Dan Osterweil

Pain in the Nursing Home

Pain is an understudied problem in geriatric medicine and especially among nursing home residents. The focus of this study was to describe the scope of the problem of pain in a long‐term care facility. Ninety‐seven subjects from a 311‐bed multilevel teaching nursing home were interviewed, and charts were reviewed for pain problems and management strategies. Functional status, depression, and cognitive impairment were also evaluated. Results indicate that 71% of residents had at least one pain complaint (range, 1–4). Of subjects with pain, 34% described constant (continuous) pain and 66% described intermittent pain. Of 43 subjects with intermittent pain, 51% described pain on a daily basis. Major sources of pain included low back pain (40%), arthritis of appendicular joints (24%), previous fracture sites (14%), and neuropathies (11%). Moderately strong correlations were found between pain and infrequent attendance at recreational and social activities (r = .50). However, little correlation was observed between pain and the Yesavage Depression Scale, the Folstein Mini‐Mental State Scale, or basic ADLs measured by the Katz Scale. Pain‐management strategies consisted of analgesic drugs, physical therapy, and heating pads. Only 15% of patients with pain had received medication within the previous 24 hours. The findings suggest that pain is a major problem in long‐term care. Strategies for pain management appear to be limited in scope and application in this setting. Important barriers were identified that influence the reporting and management of pain in this setting.

The value of assessing falls in an elderly population. A randomized clinical trial.

OBJECTIVE To measure the effects of a specialized postfall assessment intended to detect causes and underlying risk factors for falls, and to recommend preventive and therapeutic interventions. DESIGN Randomized, controlled trial. SETTING A long-term residential care facility for elderly persons. SUBJECTS Within 7 days of a fall, 160 ambulatory subjects (mean age, 87 years) were randomly assigned to receive either a comprehensive postfall assessment (intervention group, n = 79) or usual care (control group, n = 81). INTERVENTION The postfall assessment included a detailed physical examination and environmental assessment by a nurse practitioner; laboratory tests; electrocardiogram; and 24-hour Holter monitoring. Probable cause or causes for the fall, identified risk factors, and therapeutic recommendations were given to the patients primary physician. MEASUREMENTS AND MAIN RESULTS Through use of the assessment, many remediable problems (for example, weakness, environmental hazards, orthostatic hypotension, drug side effects, gait dysfunction) were detected. At the end of the 2-year follow-up period, the intervention group had 26% fewer hospitalizations (P less than 0.05) and a 52% reduction in hospital days (P less than 0.01) compared with controls. Patients in the intervention group had 9% fewer falls and 17% fewer deaths than controls by 2 years, but these trends were not statistically significant. CONCLUSIONS Our study suggests that falls are a marker of underlying disorders easily identifiable by a careful postfall assessment, which in turn can reduce disability and costs.

Falls and instability in the elderly.

D r Rubenstein Falls and gait instability are among the most serious problems facing the aging population a major cause of mortality, morbidity, immobility, and premature nursing home placement. Many etiologies and risk factors predispose to falls, each requiring an individualized diagnostic and therapeutic approach to minimize likelihood of fall recurrence. In this discussion, two elderly individuals with complex, but fairly typical, fall problems are presented. These are followed by discussions of the epidemiology and common etiologies of falls, recommended diagnostic evaluations for patients following a fall, and more detailed discussion of three of the most important and least well-studied causes of falls: gait instability, muscle weakness, and environmental hazards.

Does an Exercise and Incontinence Intervention Save Healthcare Costs in a Nursing Home Population

OBJECTIVES: To determine whether an intervention that combines low‐intensity exercise and incontinence care offsets some of its costs by reducing the incidence of selected health conditions in nursing home residents.

The minimum data set pressure ulcer indicator: does it reflect differences in care processes related to pressure ulcer prevention and treatment in nursing homes?

Objectives: To determine whether nursing homes (NHs) that score in the extreme quartiles of pressure ulcer (PU) prevalence as reported on the Minimum Data Set (MDS) PU quality indicator provide different PU care.

Diabetes Mellitus in Elderly Nursing Home Patients A Survey of Clinical Characteristics and Management

The clinical features of 47 frail nursing home diabetic patients with a mean age of 81 ± 1.6 years were compared to those of 61 nondiabetic nursing home residents with a mean age of 80.2 ± 1.2 years. Diabetic patients had a higher prevalence of renal failure, proteinuria, retinopathy, neuropathy, and infections than did other nursing home residents. Macroangiopathic disease tended to be equally common in both age groups. Diabetic nursing home residents had higher body weights compared to nondiabetic nursing home residents. Surprisingly, however, 21% of nursing home diabetics were greater than 20% below average body weight (compared to 24.5% of other nursing home residents), suggesting that undernutrition is a major problem in diabetic patients in a nursing home setting. Overall, the diabetic nursing home patients had better blood glucose control than younger ambulatory diabetic patients (mean age 66.2 ± 4.7 years). The glycosylated heomglobin (HbA1) level in those on oral agents was 8.9% ± 0.7% for nursing home patients compared to 11.8% ± 0.7% in ambulatory patients (P < 0.01). The HbA1 in insulin‐treated patients was similarly lower in nursing home diabetics (9.6% ± 0.4% vs 11.8% ± 0.7, P < 0.05). There were only two mild hypoglycemic episodes in nursing home patients over 6‐month observation period, whereas 12 ambulatory patients reported hypoglycemic episodes during the same period of time. We conclude that although the diabetic nursing home patients are sicker than the ambulatory diabetics, it is possible to achieve a fair blood glucose control in nursing home patients without a significant risk of recurrent hypoglycemia.

The Minimum Data Set Weight-Loss Quality Indicator: Does It Reflect Differences in Care Processes Related to Weight Loss?

Objectives: To determine whether nursing homes (NHs) that score differently on prevalence of weight loss, according to a Minimum Data Set (MDS) quality indicator, also provide different processes of care related to weight loss.

Barriers to Effective Communication in Skilled Nursing Facilities: Differences in Perception between Nurses and Physicians

BACKGROUND: Effective communication between nurses and physicians is central to the clinical care of nursing home residents. Anecdotal evidence suggests that communication between the groups is unsatisfactory, but no empirical data exist with which to validate assumptions. The purpose of this pilot study was to compare perceptions of potential communication barriers among nurses and physicians in four California nursing homes.

Cognitive Function in Old and Very Old Residents of a Residential Facility: Relationship to Age, Education, and Dementia

OBJECTIVE: To determine if age, education, and dementia status affect neuropsychological performance in old and very old frail residential care subjects.

A standardized quality assessment system to evaluate incontinence care in the nursing home.

Objectives: To demonstrate the reliability and feasibility of a standardized protocol to assess and score urinary incontinence care in nursing homes.