The prevalence, reporting, and treatment of anxiety among older adults in nursing homes and other residential aged care facilities

Intergenerational engagement with Asian residents in long-term care facilities: a mixed method systematic review

Introduction

Asian countries are experiencing a rapid rise in their aging populations. Cognitive and physical decline associated with aging can limit social interaction. This particularly impacts on those residing in long-term care facilities and engagement with children and young people. Intergenerational engagement has known benefits on the health and wellbeing of older people, it is unclear what the impact of intergeneration engagement interventions might have on older people in Asian long-term care settings. This review aims to evaluate the effectiveness and experiences of intergenerational engagement with older people in long-term care facilities in Asia.

Methods

Ten databases were searched to locate empirical studies of any design published in English or Chinese from January 2000 to June 2023. The search was limited to papers reporting effectiveness and/or experiences of intergenerational engagement on older people residing in Asian long-term care settings. The protocol was registered with PROSPERO (CRD42023413935) and followed PRISMA guidelines for reporting. A convergent design employing narrative synthesis was used to synthesize and integrate findings.

Results

From initial searches, 1,092 records were identified, of which 13 studies were retained for the review: 7 quantitative (including 1 randomized controlled trial, 1 cross-sectional observational design, and 5 quasi-experimental designs), 3 qualitative, and 3 mixed methods. Included studies were of variable quality. Quantitative evidence revealed that intergenerational engagement reduced depression (4.47 vs. 8.67, p = 0.005), negative emotions (14.11 vs. 16.56, p = 0.030), and feelings of loneliness (p < 0.01) among older people; and increased quality of life (mean change = -1.91; 95% CI = -3.18, -0.64) and strengthens interpersonal interactions (p = 0.025). Qualitative insights suggested that intergenerational engagement could foster emotional bonds, enhance intergenerational relationships, promote lifelong learning, satisfy social needs and improve older peoples' overall quality of life. However, some challenges such as language differences and noise levels can hinder successful implementation of intergenerational engagement.

Conclusion

This review indicates that intergenerational engagement can reduce depression and loneliness, improve quality of life, and strengthen social bonds for older individuals in Asian long-term care facilities. Despite some challenges, the evidence underlines its potential to meet the emotional and social needs of older people. Recognizing and addressing delivery challenges is essential for effective implementation.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023413935, identifier: CRD42023413935.

Psychological therapies for depression in older adults residing in long-term care settings

BACKGROUND

Depression is common amongst older people residing in long-term care (LTC) facilities. Currently, most residents treated for depression are prescribed antidepressant medications, despite the potential availability of psychological therapies that are suitable for older people and a preference amongst many older people for non-pharmacological treatment approaches.

OBJECTIVES

To assess the effect of psychological therapies for depression in older people living in LTC settings, in comparison with treatment as usual, waiting list control, and non-specific attentional control; and to compare the effectiveness of different types of psychological therapies in this setting.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, five other databases, five grey literature sources, and two trial registers. We performed reference checking and citation searching, and contacted study authors to identify additional studies. The latest search was 31 October 2021.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and cluster-RCTs of any type of psychological therapy for the treatment of depression in adults aged 65 years and over residing in a LTC facility.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles/abstracts and full-text manuscripts for inclusion. Two review authors independently performed data extraction and risk of bias assessments using the Cochrane RoB 1 tool. We contacted study authors for additional information where required. Primary outcomes were level of depressive symptomatology and treatment non-acceptability; secondary outcomes included depression remission, quality of life or psychological well-being, and level of anxious symptomatology. We used Review Manager 5 to conduct meta-analyses, using pairwise random-effects models. For continuous data, we calculated standardized mean differences and 95% confidence intervals (CIs), using endpoint data, and for dichotomous data, we used odds ratios and 95% CIs. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 19 RCTs with 873 participants; 16 parallel group RCTs and three cluster-RCTs. Most studies compared psychological therapy (typically including elements of cognitive behavioural therapy, behavioural therapy, reminiscence therapy, or a combination of these) to treatment as usual or to a condition controlling for the effects of attention. We found very low-certainty evidence that psychological therapies were more effective than non-therapy control conditions in reducing symptoms of depression, with a large effect size at end-of-intervention (SMD -1.04, 95% CI -1.49 to -0.58; 18 RCTs, 644 participants) and at short-term (up to three months) follow-up (SMD -1.03, 95% CI -1.49 to -0.56; 16 RCTs, 512 participants). In addition, very low-certainty evidence from a single study with 82 participants indicated that psychological therapy was associated with a greater reduction in the number of participants presenting with major depressive disorder compared to treatment as usual control, at end-of-intervention and short-term follow-up. However, given the limited data on the effect of psychological therapies on remission of major depressive disorder, caution is advised in interpreting this result. Participants receiving psychological therapy were more likely to drop out of the trial than participants receiving a non-therapy control (odds ratio 3.44, 95% CI 1.19 to 9.93), which may indicate higher treatment non-acceptability. However, analyses were restricted due to limited dropout case data and imprecise reporting, and the finding should be interpreted with caution. There was very low-certainty evidence that psychological therapy was more effective than non-therapy control conditions in improving quality of life and psychological well-being at short-term follow-up, with a medium effect size (SMD 0.51, 95% CI 0.19 to 0.82; 5 RCTs, 170 participants), but the effect size was small at postintervention (SMD 0.40, 95% CI -0.02 to 0.82; 6 RCTs, 195 participants). There was very low-certainty evidence of no effect of psychological therapy on anxiety symptoms postintervention (SMD -0.68, 95% CI -2.50 to 1.14; 2 RCTs, 115 participants), although results lacked precision, and there was insufficient data to determine short-term outcomes.

AUTHORS' CONCLUSIONS

This systematic review suggests that cognitive behavioural therapy, behavioural therapy, and reminiscence therapy may reduce depressive symptoms compared with usual care for LTC residents, but the evidence is very uncertain. Psychological therapies may also improve quality of life and psychological well-being amongst depressed LTC residents in the short term, but may have no effect on symptoms of anxiety in depressed LTC residents, compared to control conditions. However, the evidence for these effects is very uncertain, limiting our confidence in the findings. The evidence could be strengthened by better reporting and higher-quality RCTs of psychological therapies in LTC, including trials with larger samples, reporting results separately for those with and without cognitive impairment and dementia, and longer-term outcomes to determine when effects wane.

Understanding the Barriers to and Facilitators of Anxiety Management in Residents of Long-Term Care

Older adults, 65 years of age and older, living in long-term care (LTC) commonly experience anxiety. This study aimed to understand care providers' perspectives on the barriers to and facilitators of managing anxiety in residents of LTC. Ten semi-structured interviews with care providers in LTC were completed. Framework analysis methods were used to code, thematically analyze, designate codes as barriers or facilitators, and map the codes to the Theoretical Domains Framework. Themes were categorized as acting at the resident, provider, or system level, and were labelled as either barriers to or facilitators of anxiety care. Key barriers to anxiety care at each level were resident cognitive impairment or co-morbidities; lack of staff education, staff treatment uptake and implementation; as well as the care delivery environment and access to resources. There is a need to prioritize measurement-based care for anxiety, have increased access to non-pharmacological treatments, and have a care delivery environment that supports anxiety management to improve the care for anxiety that is delivered to residents.

Anxiety Symptoms in Australian Memory Clinic Attendees with Cognitive Impairment: Differences Between Self-, Carer-, and Clinician-Report Measures

OBJECTIVES

To identify the prevalence of anxiety symptoms using a variety of instruments in an Australian memory clinic sample.

METHODS

This is an exploratory cross-sectional study using a purposive consecutive series sample of 163 individuals and their carers who attended a Brisbane, Australia, memory clinic in 2012-2015. Descriptive statistics and correlation analyses were performed to explore different approaches to measuring anxiety in the sample, using clinician-rated, self-report and carer-report measures.

RESULTS

The mean age of participants was 78 years, nearly 53% were females. Over 70% of participants with mild cognitive impairment (MCI) and dementia (n = 163) experienced mild to moderate anxiety per a clinician-rated measure (HAM-A), which moderately correlated with carer-report anxiety (IQAD; rs =.59, p < .001). Only weak correlations of these measures with self-report anxiety (GAI) were detected.

CONCLUSIONS

Mild to moderate anxiety symptoms were frequent in memory clinic attendees diagnosed with MCI or dementia using the HAM-A, suggesting experiences of subclinical anxiety symptoms.

CLINICAL IMPLICATIONS

Self- as well as carer-report screening tools should be used in memory clinics in addition to routinely administered neuropsychiatric assessments to support early identification of anxiety symptoms and mapping of available post-diagnostic care pathways for people diagnosed with cognitive impairment.

Intercultural adaptation and influencing factors analysis of the Chinese version of the anxiety scale for the older adults in a long-term care population

Objective

The purpose of this study was to translate the Geriatric Anxiety Scale-Long-Term Care into Chinese and to assess its reliability and validity in a long-term care population, as well as to explore factors contributing to anxiety in older adults requiring long-term care.

Methods

The study recruited 399 older adults residents requiring long-term care and used the Brislin double translation-back-translation method to create the initial Chinese version of the Geriatric Anxiety Scale-Long-Term Care. The study used internal consistency and split-half reliability to assess the reliability of the scale, as well as exploratory factor analysis, validation factor analysis, and content validity to assess the validity of the scale. Linear regression was used to analyze the relationship between the independent variables and anxiety levels in the long-term care population.

Results

The Cronbach's coefficient value of the Chinese version of the Geriatric Anxiety Scale-Long-Term Care was 0.81, and the split-half reliability was 0.80. The results of exploratory factor analysis showed support for a one-dimensional factor structure. The results of the validation factor analysis indicated a good fit for the one-factor model. Gender (β = 0.190, 95% CI:0.540 ~ 1.546, p < 0.001), self-rated health (β = 0.220, 95% CI:0.379 ~ 0.953, p < 0.001), life satisfaction (β = -0.315, 95% CI: -1.355 ~ -0.734, p < 0.001) and participation in activities (β = -0.106, 95% CI: -1.122 ~ -0.084, p < 0.05) were significant predictors of anxiety levels in the long-term care population.

Conclusion

The Chinese version of the Geriatric Anxiety Scale-Long-Term Care has good reliability and validity in the long-term care population. The Geriatric Anxiety Scale-Long-Term Care is effective in assessing the anxiety level of the Chinese long-term care older adults population and provides an opportunity to detect and observe anxiety disorders in the long-term care population.

The experience of intergenerational interactions and their influence on the mental health of older people living in residential care

The mental health of an increasing ageing population is an important part of healthcare. Research has explored means to enrich the lives of older adults living in residential settings, including approaches like the Eden Alternative. This is a cross-sectional, qualitative study with a quantitative component. It looks at common mental health conditions (CMHCs) in residential-living older adults in South Africa and describes their experiences of intergenerational interactions with playschool children. Participants completed a questionnaire which included the Geriatric Depression Scale and Geriatric Anxiety Scale and a semi-structured interview. Anxiety and depression were common in the sample with limited awareness of non-pharmacological therapy available at the facility. The intergenerational interactions were experienced positively with emerging themes of belonging, sense of purpose, reminiscence and positive affective experiences, but influenced by participants' preconceptions of children. The study concludes that intergenerational interactions may serve as adjunctive therapy in managing CMHCs in residential-living older adults. Recommendations are made for successful implementation of such programs.

Global prevalence of mild cognitive impairment among older adults living in nursing homes: a meta-analysis and systematic review of epidemiological surveys

Mild cognitive impairment (MCI) is the early stage of cognitive impairment between the expected cognitive decline of normal aging and the more serious decline of dementia. This meta-analysis and systematic review explored the pooled global prevalence of MCI among older adults living in nursing homes and its relevant factors. The review protocol was registered in INPLASY (INPLASY202250098). PubMed, Web of Science, Embase, PsycINFO, and CINAHL databases were systematically searched from their respective inception dates to 8 January 2022. The inclusion criteria were made based on the PICOS acronym, as follows: Participants (P): Older adults living in nursing homes; Intervention (I): not applicable; Comparison (C): not applicable; Outcome (O): prevalence of MCI or the data can generate the prevalence of MCI according to study-defined criteria; Study design (S): cohort studies (only baseline data were extracted) and cross-sectional studies with accessible data published in a peer-reviewed journal. Studies involving mixed resources, reviews, systematic reviews, meta-analyses, case studies, and commentaries were excluded. Data analyses were performed using Stata Version 15.0. Random effects model was used to synthesize the overall prevalence of MCI. An 8-item instrument for epidemiological studies was used to assess the quality of included studies. A total of 53 articles were included involving 376,039 participants with a mean age ranging from 64.42 to 86.90 years from 17 countries. The pooled prevalence of MCI in older adults in nursing homes was 21.2% (95% CI: 18.7-23.6%). Subgroup and meta-regression analyses revealed that the screening tools used were significantly associated with MCI prevalence. Studies using the Montreal Cognitive Assessment (49.8%) had a higher prevalence of MCI than those using other instruments. No significant publication bias was found. Several limitations warrant attention in this study; for example, significant heterogeneity between studies remained and some factors associated with the prevalence of MCI were not examined due to insufficient data. Adequate screening measures and allocation of resources are needed to address the high global prevalence of MCI among older adults living in nursing homes.

Detecting Anxiety in Long-Term Care Residents: A Systematic Review

Anxiety is common in long-term care (LTC), but it is unclear which anxiety detection tools are accurate when compared to a reference standard for residents of LTC. Four databases and grey literature sources were searched using the search concepts "anxiety" and "LTC". Included studies evaluated the diagnostic accuracy of an anxiety detection tool compared to a reference standard in LTC residents. Diagnostic accuracy measures were extracted. Four articles out of 4,620 met the inclusion criteria. Despite limited evidence and poorly reported study procedures and characteristics, the Geriatric Anxiety Inventory (sensitivity: 90.0%, specificity: 86.2%) and the Hospital Anxiety and Depression Scale-Anxiety (sensitivity: 90.0%, specificity: 80.6%) had the best performance when detecting generalized anxiety disorder. We identified four anxiety detection tools appropriate for use in LTC; a critical first step to diagnosing and managing anxiety in residents of LTC. Non-generalized anxiety disorders and tool feasibility must be further evaluated.

Associations between anxiety, centromedial amygdala volume, and complex verbal fluency in middle-aged to older adults

Symptoms of anxiety are related to decreases in cognitive performance in middle-aged to older adults (i.e., ages 50 and older; MOA). Verbal fluency (VF), assessed with the Delis-Kaplan Executive Function System (D-KEFS) Category Switching (VF-CS) task, captures elements of executive function such as semantic memory, response initiation and inhibition, and cognitive flexibility. The present study examined the link between anxiety symptoms and VF-CS to better understand how this association affects such executive functions in MOA. We hypothesized that higher subclinical Beck Anxiety Inventory (BAI) scores would be associated with lower VF-CS. To further investigate the underlying neurobiological basis of an expected inverse relationship, total amygdala volume, centromedial amygdala (CMA) volume, and basolateral amygdala (BLA) volume were examined as they related to VF-CS scores on the D-KEFS. Based on extant research on connectivity and functioning between the CMA and BLA, we hypothesized that larger BLA volumes would be associated with lower anxiety scores and exhibit positive relationships with VF-CS. A sample of 63 MOA were recruited from the Providence, Rhode Island area as a part of a parent study on cardiovascular diseases. Participants completed self-report measures about physical and emotional health, a neuropsychological assessment, and a magnetic resonance imaging scan (MRI). Multiple hierarchical regressions were performed to examine relationships between variables of interest. Contrary to hypotheses, no significant relationship emerged between VF-CS and BAI scores, and BLA volume was not associated with either BAI scores or VF-CS. However, a significant positive relationship was observed between CMA volume and VF-CS. The significant relationship found between CMA and VF-CS may reflect the upward slope of the quadratic relationship between arousal and cognitive performance on the Yerkes-Dodson curve. These findings newly implicate CMA volume specifically as a possible neuromarker linking emotional arousal and cognitive performance in MOA.

Non-pharmacologic and pharmacologic treatments for anxiety in long-term care: a systematic review and meta-analysis

BACKGROUND

older adults living in long-term care (LTC) commonly suffer from anxiety symptoms and disorders. We completed a systematic review and meta-analysis to identify efficacious treatments for anxiety symptoms for older adults living in LTC.

METHODS

we searched five electronic databases (MEDLINE, Embase, PsycINFO, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials) to identify treatments for anxiety that have been trialled in LTC. Included studies had to be randomised trials, include residents of LTC, and measure anxiety symptoms as an outcome.

RESULTS

the electronic search returned 6,617 articles, 519 were reviewed in full text, and 80 were included in the descriptive synthesis. Limited studies were meta-analysed (n = 10) due to differences in described treatment and comparator conditions. Limited clinically relevant evidence supporting the use of pharmacologic treatments for symptoms of anxiety in LTC was identified. Of the treatments trialled, music compared with usual care (standardised mean difference, SMD: -0.82; 95% confidence interval (CI): -1.31, -0.34), music compared with social interaction (SMD: -0.41; 95% CI: -0.72, -0.10) and massage compared with usual care (SMD: -4.32; 95% CI: -7.44, -1.19) were found to improve anxiety symptoms, however, significant heterogeneity was detected in two comparisons.

CONCLUSIONS

a range of non-pharmacologic treatments that improved anxiety symptoms were identified for use in LTC. Although limited evidence exists to support the use of particular treatments, most non-pharmacologic treatments were low-risk interventions that may be readily implemented. Further research is required to assess the treatment effect on residents of LTC with anxiety disorders or clinically relevant symptoms at baseline.

Subsyndromal generalised anxiety disorder: operationalisation and epidemiology - a systematic literature survey

The diagnosis of anxiety disorders, like other psychiatric disorders also, is operationalised since the introduction of diagnostic manuals. The diagnostic criteria of Generalised Anxiety Disorder (GAD) have been tightened in the last decades. This leads to the exclusion of patients with a high level of anxiety, but not fulfilling certain of the GAD-criteria, from effective treatment. Such so-called subsyndromal, subthreshold or subclinical GAD-states, however, often exhibit a comparable burden of disease like the full syndromal disorder and often tend to develop into the full syndromal disorder. The purpose of this review is - beside systematically reporting the papers found in respective data bases from 2013 onwards - to summarise the relevant data regarding definitions, epidemiology and consequences of subsyndromal anxiety states in order to give a comprehensive review.

Government-subsidised mental health services are underused in Australian residential aged care facilities

ObjectiveTo describe patterns of use of the available Government-subsidised mental health services among people living in Australian residential aged care facilities.MethodsA retrospective population-based trend analysis was conducted, including all non-Indigenous people living in an Australian facility between 2012 and 2017. Adjusted incidence proportions and trends were estimated for four groups of mental health services.ResultsThe use of Medicare-subsidised mental health services was very low overall. The proportion of residents who accessed primary care mental health services increased from 1.3% in 2012/2013 to 2.4% in 2016/2017, while psychiatry service use increased from 1.9 to 2.3%. Claims for clinical psychology increased from 0.18 to 0.26%, and claims for a registered psychologist, occupational therapist or social worker rose from 0.45 to 1.2%. People with dementia were less likely than people without dementia to access all services aside from psychiatry services.ConclusionsLess than 3% of residents accessed funding subsidies for mental health services and people with dementia experienced pronounced barriers to service access. Mental health care is a pillar of the publicly-funded health system in Australia, and low use of these services among aged care residents indicates a need for organisational and policy changes to improve access.

Strategies to support older adults' mental health during the transition into residential aged care: a qualitative study of multiple stakeholder perspectives

Background

The move from home into residential care is one of the most stressful life experiences for older adults. ‘Relocation stress’ is a significant risk factor for anxiety and/or depression in aged care residents. Whether long-term or recently diagnosed, these mood disorders are associated with a decline in overall well-being, daily functioning and independence. The mental health needs of older adults are often poorly recognised and supported, including during the transition into residential care. Despite growing interest in how to facilitate this major life transition, few studies have taken the perspective of multiple stakeholders. The aim of this study was to explore resident, relative and staff experiences of the transition into residential aged care, and to identify strategies to support the mental health of older adults at this time. The role of pastoral care practitioners to facilitate transitions and support residents’ mental health was also examined.

Methods

This phenomenological study involved individual interviews with 35 aged care residents, relatives and staff, between January and April 2021. Participants were selected using purposive sampling. Audio-recorded interviews were transcribed verbatim and supported by field notes. Data analysis followed Giorgi’s steps for qualitative data analysis.

Results

Results were distilled into three main categories related to the overall transition experience, recognising and responding to residents’ mental health needs, and tailoring support to individual needs. A novel contribution of this study relates to the need to address a broad misunderstanding of the role of pastoral care and subsequent under-utilisation of a potentially valuable resource.

Conclusions

By describing transition experiences and the resources to support residents’ mental health, findings of this study provide practical, ‘real world’ suggestions for reducing relocation stress. New resources developed from the findings include guides, checklists and short question-and-answer films, in which current residents and staff describe strategies to support mental health and overall quality of life. Similar resources could be used to support transitions in other care settings.

Assessment of Anxiety in Long-Term Care Residents: Issues and Strategies

The experience of clinically significant anxiety and anxiety disorders represent significant and often debilitating problems for many residents in long-term care (LTC) settings. However, anxiety problems often go undetected and untreated in this growing population. The purposes of this paper are to examine the prevalence and impact of anxiety problems among residents in LTC facilities, describe the efficacy of the current instruments that are used to detect anxiety in these settings, and provide clinical guidance for the thorough assessment of anxiety. Regarding measurement tools, the GAI, GAI-SF, GAS-LTC, and the BADS are the only self-report measures designed for older adults that have been successfully validated for use with older adults living in LTC settings. Clinicians should focus on ways to educate LTC directors and staff to emphasize the importance of screening and assessing for anxiety, using validated measures, to improve the assessment and treatment of anxiety in their residents.

Geriatric Anxiety Scale: Development and Preliminary Validation of a Long-Term Care Anxiety Assessment Measure

Objectives: Anxiety is a significant problem for many individuals in various long-term care (LTC) settings and is often undetected and under-treated. This study examined the psychometric properties of a new quantitative anxiety screening measure specifically designed for use in long-term care settings, the Geriatric Anxiety Scale - Long Term Care Version (GAS-LTC).Method: Data were collected from LTC residents (N = 66; M age = 84.4 years, range = 59 to 100 years; 74.2% women) who completed the GAS-LTC, the Geriatric Anxiety Inventory (GAI), the Geriatric Depression Scale-15 (GDS-15), and the Prospective and Retrospective Memory Questionnaire (PRMQ).Results: The GAS-LTC demonstrated good internal consistency (α = .80), and good convergent validity with the GAI (r = .70, p < .01), the GDS-15 (r = .67, p < .01), and the PRMQ (r = .54, p < .01). Internal consistency on the GAS-LTC did not significantly vary between groups with high (α = .75) and low (α = .77) self-reported subjective memory impairment.Conclusions: The results from this study preliminarily indicate that the GAS-LTC is reliable and valid for use with older adults in LTC settings.Clinical Implications: Use of the GAS-LTC in LTC settings may help improve detection and treatment for individuals experiencing elevated anxiety in LTC.

Cognitive status and use of analgesics and anxiolytics in residents of nursing homes in the Czech Republic

Background

The treatment of pain and treatment of anxiety are two of the most complex issues in nursing homes worldwide, mainly because of the large numbers of people with cognitive impairment who reside in this environment.

Aim

The aim of this study was to investigate the administration of analgesics and anxiolytics to people living in nursing homes, taking into account cognitive status.

Methods

For this cross-sectional study, we used data from 404 residents who lived in nine randomly selected nursing homes in the Czech Republic and participated in the Czech-Austrian Long-Term Care Research Project called DEMDATA. Information about medication administration was obtained from medical records. Cognitive impairment was evaluated by the Mini-Mental State Examination, and pain was measured by the Pain Assessment in Advanced Dementia. To measure anxiety, we used the Behavioral Pathology in Alzheimer’s Disease Rating Scale in residents with severe-to-moderate dementia and also the standardized questionnaire EuroQol in other residents.

Results

In all, 68% (95% CI 62–74) of residents with pain did not receive any analgesic medication and 31% (95% CI 25–38) of residents were administered some analgesics and continued to report pain. The lowest reported occurrence of pain, as well as the lowest prevalence of analgesic administration, was in residents with moderate-to-severe dementia. We found that an alarming percentage of residents in the nursing homes were not treated sufficiently.

Conclusion

This study indicates that treatment effects should be better monitored.