JAMDA - Articles in Press

A 1-Year Randomized Controlled Trial Comparing Mind Body Exercise (Tai Chi) With Stretching and Toning Exercise on Cognitive Function in Older Chinese Adults at Risk of Cognitive Decline - Corrected Proof

2012-05-14

Abstract: Objectives: To compare the effectiveness of Chinese-style mind-body exercise (24 forms simplified Tai Chi) versus stretching and toning exercise in the maintenance of cognitive abilities in Chinese elders at risk of cognitive decline.Design: A 1-year single-blind cluster randomized controlled trial.Settings: Community centers and residential homes for elders in Hong Kong.Participants: A total of 389 subjects at risk of cognitive decline (Clinical Dementia Rating, CDR 0.5 or amnestic-MCI) participated in an exercise intervention program.Intervention: A total of 171 subjects were trained with Tai Chi (Intervention [I]) and 218 were trained with stretching and toning exercise (Control [C]).Methods: Cognitive and functional performance were assessed at the baseline, and at 5, 9, and 12 months. Data were analyzed using multilevel mixed models. Primary outcomes included progression to clinical dementia as diagnosed by DSM-IV criteria, and change of cognitive and functional scores. Secondary outcomes included postural balance measured by the Berg Balance Scale neuropsychiatric and mood symptoms measured by the Neuropsychiatric Inventory, and Cornell Scale for Depression in Dementia.Results: At 1 year, 92 (54%) and 169 (78%) participants of the I and C groups completed the intervention. Multilevel logistic regression with completers-only analyses controlled for baseline differences in education revealed that the I group had a trend for lower risk of developing dementia at 1 year (odds ratio 0.21, 95% CI 0.05–0.92, P = .04). The I group had better preservation of CDR sum of boxes scores than the C group in both intention-to-treat (P = .04) and completers-only analyses (P = .004). In completers-only analyses, the I group had greater improvement in delay recall (P = .05) and Cornell Scale for Depression in Dementia scores (P = .02).Conclusion: Regular exercise, especially mind-body exercise with integrated cognitive and motor coordination, may help with preservation of global ability in elders at risk of cognitive decline; however, logistics to promote long-term practice and optimize adherence needs to be revisited.

Antipsychotics Do Not Have To Be Used “Off Label” in Dementia - Corrected Proof

Ladislav Volicer — 2012-05-14

Two factors led to the current concern about the use of antipsychotics in nursing home residents with dementia. The first was publication of studies that found serious side effects, including increased mortality, in residents treated with these medications. The second was recognition that 39.4% of nursing home residents who have cognitive impairment and behavior problems but no diagnosis of psychosis or related conditions receive antipsychotic drugs. Because antipsychotics are not approved for treatment of dementia-related behaviors, this use is “off label.” In addition, it was recognized that the use of atypical antipsychotics results in significant cost for Medicare and some use did not comply with Medicare reimbursement criteria.

Measurement Properties of the Groningen Frailty Indicator in Home-Dwelling and Institutionalized Elderly People - Corrected Proof

Lilian L. Peters, Han Boter, Erik Buskens, Joris P.J. Slaets — 2012-05-14

Abstract: Objectives: To enable prevention of poor outcome in elderly people, a valid instrument is required to detect individuals at high risk. The concept of frailty is a better predictor than age alone. The Groningen Frailty Indicator (GFI) has been developed to identify frailty. We assessed feasibility, reliability, and construct validity of the self-assessment version of the GFI.Design: Cross-sectional.Setting: Community-based.Participants: Home-dwelling and institutionalized elderly persons were included in the study (n = 353) who met the following inclusion criteria: persons 65 years and older who were able to fill out questionnaires.Measurements: The feasibility of the GFI was assessed by determining the proportion of missing values per item. The internal consistency reliability of the GFI was established by calculating the KR-20. Mann-Whitney and Kruskal-Wallis tests were applied to assess discrimination between specific subgroups (known group validity). Convergent and discriminant validity was assessed using Spearman Rank correlations between GFI and diseases and disorders, case complexity, and health care needs (INTERMED), life satisfaction (Cantril Ladder of Life), activities of daily living (Katz), quality of life (EQ-5D), and mental health (SF-36). Finally, we used multivariate regression analyses to evaluate the cutoff score of the GFI (<4 versus ≥4).Results: A total of 296 (84%) of the participants completed all items of the GFI; the internal consistency was 0.68. The GFI yielded statistically significant GFI scores for subgroups (known group validity). The correlations for the convergent (range 0.45 to 0.61) and discriminant validity (range 0.08 to 0.50) were also as hypothesized. In contrast with nonfrail participants, frail older persons had higher levels of case complexity, disability, and lower quality of life and life satisfaction.Conclusions: This study supports the feasibility, reliability, and validity of the self-assessment version of the GFI in home-dwelling and institutionalized elderly people.

Prevalence of Atrial Fibrillation in US Nursing Homes: Results from the National Nursing Home Survey, 1985–2004 - Corrected Proof

2012-05-11

Abstract: Objectives: To evaluate the prevalence of atrial fibrillation (AFib) in US nursing homes from 1985 to 2004 and to project the prevalence of AFib to 2030.Design: This study is an analysis of cross-sectional data from the US National Nursing Home Survey, years 1985, 1995, 1997, 1999, and 2004.Setting: Randomly selected long-term care facilities in the United States licensed by the state or certified for Medicaid/Medicare reimbursement.Participants: Randomly selected residents within study facilities.Measurements: National Nursing Home Survey demographics and current medical conditions data were analyzed. Population estimates were calculated using National Nursing Home Survey sample weights. Absolute observed annual linear growth of the AFib prevalence rate was calculated using linear regression. Predictive margins were estimated using logistic regression models to evaluate effect of changes in resident case-mix over the survey years. Three estimation methods predicted the number residents having AFib in 2030.Results: The sample sizes of surveyed resident groups were as follows: n = 5238 (1985); n = 8056 (1995); n = 8138 (1997); n = 8215 (1999); and n = 13,507 (2004). Prevalence rates of AFib by year were 2.8% (95% confidence interval [CI]: 2.3–3.4%; 1985), 5.1% (95% CI: 4.6–5.6%; 1995), 5.8% (95% CI: 5.3–6.3%; 1997), 6.9% (95% CI: 6.3–7.4%; 1999), and 10.9% (95% CI: 10.2–11.5%; 2004). Population estimates of nursing home residents with AFib (in thousands) were 42.2 (95% CI: 34.1–50.3; 1985), 78.7 (95% CI: 70.8–86.7; 1995), 93.6 (95% CI: 84.9–102.3; 1997), 111.8 (95% CI: 102.1–121.5; 1999), and 162.1 (95% CI: 152.4–171.7; 2004). Absolute annual linear growth in the prevalence rate of AFib was +0.38% observed (P = .022), +0.39% using unadjusted predictive margins (P = .007), and +0.37% using adjusted predictive margins (P = .007). Projected estimates showed that 272,000 (95% CI: 197,000–347,000), 300,000, or 325,000 residents would have AFib in the year 2030.Conclusion: The prevalence of AFib in US nursing home residents increased from 1985 to 2004 and is projected to grow substantially over the next 20 years, potentially resulting in an increased nursing home staff burden owing to increased stroke risk evaluations.

The Diagnostic Accuracy of Telegeriatrics for the Diagnosis of Dementia via Video Conferencing - Corrected Proof

2012-05-10

Abstract: Introduction: The suitability of video conferencing (VC) technology for clinical purposes relevant to geriatric medicine is still being established. This project aimed to determine the validity of the diagnosis of dementia via VC.Methods: This was a multisite, noninferiority, prospective cohort study. Patients, aged 50 years and older, referred by their primary care physician for cognitive assessment, were assessed at 4 memory disorder clinics. All patients were assessed independently by 2 specialist physicians. They were allocated one face-to-face (FTF) assessment (Reference standard – usual clinical practice) and an additional assessment (either usual FTF assessment or a VC assessment) on the same day. Each specialist physician had access to the patient chart and the results of a battery of standardized cognitive assessments administered FTF by the clinic nurse. Percentage agreement (P0) and the weighted kappa statistic with linear weight (Kw) were used to assess inter-rater reliability across the 2 study groups on the diagnosis of dementia (cognition normal, impaired, or demented).Results: The 205 patients were allocated to group: Videoconference (n = 100) or Standard practice (n = 105); 106 were men. The average age was 76 (SD 9, 51–95) and the average Standardized Mini-Mental State Examination Score was 23.9 (SD 4.7, 9–30). Agreement for the Videoconference group (P0= 0.71; Kw = 0.52; P < .0001) and agreement for the Standard Practice group (P0= 0.70; Kw = 0.50; P < .0001) were both statistically significant (P < .05). The summary kappa statistic of 0.51 (P = .84) indicated that VC was not inferior to FTF assessment.Conclusions: Previous studies have shown that preliminary standardized assessment tools can be reliably administered and scored via VC. This study focused on the geriatric assessment component of the interview (interpretation of standardized assessments, taking a history and formulating a diagnosis by medical specialist) and identified high levels of agreement for diagnosing dementia. A model of service incorporating either local or remote administered standardized assessments, and remote specialist assessment, is a reliable process for enabling the diagnosis of dementia for isolated older adults.

Community-Based Exercise Program is Cost-Effective by Preventing Care and Disability in Japanese Frail Older Adults - Corrected Proof

Minoru Yamada, Hidenori Arai, Takuya Sonoda, Tomoki Aoyama — 2012-05-10

Abstract: Background: In Japan, older adults are assessed by frailty checklist for care prevention. However, the effect of care prevention programs in community-dwelling frail older adults is still unclear.Objectives: The purpose of this study was to investigate whether the care prevention program would reduce care and disability and to measure its cost-effectiveness in frail older adults.Design: This is a prospective study using propensity score matching.Setting and subjects: A total of 610 community-dwelling older adults were recruited in 2 cities of Japan.Intervention: Subjects in the exercise group (n = 305) attended physical exercise sessions once a week for 16 consecutive weeks. The exercise sessions were in a standardized format consisting of moderate-intensity aerobic exercise, progressive strength training, flexibility and balance exercises, and cool-down activities. The control group (n = 305) received only screening evaluation.Measurements: Primary outcome was long-term care insurance requirement certification during the 1-year follow-up period. Secondary outcome measurements were changes of frailty checklist, and care and medical cost.Results: Twenty-five subjects (8.1%) in the exercise group and 55 (18%) in the control group were newly certified for long-term care insurance service requirement in 1 year after the intervention (RR = 2.16, 95% CI = 1.46–3.20). Consequently, the health care cost for the subjects in the exercise group was significantly lower than in the control group (P < .001). Moreover, subjects in the exercise group had significant improvements in total scores of the frailty checklist compared with the control group that worsened after 1 year (exercise group: from 7.41 ± 3.98 to 7.11 ± 4.00, control group: from 7.34 ± 4.27 to 8.02 ± 4.81, F=12.84, P < .001).Conclusion: These results suggested that physical exercise is effective in preventing the progression of frailty and further disability in older adults living in the community. We could save heath care costs by our care prevention program.

Failure to Regain Function at 3 months After Acute Hospital Admission Predicts Institutionalization Within 12 Months in Older Patients - Corrected Proof

2012-05-10

Abstract: Objectives: To study the effects of functional decline on admission to long-term institutionalized care within 12 months from acute hospital admission.Design: Pooled analyses of 3 longitudinal cohorts.Setting: Tertiary and secondary hospital.Participants: A total of 1085 community-dwelling patients older than 65 years acutely admitted to an internal medicine or orthopedic ward.Measurements: Demographic data and medical data were collected within 2 days from hospital admission. Functional status (activities of daily living [ADL]) was assessed at baseline (reflecting preadmission status 2 weeks before admission) and 3 months after admission, and function loss (change between preadmission and 3 months) was calculated. Living situation was assessed 3 and 12 months after hospitalization. Cox regression analysis was used to predict institutionalization (living in a long-term assisted care or nursing home facility) within 12 months.Results: ADL function loss in the 3 months following hospital admission increased the risk of institutionalization also in patients without preadmission impairment (loss of function in 1 item HR = 5.3, 95% CI 2.2–12.6, p < .001; ≥2 items HR = 7.3, 95% CI 3.4–15.7, p < .001) compared with patients without impairment and function loss. The risk progressively increased with higher preadmission impairment. Patients with preadmission ADL impairment in 2 or more items without additional loss of function had an increased risk (HR = 6.4, 95% CI 3.1–13.3, p < .001) for institutionalization. This model was adjusted for age, gender, cognitive impairment, social situation, use of health care services, length of hospital stay, and comorbidity.Conclusion: Loss of function in ADL tasks following hospitalization increased the risk for institutionalization, irrespective of preadmission ADL impairment. Potentially, counteracting loss of function in ADLs after acute hospital admission by more intensive rehabilitation may partly reduce the need for institutionalization.

Antibiotic Use and Resistance in Long-Term Care Facilities - Corrected Proof

2012-05-10

Abstract: Introduction: The common occurrence of infectious diseases in nursing homes and residential care facilities may result in substantial antibiotic use, and consequently antibiotic resistance. Focusing on these settings, this article aims to provide a comprehensive overview of the literature available on antibiotic use, antibiotic resistance, and strategies to reduce antibiotic resistance.Methods: Relevant literature was identified by conducting a systematic search in the MEDLINE and EMBASE databases. Additional articles were identified by reviewing the reference lists of included articles, by searching Google Scholar, and by searching Web sites of relevant organizations.Results: A total of 156 articles were included in the review. Antibiotic use in long-term care facilities is common; reported annual prevalence rates range from 47% to 79%. Part of the prescribed antibiotics is potentially inappropriate.The occurrence of antibiotic resistance is substantial in the long-term care setting. Risk factors for the acquisition of resistant pathogens include prior antibiotic use, the presence of invasive devices, such as urinary catheters and feeding tubes, lower functional status, and a variety of other resident- and facility-related factors. Infection with antibiotic-resistant pathogens is associated with increased morbidity, mortality, and health care costs.Two general strategies to reduce antibiotic resistance in long-term care facilities are the implementation of infection control measures and antibiotic stewardship.Conclusion: The findings of this review call for the conduction of research and the development of policies directed at reducing antibiotic resistance and its subsequent burden for long-term care facilities and their residents.

Apathy: Prevalence, Associated Factors, and Prognostic Value Among Frail, Older Inpatients - Corrected Proof

2012-05-10

Abstract: Objectives: The association of apathy with Alzheimer disease and other dementias and caregiver burden has been examined in a number of studies; however, less is known about its relationship with delirium and mortality. We aimed to investigate the prevalence, relationship with delirium and dementia, and prognostic value of apathy in an elderly and frail inpatient population.Setting and Participants: The cohort included 425 patients in acute geriatric wards and in 7 nursing homes in Helsinki (1999–2000). Demographic factors, physical functioning, diagnoses, and drugs were assessed with special reference for dementia, delirium, and apathy. Mortality was registered from central registers.Results: Of the patients, 98 (23.1%) suffered from apathy, and it was more frequent among men (32% versus 21% women, P = .037 ). There was no difference in mean age, number of comorbidities, or in the mean number of medications between those with and without apathy; however, those with apathy had lower mean MMSE points (9.2 versus 14.0 without apathy, P < .001), more often severe dementia according to Clinical Dementia Rating, and higher dependence in activities of daily living (P = .001). Furthermore, patients with apathy were more often suffering from delirium (37.8% versus 21.1%, P ≤ .001). Mortality during the 1-year follow-up was 34.7% (n = 34) and 22.0% (n = 72) among individuals with and without apathy, respectively (P = .011). In the Cox proportional hazard model with age, gender, activities of daily living, and delirium as covariates, apathy significantly predicted mortality (HR 1.89, 95% CI 1.24 to 2.89; P = .003).Conclusions: Apathy is a common and serious neuropsychiatric symptom associated with cognitive decline, delirium, and disability, and it also independently predicts mortality.

Understanding Risk of Falls in People With Cognitive Impairment Living in Residential Care - Corrected Proof

Julie Whitney, Jacqueline C.T. Close, Stephen H.D. Jackson, Stephen R. Lord — 2012-05-07

Abstract: Objectives: To better understand fall risk factors in older adults with cognitive impairment living in residential care.Design: A prospective observational cohort study.Setting: Residential care homes in South London, UK.Participants: Residents older than 60, with cognitive impairment who had a life expectancy of at least 6 months and were not bedbound or recently discharged from hospital.Measurements: Baseline assessments were undertaken in domains of demographics, medical history, medication use, behavior, affect, gait, balance, sensorimotor performance and neuropsychological function. Participants were followed for 6 months for falls using care home reporting systems.Results: A total of 109 participants completed baseline assessment and had adequate falls follow-up. Fallers took more medications, were more likely to be taking antidepressants, had more functional impairment, poorer balance and gait, were more impulsive and anxious, exhibited more dementia-related behaviors, and performed worse on cognitive tests involving attention and orientation, memory, and fluency. Logistic regression analysis identified 4 significant and independent predictors of falls: poor attention and orientation, increased postural sway with eyes closed, anxiety, and antidepressant use. The AUC for this model was 0.84 (95% CI 0.76–0.91).Conclusions: This study identified important risk factors for falls potentially amenable to intervention in older people with cognitive impairment living in residential care. This information may be useful in designing effective approaches to fall prevention in this high-risk population.

High Technology Coming to a Nursing Home Near You - Corrected Proof

John E. Morley — 2012-05-07

The care of the older person has classically been a high-touch person-centered endeavor, but times are a-changin’. New technologies are developing rapidly, and although uptake has been slow, they are starting to be incorporated into nursing homes. Nurses and doctors have been slow to embrace these technologies, citing difficulties in using them and lack of relevance to residents as major reasons for lack of enthusiasm. Original uptake of technology in nursing homes was for billing purposes and recording the minimum data set (MDS). provides a list of the technological advances that will likely invade the nursing home over the next few years.

Can Botulinum Toxin Decrease Carer Burden in Long-Term Care Residents with Upper Limb Spasticity? A Randomized Controlled Study - Corrected Proof

2012-04-23

Abstract: Objective: To evaluate whether botulinum toxin can decrease the burden for caregivers of long-term care patients with severe upper limb spasticity.Method: This was a double-blind placebo-controlled trial with a 24-week follow-up period.Setting: A 250-bed long-term care hospital, the infirmary units of 3 regional hospitals, and 5 care and attention homes.Participants: Participants included 55 long-term care patients with significant upper limb spasticity and difficulty in basic upper limb care.Interventions: Patients were randomized into 2 groups that received either intramuscular botulinum toxin A or saline.Main outcome measures: The primary outcome measure was provided by the carer burden scale. Secondary outcomes included goal attainment scale, measure of spasticity by modified Ashworth score, passive range of movement for shoulder abduction, and elbow extension and finger extension. Pain was assessed using the Pain Assessment in Advanced Dementia Scale.Results: A total of 55 patients (21 men; mean age = 69, SD =18) were recruited. At week 6 post-injection, 18 (60%) of 30 patients in the treatment group versus 2 (8%) of 25 patients in the control group had a significant 4-point reduction of carer burden scale (P < .001). There was also significant improvement in the goal attainment scale, as well as the modified Ashworth score, resting angle, and passive range of movement of the 3 regions (shoulder, elbow, and fingers) in the treatment group which persisted until week 24. There were also fewer spontaneous bone fractures after botulinum toxin injection, although this did not reach statistical significance. No significant difference in Pain Assessment in Advanced Dementia scale was found between the 2 groups. No serious botulinum toxin type A–related adverse effects were reported.Conclusion: Long-term care patients who were treated for upper limb spasticity with intramuscular injections of botulinum toxin A had a significant decrease in the caregiver burden. The treatment was also associated with improved scores on patient-centered outcome measures.

Process Evaluation to Explore Internal and External Validity of the “Act in Case of Depression” Care Program in Nursing Homes - Corrected Proof

2012-04-23

Abstract: Background: A multidisciplinary, evidence-based care program to improve the management of depression in nursing home residents was implemented and tested using a stepped-wedge design in 23 nursing homes (NHs): “Act in case of Depression” (AiD).Objective: Before effect analyses, to evaluate AiD process data on sampling quality (recruitment and randomization, reach) and intervention quality (relevance and feasibility, extent to which AiD was performed), which can be used for understanding internal and external validity. In this article, a model is presented that divides process evaluation data into first- and second-order process data.Methods: Qualitative and quantitative data based on personal files of residents, interviews of nursing home professionals, and a research database were analyzed according to the following process evaluation components: sampling quality and intervention quality.Setting: Nursing home.Results: The pattern of residents’ informed consent rates differed for dementia special care units and somatic units during the study. The nursing home staff was satisfied with the AiD program and reported that the program was feasible and relevant. With the exception of the first screening step (nursing staff members using a short observer-based depression scale), AiD components were not performed fully by NH staff as prescribed in the AiD protocol.Conclusion: Although NH staff found the program relevant and feasible and was satisfied with the program content, individual AiD components may have different feasibility. The results on sampling quality implied that statistical analyses of AiD effectiveness should account for the type of unit, whereas the findings on intervention quality implied that, next to the type of unit, analyses should account for the extent to which individual AiD program components were performed. In general, our first-order process data evaluation confirmed internal and external validity of the AiD trial, and this evaluation enabled further statistical fine tuning. The importance of evaluating the first-order process data before executing statistical effect analyses is thus underlined.

Profiling the Multidimensional Needs of New Nursing Home Residents: Evidence to Support Planning - Corrected Proof

2012-04-09

Abstract: Introduction: Nursing home (NH) residents have various needs that affect the care they require. This article describes the diverse needs that new NH residents have, emphasizing the proportion of people with milder needs in multiple areas.Methods: Research was conducted on all older adults newly admitted to not-for-profit NHs in the Winnipeg Health Region, between April 1, 2005, and March 31, 2007, provided that they were assessed using the Resident Assessment Instrument Minimum Data Set (RAI/MDS 2.0) within 30 days of admission (n = 1061). Using the Activities of Daily Living (ADL) Hierarchy scale, residents were first defined as low, intermediate, or high ADL dependent. Residents' needs were also defined using the RAI/MDS 2.0 cognitive performance (CPS) and pain scales, by their degree of behavioral problems and visual challenges, and by their frequency of bladder and bowel incontinence. Cluster analysis was used to create subgroups of residents by their severity of clinical challenges.Results: Of our cohort, 26.8% were low ADL dependent. Although some of these residents had moderate to severe needs in another area, many (46.8% of low ADL-dependent residents; 12.5% of our entire cohort) had milder needs across all clinical domains. Conversely, about one-third of our cohort was high ADL dependent; 31.7% of these residents had moderate to severe challenges in one clinical domain, and 35.5% had moderate to severe comorbid challenges.Conclusions: Overall, 12.5% of our cohort had lower needs, demonstrating the capacity for community-based programs to offset NH demands. Also, the diversity of residents' needs highlights the importance of having both the appropriate resources and strategies available to provide quality NH care. Future research is discussed for both low- and higher-need NH residents.

The Old Lady's Cat - Corrected Proof

I. Campbell-Taylor — 2012-04-09

“How unhygienic,” they said.“A cat in your bed.Do you know where those paws have beenAnd that tongue that she licks you with?”But you just snuggle upThrobbing with purrs,Content to be warm and lovedAnd we comfort each other.

Risk of Death Associated With Use of PPIs in Three Cohorts of Institutionalized Older People in Finland - Corrected Proof

2012-04-09

Abstract: Objectives: To (1) explore clinical and demographic characteristics of users and nonusers of PPIs in 3 cohorts of institutionalized older people in Finland, and (2) compare the risk of death associated with use of PPIs in each setting.Design: Cross-sectional assessment of 3 institutionalized cohorts with 1-year follow-up of all-cause mortality.Setting and Participants: A total of 1389 residents of 69 assisted living facilities (first cohort), 1004 residents of long-term care hospitals (second cohort), and 425 residents in acute geriatric wards or in nursing homes (third cohort).Measurements: Demographic, drug use, and diagnostic data were collected during structured assessments conducted by trained nurses or geriatricians. Cox proportional hazards models were used to compute unadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between use of PPIs and mortality.Results: In the assisted living facility, the mortality was 20.2% (n = 74) and 20.4% (n = 208) among users and nonusers of PPIs, respectively (P = 0.94). PPIs were not associated with mortality in unadjusted or adjusted analyses. In the long-term care hospitals, use of PPIs was associated with increased mortality (HR, 1.36; 95% CI 1.04–1.77) when adjusted for age, sex, comorbidity, use of SSRIs, and malnutrition. In the acute geriatric wards and nursing homes, use of PPIs was associated with increased mortality (HR, 1.90; 95% CI 1.23–2.94) when adjusted for age, sex, comorbidity, delirium, and use of aspirin and SSRIs.Conclusion: PPIs were not associated with mortality among residents in assisted living facilities, but were associated with increased mortality in settings where residents experienced higher levels of disability and possible susceptibility to adverse drug events.

The Impact of Culture Change on Elders’ Behavioral Symptoms: A Longitudinal Study - Corrected Proof

Orah R. Burack, Audrey S. Weiner, Joann P. Reinhardt — 2012-04-02

Abstract: Objectives: Distressing behavioral symptoms often associated with dementia are not uncommon in the long-term care setting. Culture change with its “person-centered approach to care” provides a potential nonpharmacological intervention to reduce these symptoms. The purpose of this study was to examine the relationship between a culture change initiative and nursing home elders’ behavioral symptoms.Design: Seven long-term-care communities (nursing units in 3 skilled nursing facilities) participated in a culture change intervention designed to transform the nursing home experience from a traditional hospital-model of care to one that is person-centered. Six comparison communities were matched to the intervention communities and continued to function along the typical nursing home organizational structure. Data were collected at baseline and 2 years later.Methods: Subjects were 101 elders (intervention group n = 50, comparison group n = 51). Each elder’s primary day certified nursing assistant completed the Cohen-Mansfield Agitation Inventory, examining frequency of behavioral symptoms, including verbal and physical agitation as well as more forceful behaviors (eg, hitting, kicking) at both data collection periods.Results: After controlling for functional status and race, a significant condition by time interaction was found for physical agitation and forceful behaviors with the person-centered group maintaining levels of behavioral symptoms as compared with a significant increase over time among the comparison group. A trend with the same pattern was found for verbal agitation.Conclusions: Person-centered care demonstrated potential as a nonpharmacological intervention for distressing behavioral symptoms. The positive impact of culture change appears to extend to elders with cognitive impairment who are less obvious beneficiaries of this model, featuring the central principals of autonomy and person-centered care.

Predicting Cause-Specific Mortality of Older Men Living in the Veterans Home by Handgrip Strength and Walking Speed: A 3-Year, Prospective Cohort Study in Taiwan - Corrected Proof

2012-03-29

Abstract: Objective: To determine prognostic value of handgrip strength (HGS) and walking speed (WS) in predicting the cause-specific mortality for older men.Design: Prospective cohort studySetting: Banciao Veterans Care HomeParticipants: 558 residents aged 75 years and older.Measurements: Anthropometric data, lifestyle factors, comorbid conditions, biomarkers, HGS, and WS at recruitment; all-cause and cause-specific mortality at 3 years after recruitment.Results: During the study period, 99 participants died and the baseline HGS and WS were significantly lower than survivors (P both <.001). Cox survival analysis showed that subjects with slowest quartile of WS were at significantly higher risk of all-cause mortality and cardiovascular mortality (hazard ratio [HR] 3.55, 95% confidence interval [CI] 1.69–7.43; HR 11.55, 95% CI 2.30–58.04, respectively), whereas the lowest quartile of HGS significantly predicted a higher risk of infection-related death (HR 5.53, 95% CI 1.09–28.09). Participants in the high-risk status with slowest quartile for WS but not those in the high-risk status with weakest quartile for HGS had similar high risk of all-cause mortality with the group with combined high-risk status (HR 2.96, 95% CI 1.68–5.23; HR 2.58, 95% CI 1.45–4.60, respectively) compared with the participants without high-risk status (reference group).Conclusions: Slow WS predicted all-cause and cardiovascular mortality, whereas weak HGS predicted a higher risk of infection-related death among elderly, institutionalized men in Taiwan. Combining HGS with WS simultaneously had no better prognostic value than using WS only in predicting all-cause mortality.

Racial Inequities in Receipt of Influenza Vaccination among Nursing Home Residents in the United States, 2008–2009: A Pattern of Low Overall Coverage in Facilities in Which Most Residents are Black - Corrected Proof

2012-03-16

Abstract: Objectives: Nationwide among nursing home residents, receipt of the influenza vaccine is 8 to 9 percentage points lower among blacks than among whites. The objective of this study was to determine if the national inequity in vaccination is because of the characteristics of facilities and/or residents.Design: Cross-sectional study with multilevel modeling.Setting and Participants: States in which 1% or more of nursing home residents were black and the difference in influenza vaccination coverage between white and black nursing home residents was 1 percentage point or higher (n = 39 states and the District of Columbia). Data on residents (n = 2,359,321) were obtained from the Centers for Medicare & Medicaid Service’s Minimum Data Set for October 1, 2008, through March 31, 2009.Measurements: Residents’ influenza vaccination status (vaccinated, refused vaccine, or not offered vaccination).Results: States with higher overall influenza vaccination coverage among nursing home residents had smaller racial inequities. In nursing homes with higher proportions of black residents, vaccination coverage was lower for both blacks and whites. The most dramatic inequities existed between whites in nursing homes with 0% blacks (L1) and blacks in nursing homes with 50% or more blacks (L5) in states with overall racial inequities of 10 percentage points or more. In these states, more black nursing home residents lived in nursing homes with 50% or more blacks (L5); in general, the same homes with low overall coverage.Conclusion: Inequities in influenza vaccination coverage among nursing home residents are largely because of low vaccination coverage in nursing homes with a high proportion of black residents. Findings indicate that implementation of culturally appropriate interventions to increase vaccination in facilities with larger proportions of black residents may reduce the racial gap in influenza vaccination as well as increase overall state-level vaccination.

Nursing Homes Appeals of Deficiencies: The Informal Dispute Resolution Process - Corrected Proof

2012-03-09

Abstract: Objective: Nursing homes that are not meeting quality standards are cited for deficiencies. Before 1995, the only recourse for a nursing home was a formal appeal process, which is lengthy and costly. In 1995, the Centers for Medicare & Medicaid Services instituted the Informal Dispute Resolution (IDR) process. This study presents for the first time national statistics about the IDR process and an analysis of the factors that influence nursing homes’ decisions to request an IDR.Design: Retrospective study including descriptive statistics and multivariate logistic hierarchical models.Setting: US nursing homes from 2005 to 2008.Participants: Participants were 15,916 Medicaid- and Medicare-certified nursing homes nationally, with 94,188 surveys and 9388 IDRs.Measures: The unit of observation was an annual survey or a complaint survey that generated at least one deficiency. The dependent variable was dichotomous and indicated whether the annual or a complaint survey triggered an IDR request. Independent variables included characteristics of the nursing home, the deficiency, the market, and the state regulatory environment.Results: Ten percent of all annual surveys and complaint surveys resulted in IDRs. There was substantial variation across states, which persisted over time. Multivariate results suggest that nursing homes’ decisions to request an IDR depend on their assessment of the probability of success and assessment of the benefits of the submission.Conclusions: Nursing homes avail themselves of the IDR process. Their propensity to do so depends on a number of factors, including the state regulatory system and the market environment in which they operate.

Efficacy and Feasibility of Nonpharmacological Interventions for Neuropsychiatric Symptoms of Dementia in Long Term Care: A Systematic Review - Corrected Proof

2012-02-20

Abstract: Background: Nonpharmacological therapies are often recommended as a first-line treatment for neuropsychiatric symptoms (NPS) of dementia in long term care (LTC); however, little is known about which nonpharmacological interventions are most effective for NPS in LTC or the feasibility of interventions, given the availability of resources in typical LTC environments.Methods: We searched the electronic databases MEDLINE, EMBASE, PsychINFO (1980–2010), the Cochrane Library, and Google Scholar using keywords and medical subject headings for randomized, controlled trials evaluating nonpharmacological interventions for NPS conducted in LTC settings. Change in severity of NPS symptoms was evaluated through the NPS outcomes measures reported in studies. We assessed study quality and described the feasibility of interventions based on various aspects of study design.Results: A total of 40 studies met inclusion criteria. Sixteen (40%) of 40 included studies reported statistically significant results in favor of nonpharmacological interventions on at least one measure of NPS. These interventions included staff training in NPS management strategies, mental health consultation and treatment planning, exercise, recreational activities, and music therapy or other forms of sensory stimulation. Many of the studies had methodological limitations that placed them at potential risk of bias. Most interventions (n = 30, 75%) required significant resources from services outside of LTC or significant time commitments from LTC nursing staff for implementation.Conclusions: There are several nonpharmacological interventions that may be effective for NPS in LTC, although there are a limited number of large-scale, high-quality studies in this area. The feasibility of some interventions will be limited in many LTC settings and further research into practical and sustainable interventions for NPS in LTC is required to improve usage of these important treatments.

Professional Caregivers’ Mental Health Problems and Burnout in Small-Scale and Traditional Long-Term Care Settings for Elderly People With Dementia in The Netherlands and Belgium - Corrected Proof

2012-02-13

Abstract: Objectives: The aim of this study was to provide an insight into burnout and mental health problems of professional caregivers working in traditional and small-scale long-term care settings for elderly residents with dementia in the Netherlands and Belgium.Design: This study was part of a larger study investigating similarities and differences between traditional and small-scale long-term care settings for elderly residents with dementia. In this article, the perspective of the professional caregiver is of central importance. A survey was conducted among professional caregivers of residents with dementia, older than 65 years, at 2 measurement moments (at baseline and after 12 months).Setting: The questionnaire was administered to professionals working in traditional and small-scale long-term care settings in the Netherlands and Belgium.Participants: Professional caregivers (n = 80) working in 5 different care settings completed a questionnaire.Measurements: The questionnaire included items on personal data, mental health problems (GHQ-12), and burnout (UBOS-C, divided into emotional exhaustion, depersonalization, and personal accomplishment). Analyses were conducted using Mixed Models analysis.Results: Although mental health problems and emotional strain increased significantly over time in both types of settings and countries, overall levels of health problems and burnout were low. As regards emotional strain, professional caregivers in small-scale living facilities showed significantly increased levels in comparison with traditional units. Two significant differences between the countries were also found, with less “depersonalization” and more “personal accomplishment” in Dutch settings compared with Belgian settings. No differences emerged for type of setting or over time on “depersonalization” and “personal accomplishment.” The analyses were controlled for age, sex, educational level, and work experience in dementia care, but did not yield significant effects.Conclusion: Owing to cutbacks in expenditure, the growing number of people with dementia, and the heavier workload, the working environment will become increasingly challenging. Future research should focus on training professional caregivers working in long-term care settings how to maximize the quality of client interaction while keeping burnout and mental health problems to a minimum.

Nonreferral of Nursing Home Patients With Suspected Breast Cancer - Corrected Proof

2012-02-13

Abstract: Introduction: People with suspected breast cancer who are not referred for diagnostic testing remain unregistered and are not included in cancer statistics. Little is known about the extent of and motivation for nonreferral of these patients.Methods: A Web-based survey was sent to all elderly care physicians (ECPs) registered at the National Association of Elderly Care Physicians and Social Geriatricians in the Netherlands, inquiring about the number of patients with suspected breast cancer they encountered and subsequent choices regarding referral.Results: Surveys were completed by 419 (34%) of 1239 ECPs; 249 (60%) of these had encountered one or more patients with suspected breast cancer in the past year. Seventy-four (33%) ECPs reported not referring the last patient. Reasons for nonreferral were end-stage dementia (57%), patient/family preference (29%), and limited life expectancy (23%). Referral was frequently thought to be too burdensome (13%). For 16% of nonreferred patients, hormonal treatment was started by the ECP without diagnostic confirmation of cancer.Conclusion: In this survey, more than 33% of nursing home patients with suspected breast cancer were not referred for further testing, in particular those with advanced dementia, limited life expectancy, and poor functional status. As the combination of dementia and suspected breast cancer is expected to double in the coming decades, now is the time to optimize cancer care for these vulnerable patients.

Functional Outcomes of Nursing Home Residents in Relation to Features of the Environment: Validity of the Professional Environmental Assessment Protocol - Corrected Proof

Susan E. Slaughter, Debra G. Morgan — 2012-02-13

Abstract: Objectives: The aim of this article was to examine associations between specific dimensions of nursing home environments and the functional ability (walking and eating) of residents with dementia, and to contribute to the ongoing psychometric development of the Professional Environmental Assessment Protocol (PEAP).Design: One-year prospective cohort study.Setting: Fifteen nursing homes in a western Canadian province.Participants: Convenience sample of 120 nursing home residents with middle-stage dementia.Measurements: Every 2 weeks we observed residents’ abilities to walk to the dining room and to feed themselves. At the end of a year of observation and immediately following a brief interview with the unit managers, we used the PEAP to measure the extent to which 9 specific dimensions of nursing home environments support the ability of residents with dementia to walk and to eat. Cox proportional hazards models were used to evaluate the effect of specific environmental features on residents’ walking and eating disability.Results: “Support of functional ability” was associated with a reduced hazard of both walking and eating disability. The environmental dimensions of “maximizing awareness and orientation” and better “quality of stimulation” were associated specifically with reduced hazard of walking disability, whereas the dimensions of the nursing home environment specifically associated with a reduced hazard of eating disability included improved “safety and security,” “opportunities for personal control,” and “regulation of stimulation.” The Cox proportional hazards models using the 13-point PEAP scale were not significantly different from nested models using the 5-point PEAP scale, indicating that the 2 scales did not differ in their ability to discriminate between more and less supportive environments for residents with dementia.Conclusions: Specific dimensions of the nursing home environment reduced the hazard of walking disability, whereas others reduced the hazard of eating disability. Modifying specific features of nursing home environments may reduce disability in nursing home residents with dementia. The 5-point PEAP scale is able to discriminate between nursing home environments as well as the 13-point scale.

Improving Care of Older Adults with Dementia: Description of 6299 Hospitalizations over 11 Years in a Special Acute Care Unit - Corrected Proof

2012-01-24

Abstract: Objective: To describe hospitalizations in a Special Acute Care inpatient Unit for older adults with Alzheimer’s disease (AD) and other related disorders.Design: An 11-year observational study of consecutive hospitalizations from 1996 to 2006.Setting: The Alzheimer Special Acute Care inpatient Unit in the Geriatrics Department of the Toulouse University Hospital, France.Participants: A total of 4708 patients with dementia accounting for 6299 consecutive hospitalizations.Measurements: Data regarding admission causes, cognition, physical disability, nutritional assessment, behavioral and psychological symptoms of dementia, and sociodemographics were recorded.Results: Data from 6299 hospitalizations are presented: 4708 (74.7%) hospitalizations accounted for first-time admissions and 1591 (25.3%) were rehospitalizations. Among the first-time admissions, complications of dementia and cognitive diagnosis experienced a significant switch in frequency. Whereas until 2001, the main cause of admission was for a diagnosis (51%), complications became the primary cause from 2003 onward with a significant increasing trend (56%) (P < .001). The most frequent cause of complications was behavioral and psychological symptoms of dementia, with a significant trend for an increased frequency (P < .001). Agitation-aggressiveness represented 60% of behavioral and psychological symptoms of dementia. Between 1996 and 2006, the age of patients at first-time admission gradually increased over time, as did the severity of cognitive impairment and the prevalence of unsatisfactory nutritional status (P for trend < .001 for each variable).Conclusions: The evolving patient characteristics and the causes of first-time admissions changed over the course of 11 years. Behavioral and psychological symptoms of dementia, especially agitation-aggressiveness, have progressively become the key drivers of Special Acute Care inpatient Unit hospitalizations. These findings suggest that the role, mission, and functioning of the Special Acute Care inpatient Unit within the Alzheimer care system has been modified over time.

Quality-of-Care Processes in Geriatric Assessment Units: Principles, Practice, and Outcomes - Corrected Proof

2012-01-12

Abstract: Objectives: To assess quality-of-care processes and to examine whether care processes are associated with short-term postdischarge outcomes in older vulnerable hospitalized patients.Design: Retrospective study.Setting: Forty-nine Geriatric Assessment Units.Participants: Patients aged 65 and older who were admitted to a Geriatric Assessment Unit for a fall with trauma.Measurements: Three care processes (comprehensiveness, informational continuity, patient-centered care) assessed through chart audit; three-month postdischarge outcomes (emergency department visit, hospital readmission, and death) obtained from national databases.Results: A total of 934 hospitalization records were included. Mean comprehensiveness and informational continuity scores were 55% ± 12% and 42% ± 16%, respectively. Items related to geriatric global assessment (eg, functional autonomy) were particularly overlooked. Patient-centered care was poorly provided, with only 24% of hospitalization records showing evidence of advance care directives and at least one patient/family meeting with the physician to discuss clinical evolution. For the three care processes, a large variability among Geriatric Assessment Units was observed. Better comprehensiveness of care was associated with lowered short-term mortality (OR = 0.73, 95% CI = 0.55–0.96, P = .023), whereas higher scores on informational continuity was associated with fewer emergency department visits (OR = 0.91, 95% CI = 0.82–1.00, P = .046), hospital readmissions (OR = 0.84, 95% CI = 0.74–0.94, P = .003), and mortality (OR = 0.72, 95% CI = 0.59–0.88, P = .002). Patient-centered care was not associated with any of the postdischarge outcomes.Conclusion: A large gap between geriatric care principles and practice in Geriatric Assessment Units has been observed. Our results show that improvement in care processes may be translated to decreased short-term health services use and mortality.

Efficacy of Progressive Resistance Training Interventions in Older Adults in Nursing Homes: A Systematic Review - Corrected Proof

Trinidad Valenzuela — 2011-12-15

Abstract: Objective: To provide a synthesis of the evidence from clinical trials to determine whether progressive resistance training, as a single exercise intervention, improves strength and functional performance in older institutionalized adults.Methods: A comprehensive systematic database search for randomized controlled trials was performed, including AMED, CINAHL, COCHRANE, and all EMB reviews: Cochrane DSR, ACP Journal Club, DARE, MEDLINE, PREMEDLINE, and PsycINFO, completed in July 2011. Studies were then assessed for potential inclusion. Study quality indicators, cohort characteristics, training intervention, muscle strength, and functional performance outcomes were extracted.Results: Thirteen studies were reviewed; the mean cohort age range was 80 to 89 years. In general, the quality of the reviewed studies was moderately robust; an average of 9 of 11 quality criteria were accounted for in the reviewed literature. Significant improvements were found in muscle strength outcomes and functional performance outcomes, including chair to stand time, stair climbing, gait speed, balance, and functional capacity following progressive resistance training interventions.Conclusions: Significant improvements in muscle strength and functional performance occur in response to progressive resistance training exercise, despite advanced age, presence of chronic diseases, extremely sedentary habits, and functional disabilities in older institutionalized individuals. Therefore, the incorporation of a progressive resistance training exercise program is an effective means to preserve independence levels by maintaining or improving the ability to perform activities of daily living and the implementation of this type of exercise program should be promoted and incorporated into the recreational schedules of long term care institutions.

Is Health-Related Quality of Life an Independent Prognostic Factor For 12-Month Mortality and Nursing Home Placement among Elderly Patients Hospitalized via the Emergency Department? - Corrected Proof

2011-11-14

Abstract: Objectives: To assess whether health-related quality of life is an independent prognostic factor for mortality or nursing home placement in frail elderly patients.Design: A prospective, multicenter study with a 12-month follow-up.Setting: Nine French hospitals.Participants: A total of 1306 patients aged 75 and older hospitalized through an emergency department.Measurements: Data obtained from sociodemographic characteristics, Comprehensive Geriatric Assessment and the Duke Health Profile (DHP) were used into a Cox model to identify prognostic variables for 12-month mortality and institutionalization.Results: Crude mortality and nursing home placement rates were 34.1% (n = 445) and 16.1% (n = 210), respectively. Independent prognostic factors identified for mortality were: Comorbidity level (moderate: hazard ratio [HR] [95% confidence interval (CI)] = 1.40 [1.09–1.78]; severe: 2.70 [1.63–4.46]), dependence for activities of daily living (1.68 [1.06–2.67]), pressure sore risk (1.49 [1.16–1.90]), risk of malnutrition (2.09 [1.46–3.00]), delirium (2.25 [1.75–2.90]), and 10-point increase in the DHP perceived health score (0.96 [0.93–0.99]). Independent prognostic factors identified for nursing home placement were the following: living alone at home (1.82 [1.30–2.55]), having 2 children or more (0.71 [0.51–0.99]), dependence for activities of daily living (2.48 [1.39–4.44]), dementia (1.93 [1.39–2.69]), unplanned hospital readmission during follow-up (2.05 [1.45–2.91]), and 10-point increase in the DHP social health score (0.90 [0.83–0.99]). Balance troubles and risk of malnutrition were no more significant when adjusted for the DHP scores and other clinical variables.Conclusion: The perceived health and social health scores of the DHP were independent prognostic factors of survival and nursing home placement among hospitalized elderly patients, respectively. When associated with Comprehensive Geriatric Assessment, they could help screen frail patients to set up as early as possible targeted interventions to restore/maintain modifiable prognostic factors, such as nutritional status, functional ability, and social support.

Creating a Quality of Life Assessment Measure for Residents in Long-Term Care - Corrected Proof

Madelyn Iris, Noel A. DeBacker, Ronald Benner, Jo Hammerman, John Ridings — 2011-11-04

Abstract: Objectives: The objectives of this study were to (1) gain an empirical understanding of how stakeholder (residents, family members, staff) groups view quality of life (QoL) for residents in long-term care; (2) create a visual map of the domain of QoL and describe differences in importance of key elements; and (3) identify key elements of QoL that could be used to develop a standardized assessment instrument for use in person-centered care planning.Design: This is a descriptive study, using a mixed-method, qualitative/quantitative approach called “concept mapping.”Setting: The study was conducted at a 240-bed skilled nursing facility located in a major metropolitan area. It is part of a not-for-profit religiously affiliated social service organization.Participants: A convenience sample included 3 groups of participants: staff members, family members of residents, and residents. Fifty-three people participated in the brain-storming sessions, and 45 people completed sorting and rating tasks. Sample sizes varied by group and by task.Measurements: Statements about the elements of QoL for residents in long-term care were elicited during 14 brain-storming sessions. Sorting and rating activities were completed using a final list of 88 items.Results: A visual map was generated, with 5 clusters of elements representing 5 conceptual areas within QoL. Importance ratings of elements were similar for family members and staff members, and a set of elements rated as high in importance but requiring attention to implementation was produced.Conclusions: Family members and staff produced similar conceptual models of QoL, and their views on the importance of the various elements were consistent. There was a high degree of consensus regarding elements considered least important and those considered most important. Elements considered most important addressed quality of care, autonomy and respect, and aspects of daily life, including food and sleep. There was less concern with the physical appearance of the facility, the amenities offered, and issues related to independence; however, all items scored above the mean of 2.5 on the 5-point rating scale. This project has shown that it is possible to use concept mapping methodology to obtain facility-specific information about stakeholders’ QoL perceptions in the long-term care setting, and that residents’ views can be assessed and incorporated.

Do SSRIs Play a Role in Decreasing Bone Mineral Density? - Corrected Proof

Fonda Chen, Theodore J. Hahn, Nancy T. Weintraub — 2011-10-31

Abstract: Osteoporosis is expected to increase as our population pyramid shifts toward old age. It is associated with increased risk of fractures, leading to complications of limitation of ambulation, loss of independence, and chronic pain. Depression is also a common occurrence in the elderly population. Currently, up to 35% of residents in long-term care may experience either major depression or clinically significant depressive symptoms. Selective serotonin receptor inhibitors constitute 62% of all antidepressant drug prescribing. Recently, serotonin transporters have been described in bone, raising the question of whether medications that block serotonin reuptake could affect bone metabolism and ultimately affect osteoporosis-related fractures. Current evidence suggests that depression, particularly in the setting of selective serotonin receptor inhibitors use, should be considered as an addition to the list of risk factors prompting clinicians to evaluate bone health status.

In-Hospital Cardiology Consultation and Evidence-Based Care for Nursing Home Residents with Heart Failure - Corrected Proof

2011-10-10

Abstract: Objectives: To determine the association between cardiology consultation and evidence-based care for nursing home (NH) residents with heart failure (HF).Participants: Hospitalized NH residents (n = 646) discharged from 106 Alabama hospitals with a primary discharge diagnosis of HF during 1998–2001.Design: Observational.Measurements of Evidence-Based Care: Preadmission estimation of left ventricular ejection fraction (LVEF) for patients with known HF (n = 494), in-hospital LVEF estimation for HF patients without known LVEF (n = 452), and discharge prescriptions of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs or ARBs) to systolic HF (LVEF <45%) patients discharged alive who were eligible to receive those drugs (n = 83). Eligibility for ACEIs or ARBs was defined as lack of prior allergy or adverse effect, serum creatinine lower than 2.5 mg/dL, serum potassium lower than 5.5 mEq/L, and systolic blood pressure higher than 100 mm Hg.Results: Preadmission LVEF was estimated in 38% and 12% of patients receiving and not receiving cardiology consultation, respectively (adjusted odds ratio [AOR], 3.49; 95% CI, 2.16–5.66; P < .001). In-hospital LVEF was estimated in 71% and 28% of patients receiving and not receiving cardiology consultation, respectively (AOR, 6.01; 95% CI, 3.69–9.79; P < .001). ACEIs or ARBs were prescribed to 62% and 82% of patients receiving and not receiving cardiology consultation, respectively (AOR, 0.24; 95% CI, 0.07–0.81; P = .022).Conclusion: In-hospital cardiology consultation was associated with significantly higher odds of LVEF estimation among NH residents with HF; however, it did not translate into higher odds of discharge prescriptions for ACEIs or ARBs to NH residents with systolic HF who were eligible for the receipt of these drugs.

Decreased Plasma Brain-Derived Neurotrophic Factor Levels in Institutionalized Elderly with Depressive Disorder - Corrected Proof

2011-09-23

Abstract: Objectives: To compare the differences in plasma brain-derived neurotrophic factor (BDNF) levels among institutionalized ethnic Chinese elderly participants with major depression, those with subclinical depression, and a nondepressed control group.Design: A cross-sectional study.Setting: The veterans' home in southern Taiwan.Participants: One hundred sixty-seven residents.Measurements: Questionnaires including the Minimum Data Set Nursing Home 2.1, Chinese-language version, and the short-form Geriatric Depression Scale, Chinese-language version. Depressive disorder was diagnosed by a well-trained psychiatrist using DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision) criteria. We measured plasma BDNF levels in the following 3 groups: nondepressive subjects (n = 122), subclinically depressive subjects (n = 33), and subjects with major depression (n = 12). Plasma BDNF was assayed using the sandwich ELISA method.Results: We noted a significantly negative association between age and plasma BDNF in the regression model. There was no significant correlation between BDNF plasma levels and body weight or platelet counts. We found that plasma BDNF was significantly lower in the major depressive group (mean, 115.1 pg/mL; SD, 57.2) than in the nondepressive group (mean, 548.8 pg/mL; SD, 370.6; P < .001). The BDNF plasma concentrations in the subclinically depressive group (mean, 231.8 pg/mL; SD, 92.4; P < .001) and control group were also significantly different.Conclusions: Our findings revealed that plasma BDNF levels were reduced not only in ethnic Chinese elderly patients with major depressive disorder but also in those with subclinical depression. This makes the plasma BDNF level a potential biological marker for clinical or subclinical depression.

Fall Prevention and Monitoring of Assisted Living Patients: An Exploratory Study of Physician Perspectives - Corrected Proof

Kirsten A. Nyrop, Sheryl Zimmerman, Philip D. Sloane, Srikant Bangdiwala — 2011-09-05

Abstract: Objective: Explore physician perspectives on their involvement in fall prevention and monitoring for residential care/assisted living (RC/AL) residents.Design: Exploratory cross-sectional study; mailed questionnaire.Setting: Four RC/AL communities, North Carolina.Participants: Primary physicians for RC/AL residents.Measurements: Past Behavior and future Intentions of physicians with regard to (1) fall risk assessment and (2) collaboration with RC/AL staff to reduce falls and fall risks among RC/AL residents were explored using Theory of Planned Behavior (TPB) constructs. Predictor variables examined (1) physicians’ views on their own responsibilities (Attitude), (2) their views of expectations from important referent groups (Subjective Norms), and (3) perceived constraints on engaging in fall prevention and monitoring (Perceived Behavioral Control).Results: Physicians reported conducting fall risk assessments of 47% of RC/AL patients and collaborating with RC/AL staff to reduce fall risks for 36% of RC/AL patients (Behavior). These proportions increased to 75% and 62%, respectively, for future Intentions. TPB-based models explained approximately 60% of the variance in self-reported Behavior and Intentions. Physician’s involvement in fall prevention and monitoring was significantly associated (P < .05) with their perceptions of barriers and facilitators—ease, time, reimbursement, and expertise.Conclusion: This study provides first data on physician beliefs regarding their involvement in fall risk assessment of RC/AL patients and collaboration with RC/AL staff to reduce fall risks of individual patients. Challenges to physician involvement identified in our study are not unique or specific to the RC/AL setting, and instead relate to clinical practice and reimbursement constraints in general.