Older Adults In Long-term Care Research Articles

Problems identified by dual sensory impaired older adults in long-term care when using a self-management program: A qualitative study.

ObjectiveTo gain insights into the problems of dual sensory impaired older adults in long-term care. Insights into these problems are essential for developing adequate policies which address the needs of the increasing population of dual sensory impaired older adults in long-term care.MethodsA qualitative study was conducted in parallel with a cluster randomized controlled trial. Dual sensory impaired older adults in the intervention group (n = 47, age range 82–98) were invited by a familiar nurse to identify the problems they wanted to address. Data were taken from the semi-structured intervention diaries in which nurses noted the older adults’ verbal responses during a five-month intervention period in 17 long-term care homes across the Netherlands. The data were analyzed using descriptive statistics and qualitative content analysis based on the Grounded Theory.FindingsThe 47 dual sensory impaired older adults identified a total of 122 problems. Qualitative content analysis showed that the older adults encountered participation problems and problems controlling what happens in their personal environment. Three categories of participation problems emerged: (1) existential concerns of not belonging or not being able to connect with other people, (2) lack of access to communication, information and mobility, and (3) the desire to be actively involved in care delivery. Two categories of control-in-personal-space problems emerged: (1) lack of control of their own physical belongings, and (2) lack of control regarding the behavior of nurses providing daily care in their personal environment.ConclusionsThe invasive problems identified indicate that dual sensory impaired older adults experience great existential pressures on their lives. Long-term care providers need to develop and implement policies that identify and address these problems, and be aware of adverse consequences of usual care, in order to improve dual sensory impaired residents’ autonomy and quality of life.

A Retrospective Chart Review of Two Different Insulin Administration Systems on Glycemic Control in Older Adults in Long-Term Care

The current retrospective chart review compared glycemic control and cost impact of two insulin administration systems, V-Go® versus usual care with standard of care (SOC) insulin injections, in eight patients residing in a nursing home (NH). A total of 1,937 blood glucose (BG) values were collected over 61 days. Significant improvements were observed for the V-Go versus SOC group in time in range 100 mg/dL to 200 mg/dL (V-Go 59.09% vs. SOC 34.02%; p < 0.001), reduced BG fluctuations as measured by standard deviation (V-Go 61.2 vs. SOC 92.1; p < 0.001), and improved mean daily BG (V-Go 159.38 mg/dL vs. SOC 223.86 mg/dL; p < 0.001). The estimated A1c change, calculated from BG values, decreased from 8.9% to 7.2% in the V-Go group and increased from 9.0% to 9.4% in the SOC group. Compared to SOC, use of V-Go decreased the mean time for insulin administration by nursing staff by 26.3 minutes per patient per day and associated labor costs by $328.75 per patient per month. Insulin administration with V-Go may improve glycemic control and reduce administration costs compared to existing care in the NH setting. [Journal of Gerontological Nursing, 43(1), 10-16.].

Effects of Nutritional Intervention in Long-Term Care in Korea.

Institutionalized older adults are known to be at high risk of malnutrition, but few nutritional interventions have been used for older adults in long-term care (LTC) settings. The purpose of the current study was to investigate the effects of implementing a nutritional intervention involving nursing staff education, facilitation, and a shared algorithm (NIEFA) for institutionalized older adults in Korea. A quasi-experimental pre- and posttest design was used. Patients in two LTC facilities were assigned to an intervention (n = 23) or control (n = 22) group. After completion of the 4-week NIEFA program, significant improvements were found in the intervention group's daily energy intake (t = 3.832, p < 0.001), total lymphocytes (t = 3.87, p < 0.001), hemoglobin levels (t = 4.991, p < 0.001), hematocrit levels (t = 4.305, p < 0.001), and Mini Nutritional Assessment scores (t = 10.223, p < 0.001). Implementation of NIEFA in a LTC facility may be effective in improving the nutritional status of older adults with or at risk of malnutrition. [Journal of Gerontological Nursing, 43(2), 55-64.].

Evaluation of nurses’ changing perceptions when trained to implement a self-management programme for dual sensory impaired older adults in long-term care: a qualitative study

ObjectivesTo gain insights into the process of nurses’ changing perceptions when trained to implement a self-management programme for dual sensory impaired older adults in long-term care, and into the factors...

Intraindividual Changes in Ambulation Associated With Falls in a Population of Vulnerable Older Adults in Long-Term Care

ObjectiveTo examine how intraindividual changes in ambulation characteristics may be used to predict falls. DesignLongitudinal study design. SettingAssisted living facility. ParticipantsAmbulatory older adults (N=26; mean age, 79y). InterventionsNot applicable. Main Outcome MeasuresContinuous measure of average weekly ambulation characteristics (time and distance walked, speed, path measures [eg, path time and distance, number of paths (where a path is at least 60s of uninterrupted walking separated by at least a 30-s stop)]), accounting for weekly changes in these ambulation characteristics on an individual level over time along with falls (yes/no) and cognitive impairment (CI) (measured by the Montreal Cognitive Assessment). ResultsIn hierarchical linear models accounting for intraindividual changes in ambulation characteristics over the 8-month course of the study and level of CI, path distance (odds ratio, 1.02; P≤.001) was associated with an increased risk of a fall. In the short-term, intraindividual changes in path distance were associated with a fall within the 4-week interval the change was noted. Path distance had fair sensitivity (.74) and specificity (.66) to a fall (area under the curve, .70). ConclusionsStudy findings suggest that falls may have specific predictors, specifically that older adults with CI are more likely to fall when walking continuously with little/no breaks. Interventions focused on reducing path-associated fatigue may effectively reduce fall incidence in this population.

Poster Number: NR 12 - Access to Psychiatrist Services for Older Adults in Long-Term Care: A Population Based Study

Poster Number: NR 12 - Access to Psychiatrist Services for Older Adults in Long-Term Care: A Population Based Study

Burden of Hepatitis C Virus Infection Among Older Adults in Long-Term Care Settings: a Systematic Review of the Literature and Meta-Analysis.

Hepatitis C virus (HCV) infection is a significant cause of morbidity and mortality worldwide. The magnitude of the HCV burden has previously been the subject of debate, as representative data tend to exclude high-risk populations, including institutionalized persons. The purpose of this systematic review and meta-analysis was to estimate the prevalence of HCV infection among older adults in long-term care (LTC) and assess factors associated with the prevalence of HCV in this setting. The Preferred Reporting Items for Systematic Review and Meta-Analyses checklist was used as the methodological guide. Two reviewers independently assessed the study quality using a validated modified quality assessment tool. Six articles met inclusion criteria; the majority were cross-sectional studies (83.3%) designed to estimate HCV infection prevalence rates and identify associated risk factors. HCV prevalence ranged from 1.4 to 11.8%. A pooled HCV infection prevalence of 3.3% (95% confidence interval: 1.5-7.2%) was estimated based on 1920 LTC residents with substantial heterogeneity noted (Q = 51.1, p < 0.001; I (2) = 90.2). Three of six studies reported statistically significant factors associated with an increased risk for HCV infection, including older age, female gender, history of blood transfusions, short duration of LTC residence, and hepatitis B virus positivity. This study reports a higher prevalence of HCV infection among older adults in LTC settings compared to community-dwelling older adults; however, accurate estimation of prevalence is limited by heterogeneity between and within studies, variation in sampling and recruitment methodologies, and absence of the HCV-RNA test to confirm active infection.

Instructors' Perceptions of Mostly Seated Exercise Classes: Exploring the Concept of Chair Based Exercise.

Chair based exercise (CBE) can be used to engage older adults unable to take part in standing exercise programmes. Defining and understanding the context of CBE have been acknowledged as a challenge. We explore instructor experiences of delivering mostly seated exercise classes for older people and how this helps us to further understand the concept of CBE. We extracted qualitative data from a cross-sectional survey with 731 exercise instructors. 378 delivered mostly seated classes and 223 of those instructors provided qualitative data. There were 155 instructors who did not provide any qualitative comments. Framework analysis was used and informed by a Delphi consensus study on CBE. Instructors perceived mostly seated classes as predominantly CBE; they defined it as an introductory class that should be offered as part of a continuum of exercise. It was considered suitable for those with limitations and older adults in long-term care and with dementia. Instructors reported CBE used inappropriately for more active older people. Instructors reported observing improvements in mood and cognition and broader social benefits. Instructors' perspectives largely support expert consensus that CBE has an important role in a continuum of exercise. Providers of CBE need to ensure that more challenging exercises are introduced where appropriate. Further research is needed to explore older adults' perceptions of CBE.

Pain May Lead to Malnutrition in Nursing Home Patients

Pain may be a factor in malnutrition in nursing home residents, according to a recent study published in Clinical Nutrition. The report points to a need for prompt assessment and treatment of pain to prevent appetite loss in this population, and consideration of the nutritional impact of drugs when selecting analgesics. In an analysis of data on individuals in 12 nursing homes, Austrian researchers looked at relationships between pain, appetite, and other factors that may have influenced malnutrition. The population assessed, in a secondary analysis from the OSiA (Optimiertes Schmerzmanagement in Altenpflegeheimen, or “optimized pain management in nursing homes”) Study, was 243 nursing home residents 60 or older who had mild or no cognitive impairment (Clin Nutr 2015;34[Suppl 1]:557). Baseline information was drawn from standardized questionnaires and medical documentation. Pain was detected with a verbal rating scale, and a Simplified Nutritional Appetite Questionnaire (SNAQ) was used to detect risk of malnutrition in the patients. A SNAQ score of at least 14 indicates that an individual is at risk of weight loss of at least 5% in the next 6 months. Cross-sectional and single-case analyses showed that overall, 66% of the nursing home residents had pain at rest or in action, 22% had no appetite because of pain, and 25% were at risk of malnourishment. Of the patients in the latter group, 30% reported pain. Pain was reported as the cause of loss of appetite by 43% of those who were at risk for both malnutrition and pain. Looking at use of analgesics in the population, the authors found that 64% of patients at risk of malnutrition, pain, and pain-associated loss of appetite were given analgesics with known adverse effects that included appetite loss, nausea, and vomiting. The drugs in this “inadequate” category that were most commonly prescribed were oral hydromorphone and transdermal fentanyl, and they were given in higher quantity than other drugs. The diagnoses that triggered use of analgesics in the study population included disorders of spine/extremities, injuries, arthrosis, and gastritis/gastralgia, and did not differ whether treatment was considered adequate or inadequate. There were also no differences in use of additional analgesics, such as local diclofenac and oral metamizol (also known as dipyrone, a non-NSAID analgesic and antipyretic not available in the United States), in patients on hydromorphone or fentanyl vs. other pain medications. Presenting the results at the 37th Congress of the European Society for Clinical Nutrition and Metabolism in Lisbon, Portugal, Maria Magdalena Schreier of the Institut of Nursing Science and Practice at Paracelsus Medical University said that screening and assessment of malnutrition should consider pain as a favoring factor for poor appetite. “Nearly two-thirds of the selected residents received analgesics with nutritional side effects. Those analgesics may play an important role in the context of malnutrition.” She encouraged clinicians caring for nursing home residents to assess them for pain systematically and to provide adequate pain treatment to prevent malnourishment in these patients. The appetite-reducing potential of drugs, too, should be considered. Judith M. Orvos, ELS, is a freelance medical writer and president of Orvos Communications in Washington, DC. In this study, 243 residents 60 years or older with no or mild cognitive impairment from 12 nursing homes were screened for pain and assessed for appetite using SNAQ (Short Nutritional Assessment Questionnaire). The results of this study indicated that pain was reported as the cause of loss of appetite by 43% of residents at risk for both malnutrition and pain. Additionally, the researchers investigated the use of analgesics in this population and reported that some of the medications used for pain — oral hydromorphone and fentanyl patches — caused side effects including appetite loss, nausea, and vomiting. The researchers concluded that pain should be evaluated for all nursing home residents using a systematic pain assessment tool and that analgesics provided should be considered for potential nutritional side effects. This study validates and quantifies the impact of pain as a risk factor for malnutrition in older adults in long-term care. In addition to other physical causes of malnutrition including impaired oral status, physical limitations, chronic disease, early satiety, and changes in taste and smell, the presence of pain should be considered when evaluating a resident's risk for malnutrition. Although medications can be helpful to control pain, there are potential side effects of medications which can have negative impacts on nutrition status, including loss of appetite, nausea, vomiting, and constipation, among others. An interdisciplinary approach including the physician, registered nurse, and dietitian should be considered when evaluating and treating pain in the institutionalized older adult. —Phyllis Famularo, DCN, RD Senior Manager, Nutrition Services, Sodexo

A Randomized Control Trial Investigating the Impact of Individualized Seating Provision for Older Adults in Long-Term Care

Abstract Date Presented 4/16/2015 This study details the results of a clinical trial examining the effectiveness of specialized seating assessment and provision within the long-term care environment for older adults with complex seating needs and the significant impact on skin integrity and postural management.

The effectiveness of group reminiscence therapy for loneliness, anxiety and depression in older adults in long-term care: A systematic review

Loneliness, anxiety and depression are common problems for older adults in long-term care. Reminiscence therapy is a non-pharmacological intervention that may be of some benefit. In comparison to individual reminiscence therapy, group reminiscence therapy is a preferred option when dealing with the resource constraints of long-term care. The aim of this paper was to systematically review the literature in order to explore the effectiveness of group reminiscence therapy for older adults with loneliness, anxiety and depression in long-term care. Results indicated that group reminiscence therapy is an effective treatment for depression in older adults, however to date, there is limited research support for its effectiveness to treat loneliness and anxiety. Further research and an improvement in methodological quality, such as using qualitative and mixed methods approaches, is recommended to help establish an evidence base and provide better understanding of the effectiveness of group reminiscence therapy.

Measuring staff perception of end-of-life experience of older adults in long-term care

BackgroundQuality of dying and death receive far less attention than quality of life. Measuring the quality of care at end-of-life (EOL) in long-term care (LTC) is essential, to ensure high standards. MethodsA questionnaire measuring staff perception of their patient's end of life experience (SPELE) was developed. Content validity (CVI) was assessed by a panel of experts, and piloting was conducted with dyads of healthcare assistants (n=15) and nurses (n=15). ResultsThe SPELE captures facets of the quality of the death and dying experience from healthcare staff's perspective. Good group inter-rater reliability was observed among subscales. One exception was the pain and symptom experience scale. Kappa values showed little agreement between nurses and healthcare assistants for certain symptoms, including pain. ConclusionFurther testing of the questionnaire is required. However it is described as a useful mechanism to enable researchers and clinicians to explore quality of care at EOL.

Summer Issue 2015.

-

Kinematic analysis of video-captured falls experienced by older adults in long-term care

Falls cause 95% of hip and wrist fractures and 60% of head injuries in older adults. Risk for such injuries depends in part on velocity at contact, and the time available during the fall to generate protective responses. However, we have no information on the impact velocities and durations of falls in older adults. We addressed this barrier through kinematic analysis of 25 real-life falls (experienced by 23 individuals of mean age 80 years (SD=9.8)) captured on video in two long-term facilities.All 25 falls involved impact to the pelvis, 12 involved head impact, and 21 involved hand impact. We determined time-varying positions by digitizing each video, using direct linear transformations calibrated for each fall, and impact velocities through differentiation.The vertical impact velocity averaged 2.14m/s (SD=0.63) for the pelvis, 2.91m/s (SD=0.86) for the head, and 2.87m/s (SD=1.60) for the hand. These values are 38%, 28%, and 4% lower, respectively, than predictions from an inverted pendulum model. Furthermore, the average pelvis impact velocity was 16% lower than values reported previously for young individuals in laboratory falling experiments. The average fall duration was 1271ms (SD=648) from the initiation of imbalance to pelvis impact, and 583ms (SD=255) from the start of descent to pelvis impact.These first measures of the kinematics of falls in older adults can inform the design and testing of fall injury prevention interventions (e.g., hip protectors, helmets, and flooring).

The Self-Efficacy for Functional Abilities Scale for older adults in long-term care: two-level exploratory and confirmatory factor analysis.

This study examines the underlying factor structure of the Self-Efficacy for Functional Abilities (SEFA) scale among older adults in long-term care settings. A secondary analysis of SEFA data for 568 residents in 16 long-term care facilities was applied. The sample was randomly split into 2 subsamples. A 2-level exploratory and confirmatory factor analysis adjusting for clustering effect of facilities was used to identify and determine the factor structures respectively. There were 1- and 2-factor models that were identified. Both models demonstrated acceptably mixed model fit. The 2-factor model had poor discriminant validity with high correlation between factors (r = .92, p < .001). The single-factor model was considered valid with moderate correlation with function (r = .301, p < .001). The SEFA scale demonstrated a unidimensional construct among older adults in long-term care settings. Future testing is needed among other older adult populations.

Improving Food and Fluid Intake for Older Adults Living in Long-Term Care: A Research Agenda

Poor food and fluid intake and malnutrition are endemic among older adults in long-term care (LTC), yet feasible and sustainable interventions that target key determinants and improve person-centered outcomes remain elusive. Without a comprehensive study addressing a range of determinants to identify those that are of greatest importance for targeting with interventions, expert consensus can be used to develop a research agenda. International experts and stakeholders convened for a 2-day meeting to participate in a nominal group process to identify and prioritize determinants of food and fluid intake for persons living in LTC. Top determinants to address with intervention research included social interactions of residents at mealtime; self-feeding ability; the dining environment; the attitudes, knowledge, and skills of staff; adequate time to eat/availability of staff to provide assistance; sensory properties of the food; hospitality and mealtime logistics; choice and variety in the dining experience; and nutrient density of food. Multimodal interventions that could target these prioritized determinants were also suggested. This consensus process has resulted in a prioritized research agenda for the development and testing of interventions to improve food and fluid intake of older adults living in LTC.

Positioning Clinical Nurse Specialists and Nurse Practitioners as Change Champions to Implement a Pain Protocol in Long-Term Care

Pain management for older adults in long-term care (LTC) has been recognized as a problem internationally. The purpose of this study was to explore the role of a clinical nurse specialist (CNS) and nurse practitioner (NP) as change champions during the implementation of an evidence-based pain protocol in LTC. In this exploratory, multiple-case design study, we collected data from two LTC homes in Ontario, Canada. Three data sources were used: participant observation of an NP and a CNS for 18 hours each over a 3-week period; CNS and NP diaries recording strategies, barriers, and facilitators to the implementation process; and interviews with members of the interdisciplinary team to explore perceptions about the NP and CNS role in implementing the pain protocol. Data were analyzed using thematic content analysis. The NP and CNS used a variety of effective strategies to promote pain management changes in practice including educational outreach with team members, reminders to nursing staff to highlight the pain protocol and educate about practice changes, chart audits and feedback to the nursing staff, interdisciplinary working group meetings, ad hoc meetings with nursing staff, and resident assessment using advanced skills. The CNS and NP are ideal champions to implement pain management protocols and likely other quality improvement initiatives.

Exploring the potential of using real life video capture to investigate the circumstances of falls among older adults in long-term care

Exploring the potential of using real life video capture to investigate the circumstances of falls among older adults in long-term care

Influenza and seasonal patterns of hospital use by older adults in long-term care and community settings in Ontario, Canada.

We compared seasonal influenza hospital use among older adults in long-term care (LTC) and community settings. We used provincial administrative data from Ontario to identify all emergency department (ED) visits and hospital admissions for pneumonia and influenza among adults older than 65 years between 2002 and 2008. We used sentinel laboratory reports to define influenza and summer seasons and estimated mean annual event rates and influenza-associated rates. Mean annual pneumonia and influenza ED visit rates were higher in LTC than the community (rate ratio [RR] for influenza season = 3.9; 95% confidence interval [CI] = 3.8, 4.0; for summer = 4.9; 95% CI = 4.8, 5.1) but this was attenuated in influenza-associated rates (RR = 2.4; 95% CI = 2.1, 2.8). The proportion of pneumonia and influenza ED visits attributable to seasonal influenza was 17% (15%-20%) in LTC and 28% (27%-29%) in the community. Results for hospital admissions were comparable. We found high rates of hospital use from LTC but evidence of lower impact of circulating influenza in the community. This differential impact of circulating influenza between the 2 environments may result from different influenza control policies.

Prevalence of and factors associated with head impact during falls in older adults in long-term care

Falls cause more than 60% of head injuries in older adults. Lack of objective evidence on the circumstances of these events is a barrier to prevention. We analyzed video footage to determine the frequency of and risk factors for head impact during falls in older adults in 2 long-term care facilities. Over 39 months, we captured on video 227 falls involving 133 residents. We used a validated questionnaire to analyze the mechanisms of each fall. We then examined whether the probability for head impact was associated with upper-limb protective responses (hand impact) and fall direction. Head impact occurred in 37% of falls, usually onto a vinyl or linoleum floor. Hand impact occurred in 74% of falls but had no significant effect on the probability of head impact (p = 0.3). An increased probability of head impact was associated with a forward initial fall direction, compared with backward falls (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.3-5.9) or sideways falls (OR 2.8, 95% CI 1.2-6.3). In 36% of sideways falls, residents rotated to land backwards, which reduced the probability of head impact (OR 0.2, 95% CI 0.04-0.8). Head impact was common in observed falls in older adults living in long-term care facilities, particularly in forward falls. Backward rotation during descent appeared to be protective, but hand impact was not. Attention to upper-limb strength and teaching rotational falling techniques (as in martial arts training) may reduce fall-related head injuries in older adults.