Services And Health For Elderly In Long TERm Care Research Articles

Frailty modifies the effect of polypharmacy and multimorbidity on the risk of death among nursing home residents: Results from the SHELTER study.

Frailty, disability, and polypharmacy are prevalent in nursing home (NH) residents, often co-occurring with multimorbidity. There may be a complex interplay among them in terms of outcomes such as mortality. Aims of the study were to (i) assess whether nursing home residents with polypharmacy (5-9 medications) or hyperpolypharmacy (≥10 drugs), have an increased risk of death and (ii) whether any association is modified by the co-presence of frailty or disability. Cohort study with longitudinal mortality data including 4,023 residents from 50 European and 7 Israeli NH facilities (mean age = 83.6 years, 73.2% female) in The Services and Health for Elderly in Long Term care (SHELTER) cohort study. Participants were evaluated with the interRAI-LongTerm Care assessment tool. Frailty was evaluated with the FRAIL-NH scale. Hazard ratio (HR) of death over 12 months was assessed with stratified Cox proportional hazards models adjusted for demographics, facilities, and cognitive status. 1,042 (25.9%) participants were not on polypharmacy, 49.8% (n = 2,002) were on polypharmacy, and 24.3% (n = 979) on hyperpolypharmacy. Frailty and disability mostly increased risk of death in the study population (frailty: HR = 1.85, 95%CI 1.49-2.28; disability: HR = 2.10, 95%CI 1.86-2.47). Among non-frail participants, multimorbidity (HR = 1.34, 95%CI = 1.01-1.82) and hyperpolypharmacy (HR = 1.61, 95%CI = 1.09-2.40) were associated with higher risk of death. Among frail participants, no other factors were associated with mortality. Polypharmacy and multimorbidity were not associated with mortality after stratification for disability. Frailty and disability are the strongest predictors of death in NH residents. Multimorbidity and hyperpolypharmacy increase mortality only in people without frailty. These findings may be relevant to identify patients who could benefit from tailored deprescription.

Characteristics of patients with cancer in European long-term care facilities

PurposeUp to 26% of residents in nursing homes (NHs) are affected by cancer. Their care represents a challenge, because NHs are not usually considered a setting focused on oncologic management and care. The aim of this paper is to describe socio-demographic and clinical features of patients with cancer residing in European NHs.MethodsCross-sectional study based on data from the Services and Health for Elderly in Long TERm care (SHELTER) study. Participants were assessed through the interRAI-LTCF, which includes cancer assessment.ResultsAmong 4140 participants (mean age 83.4 years; female 73%), 442 (10.7%) had cancer. Patients with cancer had a higher prevalence of do-not-resuscitate directives compared to those without cancer (21.1% vs 16.5%, p = 0.019). Variables directly associated with cancer were male sex (adj OR 1.67, 95% CI 1.36–2.05), pain (adj OR 1.43, 95% CI 1.16–1.77), fatigue (adj OR 1.25, 95% CI 1.01–1.55), polypharmacy (adj OR 1.59, 95% CI 1.21–2.08) and falls (adj OR. 1.30, 95% CI 1.01–1.67). Dementia was inversely associated with cancer (adj OR 0.74, 95% CI 0.58–0.94). Symptomatic drugs such as opioids (23.5% vs 12.2, p < .001), NSAIDS (7.2% vs 3.9%, p = 0.001), antidepressants (39.1% vs 33.8%, p = 0.026) and benzodiazepines (40.3% vs 34.3, p = 0.012) were all prescribed more in participants with cancer compared to those without cancer.ConclusionsCancer patients are prevalent in European NHs and they show peculiar characteristics. Studies are needed to evaluate the impact of a supportive care approach on the management of NHs residents with cancer throughout all its phases, until the end-of-life care

The Association of Anticholinergic Drugs and Delirium in Nursing Home Patients With Dementia: Results From the SHELTER Study

ObjectivesDrugs with anticholinergic properties are associated with an increased prevalence of delirium, especially in older persons. The aim of this study was to evaluate the association between the use of this class of drugs in nursing home (NH) patients and prevalence of delirium, particularly in people with dementia. DesignCross-sectional multicenter study. Setting and participants3924 nursing home patients of 57 nursing homes in 7 European countries participating in the Services and Health for Elderly in Long TERmcare (SHELTER) project. MethodsDescriptive statistics, calculation of percentage, and multivariable logistic analysis were applied to describe the relationship between anticholinergic drug use and prevalence of delirium in NH patients. The Anticholinergic Risk Scale (ARS) and the Anticholinergic Burden Scale (ACB) were used to calculate the anticholinergic load. Results54% of patients with dementia and 60% without dementia received at least 1 anticholinergic drug according to the ACB. The prevalence of delirium was higher in the dementia group (21%) compared with the nondementia group (11%). Overall, anticholinergic burden according to the ACB and ARS was associated with delirium both in patients with and without dementia, with odds ratios ranging from 1.07 [95% confidence interval (CI) 0.94-1.21] to 1.26 (95% CI 1.11-1.44). These associations reached statistical significance only in the group of patients with dementia. Among patients with dementia, delirium prevalence increased only modestly with increasing anticholinergic burden according to the ACB, from 20% (with none or minimal anticholinergic burden) to 25% (with moderate burden) and 27% delirium (with strong burden scores). Conclusions and ImplicationsThe ACB scale is relatively capable to detect anticholinergic side effects, which are positively associated with prevalence of delirium in NH patients. Given the modest nature of this association, strong recommendations are currently not warranted, and more longitudinal studies are needed.

Sex Differences in Behavioral and Psychological Signs and Symptoms of Dementia Presentation Regarding Nursing Home Residents with Cognitive Impairment Suffering from Pain – Results of the Services and Health for Elderly in Long-Term Care Study

ObjectiveBehavioral and psychological symptoms of dementia (BPSD) place a heavy burden on patients as well as caregivers. Recently, pain was identified as an important determinant of BPSD. However, it is not yet known what influence sex has on BPSD and pain. Thus, the present study aimed to identify possible associations between BPSD, pain, and sex. DesignA retrospective evaluation of cross-sectional data derived from the Services and Health for Elderly in Long-Term Care (SHELTER) Study database, a cross-national European study on nursing home residents. Setting and ParticipantsThe study involved 4156 residents who were assessed using the interRAI instrument for Long-Term Care Facilities. Included in the analysis were only patients with cognitive impairment (n = 2822) (67.9%) of which 712 (25.2%) were male and 2110 (74.8%) were female. MethodsDifferences in prevalence were tested using the χ2 test while bivariate logistic regression models were used to evaluate factors associated with sex. ResultsMen showed behavioral symptoms such as wandering, verbal and physical abuse as well as sexual uninhibited behavior significantly more often than women. Regarding psychiatric symptoms, only depression was significantly more frequent in women. Surprisingly, in the presence of pain these differences in BPSD incidence between men and women were no longer detectable. Logistic regression analysis showed that in women with dementia/communication problems, the presence of pain could be indicated by resistance to care, sleeping disorders, and possibly by the presence of delusions and anxiety whereas in men it was related to abnormal thought processes, and in both sexes to depression Conclusions and ImplicationsFrom a clinical point of view, resistance to care and sleeping disorders in women and abnormal thought processes in men as well as depression in both sexes should be seen as indicators of possible underlying pain in noncommunicative people. Thus, knowledge of sex-specific BPSD presentations can improve pain management in this particularly patient group.

Relationship between frailty and drug use among nursing homes residents: results from the SHELTER study.

1.5-8% of older adults live in nursing homes (NHs), presenting a high prevalence of frailty and polypharmacy. To investigate the association of frailty with polypharmacy and drug prescription patterns in a sample of European Nursing Home (NH) residents. Cross-sectional study based on the data from the Services and Health for Elderly in Long TERm care (SHELTER) study. 4121 NH residents in Europe and Israel. Residents' clinical, cognitive, social, and physical status were evaluated with the InterRAI LTCF tool, which allows comprehensive, standardized evaluation of persons living in NH. Polypharmacy and hyperpolypharmacy were defined as the concurrent use of ≥ 5 and ≥ 10 medications. Frailty was defined according to the FRAIL-NH scale. Of 4121 participants, 46.6% were frail (mean age 84.6 ± 9.2years; 76.4% female). Polypharmacy and hyperpolypharmacy were associated with a lower likelihood of frailty (Odds Ratio = 0.72; 95% CI = 0.59-0.87 and OR = 0.75; 95% CI = 0.60-0.94, respectively). Patterns of drug prescriptions were different between frail and non-frail residents. Symptomatic drugs (laxatives, paracetamol, and opioids) were more frequently prescribed among frail residents, while preventive drugs (bisphosphonates, vitamin D, and acetylsalicylic acid) were more frequently prescribed among non-frail residents. Frailty is associated with less polypharmacy and with higher prevalence of symptomatic drugs use among NH residents. Further studies are needed to define appropriateness of drug prescription in frail individuals.

Deprescribing in Nursing Home Residents on Polypharmacy: Incidence and Associated Factors

ObjectivesTo assess 1-year incidence and factors related to deprescribing in nursing home (NH) residents in Europe. DesignLongitudinal multicenter cohort study based on data from the Services and Health for Elderly in Long TERm care (SHELTER) study. SettingNHs in Europe and Israel. Participants1843 NH residents on polypharmacy. MethodsPolypharmacy was defined as the concurrent use of 5 or more medications. Deprescribing was defined as a reduction in the number of medications used over the study period. Residents were followed for 12 months. ResultsResidents in the study sample were using a mean number of 8.6 (standard deviation 2.9) medications at the baseline assessment. Deprescribing was observed in 658 residents (35.7%). Cognitive impairment (mild/moderate impairment vs intact, odds ratio [OR] 1.41, 95% confidence interval [CI] 1.11-1.79; severe impairment vs intact, OR 1.60, 95% CI 1.23-2.09), presence of the geriatrician within the facility staff (OR 1.41, 95% CI 1.15-1.72), and number of medications used at baseline (OR 1.10, 95% CI 1.06-1.14) were associated with higher probabilities of deprescribing. In contrast, female gender (OR 0.76, 95% CI 0.61-0.96), heart failure (OR 0.69, 95% CI 0.53-0.89), and cancer (OR 0.64, 95% CI 0.45-0.90) were associated with a lower probability of deprescribing. Conclusions and ImplicationsDeprescribing is common in NH residents on polypharmacy, and it is associated with individual and organizational factors. More evidence is needed on deprescribing, and clear strategies on how to withdraw medications should be defined in the future.

Association of Polypharmacy With 1-Year Trajectories of Cognitive and Physical Function in Nursing Home Residents: Results From a Multicenter European Study

ObjectivesTo test the association between polypharmacy and 1-year change in physical and cognitive function among nursing home (NH) residents. DesignLongitudinal multicenter cohort study based on data from the Services and Health for Elderly in Long TERm care (SHELTER) study. SettingNH in Europe (n = 50) and Israel (n = 7). Participants3234 NH older residents. MeasurementsParticipants were assessed through the interRAI long-term care facility instrument. Polypharmacy was defined as the concurrent use of 5 to 9 drugs and excessive polypharmacy as the use of ≥10 drugs. Cognitive function was assessed through the Cognitive Performance Scale (CPS). Functional status was evaluated through the Activities of Daily Living (ADL) Hierarchy scale. The change in CPS and ADL score, based on repeated assessments, was the outcome, and their association with polypharmacy was modeled via linear mixed models. The interaction between polypharmacy and time was reported [beta and 95% confidence intervals (95% CIs)]. ResultsA total of 1630 (50%) residents presented with polypharmacy and 781 (24%) excessive polypharmacy. After adjusting for potential confounders, residents on polypharmacy (beta 0.10, 95% CI 0.01-0.20) and those on excessive polypharmacy (beta 0.13, 95% CI 0.01-0.24) had a significantly higher decline in CPS score compared to those using <5 drugs. No statistically (P > .05) significant change according to polypharmacy status was shown for ADL score. ConclusionsPolypharmacy is highly prevalent among older NH residents and, over 1 year, it is associated with worsening cognitive function but not functional decline.

Health determinants and survival in nursing home residents in Europe: Results from the SHELTER study

ObjectiveThe care processes directed towards institutionalized older people needs to be tailored on goals and priorities that are relevant for this specific population. The aim of the present study was (a) to describe the distribution of selected health determinants in a sample of institutionalized older adults, and (b) to investigate the impact on survival of such measures. DesignMulticentre longitudinal cohort-study. Setting57 nursing homes (NH) in 7EU countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands) and 1 non-EU country (Israel). Participants3036 NH residents participating in the Services and Health for Elderly in Long TERm care (SHELTER) study. MeasurementsWe described the distribution of 8 health determinants (smoking habit, alcohol use, body mass index [BMI], physical activity, social participation, family visits, vaccination, and preventive visits) and their impact on 1-year mortality. ResultsDuring the one-year follow up, 611 (20%) participants died. Overweight (HR 0.79; 95% C.I. 0.64–0.97) and obesity (HR 0.64; 95% C.I. 0.48–0.87) resulted associated with lower mortality then normal weight. Similarly, physical activity (HR 0.67; 95% C.I. 0.54–0.83), social activities (HR 0.63; 95% C.I. 0.51–0.78), influenza vaccination (HR 0.66; 95% C.I. 0.55–0.80) and pneumococcal vaccination (HR 0.76 95% C.I. 0.63–0.93) were associated with lower mortality. Conversely, underweight (HR 1.28; 95% C.I. 1.03–1.60) and frequent family visits (HR 1.75; 95% C.I. 1.27–2.42) were associated with higher mortality. ConclusionsHealth determinants in older NH residents depart from those usually accounted for in younger and fitter populations. Ad hoc studies are warranted in order to describe other relevant aspects of health in frail older adults, with special attention on those institutionalized, with the ultimate goal of improving the quality of care and life.

Delivery of Care to Nursing Home Residents With Diabetes: Results From the SHELTER Study

ObjectivesTo describe health care and preventive service provision to nursing home (NH) residents with diabetes mellitus (DM) and to analyze factors determining use of selected services. DesignIn the period between 2009 and 2011, the Services and Health for Elderly in Long TERm care (SHELTER) project, a 12-month prospective cohort study, was conducted to assess 4037 NH residents aged 60 years and older residing in 59 NHs in 7 European countries and Israel. MethodsThe InterRAI tool for long-term care facilities was used to assess care needs and provided health care services. Descriptive statistics and multivariate logistic regression were applied to describe differences between NH residents with (DR) and without DM (non-DR), and to find factors determining use of services and care provided to both groups. ResultsDR more often than non-DR were hospitalized (18.2% vs 14.3%) and required rehabilitation (23.8% vs 18.2%) or clinically complex care (15.9% vs 13.7%). They also more frequently received a repositioning program (26.8% vs 22.7%), a wound care (15.1% vs 9.8%), and some preventive services as yearly eye examination (41.0% vs 35.9%), pneumococcal vaccination (33.5% vs 26.6%), mammography in women (12.1% vs 7.4%), and colonoscopy (5.6% vs 3.6%). Yet, rates of some of them (mammography, colonoscopy, hearing and dental examinations) were very low in both study cohorts with exception of annual influenza vaccination (82.1%) and yearly blood pressure checkup (95.0%). Interestingly, DM enhanced odds only for mammography [odds ratio (OR) 1.55, 95% confidence interval [CI] 1.15–2.09, P = .004) and eye examination (OR 1.21, 95% CI 1.03–1.42; P = .018). ConclusionsDR more frequently receive care related to DM clinical complexity; nevertheless, the recommended frequency of preventive procedures is not met both in DR and non-DR.

The Characteristics of Diabetic Residents in European Nursing Homes: Results from the SHELTER Study

ObjectivesThe objectives of this study were to describe the prevalence of diabetes mellitus (DM) in European nursing homes (NHs), and the health and functional characteristics of diabetic residents (DMR) aged 60 years and older. DesignBetween 2009 and 2011, the Services and Health for Elderly in Long TERm care (SHELTER) project, a 12-month prospective cohort study, was conducted to assess NH residents across different health care systems in 7 European countries and Israel. MethodsThe study included 59 NHs in 8 countries with a total of 4037 residents living in or admitted to a NH during the 3-month enrollment period. The multidimensional InterRAI instrument for Long-Term Care Facilities (InterRAI-LTCF) was used to assess health and functional status among residents. Descriptive statistics and linear, ordinal, and logistic regression were used to perform the analyses. ResultsWe found a 21.8% prevalence of DM among NH residents. Residents with DM (DMRs) were significantly younger compared with non-DMRs (82.3, SD ± 7.7; 84.6, SD ± 8.4; P < .001). DMRs were more frequently overweight or obese, and presented more often with ischemic heart disease, congestive heart failure, hypertension, and stroke than residents without DM. DMRs also took more drugs, had pressure ulcers (PU) or other wounds more often, and more frequently had urinary incontinence (UI); they also reported worse self-perceived health. DM independently of other factors increased risk of PU occurrence (odds ratio 1.38; 95% confidence interval [CI] 1.02–1.86; P = .036) and decreased probability of higher pain scores (B = −0.28; 95% CI −0.41 to −0.14; P < .001). DM was not associated with ADL dependency, cognitive impairment, and depression in NH residents. ConclusionPrevalence of DM in European NH residents is comparable to US national NH surveys, and to UK and German NH data based on glucose-level testing. DMRs compared with non-DMRs have more comorbid conditions, and a particularly higher incidence of cardiovascular diseases and obesity, PU, and severe UI. DMRs should be regarded as a specific group of residents who require an interdisciplinary approach in medical and nursing care.

Improvement needed for pain treatment

Nursing and Residential CareVol. 15, No. 8 Clinical UpdateImprovement needed for pain treatmentLinda NazarkoLinda NazarkoSearch for more papers by this authorLinda NazarkoPublished Online:29 Sep 2013https://doi.org/10.12968/nrec.2013.15.8.529aAboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Lukas A, Mayer B, Fialová D et al. (2013) Treatment of pain in European nursing homes: results from the Services and Health for Elderly in Long-TERm care (SHELTER) study. J Am Med Dir Assoc June 5: doi: 10.1016/j.jamda.2013.04.009 Google Scholar FiguresReferencesRelatedDetails 1 August 2013Volume 15Issue 8ISSN (print): 1465-9301ISSN (online): 2052-2932 Metrics History Published online 29 September 2013 Published in print 1 August 2013 Information© MA Healthcare LtdPDF download

Treatment of Pain in European Nursing Homes: Results from the Services and Health for Elderly in Long TERm Care (SHELTER) Study

To identify pharmacological and nonpharmacological pain management approaches and associated factors in nursing home residents across Europe. Cross-sectional study with 4156 residents who were assessed using the interRAI instrument for Long Term Care Facilities (interRAI LTCF), including pharmacological and nonpharmacological pain management modalities. Those reporting pain were included in the analyses (n= 1900). A deeper analysis was performed for the subsample of residents who reported "current pain," defined as pain at least 1 day within the past 3 days (n= 838), and those who reported "current pain of moderate to severe intensity" (n= 590). Up to 24% of residents who reported pain did not receive any pain medication and up to 11% received it only PRN (as-needed basis), independent of current pain-intensity levels; 61% did not receive any nonpharmacological treatment and 21% received neither pharmacological nor nonpharmacological pain modalities. Considerable differences could be demonstrated across European countries. Factors positively associated with pharmacological pain management were being of female gender, reporting cancer, and having moderate or severe pain. High turnover rates of regular staff and low-to-moderate physicians' availability were negatively associated. Factors positively associated with nonpharmacological treatment were fractures and need of assistance in activities of daily living. Dementia, large nursing home facilities, above-average and high turnover rates of nursing staff, a low physicians' availability, and severe pain intensity were negatively associated. Despite some advances in recent years, pain treatment in European nursing home residents remains to be suboptimal and requires further improvement.

Polypharmacy and Mortality Among Nursing Home Residents With Advanced Cognitive Impairment: Results From the Shelter Study

Older adults with advanced cognitive impairment have a limited life expectancy and the use of multiple drugs is of questionable benefit in this population. The aim of the present study was to assess if, in a sample of nursing home (NH) residents with advanced cognitive impairment, the effect of polypharmacy on mortality differs depending on estimated life expectancy. Data were from the Services and Health for Elderly in Long TERm care (SHELTER) project, a study collecting information on residents admitted to 57 NHs in 8 European countries. Polypharmacy was defined as the concomitant use of 10 or more drugs. Limited life expectancy was estimated based on an Advanced Dementia Prognostic Tool (ADEPT) score of 13.5 or more. A Cognitive Performance Scale score of 5 or more was used to define advanced cognitive impairment. Participants were followed for 1 year. Mean age of 822 residents with advanced cognitive impairment entering the study was 84.6 (SD 8.0) years, and 630 (86.6%) were women. Overall, 123 participants (15.0%) had an ADEPT score of 13.5 or more (indicating limited life expectancy) and 114 (13.9%) were on polypharmacy. Relative to residents with ADEPT score less than 13.5, those with ADEPT score of 13.5 or higher had a lower use of benzodiazepines, antidementia drugs, and statins but a higher use of beta-blockers, digoxin, and antibiotics. Polypharmacy was associated with increased mortality among residents with ADEPT score of 13.5 or more (adjusted hazard ratio [HR] 2.19, 95% confidence interval [CI]: 1.15-4.17), but not among those with ADEPT score less than 13.5 (adjusted HR 1.10, 95% CI: 0.71-1.71). Polypharmacy is associated with increased mortality in NH residents with advanced cognitive impairment at the end of life. These findings underline the need to assess life expectancy in older adults to improve the prescribing process and to simplify drug regimens.

The calculation of quality indicators for long term care facilities in 8 countries (SHELTER project)

BackgroundPerformance indicators in the long term care sector are important to evaluate the efficiency and quality of care delivery. We are, however, still far from being able to refer to a common set of indicators at the European level.We therefore demonstrate the calculation of Long Term Care Facility Quality Indicators (LTCFQIs) from data of the European Services and Health for Elderly in Long TERm Care (SHELTER) project. We explain how risk factors are taken into account and show how LTC facilities at facility and country level can be compared on quality of care using thresholds and a Quality Indicator sum measure.MethodsThe indicators of Long Term Care Facility quality of care are calculated based on methods that have been developed in the US. The values of these Quality Indicators (QIs) are risk adjusted on the basis of covariates resulting from logistic regression analysis on each of the QIs. To enhance the comparison of QIs between facilities and countries we have used the method of percentile thresholds and developed a QI sum measure based on percentile outcomes.ResultsIn SHELTER data have been collected with the interRAI Long Term Care Facility instrument (interRAI-LTCF). The data came from LTC facilities in 7 European countries and Israel. The unadjusted values of the LTCF Quality Indicators differ considerably between facilities in the 8 countries. After risk adjustment the differences are less, but still considerable. Our QI sum measure facilitates the overall comparison of quality of care between facilities and countries.ConclusionsWith quality indicators based on assessments with the interRAI LTCF instrument quality of care between LTC facilities in and across nations can be adequately compared.

Pain Characteristics and Pain Control in European Nursing Homes: Cross-sectional and Longitudinal Results From the Services and Health for Elderly in Long TERm care (SHELTER) Study

Few studies have compared cross-national characteristics of residents with pain in European long term care facilities. The SHELTER project, a cross-national European study on nursing home residents, provides the opportunity to examine this issue. The present study aimed to evaluate key figures about pain and compare them with seven European countries and Israel. A total of 3926 nursing home residents were assessed by the interRAI instrument for Long Term Care Facilities (interRAI LTCF). Prevalence of pain, frequency, intensity, consistency, and control were estimated and compared cross-nationally. Correlates between patient-related characteristics and inadequate pain management were tested using bivariate and multivariate logistic regression models. Overall, 1900 (48.4%) residents suffered from pain. Pain prevalence varied significantly among countries, ranging from 19.8% in Israel to 73.0% in Finland. Pain was positively associated with female gender, fractures, falls, pressure ulcers, sleeping disorders, unstable health conditions, cancer, depression, and number of drugs. It was negatively associated with dementia. In a multivariate logistic regression model, all associations remained except for sleeping disorders. Clinical correlations varied considerably among countries. Although in 88.1% of cases, pain was self-rated by the residents as sufficiently controlled, in only 56.8% of cases was pain intensity self-rated as absent or mild. Pain control and intensity improved within 1 year. Pain prevalence is high and varies considerably across Europe. Although most residents considered pain as adequately controlled, a closer look confirmed that many still suffer from high pain intensities. Analyzing the reasons behind these differences may help to improve pain management.

Polypharmacy in nursing home residents with severe cognitive impairment: Results from the SHELTER Study

ObjectivePharmacological treatment of older adults with cognitive impairment represents a challenge for prescribing physicians, and polypharmacy is common in these complex patients. The aim of the current study is to assess prevalence and factors related to polypharmacy in a sample of nursing home (nursing home) residents with advanced cognitive impairment. MethodsWe conducted a cross-sectional analysis of 1449 nursing home residents with advanced cognitive impairment participating to the Services and Health for Elderly in Long Term Care (SHELTER) project, a study collecting information on residents admitted to 57 nursing home in eight countries. Data were collected using the International Resident Assessment Instrument (InterRAI) for long-term care facilities. Polypharmacy status was categorized into three groups: nonpolypharmacy (zero to four drugs), polypharmacy (five to nine drugs), and excessive polypharmacy (≥10 drugs). ResultsPolypharmacy was observed in 735 residents (50.7%) and excessive polypharmacy was seen in 245 (16.9%). Compared with nonpolypharmacy, excessive polypharmacy was associated directly with ischemic heart disease (odds ratio [OR], 3.68; 95% confidence interval [CI], 2.01–6.74), diabetes mellitus (OR, 2.66; 95% CI; 1.46–4.84), Parkinson's disease (OR, 2.84; 95% CI, 1.36–5.85), gastrointestinal symptoms (OR, 1.20; 95% CI, 1.43–3.39), pain (OR, 3.12; 95% CI, 1.99–4.89), dyspnea (OR, 2.57; 95% CI, 1.31–5.07), and recent hospitalization (OR, 2.56; 95% CI, 1.36–5.85). An inverse relation with excessive polypharmacy was shown for age (OR, 0.74; 95% CI, 0.59–0.93), activities of daily living disability (OR, 0.79; 95% CI, 0.63–0.99) and presence of a geriatrician on the nursing home staff (OR, 0.36; 95% CI, 0.20–0.64). ConclusionPolypharmacy and excessive polypharmacy are common among nursing home residents with advanced cognitive impairment. Determinants of polypharmacy status includes not only comorbidities, but also specific symptoms, age, and functional status. A geriatrician in the facility is associated with lower prevalence of excessive polypharmacy.

Inappropriate Drugs in Elderly Patients with Severe Cognitive Impairment: Results from the Shelter Study

BackgroundIt has been estimated that Nursing Home (NH) residents with impaired cognitive status receive an average of seven to eight drugs daily. The aim of this study was to determine prevalence and factors associated with use of inappropriate drugs in elderly patients with severe cognitive impairment living in NH in Europe.MethodsCross-sectional data from a sample of 1449 NH residents with severe cognitive impairment, participating in the Services and Health for Elderly in Long TERm care (SHELTER) study were analysed. Inappropriate drug use was defined as the use of drugs classified as rarely or never appropriate in patients with severe cognitive impairment based on the Holmes criteria published in 2008.ResultsMean age of participating residents was 84.2±8.9 years, 1087 (75.0%) were women. Inappropriate drug use was observed in 643 (44.9%) residents. Most commonly used inappropriate drugs were lipid-lowering agents (9.9%), antiplatelet agents (excluding Acetylsalicylic Acid – ASA –) (9.9%), acetylcholinesterase, inhibitors (7.2%) and antispasmodics (6.9%). Inappropriate drug use was directly associated with specific diseases including diabetes (OR 1.64; 95% CI 1.21–2.24), heart failure (OR 1.48; 95% CI 1.04–2.09), stroke (OR 1.43; 95% CI 1.06–1.93), and recent hospitalization (OR 1.69; 95% CI 1.20–2.39). An inverse relation was shown between inappropriate drug use and presence of a geriatrician in the facility (OR 0.55; 95% CI 0.39–0.77).ConclusionUse of inappropriate drugs is common among older EU NH residents. Determinants of inappropriate drug use include comorbidities and recent hospitalization. Presence of a geriatrician in the facility staff is associated with a reduced rate of use of these medications.

Assessment of nursing home residents in Europe: the Services and Health for Elderly in Long TERm care (SHELTER) study

BackgroundAims of the present study are the following: 1. to describe the rationale and methodology of the Services and Health for Elderly in Long TERm care (SHELTER) study, a project funded by the European Union, aimed at implementing the interRAI instrument for Long Term Care Facilities (interRAI LTCF) as a tool to assess and gather uniform information about nursing home (NH) residents across different health systems in European countries; 2. to present the results about the test-retest and inter-rater reliability of the interRAI LTCF instrument translated into the languages of participating countries; 3 to illustrate the characteristics of NH residents at study entry.MethodsA 12 months prospective cohort study was conducted in 57 NH in 7 EU countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands) and 1 non EU country (Israel). Weighted kappa coefficients were used to evaluate the reliability of interRAI LTCF items.ResultsMean age of 4156 residents entering the study was 83.4 ± 9.4 years, 73% were female. ADL disability and cognitive impairment was observed in 81.3% and 68.0% of residents, respectively. Clinical complexity of residents was confirmed by a high prevalence of behavioral symptoms (27.5% of residents), falls (18.6%), pressure ulcers (10.4%), pain (36.0%) and urinary incontinence (73.5%). Overall, 197 of the 198 the items tested met or exceeded standard cut-offs for acceptable test-retest and inter-rater reliability after translation into the target languages.ConclusionThe interRAI LTCF appears to be a reliable instrument. It enables the creation of databases that can be used to govern the provision of long-term care across different health systems in Europe, to answer relevant research and policy questions and to compare characteristics of NH residents across countries, languages and cultures.

Polypharmacy in Nursing Home in Europe: Results From the SHELTER Study

This study assesses prevalence and patients characteristics related to polypharmacy in a sample of nursing home residents. We conducted a cross-sectional analysis on 4,023 nursing home residents participating to the Services and Health for Elderly in Long TERm care (SHELTER) project, a study collecting information on residents admitted to 57 nursing home in 8 countries. Data were collected using the interRAI instrument for long-term care facilities. Polypharmacy status was categorized in 3 groups: non-polypharmacy (0-4 drugs), polypharmacy (5-9 drugs) and excessive polypharmacy (≥ 10 drugs). Polypharmacy was observed in 2,000 (49.7%) residents and excessive polypharmacy in 979 (24.3%) residents. As compared with non-polypharmacy, excessive polypharmacy was directly associated not only with presence of chronic diseases but also with depression (odds ratio [OR] 1.81; 95% confidence interval [CI] 1.38-2.37), pain (OR 2.31; 95% CI 1.80-2.97), dyspnoea (OR 2.29; 95% CI 1.61-3.27), and gastrointestinal symptoms (OR 1.73; 95% CI 1.35-2.21). An inverse association with excessive polypharmacy was shown for age (OR for 10 years increment 0.85; 95% CI 0.74-0.96), activities of daily living disability (OR for assistance required vs independent 0.90; 95% CI 0.64-1.26; OR for dependent vs independent 0.59; 95% CI 0.40-0.86), and cognitive impairment (OR for mild or moderate vs intact 0.64; 95% CI 0.47-0.88; OR for severe vs intact 0.39; 95% CI 0.26-0.57). Polypharmacy and excessive polypharmacy are common among nursing home residents in Europe. Determinants of polypharmacy status include not only comorbidity but also specific symptoms, age, functional, and cognitive status.

Identifying elderly depression using the Depression Rating Scale as part of comprehensive standardised care assessment in nursing homes

Objectives: This study used data from the SHELTER (Services and Health for Elderly in Long TERm care) project to explore the benefits of using the Depression Rating Scale (DRS) as part of a standardised needs assessment in UK nursing homes, including a statistical method of effectively identifying characteristics linking to residents’ depression. Method: About 499 residents in nine nursing homes in south-east England were assessed with interRAI Long Term Care Facilities (interRAI LTCF), a standardised assessment tool containing the validated DRS residents who scored 3 or more on the DRS were considered ‘might suffer from depression’. A list of characteristics associated with depression was then examined using bivariate analysis and logistic regression. Results: Among the 499 residents assessed, 67.5% were not depressed (DRS < 3) and 32.3% might suffer from depression (DRS ≥ 3). The final logistic model showed ‘never married’ (p = 0.019), ‘diagnosis of COPD’ (COPD, chronic obstructive pulmonary disease) (p = 0.015), ‘feelings of pain’ (p = 0.015) and ‘trouble sleeping’ (p < 0.001) were significantly associated with reporting of DRS score of 3 and more. Conclusion: The article argued that DRS has distinctive advantages for using in UK nursing homes where a preponderance of residents is cognitively impaired, the procedure of screening depression is not regulated and resources to treat depression is relatively scarce. This article also demonstrated how using the DRS as part of a comprehensive standardised needs assessment facilitates analysis of characteristics linking to depression, which has significant policy implications in improving care quality and management.