Proxy screening tools improve the recognition of dementia in old-age homes: results of a validation study

Current situation, strengths and problems in intra- and interprofessional collaboration in German nursing homes - A holistic multiple case study

BACKGROUND

The increasing care complexity of nursing home residents living with dementia requires new care models that strengthen professional collaboration. To contribute to the sustainable implementation of new care models, it is important that they are linked to the care reality. However, little is known about intra- and interprofessional organization and provision of care in German nursing homes. Therefore, the aim of this study was to explore the current care situation, problems and strengths regarding intra- and interprofessional collaboration in the care of residents living with dementia.

METHODS

We conducted a holistic multiple case study. The individual care units in which residents living with dementia are cared for were defined as cases. The context was built by the respective nursing homes and their regional affiliation to the federal state of North Rhine-Westphalia. We used qualitative face-to-face interviews, documents and context questionnaires for data collection. The different sources of evidence served to capture complementary perspectives and to validate the findings. First, the collected qualitative data were analyzed using deductive-inductive content analysis. Second, similarities and differences between the cases were identified to elaborate case-specific and cross-case patterns and themes. The reporting followed the EQUATOR reporting guideline for organizational case studies.

RESULTS

We included four care units comprising 21 professionals (nurses, physicians, social worker, physiotherapist, pharmacist) and 14 relatives of residents living with dementia. The analysis revealed four categories to describe current intra- and interprofessional collaboration in all cases: actors and their roles, service delivery, coordination and governance, and communication channel. Moreover, we identified three categories that relate to the strengths and problems of intra- and interprofessional collaboration in all cases: role understanding, teamwork, and communication and exchange. Although we examined similar care units, we found differences in the realization of professional collaboration and resulting problems and strengths that are connected to the organizational contexts and strategies used.

CONCLUSIONS

Even though professional collaboration follows given patterns; these patterns do differ context-specifically and are perceived as problematic and fragmentary. Therefore, the identified differences and problems in collaboration need to be addressed in future research to develop and successfully implement tailored innovative care models.

The Perspective of Residents Living With Dementia Toward Their Built Environment: A Walking Interview Study in German Nursing Homes

Background and Objectives

In long-term care, the built environment can help residents maintain activities of daily living and thus positively influence their quality of life. The adequacy of the built environment can be systematically assessed using assessment tools. The German Environmental Audit Tool (G-EAT) was translated and psychometrically tested for the German setting. Previous research has shown that the perspective of people living with dementia has not been fully considered in this adaptation. To explore the residents' perspective, the question of how residents living with dementia experience the built environment of nursing homes was investigated.

Research Design and Methods

Walking interviews were conducted with residents. Inclusion criteria for participation were the presence of dementia (medically diagnosed or indicated by symptoms) and the ability to express themselves verbally in German. For data analysis, the audio material was transcribed and supplemented by the researchers' field notes and photographs. Data analysis followed an interpretative phenomenological approach.

Results

Fourteen residents from 2 nursing homes participated in the walking interviews. A total of 3 themes were identified: (1) being able to maintain the feeling "to refurnish" or having to let it go, (2) experiencing the limits and potentials of being independent because of the built environment, and (3) living in a community of residents.

Discussion and Implications

The perspective of the living environment of people living with dementia in nursing homes adds to the knowledge of assessment-based data. Boundaries between physical and social environments are experienced as fluid by residents. They do not see their living space as limited to their living unit but describe the nursing home as a living environment. This broadens the perspective of existing structural definitions in the setting.

Cognitive stimulation for people with dementia in nursing homes: a protocol for a feasibility study examining a new 24/7 approach (CogStim24)

INTRODUCTION

Based on the available evidence, cognitive stimulation is recommended as an intervention for people with dementia (PwD). Currently, cognitive stimulation is regularly offered as a group programme in care facilities. However, some residents, such as those who are bedridden, cannot participate. Furthermore, group programmes were not feasible during the pandemic. A concept that accompanies everyday life and enables cognitive stimulation in everyday communication (ie, '24/7') has been missing. Therefore, this feasibility study aims to (1) assess the feasibility of a new continuous 24/7 cognitive stimulation programme (CogStim24) based on a process evaluation and (2) examine the possible effects of CogStim24 on the primary outcome of global cognition in PwD and further PwD-related and staff-related outcomes.

METHODS AND ANALYSIS

The complex CogStim24 programme is developed to be conducted as an everyday intervention during routine care including cognitively stimulating techniques, such as reminiscence therapy, multisensory stimulation and physical activity. In this unblinded single-arm study with pre-assessments and post-assessments, four nursing homes with a total of N=20 nursing and care staff will participate in an 11-week CogStim24 training programme. The intervention will be conducted to N=60 PwD. Neuropsychological assessments will be conducted pre-staff and post-staff training, as well as after a 6-week implementation phase. A process evaluation will be performed.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the ethics committee of the Faculty of Medicine of the University of Cologne, Cologne, Germany. Although cognitive stimulation is known to be effective for enhancing global cognition and quality of life in PwD, it is currently undersupplied to PwD. Therefore, CogStim24 has the potential to reach many more PwD. This study has the potential to serve as a basis for a large multicentre cluster randomised controlled trial. An interdisciplinarity team and mixed-methods approach will help generate information on the practicality and mechanisms of impact of CogStim24. This is important for the further development of the intervention and for facilitating its implementation. The study results will be disseminated via presentations at scientific conferences and meetings for healthcare professionals and PwD and their relatives. Several manuscripts presenting results of the different study parts will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

DRKS00024381.

Measuring patients' medical treatment preferences in advance care planning: development and validation of the Treat-Me-ACP instrument - a secondary analysis of a cluster-randomized controlled trial

BACKGROUND

Advance Care Planning interventions should be evaluated as broadly as possible to gain a holistic understanding of the Advance Care Planning process. However, validated early stage outcome instruments are lacking. Therefore, the Treatment-Preference-Measure-Advance Care Planning (Treat-Me-ACP) instrument was developed and validated as part of the cluster-randomized controlled trial STADPLAN (Study on Advance Care Planning in care-dependent community-dwelling older persons) to assess the effects of Advance Care Planning interventions on patients' medical treatment preferences.

METHODS

The design of Treat-Me-ACP is based on the Emanuel Medical Directive and the Life Support Preferences Questionnaires. Using a multi-stage team approach a preliminary version of the Treat-Me-ACP was developed and pre-tested. The pre-tested instrument consists of one global medical care goal-item, five hypothetical scenarios with five hypothetical treatments, and one how would you feel-item within each scenario. A total of five scenario preference scores and five treatment preference scores can be formed. This version was subsequently applied to a subsample of the STADPLAN project (n = 80) to assess patient's preferences at baseline (T0) and at 12-month follow-up (T2). The further validation steps were based on this subsample and included: (1) acceptance by using completion rate and frequencies of missing data, (2) internal consistency by using Cronbach's α to test whether it was possible to create preference scores by scenario and treatment, (3) concurrent validation examining the association between the global medical care goal-item and the preference scores and the association between the how would you feel-items and the scenario preference scores, and (4) responsiveness of the instrument to changes in preferences for life-sustaining treatments by comparing preference scores from T0 to T2 between study groups.

RESULTS

Acceptance of the instrument was high. Results of concurrent validation indicate that the five scenarios represent the global medical care goal well. The preference scores showed an average tendency for decreasing preferences for life-sustaining treatments across all scales for the intervention group during study follow-up.

CONCLUSIONS

The Treat-Me-ACP can be used to evaluate the dynamics of patients' medical treatment preferences in Advance Care Planning. It has been validated for care-dependent community-dwelling older persons and can be used as an additional outcome measure in evaluating the effectiveness of ACP interventions.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00016886 on 04/06/2019.

[Structured case conference for sleep disturbances in nursing home residents with cognitive impairment]

Structured case conference for sleep disturbances in nursing home residents with cognitive impairment Abstract: Background: Nursing home residents living with cognitive impairment often suffer from sleep disturbances. Pharmacological interventions are not recommended to be the first-choice therapy. In general, a wide variance of non-pharmacological interventions is available, but no clearly suitable intervention can currently be specified. Aim: The case report presents the procedure of a structured analysis to support the selection of non-pharmacological interventions to promote sleep. Methods: A structured case conference was held using a developed case management template to draw up an individual intervention plan. Results: Based on the description of the situation and the determination of causes, different interventions from six main topics were planned: "offering appropriate activations during daytime", "creating bedtime routines", "checking the sleep environment", "observation of potential physical and psychological causes", "reflection on night care routines", and "use of drug therapies only in exceptional cases". Conclusions: For a successful management of sleep disturbances in nursing home residents living with cognitive impairment, it is essential that the specific sleep-related symptoms and causes are assessed systematically and interprofessionally to be able to work towards an improvement with appropriate measures. In order to obtain adequate solutions, evidence-based expertise should be taken into consideration.

Intervention for sleep problems in nursing home residents with dementia: a cluster-randomized study

OBJECTIVE

To reduce sleep problems in people living with dementia using a multi-component intervention.

DESIGN

Cluster-randomized controlled study with two parallel groups and a follow-up of 16 weeks.

SETTING

Using external concealed randomization, 24 nursing homes (NH) were allocated either to the intervention group (IG, 12 clusters, 126 participants) or the control group (12 clusters, 116 participants).

PARTICIPANTS

Participants were eligible if they had dementia or severe cognitive impairment, at least two sleep problems, and residence of at least two weeks in a NH.

INTERVENTION

The 16-week intervention consists of six components: (1) assessment of sleep-promoting activities and environmental factors in NHs, (2) implementation of two "sleep nurses," (3) basic education, (4) advanced education for staff, (5) workshops to develop sleep-promoting concepts, and (6) written information and education materials. The control group (CG) received standard care.

MEASUREMENTS

Primary outcome was ≥ two sleep problems after 16 weeks assessed with the Sleep Disorders Inventory (SDI).

RESULTS

Twenty-two clusters (IG = 10, CG = 12) with 191 participants completed the study. At baseline, 90% of people living with dementia in the IG and 93% in the CG had at least two sleep problems. After 16 weeks, rates were 59.3% (IG) vs 83.8% (CG), respectively, a difference of -24.5% (95% CI, -46.3% - -2.7%; cluster-adjusted odds ratio 0.281; 95% CI 0.087-0.909). Secondary outcomes showed a significant difference only for SDI scores after eight and 16 weeks.

CONCLUSIONS

The MoNoPol-Sleep intervention reduced sleep problems of people living with dementia in NH compared to standard care.

Effectiveness of an individually tailored complex intervention to improve activities and participation in nursing home residents with joint contractures (JointConEval): a multicentre pragmatic cluster-randomised controlled trial

OBJECTIVE

This study aims to examine the effects of the individually tailored complex intervention Participation Enabling Care in Nursing (PECAN) on activities and participation of residents with joint contractures.

DESIGN

Multicentre pragmatic cluster-randomised controlled trial.

SETTING

35 nursing homes in Germany (August 2018-February 2020).

PARTICIPANTS

562 nursing home residents aged ≥65 years with ≥1 major joint contracture (303 intervention group, 259 control group).

INTERVENTIONS

Nursing homes were randomised to PECAN (18 clusters) or optimised standard care (17 clusters) with researcher-concealed cluster allocation by facsimile. The intervention targeted impairments in activities and participation. Implementation included training and support for selected staff. Control group clusters received brief information.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint PaArticular Scales combined residents' activities and participation at 12 months. The secondary outcome comprised quality of life. Safety measures were falls, fall-related consequences and physical restraints. Residents, staff and researchers were unblinded. Data collection, data entry and statistical analysis were blinded. Primary analyses were intention-to-treat at cluster level and individual level using a generalised mixed-effect regression model and imputation of missing data.

RESULTS

Primary outcome analyses included 301 intervention group residents and 259 control group residents. The mean change on the Activities Scale was -1.47 points (SD 12.2) in the intervention group and 0.196 points (SD 12.5) in the control group and -3.87 points (SD 19.7) vs -3.18 points (SD 20.8) on the Participation Scale. The mean differences of changes between the groups were not statistically significant: Activities Scale: -1.72 (97.5% CI -6.05 to 2.61); Participation Scale: -1.24 (97.5% CI -7.02 to 4.45). We found no significant difference in the secondary outcome and no effects on safety measures.

CONCLUSION

The complex intervention did not improve the activities and participation of nursing home residents on the PaArticular Scales at 12 months. Current nursing conditions in Germany may hamper implementation.

TRIAL REGISTRATION NUMBER

DRKS00015185.

Effects of cognitive status on outcomes of groin hernia repair using various anesthesia techniques

BACKGROUND AND AIM

Because of increasing life expectancy, there is an increasing number of cognitively impaired older individuals undergoing surgeries such as groin hernia repair. Here, we evaluated the effects of cognitive status on postoperative complication rates in patients undergoing groin hernia repair using various anesthesia techniques. We also analyzed the rate of same-day hernia surgery in patients with cognitive decline.

METHODS

Patients who presented to our general surgery clinic for unilateral or bilateral inguinal or femoral hernia were prospectively classified into general (group 1), local (group 2), and spinal (group 3) anesthesia groups. The Mini-Mental State Examination (MMSE) was used for preoperative evaluation of each patient's cognitive status. The Visual Analog Scale (VAS) was used to evaluate postoperative pain. Groups were compared in terms of age, MMSE and VAS scores, cognitive decline and complication rates, and surgery duration.

RESULTS

In total, 33 (35.1%), 30 (31.9%), and 31 (33.0%) of 94 patients underwent surgery using general, local, and spinal anesthesia, respectively. The mean MMSE score did not differ among groups (p = 0.518). Cognitive decline was present in 18 (19.2%) patients, and the proportion did not significantly differ among groups. The complication rate did not differ between patients with and without cognitive decline. The mean surgery duration was similar among the three groups (p = 0.127). Group 2 had a lower mean postoperative VAS score, compared with the other groups (p < 0.001). Complications because of anesthesia and surgery were significantly more common in group 3 than in the other groups (p = 0.025). In the local anesthesia group, 7 patients had cognitive decline and 22 patients had normal cognition. There were no significant differences between patients with and without cognitive decline in terms of mean surgery duration (50.3 ± 15.4 min vs. 45.2 ± 10.7 min; p = 0.338) or mean VAS score (3.14 ± 0.90 vs. 3.13 ± 0.77; p = 0.985). Among the 22 and 7 patients without and with cognitive decline, 11 (50%) and 0 patients were discharged on the same day (p = 0.025). In the local anesthesia group, the respective median ages were 70, 52, and 59 years for patients with cognitive decline, patients with normal cognition discharged on the same day, and patients with normal cognition who were not discharged on the same day (p = 0.001).

CONCLUSION

Groin hernia repair was successfully performed under local anesthesia in all patients, including older patients with cognitive decline. Patients with cognitive decline were not discharged on the day of surgery, although the mean surgery duration and postoperative VAS score did not differ between patients with and without cognitive decline. Prolonged hospitalization in patients with cognitive decline may be related to their advanced age. Further studies are needed to determine the safety of same-day surgery in patients with cognitive decline.

Expanded nursing competencies to improve person-centred care for nursing home residents with complex health needs (Expand-Care): study protocol for an exploratory cluster-randomised trial

INTRODUCTION

Older age is associated with multimorbidity, chronic diseases and acute deteriorations and leads to complex care needs. Nursing home residents are more often unnecessarily transferred to emergency departments or hospitals than community dwellers-largely due to a lack of qualified staff and diffusion of responsibility in the institutions. In Germany, only few academically trained nurses work in nursing homes, and their potential roles are unclear. Therefore, we aim to explore feasibility and potential effects of a newly defined role profile for nurses with bachelors' degree or equivalent qualification in nursing homes.

METHODS AND ANALYSIS

A pilot study (Expand-Care) with a cluster-randomised controlled design will be conducted in 11 nursing homes (cluster) in Germany, with an allocation ratio of 5:6 to the intervention or control group, aiming to include 15 residents per cluster (165 participants in total). Nurses in the intervention group will receive training to perform role-related tasks such as case reviews and complex geriatric assessments. We will collect data at three time points (t0 baseline, t1 3 months and t2 6 months after randomisation). We will measure on residents' level: hospital admissions, further health services use and quality of life; clinical outcomes (eg, symptom burden), physical functioning and delivery of care; mortality, adverse clinical incidents and changes in care level. On nurses' level, we will measure perception of the new role profile, competencies and implementation of role-related tasks as part of the process evaluation (mixed methods). An economic evaluation will explore resource use on residents' (healthcare utilisation) and on nurses' level (costs and time expenditure).

ETHICS AND DISSEMINATION

The ethics committees of the University of Lübeck (Nr. 22-162) and the University Clinic Hamburg-Eppendorf (Nr. 2022-200452-BO-bet) approved the Expand-Care study. Informed consent is a prerequisite for participation. Study results will be published in open-access, peer-reviewed journals and reported at conferences and in local healthcare providers' networks.

TRIAL REGISTRATION NUMBER

DRKS00028708.

Perspectives on sleep of people living with dementia in nursing homes: a qualitative interview study

BACKGROUND

Disturbed sleep among people living with dementia in nursing homes is widespread and is associated with diseases and all-cause mortality. This study examined the sleep of people living with dementia from their perspectives in nursing homes and that of the nurses who care for people living with dementia.

METHODS

A qualitative cross-sectional study was conducted. A total of 15 people living with dementia and 15 nurses in 11 German nursing homes were enrolled in this study. Data was collected between February and August 2021 through semistructured interviews, which were audio recorded and transcribed. Thematic analyses were performed by three independent researchers. Thematic mind maps and controversial findings were discussed with the Research Working Group of People with Dementia of the German Alzheimer Association.

RESULTS

Thematic analysis identified five overarching themes from the nursing home participants regarding sleep patterns: (1) characteristics of good sleep, (2) characteristics of bad sleep, (3) personal influences of people living with dementia on sleep, (4) environmental factors on sleep, and (5) sleep strategies of people living with dementia. Analysis also identified five overarching themes from the nurses participants: (1) characteristics of good sleep, (2) characteristics of bad sleep, (3) personal influences on sleep, (4) environmental factors on sleep, and (5) interventions for sleep promotion.

CONCLUSIONS

The thematic analyses demonstrated that the perspectives of people living with dementia and nurses indicate the need to give more consideration to psychosocial factors and individual aspects of sleep in clinical practice. The results could also be helpful for the development of targeted assessment instruments and complex non-pharmacological interventions to promote sleep.

Optimal@NRW: optimized acute care of nursing home residents using an intersectoral telemedical cooperation network - study protocol for a stepped-wedge trial

Background

Increasing life expectancy is associated with a growing number of people living in nursing homes, while the availability of outpatient medical care, especially from family doctors, is stagnating in this sector. Consequently, numerous and often avoidable, low-threshold hospitalizations of nursing home residents are observed. This results in unnecessary use of resources such as emergency services and emergency rooms as well as in potential health risks to the nursing home residents related to hospitalization. This study aims to improve this healthcare gap by implementing an intersectoral telemedicine approach.

Methods

Twenty-five nursing homes are participating and provided with telemedical equipment to perform teleconsultations. Additionally, an early warning system and a digital patient record system are implemented. Telephysicians based at RWTH Aachen University Hospital are ready to support the nursing homes around the clock if the family doctor or an emergency service practice is not available in time. Mobile non-physician practice assistants from the telemedicine centre can be dispatched to perform delegable medical activities. General practitioners and the medical emergency practices also have access to the telemedical infrastructure and the non-physician practice assistants.

Discussion

Optimal@NRW adds a telemedicine component to standard care — combining elements of outpatient and inpatient health care as well as emergency service practices — to enable timely medical consultation for nursing home residents in case of the development of an acute medical condition. In addition to optimized medical care, the goal is to reduce unnecessary hospital admissions. The intersectoral approach allows for the appropriate use of resources to match the individually needed medical treatment.

Trial registration

ClinicalTrials.govNCT04879537. Registered on May 10, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06613-1.

Relationship between the severity of agitation and quality of life in residents with dementia living in German nursing homes - a secondary data analysis

BACKGROUND

Severe agitation and its relation to single dimensions of quality of life are not well understood. The aim of this study was to gain more knowledge about severe agitation and to examine the relationships between the severity of agitation and single dimensions of quality of life among residents with dementia living in German nursing homes.

METHODS

This exploratory secondary analysis included data from 1947 residents of 66 German nursing homes from the DemenzMonitor study. The construct of agitation was defined as a composite score of the items agitation/aggression, irritability/lability and disinhibition from the Neuropsychiatric Inventory Questionnaire (NPI-Q); the resident was classified as severely agitated if at least one of these symptoms was rated as 'severe'. The single dimensions of quality of life were measured with the short version of the QUALIDEM instrument. To avoid selection bias, two controls with mild or no agitation were selected for each resident with severe agitation using propensity score matching. Mixed linear regression models were then generated to determine the differences in the dimensions of quality of life for the severity of agitation and the defining items.

RESULTS

For four out of five dimensions of quality of life of the short version of QUALIDEM, residents with severe agitation had significantly lower values than residents without severe agitation. Converted to scale size, the greatest difference between both groups was found in the dimension social isolation with 23.0% (-2.07 (95% CI: -2.57, -1.57)). Further differences were found in the dimensions restless tense behaviour with 16.9% (-1.52 (95% CI: -2.04, -1.00)), positive affect with 14.0% (-1.68 (95% CI: -2.28, -1.09)) and social relations with 12.4% (-1.12 (95% CI: -1.54, -0.71)).

CONCLUSIONS

Severe agitation is a relevant phenomenon among nursing home residents with dementia and is associated with lower values of quality of life in the dimensions social isolation, restless tense behaviour, positive affect and social relations from the QUALIDEM instrument. Therefore, more attention should be paid to severe agitation in nursing practice and research. Moreover, care strategies used to reduce severe agitation should be considered in terms of their impact on the dimensions of quality of life.

Evaluation of a multi-component, non-pharmacological intervention to prevent and reduce sleep disturbances in people with dementia living in nursing homes (MoNoPol-sleep): study protocol for a cluster-randomized exploratory trial

BACKGROUND

Sleep problems are highly prevalent in people with dementia. Nevertheless, there is no "gold standard" intervention to prevent or reduce sleep problems in people with dementia. Existing interventions are characterized by a pronounced heterogeneity as well as insufficient knowledge about the possibilities and challenges of implementation. The aim of this study is to pilot and evaluate the effectiveness of a newly developed complex intervention to prevent and reduce sleep problems in people with dementia living in nursing homes.

METHODS

This study is a parallel group cluster-randomized controlled trial. The intervention consists of six components: (1) the assessment of established sleep-promoting interventions and an appropriate environment in the participating nursing homes, (2) the implementation of two "sleep nurses" as change agents per nursing home, (3) a basic education course for nursing staff: "Sleep problems in dementia", (4) an advanced education course for nursing staff: "Tailored problem-solving" (two workshops), (5) workshops: "Development of an institutional sleep-promoting concept" (two workshops with nursing management and sleep nurses) and (6) written information and education material (e.g. brochure and "One Minute Wonder" poster). The intervention will be performed over a period of 16 weeks and compared with usual care in the control group. Overall, 24 nursing homes in North, East and West Germany will be included and randomized in a 1:1 ratio. The primary outcome is the prevalence of sleep problems in people with dementia living in nursing homes. Secondary outcomes are quality of life, quality of sleep, daytime sleepiness and agitated behavior of people with dementia, as well as safety parameters like psychotropic medication, falls and physical restraints. The outcomes will be assessed using a mix of instruments based on self- and proxy-rating. A cost analysis and a process evaluation will be performed in conjunction with the study.

CONCLUSIONS

It is expected that the intervention will reduce the prevalence of sleep problems in people with dementia, thus not only improving the quality of life for people with dementia, but also relieving the burden on nursing staff caused by sleep problems.

TRIAL REGISTRATION

Current controlled trials: ISRCTN36015309 . Date of registration: 06/11/2020.

Effect of an interprofessional care concept on the hospitalization of nursing home residents: study protocol for a cluster-randomized controlled trial

Background

The rising number of nursing home (NH) residents and their increasingly complex treatment needs pose a challenge to the German health care system. In Germany, there is no specialized geriatric medical care for NH residents. Nursing staff and general practitioners (GPs) in particular have to compensate for the additional demand, which is compounded by organizational and structural hurdles. As a result, avoidable emergency calls and hospital admissions occur.

In the SaarPHIR project (Saarländische PflegeHeimversorgung Integriert Regelhaft), a complex intervention focusing on a medical care concept was developed in a participatory practice-based approach involving NH representatives and GPs. The complex intervention addresses the collaboration between nurses and GPs and aims to help restructure and optimize the existing daily care routine. It is expected to improve the medical care of geriatric patients in NHs and reduce stressful, costly hospital admissions. The intervention was pilot-tested during the first 12 months of the project. In the present study, its effectiveness, cost-effectiveness, and safety will be evaluated.

Methods

The study is a cluster-randomized controlled trial, comparing an intervention group with a control group. The intervention includes a concept of interprofessional collaboration, in which GPs group into regional cooperating teams. Teams are encouraged to cooperate more closely with NH staff and to provide on-call schedules, pre-weekend visits, joint team meetings, joint documentation, and improved medication safety. At least 32 NHs in Saarland, Germany (with at least 50 residents each) will be included and monitored for 12 months. The primary endpoint is hospitalization. Secondary endpoints are quality of life, quality of care, and medication safety. The control group receives treatment as usual. Process evaluation and health economic evaluation accompany the study. The data set contains claims data from German statutory health insurance companies as well as primary data. Analysis will be conducted using a generalized linear mixed model.

Conclusion

A reduction in hospital admissions of NH residents and relevant changes in secondary endpoints are expected. In turn, these will have a positive impact on the economic assessment.

Trial registration

German Clinical Trials Register: DRKS00017129. Registered on 23 April 2019. https://www.drks.de/drks_web/setLocale_EN.do.

Improving medication appropriateness in nursing homes via structured interprofessional medication-review supported by health information technology: a non-randomized controlled study

Background

In nursing home residents (NHRs), polypharmacy is widespread, accompanied by elevated risks of medication related complications. Managing medication in NHRs is a priority, but prone to several challenges, including interprofessional cooperation. Against this background, we implemented and tested an interprofessional intervention aimed to improve medication appropriateness for NHRs.

Methods

A non-randomized controlled study (SiMbA; “Sicherheit der Medikamentherapie bei AltenheimbewohnerInnen”, Safety of medication therapy in NHRs) was conducted in six nursing homes in Austria (2016–2018). Educational training, introduction of tailored health information technology (HIT) and a therapy check process were combined in an intervention aimed at healthcare professionals. Medication appropriateness was assessed using the Medication Appropriateness Index (MAI). Data was collected before (t0), during (t1, month 12) and after (t2, month 18) intervention via self-administered assessments and electronic health records.

Results

We included 6 NHs, 17 GPs (52.94% female) and 240 NHRs (68.75% female; mean age 85.0). Data of 159 NHRs could be included in the analysis. Mean MAI-change was − 3.35 (IG) vs. − 1.45 (CG). In the subgroup of NHRs with mean MAI ≥23, MAI-change was − 10.31 (IG) vs. −3.52 (CG). The intervention was a significant predictor of improvement in MAI when controlled for in a multivariable regression model.

Conclusions

Improvement of medication appropriateness was clearest in residents with inappropriate baseline MAI-scores. This improvement was independent of variances in certain covariates between the intervention and the control group. We conclude that our intervention is a feasible approach to improve NHRs’ medication appropriateness.

Trial registration

DRKS Data Management, ID: DRKS00012246. Registered 16.05.2017 – Retrospectively registered.

Assessing the Attitudes of Greek Nurses Toward Computerized Dementia Screening

BACKGROUND

Despite the abundance of research on computerized dementia screening tests, the attitudes of hospital personnel toward this screening method have not been investigated.

OBJECTIVE

1) To conduct a confirmatory factor analysis of the first part of a two-part questionnaire about computerized dementia screening. 2) To assess the attitudes of Greek nurses toward computerized dementia screening. 3) To assess barriers to future implementation of computerized dementia screening in the Greek healthcare system, as reported by nurses.

METHODS

161 Greek nurses from two urban public general hospitals who participated in a dementia training program were recruited. They were asked to complete a two-part questionnaire about computerized dementia screening. The first part of the questionnaire assesses attitudes toward dementia screening while the second part of the questionnaire assesses barriers to its implementation.

RESULTS

Confirmatory factor analysis on the first part of the questionnaire suggested a two-factor structure (feasibility/acceptability). The total score of all items loading on each factor was calculated. For feasibility, scores ranged between 10 and 25 (M = 19.38, SD = 3.80). For acceptability, scores ranged between 6 and 20 (M = 15.27, SD = 2.76). The main barriers to implementation were cost of equipment, insufficient training, lack of a plan for the integration of computerized screening tests in the daily routine of the hospital and time needed for staff training.

CONCLUSION

The positive attitude of nurses supports the implementation of computerized dementia screening in public hospitals as long as identified barriers are addressed.

Effects of strategies to improve general practitioner-nurse collaboration and communication in regard to hospital admissions of nursing home residents (interprof ACT): study protocol for a cluster randomised controlled trial

BACKGROUND

In Germany, up to 50% of nursing home residents are admitted to a hospital at least once a year. It is often unclear whether this is beneficial or even harmful. Successful interprofessional collaboration and communication involving general practitioners (GPs) and nurses may improve medical care of nursing home residents. In the previous interprof study, the six-component intervention package interprof ACT was developed to facilitate collaboration of GPs and nurses in nursing homes. The aim of this study is to evaluate the effectiveness of the interprof ACT intervention.

METHODS

This multicentre, cluster randomised controlled trial compares nursing homes receiving the interprof ACT intervention package for a duration of 12 months (e.g. comprising appointment of mutual contact persons, shared goal setting, standardised GPs' home visits) with a control group (care as usual). A total of 34 nursing homes are randomised, and overall 680 residents recruited. The intervention package is presented in a kick-off meeting to GPs, nurses, residents/relatives or their representatives. Nursing home nurses act as change agents to support local adaption and implementation of the intervention measures. Primary outcome is the cumulative incidence of hospitalisation within 12 months. Secondary outcomes include admissions to hospital, days admitted to hospital, use of other medical services, prevalence of potentially inappropriate medication and quality of life. Additionally, health economic and a mixed methods process evaluation will be performed.

DISCUSSION

This study investigates a complex intervention tailored to local needs of nursing homes. Outcomes reflect the healthcare and health of nursing home residents, as well as the feasibility of the intervention package and its impact on interprofessional communication and collaboration. Because of its systematic development and its flexible nature, interprof ACT is expected to be viable for large-scale implementation in routine care services regardless of local organisational conditions and resources available for medical care for nursing home residents on a regular basis. Recommendations will be made for an improved organisation of primary care for nursing home residents. In addition, the results may provide important knowledge and data for the development and evaluation of further strategies to improve outpatient care for elderly care-receivers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03426475 . Initially registered on 7 February 2018.

Effects of kidney function, serum albumin and hemoglobin on dementia severity in the oldest old people with newly diagnosed Alzheimer's disease in a residential aged care facility: a cross-sectional study

Background

Chronic kidney disease (CKD), low serum albumin, and anemia are known risk factors for cognitive decline in older people. We investigated the association between kidney function and cognitive impairment severity in oldest-old people with a diagnosis of Alzheimer’s disease (AD).

Methods

A cross-sectional study of patients aged 80 years and older was conducted at a veterans’ home in Taiwan between 2012 and 2016. Their estimated glomerular filtration rate (eGFR) was determined using the Modification of Diet in Renal Diseases (MDRD) equation. Cognitive function was evaluated with the Mini-Mental State Examination (MMSE) and Clinical Dementia Rating (CDR).

Results

A total of 84 patients (age mean ± SD, 86.6 ± 3.9 years) had MMSE scores of 10.1 ± 6.7, and CDR scores of 1.6 ± 0.7. The average eGFR was 61.7 ± 21.5 mL/min/1.73m². The mean hemoglobin concentration was 12.7 ± 1.7 g/dl, and the mean albumin concentration was 4.5 ± 4.8 g/dl. Multivariate regression analyses showed that scores of CDR were significantly correlated with eGFR after adjustment for potential confounders. The scores of MMSE were significantly correlated with serum albumin and hemoglobin after adjustment for potential confounders.

Conclusions

We found dementia severity was significantly associated with kidney function, serum albumin, and hemoglobin in the oldest-old with AD. We recommend that oldest-old people with a diagnosis of AD be evaluated to determine kidney function, as well as nutritional and hematological status. Further study is needed to establish whether prevention of CKD deterioration, and correction of malnutrition and anemia may help to slow cognitive decline in oldest-old people with dementia.

Empirical development of a typology on residential long-term care units in Germany - results of an exploratory multivariate data analysis

BACKGROUND

Organizational health care research focuses on describing structures and processes in organizations and investigating their impact on the quality of health care. In the setting of residential long-term care, this effort includes the examination and description of structural differences among the organizations (e.g., nursing homes). The objective of the analysis is to develop an empirical typology of living units in nursing homes that differ in their structural characteristics.

METHODS

Data from the DemenzMonitor Study were used. The DemenzMonitor is an observational study carried out in a convenience sample of 103 living units in 51 nursing homes spread over 11 German federal states. Characteristics of living units were measured by 19 variables related to staffing, work organization, building characteristics and meal preparation. Multiple correspondence analysis (MCA) and agglomerative hierarchical cluster analysis (AHC) are suitable to create a typology of living units. Both methods are multivariate and explorative. We present a comparison with a previous typology (created by a nonexplorative and nonmultivariate process) of the living units derived from the same data set.

RESULTS

The MCA revealed differences among the living units, which are defined in particular by the size of the living unit (number of beds), the additional qualifications of the head nurse, the living concept and the presence of additional financing through a separate benefit agreement. We identified three types of living units; these clusters occur significantly with a certain combination of characteristics. In terms of content, the three clusters can be defined as: "house community", "dementia special care units" and "usual care".

CONCLUSION

A typology is useful to gain a deeper understanding of the differences in the care structures of residential long-term care organizations. In addition, the study provides a practical recommendation on how to apply the results, enabling living units to be assigned to a certain type. The typology can be used as a reference for definitions.

Study on advance care planning in care dependent community-dwelling older persons in Germany (STADPLAN): protocol of a cluster-randomised controlled trial

BACKGROUND

In Germany, advance care planning (ACP) was first introduced by law in 2015. However, ACP is still uncommon in Germany and only few people have advance directive forms. This study aims to evaluate an ACP program in care dependent community-dwelling persons, compared to optimised usual care.

METHODS

A cluster-randomised controlled trial of 12 months duration will be conducted in 3 German study sites comparing the pretested ACP-counselling offered by trained nurses with a control group receiving optimised usual care. Using external concealed randomisation, 16 home care services each will be included in the intervention and the control group (30 participants per cluster; n = 960). Eligibility criteria for patients are: ≥60 years, somehow care dependent, adequate German language skills, assumed life-expectancy of ≥4 weeks, and cognitive ability for participation. ACP will be delivered by trained nurse facilitators of the respective home care services and communication will include proxy decision-makers. The primary endpoint will be patient activation, assessed by the Patient Activation Measure (PAM-13). Secondary endpoints include ACP-engagement, proportion of prepared advance directives, number and duration of hospitalisations, quality of life as well as depression and anxiety. Further, comprehensive economic and process evaluations will be conducted.

DISCUSSION

STADPLAN is the first study in Germany that assesses an adapted ACP intervention with trained nurses in home care services and the first international study focusing on cost effectiveness of ACP in community-dwelling older persons. The results will help to improve the understanding and communicating of patients' preferences regarding medical treatment and care and thereby contribute to patients' autonomy.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00016886 (Date of registration: 04.06.2019).

Quality of Life in People With Severe Dementia and Its Association With the Environment in Nursing Homes: An Observational Study

BACKGROUND AND OBJECTIVES

Theoretical models propose the environment as a factor influencing the quality of life (QoL) of nursing home residents with dementia. This study investigates whether the observed QoL differs depending on the type of care unit.

RESEARCH DESIGN AND METHODS

DemenzMonitor is an exploratory, observational study involving annual data collection in German nursing homes (2012-2014). For this analysis, we selected residents with a recorded diagnosis of dementia and severe cognitive impairment. QoL was measured with the proxy assessment QUALIDEM. Four care unit types were investigated: large integrated, large segregated, small integrated, and small segregated.

RESULTS

We did not find a significant difference between the care units. During the 2 years, the observed QoL was not affected by any of the care unit types in a statistically significant or clinically relevant manner. However, a significant interaction effect between time and care unit types was found.

DISCUSSION AND IMPLICATIONS

Structural and organizational characteristics of care units, which in turn have implications for residents characteristics and the quality of care, may influence the QoL of residents. This may explain the interaction we observed.

Severe Agitation in Dementia: An Explorative Secondary Data Analysis on the Prevalence and Associated Factors in Nursing Home Residents

Background:

The phenomena of severe agitation is not well understood and often not adequately treated.

Objective:

This article determines the prevalence and associated factors of severe agitation in nursing home residents with dementia.

Methods:

Secondary data analysis within an observational study in German nursing homes with n = 1,967 participants. We assessed severity of agitation with the Neuropsychiatric Inventory Questionnaire (NPI-Q) and defined the construct of agitation as a composite score of the NPI-Q items agitation/aggression, disinhibition, and irritability/lability; the dependent variable of severe agitation was considered as being present in residents who scored ‘severe’ in at least one of these symptoms. A binary logistic regression model was calculated to estimate associations.

Results:

The prevalence of severe agitation was 6.3% (n = 124). The strongest associations were found for elation/euphoria (OR 7.6, CI 3.1–18.5), delusions (OR 7.3, CI 4.0–13.2), apathy/indifference (OR 2.8, CI 1.7–4.7), anxiety (OR 2.2, CI 1.2–3.8), nighttime behaviors (OR 2.4, CI 1.4–4.2), motor disturbances (OR 2.4, CI 1.4–4.1), and male sex (OR 2.4. CI 1.3–4.2).

Conclusion:

Severe agitation in nursing home residents with dementia is a relevant clinical issue as approximately 70% of residents have a dementia. Residents with elation/euphoria and delusions may have a stronger risk of showing severe agitation. We consider delusions as a possible cause of agitation and therefore a prelude to agitation. Although it might be possible that elation/euphoria follows from agitation, we hypothesize that the residents first experience elation/ euphoria and exhibit agitation afterwards.

Gottfries' Cognitive Scale for Staff Proxy Rating of Cognitive Function Among Nursing Home Residents

BACKGROUND

For research purposes, there is a need for tools to assess an individual's level of cognitive function. For survey-based investigations in nursing home contexts, proxy ratings allow the assessment also of individuals with severe cognitive impairment.

OBJECTIVE

The aim of this study was to describe the feasibility and psychometric properties of Gottfries' cognitive scale when used in a nursing home context for proxy rating of cognitive function.

METHOD

The psychometric properties of Gottfries' cognitive scale were investigated in a sample of 8,492 nursing home residents in Västerbotten County, Sweden, using item response theory and classic scale theory-based approaches.

RESULTS

Cognitive function could be scored in 97.1% of the assessed individuals. The scale had a negligible floor effect, it had items with a large spread in difficulties, it appeared linear, and it distributed the assessed individuals equally over the scale. Internal consistency (Cronbach's alpha) was 0.967, and an exploratory factor analysis revealed three factors of the scale - interpreted to represent orientation to time, to place, and to person.

CONCLUSION

Gottfries' cognitive scale is a feasible tool for grading cognitive function among nursing home residents using staff proxy ratings. The scale has excellent psychometric properties with a very high internal consistency, a favorable distribution of item difficulties producing an almost rectangular distribution of scores, and a negligible floor effect. The scale thus can be recommended for use in survey-based investigations in nursing home contexts.

Impact of training and structured medication review on medication appropriateness and patient-related outcomes in nursing homes: results from the interventional study InTherAKT

BACKGROUND

Uncoordinated interprofessional communication in nursing homes increases the risk of polypharmacy and inappropriate medication use. This may lead to augmented frequency of adverse drug events, hospitalizations and mortality. The aims of this study were (1) to improve interprofessional communication and medication safety using a combined intervention and thus, (2) to improve medication appropriateness and health-related outcomes of the included residents.

METHODS

The single-arm interventional study (2014-2017) was conducted in Muenster, Germany and involved healthcare professionals and residents of nursing homes. The intervention consisted of systematic education of participating healthcare professionals and of a structured interprofessional medication review which was performed via an online communication platform. The primary endpoint was assessed using the Medication Appropriateness Index MAI. Secondary endpoints were: cognitive performance, delirium, agitation, mobility, number of drugs, number of severe drug-drug interactions and appropriateness of analgesics. Outcomes were measured before, during and after the intervention. Data were analyzed using descriptive and inference-statistical methods.

RESULTS

Fourteen general practitioners, 11 pharmacists, 9 nursing homes and 120 residents (n = 83 at all testing times) participated. Overall MAI sum-score decreased significantly over time (mean reduction: -7.1, CI95% -11.4 - - 2.8; median = - 3.0; dCohen = 0.39), especially in cases with baseline sum-score ≥ 24 points (mean reduction: -17.4, CI95% -27.6 - - 7.2; median = - 15.0; dCohen = 0.86). MAI sum-score of analgesics also decreased (dCohen = 0.45). Mean number of severe drug-drug interactions rose slightly over time (dCohen = 0.17). The proportion of residents showing agitated behavior diminished from 83.9 to 67.8%. Remaining secondary outcomes were without substantial change.

CONCLUSION

Medication appropriateness increased particularly in residents with high baseline MAI sum-scores. Cognitive decline of participating residents was seemingly decelerated when compared with epidemiologic studies. A controlled trial is required to confirm these effects. Interprofessional interaction was structured and performance of medication reviews was facilitated as the online communication platform provided unlimited and consistent access to all relevant and updated information.

TRIAL REGISTRATION

DRKS Data Management, ID: DRKS00007900 , date of registration: 2015-09-02 (retrospectively registered i.e. 6 weeks after commencement of the first data collection).

Improved participation of older people with joint contractures living in nursing homes: feasibility of study procedures in a cluster-randomised pilot trial

BACKGROUND

Acquired joint contractures have a significant impact on functioning and quality of life in nursing home residents. There is very limited evidence on measures for prevention and treatment of disability due to joint contractures. We have developed the PECAN intervention (Participation Enabling CAre in Nursing) to improve social participation in nursing home residents. A cluster-randomised pilot trial was conducted to assess the feasibility of study procedures in preparation for a main trial according to the UK Medical Research Council (MRC) framework.

METHODS

Nursing homes in two regions of Germany were randomly allocated either to the intervention or optimised standard care (control group). All residents with joint contractures aged > 65 years were eligible for the study. The residents' data were collected through structured face-to-face interviews by blinded assessors at baseline, after 3 and 6 months. The primary outcome was social participation, measured by a subscale of the PaArticular Scales. Secondary outcomes included activities and instrumental activities of daily living, health-related quality of life, falls and fall-related consequences. Data on the trial feasibility were collected via documentation forms.

RESULTS

Seven out of 12 nursing homes agreed to participate and remained in the trial. Of 265 residents who fulfilled the inclusion criteria, 129 were randomised either to the intervention (n = 64) or control group (n = 65) and analysed. A total of 109 (85%) completed the trial after 6 months. The mean age was 85.7 years (SD 7.0), 80% were women. The severity of the residents' disability differed across the clusters. The completion rate was high (> 95%), apart from the Instrumental Activities of Daily Living Scale. Some items of the PaArticular Scales were not easily understood by residents. The frequency of falls did not differ between study groups.

CONCLUSION

Our data confirmed the feasibility of the overall study design. We also revealed the need to improve the procedures for the recruitment of residents and for data collection before implementation into a main trial. The next step will be an adequately powered main trial to assess the effectiveness and cost-effectiveness of the intervention.

TRIAL REGISTRATION

German clinical trials register, ID: DRKS00010037 . Registered on 12 February 2016.

Effectiveness of a complex intervention to improve participation and activities in nursing home residents with joint contractures (JointConEval): study protocol of a multicentre cluster-randomised controlled trial [DRKS-ID:DRKS00015185]

BACKGROUND

Nursing home residents are frequently affected by joint contractures, which impacts their participation and daily activities. A complex intervention, the Participation Enabling Care in Nursing (PECAN), was previously developed and pilot tested to address their needs. Its effectiveness and safety will be evaluated in the present study.

METHODS/DESIGN

This multicentre cluster-randomised controlled trial will be conducted in 32 nursing homes spread over two regions of Germany. A total of 578 residents over 65 years old with joint contractures will be included. To compare the effect of the PECAN intervention with optimised standard care (usual care and an information session), randomisation will take place at a cluster level. The individually tailored intervention was designed using the biopsychosocial model in the International Classification of Functioning, Disability and Health (ICF) to reduce activity limitations and participation restrictions resulting from existing joint contractures by addressing barriers and by strengthening supportive factors on an individual level and an organisational level. The implementation strategy comprises a facilitators' workshop, a peer mentoring approach including a peer mentor visit and telephone peer counselling, an in-house information event, an information session for the nursing team and a training session on collegial consultation for the facilitators. The in-house information event will also take place in the nursing homes of the control group. The primary outcome is the residents' participation and activities after 12 months of follow-up as assessed using the PaArticular Scales. The secondary outcome is the residents' quality of life. A cost-effectiveness analysis (costs per additional resident who experienced a decrease of ten points in the participation or activities subscale of the PaArticular Scales) and a cost-utility analysis (costs per additional quality adjusted life year) will be conducted. We will investigate barriers and facilitators in a comprehensive process evaluation.

DISCUSSION

We expect a clinically relevant improvement of participation and activities in residents with joint contractures. Our findings will provide important insights regarding participation in the situation of the affected individuals.

TRIAL REGISTRATION

DRKS, DRKS00015185 . Registered on 1 August 2018. Universal Trial Number U1111-1218-1555. Registered on 26 July 2018.

Effect of person-centred care on antipsychotic drug use in nursing homes (EPCentCare): a cluster-randomised controlled trial

BACKGROUND

antipsychotic drugs are regularly prescribed as first-line treatment for neuropsychiatric symptoms in persons with dementia although guidelines clearly prioritise non-pharmacological interventions.

OBJECTIVE

we investigated a person-centred care approach, which has been successfully evaluated in nursing homes in the UK, and adapted it to German conditions.

DESIGN

a 2-armed 12-month cluster-randomised controlled trial.

SETTING

nursing homes in East, North and West Germany.

METHODS

all prescribing physicians from both study arms received medication reviews for individual patients and were offered access to 2 h of continuing medical education. Nursing homes in the intervention group received educational interventions on person-centred care and a continuous supervision programme. Primary outcome: proportion of residents receiving at least one antipsychotic prescription after 12 months of follow-up. Secondary outcomes: quality of life, agitated behaviour, falls and fall-related medical attention, a health economics evaluation and a process evaluation.

RESULTS

the study was conducted in 37 nursing homes with n = 1,153 residents (intervention group: n = 493; control group: n = 660). The proportion of residents with at least one antipsychotic medication changed after 12 months from 44.6% to 44.8% in the intervention group and from 39.8 to 33.3% in the control group. After 12 months, the difference in the prevalence was 11.4% between the intervention and control groups (95% confidence interval: 0.9-21.9; P = 0.033); odds ratio: 1.621 (95% confidence interval: 1.038-2.532).

CONCLUSIONS

the implementation of a proven person-centred care approach adapted to national conditions did not reduce antipsychotic prescriptions in German nursing homes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02295462.

Implementation of a multicomponent intervention to prevent physical restraints in nursing homes (IMPRINT): A pragmatic cluster randomized controlled trial

BACKGROUND

Despite clear evidence for the lack of effectiveness and safety, physical restraints are frequently applied in nursing homes. Multicomponent interventions addressing nurses' attitudes and organizational culture have been effective in reducing physical restraints.

OBJECTIVE

To evaluate the effectiveness of two versions of a guideline and theory-based multicomponent intervention to reduce physical restraints in nursing homes.

DESIGN

Pragmatic cluster randomized controlled trial.

SETTING

The study was conducted in 120 nursing homes in four regions in Germany.

PARTICIPANTS

All residents living in the participating nursing home during follow-up, newly admitted residents were also included. A total of 12,245 residents included in the primary analysis (4126 and 3547 residents in intervention group 1 and 2 and 4572 residents in the control group).

METHODS

Intervention group 1 received an updated version of a successfully tested guideline-based multicomponent intervention (comprising brief education for the nursing staff, intensive training of nominated key nurses in each cluster, introduction of a least-restraint policy and supportive material), intervention group 2 received a concise version of the original program and the control group received optimized usual care (i.e. supportive materials only). Primary outcome was physical restraint prevalence at twelve months, assessed through direct observation by blinded investigators. Intervention and control groups were compared using baseline-adjusted linear regression on cluster level, Bonferroni-adjusted for double testing. Secondary outcomes included falls, fall-related fractures, and quality of life. We also described intervention costs and performed a comprehensive process analysis.

RESULTS

At baseline, mean physical restraint prevalence was 17.4% and 19.6% in intervention groups 1 and 2, and 18.8% in the control group. After twelve months, mean prevalence was 14.6%, 15.7%, and 17.6%. Baseline-adjusted differences between mean prevalences were 2.0% (97.5% CI, -5.8 to 1.9) lower in intervention group 1 and 2.5% (97.5% CI, -6.4 to 1.4) lower in intervention group 2 compared to controls. Physical restraint prevalence showed a pronounced variation between the different clusters in all study groups. We found no significant differences in the secondary outcomes. According to the process evaluation, the intervention was mainly implemented as planned, but the expected change towards a least restraint culture of care was not achieved in all clusters.

CONCLUSIONS

Neither intervention showed a clear advantage compared to control. The pronounced center variation in physical restraint prevalence indicates that other approaches like governmental policies are needed to sustainably change physical restraint practice and reduce center variations in nursing homes.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT02341898.

Item distribution and inter-rater reliability of the German version of the quality of life in Alzheimer's disease scale (QoL-AD) proxy for people with dementia living in nursing homes

Background

The Quality of Life in Alzheimer’s disease scale (QoL-AD) is a widely used Health Related Quality of Life (HRQoL) instrument. However, studies investigating the instrument’s inter-rater reliability (IRR) are missing. This study aimed to determine the item distribution and IRR of the German proxy version of the QoL-AD (13 Items) and a nursing home-specific instrument version (QoL-AD NH, 15 Items).

Methods

The instruments were applied to 73 people with dementia living in eight nursing homes in Germany. Individuals with dementia were assessed two times by blinded proxy raters. The IRR analyses were based on methodological criteria of the quality appraisal tool for studies of diagnostic reliability (QAREL), the COSMIN group and the single-measure Intra-Class Correlation Coefficient (ICC) for absolute agreement ≥0.70.

Results

All items for both instrument versions demonstrated acceptable item difficulty, with the exception of one item (QoL-AD proxy). The IRR was moderate for the QoL-AD (ICC: 0.65) and insufficient for the QoL-AD NH (ICC: 0.18). The additional computation of the average measure ICC for two proxy-raters demonstrated a strong IRR (ICC: 0.79) for the QoL-AD and a weak IRR for the QoL-AD NH (ICC: 0.31). The detailed analysis of the IRR for each item underpinned the need for the further development of both instruments.

Conclusions

The unsatisfactory IRRs for both instruments highlight the need for the development of a user guide including general instructions for instrument application as well as definitions and examples reflecting item meaning. Priority should be given to the development of reliable proxy-person versions of both instruments.

Trial registration

ClinicalTrials.gov: NCT02295462, Date of registration: 11–20-2014.

[Standardised pain assessment in cognitively impaired nursing home residents: Comparing the use of assessment tools in dementia care units and in integrated care units]

BACKGROUND

A large number of nursing home residents with cognitive impairments (CI) suffer from chronic pain, which is also discussed as a reason for challenging behavior. To assess pain in people with severe CI, the use of an observational pain instrument is recommended; for people without or with mild CI the gold standard is a self-rating instrument. It is unknown whether in German nursing homes pain assessment in residents with severe CI is actually conducted using observational instruments and which instruments are used. Because of different resident structure we assume that in dementia care units observational pain instruments are more often used than in integrated care units. The aim of this study was to investigate the conduction of pain assessments and the instruments used in both types of care units.

METHODS

We conducted an observational study based on standardized data collection. A questionnaire was used to elicit whether pain assessment had been performed and what kind of instrument had been used last time. The cognitive status was also assessed. Based on these data, we determined for each resident whether a self- or proxy-rating instrument had been applied, considering his or her cognitive status. Afterwards, the resident data were aggregated on a care unit level. The use of single instruments was calculated in percentages. Differences between dementia care units and integrated care units were investigated with descriptive statistics and an independent t-test. A mixed-effects binary regression model was used to adjust for cluster effects.

RESULTS

The analysis sample consisted of n = 1,397 participating residents living in n = 75 care units (n = 30 dementia care units; n = 45 integrated care units). In the dementia care units, a mean of 82 % of residents with severe cognitive impairments was assessed using an observational proxy-rating assessment instrument; in the traditional integrated care units a percentage of 42 % was calculated. In the dementia care units, the median percentage of residents with severe cognitive impairments who were assessed with a self-rating instrument was below 10 %; in integrated care units it was 51 %. The differences were statistically significant. A mixed regression model confirmed the results. In the majority of dementia care units a single pain assessment tool was used for all residents; in 18 of 30 dementia care units this was a proxy-rated observational instrument.

DISCUSSION

The results indicate that pain assessment in cognitively impaired patients is suboptimal in many integrated care units because the nurses use inappropriate instruments. Also, they confirm the results of previous studies by demonstrating that instruments are used in clinical practice that are not recommended because their German-language versions are not validated. Since valid pain assessment is a prerequisite to appropriate pain treatment, we may assume that in many residents this is also not carried out as recommended.

PRACTICAL IMPLICATIONS

Especially in integrated units, a defined and consented method of pain assessment is important because of the differences in their residents' cognitive and verbal abilities. Appropriate education may help to improve this process.

Effect of training and structured medication review on medication appropriateness in nursing home residents and on cooperation between health care professionals: the InTherAKT study protocol

BACKGROUND

Pharmacotherapy in residents of nursing homes is critical due to the special vulnerability of this population. Medical care and interprofessional communication in nursing homes are often uncoordinated. As a consequence, polypharmacy and inappropriate medication use are common and may lead to hospitalizations and health hazards. The aim of this study is to optimize communication between the involved professional groups by specific training and by establishing a structured medication review process, and to improve medication appropriateness and patient-relevant health outcomes for residents of nursing homes.

METHODS/DESIGN

The trial is designed as single-arm study. It involves 300 nursing home residents aged ≥ 65 years and the members of the different professional groups practising in nursing home care (15-20 general practitioners, nurses, pharmacists). The intervention consists of interprofessional education on safe medication use in geriatric patients, and a systematic interprofessional therapy check (recording, reviewing and adapting the medication of the participating residents by means of a specific online platform). The intervention period is divided into two phases; total project period is 3 years. Primary outcome measure is the change in medication appropriateness according to the Medication Appropriateness Index. Secondary outcomes are cognitive performance, occurrence of delirium, agitation, tendency of falls, total number of drugs, number of potentially dangerous drug-drug interactions and appropriateness of recorded analgesic therapy regimens according to the Medication Appropriateness Index. Data are collected at t0 (before the start of the intervention), t1 (after the first intervention period) and t2 (after the second intervention period). Cooperation and communication between the professional groups are investigated twice by qualitative interviews.

DISCUSSION

The project aims to establish a structured system for monitoring of drug therapy in nursing home residents. The newly developed online platform is designed to systematize and to improve the communication between the professional groups and, thus, to enhance quality and safety of drug therapy. Limitations of the study are the lack of a control group and the non-randomly recruited study sample.

TRIAL REGISTRATION

DRKS Data Management, DRKS-ID: DRKS00007900.

A new look at nursing home residents' depressive symptoms: the role of basic versus expanded everyday competence

BACKGROUND

Depressive symptoms are highly prevalent in nursing home (NH) residents. The relationship between depressive symptoms and everyday competence in terms of basic (BaCo) and expanded everyday competence (ExCo; see Baltes et al., 2001) in the NH setting is, however, not clear. Applying Lewinsohn's depression model, we examined how residents' BaCo and ExCo relate to their depressive symptoms. Furthermore, we investigated the mediating role of perceived control.

METHODS

Cross-sectional data from 196 residents (M age = 83.7 years, SD = 9.4 years) of two German NHs were analyzed. Study variables were assessed by the Geriatric Depression Scale-Residential (GDS-12R), maximal gait speed (BaCo), proxy ratings of residents' in-home activity participation, and self-initiated social contact done by staff (ExCo). Structural equation modeling (SEM) was used and a simulation study was included to determine power and potential estimation bias.

RESULTS

At the descriptive level, one quarter of the residents showed symptoms of depression according to the GDS-12R cut-off criterion. Residents' BaCo and ExCo were independently and equally strongly associated with their depressive symptoms in the SEM analysis. These findings were affected neither by cognitive impairment, sex, nor age. Perceived control mediated between BaCo but not ExCo and depressive symptoms.

CONCLUSION

Future research needs to follow the connection between residents' everyday competence and their depressive symptoms longitudinally to better understand the underlying mechanisms.

The PaArticular Scales - A new outcome measure to quantify the impact of joint contractures on activities and participation in individuals in geriatric care: Development and Rasch analysis

BACKGROUND

Joint contractures are frequent conditions in individuals in geriatric care settings and are associated with activity limitations and participation restrictions. As such, relevant intervention programs should address these aspects, and the effectiveness of such programs should be determined by assessing improvement in activities and participation. However, no patient-centred and psychometrically sound outcome measures for this purpose are available so far.

OBJECTIVES

The objectives of this study were to develop and to validate a new outcome measure, the PaArticular Scales, to quantify activities and participation in older individuals with joint contractures. Specific aims were (A) to operationalize the content of an International Classification of Functioning, Disability and Health-based standard set towards meaningful questions and to combine them to a questionnaire and (B) to assess the psychometric properties of the developed questionnaire, in detail to evaluate test-retest reliability, objectivity, internal consistency reliability and criterion validity.

DESIGN

Operationalization was reached by an expert consensus conference and a subsequent expert Delphi survey. Psychometric properties were assessed in a cross-sectional study.

SETTINGS

Nursing homes, geriatric rehabilitation facilities.

PARTICIPANTS

23 experts (nurses, physicians, physical and occupational therapists) participated in the consensus conference and the Delphi survey. A total of 191 individuals with joint contractures (as confirmed by physician, nurse or physical therapist) between 65 and 102 years, living in nursing homes or as patients in geriatric rehabilitation were enrolled in the cross-sectional study.

METHODS

Rasch Partial Credit Modelling.

RESULTS

The consensus conference and Delphi survey resulted in a questionnaire with 86 items of the International Classification of Functioning, Disability and Health. Test-retest-reliability among those was acceptable (Cohen's weighted kappa: 0.779). The Rasch analysis revealed two independent interval-scaled scales with 24 items for the Activities scale and 11 items for the Participation scale with high internal consistency reliability. Cronbach's alpha was 0.96 for the Activities scale and 0.92 for the Participation scale. Criterion validity was -0.40 and -0.30 for the Activities scale and for the Participation scale, respectively.

CONCLUSIONS

The PaArticular Scales, a new patient-centred and psychometric sound outcome measures to comprehensively assess the impact of joint contractures in geriatric care, are available now. These developed scales will serve as primary outcomes in a scheduled evaluation of a complex intervention to improve participation and quality of life in nursing home residents with joint contractures.

People with dementia in nursing home research: a methodological review of the definition and identification of the study population

Background

There are various definitions and diagnostic criteria for dementia, leading to discrepancies in case ascertainment in both clinical practice and research. We reviewed the different definitions, approaches and measurements used to operationalize dementia in health care studies in German nursing homes with the aim of discussing the implications of different approaches.

Methods

We conducted a systematic search of the MEDLINE and CINAHL databases to identify pre-2016 studies conducted in German nursing homes that focused on residents with dementia or cognitive impairment. In- or exclusion of studies were consented by all authors; data extraction was independently carried out by 2 authors (RP, SJ). The studies’ sampling methods were compared with respect to their inclusion criteria, assessment tools and methods used to identify the study population.

Results

We summarized case ascertainment methods from 64 studies. Study participants were identified based on a diagnosis that was evaluated during the study, or a recorded medical dementia diagnosis, or a recorded medical diagnosis either with additional cognitive screenings or using screening tests exclusively. The descriptions of the diagnostics that were applied to assess a diagnosis of dementia were not fully transparent in most of the studies with respect to either a clear reference definition of dementia or applied diagnostic criteria. If reported, various neuropsychological tests were used, mostly without a clear rationale for their selection.

Conclusion

Pragmatic considerations often determine the sampling strategy; they also may explain the variances we detected in the different studies. Variations in sampling methods impede the comparability of study results. There is a need to consent case ascertainment strategies in dementia studies in health service research in nursing homes. These strategies should consider resource constraints and ethical issues that are related to the vulnerable population of nursing home residents. Additionally, reporting about dementia studies in nursing homes need to be improved. If a diagnosis cannot be evaluated based on either ICD or DSM criteria, the study population may not be reported as having dementia. If a diagnosis is evaluated based on ICD or DSM criteria within the study, there is a need for more transparency of the diagnostic process.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0249-7) contains supplementary material, which is available to authorized users.

Differences in Case Conferences in Dementia Specific vs Traditional Care Units in German Nursing Homes: Results from a Cross-Sectional Study

OBJECTIVES

To investigate differences in the provision and performance of case conferences for people with dementia between dementia special care units (DSCUs) and traditional care units (TCUs) in nursing homes. Because DSCUs employ more staff, we expect the likelihood of the provision of case conferences to be higher in DSCUs.

DESIGN

Observational cross-sectional study. Residents from DSCUs and TCUs were compared using genetic propensity score matching over all of the observed potential covariates, including the characteristics that served as admission criteria for DSCUs. Because of the multisite structure of the data, clustering was accounted for with a generalized mixed model.

SETTING

DSCUs are defined as units within nursing homes that offer care exclusively to residents with dementia and that charge higher rates for the specialized care provided. TCUs are defined as care units for residents with and without dementia.

PARTICIPANTS

A matched sample was drawn out of a convenience sample of 1808 residents from 51 nursing homes. It consisted of 264 residents from 16 DSCUs and 264 residents from 48 TCUs.

INTERVENTIONS

None.

MEASUREMENTS

Data regarding the provision of case conferences were collected by the nurses using the Dementia Care Questionnaire. Other collected data included challenging behavior (Neuropsychiatric Inventory Questionnaire), mobility (Physical Self-Maintenance Scale), cognitive impairment (Dementia Screening Scale), and sociodemographic information.

RESULTS

In the DSCU group, case conferences were provided to 91% (n = 224) of the residents; in the TCU group, 82.5% (n = 203) received a case conference. After adjusting for clustering, no significant difference between DSCUs and non-DSCUs was found. The topic "challenging behaviors" was discussed more often in case conferences in TCUs.

CONCLUSIONS

Case conferences are a widespread intervention in German nursing homes, including both DSCUs and TCUs. The provision of a case conference is not a special feature of DSCUs.

Implementation of a Multicomponent intervention to Prevent Physical Restraints In Nursing home residenTs (IMPRINT): study protocol for a cluster-randomised controlled trial

BACKGROUND

Physical restraints such as bedrails and belts are regularly applied in German nursing homes despite clear evidence showing their lack of effectiveness and safety. In a cluster-randomised controlled trial, the efficacy and safety of a guideline-based multicomponent intervention programme has been proven. The present study aims to evaluate the effectiveness of two different versions of the original intervention in nursing home residents in four different regions throughout Germany.

METHODS/DESIGN

The study is a pragmatic cluster-randomised controlled trial comparing two intervention groups, i.e. (1) the updated original multicomponent intervention programme and (2) the concise version of the updated programme, with a control group receiving optimised usual care. The first intervention group receives an educational programme for all nurses, additional training and structured support for nominated key nurses, printed study material and other supportive material. In the second intervention group, nurses do not receive education as part of the intervention, but may be trained by nominated key nurses who have received a short train-the-trainer module. All other components are similar to the first intervention group. The control group receives the printed study material only. Overall, 120 nursing homes including approximately 10,800 residents will be recruited and randomly assigned to one of the three groups. The primary outcome is defined as the proportion of residents with at least one physical restraint after 12 months follow-up. The use of physical restraints will be assessed by direct observation. Secondary outcomes are the residents' quality of life and safety parameters, e.g. falls and fall-related fractures. In addition, comprehensive process and economic evaluations will be performed.

CONCLUSIONS

We expect a clinically relevant reduction in the proportion of residents with physical restraints. It is also expected that the process outcomes of this trial will enrich the knowledge about facilitators and barriers for the implementation of the multicomponent intervention programme.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02341898.

Effect of person-centred care on antipsychotic drug use in nursing homes (EPCentCare): study protocol for a cluster-randomised controlled trial

Background

The majority of nursing home residents with dementia experience behavioural and psychological symptoms like apathy, agitation, and anxiety. According to analyses of prescription prevalence in Germany, antipsychotic drugs are regularly prescribed as first-line treatment of neuropsychiatric symptoms in persons with dementia, although guidelines clearly prioritise non-pharmacological interventions. Frequently, antipsychotic drugs are prescribed for inappropriate reasons and for too long without regular reviewing. The use of antipsychotics is associated with adverse events like increased risk of falling, stroke, and mortality. The aim of the study is to investigate whether a person-centred care approach, successfully evaluated in nursing homes in the United Kingdom, can be implemented in German nursing homes and, in comparison with a control group, can result in a clinically relevant reduction of the proportion of residents with antipsychotic prescriptions.

Methods/design

The study is a cluster-randomised controlled trial comparing an intervention group (two-day initial training on person-centred care and ongoing training and support programme) with a control group. Both study groups will receive, as optimised usual care, a medication review by an experienced psychiatrist/geriatrician providing feedback to the prescribing physician. Overall, 36 nursing homes in East, North, and West Germany will be randomised. The primary outcome is the proportion of residents receiving at least one antipsychotic prescription (long-term medication) after 12 months of follow-up. Secondary outcomes are residents’ quality of life, agitated behaviour, as well as safety parameters like falls and fall-related medical attention. A health economic evaluation and a process evaluation will be performed alongside the study.

Discussion

To improve care, a reduction of the current high prescription rate of antipsychotics in nursing homes by the intervention programme is expected.

Trial registration

ClinicalTrials.gov: NCT02295462

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0268-3) contains supplementary material, which is available to authorized users.

Assessing the effect of a physical activity intervention in a nursing home ecology: a natural lab approach

Background

Physical activity (PA) is not only an important marker of physical impairment, but also a pathway to improve quality of life and enhance cognitive and social functioning of old individuals. Yet, making interventional use of PA training as a means for prevention and enhancement of quality of life of nursing home residents has found very limited attention worldwide so far. That said, the project ‘Long-term Care in Motion’ (LTCMo) as a part of the INNOVAGE consortium (funded by the European Commission) has the following aims: Overall: Install and assess a socially innovative intervention in the nursing home ecology. Concrete: (a) Conceptualization of a multidimensional intervention program (resident and staff oriented) with the potential to promote PA in nursing home residents; (b) Mixed-methods assessment of the program based on automated recording as well as questionnaire data.

Methods/Design

LTCMo’s PA-related intervention has several components which are applied in parallel manner: (1) Residents are engaged in a physical exercise program that is based on multiple approaches: supervised group sessions, a serious games approach, and specific training in severely impaired persons; (2) Staff members will receive a competence training with a focus on PA motivation and facilitation of residents’ PA engagement. Primary outcome assessment (movement-related behavior of residents) is completely conducted by means of automated data collection strategies (accelerometer-based activity recording, sensor-based life space recording). This is enriched by a broad range of secondary outcomes (e.g., cognitive performance, depression of residents; behavioral and attitudinal components of staff). Pre-, post- and 3-month follow-up assessment will take place in the target intervention setting as well as in a waiting control condition in which we will also replicate the training and its assessment in a later step.

Discussion

Although we are faced with methodological challenges (e.g., rather small sample size; no randomized control trial), we believe that our approach has something to offer and indeed has some unique characteristics that may have the potential to contribute to the enhancement of nursing home residents’ quality of life and at the same time further PA-related research with vulnerable populations at large.

Trial registration

Current Controlled Trials ISRCTN96090441. Registered 31 July 2014.

Structural characteristics of specialised living units for people with dementia: a cross-sectional study in German nursing homes

Background

Living units (LU) specialised for people with dementia are an important feature of nursing homes. Little is known about their structural characteristics, and an international definition is lacking. This study explored characteristics of the environment and staff from defined LU types to identify differences between them.

Design

Cross-sectional study comparing five types of LUs. LUs were defined based on their living concept (segregated and integrated), size (small and large scale), and funding (extra funded and not extra funded). Differences were identified using descriptive statistics, Chi-Square resp. Kruskal-Wallis-Test and post-hoc analysis with Bonferroni corrections.

Results

In total, 103 LUs from 51 nursing homes participated: 63 integrated and 40 segregated LUs; 48 integrated and 31 segregated LUs were large. Sixteen large segregated LUs were extra funded. Regarding the environment, a distinctive feature of small LUs was a higher percentage of single rooms. Small integrated LUs provided and served meals more in a homelike manner than other LUs. LUs did not differ in their interior and access for the residents to use outdoor areas. Regarding the staff, small LUs provided more staff, but they were not exclusively assigned to the LUs. Large segregated LUs with additional funding provided more registered nurses and nurses with a special qualification per resident than the other large LUs.

Conclusion

Nursing homes implemented different features in their specialised LUs. Because single room availability, homelike provision of meals, staff quantity, quality and continuity may influence residents’ outcomes, it is necessary to investigate whether differences are apparent in future evaluation studies of specialised LUs for people with dementia.

Association of diagnostic delay with impairment severity among institutional care facility residents diagnosed with dementia in Ontario, Canada

AIM

To compare the levels of cognitive function at the time of diagnosis among institutional care facility residents with dementia, who were diagnosed either before or after admission to a facility in Ontario, Canada.

METHODS

The study utilized a population-based secondary data analysis approach, using data from the Canadian Institute for Health Information's Continuing Care Reporting System from 2009 to 2011. Cognitive function within 30 days of diagnosis was measured by a seven-point cognitive performance scale (CPS) - 0 (intact) to 6 (very severe impairment).

RESULTS

Data were extracted from 39633 institutional care facility residents who had a diagnosis of dementia on record. The average CPS score was higher for residents whose diagnosis was made after admission to a facility than for residents whose diagnosis was made before admission (3.1 vs 2.9, P=0.009). The proportion of diagnosis at CPS ≥ 4 (moderately severe to very severe impairment) was also higher in the diagnosis after admission group (29.7% vs 24.6%, P=0.001). Multivariable analysis showed that diagnoses made after admission were more likely to be at a severe stage of cognitive decline (CPS ≥ 4) than diagnoses made before admission (adjusted odds ratio 1.49, P=0.001). A similar result was also noted when comparison was made between mild and moderate-to-severe stages of cognitive decline. After admission diagnoses were more likely to be at moderate-to-severe stages of cognitive decline (CPS ≥ 3) than before admission diagnoses (adjusted odds ratio 1.70, P=0.001).

CONCLUSION

Our findings suggest that dementia diagnoses after admission to institutional care facilities are more likely to be made at poorer stages of cognitive function decline.

Longitudinal evaluation of dementia care in German nursing homes: the "DemenzMonitor" study protocol

BACKGROUND

In Germany, the number of people with dementia living in nursing homes is rapidly increasing. Providing adequate care for their special needs is a challenge for institutions and their staff members. Because of the growing number of people with dementia, changes to the conceptual orientation of nursing homes have occurred. These changes include specialized living arrangements and psychosocial interventions recommended for people with dementia. Until now, the provision of dementia care and its association to the residents' behavior and quality of life is not well investigated in Germany. The purpose of this study is to describe the provision of dementia care and to identify resident- as well as facility-related factors associated with residents behavior and quality of life.

METHODS/DESIGN

The DemenzMonitor study is designed as a longitudinal study that is repeated annually. Data will be derived from a convenience sample consisting of nursing homes across Germany. For the data collection, three questionnaires have been developed that measure information on the level of the nursing home, the living units, and the residents. Data collection will be performed by staff members from the nursing homes. The data collection procedure will be supervised by a study coordinator who is trained by the research team. Data analysis will be performed on each data level using appropriate techniques for descriptions and comparisons as well as longitudinal regression analysis.

DISCUSSION

The DemenzMonitor is the first study in Germany that assesses how dementia care is provided in nursing homes with respect to living arrangements and recommended interventions. This study links the acquired data with residents' outcome measurements, making it possible to evaluate different aspects and concepts of care.

Prevalence and associations of potentially inappropriate prescriptions in Austrian nursing home residents: secondary analysis of a cross-sectional study

BACKGROUND

Potentially inappropriate prescriptions (PIP) are an important cause of adverse medication-related events and increases morbidity, hospitalization, and health care costs, especially in nursing home residents. However, little is known about the associations between PIP and residents' characteristics.

OBJECTIVE

The aim of our study was to analyse the prevalence and associations of PIP with residents' and facilities' characteristics.

METHODS

We performed a secondary analysis of a cross-sectional study with 48 out of 50 eligible nursing homes and 1,844 out of 2,005 eligible residents in a defined rural-urban area in Austria. The Austrian list of potentially inappropriate medications was applied for the evaluation of inappropriate prescribing. Cluster-adjusted multiple regression analysis was used to investigate institutional and residents' characteristics associated with PIP.

RESULTS

Mean cluster-adjusted prevalence of residents with at least one PIP was 70.3 % (95 % CI 67.2-73.4). The number of residents with at least one psychotropic PIP was 1.014 (55 %). The most often prescribed PIP were Prothipendyl (25.9 % residents), Lorazepam (14.5 %) and Diclofenac (6.1 %). Multiple regression analysis showed an inverse association of PIP with cognitive impairment and significant positive associations with permanent restlessness and permanent negative attitude. The associations of PIP with age and male gender were inconsistent. No significant associations were found for PIP and the ratio of staff nurses to residents.

CONCLUSIONS

Our study results confirm that PIP is highly prevalent in the nursing home population. These results urgently call for effective interventions. Initiatives and successful interventions performed in other countries could serve as examples for safer prescribing in residents in Austria.

Resident-to-resident aggression in nursing homes: results from a qualitative event reconstruction study

PURPOSE

Despite its prevalence and negative consequences, research on elder abuse has rarely considered resident-to-resident aggression (RRA) in nursing homes. This study employed a qualitative event reconstruction methodology to identify the major forms of RRA that occur in nursing homes.

DESIGN AND METHODS

Events of RRA were identified within a 2-week period in all units (n = 53) in nursing homes located in New York City. Narrative reconstructions were created for each event based on information from residents and staff who were involved as well as other sources. The event reconstructions were analyzed using qualitative methods to identify common features of RRA events.

RESULTS

Analysis of the 122 event reconstructions identified 13 major forms of RRA, grouped under five themes. The resulting framework demonstrated the heterogeneity of types of RRA, the importance of considering personal, environmental, and triggering factors, and the potential emotional and physical harm to residents.

IMPLICATIONS

These results suggest the need for person-centered and environmental interventions to reduce RRA, as well as for further research on the topic.

Prevalence of psychotropic medication use among German and Austrian nursing home residents: a comparison of 3 cohorts

BACKGROUND

Despite increasing knowledge about the limited effectiveness and severe adverse effects, the prescription rate of psychotropic medications in frail elderly persons remains high. Prescriptions are mainly made to control behavioral and psychological symptoms of dementia, although factors associated with prescriptions are rarely reported. However, such information is a prerequisite to develop intervention programs aiming to safely reduce psychotropic medication in nursing home residents.

METHODS

We report the comparison of cross-sectional data of psychotropic medication prescription rates from 3 large studies including nursing home residents in Germany and Austria. We aimed to compare the prevalence of (1) psychotropic medication, (2) different classes of psychotropic medication, (3) psychotropic medication administered for bedtime use, and (4) associations between prescription of psychotropics and institutional and residents' characteristics. Confidence intervals of prevalences and multiple logistic regression analyses were adjusted for cluster correlation.

RESULTS

Data from 5336 residents in 136 long term care facilities were included. In Austria, 74.6% (95% CI 72.0-77.2%) of all residents had a prescription of at least one psychotropic medication compared to Germany with about 51.8% (95% CI 48.3-55.2%) and 52.4% (95% CI 48.7-56.1%). Of all antipsychotics, 66% (Austria) and 47% (Germany) were prescribed for bedtime use. Most prescriptions were conventional, low-potency antipsychotics. In all 3 studies, there was no statistically significant association between psychotropic medication prescription and nursing home characteristics. On the level of residents, consistent positive associations were found for higher level of care dependency and permanent restlessness. Consistent negative associations were found for older age and male gender.

CONCLUSION

Frequency of psychotropic and especially antipsychotic medication is substantial in nursing home residents in Germany and Austria. The high number of prescriptions is likely to be an indicator for a perceived or actual lack of strategies to handle behavioral and psychological symptoms of dementia.

Evaluation of special and traditional dementia care in nursing homes: results from a cross-sectional study in Germany

OBJECTIVE

Two-thirds of all residents in nursing homes in Germany suffer from some type of dementia. We investigated whether or not dementia patients receiving special (segregated or partially segregated) care exhibited a better quality of life than their counterparts residing in traditional nursing homes.

METHODS

In a cross-sectional study in 28 special dementia care facilities in the city of Hamburg (admission criterion: mobile dementia patients with behaviour problems) 594 residents were compared to a group of nursing home residents with dementia (n = 573) in 11 randomly selected nursing homes who were receiving traditional integrative care. Primary features such as cognitive and functional impairment, and behaviour problems were assessed by qualified nursing staff.

RESULTS

Controlling for confounding variables, for dementia patients in special care units as compared to a reference group in traditional integrative care, the level of volunteer caregiver involvement was higher and there was more social contact to staff, fewer physical restraints, more involvement in home activities, and more frequent use of psychiatrists. There was no significant difference between the two care settings with regard to overall use of psychotropic drugs, however, residents in special dementia care used antipsychotics significantly less often and antidepressants more often.

CONCLUSIONS

Significant differences for a number of indicators of the quality of life point in favour of special dementia care. Future evaluation studies ought to examine not only the general efficacy of types of care designed especially for dementia patients but also the efficacy of the respective individual components (i.e. caregiver ratio).

The Mini Mental State Examination: Review of cutoff points adjusted for schooling in a large Southern Brazilian sample

The increase in life expectancy can influence the prevalence of dementias in the population. Instruments that evaluate cognitive functions such as the Mini Mental State Examination (MMSE) are necessary for the investigation of dementia. The supposition that patient score on the MMSE can be influenced by academic level points to the need for establishing cut-off values that take into account educational level. The aim of this study was to review MMSE cut-off values adjusted for schooling in a large southern Brazilian sample.

Method

Demographic data and MMSE scores of 968 subjects, of which 162 were dementia patients and 806 healthy participants, were analyzed. The sample was grouped according to education. The cut-off values were established by ROC Curve analysis.

Results

The total sample mean age was 70.6±7.3 years, and the mean years of education was 7.2±5.3. The cut-off score of 23 points (sensitivity=86%, specificity=83%) was observed as the optimal level to detect dementia on the MMSE instrument for the overall sample. Regarding level of schooling, the cut-off values were: 21 for the illiterate group (sensitivity=93%, specificity=82%), 22 for the low education group (sensitivity=87%, specificity=82%), 23 for the middle education group (sensitivity=86%, specificity=87%) and 24 for the high education group (sensitivity=81%, specificity=87%).

Conclusions

The cut-off values revealed by this analysis, and adjusted for level of schooling, can improve the clinical evaluation of cognitive deficits.

Comparison of a fall risk assessment tool with nurses' judgement alone: a cluster-randomised controlled trial

BACKGROUND

the impact of fall risk assessment tools on clinical endpoints is unknown.

OBJECTIVE

we compared a standardised fall risk assessment tool alongside nurses' clinical judgement with nurses' judgement alone.

DESIGN

a 12-month cluster-randomised controlled trial.

SETTING

nursing homes in Hamburg (29 per study group).

SUBJECTS

1,125 residents (n = 574 intervention group, IG; n = 551 control group, CG).

INTERVENTIONS

all homes received structured information on fall prevention before randomisation. The IG monthly administered the Downton Index, and the CG did not use a tool. Measurements were number of participants with at least one fall, falls, fall-related injuries and medical attention, fall preventive measures, physical restraints.

RESULTS

the mean follow-up was 10.8 +/- 2.9 months in both groups: 105 (IG) and 114 (CG) residents died or moved away. There was no difference between the groups concerning the number of residents with at least one fall (IG: 52%, CG: 53%, mean difference -0.7, 95% confidence interval -10.3 to 8.9, P = 0.88) and the number of falls (n = 1,016 and n = 1,014). All other outcomes were also comparable between the IG and CG.

CONCLUSIONS

application of a fall risk assessment tool in nursing homes does not result in the better clinical outcome than reliance on nurses' clinical judgement alone.

Psychotropic medication use among nursing home residents in Austria: a cross-sectional study

Background

The use of psychotropic medications and their adverse effects in frail elderly has been debated extensively. However, recent data from European studies show that these drugs are still frequently prescribed in nursing home residents. In Austria, prevalence data are lacking. We aimed to determine the prevalence of psychotropic medication prescription in Austrian nursing homes and to explore characteristics associated with their prescription.

Methods

Cross-sectional study and association analysis in forty-eight out of 50 nursing homes with 1844 out of a total of 2005 residents in a defined urban-rural region in Austria. Prescribed medication was retrieved from residents' charts. Psychotropic medications were coded according to the Anatomical Therapeutic Chemical Classification 2005. Cluster-adjusted multiple logistic regression analysis was performed to investigate institutional and residents' characteristics associated with prescription.

Results

Residents' mean age was 81; 73% of residents were female. Mean cluster-adjusted prevalence of residents with at least one psychotropic medication was 74.6% (95% confidence interval, CI, 72.0–77.2). A total of 45.9% (95% CI 42.7–49.1) had at least one prescription of an antipsychotic medication. Two third of all antipsychotic medications were prescribed for bedtime use only. Anxiolytics were prescribed in 22.2% (95% CI 20.0–24.5), hypnotics in 13.3% (95% CI 11.3–15.4), and antidepressants in 36.8% (95% CI 34.1–39.6) of residents. None of the institutional characteristics and only few residents' characteristics were significantly associated with psychotropic medication prescription. Permanent restlessness was positively associated with psychotropic medication prescription (AOR 1.54, 95% CI 1.32–1.79) whereas cognitive impairment was inversely associated (AOR 0.70, 95% CI 0.56–0.88).

Conclusion

Frequency of psychotropic medication prescription is high in Austrian nursing homes compared to recent published data from other countries. Interventions should aim at reduction and optimisation of prescriptions.