American Medical Directors Association Research Articles

Comment on "Multicomponent or Resistance Training for Nursing Home Residents: A Systematic Review With Meta-Analysis".

We read a recent article published in the Journal of the American Medical Directors Association by Pinheiro et al.1 The results of this meta-analysis suggest that multicomponent exercise and resistance training can improve physical performance in institutionalized older adults. However, several issues deserve further discussion with the authors.

974 ASSOCIATION BETWEEN NOTTINGHAM HIP FRACTURE SCORE AND FRAILTY IN ELDERLY ACUTE HIP FRACTURE PATIENTS

Abstract Introduction Nottingham Hip Fracture Score (NHFS) is a well validated risk stratification tool that has been shown to predict 30 day mortality in elderly patients with acute hip fractures. A lot of older patients that sustain hip fractures are frail. The Rockwood Clinical Frailty Scale (CFS) has been validated as a tool to screen for frailty in acutely ill patients and has been shown to predict outcomes in acutely ill elderly patients. The aim of this study was to determine if there is any correlation between the NHFS and CFS in elderly patients with acute hip fractures and to evaluate the effect of gender on this correlation. Method A retrospective, cross-sectional analysis was carried out on patients admitted with acute hip fractures between January and December 2019 in a single centre trauma and orthopaedic unit. Data was extracted from anonymized electronic patient records. Patients were included if they were 60 years and above; those less than 60 were excluded. Patients with missing data were excluded from analysis. NHFS and CFS were calculated in these patients. SPSS 27 IBM software was used for statistical analysis. Baseline characteristics were calculated using descriptive statistics and spearman’s correlation co-efficient and linear regression were used to determine correlation. Results A total of 268 patients were analysed—65 males and 202 females. Mean age was 83 years (SD 8.5). There was statistically significant positive correlation between NHFS and CFS in all patients, male patients and female patients (r = 0.589; p < 0.001, r = 0.603; p < 0.001, and r = 0.599; p < 0.001 respectively). Conclusion NHFS is positively correlated with CFS in elderly acute hip fracture patients. Reference(s) Doherty W.J, Stubbs T.A et al. Prediction of Postoperative Outcomes Following Hip Fracture Surgery: Independent Validation and Recalibration of the Nottingham Hip Fracture Score. Journal of the American Medical Directors Association;22(3):663–669.e2.

Social Isolation of Older Adults in Long Term Care as a Result of COVID-19 Mitigation Measures During the COVID-19 Pandemic

Social Isolation of Older Adults in Long Term Care as a Result of COVID-19 Mitigation Measures During the COVID-19 Pandemic

A Better World in the Future: Part 2

A Better World in the Future: Part 2

A Wasteful and Harmful Practice: Sliding Scale Insulin Use Among Nursing Home Veterans

The American Medical Directors Association and the American Diabetes Association discourage the use of sliding scale insulin (SSI) in nursing home residents with diabetes due to its association with hypoglycemia, hyperglycemia, nursing burden, and patient discomfort. However, prevalence of SSI use is unclear. We used Veterans Affairs (VA) data from October 2013 to September 2016 to determine the weekly prevalence of SSI among 22,847 veterans with diabetes admitted to VA nursing homes (NHs). Average age was 75.3 (SD 8.3) years, mean A1c was 7.3% (SD 1.6%) and 57% were admitted from hospital. We first identified residents receiving any short-acting insulin. We then classified short-acting insulin use into three mutually exclusive regimens: (1) fixed scheduled doses, (2) SSI, defined as a variable dose of short-acting insulin without a concurrent fixed dose or (3) bolus with correction (BWC), defined as a variable dose given concurrently with a fixed dose that day. During the first week of NH admission, 64.7% of residents with diabetes received no short-acting insulin, 7.4% received fixed scheduled doses, 6.3% received BWC and 21.4% were on SSI. At week 12, the prevalence of fixed dose and BWC regimens was unchanged from baseline (fixed dose = 8.4%; BWC = 7.0%). In contrast, the prevalence of SSI decreased weekly to 15.8% (p for linear trend < 0.0001). Although SSI prevalence decreased from week 1 to week 12, 51% of residents on short-acting insulin were still using SSI in their 12th week of their NH stay.

Editorial introductions

Editorial introductions

Our sea: Music therapy in dementia and end-of-life care in the Mediterranean region

Our sea: Music therapy in dementia and end-of-life care in the Mediterranean region

Quality Improvement in Dementia Care: Dementia Management Quality Measurement Set 2018 Implementation Update

The Dementia Management Quality Measurement Set was first developed and released in 2013 by the PCPI Foundation1 (formerly the American Medical Association [AMA]–convened Physician Consortium for Performance Improvement [PCPI]). Developed by an appointed multistakeholder technical expert panel (TEP), the 2013 Measurement Set was supported by staff from AMA, American Academy of Neurology Institute (AANI), American Psychiatric Association (APA), American Medical Directors Association, and American Geriatric Society. Several of the original measures were included into the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System after being finalized through the federal rulemaking process (table 1).

Quality improvement in dementia care: Dementia Management Quality Measurement Set 2018 Implementation Update.

The Dementia Management Quality Measurement Set was first developed and released in 2013 by the PCPI Foundation1 (formerly the American Medical Association [AMA]–convened Physician Consortium for Performance Improvement [PCPI]). Developed by an appointed multistakeholder technical expert panel (TEP), the 2013 Measurement Set was supported by staff from AMA, American Academy of Neurology Institute (AANI), American Psychiatric Association (APA), American Medical Directors Association, and American Geriatric Society. Several of the original measures were included into the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System after being finalized through the federal rulemaking process (table 1).

Editorial introductions

Editorial introductions

What Makes Consumers Satisfied?

What Makes Consumers Satisfied?

Medical Directors: Why Do You Abdicate Your Advocacy With Nursing Homes?

Medical Directors: Why Do You Abdicate Your Advocacy With Nursing Homes?

The Power of a Toothbrush

The Power of a Toothbrush

Editorial introductions

Editorial introductions

LUDWIG: A CONVERSATIONAL ROBOT FOR PEOPLE WITH ALZHEIMER'S

Assistive robotics are being produced to improve the quality-of-life for people with Alzheimer's disease (AD), including aid in activities of daily living. Recently, computer programs based on the statistics of human dialogue have been shown to reduce the cost of hand-crafting complex dialogue systems. Of these, one increasingly popular approach is the partially-observable Markov decision process (POMDP). Here, dialogue is represented as statistical relationships between observations (i.e., the words spoken and other linguistic/acoustic aspects of speech), unknown states (e.g., the participant's current level of confusion), and actions that can be performed (i.e., the computer's own speech output). We have recently built POMDPs to detect and avoid trouble-indicating behaviors (TIBs), with 82% and 96.1% accuracy, respectively, in the speech of people with AD. We are developing software that uniquely embodies TIB detection, avoidance, and recovery in dialogue within an on-line assistive robot, called Ludwig. Twelve individuals with AD have been recruited from a clinical care partner. In each of three sessions, participants describe a series of photographs shown on a tablet computer, and answer questions posed by an interviewer. In the first session, the interviewer is a human volunteer. The second session replaces them with the robot Ludwig, controlled remotely. In the third session, we use a completely automated system based on recent work to avoid confusion. At the time of the conference, all three sessions will have been completed for each participant. Preliminary qualitative analysis indicates broad interest in the project, and in Ludwig specifically, but issues related to attention and executive function in participants remain a challenge. Success with the task varies directly with the cognitive status of the older adult with AD, as measured by a mini-mental state exam. Future work must focus on extra-linguistic means of interaction to focus the attention of the older adult with AD. 1. Brodaty H, Connors MH, Xu J, Woodward M, Ames D, Group PS. The course of neuropsychiatric symptoms in dementia: A 3-year longitudinal study. Journal of the American Medical Directors Association. 2015;16(5):380–387. 2. Sadak TI, Katon J, Beck C, Cochrane BB, Borson S. Key neuropsychiatric symptoms in common dementias: prevalence and implications for caregivers, clinicians, and health systems. Research in gerontological nursing. 2014;7(1):44. 3. Steinberg M, Shao H, Zandi P, et al. Point and 5-year period prevalence of neuropsychiatric symptoms in dementia: the Cache County Study. International journal of geriatric psychiatry. 2008;23(2):170. 4. Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologic management of behavioral symptoms in dementia. JAMA. 2012;308(19):2020–2029. 5. Kales HC, Gitlin LN, Lyketsos CG. State of the Art Review: Assessment and management of behavioral and psychological symptoms of dementia. BMJ: British Medical Journal. 2015;350.

What Are Nursing Facilities Doing to Reduce Potentially Avoidable Hospitalizations?

ObjectivesHospitalizations among nursing facility residents are frequent and often potentially avoidable. A number of initiatives and interventions have been developed to reduce excessive hospitalizations; however, little is known about the specific approaches nursing facilities use to address this issue. The objective of this study is to better understand which types of interventions nursing facilities have introduced to reduce potentially avoidable hospitalizations of long-stay nursing facility residents. DesignCross-sectional survey. Setting236 nursing facilities from 7 states. ParticipantsNursing facility administrators. MeasurementsWeb-based survey to measure whether facilities introduced any policies or procedures designed specifically to reduce potentially avoidable hospitalizations of long-stay nursing facility residents between 2011 and 2015. We surveyed facilities about seven types of interventions and quality improvement activities related to reducing avoidable hospitalizations, including use of Interventions to Reduce Acute Care Transfers (INTERACT) and American Medical Directors Association tools. ResultsNinety-five percent of responding nursing facilities reported having introduced at least one new policy or procedure to reduce nursing facility resident hospitalizations since January 2011. The most common practice reported was hospitalization rate tracking or review, followed by standardized communication tools, such as Situation, Background, Assessment, Recommendation (SBAR). We found some variation in the extent and types of these reported interventions. ConclusionsNearly all facilities surveyed reported having introduced a variety of initiatives to reduce potentially avoidable hospitalizations, likely driven by federal, state, and corporate initiatives to decrease hospital admissions and readmissions.

Sliding-Scale Insulin Use in Long-Term Care: An Updated Perspective.

Diabetes affects approximately 26% of individuals oldeR THAN 65 years of age in the United States and up to 33% of patients in long-term care facilities. The most commonly prescribed insulin therapy for patients in long-term care is sliding-scale insulin (SSI): the use of finger-stick blood glucose testing to assess the need for insulin administration based on current blood glucose levels. SSI has been on the Beers Criteria of Potentially Inappropriate Medications since 2012. However, its sole use for long-term treatment is specifically not recommended by the American Diabetes Association and other stakeholders in diabetes management. This review discusses recent updates to several published guidelines, including Centers for Medicare & Medicaid Services, the Beers criteria, the American Medical Directors Association, and the American Diabetes Association regarding the use of SSI-only insulin regimens for elderly patients in long-term care.

Editorial introductions

Editorial introductions

An International Position Statement on the Management of Frailty in Diabetes Mellitus: Summary of Recommendations 2017.

The International Position Statement provides the opportunity to summarise all existing clinical trial and best practice evidence for older people with frailty and diabetes. It is the first document of its kind and is intended to support clinical decisions that will enhance safety in management and promote high quality care. The Review Group sought evidence from a wide range of studies that provide sufficient confidence (in the absence of grading) for the basis of each recommendation. This was supported by a given rationale and key references for our recommendations in each section, all of which have been reviewed by leading international experts. Searches for any relevant clinical evidence were generally limited to English language citations over the previous 15 years. The following databases were examined: Embase, Medline/PubMed, Cochrane Trials Register, Cinahl, and Science Citation. Hand searching of 16 key major peer-reviewed journals was undertaken by two reviewers (AJS and AA) and these included Lancet, Diabetes, Diabetologia, Diabetes Care, British Medical Journal, New England Journal of Medicine, Journal of the American Medical Association, Journal of Frailty and Aging, Journal of the American Medical Directors Association, and Journals of Gerontology - Series A Biological Sciences and Medical Sciences. Two scientific supporting statements have been provided that relate to the area of frailty and diabetes; this is accompanied by evidence-based decisions in 9 clinical domains. The Summary has been supported by diagrammatic figures and a table relating to the inter-relations between frailty and diabetes, a frailty assessment pathway, an exercise-based programme of intervention, a glucose-lowering algorithm with a description of available therapies. We have provided an up to date evidence-based approach to practical decision-making for older adults with frailty and diabetes. This Summary document includes a user-friendly set of recommendations that should be considered for implementation in primary, community-based and secondary care settings.

Sarcopenia in Orthopedic Surgery.

Sarcopenia is a loss of skeletal muscle mass in the elderly that is an independent risk factor for falls, disability, postoperative complications, and mortality. Although its cause is not completely understood, sarcopenia generally results from a complex bone-muscle interaction in the setting of chronic disease and aging. Sarcopenia cannot be diagnosed by muscle mass alone. Diagnosis requires 2 of the following 3 criteria: low skeletal muscle mass, inadequate muscle strength, and inadequate physical performance. Forty-four percent of elderly patients undergoing orthopedic surgery and 24% of all patients 65 to 70 years old are sarcopenic. Although dual-energy x-ray absorptiometry and bioelectrical impedance analysis may be used to measure sarcopenia and are relatively inexpensive and accessible, they are generally considered less specific for sarcopenia compared with computed tomography and magnetic resonance imaging. Sarcopenia has been shown to predict poor outcomes within the medical and surgical populations and has been directly correlated with increases in taxpayer costs. Strengthening therapy and nutritional supplementation have become the mainstays of sarcopenia treatment. Specifically, the American Medical Directors Association has released guidelines for nutritional supplementation. Although sarcopenia frequently occurs with osteoporosis, it is an independent predictor of fragility fractures. Initiatives to diagnose, treat, and prevent sarcopenia in orthopedic patients are needed. Further investigation must also explore sarcopenia as a predictor of surgical outcomes in orthopedic patients.