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Objective: To describe the differences in prevalence of tube feeding among states and to examine possible factors that could explain practice patterns., Design: Analysis of random samples from an interstate data bank comprised of the Minimum Data Set (MDS), a standardized, federally mandated assessment instrument for nursing home residents., Setting: Nursing homes in four states participating in a federal demonstration project of case mix payment plus five others with existing MDS data systems., Participants: Individuals 65 years of age and older (N = 57,029), who had very severe cognitive impairment, including total dependence in eating, and who resided in nursing homes during 1994, the most recent year for which uniform data were available., Measurements: State-by-state differences in prevalence of tube feeding, controlling for demographic and clinical variables., Results: The prevalence of tube feeding ranged from 7.5% in Maine to 40.1% in Mississippi. Each state had a significantly elevated prevalence of tube feeding compared with Maine, with odds ratios (ORs) ranging from 1.50 to 5.83, P < .001. Specific directives not to provide tube feeding (OR 0.41, P < .001), and white race (OR 0.45, P < .001) were strongly and negatively associated with tube feeding., Conclusions: Wide regional variations exist in the use of tube feeding of nursing home residents with equivalent impairments. Sociodemographic factors could be important, but more study is needed to determine whether physician characteristics, such as race, attitudes, or knowledge, have an impact and to clarify medical standards for the use of tube feeding in this population.

Objective: The GDS (Geriatric Depression Scale) has demonstrated validity among ambulatory elderly but is less useful in nursing home (NH) populations, probably because of high rates of cognitive impairment. We, therefore, sought the lowest level of Mini-Mental Status Exam (MMSE) score for which the GDS would remain valid., Design: Validation Study., Setting: Nursing Homes in New York City., Participants: A total of 66 of 168 newly admitted residents to the NH were able to complete psychiatric assessment, undergo an MMSE, and complete the GDS. The psychiatrists and testers (all non-MDs) were blinded to each others' results. Using a cutoff of 10 or greater on the GDS to indicate depression, the GDS's validity (when compared with the psychiatric diagnoses) was sought at ever decreasing levels of cognitive function as measured by the MMSE., Results: The results of all participants (n = 66) revealed a sensitivity of 63% and a specificity of 83%. When only those with an MMSE score > or = 15 (the best cutoff score) were included, 44 (64%) participants were selected, with a sensitivity and specificity of 84% and 91%, respectively., Conclusions: The two-step procedure of first selecting those with MMSE scores > or = 15 and then giving the GDS significantly increases the utility of the GDS in detecting depression in NH residents and should improve the diagnostic process for this widely underdetected problem.

This study supports the importance of assessing the intrinsic and extrinsic attitudes and perceptions of staff on physical restraints. Any program developed to remove physical restraints in nursing homes should focus on safety issues and behavioral interventions that prevent injury to staff and resident. Environmental adaptations that would enhance residents' safety, such as alarms and wedge cushions, would be useful in a restraint reduction program. Educating staff about the risks of physical restraints and about safe alternative interventions might change their attitudes. By developing an educational program that focuses on a few residents at a time and by involving a multidisciplinary team, a truly individualized approach to restraint-free care for residents might be developed.

Long-term care institutions are beginning to grapple with ethical issues on a regular basis. This has encouraged facilities to develop new mechanisms to deal with these issues. Described is a tripartite program that incorporates direct service, education, and research in ethics.

We reviewed the clinical characteristics and outcome of cases of acute myocardial infarction occurring from January 1, 1985, through December 31, 1987, in the population of a long-term care institution for the elderly. The total number of patients in the series was 43. Comparisons were made between those patients transferred to a general acute-care hospital and those who remained at the facility. The most common initial symptoms of acute myocardial infarction in 32 of 48 patients were, in order, dyspnea, dizziness or syncope, precordial pain, and abdominal pain. Nine (of 43) patients were asymptomatic. In the 14 (of 43) patients transferred to an acute-care hospital, cardiac failure, arrhythmias, and cardiogenic shock were much more frequent than among those retained in the long-term care facility. We concluded that a high index of suspicion for the diagnosis of acute myocardial infarction in the institutionalized elderly is indicated. Patients with mild infarction can be retained in long-term care institutions; resulting mortality from cardiac disorders should be low in adequately staffed and equipped long-term care institutions.

We interviewed 44 residents of a nursing home to assess their preferences for care. Using case vignettes, we asked residents about resuscitation, hospital transfer, feeding tubes, and restraint use. Most were opposed to aggressive care unless the purpose was to enhance comfort or safety. However, sufficient diversity of opinions points to the need for advanced directives.

This case-control study examines the relationship between falls and drug use in elderly residents of a long-term care facility. The drug use and functional status of 57 first-time fallers were compared retrospectively with those of 90 residents who had never fallen. Fallers were taking significantly more drugs than controls. Hypnotic/anxiolytics and cardiac drugs carried a twofold increase in the risk of falling. Fallers were restrained less often, were more often ambulatory, and had been at the institution for a shorter time than controls. Previous studies have failed to use control groups or have selected controls by length of stay, possibly introducing bias into the results. A large prospective study is needed to determine whether these results are generalizable to the elderly institutionalized population as a whole.

In an attempt to identify indicators of risk for psychosocial maladjustment in new nursing home residents, we evaluated the first-year course of 88 new nursing home residents. These 88 study patients constituted all the new residents admitted in 1987 to the Kingsbridge Center of the Jewish Home and Hospital for Aged, Bronx, NY, and assigned to the health-related floors (indicating less serious impairments). Social work intake and progress notes were abstracted to evaluate their utility in identifying indicators of risk for medical and psychosocial maladjustment among these patients. Patients admitted from home fared worse (had more medical visits) than those admitted from hospitals. Lack of additional findings suggests that more uniform and structured intake and progress assessments be made.