Cognitive Status of Older Adults on Admission to a Skilled Nursing Facility According to a Hospital Discharge Diagnosis of Dementia

Post-Acute Care Rehabilitation for Persons Living With Dementia: A Systematic Review

OBJECTIVES

To identify the results of post-acute care (PAC) rehabilitation for persons living with dementia (PLWD).

DESIGN

Systematic review of published literature without date restrictions through April 2023.

SETTING AND PARTICIPANTS

PLWD undergoing rehabilitation in PAC facilities after an acute care hospitalization.

METHODS

A systematic search was carried out in PubMed, Scopus, Google Scholar, Embase, Medline, PsycINFO, CINAHL, Cochrane Library, and Web of Science. Included studies were peer-reviewed, available in English, and focused on PLWD admitted to rehabilitation facilities following hospitalization in the US and international settings. Studies on long-term care and acute inpatient rehabilitation units were excluded. Two reviewers independently screened articles and conducted a quality appraisal of selected studies. A narrative synthesis approach was used for analysis of results with rehabilitation themes encompassing "outcomes" and "experiences."

RESULTS

Forty-one articles met inclusion criteria, with a heterogeneity of study designs including observational (n = 33), randomized clinical trials (n = 3), and qualitative studies (n = 5). Narrative synthesis demonstrated that PAC rehabilitation for PLWD contained themes of "outcomes," including health service utilization and physical and cognitive function, providing evidence for a lower likelihood to return home and achieving less functional improvement compared to individuals without cognitive impairment. The second theme, "experiences," included health care transitions, knowledge and education, goal alignment, and care models. Findings detailed poor communication around care transitions, lack of dementia knowledge among health care workers, goal alignment strategies, and innovative rehabilitation models specific for PLWD.

CONCLUSIONS AND IMPLICATIONS

Overall, this systematic review covers a breadth of literature across time and international settings on PAC rehabilitation for PLWD. The findings highlight the importance of rehabilitation models specific for dementia care, with a need for personalized approaches around care transitions, goal setting, and increased dementia education. Addressing these aspects of rehabilitative care for PLWD may enhance the delivery of PAC and improve health care outcomes and experiences.

How Do Nurses Assess Cognition in Adults With Neurological Conditions? A Scoping Review

BACKGROUND

According to epidemiological studies, neurological cognitive problems are increasingly prevalent in the aging population, with estimates that the number of people living with cognitive impairment will triple by 2050. Therefore, early detection in rehabilitation settings is needed to manage cognitive changes to ensure that individuals living with these conditions receive care and support that addresses their needs.

PURPOSE

This scoping review, based on the Arksey and O'Malley method, aims to investigate the cognitive assessments used for patients with neurological conditions in current nursing practice.

METHOD

PubMed, Ovid Medline, and CINAHL databases were searched to identify relevant articles published from 2017 to 2023 in English. Twenty-four articles met the inclusion criteria. Cognitive assessments were evaluated across acute care/hospital, outpatient/clinic, community, and long-term care/nursing home settings.

RESULTS

The Mini-Mental State Examination is the most frequently used tool across all settings except for long-term care. Cognition includes many different domains such as executive functioning and speed of processing information; however, most tools only capture memory. The nursing profession must expand its standardized nursing vocabulary to capture cognition better.

CONCLUSIONS

As rehabilitation nurses navigate diverse clinical environments, recognition of contextual nuances is important in selecting cognitive function measurement tools most suitable for their setting.

Clinical and Adverse Outcomes Associated With Concomitant Use of CYP2D6-Metabolized Opioids With Antidepressants in Older Nursing Home Residents : A Target Trial Emulation Study

BACKGROUND

Limited evidence exists on the safety of pharmacokinetic interactions of cytochrome P450 (CYP) 2D6 (CYP2D6)-metabolized opioids with antidepressants among older nursing home (NH) residents.

OBJECTIVE

To investigate the associations of concomitant use of CYP2D6-metabolized opioids and antidepressants with clinical outcomes and opioid-related adverse events (ORAEs).

DESIGN

Retrospective cohort study using a target trial emulation framework.

SETTING

100% Medicare NH sample linked to Minimum Data Set (MDS) from 2010 to 2021.

PARTICIPANTS

Long-term residents aged 65 years and older receiving CYP2D6-metabolized opioids with a disease indication for antidepressant use.

INTERVENTION

Initiating CYP2D6-inhibiting versus CYP2D6-neutral antidepressants that overlapped with use of CYP2D6-metabolized opioids for 1 day or more.

MEASUREMENTS

Clinical outcomes were worsening pain, physical function, and depression from baseline to quarterly MDS assessments and were analyzed using modified Poisson regression models. The ORAE outcomes included counts of pain-related hospitalizations and emergency department (ED) visits, opioid use disorder (OUD), and opioid overdose and were analyzed with negative binomial or Poisson regression models. All models were adjusted for baseline covariates via inverse probability of treatment weighting.

RESULTS

Among 29 435 identified residents, use of CYP2D6-metabolized opioids concomitantly with CYP2D6-inhibiting (vs. CYP2D6-neutral) antidepressants was associated with a higher adjusted rate ratio of worsening pain (1.13 [95% CI, 1.09 to 1.17]) and higher adjusted incidence rate ratios of pain-related hospitalization (1.37 [CI, 1.19 to 1.59]), pain-related ED visit (1.49 [CI, 1.24 to 1.80]), and OUD (1.93 [CI, 1.37 to 2.73]), with no difference in physical function, depression, and opioid overdose.

LIMITATION

Findings are generalizable to NH populations only.

CONCLUSION

Use of CYP2D6-metabolized opioids concomitantly with CYP2D6-inhibiting (vs. CYP2D6-neutral) antidepressants was associated with worsening pain and increased risk for most assessed ORAEs among older NH residents.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Factors Influencing Hospitalization of Nursing Home Residents in Korea Using Regularized Negative Binomial Regression

The appropriateness of hospitalization for nursing home (NH) residents is still up for debate, with determining factors including timeliness, available treatment, healthcare staff, medication options in hospitals, and safety issues. Although the factors leading to hospitalization have been studied expansively, research on staffing is limited. Thus, this study aimed to investigate organizational predictors, nurse staffing, and government incentives and find important factors to hospitalization due to infection or disease among NH residents in Korea. A cross-sectional design was used, and data were collected via survey from a total of 51 NHs from August 27, 2021 to March 25, 2022. A total of 32 explanatory variables were included. The response variable was the count of hospitalized residents due to infection or disease. We analyzed data using least absolute shrinkage and negative binomial regression. We found that registered nurses' increased hours per resident day were related to decreased hospitalizations due to infection or disease. Appropriate retention and recruitment of nurse staffing with professional leadership should be performed to increase the quality of care for NH residents.

Short- and long-term safety of discontinuing chronic opioid therapy among older adults with Alzheimer's disease and related dementia

BACKGROUND

Limited evidence exists on the short- and long-term safety of discontinuing versus continuing chronic opioid therapy (COT) among patients with Alzheimer's disease and related dementias (ADRD).

METHODS

This cohort study was conducted among 162,677 older residents with ADRD and receipt of COT using a 100% Medicare nursing home sample. Discontinuation of COT was defined as no opioid refills for ≥90 days. Primary outcomes were rates of pain-related hospitalisation, pain-related emergency department visit, injury, opioid use disorder (OUD) and opioid overdose (OD) measured by diagnosis codes at quarterly intervals during 1- and 2-year follow-ups. Poisson regression models were fit using generalised estimating equations with inverse probability of treatment weights to model quarterly outcome rates between residents who discontinued versus continued COT.

RESULTS

The study sample consisted of 218,040 resident episodes with COT; of these episodes, 180,916 residents (83%) continued COT, whereas 37,124 residents (17%) subsequently discontinued COT. Discontinuing (vs. continuing) COT was associated with higher rates of all outcomes in the first quarter, but these associations attenuated over time. The adjusted rates of injury, OUD and OD were 0, 69 and 60% lower at the 1-year follow-up and 11, 81 and 79% lower at the 2-year follow-up, respectively, for residents who discontinued versus continued COT, with no difference in the adjusted rates of pain-related hospitalisations or emergency department visits.

CONCLUSIONS

The rates of adverse outcomes were higher in the first quarter but lower or non-differential at 1-year and 2-year follow-ups between COT discontinuers versus continuers among older residents with ADRD.

Pain intensity, physical function, and depressive symptoms associated with discontinuing long-term opioid therapy in older adults with Alzheimer's disease and related dementias

INTRODUCTION

Limited evidence exists on the associations of discontinuing versus continuing long-term opioid therapy (LTOT) with pain intensity, physical function, and depression among patients with Alzheimer's disease and related dementias (ADRD).

METHODS

A cohort study among 138,059 older residents with mild-to-moderate ADRD and receipt of LTOT was conducted using a 100% Medicare nursing home sample. Discontinuation of LTOT was defined as no opioid refills for ≥ 60 days. Outcomes were worsening pain, physical function, and depression from baseline to quarterly assessments during 1- and 2-year follow-ups.

RESULTS

The adjusted odds of worsening pain and depressive symptoms were 29% and 5% lower at the 1-year follow-up and 35% and 9% lower at the 2-year follow-up for residents who discontinued versus continued LTOT, with no difference in physical function.

DISCUSSION

Discontinuing LTOT was associated with lower short- and long-term worsening pain and depressive symptoms than continuing LTOT among older residents with ADRD.

HIGHLIGHTS

Discontinuing long-term opioid therapy (LTOT) was associated with lower short- and long-term worsening pain. Discontinuing LTOT was related to lower short- and long-term worsening depression. Discontinuing LTOT was not associated with short- and long-term physical function.

Risk of Discharge to Lower-Quality Nursing Homes Among Hospitalized Older Adults With Alzheimer Disease and Related Dementias

IMPORTANCE

Individuals with Alzheimer disease and related dementias (ADRD) frequently require skilled nursing facility (SNF) care following hospitalization. Despite lower SNF incentives to care for the ADRD population, knowledge on how the quality of SNF care differs for those with vs without ADRD is limited.

OBJECTIVE

To examine whether persons with ADRD are systematically admitted to lower-quality SNFs.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analysis of Medicare beneficiaries hospitalized between January 1, 2017, and December 31, 2019, was conducted. Data analysis was performed from January 15 to May 30, 2022. Participants were discharged to a Medicare-certified SNF from a general acute hospital. Patients younger than 65 years, enrolled in Medicare Advantage, and with prior SNF or long-term nursing home use within 1 year of hospitalization were excluded.

EXPOSURES

The quality level of all SNFs available at the patient's discharge, measured using publicly reported 5-star staffing ratings. The 5-star ratings were grouped into 3 levels (1-2 stars [reference category, low-quality], 3 stars [average-quality], and 4-5 stars [high-quality]).

MAIN OUTCOMES AND MEASURES

The outcome was the SNF a patient entered among the possible SNF destinations available at discharge. Differences in the association between SNF quality and SNF entry for patients with and without ADRD were assessed using a conditional logit model, which simultaneously controls for differences in discharging hospital, residential neighborhood, and the other characteristics (eg, postacute care specialization) of all SNFs available at discharge.

RESULTS

The sample included 2 619 464 patients (mean [SD] age, 81.3 [8.6] years; 61% women; 87% were White; 8% were Black; 22% with ADRD). The probability of discharge to higher quality SNFs was lower for patients with ADRD. If the star rating of an SNF was high instead of low, the log-odds of being discharged to it increased by 0.31 for patients with ADRD and by 0.47 for those without ADRD (difference, -0.16; P < .001). The weaker association between quality and entry for patients with ADRD indicates that they are less likely to be discharged to high-quality SNFs.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that patients with ADRD are more likely to be discharged to lower-quality SNFs. Targeted reforms, such as ADRD-specific compensation adjustments, may be needed to improve access to better SNFs for patients with ADRD.

Dementia prevalence, a contextual factor associated with SARS-CoV-2 in veterans affairs community living centers

BACKGROUND

Alzheimer's disease and related dementias (ADRD) impact the diagnosis and infection control of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in nursing homes (NH) by influencing the behavior of residents and their caregivers. Health system data show an association between ADRD and SARS-CoV-2. Whether this association is present in NH populations remains unknown. How increased SARS-CoV-2 risk among residents with ADRD impacts the greater NH population also remains unknown.

METHODS

This retrospective cohort study used electronic health record data on Veterans residing in 133 Veterans Affairs Community Living Centers (CLC) and 15 spinal cord injury units from March 1, 2020 to December 13, 2020. We measured ADRD using diagnostic codes 12 months before an index SARS-CoV-2 test date for each resident. We used Poisson regression to determine the relative risk of SARS-CoV-2 for the highest quartile of facility ADRD prevalence versus the lowest, stratifying by individual ADRD status, and adjusting for covariates, with and without a random intercept to account for facility clustering.

RESULTS

Across the study period, 15,043 residents resided in CLCs, 1952 (13.0%) had SARS-CoV-2, and 8067 (53.6%) had ADRD. There was an estimated 60% increased risk of SARS-CoV-2 in facilities with highest dementia prevalence versus lowest (relative risk, 1.6 [95% confidence interval 0.95, 2.7]).

CONCLUSIONS

CLC residents had a greater likelihood of SARS-CoV-2 infection in facilities with greater ADRD prevalence. Facility characteristics other than ADRD prevalence may account for this association.

Examining the Clinical Utility of the Brief Interview for Mental Status

The Brief Interview for Mental Status (BIMS) is used to identify delirium and needed supports in patients living in skilled nursing facilities (SNFs) and long-term care facilities (LTCFs). We analyzed 3,537,404 patients discharged from acute hospitals to SNFs or LTCFs with factor and Rasch analyses to examine the clinical utility of the BIMS. More than 40% of the sample had maximum scores, indicating a ceiling effect. "Repetition of three words" was the easiest and the only misfit item (Outfit = 3.14). The ability of the BIMS to distinguish individuals into two cognitive levels (with person strata of 1.48) was limited. Although the BIMS is a widely used screening tool for cognitive impairment, we found it lacked sensitivity for approximately one half of patients admitted to SNFs/LTCFs. Our results suggest the BIMS should be interpreted with caution, particularly for patients with mild cognitive impairment. [Research in Gerontological Nursing, 15(3), 124-130.].

Trends and variation in benzodiazepine use in nursing homes in the USA

PURPOSE

Because of toxicities, benzodiazepines are not usually recommended in older adults. We therefore sought to describe the trends in benzodiazepine use in long-term care and examine the variation in benzodiazepine use among nursing homes.

METHODS

In this retrospective repeated cross-sectional analysis of Medicare Parts A, B, and D claims data linked to the Minimum Data Set from 2013 to 2018, we included long-term residents who stayed in a nursing home for at least one entire quarter of a calendar year in 2013-2018. The outcome was whether residents were prescribed a benzodiazepine drug for at least 30 days during each quarter stay. We use mixed effects logistic regression models to assess the variation in benzodiazepine use among nursing homes, adjusting for patient and nursing home characteristics.

RESULTS

The cohort for the time trend analysis included 270,566 unique residents and 1,843,580 quarter stays for 2013-2018. Prescribing rates for short-acting benzodiazepines were stable over 2013-2016, then declined from 12.1% in 2016 to 10.6% in 2018. The rate of long-acting benzodiazepine use remained relatively steady at around 4% over 2013-2018. During 2017-2018, the variation among nursing homes in benzodiazepine use was 7.2% for short-acting vs. 9.3% for long-acting benzodiazepines, after controlling for resident characteristics.

CONCLUSION

Prescribing for short-acting benzodiazepines in long-term care declined after 2016, while long-acting benzodiazepine use did not change. The variation in benzodiazepine use among nursing homes is substantial. Identifying factors that explain this variation may help in developing strategies for deprescribing benzodiazepines in nursing home residents.

Association Between Cognitive Status and Falls With and Without Injury During a Skilled Nursing Facility Short Stay

OBJECTIVES

To examine the relationship between cognitive status and falls with and without injury among older adults during the first 18 days of a skilled nursing facility (SNF) and determine if this association is mediated by limitations in activities of daily living (ADL) and impaired balance.

DESIGN

Cohort study of Medicare fee-for-service beneficiaries admitted to an SNF between October 1, 2016, and September 31, 2017.

SETTINGS AND PARTICIPANTS

815,927 short-stay nursing home residents admitted to an SNF within 3 days of hospital discharge.

METHODS

Cognitive status at SNF admission was classified as intact, mild, moderate, or severe impairment. Residents were classified as having no falls, a fall without injury, and a fall with a minor or major injury. We used ordinal logistic regression to model the association between cognitive status and falls adjusting for resident and facility characteristics. A causal mediation analysis was used to test for the mediating effects of ADL limitations and impaired balance on the association between cognitive status and falls with an injury.

RESULTS

Mild, moderate, and severe cognitive impairment were associated with 1.72 (95% CI: 1.68-1.75), 2.72 (95% CI: 2.66-2.78), and 2.61 (95% CI: 2.48-2.75) higher odds of being in a higher fall severity category, respectively, compared to being cognitively unimpaired. Greater ADL limitations and impaired balance were significantly associated with falls, but each mediated the association between cognitive status and falls by less than 2%.

CONCLUSIONS AND IMPLICATIONS

Older adults with cognitive impairment are more likely to experience a fall during an SNF stay. ADL limitations and impaired balance are risk factors for falls but may not contribute to the increased fall risk for SNF residents with cognitive impairment. Continued research is needed to better understand the risk factors for falls among SNF residents with cognitive impairment.

Relationship Between Nursing Home Compare Improvement in Function Quality Measure and Physical Recovery After Hip Replacement

OBJECTIVE

To determine whether patients with a total or partial hip replacement admitted to a skilled nursing facility (SNF) after the improvement in function quality measure was added to Nursing Home Compare in July 2016 have greater physical recovery than patients admitted before July 2016.

DESIGN

Pre (January 1, 2015-June 30, 2016) vs post (July 1, 2016-December 31, 2017) design.

SETTING

Skilled nursing facilities (n=12,829).

PARTICIPANTS

Medicare fee-for-service beneficiaries (N=106,832) discharged from acute hospitals to SNF after hip replacement between January 1, 2015 and December 31, 2017.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The 5- and 14-day minimum data set assessments were used to calculate total scores for the quality measure, self-care, mobility, and balance. We calculated the average adjusted change per 10 days and any improvement between the 5- and 14-day assessments.

RESULTS

The average adjusted change per 10 days for the quality measure total score for patients admitted before July 2016 and after July 2016 was 1.00 points (standard error, 0010) and 1.06 points (standard error, 0.010), respectively (P<.01). This was a relative increase of 6.0%. Among patients admitted to a SNF before July 2016, 44.4% (standard error, 0.06) had any improvement in the quality measure total score compared with 45.5% (standard error, 0.23) of patients admitted after July 2016 (P<.01). This was a relative increase of 2.5%. The adjusted change per 10 days and percentage of patients who had any improvement in the total scores for self-care, mobility, and balance were all significantly higher after July 2016.

CONCLUSIONS

Patients admitted to a SNF after a hip replacement after July 2016 had greater physical recovery than patients admitted before the improvement in function quality measure was added to Nursing Home Compare.

Psychological interventions with older adults during inpatient postacute rehabilitation: A systematic review

Objective: Older adults in inpatient postacute care settings report high rates of depression and anxiety. Psychological interventions address these symptoms through educational, cognitive, behavioral, relaxation, and/or psychosocial approaches. The purpose of this study was to systematically evaluate the quality of existing literature on psychological interventions for depression and/or anxiety among older adults during an inpatient postacute care stay. Method: Medline, Embase, Cochrane Library, CINAHL, PsycINFO, and Google Scholar were searched for key concepts. Studies were included that (a) sampled skilled nursing facility or inpatient rehabilitation facility patients, (b) evaluated a psychological intervention, (c) measured depression and/or anxiety symptoms before and after interventions, and (d) had a mean or median age of 65+. Two raters assessed articles for inclusion and risk of bias. Results: Search strategies identified 7,506 articles for screening; nine met inclusion criteria. Included studies varied by study design, intervention type, and methodological quality. Only one study had low overall risk of bias. Four studies demonstrated preliminary treatment benefits for depression symptoms; none reported benefits for anxiety symptoms. Conclusions: Most of the included studies were limited by small sample size and high risk of bias. Thus, currently, there is insufficient evidence to support the effectiveness of psychological interventions for depression or anxiety among older adults during an inpatient postacute care stay. The authors offer a detailed discussion of methodological limitations, empirical gaps, and future directions to develop this body of literature. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Uncontrolled Pain and Risk for Depression and Behavioral Symptoms in Residents With Dementia

OBJECTIVES

Limited cohort studies have assessed the association between uncontrolled pain and risk for behavioral and psychological symptoms of dementia (BPSDs). We conducted a longitudinal cohort study to examine whether associations exist between uncontrolled pain and risk for 2 common BPSDs-depression and behavioral symptoms-among long-term care (LTC) residents with Alzheimer disease and related dementia (ADRD).

DESIGN

This retrospective cohort study analyzed quarterly data from the 5% Medicare sample linked to Minimum Data Set (MDS) 3.0 between January 1, 2011, and December 31, 2015.

SETTING AND PARTICIPANTS

LTC residents aged 50 years or older with ADRD who had chronic pain and at least 2 quarterly MDS 3.0 assessments.

METHODS

LTC residents were followed up quarterly from first observed quarterly MDS 3.0 until first outcome event or last observed quarterly MDS 3.0. Uncontrolled pain was defined as numerical rating scale >4, verbal descriptor scale of moderate or severe pain, or ≥1 pain indicators on the Checklist of Nonverbal Pain Indicators. Depression was defined as ≥10 on the Patient Health Questionnaire 9; behavioral symptoms were defined as the presence of psychotic (delusions or hallucinations) or disruptive behaviors (rejection of care, or physical, verbal, or other aggressive behaviors). Generalized linear models (GLMs) with marginal structural modeling (MSM) stabilized weights were used to examine uncontrolled pain and outcome risk.

RESULTS

The incidence rate of depression and behavioral symptoms during follow-up was 9.4 and 23.1 per 100 resident-years, respectively. Results from the MSM-GLMs showed that LTC residents with uncontrolled pain had a higher risk than those with controlled pain for developing depression [hazard ratio 1.67, 95% confidence interval (CI) 1.54-1.81] and behavioral symptoms (hazard ratio 1.28, 95% CI 1.19-1.37).

CONCLUSIONS AND IMPLICATIONS

Uncontrolled pain was associated with elevated risk for depressive and behavioral symptoms in dementia, underscoring the importance of pain assessment and control among LTC residents with ADRD.

How Well Does the Brief Interview for Mental Status Identify Risk for Cognition Mediated Functional Impairment in a Community Sample?

OBJECTIVE

To determine the adequacy of the Brief Interview for Mental Status (BIMS) compared with other screening tools in identifying individuals with limitations in functional cognition and instrumental activities of daily living (IADL).

DESIGN

Cross-sectional observational study.

SETTING

Midsized midwestern city.

PARTICIPANTS

We assessed a convenience sample of community dwelling individuals (N=197) aged 55 years and older who were living independently.

MAIN OUTCOME MEASURES

Participant scores on the BIMS, Mini-Cog, Menu Task, and Montreal Cognitive Assessment (MoCA) were compared with the Performance Assessment of Self-Care Skills Checkbook Balancing and Shopping tasks (PCST), which are known to predict impairment in complex IADLs associated with a diagnosis of mild cognitive impairment. Multiple logistic regression analyses controlling for participant demographics, as well as sensitivity and specificity, were computed for each screening measure using the PCST as the criterion measure.

RESULTS

The Mini-Cog, Menu Task, and MoCA identified 25.89%, 32.49%, and 47.21% more individuals, respectively, as impaired than the BIMS. In multiple logistical regression analyses, the BIMS correctly identified 58% of those impaired on the PCST. However, each of the alternate screening measures correctly identified at least 70% of individuals as impaired on the PCST.

CONCLUSIONS

In this community sample, the BIMS was insensitive to subtle impairments with the potential to compromise community living, suggesting that the BIMS may be inappropriate for use outside nursing home settings.

Time Trends in Opioid Use by Dementia Severity in Long-Term Care Nursing Home Residents

OBJECTIVE

Current information on opioid use in nursing home residents, particularly those with dementia, is unknown. We examined the temporal trends in opioid use by dementia severity and the association of dementia severity with opioid use in long-term care nursing home residents.

DESIGN

Repeated measures cross-sectional study.

SETTING

Long-term care nursing homes.

PARTICIPANTS

Using 20% Minimum Data Set (MDS) and Medicare claims from 2011-2017, we included long-term care residents (n = 734,739) from each year who had 120 days of consecutive stay. In a secondary analysis, we included residents who had an emergency department visit for a fracture (n = 12,927).

MEASUREMENTS

Dementia was classified as no, mild, moderate, and severe based on the first MDS assessment each year. In the 120 days of nursing home stay, opioid use was measured as any, prolonged (>90 days), and high-dose (≥90 morphine milligram equivalent dose/day). For residents with a fracture, opioid use was measured within 7 days after emergency department discharge. Association of dementia severity with opioid use was evaluated using logistic regression.

RESULTS

Overall, any opioid use declined by 8.5% (35.2% to 32.2%, P < .001), prolonged use by 5.0% (14.1% to 13.4%, P < .001), and high-dose by 21.4% (1.4% to 1.1%, P < .001) from 2011 to 2017. Opioid use declined across 4 dementia severity groups. Among residents with fracture, opioid use declined by 9% in mild, 9.5% in moderate, and 12.3% in severe dementia. The odds of receiving any, prolonged, and high-dose opioids decreased with increasing severity of dementia. For example, severe dementia reduced the odds of any [23.5% vs 47.6%; odds ratio (OR) 0.56, 95% confidence interval (CI) 0.55-0.57], prolonged (9.8% vs 20.7%; OR 0.69, 95% CI 0.67-0.71), and high-dose (1.0% vs 2.3%; OR 0.69, 95% CI 0.63-0.74) opioids.

CONCLUSIONS AND IMPLICATIONS

Use of opioids declined in nursing home residents from 2011 to 2017, and the use was lower in residents with dementia, possibly reflecting suboptimal pain management in this population.