Philip D. Sloane

The MDS Cognition Scale: A Valid Instrument for Identifying and Staging Nursing Home Residents with Dementia Using the Minimum Data Set

OBJECTIVE: We report the development and validation of an MDS‐based cognitive index, the MDS Cognition Scale (MDS‐COGS), by evaluating it against two popular dementia rating scales, the Global Deterioration Scale (GDS) and the Mini‐Mental State Examination (MMSE).

Effect of person-centered showering and the towel bath on bathing-associated aggression, agitation, and discomfort in nursing home residents with dementia : a randomized, controlled trial

Objectives: To evaluate the efficacy of two nonpharmacological techniques in reducing agitation, aggression, and discomfort in nursing home residents with dementia. The techniques evaluated were person‐centered showering and the towel bath (a person‐centered, in‐bed bag‐bath with no‐rinse soap).

Nursing home facility risk factors for infection and hospitalization: importance of registered nurse turnover, administration, and social factors.

OBJECTIVES: Determine the relationship between a broad array of structure and process elements of nursing home care and (a) resident infection and (b) hospitalization for infection.

Dizziness in a Community Elderly Population

Dizziness was studied in 1,622 community‐dwelling adults aged 60 and older who were interviewed as part of the Duke Epidemiologic Catchment Area study. The lifetime prevalence of dizziness (defined as severe enough to see a physician, to take a medication, or to interfere with daily activities) was 29.3%; the 1‐year prevalence was 18.2%. When the subgroup with dizziness was compared with those who never suffered dizziness, using logistic regression, four variables displayed the strongest associations: a constructed variable of risk for multiple neurosensory deficits, a cardiovascular risk score, a depression symptom inventory, and perception of self as a nervous person. In this population, dizziness was not associated with increased risk of death or institutionalization at the 1‐year follow up.

Dizziness: state of the science.

Dizziness is one of the most challenging symptoms in medicine. It is difficult to define, impossible to measure, a challenge to diagnose, and troublesome to treat. The word dizziness is used to mean various sensations of body orientation and position that are frequently difficult for patients to describe (1, 2). Dizziness can be caused by a wide range of benign and serious conditions, many of which are not well understood. For most patients, the symptom resolves spontaneously, but an important minority of patients develop chronic, disabling symptoms, and a few have a life-threatening condition (3-5). Most of those with chronic symptoms are not relieved by medical treatment (6). The past decade has seen an increasing focus on evidence-based practice in medicine (7). In this context, a series of steps develop an empirical approach to a symptom such as dizziness (Figure). First, the symptom must be defined and its subtypes delineated in a consistent, widely accepted format. Second, these definitions must be used in epidemiologic studies across many clinical settings, so that the clinical epidemiology of the symptom can be appreciated. Third, the conditions that the symptom may represent must be clearly delineated, with diagnostic criteria. Fourth, the diagnostic criteria must be used in epidemiologic studies to elucidate the clinical picture of the symptom and its diagnoses. Certain life-threatening or potentially remediable diagnoses that practicing physicians need to rule in or out should be targeted. For each of these diagnoses, data should be gathered on clinical diagnostic maneuvers and tests (sensitivity, specificity, and likelihood ratios) and the effectiveness of treatment. Once these steps have been completed, we will have adequate data for development of empirically based practice guidelines, clinical pathways, and other methods of ensuring quality, consistency, and cost-effectiveness in medical practice. Figure 1. Steps in the development of a scientific database for medical management of a symptom. We review current knowledge about dizziness by following the steps outlined in the Figure and make recommendations for clinical practice and further research. Defining and Describing Dizziness Dizziness refers to various abnormal sensations relating to perception of the bodys relationship to space (8). In a classic paper, Drachman and Hart (1) described four subtypes: vertigo, presyncopal lightheadedness, disequilibrium, and other dizziness. Nearly 30 years later, this typology remains the basis of dizziness definition and classification, having long since displaced the narrower definition (vertigo) used in earlier studies (9, 10). The dizziness subtypes are described in Table 1. Vertigo is a false sensation that the body or the environment is moving (usually spinning). It suggests a disturbance of the vestibular system, although psychological states, such as panic disorder, can also produce it (11). Presyncope is a feeling of lightheadedness that is often described as a sensation of an impending faint. It is episodic and usually results from diffuse temporary cerebral ischemia. Disequilibrium is a sense of imbalance (postural instability) that is generally described as involving the legs and trunk without a sensation in the head. Isolated symptoms of disequilibrium are generally attributed to neuromuscular problems; imbalance that accompanies other types of dizziness is generally a secondary symptom. Other dizziness is typically described as vague or floating, or the patient may have difficulty describing the sensation. Such dizziness is generally present much of the time and is most often caused by psychological disturbances (1). It is often accompanied by other somatic symptoms, such as headache and abdominal pain (1, 9). In the category of other dizziness are also two distinct though rare forms of dizziness: ocular dizziness due to rapid vision change, as after cataract surgery or a change in a corrective prescription (12), and dizziness described as a tilting of the environment, which is generally attributed to an otolith problem (13, 14). Table 1. Approach to the Differentiation of Dizziness Subtypes This typology is not without problems. Many patients, particularly elderly ones, cannot place their dizziness in one category; approximately half of older persons describe two or more subtypes (2, 15). This is largely because disequilibrium often accompanies other kinds of dizziness in older persons who do not have intact compensatory systems, making it necessary to distinguish between the primary symptom and the secondary disequilibrium. In addition, the causes of presyncope almost completely overlap those of syncope (9, 16), so from the standpoint of differential diagnosis, the differentiation of one from the other is probably artificial. Finally, distinguishing between acute and chronic dizziness may be important because increased symptom duration is a risk factor for functional impairment (4). No consensus exists, however, on the dividing line between acute and chronic dizziness. Epidemiology of Dizziness Many studies have described the epidemiology of dizziness in the community and in primary care settings [3, 6, 15, 17-21]. Although the studies have been inconsistent in their definition of dizziness, the accumulated evidence indicates that 1) dizziness is common in all adult age groups and is more common in women than in men and 2) the prevalence of dizziness increases modestly with age in the community and markedly with age in medical practice (Table 2). In both the primary care and the referral setting, dizziness symptoms often involve more than one dizziness subtype, especially in the elderly, and dizziness is more often reported to be episodic rather than continuous (2, 5). Table 2. Prevalence of Dizziness in Selected Studies In recent decades, several studies have reported that dizziness in older persons is associated with an accumulation of cardiovascular, neurosensory, and psychiatric conditions and with use of multiple medications (1, 3, 15, 18, 22, 23). These findings led Tinetti and colleagues (15) to suggest that dizziness in older persons may constitute a geriatric syndromea final common pathway resulting from the interplay of multiple impairments. Such a viewpoint would support the idea of approaching dizziness from a functional point of view rather than trying to define a symptom subtype, a single mechanism, and a unifying diagnosis. Such an approach is untried, but several recently developed instruments could provide a framework (Table 3) (24-27), and research in this area should be encouraged. Caution is warranted, however. As Drachman noted (28), calling dizziness in the elderly a geriatric syndrome runs the risk of implying that it is due to old age and therefore not treatable, whereas it is usually possible to identify one or more underlying disorders or diseases. Table 3. Standardized Instruments for Evaluating the Severity and Effect of Dizziness on Quality of Life The prognosis of dizziness is generally benign. In one study (4), nearly three quarters of patients who presented with dizziness to primary care offices reported no effect on their lives 3 months later, and two population-based outcome studies (3, 23) suggested that dizziness is not an independent predictor of institutionalization, death, or functional decline. However, it should be noted that most epidemiologic studies of dizziness have oversampled persons with chronic dizziness and underrepresented persons with acute forms of dizziness, who would be most likely to have life-threatening illnesses. Further, many persons with dizziness and a benign prognosis report great impairment of daily activities, depressed mood, and symptom-related fears [4, 23, 24, 27]. Nevertheless, the fact that most dizziness-related conditions are self-limited suggests that 1) seeking out unreported dizziness in community populations and asking about dizziness on a routine symptom review may not be warranted and 2) other symptoms may have greater specificity in screening for serious disease. Diagnosing Dizziness Effective clinical decision making uses data on which diagnoses are common and, therefore, most likely in a given patient (29). Data on the frequency of diagnoses in similar settings are particularly useful in the evaluation of symptoms, like dizziness, that have a broad range of diagnostic possibilities. Table 4 summarizes 11 studies reporting diagnoses for patients with dizziness (1, 2, 5, 30-37). Peripheral vestibular problems constitute a sizeable minority of diagnoses. Acute labyrinthitis (or vestibular neuronitis) is the most common peripheral vestibular disorder seen in primary care offices (30). In referral settings, recurrent peripheral vestibular disorders, such as benign paroxysmal positional vertigo, recurrent vestibulopathy (38), and Mnire disease (39), predominate (1, 2, 35, 36). Central vestibular causes, such as brain tumors, cerebellar atrophy, migraine, multiple sclerosis, and seizure disorders, are rare or unreported in most studies; of 4536 patients from various settings, 0.7% had brain tumor and 1.2% had other central vestibular causes (39). Table 4. Reported Frequency of Causes of Dizziness in Selected Clinical Studies Most patients with dizziness have nonvestibular diagnoses, and the relative frequencies of specific diagnoses vary widely across settings. In primary care, infections, metabolic problems, and adverse effects of drugs are relatively common. Almost any patient with a systemic viral or bacterial infection can present with dizziness, which is presumably due to postural hypotension (30). Metabolic disturbances reported to cause dizziness include hypoglycemia, hyperglycemia, electrolyte disturbances, thyrotoxicosis, and anemia (39, 40). A wide variety of medications may lead to dizziness (see the Appendix Table) (41-44). Benign positional vertigo, other vestibular problems, and psychiatric disorders p

Behavioral Symptoms in Residential Care/Assisted Living Facilities: Prevalence, Risk Factors, and Medication Management

Objectives: To examine the prevalence, correlates, and medication management of behavioral symptoms in elderly people living in residential care/assisted living (RC/AL) facilities.

The prevalence of osteoporosis in nursing home residents

Abstract: This study describes the prevalence of osteoporosis in a statewide sample of nursing home residents. Composite forearm bone mineral density (BMD) (including the distal radius and the distal ulna) of 1475 residents aged 65 years and older from 34 randomly selected, stratified nursing homes was assessed. BMD was expressed with reference to World Health Organization diagnostic criteria. Trends with age, gender and race were consistent with other populations. However, prevalence estimates were higher than community-based age-specific rates. The prevalence of osteoporosis for white female residents increased from 63.5% for women aged 65–74 years to 85.8% for women over 85 years of age. Only 3% had composite forearm BMD within 1 standard deviation of the young adult mean. The significance of the high prevalence of low BMD in nursing home residents is the increased fracture risk it may confer. In community cohorts of white women, the risk of hip fracture increases approximately 50% for every 1 standard deviation decrease in bone mass. However, the degree to which BMD contributes to fracture risk in this population has not been well established.

Inappropriate Medication Prescribing in Residential Care/Assisted Living Facilities

OBJECTIVES: To identify the extent to which inappropriately prescribed medications (IPMs) are administered to older patients in residential care/assisted living (RC/AL) facilities and to describe facility and resident factors associated with receipt of one or more IPMs.

High-intensity environmental light in dementia: Effect on sleep and activity

OBJECTIVES: To determine whether high‐intensity ambient light in public areas of long‐term care facilities will improve sleeping patterns and circadian rhythms of persons with dementia.

Beyond the Medical Model: The Culture Change Revolution in Long-Term Care

Culture change in long-term care facilities involves a shift in philosophy and practice from an overemphasis on safety, uniformity, and medical issues toward resident-directed, consumer-driven health promotion and quality of life. Fundamental to this shift is a focus on the importance of the relationships between residents and direct care staff. This review presents and discusses the key elements of culture change, including workforce redesign, resident-centered care, leadership, and the implementation process and evaluation. A case report describes how medical staff can participate in this grassroots movement and help foster the social, cultural, programmatic, and physical changes that can alter the culture of long-term care one home at a time.