Setting of care modifies risk of nursing home placement for older adults with dementia

Factors related to advance directives completion among cancer patients: a systematic review

INTRODUCTION

Advance directives (ADs) has recently been considered as an important component of palliative care for patients with advanced cancer and is a legally binding directive regarding a person's future medical care. It is used when a person is unable to participate in the decision-making process about their own care. Therefore, the present systematic review investigated the factors related to ADs from the perspective of cancer patients.

METHODS

A systematic review study was searched in four scientific databases: PubMed, Medline, Scopus, Web of Science, and ProQuest using with related keywords and without date restrictions. The quality of the studies was assessed using the Hawker criterion. The research papers were analyzed as directed content analysis based on the theory of planned behavior.

RESULTS

Out of 5900 research papers found, 22 were included in the study. The perspectives of 9061 cancer patients were investigated, of whom 4347 were men and 4714 were women. The mean ± SD of the patients' age was 62.04 ± 6.44. According to TPB, factors affecting ADs were categorized into four categories, including attitude, subjective norm, perceived behavioral control, and external factors affecting the model. The attitude category includes two subcategories: "Lack of knowledge of the ADs concept" and "Previous experience of the disease", the subjective norm category includes three subcategories: "Social support and interaction with family", "Respecting the patient's wishes" and "EOL care choices". Also, the category of perceived control behavior was categorized into two sub-categories: "Decision-making" and "Access to the healthcare system", as well as external factors affecting the model, including "socio-demographic characteristics".

CONCLUSION

The studies indicate that attention to EOL care and the wishes of patients regarding receiving medical care and preservation of human dignity, the importance of facilitating open communication between patients and their families, and different perspectives on providing information, communicating bad news and making decisions require culturally sensitive approaches. Finally, the training of cancer care professionals in the palliative care practice, promoting the participation of health care professionals in ADs activities and creating an AD-positive attitude should be strongly encouraged.

Access to Long-Term Care for Minority Populations: A Systematic Review

It has been shown that there is disparity in access to long-term care and other services for minority populations. This study assessed long-term care access among older individuals belonging to minority populations including visible, ethnocultural, linguistic, and sexual minorities. Barriers and facilitators influencing admission were identified and evaluated.A search for articles from 10 databases published between January 2000 and January 2021 was conducted. Included studies evaluated factors affecting minority populations' admission to long-term care, and non-residents' perceptions of future admission. This review was registered with PROSPERO: CRD42018038662. Sixty included quantitative and qualitative studies, ranging in quality from fair to excellent. Findings suggest minority status is associated with reduced admission to long-term care, controlling for confounding variables. Barriers identified include discordant language, fear of discrimination, lack of information, and family obligations. Findings suggest that minority populations experienced barriers accessing long-term care and had unmet cultural and language needs while receiving care in this setting.

Do assisted living facilities that offer a dementia care program differ from those that do not? A population-level cross-sectional study in Ontario, Canada

Background

Many residents of assisted living facilities live with dementia, but little is known about the characteristics of assisted living facilities that provide specialized care for older adults who live with dementia. In this study, we identify the characteristics of assisted living facilities that offer a dementia care program, compared to those that do not offer such a program.

Methods

We conducted a population-level cross-sectional study on all licensed assisted living facilities in Ontario, Canada in 2018 (n = 738). Facility-level characteristics (e.g., resident and suite capacities, etc.) and the provision of the other 12 provincially regulated care services (e.g., pharmacist and medical services, skin and wound care, etc.) attributed to assisted living facilities were examined. Multivariable Poisson regression with robust standard errors was used to model the characteristics of assisted living facilities associated with the provision of a dementia care program.

Results

There were 123 assisted living facilities that offered a dementia care program (16.7% versus 83.3% no dementia care). Nearly half of these facilities had a resident capacity exceeding 140 older adults (44.7% versus 21.6% no dementia care) and more than 115 suites (46.3% versus 20.8% no dementia care). All assisted living facilities that offered a dementia care program also offered nursing services, meals, assistance with bathing and hygiene, and administered medications. After adjustment for facility characteristics and other provincially regulated care services, the prevalence of a dementia care program was nearly three times greater in assisted living facilities that offered assistance with feeding (Prevalence Ratio [PR] 2.91, 95% Confidence Interval [CI] 1.98 to 4.29), and almost twice as great among assisted living facilities that offered medical services (PR 1.78, 95% CI 1.00 to 3.17), compared to those that did not.

Conclusions

A dementia care program was more prevalent in assisted living facilities that housed many older adults, had many suites, and offered at least five of the other 12 regulated care services. Our findings deepen the understanding of specialized care for dementia in assisted living facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02400-w.

Influence of senior housing types on cognitive decline and nursing home admission among lower-income older adults

Objectives: Focusing on unique ageing populations in subsidized senior housing for lower-income older adults, this study contributes to literature on housing and aging; provides initial understanding of existing housing types; and explores the extent to which living in different housing types may influence changes in cognitive function and likelihood of nursing home admission.Method: Data came from seven waves (2002-2014) of the Health and Retirement Study. A latent-class clustering approach was used to identify senior-housing types among lower-income older people;Results: We identified four discernible housing types among lower-income older adults: (1) High physical & Low service, (2) Low physical & Low service, (3) High physical & High service, and (4) Medium physical & High service. Individuals in Medium physical & High service and High physical & Low service types were likely to have higher cognitive-function levels at baseline (B = 0.58, p < .001; 0.58, p < .001) and slower rates of decline over time (B = 0.42, p < .001; B = 0.32, p < .01). Older adults in High physical & High service are significantly less likely to be admitted to a nursing home (OR = 0.55, p < .00).Conclusion: The mismatch between health needs and lack of service and support suggests that current residents in each housing type relocate, based on knowledge of subsidized housing or availability. Future studies should examine possible mismatches between health needs and housing environment.

Housing equity withdrawal for development of assisted-living facilities

Purpose

The purpose of this study is to develop new type of reverse mortgage contract. How to provide adequate services and housing for an increasing number of people that are dependent on the help of others is a crucial question in the European Union (EU). The housing stock in Europe is not fit to support a shift from institutional care to the home-based independent living. Some 90% of houses in the UK and 70%–80% in Germany are not adequately built, as they contain accessibility barriers for people with emerging functional impairments. The available reverse mortgage contracts do not allow for relocation to their own adapted facilities. How to finance the adaptation from housing equity is discussed.

Design/methodology/approach

The authors have extended the existing loan reverse mortgage model. Actuarial methods based on the equivalence of the actuarial present values and the multiple decrement approach are used to evaluate premiums for flexible longevity and lifetime long-term care (LTC) insurance for financing adequate facilities.

Findings

The adequate, age-friendly housing provision that is appropriate to support the independence and autonomy of seniors with declining functional capacities can lower the cost of health care and improve the well-being of older adults. For financing the development of this kind of facilities for seniors, the authors developed the reverse mortgage scheme with embedded longevity and LTC insurance as a possible financial instrument for better LTC services and housing with care in assisted-living facilities. This kind of facilities should be available for the rapid growth of older cohorts.

Research limitations/implications

The numerical example is based on rather crude numbers, because of lack of data, as the developed reverse mortgage product with LTC insurance is a novelty. Intensity of care and probabilities of care in certain category of care will change after the introduction of this product.

Practical implications

The model results indicate that it is possible to successfully tie an insurance product to the insured and not to the object.

Social implications

The introduction of this insurance option will allow many older adult with low pension benefits and a substantial home equity to safely opt for a reverse mortgage and benefit from better social care.

Originality/value

While currently available reverse mortgage contracts lapse when the homeowner moves to assisted-living facilities in any EU Member State, in the paper a new method is developed where multiple adjustments of housing to the functional capacities with relocation is possible, under the same insurance and reverse mortgage contract. The case of Slovenia is presented as a numerical example. These insurance products, as a novelty, are portable, so the homeowner can move in own specialised housing unit in assisted-living facilities and keep the existing reverse mortgage contract with no additional costs, which is not possible in the current insurance products. With some small modifications, the method is useful for any EU Member State.

The effective ingredients of social support at home for people with dementia: a literature review

Purpose

Recent years have seen an increasing reliance on social support at home for people with dementia and the advocacy of a person centred and integrated approach in its provision. However, little is known about the effective ingredients of this support and how they differ from more generic or health-based services. The purpose of this paper is to explore the existing evidence base.

Design/methodology/approach

A review of relevant literature was carried out, combining a systematic search and selection of articles with a narrative analysis.

Findings

The review identified 14 relevant studies of varying research designs which yielded conflicting findings with regard to the optimal timing of interventions and their overall impact. This highlights the problems of review and generalisability when attempting to compare findings of research in this area. This was exacerbated by the blurred divide between health and social care and ambiguities in the meaning of the latter.

Research limitations/implications

This methodological heterogeneity demonstrates the need for consistency in research approaches if comparisons are to be made. Further questions include the precise components that distinguish social care from health care, the optimal timing for the introduction of this care and whether adherence to good practice in this area can be linked to cost effectiveness.

Originality/value

The review identifies relevant issues in need of further investigation and tentative themes emerging from the literature which suggest the utility of an adequately resourced, integrated and responsive approach to intervention.

Awareness and completion of advance directives in older Korean-American adults

There has been growing concern about racial and ethnic disparities in completion rates of advance directives (ADs) in community-dwelling older populations. Although differences in AD completion rates between non-Hispanic whites and African Americans have been reported, not much is known about the awareness and completion of ADs in other groups of ethnic minorities. Using a sample of community-dwelling Korean-American older adults (n=675) as a target, factors associated with their awareness and completion of ADs were explored. Guided by Andersen's behavioral health model, predisposing (age, sex, marital status, education), need (chronic conditions, functional disability), and enabling (health insurance, acculturation) variables were included in the separate logistic regression models of AD awareness and AD completion. In both models, acculturation was found to be a significant predictor; those who were more acculturated were more likely to be aware of ADs and to have completed ADs. This study contributes to the knowledge about the role of acculturation in explaining AD awareness and completion in Korean-American older adults and provides recommendations for possible AD educational interventions for this older adult minority population.

Identifying the Potential for Robotics to Assist Older Adults in Different Living Environments

As the older adult population grows and becomes more diverse, so will their needs and preferences for living environments. Many adults over 65 years of age require some assistance [1, 2]; yet it is important for their feelings of well-being that the assistance not restrict their autonomy [3]. Not only is autonomy correlated with quality of life [4], autonomy enhancement may improve functionality [2, 5]. The goal of this paper is to provide guidance for the development of technology to enhance autonomy and quality of life for older adults. We explore the potential for robotics to meet these needs. We evaluated older adults' diverse living situations and the predictors of residential moves to higher levels of care in the United States. We also examined older adults' needs for assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and medical conditions when living independently or in a long-term care residence. By providing support for older adults, mobile manipulator robots may reduce need-driven, undesired moves from residences with lower levels of care (i.e., private homes, assisted living) to those with higher levels of care (i.e., skilled nursing).

The use and costs of formal care in newly diagnosed dementia: a three-year prospective follow-up study

OBJECTIVE

To investigate the use of formal care during the first three years after diagnosis of mild dementia and identify cost-predicting factors.

DESIGN

Prospective longitudinal study over three years.

SETTING

An incidence-based bottom-up cost-of-illness study where information about formal health care services was drawn from the municipalities' registers during the first three years after the diagnosis of mild dementia.

PARTICIPANTS

109 patients with mild dementia at baseline, diagnosed according to consensus criteria based on standardized assessments.

MEASUREMENT

The use of formal care as registered by the municipalities' registration systems. Costs were estimated by applying unit costs, including municipal expenses and out-of-pocket contributions. Clinical data were collected at baseline to identify cost-predicting factors.

RESULTS

Costs for formal care were increasing from € 535 per month of survival (MOS) at baseline to € 3,611 per MOS during the third year, with a mean of € 2,420 during the whole observation period. The major cost driver (74%) was institutional care. The costs for people with dementia with Lewy bodies (€ 3,247 per MOS) were significantly higher than for people with Alzheimer disease (€ 1,855 per MOS). The most important cost-predicting factors we identified were the living situation, a diagnosis of non-Alzheimer disease, comorbidity, and daily living functioning. The use of cholinesterase inhibitors was related to lower costs.

CONCLUSION

Formal care costs increased significantly over time with institutional care being the heaviest cost driver. Studies with longer observation periods will be necessary to evaluate the complete socioeconomic impact of the course of dementia.

A Model of Risk Reduction for Older Adults Vulnerable to Nursing Home Placement

Because of the cost of nursing home care and desire of older adults to stay in their homes, it is important for health care providers to understand the factors that place older adults at risk for nursing home placement. This integrative review of 12 years of research, as published in 148 articles, explores the risk factors for nursing home placement of older adults. Using the framework of the vulnerable populations conceptual model developed by Flaskerud and Winslow (1998), we explored factors related to resource availability, relative risks, and health status. Important factors include socioeconomic status, having a caregiver, the availability and use of home- and community-based support services, race, acute illness particularly if hospitalization is required, medications, dementia, multiple chronic conditions, functional disability, and falls. Few intervention studies were identified. Development of evidence-based interventions and creation of policies to address modifiable risk factors are important next steps.

The relationship between older Americans Act Title III state expenditures and prevalence of low-care nursing home residents

OBJECTIVE

To test the relationship between older Americans Act (OAA) program expenditures and the prevalence of low-care residents in nursing homes (NHs). DATA SOURCES AND COLLECTION: Two secondary data sources: State Program Reports (state expenditure data) and NH facility-level data downloaded from LTCfocUS.org for 16,030 US NHs (2000-2009).

STUDY DESIGN

Using a two-way fixed effects model, we examined the relationship between state spending on OAA services and the percentage of low-care residents in NHs, controlling for facility characteristics, market characteristics, and secular trends.

PRINCIPAL FINDINGS

Results indicate that increased spending on home-delivered meals was associated with fewer residents in NHs with low-care needs.

CONCLUSIONS

States that have invested in their community-based service networks, particularly home-delivered meal programs, have proportionally fewer low-care NH residents.

The influence of hospice use on nursing home and hospital use in assisted living among dual-eligible enrollees

OBJECTIVE

This study examined the impact of hospice enrollment on the probabilities of hospital and nursing home admissions among a sample of frail dual-eligible assisted living (AL) residents.

DESIGN

The study used a retrospective cohort design. We estimated bivariate probit models with 2 binary outcome variables: any hospital admissions and any nursing home admissions after assisted living enrollment.

SETTING

A total of 328 licensed AL communities accepting Medicaid waivers in Florida.

PARTICIPANTS

We identified all newly admitted dual-eligible AL residents in Florida between January and June of 2003 who had complete state assessment data (n = 658) and followed them for 6 to 12 months.

MEASUREMENTS

Using the Andersen behavioral model, predisposing (age, gender, race), enabling (marital status, available caregiver, hospice use), and need (ADL/IADL, comorbidity conditions, and incontinence) characteristics were included as predictors of 2 binary outcomes (hospital and nursing home admission). Demographics, functional status, and caregiver availability were obtained from the state client assessment database. Data on diagnosis and hospital, nursing home, and hospice use were obtained from Medicare and Medicaid claims. Death dates were obtained from the state vital statistics death certificate data.

RESULTS

The mean age of the study sample was 81.5 years. Three-fourths were female and 63% were White. The average resident had a combined ADL/IADL dependency score of 11.49. Fifty-eight percent of the sample had dementia. During the average 8.9-month follow-up period, 6.8% were enrolled in hospice and 10.2% died. Approximately 33% of the sample had been admitted into a hospital and 20% had been admitted into a nursing home. Bivariate probit models simultaneously predicting the likelihood of hospital and nursing home admissions showed that hospice enrollment was associated with lower likelihood of hospital (OR = 0.24, P < .01) and nursing home admissions (OR = 0.56, P < .05). Significant predictors of hospital admissions included higher Charlson Comorbidity Index score and incontinence. Predictors of nursing home admissions included higher Charlson Comorbidity Index score, the absence of available informal caregiver, and incontinence.

CONCLUSIONS

Hospice enrollment was associated with a lower likelihood of hospital and nursing home admissions, and, thus, may have allowed AL residents in need of palliative care to remain in the AL community. AL providers should support and facilitate hospice care among older frail dual-eligible AL residents. More research is needed to examine the impact of hospice care on resident quality of life and total health care expenditures among AL residents.