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A qualitative, emergent, case study design guided the description of care provided to nursing home residents with urinary incontinence in three Midwestern nursing facilities. Participants included 17 residents and 16 family members or friends of the respective residents. Staff and managers involved in the planning and delivery of care to the participating residents also were included. The three facilities represented variation in size, location, ownership, and Medicare certification. Data were collected via observation, resident record audit, and semi-structured interview. Definitions of incontinence varied among staff. A collectively held expectation that residents would be toileted every 2 hours was not met. Maintaining skin integrity was the primary motivation for keeping residents clean and dry. Medical directors viewed incontinence as a nursing problem. Staff described situations in which incontinence was improved for specific residents, but there was little evidence of formal programs to maintain continence or improve incontinence. [ABSTRACT FROM AUTHOR]

Data obtained from three Midwestern nursing homes were used to identify and describe contextual factors that influenced resident care. A qualitative, emergent, case study design guided the study. In addition to 17 residents and 16 family members or friends of the respective residents, participants included 66 staff members and 9 managers involved in the planning and delivery of care to the participating residents. Data were collected via observation, semi-structured interview, and resident record audit. Contextual factors seemed to integrate or fragment care planning and delivery. Important integrators were shared values, the role of the Minimum Data Set coordinator, the role of other leaders, and family influence. Two fragmenting factors, competing demands for the staff members' time and a task orientation to care, appeared to be ubiquitous. External accountability also fragmented care to a discernible degree. [ABSTRACT FROM AUTHOR]

This study was designed to describe the care-planning process used in nursing homes and identify links among care planning, care provided, and the Resident Assessment Instrument and Minimum Data Set (MDS). Study participants in three Midwestern nursing homes included residents and family members, MDS coordinators, direct care staff, administrators, directors of nursing, and medical directors. Data were collected via semi-structured interview, observation, and resident record audit. The care-planning process differed among the three facilities despite the common MDS system structure. Care planning and the MDS system were linked to the care provided to residents through documentation in residents' records, translation of the MDS care plan to the documents used for daily care, and ongoing communication through end-of-shift report and other venues. [ABSTRACT FROM AUTHOR]

Persons with lactose intolerance are unable to digest significant amounts of lactose because of a genetically inadequate amount of the enzyme lactase. Common symptoms include abdominal pain and bloating, excessive flatus, and watery stool following the ingestion of foods containing lactose. Lactase deficiency is present in up to 15 percent of persons of northern European descent, up to 80 percent of blacks and Latinos, and up to 100 percent of American Indians and Asians. A sizable number of adults believe they are lactose intolerant but do not actually have impaired lactose digestion, and some persons with lactase deficiency can tolerate moderate amounts of ingested lactose. A diagnosis of lactose intolerance can usually be made with a careful history supported by dietary manipulation. If necessary, diagnosis can be confirmed by using a breath hydrogen or lactose tolerance test. Treatment consists primarily of avoiding lactose-containing foods. Lactase enzyme supplements may be helpful. The degree of lactose malabsorption varies greatly among patients with lactose intolerance, but most of them can ingest up to 12 oz of milk daily without symptoms. Lactose-intolerant patients must ensure adequate calcium intake. [ABSTRACT FROM AUTHOR]

Osteoarthritis is one of the most prevalent and disabling chronic conditions affecting older adults and a significant public health problem among adults of working age. As the bulk of the U.S. population ages, the prevalence of osteoarthritis is expected to rise. Although the incidence of osteoarthritis increases with age, the condition is not a normal part of the aging process. More severe symptoms tend to occur in the radiographically more advanced stage of the disease; however, considerable discrepancy may exist between symptoms and the radiographic stage. Roentgenograms of involved joints may be useful in confirming the diagnosis of osteoarthritis, assessing the severity of the disease, reassuring the patient and excluding other pathologic conditions. The diagnosis of osteoarthritis is based primarily on the history and physical examination, but radiographic findings, including asymmetric joint space narrowing, subchondral sclerosis, osteophyte formation, subluxation and distribution patterns of osteoarthritic changes, can be helpful when the diagnosis is in question. [ABSTRACT FROM AUTHOR]

Elder mistreatment is a widespread problem in our society that is often under-recognized by physicians. As a result of growing public outcry over the past 20 years, all states now have abuse laws that are specific to older adults; most states have mandated reporting by all health care professionals. The term 'mistreatment' includes physical abuse and neglect, psychologic abuse, financial exploitation and violation of rights. Poor health, physical or cognitive impairment, alcohol abuse and a history of domestic violence are some of the risk factors for elder mistreatment. Diagnosis of elder mistreatment depends on acquiring a detailed history from the patient and the caregiver. It also involves performing a comprehensive physical examination. Only through awareness, a healthy suspicion and the performing of certain procedures are physicians able to detect elder mistreatment. Once it is suspected, elder mistreatment should be reported to adult protective services. [ABSTRACT FROM AUTHOR]

Understanding how quality improvement affects costs is important. Unfortunately, low-cost, reliable ways of measuring direct costs are scarce. This article builds on the principles of process improvement to develop a costing strategy that meets both criteria. Process-based costing has 4 steps: developing a flowchart, estimating resource use, valuing resources, and calculating direct costs. To illustrate the technique, this article uses it to cost the care planning process in 3 long-term care facilities. We conclude that process-based costing is easy to implement; generates reliable, valid data; and allows nursing managers to assess the costs of new or modified processes.

Meeting the healthcare needs of patients who require long-term care presents many challenges, not the least of which are local and federal regulations, a formidable bureaucracy, and confusing paperwork. Despite these obstacles, long-term care patients often are among those with the greatest need for well-trained physicians and high-quality medical services. This article reviews elements of long-term care, with an emphasis on how primary care physicians should order and provide services.

Several factors place older patients at risk for malnutrition, including physiologic effects of aging, chronic medical disease, psychiatric disease, various psychosocial problems, and effects of medication. Many of these factors are reversible but require early recognition and assessment. Cholesterol and albumin measurements may help confirm a diagnosis of malnutrition, but the most important indicator is weight loss. The primary interventions for nutritional compromise are increasing caloric, protein, and fluid intakes. Nutritional supplements may need to be prescribed for repletion and maintenance. Other nutrition-promoting interventions include exercise, avoiding constipation, and dental care.

Hearing loss is a commonly encountered impairment in the elderly. It can profoundly affect physical, psychosocial and cognitive function. In addition to the actual hearing loss, other factors contribute to the hearing handicap experienced by older persons. These include difficulty in understanding speech in noisy situations, difficulty in supplementing hearing with visual information, and the slowing of cognitive and psychologic processes. Many forms of amplification are available and can be very useful in reversing much of the functional impairment associated with hearing loss. A comprehensive audiological assessment should be recommended before selecting the type of hearing aid or assistive listening device. Such a referral also affords an opportunity for more extensive aural rehabilitation.

Low vision is an extremely common problem in the elderly, which may have devastating consequences for functional independence and health status. It ranks only behind arthritis and heart disease as the etiology for impaired function in those over the age of 70. Macular degeneration is a leading cause of blindness and poor vision in the elderly. The central vision loss of this disorder can sometimes be postponed through laser therapy. Otherwise, the low visual state is best addressed with vision-enhancing devices, non-optical adaptive equipment, and patient education available through most occupational therapists. Referral to a low-vision rehabilitation program is sometimes needed for more comprehensive evaluation and intervention. Individual adaptation and supportive services often result in a significant improvement in function and quality of life for those elders with low vision.

Cervical spondylosis is a very common disorder in the elderly that leads to osteophyte formation and degenerative disc disease. Compression of the cervical cord and nerve roots can occur in a small number of patients, often dependent upon a congenitally narrow canal. Cord compression produces progressive spastic paraparesis, frequently asymmetric, and often accompanied by paresthesias and sensory loss in the feet and hands. The course is quite variable. Often, symptoms are mild and do not progress. Such cases are best treated conservatively with a cervical collar and physical therapy. Elderly patients often experience progression of symptoms and more serious neurologic impairment. Surgery should be recommended to arrest progression of myelopathic symptoms in patients whose general condition is satisfactory.