Older Patients In Nursing Homes Research Articles

Medication Appropriateness for Older Nursing Home Patients With a Limited Life Expectancy: From STOPP/START Version 2 to the ReNeWAL Criteria

ObjectivesTo adapt the 2015 Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria to older nursing home patients with a limited life expectancy of 1.5 to 2 years. DesignA modified Delphi consensus study. Setting and ParticipantsThe study was established in The Netherlands and conducted online. The international panel consisted of 23 experts with experience in medicine for older people. MethodsThe expert panel was presented with the 2015 STOPP/START criteria using an online survey program (Survey Monkey). The panelists were asked for their opinion on the appropriateness of the STOPP and START criteria, and adaptations to these criteria for older nursing home patients with a limited life expectancy on 4-point Likert scales. Consensus was defined as ≥70% of the panelists answering (very) inappropriate or (very) appropriate, and (completely) disagree or (completely) agree. ResultsTwenty-one panelists completed all 3 Delphi rounds. The final list of “Represcribing for Nursing home residents With A Limited life expectancy (ReNeWAL)” criteria comprises 132 criteria: 98 criteria to stop (70 original STOPP criteria and 28 adapted) and 34 criteria to start (16 original START criteria and 18 adapted) for older nursing home patients with a limited life expectancy. Considerations that panelists mentioned for adapting criteria were mainly prevention and treatment of discomfort. Conclusion and ImplicationsIt is clear that represcribing for older nursing home patients is highly complex and requires the consideration of various elements. The ReNeWAL criteria may be useful in enhancing represcribing for older nursing home patients with a limited life expectancy.

Impact of Motivation for Eating Habits, Appetite and Food Satisfaction, and Food Consciousness on Food Intake and Weight Loss in Older Nursing Home Patients.

This study analyzed data from the Long-term care Information system For Evidence (LIFE) database to examine the effects of motivation to eat, appetite and food satisfaction, and food consciousness on food intake and weight loss. Of the 748 nursing home residents enrolled in the LIFE database, 336 met the eligibility criteria for this cross-sectional study. Motivation to eat, appetite and food satisfaction, and food consciousness were rated on five-point Likert scales (e.g., good, fair, normal, not so good, and not good). We applied Spearman rank correlation coefficient and multiple regression analyses to analyze the relationships between these three items, daily energy and protein intake, and body weight loss over 6 months. The mean participant age was 87.4±8.1 years and 259 (77%) were female. The required levels of care included-level 1, 1 (0%); level 2, 4 (1%); level 3, 107 (32%); level 4, 135 (40%); and level 5, 89 (27%). The mean daily energy intake was 28.2±7.8 kcal/kg. The mean daily protein intake was 1.1±0.3 g/kg. The mean weight loss over six months was 1.2±0.7 kg. We observed strong positive correlations among motivation to eat, appetite and food satisfaction, and food consciousness (r>0.8). These three items were significantly associated with higher daily energy intake but not with daily protein intake. Only appetite and food satisfaction were significantly associated with lower weight loss over six months. The observed associations of appetite and food satisfaction suggest that these factors may be more important to assess than motivation to eat or food consciousness among older adult residents of long-term care facilities.

The Quality of Dying in Frail Institutionalized Older Patients After Nonoperative and Operative Management of a Proximal Femoral Fracture: An In-Depth Analysis.

Proximal femoral fractures in frail patients have a poor prognosis. Despite the high mortality, little is known about the quality of dying (QoD) while this is an integral part of palliative care and could influence decision making on nonoperative- (NOM) or operative management (OM). To identify the QoD in frail patients with a proximal femoral fracture. Data from the prospective FRAIL-HIP study, that studied the outcomes of NOM and OM in institutionalized older patients ≥70 years with a limited life expectancy who sustained a proximal femoral fracture, was analyzed. This study included patients who died within the 6-month study period and whose proxies evaluated the QoD. The QoD was evaluated with the Quality of Dying and Death (QODD) questionnaire resulting in an overall score and 4 subcategory scores (Symptom control, Preparation, Connectedness, and Transcendence). In total 52 (64% of NOM) and 21 (53% of OM) of the proxies responded to the QODD. The overall QODD score was 6.8 (P25-P75 5.7-7.7) (intermediate), with 34 (47%) of the proxies rating the QODD 'good to almost perfect'. Significant differences in the QODD scores between groups were not noted (NOM; 7.0 (P25-P75 5.7-7.8) vs OM; 6.6 (P25-P75 6.1-7.2), P = .73). Symptom control was the lowest rated subcategory in both groups. The QoD in frail older nursing home patients with a proximal femoral fracture is good and humane. QODD scores after NOM are at least as good as OM. Improving symptom control would further increase the QoD.

No association between subnormal serum vitamin B12 and anemia in older nursing home patients.

Since evidence of an association between vitamin B12 (B12) deficiency and anemia in older people is limited and inconclusive, we wanted to investigate this association in old, frail nursing home patients. The study includes patients admitted to short-term, post-acute care (n = 765) and residents in long-term care (LTC) (n = 1665), in the municipality of Bergen. Anemia was defined according to the WHO criteria: Hb < 13g/dL in men and < 12g/dL in women, and as Hb < 11g/dL, in both sex (moderate/severe anemia). The presence of anemia was analyzed in patients with subnormal (< 250pmol/L), normal (250-650pmol/L) and high (> 650pmol/L) B12, and the association between anemia and clinical parameters, and including B12, was analyzed using logistic regression models. The use of B12 supplementation was investigated in the LTC patients. Mean age of the 2430 patients was 86 ± 7years. WHO-defined anemia was seen in 1023 (42%), and moderate/severe anemia in 384 (16%) of the patients. In multiple logistic regression analyses, we found no statistically significant associations of subnormal B12 with WHO-defined anemia or moderate/severe anemia. Renal insufficiency, iron deficiency and CRP > 10mg/L were significantly associated with both types of anemia, (p < 0.001). Among the LTC residents, 405 (24%) received B12 supplements, 112 (7%) of them had elevated B12 > 650pmol/L. In older nursing home patients, no association was observed between subnormal B12 and anemia. Older patients in Western societies with mild/moderate anemia should not be treated with B12 supplements without further investigation.

From Sleeplessness to Slumber: Person-Centered Approach to Insomnia

From Sleeplessness to Slumber: Person-Centered Approach to Insomnia

Assessing the Impact of an Interdisciplinary Team Approach Using the ARMOR Protocol on the Rate of Psychotropic Medications and Other Quality Indicators in Long-Term Care Facilities

Polypharmacy in older nursing home patients is a well-documented concern. Several large studies have demonstrated an association between treatment with antipsychotics and increased morbidity and mortality in people with dementia, and the economic impact of polypharmacy is also substantial, with annual medicationrelated issues costing $7.6 billion in nursing facilities alone. We chose to use the Assess, Review, Minimize, Optimize, Reassess (ARMOR) protocol for our team-based intervention to address inappropriate prescribing in older residents. A reduction in the use of psychotropic medications was associated with an improvement in activities of daily living and fewer reports of depression but was also linked to an increase in the rate of falls and reports of pain. The lower use of antipsychotics also appears to unmask untreated anxiety, expressed in the results as the increased rate of antianxiety medications.

Factors influencing the referral of nursing home patients to the hospital

Hospitalisation may cause negative effects on elderly patients. Therefore, it is important that referral and admission of older nursing home patients is well-considered. The aim of this study is to investigate the factors that affect the decision making process. Questionnaire survey among elderly care physicians and physicians following the elderly care physician training program. Of the 1,540 surveys, 200 were returned (response rate of 13%). Over 60% of the respondents had referred anursing home patient to the hospital in the previous month. Astay at ageriatric rehabilitation ward, suspicion of afracture, agood quality of life, apatient's or family's wish for referral, no treatment restrictions, and follow-up appointments in the hospital were factors which made referral to the hospital more likely according to the respondents. Medical specialist consultation and the in hospital presence of aphysician specialised in geriatric care were considered to be important. Referral was less likely if apatient was diagnosed with dementia, had alow quality of life or had treatment restrictions. Both patient-related and non-patient-related factors influence hospital referral of nursing home patients. Further research is needed to determine whether these different factors contribute to the different outcomes of ahospital admission, to facilitate proper decision-making for elderly care physicians.

Deprescribing in Older Nursing Home Patients: Focus on Innovative Composite Measures for Dosage Deintensification.

Deprescribing, which includes stopping or reducing the dosage of medications, is designed to improve safety and prevent adverse drug reactions in older patients. To date, there has been limited work on measuring decreases in dosage intensity, or deintensification, across therapeutic classes of medications. Given the ongoing focus on central nervous system (CNS) medications and the frequency with which providers encounter hypertension and diabetes in older nursing home patients, the objective of this expert review is to describe and critique innovative composite dosage intensity measures that have been, or could be, applied to quantify deintensification within three therapeutic medication targets commonly encountered in nursing home patients: CNS agents, antihypertensive therapy, and antidiabetic therapy and the extent to which they are associated with health outcomes. Composite measures for CNS medication intensity considered dividing a patient's daily dose by defined daily dosage (DDD), or the minimum effective adult or geriatric daily dosage. In contrast, composite measures for antihypertensives used either DDD or maximum recommended daily dosage in the denominator. We were not able to identify any composite measure of intensity for antidiabetic classes. There was a paucity of interventional studies that showed reducing the dosage intensity resulted in improved health outcomes. In conclusion, we identified several innovative composite measures of dosage intensity for CNS and antihypertensive medications, and discussed possible approaches for developing an antidiabetic regimen composite measure. It is critical for future research to compare and contrast various measures and to determine their impact on important clinical outcomes.

The burden of comorbidity is associated with symptomatic polymicrobial urinary tract infection among institutionalized elderly.

Urinary tract infections (UTIs), often sustained by polymicrobial flora (p-UTIs), are a common finding among nursing home patients, and associated with adverse outcomes and increased healthcare costs. P-UTIs have been extensively studied with regard to microbiological aspects. However, little is known about the characteristics of the host. The aim of this study is to verify to which extent comorbidity characterizes elderly nursing home patients with p-UTIs. We enrolled 299 patients with culture-positive UTI consecutively admitted to the nursing home of the "Fondazione San Raffaele Cittadella della Carità", Taranto, Italy. P-UTI was diagnosed when two uropathogens were simultaneously isolated. The burden of comorbidity was quantified using the Charlson comorbidity score index. Logistic regression analysis was used to assess the adjusted association of the variables of interest with the presence of p-UTI. P-UTIs were detected in 118/299 (39%) patients. According to logistic regression, the presence of p-UTIs was independently associated with the Charlson index (OR 1.70; 95% CI 1.06-2.72; P = .026). This association remained also after excluding participants without urinary catheter (OR 1.88; 95% CI 1.13-3.11; P = .015). The presence of P-UTIs is associated with the burden of comorbidity, but not with individual diseases. Older nursing home patients with comorbidity should be screened for the presence of p-UTIs; further studies are needed to evaluate the impact of early detection and treatment of p-UTIs on the development of comorbidity.

Severe Hypoglycemia Is Associated With Antidiabetic Oral Treatment Compared With Insulin Analogs in Nursing Home Patients With Type 2 Diabetes and Dementia: Results From the DIMORA Study

ObjectivesSevere hypoglycemia is associated with cognitive decline and dementia in older persons with type 2 diabetes. The role of antidiabetic treatments on severe hypoglycemia is unknown in dementia. The aims were to determine the prevalence of severe hypoglycemic events and investigate associations among severe hypoglycemic and specific antidiabetic treatments (classes of oral agents and types of insulin analogs) in a large sample of nursing home patients with diabetes according to dementia status. DesignCross-sectional observational study. SettingA total of 150 nursing homes across Italy. ParticipantsA total of 2258 patients with type 2 diabetes (dementia = 1138, no dementia = 1120). MeasurementsDiagnosis of dementia before nursing home admission. Data were collected regarding functional status, glycemic control, antidiabetic treatments, comorbidities, and biochemical and clinical measurements. Logistic regression models with severe hypoglycemia as the dependent variable were used to test associations with antidiabetic agents. ResultsPatients had a mean age (SD) of 82 (8) years, body mass index (BMI) of 25.4 (4.8), fasting plasma glucose (FPG) of 7.5 (3.0) mmol/L, postprandial glucose (PPG) of 10.3 (3.6) mmol/L, HbA1c of 7.1% (54 mmol/L), and impairments in activities of daily living (ADLs) of 3.7 (2.1). Severe hypoglycemia was more prevalent in patients with dementia (18%) compared with patients without dementia (8%). Patients with dementia were older, showed greater ADL impairments, greater number of comorbidities, lower FPG, and higher PPG compared with those without dementia. Adjusted logistic regression models in patients with dementia showed that rapid- and long-acting insulin analogs were associated with reduced odds ratio (OR) (OR 0.333; 95% confidence interval [CI] 0.184–0.602; OR 0.248, 95% CI 0.070–0.882, respectively), whereas sulphonylureas and combined metformin + sulphonylurea were associated with increased ORs (OR 8.805, 95% CI 4.260–18.201; OR 6.639; 95% CI 3.273–14.710, respectively) of experiencing severe hypoglycemia. No correlations were found in patients without dementia. ConclusionIn older nursing home patients with type 2 diabetes, severe hypoglycemia was significantly higher in dementia. Our findings suggest that sulphonylureas should be used with caution, whereas rapid- and long-acting insulin analogs seem safer.

The FACIT‐Sp spiritual well‐being scale: an investigation of the dimensionality, reliability and construct validity in a cognitively intact nursing home population

Spiritual well-being has been found to be a strong individual predictor of overall nursing home satisfaction and a fundamental dimension of global as well as health-related quality-in-life among nursing home patients. Therefore, access to a valid and reliable measure of spiritual well-being among nursing home patients is highly warranted. The aim of this study was to investigate the dimensionality, reliability and construct validity of the Functional Assessment of Chronic Illness Therapy Spiritual Wellbeing scale in a cognitively intact nursing home population. A cross-sectional design was applied, selecting two counties in central Norway from which 20 municipalities representing 44 different nursing homes took part in this study. Long-term care was defined as 24-hour care with duration of 6 months or longer. Participants were 202 cognitively intact long-term nursing home patients fulfilling the inclusion criteria. Approval by all regulatory institutions dealing with research issues in Norway and the Management Unit at the 44 nursing homes was obtained. Explorative and confirmative factor analyses as well as correlation with selected construct were used. Though three items loaded very low (λ = 0.22, 0.26, 0.32) indicating low reliability, the three-factor model for the FACIT-Sp spiritual well-being scale provided an acceptable fit (χ(2) = 101.15 (df = 50), p-value <0.001, RMSEA = 0.075 p = 0.030, NFI = 0.90, GFI = 0.91, AGFI = 0.85) for older nursing home patients, demonstrating acceptable measurement reliability. Construct validity was supported by significant correlations in the hypothesised direction with the selected constructs. The three-factor model is an improvement over the original two-factor construct, based on these nursing home data. The measure yielded significantly factor loadings, good composite reliability and construct validity.

Meaning-in-Life in Nursing Home Patients: A Validation Study of the Purpose-in-Life Test

The experience of meaning has been found to be a strong individual predictor of life satisfaction and an important psychological variable that promotes well-being. Therefore, a valid and reliable measurement of meaning-in-life among nursing home patients is highly warranted. This study intended to further investigate (a) the factor structure of the Purpose-in-Life test (PIL), (b) the reliability of PIL scores, and (c) the construct validity of the PIL test in a nursing home population. Participants were 202 cognitively intact nursing home patients representing 44 different Norwegian nursing homes. Concerning the dimensionality of the PIL, the following 3 measurement models were tested using confirmatory factor analysis; the original 1-factor, a 2-factor, and a 3-factor model. With the exclusion of 10 items, a previously published and supported 2-factor construct for the PIL by Morgan and Farsides (2007) provided a good fit for older nursing home patients, demonstrating good measurement reliability and construct validity. The 2-factor model by Morgan and Farsides, comprising 10 items, is an improvement over the original 20-items PIL, based on these nursing home data. The measure yielded highly significantly factor loadings, good values for average variance extracted and composite reliability, as well as significant correlations in the expected direction for relevant selected measures; all supporting the construct validity.

Comparison of Different Approaches to Confounding Adjustment in a Study on the Association of Antipsychotic Medication With Mortality in Older Nursing Home Patients

Selective prescribing of conventional antipsychotic medication (APM) to frailer patients is thought to have led to overestimation of the association with mortality in pharmacoepidemiologic studies relying on claims data. The authors assessed the validity of different analytic techniques to address such confounding. The cohort included 82,012 persons initiating APM use after admission to a nursing home in 45 states with 2001-2005 Medicaid/Medicare data, linked to clinical data (Minimum Data Set) and institutional characteristics. The authors compared the association between APM class and 180-day mortality with multivariate outcome modeling, propensity score (PS) adjustment, and instrumental variables. The unadjusted risk difference (per 100 patients) of 10.6 (95% confidence interval (CI): 9.4, 11.7) comparing use of conventional medication with atypical APM was reduced to 7.8 (95% CI: 6.6, 9.0) and 7.0 (95% CI: 5.8, 8.2) after PS adjustment and high-dimensional PS (hdPS) adjustment, respectively. Results were similar in analyses limited to claims-based Medicaid /Medicare variables (risk difference = 8.2 for PS, 7.1 for hdPS). Instrumental-variable estimates were imprecise (risk difference = 8.8, 95% CI: -1.3, 19.0) because of the weak instrument. These results suggest that residual confounding has a relatively small impact on the effect estimate and that hdPS methods based on claims alone provide estimates at least as good as those from conventional analyses using claims enriched with clinical information.

Comparison of Different Approaches to Confounding Adjustment in a Study on the Association of Antipsychotic Medication With Mortality in Older Nursing Home Patients

Comparison of Different Approaches to Confounding Adjustment in a Study on the Association of Antipsychotic Medication With Mortality in Older Nursing Home Patients

A Novel Measurement Index for Antihypertensive Medication Burden and Its Use

To the Editor: With the widespread use of blood pressure medications, it has become extremely difficult to assess the effects of elevated blood pressure on physiological and pathological phenomena without the confounding effects of antihypertensives. In both observational studies and randomized clinical trials, attempts to account for the antihypertensive effects have ranged from overly simplified dichotomous measures (either on or not on treatment) to tedious formulas that, in most instances, cannot be calculated in the population studied. Here, we propose a novel yet simple measurement index that not only takes into consideration whether an individual is on treatment but also accounts for the number and doses of each antihypertensive medication taken. We are suggesting that this measure maybe superior to the dichotomous measure and can be used to prospectively assess changes in blood pressure treatment. The developed measure was used in an ongoing trial, the Antihypertensive and Vascular, Endothelial, …

Evaluation of the Norwegian Version of the Mini Nutritional Assessment (MNA®) among Older Nursing Home Patients

Background:The Mini Nutritional Assessment (MNA®) is a well-known clinical scale that is often used for nutritional screening of older people in different settings recommended by several international clinical and scientific organizations. Aims:The aims of this article were: 1) to translate the MNA® from English to Norwegian and 2) to test the Norwegian version of the instrument for reliability and validity in a small sample of older nursing home patients. Methods:The English version of the MNA® was translated according to recommended procedures. A convenience sample of 26 older nursing home patients was screened with the MNA® by 10 registered nurses. Reliability and validity of the instrument were assessed. Conclusion:Positive support for sufficient quality of the Norwegian version of the MNA® was shown, but further testing of the instrument is needed.

Ageing and infection.

An increased morbidity and mortality due to infectious disease has been noted in the ageing. Two alternative explanations may account for this. Changes in the immune system and inflammatory responses with age or an increase in age-related diseases may underlie the increased susceptibility. A review of studies of healthy older individuals demonstrates changes in the immune system with ageing but minimal change in the inflammatory response. Investigations of severe infection in older nursing-home patients requiring hospitalization indicate that infection as a cause of admission and death is significantly more common in individuals who are bedridden because of serious cardiovascular or neurological disease and require urinary catheterization. The evidence indicates that underlying disease, not the senescence of host resistance, leads to severe infection in the ageing.

Diagnostic accuracy of the original 30-item and shortened versions of the Geriatric Depression Scale in nursing home patients

To determine the diagnostic accuracy of the 30-item and shortened versions of the Geriatric Depression Scale (GDS) in diagnosing depression in older nursing home patients. Three hundred and thirty-three older nursing home patients participated in a prospective cross-sectional study in the Netherlands. Sensitivity and specificity, positive and negative predictive values, and the area under the receiver operating curve (ROC) were assessed. Cronbach alphas were also calculated. Both major depression (MDD) and minor depression (MinD) according to the DSM-IV criteria, measured with the Schedules of Clinical Assessment in Neuropsychiatry (SCAN), were used as 'gold standard'. The cut-off point > or = 11 on the GDS-30 gave a sensitivity of 96.3% for MDD and 85.1% for MinD, with a specificity of 69.1%. The sensitivity of most of the shortened versions was sufficient, varying between 88.9% and 100% for MDD, and between 63.8% and 97.9% for MinD. With regard to the shortened versions, best sensitivity (96.3% and 78.7%) and specificity (69.5%) were found for the GDS-10 developed by D'Ath et al. (1994). The specificity rates for most of the shortened versions were found to be less satisfactory, varying between 18.9% and 74.1%. Sufficient internal consistency was found for the GDS-30, the GDS-15, the GDS-12 and the GDS-10, with Cronbach's alphas varying between 0.88 and 0.72. The GDS-30 was found to be a valid and reliable case-finding tool for both major and minor depression in nursing home patients with no cognitive impairment and in patients with mild to moderate cognitively impairment (MMSE > or = 15). The GDS-10 (D'Ath et al., 1994) appeared to be the best least time-consuming alternative for the nursing home setting.

Fecal Incontinence in Older Patients

Fecal incontinence (FI), the involuntary passage of fecal material through the anus, is a common medical problem in older people, especially in frail older nursing home residents. FI is often associated with urinary incontinence. Severe constipation leading to fecal impaction, laxative abuse, diarrhea, cognitive impairment, senescence, and neuromuscular disorders including autonomic neuropathy, are among the leading causes of FI in older patients. FI affects patients' physical and psychological well-being, and is responsible for considerable morbidity and mortality in older patients. This results in significant healthcare costs. Comprehensive management of this disorder requires a systematic approach including thorough history, physical examination, and step-wise evaluation. This review in contrast to others published in last decade,^1–9 focuses on management of FI in frail older nursing home patients, who require an individualized approach, which should be minimally invasive and cost-effective. In many cases of FI, treatment of the underlying condition; adequate control of diarrhea, constipation, or fecal impaction; adjustment of medications; and proper feeding may control or reduce FI. Advanced tests are often not necessary in this population.

Effects of a Care Protocol on Care Outcomes in Older Nursing Home Patients with Chronic Obstructive Pulmonary Disease

To evaluate the effects of a care protocol used by community nurses to support nursing home staff in the care of patients with chronic obstructive pulmonary disease (COPD). Matched, randomized case-control trial. Forty-five nursing homes of the New Territories South (NTS) cluster of Hong Kong. Eighty-nine older people (> or =65, present resident of a nursing home in the NTS region, main diagnosis of COPD, at least one hospital admission in previous 6 months) discharged to the nursing homes from the geriatric units of two hospitals. Using a care protocol, community nurses followed up older patients in the experimental group for 6 months after their discharge from the hospitals to the nursing homes. Data on functional, respiratory, and psychological parameters were collected at entry to study and 6 months later with standard measures. Data on hospital service utilization, nursing home staff, and patient satisfaction were also collected at 6 months. Experimental group participants had significant (P =.008) improvements in psychological well-being. Nursing home staff and experimental group patients were highly satisfied with the use of the protocol. There was no significant difference between the two groups in functional and respiratory outcomes or hospital service utilization. Psychological well-being as an important factor in rehabilitation in chronic illness has been much neglected in the literature. Supporting nursing home staff in the care of COPD patients through community nursing visits can enhance older residents' psychological well-being. Psychological aspects of care should be emphasized and incorporated into the delivery of regular nursing home care.