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1.  Sexual Aggression between Residents in Nursing Homes: Literature Synthesis for an Underrecognized Issue 
Evidence exists suggesting that most sexual aggression against older adults occurs in long-term care facilities. Fellow residents are the most common perpetrators, often due to inappropriate hypersexual behavior caused by dementing illness. This resident-to-resident sexual aggression (RRSA) is defined as sexual interactions between long-term care residents that in a community setting would likely be construed as unwelcome by at least one of the recipients and have high potential to cause physical or psychological distress in one or both of the involved. Although RRSA may be common and physical and psychological consequences for victims may be significant, this phenomenon has received little direct attention from researchers to date. We review the existing literature and relevant related research examining elder sexual abuse and hypersexual behavior to describe the epidemiologic features of this phenomenon, including risk factors for perpetrators and victims. Preventing and managing sexual aggression in nursing homes is made more challenging due to the legitimate and recognized need for nursing home residents, even those with advanced dementing illness, to sexually express themselves. We discuss the ethical dilemma this situation creates and the need to evaluate the capacity to consent to sexual activity among residents with dementing illness and to re-evaluate capacity as the diseases progress. We offer suggestions for managing RRSA incidents and for future research, including the importance of designing effective interventions.
PMCID: PMC3625650  PMID: 20840462
aggressive behavior; sexual abuse; nursing homes; sexual behavior; dementia
2.  Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff 
To more fully characterize the spectrum of RRA.
A focus group study of nursing home staff members and residents who could reliably self-report.
A large urban, not-for-profit long-term care facility in New York City
7 residents and 96 staff members from multiple clinical and non-clinical occupational groups.
16 focus groups were conducted. Content was analyzed with nVivo 7 software for qualitative data.
35 different types of physical, verbal and sexual RRA were described, with screaming and/or yelling being the most common. Calling out and making noise were the most frequent of 29 antecedents identified as instigating episodes of RRA. RRA was most frequent in dining and residents’ rooms, and in the afternoon, though it occurred regularly throughout the facility at all times. While no proven strategies exist to manage RRA, staff described 25 self-initiated techniques to address the issue.
RRA is a ubiquitous phenomenon in nursing home settings with important consequences for affected individuals and facilities. Further epidemiologic research is necessary to more fully describe the phenomenon and identify risk factors and preventative strategies.
PMCID: PMC2755096  PMID: 18637979
nursing home; dementia-related behaviors; focus groups
3.  Resident-to-Resident Aggression in Nursing Homes: Results from a Qualitative Event Reconstruction Study 
The Gerontologist  2011;52(1):24-33.
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.
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.
These results suggest the need for person-centered and environmental interventions to reduce RRA, as well as for further research on the topic.
PMCID: PMC3265555  PMID: 22048811
Abuse/neglect; Behavior; Long-term care; Aggression
4.  Prevalence of physical and verbal aggressive behaviours and associated factors among older adults in long-term care facilities 
BMC Geriatrics  2005;5:13.
Verbal and physical aggressive behaviours are among the most disturbing and distressing behaviours displayed by older patients in long-term care facilities. Aggressive behaviour (AB) is often the reason for using physical or chemical restraints with nursing home residents and is a major concern for caregivers. AB is associated with increased health care costs due to staff turnover and absenteeism.
The goals of this secondary analysis of a cross-sectional study are to determine the prevalence of verbal and physical aggressive behaviours and to identify associated factors among older adults in long-term care facilities in the Quebec City area (n = 2 332).
The same percentage of older adults displayed physical aggressive behaviour (21.2%) or verbal aggressive behaviour (21.5%), whereas 11.2% displayed both types of aggressive behaviour. Factors associated with aggressive behaviour (both verbal and physical) were male gender, neuroleptic drug use, mild and severe cognitive impairment, insomnia, psychological distress, and physical restraints. Factors associated with physical aggressive behaviour were older age, male gender, neuroleptic drug use, mild or severe cognitive impairment, insomnia and psychological distress. Finally, factors associated with verbal aggressive behaviour were benzodiazepine and neuroleptic drug use, functional dependency, mild or severe cognitive impairment and insomnia.
Cognitive impairment severity is the most significant predisposing factor for aggressive behaviour among older adults in long-term care facilities in the Quebec City area. Physical and chemical restraints were also significantly associated with AB. Based on these results, we suggest that caregivers should provide care to older adults with AB using approaches such as the progressively lowered stress threshold model and reactance theory which stress the importance of paying attention to the severity of cognitive impairment and avoiding the use of chemical or physical restraints.
PMCID: PMC1310539  PMID: 16280091
5.  The Involvement of Girls and Boys with Bullying: An Analysis of Gender Differences 
This exploratory and cross-sectional study aimed to identify the prevalence of bullying in a group of students and analyze the data regarding the gender of those involved in the violence. A questionnaire adapted from Olweus was applied in seven elementary education schools in Portugal. The sample consisted of 387 students between 7 and 14 years old. Data are presented in terms of descriptive statistics and differences between proportions were analyzed using chi-square tests. The gender analysis of victimization and aggression shows that boys and girls are both victims and aggressors, and there are significant differences in involvement in bullying between genders and the roles played. Boys are victims more often when considering different types of bullying, although significant differences were only found for physical aggression. Strategies that include gender roles are a priority for prevention and careful attention to this phenomenon in the school context. The questions addressed contribute to a broader understanding of the phenomenon, emphasizing the differential participation of boys and girls in bullying.
PMCID: PMC3881143  PMID: 24317387
school health services; bullying; public health
6.  ïSCOPE: Safer care for older persons (in residential) environments: A study protocol 
The current profile of residents living in Canadian nursing homes includes elder persons with complex physical and social needs. High resident acuity can result in increased staff workload and decreased quality of work life.
Safer Care for Older Persons [in residential] Environments is a two year (2010 to 2012) proof-of-principle pilot study conducted in seven nursing homes in western Canada. The purpose of the study is to evaluate the feasibility of engaging front line staff to use quality improvement methods to integrate best practices into resident care. The goals of the study are to improve the quality of work life for staff, in particular healthcare aides, and to improve residents' quality of life.
The study has parallel research and quality improvement intervention arms. It includes an education and support intervention for direct caregivers to improve the safety and quality of their care delivery. We hypothesize that this intervention will improve not only the care provided to residents but also the quality of work life for healthcare aides. The study employs tools adapted from the Institute for Healthcare Improvement's Breakthrough Series: Collaborative Model and Canada's Safer Healthcare Now! improvement campaign. Local improvement teams in each nursing home (1 to 2 per facility) are led by healthcare aides (non-regulated caregivers) and focus on the management of specific areas of resident care. Critical elements of the program include local measurement, virtual and face-to-face learning sessions involving change management, quality improvement methods and clinical expertise, ongoing virtual and in person support, and networking.
There are two sustainability challenges in this study: ongoing staff and leadership engagement, and organizational infrastructure. Addressing these challenges will require strategic planning with input from key stakeholders for sustaining quality improvement initiatives in the long-term care sector.
PMCID: PMC3155478  PMID: 21745382
7.  Linking Resident Behavior to Dementia Care Communication: Effects of Emotional Tone 
Behavior therapy  2010;42(1):42-46.
Care for older adults with dementia is complicated by behaviors such as verbal and physical aggression and withdrawal that disrupt and increase the costs of providing care. These behaviors, referred to as resistiveness to care (RTC), have been linked to staff elderspeak communication, measured by behaviorally coded explicit behaviors. This study examined videotapes of nursing home (NH) residents with dementia interacting with staff during bathing to explore the relationships between implicit messages communicated by nursing staff and resident RTC behavior.
Implicit messages in nursing staff communication were rated using the Emotional Tone Rating Scale by naïve coders. Associations between implicit ratings of care, respect, and control were analyzed in relation to RTC scale scores. Highly controlling communication was significantly correlated with increased resident RTC (r = .49, p < .05). Associations between the care and respect dimensions of communication were not significantly correlated with RTC; however, trends in hypothesized directions were identified. The association between emotional tone and RTC found in this study suggests that it is an important factor in care. Understanding affective messages is a first step in modifying these implicit messages conveyed during staff-resident communication. Research is needed to confirm these findings and to identify and test interventions to teach staff to reduce controlling messages that will to reduce RTC and improve care.
PMCID: PMC3485306  PMID: 21292050
8.  Physically Abused Women’s Experiences of Sexual Victimization and their Children’s Disruptive Behavior Problems 
Psychology of violence  2012;2(4):401-410.
Despite the substantial co-occurrence of women’s experiences of physical and sexual violence, very little is known about their separate and combined effects on child functioning. The present study examines whether sexual victimization experienced by physically abused women is associated with their children’s disruptive behavior problems, after controlling for mothers’ physical victimization and parent to child aggression. It also tests the hypothesis that maternal distress mediates the association between women’s sexual victimization and their children’s disruptive behavior problems.
The sample includes 449 mothers and their children (4–8 years) who were recruited while residing in domestic violence shelters. Mothers reported on their experiences of physical and sexual victimization over the past year and their current symptoms of psychological distress. Trained diagnosticians interviewed mothers about their children’s disruptive behavior problems.
Approximately 75% of the women reported experiences of sexual victimization. Physically abused women’s experiences of sexual victimization correlated positively with their children’s disruptive behavior problems and their own psychological distress. The results of path analyses indicated that maternal psychological distress mediates the relation between women’s experiences of sexual victimization and their children’s disruptive behavior problems.
This research suggests that physically abused women’s experiences of sexual victimization are important for understanding their children’s disruptive behavior problems. Additionally, this research provides further evidence that maternal psychological distress is important for understanding how intimate partner violence might influence children.
PMCID: PMC3499602  PMID: 23166861
intimate partner violence; sexual victimization; co-occurrence of violence; children’s disruptive behavior
9.  Culture Change in Long-term Care: Participatory Action Research and the Role of the Resident 
The Gerontologist  2010;51(2):212-225.
Purpose: This study's purpose was to advance the process of culture change within long-term care (LTC) and assisted living settings by using participatory action research (PAR) to promote residents’ competence and nourish the culture change process with the active engagement and leadership of residents. Design and Methods: Seven unit-specific PAR groups, each consisting of 4–7 residents, 1–2 family members, and 1–3 staff, met 1 hour per week for 4 months in their nursing home or assisted living units to identify areas in need of improvement and to generate ideas for community change. PAR groups included residents with varied levels of physical and cognitive challenges. Residents were defined as visionaries with expertise based on their 24/7 experience in the facility and prior life experiences. Results: All PAR groups generated novel ideas for creative improvements and reforms in their communities and showed initiative to implement their ideas. Challenges to the process included staff participation and sustainability. Implications: PAR is a viable method to stimulate creative resident-led reform ideas and initiatives in LTC. Residents’ expertise has been overlooked within prominent culture change efforts that have developed and facilitated changes from outside-in and top-down. PAR may be incorporated productively within myriad reform efforts to engage residents’ competence. PAR has indirect positive quality of life benefits as a forum of meaningful social engagement and age integration that may transform routinized and often ageist modes of relationships within LTC.
PMCID: PMC3140257  PMID: 21163911
Institutional care; Ageism; QOL; Age integration; Competence; Helplessness
10.  Behavioural Indicators of Motives for Barroom Aggression: Implications for Preventing Bar Violence 
Drug and alcohol review  2011;30(5):554-563.
To develop new strategies for preventing violence in high risk licensed premises, we identify behavioural indicators of apparent motives for aggression in these settings and outline the implications of different motivation for prevention.
The four types of motives for aggressive or coercive acts defined by the theory of coercive actions framed the research: gaining compliance, expressing grievances/restoring justice, attaining a favourable social identity, and pursuing fun/excitement. Incidents of aggression from the Safer Bars evaluation research [1] were analysed to identify behavioural indicators of each motivation.
Compliance-motivated aggression typically takes the form of unwanted social overtures, third party intervention to stop conflicts or staff rule enforcement. Prevention strategies include keeping the aggressor’s focus on compliance to avoid provoking grievance and identity motives which are likely to escalate aggression. Grievance motives are typically elicited by perceived wrongdoing and, therefore, prevention should focus on eliminating sources of grievances and adopting policies/practices to resolve grievances peacefully. Social identity motives are endemic to many drinking establishments especially among male patrons and staff. Prevention involves reducing identity cues in the environment, hiring staff who do not have identity concerns, and training staff to avoid provoking identity concerns. Aggression motivated by fun/excitement often involves low-level aggression where escalation can be prevented by avoiding grievances and attacks on identity.
Knowledge of behavioural indicators of motives can be used to enhance staff hiring and training practices, reduce environmental triggers for aggression, and develop policies to reduce motivation for aggression.
PMCID: PMC3175098  PMID: 21896078
alcohol & violence; licensed premises; prevention; motivation; gender issues
11.  An Internet Training to Reduce Assaults in Long Term Care 
Physical and verbal assaults by residents on care staff are not uncommon in long-term residential care facilities (LTCs). This research evaluated an Internet training designed to teach Nurse Aides (NAs) strategies to work with aggressive resident behaviors. Six LTCs were randomized in an immediate treatment (IT) and delayed treatment (DT) design, and NAs were recruited in each (IT: n = 58; DT; n = 45). The treatment involved two weekly visits to the on-line training. Hard copy assessments collected participant responses at baseline (T1), 8 weeks (T2), and at 16 weeks (T3). The DT group viewed the program after T2. HLM models show significant group differences at T2 in knowledge and the levels were maintained at T3. The number of aggressive incidents reported per day by the IT group were non-significant at T2, but decreased significantly from T1 to T3 with a very large effect size. The program was well received by users. These results suggest that the Internet training was an effective tool to reduce assaults in LTCs, and training effects may improve over time as NAs gain experience using the techniques.
PMCID: PMC3268852  PMID: 22209192
resident aggression; training; Internet; Nurse Aides; long term care; nursing homes
Journal of advanced nursing  2005;49(4):377-386.
While various efforts have described the ramifications of staff-resident interactions in nursing homes, few studies identify the factors that potentially influence staff members' perceptions of residents in multiple long-term care settings.
This paper reports a study to determine how facility-, resident-, family-, and staff-level indicators are empirically associated with staff members' perceptions of residents in nursing homes, assisted living facilities, and family care homes.
The participants were 41 care staff located in 5 nursing homes, 5 assisted living facilities, and 16 family care homes randomly selected in the United States of America. Face-to-face and telephone interviews were conducted with care staff, residents in their care, family members of residents, and administrators of participating facilities. Telephone interviews measured staff perceptions of residents on two domains: cohesion (perceived feelings of closeness between staff and residents) and knowledge of residents' personal lives and care needs.
Regression models found that staff who were married, reported more positive attitudes toward family members, and worked in smaller facilities reported greater staff-resident cohesion. In addition, staff who cared for a higher percentage of residents with learning difficulties indicated greater knowledge of residents.
The findings emphasize the need to consider elements of staff-family relationships when considering staff perceptions of residents. The results also imply that clinical interventions designed to enhance social relationships in nursing homes can be extended across the long-term care landscape to positively influence the staff-resident-family triad.
PMCID: PMC2365472  PMID: 15701152
Long-term care; Residential homes; staff; residents; relatives; nursing
13.  Longitudinal Examination of Physical and Relational Aggression as Precursors to Later Problem Behaviors in Adolescents 
Violence and victims  2009;24(1):3-19.
Research has addressed the consequences of being a victim of physical and relational aggression, but less so the consequences of being an aggressor during adolescence. Consequently, relatively little is known about the extent to which aggression in early adolescence increases the risk of later aggression and other psychosocial problems. This study involves a representative sample of 7th- and 9th-grade students from Washington State (N = 1,942). Students were surveyed upon recruitment, and then again 1 and 2 years later, to learn about ongoing behavior problems, substance use, depression, and self-harm behaviors. Surveys also included measures of several hypothesized promotive factors: attachment to family, school commitment, and academic achievement. Findings suggest that being physically and/or relationally aggressive in Grades 7–9 increases the risk of aggression and possibly other problem behaviors after accounting for age, gender, race, and a prior measures of each outcome. Independent promotive effects were observed in most analyses, although family attachment appeared a less robust predictor overall. Implications for prevention include reducing aggression and enhancing promotive influences to lessen the risk of ongoing problems.
PMCID: PMC2659462  PMID: 19297882
physical aggression; relational aggression; adolescence
14.  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 
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.
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.
The design was a prospective cluster randomized trial with randomization at the unit level.
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.
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).
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.
PMCID: PMC3677710  PMID: 23159018
Resident-to-resident elder mistreatment (R-REM); nursing homes; long term care; older people; elder abuse; staff education; staff training
15.  Resident-Directed Long-Term Care: Staff Provision of Choice During Morning Care 
The Gerontologist  2011;51(6):867-875.
Purpose: To develop an observational protocol to assess the quality of staff–resident communication relevant to choice and describe staff–resident interactions as preliminary evidence of the usefulness of the tool to assess current nursing home practices related to offering choice during morning care provision. Design and Methods: This study included 73 long-stay residents in 2 facilities. Research staff conducted observations for 4 consecutive morning hours during targeted care activities (transfer out of bed, incontinence, dressing, and dining location). Observations were conducted weekly for 12 consecutive weeks. Staff–resident interactions were measured related to staff offers of choice and residents’ responses. Results: Interrater agreement was achieved for measures of staff offers of choice (kappa = .83, p < .001), type of choice provided (kappa = .75, p < .001), and resident requests related to choice (kappa = .72, p < .001). Observations over 2,766 care episodes during 4 aspects of morning care showed that staff offered residents choice during 18% of the episodes. Most observations (70%) were coded as staff offering “no choice.” Implications: Nursing home staff can use a simplified version of this standardized observational tool to reliably measure staff–resident interactions related to choice during morning care provision as a first step toward improving resident-directed care practice.
PMCID: PMC3220665  PMID: 21719629
Long-term care; Quality of care; Measurement; Quality of life; Assessment of conditions/people; Consumer-directed care
16.  The relationship between pain and disruptive behaviors in nursing home resident with dementia 
BMC Geriatrics  2013;13:14.
Nursing home residents with dementia gradually lose the ability to process information so that they are less likely to express pain in typical ways. These residents may express pain through disruptive behaviors because they cannot appropriately verbalize their pain experience. The objective of this study was to investigate the effect of pain on disruptive behaviors in nursing home residents with dementia.
This is a secondary analysis of the Minimum Data Set (MDS 2.0) assessment data on long-term care from the state of Florida. The data used in this study were the first comprehensive assessment data from NH residents with dementia aged 65 and older (N = 56,577) in Medicare- or Medicaid-certified nursing homes between January 1, 2009 and December 31, 2009. Variables examined were pain, wandering, aggression, agitation, cognitive impairment, activities of daily living impairments, and demographic characteristics. Ordinal logistic regression was used to evaluate the effect of pain on disruptive behaviors.
Residents with more severe pain are less likely to display wandering behaviors (OR = .77, 95% CI for OR = [0.73, 0.81]), but more likely to display aggressive and agitated behaviors (OR = 1.04, 95% CI for OR = [1.01, 1.08]; OR = 1.17, 95% CI for OR = [1.13, 1.20]).
The relationship between pain and disruptive behaviors depends on the type of behaviors. Pain is positively correlated with disruptive behaviors that do not involve locomotion (e.g., aggression and agitation), but negatively related to disruptive behaviors that are accompanied by locomotion (e.g., wandering). These findings indicate that effective pain management may help to reduce aggression and agitation, and to promote mobility in persons with dementia.
PMCID: PMC3573898  PMID: 23399452
Disruptive behaviors; Pain; Dementia; Nursing home
17.  Failure to Identify Behavioral Symptoms of People with Dementia and the Need for Follow-Up Physical Assessment 
This descriptively designed study examined sensitivity and specificity of staff nurses identification of behavior change in nursing home residents with dementia. Behavior changes and whether further physical assessment was indicated were described and compared to judgments made by one expert advanced practice nurse. The convenience sample included 155 residents and 38 staff nurses from eleven nursing homes. Verbal symptoms and body part cues were the most prevalent behaviors regardless of the assessor. Sensitivity, or probability of identifying a real behavior change, was generally low for the staff nurses, ranging between 35–65% for the different types of behaviors, while specificity was quite high at over 95%. Additional assessment was felt to be needed for 51% of residents by the staff nurse and for 73% of residents by the expert. This study found that staff nurses are under-identifying behavior changes and the need for additional physical assessment.
PMCID: PMC3161167  PMID: 21598865
18.  Physical restraint use among nursing home residents: A comparison of two data collection methods 
BMC Nursing  2004;3:5.
In view of the issues surrounding physical restraint use, it is important to have a method of measurement as valid and reliable as possible. We determined the sensitivity and specificity of physical restraint use a) reported by nursing staff and b) reviewed from medical and nursing records in nursing home settings, by comparing these methods with direct observation.
We sampled eight care units in skilled nursing homes, seven care units in nursing homes and one long-term care unit in a hospital, from eight facilities which included 28 nurses and 377 residents. Physical restraint use was assessed the day following three periods of direct observation by two different means: interview with one or several members of the regular nursing staff, and review of medical and nursing records. Sensitivity and specificity values were calculated according to 2-by-2 contingency tables. Differences between the methods were assessed using the phi coefficient. Other information collected included: demographic characteristics, disruptive behaviors, body alignment problems, cognitive and functional skills.
Compared to direct observation (gold standard), reported restraint use by nursing staff yielded a sensitivity of 87.4% at a specificity of 93.7% (phi = 0.84). When data was reviewed from subjects' medical and nursing records, sensitivity was reduced to 74.8%, and specificity to 86.3% (phi = 0.54). Justifications for restraint use including risk for falls, agitation, body alignment problems and aggressiveness were associated with the use of physical restraints.
The interview of nursing staff and the review of medical and nursing records are both valid and reliable techniques for measuring physical restraint use among nursing home residents. Higher sensitivity and specificity values were achieved when nursing staff was interviewed as compared to reviewing medical records. This study suggests that the interview of nursing staff is a more reliable method of data collection.
PMCID: PMC526298  PMID: 15488144
19.  The Quality of Advanced Dementia Care in the Nursing Home: The Role of Special Care Units 
Medical care  2012;50(10):856-862.
The quality of nursing home care for residents with advanced dementia has been described as suboptimal. One relatively understudied factor is the impact of special care units (SCUs) for dementia for residents at the end-stage of this disease.
To examine the association between residence in an SCU and the quality of end-of-life care for nursing home residents with advanced dementia.
Research Design
This study employed longitudinal data on 323 nursing home residents with advanced dementia living in 22 Boston-area facilities. Using multivariate methods, we analyzed the association between residence in an SCU and measures of quality of end-of-life care including: treatment of pain and dyspnea, prevalence of pressure ulcers, hospitalization, tube feeding, antipsychotic drug use, advance care planning, and health care proxy (HCP) satisfaction with care.
A total of 43.7% residents were cared for in an SCU. After multivariate adjustment, residents in SCUs were more likely to receive treatment for dyspnea, had fewer hospitalizations, were less likely to be tube fed, and more likely to have a do-not-hospitalize order, compared to non-SCU residents. However, non-SCU residents were more likely to be treated for pain, had fewer pressure ulcers, and less frequent use of antipsychotic drugs than SCU residents. HCPs of SCU residents reported greater satisfaction with care than HCPs of non-SCU residents.
Residence in an SCU is associated with some, but not all, markers of better quality end-of-life care among nursing home residents with advanced dementia.
PMCID: PMC3444818  PMID: 22982735
special care units; quality of care; dementia; end-of-life care
20.  A prospective study of symptoms, function, and medication use during acute illness in nursing home residents: design, rationale and cohort description 
BMC Geriatrics  2010;10:47.
Nursing home residents are at high risk for developing acute illnesses. Compared with community dwelling adults, nursing home residents are often more frail, prone to multiple medical problems and symptoms, and are at higher risk for adverse outcomes from acute illnesses. In addition, because of polypharmacy and the high burden of chronic disease, nursing home residents are particularly vulnerable to disruptions in transitions of care such as medication interruptions in the setting of acute illness. In order to better estimate the effect of acute illness on nursing home residents, we have initiated a prospective cohort which will allow us to observe patterns of acute illnesses and the consequence of acute illnesses, including symptoms and function, among nursing home residents. We also aim to examine the patterns of medication interruption, and identify patient, provider and environmental factors that influence continuity of medication prescribing at different points of care transition.
This is a prospective cohort of nursing home residents residing in two nursing homes in a metropolitan area. Baseline characteristics including age, gender, race, and comorbid conditions are recorded. Participants are followed longitudinally for a planned period of 3 years. We record acute illness incidence and characteristics, and measure symptoms including depression, pain, withdrawal symptoms, and function using standardized scales.
76 nursing home residents have been followed for a median of 666 days to date. At baseline, mean age of residents was 74.4 (± 11.9); 32% were female; 59% were white. The most common chronic conditions were dementia (41%), depression (38%), congestive heart failure (25%) and chronic obstructive lung disease (27%). Mean pain score was 4.7 (± 3.6) on a scale of 0 to 10; Geriatric Depression Scale (GDS-15) score was 5.2 (± 4.4). During follow up, 138 acute illness episodes were identified, for an incidence of 1.5 (SD 2.0) episodes per resident per year; 74% were managed in the nursing home and 26% managed in the acute care setting.
In this report, we describe the conceptual model and methods of designing a longitudinal cohort to measure acute illness patterns and symptoms among nursing home residents, and describe the characteristics of our cohort at baseline. In our planned analysis, we will further estimate the effect of the use and interruption of medications on withdrawal and relapse symptoms and illness outcomes.
PMCID: PMC2916000  PMID: 20630095
21.  Rudimentary Sympathy in Preverbal Infants: Preference for Others in Distress 
PLoS ONE  2013;8(6):e65292.
Despite its essential role in human coexistence, the developmental origins and progression of sympathy in infancy are not yet fully understood. We show that preverbal 10-month-olds manifest sympathetic responses, evinced in their preference for attacked others according to their evaluations of the respective roles of victim, aggressor, and neutral party. In Experiment 1, infants viewing an aggressive social interaction between a victim and an aggressor exhibited preference for the victim. In Experiment 2, when comparing the victim and the aggressor to a neutral object, infants preferred the victim and avoided the aggressor. These findings indicate that 10-month-olds not only evaluate the roles of victims and aggressors in interactions but also show rudimentary sympathy toward others in distress based on that evaluation. This simple preference may function as a foundation for full-fledged sympathetic behavior later on.
PMCID: PMC3680456  PMID: 23776467
22.  Do nursing home residents make greater demands on GPs? A prospective comparative study. 
BACKGROUND: The number of people residing in nursing homes has increased. General practitioners (GPs) receive an increased capitation fee for elderly patients in recognition of their higher consultation rate. However, there is no distinction between elderly patients residing in nursing homes and those in the community. AIM: To determine whether nursing home residents receive greater general practice input than people residing in the community. METHOD: Prospective comparative study of all 345 residents of eight nursing homes in Glasgow and a 2:1 age, sex, and GP matched comparison group residing in the community. A comparison of contacts with primary care over three months in terms of frequency, nature, length, and outcome was carried out. RESULTS: Nursing home residents received more total contacts with primary care staff (P < 0.0001) and more face-to-face consultations with GPs (P < 0.0001). They were more likely to be seen as an emergency (P < 0.01) but were no more likely to be referred to hospital, and were less likely to be followed-up by their GP (P < 0.0001). Although individual consultations with nursing home residents were shorter than those with the community group (P < 0.0001), the overall time spent consulting with them was longer (P < 0.001). This equated to an additional 28 minutes of time per patient per annum. Some of this time would have been offset by less time spent travelling, since 61% of nursing home consultations were done during the same visit as other consultations, compared with only 3% of community consultations (P < 0.0001). CONCLUSION: Our study suggests that nursing home residents do require a greater input from general practice than people of the same age and sex who are residing in the community. While consideration may be given to greater financial reimbursement of GPs who provide medical care to nursing home residents, consideration should also be given to restructuring the medical cover for nursing home residents. This would result in a greater scope for proactive and preventive interventions and for consulting with several patients during one visit.
PMCID: PMC1313470  PMID: 10621985
23.  Cost-effectiveness of nutrition interventions in nursing home residents: A pilot intervention 
Unintentional weight loss is a prevalent and costly clinical problem among nursing home (NH) residents. One of the most common nutrition interventions for residents at risk for weight loss is oral liquid nutrition supplementation. The purpose of this study was to determine the cost effectiveness of supplements relative to offering residents’ snack foods and fluids between meals to increase caloric intake.
Randomized, controlled trial.
Three long-term care facilities.
Sixty-three long-stay residents who had an order for nutrition supplementation.
Participants were randomized into one of three groups: (1) usual NH care control; (2) supplement, or (3) between-meal snacks. For groups two and three, trained research staff provided supplements or snacks twice daily between meals, five days per week, for six weeks with assistance and encouragement to promote consumption.
Research staff observed residents during and between meals for two days at baseline, weekly, and post six weeks to estimate total daily caloric intake. For both intervention groups, research staff documented residents’ caloric intake between meals from supplements or snack items, refusal rates and the amount of staff time required to provide each intervention.
Both interventions increased between meal caloric intake significantly relative to the control group and required more staff time than usual NH care. The snack intervention was slightly less expensive and more effective than the supplement intervention.
Offering residents a choice among a variety of foods and fluids twice per day may be a more effective nutrition intervention than oral liquid nutrition supplementation.
PMCID: PMC3686278  PMID: 20424804
nursing homes; weight loss; intervention; nutrition supplementation
Violence against women  2010;16(1):84-98.
This study is among the first attempts to address a frequently articulated, yet unsubstantiated claim that sample inclusion criterion based on women’s physical aggression or victimization will yield different distributions of severity and type of partner violence and injury. Independent samples of African-American women participated in separate studies based on either inclusion criterion of women’s physical aggression or victimization. Between-groups comparisons showed that samples did not differ in physical, sexual, or psychological aggression; physical, sexual, or psychological victimization; inflicted or sustained injury. Therefore, inclusion criterion based on physical aggression or victimization did not yield unique samples of “aggressors” and “victims.”
PMCID: PMC2967017  PMID: 19949230
Partner violence; Inclusion criteria; Victimization; Aggression
25.  The prevalence and management of heart failure in Dutch nursing homes; design of a multi-centre cross-sectional study 
BMC Geriatrics  2012;12:29.
Heart failure is likely to be particularly prevalent in the nursing home population, but reliable data about the prevalence of heart failure in nursing homes are lacking. Therefore the aims of this study are to investigate (a) the prevalence and management of heart failure in nursing home residents and (b) the relation between heart failure and care dependency as well as heart failure and quality of life in nursing home residents.
Nursing home residents in the southern part of the Netherlands, aged over 65 years and receiving long-term somatic or psychogeriatric care will be included in the study. A panel of two cardiologists and a geriatrician will diagnose heart failure based on data collected from actual clinical examinations (including history, physical examination, ECG, cardiac markers and echocardiography), patient records and questionnaires. Care dependency will be measured using the Care Dependency Scale. To measure the quality of life of the participating residents, the Qualidem will be used for psychogeriatric residents and the SF-12 and VAS for somatic residents.
The study will provide an insight into the actual prevalence and management of heart failure in nursing home residents as well as their quality of life and care dependency.
Trial registration
Dutch trial register NTR2663
PMCID: PMC3462700  PMID: 22686685

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