Mildred Ramirez

Prevalence of depression and depression recognition in nursing homes

Background The aim of this study was to estimate the prevalence of depression among nursing home residents, and the extent of depression recognition among nursing home staff. Random samples totaling 319 nursing home residents, drawn from a simple random sample of six downstate New York nursing homes were evaluated psychiatrically for depression. Samples of nurse aides, nurses and social workers also assessed the same residents for the presence of depressive symptomatology. Method Psychiatrists assessed residents using the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) criteria. Depression measures used were the Cornell Scale for Depression in Dementia, the Feeling Tone Questionnaire, the Hamilton Depression Rating and the Structured Clinical Interview for DSM-III-R Personality Disorders Scale. Nursing and social services staff assessed residents using Depression Recognition Measures. Results Based on psychiatric evaluation, the prevalence estimate for probable and/or definite major depressive disorder among testable subjects was 14.4 % (95 % CI of 10.6 %–19.3 %); 15.4 % were not able to be assessed due to their refusal, impairment of consciousness, or severe physical illness. The estimate for minor depression was 16.8 % (95 % CI of 12.6 %–21.9 %). The prevalence of significant depressive symptomatology (including the category of possible depression) was 44.2 % (95 % CI of 38.2 %–50.3 %). The corresponding estimates of any depression were 19.7 % for social workers, 29 % for nurses and 32.1 % for nurse aides. Conclusions The prevalence of depressive disorders among nursing home residents is high; depression recognition is relatively low, with only 37 %–45 % of cases diagnosed by psychiatrists recognized as depressed by staff. A structured Depression Recognition Scale increased the rates of recognition (sensitivity of staff ratings) to 47 %–55 %, demonstrating the utility of the scale in increasing awareness of symptomatology.

Differential item functioning (DIF) and the Mini-Mental State Examination (MMSE) : Overview, sample, and issues of translation

Background:Various forms of differential item functioning (DIF) in the Mini-Mental State Examination (MMSE) have been identified. Items have been found to perform differently for individuals of different educational levels, racial/ethnic groups, and/or of groups whose first language is not English. The articles in this section illustrate the use of different methods to examine DIF in relation to English and Spanish language administration of the MMSE. Objectives:The aim of this article is to provide a context for interpretation of the findings contained in the following set of papers examining DIF in the MMSE. Methods:The performance of the MMSE, when administered in English and Spanish, was reviewed. “Translation” has been discussed in the context of measurement bias, illustrating the variability in Spanish translations. Presented are the readability of the MMSE, description of the translation method, the study design and sample for the data set used, together with treatment of missing data, and model assumptions related to the analyses described in the accompanying set of papers examining DIF. Conclusions:The examination of item bias in cognitive impairment assessment instruments has practical and theoretical implications in the context of health disparities. Considerable DIF has been identified in the MMSE. A critical factor that may contribute to measurement bias is language translation and conversion. Once DIF has been established consistently in a measure, decisions regarding adjustments proceed. Perhaps the development of guidelines for appropriate adjustments for DIF correction in self-reported measures represents the next challenge in addressing measurement equivalence in crosscultural research.

Resident-to-Resident Aggression in Nursing Homes: Results from a Qualitative Event Reconstruction Study

PURPOSE Despite its prevalence and negative consequences, research on elder abuse has rarely considered resident-to-resident aggression (RRA) in nursing homes. This study employed a qualitative event reconstruction methodology to identify the major forms of RRA that occur in nursing homes. DESIGN AND METHODS Events of RRA were identified within a 2-week period in all units (n = 53) in nursing homes located in New York City. Narrative reconstructions were created for each event based on information from residents and staff who were involved as well as other sources. The event reconstructions were analyzed using qualitative methods to identify common features of RRA events. RESULTS Analysis of the 122 event reconstructions identified 13 major forms of RRA, grouped under five themes. The resulting framework demonstrated the heterogeneity of types of RRA, the importance of considering personal, environmental, and triggering factors, and the potential emotional and physical harm to residents. IMPLICATIONS These results suggest the need for person-centered and environmental interventions to reduce RRA, as well as for further research on the topic.

A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: results from a cluster randomized trial.

BACKGROUND Elder abuse in long-term care has received considerable attention; however, resident-to-resident elder mistreatment (R-REM) has not been well researched. Preliminary findings from studies of R-REM suggest that it is sufficiently widespread to merit concern, and is likely to have serious detrimental outcomes for residents. However, no evidence-based training, intervention and implementation strategies exist that address this issue. OBJECTIVES The objective was to evaluate the impact of a newly developed R-REM training intervention for nursing staff on knowledge, recognition and reporting of R-REM. DESIGN The design was a prospective cluster randomized trial with randomization at the unit level. METHODS A sample of 1405 residents (685 in the control and 720 in the intervention group) from 47 New York City nursing home units (23 experimental and 24 control) in 5 nursing homes was assessed. Data were collected at three waves: baseline, 6 and 12 months. Staff on the experimental units received the training and implementation protocols, while those on the comparison units did not. Evaluation of outcomes was conducted on an intent-to-treat basis using mixed (random and fixed effects) models for continuous knowledge variables and Poisson regressions for longitudinal count data measuring recognition and reporting. RESULTS There was a significant increase in knowledge post-training, controlling for pre-training levels for the intervention group (p<0.001), significantly increased recognition of R-REM (p<0.001), and longitudinal reporting in the intervention as contrasted with the control group (p=0.0058). CONCLUSIONS A longitudinal evaluation demonstrated that the training intervention was effective in enhancing knowledge, recognition and reporting of R-REM. It is recommended that this training program be implemented in long-term care facilities.

Health Care Utilization and Self-Care Behaviors of Medicare Beneficiaries with Diabetes: Comparison of National and Ethnically Diverse Underserved Populations

Caring for persons with diabetes is expensive, and this burden is increasing. Little is known about service use, behaviors, and self-care of older individuals with diabetes who live in underserved communities. Information about self-care, informal care, and service utilization in urban (largely Latino, n = 695) and rural (mostly white, n = 819) Medicare beneficiaries with diabetes living in federally designated medically underserved areas was collected using computer-aided telephone interviews as part of the baseline assessment in the Informatics and Diabetes Education and Telemedicine (IDEATel) Project. Where items were comparable, service use was compared with that of a nationally representative group of Medicare beneficiaries with diabetes, using data from the Medical Expenditure Panel Survey. Compared to nationally representative groups, the underserved groups reported worse general health but similar health care service use, with the exception of home care. However, compared to the underserved rural group, the underserved, largely minority urban group, reported worse general health (P < 0.0001); more inpatient nights (P = 0.003), emergency room visits (P < 0.001), and home health care (P < 0.001); spent more time on self-care; and had more difficulty with housework, meal preparation, and personal care. Differences in service use between urban and rural groups within the underserved group substantially exceeded differences between the underserved and nationally representative groups. These findings address a gap in knowledge about older, ethnically diverse individuals with diabetes living in medically underserved areas. This profile of disparate service use and health care practices among urban minority and rural majority underserved adults with diabetes can assist in the planning of future interventions.

Applications of Item Response Theory to the Examination of the Psychometric Properties and Differential Item Functioning of the Comprehensive Assessment and Referral Evaluation Dementia Diagnostic Scale among Samples of Latino, African American, and White Non-Latino Elderly

Item response theory was used to examine the psychometric properties of a cognitive screening measure used in several epidemiological surveys among Latino, African American, and White non-Latino elderly. Estimates of precision (reliability) examined across several values of Θ (the estimate of degree of cognitive impairment) were good (.70s to .90s) in the range representing most respondents. Overall reliability, although adequate, was lower among the White non-Latino and high-education subgroups relative to other racial/ethnic and education subgroups. Differential item functioning (DIF) was examined using several area- and model-based tests. Tests of the magnitude of DIF showed the measure to be relatively free of DIF for the racial/ethnic subgroup and education subgroups examined. However, one item related to remembering the telephone number was more difficult for Latinos than for other racial/ethnic subgroups. Several other items evidenced mild DIF, and one (difficulty remembering words or names) was a poorly discriminating item. The subjective memory items, intended to provide additional information at the earlier, “borderzone” stages of cognitive impairment, did provide more information at the mild to moderate levels of impairment, although maximum information was not provided at these borderzone ranges.

Modifying measures based on differential item functioning (DIF) impact analyses.

Objectives: Measure modification can impact comparability of scores across groups and settings. Changes in items can affect the percent admitting to a symptom. Methods: Using item response theory (IRT) methods, well-calibrated items can be used interchangeably, and the exact same item does not have to be administered to each respondent, theoretically permitting wider latitude in terms of modification. Results: Recommendations regarding modifications vary, depending on the use of the measure. In the context of research, adjustments can be made at the analytic level by freeing and fixing parameters based on findings of differential item functioning (DIF). The consequences of DIF for clinical decision making depend on whether or not the patient’s performance level approaches the scale decision cutpoint. High-stakes testing may require item removal or separate calibrations to ensure accurate assessment. Discussion: Guidelines for modification based on DIF analyses and illustrations of the impact of adjustments are presented.

An Evaluation of a Monitoring System Intervention Falls, Injuries, and Affect in Nursing Homes

This project assessed the extent to which modern technology (Vigil) can augment or substitute for direct staff intervention in nonacute late-evening and nighttime situations in a nursing home setting. Vigil was implemented for dementia residents of a special care unit (SCU) in a large nursing home. An SCU matched in terms of unit-wide case mix and cognition was used for comparison. Results showed that there was no significant reduction in falls and injuries, but there was a significant improvement in affective disorder in the intervention group as contrasted with the comparison group. There was no significant increase in staff-perceived burden, despite the significant increase in the amount of direct care time logged. Additional time spent in staff care was significantly related to decreased affective disorder. The findings related to Vigil are generally mixed. The question remains as to whether the improvement in affect was due to Vigil or vigilance.

The Prevalence of Resident-to-Resident Elder Mistreatment in Nursing Homes

Growing indirect evidence suggests that verbal and physical conflict between nursing home residents may be a large and pervasive problem. Media coverage regularly documents serious assaults of nursing home residents by other residents (13). The only empirical study of cases of physical aggression between nursing home residents (4) included cases reported to a state ombudsman program over 1 year. Although this was an important early contribution to the field, the cases were not systematically identified by using research methods. No study has used standardized and validated case-finding methodology expressly developed for estimating the prevalence of resident-to-resident elder mistreatment (R-REM) in the nursing home; indeed, a recent systematic review on the topic concluded that individual studies could not produce a prevalence rate on the basis of their design, nor could the results be meaningfully pooled because of heterogeneity (5). We provide prevalence estimates from what we believe is the first large-scale, systematic study of R-REM in the nursing home. Our goal was to estimate the prevalence of R-REM, including verbal, physical, and sexual mistreatment, and examine the prevalence according to location and timing of events and patient-, environment-, and facility-level characteristics. Methods Definition of R-REM The following definition guided the gold-standard consensus classification in adjudicating R-REM caseness (Supplements 1 and 2): Negative and aggressive physical, sexual, or verbal interactions between long-term care residents that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient. Supplement. Supplementary Material Study Design This was an observational prevalence study. The protocol was reviewed and approved by the institutional review board at Weill Cornell Medical College. Study Population Recruitment of Facilities Twelve nursing homes in New York state were selected at random by using a pseudo-random number generator procedure; 6 were selected from among the 21 nursing homes with 250 or more beds in urban regions, and 6 from among the 13 large nursing homes (200 or more beds) in suburban regions. Facilities were offered incentives for participation: a

Comparative effectiveness of implementing evidence-based education and best practices in nursing homes: Effects on falls, quality-of-life and societal costs

2000 stipend as compensation for administrative and staff time, and training in R-REM detection and a training package on R-REM at study end. Ten of the 12 facilities agreed, yielding a participation rate of 83%. With rolling enrollment, data were collected between July 2009 and September 2011 in the urban facilities and between September 2011 and June 2013 in the suburban facilities. Eligible Residents All long-stay residents except those in hospice, subacute, or short-term care (whose expected length of stay would be less than the prevalence look-back period) were invited to participate. For residents who could not complete the consent process (for example, owing to cognitive impairment, language barrier, or health impairment), consent was sought by designated proxies (families or legal guardians). Residents who could not respond were excluded from self-reported measures; however, chart review, staff informant, and observational measures were performed for individuals with proxy approval. Residents who met the above exclusion criteria or who died or were discharged before enrollment were excluded from the denominator in prevalence estimates. The final analytical sample included 2011 residents, for a participation rate of 84% (Figure 1). Figure 1. Study flow diagram. Procedures The research team entered each facility for 2 to 3 months and enrolled residents sequentially. First, a 2-stage screening instrument on cognitive capacity was administered to determine the residents ability to provide consent for participation in noninvasive research. A second-stage screening instrument was used to determine his or her ability to provide an extended R-REM interview. Because the protocol was to interview staff first, and then residents as soon as possible after the staff interview (usually within 2 weeks), we specified a 1-month period during which we included reports from both staff and residents. The index date was defined as the earlier of the date of the R-REM staff interview or the resident interview (which asked about events in the prior 2 weeks). The index period included the 2 weeks before and after the index date. This interval was defined as the 1-month prevalence period. The staff interview was nearly always used to set the index date. For the 26 cases in which only a resident interview was available, that date was set as the index date. Accordingly, shift coupons, incident reports, and event log data collected during this same 4-week period were selected as potential R-REM events by a computer algorithm if they were in the specified date range. When R-REM involved nonparticipating residents, those residents were not interviewed and no clinical or other information was collected. However, it was recorded that an event was reported, so that an estimate could be made of the number of possible R-REM events among nonparticipants. R-REM Measures and Case Finding Pilot research indicated that episodes of R-REM can be sudden, may occur in private areas, or may involve residents with significant memory impairment. Therefore, a single methodology (such as only direct observation of events or only interviews) is inadequate to identify cases. Instead, we used triangulation for identification, each component of which contributed to case finding and overall prevalence. Potential cases of R-REM were identified through 6 methods: resident interviews, staff interviews, shift coupons, observation, chart review, and accident or incident reports. An R-REM event was defined as that identified by any of these 6 methods during the 1-month prevalence period. R-REM Interview Instruments Residents. Residents with sufficient cognition were administered an R-REM instrument that asked about 22 forms of physical, verbal, or sexual events in the prior 2 weeks (6, 7) (Supplement 3). Staff. For all residents who gave consent (regardless of their cognitive status), the primary certified nursing assistant (CNA) for the resident was interviewed with the staff version of the instrument (7) (Supplements 3 and 4). R-REM Shift Coupons Shift coupon methodology was adopted from nursing studies of brief but important events that are difficult to capture in a busy health setting (8). As events were observed, staff completed an R-REM event form on a preprinted, prescription-sized pad that had detachable sheets with basic information about events. These shift coupons were deposited in a box at the nursing station (Supplement 5). Observation A small number of events were directly observed by research staff members who were continuously stationed in each facility during the study period. Chart Review Chart reviews were performed by using a standardized, computerized abstraction protocol to determine whether episodes of R-REM were reported in the medical record. Accident or Incident Reports Facility incident reports were reviewed over the prevalence period for episodes of R-REM. Covariates We collected covariate data to explore whether selected resident, environmental, and facility characteristics were associated with R-REM. Respondents were administered the Care Dementia Diagnostic assessment (9, 10). This 14-item measure permits 5 classifications of cognitive impairment: none, mild, moderate, severe, and very severe. The Cronbach coefficient estimated for this sample was 0.875, and the McDonald total estimate from a single common factor model was 0.95. A standardized battery assessing mood, behaviors, functional status, and a variety of other covariates was used to measure contextual factors of R-REM incidents. Case Conference and Adjudication Process Cases All R-REM events, regardless of reporting source, underwent a case conference and adjudication process developed for the study. The purpose of this process was 1) to achieve consensus on cases of R-REM that were deemed by 1 or more investigators to be equivocal and 2) to designate a primary (most egregious, serious action, with the highest risk for harm) form when multiple types of R-REM occurred over the prevalence period. An electronic template was created to aggregate all available deidentified resident-level individual and environmental data to ensure a comprehensive review of each participants data. All facets of potential R-REM events (such as location of incident, reporting source, residents involved, witnesses, and a description of the event) gathered via the 6 R-REM reporting methods were included in this template. All potential cases of R-REM from any source were reviewed and adjudicated in a case-conferencing process involving 7 experts in clinical geriatrics, long-term care nursing, psychology, law, and social gerontology with specific interest and experience in the field of elder abuse. An additional random sample of nonR-REM cases from the study population was similarly reviewed. The case conference and adjudication process is described in Supplements 1, 2, and 6. As shown in Figure 2, a total of 771 potential R-REM cases and noncases among 2011 residents were adjudicated. All cases identified by any source were adjudicated (n= 508). Figure 2. Adjudication process. R-REM= resident-to-resident elder mistreatment.* Instances of R-REM were identified on the basis of at least 1 report from any of 6 sources. Events adjudicated as R-REM had to involve at least 2 residents; events involving staff or family members were excluded. For urban facilities, there was random selection of 30 residents per facility; for suburban facilities, there was 1 person for each R-REM case per facility. Adjudication of Noncases A random sample of 263 residents without indication of R-REM was selected. The goal was to have a minimum of 30 per facilit