JAMDA

Increasing Awareness of the Factors Producing Falls: The Mini Falls Assessment

John E. Morley, Yves Rolland, Debbie Tolson, Bruno Vellas — 2011-12-15

Falls represent one of the most common harmful occurrences in nursing homes, and injurious falls account for approximately 60% of all liability cases filed against nursing homes. Persons in nursing homes fall three times more frequently than persons living in the community. There are approximately 1.7 (0.6–3.6) falls per nursing home bed per year. Falls are the major cause of hip fractures, head trauma, lacerations, other fractures, and soft tissue injuries. As we age, falls are inevitable; therefore, our goals are to decrease the number of falls and prevent injuries where possible. Among nursing home residents, rates of hip fracture can be as high as 6.2% in women and 4.9% in men. The cost of falls in the United States is estimated to be $40 billion by 2020. Although single intervention programs have minor effects on falls, the Cochrane review has found that multifactorial interventions successfully reduce falls. Despite this, certified nursing aides believe that falls are not preventable.

Incentivizing Nursing Home Quality and Physician Performance

Arif Nazir, Greg Arling, Paul R. Katz — 2011-05-30

Nursing homes (NHs) are under increasing pressure to accurately gauge and improve the quality of care they provide to their residents. Higher patient acuity, demand from consumers and policy-makers, and media reports of inadequate care are providing the impetus for change. In response to these pressures, researchers are devising more appropriate indicators of quality, states are creating innovative financial models to reward the delivery of higher quality care, and the American Medical Directors Association (AMDA) is developing strategies to better gauge the performance of NH physicians and medical directors. The interplay of these factors not only has provided new opportunities to impact approaches to quality measurement in the NH but also has rejuvenated interest in measuring the impact of physician performance on NH quality. In this article, we highlight the efforts of one state that is in process of implementing an incentivized model for high-quality care that includes physician certification in the model. We end by offering potential solutions to enhancing physician involvement in NH affairs and weaving physician performance into these evolving models.

The Specificity of Geriatric Rehabilitation: Myth or Reality? A Debate from an Italian Perspective

Giuseppe Bellelli, Bruno Bernardini, Marco Trabucchi — 2011-08-22

Despite increasing evidence about its effectiveness, the specificity of geriatric rehabilitation too often remains an elusive question. In fact, the term “geriatric rehabilitation” is used to target a specific population (ie, older patients) rather than a specific approach. Recently in our country, a government guideline failed to indicate specific directions in this field, with negative consequences on the practice of old citizens’ rehabilitation. In this historical period in Italy, the rehabilitation of old persons lacks a scientific background to be followed by different services. In these conditions, because of the limited availability of economic resources and high demand for services with a proven cost-effectiveness, geriatric rehabilitation is at high risk of being overshadowed unless its proper value can be demonstrated.

Geriatric Conditions and Adverse Drug Reactions in Elderly Hospitalized Patients

2011-05-30

Abstract: Objectives: To investigate the relationship between clinical conditions typically observed in the geriatric patients (geriatric conditions) and adverse drug reactions in older patients admitted to acute care hospitals.Design and Setting: Prospective observational study conducted in 11 acute care medical wards throughout Italy.Participants: Five hundred six patients aged 65 years or older consecutively admitted to participating wards.Measurements: The outcome of the study was the occurrence of any adverse drug reactions during the hospital stay. Geriatric conditions considered in the analysis were basic activities of daily living, history of falls, slow walking speed, malnutrition, dementia, depression, 1 or more unplanned admissions in the previous 3 months, history of stroke, unintentional weight loss, and exhaustion. The relationship between risk factors and outcomes was assessed using logistic regression.Results: Female gender (odds ratio [OR] 2.29; 95% confidence interval [CI] 1.18–4.45) and number of medications taken during hospitalization (OR 1.12; 95% CI 1.06–1.18), but not individual Geriatric conditions, were associated with the outcome after correction for potential confounders. However, the simultaneous presence of history of falls and dependency in at least 1 activities of daily living (OR 2.18; 95% CI 1.13–4.19) was associated with adverse drug reactions during stay.Conclusion: The simultaneous presence of history of falls and dependency in at least one activity of daily living defines a condition of particular vulnerability of elderly hospitalized patients to adverse drug reactions. Physicians should be aware of this high-risk condition when prescribing new drugs to disabled older people.

Light Therapy for Seniors in Long Term Care

2011-06-17

Abstract: Objectives: To investigate the effects of light therapy on cognition, depression, sleep, and circadian rhythms in a general, nonselected population of seniors living in a long term care facility.Design: A double-blind, placebo-controlled trial.Setting: The experiment took place at a long term care facility in Pennsylvania.Participants: Study participants (15 treatment, 13 placebo) were residents receiving either personal care or skilled nursing care.Intervention: Treatment consisted of approximately 400 lux of blue light administered for 30 minutes per day, Monday through Friday, for 4 weeks. The placebo was approximately 75 lux of red light generated from the same device.Measurements: Behavioral assessments were made using the MicroCog Assessment of Cognitive Functioning, Geriatric Depression Scale, and Profile of Mood States. Daytime sleepiness was evaluated using the Epworth Sleepiness Scale.Results: Three of the 4 composite scores from the MicroCog as well as the mean Tension/Anxiety score from the Profile of Mood States showed a significant treatment versus placebo effect.Conclusion: Blue light treatment led to significant cognitive improvements compared with placebo red light and may be a promising environmental intervention to reduce cognitive symptoms in elderly, long-term care residents.

The Use of Data for Process and Quality Improvement in Long Term Care and Home Care: A Systematic Review of the Literature

2011-02-18

Abstract: Background: Standardized resident or client assessments, including the Resident Assessment Instrument (RAI), have been available in long term care and home care settings (continuing care sector) in many jurisdictions for a number of years. Although using these data can make quality improvement activities more efficient and less costly, there has not been a review of the literature reporting quality improvement interventions using standardized data.Objectives: To address 2 questions: (1) How have RAI and other standardized data been used in process or quality improvement activities in the continuing care sector? and (2) Has the use of RAI and similar data resulted in improvements to resident or other outcomes?Data Sources: Searches using a combination of keyword and controlled vocabulary term searches were conducted in MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, the Cochrane Library, and PsychINFO.Eligibility Criteria, Participants, and Interventions: English language publications from database inception to October 2008 were included. Eligibility criteria included the following: (1) set in continuing care (long-term care facility or home care), (2) involved some form of intervention designed to improve quality or process of care, and (3) used standardized data in the quality or process improvement intervention.Study Appraisal and Synthesis Methods: After reviewing the articles, we grouped the studies according to the type of intervention used to initiate process improvement. Four different intervention types were identified. We organized the results and discussion by these 4 intervention types.Results: Key word searches identified 713 articles, of which we excluded 639 on abstract review because they did not meet inclusion criteria. A further 50 articles were excluded on full-text review, leaving a total of 24 articles. Of the 24 studies, 10 used a defined process improvement model, 8 used a combination of interventions (multimodal), 5 implemented new guidelines or protocols, and 1 used an education intervention.Conclusions/Implications: The most frequently cited issues contributing to unsuccessful quality improvement interventions were lack of staff, high staff turnover, and limited time available to train staff in ways that would improve client care. Innovative strategies and supporting research are required to determine how to intervene successfully to improve quality in these settings characterized by low staffing levels and predominantly nonprofessional staff. Research on how to effectively enable practitioners to use data to improve quality of care, and ultimately quality of life, needs to be a priority.

Socially Assistive Robots in Elderly Care: A Systematic Review into Effects and Effectiveness

Roger Bemelmans, Gert Jan Gelderblom, Pieter Jonker, Luc de Witte — 2010-12-16

Abstract: The ongoing development of robotics on the one hand and, on the other hand, the foreseen relative growth in number of elderly individuals suffering from dementia, raises the question of which contribution robotics could have to rationalize and maintain, or even improve the quality of care.The objective of this review was to assess the published effects and effectiveness of robot interventions aiming at social assistance in elderly care.We searched, using Medical Subject Headings terms and free words, in the CINAHL, MEDLINE, Cochrane, BIOMED, PUBMED, PsycINFO, and EMBASE databases. Also the IEEE Digital Library was searched. No limitations were applied for the date of publication. Only articles written in English were taken into account. Collected publications went through a selection process. In the first step, publications were collected from major databases using a search query. In the second step, 3 reviewers independently selected publications on their title, using predefined selection criteria. In the third step, publications were judged based on their abstracts by the same reviewers, using the same selection criteria. In the fourth step, one reviewer made the final selection of publications based on complete content.Finally, 41 publications were included in the review, describing 17 studies involving 4 robot systems. Most studies reported positive effects of companion-type robots on (socio)psychological (eg, mood, loneliness, and social connections and communication) and physiological (eg, stress reduction) parameters. The methodological quality of the studies was, mostly, low.Although positive effects were reported, the scientific value of the evidence was limited. The positive results described, however, prompt further effectiveness research in this field.

Sarcopenia and Mortality among Older Nursing Home Residents

2011-08-22

Abstract: Background and Aims: Sarcopenia has been indicated as a reliable marker of frailty and poor prognosis among the oldest individuals. At present, no data are available on sarcopenia in the nursing home population. The aim of the current study was to explore the relationship between sarcopenia and all-cause mortality in a population of elderly persons aged 70 years and older living in a nursing home in Italy.Methods: This study was conducted among all subjects (n = 122) aged 70 years and older who lived in the teaching nursing home of Catholic University of Rome between August 1, 2010, and September 30, 2010. According to the European Working Group on Sarcopenia in Older People (EWGSOP), sarcopenia was diagnosed in presence of low muscle mass plus either low muscle strength or low physical performance. The primary outcome measure was survival after 6 months.Results: Forty residents (32.8%) were indentified as affected by sarcopenia. This condition was more common in men (68%) than in women (21%). During the follow-up period, 26 (21.3%) patients died. After adjusting for age, gender, cerebrovascular diseases, osteoarthritis, chronic obstructive pulmonary disease, activity of daily living impairment, and body mass index, residents with sarcopenia were more likely to die compared with those without sarcopenia (adjusted hazard ratio 2.34; 95% confidence interval 1.04–5.24).Conclusions: The present study suggests that among subjects living in a nursing home, sarcopenia is highly prevalent and is associated with a significantly increased risk of all-cause death. The current findings support the possibility that sarcopenia has an independent effect on survival among nursing home residents.

Can Standardized Sleep Questionnaires be Used to Identify Excessive Daytime Sleeping in Older Post-Acute Rehabilitation Patients?

2010-10-04

Abstract: Objectives: Excessive daytime sleeping is associated with poorer functional outcomes in rehabilitation populations and may be improved with targeted interventions. The purpose of this study was to test simple methods of screening for excessive daytime sleeping among older adults admitted for postacute rehabilitation.Design: Secondary analysis of data from 2 clinical samples.Setting: Two postacute rehabilitation (PAR) units in southern California.Participants: Two hundred twenty-six patients older than 65 years with Mini-Mental State Examination (MMSE) score higher than 11 undergoing rehabilitation.Measurements: The primary outcome was excessive daytime sleeping, defined as greater than 15% (1.8 hours) of daytime hours (8 am to 8 pm) sleeping as measured by actigraphy.Results: Participants spent, on average, 16.2% (SD 12.5%) of daytime hours sleeping as measured by actigraphy. Thirty-nine percent of participants had excessive daytime sleeping. The Pittsburgh Sleep Quality Index (PSQI) was significantly associated with actigraphically measured daytime sleeping (P = .0038), but the Epworth Sleepiness Scale (ESS) was not (P = .49). Neither the ESS nor the PSQI achieved sufficient sensitivity and specificity to be used as a screening tool for excessive daytime sleeping. Two additional models using items from these questionnaires were not significantly associated with the outcome.Conclusions: In an older PAR population, self-report items from existing sleep questionnaires do not identify excessive daytime sleeping. Therefore we recommend objective measures for the evaluation of excessive daytime sleeping as well as further research to identify new self-report items that may be more applicable in PAR populations.

Has the Prevalence of Disability Increased Over the Past Decade (2000–2007) in Elderly People? A Spanish Population-based Survey

2010-10-04

Abstract: Objectives: The main objectives of the current study were (1) to describe the prevalence of disability according to sociodemographic features, self-perceived health status, comorbidity, and lifestyle habits; (2) to determine factors associated with disability in men and women; and (3) to study the time trends prevalence of disability in the period 2000 to 2007.Methods: We analyzed data taken from the Spanish National Health Surveys conducted in 2001 (n = 21,058), 2003 (n = 21,650), and 2006 (n = 29,478). For the current study, we included answers from adults aged 65 years and older. The main variable was disability including basic activities of daily living (ADLs), instrumental ADLs (IADLs), and mobility disability. We stratified the adjusted models by the main variables. We analyzed sociodemographic characteristics, self-perceived health status, lifestyle habits, and comorbid conditions using multivariate logistic regression models.Results: The total number of individuals aged 65 years and older was 18,325 (11,346 women, 6,979 men). Women were significantly older than men in all the surveys (P < .001). Women showed higher prevalence of disability (ADL, IADL, and mobility) as compared with men in all surveys. Time trends in the total disability prevalence and whole age range showed a significant increase from 2000 to 2007 in both men and women (OR 1.13, 95% CI 1.1–1.7), particularly in individuals with older age. The variables significantly associated with a higher likelihood of reporting ADL and IADL disability were age older than 84, lower educational level, 2 or more comorbid chronic conditions, obesity (only in women), sleeping more than 8 hours per day, and not practicing physical exercise. Finally, variables that increased the probability of having mobility disability were age older than 84 years, lower educational level, 2 or more comorbid chronic conditions, and not practicing physical exercise. In addition, subjects with disability had a worse self-reported health status.Conclusions: The current study revealed an increase in disability from 2000 to 2007 in the older Spanish population. We found that age older than 84 years, lower education levels, obesity, not practicing physical activity and sleeping more than 8 hours per day were associated with higher disability. Individuals with disability reported a worse self-perceived health status and a greater number of comorbid conditions.

A Survey of Emergency Department Staff About Challenges and Recommendations for Emergency Department Care of Extended Care Facility Patients

2010-08-05

Abstract: Objectives: Extended care facility (ECF) patients who transfer to emergency departments (EDs) can pose problems when complicated health problems require extra resources. Higher numbers of older patients are projected to use EDs, so we aimed to identify problems now to implement solutions before they worsen in the future.Design: This was a prospective survey research study.Setting: ED in a safety net teaching hospital in the Midwest.Participants: ED personnel.Measurements: Confidential, anonymous survey collected views and opinions of ED personnel about problematic issues related to emergency care of ECF residents. The survey targeted communication problems, patient satisfaction concerns, difficult characteristics of patient population, need for education, need for research—and solicited open-ended remarks.Results: ED staff reported concern about flawed communication and poor documentation from the ECF. Based on job title, divergent viewpoints were reported about pharmacological challenges and comfort levels in managing older patients in the ED. Top training priorities were special needs of older adults, detecting abuse in older adults, and specific medical and psychosocial issues associated with older adults. Increased communication among all levels of geriatric care is recommended, especially from extended care facility staff before patient arrival at the ED.Conclusion: Because population projections predict an increasing trend of older adults, health care providers must think ahead and prepare for future medical needs. This survey was an inexpensive and effective way to identify next steps. We plan to use the survey results to initiate collaboration with ED staff, EMS providers, and ECF staff to identify specific actions to improve acute care for elderly patients—for the present and the future.

Chronic Kidney Disease Staging in Nursing Home and Community Older Adults: Does the Choice of Cockcroft-Gault, Modification of Diet in Renal Disease Study, or the Chronic Kidney Disease Epidemiology Collaboration Initiative Equations Matter?

T.S. Dharmarajan, Jinil Yoo, Robin O. Russell, Edward P. Norkus — 2010-12-23

Abstract: Objective: To compare the chronic kidney disease (CKD) stages derived from GFR estimates using 3 different formulae in a sample of older adults from the community and long term care settings.Participants: Data from 1535 older, hospitalized patients (2000–2008) were collected; individuals were hospitalized for acute illness unrelated to renal function.Measurements: Patient demographics, pertinent medical history, and routine laboratory test results were collected. Estimate of glomerular filtration rate and creatinine clearance values were determined by the Cockcroft-Gault, Modification of Diet in Renal Disease Study, and Chronic Kidney Disease Epidemiology Collaboration equations.Results: The Cockcroft-Gault equation generated significantly lower mean estimate of glomerular filtration rate values than either Modification of Diet in Renal Disease Study or Chronic Kidney Disease Epidemiology Collaboration equations in the total sample (P < .0005) and in a subset of patients diagnosed as renal insufficiency (P < .00005). Using the 3 formulae produced a significant disconnect in CKD staging resulting in the potential for different recommendations for monitoring and management across formulae (National Kidney Foundation Guidelines) (P < .0005). When stratified by age, the 3 equations produce nearly identical glomerular filtration rate estimates in patients younger than 70 years (P = .989) but significantly different glomerular filtration rate estimates in patients from 70 to 104 years (P < .0005).Conclusions: The Cockcroft-Gault equation systematically provides lower (more severe) estimates of renal function than the Modification of Diet in Renal Disease Study and Chronic Kidney Disease Epidemiology Collaboration equation in patients older than 70 years. However, significant differences in CKD staging derived from estimate of glomerular filtration rate or creatinine clearance were not observed in adults from 59 to 69 years of age. These findings do not validate one formula over the others, but demonstrate that disparities exist; it may be prudent to use the same formula over time in a given patient to monitor changes in renal function.

Antibiotics and Mortality in Patients with Lower Respiratory Infection and Advanced Dementia

2010-10-08

Abstract: Objectives: To describe long-term mortality rate and to assess associations between mortality rate and antibiotic treatment of lower respiratory infection in patients with advanced dementia; antibiotic treatment allocation was independent of mortality risk—leaving less room for biased associations than in previous multicenter observational studies.Design: Prospective study (2004–2009). Multilevel Cox proportional hazard analyses with adjustment for mortality risk were used to assess associations between antibiotics and mortality using time-dependent covariates.Setting: A US Department of Veterans Affairs nursing home.Participants: Ninety-four residents with advanced dementia who developed 109 episodes.Measurements: Survival, treatment, mortality risk, illness severity, fluid intake, and several other patient characteristics.Results: Ten-day mortality was 48%, and 6-month mortality was 74%. Antibiotics were used in 77% of episodes. Overall, antibiotics were not associated with mortality rate (Hazard Ratio [HR] 0.70, Confidence Interval [CI] 0.38–1.30); however, antibiotics were associated with reduced 10-day mortality rate (HR 0.51, CI, 0.30–0.87; rate after 10 days: 1.5, CI 0.42–5.2). Benefit from antibiotics was less likely with inadequate fluid intake, and when experiencing the first episode.Conclusion: In our sample of male nursing home residents with advanced dementia and lower respiratory infection, mortality was substantial despite antibiotic treatment. Antibiotics prolonged life but in many cases only for several days. Treatment decisions should take into account that antibiotics may delay death but may also prolong the dying process, indicating a need for accurate prediction of mortality and study of characteristics that may alter effectiveness of antibiotics.

Health Care Professionals’ Perceptions and Use of the Medical Orders for Scope of Treatment (MOST) Form in North Carolina Nursing Homes

Anthony J. Caprio, Victoria P. Rollins, Ellen Roberts — 2010-11-08

Abstract: Objectives: To characterize the self-reported practices and opinions of nursing home (NH) health care professionals using the North Carolina Medical Orders for Scope of Treatment (MOST) form, an adaptation of the Physician Orders for Life-Sustaining Treatment (POLST) paradigm.Design: A cross-sectional survey and semistructured interviews.Participants and Setting: Six physicians, 3 nurse practitioners, and 2 social workers from 2 NHs in North Carolina.Measurements: Survey items covered timing and appropriateness of form completion, review criteria, barriers, and concerns about using the form. Interviews clarified survey responses and elicited descriptions of how subjects explain the scope of medical interventions to patients/families.Results: NH admission and routine care plan meetings were considered the most important times to complete the MOST form. Treatment options on the form were often introduced in the context of patient preferences for hospitalization; however, there were considerable differences in how health care professionals explained and interpreted the scope of medical interventions. Nearly all health care professionals (10/11) believed that the form improves communication between physicians and patients/families. Only 3 of 11 respondents were aware of all of the MOST form’s review requirements. Time was the most commonly cited barrier to use of the form. Respondents were concerned about forms getting lost or not being honored outside of the NH.Conclusion: Health care professionals generally viewed the MOST form as a useful tool for communicating patient treatment preferences in the NH. However, they may need specific strategies for explaining and interpreting the scope of medical interventions section and for meeting the form’s review requirements.

Usage of Community Services and Domestic Helpers Predicted Institutionalization of Elders Having Functional or Cognitive Impairments: A 12-Month Longitudinal Study in Hong Kong

Pui Hing Chau, Jean Woo, Timothy Kwok, Felix Chan, Elsie Hui, Kam Che Chan — 2010-10-21

Abstract: Objectives: To estimate the 12-month institutionalization rate and to identify the associated predictors among functionally impaired elders with or without cognitive impairment.Methods: A cohort of Hong Kong community-dwelling elders aged 65 or older with functional and/or cognitive impairments was recruited and interviewed from 2007 to 2008. Twelve months after the baseline interview, the family caregivers or elders were interviewed to update the residence status of the elders. Logistic regressions were used to examine the association between institutionalization and the baseline variables.Results: Eighty elders (of 749 respondents) had been institutionalized within 12 months from baseline. The institutionalization rates were 6.2% (95% confidence interval (CI): 4.0%–8.5%) for elders with functional impairment only and 17.3% (95% CI: 13.0%–21.6%) for elders with both functional and cognitive impairments. Stepwise multiple logistic regressions found that more usage of community services was the single predictor to institutionalization in 1 year for the elders with functional impairment only. The risk was doubled (odd ratio = 2.166, 95% CI: 1.286–3.647) for usage in 1 more community service. For elders with both functional and cognitive impairments, the institutionalization risk was reduced by about 70% with employment of a domestic helper (odd ratio = 0.268, 95% CI: 0.120–0.598), despite increased risk being associated with advancing age of caregiver, caregiver being male, and deteriorating functional status of the elder.Conclusion: Among the functionally impaired elders, more usage of community services predicted increased institutionalization, whereas among the functionally and cognitively impaired elders, employment of a domestic helper predicted reduced institutionalization. Innovative services and care models are needed to prevent unnecessary institutionalization and to postpone premature institutionalization. Further research needs to be conducted to investigate the long term care needs of the elders from the perspective of both the elders and their caregivers.

Muslim Nursing Homes in the United States: Barriers and Prospects

Ziad Alfarah, Fadi H. Ramadan, Emily Cury, Gary H. Brandeis — 2011-09-05

Abstract: Historically, many nursing homes in the United States have been established by religious groups. This was done to provide care for the elderly when care could not be furnished in other venues.Despite several attempts reported in the literature, there are currently no Muslim nursing homes in the United States. In the Arab and Muslim world, the acceptance and success of such an institution has been somewhat variable. As the Arab Muslim population in the United States ages and becomes more frail, the Muslim community will have to evaluate the need to establish nursing homes to provide care for elderly.

Minimal Trauma Fractures: Lifting the Specter of Misconduct by Identifying Risk Factors and Planning for Prevention

Erin Hommel, Adline Ghazi, Heidi White — 2011-06-17

Abstract: Minimal trauma fractures are an unfortunate, yet not uncommon, event for frail elderly individuals in long term care facilities. These fractures result in significant morbidity including pain and loss of function along with significantly increased mortality. Further concern exists for the medico-legal issues raised after a minimal trauma fracture is discovered. The controversy at hand is whether such fractures are primarily the result of inadequate, careless, or abusive care practices. We build a case to the contrary. Although the data regarding this condition are limited, there exists a reasonable evidence base to identify an at-risk patient population. We present a representative case and subsequent literature review of minimal trauma fractures to illustrate the condition, including risk factors, mode of presentation, and patient outcomes. No direct research has been conducted on the pathophysiology of these fractures. Extrapolating from other similar conditions and likely associated comorbid illnesses, we explore possible physiologic explanations for their occurrence. Again, no direct investigation into prevention or treatment of minimal trauma fractures has been published. Instead, we consider a variety of pharmacologic and nonpharmacologic interventions that may modify the risk for minimal trauma fractures considering the previously identified risk factors and probable pathophysiologic changes leading to fracture development. We propose that reducing minimal trauma fractures in the frail elderly nursing home population will require careful staff education, close attention to identify at-risk patients, and implementation of select interventions aimed at preventing such fractures.

Epidemiology of Falls in Residential Aged Care: Analysis of More Than 70,000 Falls From Residents of Bavarian Nursing Homes

Kilian Rapp, Clemens Becker, Ian D. Cameron, Hans-Helmut König, Gisela Büchele — 2011-08-05

Abstract: Objective: Falls and fall-related injuries are leading problems in residential aged care facilities. The objective of this study was to provide descriptive data about falls in nursing homes.Design/Setting/Participants: Prospective recording of all falls over 1 year covering all residents from 528 nursing homes in Bavaria, Germany.Measurements: Falls were reported on a standardized form that included a facility identification code, date, time of the day, sex, age, degree of care need, location of the fall, and activity leading to the fall. Data detailing homes' bed capacities and occupancy levels were used to estimate total person-years under exposure and to calculate fall rates. All analyses were stratified by residents' degree of care need.Results: More than 70,000 falls were recorded during 42,843 person-years. The fall rate was higher in men than in women (2.18 and 1.49 falls per person-year, respectively). Fall risk differed by degree of care need with lower fall risks both in the least and highest care categories. About 75% of all falls occurred in the residents' rooms or in the bathrooms and only 22% were reported within the common areas. Transfers and walking were responsible for 41% and 36% of all falls respectively. Fall risk varied during the day. Most falls were observed between 10 am and midday and between 2 pm and 8 pm.Conclusion: The differing fall risk patterns in specific subgroups may help to target preventive measures.

Prevalence of Psychotropic Medication Use among German and Austrian Nursing Home Residents: A Comparison of 3 Cohorts

Tanja Richter, Eva Mann, Gabriele Meyer, Burkhard Haastert, Sascha Köpke — 2011-05-09

Abstract: Background: Despite increasing knowledge about the limited effectiveness and severe adverse effects, the prescription rate of psychotropic medications in frail elderly persons remains high. Prescriptions are mainly made to control behavioral and psychological symptoms of dementia, although factors associated with prescriptions are rarely reported. However, such information is a prerequisite to develop intervention programs aiming to safely reduce psychotropic medication in nursing home residents.Methods: We report the comparison of cross-sectional data of psychotropic medication prescription rates from 3 large studies including nursing home residents in Germany and Austria. We aimed to compare the prevalence of (1) psychotropic medication, (2) different classes of psychotropic medication, (3) psychotropic medication administered for bedtime use, and (4) associations between prescription of psychotropics and institutional and residents’ characteristics. Confidence intervals of prevalences and multiple logistic regression analyses were adjusted for cluster correlation.Results: Data from 5336 residents in 136 long term care facilities were included. In Austria, 74.6% (95% CI 72.0–77.2%) of all residents had a prescription of at least one psychotropic medication compared to Germany with about 51.8% (95% CI 48.3–55.2%) and 52.4% (95% CI 48.7–56.1%). Of all antipsychotics, 66% (Austria) and 47% (Germany) were prescribed for bedtime use. Most prescriptions were conventional, low-potency antipsychotics. In all 3 studies, there was no statistically significant association between psychotropic medication prescription and nursing home characteristics. On the level of residents, consistent positive associations were found for higher level of care dependency and permanent restlessness. Consistent negative associations were found for older age and male gender.Conclusion: Frequency of psychotropic and especially antipsychotic medication is substantial in nursing home residents in Germany and Austria. The high number of prescriptions is likely to be an indicator for a perceived or actual lack of strategies to handle behavioral and psychological symptoms of dementia.

Vision in the Global Evaluation of Older Individuals Hospitalized Following a Fall

Tanguy Boutin, Marie-Jeanne Kergoat, Judith Latour, Fadi Massoud, Hélène Kergoat — 2011-05-30

Abstract: Introduction: The objective of this study was to verify if vision is appropriately evaluated in older individuals admitted to a Geriatric Assessment Unit following a fall.Methods: A retrospective clinical chart review of 158 patients from 3 university-based Geriatric Assessment Units is presented. The clinical charts of patients admitted following a fall in the Geriatric Assessment Units of 3 Montreal hospitals, between April 2006 and 2008, were reviewed. Clinical charts from age- and sex-matched controls hospitalized in the Geriatric Assessment Units during the same period but without a history of fall or fracture, were also reviewed. Pertinent sociodemographic, medical, and visual characteristics were extracted from the charts and entered into a database for analysis.Results: The mean age ± standard deviation for the cases (n = 79) and controls (n = 79) were 82.3 ± 6.2 years and 81.7 ± 6.4 years, respectively. Most falls were not a result of accidents, but rather were more often related to underlying medical problems that were multifactorial in origin. More cases than controls were taking antiarrhythmic and antidepressant medications, whereas more controls were taking calcium channel blockers. Cases were more likely to have cataracts, age-related macular degeneration, and decreased visual acuity. Although cases were referred more often than controls for an eye examination, they were not referred in a systematic fashion.Discussion: Our results indicate that more visual problems are identified in persons who fall and, even if they are referred more often than controls for an eye examination, their vision is not evaluated systematically by an eye care specialist despite current clinical recommendations.Conclusion: These data indicate that eye care professionals should work more closely with the medical team to improve the overall clinical care of older individuals with a history of falls.

Associations Between Published Quality Ratings of Skilled Nursing Facilities and Outcomes of Medicare Beneficiaries with Heart Failure

2011-05-30

Abstract: Introduction: Nursing Home Compare quality ratings are designed to allow patients, families, and clinicians to compare facilities based on quality, but associations of the current measures with important clinical outcomes are not known. Our study examined associations between ratings and readmission and mortality among Medicare beneficiaries admitted to a skilled nursing facility with a primary diagnosis of heart failure.Methods: We conducted a retrospective cohort study of 164,672 Medicare beneficiaries discharged to skilled nursing facilities after hospitalization for heart failure in 2006–2007. The main outcome measures were readmission and mortality within 90 days.Results: One-fifth of the 13,619 skilled nursing facilities received a 1-star rating and 11% received a 5-star rating. Nearly half of the patients discharged to a skilled nursing facility were readmitted to a hospital within 90 days after discharge, and 30% died within 90 days. Compared with patients in 5-star skilled nursing facilities, patients in 1-star facilities had higher risks of 90-day readmission (hazard ratio, 1.08) and mortality (1.15). After adjustment for facility size and ownership type, the associations between the quality rating and readmission were not statistically significant, but the associations with mortality were significant.Conclusion: Publicly reported Nursing Home Compare quality ratings of Medicare-certified skilled nursing facilities were modestly associated with 90-day readmission and mortality among Medicare beneficiaries discharged to these facilities after hospitalization for heart failure.

Scope and Severity Index: A Metric for Quantifying Nursing Home Survey Deficiency Number, Scope, and Severity Adjusted for the State-Related Measurement Bias

Evgeniya Antonova, David Zimmerman — 2011-06-17

Abstract: Objectives: To develop a metric (scope and severity index [SSI]) to measure nursing home deficiency number, scope, and severity adjusted for the state-related bias and to test its convergent and predictive validity.Design: We assigned scope and severity weights to each level of scope and severity (A-L). SSI was calculated as a sum of all weights per survey which was further corrected for the state-level bias by dividing by the state average number of health deficiencies and multiplying by the national average number of health deficiencies. Data source - National Online Survey, Certification, and Reporting system.Setting: All Medicare/Medicaid-certified skilled nursing facilities.Measurements: We correlated SSI with nursing home staffing levels (convergent validity) and denial of payment for new admissions (predictive validity).Results: The expert panel reached agreement on the scope and severity weights: Level A = 5, B = 10, C = 15, D = 20, E = 30, F = 40, G = 35, H = 50, I = 65, J = 55, K = 75, and L = 100 points. Scope and severity per deficiency was positively correlated with the number of deficiencies in that survey. SSI contained almost no state-related bias, but yet related state-level variability. It demonstrated strong face, convergent, and predictive validity.Conclusions: SSI rendered a valuable metric to conduct quantitative analyses of nursing home deficiency number, scope, and severity across states. Future research should investigate the positive relationship between scope and severity of deficiencies and their number. Better understanding and correction of other factors introducing systematic bias to the survey results (e.g. regional impact) can further improve the accuracy of survey result evaluation.

Effectiveness of Intervention Programs In Preventing Falls: A Systematic Review of Recent 10 Years and Meta-Analysis

Myunghan Choi, Melvin Hector — 2011-06-16

Abstract: Objective: To examine the reported effectiveness of fall-prevention programs for older adults by reviewing randomized controlled trials from 2000 to 2009.Design: Systematic review and meta-analysis of randomized controlled trials.Data Sources: A systematic literature search of articles was conducted using 5 electronic databases (Medline, PubMed, PsycINFO, CINAHL, and RefWorks), including articles describing interventions designed to prevent falls, in English with full text availability, from 2000 through 2009.Review Methods: Of a potential 227 studies, we identified 17 randomized controlled trials with a duration of intervention of at least 5 months of follow-up. Inclusion and exclusion criteria were used to assess the methodological qualities of the studies. We excluded unidentified study design, quasi-experimental studies, and/or studies that were nonspecific regarding inclusion criteria.Data Extraction: Primary outcome measures were number of falls and fall rate. Methodological quality assessment included internal and external validity, reporting, and power. Data were extracted independently by 2 investigators and analyzed using a random-effects model. We analyzed the effectiveness of these fall intervention programs using their risk ratios (RR) in 2 single-intervention versus 15 multifactorial intervention trials, 3 nursing homes versus 14 community randomized controlled trials, and 8 Model 1 (initial intervention with subsequent follow up) versus 9 Model II (ongoing intervention throughout the follow-up) studies.Results: The combined RR for the number of falls among 17 studies was 0.855 (z = –2.168; p = .030; 95% CI = 0.742–0.985; Q = 196.204, df = 16, P = .000, I2 = 91.845), demonstrating that fall-prevention programs across the studies were effective by reducing fall rates by 14%, but with substantial heterogeneity. Subgroup analysis indicated that there was a significant fall reduction of 14% in multifactorial intervention (RR = 0.856, z = –2.039, P = .041) with no variation between multifactorial and single-intervention groups (Q = 0.002, P = .961), 55% in the nursing home setting (RR = 0.453, z = –9.366, P = .000) with significant variation between nursing home and community groups (Q = 62.788, P = .000), and no significant effect was gained by dividing studies into either in Model I or II. Sensitivity analysis found homogeneity (Q = 18.582, df = 12, P = .099, I2 = 35.423) across studies with a 9% overall fall reduction (RR = 0.906, 95% CI = 0.853–0.963, z = –3.179, P = .001), including a fall-reduction rate of 10% in multifactorial intervention (RR = 0.904, z = –3.036, P = .002), 9% in community (RR = 0.909, z = –3.179, P = .001), and 12% in Model I (RR = 0.876, z = –3.534, P = .000) with no variations among all the groups. Meta regression suggested that the model fit explained 68.6% of the relevant variance.Conclusions: The meta-sensitivity analysis indicates that randomized controlled trials of fall-prevention programs conducted within the past 10 years (2000–2009) are effective in overall reduction of fall rates of 9% with a reduction of fall rates of 10% in multifactorial interventions, 9% in community settings, and 12% in Model I interventions (initial intervention efforts and then subsequent follow-up).

Raloxifene and Tibolone in Elderly Women: A Randomized, Double-Blind, Double-Dummy, Placebo-Controlled Trial

Didy E. Jacobsen, René J.F. Melis, Harald J.J. Verhaar, Marcel G.M. Olde Rikkert — 2011-07-11

Abstract: Objectives: The authors’ first aim was to study the effects of raloxifene and tibolone on body mass density, handgrip strength, and other secondary frailty components. The secondary aim was to compare the effects of raloxifene and tibolone and their safety in older women.Design/Setting/Participants: A randomized, double-blind, double- dummy, placebo-controlled trial conducted in an academic hospital in the Netherlands among 318 community living women aged >70 were randomized; 290 received the allocated intervention: 97 placebo, 101 raloxifene, and 92 tibolone.Interventions: Randomization was made to raloxifene 60 mg, tibolone 1.25 mg, or placebo. Assessments were performed at baseline and after 3, 6, 12, and 24 months. The study was conducted from July 2003 to January 2008. The tibolone group stopped earlier in February 2006, because of results of the Long-Term Intervention on Fractures with Tibolone study, suggesting an increased risk of cerebrovascular accident.Measurements: Primary endpoints were body mass density and handgrip strength. Secondary endpoints were muscle power and strength, mobility measures, body composition, verbal memory, mental processing speed, anxiety, mood, and quality of life.Results: Tibolone and raloxifene had similar body mass density-effect sizes (d = .24–.47), and had no effect on handgrip muscle strength. For the 15 words test the effect on direct recall of concrete and abstract words (d = .40 and d =.27, respectively) and on delayed recall of concrete words (d = .77) were significantly higher in the raloxifene group compared to placebo and to tibolone. In the raloxifene group the health status (EuroQol VAS (0–100) was improved 2.4 points [95% CI 0.5–4.2; P = .012] over 24 months.Conclusion: In women >70 years old, raloxifene and tibolone significantly and similarly increased body mass density but not muscle strength. Raloxifene had also positive effects on verbal memory and health status. New research with selective estrogen receptor modulators like raloxifene might be promising on frailty endpoints in elderly women.Trial registration number: Nederlands Trial Register: 1232

The Influence of Hospice Use on Nursing Home and Hospital Use in Assisted Living Among Dual-Eligible Enrollees

Debra Dobbs, Hongdao Meng, Kathyrn Hyer, Ladi Volicer — 2011-07-18

Abstract: Objective: This study examined the impact of hospice enrollment on the probabilities of hospital and nursing home admissions among a sample of frail dual-eligible assisted living (AL) residents.Design: The study used a retrospective cohort design. We estimated bivariate probit models with 2 binary outcome variables: any hospital admissions and any nursing home admissions after assisted living enrollment.Setting: A total of 328 licensed AL communities accepting Medicaid waivers in Florida.Participants: We identified all newly admitted dual-eligible AL residents in Florida between January and June of 2003 who had complete state assessment data (n = 658) and followed them for 6 to 12 months.Measurements: Using the Andersen behavioral model, predisposing (age, gender, race), enabling (marital status, available caregiver, hospice use), and need (ADL/IADL, comorbidity conditions, and incontinence) characteristics were included as predictors of 2 binary outcomes (hospital and nursing home admission). Demographics, functional status, and caregiver availability were obtained from the state client assessment database. Data on diagnosis and hospital, nursing home, and hospice use were obtained from Medicare and Medicaid claims. Death dates were obtained from the state vital statistics death certificate data.Results: The mean age of the study sample was 81.5 years. Three-fourths were female and 63% were White. The average resident had a combined ADL/IADL dependency score of 11.49. Fifty-eight percent of the sample had dementia. During the average 8.9-month follow-up period, 6.8% were enrolled in hospice and 10.2% died. Approximately 33% of the sample had been admitted into a hospital and 20% had been admitted into a nursing home. Bivariate probit models simultaneously predicting the likelihood of hospital and nursing home admissions showed that hospice enrollment was associated with lower likelihood of hospital (OR = 0.24, P < .01) and nursing home admissions (OR = 0.56, P < .05). Significant predictors of hospital admissions included higher Charlson Comorbidity Index score and incontinence. Predictors of nursing home admissions included higher Charlson Comorbidity Index score, the absence of available informal caregiver, and incontinence.Conclusions: Hospice enrollment was associated with a lower likelihood of hospital and nursing home admissions, and, thus, may have allowed AL residents in need of palliative care to remain in the AL community. AL providers should support and facilitate hospice care among older frail dual-eligible AL residents. More research is needed to examine the impact of hospice care on resident quality of life and total health care expenditures among AL residents.

To Evacuate or Shelter in Place: Implications of Universal Hurricane Evacuation Policies on Nursing Home Residents

2011-09-01

Abstract: Objective: To examine the differential morbidity/mortality associated with evacuation versus sheltering in place for nursing home (NH) residents exposed to the 4 most recent Gulf hurricanes.Methods: Observational study using Medicare claims and NH data sources. We compared the differential mortality/morbidity for long-stay residents exposed to 4 recent hurricanes (Katrina, Rita, Gustav, and Ike) relative to those residing at the same NHs over the same time periods during the prior 2 nonhurricane years as a control. Using an instrumental variable analysis, we then evaluated the independent effect of evacuation on outcomes at 90 days.Results: Among 36,389 NH residents exposed to a storm, the 30- and 90-day mortality/hospitalization rates increased compared with nonhurricane control years. There were a cumulative total of 277 extra deaths and 872 extra hospitalizations at 30 days. At 90 days, 579 extra deaths and 544 extra hospitalizations were observed. Using the instrumental variable analysis, evacuation increased the probability of death at 90 days from 2.7% to 5.3% and hospitalization by 1.8% to 8.3%, independent of other factors.Conclusion: Among residents exposed to hurricanes, evacuation significantly exacerbated subsequent morbidity/mortality.

Psychosocial Assessment of Nursing Home Residents via MDS 3.0: Recommendations for Social Service Training, Staffing, and Roles in Interdisciplinary Care

2011-08-22

Abstract: The Minimum Data Set 3.0 has introduced a higher set of expectations for assessment of residents’ psychosocial needs, including new interviewing requirements, new measures of depression and resident choice, and new discharge screening procedures. Social service staff are primary providers of psychosocial assessment and care in nursing homes; yet, research demonstrates that many do not possess the minimum qualifications, as specified in federal regulations, to effectively provide these services given the clinical complexity of this client population. Likewise, social service caseloads generally exceed manageable levels. This article addresses the need for enhanced training and support of social service and interdisciplinary staff in long term care facilities in light of the new Minimum Data Set 3.0 assessment procedures as well as new survey and certification guidelines emphasizing quality of life. A set of recommendations will be made with regard to training, appropriate role functions within the context of interdisciplinary care, and needs for more realistic staffing ratios.

Can Background Checks of Long Term Care Residents Improve Safety?

Kristen Thornton — 2011-11-21

The recent article in the Journal of the American Medical Association, “State policies for the residency of offenders in long term care facilities: Balancing right to care with safety,” outlines an important area of concern for practitioners. Until recently, the complexities of criminal offenders requiring long term care have been largely unexplored. The thought of a vulnerable loved one living in close proximity to a criminal offender is a frightening idea for families, and the public will increasingly look to the long term care medicine community to ensure the protection of residents. To further facilitate the establishment of best practices surrounding this issue, the American Medical Directors Association recently passed a resolution to explore how nursing homes can best address the anticipated future increase in residents with criminal/correctional histories.

Editorial Board

2012-02-01

Author Guidelines

2012-02-01

General Information

2012-02-01

Directions & Connections

2012-02-01

JAMDA

Increasing Awareness of the Factors Producing Falls: The Mini Falls Assessment

Incentivizing Nursing Home Quality and Physician Performance

The Specificity of Geriatric Rehabilitation: Myth or Reality? A Debate from an Italian Perspective

Geriatric Conditions and Adverse Drug Reactions in Elderly Hospitalized Patients

Light Therapy for Seniors in Long Term Care

The Use of Data for Process and Quality Improvement in Long Term Care and Home Care: A Systematic Review of the Literature

Socially Assistive Robots in Elderly Care: A Systematic Review into Effects and Effectiveness

Sarcopenia and Mortality among Older Nursing Home Residents

Can Standardized Sleep Questionnaires be Used to Identify Excessive Daytime Sleeping in Older Post-Acute Rehabilitation Patients?

Has the Prevalence of Disability Increased Over the Past Decade (2000–2007) in Elderly People? A Spanish Population-based Survey

A Survey of Emergency Department Staff About Challenges and Recommendations for Emergency Department Care of Extended Care Facility Patients

Chronic Kidney Disease Staging in Nursing Home and Community Older Adults: Does the Choice of Cockcroft-Gault, Modification of Diet in Renal Disease Study, or the Chronic Kidney Disease Epidemiology Collaboration Initiative Equations Matter?

Antibiotics and Mortality in Patients with Lower Respiratory Infection and Advanced Dementia

Health Care Professionals’ Perceptions and Use of the Medical Orders for Scope of Treatment (MOST) Form in North Carolina Nursing Homes

Usage of Community Services and Domestic Helpers Predicted Institutionalization of Elders Having Functional or Cognitive Impairments: A 12-Month Longitudinal Study in Hong Kong

Muslim Nursing Homes in the United States: Barriers and Prospects

Minimal Trauma Fractures: Lifting the Specter of Misconduct by Identifying Risk Factors and Planning for Prevention

Epidemiology of Falls in Residential Aged Care: Analysis of More Than 70,000 Falls From Residents of Bavarian Nursing Homes

Prevalence of Psychotropic Medication Use among German and Austrian Nursing Home Residents: A Comparison of 3 Cohorts

Vision in the Global Evaluation of Older Individuals Hospitalized Following a Fall

Associations Between Published Quality Ratings of Skilled Nursing Facilities and Outcomes of Medicare Beneficiaries with Heart Failure

Scope and Severity Index: A Metric for Quantifying Nursing Home Survey Deficiency Number, Scope, and Severity Adjusted for the State-Related Measurement Bias

Effectiveness of Intervention Programs In Preventing Falls: A Systematic Review of Recent 10 Years and Meta-Analysis

Raloxifene and Tibolone in Elderly Women: A Randomized, Double-Blind, Double-Dummy, Placebo-Controlled Trial

The Influence of Hospice Use on Nursing Home and Hospital Use in Assisted Living Among Dual-Eligible Enrollees

To Evacuate or Shelter in Place: Implications of Universal Hurricane Evacuation Policies on Nursing Home Residents

Psychosocial Assessment of Nursing Home Residents via MDS 3.0: Recommendations for Social Service Training, Staffing, and Roles in Interdisciplinary Care

Can Background Checks of Long Term Care Residents Improve Safety?

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