March 2006-From the Journal of the American Geriatrics Society

Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention
Eric A. Coleman, MD, MPH, Jodi D. Smith, ND, GNP, Janet C. Frank, DrPH, Sung-Joon Min, AM, Carla Parry, PhD, MSW, and Andrew M. Kramer, MD

Objectives: To test whether an intervention designed to encourage older patients and their caregivers to assert a more active role during care transitions can reduce rehospitalization rates.

Design: Quasi-experimental design whereby subjects receiving the intervention (n=158) were compared with control subjects derived from administrative data (n=1,235).

Setting: A large integrated delivery system in Colorado.

Participants: Community-dwelling adults aged 65 and older admitted to the study hospital with one of nine selected conditions.

Intervention: Intervention subjects received tools to promote cross-site communication, encouragement to take a more active role in their care and assert their preferences, and continuity across settings and guidance from a transition coach.

Measurements: Rates of postdischarge hospital use at 30, 60, and 90 days. Intervention subjects’ care experience was assessed using the care transitions measure.

Results: The adjusted odds ratio comparing rehospitalization of intervention subjects with that of controls was 0.52 (95% confidence interval (CI)=0.28-0.96) at 30 days, 0.43 (95% CI= 0.25-0.72) at 90 days, and 0.57 (95% CI=0.36-0.92) at 180 days. Intervention patients reported high levels of confidence in obtaining essential information for managing their condition, communicating with members of the healthcare team, and understanding their medication regimen.

Conclusion: Supporting patients and caregivers to take a more active role during care transitions appears promising for reducing rates of subsequent hospitalization. Further testing may include more diverse populations and patients at risk for transitions who are not acutely ill. J Am Geriatr Soc 2004;52(11): 1817-1825.

----------

The Coming Epidemic of Obesity in Elderly Americans
David E. Arterburn, MD, MPH, Paul K. Crane, MD, MPH, and Sean D. Sullivan, PhD

Objectives: To estimate the prevalence of obesity in elderly Americans in 2010 and to discuss the health and economic implications of these estimates.

Design: Three methods of generating future point-prevalence estimates using data from consecutive cross-sectional studies.

Setting: All regions of the United States.

Participants: Estimates were based on five nationally representative surveys of the adult population of the United States, conducted from 1960 to 2000, and population estimates from the U.S. Census Bureau.

Measurements: Changes in obesity (body mass index [BMI] ≥ 30 kg/m2) and normal weight (BMI <25 kg/m2) prevalence for men and women by 10-year U.S. birth cohorts were examined. The prevalence of obesity and normal weight in the elderly in 2010 was estimated under three different scenarios of obesity prevalence change.

Results: It was estimated that the prevalence of obesity in adults aged 60 and older will increase from 32.0% in 2000 to 37.4% in 2010 (range 33.6-39.6%). The number of obese adults aged 60 and older will increase from 14.6 to 20.9 million (range 18.8-22.2 million). Similarly, it was estimated that the prevalence of normal weight among adults aged 60 and older will decrease from 30.6% in 2000 to 26.7% in 2010 (range 31.0-24.7%).

Conclusion: The prevalence of obesity in elderly Americans will likely continue to increase, challenging healthcare delivery and financing systems in the United States. J Am Geriatr Soc 2004;52(11):1907-1912.

----------

Resistance Training in the Early Postoperative Phase Reduces Hospitalization and Leads to Muscle Hypertrophy in Elderly Hip Surgery Patients—A Controlled, Randomized Study
Charlotte Suetta, MD, S. Peter Magnusson, DMSc, Anna Rosted, MD, Per Aagaard, PhD, Prof, Ane K. Jakobsen, Lone H. Larsen, PT, Benn Duus, MD, and Michael Kjaer, DMSc, Prof

Objectives: To better understand how immobilization and surgery affect muscle size and function in the elderly and to identify effective training regimes.

Design: A prospective randomized, controlled study.

Setting: Bispebjerg University Hospital, Copenhagen, Denmark.

Participants: Thirty-six patients (aged 60-86) scheduled for unilateral hip replacement due to primary hip osteoarthrosis.

Intervention: Patients were randomized to standard home-based rehabilitation (1 h/d x 12 weeks), unilateral neuromuscular electrical stimulation of the operated side (1 h/d x 12 weeks), or unilateral resistance training of the operated side (3/wk x 12 weeks).

Measurements: Hospital length of stay (LOS), quadriceps muscle cross-sectional area (CSA), isokinetic muscle strength, and functional performance. Patients were tested presurgery and 5 and 12 weeks postsurgery.

Results: Mean±standard error LOS was shorter for the resistance training group (10.0±2.4 days, P<.05) than for the standard rehabilitation group (16.0±7.2 days). Resistance training, but not electrical stimulation or standard rehabilitation, resulted in increased CSA (12%, P<.05) and muscle strength (22-28%, P<.05). Functional muscle performance increased after resistance training (30%, P<.001) and electrical stimulation (15%, P<.05) but not after standard rehabilitation.

Conclusion: Postoperative resistance training effectively increased maximal muscle strength, muscle mass, and muscle function more than a standard rehabilitation regime. Furthermore, it markedly reduced LOS in elderly postoperative patients. J Am Geriatr Soc 2004;52(12):2016-2022.

----------

Disruptive Behaviors in Veterans Affairs Nursing Home Residents: How Different Are Residents with Serious Mental Illness?
John F. McCarthy, PhD, Frederic C. Blow, PhD, and Helen C. Kales, MD

Objectives: To determine the prevalence and correlates of behavior problems of residents of Veterans Affairs (VA) nursing homes and to compare residents with serious mental illness (SMI) with other resident groups.

Design: This study combined cross-sectional resident assessments with administrative data for all residents in VA nursing homes. Multivariate ordinal logistic regression was used to evaluate associations between resident characteristics and problem behaviors.

Setting: Nursing home care units in the VA healthcare system.

Participants: A total of 9,618 nursing home residents assessed as part of the VA’s April 2001 national resident census.

Measurements: The Patient Assessment Instrument assessed each resident’s verbally disruptive, physically aggressive, and socially inappropriate behaviors in the prior 4 weeks. Functional limitations in eating, mobility, toileting, and transfer were assessed. Diagnoses were evaluated for the stay and up to 6 months before assessment.

Results: Almost one-fifth (17.9%) of residents received a diagnosis of SMI. Residents with SMI or dementia had greater behavior problems than residents with neither condition. Residents with SMI (and without dementia) exhibited more verbal disruption than residents with dementia (and without SMI), but the two subgroups did not differ in physically aggressive or socially inappropriate behavior.

Conclusion: Many VA nursing home residents have SMI. Their level of behavior problems is comparable with that of residents with dementia. Clinical practice and nursing home staff training must encompass geriatric mental health and behavior management to meet the needs of residents with SMI. J Am Geriatr Soc 2004;52(12):2031-2038.

----------

CLINICAL INVESTIGATIONS

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
Philip D. Sloane, MD, MPH, Beverly Hoeffer, DNSc, RN, C. Madeline Mitchell, MURP, Darlene A. McKenzie, PhD, RN, Ann Louise Barrick, PhD, Joanne Rader, MN, RN, Barbara J. Stewart, PhD, Karen Amann Talerico, PhD, RN, Joyce H. Rasin, PhD, RN, Richard C. Zink, MS, and Gary G. Koch, PhD

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).

Design: A randomized, controlled trial, with a usual-care control group and two experimental groups, with crossover.

Setting: Nine skilled nursing facilities in Oregon and six in North Carolina.

Participants: Seventy-three residents with agitation during bathing (69 completed the trial) and 37 nursing assistants who bathed them.

Measurements: Agitation and aggression were measured using the Care Recipient Behavior Assessment; discomfort was measured using a modification of the Discomfort Scale for Dementia of the Alzheimer Type. Raters who were blinded to subject status coded both from videotaped baths. Secondary measures of effect included bath duration, bath completeness, skin condition, and skin microbial flora.

Results: All measures of agitation and aggression declined significantly in both treatment groups but not in the control group, with aggressive incidents declining 53% in the person-centered shower group (P<.001) and 60% in the towel-bath group (P<.001). Discomfort scores also declined significantly in both intervention groups (P<.001) but not in the control group. The two interventions did not differ in agitation/aggression reduction, but discomfort was less with the towel bath (P=.003). Average bath duration increased significantly (by a mean of 3.3 minutes) with person-centered showering but not with the towel bath. Neither intervention resulted in fewer body parts being bathed; both improved skin condition; and neither increased colonization with potentially pathogenic bacteria, corynebacteria, or Candida albicans.

Conclusion: Person-centered showering and the towel bath constitute safe, effective methods of reducing agitation, aggression, and discomfort during bathing of persons with dementia. J Am Geriatr Soc 2004;52(11):1795-1804.

----------

How Should Clinicians Describe Hospice to Patients and Families?
David J. Casarett, MD, MA, Roxane L. Crowley, B, and Karen B. Hirschman, PhD

Objectives: To describe hospice enrollment from the perspective of bereaved family members and to identify information about hospice that would encourage patients and families to enroll sooner.

Design: Cross-sectional interviews.

Setting: Three Medicare-certified hospice organizations.

Participants: One hundred family members of 100 patients who died in hospice.

Measurements: Semistructured interviews assessed prior knowledge of hospice, patients’ and physicians’ involvement in the enrollment process, features of hospice that motivated enrollment, and features that patients and families wished they had learned about sooner.

Results: Almost all family members (n= 92) and patients (n=71) knew about hospice before the patient’s illness. Almost half the patients (n=44) were not involved at all in the hospice enrollment decision. The patient’s physician (n=51) or the patient or family (n=34) initiated most hospice discussions, but patients and families usually obtained information about hospice from a hospice representative (n=75) rather than from the patient’s physician (n= 22). Family members identified several kinds of information about hospice that were particularly helpful in deciding whether to enroll and described several aspects of hospice that they wished they had known about sooner.

Conclusion: Many patients and families learn about hospice from someone other than the patient’s physician, and most learn about valuable hospice features and services only after enrollment. By providing more information about hospice earlier in the illness course, clinicians may be able to facilitate more-informed and more-timely decisions about hospice enrollment. J Am Geriatr Soc 2004;52(11):1923-1928.

----------

Persistent Pain in Frail Older Adults After Hip Fracture Repair
Cynthia Herrick, BA, Karen Steger-May, MA, David R. Sinacore, PhD, Marybeth Brown, PhD, Kenneth B. Schechtman, PhD, and Ellen F. Binder, MD

Objectives: To identify factors associated with persistent hip pain in elderly hip fracture patients with physical frailty.

Design: Cohort study. Setting: Community-based study conducted at academic medical center.

Participants: Eighty-eight men and women (mean age±standard deviation 80±7 years) with a recent hip fracture (mean 14.5±4.8 weeks after hip fracture repair) and physical frailty, defined as a modified Physical Performance Test Score between 12 and 28, enrolled in an exercise intervention trial.

Measurements: Dependent variable was self-report of moderate to severe regional hip pain in the week preceding the baseline interview. Independent variables were self-reported demographic information, health characteristics, and activity of daily living (ADL) function; Yesavage Mood Score (YMS); 36-item Short Form percentile scores; and objective measurements of lower extremity strength, range of motion, balance, and gait.

Results: Forty-two percent of the sample reported moderate or severe hip pain at the baseline assessment. Moderate/severe pain was related to difficulty with ADL performance and multiple measures of quality of life. Variables independently associated with moderate/severe hip pain were frequency of pain medication use (adjusted odds ratio (AOR)=5.75, 95% confidence interval (CI)=2.23-14.82, P=.003), YMS score (AOR=2.69, 95% CI=1.18-6.12, P= .02), and knee extension at 60°/s in the fractured limb (AOR=0.96, 95% CI=0.92-1.0, P=.05, model coefficient of determination=0.34).

Conclusion: Persistent hip pain is a frequent symptom in frail elderly community-dwelling hip fracture patients. Pain medication use, symptoms of depression, and skeletal muscle weakness of the fractured leg are independent correlates of moderate to severe hip pain in this patient population. Clinicians should assess for, and address, persistent pain in this patient population. J Am Geriatr Soc 2004;52(12): 2062-2068.

----------

Translating Research into Clinical Practice: Making Change Happen
Elizabeth H. Bradley, PhD, Mark Schlesinger, PhD, Tashonna R. Webster, MPH, Dorothy Baker, PhD, RNCS, and Sharon K. Inouye, MD, MPH

Objectives: To describe the process of adoption of an evidence-based, multifaceted, innovative program into the hospital setting, with particular attention to issues that promoted or impeded its implementation. This study examined common challenges faced by hospitals implementing the Hospital Elder Life Program (HELP) and strategies used to address these challenges.

Design: Qualitative study design based on in-depth, open-ended telephone interviews.

Setting: Nine hospitals implementing HELP throughout the United States.

Participants: Thirty-two key staff members (physician, nursing, volunteer, and administrative staff) who were directly involved with the HELP implementation.

Measurements: Staff experiences implementing the program, including challenges and strategies they viewed as successful in overcoming challenges of implementation.

Results: Six common challenges faced hospital staff: (1) gaining internal support for the program despite differing requirements and goals of administration and clinical staff, (2) ensuring effective clinician leadership, (3) integrating with existing geriatric programs, (4) balancing program fidelity with hospital-specific circumstances, (5) documenting positive outcomes of the program despite limited resources for data collection and analysis, and (6) maintaining the momentum of implementation in the face of unrealistic time frames and limited resources. Strategies perceived to be successful in addressing each challenge are described.

Conclusion: Translating research into clinical practice is challenging for staff across disciplines. Developing strategies to address common challenges identified in this study may facilitate the adoption of innovative programs within healthcare organizations. J Am Geriatr Soc 2004;52(11): 1875-1882.