- Email: [email protected]
Nutrition assessment in the adult day care center
Nutrition Assessment
in the Adult Day Care Center Evaluation and patient teaching are the keys to establishing a successful program. CONNIE E. VICKERY BESSIE McANENY EVA DAICAR Once adult day care programs were established to help older adults with their daily activities and to allow resConnie E. Vickery, RD, PHD, is an assistant professor at the Department of Nutrition and Dietetics, University of Delaware, and Bessie McAneny, RN, MS, is head nurse and Eva Dalcar, MSc, is director ofthe Adult Day Care Center of the University of Delaware, Newark, DE.
pite for their caregivers, plans for a nutrition program that goes beyond the usual two meals and snacks could not be far behind. Because elderly Americans have been identified as nutritionally vulnerable, it is essential that adequate nutrition be recognized and emphasized as a major factor to their well-being(1-3). In fact, congregate feeding programs were established by the Title VII Amendment to the Older Americans Act of 1965 partly in response to the dietrelated problems ofnoninstitutionalized older adults. As part of an expansion ofservices to clients in the Adult Day Care Center of the University of Delaware in Newark, a nutrition monitoring program was developed to enhance daily
meal service. Since this center opened in March 1984, enrollment has increased to its maximum capacity of 31 clients; the average daily census is 15. Soon, the center will move to larger quarters, which will accommodate 35 to 40 clients. Staffed by an administrator with a master's degree in clinical psychology, two registered nurses, a driver/ geriatric aide, and a secretary, the center offers services to those 60 years or older who can't be left alone during the day. No income requirements or fees are established, but voluntary donations are accepted. The nutrition monitoring program is the collaborative effort of the administrator, registered nurse, registered dietitian, and student dietitian.
As with any program, the assessment model is the first priority. How an assessment tool meets the needs of the client population is most significant. Therefore, this model had to satisfy two objectives. First, the nutrition assessment model must identify routinely available data that
Admission Review Update
1 1
1 •
L
L
Nutrition Assessment Profile
'lC,ent
..... IPhysictan - - _
M F Birth Religion
Height Weight:. Curreni MAC ..... { Weight history
/
~[
Single Married Widowed Oivorced Separated Resides w/ ......
Change? Y N Wrist Reasonable { _. %tie) MAMC . . . . ( . ....... .....
S M L Elbow breadth % R B W ) Usual ( ...... . %ile) TSF ( _. . . .
Summarize medical status (incluo-mg pertinent therapieS):
accurately assess clients' nutritional statuses and establish priorities of in, tervention and referral. Second, data from the model must serve as a needs assessment in the formulation of nutrition education programs developed for clients. Program Status Phase I of the program involves the development, evaluation, and refinement of a nutrition screening tool. The interview form, which is retained in the client record, is based on an interview between the client and/or sponsor and the center's ad-
List OTC medications V-daminlminaral supplements Other: . . . . . . . . . . . . . . . . . . . . . . . Prescribed drug(s) IndicaUon
!111_
Alb
Hgb : ~ ] Other: .
H .
~!
.
~ .
.
BUN K ~ . .
Laxatives Nutriti-Onal' implications
Chol Fe Na - - T I B C - ~ . .
.
Glucose Other:
Physical signs indicative of nutritional status Teeth:
no teeth naturalteeth partial plate dentures Chewing difficulties swallowing difficulties
Hair:
shiny firm thin/sparse dysplgmented easlly ptucked
Eyes:
bright/clear paJeconjuncthrae Bitot spots dry
Ups:
smooth ChappeO angular fissures/scars
Tongue: deep red/swollen scarlet/raw magenta pale/smooth sores GuDxs:
healthy recession swollen bleeding
Skin:
normal dry folliCUlar hyperkeratosis petec,~ae bruises
Ncdla;
firm/pink spoon-shaped brittle/rigid
Face:
uniform cOlOr/not swollen depigmentation dark cheeks dark under eyes nas01ablal seborrhea
Edema:
¢=Stlocations)
Decub~ (!iSt tY13eand d~gree) Bowel/bladder function [] ImPainxmnt:
¢~ne ¢tu~d severe
D Incontinent: bowe~ bladder
ministrator. Included on this form are demographic data, identified health problems with corresponding therapeutic modalities, and psychosocial factors. A health history form, completed by the client's physician, summarizes both the client's health history and current status, detailing medications prescribed and identifying any particular therapies. Dietary modification is included as well. If consultation with staff is sought, interviews with clients and/or sponsors are conducted. At the start of the program, data
[] Olarrhee: frequency [] Constipatio~
frequency.
Residence [] Alone [] with: El House [3 Apartment DOt her: Smoking hab~/tdstory ACtiVity level Ambulates: O in0ependently D w/assistanse [] wheelchair [] immobile 8defly describe/assess: Behavior i Alert/coherent
IIII
Alert/confused
IIIIIII II
Withdrawn/disorlented
I
Geriatric Nursing September/October 1988 293
S M %UBW) = */die)
tained for the clicnt record. Reevaluation of clients necessitated the subsequent design of the Nutrition Assessment Profile Update, a form similar to the first but which records change.Unless otherwise needed, status is reevaluated in a period not exceeding six months and a new summary is prepared. All data are categorized in the following manner: demographic, clinical, physical, psychosocial, and dietary. The data is then exchanged and used to inform, confirm, elucidate, compare information, and identify problems. Whether probable ("nutrient absorption impairment secondary to laxative abuse"), possible ("inadequate calcium intake"), or documented ("diabetes mellitus"), each problem is countered with practical recommendations directed at its resolution. Thus, the Nutrition Assessment Profile Summary serves as
collected on the initial 10 clients were reviewed by the RD and SD, and a preliminary Nutrition Assessment Profile was designed. This form was then used to assess the next 15 clients, who were evaluated by the administrator, RN, RD, and SD. Each time, the form was further re-
fined to accommodate client need. Within one week of the client's first visit, nutrition assessment profiles are initiated. The information obtained from this form is then used to prepare a summary for the client and/or sponsor, and a copy is re-
Nutrition A s s e s s m e n t Profile Clinical R o w s h e e t
,, Wrist(in). . . . . .
Client Height (in')
RBW (lb) i [
S M L Elbow breadth Blrlh
Ii~ Parameter
SML
.... UBW (lbl
/. /
.... M F
a communication vehicle for staff and clients and/or sponsors. The open interaction between the staffand the RD and SD is implicit in this project and model. The consulting RD is scheduled to make weekly visits. This person may discuss concerns with families by appointment at the center or by phone. As areas of Concern are identified, means of addressing these needs are sought. For example, pamphlets were mailed to all enrollees when it was noted that a calcium source in many clients' diets was missing. Completion of the Nutrition Assessment Profile is the primary responsibility of the consulting nutritionist, although students participate in the process with appropriate supervision. It is then translated into a practical plan in the summary. Change ofeating patterns is not only in response to education, medical needs and social factors have been reported to be the most significant factors in changing food habits of the elderly(4). A computer dietary analysis has been added to the Nutrition A s s e s s -
R~DaIes m
, I ,I,
_[.l /
_1. l
l
]
1
I
~elght Oh) a.s % R B w ~s % UBW Midarm circumference ...... % g e
~i(18n'n muscle circumference %ge
r~
~fokS %Ue
-,-, ...... +
+-
!
'][
,-t--i -
-
-
+
....
t-+ ,,,,,,
~
rill
IJ
+
L:'
i ! llrrJ,
il
1 t l;J [l_t.l
il]
I_LI
tiiJn
m
~1
Illillli)l)ltl 11 I . l . i l l d ] t.I, 4,, i i I i 1 i i i i 11 [ L L L I d
I I [_Li[[il/ I I I J | l i I I til 1! I ~ l t [~LT_T-_i[IAA 1 J i l l i [lli lt!! itl .ll l i l t , l i t 1 i 1_1 I L i - i l l VIH~!It i i 1. i t I t ~ " ~ i " , I_tit
it,
i it
i i tt-lf-f-t:-l-i-t-t-t-V'H-+
i
ITVVIH~LI~I-LLLL-LLtT!_LJl] i T--r::r-r.-I-...q-1
I1 i liI. l t i
i ~ ]
J 1 1t_i i i 1I i lI L_.L/J i~X_l I 1.1.1 tl
Time (weeks) II
Ill
II I
294 Gcriatric Nursing Scptembcr/Octobcr 1988
III
lllll
1
ment Profile. A dietary recall and food frequency questionnaire are completed by each newly admitted client and/or a family member familiar with the client's dietary habits. This is repeated when a client's nutritional status is reevaluated. Data are then coded and a dietary analysis is generated using the Nutritionist III Program (N-Squared Computing, Siverton, OR). The resuits are shared with the client and family in general terms. That is, when the intake of a nutrient is below 67 percent of the Recommended Dietary Allowance, it is discussed in terms of "less than recommended" and the food sources that might improve the status(5). Clients' food preferences are al-
ways considered in making suggestions as a nutrient source is not beneficial if people will not eat it. A simple bar graph may also be shown to clients who are able to comprehend and take an active role in their own nutritional care. The results of the dietary analysis
ing at the center. Each student must observe clients and interview staffregarding possible activities appropriate for age and ability. Topics selected among those identified via the ongoing needs assessment include "Increasing Fiber to Relieve Constipation," "Living on a Fat-Controlled
tntendew [
ale~l / N~/~,osstnenl
,ot
Vrome~amary
Using a nutrition profile as a base, an education program can be developed to meet patients' dietary needs and detect potential problems.
are reviewed in detail with the staffto reinforce information provided to clients and families by the nutritionist. Because of the frequency with which staff members interact with clients and families, they are able to assess the comprehension and compliance levels which are then shared with the nutritionist. At this point, potential problems can be identified and addressed. Phase II represents the natural evolution of a needs assessment regarding nutrition education. Topics amenable to nutrition intervention include healthful eating patterns, inappropriate body weight status, lack of appetite, mastication difficulties, constipation, simple meal preparation techniques, and drug and nu-
trient interactions. These education efforts involve individualized counseling and group classes presented by a US cooperative extension agent or by Dairy Council, Inc.
Student Experiences A large segment of the nutrition education need has been met by SDs who have opted to fulfill their academic requirement for group teach-
Diet," "Getting Enough Fluid," and "Shaking the Salt Habit." The staff is consulted before SDs develop a formal lesson plan. Staffattend all presentations and later provide evaluative comments. Clients appear to enjoy the activities, staff appreciate the students, and students find the process rewarding.
Future Expectations Plans are underway to expand the clinical opportunities offered in the program. Two students will fulfill a five-week community nutrition rotation with nutrition assessment and nutrition education activities. Because the nutrition monitoring program lends itself quite well to student participation, it need not be limited to dietetic or nutrition students only. Nursing students could benefit in working closely with older adults and understanding the complexity of health and nutrition problems germane to this growing population. Programs designed for families of clients will be developed so that they will also be able to provide additional nutritional assistance and support. Continuing education of staff members is also among the proposed assignments of the program. While themes for nutrition education programs will continue to originate from those problems that are identified from client assessments, innovative techniques of affecting behavior patterns will be the quest. Including messages on nutrition in the monthly clients' newsletter is one
,.,
ii ,,
aie,t s
,,,
Re~r~u~
RBW ± 20% ? Y e s - ~ months IBW ± 10% ? ~ Y e s - ~ 3 months A n l h r o t ~ t lrics 5*AJle?--Yes.,-~3 months /
6 ~as ,
,,,,
,
,
,
,,
,
,
,,
,,
,
way of keeping clients aware and informed about the importance of nutrition to one's health. In addition, more contact between the nutritionist and sponsors will be encouraged as everyone involved thus far is pleased with the process. This project is not considered a solution but rather a beginning to providing much needed health care services for older adults.
References 1. Todhunter, E. N. Nutrition care of the elderly. FoodNutr.News 52(I):I--4, 1980. 2. U.S.Centers for Disease Control. Ten-StateNutrition Surrey 1968-1970, Five Volumes (DHEW Publ. No. (HSM)72-8134). Washington, D.C., U.S. Government Printing Office, 1972. 3. Carroll, M. D., and others. Dietary intake source data: United States, 1976-1980. Vital and llealth Statistics. Series IL Data from the llealth Examination, No. 23L (DHHS Publ. No. (PHS)83-1681). Washington, D.C., U.S. Government Printing Of. rice, 1983. 4. Jordan, M., and others. Dietary habits of persons living alone. Geriatrics 9:230--232, May 1954. 5. National Research Council, Committee on Dietary Allowances. Recommended Dietary Allowances. 9th ed. Washington, D.C., National Academy of Sciences, 1980.
Geriatric Nursing Semember/October 1988 295
o
in the Adult Day Care Center Evaluation and patient teaching are the keys to establishing a successful program. CONNIE E. VICKERY BESSIE McANENY EVA DAICAR Once adult day care programs were established to help older adults with their daily activities and to allow resConnie E. Vickery, RD, PHD, is an assistant professor at the Department of Nutrition and Dietetics, University of Delaware, and Bessie McAneny, RN, MS, is head nurse and Eva Dalcar, MSc, is director ofthe Adult Day Care Center of the University of Delaware, Newark, DE.
pite for their caregivers, plans for a nutrition program that goes beyond the usual two meals and snacks could not be far behind. Because elderly Americans have been identified as nutritionally vulnerable, it is essential that adequate nutrition be recognized and emphasized as a major factor to their well-being(1-3). In fact, congregate feeding programs were established by the Title VII Amendment to the Older Americans Act of 1965 partly in response to the dietrelated problems ofnoninstitutionalized older adults. As part of an expansion ofservices to clients in the Adult Day Care Center of the University of Delaware in Newark, a nutrition monitoring program was developed to enhance daily
meal service. Since this center opened in March 1984, enrollment has increased to its maximum capacity of 31 clients; the average daily census is 15. Soon, the center will move to larger quarters, which will accommodate 35 to 40 clients. Staffed by an administrator with a master's degree in clinical psychology, two registered nurses, a driver/ geriatric aide, and a secretary, the center offers services to those 60 years or older who can't be left alone during the day. No income requirements or fees are established, but voluntary donations are accepted. The nutrition monitoring program is the collaborative effort of the administrator, registered nurse, registered dietitian, and student dietitian.
As with any program, the assessment model is the first priority. How an assessment tool meets the needs of the client population is most significant. Therefore, this model had to satisfy two objectives. First, the nutrition assessment model must identify routinely available data that
Admission Review Update
1 1
1 •
L
L
Nutrition Assessment Profile
'lC,ent
..... IPhysictan - - _
M F Birth Religion
Height Weight:. Curreni MAC ..... { Weight history
/
~[
Single Married Widowed Oivorced Separated Resides w/ ......
Change? Y N Wrist Reasonable { _. %tie) MAMC . . . . ( . ....... .....
S M L Elbow breadth % R B W ) Usual ( ...... . %ile) TSF ( _. . . .
Summarize medical status (incluo-mg pertinent therapieS):
accurately assess clients' nutritional statuses and establish priorities of in, tervention and referral. Second, data from the model must serve as a needs assessment in the formulation of nutrition education programs developed for clients. Program Status Phase I of the program involves the development, evaluation, and refinement of a nutrition screening tool. The interview form, which is retained in the client record, is based on an interview between the client and/or sponsor and the center's ad-
List OTC medications V-daminlminaral supplements Other: . . . . . . . . . . . . . . . . . . . . . . . Prescribed drug(s) IndicaUon
!111_
Alb
Hgb : ~ ] Other: .
H .
~!
.
~ .
.
BUN K ~ . .
Laxatives Nutriti-Onal' implications
Chol Fe Na - - T I B C - ~ . .
.
Glucose Other:
Physical signs indicative of nutritional status Teeth:
no teeth naturalteeth partial plate dentures Chewing difficulties swallowing difficulties
Hair:
shiny firm thin/sparse dysplgmented easlly ptucked
Eyes:
bright/clear paJeconjuncthrae Bitot spots dry
Ups:
smooth ChappeO angular fissures/scars
Tongue: deep red/swollen scarlet/raw magenta pale/smooth sores GuDxs:
healthy recession swollen bleeding
Skin:
normal dry folliCUlar hyperkeratosis petec,~ae bruises
Ncdla;
firm/pink spoon-shaped brittle/rigid
Face:
uniform cOlOr/not swollen depigmentation dark cheeks dark under eyes nas01ablal seborrhea
Edema:
¢=Stlocations)
Decub~ (!iSt tY13eand d~gree) Bowel/bladder function [] ImPainxmnt:
¢~ne ¢tu~d severe
D Incontinent: bowe~ bladder
ministrator. Included on this form are demographic data, identified health problems with corresponding therapeutic modalities, and psychosocial factors. A health history form, completed by the client's physician, summarizes both the client's health history and current status, detailing medications prescribed and identifying any particular therapies. Dietary modification is included as well. If consultation with staff is sought, interviews with clients and/or sponsors are conducted. At the start of the program, data
[] Olarrhee: frequency [] Constipatio~
frequency.
Residence [] Alone [] with: El House [3 Apartment DOt her: Smoking hab~/tdstory ACtiVity level Ambulates: O in0ependently D w/assistanse [] wheelchair [] immobile 8defly describe/assess: Behavior i Alert/coherent
IIII
Alert/confused
IIIIIII II
Withdrawn/disorlented
I
Geriatric Nursing September/October 1988 293
S M %UBW) = */die)
tained for the clicnt record. Reevaluation of clients necessitated the subsequent design of the Nutrition Assessment Profile Update, a form similar to the first but which records change.Unless otherwise needed, status is reevaluated in a period not exceeding six months and a new summary is prepared. All data are categorized in the following manner: demographic, clinical, physical, psychosocial, and dietary. The data is then exchanged and used to inform, confirm, elucidate, compare information, and identify problems. Whether probable ("nutrient absorption impairment secondary to laxative abuse"), possible ("inadequate calcium intake"), or documented ("diabetes mellitus"), each problem is countered with practical recommendations directed at its resolution. Thus, the Nutrition Assessment Profile Summary serves as
collected on the initial 10 clients were reviewed by the RD and SD, and a preliminary Nutrition Assessment Profile was designed. This form was then used to assess the next 15 clients, who were evaluated by the administrator, RN, RD, and SD. Each time, the form was further re-
fined to accommodate client need. Within one week of the client's first visit, nutrition assessment profiles are initiated. The information obtained from this form is then used to prepare a summary for the client and/or sponsor, and a copy is re-
Nutrition A s s e s s m e n t Profile Clinical R o w s h e e t
,, Wrist(in). . . . . .
Client Height (in')
RBW (lb) i [
S M L Elbow breadth Blrlh
Ii~ Parameter
SML
.... UBW (lbl
/. /
.... M F
a communication vehicle for staff and clients and/or sponsors. The open interaction between the staffand the RD and SD is implicit in this project and model. The consulting RD is scheduled to make weekly visits. This person may discuss concerns with families by appointment at the center or by phone. As areas of Concern are identified, means of addressing these needs are sought. For example, pamphlets were mailed to all enrollees when it was noted that a calcium source in many clients' diets was missing. Completion of the Nutrition Assessment Profile is the primary responsibility of the consulting nutritionist, although students participate in the process with appropriate supervision. It is then translated into a practical plan in the summary. Change ofeating patterns is not only in response to education, medical needs and social factors have been reported to be the most significant factors in changing food habits of the elderly(4). A computer dietary analysis has been added to the Nutrition A s s e s s -
R~DaIes m
, I ,I,
_[.l /
_1. l
l
]
1
I
~elght Oh) a.s % R B w ~s % UBW Midarm circumference ...... % g e
~i(18n'n muscle circumference %ge
r~
~fokS %Ue
-,-, ...... +
+-
!
'][
,-t--i -
-
-
+
....
t-+ ,,,,,,
~
rill
IJ
+
L:'
i ! llrrJ,
il
1 t l;J [l_t.l
il]
I_LI
tiiJn
m
~1
Illillli)l)ltl 11 I . l . i l l d ] t.I, 4,, i i I i 1 i i i i 11 [ L L L I d
I I [_Li[[il/ I I I J | l i I I til 1! I ~ l t [~LT_T-_i[IAA 1 J i l l i [lli lt!! itl .ll l i l t , l i t 1 i 1_1 I L i - i l l VIH~!It i i 1. i t I t ~ " ~ i " , I_tit
it,
i it
i i tt-lf-f-t:-l-i-t-t-t-V'H-+
i
ITVVIH~LI~I-LLLL-LLtT!_LJl] i T--r::r-r.-I-...q-1
I1 i liI. l t i
i ~ ]
J 1 1t_i i i 1I i lI L_.L/J i~X_l I 1.1.1 tl
Time (weeks) II
Ill
II I
294 Gcriatric Nursing Scptembcr/Octobcr 1988
III
lllll
1
ment Profile. A dietary recall and food frequency questionnaire are completed by each newly admitted client and/or a family member familiar with the client's dietary habits. This is repeated when a client's nutritional status is reevaluated. Data are then coded and a dietary analysis is generated using the Nutritionist III Program (N-Squared Computing, Siverton, OR). The resuits are shared with the client and family in general terms. That is, when the intake of a nutrient is below 67 percent of the Recommended Dietary Allowance, it is discussed in terms of "less than recommended" and the food sources that might improve the status(5). Clients' food preferences are al-
ways considered in making suggestions as a nutrient source is not beneficial if people will not eat it. A simple bar graph may also be shown to clients who are able to comprehend and take an active role in their own nutritional care. The results of the dietary analysis
ing at the center. Each student must observe clients and interview staffregarding possible activities appropriate for age and ability. Topics selected among those identified via the ongoing needs assessment include "Increasing Fiber to Relieve Constipation," "Living on a Fat-Controlled
tntendew [
ale~l / N~/~,osstnenl
,ot
Vrome~amary
Using a nutrition profile as a base, an education program can be developed to meet patients' dietary needs and detect potential problems.
are reviewed in detail with the staffto reinforce information provided to clients and families by the nutritionist. Because of the frequency with which staff members interact with clients and families, they are able to assess the comprehension and compliance levels which are then shared with the nutritionist. At this point, potential problems can be identified and addressed. Phase II represents the natural evolution of a needs assessment regarding nutrition education. Topics amenable to nutrition intervention include healthful eating patterns, inappropriate body weight status, lack of appetite, mastication difficulties, constipation, simple meal preparation techniques, and drug and nu-
trient interactions. These education efforts involve individualized counseling and group classes presented by a US cooperative extension agent or by Dairy Council, Inc.
Student Experiences A large segment of the nutrition education need has been met by SDs who have opted to fulfill their academic requirement for group teach-
Diet," "Getting Enough Fluid," and "Shaking the Salt Habit." The staff is consulted before SDs develop a formal lesson plan. Staffattend all presentations and later provide evaluative comments. Clients appear to enjoy the activities, staff appreciate the students, and students find the process rewarding.
Future Expectations Plans are underway to expand the clinical opportunities offered in the program. Two students will fulfill a five-week community nutrition rotation with nutrition assessment and nutrition education activities. Because the nutrition monitoring program lends itself quite well to student participation, it need not be limited to dietetic or nutrition students only. Nursing students could benefit in working closely with older adults and understanding the complexity of health and nutrition problems germane to this growing population. Programs designed for families of clients will be developed so that they will also be able to provide additional nutritional assistance and support. Continuing education of staff members is also among the proposed assignments of the program. While themes for nutrition education programs will continue to originate from those problems that are identified from client assessments, innovative techniques of affecting behavior patterns will be the quest. Including messages on nutrition in the monthly clients' newsletter is one
,.,
ii ,,
aie,t s
,,,
Re~r~u~
RBW ± 20% ? Y e s - ~ months IBW ± 10% ? ~ Y e s - ~ 3 months A n l h r o t ~ t lrics 5*AJle?--Yes.,-~3 months /
6 ~as ,
,,,,
,
,
,
,,
,
,
,,
,,
,
way of keeping clients aware and informed about the importance of nutrition to one's health. In addition, more contact between the nutritionist and sponsors will be encouraged as everyone involved thus far is pleased with the process. This project is not considered a solution but rather a beginning to providing much needed health care services for older adults.
References 1. Todhunter, E. N. Nutrition care of the elderly. FoodNutr.News 52(I):I--4, 1980. 2. U.S.Centers for Disease Control. Ten-StateNutrition Surrey 1968-1970, Five Volumes (DHEW Publ. No. (HSM)72-8134). Washington, D.C., U.S. Government Printing Office, 1972. 3. Carroll, M. D., and others. Dietary intake source data: United States, 1976-1980. Vital and llealth Statistics. Series IL Data from the llealth Examination, No. 23L (DHHS Publ. No. (PHS)83-1681). Washington, D.C., U.S. Government Printing Of. rice, 1983. 4. Jordan, M., and others. Dietary habits of persons living alone. Geriatrics 9:230--232, May 1954. 5. National Research Council, Committee on Dietary Allowances. Recommended Dietary Allowances. 9th ed. Washington, D.C., National Academy of Sciences, 1980.
Geriatric Nursing Semember/October 1988 295
o