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Too often, the role of nursing in geriatric neurorehabilitation is defined in terms of extending the care of other disciplines and assuring continuity of selected aspects of care over 24 hours. This article argues that nursing has made significant clinical and scientific progress in contributing, independently and interdependently, to quality rehabilitation care for older adults; and that the role of nursing clearly exceeds the realm of mere extension and continuity of care. Reviewed are nursing's innovations in the areas of promoting comprehensive assessment; fostering functional independence, self-care, and self-care agency; enhancing communication; encouraging family involvement; improving cognitive status; and assuring quality physical care. We conclude with a discussion of the relationship of nursing to other disciplines, and how nursing's contributions can be optimized within the broader context of multidisciplinary geriatric rehabilitation.

Objectives. This study examined the prospective effect of reported access to medical care on health-related quality-of-life outcomes in patients with symptomatic human immunodeficiency virus (HIV) disease. Methods. A cohort study was designed with interviews at baseline, follow-up interviews at 3 months after baseline, mortality follow-up through 6 months after baseline, and medical record reviews for selected baseline clinical data. Participants were HIV-infected patients who were receiving ambulatory and/or hospital care at one county-run municipal and one Veterans Administration hospital in metropolitan Los Angeles and were interviewed about access to medical care (using a reliable 9-item scale assessing affordability, availability, and convenience of medical care). Access to care reported by this sample was compared with that of 2,471 patients with other chronic diseases from the Medical Outcomes Study. The main outcome measures were composite scores for physical and mental health-related quality of life 3 months after baseline, derived from a validated 56-item instrument, scored from 0 to 100, and controlling for baseline health-related quality of life. Results. Overall reported access to medical care in this sample was significantly poorer than that for patients with other chronic diseases (means scores were 63 and 73, respectively). The sample was categorized into tertiles of initial physical and mental health-related quality of life and into groups with initial high versus low access to care. Among those in the middle tertile of physical health-related quality of life at baseline, those with high access improved in physical health scores by 10.2 points relative to those with low access. Those in the low and middle tertiles of initial mental health improved in mental health to a significantly greater extent for those with high versus low access. There were nonsignificant trends toward similar effects for most other subgroups. The effects of access on health-related quality-of-life outcomes were generally robust in multivariate regression analyses that included CD4, hemoglobin, albumin, insurance status, and sociodemographic characteristics. Conclusions. Access to care at baseline predicted better physical and mental health outcomes at 3 months for those in the middle tertile of physical health and for those in the bottom and middle tertiles of mental health at baseline. Increasing access to care for poor public hospital patients with HIV infection may help to improve health-related quality-of-life outcomes among selected persons with advanced disease.

Patients with Alzheimer's disease experience a range of symptoms that may overwhelm the patients, their families, and the people responsible for their care. With today's drive to reduce health care costs, any plan for managing these patients must produce maximum effectiveness at the lowest possible cost. A multidisciplinary team potentially offers both effective and efficient dementia care by eliminating duplicative or ineffective services and maintaining the optimum health of the patient and family.

Functional performance is a critical outcome to examine in dementia. The authors review some of the limitations of current research on functional performance and identify a conceptual framework for outcomes research. When considering conceptual frameworks to apply to functional assessment for outcomes research, five broad issues emerge: variability in definitions, an assumed equality between functional performance and capacity, measurement of global task abilities but not abilities for task components, lack of a contextual perspective, and use of a physical disability framework that excludes cognitive disability. When selecting assessment methods, researchers also must consider the implications of informant-based instruments and performance-based instruments. The authors also discuss a conceptual framework for evaluating current functional performance assessment instruments.

To evaluate the role of proton (hydrogen-1) magnetic resonance (MR) spectroscopy in the differential diagnosis of focal brain lesions in patients with acquired immunodeficiency syndrome (AIDS).Twenty-six men with 35 AIDS-related brain lesions underwent MR imaging and localized H-1 MR spectroscopy. Lesions consisted of 11 toxoplasmic abscesses, 12 progressive multifocal leukoencephalopathic lesions, eight lymphomas, and four cryptococcomas. Metabolite peak areas in the lesions were compared with those in the contralateral hemisphere in each patient.H-1 MR spectroscopic findings showed significantly different biochemical profiles for each diagnostic group (P = .0001) with regard to N-acetyl compounds, total creatine pool, choline-containing compounds, myoinositol, and lactate. H-1 MR spectroscopy alone helped correctly diagnose 94% (84% with jackknifed classification) of the brain lesions, without overlap between toxoplasmosis and lymphoma.H-1 MR spectroscopy is a sensitive and potentially specific noninvasive adjunctive method for differential diagnosis of focal brain lesions in AIDS.

Studies aimed at explaining and decreasing disruptive behaviors need to be designed within conceptual frameworks. A number of researchers provide examples of such efforts. Meddaugh is examining the theory of reactance, Matteson et al are examining Piagetian concepts (personal communication, 1992), and Hurley is examining the concept of resistance. Such efforts will serve to enlighten our understanding of the dynamics of disruptive behavior and eventually may result in a common multicausal conceptualization of its cause. Additional study of the cause of disruptive behaviors also is needed. Currently the explanations for disruptive behaviors involve a variety of conceptual frameworks with little consistency among studies. Furthermore, many studies designed to decrease these behaviors do not clearly base their interventions on conceptual explanations for the behaviors. Studies aimed at explaining and decreasing disruptive behaviors need to be designed within conceptual frameworks. A number of researchers provide examples of such efforts. Meddaugh is examining the theory of reactance, Matteson et al are examining Piagetian concepts (personal communication, 1992), and Hurley is examining the concept of resistance. Such efforts will serve to enlighten our understanding of the dynamics of disruptive behavior and eventually may result in a common multicausal conceptualization of its cause. This developing conceptualization of causes needs to encompass biologic as well as psychosocial explanations. A number of researchers are conducting studies that will contribute to the understanding of the role of biologic factors. Examples of such efforts include Kolanowski's and Satlin et al's work on the effects of artificial lighting on disruptive behavior and Meddaugh's study of the role of exercise. As interventions are designed for decreasing disruptive behaviors, systems of care that use these interventions need to be evaluated for their cost effectiveness and their impact on quality of life.