Long-term Care For Older People Research Articles

Palliative Care Development in European Care Homes and Nursing Homes: Application of a Typology of Implementation

BackgroundThe provision of institutional long-term care for older people varies across Europe reflecting different models of health care delivery. Care for dying residents requires integration of palliative care into current care work, but little is known internationally of the different ways in which palliative care is being implemented in the care home setting. ObjectivesTo identify and classify, using a new typology, the variety of different strategic, operational, and organizational activities related to palliative care implementation in care homes across Europe. Design and methodsWe undertook a mapping exercise in 29 European countries, using 2 methods of data collection: (1) a survey of country informants, and (2) a review of data from publically available secondary data sources and published research. Through a descriptive and thematic analysis of the survey data, we identified factors that contribute to the development and implementation of palliative care into care homes at different structural levels. From these data, a typology of palliative care implementation for the care home sector was developed and applied to the countries surveyed. ResultsWe identified 3 levels of palliative care implementation in care homes: macro (national/regional policy, legislation, financial and regulatory drivers), meso (implementation activities, such as education, tools/frameworks, service models, and research), and micro (palliative care service delivery). This typology was applied to data collected from 29 European countries and demonstrates the diversity of palliative care implementation activity across Europe with respect to the scope, type of development, and means of provision. We found that macro and meso factors at 2 levels shape palliative care implementation and provision in care homes at the micro organizational level. ConclusionsImplementation at the meso and micro levels is supported by macro-level engagement, but can happen with limited macro strategic drivers. Ensuring the delivery of consistent and high-quality palliative care in care homes is supported by implementation activity at these 3 levels. Understanding where each country is in terms of activity at these 3 levels (macro, meso, and micro) will allow strategic focus on future implementation work in each country.

Valuing and Integrating Informal Care as a Core Component of Long-Term Care for Older People: A Comparison of Recent Developments in Italy and Spain

ABSTRACTThe international long-term care (LTC) debate has recently been focusing on how to strengthen home care provision. In this regard, a major role has been played by informal care and how to best integrate it in a holistic care approach. Italy and Spain, usually labeled as “familialist” or “family-based” care models, have been promoting national reforms or actions to support the integration of “informal” actors into the overall LTC system. Through a comparative review of recent trends observed in the two care regimes, this article aims at contributing to improve our cross-national understanding of how LTC is changing across Europe, identifying the basic approaches adopted in Italy and Spain and highlighting both their strengths and drawbacks.

The role and influence of micro-cultures in long-term care on the mental health and wellbeing of older people: a scoping review of evidence

Purpose The purpose of this paper is to explore evidence about the role played by micro-cultures in long-term care (LTC) settings in shaping residents’ mental health and wellbeing. Design/methodology/approach A scoping review on micro-cultures in LTC, including database search of academic and grey literature using pre-determined combinations of key terms and specific inclusion/exclusion criteria. The review followed the methodological framework of Arksey and O’Malley (2005). Findings Micro-cultures (localised, distinctive cultures of a small group of people) in LTC are complex, multi-faceted and multi-directional; they include social dynamics as well as structural and environmental factors. Although much work has been done on the nature of micro-cultures, limited work has focused on LTC for older people. Initiatives to promote the mental health and wellbeing of residents rarely consider micro-cultures in any holistic way; they tend to be taken into account either as part of a contextual backdrop, or as a uni-directional process often equated with the concept of “care culture” or “organisational culture”. Originality/value The role played by micro-cultures in influencing the mental health and wellbeing of older people living in LTC settings is significantly under researched. The findings of this review suggest that their complexity and multidimensionality challenges researchers. However if the authors are to develop interventions that promote the mental health and wellbeing of residents it is important to invest in work to explore their nature and systemic influence.

Older People Using e-Health Services—Exploring Frequency of Use and Associations with Perceived Benefits for Spouse Caregivers

ICT, information- and communication technologies, and e-health services are essential for meeting future care demands. Greater knowledge regarding the implementation of e-health services in long-term care for older people is needed. The purpose of the study was to explore older people’s use of e-health services and associations between frequency of use and perceived benefits. In the longitudinal comparative intervention study (n = 65), intervention group participants (n = 42) used an e-health service for 1.5 years. A control group (n = 23) used similar services provided in a traditional manner. Data was collected through questionnaires and analyzed using linear and logistic regressions. Although general use of the Internet was similar in both groups, the e-health group perceived significantly higher benefits. The component information- and education programs, developed specifically for the e-health service, had the highest association with benefits. Conclusion: e-health services targeted at supporting older people who care for a spouse at home can provide benefits which most likely will not be obtained without participation in an organized e-service. Care professionals play an essential role in encouraging spouse caregivers to become e-service users.

The PiTSTOP study: a feasibility cluster randomized trial of delirium prevention in care homes for older people.

Background and objectives: delirium is a distressing but potentially preventable condition common in older people in long-term care. It is associated with increased morbidity, mortality, functional decline, hospitalization and significant healthcare costs. Multicomponent interventions, addressing delirium risk factors, have been shown to reduce delirium by one-third in hospitals. It is not known whether this approach is also effective in long-term care. In previous work, we designed a bespoke delirium prevention intervention, called ‘Stop Delirium!’ In preparation for a definitive trial of Stop Delirium, we sought to address key aspects of trial design for the particular circumstances of care homes.Design: a cluster randomized feasibility study with an embedded process evaluation.Setting and participants: residents of 14 care homes for older people in one metropolitan district in the UK.Intervention: Stop Delirium!: a 16-month-enhanced educational package to support care home staff to address key delirium risk factors. Control homes received usual care.Measurements: we collected data to determine the following: recruitment and attrition; delirium rates and variability between homes; feasibility of measuring delirium, resource use, quality of life, hospital admissions and falls; and intervention implementation and adherence.Results: two-thirds (215) of eligible care home residents were recruited. One-month delirium prevalence was 4.0% in intervention and 7.1% in control homes. Proposed outcome measurements were feasible, although our approach appeared to underestimate delirium. Health economic evaluation was feasible using routinely collected data.Conclusion: a definitive trial of delirium prevention in long-term care is needed but will require some further design modifications and pilot work.

Effectiveness of Web-Based Psychosocial Interventions for Family Caregivers of Older People: What Do We Know?

The contribution of family caregivers to long-term care of older people is a relevant issue. Family caregivers may face different psychological and social needs arising from the challenging caregiving situation. In this respect, webbased psychosocial programs are progressively being refined and demonstrating they can be effective in supporting caregivers. This commentary describes the main types of web-based interventions for family caregivers of older people and available evidence on their effectiveness. Psychoeducational, peer and multicomponent programs have been the main object of research so far and can improve, under certain conditions, psychological wellbeing and social inclusion of caregivers. General integration, user and transferability issues are also discussed and call for future research in the field.

The Dutch Long-Term Care System in Transition: Implications for Municipalities.

The aim of this study is to examine the preparedness of Dutch municipalities (in terms of system readiness for innovation) for the challenges resulting from their new responsibilities under the long-term care reform of January 1, 2015. A qualitative research approach was used by conducting semi-structured interviews with representatives of nine Dutch municipalities responsible for the long-term care of older people in their respective municipalities. Municipalities consider themselves to be largely prepared for their new responsibilities resulting from the long-term care reform. However, this perception mainly applies to practical changes (related to municipalities' organizational preparation for their new responsibilities) occurring in the short-term transition phase, not to the more long-term transformation phase. We argue that municipalities highly underestimate the long-term challenges that lie ahead of them (such as the development of a dedicated 'participation society') and, in fact, seem to fear the uncertainty of the consequences of these challenges.

Use of fall risk increasing drugs in residents of retirement villages: a pilot study of long term care and retirement home residents in Ontario, Canada.

BackgroundFalls continue to be a problem for older people in long-term care (LTC) and retirement home (RH) settings and are associated with significant morbidity and health care use. Fall-risk increasing drugs (FRIDs) are known to increase fall risk and represent modifiable risk factors. There are limited data regarding the use of FRIDs in contemporary LTC and RH settings, and it has not been well documented to what extent medication regimens are reviewed and modified for those who have sustained falls. The objective of this study is to characterize medication related fall risk factors in LTC and RH residents and on-going use of medications known to increase fall risk.MethodsRetrospective chart review of residents aged >65 who sustained one or more falls living in LTC or RH settings.Results105 residents who fell one or more times during 2009–2010 were identified with a mean age of 89 years, a mean of nine scheduled medications and seven diagnoses, and 83 % were women. Residents in LTC were ostensibly at higher risk for falls relative to those in RH settings as suggested by higher proportion of residents with multiple falls, multiple comorbidities, comorbidities that increase fall risk and visual impairment. Post fall injuries were sustained by 42 % of residents, and residents in RH sustained more injuries relative to LTC residents (47 vs 34 %). Use of FRIDs such as benzodiazepines, antipsychotic, antidepressant and various antihypertensive drugs was common in the present sample. No medication regimen changes were noted in the 6-month post fall period.ConclusionsThe present study documented common use FRIDs by LTC and RH residents with multiple falls. These potentially modifiable falls risk factors are not being adequately addressed in contemporary practice, demonstrating that there is much room for improvement with regards to the safe and appropriate use of medications in LTC and RH residents.

Patient, resident, or person: Recognition and the continuity of self in long-term care for older people

Becoming a resident in a long-term care facility challenges older people's continuity of self in two major ways. Firstly, as they leave behind their previous home, neighborhood, and often their social surroundings, older people have to change their life-long lifestyles, causing fears of the loss of one's self. Secondly, modern-day care facilities have some features of ‘total’ institutions that produce patient-like role expectations and thus challenge older people's selves. Our ethnographic study in a geriatric hospital and a sheltered home in Finland aims to find out what features of daily life either support or challenge older people's continuity of self. A philosophical reading of the concept of recognition is used to explore how various daily practices and interactions support recognizing people as persons in long-term care. Categories of institution-centered and person-centered features are described to illustrate multiple ways in which people are recognized and misrecognized. The discussion highlights some ways in which long-term care providers could use the results of the study.

Age in antiretroviral therapy programmes in South Africa: a retrospective, multicentre, observational cohort study

As access to antiretroviral therapy (ART) expands, increasing numbers of older patients will start treatment and need specialised long-term care. However, the effect of age in ART programmes in resource-constrained settings is poorly understood. The HIV epidemic is ageing rapidly and South Africa has one of the highest HIV population prevalences worldwide. We explored the effect of age on mortality of patients on ART in South Africa and whether this effect is mediated by baseline immunological status. In this retrospective cohort analysis, we studied HIV-positive patients aged 16-80 years who started ART for the first time in six large South African cohorts of the International Epidemiologic Databases to Evaluate AIDS-Southern Africa collaboration, in KwaZulu-Natal, Gauteng, and Western Cape (two primary care clinics, three hospitals, and a large rural cohort). The primary outcome was mortality. We ascertained patients' vital status through linkage to the National Population Register. We used inverse probability weighting to correct mortality for loss to follow-up. We estimated mortality using Cox's proportional hazards and competing risks regression. We tested the interaction between baseline CD4 cell count and age. Between Jan 1, 2004, and Dec 31, 2013, 84,078 eligible adults started ART. Of these, we followed up 83,566 patients for 174,640 patient-years. 8% (1817 of 23,258) of patients aged 16-29 years died compared with 19% (93 of 492) of patients aged 65 years or older. The age adjusted mortality hazard ratio was 2·52 (95% CI 2·01-3·17) for people aged 65 years or older compared with those 16-29 years of age. In patients starting ART with a CD4 count of less than 50 cells per μL, the adjusted mortality hazard ratio was 2·52 (2·04-3·11) for people aged 50 years or older compared with those 16-39 years old. Mortality was highest in patients with CD4 counts of less than 50 cells per μL, and 15% (1103 of 7295) of all patients aged 50 years or older starting ART were in this group. The proportion of patients aged 50 years or older enrolling in ART increased with successive years, from 6% (290 of 4999) in 2004 to 10% (961 of 9657) in 2012-13, comprising 9% of total enrolment (7295 of 83 566). At the end of the study, 6304 (14%) of 44,909 patients still alive and in care were aged 50 years or older. Health services need reorientation towards HIV diagnosis and starting of ART in older individuals. Policies are needed for long-term care of older people with HIV. National Institutes of Health (National Institute of Allergy and Infectious Diseases), US Agency for International Development, and South African Centre for Epidemiological Modelling and Analysis.

Older people's exercising of choice in long-term care: a comparative analysis of England and Japan

ABSTRACTThere has been an increasing emphasis on choice for older people in long-term care in both England and Japan. However, despite the emphasis on the importance of choice, the perspectives of older people have been given little attention. Considering national and local policies in Bristol, England and Kyoto, Japan, the article explores how older people are exercising (and not exercising) choice in care practice through examining the perspectives of the older people themselves, as well as key informants in the field. Empirical data were collected from interviews with older people and key informants in the two countries, and were analysed using qualitative and comparative approaches. Choice in policy is regarded as a mechanism of the market with an assumption of the independent autonomous individual who can exercise ‘rational choice’. However, the findings have reflected older people's relational decision-making, which does not conform to the rational model of decision-making, and illustrates the value of ‘interdependence’. The findings from care practice have shown that choice was considered an important value in involving older people's views and ensuring their needs are met sensitively and respectfully. The findings also suggested that consideration of the psychological aspects of choice is an important aspect of ‘care’, facilitating the inclusion of older people's views in the process of making judgements, in order to meet their needs.

The influence of the economic crisis on quality of care for older people: system readiness for innovation in Europe

The aim of this study is to examine the influence of the recent economic crisis on the quality of long-term care for older people in Belgium and the Netherlands. A mixed-method approach was applied, primarily focused on conducting semi-structured qualitative interviews with health professionals working in a management role in organizations providing long-term care for older people. The results show that Dutch organizations seem to be prepared for the influences of the economic crisis on the quality of its care provision primarily in terms of a sound system readiness. At the same time, Belgian organizations seem to be prepared for the influences of the economic crisis on the quality of its care provision primarily in terms of a favorable sociopolitical context. Comparing two countries allows for reciprocal lesson-drawing. The conclusion drawn in this study is that a sustainable long-term care system requires above all stability and structure.

Improving oral health of institutionalized older people with diagnosed dementia

Objective: Previous research has revealed poor oral hygiene and health among older people suffering from dementia. To evaluate the oral health and denture hygiene of older people with and without dementia, six months after carer have followed a dental education programme.Method: Ninety-three older people living in four long-term care homes in south-western Germany were included in this longitudinal cohort study. All participants were allocated into two groups on basis of the medical dementia diagnosis extracted from the medical records in the care documentation: suffering from dementia (n = 33) or not (n = 60). For each participant plaque control record, gingival bleeding index (GBI), community periodontal index of treatment needs (CPITN), and denture hygiene index (DHI) were assessed at baseline and six months after carer have followed a dental education programme, and after use of ultrasonic devices for denture cleaning. Differences between all target variables from baseline to follow-up, and between participants with and without dementia, were evaluated by bivariate and multivariate testing.Results: In bivariate testing, participants with dementia had a significantly lower DHI (p < 0.001), a lower GBI (p < 0.05), and a lower CPITN (p < 0.01) at follow-up. In participants without dementia, only for DHI (p < 0.001) a significant improvement was observed. In multivariate analyses, the significant association could not be reproduced (p > 0.05).Conclusions: Use of ultrasonic baths can be a successful means for improving denture hygiene among older people in long-term care with and without dementia. Education for carer in order to improve oral hygiene, however, seems to be of minor significance and to be more effective for people with dementia.

An Overview of Potential Labor-Saving and Quality-Improving Innovations in Long-Term Care for Older People

ObjectivesIncreasing demands in long-term care for older people and a decrease in workforce availability can be expected in the future. These developments challenge the sustainability and quality of long-term care for older people. To address these challenges, long-term care organizations are forced to innovate. The aim of this study is to provide an overview of potential labor-saving and quality-improving innovations long-term care organizations are working on and to assess the self-reported extent of effectiveness. DesignThis is a descriptive cross-sectional study. MethodsIn total, 32 long-term care organizations in the region of Limburg in The Netherlands were invited to participate in the study. The inventory was performed by means of semistructured interviews with chief executive officers, managers, and staff members of the long-term care organizations. Based on the interview data, all innovations were described in a standardized form and subsequently checked by the participants. All innovations were clustered into product, process, organizational, and marketing innovations. ResultsIn total, 26 long-term care organizations delivering home and/or institutional long-term care for older people participated in the study. Overall, 228 innovations were identified; some innovations were described in a similar way by different organizations. The majority of innovations were product innovations (n = 96), followed by organizational innovations (n = 75), and process innovations (n = 42). In addition to the main types, 15 other innovations incorporating characteristics of different types of innovations were detected. Little evidence about the effectiveness of the innovations was reported by the organizations. ConclusionsThis study shows that a large number and a broad variety of innovations have been implemented or are currently being developed in long-term care organizations for older people. However, according to the organizations, there is relatively little (scientific) evidence confirming the effectiveness of these innovations. More research is needed to evaluate the effects of the innovations and to indicate whether they provide real solutions to future challenges.

SS2.04: Long-term care for older people across time and countries, in Europe, with help of interRAI-instruments

SS2.04: Long-term care for older people across time and countries, in Europe, with help of interRAI-instruments

Methodological development of the interactive INTERLINKS Framework for Long-term Care.

There is increasing international research into health and social care services for older people in need of long-term care (LTC), but problems remain with respect to acquiring robust comparative information to enable judgements to be made regarding the most beneficial and cost-effective approaches. The project 'INTERLINKS' ('Health systems and LTC for older people in Europe') funded by the EU 7th Framework programme was developed to address the challenges associated with the accumulation and comparison of evidence in LTC across Europe. It developed a concept and method to describe and analyse LTC and its links with the health and social care system through the accumulation of policy and practice examples on an interactive web-based framework for LTC. This paper provides a critical overview of the theoretical and methodological approaches used to develop and implement the INTERLINKS Framework for LTC, with the aim of providing some guidance to researchers in this area. INTERLINKS has made a significant contribution to knowledge but robust evidence and comparability across European countries remain problematic due to the current and growing complexity and diversity of integrated LTC implementation.

Dignity and the capabilities approach in long‐term care for older people

The ageing populations of the Western world present a wide range of economic, social, and cultural implications, and given the challenges posed by deteriorating maintenance ratios, the scenario is somewhat worrying. In this paper, I investigate whether Martha C. Nussbaum's capabilities approach could secure dignity for older people in long-term care, despite the per capita decreases in resources. My key research question asks, 'What implications does Nussbaum's list of central human capabilities have for practical social care?' My methodology combines Nussbaum's list with ethnographic data gathered from a Finnish sheltered home for older people. On the basis of this study, it seems that the capabilities approach is a plausible framework for the ethics of care because it highlights differences in the ability to function and thus differences in opportunities to pursue a good life. The ideas presented in this article could assist social policy planners and executives in creating policies and practices that help old people to maintain their dignity until the end of their days.

Interventions for preventing delirium in older people in institutional long-term care

Delirium is a common and distressing complication of a range of stressor events including infection, new medications and environment change that is often experienced by older people with frailty and dementia. Older people living in institutional long-term care (LTC)are at high risk of delirium, which increases the risk of admission to hospital, development of or worsening of dementia, and mortality.Delirium is also associated with substantial healthcare costs. Although it is possible to prevent delirium in the hospital setting by providing multicomponent delirium prevention interventions it is currently unclear whether interventions to prevent delirium in LTCare effective. To assess the effectiveness of interventions for preventing delirium in older people in long term care. We searched ALOIS (www.medicine.ox.ac.uk/alois) - the Cochrane Dementia and Cognitive Improvement Group's Specialised Register- on 23 April 2013. The search was as sensitive as possible to identify all studies on ALOIS relating to delirium. We ran additional separate searches in major healthcare databases, trial registers, the Cochrane Central Register of Controlled Trials (CENTRAL) and grey literature sources, to ensure that the search was as comprehensive as possible. We included randomised controlled trials (RCTs) and cluster-randomised controlled trials (cluster-RCTs) of single- and multi componentn on-pharmacological and pharmacological interventions for preventing delirium in older people (aged 65 years and over) in permanent LTC residence. Two independent review authors examined the titles and abstracts of citations identified by the search for eligibility and extracted data, with any disagreements settled by consensus. Primary outcomes were prevalence, incidence and severity of delirium. Secondary outcomes included new diagnosis of dementia, activities of daily living, quality of life and adverse outcomes. We used risk ratios (RRs)as measures of treatment effect for dichotomous outcomes and hazard ratios (HR) for time to event data.Main results We included two trials that recruited 3636 participants.Both were complex single-component non-pharmacological delirium prevention interventions. Risk of bias for many items was unclear due to inadequate reporting. Notably, there was no evidence of blinding of trial participants or assessors in either trial. One small cluster-RCT (n = 98) of a hydration-based intervention reported no reduction in delirium incidence in the intervention group compared to control (RR 0.85, 95% confidence interval (CI) 0.18 to 4.00, analysis not adjusted for clustering, very low quality evidence). Results were imprecise and there were serious limitations evident in trial design.One large cluster-RCT (n = 3538) of a computerised system to identify medications that may contribute to delirium risk and trigger a pharmacist-led medication review reported a large reduction in delirium incidence (12-month HR 0.42, CI 0.34 to 0.51, moderat equality evidence) but no clear evidence of reduction in hospital admissions (HR 0.89, CI 0.72 to 1.10, moderate quality evidence), in mortality (HR 0.88, CI 0.66 to 1.17, moderate quality evidence) or in falls risk (HR 1.03, CI 0.92 to 1.15, moderate quality evidence).Authors' conclusions Our review identified very limited evidence on interventions for preventing deliriumin older people in LTC. Introduction of a software based intervention to identify medications that could contribute to delirium risk so that a pharmacist-led medication review and monitoring plan can be initiated may reduce incidence of delirium for older people in institutional LTC. This is based on one large RCT in the United States and may not be practical in other countries which do not have comparable information technology services available in care homes. Our review identified only one ongoing pilot trial of a multicomponent delirium prevention intervention and no trials of pharmacological agents. Future trials of computerised medication management systems and multicomponent non-pharmacological and pharmacological delirium prevention interventions for older people in LTC are needed to help inform the provision of evidence based care for this vulnerable group.

Care workers in long-term care for older people: challenges of quantity and quality

This article, drawing on a qualitative study in England, the Netherlands and Taiwan, explores how countries with very different care systems address the challenge of securing sufficient numbers of care workers with appropriate skills in ageing care. The analysis exposes the salient features of care systems, ageing-care markets and the ageing-care workforce in the three countries. To support the analysis, examples of how the countries attempt to recruit and retain ageing-care workers are provided. Key findings are that to secure an adequate number of skilled ageing-care workers, job satisfaction, coherence between care and labour policies and equal working conditions across sectors are vital. A quality ageing-care worker requires regular professional supervision and support, resources for ongoing training and career development opportunities. Most importantly, securing a sufficient number of ageing-care workers and ensuring they have appropriate skills are not isolated challenges but are interlinked and require collaboration between a range of care actors.

Is there randomized controlled trial evidence to support the use of physical rehabilitation in older people in long-term care?

Is there randomized controlled trial evidence to support the use of physical rehabilitation in older people in long-term care?