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Objectives To explore patterns of change in nursing home ( NH) residents' activities of daily living ( ADLs), particularly surrounding acute hospital stays. Design Longitudinal study using Medicare and Minimum Data Set ( MDS) assessments. Setting National sample of long-stay NH residents. Participants NH residents who were hospitalized for the seven most-common inpatient diagnoses (N = 40,128). Each hospital admission was at least 90 days after any prior hospitalization and had at least two preceding MDS assessments. Measurements The MDS ADL long-form score, a simple sum of seven self-care variables coded from 0 (independent) to 4 (totally dependent) was used to indicate resident ADL function. Scores ranged from 0 to 28, with higher scores indicating greater impairment. A linear mixed model describing ADL trajectories was jointly estimated with time-to-event models for mortality and hospital readmission. Results Before hospitalization, the most common trajectory was stable (53.7%), with 27.5% of residents worsening and 18.8% improving. ADL function after hospital discharge was most often characterized as stable (43.1%) or worsening (39.2%). Mortality (20.3%) was higher for those with worsening prehospital ADL function (28.9%) than for those with stable (19.1%) or improving (11.3%) trajectories. Hospital diagnosis was associated with amount of ADL worsening and rate of subsequent ADL change. Most residents with the best initial function continued to worsen after hospital discharge. Cognitive impairment was associated with poorer ADL function and accelerated worsening of ADLs. Conclusion For many long-stay NH residents, substantial and sustained ADL worsening accompanies acute hospitalization, so acute hospitalization presents an opportunity to revisit care goals; the results of the current study can help inform decision-making. [ABSTRACT FROM AUTHOR]

Background: Previous work has validated a single question to screen for hazardous or harmful drinking, but identifying those patients who have an alcohol use disorder (AUD) among those who screen positive is still time consuming. We therefore sought to develop and validate a brief assessment instrument using DSM-IV criteria for use in primary care medical practice. Methods: Four cross-sectional surveys of past-year drinkers. The developmental sample included patients presenting to emergency departments with an acute injury. The second sample, from the same study, was recruited by random-digit dialing. The third sample was recruited in 5 family medicine practices in Georgia. The fourth sample was the National Epidemiologic Survey on Alcohol and Related Conditions. Interviews with the first 3 samples used the Diagnostic Interview Schedule. The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) used the Alcohol Use Disorder and Associated Disabilities Interview Schedule. Results: Two constructs with promising test characteristics were identified: recurrent drinking in hazardous situations and drinking more than intended. Among those who screened positive with the single question in the developmental sample ( N=959), if either of the 2 items was positive, the sensitivity for current AUD was 95% and the specificity was 77%. In the second ( N=494) and third ( N=280) samples, the sensitivity was 94 and 95% and the specificity was 62 and 66%, respectively, among those with a positive screen. In the NESARC sample, including those with at least 1 occasion in the past year of drinking 5 or more drinks ( N=7,890), the sensitivity and specificity were 77 and 86%, respectively. Conclusions: The sensitivity and specificity of these 2 items across 4 samples suggest that they could be formulated into 2 questions, potentially providing busy primary care clinicians with an efficient, reasonably accurate assessment instrument to identify AUD among those patients who screen positive with the single screening question. [ABSTRACT FROM AUTHOR]

To compare treatment of nursing home residents with dementia and lower respiratory tract infection (LRI) in Missouri and the Netherlands. Two separate but simultaneous prospective cohort studies. Nursing homes in Missouri (n=36) and the Netherlands (n=61). Selected residents (701 from Missouri and 551 from the Netherlands) diagnosed with LRI and dementia. Treatment, dementia severity, symptoms and signs of LRI, and general health condition were recorded at the time of diagnosis of LRI. Death was monitored at follow-up. Treatment and mortality, stratified for dementia severity, are reported. Treatment of nursing home-acquired LRI in Missouri residents involved a larger number of antibiotics, more frequent hospitalization, and greater use of intravenous antibiotics and rehydration therapy than in Dutch residents of equal dementia severity. Furthermore, for Missouri residents, intensive interventions were more often provided irrespective of severe dementia. By contrast, in both countries, treatments to relieve symptoms of LRI were provided for only a minority of residents. Dutch mortality rates were higher overall. Care for U.S. nursing home residents with LRI and dementia is more aggressive than care for Dutch residents, particularly in residents with severe dementia. These results are relevant to the debate on optimal care in relation to curative or palliative treatment goals. [ABSTRACT FROM AUTHOR]

To determine resident and facility characteristics associated with do-not-resuscitate (DNR) orders and to test the effect of DNR orders on hospitalization of acutely ill nursing home (NH) residents with lower respiratory tract infections (LRIs). Prospective cohort. Thirty-six NHs (almost 4,000 residents) in central and eastern Missouri in the Missouri Lower Respiratory Infection study. NH residents with a LRI (n=1031). Data were obtained from new Minimum Data Set evaluations, resident examination, and chart review. Associations between resident, physician, and facility characteristics and the presence of a DNR order and hospitalization within 30 days from evaluation for an LRI were analyzed. Sixty percent of subjects had a DNR order, and 2% had a do-not-hospitalize order. Resident characteristics associated with a DNR order included older age, white race, having a surrogate decision-maker, NH residence for longer than 3 years, and more-impaired cognition. Residents with DNR orders were more likely to live in facilities with more licensed beds, a lower proportion of Medicaid recipients, and a higher prevalence of influenza vaccination. After controlling for potential confounders, residents with a DNR order before the acute illness episode were significantly less likely to be hospitalized (adjusted odds ratio=0.69, 95% confidence interval=0.49–0.97). DNR orders independently reduce the risk of hospitalization for LRI and may function as a marker for undocumented care limitations or as a mandate to limit care (unrelated to resuscitation) in NH residents with LRI. [ABSTRACT FROM AUTHOR]

Background Although lower respiratory tract infections (LRI) cause considerable morbidity and mortality among nursing home residents with dementia, the effects of care and treatment are largely unknown. Few large prospective studies have been conducted. Methods We pooled data from two large prospective cohort studies in 61 Dutch nursing homes and 36 nursing homes in the state of Missouri, United States. We included 551 US residents and 381 Dutch residents with dementia and LRI. Main outcome measures were 3-month mortality and decline in activities of daily living (ADL) function after 3 months compared with pre-illness status. Using multivariable multinomial logistic regression to control for confounding, we assessed associations of restraint use and antibiotic type (oral compared with parenteral), with outcomes of lower respiratory tract infection (LRI). Survival without ADL decline was the reference category. Results After multivariable adjustment, restraint use was associated with ADL decline (OR 1.9, 95% CI 1.1–3.3). Oral antibiotics were not associated with 3-month mortality (OR 0.83; 95% CI 0.56–1.2). Severe dementia was the strongest independent predictor of decline; mortality was most strongly associated with male gender. Conclusions Among Dutch and US nursing home residents with dementia and LRI, restrained residents suffered more decline. Parenteral antibiotic treatment was not associated with better outcome in residents at low to moderate risk of mortality. Aggressive treatment strategies may provide little benefit for the majority of nursing home residents with dementia and LRI. Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Both senior residents and faculty members evaluate family practice interns (PGY-1) on the inpatient family medicine service at the University of Missouri-Columbia. The purpose of this study was to investigate the content and nature of narrative comments on a clinical evaluation sheet. Objective 1. The authors placed the subjective comments made by faculty and senior residents in their evaluations of PGY-1 residents into 12 distinctive categories. Objective 2. Comments were coded with a positive or negative valence. Objective 3. The genders of the evaluator and learner were recorded. All evaluations made between 1996 and 1999 were analysed. A total of 1341 individual comments were reviewed. Objective 1. Categories used most often were generic comments (20.2%), personal attributes (18%), and clinical competence (14.1%). There was no difference in category use based on the experience level of the evaluator ( P = 0.17). Objective 2. The majority of the comments (81.9%) were positive in nature. Senior faculty members were significantly less likely to make negative comments than were junior faculty members or senior residents ( P = 0.004). Objective 3. There were no differences in category use based on the gender of the evaluator ( P = 0.13). Objective 1. Narrative evaluation comments may be placed into 12 distinctive categories. Most comments are generic and do not help to inform learning. Objective 2. A total of 82% of comments were positive. Residents were more likely to make negative comments than senior faculty members. Objective 3. There was no demonstrable gender bias in writing negative comments. [ABSTRACT FROM AUTHOR]

Background Accurately defining severe dementia is important for care and prognosis, but is not explicitly included in the Minimum Data Set (MDS). Objective To define severe dementia using the MDS, we used data for nursing home residents with moderate to severe dementia. Methods Two cross-sectional studies enrolled 175 residents; 89 residents from one US Veterans Affairs nursing home, and 86 residents from nine Dutch nursing homes. Measurements included the Cognitive Performance Scale (CPS; range: 0–6), activities of daily living (ADL) dependency, and the Bedford Alzheimer Nursing Severity-Scale (BANS-S; range: 7–28), a staging instrument specific for severe dementia. Results Half of the residents received CPS scores of 5, and their BANS-S scores varied widely. There was fair agreement (kappa = 0.36) between severe cognitive impairment as defined by the CPS (scores 5 and 6) and the BANS-S (score 17 or higher). Addition of an ADL dependency requirement to the CPS definition improved agreement (kappa = 0.75). The observed patterns were similar but more obvious for US residents than for Dutch residents. Conclusion Cognitively impaired residents comprise a heterogeneous group with a wide variety of function. Restriction with respect to ADL dependency allows for distinction between moderate and severe dementia. We propose the following MDS-based definition of severe dementia: a CPS score of 5 or 6 with a minimum score of at least 10 points on the MDS ADL-Short Form. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]