' and are deemed inappropriately placed in an institution. We compare the prevalence and characteristics of this population in Denmark, Iceland, Italy, Japan, Sweden and the USA, using the Resident Assessment Instrument Minimum Data Set.

RESULTS

among the six nations, the percentage of low-care cases ranged from 27 to 52% using a broad definition of no physical assistance required in late-loss ADLs (bed mobility, toileting, transfer and eating). With a more narrow definition which additionally excludes those falling into the Resource Utilization Groups, version III categories of rehabilitation, clinically complex, impaired cognition and behaviour problems, the percentages seen range from 9 to 35%. Finally, 2-14% meet the most restrictive definition, which further excluded residents requiring any supervision in late-loss ADLs, with any deficits in early-loss ADLs (dressing or grooming) or needing medical and psychiatric supervision.

CONCLUSION

although long-term care settings differ, making comparison by country difficult, the use of the same standard assessment form makes it possible to compare the many reasons for institutionalization.

Efforts to establish the reliability of the Resident Assessment Instrument

BACKGROUND

since its original implementation in the USA, the Resident Assessment Instrument (RAI) has been used in many countries in languages other than English. This paper describes the efforts that have been made to test the inter-rater reliability of the core set of items forming the minimum data set items in the USA and in non-English speaking countries (Denmark, Iceland, Italy, Japan, Sweden and Switzerland).

RESULTS

a large proportion (from 70 to 96%) of the items in the RAI achieved an adequate to excellent level of reliability, with no substantial differences across countries. The RAI met the standard for good reliability (i.e. a kappa value of 0.6 or higher) in crucial areas of functional status, such as memory, activities of daily living self-performance and support, and bowel and bladder continence in most of the countries. Indicators of mood and behavioural problems achieved adequate reliability levels of 0.4 or higher.

A commitment to change: revision of HCFA's RAI

OBJECTIVE

To describe the reliability of new assessment items and their clinical utility as judged by experienced nurse assessors, based on the results from the field test of Version 2.0 of the Resident Assessment Instrument (RAI).

DESIGN

Independent dual assessment of residents of nursing facilities by staff nurses using a draft of Version 2.0 of the minimum data set (MDS).

SETTING AND PARTICIPANTS

A total of 187 randomly selected residents from 21 nursing homes in seven states volunteered to test Version 2.0 of the MDS.

MEASUREMENT

The full array of MDS assessment items included measures in the following areas: Background information, cognitive patterns, communication/hearing, vision, mood and behavior, psychosocial well-being, physical functioning and structural problems, continence, disease diagnoses, health condition, oral/nutritional status, dental status, skin condition, activity pursuit patterns, medications, special treatments and procedures, and discharge potential and overall status.

RESULTS

Evaluative data address issues of MDS item utility and reliability. For new items, almost all achieved a reasonably high-weighted Kappa interrater reliability; revised items also surpassed earlier items, and with the updated training materials, even the non-changed items had higher average reliability levels. Based on the success of the field test and the positive response of the industry, Version 2.0 of the RAI has been adopted, and HCFA has initiated a more long-range process to update further the RAI when necessary.

CONCLUSION

Findings support the reliability and clinical utility of the new and revised assessment items incorporated by HCFA in Version 2.0 of the MDS.

The OBRA-87 nursing home regulations and implementation of the Resident Assessment Instrument: effects on process quality

OBJECTIVE

To characterize changes in key aspects of process quality received by nursing home residents before and after the implementation of the national nursing home Resident Assessment Instrument (RAI) and other aspects of the Omnibus Budget Reconciliation Act (OBRA) nursing home reforms.

DESIGN

A quasi-experimental study using a complex, multistage probability-based sample design, with data collected before (1990) and after (1993) implementation of the RAI and other OBRA provisions.

SETTING AND PARTICIPANTS

Two independent cohorts (n > 2000) of residents in a random sample of 254 nursing facilities located in metropolitan statistical areas in 10 states.

INTERVENTION

OBRA-87 enhanced the regulation of nursing homes and included new requirements on quality of care, resident assessment, care planning, and the use of neuroleptic drugs and physical restraints. One of the key provisions, used to help implement the OBRA requirements in daily nursing home practice, was the mandatory use of a standardized, comprehensive system, known as the RAI, to assist in assessment and care planning. OBRA provisions went into effect in federal law on October 1, 1990, although delays issuing the regulations led to actual implementation of the RAI during the Spring of 1991. MEASUREMENTS AND ANALYSES: Research nurses spent an average of 4 days per facility in each data collection round, assessing a sample of residents, collecting data through interviews with and observations of residents, interviews with multiple shifts of direct staff caregivers for the sampled residents, and review of medical records, including physician's orders, treatment and care plans, nursing progress notes, and medication records. The RNs collected data on the characteristics of the sampled residents, on the care they received, and on facility practices. The effect of being a member of the 1990 pre-OBRA or the 1993 post-OBRA cohort was assessed on the accuracy of information in the residents' medical records, the comprehensiveness of care plans, and on other key aspects of process quality while controlling for any changes in resident case-mix. The data were analyzed using contingency tables and logistic regression and a special statistical software (SUDAAN) to assure proper variance estimation.

RESULTS

Overall, the process of care in nursing homes improved in several important areas. The accuracy of information in residents' medical records increased substantially, as did the comprehensiveness of care plans. In addition, several problematic care practices declined during this period, including use of physical restraints (37.4 to 28.1% (P < .001)) and indwelling urinary catheters (9.8 to 7% (P < .001)). There were also increases in good care practices, such as the presence of advanced directives, participation in activities, and use of toileting programs for residents with bowel incontinence. These results were sustained after controlling for differences in the resident characteristics between 1990 and 1993. Other practices, such as use of antipsychotic drugs, behavior management programs, preventive skin care, and provision of therapies were unaffected, or the differences were not statistically significant, after adjusting for changes in resident case-mix.

CONCLUSION

The OBRA reforms and introduction of the RAI constituted an unprecedented implementation of comprehensive geriatric assessment in Medicare- and Medicaid-certified nursing homes. The evaluation of the effects of these interventions demonstrates significant improvements in the quality of care provided to residents. At the same time, these findings suggest that more needs to be done to improve process quality. The results suggest the RAI is one tool that facility staff, therapists, pharmacy consultants, and physicians can use to support their continuing efforts to provide high quality of care and life to the nation's 1.7 million nursing home residents.

Comprehensive clinical assessment in community setting: applicability of the MDS-HC

OBJECTIVE

To describe the results of an international trial of the home care version of the MDS assessment and problem identification system (the MDS-HC), including reliability estimates, a comparison of MDS-HC reliabilities with reliabilities of the same items in the MDS 2.0 nursing home assessment instrument, and an examination of the types of problems found in home care clients using the MDS-HC.

DESIGN

Independent, dual assessment of clients of home-care agencies by trained clinicians using a draft of the MDS-HC, with additional descriptive data regarding problem profiles for home care clients.

SETTING AND PARTICIPANTS

Reliability data from dual assessments of 241 randomly selected clients of home care agencies in five countries, all of whom volunteered to test the MDS-HC. Also included are an expanded sample of 780 home care assessments from these countries and 187 dually assessed residents from 21 nursing homes in the United States.

MEASUREMENTS

The array of MDS-HC assessment items included measures in the following areas: personal items, cognitive patterns, communication/hearing, vision, mood and behavior, social functioning, informal support services, physical functioning, continence, disease diagnoses health conditions and preventive health measures, nutrition/hydration, dental status, skin condition, environmental assessment, service utilization, and medications.

RESULTS

Forty-seven percent of the functional, health status, social environment, and service items in the MDS-HC were taken from the MDS 2.0 for nursing homes. For this item set, it is estimated that the average weighted Kappa is .74 for the MDS-HC and .75 for the MDS 2.0. Similarly, high reliability values were found for items newly introduced in the MDS-HC (weighted Kappa = .70). Descriptive findings also characterize the problems of home care clients, with subanalyses within cognitive performance levels.

CONCLUSION

Findings indicate that the core set of items in the MDS 2.0 work equally well in community and nursing home settings. New items are highly reliable. In tandem, these instruments can be used within the international community, assisting and planning care for older adults within a broad spectrum of service settings, including nursing homes and home care programs. With this community-based, second-generation problem and care plan-driven assessment instrument, disability assessment can be performed consistently across the world.

Effect of the National Resident Assessment Instrument on selected health conditions and problems

OBJECTIVE

To evaluate the effect of the implementation of the National Resident Assessment Instrument (RAI) system on selected conditions representing outcomes for nursing home residents.

DESIGN

Quasi-experimental, pre-/post-design, with assessments at baseline and 6-month follow-up.

SAMPLE

Two thousand one hundred twenty-eight residents from 268 nursing homes in 10 states before RAI implementation, and 2,088 from 254 of the same nursing homes after implementation.

MEASURES

From the full RAI Minimum Data Set, measures of dehydration, falls, decubitus, vision problems, stasis ulcer, pain, dental status (poor teeth), and malnutrition were examined at baseline and 6 months later. Poor nutrition was evaluated using a body mass index score below 20 and vision using a 4-level scale; other conditions were represented by their presence or absence. Decline and improvement were computed as the changes in level between baseline and follow-up, limiting the sample to those who could manifest each such change.

MAIN RESULTS

Of eight health conditions representing poorer health status, dehydration and stasis ulcer had significantly lower prevalence after the implementation of the RAI (1993) compared with 1990. At the same time, there was an increase in the prevalence of daily pain. Fewer residents declined over 6 months in nutrition and vision after implementation. Although for these two conditions there were also significantly reduced rates of improvement, the net was an overall reduction in the 6-month rate of decline for all residents. Pain also demonstrated a decline in the postimplementation rate of improvement. The combined eight conditions showed reductions in the rates of both decline and improvement.

CONCLUSIONS

Several outcomes for nursing home residents improved after implementation of the RAI. Of the four conditions for which there are significant declines in prevalence or outcome changes, three are specifically addressed in the care planning guidelines incorporated the RAI system (all except stasis ulcer, although there is a RAP for decubitus ulcer). Pain, the only other condition with a significant result --an increase in baseline prevalence--also has no RAP. Although the changes might be ascribed otherwise, they support the premise that the RAI has directly contributed to improved outcomes for nursing home residents.

Association of the Resident Assessment Instrument (RAI) with changes in function, cognition, and psychosocial status

OBJECTIVE

To evaluate the impact of the Resident Assessment Instrument (RAI) on changes in nursing home residents' functional status, cognitive status, and psychosocial well-being.

DESIGN

A quasi-experiment involving the collection of longitudinal data on two cohorts of nursing home residents. One cohort was assessed before the implementation of the RAI, and the other was assessed after the implementation of the new assessment process.

SETTING AND PARTICIPANTS

Over 2000 nursing home residents in 267 nursing homes located in 10 geographic areas were assessed during the pre-RAI period. In the post-RAI period, 2000 new residents in 254 of the same facilities were assessed.

INTERVENTION

RAI implementation began in October 1990 and continued until October 1991. The RAI includes a structured, multidimensional resident assessment and problem identification system designed to form the basis for residents' care plans.

MEASUREMENTS

All residents were assessed at baseline and at 6 months using the Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS) and its protocols. All data were collected by research nurses employed and trained by the research team.

RESULTS

Implementation of the RAI significantly reduced the rate of decline in seven of the nine outcomes under consideration. Reductions in improvement were also observed in all outcomes. In activities of daily living, social engagement, and cognitive function, the reduced decline far outweighed any reductions in improvement. In mood problems, problem behaviors, and understanding others, however, reductions in improvement were greater than any reductions in decline. Changes in the rates of decline and improvement were not uniform across all residents.

CONCLUSION

The RAI may have improved the quality of care of nursing home residents by reducing overall rates of decline in important areas of resident function. However, this innovation may have generated trade-offs in that it may have reduced improvement rates in some areas of function. The system's implementation also seems to have focused staff's attention on the needs and strengths of specific subpopulations of residents. Revisions of the RAI must assist staff in generalizing their efforts to all residents and to increasing improvement rates, especially in areas related to mood and behavior.

Walking to health

Walking is a rhythmic, dynamic, aerobic activity of large skeletal muscles that confers the multifarious benefits of this with minimal adverse effects. Walking, faster than customary, and regularly in sufficient quantity into the 'training zone' of over 70% of maximal heart rate, develops and sustains physical fitness: the cardiovascular capacity and endurance (stamina) for bodily work and movement in everyday life that also provides reserves for meeting exceptional demands. Muscles of the legs, limb girdle and lower trunk are strengthened and the flexibility of their cardinal joints preserved; posture and carriage may improve. Any amount of walking, and at any pace, expends energy. Hence the potential, long term, of walking for weight control. Dynamic aerobic exercise, as in walking, enhances a multitude of bodily processes that are inherent in skeletal muscle activity, including the metabolism of high density lipoproteins and insulin/glucose dynamics. Walking is also the most common weight-bearing activity, and there are indications at all ages of an increase in related bone strength. The pleasurable and therapeutic, psychological and social dimensions of walking, whilst evident, have been surprisingly little studied. Nor has an economic assessment of the benefits and costs of walking been attempted. Walking is beneficial through engendering improved fitness and/or greater physiological activity and energy turnover. Two main modes of such action are distinguished as: (i) acute, short term effects of the exercise; and (ii) chronic, cumulative adaptations depending on habitual activity over weeks and months. Walking is often included in studies of exercise in relation to disease but it has seldom been specifically tested. There is, nevertheless, growing evidence of gains in the prevention of heart attack and reduction of total death rates, in the treatment of hypertension, intermittent claudication and musculoskeletal disorders, and in rehabilitation after heart attack and in chronic respiratory disease. Walking is the most natural activity and the only sustained dynamic aerobic exercise that is common to everyone except for the seriously disabled or very frail. No special skills or equipment are required. Walking is convenient and may be accommodated in occupational and domestic routines. It is self-regulated in intensity, duration and frequency, and, having a low ground impact, is inherently safe. Unlike so much physical activity, there is little, if any, decline in middle age. It is a year-round, readily repeatable, self-reinforcing, habit-forming activity and the main option for increasing physical activity in sedentary populations. Present levels of walking are often low. Familiar social inequalities may be evident. There are indications of a serious decline of walking in children, though further surveys of their activity, fitness and health are required. The downside relates to the incidence of fatal and non-fatal road casualties, especially among children and old people, and the deteriorating air quality due to traffic fumes which mounting evidence implicates in the several stages of respiratory disease. Walking is ideal as a gentle start-up for the sedentary, including the inactive, immobile elderly, bringing a bonus of independence and social well-being. As general policy, a gradual progression is indicated from slow, to regular pace and on to 30 minutes or more of brisk (i.e. 6.4 km/h) walking on most days. These levels should achieve the major gains of activity and health-related fitness without adverse effects. Alternatively, such targets as this can be suggested for personal motivation, clinical practice, and public health. The average middle-aged person should be able to walk 1.6 km comfortably on the level at 6.4 km/h and on a slope of 1 in 20 at 4.8 km/h, however, many cannot do so because of inactivity-induced unfitness. The physiological threshold of 'comfort' represents 70% of maximum heart rate. (ABSTRACT TRUNCATED)

The prevalence of potentially remediable urinary incontinence in frail older people: a study using the Minimum Data Set

OBJECTIVES

To use the Minimum Data Set (MDS) to describe the frequency and correlates of potentially treatable causes of urinary incontinence among a representative sample of American nursing home residents. To describe current management practices of urinary incontinence in the same population.

DESIGN

Cross-sectional study using the dataset that was part of the Health Care Financing Administration (HCFA) evaluation of the MDS.

SETTING

270 Medicaid-certified nursing homes in 10 states.

PARTICIPANTS

A total of 2014 nursing home residents 60 years or older (mean = 84.3 +/- 8.7), 75.5% women, 81.9% white, who lived in a nursing home during the fall of 1990 were randomly selected to sample a fixed number of residents for each facility based on facility size.

MEASUREMENTS

Incontinence was defined as the presence of at least two episodes of urinary leakage per week in the previous 2 weeks. Management techniques (toileting, pads/briefs, catheters) were those listed in the MDS. Potentially remediable causes of urinary incontinence available in the MDS were: medications (antipsychotics, antidepressants, and antianxiety/hypnotics); congestive heart failure; diabetes mellitus; pedal edema; delirium; depression; and impairments in activities of daily living (ADLs) (transferring, locomotion, dressing, toileting; bedrails; trunk restraints; and chair restraints).

RESULTS

Forty-nine percent of residents were incontinent. Of these, 84.0% were managed by pads/briefs, 38.7% by scheduled toileting, 3.5% by indwelling catheter, and 1.2% by external catheter. Of the potentially reversible causes, bivariate analysis revealed associations (P < .1) with use of antidepressants, antipsychotics, and antianxiety/hypnotics; delirium; bedrails; trunk restraints; chair restraints; and ADL impairment. Dementia was also associated with incontinence (P < .1). Multivariate analysis revealed that urinary incontinence was independently associated with impairment in ADLs (OR = 4.2; CI = 3.2,5.6), dementia (OR = 2.3;CI = 1.8,3.0), restraints-trunk (OR = 1.7; CI = 1.5,2.0), chair (OR = 1.4; CI = 1.2,1.6), bedrails (OR = 1.3; CI = 1.1,1.5), and use of antianxiety/hypnotic medications (OR = .7;CI = .5,1.0) (all P < .04).

CONCLUSIONS

Current management practices for urinary incontinence are inconsistent with advocated guidelines. These data also confirm the association between incontinence and several potentially remediable conditions and suggest that, even in the nursing home setting, urinary incontinence may respond to efforts to improve conditions not directly related to bladder function. This study underscores the need to examine the impact on urinary incontinence of strategies to address such conditions.