Efforts to establish the reliability of the Resident Assessment Instrument

Association between rehabilitation care practices and care quality in long-term care facilities

This article analyzes the association between rehabilitation care practices and quality outcomes in Finland and represents unit-level (n = 256) associations between rehabilitation nursing and quality outcomes. Units classified as units providing a high frequency of rehabilitation care practices had better outcomes in 2 of 5 quality outcomes.

Patient depression and caregiver attitudes: results from The AgeD in HOme Care study

BACKGROUND

The present cross-sectional study was aimed to evaluate the association between care recipient depression and caregiver attitudes.

METHODS

Data were from The AgeD in HOme Care project, a study enrolling subjects aged >or=65 years receiving home care in Europe. Depression was diagnosed as a score >or=3 on the MDS Depression Rating Scale. Caregiver attitudes were assessed using two measures: 1) caregiver dissatisfaction (the caregiver was dissatisfied with the support received from family and friends); and 2) caregiver distress (the caregiver expressed feelings of distress, anger, or depression).

RESULTS

Mean age of 3415 participants was 82.4 years, 2503 (73.3%) were women and 430 (12.6%) were depressed. Dissatisfaction was significantly more common among caregivers of depressed, compared with those of non depressed patients (32/430, 7.4% vs. 78/2985, 2.6%; p=<0.001). After adjusting for potential confounders, patient depression was still significantly associated with caregiver dissatisfaction (OR: 1.84; 95% CI: 1.12-3.03). Similarly, distress was significantly more common among caregivers of depressed patients, compared with those of non depressed patients (81/430, 18.8% vs. 175/2985, 5.9%; p<0.001). After adjusting for potential confounders, patient depression was still significantly associated with caregiver distress (OR: 2.41; 95% CI: 1.72-3.39).

LIMITATIONS

The cross-sectional design of the study cannot provide the cause-effect relationship between depression and caregiver attitude; no data were collected on caregiver characteristics.

CONCLUSIONS

Among older adults depression is associated with increased caregiver dissatisfaction and distress. Knowledge of factors influencing caregiver attitudes may be valuable to study interventions aimed to promote patient and caregiver well being.

Relatives' struggle for an improved and more just care for older people in community care

AIMS AND OBJECTIVES

The aim of the present study was to describe the relatives' experience concerning older family members living in special housing facilities.

BACKGROUND

During the 21st century, the relatives of older people and their efforts related to the care and nursing of older people have been observed. The interest in these relatives is because of factors such as demographic changes, where the number of older people has increased and the increasing gap between the resources that are available for geriatric care and the care needed for older people.

DESIGN

The present study has a descriptive design and is part of a project including 24 specific residences, called special housing facilities.

METHOD

The study focused on the narratives supplied by the relatives that were analysed using qualitative latent content analysis, an interpretative process where the researcher considers the content of the text.

RESULTS

The relatives' experience of having an older person in a special housing facility that emerged from the study, was expressed in one main theme: The relatives' struggle for an improved and just care for older people and four sub-themes: (i)'To trust in caregivers'; (ii) 'To be confirmed'; (iii) 'To trust in care'; (iv) 'To receive the kind of care that one considers one has the right to receive'.

CONCLUSIONS

The study shows that the relatives need more support and more opportunities, so that they can participate in the care. The study shows the relatives engagement in working for a just society's obligation towards the protection of older peoples rights and the staff's working conditions.

RELEVANCE TO CLINICAL PRACTICE

It is important that caregivers and management working with older people realize that they, together with them and their relatives, are a part of society and that all individuals are influenced by the discourse of that society.

Pain in the nursing home: assessment and treatment on different types of care wards

The assessment and management of pain in nursing homes have been shown to be suboptimal, but no study has evaluated differences in clinical setting within these homes. The prevalence and management of pain on different care wards (psychogeriatric, somatic, and rehabilitation) was studied on 562 newly admitted Dutch nursing home residents. Pain was measured according to the Nottingham Health Profile (perceived pain) and the Minimum Data Set pain observation items (frequency and intensity). Pain frequency differed significantly across the different ward types: on psychogeriatric wards (n=247), it was 27.1%; on somatic wards (n=181), 53.9%; and on rehabilitation wards (n=129), 57.8%. Being admitted on a psychogeriatric ward was significantly related to less pain compared to being admitted on a somatic ward, even when adjusted for possible confounders such as age, gender, cognitive status, activities of daily living, pain-related disorders, and depression (odds ratio [OR] 0.38 [95% confidence interval (CI)=0.23-0.62]). Patients on psychogeriatric wards who had pain received less pain medication, adjusted for frequency and intensity of pain (OR 0.37 [95% CI=0.23-0.59]), compared to patients on somatic wards. We conclude that admission to a psychogeriatric care ward, independent of cognition, is associated with lower pain prevalence, and also with lower levels of pain treatment.

Cost and Quality

BACKGROUND

Although both quality and cost are important concerns for long term care (LTC) facility management and policy, the relationship between cost and quality is poorly understood. Such knowledge is necessary to guide facility management and policy action.

OBJECTIVE

We sought to determine the net effect of quality on cost in LTC hospital settings.

STUDY SAMPLE

A 4-year panel dataset from April 1997 through March 2002 comprising observations from 99 LTC hospitals were included in this analysis.

METHODS

We examined the relationship between direct resident costs and 7 indicators of quality for long-stay residents. We used panel data methods to control for unobserved facility-level characteristics.

RESULTS

We found that increases in restraint use and incident pressure/skin ulcers were associated with lower per diem costs, whereas incontinence prevalence was associated with higher per diem costs.

CONCLUSIONS

Our results point to different implications regarding cost and quality for different quality indicators. Although facilities have a strong internal business case to improve quality in incontinence, policy-makers may need to provide financial incentives to encourage reductions in restraint use and incident skin ulcers so as to defray potential higher costs associated with improving quality in these areas.

Use of osteoporosis medications in older nursing facility residents

INTRODUCTION

Epidemiologic studies demonstrated that 70% to 85% of nursing home residents have osteoporosis. Few studies report comprehensive information about treatment of osteoporosis in nursing facilities.

OBJECTIVE

To determine the prevalence of osteoporosis treatment and identify resident characteristics associated with the use of antiresorptive medications or supplements indicated to treat osteoporosis in nursing homes.

METHODS

The study design was cross-sectional. The Systematic Assessment of Geriatric Drug Use via Epidemiology database provided the data. From this database, 186,221 residents were identified as newly admitted to nursing facilities in Kansas, Maine, Missouri, Ohio, and South Dakota between 1998 and 2000. The outcome measure was the use of antiresorptive medications (alendronate, risedronate, calcitonin, estrogen, raloxifene) or supplements (calcium with vitamin D) indicated for treatment of osteoporosis. The independent variables included demographic, health status, and fracture risk factors.

RESULTS

Of the overall sample, 9.1% received antiresorptive medications and/or supplements indicated for osteoporosis treatment. The most commonly used treatment was the combination of calcium and vitamin D (5.0%). Calcitonin (2.5%) use exceeded that of any other antiresorptive. Multivariable logistic regression analyses revealed that a diagnosis of osteoporosis and female gender were strongly associated with being more likely to receive an osteoporosis treatment (OR 6.34 with 95% CI 6.11-6.64 and OR 2.67 with 95% CI 2.53-2.83 respectively). The number of medications residents received was also strongly associated with receiving osteoporosis treatment. Being black and having 4 or more active diagnoses were strongly associated with lower odds of receiving treatment (OR 0.63 with 95% CI 0.57-0.68 and OR 0.71 with 95% CI 0.68-0.74 for 4 to 6 diagnoses).

DISCUSSION

Newly admitted nursing facility residents infrequently received an indicated osteoporosis treatment, including calcium with vitamin D, despite the expected high prevalence of osteoporosis in this setting. Few demographic, health status, and fracture risk factors were strongly associated with receiving indicated treatment.

Study of observed and self-reported HRQL in older frail adults found group-level congruence and individual-level differences

OBJECTIVE

To evaluate the consistency of self-reported health-related quality of life (HRQL) using the Health Utilities Index Mark 2 (HUI2) with observer rated HRQL using the Minimum Data Set Health-Status Index (MDS-HSI).

STUDY DESIGN AND SETTING

Frail older home care clients in Calgary Alberta and Wayne County, Michigan responded to HUI2 questionnaires and were assessed using the Minimum Data Set Home Care tool (n=514). HRQL scores were calculated and compared for the HUI2 and the MDS-HSI. The intraclass correlation coefficient (ICC) was used to assess individual level agreement.

RESULTS

The MDS-HSI provided HRQL scores that consistently averaged 0.10 points higher than HUI2 self-reported HRQL scores overall and within client characteristics. The ICC was 0.46 in the full population but increased to 0.63 when 10% of the sample with the largest discrepant scores was removed. Pain and emotion health attributes showed the lowest level of agreement.

CONCLUSION

The MDS-HSI and HUI2 provide analogous group-level results but only moderate individual-level agreement. When HUI2 survey data are not available, the MDS-HSI can be used to substitute for the HUI2 in group-level comparisons but not for individual clinical evaluation comparisons.

Cross-sectional association between behavioral symptoms and potential elder abuse among subjects in home care in Italy: results from the Silvernet Study

OBJECTIVES

The objectives of this study were to evaluate the prevalence of potential elder abuse among older adults receiving home care and to assess the association between behavioral symptoms and potential abuse.

METHODS

Data on 4,630 subjects aged 65 or older receiving home care in Italy were collected using the Minimum Data Set for Home Care assessment. Potential abuse included signs of physical or emotional abuse and neglect. Behavioral symptoms were present if the participant exhibited one or more of the following symptoms in the 3 days before the assessment: wandering, verbally abusive, physically abusive, socially inappropriate behavior, and active resistance to care.

RESULTS

Mean age of participants was 80.5 years (standard deviation: 7.7) and 2,761 (60%) were female. Signs of potential abuse were identified in 336 of 3,869 (9%) participants without behavioral symptoms and 126 of 761 (17%) with behavioral symptoms. After adjustment for potential confounders, presence of behavioral symptoms was significantly associated with potential abuse (odds ratio [OR]: 1.56; 95% confidence interval [CI]: 1.21-2.00). Examining behavioral symptoms separately, wandering was negatively associated with potential abuse (OR: 0.58; 95% CI: 0.36-0.97), whereas other symptoms were positively associated with this outcome (verbally abusive behavior OR: 1.69, 95% CI: 1.24-2.31; physically abusive behavior OR: 1.42, 95% CI: 1.00-2.03; socially inappropriate behavior OR: 1.78, 95% CI: 1.26-2.53; active resistance of care OR: 1.69, 95% CI: 1.20-2.38).

CONCLUSION

Signs of potential abuse are common among older adults in home care in Italy and they are associated with the presence of behavioral symptoms.

Cardiovascular risk factors in cognitively impaired nursing home patients: a relationship with pain?

Cardiovascular risk factors (CRF) such as hypertension and diabetes mellitus favour the development of both vascular dementia (VaD) and Alzheimer's disease (AD). The resulting deafferentation may increase the experience of pain in VaD and in AD. The goal of the present study was to examine the relationship between CRF and pain in a sample of 107 cognitively impaired nursing home patients who had also a chronic pain condition. The prevalence of pain in patients with hypertension or diabetes mellitus was higher (25/41=61% of them had pain) than those without diabetes or hypertension (of whom 24/66=36.4% had pain, p=0.017). In a multivariate logistic regression model (adjusted for gender, age and depression) the presence of diabetes or hypertension was a risk indicator for pain: odds ratio: 3.48, p=0.005, 95% CI: 1.45-8.38. This finding supports the hypothesis that as a result of CRF, disruptions of cortico-cortico and cortico-subcortical pathways occur, and consequently, enhances pain in this group of patients.

Non malignant daily pain and risk of disability among older adults in home care in Europe

Aim of the present observational study was to evaluate the association between daily pain and incident disability in elderly subjects living in the community. We used data from the AgeD in HOme Care (AD-HOC) project, a 1 year longitudinal study enrolling subjects aged 65 or older receiving home care in 11 European countries. Daily pain was defined as any type of pain or discomfort in any part of the body manifested every day in the seven days before the baseline assessment. Disability performing activities of daily living (ADLs) was defined as the need of assistance in 1 or more of the following ADL: eating, dressing, transferring, mobility in bed, personal hygiene and toileting. Mean age of 1520 subjects participating the study was 82.1 (standard deviation 6.9) years, and 1178 (77.5%) were women and 695 (45.7%) reported daily pain at the baseline assessment. Overall, 123/825 participants (19.0%) with daily pain and 132/695 (14.9%) without daily pain reported incident disability during the 1 year follow up of the study. After adjustment for potential confounders, participants with daily pain had a significantly higher risk of developing disability, compared with other participants (hazard ratio 1.36; 95% CI: 1.05-1.78). The risk of disability increased with pain severity and with number of painful sites. In conclusion among old subjects living in the community, daily pain is associated with an increased risk of disability.

Depressive symptoms in newly admitted nursing home residents

OBJECTIVES

To study the relationship between the prevalence of depressive symptoms in newly admitted nursing home residents and their previous place of residence.

METHODS

In 65 nursing homes in the Netherlands trained physicians assessed 562 residents (mean age 78.5, range 28-101, 64.6% female) within 10 days after admission. Depressive symptoms were assessed with the Minimum Data Set (MDS) Depression Rating Scale (DRS), and the MDS items: 'diagnosis of major or minor depression', 'change in depression' and 'indicators of persistent depressed, sad or anxious mood disorder present'. Previous place of residence was categorized as 'own home', 'hospital' or 'sheltered living facility'. Adjustments were performed for demographic and health related factors measured with the MDS.

RESULTS

The prevalence of depressive symptoms (DRS > or = 3) for all 562 residents was 26.9%; it was higher in residents admitted from their own home (34.3%) than in residents admitted from the hospital (19.7%) (p = 0.002). Residents who were admitted from the hospital have an adjusted Odds Ratio for having many depressive symptoms of 0.54 (95% CI 0.31-0.94) compared to residents admitted from their own home. There is, after adjustment, no statistical significant difference between residents admitted from their own home, or residents admitted from a sheltered living facility.

CONCLUSIONS

Depressive symptoms are very prevalent in nursing homes. Residents who are admitted from their own home, or from a residential facility, have more depressive symptoms than residents admitted from the hospital. This may reflect different conceptualizations or different adjustment patterns for those groups. For a better understanding of the factors associated with nursing home depression, future studies in detection, prevention and management of depressive symptoms should start prior to or directly after admission, especially for those who have no prior institutional history.

Provision of rehabilitation nursing in long-term care facilities

AIM

This paper reports an investigation into rehabilitation nursing provided in long-term care settings in Finland, focusing on the amount of time spent with residents, types of rehabilitation nursing provided and resident characteristics associated with rehabilitation nursing.

BACKGROUND

In long-term care, nurses have important roles as members of multidisciplinary care teams in the provision of rehabilitation care. Evidence suggests that rehabilitation nursing has a positive impact on maintaining residents' functional performance. However, there is little information on the patterns and scope of rehabilitation nursing in long-term care facilities.

METHODS

A quantitative, retrospective and cross-sectional study was designed with the data collected between July and December 2002. Rehabilitation nursing was analysed using the Resident Assessment Instrument used in Finland (n = 5312). The frequency and focus of rehabilitation nursing were presented by mean scores and 95% confidence intervals. Univariate and multivariate logistic regression models were built to describe the factors associated with rehabilitation nursing. Odds ratios and confidence intervals were derived from these models.

RESULTS

About 64% of residents received some rehabilitation nursing. Residents assessed as having rehabilitation potential received statistically significantly more rehabilitation nursing than others, such as skills practice in transfer, walking and dressing. Resident factors associated with rehabilitation nursing were cognition, activities of daily living, urinary incontinence, instability of health condition, falls, depression and greater social engagement.

CONCLUSION

Specific resident characteristics and nurses' views of rehabilitation potential determine the provision of rehabilitation nursing. This information could be useful in both targeting and planning rehabilitation nursing in long-term care.

Long-term effects of analgesics in a population of elderly nursing home residents with persistent nonmalignant pain

BACKGROUND

Little is known about the long-term effects of analgesics on functional status and well-being of nursing home residents with chronic pain.

METHODS

Using the Minimum Data Set, we performed a longitudinal study of nursing home residents (n = 10,372) with persistent pain. Using propensity score adjustment techniques, we compared the effect of different analgesics on changes in physical, cognitive, emotional, and social functioning, and examined rates of adverse events over a 6-month period.

RESULTS

There was no change in the analgesic class for at least 6 months for 35.4% of residents, including 40% who received no analgesics during this time. Use of nonopioids was 37.9%, short-acting opioids was 18.9%, and long-acting opioids was 3.3%. We found improvement in functional status (adjusted hazard ratio = 1.85; 95% confidence interval [CI], 1.05-3.23) and social engagement (adjusted hazard ratio = 1.58; 95%, CI, 0.99-2.50) with long-acting opioids compared with short-acting opioids. There were no changes in cognitive status or mood status, or increased risk of depression with use of any analgesics, including opioids. There was a trend toward a lower risk of falls with use of any analgesics (adjusted odds ratio = 0.87; 95% CI, 0.70-1.06). Rates of other adverse events (i.e., constipation, delirium, dehydration, pneumonia) were not found to be higher among chronic opioid users compared to those taking no analgesics or nonopioids.

CONCLUSIONS

The use of long-acting opioids may be a relatively safe option in the management of persistent nonmalignant pain in the nursing home population, yielding benefits in functional status and social engagement.

Evaluation of an educational "toolbox" for improving nursing staff competence and psychosocial work environment in elderly care: results of a prospective, non-randomized controlled intervention

BACKGROUND

Lack of professional development opportunities among nursing staff is a major concern in elderly care and has been associated with work dissatisfaction and staff turnover. There is a lack of prospective, controlled studies evaluating the effects of educational interventions on nursing competence and work satisfaction.

OBJECTIVES

The aim of this study was to evaluate the possible effects of an educational "toolbox" intervention on nursing staff ratings of their competence, psychosocial work environment and overall work satisfaction.

DESIGN

The study was a prospective, non-randomized, controlled intervention.

PARTICIPANTS AND SETTINGS

Nursing staff in two municipal elderly care organizations in western Sweden.

METHODS

In an initial questionnaire survey, nursing staff in the intervention municipality described several areas in which they felt a need for competence development. Measurement instruments and educational materials for improving staff knowledge and work practices were then collated by researchers and managers in a "toolbox." Nursing staff ratings of their competence and work were measured pre and post-intervention by questionnaire. Staff ratings in the intervention municipality were compared to staff ratings in the reference municipality, where no toolbox was introduced.

RESULTS

Nursing staff ratings of their competence and psychosocial work environment, including overall work satisfaction, improved significantly over time in the intervention municipality, compared to the reference group. Both competence and work environment ratings were largely unchanged among reference municipality staff. Multivariate analysis revealed a significant interaction effect between municipalities over time for nursing staff ratings of participation, leadership, performance feedback and skills' development. Staff ratings for these four scales improved significantly in the intervention municipality as compared to the reference municipality.

CONCLUSIONS

Compared to a reference municipality, nursing staff ratings of their competence and the psychosocial work environment improved in the municipality where the toolbox was introduced.

Use of antipsychotic medications among elderly residents in long-term institutional care: a three-year follow-up

OBJECTIVE

To analyse the use of antipsychotic medications, change over time and associated factors in a three-year follow-up among elderly residents in long-term institutional care.

DESIGN

Retrospective study was designed with three identical cross-sectional samples originating from the same long-term care facilities, and collected 1 July to 31 December in 2001, 2002 and 2003, in Finland. These were extracted from the Resident Assessment Instrument (RAI) database, based on Minimum Data Set (MDS) assessments.

SETTING

Of the data providers 16 were hospital-based institutions and 25 residential homes.

PARTICIPANTS

Each of the data sets included 3,662-3,867 resident assessments.

RESULTS

The prevalence use of one or more antipsychotic decreased from 42% in 2001 to 39% in 2003. The overall confounder-adjusted decrease in antipsychotic use was not statistically significant. However, the use of antipsychotics decreased among residents who had wandering as a behavioural problem (OR 0.79, 95% CI 0.63-0.99) and increased among residents with concomitant use of anxiolytic medications (OR 1.23, 95% CI 1.03-1.48).

CONCLUSIONS

The use of antipsychotic medications among residents in long-term institutional care was common and the caring patterns were quite stable during the observation period. Adequate indications may not have been achieved in all cases. More attention should be paid to the appropriate use of antipsychotics in this frail population.

Impact of Pain on Outcomes in Long-Term Care Residents with and without Multiple Sclerosis

OBJECTIVES

To compare long-term care (LTC) residents with and without multiple sclerosis (MS); to compare admission status of pain, physical disability, pressure ulcers, depression, and cognitive performance in LTC residents with and without MS; and to examine the impact of MS and pain on outcomes 90 and 180 days after LTC admission.

DESIGN

Retrospective analysis of a large data set.

SETTING

LTC facilities in Missouri.

PARTICIPANTS

Residents admitted to non-hospital-based LTC facilities.

MEASUREMENTS

Minimum Data Set/Resident Assessment Instrument, Version 2.0; Activities of Daily Living Scale; Cognitive Performance Scale.

RESULTS

Residents with and without MS had similar pain prevalence and intensity after admission, with daily pain more frequent in residents with MS (P=.03). On admission, residents with MS had more physical disability (P<.001) and a greater prevalence of pressure ulcers (P=.004) and depression (P<.001) than residents without MS. In all LTC residents, initial pain status was associated with physical disability (P<.001), pressure ulcers (P<.001), depression (P<.001), and cognitive performance (P<.001) 90 and 180 days after admission. A diagnosis of MS was associated with physical disability (P<.001) 90 and 180 days after admission and pressure ulcer development 180 days after admission (P=.02).

CONCLUSION

Residents with MS were more physically disabled and had more frequent pain and a higher prevalence of pressure ulcers and depression on admission than residents without MS. Pain, or lack thereof, in residents with and without MS on admission may warn of problems that could occur within 6 months after admission to a LTC facility.

Skilled nursing facility rehabilitation and discharge to home after stroke

OBJECTIVE

To determine the relation between rehabilitation therapy (RT) intensity and time to discharge home for stroke patients in skilled nursing facilities (SNFs).

DESIGN

Retrospective cohort study. We used regression analyses, stratified by expected outcome, and propensity score adjustment. Setting All SNFs in Ohio, Michigan, and Ontario, Canada.

PARTICIPANTS

A cohort of residents, aged 65 and over, admitted from hospitals to SNFs with a diagnosis of stroke (N=23,824).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Time to discharge home from an SNF.

RESULTS

RT was given to more than 95% of residents for whom discharge was expected within 90 days and to more than 60% of residents for whom discharge was uncertain or not expected. RT increased the likelihood of discharge to the community for all groups except those expected to be discharged within 30 days. The dose-response relation was strongest for residents with either an uncertain discharge prognosis or no discharge expected.

CONCLUSIONS

Postacute residents with an uncertain prognosis are an important target population for intensive RT.

A national study showed that diagnoses varied by age group in nursing home residents under age 65

OBJECTIVE

Those aged <65 in nursing homes (NHs) are substantially different from elderly residents. This study uses data gathered from the Resident Assessment Instrument's Minimum Data Set (MDS) to describe these relatively rare residents.

STUDY DESIGN AND SETTING

The study uses MDS assessments of close to three-quarter million residents in nine states from 1994 to 1996. Residents are described within chronological age group (0-4, 5-14, etc.). Factor analysis is used to develop diagnostic clusters, and the prevalence of these clusters, functional problems, other conditions, and treatments is described for each group.

RESULTS

Thirteen diagnostic clusters describe nearly 85% of all NH residents and highlight differences between age groups. Pediatric residents are substantially more physically and cognitively impaired than young adult residents, and have the highest case mix burden of care. The youngest population primarily has diagnoses related to mental retardation and developmental disabilities, young adults have the highest prevalence of hemi- and quadriplegia, while older residents are typified by increasing prevalence of neurological diagnoses.

CONCLUSION

This study offers an initial description of NH residents <65. The prevalence of residents with unique conditions may suggest the need to modify the MDS assessment instrument.

Physical rehabilitation following medicare prospective payment for skilled nursing facilities

OBJECTIVE

To examine the effect of the Medicare prospective payment system (PPS) for skilled nursing facilities (SNF) on the delivery of rehabilitation therapy to residents.

DATA SOURCES

Resident-level data are based on the Resident Assessment Instrument Minimum Data Set for nursing facilities. All elderly residents admitted to SNFs in Michigan and Ohio in 1998 and 1999 form the study population (n=99,952).

STUDY DESIGN

A differences-in-differences identification strategy is used to compare rehabilitation therapy for SNF residents before and after a change in Medicare SNF payment. Logistic and linear regression analyses are used to examine the effect of PPS on receipt of physical, occupational, or speech therapy and total therapy time.

DATA EXTRACTION

Data for the present study were extracted from the University of Michigan Assessment Archive Project (UMAAP). One assessment was obtained for each resident admitted to nursing facilities during the study period.

PRINCIPAL FINDINGS

The introduction of PPS for all U.S. Medicare residents in July of 1998 was associated with specific targeting of rehabilitation treatment time to the most profitable levels of therapy. The PPS was also associated with increased likelihood of therapy but less rehabilitation therapy time for Medicare residents.

CONCLUSIONS

The present results indicate that rehabilitation therapy is sensitive to the specific payment incentives associated with PPS.

Community care in Europe. The Aged in Home Care project (AdHOC)

BACKGROUND AND AIMS

Community care for older people is increasing dramatically in most European countries as the preferred option to hospital and long-term care. While there has been a rapid expansion in Evidence-Based Medicine, apart from studies of specific interventions such as home visiting and hospital at home (specialist visits or hospital services provided to people in their own homes in the community), there is little evidence of characteristics of the recipients of community care services or the organisation of services that produce the best outcomes for them and their informal carers. The AdHOC Study was designed to compare outcomes of different models of community care using a structured comparison of services and a comprehensive standardised assessment instrument across 11 European countries. This paper describes the study and baseline data.

METHODS

4,500 people 65 years and older already receiving home care services within the urban areas selected in each country were randomly sampled. They were assessed with the MDS-HC (Minimum Data Set-Home Care) instrument, containing over 300 items, including socio-demographic, physical and cognitive characteristics of patients as well as medical diagnoses and medications received. These data were linked to information on the setting, services structures and services utilization, including use of hospital and long-term care. After baseline assessment, patients were re-evaluated at 6 months with an abbreviated version of the instrument, and then at the end of one year. Data collection was performed by specially-trained personnel. In this paper, socio-demographics, physical and cognitive function and provision of hours of formal care are compared between countries at baseline.

RESULTS

The final study sample comprised 3,785 patients; mean age was 82+/-7.2 years, 74.2% were females. Marital and living status reflected close family relationships in southern Europe relative to Nordic countries, where 5 times as many patients live alone. Recipients of community care in France and Italy are characterised by very high physical and cognitive impairment compared with those in northern Europe, who have comparatively little impairment in Activities of Daily Living and cognitive function. The provision of formal care to people with similar dependency varies extremely widely with very little formal care in Italy and more than double the average across all levels of dependency in the UK.

CONCLUSIONS

The AdHOC study, by virtue of the use of a common comprehensive standardised assessment instrument, is a unique tool in examining older recipients of community care services in European countries and their widely varied organisation. The extreme differences seen in dependency and hours of care illustrate the probable contribution the study will make to developing an evidence based on the structure, quantity and targeting of community care, which will have major policy implications.

Advance orders to limit therapy in 67 long-term care facilities in Finland

OBJECTIVE

To assess the documentation of a do-not-attempt-resuscitation (DNAR) or do-not-hospitalize (DNH) orders in the medical record and to determine factors related to these orders.

MATERIALS AND METHODS

Five thousand six hundred and fifty four subjects from three different levels of institutional long-term care (LTC), chronic care hospitals (n = 1989), nursing homes (n = 3310), and assisted living (n = 335) in 67 LTC facilities in 19 municipalities were assessed.

RESULTS

Out of these patients, 751 (13%) had a DNAR order and only 36 (0.6%) had a DNH order. The variation in DNAR orders between individual LTC institutions was enormous, ranging from 0 to 92%. In logistic regression analysis, individual institutions and their local caring cultures had the strongest explanatory value (R(2) = 0.49) for advance orders to limit therapy. Impaired activity in daily living (ADL) function (R(2) = 0.11), impaired cognition (R(2) = 0.07), level of LTC (R(2) = 0.05), and diagnoses (R(2) = 0.04) did not provide adequate explanations. Terminal prognosis was not significantly associated with advance orders.

CONCLUSIONS

We found marked differences in the use of DNAR and DNH orders between caring units. Diseases and ADL status were only weakly significant as background factors. Open discussions, general guidelines, and research about the adequacy of DNAR decisions are needed to improve equality and self-empowerment among the elderly residing in institutions.

Does quality influence consumer choice of nursing homes? Evidence from nursing home to nursing home transfers

We estimated Cox proportional hazards models using assessment data from the Minimum Data Set to test whether nursing home residents and their proxies respond to quality of care by changing providers. Various indicators of poor quality increased the likelihood of transfer. Residents of for-profit homes or homes with excess capacity also were more likely to transfer. Inability to participate in care decisions and factors indicating frailty limited residents' ability to transfer. The apparent responsiveness to quality is encouraging. Nonetheless, because the absolute transfer rate is low, significant barriers to movement among nursing homes still may exist.

Payer incentives and physical rehabilitation therapy for nonelderly institutional long-term care residents: evidence from Michigan and Ontario

OBJECTIVE

To examine the effect of payment incentives on the provision of rehabilitation therapy to non elderly nursing home residents.

DESIGN

Retrospective cross-sectional study.

SETTING

Nursing homes in Michigan or complex continuing care facilities in Ontario, Canada, in 1998 or 1999.

PARTICIPANTS

Non elderly nursing home residents (N=5189) admitted to nursing homes.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The effect of payment on access to physical therapy (PT) and occupational therapy (OT) and total weekly time for each therapy type.

RESULTS

A Medicare policy change from cost-based to a patient-specific case-mix payment method was associated with greater likelihood of receiving OT but reduced weekly minutes of PT and OT provided to residents. Medicare cost-based and private insurance were associated with greater likelihood of receiving OT and PT and more therapy time for both types of therapy compared with private-pay residents. Global budget payment was associated with greater access to PT but fewer weekly minutes of OT and PT.

CONCLUSIONS

Little information exists to describe the characteristics and treatment of non elderly nursing home residents. This study found that many of these residents received rehabilitation and that residents whose care was paid for by more generous payers, such as Medicare, received more therapy than those paid for by less generous payers.

Variations in nursing home discharge rates for urban and rural nursing facility residents with hip fracture

CONTEXT

The more limited availability and use of community-based long-term care services in rural areas may be a factor in higher rates of nursing home use among rural residents.

PURPOSE

This study examined differences in the rates of nursing home discharge for older adults receiving posthospital care in a nursing facility.

METHODS

The study sample was comprised of a cohort of rural and urban residents newly admitted to nursing home care in Maine following surgery for hip fracture.

FINDINGS

The results indicated that rural residents who were hospitalized for hip fracture and subsequently admitted to a nursing facility for rehabilitation were significantly less likely than urban residents to be discharged within the first 30 days of their admission. Rural residents who stayed in the nursing facility beyond 30 days were also less likely to be discharged in the first 6 months. These geographic differences were not explained by service use and resident characteristics such as age, health, or functional status.

CONCLUSIONS

The finding of lower discharge rates among rural nursing facility residents appears to be consistent with previous studies demonstrating higher rates of nursing home use among rural residents. There continues to be a need for a better understanding of the role that service supply and accessibility and other factors play in the patterns and outcomes of rural long-term care.

The protective effect of social engagement on 1-year mortality in a long-stay nursing home population

We examined the effect of social engagement (SE) on mortality in 30,070 long-stay nursing home residents who were > or =65 years of age and did not have a serious communication problem. Information on SE and resident characteristics were obtained from the Minimum Data Set, and death information was obtained from the National Death Index. Life table analyses show that greater levels of SE are associated with longer survival (P=.0001). Adjusted proportional hazards regression results show that for each increase in the SE scale, residents are 0.94 (range 0.92-0.95) times as likely to die during the follow-up period, independent of known factors associated with mortality. Future studies are needed to understand psychological and other factors related to residents' capacity and motivation for social engagement that could increase quality and quantity of life in nursing home residents.

The effect of depression on social engagement in newly admitted Dutch nursing home residents

PURPOSE

To study the effect of depression (high levels of depressive symptoms) on social engagement.

DESIGN AND METHODS

In 65 nursing homes in the Netherlands, 562 newly admitted residents were assessed at admission. Social engagement was measured with the MDS Index of Social Engagement. A multivariate logistic regression model was used to study the effect of depression, measured according to the MDS-depression rating scale and controlled for confounders, on social engagement.

RESULTS

Fifty-one percent of the newly admitted residents had a low level of social engagement; twenty seven percent were depressed (high levels of depressive symptoms). Residents with a depression were significantly more often found to have low social engagement (OR 3.3), and confounders did not influence the strength of this relationship. Low social engagement on admission is predicted by depression and low cognitive performance, and to a lesser extent by impairments in vision and ADL.

IMPLICATIONS

Low social engagement is very common in newly admitted nursing home residents, and depression is an important independent risk factor.

Influence of poststroke urinary incontinence on disability: the nursing home setting

OBJECTIVE

To characterize the association of poststroke urinary incontinence with disability progression in nursing home residents.

DESIGN

In this prospective cohort study, the Minimum Data Set from the State of New York between 1994 and 1997 was utilized. From a pool of over 240,000 potential subjects, 500 met inclusion/exclusion criteria. Previously continent, first-time stroke survivors were classified as being continent or incontinent immediately after their stroke and were followed for changes in activities of daily living status (disability) at quarterly intervals for a 1 yr. In addition, a post hoc analysis was performed examining changes in activities of daily living status from the prestroke condition and exploring the relationship between poststroke impairments in continence and limitations in mobility.

RESULTS

An almost 2-fold difference in level of disability was noted poststroke among those who were incontinent those who were continent (P < 0.001). This difference in disability level remained unchanged for 1 yr. Through the post hoc analysis, it was determined that, although the onset of stroke produced significant elevations in disability for both continent and incontinent stroke survivors (P < 0.001), the presence of an impairment in urinary continence was associated with a significantly greater increase (94% 13%) in disability (P < 0.001). In addition, incontinence occurred more frequently among those who had a loss in mobility function.

CONCLUSION

Incontinence is a clinical factor after stroke that is associated with greater disability among nursing home residents. These findings have clinical implications for physiatrists and nursing home clinicians and provide a context in which future disability research can be conducted.

Risk adjusting outcome measures for post-acute care

This article examines whether different risk adjusters are needed for home care outcome measures for post-acute care clients. Multiple risk adjusters that met clinical and policy criteria were tested using multiple logistic regression on a sample of 4403 post-acute home care clients from Michigan. Two of the 6 outcome measures had substantially different risk adjusters for the post-acute care population versus the general population. Care should be taken to select outcome measures and risk adjusters for special home care populations.

The MDS-CHESS scale: a new measure to predict mortality in institutionalized older people

OBJECTIVES

To develop a scale predicting mortality and other adverse outcomes associated with frailty.

DESIGN

Observational study based on Minimum Data Set (MDS) 2.0 and mortality data.

SETTING

Ontario chronic hospitals.

PARTICIPANTS

All chronic hospital patients (N = 28,495) assessed with the MDS 2.0 after mandatory implementation in July 1996 followed until May 1999.

MEASUREMENTS

MDS 2.0 assessments done as part of normal practice mainly by registered nurses or multidisciplinary teams in a chronic hospital. Mortality data are available from the accompanying discharge tracking form.

RESULTS

The MDS-Changes in Health, End-stage disease and Symptoms and Signs (CHESS) score is a composite measure addressing changes in health, end-stage disease, and symptoms and signs of medical problems. It is a strong predictor of mortality (P <.0001) independent of the effects of age, sex, activities of daily living impairment, cognition, and do-not-resuscitate orders. It is also strongly associated with physician activity, complex medical procedures, and pain (P <.001 for each dependent variable).

CONCLUSIONS

The CHESS score provides a useful new MDS-based test to predict mortality and to measure instability in health as a clinical outcome.

The Resident Assessment Instrument-Mental Health (RAI-MH): inter-rater reliability and convergent validity

An important challenge facing behavioral health services is the lack of good quality, clinically relevant data at the individual level. The article describes a multinational research effort to develop a comprehensive, multidisciplinary mental health assessment system for use with adults in facilities providing acute, long-stay, forensic, and geriatric services. The Resident Assessment Instrument-Mental Health (RAI-MH) comprehensively assesses psychiatric, social, environmental, and medical issues at intake, emphasizing patient functioning. Data from the RAI-MH are intended to support care planning, quality improvement, outcome measurement, and case mix-based payment systems. The article provides the first set of evidence on the reliability and validity of the RAI-MH.

Oral status, cognitive and functional capacity versus oral treatment need in nursing home residents: a comparison between assessments by dental and ward staff

OBJECTIVES

The aim of this study was to study the relationships between cognitive and functional capacity versus oral health and treatment need and to compare oral status assessments and oral treatment need, assessed by nurses and dental professionals, respectively.

DESIGN

Cross-sectional survey.

SETTING

Nursing home.

SUBJECTS

One hundred and ninety-two nursing home residents were examined in 1997.

MAIN OUTCOME MEASURES

Cognitive and functional capacity in different groups of residents regarding oral health and treatment need, measured by a comprehensive assessment with the Resident Assessment Instrument (RAI) and dental status in a separate examination protocol, recorded by a dentist.

RESULTS

There was a significant correlation between being dentate and having need of oral treatment. Those who were able to chew also had significantly better cognitive and functional capacity. Oral treatment need was identified most often by the dentist, intermediately by the RAI assessment and least frequently by the residents themselves.

CONCLUSIONS

Being dentate and having a loss of cognitive and functional capacity is predictive of oral treatment need among nursing home residents. Enhanced interaction between nurses and dental professionals needs to be promoted for better awareness of preventive measures and better regular oral care for frail and dependent elderly persons.

The impact of rural residence on multiple hospitalizations in nursing facility residents

PURPOSE

This study explored issues surrounding hospitalization rates among rural and urban nursing facility (NF) residents.

DESIGN AND METHODS

Data from the Minimum Data Set (MDS+) collected by states participating in the national Multi-State Case Mix Demonstration were used to assess whether rural NF residents experience higher rates of hospitalization compared with urban residents and to understand the extent that resident, facility, and market/area characteristics contribute to these differences.

RESULTS

Rural NF residents were more likely than urban residents to have multiple hospitalizations. Further analysis demonstrated that the effect of rural residence on the probability of multiple hospitalizations is greater among newly admitted rural residents than among rural residents not classified as new admissions. In addition to rural residence, other factors associated with an increased likelihood of multiple hospitalizations included state of residence, diagnosis of congestive heart failure, and no discharge planned at the time of NF admission.

IMPLICATIONS

The findings of this study have important implications for both clinical care and health policy related to the financing and administration of NFs.

Associating the onset of motor impairments with disability progression in nursing home residents

OBJECTIVES

To evaluate the association between the onset of movement impairments and disability progression in nursing home residents.

DESIGN

Retrospective cohort analysis of data from the State of New York Minimal Data Set, version 2.0, between November 1998 and October 1999. Participants were nursing home residents (n = 84,346) in the State of New York. Items defined as "functional limitation in range of motion" and "lack of voluntary movement" served as measures of movement impairments. Scores on the activities of daily living summary scale served as a measure of disability. Age, sex, measures of cognition, depression, and measures of medical stability served as adjustment variables.

RESULTS

After adjusting for age, sex, cognition, depression, and measures of medical stability, the onset of either singular or combined movement impairments in voluntary movement or range of motion was associated with a concurrent step-wise loss in activities of daily living (P < 0.001). The progression in activities of daily living loss occurred regardless of location or limb type.

CONCLUSION

This study directly links the onset of movement impairments with disability progression. These findings have important implications for physiatrists and other practitioners of geriatric rehabilitation.

Clinical challenges in the care of frail older persons

The clinical challenges of meeting the needs of frail older persons are essentially those encompassed by chronic disease multiplied by the special problems presented by aging, namely the presentation and management of disease and the special syndromes associated with geriatrics. The need to develop an approach to the care of frail older persons reflects a more general need to address system reform for chronic disease. The steps include new roles for patients and their families, the use of information technology to monitor changes in patients' status more continuously and to intervene in a more timely way, and a re-evaluation of the use of personnel at all levels. At present, we know more about how to deliver effective chronic care than we practice. The barriers to implementation include both a general reluctance to change and negative financial incentives to implement what has been shown to be effective.

Stroke patients in nursing homes: eating, feeding, nutrition and related care

The purpose of this study was to explore eating, feeding and nutrition among stroke patients in nursing homes as described by their nurses and by assessments. Registered Nurses were interviewed about an individual stroke patient's state of health, care needs and nursing care received and nursing records were reviewed. Information on eating, feeding and nutrition was extracted from the interviews and nursing records. A comprehensive instrument, the Resident Assessment Instrument, was also used to assess these patients' state of health. The domains of eating, feeding and nutrition were focused on in this study. Manifest content analysis was used. The results showed that more than 80% of the stroke patients in nursing homes were assessed as having some sort of dependence in eating. According to the Registered Nurses, 22 out of 40 patients demonstrated different eating disabilities. The number of eating disabilities in individual patients ranged from 1 to 7, which emphasized the complexity of eating disabilities in stroke patients. Dysphagia was reported in almost one-fourth of the patients and 30% were described and/or assessed as having a poor food intake or poor appetite. The Registered Nurses' descriptions of the eating disabilities, nutritional problems and their care were often vague and unspecific. Only six weights were documented in the nursing records and there were no nutritional records. The findings highlight the importance of making careful observations and assessments, and of maintaining documentation about eating and nutrition early after a patient's arrival in the nursing home to enable appropriate care and promotion of health.

Use of potentially inappropriate drugs in nursing homes

STUDY OBJECTIVES

To examine patterns and determine predictors of inappropriate drug use in nursing homes.

DESIGN

Retrospective study.

SETTING

One thousand four hundred ninety-two nursing homes in five states.

PATIENTS

A total of 44,562 residents admitted to nursing homes over 1 year.

METHODS

Frequency of discontinuation and initiation of potentially inappropriate drugs over the first 90 days after admission to a nursing home was calculated. Data were collected using the minimum data set.

RESULTS

On admission, 33% of residents were receiving at least one potentially inappropriate drug. After 90 days, the drug was discontinued in 16% of these residents. Of those not receiving a potentially inappropriate drug on admission, one was begun in 18%. Demographic factors and number of drugs taken by patients were associated with the use of potentially inappropriate drugs. CONCLUSIONS; Use of potentially inappropriate drugs was prevalent on admission and at 90 days after admission. Discontinuation was highest among patients with conditions for which potentially safer therapeutic alternatives existed.

Racial and state differences in the designation of advance directives in nursing home residents

OBJECTIVES

To examine racial and state differences in the use of advance directives and surrogate decision-making in a nursing home population.

DESIGN

A retrospective cohort study.

SETTING

Nursing homes in the states of California (CA), Massachusetts (MA), New York (NY), and Ohio (OH).

PARTICIPANTS

Nursing home residents: 130,308 in CA, 59,691 in MA, 112,080 in NY, and 98,954 in OH.

MEASUREMENTS

Minimum Data Set information concerning resident race and whether or not residents have a living will (LW), a do not resuscitate (DNR) order, or a surrogate decision-maker (SDM).

RESULTS

The proportion of LWs, DNR orders, and SDMs varied significantly (P < .0001) by racial categories in each state. In general, whites were distinctly different from other racial categories. Whites were significantly more likely to have a LW (odds ratio (OR) = 1.9 (CA), OR = 2.2 (NY), OR = 4.9 (OH)), a DNR order (OR = 2.4 (CA), OR = 2.4 (MA), OR = 3.3 (NY), OR = 3.2 (OH)), and a SDM (OR = 1.1 (CA), OR = 1.2 (NY), OR = 1.6 (OH)) than were nonwhites, after adjusting for potentially confounding factors. Significant state differences (P < .0001) were observed in LWs, DNR orders, and SDMs and were most pronounced in residents of Ohio, who were significantly more likely to have a LW than were residents in other states (OR = 9.3).

CONCLUSIONS

Various resident characteristics explain some of the racial differences, although whites are still more likely to have a LW, a DNR order, or an SDM independent of various resident characteristics included in the adjusted analyses. This pattern is observed in all states, although the ORs varied by state. Some of these differences may be due to distinct cultural approaches to end-of-life care and lack of knowledge and understanding of advance directives. The distinctly higher rates of LWs among all racial groups in Ohio than in other states suggest that states can potentially increase the use of advance directives through intervention.

Pain in U.S. nursing homes: validating a pain scale for the minimum data set

PURPOSE

The aim of this study was to validate a pain scale for the Minimum Data Set (MDS) assessment instrument and examine prevalence of pain in major nursing home subpopulations, including type of admission and cognitive status.

DESIGN AND METHODS

This study considered validation of the MDS pain items and derivation of scale performed against the Visual Analogue Scale (VAS), using Automatic Interaction Detection. The derivation data describe 95 postacute care nursing home patients who are able to communicate. The scale is then used in retrospective analysis of 34,675 Michigan nursing home residents.

RESULTS

A four-group scale was highly predictive of VAS pain scores (variance explanation 56%) and therefore quite valid in detecting pain. In the prevalence sample, only 47% of postacute patients compared to 63% of postadmission patients reported no pain, and these percentages rose with increasing cognitive impairment.

IMPLICATIONS

Pain is prevalent in nursing home residents, especially in those with cognitive dysfunction, and often untreated.

Assessment in long-term care

Long-term care has begun to rely heavily on assessment as a basis for determining eligibility and payment for services, as well as for planning needed care. Mandated assessments have been introduced into nursing homes and will soon be required for home health care and rehabilitation. Many states use a formal structured assessment process to establish clients' eligibility for institutional or community-based care. The common feature of such assessment is attention to physical functioning, but other domains are also relevant, including affect, social function, cognition, pain and discomfort, and satisfaction. Taken together, this cluster is often referred to as quality of life. While some measures attempt to infer this information from clients' behavior, it is best obtained directly from clients' responses whenever possible. The other major component of a long term care assessment relates to obtaining information on clients' preferences and values. These data are important both for weighting the individual components of an assessment and for directly addressing preferences about the care and lifestyle available.

State practice variations in the use of tube feeding for nursing home residents with severe cognitive impairment

OBJECTIVE

To describe the differences in prevalence of tube feeding among states and to examine possible factors that could explain practice patterns.

DESIGN

Analysis of random samples from an interstate data bank comprised of the Minimum Data Set (MDS), a standardized, federally mandated assessment instrument for nursing home residents.

SETTING

Nursing homes in four states participating in a federal demonstration project of case mix payment plus five others with existing MDS data systems.

PARTICIPANTS

Individuals 65 years of age and older (N = 57,029), who had very severe cognitive impairment, including total dependence in eating, and who resided in nursing homes during 1994, the most recent year for which uniform data were available.

MEASUREMENTS

State-by-state differences in prevalence of tube feeding, controlling for demographic and clinical variables.

RESULTS

The prevalence of tube feeding ranged from 7.5% in Maine to 40.1% in Mississippi. Each state had a significantly elevated prevalence of tube feeding compared with Maine, with odds ratios (ORs) ranging from 1.50 to 5.83, P < .001. Specific directives not to provide tube feeding (OR 0.41, P < .001), and white race (OR 0.45, P < .001) were strongly and negatively associated with tube feeding.

CONCLUSIONS

Wide regional variations exist in the use of tube feeding of nursing home residents with equivalent impairments. Sociodemographic factors could be important, but more study is needed to determine whether physician characteristics, such as race, attitudes, or knowledge, have an impact and to clarify medical standards for the use of tube feeding in this population.

Minimum data set for home care: a valid instrument to assess frail older people living in the community

BACKGROUND

Optimal care for frail elderly patients depends on comprehensive assessment. This is especially true in the complex setting of interdisciplinary home care programs. To facilitate comprehensive assessment, as well as to generate a useful, policy-relevant patient database, standardized, multidimensional, and validated instruments are very helpful.

OBJECTIVES

The aim of the present study was to demonstrate that the Minimum Data Set assessment instrument for Home Care (MDS-HC) can be used to detect functional and cognitive impairment as defined by analogous research instruments.

RESEARCH DESIGN

This was a cross-sectional correlation study.

SUBJECTS

We studied 95 patients admitted to home care services of the Health Care Agency of Bergamo (Italy).

MEASURES

The MDS-HC form was completed for all patients by well-trained nurses, independently of and with nurses blinded to the results from the research rating scales. The Barthel Activities of Daily Living (ADL) Index, the Instrumental Activities of Daily Living of Lawton (IADL), and the Mini Mental State Examination (MMSE) were considered the gold standard.

RESULTS

Agreement between the MDS-HC scales and the research rating scales was assessed with Pearson's correlation coefficient. This coefficient was 0.74 for MDS-ADL versus Barthel Index, 0.81 for MDS-IADL versus Lawton Index, and 0.81 for Cognitive Performance Scale versus MMSE, indicating an excellent agreement.

CONCLUSIONS

The MDS-HC scales, when performed by trained nurses using recommended protocols, provide a valid measure of function and cognitive status in frail home care patients. These findings point out the overall validity of the functional and clinical data contained in the MDS-HC assessment. Use of the MDS-HC gives the unique opportunity of setting up a database, a prerequisite for all epidemiological evidence-based medicine studies.

The protective effect of social engagement on mortality in long-term care

OBJECTIVES

To examine the effect of social engagement (SE) on mortality in long-term care.

DESIGN

A retrospective cohort study.

SETTING

A 725-bed long-term care facility.

PARTICIPANTS

A total of 927 long-term care residents who had SE measurements and did not have a serious communication problem.

MEASUREMENTS

Minimum Data Set information including psychosocial items comprising an internally reliable and valid SE scale, and mortality risk factor measurements. Mortality data during the 1,721-day follow-up period was obtained from facility records.

RESULTS

Life table analyses indicate that higher levels of SE are associated with longer survival (P = .0001). Unadjusted proportional hazards analyses show that residents who did not engage socially were 2.3 times more likely to die during the follow-up period compared with residents who were the most socially engaged. Multivariate adjusted analyses showed the protective effect of SE on mortality remained even after simultaneously adjusting for mortality risk factors. Residents who did not engage socially were 1.4 times as likely to die during the follow-up period compared with residents who were the most socially engaged.

CONCLUSIONS

Increased levels of SE were associated with longer survival independent of mortality risk factors. SE may be a modifiable risk factor for death among long-term care residents. More research is needed to understand psychological factors that may influence residents' desire and ability to engage socially.