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General acceptance of a pattern of activities of daily living (ADL) dependency has led to the use of an additive method of determining self-care dependency and need for long-term care. This traditional method of determining ADL levels is convenient, and it is practical to the extent that individuals in a long-term care population do fit a scaled pattern of dependency. This research was based on 3611 cases from the Preadmission Screening Program of the Virginia Medical Assistance Program. Tabular and staged logistic regression analyses examined: 1) characteristics of this group of long-term care elders, 2) the extent of ADL divergence in various recommended care settings, 3) the relationship between rehabilitation status and ADL divergence, 4) other factors influencing divergence from the ADL dependency hierarchy. The results of this study demonstrated that a large proportion of those screened did not match the original Index of ADL. Therefore, the justification for counting ADL dependency, based on an underlying hierarchy of ADL, was not upheld. Further research was indicated for improving eligibility and placement criteria that would reflect a fluid rather than a static system of long-term care. For example, rehabilitative trajectory could serve as an indicator of projected changes in assistance for self-care. / Ph. D. / incomplete_metadata

Over the past decade, efforts led by the U.S. Department of Health and Human Services (HHS) have reduced healthcare-associated infections in acute care settings nationally. In 2013, HHS identified that the next phase of these healthcare-associated infection reduction initiatives would target long-term care facilities through the publication of a new chapter in the National Action Plan to Prevent Health Care Associated Infections devoted to this setting. Long-term care facilities are nursing facilities that provide “medical, skilled nursing and rehabilitative services on an inpatient basis to individuals who need assistance preforming activities of daily living, such as bathing and dressing”. These facilities are the primary residence for 2.5 million, predominantly elderly Americans and represented $143 billion nationally in healthcare costs as of 2010. Accordingly, it is a national priority to reduce healthcare-associated infections in this setting and protect this vulnerable population. Healthcare-associated infections caused by multidrug-resistant organisms (MDROs) are a particular burden in the long-term care population. These pathogens, usually bacteria, are defined as being resistant to one or more classes of antimicrobial agents. However, MDROs frequently exhibit resistance to nearly all antimicrobial drugs. Clinical infection control guidelines recommend isolation precautions to prevent MDRO transmission, based on evidence collected in acute care settings. However, the limited evidence that is available from studies in long-term care facilities suggests that isolation precautions may not be effective in this setting. Given that the reduction of antibiotic resistant infections is a priority of the HHS, The White House, Healthy People 2020, and the World Health Organization, it is necessary to confirm and support the appropriate use of isolation precautions for MDROs with evidence specific to long-term care facilities. Therefore, this dissertation describes the current evidence for and use of isolation precautions in long-term care facilities for MDROs. Further, it offers the most comprehensive descriptions of both isolation precautions use and predictors of MDRO infection in nursing homes (NHs), a specific type of long-term care residential setting. To assist the reader, Chapter 1 will provide background for these studies including context for current infection control and prevention practices in long-term care facilities, the importance of MDRO infections and the need for new evidence regarding isolation precautions in long-term care. It will also discuss the aims and significance of this dissertation in context of a conceptual framework, gaps in the literature and potential to improve clinical practice. Next, Chapters 2 and 3 of this dissertation systematically review the current evidence regarding effectiveness of isolation precautions against MDROs and the cost of infection prevention and control in this setting, respectively. These chapters outline how publications focused on long-term care are lacking in quality and quantity and offer suggestions for improvement in future research. Chapter 4 qualitatively describes decision-making process regarding use of isolation-based infection prevention techniques in NHs, which depends on four key considerations: perceived risk of transmission, conflict with quality of life goals, resource availability and lack of understanding. Chapter 5 builds on this qualitative analysis by quantitatively examining predictors of isolation precautions use for MDRO infection in a large, national dataset. This analysis confirms that isolation is rarely used and there is variation across NHs’ practice. However, NH staff may be tailoring infection prevention and control practice to the needs of specific residents, as would be expected based on the results of the qualitative analysis. Chapter 6 presents an analysis of MDRO infection predictors among elderly NH residents across the U.S. This study confirms concepts associated with MDRO infection in previous studies (e.g., low functionality) and provides more specificity in operationalization of these concepts than has been previously determined (e.g., needing support with locomotion), which can inform future use of isolation precautions in NHs. Finally, Chapter 7 contains a synthesis and discussion of these findings, as well as recommendations for health policy and future research regarding contact isolation precautions against MDROs in NHs.

Training and empirically evaluating caregivers’ implementation of behavior management skills is a particularly challenging task in large residential contexts. A pyramidal training approach provides an efficient and effective way to conduct large-scale competency-based behavior skills training. The purpose of this project was to develop and evaluate a large-scale pyramidal staff training program for behavior management skills. One hundred nine caregivers and 11 behavior service professionals at a large, residential care facility participated in this project. Interobserver agreement was utilized to develop and refine measurements systems to detect caregiver acquisition of skills, behavior service professionals’ ability to score caregiver performance and behavior service professionals’ ability to deliver a specified portion of the curriculum. Pre- and post-test probes were conducted utilizing standard role play scenarios and checklists to evaluate caregiver acquisition of three specific behavior management skills. The results supported the following conclusions: first, interobserver agreement measures were useful to develop a reliable measurement system, to refine some curriculum elements, and to evaluate measurement conducted by behavior service professionals. Second, behavior skills training (BST) resulted in caregiver acquisition of all three behavior management techniques. Third, the pyramidal training approach was effective to teach behavior service professionals to deliver BST and accurately measure the performances of trainees.

Sammanfattning  Introduktion; Det finns mätningar som visar att 58%, av äldre som bor på särskilt boende, ligger i riskzonen för att bli undernärda. Undersköterskor är en yrkesgrupp som möter äldre som inte vill äta och riskerar att drabbas av undernäring. Varför äldre inte vill äta kan bero på olika anledningar exempelvis vilken mat som serveras, hur och var den serveras. Nutrition är ett icke prioriterat område inom vård- och omsorg av äldre, däremot finns kunskap hos vårdpersonal om att undernäring påverkar kroppen negativt och ett gott nutritionsstatus bidrar till ökad hälsa. Syfte; Syftet med denna studie var att beskriva undersköterskors erfarenheter av att vårda äldre på särskilt boende som inte vill äta. Metod; Studien hade en deskriptiv design med kvalitativ ansats. Semistrukturerade intervjuer genomfördes med sju undersköterskor och data analyserades utifrån en manifest och latent innehållsanalys. Huvudresultat; Det underliggande temat var ”Att vara lyhörd och känna tillit i att vårda äldre i deras hälsa och ohälsa.” Temat bestod av fyra kategorier som var Att vilja äta, Att inte vilja äta, Betydelse av omvårdnad och Utmaningar i arbetet. Slutsats; Det var vanligt förekommande att undersköterskor mötte äldre som inte ville äta. När sådan situation uppstod började undersköterskorna att utreda varför den äldre inte ville äta, därefter utfördes lämpliga åtgärder och insatser. Tillit mellan den äldre och undersköterskan skapade förutsättning för att goda omvårdnads-insatser kunde genomföras.

A elevação da expectativa de vida ocasionou a expansão do contingente de idosos no mundo e ascendeu à preocupação quanto à qualidade de vida dos mesmos. Os idosos solitários geralmente permanecem sob os cuidados dos familiares, que muitas vezes carecem de tempo para os assistirem adequadamente, e assim os alocam em Instituições de Longa Permanência (ILPIs), com a certeza de que receberão uma assistência adequada. Os moradores de ILPIs em sua grande maioria apresentam o aumento do sedentarismo, maior perda de autonomia, ausência de familiares e outros fatores que contribuem para uma qualidade de vida deficiente e maior incidência de enfermidades, sobretudo mentais. O objetivo do presente estudo foi avaliar a qualidade de vida de idosos residentes em ILPIs, verificar seu estado de saúde mental e correlacionar esses dois aspectos. O estudo foi realizado em 15 ILPIs do município de Ribeirão Preto, estado de São Paulo, Brasil. Foi aplicado o Mini Exame do Estado Mental (MEEM) em 357 idosos para a seleção dos que seriam inclusos do estudo e foram selecionados 99, nos quais foram aplicadas as escalas: WOQOL-Bref, WOQOL-Old e Inventário de Saúde Mental (MHI). Os escores médios dos domínios do WOQOL-Bref foram: Físico 46,57, Psicológico 53,58, Relações Sociais 66,08 e Meio Ambiente 57,58, sendo o domínio que mais favoreceu a QV foi o das Relações Sociais e o que mais desfavoreceu foi o Físico. Os escores dos domínios do WOQOL-Old foram: Funcionamento Sensorial 35,86; Autonomia 43,12; Participação social 53,35; Atividades Passadas, Presentes e Futuras 59,03; Morte e Morrer 32,5 e Intimidade 72,85. A faceta que apresentou o menor escore foi Morte e Morrer seguidos de Funcionamento Sensorial e Autonomia, demonstrando que estes aspectos estão rebaixados e contribuem desfavorecendo a QV. O escore total médio obtido pelo WOQOL-Old foi de 49,46, mostrando que a QV dos idosos entrevistados não está satisfatória nem insatisfatória, em virtude principalmente de alguns aspectos, próprios do idoso, de um modo geral, que contribuem negativamente para tal resultado, como o aspecto Morte e Morrer, o Funcionamento Sensorial e a Autonomia. O escore médio total do MHI foi de 30, 70, mostrando uma saúde mental deficiente. Foram encontradas correlações moderadas entre as dimensões de QV e SM, portanto, se as dimensões da QV forem satisfatórias, as da SM tenderão também a ser e vice-versa. Conclui-se, portanto, que a qualidade de vida da população estudada é mediana e sua saúde mental deficitária, sendo assim importante se atentar tanto à qualidade de vida, quanto à saúde mental desta população, pois elas se correlacionam. / The recent rise in life expectancy has led to a higher number of elderly people in the world and brought up concerns regarding their welfare. The elderly generaly remains under their family care, alone, due to the fact that their relatives lack the time to assist them properly, which leads their families to allocate them into Long-Term Care Facilities (LTCF) so that they can rest assured that they will receiver proper care. LTCF residents in general develop traits of sedentary lifestyle and become dependent, that\'s due to the absence of their relatives and other factors that lead to an impaired life with higher rates of diseases, mostly mental diseases. The goal of this research is to evaluate the life quality of LTCF residents, verify their mental health state and correlate both of these aspects. The research was conducted in 15 LTCF in the city of Ribeirão Preto, in the State of São Paulo, Brazil. 357 elders went through the Mini Mental State Examination (MMSE) to select the ones who were going to be included in this research and 99 of them were selected, in which the following scales were applied to: WOQOL-Bref, WOQOL-Old and Mental Health Inventory (MHI). The average WOQOLBref scores were: Physical 46,57, Psychological 53,58, Social Relationships 66,08 and Environmental 57,58, of which the one that favored the QV the most was Social Relationships and the least favored was the Physical domain. The WOQOL-Old domain scores were: Sensory Function 35,86; Autonomy 43,12; Social Participation 53,35; Past, Present and Future Activities 59,03; Death and Dying 32,5; Privacy 72,85. The domain with the lowest score was Death and Dying followed by Sensory Function and Autonomy, this shows that these aspects are lowered and they contribute unfavoring the QV. The average score obtained by the WOQOL-Old was 49,46, this means that the QV of the elderly interviewed is neither satisfactory nor unsatisfactory, mainly due to some aspects that are characteristic of aged people, which contribute in an unfavorable way towards the aforementioned domains (Death and Dying, Sensory Function and Autonomy). The MHI total score average was 30, 70, which means a deficient mental health. Moderate correlations were found in between the dimensions of the QV and the SM, therefore, if the dimensions of the QV are satisfactory,so are the SM dimensions and vice-versa. It can be concluded that the life quality of the population interviewed is average and their mental health is deficient, therefore it is important to look into this population\'s mental health because it is correlated to their life quality.

Thesis (M.Sc.)--Memorial University of Newfoundland, 1998. / Typescript. Bibliography: leaves 84-96.

This study examined the effects of volunteer counselor training (empathy training versus information only) and age of volunteer (senior citizens versus adolescents) upon depression level of nursing home residents. Results showed that residents who received a volunteer counselor significantly improved (p < .01) in level of depression compared to the no volunteer control group. The empathy trained counselors were not significantly more effective than the information only group. The age of the. volunteer counselor was found not to be a significant variable.