John F. Schnelle

The Quality of Medical Care Provided to Vulnerable Community-Dwelling Older Patients

Context Many Americans 65 years of age and older are at risk for functional decline, yet we know little about the quality of care for geriatric conditions. Contribution This study used a 13-item survey about functional status to evaluate the care of 420 people 65 years of age and older whom the investigators identified as vulnerable to functional decline. Quality of care was highly variable from condition to condition but was generally better for general medical conditions, such as diabetes, than for geriatric conditions, such as incontinence. Implications Efforts to improve care for vulnerable elders should focus on the geriatric conditions that profoundly influence functional status. The Editors The quality of care among patients 65 years of age and older has not been extensively investigated, and most existing studies have focused on general adult medical conditions. This is surprising, considering that more than 40% of all medical expenditures are for persons 65 years of age and older (1). The most comprehensive study to date of quality of care among older patients evaluated 24 process indicators among U.S. Medicare beneficiaries in all 50 states between 1997 and 1999 (2). Care for acute myocardial infarction, heart failure, stroke, and pneumonia was evaluated by using inpatient medical records. Pneumonia, breast cancer, and diabetes indicators were evaluated by using survey and Medicare claims data. The investigators found that the percentage of patients receiving appropriate care varied widely by measure and state. Several other studies of older patients evaluated cardiovascular conditions, diabetes, or aspects of preventive care and medication use (3-10). No study, however, has assessed the quality of medical care provided for geriatric conditions that profoundly affect the lives of vulnerable older patients. Furthermore, surveys find that older persons often prioritize function and comfort over disease treatment and prolongation of life (11). Quality-of-care measurement for older patients that examines only a few conditions and only indicators aimed at prolonging life yields an incomplete assessment because it ignores other conditions and aspects of care that are of equal or even greater importance to older patients. For this reason, we developed a quality assessment system that assesses more conditions. Together, these conditions account for a majority of all of the care older patients receive (12) and include several geriatric syndromes. We used this quality assessment system to evaluate the care provided to a sample of vulnerable elders at increased risk for death or functional decline. Methods The Assessing Care of Vulnerable Elders (ACOVE) project developed and applied a quality assessment system for vulnerable older persons. The assessment system aimed to develop quality indicators (QIs) that cover the spectrum of care for these patients. Indicators were implemented by using medical record abstraction and patient interview. The ACOVE Quality-of-Care Assessment System The ACOVE investigators developed a system of QIs to cover the most important conditions vulnerable elders encounter in all care venues. This system focused on processes (care behaviors) rather than outcomes for 2 reasons. First, although most agree that outcomes should be adjusted for risk when quality is measured, there is little consensus regarding the best severity measurement system (13). Second, measurement of processes of care is thought to be a more direct assessment of quality than measurement of outcomes (14). The process measures were selected to represent the various domains of care: screening and prevention, diagnosis, treatment, and follow-up. The development of the assessment system was guided by a Policy Advisory Committee, which helped to direct the focus toward practical applications, and by a Clinical Committee, which provided clinical expertise for development and monitored the assembly of the QIs into a comprehensive system (15). The methods for selecting conditions and developing the QIs have been described in detail elsewhere (12, 16). In brief, the Clinical Committee used the criteria of prevalence, impact, effectiveness of prevention or treatment, need for quality improvement, feasibility of measurement, and geriatric niche in a formal group rating process to identify 22 target conditions for quality improvement (12). For each of the 22 conditions, we developed a set of evidence-based QIs for vulnerable elders using a combination of systematic reviews and expert judgment (16). Of 420 proposed QIs, the 2 expert panels, the Clinical Committee, and the American College of Physicians Task Force on Aging accepted 236 as valid indicators; these were assembled into the ACOVE QI set (17). The 236 QIs covered the domains of care as follows: Sixty-one (26%) focused on screening and prevention, 50 (21%) focused on diagnosis, 84 (36%) focused on treatment, and 41 (17%) focused on follow-up and continuity of care. Examples of ACOVE QIs for each condition are presented in Table 1. Table 1. Examples of Assessing Care of Vulnerable Elders Quality Indicators Patients and Data Collection Using the ACOVE QI set, we assessed care provided to seniors who were enrolled in 2 managed care organizations. These patients were defined as vulnerable on the basis of self-report or proxy report on a brief, 13-item screening survey (Vulnerable Elders-13 [VE-13] Survey [18]). Vulnerable elders, identified by this function-based survey, are community-dwelling persons 65 years of age and older who have 4 times the risk for functional decline or death over the next 2 years compared with individuals not identified as vulnerable (18). Each managed care organization, 1 in the northeastern United States and the other in the southwestern United States, had more than 20 000 elderly enrollees and contracted with a network of providers to deliver care. Eligibility criteria included continuous enrollment in the managed care organization for at least 13 months and no out-of-plan care or active treatment for malignant conditions (excluding nonmelanoma skin cancer) during this period. A random sample of 3207 community-dwelling elderly adults was drawn from eligible persons in each managed care organization by using a random-number generator. Vulnerable elders were identified by using the VE-13 Survey as part of a telephone interview. Patients who did not speak English were not eligible to participate. The RAND Institutional Review Board approved the study protocol. Medical Record Review Using administrative data, we identified all inpatient and outpatient medical care received by study participants during the 13-month period of 1 July 1998 to 31 July 1999. Medical records were requested from primary care and specialist providers (including eye care and mental health providers), acute care hospitals, skilled-nursing facilities, home health agencies, and facilities providing outpatient services (for example, physical therapy). Identifying information of patients and providers was removed from the medical records. Trained nurses with previous experience in quality assessment performed medical record abstraction. Abstractors were provided with written abstraction guidelines and real-time consultation with a senior nurse reviewer. The abstractor considered all of a patients records when assessing whether he or she was eligible for and received the indicated care processes. In other words, information on eligibility for a QI could have been derived from 1 record (such as an outpatient note) while the care process was delivered and documented in another setting (for example, inpatient medical record). If the care process was performed in the defined time interval, care was scored as complying with the QI. The senior nurse reviewer also assessed each completed medical record abstraction. Physicians reviewed QIs that required a more detailed level of clinical assessment. Examples include whether the elements of a delirium evaluation had been completed or whether an adequate intervention was performed for hyperlipidemia. An ophthalmologist evaluated selected data elements addressing vision care. Ten percent of all records were reabstracted to evaluate reliability of the abstraction process. Exact agreement on QI eligibility and score was 95%. (For details of abstractor preparation and abstraction materials, see the Appendix.) Quality-of-Care Interview A quality-of-care interview was conducted to ask study participants (or, if participants were incapable of responding, their proxies) about aspects of their care that might not be captured in the medical record (for example, physicianpatient counseling). On the basis of conditions and medications reported during the interview, patients were asked about specific processes of care they had received. Patients were also asked about care preferences that might affect the applicability of QIs. In addition, the interview included demographic questions and functional status items. The quality-of-care interview was conducted by telephone between August and October 2000 and required, on average, 44 minutes to complete. Statistical Analysis Of the 236 QIs, we were able to evaluate 207 using chart abstraction (n = 185 [89%]) or interview (n = 22 [11%]). Interview was used to score QIs for data elements that we did not collect from the medical record. A QI was scored for a patient if he or she satisfied the IF statement of the QI and thus was eligible to receive the specified care process (Table 1). A score of 1 was awarded if the care process was carried out, and a score of 0 was assigned if it was not. For QIs that included several triggering events, a score between 0 and 1 was possible. If the medical record indicated that the patient declined the care process, the QI was considered to be passed (the care was credited in both the numerator and the denominator of the indicator score). On the other hand, if the patient had a pre

Translating clinical research into practice: A randomized controlled trial of exercise and incontinence care with nursing home residents

OBJECTIVES: To examine clinical outcomes and describe the staffing requirements of an incontinence and exercise intervention.

Delirium in Older Emergency Department Patients: Recognition, Risk Factors, and Psychomotor Subtypes

OBJECTIVES Missing delirium in the emergency department (ED) has been described as a medical error, yet this diagnosis is frequently unrecognized by emergency physicians (EPs). Identifying a subset of patients at high risk for delirium may improve delirium screening compliance by EPs. The authors sought to determine how often delirium is missed in the ED and how often these missed cases are detected by admitting hospital physicians at the time of admission, to identify delirium risk factors in older ED patients, and to characterize delirium by psychomotor subtypes in the ED setting. METHODS This cross-sectional study was a convenience sample of patients conducted at a tertiary care, academic ED. English-speaking patients who were 65 years and older and present in the ED for less than 12 hours at the time of enrollment were included. Patients were excluded if they refused consent, were previously enrolled, had severe dementia, were unarousable to verbal stimuli for all delirium assessments, or had incomplete data. Delirium status was determined by using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) administered by trained research assistants (RAs). Recognition of delirium by emergency and hospital physicians was determined from the medical record, blinded to CAM-ICU status. Multivariable logistic regression was used to identify independent delirium risk factors. The Richmond Agitation and Sedation Scale was used to classify delirium by its psychomotor subtypes. RESULTS Inclusion and exclusion criteria were met in 303 patients, and 25 (8.3%) presented to the ED with delirium. The vast majority (92.0%, 95% confidence interval [CI] = 74.0% to 99.0%) of delirious patients had the hypoactive psychomotor subtype. Of the 25 patients with delirium, 19 (76.0%, 95% CI = 54.9% to 90.6%) were not recognized to be delirious by the EP. Of the 16 admitted delirious patients who were undiagnosed by the EPs, 15 (93.8%, 95% CI = 69.8% to 99.8%) remained unrecognized by the hospital physician at the time of admission. Dementia, a Katz Activities of Daily Living (ADL) < or = 4, and hearing impairment were independently associated with presenting with delirium in the ED. Based on the multivariable model, a delirium risk score was constructed. Dementia, Katz ADL < or = 4, and hearing impairment were weighed equally. Patients with higher risk scores were more likely to be CAM-ICU positive (area under the receiver operating characteristic [ROC] curve = 0.82). If older ED patients with one or more delirium risk factors were screened for delirium, 165 (54.5%, 95% CI = 48.7% to 60.2%) would have required a delirium assessment at the expense of missing 1 patient with delirium, while screening 141 patients without delirium. CONCLUSIONS Delirium was a common occurrence in the ED, and the vast majority of delirium in the ED was of the hypoactive subtype. EPs missed delirium in 76% of the cases. Delirium that was missed in the ED was nearly always missed by hospital physicians at the time of admission. Using a delirium risk score has the potential to improve delirium screening efficiency in the ED setting.

A randomized trial of a combined physical activity and environmental intervention in nursing home residents: do sleep and agitation improve?

OBJECTIVES: The purpose of this study was to test whether an intervention combining increased daytime physical activity with improvement in the nighttime environment improves sleep and decreases agitation in nursing home residents.

Functional Incidental Training, Mobility Performance, and Incontinence Care with Nursing Home Residents

OBJECTIVE: To determine if an exercise intervention, Functional Incidental Training (FIT), results in improvements in mobility endurance and physical activity when compared with prompted voiding (PV) among cognitively and mobility impaired nursing home residents.

A Walking Program for Nursing Home Residents: Effects on Walk Endurance, Physical Activity, Mobility, and Quality of Life

OBJECTIVES: To determine the effects of a 12‐week walking program on walk endurance capacity, physical activity level, mobility, and quality of life in ambulatory nursing home residents who had been identified as having low physical activity levels and low walk endurance capacities. To determine the effects of 12 versus 22 weeks of walk training on walk endurance capacity, physical activity level, mobility, and quality of life in ambulatory nursing home residents.

Does eradicating bacteriuria affect the severity of chronic urinary incontinence in nursing home residents

Urinary incontinence is a multibillion-dollar health problem that afflicts almost 60% of some 2 million residents of the 20 000 nursing homes in the United States. Bacteriuria is also prevalent in this population, and the two conditions commonly coexist [1]. Incontinent nursing home residents are frequently prescribed antimicrobial agents for urinary tract infections, but the quality and appropriateness of such prescriptions have been questioned [2-5]. Unnecessary antimicrobial treatment may result in the undesired development of resistant organisms and substantial unnecessary morbidity and health care expenditure. Well-designed clinical trials have documented that treating asymptomatic bacteriuria in the nursing home population has no significant effects on morbidity and mortality and that it actually leads to the development of strains of bacteria that are resistant to commonly prescribed antimicrobial agents [6, 7]. However, no studies have carefully examined the effects of eradicating bacteriuria on the severity of incontinence in this population. In a longitudinal study of a cohort of older women, Boscia and colleagues [8] found no difference in self-reported symptoms of incontinence in patients with and without bacteriuria. This was, however, a study of bacteriuria and not of incontinence, and the participants had, on average, mild incontinence [9]. In one study of behavioral therapy for incontinence in nursing home residents, incontinence appeared to worsen in several of the study participants when bacteriuria developed [10]. Epidemiologic studies from Europe have reached different conclusions about the association between bacteriuria and incontinence in the geriatric population [11, 12]. Despite a lack of definitive data on the relation of bacteriuria to the pathogenesis and severity of incontinence in the nursing home population, recently implemented federal guidelines for the care of incontinence in nursing homes (Resident Assessment Protocol) [13] suggest that bacteriuria should be treated only when symptoms of urinary tract infection other than stable incontinence are present. If eradicating bacteriuria makes the bladder less irritable in this patient population, then the severity of incontinence and the use of expensive adult diapers might be reduced [14]. If, however, eradicating bacteriuria has no effect on the severity of incontinence, no rationale would exist for exposing incontinent nursing home residents with bacteriuria to the potential added morbidity and expense of antimicrobial therapy. We conducted a clinical trial to determine whether eradicating bacteriuria affects the severity of incontinence among nursing home residents. We defined bacteriuria as would a practicing clinician in a nursing home rather than by the strict definition used in most studies of the epidemiology of asymptomatic bacteriuria (that is, two consecutive cultures with growth of more than 105 colony-forming units [CFUs] of the same organism). We hypothesized that sterilizing the urine would have no short-term effect on the severity of chronic incontinence in this population. Methods Setting Our study was the first phase of a multifaceted clinical trial addressing the assessment and treatment of incontinence in nursing homes. It was done in one nonprofit and five proprietary nursing homes located close to the offices of the University of California at Los Angeles Borun Center for Gerontological Research at the Jewish Home for the Aging. The nursing homes had a total of 1011 beds (range, 99 to 256 beds) and a total of 832 residents. Patients We identified potential patients by asking nursing home staff to identify residents who were incontinent of urine on a regular basis [that is, several times per week to several times per day]. Patients were excluded if 1) their care was being reimbursed by Medicare [indicating either short-term rehabilitation or medical instability]; 2) their prognosis, as determined by the research staff nurse, was so poor that they would probably not live at least 3 to 4 months to complete the protocol; 3) daytime incontinence was not documented by random-hour checks for wetness [described below]; 4) the resident had a permanent indwelling bladder catheter; 5) the resident failed a cognitive status screening test [to pass, the resident had to either say their name or reliably point to one of two objects]; and 6) the resident manifested a severe behavioral disturbance, such as physical aggression or verbal abusiveness, during the wet-checking procedures. Informed consent was obtained from residents who could provide it (as determined by a facility nurse or social worker). If the resident was not capable of consenting, their assent was obtained (by describing a simple version of the protocol and then observing their cooperation as the protocol was initiated), and consent was then obtained from a responsible party. Procedures All patients for whom informed consent was obtained had a focused history, functional status assessment, cognitive assessment with the 30-point Mini-Mental State Examination, targeted physical examination, urinalysis, and urine culture. For the functional assessment, research staff used the Multidimensional Observational Scale for the Elderly Subject [15] to interview nursing home staff who knew the residents well. (When our study was implemented, the Minimum Data Set was not yet available.) Research staff used a standardized scale (Performance on Timed Toileting Instrument [16]) to objectively assess functional status specifically related to toileting skills. The physical examination was done by research staff and a physician coinvestigator and included abdominal, genital, pelvic, rectal, and neurologic examinations. Research staff collected urine from female patients by cleaning the perineal area with Betadine and having them void into a fracture bed pan or measuring hat that had been cleaned with an antiseptic solution. We compared the culture results of urine samples obtained by this procedure to urine samples obtained by catheterization in 101 of our female patients [17]. The prevalence of bacteriuria in the catheterized specimens was 29%. The sensitivity, specificity, and positive and negative predictive values of this procedure in detecting bacteriuria (with a catheter specimen used as the criterion standard) are 90%, 92%, 81%, and 95%, respectively. For men who could not void voluntarily, we used a previously validated technique that involved cleaning the glans penis with Betadine, applying a clean condom catheter, and processing the first voided specimen [18]. Urine specimens were subjected to screening tests done by research staff (including a dipstick method for leukocyte esterase and nitrite and a rapid enzyme-based test for bacteriuria [Uriscreen, Ventrex Laboratories, Portland, Maine]). A bioclinical laboratory used standard techniques to do a microscopic urinalysis and a urine culture and sensitivity test. We defined pyuria as the presence of more than 10 leukocytes per high-power field on microscopic examination of spun urine. Cultured specimens that grew more than 50 000 CFUs were considered to have significant growth. If significant growth of one or more urinary pathogens occurred on a second specimen, the patient was considered to be bacteriuric. Patients whose urine had significant growth of organisms that are not typically pathogens (for example, lactobacillus and -streptococcus) were not considered to be bacteriuric. Our quantitative definition of bacteriuria differs from the standard definition (presence of more than 100 000 CFUs) that has been used in most epidemiologic studies and intervention trials. However, there is controversy about the clinical significance of lower levels of growth [19], and in some studies in the elderly, bacteriuria has been defined as growth of less than 100 000 CFUs [20, 21]. We used the cutoff of 50 000 CFUs because our clinical laboratory reported results at this level, and we believe that most clinicians who practice in nursing homes would consider this to be significant growth when making decisions about treatment. Less than 10% of our cultures that were considered to have significant bacteriuria had growth of more than 50 000 CFUs. In addition, each patient identified as bacteriuric who had growth of more than 50 000 CFUs on one culture did have a second culture with growth of more than 100 000 CFUs; the only exceptions were two patients whose urine samples before treatment were collected by catheterization (see below). Most specimens obtained after antimicrobial treatment were collected by catheterization, which was done for a determination of postvoid residual volume in the second phase of the longer ongoing clinical trial. Six patients whose urine was initially not bacteriuric by the criteria outlined above were considered to be bacteriuric on the basis of the catheterized specimen and were enrolled in the antimicrobial trial. For these patients, follow-up urine samples were collected by the methods described above rather than by repeat catheterization. Eradication of bacteriuria was documented by culture in all but seven cases; in these cases, the screening tests were used to document that bacteriuria had been eradicated. We have shown that in our population, the presence of at least two negative results on these screening tests has a negative predictive value of more than 90% [22]. Bacteriuric patients were randomly assigned to receive either immediate treatment or delayed treatment (which was administered 2 to 3 weeks after the immediate treatment group had been treated) with a 7-day course of norfloxacin, 400 mg orally twice daily. In three cases, the organism or organisms were not susceptible to norfloxacin, and another antimicrobial agent (trimethoprim-sulfamethoxazole) was used on the basis of results of the sensitivity testing. Wet checks, the outcome measure used in our study and described in detail below, w

Does Oxybutynin Add to the Effectiveness of Prompted Voiding For Urinary Incontinence Among Nursing Home Residents? A Placebo-Controlled Trial

OBJECTIVE: To determine if oxybutynin, a bladder relaxant medication, adds to the effectiveness of prompted voiding (PV) in the management of urinary incontinence among nursing home residents.

Incontinence in the Nursing Home

Incontinence is one of the most common conditions encountered in the nursing home population. Recently implemented rules and regulations for nursing home care (Omnibus Budget Reconciliation Act [OBRA] 1987) [1] require that incontinent nursing home residents have a basic diagnostic assessment and that residents managed by an indwelling bladder catheter have an appropriate indication for this device documented in their medical record. The federally mandated Minimum Data Set (MDS) [2] includes a separate section for the documentation of continence status that is completed by nursing home staff within 14 days of admission and updated on a quarterly basis. Incontinence documented on the MDS should trigger the use of the Resident Assessment Protocol for incontinence [3]. Some of this assessment can be done by a trained nurse practitioner, physicians assistant, or clinical nurse specialist with input from members of the nursing home interdisciplinary team. The assessment does, however, require the involvement of the primary physician. We provide an overview of the assessment and treatment of incontinence in the nursing home setting. Prevalence and Morbidity Urinary incontinence affects approximately half of nursing home residents [4, 5]. The prevalence varies among individual facilities depending on the case mix; rates may range from 40% to 70% or even higher in facilities with a functionally impaired resident population. In contrast to urinary incontinence among ambulatory community-dwelling geriatric patients, urinary incontinence among nursing home residents is more severe and more commonly associated with fecal incontinence. Incontinent nursing home residents generally have multiple episodes of urinary incontinence throughout the day and night, and approximately half are also incontinent of stool more than once per week [5, 6]. Urinary incontinence in the nursing home is associated with substantial morbidity and cost. It can predispose patients to skin irritation, make pressure ulcers difficult to heal [7], and result in symptomatic urinary tract infection when urinary retention with overflow urinary incontinence remains undiagnosed or when urinary incontinence is inappropriately managed by long-term use of an indwelling catheter [8, 9]. It may also lead to falls among residents with nocturia and urge urinary incontinence and impaired balance or gait [10]. The adverse psychological effects of urinary incontinence among nursing home residents have been difficult to document systematically [11], but incontinent residents who do not have severe dementia are often embarrassed and frustrated by their urinary incontinence. Nursing home staff generally consider urinary incontinence to be one of the most onerous and difficult conditions for which they care, and they perceive that they spend a disproportionate amount of time on the care of incontinent residents. The economic costs of urinary incontinence in the nursing home have been estimated to be close to

Selecting Target Conditions for Quality of Care Improvement in Vulnerable Older Adults

5 billion annually, including the costs of staff time, laundry, and supplies [12]. Types and Causes of Urinary Incontinence The pathogenesis of urinary incontinence among nursing home residents is often multifactorial, involving urologic and gynecologic conditions, neurologic disorders, behavioral and psychological factors, and functional impairments. Thus, the approach to assessment and treatment must be comprehensive and consider all of these potential factors. The most important factors to consider are those that are reversible. Potentially reversible conditions that can contribute to urinary incontinence in nursing home residents are listed in Table 1. These factors can be recalled by the acronym DRIP (delirium; restricted mobility, retention; infection, inflammation, impaction; polyuria, pharmaceuticals). Although identification and management of these reversible factors may not cure the urinary incontinence, its severity may be reduced and thereby be made more manageable by other interventions. In addition, identification and management of these conditions may have important benefits for the residents overall functioning and quality of life. Table 1. Potentially Reversible Conditions That Can Cause or Contribute to Urinary Incontinence in Nursing Home Residents A classification of the basic types of persistent urinary incontinence is shown in Table 2. Three important features of this classification should be noted. First, from a neurologic perspective, this classification is greatly simplified and does not include all of the pathophysiologic types of urinary incontinence. For example, patients with suprasacral spinal cord lesions, such as those that can occur in multiple sclerosis, may have detrusor hyperreflexia with external sphincter dyssynergy that can result in incontinence and incomplete bladder emptying (detrusor-sphincter dyssynergy). Second, many incontinent nursing home residents have mixtures of these types of incontinence. The predominant abnormality of lower urinary tract functioning found among nursing home residents is detrusor hyperactivity (involuntary bladder contractions found on cystometry; also called detrusor instability, unstable bladder, and detrusor hyperreflexia [the latter occurs in the presence of a neurologic disorder]). Although most often associated with urge urinary incontinence, detrusor hyperactivity is commonly seen with sphincter weakness and stress urinary incontinence among women and with obstruction in men with benign or malignant enlargement of the prostate. Interestingly, detrusor hyperactivity is also seen in continent elderly people (men more frequently than women) [13, 14]; thus, its precise role in the pathogenesis of incontinence in the nursing home population is incompletely understood. In nursing home residents, detrusor hyperactivity is commonly associated with impaired bladder contractility that results in incomplete bladder emptying (called detrusor hyperactivity with impaired contractility) [15, 16]. Nursing home residents with this disorder may have symptoms that mimic stress, overflow, or urge incontinence. Third, and most importantly, functional urinary incontinence should be a diagnosis of exclusion because most nursing home residents have impairments of cognitive or physical functioning that may interfere with their ability to use a toilet. These residents may also have other potentially treatable conditions that contribute to their urinary incontinence. Thus, a search for reversible factors and other types of urinary incontinence should be done before a nursing home residents urinary incontinence is labeled as functional. Table 2. Types and Causes of Urinary Incontinence Assessment Nursing home residents are heterogeneous, and a realistic and appropriate goal for one type of resident may be unrealistic and inappropriate for another [17, 18]. The approach to urinary incontinence brings this concept into sharp focus. A resident having active rehabilitation after a hip fracture or a stroke may, after a thorough incontinence assessment, benefit from a specific bladder-retraining protocol or pharmacologic therapy for detrusor hyperactivity; incontinence undergarments and indwelling catheters are probably inappropriate for this type of resident. On the other hand, a resident with end-stage dementia and severe agitation may be most appropriately managed by an incontinence undergarment after reversible causes of their urinary incontinence have been excluded. Thus, an important aspect of incontinence care is to determine, through the interdisciplinary care-planning process, if a particular resident has the potential to respond to specific interventions for the urinary incontinence. Because even severely impaired residents may respond well to a prompted voiding program (see below), a bias in favor of thorough assessment and a therapeutic trial is appropriate. Basic assessment of bladder and bowel function as indicated on the MDS is required for all newly admitted nursing home residents. A bladder and bowel record is helpful in documenting the continence status of new residents and can also be used as part of periodic reassessments. A legible record, such as the one shown in Figure 1, should be used [19]. The specific symbols used are not important, but the record should provide a simple way of documenting wetness, dryness, appropriate toileting, and bowel status and a space for comments. Records such as the one shown in Figure 1 can be reduced so that several records fit on one page. This type of record is also helpful in monitoring responses to therapeutic interventions. Because many newly admitted residents come from acute-care hospitals, they frequently arrive at the nursing home with an indwelling bladder catheter. In this situation, it is essential to determine why the catheter was placed (for example, to monitor urinary output or for urinary retention or management of urinary incontinence) and to consider the resident for a bladder-retraining program. The catheter should be removed unless there is an appropriate indication for retaining it. Figure 1. Example of a record that is helpful in assessing incontinent nursing home residents and in following their response to intervention. Basic Evaluation After these initial assessments and documentation, incontinent nursing home residents should have a basic evaluation that includes a history, physical examination, urinalysis, and determination of postvoid residual urine volume. Much of this evaluation can be done by nursing home staff and a physician extender [nurse practitioner, physicians assistant, or clinical nurse specialist]. This basic evaluation has three objectives: 1) to identify potentially reversible factors (Table 1); 2) to identify potentially serious underlying conditions or conditions that may require further urologic, gynecologic, or urodynamic evaluation (Table 3); and 3) to determine the type of incontinence (urge, stress, overflow, or mix