Long-term Nursing Home Residents Research Articles

157 Prevalence and Patterns of Drug-Disease Interactions in Long-Term Residents in Nursing Home Facilities in the Czech Republic

Abstract Introduction Prescription of potentially inappropriate medications, non-geriatric doses and drug-disease interactions contribute to high prevalence of adverse drug events, geriatric syndromes and symptoms, and increased frailty in older adults. Despite serious health and socio-economic consequences, a very few studies have been published on phenomenon of prescribing of drug-disease interactions (DDI) in older patients in Central and Eastern Europe. Methods This study aimed to investigate the prevalence of DDI and differences across nursing home (NH) facilities applying relevant parts of Beers 2012 criteria, Czech national consensus 2012 (CNC), and STOPP/START criteria vers.1. This is a retrospective cross-sectional study that analysed semi-implicitly InterRAI-LTC assessment protocols of 490 NH residents from 10 Czech NH facilities (N = 490, 65+) participating in the EU SHELTER project. Retrospective analyses were conducted in 2019 year. Results Prevalence of potentially inappropriate DDI ranged from 44.5% to 62.3% identified by STOPP criteria and CNC, respectively. The most common DDIs were long-term use of benzodiazepines in depressive residents (7.8%) and use of opioids in residents with chronic constipation without osmotic laxative treatment (7.4%). The prevalence of undertreatment identified by START criteria was 52.9%, mainly due to absence of statins in NH residents with diabetes mellitus and cardiovascular risk factors (9.8%) and the absence of anticoagulation therapy in patients with atrial fibrillation (7.1%). Conclusions Potentially inappropriate DDI were highly prevalent in Czech long-term NH residents with significant differences across NH facilities. Using method of semi-implicit medication reviews, we cannot judge the real quality of drug treatment, but there is a necessity to reduce the high prevalence of DDI in NHs in order to prevent potential adverse drug events. Grant support: InoMed project (reg. No: CZ.02.1.01/0.0/0.0/18_069/0010046, 2019–2022), H2020-MCSF-ITN-764632, PROGRESS Q42 FoP, Charles University, FP7-HEALTH-F4–2008-201,917, SVV 260417.

Higher Resource Utilization and Costs in Long-Term Nursing Home Residents With Overactive Bladder: A Retrospective Study of Medicare Beneficiaries

ObjectivesTo determine the all-cause health care resource utilization and costs among long-term nursing home (LTNH) residents with and without overactive bladder (OAB). DesignRetrospective cohort study. Setting and ParticipantsMinimum Data Set (MDS)–linked Medicare Part A, B, and D claims data from 2013 to 2015 were analyzed. LTNH residents aged 65 years or older with a diagnosis of OAB (n = 216,731) were propensity score matched with LTNH residents without OAB (n = 300,327) (non-OAB cohort). MethodsWe measured health care resource utilization and costs associated with OAB by setting (inpatient, outpatient, emergency department, or prescription) during the 6 months following nursing home admission. Descriptive and multivariate (negative binomial for health care resource utilization and 2-part model for costs) analyses were performed to examine the health care resource utilization and costs among LTNH residents with and without OAB. The annual cost attributed to OAB was calculated as the difference between total annual OAB costs and total annual non-OAB costs. ResultsA total of 214,505 patients were included in each matched cohort. Across all health care resource categories, LTNH residents with OAB had higher health care resource utilization and costs compared to the non-OAB cohort (all P < .001). The mean annual direct total cost was $57,984 in the OAB cohort compared with $54,285 in the non-OAB cohort. The annual cost of OAB in nursing homes was estimated at $793 million. Adjusted analyses revealed that the OAB cohort was 9% more likely to have hospitalization and emergency department visits, 15% more likely to have outpatient visits, 27% more likely to have physician visits, and 12% more likely to have prescription counts compared with the non-OAB cohort. Conclusions and ImplicationsThe study findings suggest that LTNH residents with OAB have significantly more health care resource utilization compared with patients without OAB. These results provide health care decision makers with recent estimates of the burden of OAB in LTNH to assist them with resource planning.

Hospital Elder Life Program in Long-Term Care (HELP-LTC): A Cluster Randomized Controlled Trial.

The Hospital Elder Life Program (HELP) has been shown to prevent delirium in hospitalized older adults. The objective of this study was to test the efficacy of HELP adapted to long-term care (HELP-LTC). Cluster randomized controlled trial. A 514-bed academic urban nursing home. A total of 219 long-term nursing home residents who developed an acute illness or change in condition were randomly assigned to HELP-LTC (n = 105) or usual care (n = 114) by unit. HELP-LTC is a multicomponent intervention targeting delirium risk factors of cognitive impairment, immobility, dehydration, and malnutrition. Two certified nursing assistants (CNAs) delivered HELP-LTC components twice daily 7 days per week. In addition, recommendations were given to primary providers to reduce medications associated with delirium. Delirium (primary outcome) and delirium severity were ascertained each weekday by a research assistant blinded to group assignment, using the Confusion Assessment Method (CAM) and CAM severity score (CAM-S), respectively. Cognitive function was determined using the Cognitive Performance Scale (CPS). Hospitalization was ascertained by chart review. Participants were 81.7 years of age on average and 65.3% female. At baseline, usual care group participants had better cognitive function than intervention group participants (CPS = 1.33 vs 2.25; P = .004). Delirium symptoms declined over the course of the episode (mean CAM-S = 3.63 at start vs 3.27 at end). Overall, 33.8% of the total sample experienced incident delirium. After adjusting for baseline cognitive function, no significant differences were found in delirium or delirium severity between intervention and usual care groups. Hospitalization was not significantly different between groups. An intervention targeting delirium risk in long-term nursing home residents did not prevent delirium or reduce delirium symptoms. Baseline differences in cognitive function between groups, greater than expected improvements in both groups, quality-enhancing practices such as consistent assignments delivered to both groups, and adaptations of the intervention may have biased results toward null. J Am Geriatr Soc 68:2329-2335, 2020.

Utilization by Long-Term Nursing Home Residents Under Accountable Care Organizations

ObjectivesNursing home care is common and costly. Accountable care organization (ACO) payment models, which have incentives for care that is better coordinated and less reliant on acute settings, have the potential to improve care for this high-cost population. We examined the association between ACO attribution status and utilization and Medicare spending among long-term nursing home residents and hypothesized that attribution of nursing home residents to an ACO will be associated with lower total spending and acute care use. DesignObservational propensity-matched study. Setting and ParticipantsMedicare fee-for-service beneficiaries who were long-term nursing home residents residing in areas with ≥5% ACO penetration. MethodsACO attribution and covariates used in propensity matching were measured in 2013 and outcomes were measured in 2014, including hospitalization (total and ambulatory care sensitive conditions), outpatient emergency department visits, and Medicare spending. ResultsNearly one-quarter (23.3%) of nursing home residents who survived into 2014 (n = 522,085, 76.1% of 2013 residents) were attributed to an ACO in 2013 in areas with ≥5% ACO penetration. After propensity score matching, ACO-attributed residents had significantly (P < .001) lower hospitalization rates per 1000 (total: 402.9 vs 419.9; ambulatory care sensitive conditions: 64.4 vs 71.4) and fewer outpatient ED visits (29.9 vs 33.3 per 100) but no difference in total spending ($14,071 vs $14,293 per resident, P = .058). Between 2013 and 2014, a sizeable proportion of residents’ attribution status switched (14.6%), either into or out of an ACO. Conclusions and ImplicationsACO nursing home residents had fewer hospitalizations and ED visits, but did not have significantly lower total Medicare spending. Among residents, attribution was not stable year over year.

Antimuscarinic Discontinuation in Patients with Overactive Bladder in Nursing Homes: A Retrospective Study of Medicare Beneficiaries.

IntroductionAlthough antimuscarinics form the first-line therapy in overactive bladder (OAB), little is known regarding antimuscarinic discontinuation among OAB patients in nursing homes. This study examined treatment patterns and predictors of antimuscarinic discontinuation among long-term nursing home (LTNH) residents with OAB.MethodsThe study cohort included LTNH residents (defined as residents staying ≥ 101 consecutive days) from the Minimum Data Set linked 2013–2015 Medicare claims data. Patients with OAB were defined by OAB-related claims and medication codes. Treatment patterns and discontinuation (medication gap ≥ 30 days) were characterized by examining OAB-specific antimuscarinics prescribed during LTNH stays. The Andersen Behavioral Model was used to identify predisposing, enabling and need factors that predict discontinuation. Kaplan-Meier curves and multivariable Cox proportional hazards regression model were used to assess the unadjusted and adjusted times to discontinuation, respectively, among different antimuscarinics.ResultsThe mean age of the study cohort (n = 11,012) was 81.6 years (± 8.5), 74.6% were female, and 89.8% were non-Hispanic White. The mean duration of nursing home stay was 530.1 (± 268.4) days. The most commonly prescribed OAB-specific antimuscarinic was oxybutynin (69.8%). Overall, 66.5% of the study cohort discontinued the index antimuscarinic. Multivariable Cox PH regression analysis revealed that compared to LTNH residents who initiated treatment with oxybutynin, treatment discontinuation was lower with solifenacin or fesoterodin and discontinuation was more frequent when treatment was initiated with tolterodine, darifenacin or trospium compared with oxybutynin. In addition, several need factors (comorbidities, medication use and anticholinergic burden, etc.) were associated with antimuscarinic discontinuation.ConclusionAbout two-thirds of LTNH residents with OAB discontinued their index antimuscarinic during their nursing home stay. There was significant variation in discontinuation based on the index antimuscarinic agent with lowest risk of discontiuation with solifenacin and fesoterodin. Concerted efforts to optimize antimuscarinic use are needed to improve the management of OAB in nursing homes.Electronic Supplementary MaterialThe online version of this article (10.1007/s12325-020-01412-z) contains supplementary material, which is available to authorized users.

Nurse-patient interaction and self-transcendence: assets for a meaningful life in nursing home residents?

BackgroundDue to the shift to an older population worldwide and an increased need for 24-h care, finding new and alternative approaches to increase wellbeing among nursing home (NH) residents is highly warranted. To guide clinical practice in boosting wellbeing among NH residents, knowledge about nurse-patient interaction (NPI), inter- (ST1) and intra-personal (ST2) self-transcendence and meaning-in-life (PIL) seems vital. This study tests six hypotheses of the relationships between NPI, ST1, ST2 and PIL among cognitively intact NH residents.MethodsIn a cross-sectional design, 188 (92% response rate) out of 204 long-term NH residents representing 27 NHs responded to NPI, ST, and the PIL scales. Inclusion criteria were: (1) municipality authority’s decision of long-term NH care; (2) residential time 3 months or longer; (3) informed consent competency recognized by responsible doctor and nurse; and (4) capable of being interviewed. The hypothesized relations between the latent constructs were tested through structural equation modeling (SEM) using Stata 15.1.ResultsThe SEM-model yielded a good fit (χ2 = 146.824, p = 0.021, df = 114, χ2/df = 1.29 RMSEA = 0.040, p-close 0.811, CFI = 0.97, TLI = 0.96, and SRMR = 0.063), supporting five of the six hypothesized relationships between the constructs of NPI, ST1, ST2 and PIL.ConclusionNPI significantly relates to both ST1, ST2 and PIL in NH residents. ST revealed a fundamental influence on perceived PIL, while NPI demonstrated a significant indirect influence on PIL, mediated by ST.

Comparing Outcomes Between Thiazide Diuretics and Other First-line Antihypertensive Drugs in Long-term Nursing Home Residents

PurposeHypertension occurs in >50% of US nursing home (NH) residents, but it is unclear which antihypertensive classes offer the best balance of benefits and risks in this population. The objectives of this study were to describe the patterns of antihypertensive medication treatment in this population, focusing on thiazide diuretics, and to determine the association between thiazide diuretics (DIURs) and outcomes important to NH patients. MethodsThis observational cohort study was conducted in long-term NH residents treated for hypertension in the second quarter (Q2) of 2013, from all US NHs. The primary exposure was the frequency of use of antihypertensive treatment class (DIURs, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers [ARBs], calcium channel blockers, and β-blockers) according to Medicare Part D dispensing data. Because DIUR-related urinary symptoms were a focus, residents receiving nonthiazide diuretics were excluded. We ascertained continued medication use by class from Q2 to Q4 of 2013, and ascertained 6-month incontinence and hospitalization using data from Medicare claims and the Minimum Data Set. FindingsOf 152,902 NH residents treated for hypertension, 52.2% were treated with β-blockers (22% as a single agent), 39.7% with calcium channel blockers (14% as a single agent), 38.8% with angiotensin-converting enzyme inhibitors (14% as a single agent), 14.2% with DIURs (2% as a single agent), and 13.2% with ARBs (4% as a single agent). Overall, 55.1% were treated with 1 drug; 33.2%, with 2 drugs; and 11.8%, with 3 or more drugs. From Q2 to Q4, DIURs were more likely to have been discontinued than any other class (19.4% vs 14.1%–16.1% for each of the other 4 classes; all, p < 0.05) and less likely to have been started than any other class except ARBs (1.4% vs 3.8%–5.3% for each of the other 3 classes). Urinary incontinence occurred in 76.6% of the sample. In a multivariate logistic regression model, new DIUR use from Q2 to Q4 of 2013 was not significantly associated with urinary incontinence in Q4, and none of the antihypertensive drug classes were associated with 6-month hospitalization. ImplicationsIn 2013, long-term NH residents treated for hypertension were least likely to receive, more likely to discontinue, and less likely to start a new DIUR than any other first-line antihypertensive medication. DIURs were not associated with increased incontinence or hospitalization, so in the absence of indications for other drugs, DIURs may be a reasonable first-line choice for hypertension treatment in this population.

Assessing quality of life in older adults: psychometric properties of the OPQoL-brief questionnaire in a nursing home population

BackgroundWell-adapted and validated quality-of-life measurement models for the nursing home population are scarce. Therefore, the aim of this study was to test the psychometrical properties of the OPQoL-brief questionnaire among cognitively intact nursing home residents. The research question addressed evidence related to the dimensionality, reliability and construct validity, all of which considered interrelated measurement properties.MethodsCross-sectional data were collected during 2017–2018, in 27 nursing homes representing four different Norwegian municipalities, located in Western and Mid-Norway. The total sample comprised 188 of 204 (92% response rate) long-term nursing home residents who met the inclusion criteria: (1) municipality authority’s decision of long-term nursing home care; (2) residential time 3 months or longer; (3) informed consent competency recognized by responsible doctor and nurse; and (4) capable of being interviewed.ResultsPrincipal component analysis and confirmative factor analyses indicated a unidimensional solution. Five of the original 13 items showed low reliability and validity; excluding these items revealed a good model fit for the one-dimensional 8-items measurement model, showing good internal consistency and validity for these 8 items.ConclusionFive out of the 13 original items were not high-quality indicators of quality-of-life showing low reliability and validity in this nursing home population. Significant factor loadings, goodness-of-fit indices and significant correlations in the expected directions with the selected constructs (anxiety, depression, self-transcendence, meaning-in-life, nurse-patient interaction, and joy-of-life) supported the psychometric properties of the OPQoL-brief questionnaire. Exploring the essence of quality-of-life when residing in a nursing home is highly warranted, followed by development and validation of new tools assessing quality-of-life in this population. Such knowledge and well-adapted scales for the nursing home population are beneficial and important for the further development of care quality in nursing homes, and consequently for quality-of-life and wellbeing in this population.

Comparison Between Multicomponent Exercise and Walking Interventions in Long-Term Nursing Homes: A Randomized Controlled Trial.

There is evidence that exercise interventions counteract the functional and cognitive decline experienced by long-term nursing home (LTNH) residents. To determine the most effective exercise intervention, we compared the effects of a multicomponent exercise intervention and a walking intervention on physical and cognitive performance, habitual physical activity, affective function, and quality of life among older adults living in LTNHs. This 3-month single-blind randomized controlled trial (NCT03996083) involved 81 participants at 9 LTNHs randomly assigned to a multicomponent (MG) or a walking (WG) group. The MG participated in a twice-a-week individualized and progressive program composed of strength and balance exercises for 3 months. The WG was also individualized and participants walked up to 20 min per day. The primary outcome was the score on the short physical performance battery (SPPB). Secondary outcomes included other physical performance tests, habitual physical activity, cognitive performance, affective function, and quality of life. Compared with the WG, the MG group showed greater improvements in physical performance, including the SPPB (p < .05). No significant differences were observed in cognitive performance or habitual physical activity. Both groups showed improvements in anxiety and quality of life (p < .05). Although both interventions were effective in maintaining or improving affective function, the MG conferred greater improvements in physical function. Therefore, multicomponent interventions would be preferable over walking-only interventions. Otherwise, individualized and progressive walking interventions should be implemented to face the rapid decline in functionality encountered in LTNHs.

HYPERTENSION TREATMENT IN U.S. LONG-TERM NURSING HOME RESIDENTS WITH AND WITHOUT DEMENTIA

Background: Treatment of hypertension in individuals with dementia has benefit-harm tradeoffs. The objectives of this study were to describe patterns of antihypertensive treatment in U.S. nursing home (NH) residents and determine the association between intensity of antihypertensive treatment and outcomes important for persons with dementia. Methods: Medicare claims and Minimum Data Set (MDS) assessments were used to capture information on dementia, hypertension, comorbid conditions, cognitive function, activities of daily living (ADLs), and hospitalizations in Medicare-enrolled long-term care residents in 2013. Intensity of hypertension treatment was defined as number of antihypertensive drugs received on the date of an index MDS according to Medicare part D claims. Outcomes ascertained were hospitalizations, ADL decline, and mortality within 180 days of the index MDS. Results: A total of 262,285 residents had both hypertension and dementia. Residents were 85.7 years old on average and 77% female. At baseline, 30%, 40%, and 30% were receiving 0, 1, and 2+ antihypertensive medications, respectively. In multivariable logistic regression models, increased intensity of antihypertensive treatment was associated with increased hospitalization among residents with dementia (OR 1.03 per added medication; 95%CI 1.01-1.04), but decreased hospitalization among residents without dementia (OR .98 per added medication; 95%CI .97-1.00; p-value for interaction < .0001). In residents with and without dementia, increased intensity of antihypertensive treatment was associated with increased hospitalization for cardiovascular diseases, but small decreases in ADL decline and mortality. Conclusion: Study findings suggest that long-term NH residents with hypertension and dementia may not experience benefit from more intensive blood pressure control.

Inclusion of Nursing Homes and Long-term Residents in Medicare ACOs

Long-term nursing home residents have complex needs that often require services from acute care settings. The accountable care organization (ACO) model provides an opportunity to improve care by creating payment incentives for more coordinated, higher quality care. To assess the extent of nursing home participation in ACOs, and the characteristics of residents and their nursing homes connected to ACOs. This was a cross-sectional study. Medicare nursing home residents identified from 2014 Minimum Data Set assessments. Residents were attributed to ACOs based on Medicare methods. Individuals' demographics, clinical characteristics, health care utilization, and nursing home characteristics. Among 660,780 nursing home residents, a quarter of them were attributed to ACOs. ACO residents had only small differences from non-ACO residents: age 85 years and older (47.1% vs. 45.3%), % black (10.5% vs. 12.7%), % dual eligible (74.3% vs. 75.8%), and emergency department visits (55.1 vs. 57.3 per 100). Of the 14,868 nursing homes with study residents, few were ACO providers (N=222, 1.6% of total residents) yet many had at least one ACO resident (N=8077, 76.4% of total residents); one-fifth had at least 20 (N=2839, 33.4% of total residents). ACO-provider homes were more likely than other homes to have a 5-star rating, be hospital-based and have Medicare as the primary payer. With a quarter of long-term nursing home residents attributed to an ACO, and one-fifth of nursing homes caring for a large number of ACO residents, outcomes and spending in this setting are important for ACOs to consider when designing patient care strategies.

PC-FACS

PC-FACS

Hypertension Treatment in US Long-Term Nursing Home Residents With and Without Dementia.

To describe patterns of antihypertensive medication treatment in hypertensive nursing home (NH) residents with and without dementia and determine the association between antihypertensive treatment and outcomes important to individuals with dementia. Observational cohort study. All US NHs. Long-term NH residents treated for hypertension in the second quarter of 2013, with and without moderate or severe cognitive impairment, as defined by the NH Minimum Data Set (MDS) Cognitive Function Scale. The primary exposure was intensity of antihypertensive treatment, as defined as number of first-line antihypertensive medications in Medicare Part D dispensing data. The outcome measures were hospitalization, hospitalization for cardiovascular diseases using Medicare Hierarchical Condition Categories, decline in physical function using the MDS Activities of Daily Living (ADLs) scale, and death during a 180-day follow-up period. Of 255 670 NH residents treated for hypertension, 117 732 (46.0%) had moderate or severe cognitive impairment. At baseline, 54.4%, 34.3%, and 11.4% received one, two, and three or more antihypertensive medications, respectively. Moderate or severe cognitive impairment (odds ratio [OR] = 0.80 vs no or mild impairment; P < .0001), worse physical function (OR = 0.64 worst vs best tertile; P < .0001), and hospice or less than a 6-month life expectancy (OR = 0.80; P < .0001) were associated with receipt of fewer antihypertensive medications. Increased intensity of antihypertensive treatment was associated with small increases in hospitalization (difference per additional medication = 0.24%; 95% confidence interval = 0.03%-0.45%) and cardiovascular hospitalization (difference per additional medication = 0.30%; 95% confidence interval = 0.21%-0.39%) and a small decrease in ADL decline (difference per additional medication = -0.46%; 95% confidence interval = -0.67% to -0.25%). There was no significant difference in mortality (difference per additional medication = -0.05%; 95% confidence interval = -0.23% to 0.13%). Long-term NH residents with hypertension do not experience significant benefits from more intensive antihypertensive treatment. Antihypertensive medications are reasonable targets for deintensification in residents in whom this is consistent with goals of care. J Am Geriatr Soc 67:2058-2064, 2019.

Serum adiponectin is associated with body composition and cognitive and psychological status in older adults living in long-term nursing homes.

Frailty is a geriatric syndrome characterized by decreasing functional reserves and increasing vulnerability to falls, injuries and declining health, leading to dependence upon caregivers. Frailty is associated not only with physical decline, but also with cognitive and psychological impairments in aging people. Higher serum adiponectin concentration has been linked to better performance on frailty measures but also to worse cognitive status. Nonetheless, several studies have proposed adiponectin as a frailty biomarker. To further delineate the relationship between adiponectin serum levels and frailty-related parameters, we studied a population of 112 long-term nursing home residents (aged 84.9 ± 6.7) and analyzed their serum adiponectin levels in conjunction with frailty-related parameters including body composition, physical fitness, cognitive function, psychological parameters and quality of life. Frailty was assessed following the Fried Frailty Criteria, the Clinical Frailty Scale and the Tilburg Frailty Indicator. In women, higher serum adiponectin levels were associated with lower body weight, body mass index, body fat mass, fat mass/height2, lean mass, lean mass/height2 and smaller waist circumference and hip circumference (p < 0.05). In men, the association was positive (p < 0.05) between serum adiponectin and percentage of fat mass and negative between serum adiponectin and percentage of lean mass. Interestingly, in men, better cognitive function was inversely related to adiponectin (p < 0.05) while decreased anxiety was linked to a higher concentration of adiponectin in women (p < 0.05). According to the Tilburg Frailty Indicator, frail men had lower levels of adiponectin than those who were not frail (p < 0.05). Variables that predicted adiponectin concentration in multiple regression models were different for women and men. In women, lean mass and anxiety were independent negative predictors of blood adiponectin (β = -0.363, p = 0.002; β = -0.204, p = 0.067, respectively). In men, the Montreal Cognitive Assessment (MOCA) test was the only parameter to remain significant in the regression model (β = -439, p = 0.015). The results of our study show that adiponectin is linked to body composition, cognitive function and anxiety in long-term nursing home residents with differential relationships by sex. Further studies should be conducted to determine whether adiponectin is a valid and reliable frailty biomarker.

Screening Mammography Among Older Women: A Review of United States Guidelines and Potential Harms.

In the United States, older women (aged ≥65 years) continue to receive routine screening mammography surveillance, despite limited evidence supporting the benefits to this subpopulation. This article reviews screening mammography guidelines and the potential harms of such screening for older women in the United States. Published guidelines and recommendations on screening mammography for older women from professional medical societies and organizations in the United States were reviewed from the mid-20th century to present. Observational data were then synthesized to present the documented harms from screening mammography among older women. In 1976, the American Cancer Society recommended to screen all women aged ≥40 years with no upper age limit. With time, other major U.S. medical societies adopted their own screening guidelines without a consensus on age of screening cessation. A population-wide screening effort has largely continued without an upper age limit and with it, a growing body of literature on the harms of screening older women. Reported harms from screening mammography procedures have included physical pain, psychological distress, excessive use of health services from overdiagnoses/false positives, and undue financial expenses. These costs are particularly pronounced among special populations with limited life expectancies such as those of very advanced age ≥80 years, long-term nursing home residents, and the cognitively impaired. When potential harms, remaining life years, and the viability of available treatments are considered, the burdens of screening mammography often outweigh the benefits for older women. For some cases, an individualized approach to recommendations would be appropriate. National guidelines should be updated to provide clear guidance for screening women of advanced age, especially those in special populations with limited life expectancies.

A randomized controlled trial protocol to test the efficacy of a dual-task multicomponent exercise program in the attenuation of frailty in long-term nursing home residents: Aging-ONDUAL-TASK study

BackgroundThe purpose of the Aging-ONDUAL-TASK study is to determine if a supervised dual-task program carried out in long-term nursing homes is able to attenuate frailty in a greater extent than the same multicomponent exercise program alone.MethodsThis multicenter randomized controlled trial will include 188 participants who will be randomly allocated to either a multicomponent exercise program or to the same multicomponent program with simultaneous cognitive training (dual-task training). Inclusion criteria are as follows: ≥ 70 years, ≥ 50 on the Barthel Index, ≥ 20 on the Mini Examen Cognoscitivo (MEC-35) who are able to stand up and walk independently for 10 m. Subjects in the multicomponent group will attend a twice-a-week multicomponent exercise program of 1-h duration per session, consisting of strength and balance exercises. Participants in the dual-task group will perform the same multicomponent exercise program with concurrent individually tailored cognitive tasks. Study assessments will be conducted at baseline and at 3 months. The primary outcome measure will be gait speed under dual-task conditions and secondary outcomes will include physical fitness measurements, gait spatiotemporal parameters, cognition and emotional assessments, several frailty scales and objectively measured physical activity.DiscussionThe present research will add valuable information to the knowledge around the effects of the dual-task program in long-term nursing home residents, taking altogether physical, cognitive and emotional variables linked to frailty.Trial registrationAustralian and New Zealand Clinical Trials Registry (ANZCTR) with the identifier: ACTRN12618000536268. Registration date: 11/04/2018.

Serum Myostatin Levels Are Higher in Fitter, More Active, and Non-Frail Long-Term Nursing Home Residents and Increase after a Physical Exercise Intervention

Background: Myostatin has been proposed as a candidate biomarker for frailty and sarcopenia. However, the relationship of myostatin with these conditions remains inconclusive. Objective: To determine the association of serum myostatin concentration with body composition, physical fitness, physical activity level, and frailty in long-term nursing home residents. We also aimed to ascertain the effect of an exercise program on myostatin levels. Methods: We obtained study data on 112 participants from long-term nursing homes. Participants were randomly assigned to a control or an intervention group and performed a 6-month multicomponent exercise program. Serum myostatin levels were analyzed by ELISA. Assessments also included body composition (anthropometry and bioelectrical impedance), physical fitness (Senior Fitness Test), physical activity level (accelerometry), and frailty (Fried frailty criteria, Clinical Frailty Scale, and Tilburg frailty indicator). Results: The concentration of myostatin at baseline was positively correlated with: a leaner body composition (p < 0.05), and a higher number of steps per day and light and moderate-vigorous physical activity in women (p < 0.005); greater upper and lower limb strength, endurance, and poorer flexibility (p < 0.05) in men; and better performance (less time) in the 8-ft timed up-and-go test in both women (p < 0.01) and men (p < 0.005). We observed higher concentrations of serum myostatin in non-frail than in frail participants (p < 0.05). Additionally, we found that the implemented physical exercise intervention, which was effective to improve physical fitness, increased myostatin concentration in men (p < 0.05) but not in women. The improvements in physical condition were related with increases in serum myostatin only in men (p < 0.05–0.01). Conclusions: Higher serum levels of myostatin were found to be associated with better physical fitness. The improvements in physical fitness after the intervention were positively related to increases in myostatin concentrations in men. These results seem to rule out the idea that high serum myostatin levels are indicative of frailty in long-term nursing home residents. However, although the direction of association was opposite to that expected for the function of myostatin, the use of this protein as a biomarker for physical fitness, rather than frailty, merits further study.

Racial and Ethnic Differences in the Prevalence of Depressive Symptoms Among U.S. Nursing Home Residents

ABSTRACTThis study aimed to examine racial and ethnic differences in significant depressive symptoms among long-term nursing home residents. We analyzed the 2014 national Minimum Data Set linked to a nursing home file and estimated multivariable logistic regressions to determine the associations of race and ethnicities with significant depressive symptoms (score ≥ 10 on the 9-item Patient Health Questionnaire [PHQ-9] scale) and whether associations were explained by resident and nursing home covariates. Stratified analyses further determined independent associations in subgroups of residents. We found that the prevalence rate of PHQ-9 scores ≥ 10 was 8.8% among non-Hispanic White residents (n = 653,031) and 7.4%, 6.9%, and 6.6% among Black (n = 97,629), Hispanic (n = 39,752), and Asian (n = 16,636) residents, respectively. The reduced likelihoods of significant depressive symptoms for minority residents compared to non-Hispanic Whites persisted after sequential adjustments for resident and nursing home covariates, as well as in stratified analyses. The persistently lower rate of significant depressive symptoms among racial and ethnic minority residents suggests that training of nursing home caregivers for culturally sensitive depression screening is needed for improved symptom recognition among minority residents.

Clinical characteristics associated with the onset of delirium among long-term nursing home residents

BackgroundNursing home residents are frail, have multiple medical comorbidities, and are at high risk for delirium. Most of the existing evidence base on delirium is derived from studies in the acute in-patient population. We examine the association between clinical characteristics and medication use with the incidence of delirium during the nursing home stay.MethodsThis is a retrospective cohort study of 1571 residents from 12 nursing homes operated by a single care provider in Ontario, Canada. Residents were over the age of 55 and admitted between February 2010 and December 2015 with no baseline delirium and a minimum stay of 180 days. Residents with moderate or worse cognitive impairment at baseline were excluded. The baseline and follow-up characteristics of residents were collected from the Resident Assessment Instrument-Minimal Data Set 2.0 completed at admission and repeated quarterly until death or discharge. Multivariate logistic regression was used to identify characteristics and medication use associated with the onset of delirium.ResultsThe incidence of delirium was 40.4% over the nursing home stay (mean LOS: 32 months). A diagnosis of dementia (OR: 2.54, p < .001), the presence of pain (OR: 1.64, p < .001), and the use of antipsychotics (OR: 1.87, p < .001) were significantly associated with the onset of delirium. Compared to residents who did not develop delirium, residents who developed a delirium had a greater increase in the use of antipsychotics and antidepressants over the nursing home stay.ConclusionsDementia, the presence of pain, and the use of antipsychotics were associated with the onset of delirium. Pain monitoring and treatment may be important to decrease delirium in nursing homes. Future studies are necessary to examine the prescribing patterns in nursing homes and their association with delirium.

A multicomponent exercise program improves physical function in long-term nursing home residents: A randomized controlled trial

To investigate the impact of a multicomponent exercise program on anthropometry, physical function, and physical activity on older adults living in long-term nursing homes (LTNH), we conducted a randomized controlled trial involving 112 participants aged 84.9 ± 6.9 years. Participants were randomly assigned to an intervention (IG) or control group (CG). The IG participated in a 3-month multicomponent exercise intervention focused on strength, balance, stretching exercises, and walking recommendations. Subjects in the CG participated in routine activities. Analyses of outcome parameters were performed in the entire sample and in two subgroups, classified according to participants' physical function score at baseline. The group-by-time interaction, favoring the IG, was significant for the entire sample and for the participants in the low physical function subgroup for the following parameters: waist circumference, 30-s chair-stand, arm-curl, 8-ft timed up-and-go, SPPB score, gait speed, and Berg scale (p < .05). In participants with higher physical function at baseline, significant group-by-time interaction was observed in the SPPB score and Berg scale (p < .05). When differences were analyzed within groups, the IG maintained or improved in all assessed parameters, while participants in the CG showed a marked decline. Our study showed that a multicomponent exercise program is effective for older people living in LTNH. This is especially relevant in those with lower physical function scores. The lower efficacy of the program in participants with better function might be due to the insufficient exercise demands of our intervention for more fit residents. Future studies should analyze the effects of programs with higher intensities in older people with intermediate to high physical function.