Is Aging in Place Delaying Nursing Home Admission?

Incontinence in people living with dementia

Dementia and incontinence are both prevalent in older age; yet, neither are an inevitable or normal part of ageing. It has been recognised that there is a skills and knowledge gap in professionals assessing and managing incontinence for people living with dementia. All too often, assumptions are made that incontinence is a symptom of dementia and that nothing can be done if a person living with dementia experiences episodes of incontinence. While dementia may impact on a person's ability to remain continent, it may not be the sole cause, and there may be treatments and strategies that can reduce the incidence in those affected. Therefore, a person-centred continence assessment should be undertaken to promote continence and reduce the impact of incontinence for people living with dementia and those who care for them. This paper will highlight some of the issues that are important for health and social care professionals to explore and identify, assess and manage incontinence to improve outcomes for families affected by dementia.

Home Health Care to Asian Americans: a Systematic Review

OBJECTIVE

Despite being the fastest growing minority group in the USA, Asian Americans are among the least studied ones, particularly in the home and community-based services settings. This study aimed to review and synthesize extant evidence on Asian American's access, utilization, and outcomes of home health care.

METHODS

This is a systematic review study. A comprehensive literature search was conducted in PubMed and CINAHL as well as hand search. Each study was screened, reviewed, and evaluated for quality by at least two reviewers independently.

RESULTS

Twelve articles were determined eligible and included for review. Asian Americans were less likely to be discharged to home health care following hospitalization. At admission to home health care, Asian Americans had a high rate of inappropriate medication issues (28%) and they also had poorer functional status compared to White Americans. Asian Americans were also reported with less improvement in functional status at the end of home health care; however, there were some inconsistencies in the evidence on Asian Americans' utilization of formal/skilled home health care. Quality evaluation indicated that findings from some studies were limited by small sample size, single site/home health agency, analytic approaches, and other methodologic limitations.

CONCLUSIONS

Asian Americans often experience inequities in home health care access, utilization, and outcomes. Multilevel factors may contribute to such inequities, including structural racism. Robust research using population-based data and advanced methodology is needed to better understand home health care to Asian Americans.

Identifying incontinence and promoting continence in people living with dementia

Urinary and faecal incontinence are more prevalent among older people but, like dementia, incontinence is not a normal or inevitable part of ageing. The number of people living with dementia who experience continence issues is likely to be underestimated because many people avoid reporting them as a result of embarrassment and stigma, or because they think incontinence is an inevitable symptom of dementia and that nothing can be done about it. Increased awareness and understanding of the relationship between dementia and incontinence is needed so that nurses can persuade people living with dementia and their family carers to discuss continence issues, assess their needs and provide support. There are several practical strategies that can reduce the incidence of incontinence, counter its negative effects and promote continence in people living with dementia.

Risk factors for inpatient facility admission among home health care patients with diabetes

BACKGROUND

Home health care (HHC) patients with diabetes are at high risk for inpatient admissions.

PURPOSE

To identify variables associated with inpatient admissions among adults age ≥50 with diabetes receiving HHC in the community and in assisted living (AL).

METHODS

Retrospective HHC data (collected October 2021 to March 2022 in the Southern United States) from the Outcome and Assessment Information Set D were analyzed with logistic regression (n = 5,308 patients).

DISCUSSION

The inpatient admission rate was 29.5%. For community-dwelling patients, multiple hospitalizations, depression, limited cognitive function, decreased activities of daily living (ADL) performance, and unhealed pressure ulcer or injury ≥stage 2 were significantly associated with inpatient admission. For those in AL, multiple prior hospitalizations and decreased ability to perform ADLs were associated with inpatient admission.

CONCLUSION

Understanding risk factors for inpatient admissions among patients with diabetes can support the identification of at-risk patients and inform interventions.

Ageing in place or stuck in place: Preferred care setting for community-dwelling older persons in a low-resource country in Sub Saharan Africa

BACKGROUND

Ageing in Place is the emerging social policy drive for long-term care coordination of older persons globally. This decision may be the only viable option in many low- and middle-income countries like Nigeria. Nevertheless, the risk of older persons being 'stuck in place' is high if their preferences are not considered or other alternatives are neither acceptable nor available. This study determined factors associated with the preferred care setting among community-dwelling older persons and explored their views about their choices.

METHODS

The study utilised a mixed-methods approach. Participants were older persons (≥ 60 years) in a selected rural and urban community in Oyo State, south-western Nigeria. Quantitative data were collected using an interviewer-administered, semi-structured questionnaire and analysed using Stata version 14 at p<0.05. Qualitative data collection involved 22 Focus Group Discussions (FGD). The discussions were audiotaped, transcribed verbatim and analysed thematically using ATLAS.ti version 8. Selected quotations were used to illustrate themes.

RESULTS

1,180 participants (588 rural vs 592 urban) were interviewed with a mean age of 73.2 ±9.3 years. More rural participants preferred to AIP (61.6%) compared to urban participants (39.2%), p = 0.001. Factors associated with the decision for rural participants were older age [OR:2.07 (95%CI:1.37-3.14)], being male [OR:2.41(95%CI:1.53-3.81)] and having assistance at home [OR:1.79 (95%CI:1.15-2.79)]. In comparison, significant factors for urban participants were older age (≥70years) [OR:1.54(95%CI:1.03-2.31)] and home-ownership [OR:5.83 (95%CI:3.82-8.91)]. The FGD revealed that the traditional expectation of reciprocity of care mostly influenced the desire to AIP. Advantages include improved social connectedness, quality of care, community participation and reduced isolation. Interestingly, participants were not opposed to the option of institutional care.

CONCLUSION

Ageing in place is preferred and influenced by advanced age and home ownership in our setting. Information provided could guide age-friendly housing policies and community-based programmes for the care of older persons.

Investigating community-based care service factors delaying residential care home admission of community dwelling older adults and cost consequence

OBJECTIVES

To examine factors contributing to delaying care home admission; and compare the rates of care home admission and cost consequence between two government subsidised programmes, Veterans' Affairs Community Nursing (VCN) and Home Care Package (HCP).

METHODS

Our national, population-based retrospective cohort study and cost analysis used existing, de-identified veterans' claims databases (2010-19) and the Registry of Senior Australians Historical Cohort (2010-17), plus aggregate programme expenditure data. This involved 21,636 VCN clients (20,980 aged 65-100 years), and an age- and sex-matched HCP cohort (N = 20,980).

RESULTS

Service factors associated with lower risk of care home admission in the VCN cohort were periodic (versus continuous) service delivery (HR 0.27 [95%CI, 0.24-0.31] for ≤18 months; HR 0.89 [95%CI, 0.84-0.95] for >18 months), and majority care delivered by registered nurses (versus personal care workers) (HR 0.86 [95%CI, 0.75-0.99] for ≤18 months; HR 0.91 [95%CI, 0.85-0.98] for >18 months). In the matched cohorts, the time to care home admission for VCN clients (median 28 months, IQR 14-42) was higher than for HCP clients (14, IQR 6-27). Within 5 years of service access, 57.6% (95%CI, 56.9-58.4) of HCP clients and 26.6% (95%CI, 26.0-27.2) of VCN clients had care home admission. The estimated cost saving for VCN recipients compared to HCP recipients over 5 years for relevant government providers was over A$1 billion.

CONCLUSIONS

Compared to an HCP model, individuals receiving VCN services remained at home longer, with potentially significant cost savings. This new understanding suggests timely opportunity for many countries' efforts to enhance community-based care services.

Palliative care delivery at nursing homes before and after an educational intervention from professionals' perspective: A pre-post design

BACKGROUND

The principles of palliative care were developed in hospices and specialised palliative care units and have not been sufficiently adapted to and evaluated in nursing homes. Therefore, an educational intervention from an interprofessional education perspective was performed within the project Implementation of Knowledge-Based Palliative Care in Nursing Homes. The aim of this study was to evaluate professionals' experience of palliative care delivery before and after the educational intervention.

METHODS

The educational intervention for nursing home professionals consisted of five 2-h seminars over 6 months at 20 nursing homes. The intervention and control groups consisted of 129 and 160 professionals from 30 nursing homes respectively. The questionnaire 'Your experience of palliative care' was completed 1 month before (baseline) and after (follow-up) the intervention. Descriptive and inferential statistics were calculated.

RESULTS

The positive effects at follow-up concerned the use of a valid scale for grading symptoms, attendance to the needs of next of kin (including bereavement support), documentation of older persons' wishes regarding place to die and conversations about their transition to palliative care and about how they were treated.

CONCLUSIONS

This study demonstrates a promising interprofessional educational model. However, the paucity of improvements brought to light at follow-up indicates a need for research directed towards a revision of this model. Supervision of professionals during palliative care delivery is one suggestion for change.

Determinants associated with medical-related long-term care service use among community-dwelling older adults in Taiwan

INTRODUCTION

Medical-related long-term care (LTC) service use among community-dwelling older adults in Taiwan is resource-intensive, and planning is essential to promote aging-in-place.

METHODS

Administrative data from 4/1/2017 to 11/26/2019 among more than 14,000 residents were analyzed with generalized estimating equations (GEEs) to identify determinants of medical-related LTC service use.

RESULTS

Older adults using medical-related LTC services tended to be younger (79.9 vs. 80.7; p<.0001), male (42.7% vs. 38.5%; p<.0001), multi-morbid (3.1 vs. 2.5; p<.0001), and higher mean activities of daily living (ADL) disability (8.2 vs. 4.2; p<.0001), instrumental ADL (IADL) disability (11.0 vs. 9.1; p<.0001), and hospitalizations (1.1 vs. 0.4; p<.0001). Significant determinants of medical-related LTC services include age, education, stroke, coronary heart disease, diabetes, vision impairment, ADL disability, and prior hospitalization.

DISCUSSION

The success of LTC 2.0 will depend on ADL support and care coordination to manage chronic conditions such as diabetes, vision impairment, coronary heart disease, and stroke.

Barriers to Aging in Place for Rural, Institutionalized Older Adults: A Qualitative Exploration

OBJECTIVES

Although the majority of older adults wish to "age in place" in their communities, rural contexts pose challenges to maintaining long-term independence. The purpose of this study was to develop an understanding of the experiences of rural older adults who live in Skilled Nursing Facilities (SNFs) and thus have not aged in place. By retrospectively analyzing their pre-institution care situation, we aim to generate foundational knowledge on the barriers to aging in place in rural settings.

METHODS

A series of individual and group interviews was conducted in SNFs across seven rural communities. A grounded, thematic analysis was used to interpret interview findings, and coding was informed by the socio-ecological model (SEM).

RESULTS

Participants were 32 adults with a mean age of 72 years (SD = 5.7 years) and an average SNF residence of 3.9 years. Two themes emerged as primary barriers to successful aging in place: (1) Caregiver-related support issues and (2) Present focus, or lack of advanced care-planning.

CONCLUSIONS

Findings suggest the importance of specifically supporting caregivers, to ease burden and allow for increased agency for rural older adults. A lack of access to caregiver supports and other services limits the ability of community-dwelling rural older adults to age in place or plan for the future.

CLINICAL IMPLICATIONS

Existing networks of rural community resources and innovative solutions should be leveraged to improve access to services for older adults and their informal caregivers.

Psychotherapy for late-life psychopathology – Updates to promote aging in place

Psychopathology in late life does not always meet the criterion for a psychiatric diagnosis. Nevertheless, it affects the aging person, their family, employers, and society as a whole. Making psychotherapy accessible for older adults, allowing aging in place, must overcome barriers of mobility, stigma, and emotional difficulty to ask for help. Hence, dedicated counseling and treatment centers should be established in the local authorities for the older adults and their caregivers. Such a local center is described, providing low-cost psychotherapy within an academic environment, accompanied by research to promote suitable therapy of older adults, as well as training programs for professional therapists, not just psychologists, with unique emphasis on late-life psychopathology. This model should be implemented, the more the merrier.

Professionals´ readiness for change to knowledge-based palliative care at nursing homes: a qualitative follow-up study after an educational intervention

Background

There has been a global increase in the number of people who are dying of old age. This development implies a need for good palliative care among older persons at the end of life. Here nursing homes have an important role to play. However, the principles of palliative care have not been sufficiently applied in nursing homes, and there is a need to increase the implementation of palliative care in these settings. Therefore the project named Implementation of Knowledge-Based Palliative Care in Nursing Homes (the KUPA project, to use its Swedish acronym) was started as a contribution to filling this knowledge gap. The aim of the present study was to investigate the professionals’ experiences of readiness for change to knowledge-based palliative care at nursing homes after the educational intervention within the KUPA project.

Methods

The focus group method was used to interview 39 health-care professionals with the aid of semistructured questions based on the Organizational Readiness for Change theoretical framework. Six focus groups were formed at six nursing homes in two counties in southern Sweden. The groups included different types of professionals: assistant nurses, nurses, occupational therapists, physiotherapists and social workers. The analysis was conducted with an abductive approach and included deductive and inductive content analysis.

Results

The analysis revealed one overarching theme: hopeful readiness for change in palliative care despite remaining barriers. The main categories were increased knowledge facilitating development, enhanced team spirit, uncertainty about future plans connected with hopeful readiness and remaining organizational barriers.

Conclusions

This study adds knowledge and understanding concerning professionals’ readiness for change palliative care in nursing homes and shows how ready nursing home settings undertake these changes in practice. The Organizational Readiness for Change theory proved suitable for application in nursing homes to assess the professionals’ experiences and to evaluate educational interventions regardless of the organization’s readiness for change.

Trial registration

ClinicalTrials NCT02708498, first registration 15/03/2016.

Experiences of intimate continence care and the impact on the family dyad relationship for people living at home with dementia and their co-resident family members

OBJECTIVES

The experience of providing/receiving intimate continence care between family members can be difficult and emotive. Often, for people living with dementia this seems an area of care overlooked by professionals. This study investigated the experiences of intimate continence care for people living with dementia and their family member (the family dyad), and whether they viewed this as impacting on their relationship.

METHOD

Face-to-face interviews were conducted at 6 monthly intervals over a 12-month period with 13 carers (all family members) and one person living with dementia (13 family dyads) in England. Interviews were recorded and transcribed. Analysis of the data was achieved using a descriptive phenomenological method.

FINDINGS

Carers' attitudes towards providing intimate continence care revealed a task-focused approach for some but feelings of disgust and distress for others. Four participants (including the participant living with dementia) reported that intimate continence care had strengthened their dyad relationship. However, some carers perceived the care and support received from health and social care practitioners to be insufficient, which placed extra stress on them and adversely affected their family dyad relationship.

CONCLUSION

Implications of the study suggest that integrated and effective continence care and support for people living with dementia and their carers could (1) maintain the quality of the family dyad relationship, (2) help keep the person living at home, delaying an unwanted move to a care home and (3) consequently improve overall quality of life for individuals in the family dyad. Assuring integrated and effective continence care should be a priority for service funders and quality assurance regulators.

Professionals' Expectations and Preparedness to Implement Knowledge-Based Palliative Care at Nursing Homes before an Educational Intervention: A Focus Group Interview Study

The provision of knowledge-based palliative care is rare in nursing homes. There are obstacles to practically performing this because it can be difficult to identify when the final stage of life begins for older persons. Educational interventions in palliative care in nursing homes are a challenge, and joint efforts are needed in an organisation, including preparedness. The aim was to explore professionals' expectations and preparedness to implement knowledge-based palliative care in nursing homes before an educational intervention. This study has a qualitative focus group design, and a total of 48 professionals working in nursing homes were interviewed with a semi-structured interview guide. Qualitative content analysis with an inductive approach was used for the analysis. One major theme was identified: professionals were hopeful yet doubtful about the organisation's readiness. The main categories of increased knowledge, consensus in the team, and a vision for the future illustrate the hopefulness, while insufficient resources and prioritisation illustrate the doubts about the organisation's readiness. This study contributes valuable knowledge about professionals' expectations and preparedness, which are essential for researchers to consider in the planning phase of an implementation study. The successful implementation of changes needs to involve strategies that circumvent the identified obstacles to organisations' readiness.

Care-Partner Support and Hospitalization in Assisted Living During Transitional Home Health Care

BACKGROUND/OBJECTIVES

Care-partner support affects outcomes among assisted living (AL) residents. Yet, little is known about care-partner support and its effects on hospitalization during post-acute care transitions. This study examined the variation in care-partner support and its impact on hospitalizations among AL residents receiving Medicare home health (HH) services.

DESIGN

Analysis of national data from the Outcome and Assessment Information Set, Medicare claims, Area Health Resources File, and the Social Deprivation Index File.

SETTING

AL facilities and Medicare HH agencies in the United States.

PARTICIPANTS

741,926 Medicare HH admissions of AL residents in 2017.

MEASUREMENTS

Care-partner support during the HH admission was measured based on the type and frequency of assistance from AL staff in seven domains (i.e., activities of daily living (ADL), instrumental ADLs, medication administration, treatment, medical equipment, home safety, and transportation). Care-partner support in each domain was measured as "assistance not needed" (reference group), "Care-partner currently provides assistance," "care-partner need additional training/support to provide assistance" (i.e., inadequate care-partner support), and "care-partner unavailable/unlikely to provide assistance" (i.e., unavailable care-partner support). Outcome was time-to-hospitalization during the HH admission.

RESULTS

Among the 741,926 Medicare HH admissions of AL residents, inadequate care-partner support was identified for all seven domains that ranged from 13.1% (for transportation) to 49.8% (for treatment), and care-partner support was unavailable from 0.9% (for transportation) to 11.0% (for treatment). In Cox proportional hazard models adjusted for patient covariates and geography, compared with "assistance not needed", having inadequate and unavailable care-partner support was related to increased risk of hospitalization by 8.9% (treatment (hazard ratio (HR) =1.089, P < .001)) to 41.3% (medication administration (HR =1.413, P < .001)).

CONCLUSION

For AL residents receiving HH services, having less care-partner support was related to increased risk of hospitalization, particularly regarding medication administration, medical equipment, and transportation/advocacy.

Utilization and Functional Outcomes Among Medicare Home Health Recipients Varied Across Living Situations

BACKGROUND/OBJECTIVES

Home health (HH) is a major type of home-based skilled care available to Medicare beneficiaries. We examined the association between living situation (home alone, home with others, and assisted living (AL) residence) and utilization and functional outcomes among Medicare HH recipients.

DESIGN

Analysis of national data from the Outcome and Assessment Information Set, HH Compare, Medicare claims, and Area Health Resource Files.

SETTING

Medicare-certified HH agencies in the United States.

PARTICIPANTS

National population of Medicare beneficiaries ≥65 years old who received HH care in CY 2017 (N = 6,637,496).

MEASUREMENTS

Outcomes included time-to-event measures of hospitalization and emergency department (ED) visits, and improvement in activities of daily living (ADL) from the start to the end of the HH admission.

RESULTS

AL residents (12%) and patients living alone at home (24%) had longer survival time without hospitalization and ED visits than patients living with others at home (64%). Adjusting for covariates and HH agency-level random effects, and compared with patients living with others, AL residents had lower risk of hospitalization (hazard ratio (HR) = 0.85, P < .001) and ED visit (HR = 0.92, P < .001); however, less ADL improvement (β = 0.29 (29% less of total independence in one ADL)); and patients living alone had lower risk of hospitalization (HR = 0.94, P < .001) and ED visit (HR = 0.93, P < .001), yet more ADL improvement (β = -0.15 (15% more of total independence in one ADL)).

CONCLUSION

In the national population of Medicare HH recipients, patients living with others at home had the highest risk of hospitalization and ED visits, whereas AL residents had the lowest risk of hospitalization and patients living alone at home had the lowest risk of ED visits, meaning that combined support from HH and AL reduces acute care admissions. Evidence-based interventions are needed for HH patients living with others at home to avoid unnecessary acute care use.

The impact of different patterns of home- and community-based services on nursing home admission: National data from Taiwan

BACKGROUND

This study had two aims: (a) to identify the different patterns of use of home- and community-based services (HCBS) among older adults in Taiwan, and (b) to examine the effects of the different use patterns on HCBS recipients' use of institutional long-term care services.

METHODS

The study analyzed cohort data from Taiwan's first National 10-Year Long-Term Care Plan database and from National Health Insurance Claim Data. We extracted baseline information on older adults who were first evaluated for and prescribed HCBS from 2010 through 2013 (N = 71,260). We used latent class analysis to specify the underlying subgroups of recipients with similar patterns of HCBS use. We used hierarchical multinomial logistic regression to examine the effect of the different use patterns on the risk of institutional (e.g., nursing home) placement from 4 to 15 months after initial HCBS evaluation.

RESULTS

Four subgroups of HCBS recipients were identified, with patterns of home-based personal care (PC), home-based personal care and medical care (PC/MC), home-based medical care (MC), and community care services. Compared to the home-based PC/MC group, people in the home-based MC group had lower risk (OR = 0.54) and people in the community care group had higher risk (OR = 1.76) of admission to a nursing home.

CONCLUSIONS

Study findings may provide insights for policy makers regarding the usefulness of integrating medical care and other types of long-term care services into adult day care.

Leadership styles and leadership outcomes in nursing homes: a cross-sectional analysis

Background

Although leadership is considered as a key factor in health care, leadership styles and outcomes in nursing homes often remain a black box. Therefore, this study explored leadership styles and leadership outcomes of head nurses and directors of nursing (DoN) in nursing homes based on well-defined leadership concepts.

Methods

A multicenter cross-sectional analysis was conducted on baseline data of an ongoing cohort study comprising a convenience sample of nursing home staff (n = 302). Leadership styles and leadership outcomes of head nurses and DoN were measured through the rater form of the Multifactor Leadership Questionnaire 5X (MLQ-5X). Based on the Full Range of Leadership Model, the MLQ-5X visualizes transformational (relation and change focused), transactional (task-focused) and passive-avoidant (absence of leadership) leadership styles. Scores of head nurses and DoN for leadership styles and outcomes were compared with European Reference Scores (ERS) using two-sided one-sample t-tests.

Results

Compared with ERS, head nurses and DoN scored significantly lower (p < 0.001) on transformational and transactional leadership styles and significantly higher (p < 0.001) on passive-avoidant leadership styles. All leadership outcomes were significantly lower (p < 0.001) for head nurses. Similar results, however not statistically significant, were found concerning leadership outcomes of DoN.

Conclusions

Results indicate that passive-avoidant leadership styles are excessively present in contrast to transformational leadership styles in nursing homes. This highlights an urgent need to invest in leadership development. Therefore, future research should focus on interventions for the development of transformational leadership.

Deciding about the use of a Personal Safety Alerting Device-The need for a legitimation process: A qualitative study

Aims

To explore reasons, thoughts, motives, and influencing factors regarding the use or non‐use of Personal Safety Alerting Devices (PSADs) in the daily lives of community‐dwelling older persons.

Design

A qualitative descriptive study design was used.

Methods

Six focus groups were conducted with a total of 32 older persons between February–August 2016. Data analysis followed the Qualitative Analysis Guide of Leuven.

Results

The participants described the use or non‐use of PSADs as a decision resulting from a “legitimation process”. This process implies that a person needs to perceive the necessity for a PSAD and then determine the right moment at which to start using it. During this process, each person weighs her or his “ageing self” and “perception of technology” then decides whether to start using a device or to delay its use. “Critical events” initiate this process, compelling the person to consider their own safety and their possible need for assistance.

Conclusion

The legitimation process suggests that the initiation of PSAD use represents a turning point in life. Using a PSAD is not simply a matter of obtaining one. It is a complex decision‐making process establishing legitimation for its use, which is interwoven with one's individual ageing, self‐perception, and the meaning attributed to the device.

Impact

Older persons need to be supported; in particular, they require time to go through the legitimation process for PSAD use. Nurses can empower them in this process, such that they perceive using a PSAD as a means to restore their frailty balance and feel enabled to (re)gain control over their own life and thus to preserve their independence.

Functional outcome in home health: Do racial and ethnic minority patients with dementia fare worse?

Objectives

Evaluate the independent and interactive effects of dementia and racial/ethnic minority status on functional outcomes during a home health (HH) admission among Medicare beneficiaries.

Methods

Secondary analysis of data from the Outcome and Assessment Information Set [OASIS] and billing records in a non-profit HH agency in New York. Participants were adults ≥ 65 years old who received HH in CY 2017 with OASIS records at HH admission and HH discharge. Dementia was identified by diagnosis (ICD-10 codes) and cognitive impairment (OASIS: M1700, M1710, M1740). We used OASIS records to assess race/ethnicity (M0140) and functional status (M1800-M1870 on activities of daily living [ADL]). Functional outcome was measured as change in the composite ADL score from HH admission to HH discharge, where a negative score means improvement and a positive score means decline.

Results

The sample included 4,783 patients, among whom 93.9% improved in ADLs at HH discharge. In multivariable linear regression that adjusted for HH service use and covariates (R² = 0.23), being African American (β = 0.21, 95% confidence interval [CI]: 0.06, 0.35, p = 0.005) and having dementia (β = 0.51, 95% CI: 0.41, 0.62, p<0.001) were independently related to less ADL improvement at HH discharge, with significant interaction related to further decrease in ADL improvement. Relative to white patients without dementia, African American patients with dementia (β = 1.08, 95% CI: 0.81, 1.35, p<0.001), Hispanics with dementia (β = 0.92, 95% CI: 0.38, 1.47, p = 0.001) and Asian Americans with dementia (β = 1.47, 95% CI: 0.81, 2.13, p<0.001) showed the least ADL improvement at HH discharge.

Conclusion

Racial/ethnic minority status and dementia were associated with less ADL improvement in HH with independent and interactive effects. Policies should ensure that these patients have equitable access to appropriate, adequate community-based services to meet their needs in ADLs and disease management for improved outcomes.

Perceived sleep quality, coping behavior, and associations with major depression among older adults

In older adults, we determined (1) the association of perceived sleep quality with stress-coping behaviors (drinking alcohol, smoking tobacco, medication/drug use, overeating, prayer, exercise, social support, and treatment from a health professional) and (2) whether coping behavior mediated the relationship of perceived sleep quality with depression. Data came from the US Health and Retirement Study 2008-2010 (n = 1174). Using logistic regression, poor perceived sleep quality was associated with medication/drug use (odds ratio = 2.9; 95% confidence interval = 1.4-6.0) and overeating (odds ratio = 1.6; 95% confidence interval = 1.1-2.5). However, using structural equation modeling, coping behavior did not mediate the relationship of perceived sleep quality with depression symptomology (p = 0.14).

Social Support and Patterns of Institutionalization Among Older Adults: A Longitudinal Study

OBJECTIVES

To identify participants living at home and to estimate the risk of their transition into an institutional setting.

DESIGN

Prospective cohort study from the National Health and Aging Trends Study (NHATS), a nationally representative survey of US adults aged 65 and older.

SETTING

US national sample.

PARTICIPANTS

A total of 4712 NHATS participants were living at home in 2011. Residential transitions were described every year through 2017.

MEASUREMENTS

The primary outcome was transition time into an institutional setting. Primary predictors were social support factors (living spouse, lives with others, presence of social network, and participation in social activities). Covariates included age, sex, race, cognitive status, functional disability, multimorbidity, and Medicaid enrollment. A Fine and Gray hazards model estimated the risk of transition into an institutional setting, with death before institutionalization considered a competing risk.

RESULTS

In 2011, 4712 NHATS participants were living at home (78 ± 8 y; 57% female; 80% white; 10% probable dementia; 7% with three or more activities of daily living disabilities). By 2017, 58% remained at home, 17% had either transitioned to an institution or died in an institution, and 25% died before institutionalization. In multivariable analyses that adjusted for age, sex, race, cognitive status, functional disability, multimorbidity, and Medicaid enrollment, participants were more likely to move out of the home into an institution if they had no social network (0 vs three or more people; subhazard ratio [sHR] = 1.8; 95% confidence interval [CI] = 1.2-2.5; P = .003) or lived alone (sHR = 1.9; 95% CI = 1.6-2.2; P < .0001). Older adults who enjoyed going to the movies, dinner, or the casino and visiting family or friends had a lower probability of institutionalization compared with participants who did not enjoy these activities or did not visit family or friends (adjusted sHR = .7; 95% CI = .6-.9; adjusted sHR = .7; 95% CI = .6-.9, respectively).

CONCLUSION

Policy initiatives should target older adults with limited social support to reduce the risk of moving from home into an institution. J Am Geriatr Soc 67:2622-2627, 2019.

Data Resource Profile: the Scottish Social Care Survey (SCS) and the Scottish Care Home Census (SCHC)

Introduction

Linked health care datasets have been used effectively in Scotland for some time. Use of social care data has been much more limited, partly because responsibility for these services is distributed across multiple local authorities. However, there are substantial interactions between health and social care (also known internationally as long-term care) services, and keen policy interest in better understanding these. We introduce two social care resources that can now be linked to health datasets at a population level across Scotland to study these interdependencies. These data emerge from the Scottish Government’s centralised collation of data from mandatory returns provided by local authorities and care homes.

Methods

Deterministic and Probabilistic methods were used to match the Social Care Survey (SCS) and Scottish Care Home Census (SCHC) to the Community Health Index (CHI) number via the National Records of Scotland (NRS) Research Indexing Spine.

Results

For the years 2010/11 to 2015/16, an overall match rate of 91.2% was achieved for the SCS to CHI from 31 of Scotland’s 32 local authority areas. This rate varied from 76.7% to 98.5% for local authority areas. A match rate of 89.8% to CHI was achieved for the SCHC in years 2012/13 to 2015/16 but only 52.5% for the years 2010/11 to 2011/12.

Conclusion

Indexing of the SCS and SCHC to CHI offers a new and rich resource of data for health and social care research.

The Impact of Cohousing on Older Adults' Quality of Life

The global population including Canada's is aging, which demands planning for housing that will support older adults' quality of life. This mixed-method study is the first Canadian study to examine the impact of cohousing on older adults' quality of life and involved 23 participants. The older adults rated their quality of life very high, especially in the environmental, physical, and psychological domains of the World Health Organization Quality of Life (WHOQOL_BREF) survey; quality of life in the social domain was rated low, which was surprising in light of the focus group data findings. Four themes of "belonging in a community", "life in the community", "changes associated with aging," and "aging in place" emerged from the qualitative data to explain factors that influence older adults' quality of life. This research provides foundational, strong evidence that seniors' cohousing is an innovative housing solution that can support older adults' quality of life.

A cross sectional study on the different domains of frailty for independent living older adults

BACKGROUND

With the ageing population, there is a stronger focus on supporting older people to live independently as long as possible. One of the important factors to take into consideration for independent living older adults is frailty. This manuscript aims to provide insight into the relation between the different domains of frailty (physical, social and psychological or a combination), health outcomes and wellbeing aspects for independent living older adults.

METHODS

This cross sectional community-based study included independent living older adults of 65 years and over who are member of a welfare organisation. The questionnaire contained items on background characteristics, health, quality of life, frailty (Tilburg Frailty Indicator), activities and loneliness. A multivariate analysis, one Way ANOVA's and chi-square tests with post-hoc analyses were used to identify significant differences between the following outcomes: Age, gender, marital status, living situation, income, health perception, number of conditions, activities of daily living, home care and informal care, Quality of life, loneliness, going outside, meeting people and the different domains of frailty.

RESULTS

1768 (35.1%) participants completed the questionnaire. 68.9% of the respondents was frail on one or multiple domains and 51.6% of the respondents was frail based on the total score on the TFI. Social frailty (18.4%) was most often present followed by 10.3% for frailty on all three domains of the TFI. All variables tested, except for income, showed significant differences between the different domains of frailty.

CONCLUSION

Distinguishing the different domains of frailty provides information about the older adult's needs which is valuable for policymakers and care providers, to anticipate to the increasing number of independent living older adults and deliver them tailored care and support to contribute to their independent living situation and wellbeing.

Changes in vulnerability among older patients with cardiovascular disease in the first 90 days after hospital discharge: A secondary analysis of a cohort study

OBJECTIVES

(1) To compare changes in vulnerability after hospital discharge among older patients with cardiovascular disease who were discharged home with self-care versus a home healthcare (HHC) referral and (2) to examine factors associated with changes in vulnerability in this period.

DESIGN

Secondary analysis of longitudinal data from a cohort study.

PARTICIPANTS AND SETTING

834 older (≥65 years) patients hospitalised for acute coronary syndromes and/or acute decompensated heart failure who were discharged home with self-care (n=713) or an HHC referral (n=121).

OUTCOME

Vulnerability was measured using Vulnerable Elders Survey 13 (VES-13) at baseline (prior to hospital admission) and 30 days and/or 90 days after hospital discharge. Effects of HHC referral on postdischarge change in vulnerability were examined using three linear regression approaches, with potential confounding on HHC referral adjusted by propensity score matching.

RESULTS

Overall, 44.4% of the participants were vulnerable at prehospitalisation baseline and 34.4% were vulnerable at 90 days after hospital discharge. Compared with self-care patients, HHC-referred patients were more vulnerable at baseline (66.9% vs 40.3%), had more increase (worsening) in VES-13 score change (B=-1.34(-2.07, -0.61), p<0.001) in the initial 30 days and more decrease (improvement) in VES-13 score change (B=0.83(0.20, 1.45), p=0.01) from 30 to 90 days after hospital discharge. Baseline vulnerability and the HHC referral attributed to 14%-16% of the variance in vulnerability change during the 90 postdischarge days, and 6% was attributed by patient age, race (African-American), depressive symptoms, and outpatient visits and hospitalisations in the past year.

CONCLUSION

After adjusting for preceding vulnerability and covariates, older hospitalised patients with cardiovascular disease referred to HHC had delayed recovery in vulnerability in first initial 30 days after hospital discharge and greater improvement in vulnerability from 30 to 90 days after hospital discharge. HHC seemed to facilitate improvement in vulnerability among older patients with cardiovascular disease from 30 to 90 days after hospital discharge.

Inverse Dose-Response Relationship Between Home Health Care Services and Rehospitalization in Older Adults

OBJECTIVES

(1) To examine the impact of specific services [skilled nursing (SN), physical therapy (PT), occupational therapy (OT), and home health aide (HA)] in Medicare-certified home health care (HHC) on subsequent rehospitalization among older patients during a 60-day HHC episode and (2) to test the moderating effect of functional limitation on these services.

DESIGN

Secondary analysis of data from the Outcome and Assessment Information Set (OASIS) and HHC administrative records of a statewide not-for-profit HHC agency from January 1, 2016, to December 31, 2016.

SETTING AND PARTICIPANTS

Participants were ≥65 years old and were admitted to HHC within 48 hours of hospital discharge.

MEASURES

Outcome was time to rehospitalization during the 60-day HHC episode (ie, number of days). Independent variables were visit intensity (number of visits/week) of SN, PT, OT, and HA, respectively. Functional limitation was measured by a composite score generated from 9 OASIS items on physical function. Multivariate Cox Proportional hazard analyses were conducted. Subgroup analysis (high vs low functional limitation) was conducted to examine the moderating effect of functional limitation on specific HHC services. Ad hoc analysis was conducted to examine potential interaction between specific HHC services that were significantly related to rehospitalization.

RESULTS

The sample included 1377 participants, among whom 11.5% were rehospitalized during the 60-day HHC episode. At the threshold dose of 1 PT or 2 SN visits/week, higher visit intensity significantly reduced the hazard of rehospitalization in these patients by up to 82% for PT (2.30 visits/week; hazard ratio [HR] = 0.18, P value < .001) and 48% for SN visits (2.51 visits/week; HR = 0.52, P value < .05). The effect of PT on reducing the risk of rehospitalization was more pronounced in patients with low versus high functional limitation (2.30 visits/week, HR = 0.08 vs 0.24, both P < .001). SN was only effective in reducing the hazard of rehospitalization in the low functional limitation group (1.70 visits/week, HR = 0.41, P < .05; 2.51 visits/week, HR = 0.29, P < .05), but not in the high functional limitation group (P > .05 at all intensity levels). Visit intensity of HA or OT was not significantly related to rehospitalization.

CONCLUSIONS/RELEVANCE

At a threshold of 1 PT visit or 2 SN visits/week, HHC lowered the risk of rehospitalization in older patients by up to 82% and 48%, respectively. Both PT and SN were more effective in avoiding rehospitalization in patients with low functional limitation than in those with high functional limitation. Older patients should receive enough HHC services (especially PT and SN) to avoid rehospitalizations with consideration of their functional limitation.

Integrated and Person-Centered Care for Community-Living Older Adults: A Cost-Effectiveness Study

OBJECTIVES

To assess the cost-effectiveness of Embrace, an integrated primary care service for older adults.

DATA SOURCES

Care and support claims from health care insurers, long-term care administration, and municipalities for enrolled older adults between 2011 and 2013.

STUDY DESIGN

A total of 1,456 older adults, listed with 15 general practitioners practices in the Netherlands, were stratified into risk profiles ("Robust," "Frail," and "Complex care needs") and randomized to Embrace or care-as-usual groups. Incremental costs were calculated per quality-adjusted life year, per day able to age in place, and per percentage point risk profile improvement.

PRINCIPAL FINDINGS

Total average costs were higher for Embrace compared to care-as-usual. Differences in health-associated outcomes were small and not statistically significant. Probabilities that Embrace is cost-effective were below 80 percent, except for "risk profile improvements" within risk profile "Complex care needs." Complete case analysis resulted in smaller differences in total average costs across conditions and differences in health-associated outcomes remained small.

CONCLUSIONS

According to current standards, Embrace is not considered cost effective after 12 months. However, it could be considered worthwhile in terms of "risk profile improvements" for older adults with "Complex care needs," if society is willing to invest substantially.

Towards evidence-based palliative care in nursing homes in Sweden: a qualitative study informed by the organizational readiness to change theory

BACKGROUND

Sweden has a policy of supporting older people to live a normal life at home for as long as possible. Therefore, it is often the oldest, most frail people who move into nursing homes. Nursing home staff are expected to meet the existential needs of the residents, yet conversations about death and dying tend to cause emotional strain. This study explores organizational readiness to implement palliative care based on evidence-based guidelines in nursing homes in Sweden. The aim was to identify barriers and facilitators to implementing evidence-based palliative care in nursing homes.

METHODS

Interviews were carried out with 20 managers from 20 nursing homes in two municipalities who had participated along with staff members in seminars aimed at conveying knowledge and skills of relevance for providing evidence-based palliative care. Two managers responsible for all elderly care in each municipality were also interviewed. The questions were informed by the theory of Organizational Readiness for Change (ORC). ORC was also used as a framework to analyze the data by means of categorizing barriers and facilitators for implementing evidence-based palliative care.

RESULTS

Analysis of the data yielded ten factors (i.e., sub-categories) acting as facilitators and/or barriers. Four factors constituted barriers: the staff's beliefs in their capabilities to face dying residents, their attitudes to changes at work as well as the resources and time required. Five factors functioned as either facilitators or barriers because there was considerable variation with regard to the staff's competence and confidence, motivation, and attitudes to work in general, as well as the managers' plans and decisional latitude concerning efforts to develop evidence-based palliative care. Leadership was a facilitator to implementing evidence-based palliative care.

CONCLUSIONS

There is a limited organizational readiness to develop evidence-based palliative care as a result of variation in the nursing home staff's change efficacy and change commitment as well as restrictions in many contextual conditions. There are considerable individual- and organizational-level challenges to achieving evidence-based palliative care in this setting. The educational intervention represents one of many steps towards developing a culture conducive to evidence-based nursing home palliative care.

New Institutionalization in Long-Term Care After Hospital Discharge to Skilled Nursing Facility

BACKGROUND/OBJECTIVES

Approximately half of individuals newly admitted to long-term care (LTC) nursing homes (NHs) experienced a prior hospitalization followed by discharge to a skilled nursing facility (SNF). The objective was to examine characteristics associated with new institutionalizations of older adults on this care trajectory.

DESIGN

Retrospective cohort study.

SETTING

SNFs and LTC NHs.

PATIENTS

Medicare fee-for-service beneficiaries admitted to 7,442 SNFs in 2013 (N = 597,986).

MEASUREMENTS

We used demographic and clinical characteristics from Medicare data and the Minimum Data Set. We defined "new institutionalization" as LTC NH residence for longer than 90 non-SNF days, starting within 6 months of hospital discharge.

RESULTS

For individuals who survived 6 months after hospital discharge, the overall rate of new LTC institutionalizations was 10.0% (N = 59,736). Older age, white race, being unmarried, Medicaid eligibility, higher income, more comorbidities, cognitive impairment, depression, functional limitations, hallucinations and delusions, aggressive behavior, incontinence, and pressure ulcers were associated with higher adjusted odds of new LTC institutionalization. In analyses stratified according to race and ethnicity, higher income was associated with lower odds of LTC institutionalization for whites (odds ratio (OR) = 0.92, 95% confidence interval (CI) = 0.89-0.96) and greater odds for blacks (OR = 1.40, 95% CI = 1.27-1.55) and Hispanics (OR = 1.44, 95% CI = 1.25-1.66). Moderate or severe depression, functional limitations, hallucinations and delusions, aggressive behavior, and being unmarried were stronger risk factors for LTC for cognitively intact individuals than for those with moderate to severe cognitive impairment. Being unmarried and having more comorbidities were stronger predictors in those aged 66 to 70 than in those aged 81 to 85 and 91 and older.

CONCLUSION

Associations between risk factors and new LTC institutionalizations varied according to race and ethnicity, age, and level of cognitive function. Programs that target older adults at greater risk may be an effective strategy for reducing new institutionalizations and fostering aging in place.