JAMDA

Physical Restraints: Abusive and Harmful

Debbie Tolson, John E. Morley — 2012-03-29

Contemporary health care policy around the world promotes the use of evidence-based medicine and, as such, it is reasonable to assume that this would lead to similarities in health care practices in comparable economies. Interestingly, this does not seem to be the case with the use of restraining technologies and restraint policies implemented within hospitals and nursing homes. Definitional ambiguity surrounding what is an abusive act may in part account for these practice variations, given that interpretations of an abusive act are contingent on particular circumstances. For example, if a practitioner restrains a patient who is behaving aggressively, it might be interpreted as a justifiable act, or an act of abuse that may be criminal, depending on the situation.

On Assisted Living, Are We Hitting the Mark or Missing the Boat?

Steven A. Levenson — 2012-03-09

This issue of the Journal of the American Medical Directors Association includes a study by Becker et al, looking at predictors of avoidable hospitalizations among Medicaid-enrolled assisted living residents with so-called “ambulatory-care sensitive” (ACS) conditions during 2003 to 2008. The study concludes that increased age, being of certain race or ethnicity, and having comorbid physical health conditions were associated with a higher risk of ACS hospitalization. In contrast, the risk of ACS hospitalization was reduced for older residents, those with a dementia diagnosis, and those of African American ethnicity. The study also identified that the risk of hospitalization was lower in African Americans with dementia and younger individuals with a major psychotic disorder. The authors conclude that there is a need to investigate further whether the health needs of people with certain psychosocial characteristics are being met adequately, and that various ethnic and racial characteristics may result in inadequate care that results in avoidable hospitalization.

Pain—“God’s Megaphone”

John E. Morley — 2012-03-29

“I’m just pain covered in skin.”—Mrs WilsonThe Grapes of WrathJohn Steinbeck Pain is considered to be the fifth vital sign. Pain is complex. Although pain is derived from a noxious sensory stimulus, how it is perceived is highly subjective. A person’s emotional state, past experiences, and expectations all can modify the intensity of the perceived pain. C.S. Lewis called pain “God’s megaphone,” but this does not provide an excuse for health care professionals not to treat pain.

Mobility in Elderly People With a Lower Limb Amputation: A Systematic Review

2011-03-18

Abstract: Elderly people with a lower limb amputation impose a heavy burden on health resources, requiring extensive rehabilitation and long term care. Mobility is key to regaining independence; however, the impact of multiple comorbidities in this patient group can make regaining mobility a particularly challenging task. An evidence-based prognosis for mobility is needed for rehabilitation and long term care planning. This systematic review summarizes the prosthetic and nonprosthetic mobility outcomes achieved by elderly people with a lower limb amputation, to determine whether an accurate prognosis for mobility can be made. MEDLINE, EMBASE, and CINAHL were searched for studies published before May 2010 in English, German, Dutch, or French, using keywords and synonyms for elderly, mobility, rehabilitation, and amputation. Mobility focused on actual movement (moving from one place to another) and was limited to long-term measurements, 6 months after amputation or 3 months after discharge from rehabilitation. The 15 included studies featured a diversity of objective outcome measures and mobility grades that proved difficult to compare meaningfully. In general, studies that included selected populations of prosthetic walkers showed that advanced prosthetic mobility skills can be achieved by the elderly person with a lower limb amputation, including outdoor/community walking. Studies that included all subjects undergoing a lower limb amputation reported that less than half of the elderly population achieved a household level of prosthetic mobility. The predominant findings from the included studies were incomplete reporting of study populations and poor reporting of the reliability of the mobility measures used. The strength of conclusions from this review was therefore limited and the prognosis for mobility in elderly people after lower limb amputation remains unclear. Further research into mobility outcomes of this population is needed to provide evidence that enables more informed choices in rehabilitation and long term care.

A Review of the Effectiveness of Antidepressant Medications for Depressed Nursing Home Residents

2011-10-24

Abstract: Background: Antidepressant medications are the most common psychopharmacologic therapy used to treat depressed nursing home (NH) residents. Despite a significant increase in the rate of antidepressant prescribing over the past several decades, little is known about the effectiveness of these agents in the NH population.Objective: To conduct a systematic review of the literature to examine and compare the effectiveness of antidepressant medications for treating major depressive symptoms in elderly NH residents.Methods: The following databases were searched with searches completed prior to January 2011 and no language restriction: MEDLINE, Embase, PsycINFO, CINHAL, CENTRAL, LILACS, ClinicalTrials.gov, International Standard Randomized Controlled Trial Number Register, and the WHO International Clinical Trial Registry Platform. Additional studies were identified from citations in evidence-based guidelines and reviews as well as book chapters on geriatric depression and pharmacotherapy from several clinical references. Studies were included if they described a clinical trial that assessed the effectiveness of any currently-marketed antidepressant for adults aged 65 years or older, who resided in the NH, and were diagnosed by DSM criteria and/or standardized validated screening instruments with Major Depressive Disorder, minor depression, dysthymic disorder, or Depression in Alzheimer's disease.Results: A total of eleven studies, including four randomized and seven non-randomized open-label trials, met all inclusion and exclusion criteria. It was not feasible to conduct a meta-analysis because the studies were heterogeneous in terms of study design, operational definitions of depression, participant characteristics, pharmacologic interventions, and outcome measures. Of the four randomized trials, two had a control group and did not demonstrate a statistically-significant benefit for antidepressant pharmacotherapy over placebo. While six of the seven non-randomized studies identified a response to an antidepressant, their results must be interpreted with caution as they lacked a comparison group.Conclusions: The limited amount of evidence from randomized and non-randomized open-label trials suggests that depressed NH residents have a modest response to antidepressant medications. Further research using rigorous study designs are needed to examine the effectiveness and safety of antidepressants in depressed NH residents, and to determine the various facility, provider, and patient factors associated with response to treatment.

Nursing Home Revenue Source and Information Availability During the Emergency Department Evaluation of Nursing Home Residents

2011-02-14

Abstract: Objectives: Lack of access to medical information for nursing home residents during emergency department (ED) evaluation is a barrier to quality care. We hypothesized that the quantity of information available in the ED differs based on the funding source of the resident’s nursing home.Design: Cross-sectional observational study.Setting: Single academic ED.Participants: Participants were 128 skilled nursing facility (SNF) residents age 65 or older from 12 SNFs.Measurements: Emergency physicians documented knowledge of 9 essential information items. SNFs were categorized as accepting or not accepting Medicaid.Results: Questionnaires were completed for 128 patients, of whom 95 (74%) were from 1 of 8 Medicaid-funded SNFs and 33 (26%) were from 1 of 4 SNFs not accepting Medicaid. Patients from SNFs accepting Medicaid were younger (79 versus 87, P < .001) and less frequently white (62% versus 97%, P < .001). The mean number of 9 possible information items available was lower for patients from SNFs that accept Medicaid (7.13 versus 8.15, P < .001). Emergency providers also reported lower satisfaction regarding access to information for residents from SNFs that accept Medicaid (P < .05). The association between residence in an SNF that accepts Medicaid and lower ED information scores remained after linear regression with clustering by SNF controlling for age, gender, and race. The most common source of information for residents from both types of SNFs was transfer papers from the SNF.Conclusion: Less information is available to ED providers for patients from SNFs that accept Medicaid than for residents from SNFs that do not accept Medicaid. Further study is needed to examine this information gap.

Factors Associated With Potentially Preventable Hospitalization Among Nursing Home Residents in New York State With Chronic Kidney Disease

Roy Mathew, Yuchi Young, Srishti Shrestha — 2011-02-28

Abstract: Objective: Identify clinical and organizational factors associated with potentially preventable ambulatory care sensitive (ACS) hospitalization among nursing home residents with chronic kidney disease.Methods: New York State Nursing home residents (n = 5449) age 60+ with chronic kidney disease and were hospitalized in 2007. Data included residents’ sociodemographic and clinical characteristics, nursing home organizational factors, and ACS hospitalizations. Multivariate logistic regression quantified the association between potential determinants and ACS hospitalizations (yes versus no).Results: Prevalence of chronic kidney disease among nursing home residents is 24%. Potentially avoidable ACS hospitalization among older nursing home residents with chronic kidney disease is 27%. Three potentially modifiable factors associated with significantly higher odds of ACS hospitalization include the following: presence of congestive heart failure (OR = 1.4; 95% CI 1.24–1.65), excessive medication use (OR = 1.3; 95% CI 1.11–1.48), and the lack of training provided to nursing staff on how to communicate effectively with physician about the resident’s condition. (OR = 1.3; 95% CI 0.59–0.96).Conclusion: To reduce potentially preventable ACS hospitalization among chronic kidney disease patients, congestive heart failure and excessive medication use can be kept stable using relatively simple interventions by periodic multidisciplinary review of medications and assessing appropriate response to therapy; and communication training be provided to nursing staff on how to articulate to the responsible physician important changes in the patients’ condition.

The Association Between Pain and Measures of Well-Being Among Nursing Home Residents

Kate L. Lapane, Brian J. Quilliam, Wing Chow, Myoung Kim — 2011-03-24

Abstract: Objectives: To determine the extent to which pain is associated with well-being indices among nursing home residents.Design: Cross-sectional.Setting: A total of 185 for-profit nursing homes from 19 states.Participants: Participants were 9952 long-stay residents without cancer.Measurements: Minimum Data Set assessments on pain; analgesics; and cognitive, functional, and emotional status. Logistic regression models provided estimates of the association between persistent/intensified pain and intermittent pain on increases in depressed or anxious mood, reduced time involved in activities, resisting care, as well as verbal and physical aggression.Results: Twenty-five percent had pain documented on 2 consecutive assessments; these residents were more likely to have arthritis, an anxiety disorder, depression, or insomnia and less likely to have cognitive impairment than patients without pain. Residents with persistent pain were 79% as likely to experience mood impairments (adjusted odds ratio [AOR]: 1.79; 95% confidence interval [CI]: 1.61–1.99) and 90% as likely to have less than one-third of time involved with activities (AOR: 1.90; 95% CI: 1.32–2.75) relative to those without pain. Residents with intermittent pain were 30% as likely to experience mood impairments (AOR: 1.30; 95% CI: 1.18–1.45) and 55% as likely to have less than one-third of time involved with activities (AOR: 1.55; 95% CI: 1.08–2.23) relative to those without pain. No association was observed with resisting care or verbal or physical aggression.Conclusion: In nursing home residents, pain is highly prevalent and affects measures of well-being. Initiatives to recognize and appropriately treat pain may lead to increased measures of well-being.

Likelihood of Nursing Home Referral for Fecally Incontinent Elderly Patients is Influenced by Physician Views on Nursing Home Care and Outpatient Management of Fecal Incontinence

2011-03-14

Abstract: Objectives: (1) Characterize physicians’ management practices for fecal incontinence (FI) among elderly patients, (2) describe physician perceptions of the quality of care for FI provided in nursing homes (NH), and (3) identify physician views and attributes associated with referral of elderly patients with FI to an NH.Design: Cross-sectional.Setting: United States.Participants: Physician members of the American Geriatrics Society.Measurements: Questionnaire pertaining to physician views on (1) their own FI management practices, (2) management of FI in NHs, and (3) referral of an elderly patient with FI to an NH.Results: Of the respondents (n = 606), 54.1% reported screening for FI and 59.3% thought FI could be managed conservatively on an outpatient basis. Only 32.9% believed NHs provide good care for FI, and 27.1% believed NH care conditions exacerbate FI. Responding to a hypothetical vignette, 10.6% would probably or definitely refer an older adult patient with only FI to an NH, and 17.2% were uncertain about whether or not to refer. Logistic regression analysis identified physician characteristics associated with decreased likelihood of NH referral as the belief that FI can be managed conservatively, the belief that NHs provide poor care for FI, longer practice experience, and practicing in an academic medical center.Conclusion: Most geriatricians believe FI can be managed conservatively and that NHs provide poor care for FI. These beliefs plus longer years of practice and practice in an academic setting decrease the likelihood of referral to NH for patients with FI.

Predictors of Avoidable Hospitalizations Among Assisted Living Residents

Marion Becker, Timothy Boaz, Ross Andel, Anne DeMuth — 2011-03-14

Abstract: Objectives: Hospitalizations for long term care residents, including those from assisted living facilities (ALFs), are very costly, often traumatic, and increase risk for iatrogenic disorders for those involved. Currently, hospital expenditures account for approximately one-third of total national health care spending. Hospitalizations for ambulatory care–sensitive (ACS) conditions are considered potentially avoidable, as these are physical health conditions that can often be treated safely at a lower level of care or occur as a result of lack of timely, adequate treatment at a lower level of care. The goal was to examine risk factors for hospitalization for an ACS condition of Medicaid-enrolled younger and older ALF residents during 2003–2008.Design: This is a retrospective cohort study that used 5 years of Medicaid enrollment and fee-for-service claims data.Participants: The study sample included 16,208 Medicaid-enrolled ALF residents in Florida, 7991 (49%) of whom were 65 years of age or older.Results: In total, study participants had 22,114 hospitalizations, 3759 (17%) of which were for an ACS condition. Sixteen percent of all ALF residents (n = 2587), about 12% of the younger residents and 20% of the older residents, had at least one ACS hospitalization. ACS hospitalizations constitute 13% of all hospitalizations for the younger residents and 22% of all hospitalizations for the older residents. Using Cox proportional hazard regression, we found that for both age groups, increased age, being Hispanic or of other race/ethnicity, and having comorbid physical health conditions were associated with a higher risk of ACS hospitalization. For older residents, having a dementia diagnosis and being African American reduced the risk of ACS hospitalization, whereas for younger residents having a major psychotic disorder reduced the risk of ACS hospitalization.Conclusion: The results highlight the need for increased education, communication, and future research on these predictive factors. The increased frequency of hospitalization for ACS conditions among ALF residents with minority status and older age may well indicate that their more complex health care needs are not being adequately addressed. The role of serious mental illness and dementia in risk for ACS hospitalization also deserves further attention.

“The Way We Do Things Around Here”: An International Comparison of Treatment Culture in Nursing Homes

2011-04-22

Abstract: Objectives: In this study, we sought to measure treatment culture (beliefs, values, and normative practices associated with medication prescribing and administration) in two samples of nursing homes (in Northern Ireland and New Zealand) and to document the range of scoring achieved by staff in both countries. Responses between nurse managers and registered nurses were also compared.Design: A cross-sectional study using an adapted treatment culture questionnaire was distributed by mail (in June and September 2008) to 159 nursing homes in Northern Ireland and completed by the nurse manager and registered nurses. In New Zealand, staff in 14 facilities participated and questionnaires were distributed by a research assistant who visited the homes (March to November 2008).Measurements: Completed questionnaires were scored using a prespecified scoring system, with a higher score indicating a more resident-centered treatment culture and a lower score indicating a more traditional approach to care. The maximum score possible was 75. Scores were compared between countries and between different categories of staff. Views were also sought and knowledge tested (from structured questions) on the use of psychotropic prescribing in the nursing home environment.Results: The response rates for nurse managers and nurses in Northern Ireland were 35.5% and 10.1%, respectively; in New Zealand, the response rate was 90.9% for managers and 71% for nurses. The mean score for the Northern Ireland and New Zealand homes was 39.5 and 39.1, respectively (P > .05). There were also no differences between scores achieved by nurse managers and registered nurses between and across both countries. There were some cross-country differences on the approach to challenging behavior in residents and nurses (in both countries) were more likely than nurse managers to report (incorrectly) that haloperidol is indicated for short-term insomnia.Conclusion: This quantitative assessment has raised interesting issues in relation to the measurement of treatment culture in the nursing home setting in two countries. Further insights into the importance of treatment culture will be pursued in qualitative studies.

A Family Booklet About Comfort Care in Advanced Dementia: Three-Country Evaluation

2011-03-21

Abstract: Objectives: To evaluate a booklet on comfort care in dementia from the perspective of family with relevant experience, and assess nursing home resident and family factors associated with evaluations.Design: Retrospective study.Setting: Long term care facilities in French-speaking Canada, and the Netherlands and Italy.Participants: Bereaved family (n = 138).Measurements: An 8-item scale assessed the booklet’s acceptability. Usefulness was rated on a 0 to 10 scale, and perceived usefulness referred to usefulness if family had had the booklet during the resident’s stay. Families indicated preferred ways of obtaining, and the most appropriate time to get the booklet.Results: Almost all families (94%) perceived the booklet as useful. Canadian and Dutch families evaluated the booklet’s contents and format favorably, whereas Italian families’ evaluations were less favorable. Almost all families endorsed roles for physicians or nurses and about half additionally accepted availability through own initiative, in print or through the Internet. Preference of timing was highly variable. Better acceptability, usefulness, and availability through own initiative were independently associated with non-Italian nationality, presence of more physical signs discussed in the booklet, feeling ill-prepared, and higher satisfaction with care. A preference of receiving the booklet early was more likely in Italian families, those without university education, and those involved with older residents.Conclusion: The booklet is suitable to inform Dutch and Canadian families on comfort care in dementia, but implementation in Italy requires further consideration. The booklet may be integrated in advance care planning in long term care, and made available outside long term care settings to serve families who wish to be informed early.

Mortality Following Nursing Home–Acquired Lower Respiratory Infection: LRI Severity, Antibiotic Treatment, and Water Intake

2011-04-25

Abstract: Objective: In some nursing home populations, antibiotic treatment may not reduce mortality following lower respiratory infection (LRI). To better inform treatment decisions, we determined influences on mortality following LRI among antibiotic-treated and non–antibiotic-treated residents in 2 populations.Design: Observational, prospective, cohort studies.Setting: Ninety-seven nursing homes (36 US, 61 Netherlands).Participants: Residents (1044 US, 513 Netherlands) who met a standardized study definition for LRI.Measurements: Demographics, symptoms and physical findings of LRI, functional status, major illness diagnoses, dementia status, treatments, and date of death within 6 months after diagnosis.Methods: We estimated a 2-period (0–14/15–90 days) weighted proportional hazards model of mortality for antibiotic-treated (n = 1280) and non–antibiotic-treated (n = 277) residents; both weights and regressors provide “doubly robust” risk adjustment—for LRI (illness) severity using a prognostic score and for nonrandom receipt of antibiotic treatment using a propensity score.Results: In both the United States and the Netherlands, 14-day mortality was associated with three factors—LRI severity, water intake at diagnosis, and antibiotic use (not directly by severe dementia)—that accounted for 82% or, sequentially, 39%, 42%, and 1% of the cross-national mortality difference. The LRI Severity Score (based only on at-diagnosis eating dependency, pulse rate, decreased alertness, and breathing difficulty, with adequate discrimination [c ≥ 0.74] and calibration, and cross-indexed to commonly used LRI mortality measures) was related to mortality through 90 days, regardless of treatment. With sufficient water intake at diagnosis, 14-day mortality was unrelated to not receiving antibiotic treatment (adjusted hazard ratio [AHR], 1.20; 95% confidence interval, 0.70–2.04); insufficient water intake was related to increased 14-day mortality with antibiotics (AHR, 1.90; 1.38–2.60) or without (AHR, 7.12; 4.83–10.5). After 14 days, relative mortality worsened for antibiotic-treated residents with insufficient water intake. Inadequate water intake was related to increased eating dependence at onset of the LRI (OR, 4.2; 3.0–5.8).Conclusion: LRI severity, water intake, and antibiotic use explain mortality in both studies and reconcile cross-study Dutch/US 14-day mortality differences. LRI severity, derived at 14 days, is related to mortality through 90 days, regardless of treatment, and is key to risk adjustment. With adequate hydration, the survival benefit from antibiotic use is nonsignificant. Conversely, hydration, even without antibiotic treatment, appears central to curative treatment. In LRI guidelines, treatment, and research, the relative benefits of antibiotics and hydration for curative treatment should be addressed.

Which Score Most Likely Represents Pain on the Observational PAINAD Pain Scale for Patients with Dementia?

Sandra M.G. Zwakhalen, Jenny T. van der Steen, M.D. Najim — 2011-06-06

Abstract: Objectives: We sought to determine a cutoff score for the observational Pain Assessment in Advanced Dementia (PAINAD), to adequately assess pain in clinical nursing home practice and research.Design and Setting: We used data from multiple sources. We performed a literature review on PAINAD, performed secondary data analysis of a study examining psychometric properties of PAINAD in nursing home patients with dementia, and performed another study in nursing home patients with dementia specifically aimed at determining a cutoff score for PAINAD.Participants: Patients with dementia in long term care facilities.Measurements: We related PAINAD scores (range 0 to 10) to (1) self-reported and proxy-reported pain by global clinical judgment and (2) scores on another pain assessment instrument (DOLOPLUS-2), and (3) we compared scores between painful and supposedly less painful conditions.Results: Findings from this study showed that a cutoff value of 2 should serve as a trigger for a trial with pain treatment. Although the majority of patients scoring 1 or 0 were not in pain, pain could be ruled out.Conclusion: Based on the findings of multiple available data sources, we recommend that a PAINAD score of 2 or more can be used as an indicator of probable pain. A score of 1 is a sign to be attentive to possible pain. Future work may focus on cutoff scores for the presence of pain and severe pain in other frequently used pain tools, and on further development of methodology to assess cutoff scores.

The Role of Cognitive Impairment in the Use of the Diskus Inhaler

Malcolm Fraser, Meenakshi Patel, Edward Paul Norkus, Cyndi Whittington — 2011-05-30

Abstract: Background and Purpose: Drugs delivered by metered-dose inhalers and dry powder inhalers (DPIs) are a mainstay in the treatment of chronic lung disease; however, previous studies suggest cognitive impairment hinders proper use of inhalers. The purpose of this study was to determine the relationship between the score on the Mini-Mental State Exam (MMSE) and the ability of nursing facility residents to complete the steps required for proper use of a multiunit-dose DPI (Diskus).Methods: Nursing facility residents who had never used a multiunit-dose DPI (Diskus), who scored between 10 and 24 inclusive on the MMSE, and who were able to hold a breath for 10 seconds were recruited for an observational study to test their ability to use a placebo-loaded Diskus when supervised and assisted by personnel trained in the proper use the Diskus. Ability to use the DPI was assessed by the Diskus Evaluation Rating Scale (DERS), an instrument developed specifically for this study. Possible scores on the DERS ranged from 0 to 19, with a score of 0 indicating no limitations in any of the steps involved in using the Diskus and 19 indicating inability to do any of the steps after 3 supervised attempts.Results: Forty Diskus-naïve nursing facility residents (86 ± 9 years of age; 32 women) with MMSE scores between 10 and 24 inclusive and the ability to hold a breath for 10 seconds were enrolled in the study. Mean MMSE scores were 17.4 ± 4.2, whereas the mean score on the DERS was 5.1 ± 3.2 (range 1–16). After controlling for age, gender, and education, a significant inverse relationship was noted between scores on the MMSE and the DERS such that for every 1-point increase on the MMSE, the subject's DERS score decreased by 0.345 points (P = .003). Overall, 38 of the 40 subjects with MMSE scores between 10 and 24 inclusive were able to use the Diskus successfully.Conclusion: For MMSE scores, the better the performance on the MMSE, the better the performance on the DERS. More important, 95% of the subjects in this study could use the Diskus successfully when properly supervised. In contrast to earlier studies, these findings suggest that a multiunit-dose DPI can be prescribed as one component of the regimen for chronic lung disease in patients with substantial cognitive impairment.

Family Caregiving in Advanced Chronic Organ Failure

Daisy J.A. Janssen, Martijn A. Spruit, Emiel F.M. Wouters, Jos M.G.A. Schols — 2011-05-30

Abstract: Objectives: To assess caregiver burden as well as positive aspects of family caregiving in advanced chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), and chronic renal failure (CRF).Design: Cross-sectional observational study.Setting: Patients recruited at the outpatient clinics of academic and general hospitals in the Netherlands.Participants: Patients with advanced COPD (n = 73), CHF (n = 45), and CRF (n = 41) and their family caregivers.Measurements: Caregiver burden and positive aspects of caregiving were assessed using the Family Appraisal of Caregiving Questionnaire for Palliative Care and were compared among family caregivers of patients with COPD, CHF, or CRF using linear regression analysis while controlling for characteristics of patients and family caregivers.Results: Most family caregivers were female partners of participating patients. Caregiver distress and caregiver strain scores were relatively low, whereas scores for positive caregiving appraisals and family well-being were relatively positive. Caregiver strain, positive caregiving appraisals, and family well-being were comparable for family caregivers of patients with COPD, CHF, or CRF. Caregiver distress was higher for family caregivers of patients with COPD than CHF. The experience of caregiving was influenced by being the patient's spouse, patient's psychological symptoms, and the presence of comorbidities.Conclusions: Family caregiving for patients with COPD, CHF, or CRF should not only be seen as a burden, but also as a positive experience. To support family caregivers, attention should be paid to caregiver burden and the positive aspects of family caregiving.

What Are the Barriers to Performing Nonpharmacological Interventions for Behavioral Symptoms in the Nursing Home?

Jiska Cohen-Mansfield, Khin Thein, Marcia S. Marx, Maha Dakheel-Ali — 2011-08-29

Abstract: Objective: Behavioral symptoms are common in persons with dementia, and nonpharmacological interventions are recommended as the first line of therapy. We describe barriers to conducting nonpharmacological interventions for behavioral symptoms.Design: A descriptive study of barriers to intervention delivery in a controlled trial.Settings: The study was conducted in six nursing homes in Maryland.Participants: Participants were 89 agitated nursing home residents with dementia.Intervention: Personalized interventions were developed using the Treatment Routes for Exploring Agitation decision tree protocol. Trained research assistants prepared and delivered the interventions. Feasibility of the interventions was determined.Measurements: Barriers to Intervention Delivery Assessment, activities of daily living, cognitive functioning, depressed affect, pain, observed agitation, and observed affect.Results: Barriers were observed for the categories of resident barriers (specifically, unwillingness to participate; resident attributes, such as unresponsive), barriers related to resident unavailability (resident asleep or eating), and external barriers (staff-related barriers, family-related barriers, environmental barriers, and system process variables). Interventions pertaining to food/drink and to 1-on-1 socializing were found to have the fewest barriers, whereas higher numbers of barriers occurred with puzzles/board games and arts and crafts activities. Moreover, when successful interventions were presented to participants after the feasibility period, we noted fewer barriers, presumably because barrier identification had been used to better tailor interventions to each participant and to the environment.Conclusion: Knowledge of barriers provides a tool by which to tailor interventions so as to anticipate or circumvent barriers, thereby maximizing intervention delivery.

Interdisciplinary Geriatric and Psychiatric Care Reduces Potentially Inappropriate Prescribing in the Hospital: Interventional Study in 150 Acutely Ill Elderly Patients with Mental and Somatic Comorbid Conditions

2011-05-19

Abstract: Background: Potentially inappropriate medications and prescription omissions (PO) are highly prevalent in older patients with mental comorbidities.Objective: To evaluate the effect of interdisciplinary geriatric and psychiatric care on the appropriateness of prescribing.Design: Prospective and interventional study.Setting: Medical-psychiatric unit in an academic geriatric department.Participants: Participants were 150 consecutive acutely ill patients aged on average 80.0 ± 8.1 years suffering from mental comorbidities and hospitalized for any acute somatic condition.Intervention: From admission to discharge, daily collaboration provided by senior geriatrician and psychiatrist working in a usual geriatric interdisciplinary care team.Measurements: Potentially inappropriate medications and PO were detected and recorded by a trained independent investigator using STOPP/START criteria at admission and discharge.Results: Compared with admission, the intervention reduced the total number of medications prescribed at discharge from 1347 to 790 (P < .0001) and incidence rates for potentially inappropriate medications and PO reduced from 77% to 19% (P < .0001) and from 65% to 11% (P < .0001), respectively. Independent predictive factors for PIP at discharge were being a faller (odds ratio [OR] 1.85; 95% confidence interval [CI] 1.43–2.09) and for PO, the increased number of medications (OR 1.54; 95% CI 1.13–1.89) and a Charlson comorbidity index greater than 2 (OR 1.85; 95% CI 1.38 – 2.13). Dementia and/or presence of psychiatric comorbidities were predictive factors for both potentially inappropriate medications and PO at discharge.Conclusion: These findings hold substantial promise for the prevention of IP and OP in such a comorbid and polymedicated population. Further evaluations are, however, still needed to determine if such an intervention reduces potentially inappropriate prescribing medication-related outcomes, such as incidence of adverse drug events, rehospitalization, or mortality.

Current Dilemmas of Nursing Homes in Chengdu: A Cross-Sectional Survey

Qiukui Hao, Shiying Wu, Li Ying, Li Luo, Dingwen Dong, Birong Dong — 2011-10-05

Abstract: Objectives: Chengdu, China, is facing challenges from the growth of the elderly population. There are nursing homes in Chengdu, but there is no study on the current status of these nursing homes and their residents. The present study was conducted to investigate the current situation of nursing homes in Chengdu.Design, Setting, and Participants: This cross-sectional study randomly selected 10 nursing agencies from the 110 agencies in Chengdu (5 main zones and districts) using a cluster random sampling method. Descriptive statistics were used to analyze the data.Results: Ten agencies (10%) were surveyed: 5 government-run social welfare, 2 collective run, and 3 private institutions. The basic service in the nursing home includes personal care, basic medical care, room cleaning, meals, and laundry. Standard setting, assessment, rehabilitation therapy, and some equipment and volunteer service monitoring are inadequate. Most care staff receive little training in elder care. Some have no qualified certification and they have low income, heavy work, and insufficient knowledge. The whole team has a high mobility.Conclusions: Nursing homes in Chengdu are at a lower level than those in developed countries.

Antidepressant Prescribing Patterns in the Nursing Home: Second-Generation Issues Revisited

Shruti Shah, Ben Schoenbachler, Joel Streim, Suzanne Meeks — 2011-10-31

Abstract: Introduction: The object of this study was to provide an updated evaluation of the quality of antidepressant management and prescribing patterns in nursing homes in the context of organizational and resident factors.Design: Pearson correlation and chi-square analyses were conducted using information gathered from random nursing home charts.Setting: Nursing home facilities in and around the Louisville, KY, metropolitan area (n = 10).Participants: Chart reviews were randomly chosen for 20% of long term care resident records in participating homes (n = 209).Measurements: Demographic information, documentation of depression diagnoses, and antidepressant prescribing patterns were evaluated using the Quality of Depression Management and Antidepressant Prescribing rating scale and information found in the Minimum Data Set 2.0.Results: Of the sample, 59.8% was prescribed antidepressants at the time of the chart review; 205 chart reviews indicated the absence or presence of a depression diagnosis. For those with documented depression diagnoses (n = 126), nearly one-quarter were not prescribed antidepressants. Of 79 chart reviews indicating no depression diagnosis, nearly a third were receiving an antidepressant. Documentation related to changes in dosing, the presence or absence of side effects, or reasons for continuation were suboptimal.Conclusion: Discrepancy between antidepressant prescribing and the presence/absence of depression diagnoses continue to exist for nursing home residents. The quality of antidepressant documentation in nursing home charts continues to be inadequate. Future research should aim to explore possible solutions to these discrepancies and deficiencies in documentation.

Prognosis of an Abnormal One-Leg Balance in Community-Dwelling Patients With Alzheimer’s Disease: A 2-Year Prospective Study in 686 Patients of the REAL.FR Study

2012-01-09

Abstract: Objectives: The aim of this study was to explore the predictive value of an abnormal one-leg balance (OLB) test for functional decline, nursing home admission, and mortality in community-dwelling patients affected with Alzheimer’s disease (AD).Design: A 2-year prospective, observational cohort study.Setting: Nineteen memory centers across France.Participants: A total of 686 community-dwelling patients with AD.Measurements: Mini-mental state examination, Activity of Daily Living scale, and balance (ability to stand unassisted for 5 seconds on 1 leg) were reported every 6 months. Functional decline was defined as a loss of 0.5 or more points at a 5-point Activity of Daily Living score (bathing, dressing, toileting, continence, and feeding). Nursing home admission and mortality were recorded. Neuropsychiatric symptoms, medication, and caregiver’s burden were assessed every 6 months. Time-to-event analyses were used.Results: At baseline, 632 patients with AD had a balance measurement (mean age = 77.8 years, SD = 6.9; 72.2% were women) and 15.2% had an abnormal OLB test: these patients were older, had lower mini-mental state examination and Activity of Daily Living scores, and more neuropsychiatric symptoms, osteoarthritis, comorbidities and medications (all P < .05). After adjustment for age and sex, the risk of functional decline (hazard ratio [HR]: 1.69; 95% confidence interval [CI], 1.26–2.26), nursing home admission (HR: 2.51; 95% CI, 1.69–3.73), and death (HR: 2.42; 95% CI, 1.43–4.11) was higher in patients with an abnormal OLB. After adjustment for other potential confounders, the presence of an abnormal OLB was significantly associated only with nursing home admission (HR: 1.73, 95% CI, 1.09–2.75).Conclusion: In the present study, an abnormal OLB predicts nursing home admission in patients with AD. Although statistically significant when solely adjusted for age and sex, an abnormal OLB test failed to predict functional decline and mortality when adjusted for multiple confounders.

Psychotropic Drug Consumption at Admission and Discharge of Nursing Home Residents

2012-01-24

Abstract: Objectives: To quantify transitions of residents into or out of nursing homes (NHs) and to describe psychotropic drug prescription at admission and discharge and with regard to dementia diagnosis.Design: A descriptive, cross-sectional, noninterventional study.Setting: The setting included 300 NH in France.Participants: Participants included 2231 NH residents.Measurements: Participants reported the number, origin, and destination of residents transiting into or out of the NH in the previous 3 months and provided information on NH characteristics. For eight residents admitted or discharged by the NH, information was collected on medical characteristics, including psychotropic and antidementia drug prescription, and dementia status.Results: The mean number of beds in participating NHs was 85.9 ± 33.2 (mean occupation rate = 96.6%). The mean number of admissions and discharges in the previous 3 months was 13.7 ± 8.5 and 11.2 ± 4.3, respectively. Most admissions (direct admission 3.2 ± 3.3 or readmission 6.4 ± 6.0) and discharges (4.4 ± 6.7) were from and to the hospital. Of the 2231 residents included, 1005 (45.0%) were diagnosed with dementia. At least one psychotropic drug (antidepressant, hypnotic, antipsychotic, or anxiolytic) was prescribed to 70.7% of residents and in particular an antipsychotic to 19.1% of residents. Psychotropic drugs, and in particular antipsychotic drugs, were significantly more prescribed to demented residents than to nondemented residents (76.2% vs 64.3% and 28.0% vs 11.8%, respectively). The extent of prescription (at least one psychotropic drug) was similar in residents admitted to (70.2%) and discharged from (67.5%) the NHs. Antidementia drugs (acetylcholinesterase inhibitors or NMDA receptor antagonists) were prescribed to 53.7% of demented residents.Conclusion: Movement of residents into and out of NHs and especially from and to the hospital is extensive and the prescription rate for psychotropic drugs is very high in this population, especially in residents with dementia. Multiple groups of health care providers should be targeted by educational measures to improve the quality of care for NH residents.

Editorial Board

2012-05-01

Author Guidelines

2012-05-01

General Information

2012-05-01

Directions & Connections

2012-05-01

JAMDA

Physical Restraints: Abusive and Harmful

On Assisted Living, Are We Hitting the Mark or Missing the Boat?

Pain—“God’s Megaphone”

Mobility in Elderly People With a Lower Limb Amputation: A Systematic Review

A Review of the Effectiveness of Antidepressant Medications for Depressed Nursing Home Residents

Nursing Home Revenue Source and Information Availability During the Emergency Department Evaluation of Nursing Home Residents

Factors Associated With Potentially Preventable Hospitalization Among Nursing Home Residents in New York State With Chronic Kidney Disease

The Association Between Pain and Measures of Well-Being Among Nursing Home Residents

Likelihood of Nursing Home Referral for Fecally Incontinent Elderly Patients is Influenced by Physician Views on Nursing Home Care and Outpatient Management of Fecal Incontinence

Predictors of Avoidable Hospitalizations Among Assisted Living Residents

“The Way We Do Things Around Here”: An International Comparison of Treatment Culture in Nursing Homes

A Family Booklet About Comfort Care in Advanced Dementia: Three-Country Evaluation

Mortality Following Nursing Home–Acquired Lower Respiratory Infection: LRI Severity, Antibiotic Treatment, and Water Intake

Which Score Most Likely Represents Pain on the Observational PAINAD Pain Scale for Patients with Dementia?

The Role of Cognitive Impairment in the Use of the Diskus Inhaler

Family Caregiving in Advanced Chronic Organ Failure

What Are the Barriers to Performing Nonpharmacological Interventions for Behavioral Symptoms in the Nursing Home?

Interdisciplinary Geriatric and Psychiatric Care Reduces Potentially Inappropriate Prescribing in the Hospital: Interventional Study in 150 Acutely Ill Elderly Patients with Mental and Somatic Comorbid Conditions

Current Dilemmas of Nursing Homes in Chengdu: A Cross-Sectional Survey

Antidepressant Prescribing Patterns in the Nursing Home: Second-Generation Issues Revisited

Prognosis of an Abnormal One-Leg Balance in Community-Dwelling Patients With Alzheimer’s Disease: A 2-Year Prospective Study in 686 Patients of the REAL.FR Study

Psychotropic Drug Consumption at Admission and Discharge of Nursing Home Residents

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