Development of a minimum data set-based depression rating scale for use in nursing homes

Intentional rounding delivering tailored prompts to promote independent eating in older people during lunchtime meals in Nursing Home: a pragmatic clustered pre-post intervention study

BACKGROUND

Eating difficulties may lead to malnutrition in older adults living in nursing homes (NHs). Prompts to encourage independence have been shown to be effective. However, due to limited resources and the varying quality of dining rooms where residents sit together at the table, it is difficult to provide tailored prompts.

OBJECTIVE

Evaluating the effects of interventions based on tailored prompts delivered by deliberately circling the tables (hereinafter, intentional rounding) in the dining room where residents sit to eat their meals on (a) independence in eating, (b) fluid and (c) food intake, and (d) time taken to eat the meal, compared with usual care in NHs with different quality environments.

METHODS

A pre- and post-intervention pragmatic cluster study with 106 residents of four Italian NHs (NH1, 2, 3 and 4). During lunch, residents were seated at a table and received tailored prompts with a positive focus, mediated by intentional rounding. Data was collected at baseline (T0 and T1, three weeks), during the implementation of the intervention (T2 and T3, one week each) and at follow-up (T4, after one week interruption of the intervention). Self-feeding dependency (Edinburgh Feeding Evaluation in Dementia scale), food and fluid intake (from 0 to 100% of total meal or fluid served) and meal duration (in minutes) were analysed using Seemingly Unrelated Regression, adjusting for the quality of the NH environment and the number of family caregivers present.

RESULTS

Eating performance improved in all residents and food and fluid intake increased from baseline (T0) to the end of the intervention (T3); however, residents did not maintain their intake after the intervention was interrupted. The time required for residents to complete the meal was > 19 min at T0 and > 21 min at T3. There were differences in the effectiveness of the intervention depending on the quality of the environment in the NHs.

CONCLUSIONS

Compared to usual daily care, prompts from caregivers through scheduled rounds at the tables where residents sit to eat their lunch are effective in improving feeding performance and food and fluid intake. However, after one week, when usual care is resumed, all outcomes deteriorate slightly, indicating that the interventions require continuity.

CLINICAL TRIAL NUMBER

Not applicable.

Changes in Home Care Clients' Sensory Impairment Status and Its Association With Functioning Over 18 Months: A Longitudinal Register-Based Study

We investigated the changes in home care clients' vision and hearing over 18 months and examined the role of sensory impairments in maintaining their functioning. We used data from the Finnish Resident Assessment Instrument (RAI) database (n = 7013). Sensory impairment status was categorized by type (single or dual) and severity (mild or moderate/severe). The association between sensory impairment and functioning over 18 months was examined using binary logistic regression analysis with generalized estimating equations. Of 7013 home care clients, 48% had sensory impairment at baseline. Over 18 months, sensory impairment improved in 7% (n = 482) and worsened in 23% (n = 1605) of the clients. Sensory impairments were associated with impaired physical, cognitive, and psychosocial functioning at baseline. Especially moderate to severe dual impairment was associated with increased impairment in cognitive and physical functioning over time. Sensory impairments should be considered as an integral part of maintaining home care clients' overall health and well-being.

Factors Associated with Mood Transitions among Older Canadian Long-Term Care Residents: A Multistate Transition Model

OBJECTIVES

This study examines the complex transitions between the different mood states and absorbing states out of long-term care settings, as well as the factors affecting those transitions.

DESIGN

A retrospective longitudinal analysis of older residents in Canadian long-term care homes in 3 provinces.

SETTING AND PARTICIPANTS

Residents residing in long-term care homes in 3 Canadian provinces (Alberta, British Columbia, and Ontario) over a 10-year period from January 2010 to February 2020, with an age of at least 65.

METHODS

We used a 1-step Markov multistate transition model to examine transitions in mood over time as well as the factors affecting those transitions using the standardized interRAI MDS 2.0 comprehensive health assessment. The MDS 2.0 assessments are completed by trained assessors within 2 weeks of the resident's admission.

RESULTS

Our results showed that 46% of residents initially present with no mood disturbance on admission and 31% with mild mood disturbance on admission and 23% with moderate/severe mood disturbance on admission. Factors associated with worsening of mood include aggressive behavior; health instability; impaired cognition; major comorbidities; pain or poor sleep; conflict with family, friends, or other residents; and anxiety. Of the facility-level attributes, Alberta was associated with worsening of mood.

CONCLUSIONS AND IMPLICATIONS

Our study identified key factors influencing mood transitions, highlighting pain and aggressive behavior as significant contributors to worsening mood, both of which are modifiable through targeted interventions. The findings suggest substantial opportunities for mood improvement in long-term care settings.

Clinical Characteristics of Adults Living with a Spinal Cord Injury Across the Continuum of Care: A Population-Based Cross-Sectional Study

Background/Objectives: People living with a spinal cord injury (PwSCI) present numerous complications at a systemic level that negatively impact their physical and mental health as well as their quality of life. The purpose of this study was to describe the clinical profile of PwSCI living in nursing homes (NHs), Complex Continuing Care Systems (CCCs), home care (HC), and inpatient mental health facilities (MHs) in nine Canadian provinces and territories. Methods: We analyzed data collected with the following assessment tools: Resident Assessment Instrument (RAI) Minimum Data Set (RAI-MDS 2.0), RAI-MH, RAI-HC, Cognitive Performance Scale, Activities of Daily Living (ADL) Hierarchy Scale and impairments in instrumental ADLs (IADLs), Pain Scale, Changes in Health, End-Stage Disease, Signs, and Symptoms (CHESS) Scale, Depression Rating Scale, and Deafblind Severity Index (DBSI). We reported counts (n) and percentages (%) and performed Chi-square tests with a Bonferroni correction to determine the statistical significance of the differences in frequencies within and between care settings. Results: We identified 13,136 PwSCI, predominantly males and younger than comparison groups. PwSCI presented fewer comorbidities but reported higher pain than comparison groups. Almost all of the PwSCI in NHs (99.4%) and CCCs (98.9%) needed assistance to perform ADLs. Conclusions: The prevalence of comorbidities and impairments following SCI varies based on the clinical setting. The present clinical profile of PwSCI will inform interventions to improve health of PwSCI across the continuum of care.

Protocol of the pilot study to test and evaluate the iCARE tool: a machine learning-based e-platform tool to make health prognoses and support decision-making for the care of older persons with complex chronic conditions

INTRODUCTION

The provision of optimal care for older adults with complex chronic conditions (CCCs) poses significant challenges due to the interplay of multiple medical, pharmacological, functional and psychosocial factors. To address these challenges, the I-CARE4OLD project, funded by the EU-Horizon 2020 programme, developed an advanced clinical decision support tool-the iCARE tool-leveraging large longitudinal data from millions of home care and nursing home recipients across eight countries. The tool uses machine learning techniques applied to data from interRAI assessments, enriched with registry data, to predict health trajectories and evaluate pharmacological and non-pharmacological interventions. This study aims to pilot the iCARE tool and assess its feasibility, usability and impact on clinical decision-making among healthcare professionals.

METHODS AND ANALYSIS

A minimum of 20 participants from each of the seven countries (Italy, Belgium, the Netherlands, Poland, Finland, Czechia and the USA) participated in the study. Participants were general practitioners, geriatricians and other medical specialists, nurses, physiotherapists and other healthcare providers involved in the care of older adults with CCC. The study design involved pre-surveys and post-surveys, tool testing with hypothetical patient cases and evaluations of predictions and treatment recommendations. Two pilot modalities-decision loop and non-decision loop-were implemented to assess the effect of the iCARE tool on clinical decisions. Descriptive statistics and bivariate and multivariate analysis will be conducted. All notes and text field data will be translated into English, and a thematic analysis will be performed. The pilot testing started in September 2024, and data collection ended in January 2025. At the time this protocol was submitted for publication, data collection was complete but data analysis had not yet begun.

ETHICS AND DISSEMINATION

Ethical approvals were granted in each participating country before the start of the pilot. All participants gave informed consent to participate in the study. The results of the study will be published in peer-reviewed journals and disseminated during national and international scientific and professional conferences and meetings. Stakeholders will also be informed via the project website and social media, and through targeted methods such as webinars, factsheets and (feedback) workshops. The I-CARE4OLD consortium will strive to publish as much as possible open access, including analytical scripts. Databases will not become publicly available, but the data sets used and/or analysed as part of the project can be made available on reasonable request and with the permission of the I-CARE4OLD consortium.

How to define and quantify a bad death in palliative home care? Across-sectional and exploratory study using Canadian interRAI data

BACKGROUND

Dying is a complex process comprised of physical, social, cultural, spiritual, environmental, and interpersonal relationship factors that contribute to both good and bad death experiences. Bad deaths have historically been explored with a qualitative lens. This study aimed to identify key indicators of a bad death and examine predictors for each indicator using population-level data.

METHODS

This cross-sectional study analyzed routinely collected clinical and sociodemographic data using the Resident Assessment Instrument for Home Care (RAI-HC) between April 2007 and March 2020. 16,586 home care clients aged 18 years and older who died and had an assessment completed within 30 days of their death were included. Four indicators of a bad death were examined: self-reported loneliness, severe depressive symptoms, daily pain that is horrible or excruciating, and pain that is severe/excruciating and uncontrolled by medications. These indicators were interRAI specific variables that captured common bad death constructs in the existing literature. The study sample was separated into groups based on these four indicators and each individual could populate more than one group. Chi-square analyses were used to examine the relationship between potential risk factors and each bad death indicator.

RESULTS

Of the total sample, 50.9% were 85 + years of age, and 54.7% were female. The prevalence of experiencing at least one of the bad death indicators was 33.5%. Each indicator significantly increased the likelihood of experiencing one of the other indicators with the ORs ranging from 1.70 to 3.26. Other important predictors that increased the odds of experiencing each bad death indicator included: any psychiatric diagnoses (OR range: 1.29-1.89), experiencing conflict with family or friends (OR range: 1.21-3.40), and a decline in social interaction which was distressing to the person (OR range: 2.06-3.70).

CONCLUSIONS

These four bad death indicators were common among community-dwelling adults. This study found that there was an interconnectedness between the bad death indicators. Clinically, the relationship between these indicators means that addressing one aspect of a bad death may positively influence the others. Early identification of these issues, along with client and family collaboration, can aid in optimizing the likelihood of a good death.

Building Consensus on the Relevant Criteria to Screen for Depressive Symptoms Among Near-Centenarians and Centenarians: Modified e-Delphi Study

BACKGROUND

The number of centenarians worldwide is expected to increase dramatically, reaching 3.4 million by 2050 and >25 million by 2100. Despite these projections, depression remains a prevalent yet underdiagnosed and undertreated condition among this population that carries significant health risks.

OBJECTIVE

This study aimed to identify and achieve consensus on the most representative signs and symptoms of depression in near-centenarians and centenarians (aged ≥95 years) through an e-Delphi study with an international and interdisciplinary panel of experts. Ultimately, the outcomes of this study might help create a screening instrument that is specifically designed for this unique population.

METHODS

A modified e-Delphi study was carried out to achieve expert consensus on depressive symptoms in near-centenarians and centenarians. A panel of 28 international experts was recruited. Consensus was defined as 70% agreement on the relevance of each item. Data were collected through a web-based questionnaire over 3 rounds. Experts rated 104 items that were divided into 24 dimensions and 80 criteria to identify the most representative signs and symptoms of depression in this age group.

RESULTS

The panel consisted of experts from various countries, including physicians with experience in old age psychiatry or geriatrics as well as nurses and psychologists. The response rate remained consistent over the rounds (20/28, 71% to 21/28, 75%). In total, 4 new dimensions and 8 new criteria were proposed by the experts, and consensus was reached on 86% (24/28) of the dimensions and 80% (70/88) of the criteria. The most consensual potentially relevant dimensions were lack of hope (21/21, 100%), loss of interest (27/28, 96%), lack of reactivity to pleasant events (27/28, 96%), depressed mood (26/28, 93%), and previous episodes of depression or diagnosed depression (19/21, 90%). In addition, the most consensual potentially relevant criteria were despondency, gloom, and despair (25/25, 100%); depressed (27/27, 100%); lack of reactivity to pleasant events or circumstances (28/28, 100%); suicidal ideation (28/28, 100%); suicide attempt(s) (28/28, 100%); ruminations (27/28, 96%); recurrent thoughts of death or suicide (27/28, 96%); feelings of worthlessness (25/26, 96%); critical life events (20/21, 95%); anhedonia (20/21, 95%); loss of interest in activities (26/28, 93%); loss of pleasure in activities (26/28, 93%); and sadness (24/26, 92%). Moreover, when assessing depression in very old age, the duration, number, frequency, and severity of signs and symptoms should also be considered, as evidenced by the high expert agreement.

CONCLUSIONS

The classification of most elements as relevant highlights the importance of a multidimensional approach for optimal depression screening among individuals of very old age. This study offers a first step toward improving depression assessment in near-centenarians and centenarians. The development of a more adapted screening tool could improve early detection and intervention, enhancing the quality of mental health care for this population.

Prevalence and Predictors of Caregiver Distress in Six European Communities: Data From the IBenC Study, Using interRAI-Home Care Assessments

BACKGROUND

In a changing world where populations are ageing and older people need assistance to live at home, caring for an older relative can be challenging and have various consequences for caregivers.

METHODS

In this cross-sectional study, caregiver distress in six European countries-Iceland, Belgium, Finland, Germany, Italy and the Netherlands-was examined and compared. The study aimed to determine the prevalence of distress among caregivers of older people receiving home care in these six countries and identify if factors related to the older person's condition, such as health or function, predict it. The analysis drew on data collected from 2014 to 2016 for the IBenC study (Identifying Best Practices for care-dependent elderly by Benchmarking Costs and Outcomes of Community Care), using the interRAI-Home Care (HC) instrument. A total of 2884 home care clients > 65 years from the six countries participated in the study. Descriptive statistics indicated the characteristics of the sample, and bivariate and multivariate logistic regression models established predictive independent variables for caregiver distress.

RESULTS

The percentage of caregiver distress was highest among Icelandic caregivers (34%). In the other countries, it varied from 9% to 22% and was lowest in Finland. Caregivers of clients with signs of depression, clients who have bladder incontinence or who had stayed in hospital in the last 90 days were more likely to experience caregiver distress. Caregiver distress was more prevalent if a client was at risk of severe health decline and had increased care needs.

CONCLUSION

Using data from interRAI-HC assessments makes it possible to relate indications of caregiver distress to the characteristics of the older person cared for. Hence, improving their condition might have favourable effects on caregivers. Alertness to caregiver distress is crucial.

Oral health of nursing home residents in Flanders, Belgium, and its associated factors

Oral health in care-dependent older adults is often compromised due to care dependency associated with deteriorating general health. This cross-sectional study assessed the oral health of 458 nursing home residents in Flanders, with a mean age of 82.7 years (70.3% female), using the optimised Oral Health Section of the interRAI Suite of Instruments and validated dental indices. Among residents with natural teeth (53.9%), poor oral hygiene (75.7%), poor tooth condition (56.6%), and poor gum condition (49.9%) were common. High dental plaque levels yielded a mean Oral Hygiene Index of 4.5, and 44.0% of participants had untreated caries with pulp involvement. A mean Modified Gingival Index of 1.8 indicated mild inflammation of the entire gingiva. Denture hygiene was inadequate in 68.5% of cases. Self-reported issues included dry mouth (32.8%) and chewing difficulties (23.4%). The higher correlation coefficients were observed between oral hygiene and gum condition (r = 0.324, p < 0.0001) and between chewing difficulty and pain (r = 0.247, p < 0.0001). Bivariate analyses showed cognitive and functional impairments were strongly linked to poor oral hygiene and gingival health. These findings highlighted the persistent need to improve oral health care in nursing home residents, particularly among those with cognitive decline or reduced self-care abilities.Trial registration: ClinicalTrials.gov NCT06536322- Retrospectively registered July 23rd, 2024.

[The physical and mental health of home care recipients: A quantitative secondary data analysis]

The physical and mental health of home care recipients: A quantitative secondary data analysis Abstract: Background: Although more and more people are being supported by home care services, there is a lack of information regarding the health limitations and needs of this group. Aim: The objective of this study was to examine the health status of people with home care needs in Switzerland. Method: A secondary data analysis based on the HomeCareData database, which contains routine data on people with home care requirements in Switzerland, was conducted. All cases with a fully completed Resident Assessment Instrument (RAI-HC) were included. Data on various items of the RAI-HC and other standardized scale scores with reference to physical or mental health were analyzed using descriptive statistics. Results: In total, 74,674 data records were evaluated. Physical limitations most frequently manifested in the form of fatigue (40.6%), pain (29.7%) or within the scope of impaired hearing (21.9%). Around a third of individuals sampled had experienced a fall in the last 90 days. With regard to mental health, the most frequent signs were fear of falling (33.5%), loneliness (13.9%), depression (12.8%) and anxiety (4%). Approximately one third showed signs of impaired cognition and polypharmacy was detected in almost 68% of those evaluated. Conclusion: Considering the comparatively high prevalence of mental health problems among people with home care requirements, there is a need to develop appropriate skills of employees in home care services and for adequate care planning.

Loneliness in older persons with schizophrenia

BACKGROUND

In tandem with the rise in numbers of older adults in the general population, more people with schizophrenia (PwS) are also living longer. This vulnerable population has several trajectories of ageing driven by a number of social determinants of health, including the experience of loneliness and they may be more at risk of experiencing loneliness.

AIM

This study aimed to examine demographic, psychosocial and clinical variables and their relative contribution to the loneliness of older PwS (OPwS) in a large New Zealand community sample.

METHOD

New Zealanders 65 years and older who completed their first interRAI assessment during the study period were included. Data from 1,883 OPwS participants was analysed [mean age, 75.1 + 7.7 years; 1,132 (60.3%) females]. The majority were of European ethnicity (64.8%; Māori 15.7%, Pacifica 5.7%) and only a minority were married (20.6%). Chi-square analysis was used to examine relationships between loneliness and demographic and psychosocial variables. Logistic regression was used to measure the relative contribution of these variables to loneliness.

RESULTS

Being lonely was reported for 25.9% of OPwS, a significantly higher rate than that reported in the general population of people over 65 years-of-age. A relationship with loneliness was found for marital status, depression and living arrangements but not gender, ethnicity or social engagement. Co-morbid depression and not being in a marital-type partnership were identified as significant predictors of being lonely. Conversely, living with someone predicted being not lonely.

CONCLUSIONS

Older community dwelling PwS experience higher rates of loneliness than older adults in a general population. Addressing loneliness, as well as its correlates, co-morbid depressive symptoms and living arrangements, is crucial to supporting the wellbeing of OPwS.

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

INTRODUCTION

Previous research has raised concerns about high prevalence of drug-related problems, polypharmacy and inappropriate benzodiazepine prescribing in nursing homes (NHs) and confirmed lack of studies from Central and South-Eastern Europe. The aim of our study was to determine the prevalence and characteristics of polypharmacy, hyperpolypharmacy and inappropriate benzodiazepine prescribing in NH residents in Croatia.

METHODS

Data from 226 older NH residents from five Croatian NHs were collected using the InterRAI Long-Term Care Facilities assessment form. The prevalence and determinants of polypharmacy/hyperpolypharmacy and patterns of inappropriate benzodiazepine prescribing were documented.

RESULTS

The prevalence of polypharmacy (49.6%) and hyperpolypharmacy (25.7%) among NH residents was high. In our study, 72.1% of NH residents were prescribed at least one psychotropic agent, 36.7% used 2-3 psychotropics and 6.6% used 4+ psychotropics. Among benzodiazepine users (55.8%), 28% of residents were prescribed benzodiazepines in higher than recommended geriatric doses, 75% used them for the long term and 48% were prescribed concomitant interacting medications. The odds of being prescribed polypharmacy/hyperpolypharmacy were significantly higher for older patients with polymorbidity (6+ disorders, proportional odds ratio (POR) = 19.8), type II diabetes (POR = 5.2), ischemic heart disease (POR = 4.6), higher frailty (Clinical Frailty Scale (CFS ≥5); POR = 4.3) and gastrointestinal problems (POR = 4.8).

CONCLUSIONS

Our research underscores the persistent challenge of inappropriate medication use and drug-related harms among older NH residents, despite existing evidence and professional campaigns. Effective regulatory and policy interventions, including the implementation of geriatrician and clinical pharmacy services, are essential to address this critical issue and ensure optimal medication management for vulnerable NH populations.

Investigating the Prevalence and Predictors of Apathy among the Canadian Long-Term Care Residents: A Secondary Data Analysis

BACKGROUND

In long-term care facilities (LTCF), apathy is a prevalent issue, leading to cognitive decline, functional impairment, and increased mortality risk. Despite its significance, apathy often remains underrecognized and undermanaged in these settings. Recognizing and addressing the predictors of apathy is critical for early intervention and improved care outcomes.

PURPOSE

This study aims to assess the prevalence of apathy and identify its associated risk factors among newly admitted residents in the Canadian LTCF, using the InterRAI Minimum Data Set (MDS 2.0).

METHODS

We conducted a cross-sectional analysis of MDS 2.0 admission assessment data between 2015 and 2019, covering 157,596 residents across six Canadian provinces and one territory. Apathy was measured using the Apathy Index of the MDS 2.0, with the biopsychosocial model guiding the analysis.

RESULTS

The prevalence of apathy was 12.5% (19,758 individuals). The most significant predictors include cognitive impairments, specific age groups, hearing impairments, vision impairments, facility size and location.

CONCLUSIONS

The findings of this study underscore the need for tailored strategies in LTCF to address apathy, considering individual, institutional, and regional variations. Emphasis on environmental and personal factors is crucial in the management and prevention of apathy in these settings.

Association of Disease Trajectory and Place of Care with End-of-Life Burdensome Transitions: A Retrospective Cohort Study

OBJECTIVES

End-of-life (EOL) transitions to hospital can be burdensome for older adults and may contribute to poor outcomes. We investigated the association of disease trajectory and place of care with EOL burdensome transitions.

DESIGN

Retrospective cohort study using administrative data.

SETTING/PARTICIPANTS

Ontarians aged ≥65 years who died between 2015 and 2018 and received long-term care (LTC) or home care 6 months before death.

METHODS

Disease trajectories were defined based on EOL functional decline: terminal illness, organ failure, frailty, sudden death, and other. Places of care included LTC, EOL home care, and non-EOL home care. Burdensome transitions were defined as early (≥3 hospitalizations for any reason or ≥2 hospitalizations due to pneumonia, urinary tract infection, sepsis, or dehydration in the last 90 days of life) or late (≥1 hospitalizations for any reason in the last 3 days of life). Multinomial logistic regression tested for effect modification between disease trajectory and places of care on burdensome transitions.

RESULTS

Of 110,776 decedents, 40.7% had organ failure, 37.5% had frailty, and 12.8% had a terminal illness, with the remainder in sudden death or other categories. Most were in LTC (62.5%), and 37.5% received home care, with 6.8% receiving designated EOL home care and 30.7% non-EOL home care. There was a significant interaction (P < .001) between disease trajectory and care settings. Compared with terminal illness, organ failure was associated with increased odds of early transitions across all care settings [odds ratios (ORs) ranging 1.14-1.21]. Frailty was associated with increased odds of early transitions solely for non-EOL home care recipients (OR 1.17, 95% CI 1.06-1.28). Organ failure and frailty were associated with increased odds of late transitions across all settings, with organ failure having greater odds in LTC (organ failure OR 2.29, 95% CI 2.02-2.60, vs frailty OR 1.79, 95% CI 1.58-2.04).

CONCLUSIONS AND IMPLICATIONS

Disparities exist in burdensome transitions, notably for noncancer decedents with organ failure in LTC. Enhancing palliative care may help reduce burdensome transitions and improve patient outcomes.

Association Between Organizational Context and Resident Pain in Assisted Living: A Repeated Cross-Sectional Study

OBJECTIVES

Resident pain has been a common quality challenge in congregate care for older adults, and organizational context may explain variations in resident pain beyond resident-level factors. Most studies have focused on nursing homes (NHs), largely neglecting assisted living (AL). AL residents are at similar risk for pain as NH resident, but with AL providing fewer services and staffing resources. Our objective was to examine whether organizational context in AL was associated with resident pain during the first two waves of the COVID-19 pandemic.

METHODS

This repeated cross-sectional study linked AL home surveys, collected in COVID-19 waves 1 (March-June 2020) and 2 (October 2020-February 2021) from a key contact, to administrative Resident Assessment Instrument-Home Care (RAI-HC) records in these homes. Surveys assessed preparedness for COVID-19 outbreaks, availability of a registered nurse or nurse practitioner, direct care staff shortages, decreased staff morale, COVID-19 outbreaks, confinement of residents to their rooms, supporting video calls with physicians, facilitating caregiver involvement. The dependent variable (moderate daily pain or pain of a severe intensity) and resident covariates came from the RAI-HC. Using general estimating equations, adjusted for repeated resident assessments and covariates, we assessed whether AL organizational context was associated with resident pain during the pandemic.

RESULTS

We included 985 residents in 41 facilities (wave 1), and 1134 residents in 42 facilities (wave 2). Pain prevalence [95% confidence interval] decreased non-significantly from 20.6% [18.6%-23.2%] (March-June 2019) to 19.1% [16.9%-21.6%] (October 2020-February 2021). Better preparedness (odds ratio = 1.383 [1.025-1.866]), confinement of residents to their rooms (OR = 1.616 [1.212-2.155]), availability of a nurse practitioner (OR = 0.761 [0.591-0.981]), and staff shortages (OR = 0.684 [0.527-0.888]) were associated with resident pain.

CONCLUSIONS

AL organizational context factors were associated with resident pain. Policy and management interventions can and must address such factors, providing potentially powerful levers for improving AL resident quality of care.

A Longitudinal Treatment Effect Analysis of Antipsychotics on Behavior of Residents in Long-Term Care

OBJECTIVE

The proportion of long-term care (LTC) residents being treated with antipsychotic medication is high, and these medications may exacerbate behavioral symptoms. We used propensity scores to investigate the effect of antipsychotic use on the worsening of behavioral symptoms among residents in LTC facilities.

DESIGN

A retrospective study.

SETTING AND PARTICIPANTS

Residents in LTC in 8 provinces and 1 territory in Canada, without severe aggressive behavior at baseline and reassessed at follow-up, between March 2000 and March 2022.

METHODS

We used propensity score matching and weighting to balance baseline covariates and logistic regression to estimate the effect of antipsychotics on the worsening of behavioral symptoms in the original, matched, and weighted cohorts. The treatment variable was use of antipsychotic medication at baseline and the outcome was worsening of behavior at follow-up.

RESULTS

A total of 494,215 participants were included [318,234 women and 175,981 men; mean age 82.8 years (SD 10.1; range 18-112)].130 558 (26.4%) used antipsychotics at baseline and 88,632 (17.9%) had worsening behavior in follow-up. In the matched cohort, there were 249,698 participants, and 124,849 were matched (1:1) in each treatment group. There was a significant association between antipsychotic use at baseline and worsening in behavior at follow-up in the adjusted regression models [OR 1.27 (95% CI 1.25-1.29), <0.0001] as well as in matched [OR 1.20 (95% CI 1.17-1.21), <0.0001] and weighted [OR 1.26 (95% CI 1.24-1.28), <0.0001] cohorts.

CONCLUSIONS AND IMPLICATIONS

This study further evidence to support the cautious use of antipsychotics in LTC facilities. Future research in LTC facilities could include a more granular analyses of behavior change, including bidirectional analyses between different symptom severity classifications.

Derivation and validation of an algorithm to predict transitions from community to residential long-term care among persons with dementia-A retrospective cohort study

OBJECTIVES

To develop and validate a model to predict time-to-LTC admissions among individuals with dementia.

DESIGN

Population-based retrospective cohort study using health administrative data.

SETTING AND PARTICIPANTS

Community-dwelling older adults (65+) in Ontario living with dementia and assessed with the Resident Assessment Instrument for Home Care (RAI-HC) between April 1, 2010 and March 31, 2017.

METHODS

Individuals in the derivation cohort (n = 95,813; assessed before March 31, 2015) were followed for up to 360 days after the index RAI-HC assessment for admission into LTC. We used a multivariable Fine Gray sub-distribution hazard model to predict the cumulative incidence of LTC entry while accounting for all-cause mortality as a competing risk. The model was validated in 34,038 older adults with dementia with an index RAI-HC assessment between April 1, 2015 and March 31, 2017.

RESULTS

Within one year of a RAI-HC assessment, 35,513 (37.1%) individuals in the derivation cohort and 10,735 (31.5%) in the validation cohort entered LTC. Our algorithm was well-calibrated (Emax = 0.119, ICIavg = 0.057) and achieved a c-statistic of 0.707 (95% confidence interval: 0.703-0.712) in the validation cohort.

CONCLUSIONS AND IMPLICATIONS

We developed an algorithm to predict time to LTC entry among individuals living with dementia. This tool can inform care planning for individuals with dementia and their family caregivers.

Pan-Canadian estimates of the prevalence and risks associated with critical wandering among home care clients

INTRODUCTION

We used clinical assessment records to provide pan-Canadian estimates of the prevalence and risks associated with recent (within the last 3 days) critical wandering among home care clients, with and without dementia.

METHODS

The data source is interRAI Home Care (interRAI HC) assessments. The population was all long-stay home care clients assessed between 2004 and 2021 in seven Canadian provinces and territories (N = 1,598,191). We tested associations between wandering and cognition and dementia diagnoses using chi-square tests and logistic regression.

RESULTS

Approximately 84% of the sample was over the age of 65. The overall rate of recent wandering was 3.0%. Dementia diagnosis was strongly associated with two to four times higher rates in the prevalence of recent critical wandering.

DISCUSSION

InterRAI HC offers insights into the wandering risk of home care clients. This information should be used to manage risks in the community and could be shared with first responders.

HIGHLIGHTS

In all the study regions combined, the rate of recent wandering is 3.0%. Dementia was associated with 18 times greater prevalence of recent critical wandering. Home care clients at risk of wandering have complex clinical profiles that pose important risks for their health and well-being. Collaboration and information sharing between search and rescue and health professions is essential for managing risks related to critical wandering.

Determinants of received care time among Finnish home care clients and assisted living facility residents: a time-motion study

BACKGROUND

Ageing populations and care workforce shortages across Europe are causing challenges for care services for older people. Therefore, it is paramount that limited care resources are allocated optimally, based on the clients' care needs. Multiple functioning-related factors have been identified that determine the amount of care time clients receive, while organizational and other factors remain largely unexplored. The aim was to examine how various individual and organizational factors are associated with clients' received care time in different care settings.

METHODS

Cross-sectional observational study design with data from time and motion study, registers, and surveys was used. In total, 1477 home care clients and 1538 residents from assisted living facilities with 24/7 service participated, from 61 Finnish care units. Linear mixed-effect modeling was used to examine the association between individual and organizational-level variables and received care time.

RESULTS

Physical functioning was the strongest predictor of received care time in both care settings. In home care, greater pain, more unstable health, and higher team autonomy were associated with increased care time. In assisted living, depressive mood and higher staffing level of the organization were associated with care time. Clients who received informal care also received significantly more care time from nurses in both care settings.

CONCLUSIONS

Physical functioning was the main driver of received care time. Interventions that maintain or improve physical functioning can help restrain the growing need of care resources, although it is important to ensure that each client receives care according to their holistic care needs.

First Evidence on the Validity of the Complexity Index Derived from the Resident Assessment Instrument for Home Care in Home Care Patients

OBJECTIVES

Recently, a Complexity Index (CI), based on the multidimensional complexity model and derived from the Resident Assessment Instrument for Home Care (interRAI HC) was proposed as a decision-support tool to help frontline health care professionals in their clinical evaluation to identify and analyze complex situations. This study aims to test the CI: (1) concurrent validity with another measure of complexity (ie, the COMID), (2) convergent validity with related constructs assessed by interRAI HC scales (eg, depression), (3) divergent validity (comparison between CI-COMID and scales-COMID correlations), and (4) predictive validity on coordination meetings.

DESIGN

A cross-sectional observational design was used for a secondary analysis of interRAI HC and COMID data collected in routine home care nursing practice (July-December 2021).

SETTING AND PARTICIPANTS

Participants were community-dwelling adults receiving home care, with full interRAI HC and COMID assessments (N = 3533).

METHODS

Correlational analyses were conducted to test the concurrent validity of the CI (with the COMID) and the convergent and divergent validity of the CI (with interRAI HCSwitzerland scales, eg, Depression Rating Scale, Method for Assigning Priority Levels, and a Frailty Index). A receiver operating characteristic (ROC) analysis was conducted to test the discriminative ability of CI on specific professional team coordination meetings.

RESULTS

Results showed that the CI correlated positively and strongly with the COMID (ρ = 0.691, P < .001, concurrent validity), positively with all the tested scales (P < .001, convergent validity), whereas the CI-COMID correlation was higher than the interRAI HC scales-COMID correlations (divergent validity). The ROC analysis showed the CI had a high area under the curve (AUC = 0.719, predictive validity).

CONCLUSIONS AND IMPLICATIONS

The CI demonstrates good validity properties with a strong correlation with the COMID and a high predictive value for coordination meeting. It is distinct from the other interRAI HC scales and has its place among them to support the clinical analysis of complex situations.

Antipsychotic Discontinuation and New Trazodone Use in Ontario Nursing Homes: Evidence of Medication Substitution

OBJECTIVES

An unintended consequence of efforts to reduce antipsychotic medications in nursing homes is the increase in use of other psychotropic medications; however, evidence of substitution remains limited. Our objective was to measure individual-level prescribing patterns consistent with substitution of trazodone for antipsychotics.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Residents of Ontario nursing homes aged 66-105 years with an admission assessment between April 1, 2010, and March 31, 2019, who were receiving an antipsychotic and had no antidepressant medication use at admission to the nursing home.

METHODS

We used linked health administrative data to examine changes in medication use over three quarterly assessments following admission. Antipsychotic and trazodone use were measured at each assessment. The rate of trazodone initiation was compared between residents no longer dispensed an antipsychotic (discontinued) and those with an ongoing antipsychotic (continued) using discrete time survival analysis, controlling for baseline resident characteristics.

RESULTS

We identified 13,306 residents dispensed an antipsychotic with no antidepressant use at admission (mean age 84 years, 61.5% women, 82.8% with dementia). As of the first quarterly assessment, nearly 20% of residents no longer received an antipsychotic and 9% received a new trazodone medication. Over time, residents who discontinued antipsychotics had a rate of trazodone initiation that was 82% higher compared to residents who continued (adjusted hazard ratio 1.82, 95% CI 1.66-2.00).

CONCLUSIONS AND IMPLICATIONS

Residents admitted to a nursing home with antipsychotic use had a higher rate of trazodone initiation if they discontinued (vs continued) an antipsychotic. These findings suggest antipsychotic substitution with trazodone after entering a nursing home.

Factors Associated With the Initiation of Comfort-Focused Nutrition Care Orders for Long-Term Care Residents at End of Life

BACKGROUND

Comfort-focused nutrition orders are recommended to manage eating changes among long-term care (LTC) residents nearing the end of life, though little is known about their current use. This investigation aims to describe current practices and identify resident-level and time-dependent factors associated with comfort-focused nutrition orders in this context.

METHODS

Data were retrospectively extracted from resident charts of decedents (≥65 years at death, admitted ≥6 months) in 18 LTC homes from two sampling frames across southern Ontario, Canada. Observations occurred at 6 months (baseline), 3 months, 1 month and 2 weeks prior to death. Extracted data included functional measures (e.g. cognitive performance, health instability) at baseline, formalised restorative and comfort-focused nutrition care interventions at each timepoint and eating changes reported in the progress notes in 2 weeks following each timepoint. Logistic regression and time-varying logistic regression models determined resident-level (e.g. functional characteristics) and time-dependent factors (e.g. eating changes) associated with receiving a comfort-focused nutrition order.

RESULTS

Less than one-third (30.5%; n = 50) of 164 participants (61.0% female; mean age = 88.3 ± 7.5 years) received a comfort-focused nutrition order, whereas most (99%) received at least one restorative nutrition intervention to support oral food intake. Discontinuation of nutrition interventions was rare (8.5%). Comfort orders were more likely with health instability (OR [95% CI] = 4.35 [1.49, 13.76]), within 2 weeks of death (OR = 5.50 [1.70, 17.11]), when an end-of-life conversation had occurred since the previous timepoint (OR = 5.66 [2.83, 11.33]), with discontinued nutrition interventions (OR = 6.31 [1.75, 22.72]), with co-occurrence of other care plan modifications (OR = 1.48 [1.10, 1.98]) and with a greater number of eating changes (OR = 1.19 [1.02, 1.38]), especially dysphagia (OR = 2.59 [1.09, 6.17]), at the preceding timepoint.

CONCLUSIONS

Comfort-focused nutrition orders were initiated for less than one-third of decedents and most often in the end stages of life, possibly representing missed opportunities to support the quality of life for this vulnerable population. An increase in eating changes, including new dysphagia, may signal a need for proactive end-of-life conversations involving comfort nutrition care options.

IMPLICATIONS FOR PRACTICE

Early and open conversations with residents and family about potential eating changes and comfort-focused nutrition care options should be encouraged and planned for among geriatric nursing teams working in LTC. These conversations may be beneficial even as early as resident admission to the home.

EXploring Patterns of Use and Effects of Adult Day Programs to Improve Trajectories of Continuing Care (EXPEDITE): Protocol for a Retrospective Cohort Study

BACKGROUND

Adult day programs provide critical supports to older adults and their family or friend caregivers. High-quality care in the community for as long as possible and minimizing facility-based continuing care are key priorities of older adults, their caregivers, and health care systems. While most older adults in need of care live in the community, about 10% of newly admitted care home residents have relatively low care needs that could be met in the community with the right supports. However, research on the effects of day programs is inconsistent. The methodological quality of studies is poor, and we especially lack robust, longitudinal research.

OBJECTIVE

Our research objectives are to (1) compare patterns of day program use (including nonuse) by province (Alberta, British Columbia, and Manitoba) and time; (2) compare characteristics of older adults by day program use pattern (including nonuse), province, and time; and (3) assess effects of day programs on attendees, compared with a propensity score-matched cohort of older nonattendees in the community.

METHODS

In this population-based retrospective cohort study, we will use clinical and health administrative data of older adults (65+ years of age) who received publicly funded continuing care in the community in the Canadian provinces of Alberta, British Columbia, and Manitoba between January 1, 2012, and December 31, 2024. We will compare patterns of day program use between provinces and assess changes over time. We will then compare characteristics of older adults (eg, age, sex, physical or cognitive disability, area-based deprivation indices, and caregiver availability or distress) by pattern of day program use or nonuse, province, and time. Finally, we will create a propensity score-matched comparison group of older adults in the community, who have not attended a day program. Using time-to-event models and general estimating equations, we will assess whether day program attendees compared with nonattendees enter care homes later; use emergency, acute, or primary care less frequently; experience less cognitive and physical decline; and have better mental health.

RESULTS

This will be a 3-year study (July 1, 2024, to June 30, 2027). We received ethics approvals from the relevant ethics boards. Starting on July 1, 2024, we will work with the 3 provincial health systems on data access and linkage, and we expect data analyses to start in early 2025.

CONCLUSIONS

This study will generate robust Canadian evidence on the question whether day programs have positive, negative, or no effects on various older adult and caregiver outcomes. This will be a prerequisite to improving the quality of care provided to older adults in day programs, ultimately improving the quality of life of older adults and their caregivers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06440447; https://clinicaltrials.gov/study/NCT06440447.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/60896.

Associations between specialized dementia care, COVID-19 and central nervous system medication use in assisted living: a population-based repeated cross-sectional study

BACKGROUND

Assisted living (AL) is an increasingly common residential setting for persons with dementia; yet concerns exist about sub-optimal care of this population in AL given its lower levels of staffing and services. Our objectives were to (i) examine associations between AL setting (dementia care vs. other), COVID-19 pandemic waves, and prevalent antipsychotic, antidepressant, anti-dementia, benzodiazepine, and anticonvulsant drug use among residents with dementia/cognitive impairment, and (ii) explore associations between resident and home characteristics and prevalent medication use.

METHODS

We conducted a population-based, repeated cross-sectional study using linked clinical and health administrative databases for all publicly funded AL homes in Alberta, Canada, examined between January 2018 - December 2021. The quarterly proportion of residents dispensed a study medication was examined for each setting and period (pandemic vs. comparable historical [2018/2019 combined]) focusing on four pandemic waves (March-May 2020, September 2020-February 2021, March-May 2021, September-December 2021). Log-binomial GEE models estimated prevalence ratios (PR) for period (pandemic vs. historical periods), setting (dementia care vs. other) and period-setting interactions, adjusting for resident (age, sex) and home (COVID-19 cases, health region, ownership) characteristics.

RESULTS

On March 1, 2020, there were 2,779 dementia care and 3,013 other AL residents (mean age 83, 69% female) with dementia/cognitive impairment. Antipsychotic use increased during waves 2-4 in both settings, but this was more pronounced in dementia care than other AL during waves 3 and 4 (e.g., adjusted [adj]PR 1.20, 95% CI 1.14-1.27 vs. adjPR 1.09, 95% CI 1.02-1.17, interaction p = 0.023, wave 3). Both settings showed a statistically significant but modest increase in antidepressant use and decrease in benzodiazepine use. For dementia care AL residents only, there was a statistically significant increase in gabapentinoid use during several waves (e.g., adjPR 1.32, 95% CI 1.10-1.59, wave 3). Other than a modest decrease in prevalent anti-dementia drug use for both settings in wave 2, no other significant pandemic effects were observed.

CONCLUSIONS

The persistence of the pandemic-associated increase in antipsychotic and antidepressant use in AL residents coupled with a greater increase in antipsychotic and gabapentinoid use for dementia care settings raises concerns about the attendant risks for residents with cognitive impairment.

Intrinsic capacity and recent falls in adults 80 years and older living in the community: results from the ilSIRENTE Study

BACKGROUND

Falls in older adults significantly impact overall health and healthcare costs. Intrinsic capacity (IC) reflects functional reserve and is an indicator of healthy aging.

AIMS

To explore the association between IC and recent falls (≤ 90 days) in community-dwelling octogenarians from the Aging and Longevity in the Sirente geographic area (IlSIRENTE) study.

METHODS

The Minimum Data Set for Home Care (MDS-HC) and supplementary questionnaires and tests were used to assess the five IC domains: locomotion, cognition, vitality, psychology, and sensory. Scores in each domain were rescaled using the percent of maximum possible score method and averaged to obtain an overall IC score (range 0-100).

RESULTS

The study included 319 participants (mean age 85.5 ± 4.8 years, 67.1% women). Mean IC score was 80.5 ± 14.2. The optimal IC score cut-off for predicting the two-year risk of incident loss of at least one activity of daily living (ADL) was determined and validated in a subset of 240 individuals without ADL disability at baseline (mean age 84.7 ± 4.4 years, 67.1% women). Participants were then stratified into low (< 77.6) and high (≥ 77.6) IC categories. Those with high IC (63.9%) were younger, more often males, and had lower prevalence of recent falls, disability, multimorbidity, and polypharmacy. Logistic regression models including IC as a continuous variable revealed a significant association between higher IC and lower odds of falls. This association was significant in the unadjusted (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.94-0.98, p < 0.001), age- and sex-adjusted (OR 0.96, 95% CI 0.94-0.98, p < 0.001), and fully adjusted models (OR 0.96, 95% CI 0.93-0.99, p = 0.003). When considering IC as a categorical variable, unadjusted logistic regression showed a strong association between high IC and lower odds of falls (OR 0.31, 95% CI 0.16-0.60, p < 0.001). This association remained significant in both the age- and sex-adjusted (OR 0.30, 95% CI 0.15-0.59, p < 0.001) and fully adjusted models (OR 0.33, 95% CI 0.16-0.82, p = 0.007). The locomotion domain was independently associated with falls in the unadjusted (OR 0.98, 95% CI 0.97-0.99, p < 0.001), age- and sex-adjusted (OR 0.97, 95% CI 0.96-0.99, p < 0.001), and fully adjusted model (OR 0.98, 95% CI 0.96-0.99, p < 0.001).

DISCUSSION

This is the first study using an MDS-HC-derived instrument to assess IC. Individuals with higher IC were less likely to report recent falls, with locomotion being an independently associated domain.

CONCLUSIONS

Lower IC is linked to increased odds of falls. Interventions to maintain and improve IC, especially the locomotion domain, may reduce fall risk in community-dwelling octogenarians.

Comparison of hospitalization events among residents of assisted living and nursing homes during COVID-19: Do settings respond differently during public health crises?

BACKGROUND

COVID-19 and resulting health system and policy decisions led to significant changes in healthcare use by nursing homes (NH) residents. It is unclear whether healthcare outcomes were similarly affected among older adults in assisted living (AL). This study compared hospitalization events in AL and NHs during COVID-19 pandemic waves 1 through 4, relative to historical periods.

METHODS

This was a population-based, repeated cross-sectional study using linked clinical and health administrative databases (January 2018 to December 2021) for residents of all publicly subsidized AL and NH settings in Alberta, Canada. Setting-specific monthly cohorts were derived for pandemic (starting March 1, 2020) and comparable historical (2018/2019 combined) periods. Monthly rates (per 100 person-days) of all-cause hospitalization, hospitalization with delayed discharge, and hospitalization with death were plotted and rate ratios (RR) estimated for period (pandemic wave vs historical comparison), setting (AL vs NH) and period-setting interactions, using Poisson regression with generalized estimating equations, adjusting for resident and home characteristics.

RESULTS

On March 1, 2020, there were 9,485 AL and 14,319 NH residents, comparable in age (mean 81 years), sex (>60% female) and dementia prevalence (58-62%). All-cause hospitalization rates declined in both settings during waves 1 (AL: adjusted RR 0.60, 95%CI 0.51-0.71; NH: 0.74, 0.64-0.85) and 4 (AL: 0.76, 0.66-0.88; NH: 0.65, 0.56-0.75) but unlike NHs, AL rates were not significantly lower during wave 2 (and increased 27% vs NH, January 2021). Hospitalization with delayed discharge increased in NHs only (during and immediately after wave 1). Both settings showed a significant increase in hospitalization with death in wave 2, this increase was larger and persisted longer for AL.

CONCLUSIONS

Pandemic-related changes in hospitalization events differed for AL and NH residents and by wave, suggesting unique system and setting factors driving healthcare use and outcomes in these settings in response to this external stress.

Burnout Among Nursing Home Care Aides and the Effects on Resident Outcomes

While burnout among health care workers has been well studied, little is known about the extent to which burnout among health care workers impacts the outcomes of their care recipients. To test this, we used a multi-year (2014-2020) survey of care aides working in approximately 90 nursing homes (NHs); the survey focused on work-life measures, including the Maslach Burnout Inventory (MBI) and work-unit identifier. Resident Assessment Instrument Minimum Data Set (RAI-MDS 2.0) data were obtained on all residents in the sampled NHs during this time and included a unit identifier for each resident. We used multi-level models to test associations between the MBI emotional exhaustion and cynicism sub-scales reported by care aides and the resident outcomes of antipsychotics without indication, depressive symptoms, and responsive behaviors among residents on units. In 2019/2020, our sample included 3,547 care aides and 10,117 residents in 282 units. The mean frequency of emotional exhaustion and cynicism across units was 43% and 50%, respectively. While residents frequently experienced antipsychotics without indication 1,852 (18.3%), depressive symptoms 2,089 (20.7%), and responsive behaviors 3,891 (38.5%), none were found to be associated with either emotional exhaustion or cynicism among care aides.

Factors associated with dietitian referrals to support long-term care residents advancing towards the end of life

BACKGROUND

Dietitians are central members of the multidisciplinary long-term care (LTC) healthcare team. The overall aim of this current investigation is to gain a better understanding of dietitian involvement in LTC resident's end-of-life care via referrals.

METHODS

Retrospective chart reviews for 164 deceased residents (mean age = 88.3 ± 7.3; 61% female) in 18 LTC homes in Ontario, Canada, identified dietitian referrals and documented eating challenges recorded over 2-week periods at four time points (i.e., 6 months, 3 months, 1 month and 2 weeks) prior to death. Nutrition care plans at the beginning of these time points were also noted. Logistic mixed effects regression models identified time-varying predictors of dietitian referrals. Bivariate tests identified associations between nutrition orders and dietitian referrals that occurred in the last month of life.

RESULTS

Nearly three-quarters (73%) of participants had at least one dietitian referral across the four observations. Referrals increased significantly with proximity to death; 45% of residents had a referral documented in the last 2 weeks of life. Dietitian referrals were associated with the number of eating challenges (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.27, 1.58). Comfort-focused nutrition care orders were significantly more common when a dietitian was referred (25%) compared with when a dietitian was not referred (12%) in the final month of life (p = 0.04).

CONCLUSIONS

Our findings suggest that dietitians are involved in end-of-life and comfort-focused nutrition care initiatives, yet they are not engaged consistently for this purpose. This presents a significant opportunity for dietitians to upskill and champion palliative approaches to nutrition care within the multidisciplinary LTC team.

Profiling the medical, functional, cognitive, and psychosocial care needs of adults assessed for home care in Ontario, Canada: The case for long-term 'life care' at home

Calls to leverage routinely collected data to inform health system improvements have been made. Misalignment between home care services and client needs can result in poor client, caregiver, and system outcomes. To inform development of an integrated model of community-based home care, grounded in a holistic definition of health, comprehensive clinical profiles were created using Ontario, Canada home care assessment data. Retrospective, cross-sectional analyses of 2017-2018 Resident Assessment Instrument Home Care (RAI-HC) assessments (n = 162,523) were completed to group home care clients by service needs and generate comprehensive profiles of each group's dominant medical, functional, cognitive, and psychosocial care needs. Six unique groups were identified, with care profiles representing home care clients living with Geriatric Syndromes, Medical Complexity, Cognitive Impairment and Behaviours, Caregiver Distress and Social Frailty. Depending on group membership, between 51% and 81% of clients had identified care needs spanning four or more Positive Health dimensions, demonstrating both the heterogeneity and complexity of clients served by home care. Comprehensive clinical profiles, developed from routinely collected assessment data, support a future-focused, evidence-informed, and community-engaged approach to research and practice in integrated home-based health and social care.

Deprescribing potential of commonly used medications among community-dwelling older adults: insights from a pharmacist's geriatric assessment

Pharmacist's geriatric assessment can provide valuable insights into potential deprescribing targets, while including important information on various health-related domains. Data collected from a geriatric assessment questionnaire, for 388 patients, from the Croatian cohort of the EuroAgeism H2020 ESR 7 international project, along with guideline-based deprescribing criteria, were used to analyse potentially inappropriate prescribing of four medication groups (benzodiazepines (BZN), proton pump inhibitors (PPI), opioids, and non-steroidal anti-inflammatory drugs (NSAID)), and to assess the deprescribing potential. Binary logistic regression was used to explore the effects of age, gender, number of medicines and diagnoses, self-reported health, frailty score, and healthcare utilization on the likelihood of needing deprescribing. More than half of participants (n = 216, 55.2%) are candidates for deprescribing, with 31.1% of PPI, 74.8% of NSAID, 75% of opioid, and 96.1% of BZN users meeting at least one criterion. Most common criteria for deprescribing were inappropriately long use and safety concerns. Women (aOR = 2.58; p < 0.001), those reporting poor self-reported health (aOR = 5.14; p < 0.001), and those exposed to polypharmacy (aOR = 1.29; p < 0.001) had higher odds of needing to have medicines deprescribed. The high rate of deprescribing potential warrants prompt action to increase patient safety and decrease polypharmacy. Pharmacist's geriatric assessment and deprescribing-focused medication review could be used to lead a personalised approach.

Prevalence, country-specific prescribing patterns and determinants of benzodiazepine use in community-residing older adults in 7 European countries

BACKGROUND

The use of benzodiazepines (BZDs) in older population is often accompanied by drug-related complications. Inappropriate BZD use significantly alters older adults' clinical and functional status. This study compares the prevalence, prescribing patterns and factors associated with BZD use in community-dwelling older patients in 7 European countries.

METHODS

International, cross-sectional study was conducted in community-dwelling older adults (65 +) in the Czech Republic, Serbia, Estonia, Bulgaria, Croatia, Turkey, and Spain between Feb2019 and Mar2020. Structured and standardized questionnaire based on interRAI assessment scales was applied. Logistic regression was used to evaluate factors associated with BZD use.

RESULTS

Out of 2,865 older patients (mean age 73.2 years ± 6.8, 61.2% women) 14.9% were BZD users. The highest prevalence of BZD use was identified in Croatia (35.5%), Spain (33.5%) and Serbia (31.3%). The most frequently prescribed BZDs were diazepam (27.9% of 426 BZD users), alprazolam (23.7%), bromazepam (22.8%) and lorazepam (16.7%). Independent factors associated with BZD use were female gender (OR 1.58, 95%CI 1.19-2.10), hyperpolypharmacy (OR 1.97, 95%CI 1.22-3.16), anxiety (OR 4.26, 95%CI 2.86-6.38), sleeping problems (OR 4.47, 95%CI 3.38-5.92), depression (OR 1.95, 95%CI 1.29-2.95), repetitive anxious complaints (OR 1.77, 95%CI 1.29-2.42), problems with syncope (OR 1.78, 95%CI 1.03-3.06), and loss of appetite (OR 0.60, 95%CI 0.38-0.94). In comparison to Croatia, residing in other countries was associated with lower odds of BZD use (ORs varied from 0.49 (95%CI 0.32-0.75) in Spain to 0.01 (95%CI 0.00-0.03) in Turkey), excluding Serbia (OR 1.11, 95%CI 0.79-1.56).

CONCLUSIONS

Despite well-known negative effects, BZDs are still frequently prescribed in older outpatient population in European countries. Principles of safer geriatric prescribing and effective deprescribing strategies should be individually applied in older BZD users.

The relationship between sensory impairment and home care client's received care time-A cross-sectional study

AIM

The aim of this study was to explore the relationship between sensory impairment and home care client's received care time.

DESIGN

A cross-sectional multi-source study.

METHODS

Data from a self-reported staff survey on care time allocation were merged with registry data from the Resident Assessment Instrument registry (n = 1477). The data were collected during 1 week from 17 home care units in Finland in October 2021. The relationship between sensory impairment and clients received care time was examined using linear regression analyses.

RESULTS

The linear regression analyses showed that having vision impairment alone increased care time, while dual sensory impairment resulted in decreased received care time. Hearing impairment alone was not statistically significantly associated with care time.

CONCLUSION

The holistic care need of home care clients with dual sensory impairment may not be adequate. To ensure equality and the individually tailored care of clients, further attention must be paid to clients with sensory impairments, especially those with dual sensory impairment. Furthermore, the competence of home care workers to encounter and communicate with clients with sensory impairment must be developed to support the holistic care.

IMPLICATIONS FOR THE PATIENT CARE

The sensory impairments of home care clients must be identified in time and considered in care planning and encountering clients.

IMPACT

As there is a risk that clients with dual sensory impairment are not able to fully express themselves, it is imperative that further attention is paid to clients with sensory impairments, to better understand and support this vulnerable group. Increased awareness and continuous education are needed to better identify and support home care clients with sensory impairment.

REPORTING METHOD

The study adheres to the STROBE reporting guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

The prevalence of non-pharmacological interventions in older homecare recipients: an overview from six European countries

PURPOSE

Non-pharmacological interventions (NPIs) play an important role in the management of older people receiving homecare. However, little is known about how often specific NPIs are being used and to what extent usage varies between countries. The aim of the current study was to investigate the prevalence of NPIs in older homecare recipients in six European countries.

METHODS

This is a cross-sectional study of older homecare recipients (65+) using baseline data from the longitudinal cohort study 'Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of community care' (IBenC). The analyzed NPIs are based on the interRAI Home Care instrument, a comprehensive geriatric assessment instrument. The prevalence of 24 NPIs was analyzed in Belgium, Germany, Finland, Iceland, Italy and the Netherlands. NPIs from seven groups were considered: psychosocial interventions, physical activity, regular care interventions, special therapies, preventive measures, special aids and environmental interventions.

RESULTS

A total of 2884 homecare recipients were included. The mean age at baseline was 82.9 years and of all participants, 66.9% were female. The intervention with the highest prevalence in the study sample was 'emergency assistance available' (74%). Two other highly prevalent interventions were 'physical activity' (69%) and 'home nurse' (62%). Large differences between countries in the use of NPIs were observed and included, for example, 'going outside' (range 7-82%), 'home health aids' (range 12-93%), and 'physician visit' (range 24-94%).

CONCLUSIONS

The use of NPIs varied considerably between homecare users in different European countries. It is important to better understand the barriers and facilitators of use of these potentially beneficial interventions in order to design successful uptake strategies.

Language and pain predict persistent depression among seriously ill home care clients

OBJECTIVES

This study examined potential predictors of persistent depressive symptoms in a cohort of seriously ill older adults (aged 65+ years) receiving home care services.

METHODS

This was a retrospective cohort study using secondary data collected from the Resident Assessment Instrument for Home Care for all assessments completed between 2001 and 2020. The cohort included seriously ill individuals with depressive symptoms at baseline and who continued to have depressive symptoms on reassessment within 12 months (n = 8,304). Serious illness was defined as having severe health instability, a prognosis of less than 6 months, or a goal of care related to palliative care (PC) on admission to the home care program.

RESULTS

The mean age of the sample was 80.8 years (standard deviation [SD] = 7.7), 61.1% were female, and 82.1% spoke English as their primary language. The average length of time between assessments was 4.9 months (SD = 3.3). During that time, 64% of clients had persistent symptoms of depression. A multivariate logistic regression model found that language, pain, caregiver burden, and cognitive impairment were the most significant predictors of experiencing persistent depressive symptoms.

SIGNIFICANCE OF RESULTS

Persistent depressive symptoms are highly prevalent in this population and, left untreated, could contribute to the person experiencing a "bad death." Some of the risk factors for this outcome are amenable to change, making it important to continually assess and flag these factors so interventions can be implemented to optimize the person's quality of life for as long as possible.

Psychotropic, Anticonvulsant, and Opioid Use in Assisted Living Residents Before and During the COVID-19 Pandemic

OBJECTIVES

To examine the associations between COVID-19 pandemic waves (1-4) and prevalent antipsychotic, antidepressant, benzodiazepine, anticonvulsant, and opioid use among assisted living (AL) residents, by setting (dementia care vs other).

DESIGN

Population-based, repeated cross-sectional study.

SETTING AND PARTICIPANTS

Linked clinical and health administrative databases for residents of all publicly subsidized AL homes (N = 256) in Alberta, Canada, examined from January 2018 to December 2021. Setting-specific quarterly cohorts of residents were derived for pandemic (starting March 1, 2020) and comparable historical (2018/2019 combined) periods.

METHODS

The quarterly proportion of residents dispensed an antipsychotic, antidepressant, benzodiazepine, anticonvulsant, or opioid was examined for each setting and period. Log-binomial generalized estimating equations models estimated prevalence ratios (PR) for period (pandemic vs historical quarterly periods), setting (dementia care vs other AL), and period-setting interactions.

RESULTS

On March 1, 2020, there were 2874 dementia care and 6611 other AL residents (mean age 82.4 vs 79.9 years, 68.2% vs 66.1% female, 93.5% vs 42.6% with dementia, respectively). Antipsychotic use increased during waves 2 to 4 for residents of both settings, but this increase was significantly greater for dementia care than other AL residents during waves 3 and 4 (eg, wave 3, PR 1.21, 95% CI 1.14-1.27 vs PR 1.12, 95% CI 1.07-1.17, interaction term P = .029). In both settings, there was a significant but modest increase in antidepressant use and a significant decrease in benzodiazepine use during several pandemic waves. For other AL residents only, there was a small statistically significant increase in anticonvulsant use during waves 2 to 4. No significant pandemic effect was observed for prevalent opioid use in either setting.

CONCLUSIONS AND IMPLICATIONS

The persistence of the pandemic-associated increase in antipsychotic, antidepressant, and anticonvulsant use in AL residents, and greater increase in antipsychotic use for dementia care settings, raises concerns about the attendant risks for residents, especially those with dementia.

Falls Risk in Long-Term Care Residents With Cognitive Impairment: Effects of COVID-19 Pandemic

OBJECTIVES

The aim of this study was to investigate the impact of the COVID-19 pandemic on falls rates in long-term care residents with cognitive impairment.

DESIGN

An observational study using routinely collected national interRAI data.

SETTING AND PARTICIPANTS

Participants were from long-term care residents (age ≥60 years) who received an interRAI Long Term Care Facility assessment anywhere in New Zealand between August 17, 2018, and August 16, 2022.

METHODS

The primary outcome was "At least 1 fall in the last 30 days." Based on the Cognitive Performance Scale (CPS), cognitive impairment was categorized into 3 levels: intact or borderline intact (0-1), mild to moderate impairment (2-3), and moderately to very severe impairment (4-6). The COVID-19 pandemic was divided into 3 periods (First wave: March 21, 2020, to June 8, 2020; Varying level of community outbreaks: June 9, 2020 to August 16, 2021; and Delta-Omicron wave: August 17, 2021, to August 16, 2021) and compared to a pre-COVID-19 period (August 17, 2018, to March 20, 2020). Cox regression modeling was used to study falls and interactions between CPS and COVID-19 pandemic periods, along with other established falls risk factors in the literature.

RESULTS

A total of 282,518 interRAI-LTCF assessments from 75,132 unique residents were included. Interactions between CPS and COVID-19 pandemic periods found that cognitive impairment was associated with a higher hazard ratio (ranged from 1.22 to 1.37) in each of the 3 COVID-19 pandemic periods. We also found unstable health, unsteady gait, wandering, and moderate to severe ADL dependency were the strongest risk factors for falls.

CONCLUSIONS AND IMPLICATIONS

Cognitively impaired long-term care residents had an increased risk for falls during the COVID-19 pandemic. This risk was influenced by several factors. In future pandemic or infection control related isolation, residents who are most at risk can be identified for targeted falls prevention programs.

Neighborhood resources and risk of cognitive decline among a community-dwelling long-term care population in the U.S

Objective

To examine the associations between neighborhood resources (i.e., number of restaurants, recreation centers, or social services for seniors and persons with disability per land area) and cognitive decline among a community-dwelling long-term care population and whether they differ by baseline cognition status.

Study design

Prospective longitudinal cohort study.

Methods

We used a longitudinal dataset that assessed over a two-year period older adults receiving state-funded home- and community-based services in Michigan Metropolitan areas (N = 9,802) and applied nonlinear mixed models with a random intercept with Poisson distribution.

Results

Cognitively intact older adults were less likely to experience cognitive decline when they resided in resource-rich neighborhoods, compared to those cognitively intact but living in neighborhoods that lacked resources. But their cognitively impaired or dementia-diagnosed counterparts did not similarly benefit from living in neighborhoods with rich resources.

Conclusions

Neighborhood resources may be an important aspect of intervention to mitigate cognitive decline before older adults become cognitively impaired.

Comparing quality of care outcomes between assisted living and nursing homes before and during the COVID-19 pandemic

BACKGROUND

While assisted living (AL) and nursing home (NHs) residents in share vulnerabilities, AL provides fewer staffing resources and services. Research has largely neglected AL, especially during the COVID-19 pandemic. Our study compared trends of practice-sensitive, risk-adjusted quality indicators between AL and NHs, and changes in these trends after the start of the pandemic.

METHODS

This repeated cross-sectional study used population-based resident data in Alberta, Canada. Using Resident Assessment Instrument data (01/2017-12/2021), we created quarterly cohorts, using each resident's latest assessment in each quarter. We applied validated inclusion/exclusion criteria and risk-adjustments to create nine quality indicators and their 95% confidence intervals (CIs): potentially inappropriate antipsychotic use, pain, depressive symptoms, total dependency in late-loss activities of daily living, physical restraint use, pressure ulcers, delirium, weight loss, urinary tract infections. Run charts compared quality indicators between AL and NHs over time and segmented regressions assessed whether these trends changed after the start of the pandemic.

RESULTS

Quarterly samples included 2015-2710 AL residents and 12,881-13,807 NH residents. Antipsychotic use (21%-26%), pain (20%-24%), and depressive symptoms (17%-25%) were most common in AL. In NHs, they were physical dependency (33%-36%), depressive symptoms (26%-32%), and antipsychotic use (17%-22%). Antipsychotic use and pain were consistently higher in AL. Depressive symptoms, physical dependency, physical restraint use, delirium, weight loss were consistently lower in AL. The most notable segmented regression findings were an increase in antipsychotic use during the pandemic in both settings (AL: change in slope = 0.6% [95% CI: 0.1%-1.0%], p = 0.0140; NHs: change in slope = 0.4% [95% CI: 0.3%-0.5%], p < 0.0001), and an increase in physical dependency in AL only (change in slope = 0.5% [95% CI: 0.1%-0.8%], p = 0.0222).

CONCLUSIONS

QIs differed significantly between AL and NHs before and during the pandemic. Any changes implemented to address deficiencies in either setting need to account for these differences and require monitoring to assess their impact.

Health effects of social connectedness in older adults living in congregate long-term care settings: A systematic review of quantitative and qualitative evidence

BACKGROUND

The overall impact of social connectedness on health outcomes in older adults living in nursing homes and assisted living settings is unknown. Given the unclear health impact of social connectedness for older adults in congregate long-term care settings worldwide, a comprehensive systematic review is required to evaluate the overall relationship between social connectedness and health outcomes for them.

OBJECTIVES

The purpose of this article was to synthesize the literature regarding the health impact of social connectedness among older adults living in nursing homes or assisted living settings.

METHODS

Using PRISMA guidelines, we identified eligible studies from Scopus, MEDLINE, PsycINFO, CINAHL and Cochrane databases (1990-2021). Bias and quality reporting assessment was performed using standardized criteria for cohort, cross sectional and qualitative studies. At each stage, ≥ 2 researchers conducted independent evaluations.

RESULTS

Of the 7350 articles identified, 25 cohort (follow-up range: 1 month-11 years; with two also contributing to cross sectional), 86 cross sectional, eight qualitative and two mixed methods were eligible. Despite different instruments used, many residents living in nursing homes and assisted living settings had reduced social engagement. Quantitative evidence supports a link between higher social engagement and health outcomes most studied (e.g. depression, quality of life). Few studies evaluated important health outcomes (e.g. cognitive and functional decline). Most cohort studies showed that lack of social connectedness accelerated time to death.

CONCLUSIONS

Social connectedness may be an important modifiable risk factor for adverse health outcomes for older adults living in nursing homes and assisted living facilities. Most studies were cross sectional and focused on quality of life and mental health outcomes. Longitudinal studies suggest that higher social engagement delays time to death. Evidence regarding other health outcomes important to older adults was scant and requires further longitudinal studies.

The role of geriatric syndromes in predicting unplanned hospitalizations: a population-based study using Minimum Data Set for Home Care

BACKGROUND

The predictive accuracies of screening instruments for identifying home-dwelling old people at risk of hospitalization have ranged from poor to moderate, particularly among the oldest persons. This study aimed to identify variables that could improve the accuracy of a Minimum Data Set for Home Care (MDS-HC) based algorithm, the Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) Scale, in classifying home care clients' risk for unplanned hospitalization.

METHODS

In this register-based retrospective study, factors associated with hospitalization among home care clients aged ≥ 80 years in the City of Tampere, Finland, were analyzed by linking MDS-HC assessments with hospital discharge records. MDS-HC determinants associated with hospitalization within 180 days after the assessment were analyzed for clients at low (DIVERT 1), moderate (DIVERT 2-3) and high (DIVERT 4-6) risk of hospitalization. Then, two new variables were selected to supplement the DIVERT algorithm. Finally, area under curve (AUC) values of the original and modified DIVERT scales were determined using the data of MDS-HC assessments of all home care clients in the City of Tampere to examine if addition of the variables related to the oldest age groups improved the accuracy of DIVERT.

RESULTS

Of home care clients aged ≥ 80 years, 1,291 (65.4%) were hospitalized at least once during the two-year study period. Unplanned hospitalization occurred following 15.9%, 22.8%, and 33.9% MDS-HC assessments with DIVERT group 1, 2-3 and 4-6, respectively. Infectious diseases were the most common diagnosis within each DIVERT groups. Many MDS-HC variables not included in the DIVERT algorithm were associated with hospitalization, including e.g. poor self-rated health and old fracture (other than hip fracture) (p 0.001) in DIVERT 1; impaired cognition and decision-making, urinary incontinence, unstable walking and fear of falling (p < 0.001) in DIVERT 2-3; and urinary incontinence, poor self-rated health (p < 0.001), and decreased social interaction (p 0.001) in DIVERT 4-6. Adding impaired cognition and urinary incontinence to the DIVERT algorithm improved sensitivity but not accuracy (AUC 0.64 (95% CI 0.62-0.65) vs. 0.62 (0.60-0.64) of the original DIVERT). More admissions occurred among the clients with higher scores in the modified than in the original DIVERT scale.

CONCLUSIONS

Certain geriatric syndromes and diagnosis groups were associated with unplanned hospitalization among home care clients at low or moderate risk level of hospitalization. However, the predictive accuracy of the DIVERT could not be improved. In a complex clinical context of home care clients, more important than existence of a set of risk factors related to an algorithm may be the various individual combinations of risk factors.

Connecting Today: Feasibility and acceptability of a remote visiting program for people living with dementia in long-term care homes

OBJECTIVES

Social isolation and loneliness affect the quality of life of people living with dementia, yet few interventions have been developed for this population. The purpose of this study was to assess the feasibility and acceptability of 'Connecting Today', a remote visiting program designed for use with care home residents living with dementia.

METHODS

This was a feasibility study to assess whether Connecting Today can be delivered in care homes, and was acceptable to family and friends and people living with dementia. We used a single-group before/after design and included residents ≥ 65 years old with a dementia diagnosis from two care homes in Alberta, Canada. Connecting Today involved up to 60 min per week of facilitated remote visits for 6 weeks. To understand feasibility, we assessed rates and reasons for non-enrollment, withdrawal and missing data. We assessed acceptability with the Observed Emotion Rating Scale (residents) and a Treatment Perception and Preferences Questionnaire (family and friends). Data were analyzed with descriptive statistics.

RESULTS

Of 122 eligible residents, 19.7% (n = 24) enrolled (mean age = 87.9 years, 70.8% females). Three residents withdrew from the study before the first week of calls. Among 21 remaining residents, 62%-90% completed at least 1 call each week. All the calls were completed by videoconference, rather than by phone. Alertness and pleasure were observed for ≥92% of residents during calls. The 24 contacts rated Connecting Today as logical, effective and low risk.

CONCLUSIONS

Facilitated, remote visits are feasible and highly acceptable to residents and their family and friend contacts. Connecting Today shows promise to address social isolation and loneliness for people living with moderate to severe dementia because it can promote positive engagement in meaningful interactions with their family and friends while they are living in a care home. Future studies will test effectiveness of Connecting Today in a large sample.

Nutrition and Non-Nutrition-Related Challenges Predict Time to Death in Long-Term Care Residents: A Retrospective Chart Review

Purpose

Signals of end-of-life decline observed in daily habits, such as mealtime participation, are important for moving towards comfort-focused goals of care in the final months of life of long-term care (LTC) residents. It is unclear how eating issues observed in real-time in LTC homes are used as indicators of suspected end of life. The study quantifies nutrition and key non-nutrition related signals (eg, general decline, unstable vitals) documented to describe end-of-life decline and the subsequent time to death.

Patients and Methods

A retrospective chart review identified the first documented conversation where end-of-life decline was considered by members of the care team (eg, nurses, physicians, dietitian, family member) for 76 randomly selected decedents from 9 LTC homes in southwestern Ontario, Canada. Time (days) to death was calculated. A directed content analysis of the free-text description of the suspected end-of-life decline was used to categorize signals. Cox proportional hazards regression analysis tested the risk of mortality associated with each categorized signal.

Results

Time to death of residents (mean age = 88 ± 7 years; 60% female) from the first documentation of potential end-of-life decline ranged from 0 days to over 2 years prior to death (median = 27.5 days). Seven nutrition-related and 18 non-nutrition related signals were identified. Swallowing difficulty (HR = 2.99; 95% CI = 1.41, 6.33), cognitive decline (HR = 0.40; 95% CI = 0.20, 0.77), delirium (HR = 13.23; 95% CI = 1.57, 111.69), and cancer (HR = 0.18; 95% CI = 0.07, 0.48) were associated with time to death.

Conclusion

This study provides insight into the signals used by care providers in LTC to suspect that residents are declining towards the end of life and identifies four signals that were associated with time to death. When identified by care providers as indicators of end-of-life decline, swallowing difficulty and delirium predicted a shorter time to death, while cancer and cognitive decline predicted a longer time to death. Recognition of nutrition and non-nutrition related signals may be leveraged to systematically introduce timely comfort care conversations.

Opioid deprescribing in long-term care in Ontario: A comparison of resident and facility characteristics

Residents of long-term care (LTC) homes have potentially painful conditions and are prescribed opioids to manage their pain, despite the risks associated with the use of these high-risk medications. Therefore, the overall aim of this study was to describe the associations between resident and facility characteristics of residents prescribed long-term opioid therapy and those who remained on opioids or had opioids deprescribed. We conducted a retrospective cohort study utilizing health administrative databases housed within ICES. Our cohort included 26,592 of 121,564 LTC residents (21.9%) of Ontario LTC homes who were prescribed long-term opioid therapy at cohort inception. Of these residents, 4,299 (16.2%) residents had opioids deprescribed during the follow-up period. Opioid deprescribing was associated with younger age, high comorbidity, and co-prescription with benzodiazepines and gabapentinoids. Our findings suggest that there is variation in the characteristics of residents who continued long-term opioid therapy and those who subsequently had opioids deprescribed, and these characteristics need to be considered as part of individualized pain management plans of care.

Determinants of access of frail, community-residing older adults to geriatricians in Ontario

OBJECTIVES

Little is known about determinants of access to community-based geriatricians. The Geriatric 5Ms™ describe geriatricians' core competencies and inform referrals to specialists for older adults with complex needs. We explored the association of the Geriatric 5Ms™ and other characteristics with outpatient access to geriatricians by home care (HC) clients.

METHODS

This was a population-based, retrospective cohort study of frail community-dwelling HC clients (≥60 years) with complex needs (n = 196,444). Health assessment information was linked to health services data in Ontario, Canada, 2012-2015. Multivariable generalized estimating equations were used to identify characteristics associated with geriatrician contact (≥1 visit in 90 days post-HC admission), including derived Geriatric 5Ms™ score, and predisposing, enabling, and need factors obtained from clinical assessments.

RESULTS

Only 5.2% of the cohort had outpatient geriatrician contact in Ontario, Canada. Derived Geriatric 5Ms™ score was associated with higher odds of contact, but the model had modest discriminatory power (c-statistic = 0.67). In the broader multivariable model, based on empirically included factors and adjusted for regional differences, age, worsening of decision-making, dementia, hallucinations, Parkinsonism, osteoporosis, and caregiver distress/institutionalization risk were associated with higher odds of geriatrician contact. Female sex, difficulties accessing home, impaired locomotion, recovery potential, hemiplegia/hemiparesis, and cancer, were associated with lower odds of contact. This model had good discriminatory power (c-statistic = 0.77).

CONCLUSIONS

Few frail, community-dwelling older adults receiving HC had any outpatient geriatrician contact. While the derived Geriatric 5Ms™ score was associated with contact, a broader empirical model performed better than the Geriatric 5Ms™ in predicting contact with an outpatient geriatrician. Contact was mainly driven by conditions common in older adults, but evidence suggests that geriatricians are not evaluating the most medically complex and unstable older adults in the community. These findings suggest a need to re-examine the referral process for geriatricians and the allocation of limited specialized resources.

Factors associated with avoidable hospital transfers among residents in Swiss nursing homes

Unplanned hospitalizations from nursing homes (NHs) may be considered potentially avoidable and can result in adverse resident outcomes. There is little information about the relationship between a clinical assessment conducted by a physician or geriatric nurse expert before hospitalization and an ensuing rating of avoidability. This study aimed to describe characteristics of unplanned hospitalizations (admitted residents with at least one night stay, emergency department visits were excluded) and to examine this relationship. We conducted a cohort study in 11 Swiss NHs and retrospectively evaluated data from the root cause analysis of 230 unplanned hospitalizations. A telephone assessment by a physician (p=.043) and the need for further medical clarification and treatment (p=<0.001) were the principal factors related to ratings of avoidability. Geriatric nurse experts can support NH teams in acute situations and assess residents while adjudicating unplanned hospitalizations. Constant support for nurses expanding their clinical role is still warranted.

Differences in clinical presentation at first hospitalization and the impact on involuntary admissions among first-generation migrant groups with non-affective psychotic disorders

BACKGROUND

Some migrant and ethnic minority groups have a higher risk of coercive pathways to care; however, it is unclear whether differences in clinical presentation contribute to this risk. We sought to assess: (i) whether there were differences in clinician-rated symptoms and behaviours across first-generation immigrant and refugee groups at the first psychiatric hospitalization after psychosis diagnosis, and (ii) whether these differences accounted for disparities in involuntary admission.

METHODS

Using population-based health administrative data from Ontario, Canada, we constructed a sample (2009-2013) of incident cases of non-affective psychotic disorder followed for two years to identify first psychiatric hospitalization. We compared clinician-rated symptoms and behaviours at admission between first-generation immigrants and refugees and the general population, and adjusted for these variables to ascertain whether the elevated prevalence of involuntary admission persisted.

RESULTS

Immigrants and refugee groups tended to have lower ratings for affective symptoms, self-harm behaviours, and substance use, as well as higher levels of medication nonadherence and poor insight. Immigrant groups were more likely to be perceived as aggressive and a risk of harm to others, and both groups were perceived as having self-care issues. Adjustment for perceived differences in clinical presentation at admission did not attenuate the higher prevalence of involuntary admission for immigrant and refugee groups.

CONCLUSIONS

First-generation migrant groups may differ in clinical presentation during the early course of psychotic illness, although these perceived differences did not explain the elevated rates of involuntary admission. Further research using outpatient samples and tools with established cross-cultural validity are warranted.

Psychosocial interventions for reducing antipsychotic medication in care home residents

BACKGROUND

Antipsychotic medications are regularly prescribed in care home residents for the management of behavioural and psychological symptoms of dementia (BPSD) despite questionable efficacy, important adverse effects, and available non-pharmacological interventions. Prescription rates are related to organisational factors, staff training and job satisfaction, patient characteristics, and specific interventions. Psychosocial intervention programmes aimed at reducing the prescription of antipsychotic drugs are available. These programmes may target care home residents (e.g. improving communication and interpersonal relationships) or target staff (e.g. by providing skills for caring for people with BPSD). Therefore, this review aimed to assess the effectiveness of these interventions, updating our earlier review published in 2012.

OBJECTIVES

To evaluate the benefits and harms of psychosocial interventions to reduce antipsychotic medication use in care home residents compared to regular care, optimised regular care, or a different psychosocial intervention.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 14 July 2022.

SELECTION CRITERIA

We included individual or cluster-randomised controlled trials comparing a psychosocial intervention aimed primarily at reducing the use of antipsychotic medication with regular care, optimised regular care, or a different psychosocial intervention. Psychosocial interventions were defined as non-pharmacological intervention with psychosocial components. We excluded medication withdrawal or substitution interventions, interventions without direct interpersonal contact and communication, and interventions solely addressing policy changes or structural interventions.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Critical appraisal of studies addressed risks of selection, performance, attrition and detection bias, as well as criteria related to cluster randomisation. We retrieved data on the complex interventions on the basis of the TIDieR (Template for Intervention Description and Replication) checklist. Our primary outcomes were 1. use of regularly prescribed antipsychotic medication and 2.

ADVERSE EVENTS

Our secondary outcomes were 3. mortality; 4. BPSD; 5. quality of life; 6. prescribing of regularly psychotropic medication; 7. regimen of regularly prescribed antipsychotic medication; 8. antipsychotic medication administered 'as needed'; 9. physical restraints; 10. cognitive status; 11. depression; 12. activities of daily living; and 13.

COSTS

We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included five cluster-randomised controlled studies (120 clusters, 8342 participants). We found pronounced clinical heterogeneity and therefore decided to present study results narratively. All studies investigated complex interventions comprising, among other components, educational approaches. Because of the heterogeneity of the results, including the direction of effects, we are uncertain about the effects of psychosocial interventions on the prescription of antipsychotic medication. One study investigating an educational intervention for care home staff assessed the use of antipsychotic medication in days of use per 100 resident-days, and found this to be lower in the intervention group (mean difference 6.30 days, 95% confidence interval (CI) 6.05 to 6.66; 1152 participants). The other four studies reported the proportion of participants with a regular antipsychotic prescription. Of two studies implementing an intervention to promote person-centred care, one found a difference in favour of the intervention group (between-group difference 19.1%, 95% CI 0.5% to 37.7%; 338 participants), while the other found a difference in favour of the control group (between-group difference 11.4%, 95% CI 0.9% to 21.9%; 862 participants). One study investigating an educational programme described as "academic detailing" found no difference between groups (odds ratio 1.06, 95% CI 0.93 to 1.20; 5363 participants). The fifth study used a factorial design to compare different combinations of interventions to supplement person-centred care. Results showed a positive effect of medication review, and no clear effect of social interaction or exercise. We considered that, overall, the evidence about this outcome was of low certainty. We found high-certainty evidence that psychosocial interventions intended primarily to reduce antipsychotic use resulted in little to no difference in the number of falls, non-elective hospitalisations, or unplanned emergency department visits. Psychosocial interventions intended primarily to reduce antipsychotic use also resulted in little to no difference in quality of life (moderate-certainty evidence), and BPSD, regular prescribing of psychotropic medication, use of physical restraints, depression, or activities of daily living (all low-certainty evidence). We also found low-certainty evidence that, in the context of these interventions, social interaction and medication review may reduce mortality, but exercise does not.

AUTHORS' CONCLUSIONS

All included interventions were complex and the components of the interventions differed considerably between studies. Interventions and intervention components were mostly not described in sufficient detail. Two studies found evidence that the complex psychosocial interventions may reduce antipsychotic medication use. In addition, one study showed that medication review might have some impact on antipsychotic prescribing rates. There were no important adverse events. Overall, the available evidence does not allow for clear generalisable recommendations.

Coronavirus Disease 2019 Vaccination Is Associated With Reduced Outpatient Antibiotic Prescribing in Older Adults With Confirmed Severe Acute Respiratory Syndrome Coronavirus 2: A Population-Wide Cohort Study

BACKGROUND

Antibiotics are frequently prescribed unnecessarily in outpatients with coronavirus disease 2019 (COVID-19). We sought to evaluate factors associated with antibiotic prescribing in outpatients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

METHODS

We performed a population-wide cohort study of outpatients aged ≥66 years with polymerase chain reaction-confirmed SARS-CoV-2 from 1 January 2020 to 31 December 2021 in Ontario, Canada. We determined rates of antibiotic prescribing within 1 week before (prediagnosis) and 1 week after (postdiagnosis) reporting of the positive SARS-CoV-2 result, compared to a self-controlled period (baseline). We evaluated predictors of prescribing, including a primary-series COVID-19 vaccination, in univariate and multivariable analyses.

RESULTS

We identified 13 529 eligible nursing home residents and 50 885 eligible community-dwelling adults with SARS-CoV-2 infection. Of the nursing home and community residents, 3020 (22%) and 6372 (13%), respectively, received at least 1 antibiotic prescription within 1 week of a SARS-CoV-2 positive result. Antibiotic prescribing in nursing home and community residents occurred, respectively, at 15.0 and 10.5 prescriptions per 1000 person-days prediagnosis and 20.9 and 9.8 per 1000 person-days postdiagnosis, higher than the baseline rates of 4.3 and 2.5 prescriptions per 1000 person-days. COVID-19 vaccination was associated with reduced prescribing in nursing home and community residents, with adjusted postdiagnosis incidence rate ratios (95% confidence interval) of 0.7 (0.4-1) and 0.3 (0.3-0.4), respectively.

CONCLUSIONS

Antibiotic prescribing was high and with little or no decline following SARS-CoV-2 diagnosis but was reduced in COVID-19-vaccinated individuals, highlighting the importance of vaccination and antibiotic stewardship in older adults with COVID-19.

Inter-provincial variation in older home care clients and their pathways: a population-based retrospective cohort study in Canada

BACKGROUND

In Canada, publicly-funded home care programs enable older adults to remain and be cared for in their home for as long as possible but they often differ in types of services offered, and the way services are delivered. This paper examines whether these differing approaches to care shape the pathway that home care clients will take. Older adult client pathways refer to trajectories within, and out of, the home care system (e.g., improvement, long term care (LTC) placement, death).

METHODS

A retrospective analysis of home care assessment data (RAI-HC was linked with health administrative data, long-term care admissions and vital statistics in Nova Scotia Health (NSH) and Winnipeg Regional Health Authority (WRHA). The study cohort consists of clients age 60 + years, admitted to home care between January 1, 2011 to December 31, 2013 and up to four years from baseline. Differences in home care service use, client characteristics and their pathways were tested across the two jurisdictions overall, and among the four discharge streams within jurisdictions using t-tests and chi-square tests of significance.

RESULTS

NS and WHRA clients were similar in age, sex, and marital status. NS clients had higher levels of need (ADL, cognitive impairment, CHESS) at base line and were more likely discharged to LTC (43% compared to 38% in WRHA). Caregiver distress was a factor correlated with being discharged to LTC. While a third remained as home care clients after 4 years; more than half were no longer in the community - either discharged to LTC placement or death. Such discharges occurred on average at around two years, a relatively short time period.

CONCLUSIONS

By following older clients over 4 years, we provide enhanced evidence of client pathways, the characteristics that influence these paths, as well as the length of time to the outcomes. This evidence is central to identification of clients at risk in the community and aids in planning for future home care servicing needs that will allow more older adults to remain living in the community.

Chronic health conditions and mortality among older adults with complex care needs in Aotearoa New Zealand

BACKGROUND

Older people have more comorbidities than younger groups and multimorbidity will increase. Often chronic conditions affect quality of life, functional ability and social participation. Our study aim was to quantify the prevalence of chronic conditions over a three-year period and their association with mortality after accounting for demographics.

METHODS

We conducted a retrospective cohort study using routinely collected health data including community-dwelling older adults in New Zealand who had an interRAI Home Care assessment between 1 January 2017 and 31 December 2017. Descriptive statistics and differences between variables of interest among ethnic groups were reported. Cumulative density plots of mortality were developed. Logistic regression models adjusted for age and sex to estimate mortality were created independently for each combination of ethnicity and disease diagnosis.

RESULTS

The study cohort consisted of 31,704 people with a mean (SD) age of 82.3 years (8.0), and of whom 18,997 (59.9%) were female. Participants were followed for a median 1.1 (range 0 to 3) years. By the end of the follow-up period 15,678 (49.5%) people had died. Nearly 62% of Māori and Pacific older adults and 57% of other ethnicities had cognitive impairment. Diabetes the next most prevalent amongst Māori and Pacific peoples, and coronary heart disease amongst Non-Māori/Non-Pacific individuals. Of the 5,184 (16.3%) who had congestive heart failure (CHF), 3,450 (66.6%) died. This was the highest mortality rate of any of the diseases. There was a decrease in mortality rate with age for both sexes and all ethnicities for those with cancer.

CONCLUSIONS

Cognitive impairment was the most common condition in community dwelling older adults who had an interRAI assessment. Cardiovascular disease (CVD) has the highest mortality risk for all ethnic groups, and in non-Māori/non-Pacific group of advanced age, risk of mortality with cognitive impairment is as high as CVD risk. We observed an inverse for cancer mortality risk with age. Important differences between ethnic groups are reported.