Longitudinal investigation of wandering behavior in department of veterans affairs nursing home care units

Objectives To explore the extent of and factors associated with male residents who change wandering status post nursing home admission. Design Longitudinal design with secondary data analyses. Admissions over a 4-year period were examined using repeat assessments with the Minimum Data Set (MDS) to formulate a model understanding the development of wandering behavior. Setting One hundred thirty-four Veterans Administration (VA) nursing homes throughout the United States. Participants: Included 6673 residents admitted to VA nursing homes between October 2000 and October 2004. Measurements MDS variables (cognitive impairment, mood, behavior problems, activities of daily living and wandering) included ratings recorded at residents’ admission to the nursing home and a minimum of two other time points at quarterly intervals. Results The majority (86%) of the sample were classified as non wanderers at admission and most of these (94%) remained non wanderers until discharge or the end of the study. Fifty one per cent of the wanderers changed status to non wanderers with 6% of these residents fluctuating in status more than two times. Admission variables associated with an increased risk of changing status from non-wandering to wandering included older age, greater cognitive impairment, more socially inappropriate behavior, resisting care, easier distractibility, and needing less help with personal hygiene. Requiring assistance with locomotion and having three or more medical comorbidities were associated with a decreased chance of changing from non-wandering to wandering status. Conclusion A resident’s change from non-wandering to wandering status may reflect an undetected medical event that affects cognition, but spares mobility.

Estimates of crowding in long-term care: Comparing two approaches

Objective: Because studies of crowding in long-term care settings are lacking, the authors sought to: (1) generate initial estimates of crowding in nursing homes and assisted living facilities; and (2) evaluate two operational approaches to its measurement. ----- ----- Background: Reactions to density and proximity are complex. Greater density intensifies people's reaction to a situation in the direction (positive or negative) that they would react if the situation were to occur under less dense conditions. People with dementia are especially reactive to the environment. ----- ----- Methods: Using a cross-sectional correlational design in nursing homes and assisted living facilities involving 185 participants, multiple observations (N = 6,455) of crowding and other environmental variables were made. Crowding, location, and sound were measured three times per observation; ambiance was measured once. Data analyses consisted of descriptive statistics, t-tests, and one-way analysis of variance. ----- ----- Results: Crowding estimates were higher for nursing homes and in dining and activity rooms. Crowding also varied across settings and locations by time of day. Overall, the interaction of location and time affected crowding significantly (N = 5,559, df [47, 511], F = 105.69, p < .0001); effects were greater within location-by-hour than between location-by-hour, but the effect explained slightly less variance in Long-Term Care Crowding Index (LTC-CI) estimates (47.41%) than location alone. Crowding had small, direct, and highly significant correlations with sound and with the engaging subscale for ambiance; a similar, though inverse, correlation was seen with the soothing subscale for ambiance. ----- ----- Conclusions: Crowding fluctuates consistent with routine activities such as meals in long-term care settings. Furthermore, a relationship between crowding and other physical characteristics of the environment was found. The LTC-CI is likely to be more sensitive than simple people counts when seeking to evaluate the effects of crowding on the behavior of elders-particularly those with dementia-in long-term care settings. aging in place.

Making sense of dementia : understanding amongst indigenous Australians

Dementia is a growing health and social concern for all Australians. Whilst the prevalence of dementia amongst Australia's indigenous people is unclear, there is some evidence that dementia rates are five times that of the general Australian population. To date no studies have examined dementia knowledge levels in indigenous communities. Purpose of the study: This paper aims to explore indigenous Australians' understanding, knowledge and misconceptions of dementia. Design and methods: Hundered and seventy-four indigenous adults participated in a cross-sectional survey using a modified version of the Alzheimer's Disease Knowledge Test (ADK). The survey included demographic information, two open-ended questions and 20 multiple choice questions. Each ADK item was examined to identify responses that revealed commonly held correct beliefs, knowledge gaps and misconceptions. Results: The overall level of understanding of dementia was poor. Younger participants were significantly more likely to have no knowledge of Alzheimer's Disease, whereas the other age groups were most likely to have at least some knowledge. It was also revealed that there are common misconceptions about Alzheimer's Disease held by both indigenous and non-indigenous communities. Implications: Culturally appropriate awareness campaigns and targeted educational interventions need to be implemented to improve the general level of understanding of dementia in indigenous communities.

‘I always look under the bed for a man’. Needs and barriers to the expression of sexuality in residential aged care: the views of residents with and without dementia

Objectives: This qualitative study canvassed residents' perceptions of the needs and barriers to the expression of sexuality in long-term care. Methods: Sixteen residents, including five with dementia, from six aged care facilities in two Australian states were interviewed. Data were analysed using a constant comparative method. Results: Four categories describe residents' views about sexuality, their needs and barriers to its expression: ‘It still matters’; ‘Reminiscence and resignation’, ‘It's personal’, and ‘It's an unconducive environment’. Discussion: Residents, including those with dementia, saw themselves as sexual beings and with a continuing need and desire to express their sexuality. The manner in which it was expressed varied. Many barriers to sexual expression were noted, including negative attitudes of staff, lack of privacy and limited opportunities for the establishment of new relationships or the continuation of old ones. Interviewees agreed that how a resident expressed their sexuality was their business and no one else's.

Telehealth for nursing homes: the utilization of specialist services for residential care

Specialist care consultations were identified by two research nurses using documentation in patient records, appointment diaries, electronic billing services and on-site observations at a 441-bed long term care facility. Over a six-month period there were 3333 consultations (a rate of 1511 consultations per year per 100 beds). Most consultations were for general practice (n = 2589, 78%); these consultations were mainly on site (99%), with only 27 taking place off site. There were 744 consultations for specialities other than general practice. A total of 146 events related to an emergency or unplanned hospital admission. The remaining medical consultations (n = 598, 18%) related to 23 medical specialities. The largest number of consultations were for surgery (n = 106), podiatry (n = 100), nursing services including wound care (n = 74), imaging (n = 41) and ophthalmology (n = 40). Many services which are currently being provided on site to metropolitan long-term care facilities could be provided by telehealth in both urban and rural facilities.

Attitudes and expectations of technologies to manage high risk wandering and elopement in persons with dementia : an Australian perspective

Wandering is aimless and repetitive locomotion that may expose persons with dementia (PWD) to elopement, getting lost and death. This study is an Australian replication of a US study. Cross-disciplinary consensus- based analysis was applied to data from five focus groups (N =47: cognitively intact LTC residents (5), carers of PWD (11), home care workers (13) allied health professionals and health-focused engineers (7) and RNs (11). Groups received briefing about wandering monitoring and elopement management systems. Consistent with US attitudes, participants in all groups agreed on what a wandering technology should do, how it should do it, and necessary technical specifications. Within each group participants raised the need for a continuum of care for PWD and the imperative for early recognition of potentially dangerous wandering and getting lost when they occur. Global Positioning System elopement management was the preferred option. Interestingly, the prospective value of GPS to recover a lost or eloped wanderer far outweighed privacy concerns, as in the US. A pervasive theme was that technologies need to augment, but cannot replace, attentive, compassionate caregiver presence. A significant theme raised only by Australian carers of PWD was the potential for development of implantable GPS technologies and the need for public debate about attendant ethical issues. Given that 60% or more of over 200,000 Australians and 4.5 million Americans with dementia will develop wandering, there is a pressing need to develop effective locator systems that may delay institutionalization, help allay carer concern and enhance PWD safety.

Development and review of vignettes representing older people with cognitive impairment

This paper describes a process undertaken to develop and review five clinical vignettes to be used in geriatric nursing educational research. The purpose of this process was to provide valid depictions of delirium and its subtypes and distinguish delirium from dementia. Five vignettes depicting hospital bedside interactions between nursing staff, family, and an older patient who displayed signs of one of the following conditions: delirium (hyper and hypo-active types respectively), dementia, or delirium (both types) superimposed on dementia were constructed. Vignette accuracy and reliability was established using a multistage process that culminated in formal review by a group of ten international nursing and medical delirium experts. The final five vignettes accurately depicted the given scenario as agreed by the experts and were at an appropriate level of simplicity and clarity. Given the increased interest in vignettes for both nursing research and educational purposes, the described method of vignette development and review has the ability to assist other vignette developers in creating reliable representations of their desired clinical scenarios.

A Survey-based Study of Knowledge of Alzheimer's Disease among Health Care Staff

Background Continued aging of the population is expected to be accompanied by substantial increases in the number of people with dementia and in the number of health care staff required to care for them. Adequate knowledge about dementia among health care staff is important to the quality of care delivered to this vulnerable population. The purpose of this study was to assess knowledge about dementia across a range of health care staff in a regional health service district. Methods Knowledge levels were investigated via the validated 30-item Alzheimer's Disease Knowledge Scale (ADKS). All health service district staff with e-mail access were invited to participate in an online survey. Knowledge levels were compared across demographic categories, professional groups, and by whether the respondent had any professional or personal experience caring for someone with dementia. The effect of dementia-specific training or education on knowledge level was also evaluated. Results A diverse staff group (N = 360), in terms of age, professional group (nursing, medicine, allied health, support staff) and work setting from a regional health service in Queensland, Australia responded. Overall knowledge about Alzheimer's disease was of a generally moderate level with significant differences being observed by professional group and whether the respondent had any professional or personal experience caring for someone with dementia. Knowledge was lower for some of the specific content domains of the ADKS, especially those that were more medically-oriented, such as 'risk factors' and 'course of the disease.' Knowledge was higher for those who had experienced dementia-specific training, such as attendance at a series of relevant workshops. Conclusions Specific deficits in dementia knowledge were identified among Australian health care staff, and the results suggest dementia-specific training might improve knowledge. As one piece of an overall plan to improve health care delivery to people with dementia, this research supports the role of introducing systematic dementia-specific education or training.

How much do residential aged care staff members know about the nutritional needs of residents?

Background Undernutrition, weight loss and dehydration are major clinical issues for people with dementia in residential care, with excessive weight loss contributing to increased risk of frailty, immobility, illness and premature morbidity. This paper discusses a nutritional knowledge and attitudes survey conducted as part of a larger project focused on improving nutritional intake of people with dementia within a residential care facility in Brisbane, Australia. Aims The specific aims of the survey were to identify (i) knowledge of the nutritional needs of aged care facility residents; (ii) mealtime practices; and (iii) attitudes towards mealtime practices and organisation. Methods A survey based on those used in other healthcare settings was completed by 76 staff members. The survey included questions about nutritional knowledge, opinions of the food service, frequency of feeding assistance provided and feeding assessment practices. Results Nutritional knowledge scores ranged from 1 to 9 of a possible 10, with a mean score of 4.67. While 76% of respondents correctly identified risk factors associated with malnutrition in nursing home residents, only 38% of participants correctly identified the need for increased protein and energy in residents with pressure ulcers, and just 15% exhibited correct knowledge of fluid requirements. Further, while nutritional assessment was considered an important part of practice by 83% of respondents, just 53% indicated that they actually carried out such assessments. Identified barriers to promoting optimal nutrition included insufficient time to observe residents (56%); being unaware of residents' feeding issues (46%); poor knowledge of nutritional assessments (44%); and unappetising appearance of food served (57%). Conclusion An important step towards improving health and quality of life for residents of aged care facilities would be to enhance staff nutritional awareness and assessment skills. This should be carried out through increased attention to both preservice curricula and on-the-job training. Implications for practice The residential facility staff surveyed demonstrated low levels of nutrition knowledge, which reflects findings from the international literature. This has implications for the provision of responsive care to residents of these facilities and should be explored further.

Appraisal of the quality of care of older people with cognitive impairment presenting to emergency departments

The medical records of 273 patients 75 years and older were reviewed to evaluate quality of emergency department (ED) care through the use of quality indicators. One hundred fifty records contained evidence of an attempt to carry out a cognitive assessment. Documented evidence of cognitive impairment (CI) was reported in 54 cases. Of these patients, 30 had no documented evidence of an acute change in cognitive function from baseline; of 26 patients discharged home with preexisting CI (i.e., no acute change from baseline), 15 had no documented evidence of previous consideration of this issue by a health care provider; and 12 of 21 discharged patients who screened positive for cognitive issues for the first time were not referred for outpatient evaluation. These findings suggest that the majority of older adults in the ED are not receiving a formal cognitive assessment, and more than half with CI do not receive quality of care according to the quality indicators for geriatric emergency care. Recommendations for improvement are discussed.

Exploring the effect of companion robots on emotional expression in older people with dementia : a pilot randomized controlled trial

This pilot study aimed to compare the effect of companion robots (PARO) to participation in an interactive reading group on emotions in people living with moderate to severe dementia in a residential care setting. A randomized crossover design, with PARO and reading control groups, was used. Eighteen residents with mid- to late-stage dementia from one aged care facility in Queensland, Australia, were recruited. Participants were assessed three times using the Quality of Life in Alzheimer’s Disease, Rating Anxiety in Dementia, Apathy Evaluation, Geriatric Depression, and Revised Algase Wandering Scales. PARO had a moderate to large positive influence on participants’ quality of life compared to the reading group. The PARO intervention group had higher pleasure scores when compared to the reading group. Findings suggest PARO may be useful as a treatment option for people with dementia; however, the need for a larger trial was identified.