MDS Cognitive Performance Scale

Short-term effects of an educational intervention on physical restraint use: a cluster randomized trial

Background

Physical restraints are still frequently used in nursing home residents despite growing evidence for the ineffectiveness and negative consequences of these methods. Therefore, reduction in the use of physical restraints in psycho-geriatric nursing home residents is very important. The aim of this study was to investigate the short-term effects of an educational intervention on the use of physical restraints in psycho-geriatric nursing home residents.

Methods

A cluster randomized trial was applied to 5 psycho-geriatric nursing home wards (n = 167 residents with dementia). The wards were assigned at random to either educational intervention (3 wards) or control status (2 wards). The restraint status was observed and residents' characteristics, such as cognitive status, were determined by using the Minimum Data Set (MDS) at baseline and 1 month after intervention.

Results

Restraint use did not change significantly over time in the experimental group (55%–56%), compared to a significant increased use (P < 0.05) in the control group (56%–70%). The mean restraint intensity and mean multiple restraint use in residents increased in the control group but no changes were shown in the experimental group. Logistic regression analysis showed that residents in the control group were more likely to experience increased restraint use than residents in the experimental group.

Conclusion

An educational programme for nurses combined with consultation with a nurse specialist did not decrease the use of physical restraints in psycho-geriatric nursing home residents in the short term. However, the residents in the control group experienced more restraint use during the study period compared to the residents in the experimental group. Whether the intervention will reduce restraint use in the long term could not be inferred from these results. Further research is necessary to gain insight into the long-term effects of this educational intervention.

Family members as proxies for satisfaction with nursing home care

BACKGROUND

Many benefits to collecting and reporting satisfaction information from nursing home residents, including promoting quality initiatives, consumer choice, and improved care, have been described. Yet barriers to collecting resident satisfaction information exist, the most significant of which is the often low cognitive status of residents. An alternative source of information can come from family members serving as proxies for the residents. A study was conducted to explore the agreement and association of nursing home residents' responses with family member proxy responses.

METHODS

Satisfaction data from 286 paired residents and family members in 42 facilities were collected in 1999. The satisfaction questionnaire consisted of 16 items evaluating the art of care, technical quality, efficacy, amenities of the care environment, and global satisfaction. Bias indexes, intraclass correlation coefficients, and Pearson's product-moment correlation coefficients were used to compare resident and proxy responses.

RESULTS

In general, proxy satisfaction ratings were higher than the same ratings given by residents. Proxy ratings varied less from residents' ratings for the amenities items, which were considered the most concrete items. Proxy ratings were much higher for the art of care and efficacy domain items--the least concrete questions.

DISCUSSION

Proxy ratings do not necessarily substitute for resident ratings and are dependent on the nature of the question asked. Examining resident-proxy responses at different points in time may be useful.

The effect of urinary incontinence on quality of life in older nursing home residents

OBJECTIVES

To determine whether nursing home residents with urinary incontinence (UI) have worse quality of life (QoL) than continent residents, whether the relationship between UI and QoL differs across strata of cognitive and functional impairment, and whether change in continence status is associated with change in QoL.

DESIGN

Retrospective cohort study using a Minimum Data Set (MDS) database to determine cross-sectional and longitudinal (6 month) associations between UI and QoL.

SETTING

All Medicare- or Medicaid-licensed nursing homes in Kansas, Maine, Mississippi, New York, and South Dakota during 1994 to 1996.

PARTICIPANTS

All residents aged 65 and older, excluding persons unable to void or with potentially unstable continence or QoL status (recent nursing home admission, coexistent delirium, large change in functional status, comatose, near death).

MEASUREMENTS

UI was defined as consistent leakage at least twice weekly over 3 months and continence as consistent dryness over 3 months. QoL was measured using the validated MDS-derived Social Engagement Scale.

RESULTS

Of 133,111 eligible residents, 90,538 had consistent continence status, 58,850 (65%) of whom were incontinent. UI was significantly associated with worse QoL in residents with moderate cognitive and functional impairment. New or worsening UI over 6 months was associated with worse QoL (odds ratio = 1.46, 95% confidence interval = 1.36-1.57) and was second only to cognitive decline and functional decline in predicting worse QoL.

CONCLUSION

This is the first study to quantitatively demonstrate that prevalent and new or worsening UI decreases QoL even in frail, functionally and cognitively impaired nursing home residents. These results provide a crucial incentive to improve continence care and quality in nursing homes and a rationale for targeting interventions to those residents most likely to benefit.

Nursing home patients in the intensive care unit: Risk factors for mortality

OBJECTIVE

To determine intensive care unit (ICU) admission characteristics predictive of mortality among older nursing home residents.

DESIGN

Retrospective cohort study.

SETTING

A 725-bed teaching nursing home and two teaching-hospital ICUs.

PATIENTS

One hundred twenty-three nursing home residents > or =75 yrs admitted to the ICU between July 1, 1999, and September 30, 2003.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Characteristics of nursing home residents admitted to the ICU were identified by medical record review at the nursing home and the hospital. Additionally, the minimum data set was used to calculate preadmission functional status using the Activities of Daily Living-Long Form (ADL-L) and cognitive status with the Cognitive Performance Scale (CPS). Our primary outcomes were hospital mortality and mortality within 90 days of ICU admission. The nursing home residents admitted to the ICU were old (87.7 +/- 5.4 yrs) with impaired cognition (CPS 2.8 +/- 1.7, range 0-6, where 6 = most impaired) and moderately dependent function (ADL-L 14.5 +/- 9.4, range 0-28, where 28 = total dependence). Of the 123 patients, 33 (27%) died in the hospital, whereas 90 (73%) survived to hospital discharge. Acute Physiology and Chronic Health Evaluation (APACHE) III score was independently associated with significantly increased odds of hospital mortality (adjusted odds ratio 1.04; 95% confidence interval 1.02, 1.07). Among the 90 patients who survived to return to the nursing home, 34 (37.8%) died within 90 days. Cox regression demonstrated that higher APACHE III score (adjusted risk ratio 1.02; 95% confidence interval 1.01, 1.04) and increasing functional dependency before ICU admission (adjusted risk ratio 1.6; 95% confidence interval 1.05, 2.57, per ADL-L quartile) were independently associated with increased mortality rate within 90 days.

CONCLUSIONS

Among vulnerable elderly nursing home residents, higher APACHE III score is independently associated with increased hospital mortality rate and mortality within 90 days. Among hospital survivors, impaired functional status is independently associated with increased mortality rate within 90 days.

Predictors of influenza immunization among home care clients in Ontario

BACKGROUND

This study examined factors associated with the receipt of influenza vaccination among Ontario home care clients.

METHODS

Home care clients were assessed, as part of a routine home visit, during a pilot study of the Resident Assessment Instrument - Home Care (RAI-HC) in 12 Ontario Community Care Access Centres (CCACs). The RAI-HC is a multidimensional assessment that identifies clients' needs and level of functional ability. Multiple logistic regression was used to identify factors associated with influenza immunization in the two years prior to assessment.

RESULTS

The overall rate of immunization reached about 80% by 2002. Factors such as age, respiratory problems, diabetes and congestive heart failure were associated with greater uptake, but overall rates of influenza immunization were lower than expected. Low education, smoking and poor medication adherence were negatively associated with influenza immunization. In addition, there was considerable variation in uptake among CCACs after adjusting for other significant individual-level independent variables.

INTERPRETATION

Comprehensive assessments like the RAI-HC can be used to help identify and respond to health promotion and disease prevention issues in this population, and to compare rates across Canada.

Medicare payment changes and nursing home quality: effects on long-stay residents

The Balanced Budget Act of 1997 dramatically changed the way that Medicare pays skilled nursing facilities, providing a natural experiment in nursing home behavior. Medicare payment policy (directed at short-stay residents) may have affected outcomes for long-stay, chronic-care residents if services for these residents were subsidized through cost-shifting prior to implementation of Medicare prospective payment for nursing homes. We link changes in both the form and level of Medicare payment at the facility level with changes in resident-level quality, as represented by pressure sores and urinary tract infections in Minimum Data Set (MDS) assessments. Results show that long-stay residents experienced increased adverse outcomes with the elimination of Medicare cost reimbursement.

Medication reconciliation for reducing drug-discrepancy adverse events

BACKGROUND

Medication reconciliation is a technique for identifying discrepancies in drug regimens prescribed in different care settings or at different time points to inform prescribing decisions and prevent medication errors.

OBJECTIVE

This study examined the effect of pharmacist-conducted medication reconciliation on the occurrence of discrepancy-related adverse drug events (ADEs) associated with drugs ordered at the time of a resident's return from the hospital to the nursing home.

METHODS

This was a preintervention/postintervention study conducted in a consecutive sample of residents of a 514-bed, urban, not-for-profit nursing home who were hospitalized in its primary referral hospital, an 1171-bed academic tertiary care hospital, and returned to the nursing home between December 2002 and January 2005. In the intervention phase, a pharmacist conducted a reconciliation of drugs ordered on return to the nursing home with those received before hospitalization, and communicated prescribing discrepancies to the physician. The primary outcome was the occurrence of discrepancy-related ADEs, as ascertained by a review of the medical records performed by 2 independent physician raters.

RESULTS

During the study period, 168 nursing home residents had 259 hospital stays. The reconciliation intervention identified 696 total prescribing discrepancies, of which physicians responded to 598 (85.9%). Among the 112 cases selected for ADE ascertainment, 11 discrepancy-related ADEs were identified, 1 in the postintervention group and 10 in the preintervention group, for an incidence of 2.3% and 14.5%, respectively (relative risk, 0.16; 95% CI, 0.02-1.2; P = NS). After adjustment for baseline ADE risk, the odds of having a discrepancy-related ADE were significantly lower in the postintervention group compared with the preintervention group (odds ratio, 0.11; 95% CI, 0.01-1.0; P = 0.05). The most commonly identified discrepancy-related ADE was pain from the omission of an analgesic (3/11 [27.3%]), and antibiotics and analgesics were the most common causes of discrepancy-related ADEs (each, 3/11 [27.3%]).

CONCLUSIONS

Pharmacist medication reconciliation and communication with the physician reduced discrepancy-related ADEs in these patients transferred between the hospital and nursing home. Studies are needed to identify the most efficient ways of carrying out this task and to adapt the reconciliation process to all care settings.

Preferences for Oral Health States in a US Community-Dwelling Functionally Impaired Older Adult Population: 2000-2001

OBJECTIVES

To determine whether and how much time in a state of ill oral health an older person would be willing to trade for optimal oral health.

METHODS

This is a cross-sectional observational study of 76 subjects (52 female, 24 male) ages 47-93 (mean 75.2) recruited from a Medicare demonstration. Subjects had to need or receive help with 2+ activities of daily living (ADLs) or 3+ instrumental ADLs plus had to have had recent significant healthcare services use. A Time Trade-Off (TTO) approach was used. TTO utility is defined as the amount of symptom-free time (i.e., the optimal oral health state) divided by the amount of time with symptoms (either their current oral health state or the worst imaginable oral health state, depending on the scenario), at the point of indifference (the point past which the person is unwilling to trade additional life expectancy).

RESULTS

When starting from their current oral health state, 39% of the subjects were willing to exchange time resulting in a shorter life with optimal oral health. They were willing to trade 14.0 months of life on average and valued each year in their current oral health state as 91% of a year in optimal oral health. When starting in the poorest oral health state, 79% of the subjects were willing to accept a shorter life. They were willing to trade 33.7 months of life on average, and valued the poorest state as worth 79% of a year in optimal oral health.

CONCLUSIONS

Dentists should take into consideration this group's preference for optimal oral health.

Advance care planning documents in nursing facilities: Results from a nationally representative survey

This study assessed clinical, demographic, facility, and regional factors associated with documented do-not-resuscitate (DNR) orders, feeding/medication/other treatment (FMT) restrictions, and living wills among nursing facility residents. Using the Nursing Home Component of the 1996 Medical Expenditure Panel Survey, a nationally representative sample of 815 facilities and 5899 residents, three separate multivariate logistic regression models were developed. DNR orders were more prevalent among residents aged 75+ and those with severe cognitive impairment, dementia, emphysema, and cancer, but less common among African Americans and Latinos than whites. Residents with living children were more likely to have DNR orders. Latinos were less likely to have FMT restrictions. Living wills were more common among residents aged 75+ and those with psychiatric/mood disorders and heart disease, but less prevalent among African Americans. Residents with less social engagement and household incomes below 400% of the Federal Poverty Level were less likely to have a living will. Residents with Medicaid as their largest payer were less likely to have an advance care plan than those with Medicare or other payment mechanisms. To increase the use of advance care plans, interventions should focus on groups with less social engagement and lower household income.

Use of antipsychotics among nonagenarian residents in long-term institutional care in Finland

BACKGROUND

There is a paucity of information about the use of antipsychotic medication in long-term care, especially among the oldest-old residents.

OBJECTIVE

To analyse the factors associated with the use of antipsychotic medication among nonagenarian residents in long-term institutional care.

DESIGN

A retrospective study was designed from cross-sectional data, gathered in the period 1 January 2003 to 30 June 2003, in Finland. Data were extracted from the Resident Assessment Instrument database, based on Minimum Data Set 2.0 assessments.

SETTING

Data were provided by 23 hospital-based institutions and 43 residential homes.

SUBJECTS

Residents aged >or=90 years were included, consisting of 1,334 resident assessments.

RESULTS

Almost a third of the residents received one or more antipsychotic medication. In the logistic regression analysis, factors associated with the use of antipsychotics among nonagenarian residents were as follows: socially inappropriate or disruptive behavioural symptoms [odds ratio (OR) 1.86, 95% confidence interval (CI) 1.36-2.54], concomitant anxiolytic medication (OR 1.83, 95% CI 1.39-2.42), recurring anxious complaints (OR 1.61, 95% CI 1.17-2.22), recurring physical movements (OR 1.43, 95% CI 1.08-1.91) and unsettled relationships (OR 1.35, 95% CI 1.15-1.57). A good sense of initiative or involvement was significantly less likely to be associated with antipsychotics (OR 0.86, 95% CI 0.80-0.94). There were no associations between any psychiatric diagnoses or symptoms and the use of antipsychotics.

CONCLUSIONS

Antipsychotic medication use in nonagenarians in long-term institutions was common and seemed in many cases to be associated with residents' negative attitudes to others. Querulous residents received antipsychotics more commonly than those with good social skills. Clearly defined indications may not be fulfilled in many cases, and an evaluation of treatment may be lacking. These may indicate that in Finland, there could be a considerable gap between antipsychotic medication recommendations and actual clinical practice.

Rural–Urban Differences in Medical Care for Nursing Home Residents with Severe Dementia at the End of Life

OBJECTIVES

To identify factors associated with the use of selected medical services near the end of life in cognitively impaired residents of rural and urban nursing homes.

DESIGN

Retrospective cohort study using Centers for Medicare and Medicaid Services administrative data for 1998 through 2002.

SETTING

Minnesota and Texas nursing homes.

PARTICIPANTS

Nursing home residents aged 65 and older with severe cognitive impairment who subsequently died during 2000/01.

MEASUREMENTS

Minimum Data Set and Medicare Provider Analysis and Review, Hospice, and Denominator files were used to identify subjects and to assess medical service use. U.S. Department of Agriculture metro-nonmetro continuum county codes defined rural (codes 6-9) and urban (codes 0-2) nursing homes. Nursing home residents with hospice or health maintenance organization benefits were excluded. Use of hospital services at the end of life was adjusted for use of corresponding services before the last year of life. Outcome variables were feeding tube use, any hospitalization, more than 10 days of hospitalization, and intensive care unit (ICU) admission.

RESULTS

The population included 3,710 subjects (1,886 rural, 1,824 urban). In multivariable logistic regression analyses (all P<.05), feeding tube use was more common in urban nursing home residents, whereas rural nursing home residents were at greater risk for hospitalization.

CONCLUSION

Rural residence was also associated with lower risk of more than 10 days of hospitalization and ICU admission. Nonwhite race and stroke were associated with higher use of all services. Rural nursing home residence is associated with lower likelihood of use of the most-intensive medical services at the end of life.

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.

Advanced dementia research in the nursing home: the CASCADE study

Despite the growing number of persons with advanced dementia, and the need to improve their end-of-life care, few studies have addressed this important topic. The objectives of this report are to present the methodology established in the CASCADE (Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life) study, and to describe how challenges specific to this research were met. The CASCADE study is an ongoing, federally funded, 5-year prospective cohort study of nursing [nursing home (NH)] residents with advanced dementia and their health care proxies (HCPs) initiated in February 2003. Subjects were recruited from 15 facilities around Boston. The recruitment and data collection protocols are described. The demographic features, ownership, staffing, and quality of care of participant facilities are presented and compared to NHs nationwide. To date, 189 resident/HCP dyads have been enrolled. Baseline data are presented, demonstrating the success of the protocol in recruiting and repeatedly assessing NH residents with advanced dementia and their HCPs. Factors challenging and enabling implementation of the protocol are described. The CASCADE experience establishes the feasibility of conducting rigorous, multisite dementia NH research, and the described methodology serves as a detailed reference for subsequent CASCADE publications as results from the study emerge.

Measuring health status and decline in at-risk seniors residing in the community using the Health Utilities Index Mark 2

PURPOSE

The purpose of this study was to assess the responsiveness of one measure of HRQL, the HUI Mark 2 (HUI2), to changes in health status over time in an older community-based population.

METHODS

The sample consisted of 192 individuals age 65 and over residing in their homes and receiving health and support services in Calgary, Canada. Subjects received three assessments at 6-month intervals using the HUI2, to measure health-related quality of life (HRQL), and the Minimum Data Set for Home Care (MDS-HC) for demographic and health status information. Change scores were calculated as the difference between scores at the second and third assessments. The relationship between the HUI2 and other measures of health status were examined using t-tests and ANOVA. Associations between the magnitude of decline in HUI2 and declines on other measures were examined using multiple linear regression.

RESULTS

Lower HUI2 scores were significantly associated with the presence of depressive symptoms, impairment in activities of daily living (ADL), and clinical instability at baseline. Over 6 months of follow-up, HUI2 decline was associated with worsening depressive symptoms, increase in the number of chronic conditions, and age 85 and over.

CONCLUSION

The HUI2 measure of HRQL in older persons at risk for institutionalization appears to reflect health status at a point in time and to be responsive to changes in health status over time.

Inter-facility transfer of patient information before and after HIPAA privacy measures

OBJECTIVES

The study objectives were (1) to test whether interfacility communication of health information at the time of patient transfer changed as a result of implementation of US privacy protection measures (HIPAA) in April 2003, and (2) to examine patient, transfer, and illness characteristics correlated with interfacility transfer document completion.

DESIGN

Observational study.

PARTICIPANTS AND SETTING

Individuals transferred between a 514-bed urban nursing home and a 1171-bed academic hospital in New York City.

MEASUREMENTS

Research staff reviewed medical records of patients transferred both ways between nursing home and hospital, examining interfacility transfer documents for 12 items important for continuity of care. Transfer document completeness equaled the percentage of items recorded and legible in transfer documents. Transfers were classified by direction (nursing home-to-hospital [NH-to-H] or hospital-to-nursing home [H-to-NH]), urgency (urgent or not), timing (weekday 9 am to 6 pm or other), and by whether they occurred before 12 am April 14, 2003 (pre-HIPAA), or after (post-HIPAA).

RESULTS

Seventy-eight nursing home residents experienced 100 hospital admissions. NH-to-H transfer documents were more complete than H-to-NH documents (86.7% vs 69.0%; P = .002). There were no significant differences between content of transfer documents between pre- and post-HIPAA transfers in either direction of transfer, with and without controlling for patient and illness characteristics. Older age, female gender, dementia diagnosis, shorter duration of nursing home residence, and off-hours hospital transfer were associated with less complete NH-to-H transfer documents, and shorter hospital length of stay was associated with less complete H-to-NH transfer documents.

CONCLUSION

There was no change in written health information communicated during patient transfer between an urban nursing home and an academic hospital before and after HIPAA privacy protection measures were implemented. This suggests that the rule's intent to not restrict the sharing of information needed to treat patients is being followed by providers at these sites in the situation of interfacility patient transfer.

Indicators of elder abuse: a crossnational comparison of psychiatric morbidity and other determinants in the Ad-HOC study

OBJECTIVE

The objective of this study was to determine crossnationally the prevalence of indicators of elder abuse and their relationship to putative risk factors, particularly depression, dementia, and lack of service provision.

METHOD

Nearly 4,000 people aged 65+ receiving health or social community services in 11 European countries were interviewed using the minimum dataset homecare (MDS-HC) interview, which includes an abuse screen used previously in elder abuse studies and questions about demographic, physical, psychiatric, cognitive, and service factors.

RESULTS

One hundred seventy-nine (4.6%) people assessed had at least one indicator of abuse. The proportion screening positive increased with severity of cognitive impairment, presence of depression, delusions, pressure ulcers, actively resisting care, less informal care, expressed conflict with family or friends, or living in Italy or Germany, but not with having a known psychiatric diagnosis.

CONCLUSION

Severity of cognitive impairment, depression, and delusions predicted screening positive for abuse in older adults, but having a known psychiatric diagnosis did not, indicating that screening for psychiatric morbidity might be rational strategies to combat elder abuse. People in Italy and Germany were most likely to screen positive for indicators of abuse, and the authors suggest that this might relate to higher levels of dependency in the participants looked after at home in these countries as a result of cultural and service provision differences.

Effect of educational level and minority status on nursing home choice after hospital discharge

OBJECTIVES

The movement to publicly report data on provider quality to inform consumer choices is predicated on assumptions of equal access and knowledge. We examine the validity of this assumption by testing whether minority/less educated Medicare patients are at greater risk of being discharged from a hospital to the lowest-quality nursing homes in a geographic area.

METHODS

We used the 2002 national Minimum Data Set to identify 62601 new Medicare admissions to nursing homes in 95 hospital service areas with at least 4 freestanding nursing homes and at least 50 African Americans aged 65 years or older with Medicare admissions to nursing homes.

RESULTS

The probability of African Americans' being admitted to nursing homes in the lowest-quality quartile in the area was greater (relative risk [RR]=1.26; 95% confidence interval [CI]=1.0, 8.45) in comparison with Whites. Individuals without a high-school degree were also more likely to be admitted to a low-quality nursing home (RR=1.22; 95% CI=1.0, 1.46).

CONCLUSIONS

African American and poorly educated patients enter the worst-quality nursing facilities. This finding raises concerns about the usefulness of the current public reporting model for certain consumers.

Predictors of mortality for lower respiratory infections in nursing home residents with dementia were validated transnationally

BACKGROUND AND OBJECTIVE

Generalizability of clinical predictors for mortality from lower respiratory infection (LRI) in nursing home residents has not been assessed for residents with dementia.

STUDY DESIGN AND SETTING

In prospective cohort studies of LRI in 61 nursing homes in the Netherlands (n = 541) and 36 nursing homes in Missouri, USA (n = 564), we examined 14-day and 1- and 3-month mortality in residents with dementia who were treated with antibiotics.

RESULTS

A logistic model predicting 14-day mortality derived from Dutch data included eating dependency, elevated pulse, decreased alertness, respiratory difficulty, insufficient fluid intake, high respiratory rate, male gender, and pressure sores. After adjusting coefficients with the heuristic shrinkage factor, the 14-day model showed good discrimination and calibration in both datasets. The apparent c-statistic for the original Dutch model was 0.80 (after correction for optimism, it was 0.75); the c-statistic was 0.74 in the U.S. validation population. The models predicting 1- and 3-month mortality showed moderate performance. A scoring system for estimating 14-day mortality performed equally well as the original model.

CONCLUSION

We identified a set of credible clinical predictors that are easily assessed and demonstrated validity in identifying residents at low risk of dying from LRI across different nursing home populations. This tool should inform decision-making for families and doctors.

Factors influencing use of home care and nursing homes

AIM

This paper reports a study comparing the characteristics of patients who use home care services and those who are cared for in nursing homes, and identifying the factors that influence the use of these care settings.

BACKGROUND

The increase in the functionally dependent older population has led to an increase in the number of nursing homes and home care agencies. It has become clear that, rather than disputing which is the better of these options, it would be better to determine the characteristics of patients who use the two long-term care services. Gaining an understanding of the unique characteristics of patients who are cared for by home care agencies and those who are cared for in nursing homes will be imperative for reforming and developing long-term care systems.

METHOD

The research model was based on the Anderson Model of Health Services Utilization. Interviews were conducted with 99 stroke survivors from two home care agencies and four nursing homes, and their family members, between May and December 2001.

RESULTS

The patient characteristics that predicted greater use of home care rather than nursing home services were: being married, poor physical function, impaired cognitive function, higher rates of comorbidity, various medical complications, and/or number of catheters (e.g. urinary catheter, naso-gastric tube).

CONCLUSION

Contrary to the findings of previous studies conducted in countries with ageing populations, our findings indicate that in South Korea home care agencies, rather than nursing homes, provide care for severely impaired patients. This may be due to differences between countries in their long-term care systems and cultural attitudes toward end-of-life care. Our results will contribute to the development or reformation of long-term care systems in countries with ageing populations, and to the development of strategies for increasing access to these services.

Predicting nursing facility residents' quality of life using external indicators

PURPOSE

A newly developed brief measure of nursing facility (NF) resident self-reported quality of life (QOL) has been proposed for inclusion in a modified version of the minimum data set (MDS). There is considerable interest in determining whether it is possible to develop indicators of QOL that are more convenient and less expensive than direct, in-person interviews with residents.

DESIGN AND METHODS

QOL interview data from 2,829 residents living in 101 NFs using a 14-item version of a longer instrument were merged with data from the MDS and the Online Survey and Certification Automated Record (OSCAR). Bivariate and multivariate hierarchical linear modeling were used to assess the association of QOL with potential resident and facility level indicators.

RESULTS

Resident and facility level indicators were associated with self-reported QOL in the expected direction. At the individual resident level, QOL is negatively associated with physical function, visual acuity, continence, being bedfast, depression, conflict in relationships, and positively associated with social engagement. At the facility level, QOL is negatively associated with citations for failing to accommodate resident needs or providing a clean, safe environment. The ratio of activities staff to residents is positively associated with QOL. This study did not find an association between QOL and either use of restraints or nurse staff levels. Approximately 9 percent of the total variance in self-reported QOL can be attributed to differences among facilities; 91 percent can be attributed to differences among residents. Resident level indicators explained about 4 percent of the variance attributable to differences among residents, and facility factors explained 49 percent of the variance attributable to differences among NFs. However, the different variables explained only 10 percent of the variance in self-reported QOL.

IMPLICATIONS

A brief self-report measure of NF resident QOL is consistently associated with measures that can be constructed from extant data sources. However, the level of prediction possible from these data sources does not justify reliance on external indicators of resident QOL for policy purposes.

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.

Measuring change in activities of daily living in nursing home residents with moderate to severe cognitive impairment

Background

The objective of this study was to assess the responsiveness of the Minimum Data Set Activities of Daily Living (MDS-ADL) Scale to change over time by examining the change in physical function in adults with moderate to severe dementia with no comorbid illness who had been resident in a nursing home for over 90 days.

Methods

Longitudinal data were collected on nursing home residents with moderate (n = 7001) or severe (n = 4616) dementia in one US state from the US national Minimum Data Set (MDS). Severity of dementia was determined by the MDS Cognitive Performance Scale (CPS). Physical function was assessed by summing the seven items (bed mobility, transfer, locomotion, dressing, eating, toilet use, personal hygiene) on the MDS activities of daily living (ADL) Long Form scale. Mean change over time of MDS-ADL scores were estimated at three and six months for residents with moderate (CPS score of 3) and severe (CPS score of 4 or 5) dementia.

Results

Physical function in residents with moderate cognitive impairment deteriorated over six months by an average of 1.78 points on the MDS-ADL Long Form scale, while those with severe cognitive impairment declined by an average of 1.70 points. Approximately one quarter of residents in both groups showed some improvement in physical function over the six month period. Residents with moderate cognitive impairment experienced the greatest deterioration in early-loss and mid-loss ADL items (personal hygiene, dressing, toilet use) and residents with severe cognitive impairment showed the greatest deterioration in activities related to eating, a late loss ADL.

Conclusion

The MDS-ADL Long Form scale detected clinically meaningful change in physical function in a large cohort of long-stay nursing home residents with moderate to severe dementia, supporting its use as a research tool in future studies.

Medicare prospective payment and quality of care for long-stay nursing facility residents

BACKGROUND

The Balanced Budget Act of 1997 dramatically changed the way that Medicare pays skilled nursing facilities and also cut per-diem rates. Previous studies have found effects on facility-wide staffing but not on quality for short-stay residents. Because facilities may combine revenue streams to be used where needed, spillover effects on quality of care for long-stay residents are possible.

OBJECTIVE

We sought to investigate effects of financial pressures from Medicare payment changes on quality of care for long-stay residents.

METHODS

We investigated the effect of Medicare's Prospective Payment System for skilled nursing facilities on incidence of urinary tract infections and pressure sores among long-stay residents while controlling for resident severity. We conducted panel data analysis of nursing home residents in Ohio, Kansas, Maine, Mississippi, and South Dakota using Minimum Data Set data from 1995 to 2000. Each facility's Medicare dependence was used to separate effects of the policy from underlying industry trends.

RESULTS

The probability of developing a urinary tract infection or pressure sore increased significantly among long-stay residents after Medicare's prospective payment system was implemented. Effects were roughly proportional to the percent of residents in a facility covered by Medicare.

CONCLUSIONS

Although Medicare prospective payment and rate cuts were directly applicable only to Medicare (largely short-stay) residents in skilled nursing facilities, the resulting financial pressures lowered the quality of care experienced by long-stay residents, as measured by the likelihood of adverse outcomes. The observed quality decreases were likely due to decreases in nurse staffing prompted by the payment reductions.

Occurrence and treatment of suspected pneumonia in long-term care residents dying with advanced dementia

OBJECTIVES

To describe the occurrence and management of suspected pneumonia in end-stage dementia and to identify factors associated with aggressiveness of antibiotic treatment.

DESIGN

Retrospective cohort study.

SETTING

A 675-bed long-term-care facility in Boston, Massachusetts.

PARTICIPANTS

Two hundred forty subjects aged 65 and older who died with advanced dementia between January 2001 and December 2003. Subjects who had suspected pneumonia during the last 6 months of life were identified.

MEASUREMENTS

Independent variables included subject characteristics and features of suspected pneumonia episodes. These variables were obtained from medical records. Antibiotic treatment for each episode was determined. Multivariate analysis was used to identify independent variables associated with aggressiveness of treatment.

RESULTS

One hundred fifty-four (64%) subjects with advanced dementia experienced 229 suspected pneumonia episodes during the last 6 months of life. Within 30 days of death, 53% of subjects had suspected pneumonia. Antibiotic treatment for the 229 episodes was as follows: none, 9%; oral only, 37%; intramuscular, 25%; and intravenous, 29%. Factors independently associated with more-invasive therapy were lack of a do-not-hospitalize order (adjusted odds ratio (AOR) = 3.24, 95% confidence interval (CI) = 2.02-5.22), aspiration (AOR = 2.75, 95% CI = 1.44-5.26), primary language not English (AOR = 2.21, 95% CI = 1.17-4.15), and unstable vital signs (AOR = 2.02, 95% CI = 1.10-3.72).

CONCLUSION

Pneumonia is a common terminal event in advanced dementia for which many patients receive parenteral antibiotics. The aggressiveness of treatment is most strongly determined by advance care planning, the patient's cultural background, and clinical features of the suspected pneumonia episode.

A typology of oral hydration problems exhibited by frail nursing home residents

Dehydration remains a substantial problem for nursing home residents, often with poor health outcomes. The purpose of this investigation was to establish 6-month prevalence of dehydration events in nursing home residents and to describe common hydration problems of nursing home residents. In this prospective observational study, 35 nursing home residents were followed for 6 months to assess problems with hydration and to evaluate the presence of dehydration. Urine specific gravity and color, bioimpedance measurements, meal intake recordings, and chart abstraction were used to assess hydration status. Field notes and informal staff interviews were used to describe specific hydration problems and clinically relevant interventions. Dehydration events occurred in 31% (11 of 35) of residents during the 6-month period. A typology of hydration problems was developed from the field observations. The typology consists of four groups (i.e., Can Drink, Can't Drink, Won't Drink, End of Life) and six corresponding subgroups. Demographic and hydration characteristics of the subgroups were compared and contrasted. Comparisons revealed the Won't Drink group is most vulnerable to dehydration events because this group has the highest percentage of dehydration events (58%, 4 of 7), the highest average specific gravity, and the lowest consumption of fluids during meals. Nursing interventions for the subgroups are discussed. Targeting nursing interventions to the specific hydration problem exhibited is proposed.

The accuracy of Minimum Data Set diagnoses in describing recent hospitalization at acute care facilities

OBJECTIVES

The Minimum Data Set (MDS) is the resident assessment instrument used to guide clinical care, reimbursement, and assess quality in long-term care facilities. This database has been used in many studies, although the accuracy of many data elements remains unknown. This study evaluated the accuracy of the MDS diagnosis variables with respect to the diagnoses for recent hospitalization from Medicare claims data.

DESIGN

Retrospective cohort study.

SETTING

945 skilled nursing facilities in Ohio.

PARTICIPANTS

17,294 residents admitted from an acute care facility during 2000.

MEASUREMENTS

Eleven diagnoses listed in the MDS were compared with Medicare hospital discharge claims. Specifically, each MDS diagnosis was compared to the primary diagnosis, the list of secondary diagnoses, and the Diagnosis Related Group (DRG).

RESULTS

Claims diagnoses were listed in the MDS with an average frequency of 79% (range: 31%-94%) for the primary diagnosis, 66% (range: 33%-90%) for any diagnosis, and 71% (range: 31%-94%) for the DRG. MDS diagnoses were listed as the primary diagnosis, any diagnosis, and DRG with an average frequency of 20% (range: 6%-81%), 62% (range: 41%-86%), and 19% (range: 7%-84%), respectively, with only hip fracture listed more than 80% of the time.

CONCLUSION

The sensitivity of the MDS for listing diagnoses from recent hospitalization appears good for most diagnoses. However, except for hip fracture, the MDS has poor predictive value with regard to the primary reason for the preceding hospitalization; this may have implications for resident care planning and the utility of this database in long-term care research.

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.

Measuring Pain Presence and Intensity in Nursing Home Residents

OBJECTIVES

To examine the extent of agreement between nursing home residents' (or their proxies') reports of pain presence and intensity as derived from an interview questionnaire and the Minimum Data Set (MDS) nearest to the interview date.

DESIGN

Cross-sectional comparison of the 2 data sources on pain measurements.

SETTING

Nursing homes included in evaluation projects of EverCare program and Minnesota Senior Health Options.

PARTICIPANTS

Nursing home residents (n = 3100) were grouped based on the type of respondent answering the interview questionnaire: resident, family proxy, or staff proxy.

MEASUREMENTS

We used kappa statistics and multinomial logit regression to examine agreement between the interview questionnaire and the MDS on pain presence and intensity.

RESULTS

Presence of pain was reported 1.3 to 1.8 times more often on the questionnaire, depending on the respondent group. Agreement on the presence of pain was slight to fair (kappa = 0.17 to 0.28) between the MDS and the questionnaire. There was slight agreement on pain intensity (kappa = 0.13 to 0.18). The family proxy respondent group showed the largest discrepancy between questionnaire and the MDS in reporting of pain presence and intensity. The staff proxy respondent group had better agreement on pain intensity than did the other respondent groups, but it achieved only slight agreement (kappa = 0.18).

CONCLUSIONS

Detecting and quantifying pain in nursing home residents is complex. Pain information is best obtained directly from residents; observations should be standardized. The MDS should be revised accordingly.

Nurse Care Coordination in Community-Based Long-Term Care

PURPOSE

To evaluate the clinical outcomes of a nurse care coordination program for people receiving services from a state-funded home and community-based waiver program called Missouri Care Options (MCO).

DESIGN

A quasi-experimental design was used to compare 55 MCO clients who received nurse care coordination (NCC) and 30 clients who received MCO services but no nurse care coordination.

METHODS

Nurse care coordination consists of the assignment of a registered nurse who provides home care services for both the MCO program and Medicare home health services. Two standardized datasets, the Minimum Data Set (MDS) for resident care and planning and the Outcome Assessment Instrument and Data Set (OASIS) were collected at baseline, 6 months, and 12 months on both groups. Cognition was measured with the MDS Cognitive Performance Scale (CPS), activities of daily living (ADL) as the sum of five MDS ADL items, depression with the MDS-Depression Rating Scale, and incontinence and pressure ulcers with specific MDS items. Three OASIS items were used to measure pain, dyspnea, and medication management. The Cochran-Mantel-Haenszel (CMH) method was used to test the association between the NCC intervention and clinical outcomes.

FINDINGS

At 12 months the NCC group scored significantly better statistically in the clinical outcomes of pain, dyspnea, and ADLs. No significant differences between groups were found in eight clinical outcome measures at 6 months.

CONCLUSIONS

Use of nurse care coordination for acute and chronic home care warrants further evaluation as a treatment approach for chronically ill older adults.

Preparing a large data set for analysis: using the minimum data set to study perineal dermatitis

AIM

The aim of this paper is to present a practical example of preparing a large set of Minimum Data Set records for analysis, operationalizing Minimum Data Set items that defined risk factors for perineal dermatitis, our outcome variable.

BACKGROUND

Research with nursing home elders remains a vital need as 'baby boomers' age. Conducting research in nursing homes is a daunting task. The Minimum Data Set is a standardized instrument used to assess many aspects of a nursing home resident's functional capability. United States Federal Regulations require a Minimum Data Set assessment of all nursing home residents. These large data would be a useful resource for research studies, but need to be extensively refined for use in most statistical analyses. Although fairly comprehensive, the Minimum Data Set does not provide direct measures of all clinical outcomes and variables of interest.

METHOD

Perineal dermatitis is not directly measured in the Minimum Data Set. Additional information from prescribers' (physician and nurse) orders was used to identify cases of perineal dermatitis. The following steps were followed to produce Minimum Data Set records appropriate for analysis: (1) identification of a subset of Minimum Data Set records specific to the research, (2) identification of perineal dermatitis cases from the prescribers' orders, (3) merging of the perineal dermatitis cases with the Minimum Data Set data set, (4) identification of Minimum Data Set items used to operationalize the variables in our model of perineal dermatitis, (5) determination of the appropriate way to aggregate individual Minimum Data Set items into composite measures of the variables, (6) refinement of these composites using item analysis and (7) assessment of the distribution of the composite variables and need for transformations to use in statistical analysis.

RESULTS

Cases of perineal dermatitis were successfully identified and composites were created that operationalized a model of perineal dermatitis.

CONCLUSION

Following these steps resulted in a data set where data analysis could be pursued with confidence. Incorporating other sources of data, such as prescribers' orders, extends the usefulness of the Minimum Data Set for research use.

Differences Between Newly Admitted Nursing Home Residents in Rural and Nonrural Areas in a National Sample

PURPOSE

Previous research in specific locales indicates that individuals admitted to rural nursing homes have lower care needs than individuals admitted to nursing homes in urban areas, and that rural nursing homes differ in their mix of short-stay and chronic-care residents. This research investigates whether differences in acuity are a function of differences in resident payer status and occur for both individuals admitted for short stays, with Medicare as payer, and those needing chronic care.

DESIGN AND METHODS

We used a representative 10% sample of national resident assessments (Minimum Data Set) for calendar year 2000 (N = 197,589). We conducted statistical analyses (means, percentages, and logistic regression) to investigate differences in Medicare and non-Medicare admissions to facilities in metropolitan and nonmetropolitan areas.

RESULTS

Non-Medicare residents admitted to rural nursing facilities have lower acuity scores than non-Medicare residents admitted to metropolitan nursing homes. However, individuals admitted under Medicare were similar in rural and urban areas.

IMPLICATIONS

Differences in resident acuity at admission among facilities in different locales were largely a function of lower acuity levels for individuals admitted to rural nursing homes for long-term or chronic care, although differences in Medicare census also played some role in facility-level differences in acuity. Other factors must be explored to determine why this lower acuity occurs and whether higher use of rural nursing homes by less impaired older persons meets their needs and preferences and represents good public policy.

Prevalence of inappropriate medication using Beers criteria in Japanese long-term care facilities

Background

The prevalence and risk factors of potentially inappropriate medication use among the elderly patients have been studied in various countries, but because of the difficulty of obtaining data on patient characteristics and medications they have not been studied in Japan.

Methods

We conducted a retrospective cross-sectional study in 17 Japanese long-term care (LTC) facilities by collecting data from the comprehensive MDS assessment forms for 1669 patients aged 65 years and over who were assessed between January and July of 2002. Potentially inappropriate medications were identified on the basis of the 2003 Beers criteria.

Results

The patients in the sample were similar in terms of demographic characteristics to those in the national survey. Our study revealed that 356 (21.1%) of the patients were treated with potentially inappropriate medication independent of disease or condition. The most commonly inappropriately prescribed medication was ticlopidine, which had been prescribed for 107 patients (6.3%). There were 300 (18.0%) patients treated with at least 1 inappropriate medication dependent on the disease or condition. The highest prevalence of inappropriate medication use dependent on the disease or condition was found in patients with chronic constipation. Multiple logistic regression analysis revealed psychotropic drug use (OR = 1.511), medication cost of per day (OR = 1.173), number of medications (OR = 1.140), and age (OR = 0.981) as factors related to inappropriate medication use independent of disease or condition. Neither patient characteristics nor facility characteristics emerged as predictors of inappropriate prescription.

Conclusion

The prevalence and predictors of inappropriate medication use in Japanese LTC facilities were similar to those in other countries.

Resident care needs and work stressors in special care units versus non-specialized long-term care units

Differences in how elderly residents' care needs affect staff's experiences of work stressors between special care units (SCUs) for dementia and psychiatric residents and non-SCUs were investigated. The data were drawn from 390 staff members in 38 long-term care SCUs, and 587 staff in 53 non-SCUs in Finland. Residents' care needs were based on the Resident Assessment Instrument (RAI) system measured by the Minimum Data Set 2.0. Work stressors (time-pressure and role-conflicts) were assessed with a staff survey questionnaire. Multiple-group regression analysis showed that residents' dependency in activities of daily living (ADL) was related to increased work stressors only in SCUs. A high proportion of behavioral problems was related to fewer work stressors for SCU staff, but more for non-SCU staff. Work stressors may be reduced by specializing, so that residents with similar care needs are placed together and care is focused.

Did the Introduction of a Prospective Payment System for Nursing Home Stays Reduce the Likelihood of Pharmacological Management of Secondary Ischaemic Stroke?

BACKGROUND

Since 1998, a prospective payment system (PPS) for Medicare services provided by nursing homes in the US has been in operation. Concerns have been expressed that the PPS may affect the quality of care delivered to residents. This study evaluates the impact of the PPS on pharmacological secondary ischaemic stroke prevention in nursing homes.

STUDY DESIGN

The nationally mandated Minimum Data Set and Online Survey Certification and Automated Record data system from 1997 and 2000 for four states were used. We conducted a quasi-experimental study comparing the pharmacological treatment rates for secondary stroke prevention in the pre-PPS period (1997) with those in the post-PPS period (2000) in residents who experienced an ischaemic stroke within 6 months (n1997 = 5008; n2000 = 5243) of living in nursing facilities (n1997 = 1226; n2000 = 1092) in Kansas, Maine, Mississippi or Ohio. The sample was stratified according to recommendations for use of warfarin. Logistic regression models adjusting for clustering effects of residents residing in homes using generalised estimating equations provided estimates of the PPS effect on use of antiplatelets and the use of warfarin.

RESULTS

The unadjusted proportion of use of pharmacological agents for the secondary prevention of stroke was similar for warfarin in both time periods and increased for antiplatelets in 2000. Relative to the pre-PPS era, the likelihood of use of antiplatelets increased in the post-PPS era (adjusted odds ratio 1.26; 95% CI 1.15, 1.38); there was no effect on the use of warfarin.

CONCLUSION

Although the lack of a PPS effect on pharmacological management of secondary ischaemic stroke is encouraging, there is still room for improvement in overall stroke management.

Management of constipation in residents with dementia: sorbitol effectiveness and cost

OBJECTIVE

The objective of this report is to describe a cost-effective strategy for management of constipation in nursing home residents with dementia.

DESIGN

We conducted a prospective observational quality improvement study of 41 residents with chronic constipation and receiving an osmotic laxative. Sorbitol was substituted for lactulose.

SETTING

The study was conducted at a dementia special care unit at a Veterans Administration hospital.

MEASUREMENT

We measured the number and amount of laxative use over a period of 4 weeks that were required to maintain regular bowel function.

RESULTS

There was no difference in efficacy of lactulose and sorbitol. Use of additional laxatives was infrequent: Milk of Magnesia on approximately 10% of days/patient, bisacodyl suppository on 2% to 4% of days/patient, and Fleet enema only on 3 occasions. The cost of constipation management using routine administration of sorbitol and as-needed use of other laxatives was 27% to 55% lower than the cost of other constipation management strategies reported in the literature.

CONCLUSION

Substitution of sorbitol for lactulose does not change efficacy of the treatment and decreases cost. Regular use of an osmotic laxative avoids the costs and discomforts of rectal laxatives.

Analyses of nursing home residents with cancer at admission

The objective of the study was to profile nursing home residents with cancer at admission to the nursing facility. We used all admission assessments in the Minimum Data Set recorded throughout the United States during 2002 to identify 61,890 residents with cancer, or 11.3% of all admissions. Nursing home residents with cancer were significantly older and more likely to be male than other residents at admission. Large proportions of nursing home residents with cancer were activities of daily living dependent and about 55% used a wheelchair as their primary mode of locomotion. More than 37% of residents with cancer experienced at least moderate daily pain at admission and almost 26% had a diagnosis of depression. At admission, more than half of residents with cancer had an unstable health condition, 21% were judged to be in their final 6 months of life, and 19% received hospice care. More than 40% of residents with cancer had no advance directives recorded at admission. Compared to other residents at admission, larger proportions of residents with cancer require heavy care. Staff at nursing facilities need to address depression, pain management, and the implementation of advance directives to improve the quality of life for residents with cancer.

Depression in patients with advanced illness: An examination of Ontario complex continuing care using the Minimum Data Set 2.0

Objective: In this study, we examined the prevalence of depression, its recognition, and its treatment in continuing care patients with advanced illness (AI).

Methods: All data were obtained from the Ontario (Canada) provincially-mandated MDS 2.0 form for chronic care. Of 3,801 patients, 524 met our empiric definition of AI, which was predicated on a previously validated algorithm. The MDS-embedded Depression Rating Scale (DRS) was used to measure psychological well-being and a score of 3 or greater indicated potential depression.

Results: Twenty-nine percent of patients with AI scored greater than 3, making them nearly twice as likely to be potentially depressed as other patients (OR 1.8, 95% CI 1.5–2.2). Despite this patients with AI were less likely to have received antidepressants (28.9% vs. 38.2%), even among those with a diagnosis (45.3% vs. 58.4%). Using logistic regression, correlates of potential depression were identified and surprisingly patients with cancer were substantially less likely to be depressed (AOR 0.37, 95% CI 0.2–0.6). Further investigation revealed that cancer patients were more likely to be treated for depression and to be recognized as being within the terminal phase of illness.

Significance of results: These findings suggest that a high proportion of terminally ill patients had unmet needs for psychological support. As well, they suggest that cancer patients received better targeted end-of-life care, which resulted in an overall decrease in psychological distress when compared to other patients with similarly advanced illness.

Rehabilitation services after the implementation of the nursing home prospective payment system: differences related to patient and nursing home characteristics

BACKGROUND

The prospective payment system (PPS) for nursing homes was designed to curtail the rapid expansion of Medicare costs for skilled nursing care. This study examines the changes that occurred in nursing home patients and rehabilitation services following the PPS.

SETTING

Free-standing Medicare and/or Medicaid certified nursing homes in Ohio.

PRIMARY OUTCOMES

The percent of new admissions receiving therapy and the amount of rehabilitation therapy provided.

SAMPLE

A total of 7006 first admissions in 1994-6 (pre-PPS) and 61,569 first admissions in 2000-1 (post-PPS).

METHODS

A logistic model predicting likelihood of rehabilitation was developed and validated in pre-PPS admissions and applied to the post-PPS patients. Rehabilitation services were compared in the pre-PPS and post-PPS cohorts overall, stratified by quintile of predicted score, diagnosis group, and by nursing home profit status.

RESULTS

Post-PPS patients had less cognitive impairment, more depression, and more family support. The amount of rehabilitation services declined the most in the higher quintiles of predicted likelihood of rehabilitation and among patients with stroke. The percent of patients receiving rehabilitation services increased the most in the lowest quintile and among patients with medical conditions. These changes were greater in for-profit nursing homes.

CONCLUSIONS

The implementation of the PPS in nursing homes has been associated with a decrease in the amount of rehabilitation services, targeted at those predicted to receive higher amounts and an increased frequency of providing services targeted at those predicted to be less likely to receive them. The outcomes of the changes deserve further study.

Ineffective communication of mental status information during care transfer of older adults

BACKGROUND

Monitoring and documenting the mental status of older patients transferred between providers or facilities is important because mental status change can be a sign of acute disease and mental status abnormalities necessitate specific approaches to care.

OBJECTIVES

To identify patient and illness factors associated with presence of a mental status description in inter-facility transfer documents and to describe the content and concurrent validity of transfer mental status descriptions when they occur.

DESIGN

Retrospective study.

PARTICIPANTS

Individuals transferred between 5 long-term and 2 acute care facilities in an urban setting.

MEASUREMENTS

Trained research personnel reviewed hospital and nursing home medical records and inter-facility transfer documents. Mental status descriptions in transfer documents were coded as abnormal or normal within 5 domains: alertness, communication, orientation/memory, behavior, and mood. Descriptions were compared with mental status items in the nursing home Minimum Data Set and in a transfer communication checklist.

RESULTS

In all, 123 nursing home residents experienced 174 hospital admissions. Mental status descriptions were present in 69% of transfer documents. A total of 67% of patients missing a transfer mental status description upon nursing home-to-hospital transfer had dementia. Factors associated with presence of a transfer mental status description were urgent transfer, nursing home of origin, and among patients without dementia, greater cognitive impairment. When present, a mean of 1.47 (SD=0.81) cognitive domains were documented in transfer mental status descriptions. Agreement between transfer mental status descriptions and comparison sources was fair to good (kappa=.31 to .73).

CONCLUSION

Mental status documentation during transfer of older adults between nursing home and hospital did not identify all patients with dementia and did not completely characterize patients' cognitive status.

Do-Not-Resuscitate and Do-Not-Hospitalize Directives of Persons Admitted to Skilled Nursing Facilities Under the Medicare Benefit

OBJECTIVES

To determine prevalence and factors associated with do-not-resuscitate (DNR) and do-not-hospitalize (DNH) directives of residents admitted under the Medicare benefit to a skilled nursing facility (SNF). To explore geographic variation in use of DNR and DNH orders.

DESIGN

Retrospective cohort study.

SETTING

Nursing homes in the United States.

PARTICIPANTS

Medicare admissions to SNFs in 2001 (n=1,962,742).

MEASUREMENTS

Logistic regression was used to select factors associated with DNR and DNH directives and state variation in their use.

RESULTS

Thirty-two percent of residents had DNR directives, whereas less than 2% had DNH directives. Factors associated with having a DNR or DNH directive at the resident level included older age, cognitive impairment, functional dependence, and Caucasian ethnicity. African-American, Hispanic, Asian, and North American Native residents were all significantly less likely than Caucasian residents to have DNR (adjusted odds ratio (OR)=0.35, 0.51, 0.61, and 0.62, respectively) or DNH (adjusted OR=0.26, 0.41, 0.43, and 0.67, respectively) directives. In contrast, residents in rural and government facilities were more likely to have DNR or DNH directives. After controlling for resident and facility characteristics, significant variation between states existed in the use of DNR and DNH directives.

CONCLUSION

Ethnic minorities are less likely to have DNR and DNH directives even after controlling for disease status, demographic, facility, and geographic characteristics. Wide variation in the likelihood of having DNR and DNH directives between states suggests a need for better-standardized methods for eliciting the care preferences of residents admitted to SNFs under the Medicare benefit.

Validity of the SF-36 five-item Mental Health Index for major depression in functionally impaired, community-dwelling elderly patients

OBJECTIVES

To examine criterion and construct validity of the five-item Mental Health Index (MHI-5) of the 36-item Short Form health survey (SF-36) in relation to the presence of major depression in functionally impaired, community-dwelling elderly patients and of eight subsamples defined by cognitive functioning, levels of functional impairment, and proxy report versus self-report.

DESIGN

Cross-sectional observational.

SETTING

Nineteen counties in western New York, West Virginia, and Ohio.

PARTICIPANTS

One thousand four hundred forty-four functionally impaired, community-dwelling Medicare beneficiaries aged 65 and older who participated in the Medicare Primary and Consumer-Directed Care Demonstration.

MEASUREMENTS

MHI-5, Mini-International Neuropsychiatric Interview Major Depressive Episode (MINI-MDE) module.

RESULTS

The MHI-5 demonstrated sufficient criterion validity (area under the receiver operating characteristic curve=0.837; sensitivity=78.7% and specificity=72.1% using a cutpoint of 59/60) with respect to the presence of depression for the entire sample. A significant correlation between MHI-5 scores and presence of major depression as identified using the MINI-MDE (Spearman correlation=-0.426, P<.001), a strong correlation between the MHI-5 and the SF-36 role emotional scale (Spearman correlation=0.522) and a weak correlation with the SF-36 physical functioning scale (Spearman correlation=0.133) provided evidence for construct validity. Additional evidence is provided by decline in mean MHI-5 score as level of formal education and number of close friends and relatives decreased. All eight subsamples demonstrated similar criterion and construct validity. A Cronbach alpha of 0.794 demonstrated internal consistency reliability.

CONCLUSION

This study provides evidence for adequate criterion and construct validity of the MHI-5 in relation to the presence of major depression among functionally impaired, community-dwelling elderly Medicare patients.

Neurocognitive testing supports a broader concept of mild cognitive impairment

The narrow concept of mild cognitive impairment (MCI) as an early form of Alzheimer s disease has been broadened by research that established the existence of alternative forms of the condition that may presage other forms of dementia. The research presented here was a naturalistic, cross-sectional study of patients in a community referral clinic-patients with MCI and mild dementia-compared to normal controls. A comprehensive, computerized neurocognitive screening battery developed by one of the authors (CNS Vital Signs) was administered to all of the subjects. Participants consisted of 36 patients with MCI and 53 patients with mild dementia, diagnosed by standard criteria, and 89 matched normal controls. Multivariate analysis indicated significant differences among the three groups for all 15 primary test variables and for all five of the domain scores. Tests of memory, processing speed, and cognitive flexibility were the most cogent discriminators between normal controls and MCI patients, and between MCI patients and patients with mild dementia. The same three tests also had the greatest sensitivity and specificity. The results of this study indicate that computerized testing can differentiate among normal controls, MCI patients, and patients with mild dementia. Also, in a diverse group of MCI and mild dementia patients, impairments in memory, processing speed, and cognitive flexibility were the most prominent observed deficits.

Proxy Sources for Information on Nursing Home Residents' Quality of Life

OBJECTIVES

This study explores how well staff and family proxies' reports on selected quality-of-life (QOL) domains (comfort, dignity, functional competence, privacy, meaningful activity, food enjoyment, relationships, security, and autonomy) correspond to residents' own reports.

METHODS

We compared QOL domain scores for nursing home residents and 1,326 staff proxies and 989 family proxies at the individual and facility level using means, Pearson correlation statistics, and intraclass correlations. Regression models adjusted for residents' age, gender, length of stay, ability to perform activities of daily living, and cognition.

RESULTS

For each domain in more than half the cases, proxy means were within 1 SD of the resident means. Resident and family proxy individual reports for selected domains were correlated at 0.14 to 0.46 (all p <.000). Resident and staff proxy individual reports were correlated at 0.13 to 0.37 (all p <.000). Correlation of mean levels by facility for staff proxies was 0.26 to 0.64 (generally p <.05) and for family proxies 0.13 to 0.61 (p <.01 except for one domain).

DISCUSSION

Although staff and family proxy domain scores are significantly correlated with resident scores, the level of correlation suggests they cannot simply be substituted for resident reports of QOL. Determining how proxy reports can be used for residents who cannot be interviewed at all remains an unresolved challenge.

Impact of cognitive function on assessments of nursing home residents' pain

OBJECTIVES

We sought to examine the impact of residents' cognitive function on the quality of Minimum Data Set (MDS) pain data using the latent variable approach.

RESEARCH DESIGN

Using the Resident Assessment Instrument (RAI) protocol, nursing home (NH) staff and well-trained study nurses independently assessed 3736 NH residents.

MEASURES

Inter-rater agreement of pain ratings between NH staff and study nurses was quantified by weighted kappas and polychoric correlations and compared among groups of residents with no/mild, moderate, and severe cognitive impairment. Probit models were built to examine the effect of residents' cognitive function on thresholds raters used to rate pain.

RESULTS

Of 3736 residents, 40.4% had no/mild, 35.9% moderate, and 23.7% severe cognitive impairment. Both NH staff and study nurses recorded less frequent and less severe pain for residents with more severe cognitive impairment. The inter-rater agreement on pain ratings between NH staff and study nurses was good-weighted kappas were greater than 0.5 and polychoric correlations greater than 0.7. The thresholds raters used to record pain were similar for NH staff and study nurses and progressively increased when raters recorded pain for residents with more severe cognitive impairment.

CONCLUSIONS

Given the RAI protocols, the quality of MDS pain data collected by NH staff was similar to that of well-trained nurses regardless of residents' cognitive function. Our results strongly support the notion that specialized pain assessment instruments are needed to adequately detect pain for the large proportion of cognitive impaired NH residents.

Reciprocal relationship between pain and depression in elderly Chinese primary care patients

BACKGROUND

Pain and depression are common in old age but the reciprocal relationship between pain and depression has not been established in a single study. Moreover, few studies have addressed this issue in a primary care setting. The purposes of this study were to examine the reciprocal relationship between pain and depression and to identify whether social support, functional disability or social functioning mediated the link between pain and depression among Hong Kong Chinese elderly primary care patients.

METHOD

Subjects were 318 patients assessed by a trained assessor with MDS-HC at baseline and these subjects were randomly selected from attendants of three randomly selected elderly health centers in Hong Kong. These patients were re-assessed one year after baseline evaluation.

RESULTS

Multiple regression analyses revealed that pain at baseline significantly predicted depression at 12-month follow-up assessment when age, gender, martial status, education, and depression at baseline were adjusted for, but depression at baseline was not associated with pain at 12-months after baseline measure while controlling for age, gender, martial status, education, and pain at baseline. However, depression did predict the onset of pain. Moreover, social support, physical disability or social functioning did not mediate the impact of pain on depression.

CONCLUSIONS

These data suggest that pain is an important predictor of depression in elderly primary care patients. Therefore, aged care service practitioners must take this risk factor into consideration in their preventive intervention and treatment for psychological well-being.

Extended Use of Indwelling Urinary Catheters in Postoperative Hip Fracture Patients

BACKGROUND

Indwelling urinary catheters are used postoperatively in hip fracture care. Their use beyond the immediate postoperative period may result in excess nosocomial infections.

OBJECTIVES

The objectives of this study were to explore the relationship between extended indwelling urinary catheterization and outcomes for patients sustaining hip fracture discharged to skilled nursing facilities (SNFs), and to describe patient and hospital predictors of extended indwelling urinary catheterization.

RESEARCH DESIGN

The authors conducted a retrospective cohort study.

SUBJECTS

This study consisted of Medicare admissions to SNFs of patients discharged from a hospital with a primary diagnosis of hip fracture in 2001 (n=111,330).

MEASURES

Dependent variables were the presence of urinary catheter at SNF admission and the patient-specific 30-day outcomes of rehospitalization for urinary tract infection, rehospitalization for sepsis, discharge to the community, and mortality. Independent variables were demographic, clinical, and hospital characteristics.

RESULTS

Thirty-two percent of hip fracture discharges to SNFs had urinary catheters. These patients had greater odds of rehospitalization for urinary tract infection (adjusted odds ratio [AOR] 1.6, P<0.001) and death (AOR 1.3, P<0.001) at 30 days than patients without catheters after adjusting for patient characteristics such as age and comorbid conditions. Western region and urban location were associated with a higher likelihood of having an indwelling urinary catheter, whereas northern region and teaching hospital status were associated with a lower likelihood of having an indwelling urinary catheter.

CONCLUSIONS

Extended use of indwelling urinary catheters postoperatively is associated with poor outcomes. The likelihood of having an indwelling urinary catheter at hospital discharge after hip fracture is associated with hospital characteristics in addition to patient characteristics. This practice variation deserves further study.

Inter-facility transfer of patient information before and after HIPAA privacy measures

OBJECTIVES

The study objectives were (1) to test whether interfacility communication of health information at the time of patient transfer changed as a result of implementation of US privacy protection measures (HIPAA) in April 2003, and (2) to examine patient, transfer, and illness characteristics correlated with interfacility transfer document completion.

DESIGN

Observational study.

PARTICIPANTS AND SETTING

Individuals transferred between a 514-bed urban nursing home and a 1171-bed academic hospital in New York City.

MEASUREMENTS

Research staff reviewed medical records of patients transferred both ways between nursing home and hospital, examining interfacility transfer documents for 12 items important for continuity of care. Transfer document completeness equaled the percentage of items recorded and legible in transfer documents. Transfers were classified by direction (nursing home-to-hospital [NH-to-H] or hospital-to-nursing home [H-to-NH]), urgency (urgent or not), timing (weekday 9 am to 6 pm or other), and by whether they occurred before 12 am April 14, 2003 (pre-HIPAA), or after (post-HIPAA).

RESULTS

Seventy-eight nursing home residents experienced 100 hospital admissions. NH-to-H transfer documents were more complete than H-to-NH documents (86.7% vs 69.0%; P = .002). There were no significant differences between content of transfer documents between pre- and post-HIPAA transfers in either direction of transfer, with and without controlling for patient and illness characteristics. Older age, female gender, dementia diagnosis, shorter duration of nursing home residence, and off-hours hospital transfer were associated with less complete NH-to-H transfer documents, and shorter hospital length of stay was associated with less complete H-to-NH transfer documents.

CONCLUSION

There was no change in written health information communicated during patient transfer between an urban nursing home and an academic hospital before and after HIPAA privacy protection measures were implemented. This suggests that the rule's intent to not restrict the sharing of information needed to treat patients is being followed by providers at these sites in the situation of interfacility patient transfer.