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Our purpose was to describe and compare Cambodian, Vietnamese, Soviet Jewish, and Ukrainian refugee caregivers and elders on life experiences, health status, and knowledge of available services. Detailed interviews were conducted with 105 female caregivers and 52 elders. Similar patterns emerged across all groups with regard to filial obligation, minimal knowledge of services, impact of immigration, and retention of cultural ties. Findings confirmed the special health and social service needs of refugee families in transition.

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Older African Americans are less likely to exercise compared with their white counterparts. Few studies have examined the facilitating factors and barriers to exercise among older African Americans living in urban communities. This study represented the first phase of a program to develop an exercise intervention in an urban community. Qualitative research was conducted to identify culturally determined attitudes that could be useful in designing an effective exercise program. Five focus groups involving 38 persons from a variety of settings were facilitated by trained professionals. Transcripts were analyzed to identify themes and contrasts among group participants. Contrary to the expectations of the investigative team, focus-group participants: (1) uniformly preferred group exercises compared with exercising at home, (2) rejected walking as a feasible option because of safety concerns, and (3) expressed limited interest in using weights or Eastern exercises such as Tai Chi. Concepts and goals of exercise differed according to the physical capabilities of the participants. The analysis of these focus-group discussions provided valuable insights with regard to the development of our community-based exercise-intervention protocol. These findings may be important in designing effective exercise programs for older African Americans in urban settings.

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CONTEXT: Changes in the healthcare system have resulted in shortened hospital stays, moving the focus of care from the hospital to the home. Patients are discharged post-operatively with ongoing needs, and whether they receive nursing care post-hospitalization can influence their recovery and survival. Little information is available about the factors that influence outcomes, including the survival of older cancer patients after cancer surgery. OBJECTIVE: To compare the length of survival of older post-surgical cancer patients who received a specialized home care intervention provided by advanced practice nurses (APNs) with that of patients who received usual follow-up care in an ambulatory setting. We also assessed potential predictors of survival in terms of depressive symptoms, symptom distress, functional status, comorbidities, length of hospital stay, age of patient, and stage of disease. DESIGN: A randomized controlled intervention study. SETTING: Discharged older cancer patients after surgery at a Comprehensive Cancer Center in southeastern Pennsylvania. PATIENTS: Three hundred seventy-five patients aged 60 to 92, newly diagnosed with solid cancers, were treated surgically between February 1993 and December 1995. One hundred ninety patients were randomized to the intervention groups and 185 to the usual care group. INTERVENTION: The intervention was a standardized protocol that consisted of standard assessment and management post-surgical guidelines, doses of instructional content, and schedules of contacts. The intervention lasted 4 weeks and consisted of three home visits and five telephone contacts provided by APNs. Both the patients and their family caregivers received comprehensive clinical assessments, monitoring, and teaching, including skills training. MAIN OUTCOME MEASURE: Time from enrollment of patients into the study until death or last date known alive at the end of November 1996. RESULTS: During the 44-month follow-up period, 93 (24.8%) of 375 patients died. Forty-one (22%) of those who died were patients in the specialized home care intervention group, compared with 52 (28%) in the usual care group. Stage of disease at diagnosis differed between the two groups at baseline (38% late stage patients in the intervention group compared with 26% in the control group, P = .01), so stratified analysis was performed. Overall, the specialized home care intervention group was found to have increased survival (P = .002 using stratified log-rank test). Among early stage patients only, there was no difference in survival between the intervention and control groups. Among late stage patients, there was improved survival in the intervention group. For example, 2-year survival among late stage intervention group cases was 67% compared with 40% among control cases. When Cox's proportional hazard model was used to adjust for significant baseline covariates, the relative hazard of death in the usual care group was 2.04 (CI: 1.33 to 3.12; P = .001) after adjusting for stage of disease and surgical hospitalization length of stay. CONCLUSIONS: This is the first empirical study of post-surgical cancer patients to link a specialized home care intervention by advanced practice nurses with improved survival. Additional research is needed to test home care interventions aimed at maintaining quality of life outcomes and their effects on survival of post-surgical cancer patients.

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Death-associated protein 5 (DAP5) (also named p97 and NAT1) is a member of the translation initiation factor 4G (eIF4G) family that lacks the eIF4E binding site. It was previously implicated in apoptosis, based on the finding that a dominant negative fragment of the protein protected against cell death. Here we address its function and two distinct levels of regulation during apoptosis that affect the protein both at translational and posttranslational levels. DAP5 protein was found to be cleaved at a single caspase cleavage site at position 790, in response to activated Fas or p53, yielding a C-terminal truncated protein of 86 kDa that is capable of generating complexes with eIF4A and eIF3. Interestingly, while the overall translation rate in apoptotic cells was reduced by 60 to 70%, in accordance with the simultaneous degradation of the two major mediators of cap-dependent translation, eIF4GI and eIF4GII, the translation rate of DAP5 protein was selectively maintained. An internal ribosome entry site (IRES) element capable of directing the translation of a reporter gene when subcloned into a bicistronic vector was identified in the 5' untranslated region of DAP5 mRNA. While cap-dependent translation from this transfected vector was reduced during Fas-induced apoptosis, the translation via the DAP5 IRES was selectively maintained. Addition of recombinant DAP5/p97 or DAP5/p86 to cell-free systems enhanced preferentially the translation through the DAP5 IRES, whereas neutralization of the endogenous DAP5 in reticulocyte lysates by adding a dominant negative DAP5 fragment interfered with this translation. The DAP5/p86 apoptotic form was more potent than DAP5/p97 in these functional assays. Altogether, the data suggest that DAP5 is a caspase-activated translation factor which mediates cap-independent translation at least from its own IRES, thus generating a positive feedback loop responsible for the continuous translation of DAP5 during apoptosis.

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In this pilot study a one group pretest posttest design was employed to identify resident characteristics and environmental factors associated with initiation of physical restraint. Predictors of restraint initiation for older adults were examined using secondary analysis of an existing data set of nursing home residents who were subjected to a federal mandate and significant restraint reduction efforts. Lower cognitive status (OR = 1.5 [for every 7-point decrease in Mini-Mental State Examination], 95% CI = 1.0, 2.1) and a higher ratio of licensed nursing personnel (OR = 3.7, 95% CI = 1.2, 11.9) were predictive of restraint initiation. Key findings suggest that restraint initiation occurs, despite significant restraint reduction efforts, when a nursing home resident is cognitively impaired or when more licensed nursing personnel (predominantly licensed practical nurses) are available for resident care. Achievement of restraint-free care in nursing homes requires specific and individualized approaches for residents who are cognitively impaired, as well as greater attention to staff mix of registered nurses, licensed practical nurses, and nursing aides.

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Nursing interventions were provided to older men following prostate surgery during a controlled clinical trial examining nursing care and its effects on quality of life outcomes. The Nursing Intervention Lexicon and Taxonomy (NILT), consisting of 7 categories of nursing interventions, was used to classify intervention statements extracted from 32 home care records. Two major categories of interventions were patient teaching (45%) and psychologically based interventions (20%). In a comparison of the types of interventions provided upon discharge from the hospital with those provided at the end of 1 month of home care, it appeared that patients had not yet shifted from the crisis to the chronic phase of their illness course based on Rolland's framework.

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OBJECTIVES: To examine predictors of continued restraint use in nursing home residents following efforts aimed at restraint reduction. DESIGN: Secondary analysis of data from a clinical trial using a one-group, pre-test post-test design. SETTING: Three nonprofit, religion-affiliated nursing homes in a metropolitan area. PARTICIPANTS: The sample consisted of 201 physically restrained nursing home residents. Following restraint reduction efforts, 135 of the sample were still restrained. Mean age of participants was 83.9 years. MEASUREMENTS: Physical restraint use was measured by observation and included any chest/vest, wrist, mitt, belt, crotch, suit, or harness restraint plus any sheet used as restraint or a geriatric chair with fixed tray table. Nursing home residents were subjected to any one of three conditions aimed at restraint reduction, including adherence to the mandate of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87), staff education, and education with consultation from a gerontological clinical nurse specialist. Resident characteristics including dependency, health status, mental status, depression, behavior, fall risk; presence of treatment devices and institutional factors were determined. RESULTS: Physical dependency, lower cognitive status, behavior, presence of treatment devices, presence of psychiatric disorders, fall risk, and fall risk as staff rationale for restraint were associated (P < .10) with continued restraint use. Nursing hours, staff mix, prevalence of restraint use by unit, and site were also associated (P < .10) with continued use of physical restraints. Following bivariate analysis, associated resident characteristics were subjected to logistic regression. Lower cognitive status (OR = 2.4 (for every 7-point decrease in MMSE), 95% CI, 1.7, 3.3) and fall risk as staff rationale for restraint (OR = 3.5, 95% CI., 1.5, 8.0) were predictive of continued restraint use. Adding nursing hours, staff mix, and prevalence of restraint use by unit to the logistic regression model was not statistically significant (partial chi-square = 2.79, df = 6, P = .834). Nursing home site was added to the model without changing the significance (P < .05) of cognitive status or fall risk as a staff rationale for restraint use. CONCLUSION: Continued restraint use in nursing home residents in this study most often occurred with severe cognitive impairment and/or when fall risk was considered by staff as a rationale for restraint. Efforts to reduce or eliminate physical restraint use with these groups will require greater efforts to educate staff in the assessment and analysis of fall risk, along with targeted interventions, particularly when cognition is also impaired.

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Five categories of problems that often result in siderail use: memory disorder, impaired mobility, injury risk, nocturia/incontinence, and sleep disturbance. As nursing homes work toward meeting the Health Care Financing Administration's mandate to examine siderail use, administrators and staff need to implement interventions that support safety and individualize care for residents. While no one intervention represents a singular solution to siderail use, a range of interventions, tailored to individual needs, exist. This article describes the process of selecting individualized interventions to reduce bed-related falls.

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BACKGROUND: A major reason cited for continued restraint use in American nursing homes is the widely held belief that restraint reduction will lead to fall-related incidents and injuries. METHODS: This study represents an analysis of data collected in a clinical trial of interventions aimed at reducing the use of restraints in nursing homes. Two different designs were employed to test the relationship between restraint reduction and falls/injuries. First, multiple logistic regression was used to compare fall/injury rates in subjects who had restraints removed (n = 38) to those who continued to be restrained (n = 88); second, survival analysis was employed to test the relationship between physical restraint removal and falls/injuries at the institutional level by comparing fall/injury rates among three nursing homes (n = 633) with varying rates of restraint reduction. RESULTS: Based on the multiple logistic regression analysis, there was no indication of increased risk of falls or injuries with restraint removal. Moreover, restraint removal significantly decreased the chance of minor injuries due to falls (adjusted odds ratio: 0.3, 95% CI: 0.1, 0.9; p < .05). The survival analysis demonstrated that the nursing home that had the least restraint reduction (11%) had a 50% higher rate of falls (p < .01) and more than twice the rate of fall-related minor injuries (p < .001) when compared to the homes with 23% and 56% restraint reduction, respectively. CONCLUSIONS: Physical restraint removal does not lead to increases in falls or subsequent fall-related injury in older nursing home residents.

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The use of bilateral siderails, similar to physical restraints, can be safely reduced by a comprehensive assessment process. This article presents an individualized assessment for evaluating siderail use to guide nurses in managing resident characteristics for falling out of bed and intervening for high-risk residents. The individualized assessment is consistent with federal resident assessment instrument requirements and includes risk factors specific to falls from bed.

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The process of apoptosis (programmed cell death) has become the subject of intensive and extensive research over the past few years. Various approaches are being used to identify and study genes which function as positive mediators of apoptosis. Here, we address a novel approach of gene cloning aimed at isolating intracellular death promoting genes by utilizing a functional screen. This method, called TKO, was based on transfection of cells with an anti-sense cDNA library, followed by the selection of transfectants which survived in the continuous presence of a killing cytokine-interferon-gamma. It led to the identification of five novel apoptotic genes and to the finding that a known protease-cathepsin D, is actively recruited to the death process. The five novel apoptotic genes (named DAP genes for: Death Associated Proteins) code for proteins which display a diverse spectrum of biochemical activities. The list comprises a novel type of calcium/calmodulin-regulated kinase which carries ankyrin repeats and a death domain (DAP-kinase), a nucleotide-binding protein (DAP-3), a small proline-rich cytoplasmic protein (DAP-1), and a novel homolog of the eIF4G translation initiation factor (DAP-5). Extensive studies proved that these genes are critical for mediating cell death initiated by interferon-gamma, and in some of the tested cases also cell death induced by Fas/APO-1, TNF-alpha, and a detachment from extracellular matrix. Moreover, one of these genes, DAP-kinase, was recently found to display strong tumor suppressive activities, coupling the control of apoptosis to metastasis. The advantage of functional approaches of gene cloning is that they select the relevant rate limiting genes along the death pathways in a complete unbiased manner. As a consequence, novel targets and unpredicted mechanisms emerged. A few examples illustrating this important point will be discussed. One relates to the calcium/calmodulin-dependent DAP-kinase, which is localized to the actin microfilaments. It was found that the correct localization of DAP-kinase to the microfilament network was critical for the execution of the apoptotic process, and more specifically for the disruption of the stress fibers--a typical hallmark of apoptosis. Another important breakthrough step in our understanding of apoptotic processes relates to the identification and analysis of the DAP-5 gene. The structure/ function features of this novel translation regulator resemble the proteolytically cleaved eIF4G which appears in cells upon infection with some RNA viruses and which directs cap-independent translation. Thus, the rescue of DAP-5 highlighted the importance of regulation of protein translation in certain apoptotic systems. Finally, the isolation of cathespin D by our method suggests that lysosomal proteases are recruited during apoptosis, in addition to the well known caspase family of proteases, and that a unique pattern of regulation affecting the processing of this protease takes place. The major challenge now is to analyse how these diverse DAP gene activities constitute biochemical pathway(s) leading to programmed cell death, and what is their functional position with respect to other known positive mediators and suppressors of apoptosis such as the Bcl2 and caspase family members.

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OBJECTIVES: To describe the changes in psychoactive drug use in nursing homes after implementation of physical restraint reduction interventions and mandates of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87). METHODS: A secondary analysis was conducted using data from a controlled clinical trial that took place in three nursing homes: a control home, one that received an educational intervention, and one that received an educational/consultation intervention. All three homes were influenced by the OBRA mandates. Complete pre- and 6 months' post-intervention data on use of psychoactive drugs and physical restraints were available for 446 resident subjects. Changes were first analyzed with the resident subjects as the unit of analysis and then using the nursing home ward (n = 16) as the unit of analysis. RESULTS: While physical restraint use declined in the home that received the educational/consultation intervention, neither neuroleptic nor benzodiazepine use increased in any of the homes after the interventions. The percentage of residents taking neuroleptics declined in the control home (18.6% to 11.3%, P = .014). Benzodiazepine use, which was more prevalent than described previously in the literature, declined in all three homes (P < .001). Of those residents whose physical restraints were discontinued, only 2% were started on neuroleptics. When the effect of OBRA mandates on appropriateness of neuroleptic use was examined, the percentage of residents on neuroleptics who lacked an OBRA-approved indication declined from 21.3% to 14.6% in the total sample, and from 39.9% to 8% in the control home. CONCLUSIONS: Interventions to reduce physical restraint did not lead to an increase in psychoactive drug use; further, reduction in both can occur simultaneously. OBRA mandates regarding psychoactive drug use were not uniformly effective, but appear, at minimum, to have increased awareness of the indications for neuroleptics.

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OBJECTIVE: To investigate the relative effects of two experimental interventions on the use of physical restraints. DESIGN: Prospective 12-month clinical trial in which three nursing homes were randomly assigned to restraint education (RE), restraint education-with-consultation (REC), or control (C). SETTING: Three voluntary nursing homes in the Philadelphia area providing both skilled and intermediate care. PARTICIPANTS: A total of 643 nursing home residents over the age of 60 were enrolled at baseline, and 463 remained to completion (1 year). INTERVENTIONS: Both RE and REC homes received intensive education by a masters-prepared gerontologic nurse to increase staff awareness of restraint hazards and knowledge about assessing and managing resident behaviors likely to lead to use of restraints. In addition, the REC home received 12 hours per week of unit-based nursing consultation to facilitate restraint reduction in residents with more complex conditions. MEASUREMENTS: Restraint status was observed systematically at baseline, immediately after the 6-month intervention, and again at 9 and 12 months. Staff levels, psychoactive drug use, and injuries were also determined. RESULTS: Compared with baseline, the REC home had a statistically significant reduction in restraint prevalence, whereas RE and C homes did not. At 9 months (3 months post-intervention), absolute decline in the percents restrained were 7% RE, 7% C, and 20% REC; at 12 months (6 months post-intervention) declines were 4% RE, 6% C, and 18% REC. However, relative to baseline, these declines represent an average reduction in restraint use of 23% RE, 11% C, and 56% REC. The differences in changes over time were consistently significant (P = .01), whether considering survivors or those present at each time point, and also when controlling for differences between groups at baseline. Further, given any change in restraint use, REC-residents were between 25% and 40% more likely than either RE or C residents to experience decreased restraint use. Results were achieved without increased staff, psychoactive drugs, or serious fall-related injuries. CONCLUSION: A 6-month-long educational program combined with unit-based, resident-centered consultation can reduce use of physical restraints in nursing homes effectively and safely. Whether extending the intervention will achieve greater reduction is not known from these results.

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A functional approach to gene cloning was applied to HeLa cells in an attempt to isolate cDNA fragments which convey resistance to gamma interferon (IFN-gamma)-induced programmed cell death. One of the rescued cDNAs, described in this work, was a fragment of a novel gene, named DAP-5. Analysis of a DAP-5 full-length cDNA clone revealed that it codes for a 97-kDa protein that is highly homologous to eukaryotic translation initiation factor 4G (eIF4G, also known as p220). According to its deduced amino acid sequence, this novel protein lacks the N-terminal region of eIF4G responsible for association with the cap binding protein eIF4E. The N-terminal part of DAP-5 has 39% identity and 63% similarity to the central region of mammalian p220. Its C-terminal part is less homologous to the corresponding region of p220, suggesting that it may possess unique functional properties. The rescued DAP-5 cDNA fragment which conveyed resistance to IFN-gamma-induced cell death was expressed from the vector in the sense orientation. Intriguingly, it comprised part of the coding region which corresponds to the less conserved C-terminal part of DAP-5 and directed the synthesis of a 28-kDa miniprotein. The miniprotein exerted a dual effect on HeLa cells. Low levels of expression protected the cells from IFN-gamma-induced programmed cell death, while high levels of expression were not compatible with continuous cell growth. The relevance of DAP-5 protein to possible changes in a cell's translational machinery during programmed cell death and growth arrest is discussed.

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A growing body of empirical evidence documenting the negative effects and the limited effectiveness of physical restraints continues to shape policy and professional standards. In addition to occurrences of serious harm from restraint devices, ethical concerns about care with dignity have supported reevaluation of restraints in all settings for all patients. Lessons from considerable research conducted in nursing homes and clinical experience with restraint reduction in long-term care facilities are applicable to acute care settings, where restraint-free care can and should be embraced.

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OBJECTIVE: To examine the relationship between restraint use and falls while controlling for the effect of psychoactive drug use among nursing home residents, including subgroups of nursing home residents with high rates of restraint use and/or falls. DESIGN: Secondary analysis of data from a longitudinal clinical trial designed to reduce restraint use. SETTING: Three nursing homes. PARTICIPANTS: Subjects (n = 322) were either restrained (n = 119) or never restrained (n = 203) at each observation point during a 9.5-month data collection period that preceded the intervention phase of the clinical trial. MEASUREMENTS: We evaluated restraint status (independent variable) three times during the data collection period by direct observation over a 72-hour period. Incident reports documenting falls and fall-related injuries (dependent variables) were reviewed. Cognitive status was measured using the Folstein Mini-Mental State Exam and functional status (including ambulation status) by the Psychogeriatric Dependency Rating Scale. Psychoactive drug use profile was obtained through record review. MAIN RESULTS: Using multiple logistic regression, we compared the effect of restraint use on fall risk between a confused ambulatory subgroup and the remaining sample and found a significant difference in the odds ratio for falls and recurrent falls (P = .02; chi-square = 5.24, df = 1; P = .003, chi-square = 9.12, df = 1). In the confused ambulatory subgroup, restraint use was associated with increased falls (odds ratio: 1.65, 95% CI: 0.69, 3.98) as well as recurrent fall risk (odds ratio: 2.46, 95% CI: 1.03, 5.88). Increased falls and recurrent fall risk was not observed in the remaining sample (falls odds ratio: 0.49, 95% CI: 0.28, 0.87; recurrent falls odds ratio: 0.42, 95% CI: 0.20, 0.91). One subgroup, the nonconfused ambulatory residents, were never restrained; after removing this subgroup, the confused ambulatory continued to be associated, though not significantly, with a higher risk of falls and injuries. Only nonconfused nonambulatory restraints were associated with a lower risk of all three outcomes: falls (odds ratio: 0.28, 95% CI: 0.05, 1.58), recurrent falls (odds ratio: 0.48, 95% CI: 0.05, 4.72), and injurious falls (odds ratio:0.42, 95% CI: 0.04, 4.01); these results, however, were not statistically significant. There was no evidence that the effect of restraint use on fall risk depended upon the use of psychoactive drugs (chi square = 4.43; df = 2, P = .11). CONCLUSION: Restraints were not associated with a significantly lower risk of falls or injuries in subgroups of residents likely to be restrained. These findings support individualized assessment of fall risk rather than routine use of physical restraints for fall prevention. Researchers and clinicians should continue to focus efforts on developing a variety of approaches that reduce risk of falls and injuries and promote mobility rather than immobility.

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Individualized care for frail elders is defined as an interdisciplinary approach which acknowledges elders as unique persons and is practiced through consistent caring relationships. The four critical attributes of individualized care for frail elders are: 1) knowing the person, 2) relationship, 3) choice, and 4) participation in and direction of care. Cognitively impaired elders can direct their care through the staff's knowledge of individual past patterns and careful observation of behavior for what is pleasing and comfortable to each resident.

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Consultation is an important function of advanced practice nurses. Within nursing practice, the process of providing consultation has been studied primarily in acute care settings. A CNS in a 180-bed, nonprofit nursing home implemented the intervention for a controlled clinical trial of nursing interventions to reduce physical restraint use. The consulting process undertaken by the CNS is described, and conclusions are offered regarding the most effective approaches to consultation by advanced practice nurses in nursing homes.

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