Debbie Tolson

International Association of Gerontology and Geriatrics: A Global Agenda for Clinical Research and Quality of Care in Nursing Homes

A workshop charged with identifying the main clinical concerns and quality of care issues within nursing homes was convened by the International Association of Gerontology and Geriatrics, with input from the World Health Organization. The workshop met in Toulouse, France, during June 2010. Drawing on the latest evidence and mindful of the international development agenda and specific regional challenges, consensus was sought on priority actions and future research. The impetus for this work was the known variation in the quality of nursing home care experiences of older people around the world. The resulting Task Force recommendations include instigation of sustainable strategies designed to enhance confidence among older people and their relatives that the care provided within nursing homes is safe, mindful of their preferences, clinically appropriate, and delivered with respect and compassion by appropriately prepared expert doctors, registered nurses, administrators, and other staff. The proposals extend across 4 domains (Reputational Enhancement and Leadership, Clinical Essentials and Care Quality Indicators, Practitioner Education, and Research) that, in concert, will enhance the reputation and status of nursing home careers among practitioners, promote effective evidence-informed quality improvements, and develop practice leadership and research capabilities.

International Survey of Nursing Home Research Priorities

This article reports the findings of a policy survey designed to establish research priorities to inform future research strategy and advance nursing home practice. The survey was administered in 2 rounds during 2013, and involved a combination of open questions and ranking exercises to move toward consensus on the research priorities. A key finding was the prioritization of research to underpin the care of people with cognitive impairment/dementia and of the management of the behavioral and psychological symptoms of dementia within the nursing home. Other important areas were end-of-life care, nutrition, polypharmacy, and developing new approaches to putting evidence-based practices into routine practice in nursing homes. It explores possible innovative educational approaches, reasons why best practices are difficult to implement, and challenges faced in developing high-quality nursing home research.

Effects of SolCos Model-Based Individual Reminiscence on Older Adults With Mild to Moderate Dementia Due to Alzheimer Disease: A Pilot Study

OBJECTIVE To examine effects of individual thematically-based reminiscence sessions based on the SolCos model for older adults with dementia because of Alzheimer disease (AD) as a pilot study. BACKGROUND Reminiscence activities are popular within nursing homes and generally considered to be enjoyable and helpful, however, there is a paucity of robust data demonstrating therapeutic impact. Criticisms of existing reminiscence studies include the failure to explicate the reminiscence protocol and to standardize delivery and choice of outcome measures. METHODS In this study, 82 older adults with probable AD were recruited from psychiatric day care, inpatient, and long term care facilities. Of the study group, 41 participants were randomly selected for individual reminiscence sessions during 4 weeks performed by 1 facilitator. A control group of 41 older adults were randomly involved and had no planned reminiscence treatment of any kind in the study period. All study participants were tested pre- and postintervention period with validated assessment scales to evaluate cognition and behavior. Analyses were based on delta scores, the differences between assessment scales pre- and postintervention scores, compared between the intervention and the control group. RESULTS A structured reminiscence protocol was developed with user involvement, and intervention group participants received 6-8 reminiscence sessions (average 7.4). The primary outcomes of Mini- Mental State Examination (MMSE) and Geriatric Depression Scale (GDS-30) delta scores of the intervention group were significantly better than those of the control group. Participants of the intervention group with both mild and moderate AD had significantly better GDS-30 delta scores compared with the control group. Significantly better MMSE delta scores were found only in the intervention sub-group with moderate AD. Logistic regression analyses with all study participants showed an impact of reminiscence sessions on depressive symptoms measured with GDS-30. CONCLUSIONS The pilot study results showed positive effects associated with individual thematically-based reminiscence on well-being such as depressive symptoms and cognition of participants. This is an encouraging finding after a relatively short period. Further study is necessary to confirm these results, determine sustainability and optimal delivery methods.

Increasing awareness of the factors producing falls: the mini falls assessment

Falls represent one of the most common harmful occurrences in nursing homes, and injurious falls account for approximately 60% of all liability cases filed against nursing homes.1,2 Persons in nursing homes fall three times more frequently than persons living in the community. There are approximately 1.7 (0.6e3.6) falls per nursing home bed per year.3 Falls are the major cause of hip fractures, head trauma, lacerations, other fractures, and soft tissue injuries. As we age, falls are inevitable; therefore, our goals are to decrease the number of falls and prevent injuries where possible. Among nursing home residents, rates of hip fracture can be as high as 6.2% in women and 4.9% in men.4 The cost of falls in the United States is estimated to be

An International Survey of Nursing Homes

40 billion by 2020.5 Although single intervention programs have minor effects on falls, the Cochrane review has found that multifactorial interventions successfully reduce falls.6,7 Despite this, certified nursing aides believe that falls are not preventable.8 Numerous physiological changes occur with aging that increase the propensity for falls. The development of frailty,9e20 weight loss,21e24 and sarcopenia,25e32 which are all common in the nursing home, leads to the increased propensity for falls. Physiological changes increasing the likelihood of falls include decreased muscle strength, altered length and height of steps, increased dual foot contact time, a broader walking base, and slowed walking speed. Both very slow ( 1.3 m/s) walking speeds are associated with increased falls.33 A decline in vestibular function (30% loss of hair cells and nerve fibers), decreased nerve conduction owing to axonal atrophy, and alterations in joint function result in a decline in propioception. This leads to increased body sway. Older persons tend to develop backward disequilibrium or retropulsion, which leads to their tendency to fall backwards or to the side. This appears to be associated with increased subcortical vascular lesions.34 The decline in executive function with aging leads to the “stops talking while walking” syndrome or problems with dual tasking. Changes in vision (decline in visual acuity, cataracts, and age-related macular degeneration)35,36 and wearing bifocals37 are also associated with falls. Most falls are caused by tripping, as the ability to see and negotiate obstacles in time, and the ability to

Advanced Practice Nurses and Attending Physicians: A Collaboration to Improve Quality of Care in the Nursing Home

This article reports the results of an exploratory survey of nursing home care in 30 countries. Most countries used either a social or nursing home model, with a physician model being less common. Resident Assessment Instruments were used in only 35% of countries. Physician visits to the nursing home occurred in 37%. All but 2 countries used advanced practice nurses. Medication use was high, with 82% of countries reporting residents taking 6 or more medicines a day.

The International Association of Gerontology and Geriatrics (IAGG) Nursing Home Initiative

The introduction of such advanced practice roles have been advocated inmany countriesandwherethisisprogressing,inter- and intraprofessional practice boundaries are becoming increasingly blurred. In the United Kingdom, current attention is on the preparation that will equip nurses to provide an advanced level of practice rather than on the establishment of APNs. The recent Department of Health (UK) position statement 2 usefully explains universal features of nurses working at an advanced level in that they use critical thinking, complex reasoning, reflection and analysis to inform their assessments, clinical judgments, and decisions. Such advanced practitioners act as nurse leaders and have the capability to improve the quality of patient care and manage complex health care situations. The following discussion reviews evidence surrounding the contributions of the APN within the long-term care setting. This editorial will focus on clinical care aspects involving the APNs, and briefly look at the international debates concerning education preparation for such roles, with highlights of an innovative pathway developed by the United Kingdom. In the United States, most APNs work in collaborative practice with one or more physicians. Guidelines for the collaborative relationship between physicians and APNs in long-term care facilities were recently published in the Journal. 3 Advanced practice nurses can specialize in their education and training. Their educational tracks may prepare them to work as nurse practitioners or as clinical nurse specialists. Clinical nurse specialists may be used in educational roles, or as consultants on special projects, such as fall prevention or restraint reduction. They may work for an outside agency or insurance company as a case manager. Other APNs (both nurse practitioners and clinical nurse specialists) may be found working in collaboration with specialists, such as geropsychiatrists, cardiologists, oncologists, and physicians specializing in wound care management. The average APN makes 12 to 18 visits a day, with mental health APNs making a smaller number. 1

Are older patients’ cardiac rehabilitation needs being met?

Nursing homes have a long history of providing inconsistent standards of care quality to older persons.1,2 In 2010, under the leadership of Professor Bruno Vellas, the International Association of Gerontology and Geriatrics (IAGG) developed a task force to focus on the needs of nursing homes and how to develop research in nursing homes. This led to a position paper setting out a global development agenda on nursing homes3 that was widely publicized.4e7 The position paper focused on 4 major areas:

Physical Restraints: Abusive and Harmful

Aims. The primary aim of this study was to examine the needs of older people in relation to cardiac rehabilitation and to determine if these were currently being met. A secondary aim was to compare illness representations, quality of life and anxiety and depression in groups with different levels of attendance at a cardiac rehabilitation programme. Background. Coronary heart disease accounted for over seven million cardiovascular deaths globally in 2001. Associated deaths increase with age and are highest in those older than 65. Effective cardiac rehabilitation can assist independent function and maintain health but programme uptake rates are low. We have, therefore, focussed specifically on the older patient to determine reasons for the low uptake. Design. Mixed methods. Methods. A purposive sample of 31 older men and women (≥65 years) completed three questionnaires to determine illness representations, quality of life and anxiety and depression. They then underwent a brief clinical assessment and participated in a face-to-face audio-taped interview. Results. Quantitative: Older adults, who did not attend a cardiac rehabilitation programme, had significantly poorer personal control and depression scores (p < 0·01) and lower quality of life scores than those who had attended. Few achieved recommended risk factor reduction targets. Qualitative: The three main themes identified as reflecting the views and experiences of and attendance at the cardiac rehabilitation programme were: ‘The sensible thing to do’, ‘Assessing the impact’ and ‘Nothing to gain’. Conclusions. Irrespective of level of attendance, cardiac rehabilitation programmes are not meeting the needs of many older people either in terms of risk factor reduction or programme uptake. More appropriate programmes are needed. Relevance to clinical practice. Cardiac rehabilitation nurses are ideally placed to identify the rehabilitation needs of older people. Identifying these from the older person’s perspective could help guide more appropriate intervention strategies.

Baseball reminiscence league: a model for supporting persons with dementia

Contemporary health care policy around the world promotes the use of evidence-based medicine and, as such, it is reasonable to assume that this would lead to similarities in health care practices in comparable economies. Interestingly, this does not seem to be the case with the use of restraining technologies and restraint policies implemented within hospitals and nursing homes. Definitional ambiguity surrounding what is an abusive act may in part account for these practice variations, given that interpretations of an abusive act are contingent on particular circumstances. For example, if a practitioner restrains a patient who is behaving aggressively, it might be interpreted as a justifiable act, or an act of abuse that may be criminal, depending on the situation. Examples of physical restraint used in acute hospitals and nursing homes include body belts, restraining vests, cuffs, and bilateral bedrails. Chemical restraints are any medication used to manage what are perceived to be challenging behaviors, such as agitation, aggression, or verbal abuse. A common feature of restraining policies is that a set of permissions is usually required before application of the restraint. These permissions often include authorization by senior medical and nursing staff, permission of relatives or a legally recognized alternate, and, where appropriate, the individual’s consent. Acquiring a restraining order is, however, an insufficient justification for restraint use, it is simply an organizational process requirement, and the decision to restrain, like any health care intervention, should be influenced by the best available evidence. Therapeutic justifications for commonly used physical and chemical restraints are usually couched in terms of safety measures associated with harm prevention and risk reduction.1 We examine this premise in terms of the strength of patient benefit evidence.1 In doing so, we are mindful of other determinants that influence practitioner decisions to use or not to use restraining devices in given situations. These broader determinants include staff perception of the benefits and acceptability of the restraining procedure, knowledge of adverse effects, local practice custom, staffing levels, opportunity to provide staff with intensive interventions, such as continuous supervision, the perceived legality of restraining devices, and societal and organizational cultural norms.