Minimum Data Set Cognitive Performance Research Articles

Effects of dipeptidyl peptidase-4 inhibitors and sulphonylureas on cognitive and physical function in nursing home residents.

Dipeptidyl peptidase-4 inhibitors (DPP4Is) may mitigate hypoglycaemia-mediated declines in cognitive and physical functioning compared with sulphonylureas (SUs), yet comparative studies are unavailable among older adults, particularly nursing home (NH) residents. We evaluated the effects of DPP4Is versus SUs on cognitive and physical functioning among NH residents. This new-user cohort study included long-stay NH residents aged ≥65 years from the 2007-2010 national US Minimum Data Set (MDS) clinical assessments and linked Medicare claims. We measured cognitive decline from the validated 6-point MDS Cognitive Performance Scale, functional decline from the validated 28-point MDS Activities of Daily Living scale, and hospitalizations or emergency department visits for altered mental status from Medicare claims. We compared 180-day outcomes in residents who initiated a DPP4I versus SU after 1:1 propensity score matching using Cox regression models. The matched cohort (N=1784) had a mean ± SD age of 80 ± 8 years and 73% were women. Approximately 46% had no or mild cognitive impairment and 35% had no or mild functional impairment before treatment initiation. Compared with SU users, DPP4I users had lower 180-day rates of cognitive decline [hazard ratio (HR)=0.61, 95% confidence interval (CI) 0.31-1.19], altered mental status events (HR=0.71, 95% CI 0.39-1.27), and functional decline (HR=0.89, 95% CI 0.51-1.56), but estimates were imprecise. Rates of cognitive and functional decline may be reduced among older NH residents using DPP4Is compared with SUs, but larger studies with greater statistical power should resolve the remaining uncertainty by providing more precise effect estimates.

Delirium During Acute Illness in Nursing Home Residents

To ascertain the incidence of delirium during acute illness in nursing home residents, describe the timing of delirium after acute illness onset, describe risk factors for delirium, and explore the relationship between delirium and complications of acute illness. Prospective observational cohort study. Three nursing homes in metropolitan New York. Individuals who were expected to remain in the nursing home for at least 2 months, who, as part of a parent study, were receiving opioids, antidepressants, or antipsychotics on a routine basis, and who did not have an acute medical illness at the time of screening. Acute illness surveillance was performed twice weekly through communication with nursing home nursing staff and medical providers using established clinical criteria for incipient cases. We followed patients for 14 days after illness onset, and, if applicable, an additional 14 days each after hospital admission and hospital discharge. Delirium was assessed 3 times weekly using the Confusion Assessment Method (CAM). Physical function decline was calculated using change in the Minimum Data Set Activities of Daily Living Scale (MDS-ADL) and cognitive function decline using change in the Minimum Data Set Cognitive performance scale (MDS-CPS). Falls were ascertained by record review. Among 136 nursing home patients followed for a mean of 11.7 months, 78 experienced 232 acute illnesses, of which 162 (71%) were managed in the nursing home. The most common diagnoses were urinary tract infection (20%), cellulitis (15%), and lower respiratory tract infection (9%). Subjects experienced delirium during 41 (17.7%) of 232 acute illnesses. Female sex was associated with a greater risk of delirium (odds ratio 2.59; 95% confidence interval [CI] 1.04-6.43) but there were no other risk factors identified. Delirium was a risk factor for cognitive function decline (odds ratio 4.59; 95% CI 1.99-10.59; P = .0004), but not ADL function decline or falling. Delirium occurred frequently as a complication of acute illness in the nursing home, and was a risk factor for cognitive function decline. This finding supports the rationale to target individuals at the onset of an acute medical problem in the design of interventions to prevent delirium in the nursing home setting.

Dying in U.S. Nursing Homes with Advanced Dementia: How Does Health Care Use Differ for Residents with, versus without, End-of-Life Medicare Skilled Nursing Facility Care?

Because Medicare policy restricts simultaneous Medicare hospice and skilled nursing facility (SNF) care, we compared hospice use and sites of death for SNF/non-SNF residents with advanced dementia; and, for those with SNF, we evaluated how subsequent hospice use was associated with dying in a hospital. This study includes (non-health maintenance organization [HMO]) residents of U.S. nursing homes (NHs) who died in 2006 with advanced dementia (n=99,370). Sites of death, Medicare SNF, and hospice use were identified using linked resident assessment and Medicare enrollment and claims data. Advanced dementia was identified by a diagnosis of Alzheimer's disease or dementia on the Minimum Data Set (MDS) or a Medicare claim in the last year of life and severe to very severe cognitive impairment (5 or 6 on the MDS cognitive performance scale). For residents with SNF, we used multivariate logistic regression with generalized estimating equations to estimate the effect of subsequent hospice enrollment on dying in a hospital. Forty percent of U.S. NH residents dying with advanced dementia in 2006 had SNF care in the last 90 days of life. Those with versus without SNF less frequently used hospice (30% versus 46%), more frequently had short (≤7 days) hospice stays (40% versus 19%), and more frequently died in hospitals (14% versus 9%). Among residents with SNF, those with subsequent hospice use had a 98% lower likelihood of a hospital death (95% confidence interval [CI]: 0.014, 0.025). Dual hospice/SNF access may result in fewer hospital deaths and higher quality of life for dying NH residents.

Screening cognitive impairment among institutionalized older Chinese men in Taiwan: A new minimum data set-based dementia screening tool is needed

Dementia screening is of great importance in various health settings for older people, long-term care facilities are no exception. The need for an effective dementia screening tool being culture sensitive is important. Minimum data set (MDS) is a population instrument for health care management in the world, which also covers dementia screening. The main purpose of this study was to evaluate the effectiveness of the MDS-based dementia screening tools among older Chinese men in the Veteran Home in Taiwan. Overall, 576 participants (mean age: 80.9 ± 5.3 years, all males, 92.7% physically independent), 18.6% had cognitive impairment according to the mini-mental state examination (MMSE) (mean score: 26.7 ± 3.9). However, the prevalence of cognitive impairment was 5.5% by MDS cognitive performance scale (CPS) and 18.9% by MDS cognition scale (MDS-COGS). The screening results of CPS and MDS-COGS were highly interrelated ( γ = 0.93, p < 0.001), and MMSE scores were also significantly associated with CPS and MDS-COGS status ( γ = −0.50, p < 0.001 and γ = −0.52, p < 0.001, respectively). Although the prevalence of cognitive impairment by MMSE and MDS-COGS are similar, the results are significantly inconsistent ( p < 0.001). In conclusion, both MDS-COGS and CPS were significantly correlated with MMSE scores, but significant inconsistence was noted between screening results of MMSE, CPS and MDS-COGS. Further study is needed to develop MDS-based dementia screening tools for older Chinese men in Taiwan.

Challenges to Achieving Adequate Sample Sizes for Facility Level Evaluations of Nursing Home Resident Satisfaction

Residents with cognitive limitations by necessity are excluded from nursing home satisfaction initiatives. We used national data from the Minimum Data Set (MDS) to examine the distribution of resident cognitive status across nursing homes to gain further insight into how residents with cognitive limitations could impact the sample size of respondents. We estimate the associations of cognitive status (using the MDS Cognitive Performance Scale, [CPS]) with length-of-stay, bed size, and hospital affiliation. The analyses were performed using approximately 3.5 million MDS records collected from nursing homes during 2001. The results show adequately precise information for long-stay residents will be available from 4 to 46% of hospital-based facilities and 67–90% of freestanding facilities, whereas information from short-stay residents will be available from 34 to 95% of hospital-based facilities and 14–50% of freestanding facilities. Several initiatives are underway to measure and report the satisfaction of nursing home residents. In all of these large satisfaction initiatives the sampling strategy of respondents needs to be sufficient to allow for nursing home comparisons, and second, to allow interfacility benchmarking comparisons. We highlight the difficulty in obtaining information for these initiatives.

Home care needs of extremely obese elderly European women

To examine the health and needs of extremely obese women aged over 65 years receiving home care in Europe. A cross-sectional assessment study based on the Aged in Home Care (AdHOC) project recruited 2974 women aged 65 or over who were receiving home care at 11 sites in European countries. Extreme obesity was defined as 'Obesity of such a degree as to interfere with normal activities, including respiration'. Resident Assessment Instrument for Home Care (RAI-HC version 2.0); Activity of Daily Living Scale; Instrumental Activity of Daily Living Scale; the Minimum Data Set Cognitive Performance Scale; and a health profile. One hundred and twenty women (4.0%) were extremely obese. They were younger than their thinner counterparts, with a median age of 78.3 versus 83.3 years, and they more often had multiple health complaints and needed more help with mobility outside the home. The extremely obese had received home care longer than the non-extremely obese (median 28.7 versus 36.6 months). Extremely obese women also needed more help with personal care than the other group and, due to lower age, they were less cognitively impaired. Extreme obesity is a problem that increasingly affects home care of elderly women.

Measuring change in activities of daily living in nursing home residents with moderate to severe cognitive impairment

BackgroundThe objective of this study was to assess the responsiveness of the Minimum Data Set Activities of Daily Living (MDS-ADL) Scale to change over time by examining the change in physical function in adults with moderate to severe dementia with no comorbid illness who had been resident in a nursing home for over 90 days.MethodsLongitudinal data were collected on nursing home residents with moderate (n = 7001) or severe (n = 4616) dementia in one US state from the US national Minimum Data Set (MDS). Severity of dementia was determined by the MDS Cognitive Performance Scale (CPS). Physical function was assessed by summing the seven items (bed mobility, transfer, locomotion, dressing, eating, toilet use, personal hygiene) on the MDS activities of daily living (ADL) Long Form scale. Mean change over time of MDS-ADL scores were estimated at three and six months for residents with moderate (CPS score of 3) and severe (CPS score of 4 or 5) dementia.ResultsPhysical function in residents with moderate cognitive impairment deteriorated over six months by an average of 1.78 points on the MDS-ADL Long Form scale, while those with severe cognitive impairment declined by an average of 1.70 points. Approximately one quarter of residents in both groups showed some improvement in physical function over the six month period. Residents with moderate cognitive impairment experienced the greatest deterioration in early-loss and mid-loss ADL items (personal hygiene, dressing, toilet use) and residents with severe cognitive impairment showed the greatest deterioration in activities related to eating, a late loss ADL.ConclusionThe MDS-ADL Long Form scale detected clinically meaningful change in physical function in a large cohort of long-stay nursing home residents with moderate to severe dementia, supporting its use as a research tool in future studies.

Nurse Care Coordination in Community‐Based Long‐Term Care

To evaluate the clinical outcomes of a nurse care coordination program for people receiving services from a state-funded home and community-based waiver program called Missouri Care Options (MCO). A quasi-experimental design was used to compare 55 MCO clients who received nurse care coordination (NCC) and 30 clients who received MCO services but no nurse care coordination. Nurse care coordination consists of the assignment of a registered nurse who provides home care services for both the MCO program and Medicare home health services. Two standardized datasets, the Minimum Data Set (MDS) for resident care and planning and the Outcome Assessment Instrument and Data Set (OASIS) were collected at baseline, 6 months, and 12 months on both groups. Cognition was measured with the MDS Cognitive Performance Scale (CPS), activities of daily living (ADL) as the sum of five MDS ADL items, depression with the MDS-Depression Rating Scale, and incontinence and pressure ulcers with specific MDS items. Three OASIS items were used to measure pain, dyspnea, and medication management. The Cochran-Mantel-Haenszel (CMH) method was used to test the association between the NCC intervention and clinical outcomes. At 12 months the NCC group scored significantly better statistically in the clinical outcomes of pain, dyspnea, and ADLs. No significant differences between groups were found in eight clinical outcome measures at 6 months. Use of nurse care coordination for acute and chronic home care warrants further evaluation as a treatment approach for chronically ill older adults.

Clinical Outcomes of Aging in Place

Programs such as Medicaid Home and Community-based Services (HCBS) have provided an alternative to institutionalization through community-based, long-term care services; however, there are limited studies on the clinical outcomes of participants in these programs as compared to nursing home (NH) residents. To compare clinical outcomes of individuals in a community-based, long-term care program to individuals of similar case mix in institutional-based, long-term care. A program called Aging in Place (AIP) was developed by the Sinclair School of Nursing in cooperation with the state of Missouri's HCBS program. The AIP intervention consisted of nurse coordination of the HCBS program and Medicare home health services. A total of 78 AIP participants were matched with 78 NH residents on admission period, activities of daily living (ADLs), cognitive status, and age. The Minimum Data Set (MDS) was collected on the AIP group at admission and every 6 months over a 30-month period. Cognition was measured by the MDS Cognitive Performance Scale (CPS), ADLs by the sum of 5 MDS ADL items, depression by the MDS-Depression Rating Scale, and incontinence by rating on 2 MDS items related to urinary continence. The Cochran-Mantel-Haenszel method was used to test the association between the AIP intervention and clinical outcomes. The AIP group clinical outcomes were better at a statistically significant level (less than .05) for the following outcomes: (a) cognition at 6, 12, and 18 months (p = .00); (b) depression at 6 and 12 months (p = .00); (c) ADL at 6 (p = .02), 12 (p = .04), and 24 (p = .00) months; and (d) incontinence at 24 (p = .02) months. In all 4 outcome measures, the AIP group stabilized or improved outcome scores whereas the NH group's outcome scores deteriorated. Study results suggest that community-based care with nurse coordination enhances clinical outcomes of long-term care participants.

AG 3: A COMPARATIVE COST ANALYSIS OF ALZHEIMER'S DISEASE VERSUS VASCULAR DEMENTIA

OBJECTIVE: The Omnibus Reconciliation Act of 1987 (OBRA ‘87) requires trained clinical professionals in nursing homes to complete an assessment called the Minimum Data Set (MDS) to evaluate the functional, medical, psychosocial, and cognitive status for each resident. The objective of this pilot study is to examine the relationship between cognitive status as measured by the MDS Cognitive Performance Scale (CPS) and qualityof-life as measured by the Quality-of-Life in Late-Stage Dementia (QUALID) scale among residents of West Virginia (WV) long-term care (LTC) facilities. METHODS: A cross-sectional study was completed using a convenience sample of 339 residents from 10 LTC facilities in WV. CPS scores for residents were calculated by a consultant pharmacist from the MDS scores. Direct care assistants assessed residents’ quality-of-life using the QUALID scale, which evaluates 11 observational behaviors on a 5-point scale with scores ranging from 11 (best) to 55 (worst). Descriptive statistics and one-way ANOVAs were conducted to examine differences in quality-of-life among residents with intact cognitive function (CPS = 0), mild cognitive impairment (CI) (CPS = 1,2), moderate CI (CPS = 3,4) and severe CI (CPS = 5,6). RESULTS: The mean age for residents was 78.5 years. QUALID and CPS mean scores were 24.07 and 3.34, respectively. Mean QUALID scores for individuals with severe CI (27.1 ± 7.8) were significantly higher (p < 0.00) than for individuals with intact cognitive function (20.0 ± 7.3), mild CI (21.4 ± 7.8) and moderate CI (22.9 ± 9.2). One-way ANOVAs showed no differences for QUALID and CPS scores based on age categories and gender. CONCLUSIONS: Results of this study show that cognitive status, as indicated by CPS scores, significantly affects QUALID scores. Based on QUALID scores, LTC residents with more severe CI have significantly lower quality-oflife. Further studies are needed to determine if improved changes in QUALID scores postpone decline of cognitive status or if interventions which delay deteriorating cognitive status improve quality-of-life.

Prevalence of Cognitively Intact Individuals Residing in Extended Care Nursing Facilities

There appears to be a relative absence of studies that have examined the prevalence of cognitively intact individuals who reside in extended care facilities. Prevalence data were collected on 296 persons who resided in 3 extended care nursing facilities in Central Virginia. Cognitive intactness was evaluated via the Minimum Data Set Cognitive Performance Scale (CPS) and an author-generated survey (i.e., Cognitively Intact Survey [CI Survey]) of select nursing staff members at each facility. The Mini-Mental State Examination (MMSE) was utilized to examine the accuracy of the two measures in identifying cognitive intactness. Findings indicated that prevalence rates of cognitively intact residents varied as a function of the measures utilized to assess intactness. Specifically, a significantly greater proportion of the total sample of residents was judged to be cognitively intact via the CI Survey (34.12%) as compared to the CPS (26.01%). The level of interjudge agreement between the two measures was found to be moderately high (K = 0.68). When the MMSE was employed to verify individuals' levels of intactness, the percentages of residents predicted to actually be cognitively intact were somewhat lower for each measure. Specifically, based on the data obtained via the CI Survey, 22.75% of the total sample were predicted to actually be cognitively intact, whereas 17.85% of the sample were predicted to be intact based on the CPS results. Findings are discussed in light of factors that may have contributed to the differential prevalence rates of cognitively intact individuals obtained across the measures utilized in this study. Concerns regarding the utilization of the MMSE as a criterion measure of cognitive intactness in persons residing in extended care nursing facilities are provided, along with data on the living environments/roommate statuses of those residents judged to be intact via the CI Survey. Implications for the design of future extended care nursing units, as well as future research, are also included.

Residential and nursing home care of elderly people with cognitive impairment: Prevalence, mortality and costs

Cognitive impairment among residents has considerable resource implications for both individuals and those responsible for publicly funded care. Two linked surveys were carried out in England: (1) a longitudinal study followed 2500 admissions to publicly funded care up to 42 months after admission; and (2) a cross-sectional survey of 618 homes collected information about 11,900 residents. Information was collected about cognitive impairment using the Minimum Data Set Cognitive Performance Scale. Cognitive impairment was associated with source of funding and type of home. Although level of cognitive impairment has some effect, fees and costs were most influenced by type of home. At the same level of impairment, self-funded residents were more likely to be located in relatively low-cost settings than publicly funded residents. In independent homes fees were lower for publicly funded than for self-funded residents. Overall median length of stay of publicly funded admissions was 18 months. For the most part length of stay was not associated with level of cognitive impairment on admission. It is concluded that more information is needed about the effect of quality of care on people with cognitive impairment in different settings. If the same quality of care can be achieved in residential and nursing homes, the evidence would suggest that changes in placement policies could result in potential savings to the public purse.

Decision-making capacity to execute a health care proxy: development and testing of guidelines.

To evaluate the reliability and validity of guidelines to determine the capacity of nursing home residents to execute a health care proxy (HCP). A cross-sectional study. A 750-bed not-for-profit nursing home located in New York City. A random sample of 200 nursing home residents: average age, 87; 99% white; 83% female; average length of stay, 3.05 years; mean Mini-Mental State Exam (MMSE) score, 15.9. Demographic characteristics (Minimum Data Set (MDS)); function and cognitive status (Institutional Comprehensive Assessment and Referral Evaluation (INCARE)); Reisberg Dementia Staging; MMSE; Minimum Data Set-Cognitive Performance Scale (MDS-COGS)); an investigator-developed measure of a nursing home resident's capacity to execute a health care proxy (Health Care Proxy (HCP) Guidelines.) The internal consistency of the decision-making scales in the HCP Guidelines, paraphrased recall and recognition, reached acceptable levels, alphas of .85 and .73, respectively. Interrater reliability estimates were .92 and .94, respectively, for the recall and recognition scales; test-retest reliability estimates were .83 and .90. The discriminant validity of these scales is promising. For example, the MMSE correlation was .51 with the Recall scale and .57 with the Recognition scale. Of residents with severe cognitive impairment (MMSE < 10), 71% completed 50% or more of the scaled items in the HCP guidelines and 95% consistently named a proxy. Seventy-three percent of testable residents, approximately three-quarters of whom were cognitively impaired, evidenced sufficient capacity to execute an HCP. Of residents with severe cognitive impairment, the HCP guidelines are potentially useful in identifying those with the capacity to execute a HCP. The guidelines are more predictive than the MMSE in identifying residents able to execute a HCP.

Prevalence of cognitively intact individuals residing in extended care nursing facilities

There appears to be a relative absence of studies that have examined the prevalence of cognitively intact individuals who reside in extended care facilities. Prevalence data were collected on 296 persons who resided in 3 extended care nursing facilities in Central Virginia. Cognitive intactness was evaluated via the Minimum Data Set Cognitive Performance Scale (CPS) and an author-generated survey (i.e., Cognitively Intact Survey [CI Survey]) of select nursing staff members at each facility. The Mini-Mental State Examination (MMSE) was utilized to examine the accuracy of the two measures in identifying cognitive intactness. Findings indicated that prevalence rates of cognitively intact residents varied as a function of the measures utilized to assess intactness. Specifically, a significantly greater proportion of the total sample of residents was judged to be cognitively intact via the CI Survey (34.12%) as compared to the CPS (26.01%). The level of interjudge agreement between the two measures was found to be moderately high (K = 0.68). When the MMSE was employed to verify individuals' levels of intactness, the percentages of residents predicted to actually be cognitively intact were somewhat lower for each measure. Specifically, based on the data obtained via the CI Survey, 22.75% of the total sample were predicted to actually be cognitively intact, whereas 17.85% of the sample were predicted to be intact based on the CPS results. Findings are discussed in light of factors that may have contributed to the differential prevalence rates of cognitively intact individuals obtained across the measures utilized in this study. Concerns regarding the utilization of the MMSE as a criterion measure of cognitive intactness in persons residing in extended care nursing facilities are provided, along with data on the living environments/roommate statuses of those residents judged to be intact via the CI Survey. Implications for the design of future extended care nursing units, as well as future research, are also included.

Validation of the Minimum Data Set Cognitive Performance Scale: agreement with the Mini-Mental State Examination.

Almost all nursing homes in the United States are required by the 1987 Omnibus Budget Reconciliation Act to assess each resident's functional, medical, psychosocial, and cognitive status using a standard instrument known as the Minimum Data Set (MDS). We report a validation study to show that the MDS Cognitive Performance Scale (CPS), a cognitive measure generated from 5 MDS items (comatose status, decision making, short-term memory, making self understood, and eating) can be used to detect cognitive impairment as defined by the Mini-Mental State Examination (MMSE). Two hundred subjects were randomly recruited from 8 nursing home facilities in North Carolina. Two medical students administered the MMSE, while a geriatric research nurse was responsible for collecting MDS cognitive items, which included the 5 items required for generating CPS scores. Cognitive impairment was defined by MMSE scores adjusted for education. Agreement between the CPS and the MMSE in identifying cognitively impaired subjects was then evaluated. The CPS showed substantial agreement with the MMSE in the identification of cognitive impairment; the sensitivity was .94 (95% confidence interval [CI]: .90, .98), the specificity was .94 (95% CI: .87, .96), and the diagnostic accuracy as measured by the area under the receiver operating characteristics (ROC) curve was .96 (95% CI: .88, 1.0). The MDS Cognitive Performance Scale, when performed by a trained research nurse using recommended protocols, provides a valid measure of cognitive status in nursing home residents.

MDS Cognitive Performance Scale(C)

Chronic cognitive impairment is a major problem in U.S. nursing homes, yet traditional assessment systems in most facilities included only limited information on cognitive status. Following the Congressional mandate in the Omnibus Reconciliation Act of 1987 (OBRA '87), U.S. nursing homes now complete the Minimum Data Set (MDS), a standardized, comprehensive assessment of each resident's functional, medical, psychosocial, and cognitive status. We designed a Cognitive Performance Scale (CPS) that uses MDS data to assign residents into easily understood cognitive performance categories. Information was drawn from three data sets, including two multistate data sets constructed for the Health Care Financing Administration. The prevalence and reliability of the MDS cognitive performance variables were established when assessed by trained nursing personnel. Five selected MDS items were combined to create the single, functionally meaningful seven-category hierarchical Cognitive Performance Scale. The CPS scale corresponded closely with scores generated by the Mini-Mental State Examination and the Test for Severe Impairment, nursing judgments of disorientation, and neurological diagnoses of Alzheimer's disease and other dementias. The new CPS provides a functional view of cognitive performance, using readily available MDS data. It should prove useful to clinicians and investigators using the MDS to determine a resident's cognitive assets.