Older Nursing Home Research Articles

Polypharmacy and potentially inappropriate prescribing of benzodiazepines in older nursing home residents

Introduction Previous research has raised concerns about high prevalence of drug-related problems, polypharmacy and inappropriate benzodiazepine prescribing in nursing homes (NHs) and confirmed lack of studies from Central and South-Eastern Europe. The aim of our study was to determine the prevalence and characteristics of polypharmacy, hyperpolypharmacy and inappropriate benzodiazepine prescribing in NH residents in Croatia. Methods Data from 226 older NH residents from five Croatian NHs were collected using the InterRAI Long-Term Care Facilities assessment form. The prevalence and determinants of polypharmacy/hyperpolypharmacy and patterns of inappropriate benzodiazepine prescribing were documented. Results The prevalence of polypharmacy (49.6%) and hyperpolypharmacy (25.7%) among NH residents was high. In our study, 72.1% of NH residents were prescribed at least one psychotropic agent, 36.7% used 2–3 psychotropics and 6.6% used 4+ psychotropics. Among benzodiazepine users (55.8%), 28% of residents were prescribed benzodiazepines in higher than recommended geriatric doses, 75% used them for the long term and 48% were prescribed concomitant interacting medications. The odds of being prescribed polypharmacy/hyperpolypharmacy were significantly higher for older patients with polymorbidity (6+ disorders, proportional odds ratio (POR) = 19.8), type II diabetes (POR = 5.2), ischemic heart disease (POR = 4.6), higher frailty (Clinical Frailty Scale (CFS ≥5); POR = 4.3) and gastrointestinal problems (POR = 4.8). Conclusions Our research underscores the persistent challenge of inappropriate medication use and drug-related harms among older NH residents, despite existing evidence and professional campaigns. Effective regulatory and policy interventions, including the implementation of geriatrician and clinical pharmacy services, are essential to address this critical issue and ensure optimal medication management for vulnerable NH populations.

Deprescribing research in nursing home residents using routinely collected healthcare data: a conceptual framework

BackgroundEfforts are needed to strengthen evidence and guidance for appropriate deprescribing for older nursing home (NH) residents, who are disproportionately affected by polypharmacy and inappropriate prescribing. Given the challenges of conducting randomized drug withdrawal studies in this population, data from observational studies of routinely collected healthcare data can be used to identify patients who are apparent candidates for deprescribing and evaluate subsequent health outcomes. To improve the design and interpretation of observational studies examining determinants, risks, and benefits of deprescribing specific medications in older NH residents, we sought to propose a conceptual framework of the determinants of deprescribing in older NH residents.MethodsWe conducted a scoping review of observational studies examining patterns and potential determinants of discontinuing or de-intensifying (i.e., reducing) medications for NH residents. We searched PubMed through September 2021 and included studies meeting the following criteria: conducted among adults aged 65 + in the NH setting; (2) observational study designs; (3) discontinuation or de-intensification as the primary outcome with key determinants as independent variables. We conceptualized deprescribing as a behavior through a social-ecological lens, potentially influenced by factors at the intrapersonal, interpersonal, organizational, community, and policy levels.ResultsOur search in PubMed identified 250 potentially relevant studies published through September 2021. A total of 14 studies were identified for inclusion and were subsequently synthesized to identify and group determinants of deprescribing into domains spanning the five core social-ecological levels. Our resulting framework acknowledges that deprescribing is strongly influenced by intrapersonal, patient-level clinical factors that modify the expected benefits and risks of deprescribing, including index condition attributes (e.g., disease severity), attributes of the medication being considered for deprescribing, co-prescribed medications, and prognostic factors. It also incorporates the hierarchical influences of interpersonal differences relating to healthcare providers and family caregivers, NH facility and health system organizational structures, community trends and norms, and finally healthcare policies.ConclusionsOur proposed framework will serve as a useful tool for future studies seeking to use routinely collected healthcare data sources and observational study designs to evaluate determinants, risks, and benefits of deprescribing for older NH residents.

Prescriber Perspectives and Experiences with Deprescribing Versus Continuing Bisphosphonates in Older Nursing Home Residents with Dementia.

Few guidelines address fracture prevention medication use in nursing home (NH) residents with dementia. We sought to identify factors that influence prescriber decision-making for deprescribing of bisphosphonates for older NH residents with dementia. We conducted 12 semi-structured interviews with prescribers who care for older adults with dementia in NHs. Interview prompts addressed experiences treating fractures, benefits, and harms of bisphosphonates, and experiences with deprescribing. Coding was guided by the social-ecological framework including patient-level (intrapersonal) and external (interpersonal, system, community, and policy) influences. Most prescribers were physicians (83%); 75% were female and 75% were White. Most (75%) spent less than half of their clinical effort in NHs and half were in the first decade of practice. Among patient-level influences, prescribers uniformly agreed that a prior bisphosphonate treatment course of several years, emergence of adverse effects, and changing goals of care or limited life expectancy were compelling reasons to deprescribe. External influences were frequently discussed as barriers to deprescribing. At the interpersonal level, prescribers noted that family/informal caregivers are diverse in their involvement in decision-making, and frequently concerned about the adverse effects of bisphosphonates, but perceive deprescribing as "withdrawing care." At the health system level, prescribers felt that frequent transitions make it difficult to determine duration of prior treatment and to implement deprescribing. At the policy level, prescribers highlighted the lack of guidelines addressing residents with limited mobility and dementia or criteria for deprescribing, including uncertainty in the setting of prior fractures and lack of bone densitometry in NHs. Systems-level barriers to evaluating bone densitometry and treatment history in NHs may impede person-centered decision-making for fracture prevention. Further research is needed to evaluate the residual benefits of bisphosphonates in medically complex residents with limited mobility and dementia to inform recommendations for deprescribing versus continued use.

Factors Associated with Health-Related Quality of Life in Older Persons Residing in Nursing Homes.

Health-related quality of life (HRQoL) is an important patient-related outcome for the assessment of interventions and treatments in older people. Understanding underlying mechanisms for HRQoL is crucial for improving care, rehabilitation and symptom relief. This study examined the associations between HRQoL and frailty, sarcopenia, dependence of ADL, physical function and nutritional status in older nursing home (NH) residents. This is a cross-sectional study employing baseline data from the Older Person's Exercise and Nutrition (OPEN) study. Residents ≥75 years and able to stand up from seated position, residing in eight nursing homes in Sweden, were recruited. The EuroQoL 5-dimension Questionnaire (EQ-5D-5L, 0-1) was used to assess HRQoL. For exposure, the FRAIL and SARC-F questionnaires, Bergs Balance Scale, Functional Independence Measure (FIM), and Mini Nutritional Assessment-Short Form (MNA-SF) were used, including chair-stand test, walking speed and some biochemical markers. Descriptive and inferential statistics including linear regression models were applied. Data from 113 residents (59% women, mean age 85 years) revealed a mean EQ-5D index of 0.76. After relevant adjustments, factors associated with low HRQoL were sarcopenia (p<0.001), cognitive function (p<0.001), dependence in ADL (p=0.002), low plasma-albumin (p=0.002) and impaired nutritional status (p=0.038). This study displays evidence that modifiable conditions like sarcopenia and malnutrition are related to HRQoL in older NH residents. Such findings indicate a potential for physical exercise, including muscle training, and improved nutritional routines, including protein supplementation, to enhance nursing home care. Future studies, in larger NH populations, on exercise and nutrition for effects on HRQoL are needed.

A Cross-Sectional Study Comparing Younger and Older Nursing Home Residents in Western Canada

Specialized care for younger nursing home (NH) residents may be necessary to meet their unique health and quality of life needs; however, key attributes of younger NH residents are poorly understood and limit the development of effective, tailored interventions. This study described differences in clinical and nonclinical characteristics of younger vs. older nursing NH residents. In a retrospective cohort study, we used SPSS and analyzed comprehensive Resident Assessment Instrument – Minimum Data Set (RAI-MDS 2.0) data from NHs in Western Canada, for the period from January 2016 to December 2017. We included all assessments (full and abbreviated) performed quarterly. These findings indicated that younger (age 18-64) vs. older (age >=65) NH residents differed considerably: younger residents were predominately male, single, more obese, more depressed, had higher prevalence of depression, cerebral vascular accident, and hemi- or quadriplegia, and required more assistance in activities of daily living than older residents. The findings will contribute a better comprehension of the characteristics of the younger NH population and how they differ from other residents. The study provides useful information to policymakers, providers, and researchers to guide them in developing tailored policies, programs, and interventions. Also, findings may guide consumers as they plan for long-term care needs of loved ones. Finally, the findings provide a baseline estimate as researchers continue to track the growth of and changes in, the populations served in nursing homes.

Physical Frailty and Cognitive Impairment in Older Nursing Home Residents: A Latent Class Analysis

Physical frailty (PF) has various clinical presentations and often co-occurs with cognitive impairment in older adults. In older adults in nursing homes (NHs), no research has examined the heterogeneous profile of PF and its association with cognitive impairment. Minimum Data Set 3.0 was used to identify older, long-stay, newly-admitted NH residents (2014-16; n=871,801). Latent class analysis was used to identify PF subgroups with FRAIL-NH items as indicators. Logistic regression was used to estimate the association between PF subgroups and cognitive impairment. The final model indicated three PF subgroups (prevalence): “mild PF” (7.6%), “moderate PF” (44.5%), and “severe PF” (47.9%). In all subgroups, residents had high probability of needing help with dressing. Older adults likely to belong to the “moderate PF” or the “severe PF” subgroups had high probabilities of requiring physical assistance to transfer between locations and inability to walk in a room. Additionally, residents likely to be in the “severe PF” subgroup had greater probability of bowel incontinence. Greater cognitive impairment was associated with increasingly higher odds to be in the “moderate PF” and “severe PF” subgroups: older residents with severe cognitive impairment were 20% more likely [adjusted odds ratio (aOR): 1.20, 95% confidence interval (CI): 1.17-1.23] and almost 7 times as likely (aOR: 6.86, 95%CI: 6.66-7.06) to belong to the “moderate PF” and “severe PF” subgroups, respectively. Findings provide new evidence for the interrelationship between PF and cognitive impairment in older NH residents and have implications for the development of interventions tailored to older residents’ specific PF experience.

Virtual Reality Therapy Takes Greenspace to Older Nursing Home Residents: A Pilot Study

Nature-based virtual reality (VR) interventions can offer a safe adjunct approach for managing depression and anxiety, but applications of this innovative technology have not been studied in the nursing home (NH) setting. Pleasant events like those generated with VR may provide a psychological time-out from the ongoing stress associated with living in an NH, and thereby, may facilitate adaptive coping. This study, conducted between January and February of 2020, aimed to pilot test the effects of ViRT-Ta-GO: Virtual Reality Therapy Takes Greenspace to Older NH residents on the severity of depressive and anxiety symptoms among NH residents aged 60 years and older and obtain estimates of effect sizes on outcome measures. Using a quasi-experimental, one-group, pretest-posttest design, nine cognitively intact NH residents (Mage = 81, SD = 10.23) were recruited from two Pennsylvania NHs. The outcome measures included the Patient Health Questionnaire-9, Geriatric Anxiety Inventory, and 10 open-ended questions. Residents participated individually in three 10-minute VR sessions per week for four weeks. There were no adverse effects. Participant attrition and self-report indicated that ViRT-Ta-GO was feasible and acceptable. At posttest, a Wilcoxon signed rank test showed a significant decrease in anxiety symptoms (z = -2.02, p = .04) with a large effect size (r = -.48). Nonsignificant trend improvements in depression were observed (p = .08), pretest to posttest. The 4-week VR intervention was effective in reducing symptoms of anxiety. Preliminary findings demonstrate utility within an NH population, suggesting it will be advantageous to evaluate ViRT-Ta-GO through controlled clinical trials.

Are Nursing Home Residents With Dementia Appropriately Treated for Fracture Prevention?

Clinicians struggle with whether to prescribe osteoporosis medications for fracture prevention for older nursing home (NH) residents with dementia, given the lack of evidence in this population. To better understand real-world clinical practice, we conducted a retrospective cohort study examining patterns of fracture prevention medication use for older NH residents with dementia and high fracture risk.Data sources included 2015–16 Medicare claims, Part D prescriptions, and Minimum Data Set (MDS) assessments. Among NH residents aged 65+ with dementia and prior fracture or high fracture risk based on the MDS FRAiL (Fracture Risk Assessment in Long-term care), we assessed medications for fracture prevention using prescription data from 1 year prior through 90 days after the first MDS assessment. Multivariable logistic regression was used to evaluate factors associated with receiving treatment. Most of the sample (n = 72,639) was >80 years (78%), female (82%), and white (88%); 63% had moderate/severe dementia and 60% had an osteoporosis diagnosis. Only 11.6% received fracture prevention medications. In adjusted analyses, treated residents were more likely to be female, Hispanic or other non-black minority, <90 years old, and newly admitted to the NH. Other associated factors included osteoporosis diagnosis, walker or wheelchair use, bone disorders (eg, Paget disease), >5 medications, steroid or proton pump inhibitor use, and regions outside of the Northeast. Resident characteristics suggestive of comorbidity burden and worsening dementia were associated with reduced likelihood of treatment. Low use of fracture prevention medications for NH residents with dementia may reflect an attempt by prescribers reconcile medication use with changing goals of care, or inappropriate underuse in patients who still have high fracture risk. Additional research is needed to help clinicians better evaluate when to use these medications in this heterogeneous and vulnerable population.

Risk for Health Events After Deprescribing Acetylcholinesterase Inhibitors in Nursing Home Residents With Severe Dementia.

Reevaluation of the appropriateness of acetylcholinesterase inhibitors (AChEIs) is recommended in older adults with severe dementia, given the lack of strong evidence to support their continued effectiveness and risk for medication-induced adverse events. We sought to evaluate the impact of deprescribing AChEIs on risk of all-cause events (hospitalizations, emergency department visits, and mortality) and serious falls or fractures in older nursing home (NH) residents with severe dementia. Analysis of 2015 to 2016 data from Medicare claims, Part D prescriptions, Minimum Data Set (MDS) version 3.0, Area Health Resource File, and Nursing Home Compare. Marginal structural models with inverse probability of treatment weights were used to evaluate the association of deprescribing AChEIs and all-cause negative events as well as serious falls or fractures. US Medicare-certified NHs. Nonskilled NH residents, aged 65 years and older, with severe dementia receiving AChEIs within the first 14 days of an MDS assessment in 2016 (n = 37 106). The sample was primarily white (78.7%), female (75.5%), and aged 80 years or older (77.4%). Deprescribing AChEIs was associated with an increased likelihood of all-cause negative events in unadjusted models (odds ratio [OR] = 1.17; 95% confidence interval [CI] = 1.11-1.23; P < .01), but not in fully adjusted models (adjusted OR [aOR] = 1.00; 95% CI = 0.94-1.06; P = .94). By contrast, deprescribing was associated with a reduced likelihood of serious falls or fractures in unadjusted models (OR = 0.59; 95% CI = 0.52-0.66; P < .001) and remained significant in adjusted models (aOR = 0.64; 95% CI = 0.56-0.73; P < .001). Deprescribing AChEIs was not associated with a significant increase in the likelihood for all-cause negative events and was associated with a reduced likelihood of falls and fractures in older NH residents with dementia. Our findings suggest that deprescribing AChEIs is a reasonable approach to reduce the risk of serious falls or fractures without increasing the risk for all-cause events. J Am Geriatr Soc 68:699-707, 2020.

Metformin Safety Warnings and Diabetes Drug Prescribing Patterns for Older Nursing Home Residents

ObjectiveDiabetes mellitus is common in US nursing homes (NHs), and the mainstay treatment, metformin, has US Food and Drug Administration (FDA) boxed warnings indicating safety concerns in those with advanced age, heart failure, or renal disease. Little is known about treatment selection in this setting, especially for metformin. We quantified the determinants of initiating sulfonylureas over metformin with the aim of understanding the impact of FDA-labeled boxed warnings in older NH residents. Design and settingNational retrospective cohort in US NHs. ParticipantsLong-stay NH residents age ≥65 years who initiated metformin or sulfonylurea monotherapy following a period of ≥6 months with no glucose-lowering treatment use between 2008 and 2010 (n = 7295). MeasurementsMeasures of patient characteristics were obtained from linked national Minimum Data Set assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare claims. Odds ratios (ORs) comparing patient characteristics and treatment initiation were estimated using univariable and multivariable multilevel logistic regression models with NH random intercepts. ResultsOf the 7295 residents in the study population, 3066 (42%) initiated metformin and 4229 (58%) initiated a sulfonylurea. In multivariable analysis, several factors were associated with sulfonylurea initiation over metformin initiation, including heart failure (odds ratio [OR] 1.2, 95% confidence interval [CI] 1.1–1.4) and renal disease (OR 2.1, 95% CI 1.7–2.5). Compared with those aged 65 to <75 years, residents 75 to <85 (OR 1.3, 95% CI 1.2–1.5), 85 to <95 (OR 2.0, 95% CI 1.7–2.3), and ≥95 (OR 4.3, 95% CI 3.2–5.8) years were more likely to initiate sulfonylureas over metformin. ConclusionsIn response to FDA warnings, providers initiated NH residents on a drug class with a known, common adverse event (hypoglycemia with sulfonylureas) over one with tenuous evidence of a rare adverse event (lactic acidosis with metformin).

Potentially inappropriate prescribing in nursing home residents detected with the community pharmacist specific GheOP(3)S-tool.

Background The Ghent Older People's Prescriptions community Pharmacy Screening (GheOP³S-)tool was recently developed to screen for potentially inappropriate prescribing (PIP). Objective We aimed (1) to determine PIP prevalence in older nursing home (NH) residents with polypharmacy using the GheOP³S-tool and (2) to identify those PIPs that are most frequently detected. Method A cross-sectional study was carried out between February and June 2014 in 10 NHs in Belgium, supplied by a community pharmacy chain. For each NH, 40 residents (≥70years, using ≥5 chronic drugs) were included. PIP prevalence was determined using the GheOP³S-tool. Results 400 NH residents were included [mean age (±SD) 86.2 (±6.3) years; median number of drugs (±IQR) 10 (7-12)]. A total of 1728 PIPs were detected in 387 (97%) participants (Median 4; IQR 2-6). The most prevalent items can be assigned to three categories: long-term use of central nervous system drugs (i.e. benzodiazepines, antidepressants and antipsychotics), use of anticholinergic drugs (mutual combinations and with underlying constipation/dementia) and underuse of osteoporosis prophylaxis. Conclusion Screening for PIP by means of the GheOP³S-tool revealed a high prevalence of PIP among older NH residents with polypharmacy. This finding urges for initiatives on the patient-level, but also on a broader, institutional level.

Predictors of Functional Changes in Italian Nursing Home Residents: The U.L.I.S.S.E. Study

ObjectivesTo identify independent predictors of the risk of functional decline in older nursing home (NH) residents. DesignA longitudinal observational study. SettingThirty-one NHs participating in the U.L.I.S.S.E. project, distributed throughout Italy. ParticipantsAll older (≥65 years) long-term NH residents without complete disability and with at least one follow-up evaluation during the 12-month study period (n = 1263). MeasurementsAll participants underwent a standardized comprehensive evaluation using the Italian version of the Minimum Data Set for NHs. The activities of daily living (ADLs) Long-Form scale was used to evaluate functional status. Facility characteristics were collected using an ad hoc designed questionnaire. ResultsOf the NH residents, 40.4% experienced a decline in the ADL during the follow-up. The mixed effect logistic regression model showed that depression (odds ratio [OR] 1.45, confidence interval [CI] 1.16–1.81, P = .005) and the use of antipsychotics (OR 1.30, CI 1.06–1.60, P = .016) were associated with a higher probability of ADL decline, whereas the presence of a geriatrician (OR 0.60, CI 0.41–0.88, P = .015) and a higher than median hour per resident per week of nursing care (OR 0.55, CI 0.37–0.80, P = .006) were associated with a lower risk. ConclusionsOur findings suggest that preventing functional decline in NH residents might be possible by optimizing the management of depression and by reducing the current high prescription rate of antipsychotics. Moreover, the presence of a geriatrician, associated with an adequate amount of nursing care, seem to be important facilities characteristics to achieve this goal. These findings should be tested in large-scale pragmatic clinical trials.

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.

Effect of medications on physical function and cognition in nursing home residents with dementia.

To assess the effectiveness of medications used in the management of Alzheimer's disease and related dementias (ADRD) on cognition and activity of daily living (ADL) trajectories and to determine whether sex modifies these effects. Two-year (2007-2008) longitudinal study. Medicare enrollment and claims data linked to the Minimum Dataset 2.0. Older nursing home (NH) residents with newly diagnosed ADRD (n = 18,950). Exposures included four medication classes: antidementia medications (ADMs), antipsychotics, antidepressants, and mood stabilizers. Outcomes included ADLs and cognition (Cognitive Performance Scale (CPS)). Marginal structural models were employed to account for time-dependent confounding. The mean age was 83.6, and 76% of the sample was female. Baseline use of ADMs was 15%, antidepressants was 40%, antipsychotics was 13%, and mood stabilizers was 3%. Mean baseline ADL and CPS scores were 16.6 and 2.1, respectively. ADM use was not associated with change in ADLs over time but was associated with a slower CPS decline (slope difference: -0.09 points/year, 99% confidence interval (CI) = -0.14 to -0.03). Antidepressant use was associated with slower declines in ADL (slope difference: -0.36 points/year, 99% CI = -0.58 to -0.14) and CPS (slope difference: -0.12 points/year, 99% CI = -0.17 to -0.08). Sex modified the effect of both antipsychotic and mood stabilizer use on ADLs; female users declined most quickly. Antipsychotic use was associated with slower CPS decline (slope difference: -0.11 points/year, 99% CI = -0.17 to -0.06), whereas mood stabilizer use had no effect. Despite the observed statistically significantly slower declines in cognition with ADMs, antidepressants, and antipsychotics and the slower ADL decline found with antidepressants, it is unlikely that these benefits are of clinical significance.

Effect of Urinary Incontinence on Older Nursing Home Residents’ Self‐Reported Quality of Life

To evaluate the effect of urinary incontinence (UI) on elderly nursing home (NH) residents' self-reported quality of life (QOL), especially on the specific QOL domains most closely associated with UI. Retrospective cross-sectional study using the Minimum Data Set (MDS) and Minnesota Nursing Home Report Card data in 2010 to compare overall QOL and its domains of residents with and without UI using propensity scores and inverse probability weighting (IPW) adjustments to reduce selection bias. All Medicare- or Medicaid-licensed NHs in Minnesota. All residents aged 65 and older except those with conditions that could readily overwhelm the effect of UI on QOL, such as coma and cerebral palsy. Urinary incontinence (UI) was defined as leakage two or more times a week (score ≥ 2 on MDS 5-point scale), and continence was defined as continent or usually continent (score 0 or 1 on MDS 5-point scale). QOL was assessed using a self-reported QOL questionnaire that measured general QOL, not QOL specific to UI symptoms. Urinary incontinence (UI) prevalence was 65.8% in 10,683 older NH residents. Self-reported QOL was good (>0.7 on a scale from 0 to 1) in 8,620 eligible residents in 371 NHs. Mood and meaningful activity domains had lower scores; dignity had the highest score. UI was associated with being older and female, ADL dependence, impaired cognitive ability, Alzheimer's disease, non-Alzheimer's dementia, bowel incontinence, diabetes mellitus, and long-term NH stay. Bivariate analysis found that residents with UI had lower QOL than those without. Using IPW to reduce selection bias, it was found that, although UI was not associated with overall QOL, it decreased the QOL domains of dignity, autonomy, and mood. To improve the QOL of residents with UI, attention should be paid to dignity, autonomy, and mood.

Underrecognition and Undertreatment of Dementia in Italian Nursing Homes

To determine the prevalence of dementia diagnoses and the use of antidementia drugs in a cohort of Italian older nursing home (NH) residents. Cross-sectional study. The NH residents participating in 2 studies: the U.L.I.S.S.E. study and the Umbria Region survey. A total of 2215 nursing home residents. Each resident underwent a comprehensive geriatric assessment at baseline by means of the RAI MDS 2.0. Dementia diagnosis was based on ICD-9 codes. The prevalence of dementia diagnosis according to ICD-9 codes was 50.7% (n = 1123), whereas 312 subjects had cognitive impairment with a cognitive performance scale score ≥3 without a diagnosis of dementia. Only 56 NH residents were treated (5% of the sample) and the main drugs used were cholinesterase inhibitor, whereas only 1 subject was treated with memantine. Limiting our analysis to patients with mild to moderate Alzheimer's disease, who are those reimbursed by the public health care system for receiving antidementia drugs, the percentage rose to 11.3%. These findings demonstrate a high rate of underdiagnosis and undertreatment of dementia in Italian NH residents. Potential explanations include the lack of systematic assessment of cognitive functions, the limitations to antidementia drug reimbursement, the complexity of the reimbursement procedure itself, and the high prevalence of patients with severe dementia. Older NH residents still lack proper access to state-of-the-art diagnosis and treatment for a devastating condition such as dementia.

Anemia Evaluation and Management in Nursing Home Residents

Anemia is often an unrecognized and/or undertreated diagnosis in older adults. Failure to diagnose anemia leads to delayed treatment and thus delayed relief of symptoms. Given the potentially significant impact of anemia on cardiovascular disease and physical performance among older nursing home (NH) residents, it is important to evaluate current clinical practice related to anemia.The purpose of this secondary data analysis was to evaluate the frequency of laboratory evaluation and medication treatment for anemia among older NH residents. Results indicated that more than half of NH residents were anemic at baseline, and of those, less than 20% had additional testing done to further evaluate for an underlying cause of their anemia and only 45.3% received any pharmacologic treatment. Future research is needed to clarify the potential benefits of timely diagnosis and appropriate treatment for anemic older adults in long-term-care settings and establish evidence-based guidelines to direct care in this area.

Older nursing home residents’ experiences with videoconferencing to communicate with family members

This study explored the experiences of older Taiwanese nursing home residents in using videoconferencing to communicate with family members. Enhancing communication between long-term care residents and their family is important. Interactions between residents and their family members can be increased through high-tech videoconferencing programmes. A qualitative, observational research design was used to gain a deeper understanding of the videoconference experiences of older nursing home residents in Taiwan. In-depth interviews were used to gather information from 34 older residents at 10 nursing homes in northern Taiwan. Participants were asked to describe their three-month experience using videoconference communication with their family in the nursing home. Participants (18 women, 16 men) had an average age of 75.38 (SD 10.19, range 60-95). Verbatim transcripts of audiotaped interviews were analysed by content analysis and Atlas.ti software. Participants experiences using videoconference communication with family members were captured by four themes: enriched life, second-best option for visiting, life adjustments and true picture of family life. Our findings may enhance policy makers' and healthcare providers' understanding of older nursing home residents' experience with videoconferencing to communicate with distant family members, thus guiding development and evaluation of nursing home videoconference services to improve older people's lives in nursing homes.

Chronic Kidney Disease, Anemia, and the Association Between Chronic Kidney Disease-Related Anemia and Activities of Daily Living in Older Nursing Home Residents

The aim of this study was to evaluate the potential association between anemia associated with chronic kidney disease (CKD) and the ability for older nursing home (NH) residents with these conditions to perform basic activities of daily living (ADL). This is a multicenter, retrospective, observational study utilizing data abstracted from medical charts, laboratory records, and Minimum Data Set (MDS) records from the 1-year period before the date of data abstraction. 24 NHs in the United States. Older (>or=65 years of age) NH residents with CKD (not receiving dialysis) who were not comatose and were alive as of the day of data abstraction were included in this analysis. Resident demographics, hemoglobin, and estimated glomerular filtration rate records, and ADL items were abstracted from the medical charts, laboratory records, and MDS. The prevalence of CKD and anemia associated with CKD was evaluated from laboratory records. The relationship between CKD, anemia, and ADLs was assessed through a repeated resampling (bootstrap) analysis. CKD was present in 45.7% of the residents. Of these, 60.5% had anemia. Residents with CKD and anemia were more likely to require limited or extensive assistance in performing ADLs such as bed mobility, transfer, walk in room, walk in corridor, locomotion on unit, dressing, and toilet use. Conversely, a greater proportion of residents with CKD but without anemia required no or slight supervision in performing these ADLs. CKD and anemia associated with CKD are common in older NH residents. The data suggest that older NH residents with CKD and anemia require greater assistance in performing ADLs than residents with CKD alone. These data support the importance of evaluating the older NH population for CKD and anemia. As with all retrospective analyses, study limitations must be considered in the interpretation of these results.

Retrospective Review of Selective Serotonin Reuptake Inhibitors and Falling in Older Nursing Home Residents

We compared the rate of falling in older nursing home residents who had been prescribed selective serotonin reuptake inhibitors (SSRIs), other classes of antidepressants, and no antidepressants. Data were obtained from pharmacy records, medical records, fall logs, and incidence reports for one nursing home (1995 data). Older adults on SSRIs were more likely to fall than older adults not on antidepressants (p = .003) and were more likely to have an injurious fall (p = .03). The association with falling remained significant even when including potential confounders (p = .007). Older nursing home residents should be treated for depression. However, SSRIs may also carry an increased risk for falling.