Life-space and movement behavior in nursing home residents: results of a new sensor-based assessment and associated factors

Background: Studies on life-space (LS) and its determinants have previously been limited to community-dwelling subjects but are lacking in institutionalized older persons. The purpose of this study was to provide an advanced descriptive analysis of LS in nursing home residents and to identify associated factors based on an established theoretical framework, using an objective, sensor-based assessment with a high spatiotemporal resolution. Methods: Cross-sectional study in two nursing homes in Heidelberg, Germany (n = 65; mean age: 82.9 years; 2/3 female). Changes of location in the nursing home (Transits) as well as time spent away from the private room (TAFR) were assessed using a wireless sensor network. Measures of physical, psychosocial, cognitive, socio-demographic, and environmental factors were assessed via established motor performance tests, interviews, and proxy-reports. Results: LS of residents was largely restricted to the private room and the surrounding living unit (90%); 10% of daytime was spent outside the living unit and/or the facility. On average, TAFR was 5.1 h per day (±2.3; Range: 0–8); seven Transits (6.9 ± 3.2; Range: 0–18) were performed per day. Linear regression analyses revealed being male, lower gait speed, higher cognitive status, and lower apathy to be associated with more Transits; higher gait speed, lower cognitive status, and less depressive symptoms were associated with more TAFR. LS was significantly increased during institutional routines (mealtimes) as compared to the rest of the day. Conclusions: The sensor-based LS assessment provided new, objective insights into LS of institutionalized persons living in nursing homes. It revealed that residents’ LS was severely limited to private rooms and adjacent living units, and that in institutional settings, daily routines such as meal times seem to be the major determinant of LS utilization. Gait speed, apathy, and depressive symptoms as well as institutional meal routines were the only modifiable predictors of Transits and/or TAFR, and thus have greatest potential to lead to an enhancement of LS when targeted with interventions. Trial registration: Current Controlled Trials ISRCTN96090441 (retrospectively registered)

Age Discrimination in Acute Care Hospital Settings? Focus on Verbal Care Interactions With Cognitively Impaired Older Patients

Objective: Acute care hospital settings represent a challenging environment for vulnerable older patients such as those with dementia. In particular, ageist behavior as reflected in so-called elderspeak communication has been considered as a crucial factor contributing to neuropsychiatric symptoms, suboptimal medical decision making, and poorer treatment outcomes in patients with dementia. Despite its linkage with negative health outcomes, the bulk of previous research on elderspeak has been conducted in nursing home settings and did not simultaneously consider multiple contextual conditions. Following a contextually-driven framework, the present dissertation concentrated on everyday care interactions between older patients and nurses (micro-level) in two German acute hospital settings differing in patient characteristics and geriatric expertise (macro-level). Paper 1 focused on the communication behavior of cognitively impaired (CI) versus cognitively unimpaired (CU) older inpatients. Paper 2 investigated nurses’ emotional tone toward older inpatients with a particular focus on the role of the acute hospital setting and patients’ cognitive impairment. Paper 3 examined the role of proximal (cognitive and functional impairment) and distal contextual factors (acute hospital setting, psychogeriatric knowledge, and evaluative age stereotypes) in predicting the occurrence of elderspeak. Method: Data of all three papers were based on a cross-sectional study focusing on elderspeak in an acute internal medicine ward (n = 36 beds, mean length of stay = 4.9 days) and an acute geriatric ward (n = 35 beds; mean length of stay = 16.5 days). A total of 106 older patients participated in the study. Patients were between 66 and 96 years old (M ± SD Years = 83.08 ± 6.19). Half of the patients (49%) were severely cognitively impaired (M ± SD 6CIT = 10.80 ± 8.60) and 56% were female. In total, 34 registered nurses took part in the study. Nurses were between 22 and 59 years old (M ± SD Years = 38.93 ± 12.30). The majority of nurses were female (79%). Based on a mixed methods design, three types of data sources were used: (a) audio-recordings during the morning (49%) or evening care (51%), (b) patient data from the medical information system, and (c) standardized interviews with patients and nurses. The first paper was based on a psychometric study validating a tool to assess communication behavior in dementia (CODEM) for use in CI patients in the acute care hospital setting. Patients were observed by trained research assistants during a standardized interview situation and rated afterward. In the second paper, an emotional tone rating procedure was performed to differentiate between a person-centered and a controlling tone of nurses’ voice toward older inpatients (Cronbach’s α = .98 for both subscales). A total number of 92 audio-recorded clips were evaluated by 12 naïve raters (M ± SD Age = 32.75 ± 9.33 years) based on their impressions of nurses’ vocal qualities. The third paper was driven by psycholinguistic analysis using manual coding (κ = .85–.97) and computer-assisted procedures for extracting likely harmful (diminutives, collective pronoun substitutions, tag questions) and hybrid features of elderspeak (sentence fragments, mean length of utterances, speech rate, type-token ratio, complex units). Results: The first paper demonstrated that CODEM is a reliable and valid tool to examine the communication behavior of CI patients in the acute care hospital setting. CI patients significantly differed from CU patients in terms of an overall lower frequency of communication behavior as well as a higher occurrence of nonverbal when compared to verbal communication behavior. The second paper revealed that the emotional tone of nurses’ voice toward older patients was perceived as largely person-centered and not so much as control-centered. Finally, the third paper provided further evidence on the existence of likely harmful diminutives (61%), collective pronouns substitutions (70%), and tag questions (97%). An important finding of Paper 2 and 3 was that functional impairment more strongly contributed to controlling tones of nurses’ voice and elderspeak than cognitive impairment and acute hospital setting. Whereas a low percentage of older patients reported perceived age discrimination (2%), more than one third of older patients (36%) endorsed at least one type of ageist event during their hospital stay. Overall, nurses’ views on aging were largely negative. Conclusions: A large interindividual variability of communication resources and deficits has been demonstrated in acutely ill older inpatients. Furthermore, key features of elderspeak have been identified at the verbal and nonverbal communication level. Taken together, the present dissertation provides initial evidence for the occurrence of ageism and elderspeak in acute care hospital settings. Furthermore, it extends previous elderspeak research by discovering the dominant role of functional impairment that may be more strongly involved in the process of negative stereotype activation than cognitive impairment. The present work also provides a unique, multi-level, and interdisciplinary measurement approach for examining ageism in naturally occurring interactions. Such an ecologically valid approach may inform future studies and help to systematically combat ageism in high-risk groups. Finally, the current outbreak of ageism underpins that evidence-based interventions are urgently needed to overcome ageism and to establish a new narrative on aging in the public discourse

Kommunikationsverhalten von kognitiv beeinträchtigten älteren Krankenhauspatienten : ein neues Setting für die Validierung des KODEM-Instruments

Background and objective: Acutely ill older patients with cognitive impairment represent a major subgroup in acute care hospitals. In this context, communication plays a crucial role for patients’ well-being, healthcare decisions, and medical outcomes. As validated measures are lacking, we tested the psychometric properties of an observational instrument to assess Communication Behavior in Dementia (CODEM) in the acute care hospital setting. As a novel feature, we were also able to incorporate linguistic and social-contextual measures. Material and methods: Data were drawn from a cross-sectional mixed methods study that focused on the occurrence of elderspeak during care interactions in two German acute care hospitals. A total of 43 acutely ill older patients with severe cognitive impairment (CI group, Mage ± SD = 83.6 ± 5.7 years) and 50 without cognitive impairment (CU group, Mage ± SD = 82.1 ± 6.3 years) were observed by trained research assistants during a standardized interview situation and rated afterwards by use of CODEM. Results: Factor analysis supported the expected two-factor solution for the CI group, i.e., a verbal content and a nonverbal relationship aspect. Findings of the current study indicated sound psychometric properties of the CODEM instrument including internal consistency, convergent, divergent, and criterion validity. Conclusion: CODEM represents a reliable and valid tool to examine the communication behavior of older patients with CI in the acute care hospital setting. Thus, CODEM might serve as an important instrument for researcher and healthcare professionals to describe and improve communication patterns in this environment.Hintergrund und Zielsetzung: Akut erkrankte Patienten mit kognitiver Beeinträchtigung stellen eine bedeutsame Subgruppe in Akutkrankenhäusern dar. In diesem Zusammenhang spielt Kommunikation eine entscheidende Rolle für das Wohlbefinden der Patienten, medizinische Entscheidungen und Outcomes. Da es an validierten Maßen mangelt, testeten wir die psychometrischen Eigenschaften eines Beobachtungsinstrumentes zur Erfassung des Kommunikationsverhaltens von Demenzpatienten (KODEM) im Akutkrankenhaussetting. Dabei war es erstmalig möglich, linguistische und sozial-kontextuelle Maße einzubeziehen. Material und Methoden: Die Daten stammten aus einer querschnittlichen "Mixed-method"-Studie, deren Fokus auf dem Vorkommen von Elderspeak während Pflegeinteraktionen in zwei deutschen Akutkrankenhäusern lag. Insgesamt 43 akut erkrankte ältere Patienten mit schwerer kognitiver Beeinträchtigung (KB-Gruppe; MAlter ± SD = 83,6 ± 5,7 Jahre) und 50 ohne kognitive Beeinträchtigung (KU-Gruppe; MAlter ± SD = 82,1 ± 6,3 Jahre) wurden von geschulten Forschungsassistenten während einer standardisierten Interviewsituation beobachtet und anschließend mittels KODEM beurteilt. Ergebnisse: Die Faktorenanalyse bestätigte die erwartete Zwei-Faktoren-Lösung für die KB-Gruppe, d. h. einen verbalen Inhalts- und einen nonverbalen Beziehungsaspekt. Die Ergebnisse der vorliegenden Studie zeigten einwandfreie psychometrische Eigenschaften des KODEM-Instruments, was die interne Konsistenz, die konvergente, divergente und die Kriteriumsvalidität betrifft. Schlussfolgerung: KODEM erwies sich als ein reliables und valides Instrument zur Erfassung des Kommunikationsverhaltens von älteren Patienten mit KB im Akutkrankenhaussetting. Somit könnte KODEM als ein wichtiges Hilfsmittel für Forscher und Gesundheitspersonal dienen, um Kommunikationsmuster in dieser Umgebung zu beschreiben und zu verbessen

Elderspeak in Acute Hospitals? The Role of Context, Cognitive and Functional Impairment

Older adults are often exposed to elderspeak, a specialized speech register linked with negative outcomes. However, previous research has mainly been conducted in nursing homes without considering multiple contextual conditions. Based on a novel contextually-driven framework, we examined elderspeak in an acute general versus geriatric German hospital setting. Individuallevel information such as cognitive impairment (CI) and audio-recorded data from care interactions between 105 older patients (M = 83.2 years; 49% with severe CI) and 34 registered nurses (M = 38.9 years) were assessed. Psycholinguistic analyses were based on manual coding (k = .85 to k = .97) and computer-assisted procedures. First, diminutives (61%), collective pronouns (70%), and tag questions (97%) were detected. Second, patients’ functional impairment emerged as an important factor for elderspeak. Our study suggests that functional impairment may be a more salient trigger of stereotype activation than CI and that elderspeak deserves more attention in acute hospital settings

Nurses' emotional tone toward older inpatients: Do cognitive impairment and acute hospital setting matter?

The emotional tone of nurses’ voice toward residents has been characterized as overly controlling and less person-centered. However, it is unclear whether this critical imbalance also applies to acutely ill older patients, who represent a major subgroup in acute hospitals. We therefore examined nurses’ emotional tone in this setting, contrasting care interactions with severely cognitively impaired (CI) versus cognitively unimpaired older patients. Furthermore, we included a general versus a geriatric acute hospital to examine the role of different hospital environments. A mixed-methods design combining audio-recordings with standardized interviews was used. Audio-recorded clips of care interactions between 34 registered nurses (Mage = 38.9 years, SD = 12.3 years) and 92 patients (Mage = 83.4 years, SD = 6.1 years; 50% with CI) were evaluated by 12 naïve raters (Mage = 32.8 years, SD = 9.3 years). Based on their impressions of the vocal qualities, raters judged nurses’ emotional tone by an established procedure which allows to differentiate between a person-centered and a controlling tone (Cronbach’s α = .98 for both subscales). Overall, findings revealed that nurses used rather person-centered tones. However, nurses’ tone was rated as more controlling for CI patients and in the geriatric hospital. When controlling for patients’ functional status, both effects lost significance. To our knowledge, this is the first study that examined nurses’ emotional tone in the acute hospital setting. Findings suggest that overall functional status of older patients may play a more important role for emotional tone in care interactions than CI and setting differences

Interactive effects of conditioned pain modulation and temporal summation of pain-the role of stimulus modality

Conditioned pain modulation (CPM) and temporal summation of pain (TSP) are 2 experimental paradigms capturing endogenous pain modulation, which have repeatedly demonstrated clinical relevance. Conditioned pain modulation describes the inhibition of the pain response to a test stimulus (Ts) when a second noxious stimulus, the conditioning stimulus (CS), is concurrently applied. Temporal summation of pain describes the enhanced pain response to a series of stimuli compared with single stimuli. Temporal summation of pain-limiting effects of CPM are likely but may depend on the stimulus modality of the Ts. This study aimed at investigating these differential effects of stimulus modality. Thirty-five healthy volunteers completed 2 experimental blocks (Ts modality: pressure vs heat) in balanced order. Both blocks consisted of 3 conditions: baseline (no CS), CPM1 (nonpainful CS: 42 degrees C water bath), and CPM2 (painful CS: 46 degrees C water bath). Single stimuli and series of stimuli were alternatingly applied to assess TSP by means of a Numerical Rating Scale. Both TSP and CPM were successfully induced with no difference between the 2 Ts modalities. We also detected a significant interaction between TSP and CPM, with higher pain reduction for a series of Ts compared with single Ts during the painful CS. Interestingly, this interaction was modality-dependent: TSP for heat Ts was completely abolished by CPM, whereas this was not the case for pressure Ts. Our findings suggest different forms of central sensitization induced by TSP using either heat or pressure stimuli, which differ in their susceptibility to CPM. Clinical implications and directions for future research are discussed