Veterans Affairs Nursing Home Residents Research Articles

PATTERNS OF ANTIHYPERTENSIVES CHANGE AND MORTALITY IN VA NURSING HOME RESIDENTS

Abstract Antihypertensive treatment is common in nursing home residents, yet data on the frequency and pattens of treatment changes in this group are lacking. We described the patterns of antihypertensive treatment changes and examined the mortality rate in 24870 Veterans Affairs (VA) nursing home residents ≥65 years with long-term stays (≥180 days) from 2006-2019. The number and dose of antihypertensive use was averaged weekly, and two change events were defined: deprescribing (reduced number of antihypertensives or dose of ≥30% compared to previous week) and intensification (opposite to deprescribing). More than 91% of residents were prescribed antihypertensive and 75% experienced at least one event during their stay. Death occurred in 7881 (32%) residents. We categorized residents into 10 distinct pattern groups: no change (27%), 1 deprescribing event (11%), 1 intensification event (10%), multiple deprescribing events (5%), multiple intensification events (7%), 1 deprescribing followed by 1 intensification (3%), 1 intensification followed by 1 deprescribing (4%), 3 changes with mixed deprescribing/intensification (7%), >3 changes with mixed deprescribing/intensification (10%), and no antihypertensive use (15%). We found treatment changes were more frequent in residents with better mobility and cognitive function. Residents who experienced deprescribing events had higher mortality than those experienced intensification events. The highest mortality was for those without medication (incidence = 344/1000 person-year) and this group also had the worst cognitive function. These findings indicate that complex patterns of medication changes exist in VA nursing home residents. A better understanding of the consequence of antihypertensive treatment changes could inform clinical practice in this population.

Systolic blood pressure, antihypertensive treatment, and cardiovascular and mortality risk in VA nursing home residents.

Optimal systolic BP (SBP) control in nursing home residents is uncertain, largely because this population has been excluded from clinical trials. We examined the association of SBP levels with the risk of cardiovascular (CV) events and mortality in Veterans Affairs (VA) nursing home residents on different numbers of antihypertensive medications. Our study included 36,634 residents aged ≥65 years with a VA nursing home stay of ≥90 days from October 2006-June 2019. SBP was averaged over the first week after admission and divided into categories. Cause-specific hazard ratios (HRs) of SBP categories with CV events (primary outcome) and all-cause mortality (secondary outcome) were examined using Cox regression and multistate modeling stratified by the number of antihypertensive medications used at admission (0, 1 or 2, and ≥3 medications). More than 76% of residents were on antihypertensive therapy and 20% received ≥3 medications. In residents on antihypertensive therapy, a low SBP < 110 mmHg (compared with SBP 130 ~ 149 mmHg) was associated with a greater CV risk (adjusted HR [95% confidence interval]: 1.47 [1.28-1.68] in 1 or 2 medications group, and 1.41 [1.19-1.67] in ≥3 medications group). In residents on no antihypertensives, both low SBP < 110 mmHg and high SBP ≥ 150 mmHg were associated with higher mortality; while in residents receiving any antihypertensives, a low SBP was associated with higher mortality and the highest point estimates were for SBP < 110 mmHg (1.36 [1.28-1.45] in 1 or 2 medications group, and 1.47 [1.31-1.64] in ≥3 medications group). The associations of SBP with CV and mortality risk varied by the intensity of antihypertensive treatment among VA nursing home residents. A low SBP among those receiving antihypertensives was associated with increased CV and mortality risk, and untreated high SBP was associated with higher mortality. More research is needed on the benefits and harms of SBP lowering in long-term care populations.

Fingerstick glucose monitoring by cognitive impairment status in Veterans Affairs nursing home residents with diabetes.

Guidelines recommend nursing home (NH) residents with cognitive impairment receive less intensive glycemic treatment and less frequent fingerstick monitoring. Our objective was to determine whether current practice aligns with guideline recommendations by examining fingerstick frequency in Veterans Affairs (VA) NH residents with diabetes across cognitive impairment levels. We identified VA NH residents with diabetes aged ≥65 residing in VA NHs for >30 days between 2016 and 2019. Residents were grouped by cognitive impairment status based on the Cognitive Function Scale: cognitively intact, mild impairment, moderate impairment, and severe impairment. We also categorized residents into mutually exclusive glucose-lowering medication (GLM) categories: (1) no GLMs, (2) metformin only, (3) sulfonylureas/other GLMs (+/- metformin but no insulin), (4) long-acting insulin (+/- oral/other GLMs but no short-acting insulin), and (5) any short-acting insulin. Our outcome was mean daily fingersticks on day 31 of NH admission. Among 13,637 NH residents, mean age was 75 years and mean hemoglobin A1c was 7.0%. The percentage of NH residents on short-acting insulin varied by cognitive status from 22.7% in residents with severe cognitive impairment to 33.9% in residents who were cognitively intact. Mean daily fingersticks overall on day 31 was 1.50 (standard deviation=1.73). There was a greater range in mean fingersticks across GLM categories compared to cognitive status. Fingersticks ranged widely across GLM categories from 0.39 per day (no GLMs) to 3.08 (short-acting insulin), while fingersticks ranged slightly across levels of cognitive impairment from 1.11 (severe cognitive impairment) to 1.59 (cognitively intact). NH residents receive frequent fingersticks regardless of level of cognitive impairment, suggesting that cognitive status is a minor consideration in monitoring decisions. Future studies should determine whether decreasing fingersticks in NH residents with moderate/severe cognitive impairment can reduce burdens without compromising safety.

Blood Pressure Control and Cardiovascular and Mortality Risk in VA Nursing Home Residents

Optimal blood pressure (BP) control in nursing home residents is controversial and this population has been excluded from trials. We evaluated the associations of BP level with cardiovascular (CV) events and all-cause mortality across antihypertensive medication categories in Veterans Affairs (VA) nursing home residents. Data for 18,589 residents aged 65 years and older was obtained from the VA Corporate Data Warehouse from October 2006 through September 2017. Baseline systolic BP (SBP) and diastolic BP (DBP) were divided into categories and analyses were stratified by antihypertensive therapy (0, 1, and ≥2 medications). Over a median follow-up of 1.8 years, CV events occurred in 3,519 (19%) residents and 15,897 (86%) residents died. In participants on no BP medications, high SBP (>150 mmHg) was associated with a greater risk of CV events (adjusted [cause-specific] hazard ratio, 1.39; 95% confidence interval, 0.94-2.06) compared with normal SBP (110-130mmHg). By contrast, in participants on ≥2 BP medications, the subgroup with low SBP (<110 mmHg) had a higher CV risk (1.38; 1.20-1.57). For DBP, in participants without BP medications, there were no differences in CV risk across DBP subgroups. Whereas among those on 1 or ≥2 medications, DBP <60 mmHg was associated with a higher CV risk (1.26; 1.03-1.55 and 1.35; 1.18-1.54, respectively) compared with normal DBP (70-80 mmHg). Participants with low SBP (<110 mmHg) and DBP (<70 mmHg) had an increased mortality risk regardless of the number of medications. These findings suggest a potential risk of low BP among nursing home residents on multiple antihypertensive medications.

Deprescribing Blood Pressure Treatment in Long-Term Care Residents.

To evaluate the incidence of deprescribing of antihypertensive medication among older adults residing in Veterans Affairs (VA) nursing homes for long-term care and rates of deprescribing after potentially triggering events. Retrospective cohort study. Long-term care residents aged 65years and older admitted to a VA nursing home from 2006 to 2019 and using blood pressure medication at admission. Data were extracted from the VA electronic health record, and Centers for Medicare & Medicaid Services Minimum Data Set and Bar Code Medication Administration. Deprescribing was defined on a rolling basis as a reduction in the number or dose of antihypertensive medications, sustained for ≥2weeks. We examined potentially triggering events for deprescribing, including low blood pressure (<90/60mmHg), acute renal impairment (creatinine increase of 50%), electrolyte imbalance (potassium below 3.5 mEq/L, sodium decrease by 5 mEq/L), and falls. Among 31,499 VA nursing home residents on antihypertensive medication, 70.4% had ≥1 deprescribing event (median length of stay= 6months), and 48.7% had a net reduction in antihypertensive medications over their stay. Deprescribing events were most common in the first 4weeks after admission and the last 4weeks of life. Among potentially triggering events, a 50% increase in serum creatinine was associated with the greatest increase in the likelihood of deprescribing over the subsequent 4weeks: residents with this event had a 41.7% chance of being deprescribed compared with 11.5% in those who did not (risk difference= 30.3%, P < .001). A fall in the past 30days was associated with the smallest magnitude increased risk of deprescribing (risk difference= 3.8%, P < .001) of the events considered. Deprescribing of antihypertensive medications is common among VA nursing home residents, especially after a potential renal adverse event.

Proportion of SARS-CoV-2 positive tests and vaccination in Veterans Affairs Community Living Centers.

Background/ObjectivesCOVID‐19 has caused significant morbidity and mortality in nursing homes. Vaccination against SARS‐COV‐2 holds promise for reduction in COVID‐19. This operational analysis describes the proportion of SARS‐COV‐2 positive tests before, during, and after vaccination.DesignRetrospective longitudinal cohort analysis from October 1, 2020 until February 14, 2021.SettingA total of 130 Department of Veterans Affairs (VA) Community Living Centers (CLC), analogous to nursing homes.InterventionVaccination for SARS‐CoV‐2.MeasurementsThe primary measure is the proportion of SARS‐CoV‐2 positive tests among CLC residents. In a pooled analysis of weekly testing and vaccine data, the proportion of positive tests was compared for the unvaccinated, first dose, and second dose. For each CLC, we identified the week in which 50% of CLC residents were vaccinated (index week). The analysis aligned the index week for CLCs and examined the proportion of SARS‐CoV‐2 positive tests at the CLC level before and after. As a reference, we plotted the proportion of positive tests in nursing homes in the same county as the CLC using publicly reported data.ResultsWithin the pooled VA CLCs, the first SARS‐CoV‐2 vaccine dose was delivered to 50% of CLC residents within 1 week of availability and second dose within 5 weeks. Relative to the index week, the risk ratio of SARS‐CoV‐2 positive tests in the vaccinated relative to unvaccinated was significantly lower in Week 4 (relative risk 0.37, 95% confidence interval 0.20–0.68). Throughout the study period, the proportion of SARS‐CoV‐2 positive tests in community nursing homes was higher compared to VA CLC and also declined after vaccine availability.ConclusionThe proportion of SARS‐CoV‐2 positive tests significantly declined in VA CLCs 4 weeks after vaccine delivery and continued to decline in vaccinated and unvaccinated residents. The results describe the importance of SARS‐CoV‐2 surveillance and vaccination in VA nursing home residents.

Fingerstick Glucose Monitoring in Veterans Affairs Nursing Home Residents with Diabetes Mellitus.

Guidelines recommend less intensive glycemic treatment and less frequent glucose monitoring for nursing home (NH) residents. However, little is known about the frequency of fingerstick (FS) glucose monitoring in this population. Our objective was to examine the frequency of FS glucose monitoring in Veterans Affairs (VA) NH residents with diabetes mellitus, type II (T2DM). National retrospective cohort study in 140 VA NHs. NH residents with T2DM and older than 65 years admitted to VA NHs between 2013 and 2015 following discharge from a VA hospital. NH residents were classified into five groups based on their highest hypoglycemia risk glucose-lowering medication (GLM) each day: no GLMs; metformin only; sulfonylureas; long-acting insulin; and any short-acting insulin. Our outcome was a daily count of FS measurements. Among 17,474 VA NH residents, mean age was 76 (standard deviation (SD) = 8) years and mean hemoglobin A1c was 7.6% (SD = 1.5%). On day 1 after NH admission, 49% of NH residents were on short-acting insulin, decreasing slightly to 43% at day 90. Overall, NH residents had an average of 1.9 (95% confidence interval (CI) = 1.8-1.9) FS measurements on NH day 1, decreasing to 1.4 (95% CI = 1.3-1.4) by day 90. NH residents on short-acting insulin had the most frequent FS measurements, with 3.0 measurements (95% CI = 2.9-3.0) on day 1, decreasing to 2.6 measurements (95% CI = 2.5-2.7) by day 90. Less frequent FS measurements were seen for NH residents receiving long-acting insulin (2.1 (95% CI = 2.0-2.2) on day 1) and sulfonylureas (1.7 (95% CI = 1.5-1.8) on day 1). Even NH residents on metformin monotherapy had 1.1 (95% CI = 1.1-1.2) measurements on day 1, decreasing to 0.5 (95% CI = 0.4-0.6) measurements on day 90. Although guidelines recommend less frequent glucose monitoring for NH residents, we found that many VA NH residents receive frequent FS monitoring. Given the uncertain benefits and potential for substantial patient burdens and harms, our results suggest decreasing FS monitoring may be warranted for many low hypoglycemia risk NH residents.

Development and Validation of a Clinical Prediction Rule to Predict Transmission of Methicillin-Resistant Staphylococcus aureus in Nursing Homes.

The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization among nursing home residents is high. Health-care workers (HCWs) often serve as a vector in MRSA transmission. The ability to identify residents who are likely to transmit MRSA to HCWs' hands and clothing during clinical care is important so that infection control measures, such as Contact Precautions, can be employed. Using data on demographic and clinical characteristics collected from residents of community nursing homes in Maryland and Michigan between 2012 and 2014, we developed a clinical prediction rule predicting the probability of MRSA transmission to HCWs' gowns. We externally validated this model in a cohort of Department of Veterans Affairs nursing home residents from 7 states between 2012 and 2016. The prediction model, which included sex, race, resident dependency on HCWs for care, the presence of any medical device, diabetes mellitus, and chronic skin breakdown, showed good performance (C statistic = 0.70; sensitivity = 76%, specificity = 49%) in the development set. The decision curve analysis indicated that this model has greater clinical utility than use of a nares surveillance culture for MRSA colonization, which is current clinical practice for placing hospital inpatients on Contact Precautions. The prediction rule demonstrated less utility in the validation cohort, suggesting that a separate rule should be developed for residents of Veterans Affairs nursing homes.

Central Nervous System Medication Burden and Risk of Recurrent Serious Falls and Hip Fractures in Veterans Affairs Nursing Home Residents.

To examine the association between central nervous system (CNS) medication dosage burden and risk of serious falls, including hip fractures, in individuals with a history of a recent fall. Nested case-control study. Veterans Health Administration (VHA) Community Living Centers (CLCs). CLC residents aged 65 and older with a history of a fall or hip fracture in the year before a CLC admission between July 1, 2005, and June 30, 2009. Each case (n = 316) was matched to four controls (n = 1264) on age, sex, and length of stay. Outcomes were serious falls identified using International Classification of Diseases, Ninth Revision (ACD-9) or Current Procedural Terminology (CPT) E codes, diagnosis codes, or procedure codes associated with a VHA emergency department visit or hospitalization during the CLC stay. Bar code medication administration data were used to calculate CNS standardized daily doses (SDDs) for opioid and benzodiazepine receptor agonists, some antidepressants, antiepileptics, and antipsychotics received in the 6 days before the outcome date by dividing residents' actual CNS daily doses by the minimum effective geriatric daily doses and adding the results. Multivariable conditional logistic regression models were used to evaluate the association between total CNS medication dosage burden, categorized as 0, 1 to 2, and 3 or more SDDs, and the outcome of recurrent serious falls. More cases (44.3%) than controls (35.8%) received 3.0 or more CNS SDDs (p = .02). Risk of serious falls was greater in residents with 3.0 or more SDDs than in those with 0 (adjusted odds ratio (aOR)=1.49, 95% confidence interval (CI)=1.03-2.14). Those with 1.0 to 2.9 SDDs had a risk similar to that of those with 0 SDDs (aOR=1.03, 95%CI=0.72-1.48). Nursing home residents with a history of a fall or hip fracture receiving 3.0 or more CNS SDDs were more likely to have a recurrent serious fall than those taking no CNS medications. Interventions targeting this vulnerable population may help reduce serious falls. J Am Geriatr Soc 67:74-80, 2019.

Changing Patterns of Glucose-Lowering Medication Use in VA Nursing Home Residents With Diabetes, 2005 to 2011

ObjectiveAlthough nursing home (NH) residents make up a large and growing proportion of Americans with diabetes mellitus, little is known about how glucose-lowering medications are used in this population. We sought to examine glucose-lowering medication use in Veterans Affairs (VA) NH residents with diabetes between 2005 and 2011. Research Design and MethodsRetrospective cohort study, using linked laboratory, pharmacy, administrative, and NH Minimum Dataset (MDS) 2.0 databases in 123 VA NHs. A total of 9431 long-stay (>90 days) VA NH residents older than 65 followed for 52,313 person-quarters. We identified receipt of glucose-lowering medications, including insulin, metformin, sulfonylureas, thiazolidinediones, and others (alpha-glucosidase inhibitors, meglitinides, glucagonlike peptide-1 analogs, dipeptidyl peptidase-4 inhibitors and amylin analogs) per quarter. ResultsThe rates of sulfonylurea use in long-stay NH residents dropped dramatically from 24% in 2005 to 12% in 2011 (P < .001), driven in large part by the dramatic decrease in glyburide use (10% to 2%, P < .001). There was sharp drop in thiazolidinedione use in 2007 (4% to <1%, P < .001). Metformin use was stable, ranging between 7% and 9% (P = .24). Insulin use increased slightly from 30% to 32% (P < .001). Use of other classes of glucose-lowering medications was stable (P = .22) and low, remaining below 1.3%. Conclusions and RelevanceBetween 2005 and 2011, there were dramatic declines in use of sulfonylureas and thiazolidinediones in VA NH residents, suggesting that prescribing practices can be quickly changed in this setting.

Use of Antipsychotics Among Older Residents in VA Nursing Homes

Antipsychotic medications are commonly prescribed to nursing home residents despite their well-established adverse event profiles. Because little is known about their use in Veterans Affairs (VA) nursing homes [ie, Community Living Centers (CLCs)], we assessed the prevalence and risk factors for antipsychotic use in older residents of VA CLCs. This cross-sectional study included 3692 Veterans age 65 or older who were admitted between January 2004 and June 2005 to one of 133 VA CLCs and had a stay of ≥90 days. We used VA Pharmacy Benefits Management data to examine antipsychotic use and VA Medical SAS datasets and the Minimum Data Set to identify evidence-based indications for antipsychotic use (eg, schizophrenia, dementia with psychosis). We used multivariable logistic regression and generalized estimating equations to identify factors independently associated with antipsychotic receipt. Overall, 948/3692(25.7%) residents received an antipsychotic, of which 59.3% had an evidence-based indication for use. Residents with aggressive behavior [odds ratio (OR)=2.74, 95% confidence interval (CI), 2.04-3.67] and polypharmacy (9+ drugs; OR=1.84, 95% CI, 1.41-2.40) were more likely to receive antipsychotics, as were users of antidepressants (OR=1.37, 95% CI, 1.14-1.66), anxiolytic/hypnotics (OR=2.30, 95% CI, 1.64-3.23), or drugs for dementia (OR=1.52, 95% CI, 1.21-1.92). Those residing in Alzheimer/dementia special care units were also more likely to receive an antipsychotic (OR=1.66, 95% CI, 1.26-2.21). Veterans with dementia but no documented psychosis were as likely as those with an evidence-based indication to receive an antipsychotic (OR=1.10, 95% CI, 0.82-1.47). Antipsychotic use is common among VA nursing home residents aged 65 and older, including those without a documented evidence-based indication for use. Further quality improvement efforts are needed to reduce potentially inappropriate antipsychotic prescribing.

Substance Use Disorders and Health Care Costs Among Veterans Affairs Nursing Home Residents

Research on the relationship between substance use disorders (SUDs) and older adults' health care costs is equivocal. A large-scale study comparing health care costs among older adults with and without SUDs has never been conducted. To determine the relation of SUDs to health care costs in a large sample of adults following entry into a Veterans Affairs (VA) nursing home. We performed a retrospective analysis of 29,997 adults aged 45+ who entered a VA nursing home in 2000. Total costs were tallied over fiscal years 1997 to 2000 by setting (outpatient, nursing home, other inpatient, and total) and included all care paid by VA. Relative to non-SUD patients, those with SUDs aged 75 to 84 years had significantly higher total costs of care (+$10,020), as did those aged 85 and above (+$16,052). Yet, SUD diagnosis was not a significant predictor of total cost or nursing home cost among persons 65 and above after controlling for demographic, clinical, and financial factors. SUDs do not directly increase health care costs among older adults entering nursing homes, although they may affect cost of care indirectly through factors such as income and marital dissolution. The generational increase in SUD rates occurring in the United States may not lead to substantially greater health care expenses if appropriate assistance can be provided before nursing home entry.

Recent Changes in the Prevalence of Psychiatric Disorders Among VA Nursing Home Residents

This study identified recent changes in the prevalence of psychiatric disorders among Department of Veterans Affairs (VA) nursing home residents. Psychiatric diagnoses in administrative databases were summarized for nursing home residents in 1998, 2002, and 2006. Census prevalence rates were compared with findings from earlier VA nursing home surveys. Prevalence rates were compared for age groups and birth cohorts of VA nursing home admissions in 1998 (N=27,734) and 2006 (N=32,543). Among residents in the census samples, prevalence rates for dementia and schizophrenia fluctuated moderately from 1990 to 2006, depression prevalence increased sharply, alcohol use disorder prevalence declined, and drug use disorder prevalence increased. Among 1998 and 2006 admissions, dementia prevalence increased for most birth cohorts but declined for most age groups (35% to 32% overall). Depression prevalence increased for all age groups and birth cohorts (27% to 37% overall), as did posttraumatic stress disorder prevalence (5% to 12% overall). Serious mental illness prevalence increased among the oldest residents and birth cohorts (19% to 22% overall). Alcohol use disorder prevalence declined for all birth cohorts and most age groups (18% to 16% overall), but drug use disorder prevalence increased substantially for younger age groups (6% to 9% overall). Examining differences in prevalence between birth cohorts and age groups can clarify trends in nursing home resident characteristics and improve projections of their future needs.

Can administrative data identify active diagnoses for long-term care resident assessment?

Many veterans receive rehabilitation services in Department of Veterans Affairs (VA) nursing homes. Efficient methods for the identification of active diagnoses could facilitate care planning and outcomes assessment. We set out to determine whether diagnostic data from VA databases can be used to identify active diagnoses for Minimum Data Set (MDS) assessments. We evaluated diagnoses being considered for inclusion in MDS version 3.0 and present in at least 15% of a sample of VA nursing home residents. A research nurse following a standardized protocol identified active diagnoses from the medical records of 120 residents. A clinical nurse also identified active diagnoses in 58 of these patients. Inpatient and outpatient diagnoses from the VA National Patient Care Database were identified for the past year. We calculated kappa, sensitivity, and specificity values, considering the nurses' assessments the gold standard. We found that kappa values comparing research nurses and databases were generally poor, with only 8 of the 19 diagnoses having a value >0.60. Levels of agreement between the clinical nurse and administrative data were generally similar. We conclude that VA administrative data cannot be used to accurately identify active diagnoses for nursing home residents. How best to efficiently collect these important data remains uncertain.

Functioning, problem behavior and health services use among nursing home residents with alcohol-use disorders: nationwide data from the VA minimum data set.

We examined (1) whether nursing home residents with alcohol-use disorders (AUDs) function more poorly, have more behavioral problems and use more health services than do demographically matched controls without such disorders, and (2) whether AUDs interact with alcohol consumption to predict poorer behavioral and health services outcomes among nursing home residents. We used Department of Veterans Affairs (VA) Patient Treatment File data to identify a nationwide sample of older VA nursing home residents with recent AUD diagnoses (n = 3,336) and a demographically matched sample without such diagnoses (n = 3,336). The groups were compared on the Resident Assessment Instrument Minimum Data Set indices of health-related functioning, substance use, problem behavior and health services use. We conducted two-way analyses of variance to determine interactions between presence of an AUD and alcohol consumption on problem behavior and health services use. Residents with AUD diagnoses functioned somewhat better than demographically matched controls. However, they were more likely to have falls and fractures, difficulties in social functioning and to use more health services. AUD diagnoses interacted with alcohol consumption to predict an elevated risk of falls and fractures and more mental health services use. Older residents with an AUD form a distinct nursing home population that functions somewhat better than residents without such disorders but they may pose more challenges to staff and use more health care services. Residents' drinking histories should be considered in formulating nursing home policies about alcohol consumption.

Residents’ care preferences as targeting criteria: Measurement issues functional incidental training: Applicability and feasibility in the Veterans Affairs nursing home patient population

In this issue of JAMDA, Ouslander and colleagues describe the applicability and feasibility of an intervention designed to improve incontinence and prevent physical functioning decline in Veterans Affairs (VA) nursing home residents. The behavioral intervention (FIT) has proven efficacious with community nursing home residents, and the results of this study suggest that the intervention is also efficacious with VA nursing home residents. Unfortunately, the VA study also found that implementing the FIT intervention would require additional staff. Furthermore, the FIT study conducted with community nursing home residents showed that the staffing costs of the intervention could not be offset by cost savings in other areas, such as the prevention of acute illnesses that might be related to incontinence and immobility. So, now we have an efficacious behavioral intervention that improves resident outcomes in both community and VA nursing home settings but that is staff time intensive and, thus, potentially not feasible to provide in daily care practice for all residents in need. Given the limited staffing resources that exist in many community and VA nursing homes, one possible solution is to target a time-intensive intervention such as FIT based on a combination of resident need (who is most likely to benefit?) and preferences (who really wants it?). Both of these objectives can be determined best by offering a trial of FIT and monitoring the resident’s response (compliance, appropriate toileting frequency) and reported preferences. The alternative approach of assessing residents’ preferences before a trial, during which they experience the intervention, could be misleading. Sixty-four percent of the VA participants reported that four offers of toileting assistance per day

Improving quality of life for Department of Veterans Affairs nursing home residents through music and art

Improving quality of life for Department of Veterans Affairs nursing home residents through music and art

Disruptive Behaviors in Veterans Affairs Nursing Home Residents: How Different Are Residents with Serious Mental Illness?

To determine the prevalence and correlates of behavior problems of residents of Veterans Affairs (VA) nursing homes and to compare residents with serious mental illness (SMI) with other resident groups. This study combined cross-sectional resident assessments with administrative data for all residents in VA nursing homes. Multivariate ordinal logistic regression was used to evaluate associations between resident characteristics and problem behaviors. Nursing home care units in the VA healthcare system. A total of 9,618 nursing home residents assessed as part of the VA's April 2001 national resident census. The Patient Assessment Instrument assessed each resident's verbally disruptive, physically aggressive, and socially inappropriate behaviors in the prior 4 weeks. Functional limitations in eating, mobility, toileting, and transfer were assessed. Diagnoses were evaluated for the stay and up to 6 months before assessment. Almost one-fifth (17.9%) of residents received a diagnosis of SMI. Residents with SMI or dementia had greater behavior problems than residents with neither condition. Residents with SMI (and without dementia) exhibited more verbal disruption than residents with dementia (and without SMI), but the two subgroups did not differ in physically aggressive or socially inappropriate behavior. Many VA nursing home residents have SMI. Their level of behavior problems is comparable with that of residents with dementia. Clinical practice and nursing home staff training must encompass geriatric mental health and behavior management to meet the needs of residents with SMI.

Observations on the Prevalence of Protein‐Calorie Undernutrition in VA Nursing Homes

To determine the prevalence of underweight and hypoalbuminemia in Veterans Affairs nursing home residents and the frequency with which physicians, nurses, and dietitians documented their awareness of the presence of underweight and hypoalbuminemia. Retrospective survey of medical records. Twenty-six Department of Veterans Affairs nursing homes located in the Department's Central Region. 2811 residents. (1) Prevalence of underweight (defined as body weight less than 80% of standard) and hypoalbuminemia (defined as serum albumin less than 3.5 g/dl); (2) frequency with which physicians, nurses, and dietitians documented the prevalence of underweight and hypoalbuminemia in the records. Three hundred thirty-two (11.8%) of the patients were underweight and 772 (27.5%) were hypoalbuminemic. The prevalence of the two conditions varied widely across nursing homes. The prevalence of low serum albumin ranged from 5% to 58% in the 26 institutions, and the prevalence of body weight less than 80% of standard ranged from 2% to 20%. In the Region as a whole, the dietician's notes in the medical charts mentioned underweight in an average of 95% of affected cases but mentioned the suboptimal albumin level in only 82% of the hypoalbuminemic individuals. In the nurses's notes, these figures were only 80% and 45%, respectively, and in the physician's notes, only 62% and 46%, respectively. The frequency of documented awareness of underweight and hypoalbuminemia by nurses and physicians varied tremendously across the 26 facilities (as few as 7% of the undernourished cases in one nursing home, 100% of the affected individuals in another). This study showed a high prevalence of calorie and protein undernutrition in the nursing home residents of VA nursing homes, wide variation in the prevalence across nursing homes, and frequent lack of documentation of these nutritional deficiencies by physicians and nurses.