Managing Persons with Dementia in the Nursing Home: High Touch Trumps High Tech

Predictors of Functional Decline in Nursing Home Residents: The Shelter Project

BACKGROUND

The aim of our study was to identify independent predictors of functional decline in older nursing home (NH) residents, taking into account both resident and facility characteristics.

METHODS

Longitudinal observational study involving 1,760 older (≥65 y) residents of NH participating in the SHELTER* study (57 NH in eight countries). All residents underwent a comprehensive geriatric assessment using the interRAI LTCF. Functional decline was defined as an increase of at least one point in the MDS Long Form ADL scale during a 1 year follow-up. Facility and country effects were taken into account.

RESULTS

During the study period 891 (50.6%), NH residents experienced ADL decline. Residents experiencing ADL decline were older, had lower disability at baseline, were more frequently affected by severe dementia and by urinary incontinence, and used more antipsychotics. In the mixed-effect logistic regression model, factors independently associated with a higher risk of functional decline were dementia and urinary incontinence, whereas the presence of a geriatrician was a protective factor.

CONCLUSIONS

Both resident and facility characteristics are associated with the risk of functional decline in NH residents. Increasing the quality of healthcare by involving a geriatrician in residents' care might be an important strategy to improve the outcome of this vulnerable population.

How Do Geriatric Principles Inform Healthy Aging?

Healthy aging long has been held as a core belief and priority of geriatrics, yet clinical, scholarly, and advocacy efforts have not kept pace with attention to multimorbidity and end-of-life care. With an aging US population and trends toward higher rates of lifestyle diseases, there is imperative for geriatricians to engage in efforts to promote healthy aging. Lifestyle medicine offers an evidence-based approach to healthy aging at any point in the life span. This emerging branch of medical practice has synergistic principles and frameworks with the field of geriatrics, which should further empower geriatricians to engage in promoting healthy aging.

A new music therapy engagement scale for persons with dementia

ABSTRACTObjectives:To develop and validate a new scale to assess music therapy engagement in persons with dementia (PWDs).

DESIGN

A draft scale was derived from literature review and >2 years of qualitative recording of PWDs during music therapy. Content validity was attained through iterative consultations, trial sessions, and revisions. The final five-item Music Therapy Engagement scale for Dementia (MTED) assessed music and non-music related elements. Internal consistency and inter-rater reliability were assessed over 120 music therapy sessions. MTED was validated with the Greater Cincinnati Chapter Well-being Observation Tool, Holden Communication Scale, and Participant Engagement Observation Checklist - Music Sessions.

SETTING AND PARTICIPANTS

A total of 62 PWDs (83.2 ± 7.7 years, modified version of the mini-mental state examination = 13.2/30 ± 4.1) in an acute hospital dementia unit were involved.

RESULTS

The mean MTED score was 13.02/30 ± 4.27; internal consistency (Cronbach's α = 0.87) and inter-rater reliability (intra-class correlation = 0.96) were good. Principal component analysis revealed a one-factor structure with Eigen value > 1 (3.27), which explained 65.4% of the variance. MTED demonstrated good construct validity. The MTED total score correlated strongly with the combined items comprising Pleasure, Interest, Sadness, and Sustained attention of the Greater Cincinnati Chapter Well-being Observation Tool (rs = 0.88, p < 0.001).

CONCLUSIONS

MTED is a clinically appropriate and psychometrically valid scale to evaluate music therapy engagement in PWDs.

Using Complementary and Alternative Medicine to Treat Pain and Agitation in Dementia: A Review of Randomized Controlled Trials from Long-Term Care with Potential Use in Critical Care

The risk of pain in adults with dementia worsens with advancing age. Painful comorbidities may be underassessed and inadequately treated. Receiving treatment in critical care settings may indicate greater occurrences of pain and complications. Pain may exacerbate behavioral and psychological symptoms of dementia (BPSD), such as agitation. Complementary and alternative medicine (CAM) therapies may alleviate pain and BPSD, and continuity of therapy may bolster these therapeutic effects. This review did not reveal an apparent benefit of aromatherapy; however, improvements in BPSD have been shown previously. Massage and human interaction did demonstrate efficacy in reducing BPSD and pain.

Predictors of Functional Changes in Italian Nursing Home Residents: The U.L.I.S.S.E. Study

OBJECTIVES

To identify independent predictors of the risk of functional decline in older nursing home (NH) residents.

DESIGN

A longitudinal observational study.

SETTING

Thirty-one NHs participating in the U.L.I.S.S.E. project, distributed throughout Italy.

PARTICIPANTS

All older (≥65 years) long-term NH residents without complete disability and with at least one follow-up evaluation during the 12-month study period (n = 1263).

MEASUREMENTS

All participants underwent a standardized comprehensive evaluation using the Italian version of the Minimum Data Set for NHs. The activities of daily living (ADLs) Long-Form scale was used to evaluate functional status. Facility characteristics were collected using an ad hoc designed questionnaire.

RESULTS

Of the NH residents, 40.4% experienced a decline in the ADL during the follow-up. The mixed effect logistic regression model showed that depression (odds ratio [OR] 1.45, confidence interval [CI] 1.16-1.81, P = .005) and the use of antipsychotics (OR 1.30, CI 1.06-1.60, P = .016) were associated with a higher probability of ADL decline, whereas the presence of a geriatrician (OR 0.60, CI 0.41-0.88, P = .015) and a higher than median hour per resident per week of nursing care (OR 0.55, CI 0.37-0.80, P = .006) were associated with a lower risk.

CONCLUSIONS

Our findings suggest that preventing functional decline in NH residents might be possible by optimizing the management of depression and by reducing the current high prescription rate of antipsychotics. Moreover, the presence of a geriatrician, associated with an adequate amount of nursing care, seem to be important facilities characteristics to achieve this goal. These findings should be tested in large-scale pragmatic clinical trials.

Long-term effects of a 12 weeks high-intensity functional exercise program on physical function and mental health in nursing home residents with dementia: a single blinded randomized controlled trial

Background

Research indicates that exercise can have a positive effect on both physical and mental health in nursing home patients with dementia, however the lasting effect is rarely studied. In a previously published article we investigated the immediate effect of a 12 weeks functional exercise program on physical function and mental health in nursing home residents with dementia. In this paper we studied the long-term effect of this exercise program. We explored the differences between the exercise and control group from baseline to 6 months follow-up and during the detraining period from month 3 to 6.

Methods

A single blind, randomized controlled trial was conducted and a total of 170 nursing home residents with dementia were included. The participants were randomly allocated to an intervention (n = 87) or a control group (n = 83). The intervention consisted of intensive strengthening and balance exercises in small groups twice a week for 12 weeks. The control condition was leisure activities. Thirty participants were lost between baseline and six-month follow-up. Linear mixed model analyses for repeated measurements were used to investigate the effect of exercise after detraining period.

Results

The exercise group improved their scores on Berg Balance Scale from baseline to 6 months follow-up by 2.7 points in average. The control group deteriorated in the same period and the difference between groups was statistically significant (p = 0.031). The exercise group also scored better on NPI agitation sub-score after 6 months (p = 0.045).

Conclusion

The results demonstrate long-time positive effects of a high intensity functional exercise program on balance and indicate a positive effect on agitation, after an intervention period of 12 weeks followed by a detraining period of 12 weeks.

Identifier at ClinicalTrials.gov: NCT02262104

Clinical update on nursing home medicine: 2013

This is the seventh article in the series of Clinical Updates on Nursing Home Care. The topics covered are antiresorptive drugs, hip fracture, hypertension, orthostatic hypotension, depression, undernutrition, anorexia, cachexia, sarcopenia, exercise, pain, and behavioral and psychological symptoms of dementia.

Medical care in the nursing home

With the advent of the graying of the baby boomers, there is an urgent need to enhance care in the nursing home. This article focuses on the areas where high-quality care can improve outcomes.

Screening cognitive impairment among institutionalized older Chinese men in Taiwan: a new minimum data set-based dementia screening tool is needed

Dementia screening is of great importance in various health settings for older people, long-term care facilities are no exception. The need for an effective dementia screening tool being culture sensitive is important. Minimum data set (MDS) is a population instrument for health care management in the world, which also covers dementia screening. The main purpose of this study was to evaluate the effectiveness of the MDS-based dementia screening tools among older Chinese men in the Veteran Home in Taiwan. Overall, 576 participants (mean age: 80.9±5.3 years, all males, 92.7% physically independent), 18.6% had cognitive impairment according to the mini-mental state examination (MMSE) (mean score: 26.7±3.9). However, the prevalence of cognitive impairment was 5.5% by MDS cognitive performance scale (CPS) and 18.9% by MDS cognition scale (MDS-COGS). The screening results of CPS and MDS-COGS were highly interrelated (γ=0.93, p<0.001), and MMSE scores were also significantly associated with CPS and MDS-COGS status (γ=-0.50, p<0.001 and γ=-0.52, p<0.001, respectively). Although the prevalence of cognitive impairment by MMSE and MDS-COGS are similar, the results are significantly inconsistent (p<0.001). In conclusion, both MDS-COGS and CPS were significantly correlated with MMSE scores, but significant inconsistence was noted between screening results of MMSE, CPS and MDS-COGS. Further study is needed to develop MDS-based dementia screening tools for older Chinese men in Taiwan.

A volunteer-based Hospital Elder Life Program to reduce delirium

A community hospital with nearly 50% of its admitted patients 70 years or older adapted the well-established Hospital Elder Life Program (HELP). The primary adaptation entailed an enhanced participation of trained volunteers in HELP interventions designed to prevent and reduce delirium. Integral program elements include detailed volunteer training, required demonstration of competencies, and regular evaluation and feedback of volunteers provided by program staff. Nurse satisfaction with HELP increased from 64% to 91% in the second year of implementation, and a survey of patients and families indicated that 95% were satisfied with HELP. This innovative volunteer-assisted model of elder care support was positively embraced by patients, their families, and the nursing staff and supported by nursing administration. The use of volunteers is a cost-effective method of enhancing the nursing care of vulnerable elders during hospitalization.

Clinical practice in nursing homes as a key for progress

With the aging of the world's population there has become a major need for the development of nursing homes throughout the world. While some countries provide high quality care for the disabled elderly, in others this is not the case. Education of a medical director has been shown to improve the quality of the nursing home. Physicians need to have knowledge of how to implement continuous quality improvement and culture change. Key medical issues include moving to a restraint free environment, subsyndromal delirium, behavioral disturbances, weight loss, pain management, pressure ulcers, falls, hip fractures, polypharmacy, depression and frailty.

Descriptive study of nursing home residents from the REHPA network

INTRODUCTION

To date, very little research has been carried out in nursing homes and it is difficult to make recommendations for quality of care that are based on actual data. The Réseau de Recherche en Etablissement d'Hébergement pour Personnes Agées (REHPA) is a functional network established in collaboration between the geriatric department of Toulouse University Hospital and 240 nursing homes with the aim of compensating for the lack of evidence-based recommendations and of enhancing research.

MATERIALS AND METHODS

A cross-sectional observational study was conducted between January and March 2008. The number of residents included (randomly selected by birth date) depended on the total number of residents of the facility. Demography, medical and drug history, disabilities and care practices were assessed by geriatrician.

RESULTS

We report the findings in 4896 residents of 240 nursing homes. Residents were 73.9% women, mean age 85.7 +/- 8.8 years, mean weight 61.9 +/- 14.8 kg, with a mean ADL score of 2.8 +/- 2.1. Dementia was diagnosed in 43.5% (of whom only 50.9% were treated), 19.6% showed aggressive behaviours, 10.8% exhibited disruptive vocalization and 10.9% were wanderers, 27.4% were treated with antipsychotic medications, 54.4% had hypertension, 8.7% had diabetes, 14.8% were osteoporotic, 4.1% had fallen during the previous week, 37.9% were in pain and 19.8% had lost weight. The mean Charlson index score was 1.6 +/- 1.4. Finally, 13.5% had been admitted to hospital within the previous three months.

CONCLUSION

The survey identifies specific issues in order to target future research in the nursing home setting.