| | Characterizing Wandering Behaviors in Persons With Traumatic Brain Injury Residing in Veterans Health Administration Nursing HomesAbstract Belanger HG, King-Kallimanis B, Nelson AL, Schonfeld L, Scott SG, Vanderploeg RD. Characterizing wandering behaviors in persons with traumatic brain injury residing in Veterans Health Administration nursing homes. ObjectiveTo examine the prevalence and correlates of wandering in persons with traumatic brain injury (TBI) in nursing homes (NHs). DesignUsing a cross-sectional design, logistic regression modeling was used to analyze a national database. SettingOne hundred thirty-four NH facilities operated by the Veterans Health Administration. ParticipantsNH residents (N=625) with TBI as well as a sample (n=164) drawn from a larger dataset of NH residents without TBI using 1:K matching on age. InterventionsNot applicable. Main Outcome MeasureWandering. ResultsWanderers with and without TBI did not differ significantly overall. The prevalence of wandering among patients with TBI was 14%, compared with 6.5% of the general nursing home population. The results of the multivariate logistic regression suggested that wandering was associated with poor memory, poor decision making, behavior problems, independence in locomotion and ambulation, and dependence in activities of daily living related to basic hygiene. ConclusionsWandering is relatively common in NH residents with TBI. As expected, it is associated with cognitive, social, and physical impairments. Further research with a larger sample should examine those with comorbid dementia and/or psychiatric diagnoses. TRAUMATIC BRAIN INJURY (TBI) is a significant cause of disability.1 Some studies2, 3, 4, 5 suggest that sustaining a TBI significantly increases one’s risk for subsequent development of dementia. Placement in a nursing home (NH) after TBI is predicted by injury severity.6 NH residents with TBI tend to be younger and require more care, presumably due to greater cognitive decline.7 Common causes of TBI include traffic collisions, falls, and assaults. However, the impact of this problem among the largely male population of veterans in long-term care is likely to increase given the number of troops returning from Iraq and Afghanistan who were victims of improvised explosive devices. Of the returning Iraqi soldiers who were wounded severely enough to require medical evacuation to Walter Reed Army Medical Center, 61% to 62% sustained a TBI.8 Patients with moderate or severe TBI are likely to exhibit sleep disorders, confusion, restlessness, agitation, and memory problems, all of which may be viewed as behavior problems in a long-term care setting. Among veterans in NH care units, TBI may be one of several disorders experienced by both younger and older residents, whether in the NH of short-term rehabilitation residents or long-term skilled nursing care. Wandering, a challenging behavior associated with general cognitive impairment, affects many residents of long-term care facilities and can result in elopement, injury, and death. Wandering typically refers to seemingly aimless or disoriented ambulation throughout a facility, often with observable patterns such as lapping, pacing, or random ambulation.9 However, specific definitions of wandering vary because wandering is not a single, simple behavior.10 Wandering among residents in NHs is a challenging behavior problem and safety issue. Adverse outcomes associated with wandering include accidents, weight loss, fatigue, sleep disturbance, abuse, getting lost, and untimely death.9, 11, 12, 13, 14, 15, 16 Wanderers are at increased risk of falling.17 Those who do fall are more likely to sustain fractures, and are at extremely high risk for hip fractures.18 Moreover, falls resulting from wandering also contribute to premature mortality.19 Because programmatic rehabilitation of patients with TBI largely began in the 1980s, the first generation of this cohort has likely begun to enter NHs. The prevalence of wandering among patients with TBI in NHs is unknown. Given the association between wandering and cognitive deficits,20, 21, 22, 23 the prevalence of wandering is likely to be greater in those NH residents with a history of TBI as compared with those lacking such history. In one of the few published studies on wandering in brain injured patients, Vaughan et al24 found that in a sample of 32 consecutive patients admitted to a brain injury rehabilitation unit (average age, 40y), wandering was found to be the best predictor of scores on the FIM instrument; as wandering increased, FIM scores tended to decrease. However, wandering was not significantly associated with discharge disposition (ie, either home with supervision or subacute and/or extended care), though a trend was noted such that the probability of requiring additional placement was higher for those patients with more frequent wandering. Similar studies in long-term care have not been published. In a recent study of wandering in Veterans Health Administration (VHA) NHs,25 the prevalence of wandering was found to be 6.5%. Frequency of wandering was associated with socially inappropriate behavior, resistance to care, use of antipsychotic medication, independence in locomotion and/or ambulation, and dependence in activities of daily living (ADLs) related to basic hygiene. Although this study examined a subset of patients with dementia, history of TBI was not examined. The purpose of the current study was to investigate wandering behaviors in patients with TBI across VHA NHs nationally. Specific questions were: (1) What is the prevalence of wandering in persons with a history of TBI in a nursing home? (2) What factors are associated with wandering in NH residents with a history of TBI? and (3) Do these factors differ from those present in wanderers without a history of TBI? We examined data from admission assessments over a 4-year period using the Minimum Data Set (MDS),26 a standard assessment tool of patient functioning used by the National Health Service, contrasting residents with a history of TBI with and without wandering behavior. Methods  Design We conducted a cross-sectional study using a retrospective review of the MDS,26 data obtained nationally from the VHA for all assessments administered from October 15, 2000, through October 15, 2004. Data use was approved by the University of South Florida, James A. Haley VA Hospital Institutional Review Board, and VHA headquarters where the national MDS data is housed for all VHA NHs. Population The VHA operates NHs at 134 medical centers across the United States and Puerto Rico. From 2000 through 2004, average daily census across all NHs ranged from 11,000 to more than 12,000 residents.27 As is the case for all NHs, these VHA facilities use the MDS for assessment purposes. During the years of this study, VHA guidelines required admission assessments on all residents admitted for 14 days or more. Those residents with lengths of stay (LOS) less than 14 days were customarily discharged without an MDS initial assessment, and therefore they were not necessarily available for inclusion in the 3 groups of the present study. The dataset available for analyses had a total of 53,493 NH residents; the prevalence of wandering in this group was 6.27% and the mean age was 70.42±11.98 years. These residents had LOSs of 14 days or longer. Participants To compare nonwanderers with wanderers, we used the following criteria to specify cases to be included in the analyses: (1) residents were first-time NH admissions (people were excluded if a previous stay in any type NH was noted on the MDS); (2) male residents (female residents constituted fewer than 2% of the cases and were excluded); (3) presence of a complete MDS admission assessment (complete basic demographics and key wandering variables in MDS Section E [Mood and Behavior Patterns]); and (4) the resident was not in a comatose state. There was a total of 625 cases with TBI (TBI nonwanderers, n=537; TBI wanderers, n=88) drawn from a larger dataset (N=53,493). Only patients with an active diagnosis of TBI were included. In other words, the TBI was deemed by the rater at admission to be currently impacting the patient’s functional status, cognitive status, mood and behavior status, medical treatment, nursing care, and/or risk of death. In addition, 164 wandering participants were drawn, using 1:K matching on age, from the larger dataset without TBI (N=52,868), comprising a third group (non-TBI wanderers) that was created in order to enable comparison between wanderers with and without TBI. Table 1 presents the basic demographic description of these 3 groups. As can be seen, there are significant differences in cognitive impairment by group. Fifty-two percent of nonwanderers with TBI were categorized as not or mildly impaired, whereas 8% of wanderers with TBI were similarly categorized. Measures The MDS26 is the standard tool for assessing NH resident functioning required by the Centers for Medicaid & Medicare Services (CMS) and is part of the mandatory Resident Assessment Instrument (RAI) for all NHs in the United States. The original MDS/RAI was introduced by CMS in 1990 and implemented in all states by mid-1991. Version 2.0 of the RAI has been in effect since January 1, 1996. MDS items are completed on NH admission and repeated quarterly thereafter and at discharge. Additional assessments are triggered by unusual events or changes in the resident’s health conditions. Wandering The MDS procedural manual describes wandering as “locomotion with no discernible, rational purpose.” Wandering may be manifested by walking or by wheelchair mobility. Wandering behavior is differentiated from purposeful movement. A related category of pacing (repetitive locomotion with no apparent goal) is not included in the “Behavioral Symptoms” section of the MDS where wandering is defined, but is instead listed in the section entitled “Indicators of Depression, Anxiety, and Sad Mood” and listed as a subtype of “Repetitive Physical Movements.” Pacing was therefore not included in the definition of wandering in this study due to potential overlap with mood-related problems as perceived by staff completing the MDS. The definition of wandering used in the present study is consistent with another well-cited peer reviewed study28 in the nursing home literature. Within the MDS Section E-4, all behavioral symptoms are rated on 2 criteria. The first, symptom frequency in last 7 days, has 4 possible ratings: not exhibited; occurred 1 to 3 days; occurred 4 to 6 days, but less than daily; or occurred daily. This criterion was used to classify wandering in the present study. It was collapsed due to the small number of wanderers. Specifically, an NH resident was considered a wanderer if symptom frequency was greater than 0 in the last 7 days and a nonwanderer if the behavior was not exhibited. Dependent measures We assessed the extent of global cognitive impairment using items from the Cognitive Performance Scale (CPS).29 The CPS comprises MDS items that are used to categorize residents according to the degree of cognitive impairment. It is generated from 5 MDS items (comatose status, decision making, short-term memory, making self understood, eating) that can be used to detect cognitive impairment as defined by the Mini-Mental State Examination (MMSE).30 It is completed by trained NH personnel and it corresponds closely to scores on the MMSE as well as to diagnostic entities such as Alzheimer’s disease and other dementias. Though the original scale has 7 points, it was recoded for simplicity into 3 levels: none/mild, moderate, or severe.31 Specifically, ratings of intact, borderline intact, and mild were combined to form the none/mild category; moderate and moderately severe were combined to form the moderate category; and severe and very severe were combined to form the severe category. To examine variables associated with wandering for people with TBI, we identified candidate MDS variables a priori from prior wandering research conducted in NHs.18 The overall factors include both single item and composite variables, drawn from the MDS: (1) short-term memory (can recall after 5min: yes, no); (2) decision making (independent or modified independent vs impaired); (3) behavior problems (none vs the presence of verbally abusive behavior, physically abusive behavior, and/or social disruption or inappropriateness); (4) mood-related problems (none vs the presence of negative statements, persistent anger, self-deprecation, unrealistic fears, recurrent statements about something terrible going to happen, sad and/or pained facial expressions, or crying and/or tearfulness); (5) locomotion on the unit (independent, requiring supervision or limited assistance, or requiring extensive assistance/dependent); and (6) personal hygiene (independent, requiring supervision or limited assistance, or requiring extensive assistance and/or dependent in ADLs). The variables shown in table 2 were modified from the MDS by collapsing due to either small proportions or due to disproportion between wanderers and nonwanderers. Specifically, short-term memory (5-min recall), decision-making ability, evidence for mood-related problems, behavior problems, locomotion on the unit, and personal hygiene were recoded. Pacing behavior was not included as evidence for mood-related problems. | | |  | Variables | MDS Items and Original Scale | New Scale (collapsed items) | |
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| Decision making | Section B item: 0=independent, 1=modified independent, 2=moderately impaired, 3=severely impaired | 0=independent or modified independent | | | | | 1=impaired | | | Short-term memory | Section B item: recall after 5 minutes | 0=memory intact | | | | 0=memory ok (recall after 5 minutes), 1=memory problem | 1=memory problem | | | Behavior problems | Section E items: Verbally abusive behavior (eg, others were threatened, screamed/cursed at); physically abusive behavior (eg, others were hit, shoved, scratched, sexually abused); socially inappropriate/disruptive behavioral symptoms (eg, made disruptive sounds, noisiness, self-abusive acts, sexual behavior or disrobing in public, smeared/threw food/feces, hoarding, rummaged through others’ belongings) | 0=behaviors did not occur | | | | 0=behavior not exhibited in last 7 days, 1=1−3 days in last 7, 2=4−6 days in last 7, and 3=behavior occurred daily | 1=behavior did occur | | | Evidence of mood problems | 15 Section E items: Negative statements, persistent anger, self-deprecation, unrealistic fears, recurrent statements about something terrible going to happen, sad/pained facial expressions, crying/tearfulness | 0=behaviors did not occur | | | | 0=behavior not exhibited in last 7 days, 1=1−3 days in last 7, 2=4−6 days in last 7, and 3=behavior occurred daily | 1=behavior did occur | | | Locomotion on unit | Section G item: How resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self sufficiency once in chair. 0=independent, 1=supervision, 2=limited assistance, 3=extensive assistance, 4=total dependence | 0=independent, 1=supervision/limited assistance, 2=extensive assistance/dependent and 8=excluded. | | | Personal hygiene | Section G item: How resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing drying hands, and perineum (exclude baths/showers). 0=independent, 1=supervision, 2=limited assistance, 3=extensive assistance, 4=total dependence | 0=independent, 1=supervision/limited assistance, 2=extensive assistance/dependent | | | | |
Statistical Analysis First, we used a multinomial logistic regression with 3 groups (TBI wanderers, TBI nonwanderers, non-TBI wanderers) to determine if the factors associated with wandering differed among the groups. Second, a model was developed using variables identified a priori from prior wandering research conducted in NHs to examine correlates of wandering within the TBI sample. These variables included age, short-term memory problems, decision making, behavior problems, mood problems, locomotion, and personal hygiene, as described above. A multivariate logistic regression model was developed with these variables to examine the strength of the associations of these variables for those who wander and those who did not. Fit statistics were investigated and model accuracy was tested by the receiver operating characteristic (ROC) curve, which allows the discriminating ability of the model to be estimated. Results In the sample of residents with TBI (n=625), 14% were identified as wanderers (n=88). Table 3 presents the frequencies of the identified potential predictor variables of wandering for each group. A multinomial regression was conducted to predict group membership from the variables thought to be associated with wandering. In a likelihood ratio test for combining alternatives, no significant differences were found between the TBI wanderers and the non-TBI wanderers, indicating that these groups could not be differentiated (χ2 test=11.15, P=.52). To follow up, chi-square tests were conducted on each individual covariate and TBI and non-TBI wanderers and no significant differences were found. As such, it was not appropriate to continue with multinomial regression. The remainder of the analyses was conducted with only the TBI groups (TBI wanderers, TBI nonwanderers). The Hosmer and Lemeshow goodness-of-fit statistic was not significant (χ82 test=3.83, P=.87), suggesting the regression model fits the data well. The area under the ROC curve for the data has a value of .891, which again suggests the model fits the data well. In normal logistic regression the threshold cutoff is normally set to .50, however, this cutoff point was reset to .14, as suggested by the ROC curve, so as to optimize the prediction of wanderers. Given this threshold cutoff, the sensitivity and specificity of the model was 88% and 79%, respectively, with 89% of residents correctly classified. As shown by the odds ratios (ORs) in table 4, cognitive and behavioral problems were associated with wandering. Specifically, an increased chance of wandering was associated with short-term memory problems (4.7 increased odds; 95% confidence interval [CI], 1.90–11.65), difficulty with daily decision-making (3.69 increased odds; 95% CI, 1.72–7.86), and behavior problems (6.61 increased odds; 95% CI, 3.47–12.6), after adjusting for all other variables in the model. | ⁎ A squared age term was included to control for the nonlinear effect of age and was not significant. |
Relationships between wandering and other variables were less striking. Evidence for mood-related problems was associated with an increased chance of wandering behavior in the univariate analysis; however, it was not significant in the multivariate analysis when other variables were included due to its relationship with behavior problems (tetrachoric correlation, .63). As expected, there was a reduced probability of wandering for residents who were dependent on others for locomotion on the unit relative to those requiring no assistance (.08 reduced odds; 95% CI, .03–.23). However, there was not a significant reduction in wandering in those requiring limited assistance for mobility. Likewise, there was not a significant relationship between age and likelihood of wandering. Finally, wandering was highly likely among NH residents who were deficient or dependent in performing personal hygiene. Compared with those who were independent in managing their personal hygiene, those who required assistance were more likely to wander, with an increased odds for those who required limited assistance (3.62 increased odds; 95% CI, 1.51–8.65) as well as for those who were physically dependent (3.12 increased odds; 95% CI, 1.14–8.55). Discussion This is the first large study exclusively examining correlates of wandering behavior in males with a history of TBI. Our goals were to determine the prevalence of wandering in an NH population with TBI and to examine predictors of wandering behavior in this population. Finally, we wanted to know whether factors associated with wandering differ based on whether a given person has a history of TBI. Wandering was found to be quite prevalent among NH residents with a history of TBI, with 14% exhibiting this behavior. For the present study, a resident was considered a wanderer if they exhibited locomotion with no discernible, rational purpose at any time over the course of their initial 7 days in the facility. This prevalence is more than double the prevalence of wandering in the NH population at large (6.5%).25 This is not a surprising finding, given the association between wandering and cognitive deficits in other studies.20, 21, 22, 23 Perhaps most surprising was that approximately 10% of wanderers had no cognitive impairment or had only mild cognitive impairment. This may be because the CPS is not a particularly sensitive instrument for more subtle cognitive decline32 and/or because some percentage of wanderers do so for reasons other than cognitive decline (ie, boredom, physical exercise, self-stimulation). In addition, residents may be incorrectly labeled as wanderers when they are actually manifesting side effects of neuroleptic medications (ie, akathisia). It is likely that in the absence of dementia, wandering among the TBI population is an indicator of confusion and short-term memory loss that may disappear with the passage of time and adaptation to the NH care unit. As expected, and consistent with other studies of wandering within an NH population,25, 33 wandering behavior in residents with a history of TBI was associated with a variety of cognitive and behavioral difficulties. Specifically, increased chance of wandering was associated with short-term memory problems, difficulty with daily decision making, and behavior problems. Wandering can be thought of as one of the many problematic behaviors typically associated with cognitive impairment in NH residents. Due to the large overlap between wandering and significant cognitive impairment in the sample with TBI, we were unable to examine any potential differences in wandering behavior between those who are demented and those who are not demented. Nonetheless, we are able to conclude that wandering is significantly associated with cognitive impairment. Associations between wandering and reduced independent mobility (ie, locomotion) were apparent such that there was a reduced probability of wandering for residents dependent on others for locomotion relative to those requiring no assistance. However, there was not a significant reduction in wandering for those requiring limited assistance. In this sample, then, those who required minimal assistance were just as likely to wander as those who were independent. A larger study of NH residents found a significant relationship between wandering and minimal locomotion assistance,25 so this may be a sample size issue, because there is no reason to expect, a priori, that residents with TBI would be different from other residents on this particular variable. Study Limitations The most notable limitation of this study was sample size. Due to the limited number of residents with a history of TBI in this national sample, we were unable to cross-validate our model using another sample. Obviously, this is an essential next step in terms of drawing any firm conclusions from these data. Another weakness is the reliance on data from the MDS. The MDS is not a research dataset, and therefore there is likely a greater deal of noise in the data than would be typical in controlled studies. The MDS is completed by NH staff and although written guidelines are provided, there is no guarantee that they are followed. As such, there may be significant differences across sites. Nonetheless, high interrater reliability of nurse-pair ratings of MDS behaviors including wandering has been shown.34 Dichotomizing the wandering variable and not recording the frequency of wandering within each day restricted our analysis of the frequency, variation, and types of wandering. Conclusions This study represents an important first step in characterizing NH residents with TBI and their wandering behavior. It is notable, for instance, that persons with a history of TBI are much more likely to wander (more than double the probability) than the general NH population. As such, screening incoming NH residents for a history of TBI is an essential component of the intake process and should be a standard part of the initial assessment. As increasing numbers of young survivors of TBI return from Iraq and Afghanistan, it will be interesting to prospectively follow those with more severe injuries to elucidate any potential differences between them and an older cohort. In other words, how might current and future TBI cohorts differ, if at all, with respect to wandering and other behavioral manifestations of cognitive impairment? One might speculate that younger, more agile patients might have increased wandering and, in turn, perhaps increased frequency and vigor of wandering. This might have implications for their safety and placement. It also remains to be seen what differences, if any, will be evident with regard to behavioral disturbances based on mechanism of injury (eg, blast injuries vs motor vehicle collisions). Acknowledgments We thank all of the members of the International Wandering Consortium for their contributions to this article. We also thank the U.S. Department of Veterans Affairs (DVA) for allowing us access to the data analyzed in this study. The views expressed herein are those of the authors and do not necessarily reflect the views of the DVA. References 1. 1Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21:33–39. 2. 2Luukinen H, Viramo P, Herala M, et al. Fall-related brain injuries and the risk of dementia in elderly people: 1 population-based study. Eur J Neurol. 2005;12:86–92. MEDLINE |
CrossRef
3. 3Lye TC, Shores EA. Traumatic brain injury as a risk factor for Alzheimer’s disease: a review. Neuropsychol Rev. 2000;10:115–129. MEDLINE |
CrossRef
4. 4Gottlieb S. Head injury doubles the risk of Alzheimer’s disease. BMJ. 2000;321:1100. 5. 5Jellinger KA, Paulus W, Wrocklage C, Litvan I. Effects of closed traumatic brain injury and genetic factors on the development of Alzheimer’s disease. Eur J Neurol. 2001;8:707–710. MEDLINE |
CrossRef
6. 6Wagner AK, Hammond FM, Grigsby JH, Norton HJ. The value of trauma scores: predicting discharge after traumatic brain injury. Am J Phys Med Rehabil. 2000;79:235–242. MEDLINE |
CrossRef
7. 7Buchanan RJ, Wang S, Huang C. Profiles of nursing home residents with traumatic brain injury using the Minimum Data Set. Brain Inj. 2003;17:507–523. MEDLINE |
CrossRef
8. 8Defense and Veterans Brain Injury Center. Blast injury. http://www.dvbic.org/blastinjury.html. 9. 9Algase DL, Beel-Bates C, Beattie ER. Wandering in long-term care. Ann Long-Term Care. 2003;11:33–39. 10. 10Hope T, Tilling KM, Gedling K, Keene JM. The structure of wandering in dementia. I J Geriatr Psychiatry. 1994;9:149–155. 11. 11Algase DL, Struble L. Wandering: what, why & how?. In: Buckwalter K editors. Geriatric mental health nursing: current and future challenges. Thorofare: Slack; 1992;p. 61–74. 12. 12Cancro R. Elopements from the C.F. Menninger Memorial Hospital. Bull Menninger Clin. 1968;32:228–238. MEDLINE 13. 13Fompa-Loy J. Wandering: causes, consequences, and care. J Psychosoc Nurs Ment Health Serv. 1998;26:8–11. MEDLINE 14. 14Rheaume Y, Riley ME, Volicer L. Meeting nutritional needs of Alzheimer’s patients who pace constantly. J Nutr Elder. 1987;7:3–52. MEDLINE |
CrossRef
15. 15Soverini S, Borghesi E. On a strange case of wandering in an arteriosclerotic demented patient. Gerontology. 1968;16:846–851. 16. 16Stokes G. Wandering, common problems with the elderly confused. Bicester: Winslow Pr; 1986;. 17. 17Kiely DK, Kiel DP, Burrows AB, Lipsitz LA. Identifying nursing home residents at risk for falling. J Am Geriatr Soc. 1998;46:551–555. MEDLINE 18. 18Snyder LH, Rupprecht P, Pyrek J, Brekhus S, Moss T. Wandering. Gerontologist. 1978;18:272–280. MEDLINE 19. 19Kopetz S, Steele CD, Brandt J, et al. Characteristics and outcomes of dementia residents in an assisted living facility. Int J Geriatr Psychiatry. 2000;15:586–593. MEDLINE |
CrossRef
20. 20Edgerly ES, Donovick PJ. Neuropsychological correlates of wandering in persons with Alzheimer’s disease. Am J Alzheimers Dis. 1998;13:317–329. 21. 21Folstein MR, Folstein SE, McHugh PR. Mini-mental state (A practical method for grading the cognitive state of patients for the clinician). J Psychiatr Res. 1975;12:189–198. MEDLINE |
CrossRef
22. 22Hope T, Keene J, McShane RH, Fairburn CG, Gedling K, Jacoby R. Wandering in dementia: a longitudinal study. Int Psychogeriatr. 2001;13:137–147. MEDLINE |
CrossRef
23. 23Hughes CP, Berg L, Danziger WL, Cohen LA, Martin RL. A new clinical scale for the staging of dementia. Br J Psychiatry. 1982;140:566–572. MEDLINE |
CrossRef
24. 24Vaughan N, Agner D, Clinchot DM. Perseveration and wandering as a predictor variable after brain injury. Brain Inj. 1997;11:815–819. MEDLINE |
CrossRef
25. 25Schonfeld L, King-Kallimanis B, Brown LM, et al. Wanderers with cognitive impairment in Department of Veterans Affairs nursing home care units. J Am Geriatr Soc. 2007;55:692–699. MEDLINE |
CrossRef
26. 26Centers for Medicare & Medicaid Services. Minimum Data Sets 2.0 overview. http://cms.hhs.gov/medicaid/mds20. 27. 27Office of the Assistant Deputy Under Secretary for HealthDepartment of Veterans Affairs. Veterans Affairs site tracking system reports FY2001 and FY2004. Washington (DC): DVA; 2006;. 28. 28Kiely DK, Morris JN, Algase DL. Resident characteristics associated with wandering in nursing homes. Int J Geriatr Psychiatry. 2000;15:1013–1020. MEDLINE |
CrossRef
29. 29Morris JN, Fries BE, Mehr DR, et al. MDS Cognitive Performance Scale. J Gerontol. 1994;49:M174–M182. MEDLINE 30. 30Hartmaier SL, Sloane PD, Guess HA, Koch GG. The MDS Cognition Scale: a valid instrument for identifying and staging nursing home residents with dementia using the minimum data set. J Am Geriatr Soc. 1994;42:1173–1179. MEDLINE 31. 31Gifford DR, Lapane KL. Estrogen use in nursing homes. Ann Long Term Care. 2000;8:53–59. 32. 32Gruber-Baldini AL, Zimmerman SI, Mortimore E, Magaziner J. The validity of the minimum data set in measuring the cognitive impairment of persons admitted to nursing homes. J Am Geriatr Soc. 2000;48:1734–1736. MEDLINE 33. 33Cohen-Mansfield J, Werner P. Longitudinal changes in behavioral problems in old age: a study in an adult day care population. J Gerontol A Biol Sci Med Sci. 1998;53:M65–M71. MEDLINE 34. 34Mor V, Angelelli J, Jones R, Roy J, Moore T, Morris J. Inter-rater reliability of nursing home quality indicators in the U.S.. BMC Health Serv Res. 2003;3:20. MEDLINE |
CrossRef
a Department of Mental Health & Behavioral Science, James A. Haley Veterans Administration Medical Center, Tampa, FL b Department of Physical Medicine & Rehabilitation, James A. Haley Veterans Administration Medical Center, Tampa, FL c Defense and Veterans Brain Injury Center, Washington, DC d Psychology Department, University of South Florida, Tampa, FL e Department of Aging and Mental Health, Louis de la Parte Florida Mental Health Institute, University of South Florida, Tampa, FL f The Patient Safety Center of Inquiry, James A. Haley Veterans Administration Medical Center, College of Nursing, University of South Florida, Tampa, FL.  Reprint requests to Heather G. Belanger, PhD, PM&R-117, 13000 Bruce B. Downs, Tampa, FL 33612
Supported by the Department of Veterans Affairs, Veterans Health Administration; the Defense and Veterans Brain Injury Center (grant no MDA 905-03-2-0003); and the Patient Safety Center of Inquiry, James A. Haley Veterans’ Hospital. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. PII: S0003-9993(07)01655-3 doi:10.1016/j.apmr.2007.08.145 © 2008 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
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