Long-term Nursing Facility Research Articles

Scheduling Smarter: Scheduling Decision Impact on Nurse-Aide Turnover

Research problem: High turnover rates in long-term nursing facilities exacerbate the existing shortage of caregivers, a trend that will only worsen as the population of the United States ages. Part-time certified nursing assistants (CNAs) provide a significant amount of patient care in these facilities. CNAs also have high annual rates of turnover, which can harm health outcomes and increase the cost of care. In this study, we empirically analyze the effect of scheduling decisions on part-time CNA turnover. We explore three research questions that examine both how much and with whom a CNA is scheduled to work. We seek to empirically answer how (1) hours worked and (2) coworker variability influence turnover for part-time CNAs and if (3) coworker variability moderates the relationship between hours worked and CNA turnover. Methodology/results: Using novel data from one of the nation’s largest nursing home organizations, which includes data for 6,221 part-time CNAs at 157 facilities in the United States over a 26-month period, we identify two scheduling levers managers may be able to use to influence turnover. As hours worked increase, turnover first decreases and then increases, demonstrating a nonlinear U-shaped relationship between hours worked and turnover. We also find that high coworker variability increases turnover while also moderating the effects of hours worked on turnover. In post hoc analyses, we demonstrate that high CNA turnover has negative impacts on patient health. Managerial implications: These findings suggest that managers may be able to leverage part-time CNA scheduling to reduce turnover, improving both the quality and cost of care. Specifically, we demonstrate that managers can reduce CNA turnover by increasing hours worked, scheduling coworkers together consistently and doing both simultaneously. Supplemental Material: The online appendices are available at https://doi.org/10.1287/msom.2021.0533 .

Co-existence of malnutrition and sarcopenia and its related factors in a long-term nursing care facility: A cross-sectional study

ObjectivesMalnutrition and sarcopenia often co-exist in older patients. This condition, called co-MS, shows a worse prognosis than either condition alone but is often overlooked and undertreated. We aimed to clarify the prevalence of co-MS and its associated factors with a focus on prescription in a long-term nursing care facility in Japan. MethodsPatients aged >65 years who resided in a long-term nursing care facility in Hyogo, Japan, were recruited for this cross-sectional study, which was conducted from July 1 to July 30, 2022. Sarcopenia and malnutrition were diagnosed using the Asian Working Group for Sarcopenia and Global Leadership Initiative on Malnutrition criteria, respectively. Patients who met both criteria were classified as having co-MS. Potentially associated factors, including age, sex, length of stay, activities of daily living, comorbidity, oral function and hygiene, swallowing ability, and the number and type of prescriptions, were assessed. ResultsThe prevalence of sarcopenia was 92 % (72/78). All malnourished patients were sarcopenic (40.3 %) and were classified as having co-MS. Oral function and hygiene, swallowing ability, comorbidity, and the presence of potentially inappropriate medications showed significant associations in univariate analyses. Of particular note, potentially inappropriate medication was an independent factor in the multivariate analysis. ConclusionsCo-MS is prevalent in long-term nursing care facilities; thus, healthcare workers should pay attention to relevant factors to identify patients at risk of co-MS and to provide appropriate care and intervention.

Outcomes for Long-Stay Nursing Facility Residents Following On-Site Acute Care under a CMS Initiative

ObjectivesThe goal of this study was to describe outcomes of long-term nursing facility (NF) residents treated for one of 6 conditions on-site in the NF and to compare outcomes to those treated for the same conditions in the hospital. DesignCross-sectional retrospective study. Settings and ParticipantsThe Centers for Medicare & Medicaid Services (CMS) Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents—Payment Reform enabled participating NFs to bill Medicare for providing on-site care to eligible long-stay residents meeting specified severity criteria due to any of 6 medical conditions, as an alternative to hospitalization. For billing purposes, residents were required to meet clinical criteria severe enough to warrant hospitalization. MethodsWe used the Minimum Data Set assessments to identify eligible long-stay NF residents. We used Medicare data to identify residents who were treated, either on-site or in the hospital, for the 6 conditions and measure outcomes including subsequent hospitalization and death. To compare residents treated in the 2 modes, we used logistic regression models and adjusted for demographics, functional and cognitive status, and comorbidities. ResultsAmong residents treated on-site for the 6 conditions, 13.6% were subsequently hospitalized and 7.8% died, within 30 days, compared to 26.5% and 17.0%, respectively, among those treated in the hospital. Based on multivariate analysis, those treated in the hospital were more likely to be readmitted (OR = 1.666, P < .001) or to die (OR = 2.251, P < .001). Conclusions and ImplicationsAlthough unable to fully account for differences in unobserved severity of illness between residents treated on-site vs in the hospital, our results do not indicate any harm, but rather a possible benefit, to being treated on-site.

Air temperature and incidence of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae

BackgroundHigher outdoor temperature may be related to an increase in antibiotic resistant bacteria. We investigated the association between local outdoor air temperature and the incidence of extended-spectrum betalactamase (ESBL)-producing Enterobacteriaceae (ESBL-PE) correcting for known drivers of antibiotic resistance. MethodsWe performed a time-series regression study using prospectively collected weekly surveillance data on all ESBL-PE isolated from in- and outpatients of the University Hospital Basel, a tertiary care center in Switzerland, between 01/2008–12/2017. Temperature was measured hourly at the meteorological institute of the University Basel next to our institution over this time period. A time-series approach using a Poisson regression model and different lag terms for delayed exposure effects was performed to assess associations between minimal, mean and maximal weekly temperature and the number of ESBL-PE recovered. ResultsOver 10 years, recovery of ESBL-PE increased (annual incidence rate ratio [IRR] 1.14, 95%CI 1.13–1.16), while mean weekly temperature measures remained stable. In multivariable analyses, increasing temperature was associated with higher recovery rates of ESBL-PE after three to four weeks, correcting for potential confounders, such as the number of admissions, proportion of long-term nursing facility- and ICU-admissions, age, Charlson comorbidity index and consumption of antimicrobials (IRRs per 10 °C ranging from 1.14 to 1.22, 95%CIs 1.07–1.33). These trends remained when analyzing correlations between temperature with the proportion of extended spectrum cephalosporin resistance of all recovered Enterobacteriaceae. ConclusionsHigher outdoor temperature may be associated with an increase of ESBL-PE-incidence, independent of important confounders, such as antimicrobial consumption and thus should be considered for future resistance-trajectories.

Pathway to Hospice: How Has Place of Care before Hospice Changed with the Growth of Hospice in the United States?

Background: Hospice use among Medicare decedents increased from 21.6% in 2000 to 51.6% in 2019. Whether this growth has been accompanied by more referrals to hospice directly from the community is not known. Objective: To assess trends in place of care before hospice enrollment. Design: Retrospective cohort from 2011 to 2018. Subjects: Medicare decedents age ≥66 years. Measure: Location of care before hospice enrollment in the last 90 days of life, defined as: the community with and without home health, short- or long-term nursing facility, or inpatient hospital. A county-level random effects model examined changes in enrollment from the community after adjusting for admitting diagnosis, age, race/ethnicity, sex, and Medicaid participation. Results: Among hospice enrollees (N = 7,650,933), 27.7% transitioned to hospice from the community, 31.8% transitioned from the hospital, and 10.1% transitioned after short- or long-term nursing facility stay. Rates of enrollment to hospice from the community remained stable from 35.1% in 2011 to 34.3% in 2018. After adjustment, the proportion enrolling in hospice from the community decreased by 1.2% (95% confidence interval -1.0% to 1.4%). Place of care before hospice enrollment in 2018 varied by hospice admitting diagnosis, with patients with cancer more likely to enroll from the community (39.5%) and patients with cerebrovascular accidents from the hospital (53.2%). Prior place of care varied by state, with Florida having the highest rate of the enrollment following hospitalization (47.8%). Conclusion: Despite the growth of hospice, the site of care before hospice enrollment has remained relatively stable and was strongly influenced by region.

Initiating second-line antidiabetic medication among older adults with type 2 diabetes on Metformin

BackgroundAntidiabetic medications (ADM), especially sulfonylureas (SFU) and basal insulin (BI), are associated with increased risk of hypoglycemia, which is especially concerning among older adults in poor health. The objective of this study was to investigate prescribing patterns of ADM in older adults according to their health status.MethodsThis case control study analyzed administrative claims between 2013 and 2017 from a large national payer. The study population was derived from a nationwide database of 84,720 U.S. adults aged ≥65, who were enrolled in Medicare Advantage health insurance plans. Participants had type 2 diabetes on metformin monotherapy, and started a second-line ADM during the study period. The exposure was a binary variable for health status, with poor health defined by end-stage medical conditions, dementia, or residence in a long-term nursing facility. The outcome was a variable identifying which second-line ADM class was started, categorized as SFU, BI, or other (i.e. all other ADM classes combined).ResultsOver half of participants (54%) received SFU as initial second-line ADM, 14% received BI, and 32% received another ADM. In multivariable models, the odds of filling SFU or BI was higher for participants in poor health than those in good or intermediate health [OR 1.13 (95% CI 1.05-1.21) and OR 2.34 (95% CI 2.14-2.55), respectively]. SFU and BI were also more commonly filled by older adults with poor glycemic control.ConclusionsDespite clinical consensus to use caution prescribing SFU and BI among older adults in poor health, these medications remain frequently used in this particularly vulnerable population.

To study the contributing factors and outcomes of Clostridioides difficile infection in patients with solid tumors

BackgroundClostridioides difficile infection (CDI) is a considerable healthcare burden, and now identified as the leading cause of acquired diarrheal illness in patients receiving antibiotics. Patients with malignancies are more prone to acquire CDI, owing to their frequent exposure to risk factors. ObjectiveThis study aims to investigate the factors affecting the outcome of Clostridioides Difficile Infection in patients with solid tumors at our community healthcare center. MethodsThis is a retrospective study that included a total of 59 patients with solid tumors who were hospitalized for Clostridioides difficile infection. ResultsThe median age of the study population was 79 years with 39 males and 20 females. The patients had a diagnosis of a malignancy involving the following sites: prostate (25), lung (19), colon (7), bladder (4), breast (3), and renal (1). There were 52 cases of first time and 7 cases of recurrent CDI admissions. 40 patients were detected to have CDI at presentation while 19 patients were diagnosed with CDI after admission. CDI was categorized as follows: non-severe (29), severe (28), and very severe (2). There were 33 patients on chemotherapy and 20 patients undergoing radiotherapy. Twenty-seven patients had a recent history of cancer care-related procedures or interventions. Twenty-nine patients were from either a rehabilitation center or a long-term nursing care facility. There were 39 recent hospitalizations with 29 patients receiving antibiotics. Almost half of the patients were on proton pump inhibitors (29) and 12 were on steroids (20.3%) at the time of developing CDI. Patients with a high-risk qSOFA score of 2 or more (p-value = 0.008) or a high white blood cell count of >15 × 109/L (p-value = 0.016) at the time of admission were found to have higher in-hospital mortality. Critical care data suggested that 9 patients required intensive care, 7 patients required vasopressor support, and 6 needed mechanical ventilation. Patients were treated with either vancomycin alone (13), or metronidazole alone (25), or combination therapy with vancomycin + metronidazole (21). The median duration of hospital stay was 6 days with 11 fatalities (18.64%). ConclusionsCDI causes significant morbidity in patients with malignancies. A high qSOFA score and leukocytosis are significantly associated with high morbidity and thus should be used to prioritize and intensify inpatient care of these patients.

Recovery of Functional Mobility with a Long-Term Nursing Facility Patient Utilizing the Fascial Distortion Model: A Case Study

Abstract Functional immobility has demonstrated a higher risk of all-cause mortality in geriatric population. It is noted that musculoskeletal pain is one major factor involved with geriatric functional immobility. The fascial distortion model (FDM) utilizes pathognomonic physical gestures to diagnose and treat musculoskeletal pain. In this case study, a long-term nursing facility patient with significantly prolonged wheelchair-to-bed transfer presented with several upper and lower extremity fascial distortions. After FDM treatment, the patient demonstrated a moderate return of functional mobility. This case presents the utility of FDM treatment in cases of decreased functional mobility due to musculoskeletal pain as well as treatment for patients in skilled nursing facility settings.

Skincare and quality of life among older residents living in Japanese nursing homes

This study aimed to clarify the practices of skincare such as bathing, face-washing, and using of skincare products, among older adults living in nursing homes in Japan. From July to August 2017, questionnaire surveys were mailed to 343 long-term care facilities in one prefecture in Japan, and 105 facilities returned the survey. Management policies on the use of facial skincare products was significantly associated with the number of resident/caregiver ratio. Meanwhile, residents in nursing homes with higher numbers of caregivers washed their faces and bathed at lower rates. There were no correlations between the number of resident/caregiver ratio, face-washing, and bathing times. When older residents could not independently perform their skin cleansing and care, that care is likely to happen less often. Sufficient manpower for the support of older residents’ skincare will improve the quality of life in long-term nursing facilities.

Air Temperature and Incidence of Extended-Spectrum Beta-Lactamase (ESBL)-Producing Enterobacteriaceae – An Observational Time-Series Regression Study

Background: Higher outdoor temperature may be related to an increase in antibiotic resistant bacteria. We investigated the association between outdoor air temperature and the incidence of extended-spectrum betalactamase (ESBL)-producing Enterobacteriaceae (ESBL-PE) correcting for known drivers of antibiotic resistance. Methods: We performed a time-series regression study using prospectively collected weekly surveillance data on all ESBL-PE isolated from in- and outpatients of the University Hospital Basel, a tertiary care center in Switzerland, between 01/2008-12/2017. Temperature was measured hourly at the meteorological institute of the University Basel next to our institution over this time period. A time-series approach using a Poisson regression model and different lag terms for delayed exposure effects was performed to assess associations between minimal, mean and maximal weekly temperature and the number of ESBL-PE recovered. Findings: Over 10 years, recovery of ESBL-PE increased (annual incidence rate ratio [IRR] 1·14, 95%CI 1·13-1·16), while mean weekly temperature measures remained stable. In multivariable analyses, increasing temperature was associated with higher recovery rates of ESBL-PE after three to four weeks, correcting for potential confounders, such as the number of admissions, proportion of long-term nursing facility- and ICU-admissions, age, Charlson comorbidity index and consumption of antimicrobials (IRRs per 10°C ranging from 1·14-1·22, 95%CIs 1·07-1·33). These trends remained when analyzing correlations between temperature with the proportion of extended spectrum cephalosporin resistance of all recovered Enterobacteriaceae. Interpretation: Higher outdoor temperature may be associated with an increase of ESBL-PE-incidence, independent of important confounders, such as antimicrobial consumption and thus should be considered for future resistance-trajectories. Funding Statement: This work was supported by the University Hospital Basel, Switzerland. No further funding was received for this study. Declaration of Interests: None of the authors has any conflict of interest related to this study. Ethics Approval Statement: This study was approved by the local ethics committee (Project-ID ID 2017-00100).

Effects of Animal-Assisted Therapy on Verbal Communication and Agitation in Adults With Dementia in Long-Term Care

The effects of Animal-Assisted Therapy (AAT) on verbal communication and agitated behaviors of older adults with mild to severe dementia were examined. We conducted a pilot study at a long-term nursing facility in rural Nebraska on five residents with various stages of dementia and agitation (over two reported incidents of agitation within two months). The study consisted of four sessions of assessment with and four sessions without the presence of a certified therapy dog. The assessment battery included a Mean Length of Utterance (MLU), and responding to a Picture Recognition Activity (PRA) task to assess the production and comprehension in verbal communication respectively. Agitation Behavioral Scale (ABS; Corrigan, 1989), and a General Care Survey (GCS) were used to measure agitation and agitated behavior. The results showed statistically significant differences in the performance of all five participants when the dog was present as compared to when it was absent. We observed an increase in verbal communication (57.4% MLU; 28% PRA), and a decrease in agitated behaviors. This pilot study brings evidence that AAT can be a cost-effective, non-pharmaceutical therapy approach for individuals with dementia to decrease agitation and increase communication.

Mortality and functional outcomes of endovascular stroke therapy in the United States

We sought to evaluate the nationwide trends in the characteristics and outcomes of for endovascular stroke therapy in contemporary practice. We selected patients with acute ischemic stroke who underwent endovascular stroke therapy between 01 October 2015 and 30 September 2019 in a large academic consortium database. The end points of this study were (a) in-hospital mortality and functional outcomes and, (b) predictors of poor functional outcome, defined as death or discharge to hospice, or to a long-term nursing facility. Among the 22,193 included patients; 50.3% were females, and 66.5% were white. Mean age was 68±15 years. Poor functional outcomes occurred in 8,274 patients (37.4%), of whom 2,741 (12.4%) died in the hospital, 1,345 (6.1%) were discharged to hospice, and 4,188 (18.9%) were discharged to other long-term facilities. Most common in-hospital complications were mechanical ventilation (32.3%), intracranial hemorrhage (18.9%), and acute kidney injury (15.6%). Median total and intensive-care length-of-stay were 7 days (IQR = 4-9), and 2 days (IQR = 1-4), respectively. Median cost was $36,609 (IQR = $26,034-$54,313). In a multi-logistic regression analysis; age, hypertension, diabetes, anemia, heart failure, vascular disease, chronic pulmonary disease, renal insufficiency, Medicare/medicaid insurance, transfer from nonendovascular capable hospital, and low procedural volume independently predicted poor functional outcomes. Tissue plasminogen activator use was associated with better functional outcomes. There is a substantial growth in the performance of endovascular stroke interventions in the United States in recent years, and those were associated with favorable short-term outcomes.

Racial Disparities Exist in Outcomes After Major Fragility Fractures.

Fractures associated with postmenopausal osteoporosis (PMO) are associated with pain, disability, and increased mortality. A recent, nationwide evaluation of racial difference in outcomes after fracture has not been performed. To determine if 1-year death, debility, and destitution rates differ by race. Observational cohort study. US Medicare data from 2010 to 2016. Non-Hispanic black and white women with PMO who have sustained a fragility fracture of interest: hip, pelvis, femur, radius, ulna, humerus, and clinical vertebral. Outcomes included 1-year: (1) mortality, identified by date of death in Medicare vital status information, (2) debility, identified as new placement in long-term nursing facilities, and (3) destitution, identified as becoming newly eligible for Medicaid. Among black and white women with PMO (n = 4,523,112), we identified 399,000 (8.8%) women who sustained a major fragility fracture. Black women had a higher prevalence of femur (9.0% vs 3.9%; P < .001) and hip (30.7% vs 28.0%; P < .001) fractures and lower prevalence of radius/ulna (14.7% vs 17.0%; P < .001) and clinical vertebral fractures (28.8% vs 33.5%; P < .001) compared with white women. We observed racial differences in the incidence of 1-year outcomes after fracture. After adjusting for age, black women had significantly higher risk of mortality 1 year after femur, hip, humerus, and radius/ulna fractures; significantly higher risk of debility 1 year after femur and hip fractures; and significantly higher risk of destitution for all fractures types. In a sample of Medicare data from 2010 to 2016, black women with PMO had significantly higher rates of mortality, debility, and destitution after fracture than white women. These findings are a first step toward understanding and reducing disparities in PMO management, fracture prevention, and clinical outcomes after fracture. J Am Geriatr Soc 68:1803-1810, 2020.

Invasive pulmonary aspergillosis in a patient with cirrhosis.

Aspergillus molds are ubiquitous environmental molds that can cause devastating invasive infections in immunocompromised patients. These infections often go unrecognized in critically ill patients. This case describes a 68 year-old female resident of a long-term nursing facility with history of dementia, nonalcoholic fatty liver disease with cirrhosis, chronic kidney disease stage III and insulin-dependent type 2 diabetes who presented with vomiting, diarrhea and leg swelling. She developed hypotension and was treated for sepsis but found to have negative routine infectious workup. Chest imaging showed nodular densities and bilateral opacities. She developed acute renal failure and hypoxic respiratory failure followed by acute decompensated cirrhosis with refractory volume overload and hypotension and was eventually transitioned to comfort care measures. Autopsy ultimately showed invasive pulmonary aspergillosis. Here we review the diagnosis and management of invasive fungal infections in critically ill patients without typical risk factors or clinical findings for invasive fungal disease. Invasive fungal infections are frequently missed and carry high mortality rates, therefore warranting consideration in critically ill populations.

A Prospective 12-Month Study of Prescriptions in Long-Term Care Nursing Facility Residents

AIM: The most frequent use of medications in the geriatric population occurs in skilled nursing facilities. This quality assurance study prospectively examines the high number of prescriptions ordered for long-term nursing facility residents throughout their first year after admission. METHODS: The investigators prospectively followed 101 consecutive long-term-stay older adult residents at the Joyce Eisenberg Keefer Medical Center, a nursing facility of Los Angeles Jewish Home for the Aging (LAJH) over a 12-month period. Preadmission prescriptions were obtained for 91 residents, as well as prescriptions at 1 week, 1 month, 3 months, 6 months, and 1 year after admission. The number of prescriptions by staff physicians and outside physicians was examined. RESULTS: Over the 12 months following admission, the mean number of scheduled prescriptions increased significantly from 11.1 prior to admission to 13.0 by 6 months and to 13.3 by 12 months (P-value < 0.05). The residents who were hospitalized during the 12 months of observation received significantly more scheduled, as needed, and total prescriptions than those not hospitalized. Physicians employed full time by LAJH ordered significantly fewer additional prescriptions than physicians with outside practices. The patients of the staff physicians also had fewer hospitalizations than those of the outside physicians. CONCLUSION: This quality assurance study reveals a statistically significant increase in the number of prescriptions made in a long-term care setting over a 12-month prospective study. Patients of staff physicians received fewer prescriptions and were hospitalized less frequently than patients of physicians who practiced outside LAJH.

Osteoporosis Medication Use: A Comparison of Elderly Females Living in Long-term Care Facilities Versus Community Dwellers.

OBJECTIVE: This study compares patterns of evidence-based osteoporosis medication use among females in community and long-term care settings enrolled in Medicare Part D.<br/> DESIGN: Pooled cross-sectional study.<br/> SETTING: Medicare beneficiaries enrolled in Medicare Parts A and B, and Part D stand-alone prescription drug plans from January 1, 2006, through December 31, 2008, or death.<br/> PARTICIPANTS: Female Medicare Part D enrollees 70 years of age and older with osteoporosis or prior hip fracture.<br/> INTERVENTIONS: NA.<br/> MAIN OUTCOME MEASUREMENTS: Use of bisphosphonates, calcitonin, teriparatide, and raloxifene was tracked by residential status over the three-year period.<br/> RESULTS: The study sample comprised 96,408 female Part D enrollees with osteoporosis. Prevalence of evidence-based medication use was 42.3% in 2006 and dropped slightly to 40.4% in 2008. In unadjusted comparisons, long-term care residents were significantly less likely to use any osteoporosis medication compared with community dwellers (40.6% vs. 53.1%). After adjustment for differences in individual characteristics, utilization was still lower among long-term care residents (relative risk [RR] = 0.89, 95% confidence interval [CI] 0.87-0.91). Bisphosphonates were the top choice among medication users, but were prescribed much less often to long-term care residents (RR = 0.79, 95% CI 0.75-0.83) compared with community residents.<br/> CONCLUSION: Prevalence of evidence-based osteoporosis medication use is low in older women enrolled in Part D whether community-dwelling or long-term care residents, but long-term nursing facility residents are more likely to be treated with nonbisphosphonates. Many events that may affect osteoporosis medication use occurred after 2008; therefore, future studies using more recent data are warranted to examine osteoporosis medication use after 2008.

Osteoporosis Medication Use: A Comparison of Elderly Females Living in Long-term Care Facilities Versus Community Dwellers

OBJECTIVE: This study compares patterns of evidence-based osteoporosis medication use among females in community and long-term care settings enrolled in Medicare Part D.<br/> DESIGN: Pooled cross-sectional study.<br/> SETTING: Medicare beneficiaries enrolled in Medicare Parts A and B, and Part D stand-alone prescription drug plans from January 1, 2006, through December 31, 2008, or death.<br/> PARTICIPANTS: Female Medicare Part D enrollees 70 years of age and older with osteoporosis or prior hip fracture.<br/> INTERVENTIONS: NA.<br/> MAIN OUTCOME MEASUREMENTS: Use of bisphosphonates, calcitonin, teriparatide, and raloxifene was tracked by residential status over the three-year period.<br/> RESULTS: The study sample comprised 96,408 female Part D enrollees with osteoporosis. Prevalence of evidence-based medication use was 42.3% in 2006 and dropped slightly to 40.4% in 2008. In unadjusted comparisons, long-term care residents were significantly less likely to use any osteoporosis medication compared with community dwellers (40.6% vs. 53.1%). After adjustment for differences in individual characteristics, utilization was still lower among long-term care residents (relative risk [RR] = 0.89, 95% confidence interval [CI] 0.87-0.91). Bisphosphonates were the top choice among medication users, but were prescribed much less often to long-term care residents (RR = 0.79, 95% CI 0.75-0.83) compared with community residents.<br/> CONCLUSION: Prevalence of evidence-based osteoporosis medication use is low in older women enrolled in Part D whether community-dwelling or long-term care residents, but long-term nursing facility residents are more likely to be treated with nonbisphosphonates. Many events that may affect osteoporosis medication use occurred after 2008; therefore, future studies using more recent data are warranted to examine osteoporosis medication use after 2008.

ONDINE'S CURSE DUE TO OSMOTIC DEMYELINATION SYNDROME

SESSION TITLE: Critical Care 3 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Osmotic Demyelination Syndrome is a life-threatening complication of sudden rise in serum osmolality after a chronic hypotonicity. The damage depends highly on the brains response to changing serum concentration and can present with many symptoms. Here we describe a patient treated for severe hyponatremia who later presented with Ondine’s curse. CASE PRESENTATION: A 67-year-old Caucasian male transferred to a tertiary facility from a rural hospital. Initially admitted and intubated for worsening shortness of breath; community-acquired pneumonia and alcohol withdrawal. History revealed a drinking habit of twelve or more bottles of alcohol daily, he also drank excessive amounts of water in the previous month with minimal eating. Laboratory data revealed serum sodium concentration was between 143 and 152 throughout hospitalization with no significant acute changes.One week after admission, multiple trails of extubation were unsuccessful and he was found to have no gag reflex, dysphagia or central hypoventilation. Therefore, Brain magnetic resonance imaging (MRI) was obtained; results showed early T2 hyperintense signal within the pons centrally in a pattern suggesting Osmotic Demyelination syndrome (ODS) (figures 1 & 2).Patient remained conscious and needed to be transferred to a long-term nursing facility after tracheostomy and percutaneous endoscopic gastrostomy. DISCUSSION: A hypotonic hyponatremia state in the body naturally forces fluid across the blood brain barrierincreasing water content. This decreased serum tonicity leads to swelling of many brain cells, mainly astrocytes. Astrocytes surround the brains capillaries with foot processes and contain the vital water channels that regulate cellular solutes and water across the blood-brain-barrier. If the brain were not able to adapt to a fall in tonicity, the cells would swell and burst causing irreversible damage. Additionally, any brain swelling would cramp the cranial cavity leading to herniation and further damage.Chronic hyponatremia leads to a more effective depletion of the osmotically active solutes that take time to replenish. So when we rapidly correct the hypotonic state in a chronically hyponatremicpatient the cells cannot osmotically compensate as well, causing them to shrink.This leads to a cascade o fapoptosis, disruption of oligodendrocytes, inflammatory cytokine release, and microglial activation. If the insult involved the respiratory center in the medulla or higher brainstem it can cause central hypoventilation syndrome which lead to decreased autonomic response to hypercapnia and hypoxiaalthough they are able to consciously control their ventilation normally and respond to non-chemoreceptive inputs for ventilation CONCLUSIONS: This case report underlines the importance of recognizing predisposing risk factors for osmotic demyelination syndrome and the potential complications if not done properly Reference #1: Jazeela Fayyaz, DO. Zab Mosenifar, M, ed. "Hypoventilation Syndromes". "Congenital central hypoventilation syndrome". Genetics Home Reference. U.S. National Library of Medicine. Reference #2: "Primary alveolar hypoventilation: Ondine's curse". A.D.A.M. Medical Encyclopedia. U.S. National Library of Medicine.Severinghaus JW; Mitchell, R. A. (1962). "Undine's curse — failure of respiratory center automaticity while awake". Clin Res. 10: 122 DISCLOSURES: No relevant relationships by Hani Badi, source=Web Response No relevant relationships by Ali Eltatawy, source=Web Response No relevant relationships by Zubair Khan, source=Web Response No relevant relationships by Tamer Said Ahmed, source=Web Response No relevant relationships by Young Sook Yoon, source=Web Response

Outcomes in nursing home patients with traumatic brain injury

BackgroundTraumatic brain injury is a leading cause of death and disability in the United States. In survivors, traumatic brain injury remains a leading contributor to long-term disability and results in many patients being admitted to skilled nursing facilities for postacute care. Despite this very large population of traumatic brain injury patients, very little is known about the long-term outcomes of traumatic brain injury survivors, including rates of discharge to home or risk of death in long-term nursing facilities. We hypothesized that patient demographics and functional status influence outcomes of patients with traumatic brain injury admitted to skilled nursing facilities. MethodsWe conducted a retrospective cohort study of Medicare fee-for-service beneficiaries aged 65 and older discharged alive and directly from hospital to a skilled nursing facility between 2011 and 2014 using the prospectively maintained Federal Minimum Data Set combined with Medicare claims data and the Centers for Medicare and Medicaid Services Vital Status files. Records were reviewed for demographic and clinical characteristics at admission to the skilled nursing facility, including age, sex, cognitive function, ability to communicate, and motor function. Activities of daily living were reassessed at discharge to calculate functional improvement. We used robust Poisson regression with skilled nursing facility fixed effects to calculate relative risks and 99% confidence intervals for mortality and functional improvement associated with the demographic and clinical characteristics present at admission. Linear regression was used to calculate adjusted mean duration of stay. ResultsOverall, 87,292 Medicare fee-for-service beneficiaries with traumatic brain injury were admitted to skilled nursing facilities. The mean age was 84 years, with 74% of patients older than age 80. Generally, older age, male sex, and poor cognitive or functional status at admission to a skilled nursing facility were associated with increased risk for poorer outcomes. Older patients (age ≥80 years) with traumatic brain injury had a 1.5 times greater risk of death within 30 days of admission compared with adults younger than 80 years (relative risk = 1.49, 99% confidence interval = 1.36, 1.64). Women were 37% less likely to die than men were (relative risk = 0.63, 99% confidence interval = 0.59, 0.68). The risk of death was greater for patients with poor cognitive function (relative risk = 2.55, 99% confidence interval = 2.32, 2.77), substantial motor impairment (relative risk = 2.44, 99% confidence interval = 2.16, 2.77), and patients with impairment in communication (relative risk = 2.58, 99% confidence interval = 2.32, 2.86) compared with those without the respective deficits. One year after admission, these risk factors continued to confer excess risk for mortality. Duration of stay was somewhat greater for older patients (30.1 compared with 27.5 average days) and patients with cognitive impairment (31.7 vs 27.5 average days). At discharge, patients with cognitive impairment (relative risk = 0.86, 99% confidence interval = 0.83, 0.88) and impairment in the ability to communicate (relative risk = 0.67, 99% confidence interval = 0.54, 0.82) were less likely to improve in physical function. ConclusionOur results suggest that among patients with traumatic brain injury admitted to skilled nursing facilities, the likelihood of adverse outcomes varies significantly by key demographic and clinical characteristics. These findings may facilitate setting expectations among patients and families as well as providers when these patients are admitted to skilled nursing facilities for rehabilitation after their acute episode.

LO57: Validation of the Ottawa 3DY in community seniors in the ED

Introduction: Cognitive dysfunction is getting more common in geriatric emergency department (ED) patients, as the number of seniors visiting our EDs is increasing. ED guidelines recommend a systematic mental status screening for seniors presenting to the ED. As the existing tools are not suitable for the busy ED environment, we need quicker and easier ways to assess altered mental status, such as the O3DY. The purpose of this study is to assess the effectiveness of the French version of the O3DY to screen for cognitive dysfunction in seniors presenting to the ED. Methods: This is a planned sub-study of the INDEED project, which was conducted between February and May 2016 in 4 hospitals across the province of Québec. Inclusion criteria were: patients aged ≥65, with an 8-hour ED stay, admitted on a care unit, independent or semi-independent in their activities of daily living. Exclusion criteria were: patient living in a long-term nursing facility, with an unstable medical condition, pre-existing psychiatric condition or severe dementia, a delirium within the 8-hour exposure to the ED. A trained research assistant collected the following data upon initial interview: socio-demographic information, cognitive assessment (TICS-m), functional assessment (OARS) and delirium screening (CAM). The O3DY was also administered at initial interview and during patient follow-ups, as well as the CAM. Results: This study population was composed of 305 participants, of which 47.7% were men. Mean age was 76 years old (SD: 10.8). Nine of these participants had a previous history of dementia. 151 of these participants (47,04%) had a negative O3DY and 154 (47,98%) a positive O3DY at the initial encounter. When compared to the CAM, the O3DY presents a sensitivity of 85.0% (95% CI [62.1, 96.8]) and a specificity of 57.7% (95% CI [51.8, 63.6]) for prevalent delirium. When compared to the TICS, the O3DY presents a sensitivity of 76.7% (95% CI [66.4, 85.2]) and a specificity of 68.1% (95% CI [61.3, 74.3]) for cognitive impairment. The combined measure presents a sensitivity of 76.7% (95% CI [66.6, 84.9]) and a specificity of 68.4% (95% CI [61.7, 74.5]). Conclusion: A negative result to the O3DY indicates the absence of prevalent delirium or undetected cognitive impairment. The O3DY could be a useful tool for the triage nurses in the ED.