Dementia in Nursing Home Residents: Findings and Issues in Current Research

1
Dementia in Nursing Home Residents Findings and
Issues in Current Research

• Based on the publications of
• Sheryl Zimmerman, Ph.D.
• Associate Professor
• School of Social Work
• University of North Carolina at Chapel Hill

2
Why Interest in Dementia in Nursing Homes

• Approximately 5 of those gt65 reside in nursing
  homes1
• 25-50 of those gt65 today will enter a nursing
  home in their lifetimes2
• 50-75 of all nursing home residents have
  dementia3

3
Topics to be Covered

• Issues in research
• Description of the population
• Special Care Units (SCUs)

4
Issues in Research Diagnosing Dementia
(Magaziner, et al., 1996)

• Multi-stage diagnostic process difficult in large
  scale research
• Chart data often unreliable
• Variable clinical judgment
• Multiple diagnostic standards
• How to accurately diagnose dementia in large,
  dispersed research populations?

5
Example Model to Diagnose Dementia in Research
Studies (Magaziner, et al., 1996)

• Lay evaluator collects data
• Older Americans Resources and Services measure
  (family)
• Mini Mental Status Exam
• Blessed Dementia Scale
• Confusion Assessment Method (nurse)
• Katz Activities of Daily Living (nurse)
• Geriatric Depression Scale
• Cornell Scale for depression (nurse)
• Psychogeriatric Dependency Rating Scale
• Demographic and medical information

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Example Model to Diagnose Dementia in Research
Studies (Magaziner, et al., 1996)

• Expert Panel
• 2 neurodegenerative neurologists
• 2 geriatric psychiatrists
• 1 geriatrician
• Evaluator data reviewed by 2 panelists
• If disagree whether dementia, goes to full panel
• Diagnoses Dementia, No dementia, Indeterminate

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Example Model to Diagnose Dementia in Research
Studies (Magaziner, et al., 1996)

• Panel diagnosis compared with direct assessment
  by geriatrician for 100 participants
• Found
• Agreement 76 of cases (kappa0.59)
• If combined No dementia and Indeterminate,
  agreement 83 (kappa0.66)
• Agreement highest for low (0-16) and high (24-30)
  MMSE
• Agreement here similar to inter-rater clinician
  agreement for dementia diagnosis

8
Issues in Research Measuring Functional Status
(Zimmerman and Magaziner, 1994)

• Because many elders cannot respond for
  themselves, proxy-derived or performance based
  data are needed
• Proxy advantages
• Efficient
• Good response agreement with older adult on
  objective questions
• physical activity
• cognitive ability
• Only way to get data for time prior to nursing
  home admission

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Proxy-Derived Data (Zimmerman and Magaziner, 1994)

• Influences on response agreement
• Proxy relationship to individual
• Objectivity of question
• Subject type
• Considerations when using proxies
• Specific concrete questions
• Assume proxies over-report disability compared to
  individual

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Performance Based Measures (Zimmerman and
Magaziner, 1994)

• Advantages
• Objective, quantifiable, valid
• Some have been designed specifically for
  cognitively impaired
• Predictive for survival, hospitalization, falls,
  long-term care
• Can be used for people with language problems

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Performance Based Measures (Zimmerman and
Magaziner, 1994)

• Disadvantages
• May not reflect demands of actual environment
• Require training, space, time
• If resources allow for a choice, use performance
  based measures over proxy reports, or consider
  data from multiple perspectives

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Issues in Research Definitional Clarity
(Magaziner and Zimmerman, 1994)

• One area of care for elders with dementia is the
  special care unit
• What exactly is a special care unit?
• What are the characteristics of those receiving
  services in special care units?
• What are good outcomes--quality of life, better
  functioning, avoiding injury, behavior
  management?
• Do special care units provide best care?

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People with Dementia in Nursing Homes
Description (Magaziner et al., 1998, Magaziner,
et al., 2000)

• As many as 75 have dementia
• Prevalence higher in small facilities and
  metropolitan areas
• Higher risk of dementia in nursing home
  residents
• age (odds ratio 2.25 for gt85 years old)
• race (odds ratio 1.69 for non-White)
• married (odds ratio 1.41 for married)
• education (odds ratio 1.52 for lt9 years education)

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People with Dementia in Nursing Homes
Description (Magaziner et al., 1998, Magaziner,
et al., 2000)

• More impaired functioning than non-demented
  (except walking)
• More behavioral problems (55 versus 21)
• More psychiatric symptoms (48 versus 36)
• Slightly lower rates of physical co-morbidities
  (91 versus 94)

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People with Dementia in Nursing Homes
Description (Magaziner et al., 1998, Magaziner,
et al., 2000)

• There is considerable overlap in health and
  functioning between people with dementia and
  those without
• People with dementia are a heterogeneous
  group--individualized services essential
• There is a sizable subgroup of residents (with
  and without dementia) with minimal functioning
  and behavior problems--appropriateness of
  placement?

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Care for People with Dementia in Nursing Homes
Medical (Burton et al., 2001)

• Fewer physician visits (10.2/yr versus 12.7/yr)
• Fewer hospital admissions (0.9/yr versus 1.2/yr)
• Less care after fever (65 with no visits, versus
  59)
• Less care after infection (73 no visits, versus
  68)

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Care for People with Dementia in Nursing Homes
Environmental (Zimmerman and Sloane, 1999)

• Exit control
• Short/no hallways
• Toilet visible from bed
• Sign/graphic on bathroom door
• Inside of bedroom visible from hallway
• Personal object outside of bedroom
• Television not routinely on
• Homelike public area

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Specific Environmental Concerns in Special Care
Units (Sloane et al, 2000)

• Illumination did not meet industry standards in
  gt50 of areas
• Variation in illumination in activity rooms,
  ratios of 41
• Background noise impaired understanding of
  conversation in dining area and nurses station
• Mechanical devices, hollering residents,
  obtrusive staff produced high intensity pulse
  noise

19
Special Care Units for Dementia Philosophy of
Care (Zimmerman, et al., 1997)

• Promote safety and security
• Mitigate disruptive behaviors
• Support cognitive functioning
• Maximize independent functioning
• Enhance connection to others
• Regulate stimulation

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Philosophy versus Practice (Zimmerman, et al.,
1997)

• Researchers observed behavior and treatment, and
  compared it with the professed philosophy of the
  special care unit
• For units stating strong support for a
  philosophy, this was the observational rating by
  researchers
• Support cognitive functioning 0.28 (0-3 scale)
• Regulate television use 1.67 (0-3 scale)
• Promote safety and security 10.17 obstacles to
  movement
• Mitigate disruptive behavior 17.8 residents
  exhibited problem behavior
• Never use restraints 15.5 residents restrained

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When Working with Nursing Home Residents with
Dementia

• Remember
• Strengths and weaknesses of proxy versus
  performance measures can be extrapolated to
  assessment processes
• Heterogeneity of population, so service must be
  individualized
• Ensure access to all needed medical care
• Advocate for dementia-sensitive care, based in
  observation, not espoused philosophy