Canadian Long-term Care Facilities Research Articles

Investigating the Prevalence and Predictors of Apathy among the Canadian Long-Term Care Residents: A Secondary Data Analysis.

In long-term care facilities (LTCF), apathy is a prevalent issue, leading to cognitive decline, functional impairment, and increased mortality risk. Despite its significance, apathy often remains underrecognized and undermanaged in these settings. Recognizing and addressing the predictors of apathy is critical for early intervention and improved care outcomes. This study aims to assess the prevalence of apathy and identify its associated risk factors among newly admitted residents in the Canadian LTCF, using the InterRAI Minimum Data Set (MDS 2.0). We conducted a cross-sectional analysis of MDS 2.0 admission assessment data between 2015 and 2019, covering 157,596 residents across six Canadian provinces and one territory. Apathy was measured using the Apathy Index of the MDS 2.0, with the biopsychosocial model guiding the analysis. The prevalence of apathy was 12.5% (19,758 individuals). The most significant predictors include cognitive impairments, specific age groups, hearing impairments, vision impairments, facility size and location. The findings of this study underscore the need for tailored strategies in LTCF to address apathy, considering individual, institutional, and regional variations. Emphasis on environmental and personal factors is crucial in the management and prevention of apathy in these settings.

"I haven't really gone through things like this": Young long-term care workers' experiences of working during the COVID-19 pandemic.

Long-term care (LTC) facilities were hard hit by the COVID-19 pandemic in Canada. Using life course theory concepts, we looked for conditions that led to worker moral distress -i.e. pain or anguish over not being able to take right action - and how life stage may influence experiences. To illuminate the experiences of adults under the age of 30 who stepped into, and/or persevered in, working in LTC during the pandemic, recognizing that this emerging workforce represents the future of LTC in Canada. This secondary analysis uses interview data from a sub-sample of 16 young workers between 18 and 29 years of age who had been working in Canadian LTC facilities for between 8 months and 7 years. Young workers expressed feeling guilt about mourning the loss of socially significant milestones as these milestones paled by comparison to the loss of life and consequences of resident isolation they witnessed at work. To manage feelings of moral distress, young workers attempted to maintain high standards of care for LTC residents and engaged in self-care activities. For some workers, this was insufficient and leaving the field of LTC was their strategy to respond to their mental health needs. The life stage of young LTC workers influenced their experiences of working during the COVID-19 pandemic. Interventions are needed to support young workers' wellbeing and job retention.

Cannabis use in a Canadian long-term care facility: a case study

BackgroundFollowing the legalization of cannabis in Canada in 2018, people aged 65 + years reported a significant increase in cannabis consumption. Despite limited research with older adults regarding the therapeutic benefits of cannabis, there is increasing interest and use among this population, particularly for those who have chronic illnesses or are at end of life. Long-term Care (LTC) facilities are required to reflect on their care and policies related to the use of cannabis, and how to address residents’ cannabis use within what they consider to be their home.MethodsUsing an exploratory case study design, this study aimed to understand how one LTC facility in western Canada addressed the major policy shift related to medical and non-medical cannabis. The case study, conducted November 2021 to August 2022, included an environmental scan of existing policies and procedures related to cannabis use at the LTC facility, a quantitative survey of Healthcare Providers’ (HCP) knowledge, attitudes, and practices related to cannabis, and qualitative interviews with HCPs and administrators. Quantitative survey data were analyzed using descriptive statistics and content analysis was used to analyze the qualitative data.ResultsA total of 71 HCPs completed the survey and 12 HCPs, including those who functioned as administrators, participated in the interview. The largest knowledge gaps were related to dosing and creating effective treatment plans for residents using cannabis. About half of HCPs reported providing care in the past month to a resident who was taking medical cannabis (54.9%) and a quarter (25.4%) to a resident that was taking non-medical cannabis. The majority of respondents (81.7%) reported that lack of knowledge, education or information about medical cannabis were barriers to medical cannabis use in LTC. From the qualitative data, we identified four key findings regarding HCPs’ attitudes, cannabis access and use, barriers to cannabis use, and non-medical cannabis use.ConclusionsWith the legalization of medical and non-medical cannabis in jurisdictions around the world, LTC facilities will be obligated to develop policies, procedures and healthcare services that are able to accommodate residents’ use of cannabis in a respectful and evidence-informed manner.

Barriers and facilitators to care for agitation and/or aggression among persons living with dementia in long-term care

BackgroundAgitation and/or aggression affect up to 60% of persons living with dementia in long-term care (LTC). It can be treated via non-pharmacological and pharmacological interventions, but the former are underused in clinical practice. In the literature, there is currently a lack of understanding of the challenges to caring for agitation and/or aggression among persons living with dementia in LTC. This study assesses what barriers and facilitators across the spectrum of care exist for agitation and/or aggression among people with dementia in LTC across stakeholder groups.MethodsThis was a qualitative study that used semi-structured interviews among persons involved in the care and/or planning of care for people with dementia in LTC. Participants were recruited via purposive and snowball sampling, with the assistance of four owner-operator models. Interviews were guided by the Theoretical Domains Framework and transcribed and analyzed using Framework Analysis.ResultsEighteen interviews were conducted across 5 stakeholder groups. Key identified barriers were a lack of agitation and/or aggression diagnostic measures, limited training for managing agitation and/or aggression in LTC, an overuse of physical and chemical restraints, and an underuse of non-pharmacological interventions. Facilitators included using an interdisciplinary team to deliver care and having competent and trained healthcare providers to administer non-pharmacological interventions.ConclusionsThis study advances care for persons living with dementia in LTC by drawing attention to unique and systemic barriers present across local and national Canadian LTC facilities. Findings will support future implementation research endeavours to eliminate these identified barriers across the spectrum of care, thus improving care outcomes among people with dementia in LTC.

Characterizing PRN Use of Psychotropic Medications for Acute Agitation in Canadian LTC Residents With Dementia Before and During COVID‐19

AbstractBackgroundAgitation is a prevalent and disabling neuropsychiatric symptom of dementia that comprises a constellation of behaviours involving excessive motor activity, physical aggression, and verbal aggression. Pro re nata (PRN) injections of antipsychotics and benzodiazepines can be administered for severe acute agitation, but best practices surrounding their use remain poorly characterized. The aim of this study was to compare the frequency of use of injectable PRN haloperidol, olanzapine, and lorazepam for acute agitation in Canadian long‐term care (LTC) residents with dementia before and during the COVID‐19 pandemic.MethodsA retrospective chart review was conducted for patients from two Canadian LTC facilities who had orders for PRN haloperidol, olanzapine, or lorazepam between January 1, 2018–May 1, 2019 (i.e. pre‐COVID‐19) and January 1, 2020–May 1, 2021 (i.e. COVID‐19). We reviewed electronic medical records to document PRN administrations of these psychotropic medications and collect data on age, sex, dementia diagnosis, days of observation, care type, medical history, and concomitant medications. Descriptive statistics and multivariate logistic and Poisson regression models were used to analyze the data.ResultsOf the 250 residents with dementia included, 45 of 103 (44%) people in the pre‐COVID‐19 period and 85 of 147 (58%) people in the COVID‐19 period with standing orders for injectable PRN haloperidol, olanzapine, or lorazepam received ≥1 injections of their prescribed medication. Haloperidol was the most frequently used agent (74% pre‐COVID‐19 and 81% during COVID‐19) and excessive motor activity (85% and 80%) was the most common indication for use in both time periods. Residents in the COVID‐19 period were two times more likely to receive PRN injections compared with those in the pre‐COVID‐19 period (OR = 1.96; 95% CI = 1.15‐3.34; p = 0.01). Count of injections per patient was not significantly different between the two time periods (IRR = 1.35; 95% CI = 0.78‐2.33; p = 0.3).ConclusionOur results contribute to the mounting evidence that agitation worsened in LTC residents with dementia during the pandemic and add to the limited existing literature on actual use of PRN psychotropic medications for acute agitation. The increased need for PRN rescue medications may be an indirect consequence of COVID‐19 restrictions, particularly the restrictions on socialization.

Moral Distress, Mental Health, and Risk and Resilience Factors among Canadian Armed Forces Personnel Deployed to Canadian Long-Term Care Facilities during COVID-19 (Operation LASER COVID-19 Response): Research Protocol and Participation Metrics.

The earliest days of the COVID-19 pandemic in Canada were marked by a significant surge in COVID cases and COVID-related deaths among residents of long-term care facilities (LTCF). As part of Canada's response to the COVID-19 pandemic, Canadian Armed Forces (CAF) personnel were mobilized for an initial emergency domestic deployment to the hardest-hit LTCFs (Operation LASER LTCF) to support the remaining civilian staff in ensuring the continued delivery of care to residents. Akin to what was observed following past CAF international humanitarian missions, there was an expected increased risk of exposure to multiple stressors that may be psychologically traumatic and potentially morally injurious in nature (i.e., related to important values; e.g., witnessing human suffering). The objective of the research study is to identify and quantify the individual-, group-, and organizational-level risk and resilience factors associated with moral distress, moral injury and traditional mental health and well-being outcomes of Operation (Op) LASER LTCF CAF personnel. The objective of this manuscript is to document the methodology, implementation procedures, and participation metrics. A multimethod research initiative was conducted, consisting of two primary data collection studies (a quantitative survey and qualitative interviews). The quantitative arm was a complete enumeration survey with online self-report questionnaires administered at three timepoints (3, 6, and 12 months post-deployment). The qualitative arm consisted of individual interviews conducted virtually, with a focus on understanding the nuanced lived experiences of individuals taking part in the Op LASER LTCF deployment. CAF personnel deployed to Op LASER LTCF (n = 2,595) were invited to participate in the study. Data collection is now complete. Overall, 1,088, 582, and 497 individuals responded to the survey at Time 1 (3 months), Time 2 (6 months), and Time 3 (12 months) post-deployment, providing a participation rate of 41.9%, 22.4%, and 19.2% for Time 1, Time 2, and Time 3, respectively. Data for all three timepoints was obtained from 212 participants (representing 19.5% of all Time 1 responses). Interest in participating in qualitative interviews surpassed expectations with over 200 individuals expressing interest; this allowed for purposive sampling across key characteristics, including gender, rank, Op LASER LTCF role, and province. In total, 53 interviews were conducted. The data generated by this research has the potential to inform and better understand the well-being and mental health of Op LASER LTCF personnel over time, identify general and Op LASER LTCF-specific risk and protective factors, provide necessary supports to the military personnel who served in this mission, and to inform preparation and interventions for future missions, especially those more of a domestic and humanitarian nature. DERR1-10.2196/44299.

Characterizing PRN Use of Psychotropic Medications for Acute Agitation in Canadian Long-Term Care Residents with Dementia Before and During COVID-19.

Agitation is a disabling neuropsychiatric symptom of dementia. Pro re nata (PRN) injections of psychotropics can be administered for severe acute agitation, but little is known about the frequency of their actual use. Characterize actual use of injectable PRN psychotropics for severe acute agitation in Canadian long-term care (LTC) residents with dementia and compare use before and during the COVID-19 pandemic. Residents from two Canadian LTC facilities with orders for PRN haloperidol, olanzapine, or lorazepam between January 1, 2018- May 1, 2019 (i.e., pre-COVID-19) and January 1, 2020- May 1, 2021 (i.e., COVID-19) were identified. Electronic medical records were reviewed to document PRN injections of psychotropic medications and collect data on reason and demographic characteristics. Descriptive statistics were used to characterize frequency, dose, and indications of use, and multivariate regression models were used to compare use between time periods. Of the 250 residents, 45 of 103 (44%) people in the pre-COVID-19 period and 85 of 147 (58%) people in the COVID-19 period with standing orders for PRN psychotropics received ≥1 injections. Haloperidol was the most frequently used agent in both time periods (74% (155/209 injections) pre-COVID-19; 81% (323/398 injections) during COVID-19). Residents in the COVID-19 period were almost two times more likely to receive injections compared with those in the pre-COVID-19 period (odds ratio = 1.96; 95% CI = 1.15-3.34; p = 0.01). Our results suggest that use of PRN injections increased in LTC during the pandemic and contribute to the mounting evidence that agitation worsened during that time.

Online Modules to Alleviate Burnout and Related Symptoms Among Interdisciplinary Staff in Long-Term Care: A Pre-post Feasibility Study.

The rising trend of providing palliative care to residents in Canadian long-term care facilities places additional demands on care staff, increasing their risk of burnout. Interventions and strategies to alleviate burnout are needed to reduce its impact on quality of patient care and overall functioning of healthcare organizations. To examine the feasibility of implementing online modules with the primary goal of determining recruitment and retention rates, completion time and satisfaction with the modules. A secondary goal was to describe changes in burnout and related symptoms associated with completing the modules. This single-arm, nonrandomized feasibility study was conducted in five long-term care sites of a publicly-funded healthcare organization in Vancouver, British Columbia, Canada. Eligible participants were clinical staff who worked at least 1day per month. A total of 103 study participants consented to participate, 31 (30.1%) of whom were lost to follow-up. Of the remaining 72 participants, 64 (88.9%) completed the modules and all questionnaires. Most participants completed the modules in an hour (89%) and found them easy to understand (98%), engaging (84%), and useful (89%). Mean scores on burnout and secondary traumatic stress decreased by .9 (95% CI: .1-1.8; d = .3) and 1.4 (95% CI: .4-2.4; d = .4), respectively; mean scores on compassion satisfaction were virtually unchanged. Modules that teach strategies to reduce burnout among staff in long-term care are feasible to deliver and have the potential to reduce burnout and related symptoms. Randomized controlled trials are needed to assess effectiveness and longer-term impact.

Institutional, therapeutic, and individual factors associated with 30-day mortality after COVID-19 diagnosis in Canadian long-term care facilities.

BackgroundCanadian long‐term care facility (LTCF) residents experienced higher death rates compared to other countries during the first wave of the COVID‐19 pandemic. This cohort study analyzes the individual, therapeutic, and institutional factors associated with death in LTCFs.MethodsInstitutional data for 17 LTCFs in Montreal, Canada were obtained from local administrative registries. Individual data for 1197 residents infected by SARS‐CoV‐2 between February 23 and July 11, 2020 were obtained through chart reviews. A multivariable modified Poisson regression model, which accounted for LTCF clustering, was used to identify resident and facility covariates associated with 30‐day mortality after COVID‐19 diagnosis.ResultsSevere shortage of licensed practical nurses (RR 2.60 95% CI 1.20–5.61) and medium‐sized facilities compared to smaller‐sized facilities (RR 2.73 95% CI 1.23–6.07) were associated with 30‐day mortality. Later COVID‐19 diagnosis (RR 0.98 95% CI 0.97–0.99 per additional day) was associated with survival. Individual risk factors for death included age (RR 1.33 95% CI 1.23–1.45 per additional 10 years), male sex (RR 1.46 95% CI 1.24–1.71), functional impairment (RR 1.08 95% CI 1.04–1.12 per unit increase of SMAF), as well as a diagnosis of congestive heart failure (RR 1.31 95% CI 1.04–1.66) and neurocognitive disorder (RR 1.31 95% CI 1.01–1.70). Among severe cases, anticoagulation was associated with survival (RR 0.70 95% CI 0.51–0.96).ConclusionsThis study identified practical nurse shortages and facility size as institutional risk factors for COVID‐19 death. Anticoagulation was associated with survival among severe cases.

Profile of Residents with Mental Disorders in Canadian Long-Term Care Facilities: A Cross-Sectional Study

<strong>Brief Summary:</strong> Residents in long-term care facilities in Canada with mental and cognitive disorders have complex care needs. To meet these needs an integrated model of care is recommended. <strong>Context:</strong> The high prevalence of mental disorders in residents of long-term care (LTC) facilities raises serious concerns for facility operators and staff. These residents have multiple vulnerabilities that facility staff should have the necessary knowledge and skills to properly meet their needs. <strong>Objectives:</strong> To describe the profile of residents with mental disorders (MD) and Alzheimer’s Disease and Related Dementias (ADRD) in Canadian long-term care (LTC) facilities. <strong>Findings:</strong> Seventy-six percent of residents had MD (40%) and ADRD (36%). These residents compared to those without such disorders were more likely to be cognitively impaired, manifest aggressive behavior, receive psychotropic drugs, and physically restrained, and less likely to be socially engaged. <strong>Strengths and Limitations:</strong> The large representative sample was a key strength. The findings add to the knowledge about the profile of LTC residents. The cross-sectional design of the study limits the findings to the population studied. <strong>Implications:</strong> Residents with MD and ADRD compared to those without such disorders are highly vulnerable because of their double burden of mental and physical comorbidities. Their profile may be of interest to LTC facility operators, clinicians, and policy makers about their complex care needs. Our findings raise awareness of the need for trained LTC facility staff for knowledge and skills in psychogeriatric conditions to assess, plan, and implement appropriate interventions for these residents. Coordinated and integrated models of care with access to psychogeriatric specialists such as psychiatrists or advanced practice nurses will also be of benefit to them.

Multifaceted strategies for the control of COVID-19 outbreaks in long-term care facilities in Ontario, Canada

The novel coronavirus disease 2019 (COVID-19) has caused severe outbreaks in Canadian long-term care facilities (LTCFs). In Canada, over 80% of COVID-19 deaths during the first pandemic wave occurred in LTCFs. We sought to evaluate the effect of mitigation measures in LTCFs including frequent testing of staff, and vaccination of staff and residents. We developed an agent-based transmission model and parameterized it with disease-specific estimates, temporal sensitivity of nasopharyngeal and saliva testing, results of vaccine efficacy trials, and data from initial COVID-19 outbreaks in LTCFs in Ontario, Canada. Characteristics of staff and residents, including contact patterns, were integrated into the model with age-dependent risk of hospitalization and death. Estimates of infection and outcomes were obtained and 95% credible intervals were generated using a bias-corrected and accelerated bootstrap method. Weekly routine testing of staff with 2-day turnaround time reduced infections among residents by at least 25.9% (95% CrI: 23.3%–28.3%), compared to baseline measures of mask-wearing, symptom screening, and staff cohorting alone. A similar reduction of hospitalizations and deaths was achieved in residents. Vaccination averted 2–4 times more infections in both staff and residents as compared to routine testing, and markedly reduced hospitalizations and deaths among residents by 95.9% (95% CrI: 95.4%–96.3%) and 95.8% (95% CrI: 95.5%–96.1%), respectively, over 200 days from the start of vaccination. Vaccination could have a substantial impact on mitigating disease burden among residents, but may not eliminate the need for other measures before population-level control of COVID-19 is achieved.

Developing an RAI-MDS Behavior-Based Pain Scale for Long-Term Care Residents With Advanced Dementia

In Canadian and many international long-term care (LTC) facilities, pain assessment frequently relies on data from the Resident Assessment Instrument – Minimum Data Set 2.0 (RAI-MDS). The RAI-MDS produces a two-item scale, measuring both pain frequency and pain intensity. This scale correlates well with self-reported pain in cognitively intact LTC residents, but despite repeated testing, is less valid for use in residents with more advanced cognitive impairment who are unable to self-report their pain. In this study we aimed to develop and validate a behaviour-based pain assessment scale for long-term care residents using data available in the RAI-MDS. To construct our initial scale, we reviewed the literature and compiled a list of observable indicators of pain (e.g., grimacing) and linked these with 28 similar items available in the RAI-MDS. Using Delphi techniques, we further refined this to 20 items. We then evaluated the psychometric properties of our scale using two independent, representative samples, of urban LTC residents in Western Canada. Exploratory factor analyses were conducted in sample one (n=16,282) and confirmatory factor analyses (CFA) were then conducted in sample two (n=15,785) in order to test, and confirm, our model. A two-factor solution was identified grouping RAI-MDS items into subscales 1) change in status (e.g., new onset restlessness) and 2) behaviours (e.g., crying). Commonly recognized model fit indices were acceptable suggesting the adequacy of the two-factor solution. Results provide preliminary support for the use of behavioural-based pain assessment scale using RAI-MDS data. Further evaluation and validation of our scale is warranted.

The use of laboratory-identified event surveillance to classify adverse outcomes due to Clostridioides difficile infection in Canadian long-term care facilities.

Adverse outcomes following Clostridioides difficile infection (CDI) are not often reported for long-term care facility (LTCF) residents. We focused on the adverse outcomes due to CDI identified in Alberta LTCFs. All positive Clostridioides difficile stool specimens identified by laboratory-identified (LabID) event surveillance in Alberta from 2011 to 2018, along with Alberta Continuing Care Information System, were used to define CDI in Alberta LTCFs. CDI cases were classified as long-term care onset, hospital onset, and community onset. Laboratory records were linked to provincial databases to analyze acute-care admissions and mortality within 30-day post CDI. Age, sex, case classification, episode, and operator type, were investigated using logistic regression. Overall, 902 CDI cases were identified in 762 LTCF residents. Of all CDI events, 860 (95.3%) were long-term care onset, 38 (4.2%) were hospital onset, and 4 (0.4%) were community onset. The CDI rate was 2.0 of 100,000 resident days. In total, 157 residents (20.6%) had 30-day all-cause mortality, 126 CDI cases (14.0%) had 30-day all-cause acute-care admissions. The 30-day all-cause mortality rate was significantly higher in residents aged >80 versus ≤80 years (24.9 vs 12.3 per 100 residents; P < .05). Residents aged >80 years, with hospital-onset CDI, and those staying in private or voluntary LTCFs were more likely to have 30-day all-cause acute-care admissions. The prevalence of CDI adverse outcomes is in LTCFs was found to be high using LabID event surveillance. Annual review of CDI adverse outcomes using LabID event can minimize the burden of surveillance and standardize the process across all Alberta LTCFs.

Provincial legislative and regulatory standards for pain assessment and management in long-term care homes: a scoping review and in-depth case analysis

BackgroundAmong Canadian residents living in long-term care (LTC) facilities, and especially among those with limited ability to communicate due to dementia, pain remains underassessed and undermanaged. Although evidence-based clinical guidelines for the assessment and management of pain exist, these clinical guidelines are not widely implemented in LTC facilities. A relatively unexplored avenue for change is the influence that statutes and regulations could exert on pain practices within LTC. This review is therefore aimed at identifying the current landscape of policy levers used across Canada to assess and manage pain among LTC residents and to evaluate the extent to which they are concordant with evidence-based clinical guidelines proposed by an international consensus group consisting of both geriatric pain and public policy experts.MethodsUsing scoping review methodology, a search for peer-reviewed journal articles and government documents pertaining to pain in Canadian LTC facilities was carried out. This scoping review was complemented by an in-depth case analysis of Alberta, Saskatchewan, and Ontario statutes and regulations.ResultsAcross provinces, pain was highly prevalent and was associated with adverse consequences among LTC residents. The considerable benefits of using a standardized pain assessment protocol, along with the barriers in implementing such a protocol, were identified. For most provinces, pain assessment and management in LTC residents was not specifically addressed in their statutes or regulations. In Alberta, Saskatchewan, and Ontario, regulations mandate the use of the interRAI suite of assessment tools for the assessment and reporting of pain.ConclusionThe prevalence of pain and the benefits of implementing standardized pain assessment protocols has been reported in the research literature. Despite occasional references to pain, however, existing regulations do not recommend assessments of pain at the frequency specified by experts. Insufficient direction on the use of specialized pain assessment tools (especially in the case of those with limited ability to communicate) that minimize reliance on subjective judgements was also identified in current regulations. Existing policies therefore fail to adequately address the underassessment and undermanagement of pain in older adults residing in LTC facilities in ways that are aligned with expert consensus.

Long-term care as contested acoustical space: Exploring resident relationships and identitiesinsound

As the global population ages, residential care facilities are challenged to create positive living environments for people in later life. Health care acoustics are increasingly recognized as a key design factor in the experience of well-being for long-term care residents; however, acoustics are being conceptualized predominantly within the medical model. Just as the modern hospital battles disease with technology, sterility and efficiency, health care acoustics are receiving similar treatment. Materialist efforts towards acoustical separation evoke images of containment, quarantine and control, as if sound was something to be isolated. Sound becomes part of the contested space of long-term care that exists in tension between hospital and home. The move towards acoustical separation denies the social significance of sound in residents’ lives. Sound does not displace care; it emplaces care and the social relationships therein. Drawing upon ethnographic fieldwork in a Canadian long-term care facility, this article will use a phenomenological lens to explore how relationships are shaped in sound among residents living in long-term care. Ethnographic vignettes illustrate how the free flow of music through the care unit incited collective engagement among residents, reduced barriers to sharing social space and constructed new social identity. The article concludes that residents’ relationships are shaped within the acoustical milieu of the care unit and that to impose acoustical separation between residents’ living spaces may further isolate residents who are already at risk of loneliness.

REDUCING ANTIPSYCHOTIC USE IN LONG-TERM CARE: CONSIDERING THE ROLE OF CULTURE OF CARE AND INFORMAL COMMUNICATION

Persons living with dementia-related disorders (PwD) can experience challenging behavioural and psychological symptoms (BPSD) as their illness progresses. There is a continued reliance on antipsychotic drugs (APD) in long-term care to manage this issue despite the well-documented risks of adverse events and increased morbidity and mortality. This study examines the role of culture of care in relation to efforts at reducing inappropriate APD use in managing BPSD within long-term care. Culture of care consists of shared norms, beliefs, and cognitive frames which guide clinical practice and inform the development and implementation of care strategies. Findings were obtained from three Canadian long-term care facilities working on reducing inappropriate use of APD. Data came from interviews with 6 nurses, 18 licenced practical nurses, 14 health care assistants, 4 activity leaders, 4 directors of care, 1 chaplain, and 10 physicians. We found that direct care providers initially varied in their perceived ability to develop and use alternate care strategies with health care assistants being most concerned about safety and exposure to violence. Change involved detective work and innovative thinking in assessing possible causes of BPSD beyond psychosis, including pain and feelings of confusion. Informal reciprocal patterns of communication emerged among health care assistants to identify effective non-pharmaceutical strategies to manage BPSD. Overall, the study shows how shared beliefs in the need for and value of alternate care practices among direct care providers along with the existence of effective informal communication can contribute to successful reduction in APD use when managing BPSD in PwD.

Optimizing Prescribing of Antipsychotics in Long-Term Care (OPAL): A Stepped-Wedge Trial

BackgroundInappropriate antipsychotic prescribing is a key quality indicator by which clinical outcomes might be monitored and improved in long-term care (LTC), but limited evidence exists on the most effective strategies for reducing inappropriate antipsychotic use. ObjectivesThe objective of the study was to evaluate a multicomponent approach to reduce inappropriate prescribing of antipsychotics in LTC. DesignA prospective, stepped-wedge study design was used to evaluate the effect of the intervention. Settings and participantsInterdisciplinary staff at 10 Canadian LTC facilities. MethodsThe intervention consisted of an educational in-service, provision of evidence-based tools to assess and monitor neuropsychiatric symptoms (NPS) in dementia, and monthly interprofessional team meetings. The primary outcome was the proportion of residents receiving an antipsychotic without a diagnosis of psychosis using a standardized antipsychotic quality indicator. ResultsThe weighted mean change in inappropriate antipsychotic prescribing rate from baseline to 12-month follow-up was −4.6% [standard deviation (SD) = 2.8%, P < .0001], representing a 16.1% (SD = 17.0) relative reduction. After adjusting for site, the odds ratio for the inappropriate antipsychotic prescribing quality indicator at 12 months compared to baseline was 0.73 (95% confidence interval = 0.48-0.94; chi-square = 6.59; P = .01). There were no significant changes in related quality indicators, including falls, restraint use, or behavioral symptoms. Conclusions and implicationsThis multicomponent intervention was effective in reducing inappropriate antipsychotic prescribing in LTC without adversely affecting other domains related to quality of care, and offers a practical means by which to improve the care of older adults with dementia in LTC.

A Profile of Regulated Nurses Employed in Canadian Long-Term Care Facilities-CORRIGENDUM.

A Profile of Regulated Nurses Employed in Canadian Long-Term Care Facilities-CORRIGENDUM.

A Profile of Regulated Nurses Employed in Canadian Long-Term Care Facilities.

ABSTRACTRegistered nurses (RNs) and licensed practical nurses (LPNs) provide the skilled component of nursing care in Canadian residential long-term care facilities, yet we know little about this important workforce. We surveyed 309 RNs and 448 LPNs from 91 nursing homes across Western Canada and report descriptively on their demographics and work and health-related outcomes. LPNs were significantly younger than RNs, worked more hours, and had less nursing experience. LPNs also experienced significantly more dementia-related responsive behaviours from residents compared to RNs. Younger LPNs and RNs reported significantly worse burnout (emotional exhaustion) and poorer mental health compared to older age groups. Significant differences in demographics and work- and health-related outcomes were also found within the LPN and RN samples by province, region, and owner-operator model. These findings can be used to inform important policy decisions and workplace planning to improve quality of work life for nurses in residential long-term care facilities.

Re-socialising sound: investigating sound, selfhood and intersubjectivity among people living with dementia in long-term care

ABSTRACTOver the last decades, an increasing amount of attention has been given to the acoustical environments of health care settings. Through innovative multi-disciplinary research and practice, sound in health care is being conceptualised as an object to be measured, controlled and minimised to improve individual well-being and health outcomes. Among the settings and populations being addressed are people living with dementia in residential long-term care. The trend toward acoustical separation between people overlooks the social possibilities of sound in care settings. This paper argues that we should resist narrow conceptualisations of sound as unwanted noise that must be reduced, and that sound should still be considered as a social tool. Drawing upon fieldwork in a Canadian long-term care facility among people living with dementia, ethnographic vignettes illustrate the significance of sound for selfhood and social relationship. Tensions between institutional control and acoustical agency are discussed, as well as implications for biomedical understandings of dementia as a loss of self. The paper concludes with a discussion of future research directions.