Functional incidental training: a randomized, controlled, crossover trial in Veterans Affairs nursing homes.
ABSTRACT To test the effects of a rehabilitative intervention directed at continence, mobility, endurance, and strength (Functional Incidental Training (FIT)) in older patients in Department of Veterans Affairs (VA) nursing homes.
Randomized, controlled, crossover trial.
Four VA nursing homes.
All 528 patients in the nursing homes were screened; 178 were eligible, and 107 were randomized to an immediate intervention group (Group 1; n=52) and a delayed intervention group (Group 2; n=55).
Trained research staff provided the FIT intervention, which included prompted voiding combined with individualized, functionally oriented endurance and strength-training exercises offered four times per day, 5 days per week, for 8 weeks. Group 1 received the intervention while Group 2 served as a control group; then Group 2 received the intervention while Group 1 crossed over to no intervention. A total of 64 subjects completed the intervention phase of the trial.
Timed measures of walking or wheeling a wheelchair (mobility), sit-to-stand exercises, independence in locomotion and toileting as assessed using the Functional Independence Measure (FIM), one-repetition maximum weight for several measures of upper and lower body strength, frequency of urine and stool incontinence, and appropriate toileting ratios.
There was a significant effect of the FIT intervention on virtually all measures of endurance, strength, and urinary incontinence but not on the FIM for locomotion or toileting. The effects of FIT were observed when Group 1 received the intervention and was compared with the control group and when Group 2 crossed over to the intervention. Group 1 deteriorated in all measures during the 8-week crossover period. Within-person comparisons also demonstrated significant effects on all measures in the 64 participants who completed the intervention; 43 (67%) of these participants were "responders" based on maintenance or improvement in at least one measure of endurance, strength, and urinary incontinence. No adverse events related to FIT occurred during the study period.
FIT improves endurance, strength, and urinary incontinence in older patients residing in VA nursing homes. Translating these positive benefits achieved under research conditions into practice will be challenging because of the implications of the intervention for staff workload and thereby the costs of care.
- SourceAvailable from: Walter A Kukull[show abstract] [hide abstract]
ABSTRACT: Exercise training for patients with Alzheimer disease combined with teaching caregivers how to manage behavioral problems may help decrease the frailty and behavioral impairment that are often prevalent in patients with Alzheimer disease. To determine whether a home-based exercise program combined with caregiver training in behavioral management techniques would reduce functional dependence and delay institutionalization among patients with Alzheimer disease. Randomized controlled trial of 153 community-dwelling patients meeting National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer Disease and Related Disorders Association criteria for Alzheimer disease, conducted between June 1994 and April 1999. Patient-caregiver dyads were randomly assigned to the combined exercise and caregiver training program, Reducing Disability in Alzheimer Disease (RDAD), or to routine medical care (RMC). The RDAD program was conducted in the patients' home over 3 months. Physical health and function (36-item Short-Form Health Survey's [SF-36] physical functioning and physical role functioning subscales and Sickness Impact Profile's Mobility subscale), and affective status (Hamilton Depression Rating Scale and Cornell Depression Scale for Depression in Dementia). At 3 months, in comparison with the routine care patients, more patients in the RDAD group exercised at least 60 min/wk (odds ratio [OR], 2.82; 95% confidence interval [CI], 1.25-6.39; P =.01) and had fewer days of restricted activity (OR, 3.10; 95% CI, 1.08-8.95; P<.001). Patients in the RDAD group also had improved scores for physical role functioning compared with worse scores for patients in the RMC group (mean difference, 19.29; 95% CI, 8.75-29.83; P<.001). Patients in the RDAD group had improved Cornell Depression Scale for Depression in Dementia scores while the patients in the RMC group had worse scores (mean difference, -1.03; 95% CI, -0.17 to -1.91; P =.02). At 2 years, the RDAD patients continued to have better physical role functioning scores than the RMC patients (mean difference, 10.89; 95% CI, 3.62-18.16; P =.003) and showed a trend (19% vs 50%) for less institutionalization due to behavioral disturbance. For patients with higher depression scores at baseline, those in the RDAD group improved significantly more at 3 months on the Hamilton Depression Rating Scale (mean difference, 2.21; 95% CI, 0.22-4.20; P =.04) and maintained that improvement at 24 months (mean difference, 2.14; 95% CI, 0.14-4.17; P =.04). Exercise training combined with teaching caregivers behavioral management techniques improved physical health and depression in patients with Alzheimer disease.JAMA The Journal of the American Medical Association 10/2003; 290(15):2015-22. · 29.98 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: To identify similarities and differences between VA nursing home residents and other nursing home residents. Comparison of cross-sectional data from three sources. Residents of VA nursing homes nationwide in early October 1986 (n = 10,117); participants in the 1985 National Nursing Home Survey (NNHS) (n = 5,243); residents assessed in New York State nursing homes in 1988 (n = 94,840). Age-stratified comparisons were made between the VA and the NNHS for gender, marital status, race, ethnicity, length of stay, activities of daily living (ADL) status, and selected diagnoses and conditions. Additionally, case-mix data were compared between the VA and the New York State populations. The population of VA nursing homes is overwhelmingly men (96.1% versus 28.4% in the NNHS), and 31.2% of the VA population is under 65 years of age compared with 11.6% in the NNHS. Young ( < 65) VA residents are considerably more impaired in ADL than young residents in the NNHS; differences are less pronounced in those over 65 years old. VA case mix is slightly higher than the overall New York State population though the distribution of residents into categories in the Resource Utilization Groups, Version II system is somewhat different. VA nursing homes contain a substantial distinctive population of seriously impaired residents under 65 years of age. Though differences exist, older VA residents have many similarities to residents of non-VA nursing homes and constitute a functionally impaired population that can provide insights into the status of nursing home residents generally.Journal of the American Geriatrics Society 10/1993; 41(10):1095-101. · 3.98 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: To determine the effects of prompted voiding on fecal continence in nursing home residents. Prospective, uncontrolled trial of prompted voiding for urinary incontinence. One hundred sixty-five nursing home residents who completed a 9 to 10-week trial. Trained research aides performed physical checks for urinary and fecal incontinence hourly from 8 AM to 6 PM for 3 days (total of 33 checks) at baseline, for the last 3 days of a 1-week trial of prompted voiding, and after 9 to 10 weeks of prompted voiding. After 9 to 10 weeks of prompted voiding, there was no significant change in the frequency of incontinent bowel movements per resident (1.1 [95% CI.83, 1.4] to .87 [95% CI.67, 1.1]; P = 0.140). There was a significant increase in the number of continent bowel movements per resident (.17 [95% CI.10, .24] to .62 [95% CI.45, .80]; P = .000). This increase occurred in residents whose urinary incontinence responded well to prompted voiding as well as those whose urinary incontinence did no respond. The percentage of bowel movements that were continent also increased significantly from 18% (95% CI 8,29) at baseline to 45% (95% CI 32,57) after 9 to 10 weeks of intervention (P = .000). In addition to these findings, we noted a marked increase in the total frequency of bowel movements after the first week of prompted voiding. This may have resulted from the relief of fecal impactions caused by the increased toileting, mobility, and fluid intake that occurred with prompted voiding. Prompted voiding did not change the frequency of incontinent bowel movements significantly in this sample of nursing home residents. However, the number of continent bowel movements and the percentage of bowel movements that were continent did increase. Our data must be interpreted cautiously because our study was designed primarily as an intervention for urinary, not fecal, incontinence and the design was neither blinded nor controlled. Trials of systematic toileting schedules specifically directed at fecal incontinence, with attention to fecal impaction, diet, fluid intake and laxative use, should be conducted.Journal of the American Geriatrics Society 05/1996; 44(4):424-8. · 3.98 Impact Factor