Antimicrobial resistance in urinary pathogens among Swedish nursing home residents remains low: a cross-sectional study comparing antimicrobial resistance from 2003 to 2012

BACKGROUND

There are several risk factors for the colonisation, infection and spreading of antibiotic resistant bacteria among elderly residents of nursing homes. An updated estimate of the native prevalence of antimicrobial resistance in uropathogens among Swedish nursing home residents is needed.

METHODS

Urine specimens were collected for culture and antimicrobial susceptibility testing against mecillinam, ampicillin, cefadroxil, trimethoprim, nitrofurantoin and quinolones from the residents of 32 and 22 nursing homes, respectively. The residents were capable of providing a voided urine sample in 2003 and 2012. In 2012 urine specimens were also collected from residents with urinary catheters. Any antibiotic treatment during the previous month was registered in 2003 as well as hospitalisation and any antibiotic treatment during the previous six months in 2012.

RESULTS

The proportion of positive urine cultures was 32% (207/651) in voided urine specimens in 2003, 35% (147/421) in 2012, and 46% (27/59) in urine samples from catheters in 2012. Escherichia coli (E. coli) was the most commonly occurring bacteria.Resistance rates in E. coli (voided urine specimens) in 2012 were; ampicillin 21%, trimethoprim 12%, mecillinam 7.7%, ciprofloxacin 3.4%, cefadroxil 2.6% and nitrofurantoin 0.85%. There were no significant changes in the average resistance rates in E. coli for antibiotics tested 2003-2012.In 2012, two isolates of E. coli produced extended spectrum beta-lactamase enzymes (ESBL) and one with plasmid mediated AmpC production.Any antibiotic treatment during the previous month increased the risk for resistance in E. coli, adjusted for age and gender; for mecillinam with an odds ratio (OR) of 7.1 (2.4-21; p = 0.00049), ampicillin OR 5.2 (2.4-11; p = 0.000036), nalidixic acid OR 4.6 (1.4-16; p = 0.014) and trimethoprim OR 3.9 (1.6-9.2; p = 0.0023). Hospitalisation during the previous six months increased the risk for antibiotic resistance in E. coli to ampicillin, ciprofloxacin and any antimicrobial tested, adjusted for age, gender and antibiotic treatments during the previous six months.

CONCLUSIONS

The average rates of antimicrobial resistance were low and did not increase between 2003 and 2012 in E. coli urinary isolates among Swedish nursing home residents. Antibiotic treatment during the previous month and hospitalisation during the previous six months predicted higher resistance rates.

New horizons in care home medicine

Care home medicine has been an under-researched area, but over the last decade there has been a substantial growth in publications. Most of these have focused on the 'geriatric giants' of falls, incontinence and mental health issues (especially dementia, behavioural disturbance and depression) as well as other key topics such as medication use and issues related to death and dying. Other areas of recent interest are around access to health services for care home residents, how such services may most effectively be developed and how the quality of life for residents can be enhanced. While many of the reported studies are small and not always well designed, evidence in several areas is emerging which begins to guide service developments. A common theme is that multi-disciplinary interventions are the most effective models of delivery. The role of care home staff as members of these teams is key to their effectiveness. Recent consensus guidelines around falls prevention in care homes synthesise the evidence and recommend multi-disciplinary interventions, and clarify the role of vitamin D and of exercise in certain populations in the care home. The benefits of pharmacist led medication reviews are beginning to emerge; although studies reviewed to date have not yet led to the 'holy grail' of hospital admission avoidance they point to benefits in reduction of drug burden. Effectiveness may be enhanced when working with GPs and care home nurses. Welcome evidence is emerging that in the UK the rate of prescription of anti-psychotics has fallen. This is clear evidence that changes in practice around care homes can be effected. The poor access to non-pharmacological therapies for care home residents with behavioural disturbance remains a significant gap in service. End-of-life care planning and delivery is an important part of care in care homes, and there is evidence that integrated pathways can improve care; however, the use of palliative care medications was limited unless specialist care staff were involved. Integrated models of care that focus on resident-centred goals and which value the role of care home staff as members of the team working to deliver these goals are most likely to result in improvements in the quality of care experienced by care home residents.

[Optimization of nursing care in emergency cases in elderly patients residing in nursing homes]

The study analyzes data on the frequency of emergencies in elderly patients residing in nursing homes. We propose to introduce into the nursing care the screening phase of emergency conditions in elderly patients residing in nursing homes based on the selection of the leading symptom. This improves the quality of the nursing process in pre-hospital geriatric care in emergencies.

Longitudinal evaluation of dementia care in German nursing homes: the "DemenzMonitor" study protocol

BACKGROUND

In Germany, the number of people with dementia living in nursing homes is rapidly increasing. Providing adequate care for their special needs is a challenge for institutions and their staff members. Because of the growing number of people with dementia, changes to the conceptual orientation of nursing homes have occurred. These changes include specialized living arrangements and psychosocial interventions recommended for people with dementia. Until now, the provision of dementia care and its association to the residents' behavior and quality of life is not well investigated in Germany. The purpose of this study is to describe the provision of dementia care and to identify resident- as well as facility-related factors associated with residents behavior and quality of life.

METHODS/DESIGN

The DemenzMonitor study is designed as a longitudinal study that is repeated annually. Data will be derived from a convenience sample consisting of nursing homes across Germany. For the data collection, three questionnaires have been developed that measure information on the level of the nursing home, the living units, and the residents. Data collection will be performed by staff members from the nursing homes. The data collection procedure will be supervised by a study coordinator who is trained by the research team. Data analysis will be performed on each data level using appropriate techniques for descriptions and comparisons as well as longitudinal regression analysis.

DISCUSSION

The DemenzMonitor is the first study in Germany that assesses how dementia care is provided in nursing homes with respect to living arrangements and recommended interventions. This study links the acquired data with residents' outcome measurements, making it possible to evaluate different aspects and concepts of care.

Gaps in nurse staffng and nursing home resident needs

Trends in nurse staffing levels in nursing homes from 1997 to 2011 varied across the category of nurse and the type of nursing home. The gaps found in this study are important to consider because nurses may become overworked and this may negatively affect the quality of services and jeopardize resident safety. Nursing home administrators should consider improving staffing strategically. Staffing should be based not only on the number of resident days, but also allocated according to particular resident needs. As the demand for nursing home care grows, bridging the gap between nurse staffing and resident nursing care needs will be especially important in light of the evidence linking nurse staffing to the quality of nursing home care. Until more efficient nursing care delivery exits, there may be no other way to safeguard quality except to increase nurse staffing in nursing homes.

Potentially inappropriate medications used by the elderly: prevalence and risk factors in Brazilian care homes

BACKGROUND

The use of potentially inappropriate medications (PIM) among the elderly is a serious public health problem because it is intrinsically linked to increased morbidity and mortality, causing high costs to public health systems. This study's objective was to verify the prevalence of and the factors associated with the use of PIMs by elderly Brazilians in institutional settings.

METHODS

We performed a transversal study, by consulting the case files of elderly people living in Long Term Care for the Elderly (LTC) in towns in the State of São Paulo, Brazil, as well as structured interviews with the nurses responsible for them.We identified PIMs using the list of recently updated Beers criteria developed by a group of specialists from the American Geriatrics Society (AGS), who reviewed the criteria based on studies with high scientific evidence levels. We defined the factors studied to evaluate the association with PIM use prior to the statistical analyses, which were the chi-square test and multiple logistic regression.

RESULTS

Among the elderly who used drugs daily, 82.6% were taking at least one PIM, with antipsychotics (26.5%) and analgesics (15.1%) being the most commonly used. Out of all the medications used, 32.4% were PIMs, with 29.7% of these being PIMs that the elderly should avoid independent of their condition, 1.1% being inappropriate medication for older adults with certain illnesses or syndromes, and 1.6% being medications that older adults should use with caution. In the multivariate analysis, the factors associated with PIM use were: polypharmacy (p = 0.0187), cerebrovascular disease (p = 0.0036), psychiatric disorders (p < 0.0001) and dependency (p = 0.0404).

CONCLUSIONS

The results of this study showed a high prevalence of PIM use in institutionalized elderly Brazilian patients. and the associated factors were polypharmacy, psychiatric disorders, cerebrovascular diseases and dependency.

Dementia, sexuality and consent in residential aged care facilities

Sexual self-determination is considered a fundamental human right by most of us living in Western societies. While we must abide by laws regarding consent and coercion, in general we expect to be able to engage in sexual behaviour whenever, and with whomever, we choose. For older people with dementia living in residential aged care facilities (RACFs), however, the issue becomes more complex. Staff often struggle to balance residents' rights with their duty of care, and negative attitudes towards older people's sexuality can lead to residents' sexual expression being overlooked, ignored, or even discouraged. In particular, questions as to whether residents with dementia are able to consent to sexual activity or physically intimate relationships pose a challenge to RACF staff, and current legislation does little to assist them. This paper will address these issues, and will argue that, while every effort should be made to ensure that no resident comes to harm, RACFs must respect the rights of residents with dementia to make decisions about their sexuality, intimacy and physical relationships.

Examining the role of information exchange in residential aged care work practices--a survey of residential aged care facilities

BACKGROUND

The provision of residential aged care is underpinned by information, and is reliant upon systems that adequately capture and effectively utilise and communicate this information. The aim of this study was to explicate and quantify the volume and method by which information is collected, exchanged within facilities and with external providers, and retrieved from facility information systems and hospitals.

METHODS

A survey of staff (n = 119), including managers, health informatics officers (HIOs), quality improvement staff, registered nurses (RNs), enrolled nurses (ENs)/endorsed enrolled nurses (EENs) and assistants in nursing (AINs) was carried out in four residential aged care facilities in New South Wales and Victoria, Australia. Sites varied in size and displayed a range of information technology (IT) capabilities. The survey investigated how and by whom information is collected, retrieved and exchanged, and the frequency and amount of time devoted to these tasks. Descriptive analysis was performed using SPSS, and open responses to questions were coded into key themes.

RESULTS

Staff completed a median of six forms each, taking a median of 30 min per shift. 68.8% of staff reported transferring information from paper to a computer system, which took a median of 30 min per shift. Handover and face-to-face communication was the most frequently used form of information exchange within facilities. There was a large amount of faxing and telephone communication between facility staff and General Practitioners and community pharmacists, with staff reporting sending a median of 2 faxes to pharmacy and 1.5 faxes to General Practitioners, and initiating 2 telephone calls to pharmacies and 1.5 calls to General Practitioners per shift. Only 38.5% of respondents reported that they always had information available at the point-of-care and only 35.4% of respondents reported that they always had access to hospital stay information of residents after hospital discharge.

CONCLUSIONS

This survey identified a high volume of information exchange activities, as well as inefficient procedures, such as the transfer of information from paper to computer systems and the reliance upon faxes for communication with external providers. These findings contribute to evidence for the need for interoperable IT systems to allow more efficient and reliable information exchange between facilities and external providers.

Sedative load of medications prescribed for older people with dementia in care homes

BACKGROUND

The objective of this study was to determine the sedative load and use of sedative and psychotropic medications among older people with dementia living in (residential) care homes.

METHODS

Medication data were collected at baseline and at two further time-points for eligible residents of six care homes participating in the EVIDEM-End Of Life (EOL) study for whom medication administration records were available. Regular medications were classified using the Anatomical Therapeutic Chemical classification system and individual sedative loads were calculated using a previously published model.

RESULTS

At baseline, medication administration records were reviewed for 115 residents; medication records were reviewed for 112 and 105 residents at time-points 2 and 3 respectively. Approximately one-third of residents were not taking any medications with sedative properties at each time-point, while a significant proportion of residents had a low sedative load score of 1 or 2 (54.8%, 59.0% and 57.1% at baseline and time-points 2 and 3 respectively). More than 10% of residents had a high sedative load score (≥ 3) at baseline (12.2%), and this increased to 14.3% at time-points 2 and 3. Approximately two-thirds of residents (66.9%) regularly used one or more psychotropic medication(s). Antidepressants, predominantly selective serotonin re-uptake inhibitors (SSRIs), were most frequently used, while antipsychotics, hypnotics and anxiolytics were less routinely administered. The prevalence of antipsychotic use among residents was 19.0%, lower than has been previously reported for nursing home residents. Throughout the duration of the study, administration of medications recognised as having prominent sedative adverse effects and/or containing sedative components outweighed the regular use of primary sedatives.

CONCLUSIONS

Sedative load scores were similar throughout the study period for residents with dementia in each of the care homes. Scores were lower than previously reported in studies conducted in long-term care wards which have on-site clinical support. Nevertheless, strategies to optimise drug therapy for care home residents with dementia which rely on clinicians external to the care home for support and medication review are required.

Relations among home- and community-based services investment and nursing home rates of use for working-age and older adults: a state-level analysis

OBJECTIVES

I examined state-level rates of nursing home use for the period from 2000 to 2007.

METHODS

I used multivariate fixed-effects models to examine associations between state sociodemographic, economic, supply, and programmatic characteristics and rates of use.

RESULTS

Nursing home use declined among older adults (aged ≥65 years) in more than two thirds of states and the District of Columbia but increased among older working-age adults (aged 31-64 years) in all but 2 states. State characteristics associated with these trends differed by age group. Although relatively greater state investment in Medicaid home- and community-based services coupled with reduced nursing home capacity was associated with reduced rates of nursing home care for adults aged 65 years and older, neither characteristic was associated with use among older working-age adults. Their use was associated with state sociodemographic characteristics, as well as chronic disease prevalence.

CONCLUSIONS

Policy efforts to expand home- and community-based services and to reduce nursing facility capacity appear warranted. To more fully extend the Supreme Court's Olmstead decision's promise to older working-age adults, additional efforts to understand factors driving their increasing use are required.

Residential aged care in Auckland, New Zealand 1988-2008: do real trends over time match predictions?

BACKGROUND

in Auckland, New Zealand in 1988, 7.7% of those aged over 65 years lived in licenced residential aged care. Age-specific rates approximately doubled for each 5-year age group after the age of 65 years. Even with changes in policies and market forces since 1988, population increases are forecast to drive large growth in demand. This study shows previously unrecognised 20-year trends in rates of care in a geographically defined population.

METHODS

four cross-sectional surveys of all facilities (rest homes and hospitals) licenced for long-term care of older people were conducted in Auckland, New Zealand in 1988, 1993, 1998 and 2008. Facility staff completed survey forms for each resident. Numbers of licenced and occupied beds and trends in age-specific and age-standardised rates in residential aged care are reported.

RESULTS

over the 20-year period, Auckland's population aged over 65 years increased by 43% (from 91,000 to 130,000) but actual numbers in care reduced slightly. Among those aged over 65 years, the proportion living in care facilities reduced from 1 in 13 to 1 in 18. Age-standardised rates in rest-home level care reduced from 65 to 33 per thousand, and in hospital level care, from 29 to 23 per thousand. Had rates remained stable, over 13,200 people, 74% more than observed, would have been in care in 2008.

CONCLUSION

growth predicted in the residential aged care sector is not yet evident. The introduction of standardised needs assessments before entry, increased availability of home-based services, and growth in retirement villages may have led to reduced utilisation.

Implementing a quality improvement programme in palliative care in care homes: a qualitative study

BACKGROUND

An increasing number of older people reach the end of life in care homes. The aim of this study is to explore the perceived benefits of, and barriers to, implementation of the Gold Standards Framework for Care Homes (GSFCH), a quality improvement programme in palliative care.

METHODS

Nine care homes involved in the GSFCH took part. We conducted semi-structured interviews with nine care home managers, eight nurses, nine care assistants, eleven residents and seven of their family members. We used the Framework approach to qualitative analysis. The analysis was deductive based on the key tasks of the GSFCH, the 7Cs: communication, coordination, control of symptoms, continuity, continued learning, carer support, and care of the dying. This enabled us to consider benefits of, and barriers to, individual components of the programme, as well as of the programme as a whole.

RESULTS

Perceived benefits of the GSFCH included: improved symptom control and team communication; finding helpful external support and expertise; increasing staff confidence; fostering residents' choice; and boosting the reputation of the home. Perceived barriers included: increased paperwork; lack of knowledge and understanding of end of life care; costs; and gaining the cooperation of GPs. Many of the tools and tasks in the GSFCH focus on improving communication. Participants described effective communication within the homes, and with external providers such as general practitioners and specialists in palliative care. However, many had experienced problems with general practitioners. Although staff described the benefits of supportive care registers, coding predicted stage of illness and advance care planning, which included improved communication, some felt the need for more experience of using these, and there were concerns about discussing death.

CONCLUSIONS

Most of the barriers described by participants are relevant to other interventions to improve end of life care in care homes. There is a need to investigate the impact of quality improvement programmes in care homes, such as the GSFCH, on a wider range of outcomes for residents and their families, and to monitor the sustainability of any resulting improvements. It is also important to explore the impact of the different components of these complex interventions.