Use In Residential Aged Care Facilities Research Articles

National Trends in Antidepressant Use in Australian Residential Aged Care Facilities (2006–2019)

ObjectivesAntipsychotics have been the focus of reforms for improving the appropriateness of psychotropic medicine use in residential aged care facilities (RACFs). Comprehensive evaluation of antidepressant use in RACFs is required to inform policy and practice initiatives targeting psychotropic medicines. This study examined national trends in antidepressant use among older people living in RACFs from 2006 to 2019. DesignNational repeated cross-sectional study. Setting and ParticipantsIndividuals aged 65 to 105 years who were permanent, long-term (≥100 days) residents of Australian RACFs between January 2006 and December 2019 were included. MethodsAnnual age- and sex-adjusted antidepressant prevalence rates and defined daily doses (DDDs) supplied per 1000 resident-days from 2006 to 2019 were determined. Age- and sex-adjusted prevalence rate ratios (aRRs) and 95% confidence intervals (CIs) were estimated using Poisson and negative binomial regression models. ResultsA total of 779,659 residents of 3371 RACFs were included (786,227,380 resident-days). Overall, antidepressant use increased from 46.1% (95% CI, 45.9–46.4) in 2006 to 58.5% (95% CI, 58.3–58.8) of residents in 2019 (aRR, 1.02; 95% CI, 1.02–1.02). Mirtazapine use increased from 8.4% (95% CI, 8.2–8.5) to 20.9% (95% CI, 20.7–21.1) from 2006 to 2019 (aRR, 1.07; 95% CI, 1.07–1.07). Antidepressant use increased from 350.3 (95% CI, 347.6–353.1) to 506.0 (95% CI, 502.8–509.3) DDDs/1000 resident-days (aRR, 1.03; 95% CI, 1.03–1.03), with mirtazapine utilization increasing by 6% annually (aRR, 1.06; 95% CI, 1.06–1.06). Conclusions and ImplicationsThis nationwide study identified a substantial increase in antidepressant use among residents of Australian RACFs, largely driven by mirtazapine. With nearly 3 in every 5 residents treated with an antidepressant in 2019, findings highlight potential off-label use and suggest that interventions to optimize care are urgently needed.

Sustaining and expanding telehealth activity: Training requirements for Australian residential aged care front-line staff.

To identify the training needs of front-line aged care staff as perceived by senior clinicians and managers at selected residential aged care facilities (RACFs). A qualitative explorative designed study using semi-structured interviews with a convenience sample of RACF senior managers and nurses. A hybrid analysis approach using a framework deductive analysis followed by inductive analysis for sub-themes. Four sub-themes emerged to sustain increased telehealth activity: technology knowledge and digital literacy skills, including understanding telehealth ecosystems and technical skills; evidence-based reviews and clinical frameworks for telehealth consultations to identify appropriate consultations and successful use cases; telehealth best practice guidelines and workflows including telehealth consultations protocols, communicating by videoconferencing, how to support families in attending telehealth consultations and optimal training models; and telehealth policy and legal guidance. Staff require comprehensive training to sustain and expand telehealth use in RACFs. Training should focus on knowledge, skills and competencies in using telehealth as well as the broad factors of policies and understanding ICT systems to support staffs' abilities and confidence. This study provides innovative findings that identify key components and associated activities and resources for training RACF staff to ensure they have sufficient knowledge, competency, skills and confidence to integrate telehealth into care provision.

Trajectories of pro re nata (PRN) medication prescribing and administration in long-term care facilities.

Little is known about changes in pro re nata (PRN) medication prescribing and administration in residential aged care facilities (RACFs) over time. To determine the prevalence and factors associated with PRN medication administration in RACFs and examine changes over 12-months. Secondary analyses utilizing data from the SIMPLER randomized controlled trial (n=242 residents, 8 RACFs) was undertaken. PRN medication data were extracted from RACF medication charts. Factors associated with PRN medication administration in the preceding week were explored using multivariable logistic regression. At baseline, 211 residents (87.2%) were prescribed ≥1PRN medication, with 77 (36.5%) administered PRN medication in the preceding week. PRN administration was more likely in non-metropolitan areas, and less likely among residents with more severe dementia symptoms and greater dependence with activities of daily living. No significant differences in overall PRN prescribing or administration in 162 residents alive at 12-month follow-up were observed. Despite being frequently prescribed, the contribution of PRNs to overall medication use in RACFs is small. PRN prescribing and administration was relatively static over 12-months despite likely changes in resident health status over this period, suggesting further exploration of PRN prescribing in relation to resident care needs may be warranted.

Antimicrobial stewardship in residential aged care facilities: A Systematic Review

Background: Antimicrobial Stewardship (AMS) programs are increasingly implemented in healthcare facilities to reduce inappropriate use of antibiotics. Inappropriate use of antimicrobials is one of the leading causes of increasing antimicrobial resistance (AMR). As such, decreasing inappropriate use of antimicrobials can reduce AMR. The main objective of this systematic review was to identify the effectiveness of AMS interventions in reducing inappropriate antimicrobial use in residential aged care facilities (RACFs).
 Methods: Multiple databases were searched to identify studies evaluating the effectiveness of AMS interventions in RACFs. Descriptive studies and those, which did not report an outcome measure related to antibiotic usage, were excluded.
 Results: Overall, 6505 studies were identified and 17 were included. Most of the studies were randomized controlled trials and single faceted interventions. All of the interventions were education and training targeted at physicians, nurses or both about appropriate use of antimicrobials in RACFs. The studies reported a high success rate with 68% of interventions being successful while 32% of interventions were found to be ineffective.
 Conclusion: Educating and training nurses and physicians about evidence-based management of infectious diseases may lead to a reduction in inappropriate antimicrobial use in RACFs. The likelihood of success increases with targeting physicians - either as the sole recipient of the intervention or together- with nurses.

Examining the use of antiviral prophylaxis for influenza outbreaks in residential aged care facilities in NSW, Australia.

Influenza attack rates in closed population settings, such as residential aged care facilities (RACFs), can be more than 50% during annual epidemics. Uncertainty about the effectiveness of neuraminidase inhibitors (NAIs) as prophylaxis for influenza outbreaks has led to variations in their use in RACFs in New South Wales (NSW), Australia. To examine the use of prophylactic NAIs by NSW RACFs for residents during influenza outbreaks in the 2015 influenza season. A prospective cohort study of influenza outbreaks reported to NSW Public Health Units from 1 June 2015 - 31 October 2015. Eighty-eight RACFs reported influenza outbreaks; 86 were included in the study. Fifty-two RACFs used prophylactic NAIs; 34 did not. The median time to start NAI prophylaxis from the onset date of the first case was 8.5 days (range 2-23). The average proportion of residents within a facility that received prophylaxis was 51%percnt; (range 0.7-95). Variations in the use of prophylactic NAIs exist across RACFs. Earlier initiation of NAI prophylaxis, improved resident coverage where appropriate and other practice changes are recommended for the management of influenza outbreaks in RACFs.

Development and evaluation of an organisational culture change intervention in residential aged care facilities

To develop and evaluate an organisational culture change intervention for residential aged care settings. This study was undertaken in five residential aged care facilities (RACFs). All staff working within participating RACFs were invited to take part. Participatory action research was used to develop a structured approach, supporting small workgroups of staff in each facility to undertake change cycles, focusing on improved leadership, teamwork and communication. Qualitative data were gathered from reflection and evaluation sessions with facility work team focus groups, interviews with managers and other staff who were not engaged in the work team, field journals and reflective discussion with research team members. Staff and management both positively evaluated the intervention and process, and there were perceived cultural shifts in communication, teamwork and staff empowerment. An organisational culture change intervention that engages work teams through brief change cycles appears to be feasible for use in RACF.

Texture-modified diets in aged care facilities: Nutrition, swallow safety and mealtime experience.

Over 35000 people live in residential aged care facilities (RACFs) in New Zealand. Texture-modified diets (TMDs) are commonplace. They are associated with malnutrition. The aim of this study was to characterise TMD prevalence and practice in RACFs. Data from 35460 residents were extracted from the interRAI™ database. Mealtime observations (including 459 residents), meal audits (IDDSI, 2018) and menu audits (Dietitians New Zealand Menu Audit Tool for RACFs 2013) were completed at 10 RACFs. One-third of residents were on TMDs. Half the residents ate full meals. Feeding assistance was more common in residents on TMDs compared to those on regular diets (P<0.001). The majority of pureed meals met IDDSI standards; none of soft and bite-sized meals complied. TMD carbohydrate and protein servings did not comply with standards. Texture-modified diets reflect 1/3 of meals produced in RACFs. This study provides insight into TMD use in RACFs and highlights service gaps and training opportunities.

SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER): study protocol for a cluster randomised controlled trial

BackgroundComplex medication regimens are highly prevalent in residential aged care facilities (RACFs). Strategies to reduce unnecessary complexity may be valuable because complex medication regimens can be burdensome for residents and are costly in terms of nursing time. The aim of this study is to investigate application of a structured process to simplify medication administration in RACFs.MethodsSImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) is a non-blinded, matched-pair, cluster randomised controlled trial of a single multidisciplinary intervention to simplify medication regimens. Trained study nurses will recruit English-speaking, permanent residents from eight South Australian RACFs. Medications taken by residents in the intervention arm will be assessed once using a structured tool (the Medication Regimen Simplification Guide for Residential Aged CarE) to identify opportunities to reduce medication regimen complexity (e.g. by administering medications at the same time, or through the use of longer-acting or combination formulations). Residents in the comparison group will receive routine care. Participants will be followed for up to 36 months after study entry. The primary outcome measure will be the total number of charted medication administration times at 4 months after study entry. Secondary outcome measures will include time spent administering medications, medication incidents, resident satisfaction, quality of life, falls, hospitalisation and mortality. Individual-level analyses that account for clustering will be undertaken to determine the impact of the intervention on the study outcomes.DiscussionEthical approval has been obtained from the Monash University Human Research Ethics Committee and the aged care provider organisation. Research findings will be disseminated through conference presentations and peer-reviewed publications. SIMPLER will enable an improved understanding of the burden of medication use in RACFs and quantify the impact of regimen simplification on a range of outcomes important to residents and care providers.Trial registrationAustralian New Zealand Clinical Trials Registry, ACTRN12617001060336. Retrospectively registered on 20 July 2017.

Acceptability and feasibility of end‐of‐life care pathways in Australian residential aged care facilities

To investigate the acceptability and feasibility of using end-of-life (EOL) care pathways in residential aged care facilities (RACFs). Multistage action research approach involving interviews, surveys and prospective audits of deaths and EOL care pathway use among residents and staff of RACFs and associated general practitioners from 14 RACFs in Victoria and South Australia between April 2009 and July 2010. Introduction of EOL care pathways. Evidence of acceptability was determined by the rate of pathway use in RACFs and through feedback from RACF managers, staff and GPs. Evidence of feasibility was determined by reductions in transfers to hospital for symptom management before death, length of time on pathways, and whether care was consistent with best practice at EOL. The use of EOL care pathways across the RACFs fell into low-, moderate- and high-uptake groups (for 10%, 34% and 68% of all deaths at the facility, respectively). Feedback from RACF staff and GPs indicated that acceptability was critical to successful implementation. The use of EOL care pathways demonstrated improvements in care, sometimes over extended periods. There were fewer unnecessary admissions to hospital before death, although not all RACF staff and GPs were aware of the project. EOL care pathways are feasible strategies for delivering EOL care consistent with best practice. However, their introduction into Australian RACFs needs to include strategies to facilitate acceptability by RACF staff and GPs.

A comparison of palliative care outcome measures used to assess the quality of palliative care provided in Residential Aged Care Facilities: a systematic review

Provision of palliative care in residential aged care facilities (RACFs) is important but limited research has been undertaken to investigate the most appropriate outcome measures for use in this setting. This systematic review aimed tomeasure the psychometric properties (reliability/validity) and feasibility of palliative outcome measures used to assess the quality of palliative care provided in residential aged care facilities. This review considered studies reporting on the psychometric properties of palliative care outcome measures that have been used in assessing the quality of palliative care provided in residential aged care facilities, including support to family. Measures may be those completed by a health professional, the person receiving care or their family. The search strategy aimed to identify both English language published and unpublished studies. A three-step strategy was followed, in which the initial phase consisted of searches of the CINAHL, MEDLINE and PsycINFO databases using keywords or terms. Second, a more extensive search was performed using the appropriate Subject Headings and/or keywords/phrase/strategy for several major databases. Finally, the reference lists or bibliographies of identified reports and articles were hand searched for additional relevant studies. Included studies were assessed by two independent reviewers for methodological quality prior to inclusion in the review using an appraisal checklist developed for the review based on the review methods of Zwakhalen et al to evaluate validity, reliability and feasibility. The database and hand searches yielded 441 articles for review of which 17 were duplicates leaving 422 abstracts which were critically appraised for relevance to the review based on the title and abstract. After applying the inclusion and exclusion criteria, twenty three abstracts were retained and full articles were retrieved for screening by the two authors. Of these twenty three articles, ten were included in the final review. The ten articles provide specific information on the psychometric properties of ten outcome measures. Of the ten included articles, four report on the psychometric properties of the outcome measure used exclusively within the residential aged care setting while the remaining six measures report the use in a sub-population. The Family Perceptions of Care Scale (FPCS) is considered by the authors as the most suitable outcome measure for use in RACFs. The FPCS has a number of properties that has led to its preferred selection, in particular the development and testing of the scale which occurred exclusively in the RACF population. This scale has excellent content validity, covering all essential domains of palliative care. It has a robust factor structure and is simple to administer and score. Of the remaining nine measures, a further two were also considered suitable for measuring quality of palliative care in RACFs. These are the Quality of Dying in Long Term Care (QOD-LTC) scale and the Toolkit Interview. Based on psychometric qualities, the outcome measure of choice from this review is the Family Perceptions of Care Scale although further psychometric and clinical research needs to be conducted. Limitations regarding the use of outcome measures for assessing quality in this setting include reliance on proxy ratings and limited psychometric testing for some of the measures specifically in the RACF population.

Development and Testing of a Modified Version of the Brief Pain Inventory for Use in Residential Aged Care Facilities

A two-phase study was conducted to refine a version of Cleeland's Brief Pain Inventory (BPI, Short Form) for use in residential aged care facilities (RACFs). The Australian Pain Society modified Cleeland's BPI by changing numerical response options to word descriptors. In Phase I, this version was tested in RACFs to determine the feasibility of its use, its stability over time, and its internal consistency reliability. Minor modifications resulted. In Phase II, the refined version was abbreviated, and the internal consistency reliability of this Modified Residents' Verbal BPI was examined. RACFs. Thirty-three residents of RACFs in Phase I, 149 in Phase II. The study revised and abbreviated the BPI to better fit it for use in RACFs, examining the reliability of the tool. Mini-Mental State Examination, Global Deterioration Scale, modified BPI. The abbreviated tool comprises three items assessing pain intensity and three assessing pain interference. It also includes an item to specify pain location and a movement protocol. Cronbach alpha coefficient for six intensity and interference items was 0.72 (N=106). This abbreviated tool requires further testing but has demonstrated adequate internal consistency reliability and is a brief, multidimensional tool that appears feasible for assessing pain in RACFs, including use with residents who have some cognitive impairment. It shows promise as a screening tool and may be useful to assess the effectiveness of pain relief interventions and to measure pain prevalence.