Is dementia special care really special? A new look at an old question

Dementia, nurse staffing, and health outcomes in nursing homes

OBJECTIVE

To estimate and contrast the relationships between nurse staffing and health outcomes in nursing homes with low and high dementia census, to understand the association of staffing hours with dementia care quality.

DATA SOURCES AND STUDY SETTING

A national sample of nursing homes during 2017-2019 (pre-COVID). Data included the Payroll-Based Journal, Medicare Claims, Nursing Home Care Compare, and Long-Term Care Focus.

STUDY DESIGN

Retrospective, regression analyses. We estimated separate linear models predicting six long-term facility-level outcomes. Independent variables included staffing hours per resident-day (HPRD) interacted with the facility percentage of dementia residents, controlling for other resident and facility characteristics.

DATA COLLECTION/EXTRACTION METHODS

Hospital-based nursing homes, those with fewer than 30% dementia residents, and missing data were excluded.

PRINCIPAL FINDINGS

We found that registered nurses and certified nurse assistants HPRDs were likely to exhibit positive returns in terms of outcomes throughout most of the range of HPRD for both high and low-census dementia facilities, although, high- and low-dementia facilities differed in most outcome rates at all staffing levels. Average predicted antipsychotics and activities of daily living as functions of HPRD were worse in higher dementia facilities, independent movement, and hospitalizations did not differ significantly, and Emergency Rooms and pressure sores were worse in lower dementia facilities. Average marginal effects were not statistically different [CI included zero] between the high and low dementia facilities for any outcome.

CONCLUSIONS

These findings suggest that increasing staffing will improve outcomes by similar increments in both low- and high-dementia facilities for all outcomes. However, at any given level of staffing, absolute differences in outcomes between low- and high-dementia facilities remain, suggesting that additional staffing alone will not suffice to close these gaps. Further studies are required to identify opportunities for improvement in performance for both low- and high-dementia census facilities.

Dementia Care Is Widespread In US Nursing Homes; Facilities With The Most Dementia Patients May Offer Better Care

More than three million US nursing home residents were diagnosed with Alzheimer's disease and related dementias (ADRD) between 2017 and 2019. This number is expected to increase as the population ages and ADRD prevalence increases. People with ADRD require specialized care from trained staff. This study addressed two questions: Are residents with ADRD concentrated in nursing homes where they are the majority? If not, what are the implications for their quality of care and life? We answered the first question by determining the ADRD census for each nursing home in the country during the period 2017-19. Using the Minimum Data Set and Medicare claims, we compared characteristics of nursing homes with high and low ADRD census along several dimensions, including staffing, resident outcomes, and resident characteristics. We found that residents with ADRD were dispersed throughout all nursing homes, with fewer than half residing in nursing homes where residents with ADRD accounted for 60-90 percent of the census. Furthermore, only facilities exceeding 90 percent of residents with ADRD seemed to offer better care. These findings raise concerns about the quality of care and life for the majority of residents with ADRD, suggesting that current National Institutes of Health dementia research initiatives and the Biden administration's policies to improve nursing home care should be coordinated.

Social Connectedness among Long-Stay Nursing Home Residents with Alzheimer's and Dementia: Exploring Individual and Facility-Level Variation

INTRODUCTION

This study sought to explore individual and facility-level variation in social connectedness among long-stay nursing home residents with Alzheimer's or other dementias (ADRD).

METHODS

We identified 721,074 long-stay residents with ADRD using 2016 Minimum Data Set 3.0 data. Social connectedness was defined using the social connectedness index (SCI) (high: SCI = 5, lower: 0 < SCI ≤ 4). Adjusted odds ratios (aOR) provided estimates of the associations between resident-level and facility-level characteristics, and high SCI was derived from logistic models.

RESULTS

The SCI Cronbach's alpha was 0.69; 78.6% had high SCI scores. Men were less likely than women to have higher SCI scores (aOR = 0.97; 95% CI: 0.97-0.98). Increasing age was associated with higher SCI scores (e.g., aOR [85-94 vs. 40-64 years]: 1.07; 95% CI: 1.06-1.07). Those with moderate cognitive impairment (aOR: 0.87) and severe cognitive impairment (aOR: 0.85) had reduced odds of SCI = 5 relative to those with mild/intact cognitive function. Residents living in homes with special care dementia units and with higher percentage of residents with dementia had decreased odds of high social connectedness.

DISCUSSION/CONCLUSION

Understanding resident- and nursing home-level variation in social connectedness may be important for targeting interventions that reduce isolation among residents with ADRD.

Prevalence and variability in use of physical and chemical restraints in residential aged care facilities: A systematic review and meta-analysis

BACKGROUND

Use of physical and chemical restraints are common in residential aged care facilities worldwide. Restraint use can pose harm to residents even causing deaths.

OBJECTIVE

To synthesize the prevalence and variability in physical and chemical restraint use, and examine factors that may contribute to this variability of prevalence rates.

METHODS

Six health science databases were searched from inception up to 21st January 2020. Quantitative studies investigating restraint use in residential aged care facilities that reported data from year 2000 onwards were included. Meta-analyses of binomial data using a random effect model were performed to pool proportions of physical or chemical restraints with 95% confidence intervals. Univariable meta-regression analyses were used to assess factors that may contribute to the variability in physical and chemical restraint prevalence. Multiple meta-regression analyses were performed where possible to construct models of factors contributing to these variations.

RESULTS

Eighty-five papers were included. The pooled proportion of physical and chemical restraint use in residential aged care facilities were 33% and 32% respectively. Bedrails (44%) and benzodiazepines (42%) were the most prevalent forms of physical and chemical restraint respectively. Studies from North America (lower prevalence) [coefficient (95% CI): -0.15 (-0.27, -0.03)], measurement approaches using direct observation (higher prevalence) [0.17 (0.02, 0.33)] and a combination of multiple measurement approaches (higher prevalence) [0.17 (0.05, 0.29)] explained 25.5% of variability in the prevalence of physical restraint. Multiple meta-regression analyses were not performed to identify factors that may explain the observed variability in chemical restraint prevalence due to the small number of studies with data available.

CONCLUSION

Variability in prevalence of physical restraint could be explained partly by different measurement approaches and geographical regions. Valid and reliable measurement approaches across different regions is required to understand cultural differences due to geographical region effects on the prevalence of physical restraint use.

Variations and factors associated with psychotropic use in cognitively impaired elderly residing in long-term care facilities in East Asia: a cross-sectional study

BACKGROUND

The aim of this cross-sectional study was to compare patterns of psychotropic prescription drug use among cognitively impaired residents in long-term care facilities in East Asia and to explore factors associated with these patterns.

METHODS

This study included elderly participants with cognitive impairments residing in long-term care facilities with and without dementia care units in Japan, South Korea, China, Taiwan, and Thailand. The Mini-Mental State Examination, the Clinical Dementia Rating, and the Neuropsychiatric Inventory, Nursing Home version were used to assess cognitive status, examine dementia severity, and evaluate behavioural psychological symptoms of dementia, respectively. The rate of psychotropic drug use and the relationship between the number of psychotropic drugs and clinical factors were examined.

RESULTS

In total, 662 people were analyzed. Facilities with dementia care units had a higher rate of anti-dementia drug use than regular elderly care sites. Among the three dementia care sites, a Japanese hospital and a Korean site had a high rate of antipsychotic use and use of other types of psychotropics, whereas these drugs were used at a low rate in a Chinese nursing home. Patterns of psychotropic drug use may be partially associated with local regulations and facility type. Poly-pharmacy was identified as a common problem at all study sites.

CONCLUSIONS

Our findings will be beneficial for health-care professionals and policymakers when developing practice guidelines and strategies to regulate overuse of psychotropics and poly-pharmacy. Prospective studies are needed to examine patterns of psychotropic prescriptions and to promote evidence-based practice.

Prevalence of behavioural and psychological symptoms of dementia in cognitively impaired elderly residents of long-term care facilities in East Asia: a cross-sectional study

OBJECTIVE

The aim of this study was to compare the prevalence of behavioural and psychological symptoms of dementia (BPSD) in cognitively impaired elderly residents of long-term care facilities in East Asia and to explore the factors associated with these patterns.

METHODS

This was a cross-sectional survey of BPSD in cognitively impaired elderly residents of long-term care facilities in Japan, South Korea, China, Taiwan, and Thailand. The Mini-Mental State Examination, Clinical Dementia Rating (CDR), and Neuropsychiatric Inventory, Nursing Home version (NPI-NH), were used to assess cognitive status, dementia severity, and BPSD, respectively. NPI-NH subscale severity scores were multiplied by frequency scores to obtain the subscale scores and aggregated into two groups based on score (clinically insignificant = 1- 3; clinically significant ≥4).

RESULTS

Data from 662 people were analyzed. Median age, median Mini-Mental State Examination scores, and median CDR scores differed significantly among the seven study sites. The prevalence of BPSD varied from 64% in Taiwan to 100% in dementia care units in Japan, and the median total NPI-NH scores ranged from 2 in Taiwan to 14 in dementia care units in Japan. After stratification of the sample by dementia severity and clinical significance of NPI-NH scores, differences in the prevalence of clinically significant BPSD were mostly observed among facilities dedicated to dementia patients in the CDR 1 group. In the CDR 3 group, the prevalence of some clinically significant BPSD, such as apathy, was high even among study sites with low median total NPI-NH scores.

CONCLUSIONS

Our findings may suggest referral and selection biases in the study sites. Future prospective studies are needed to address the impact of environmental and care factors on the occurrence of BPSD in Asian countries.

Factors influencing the quality of life perceptions of cognitively impaired older adults in a nursing home and their informal and professional caregivers: a mixed methods study

Background

Identifying the objective and subjective aspects of the quality of life (QoL) of institutionalized cognitively impaired older adults (CIOAs) is a challenge. However, it can reveal which aspects of their care require improvement.

Aim

The aim of this study was to identify the core aspects of the QoL of CIOAs living in a nursing home (NH) by involving informal and professional caregivers (PCs).

Methods

Our sequential, mixed methods study exploring the QoL of CIOAs was based on Lodgson et al’s (2002) quantitative quality of life–Alzheimer’s disease (QoL-AD) questionnaire. Subsequently, a qualitative phase study analyzed perceptions and impressions of QoL using interviews of CIOAs and their most significant informal caregivers (SICs) and PCs.

Results

Fifteen CIOAs, 12 SICs, and 2 PCs were recruited. Two-thirds of the older adults were females, overall average age was 86 years (SD=6.1), and all had a severe clinical dementia rating (CDR=3). A high level of comorbidity (measured using the Cumulative Illness Rating Scale for Geriatrics) was significantly associated with a lower QoL-AD score (P=0.046). Higher numbers of visits by SICs or family members had a positive effect on QoL-AD scores (P=0.036). No significant differences were found in overall QoL-AD scores as rated by CIOAs, SICs, and PCs (P=0.080). Combining quantitative and qualitative data analyses revealed four significant themes influencing the QoL of CIOAs: 1) human dignity and acceptance; 2) development and existence; 3) functionality and health; and 4) recognizability and safety.

Conclusion

Sequentially using mixed methods proved an appropriate way to examine the QoL of severe CIOAs living in an NH, and these results were compared with the perceptions of informal and PCs. The factors optimizing overall health were visits by SICs and family members, and the major aspect that increases the QoL was freedom of movement inside and outside the NH.

Exploring Antipsychotic Prescribing Behaviors for Nursing Home Residents With Dementia: A Qualitative Study

OBJECTIVES

Caution is advised when prescribing antipsychotics to people with dementia. This study explored the determinants of appropriate, evidence-based antipsychotic prescribing behaviors for nursing home residents with dementia, with a view to informing future quality improvement efforts and behavior change interventions.

DESIGN

Semistructured qualitative interviews based on the Theoretical Domains Framework (TDF).

SETTING AND PARTICIPANTS

A purposive sample of 27 participants from 4 nursing homes, involved in the care of nursing home residents with dementia (8 nurses, 5 general practitioners, 5 healthcare assistants, 3 family members, 2 pharmacists, 2 consultant geriatricians, and 2 consultant psychiatrists of old age) in a Southern region of Ireland.

MEASURES

Using framework analysis, the predominant TDF domains and determinants influencing these behaviors were identified, and explanatory themes developed.

RESULTS

Nine predominant TDF domains were identified as influencing appropriate antipsychotic prescribing behaviors. Participants' effort to achieve "a fine balance" between the risks and benefits of antipsychotics was identified as the cross-cutting theme that underpinned many of the behavioral determinants. On one hand, neither healthcare workers nor family members wanted to see residents over-sedated and without a quality of life. Conversely, the reality of needing to protect staff, family members, and residents from potentially dangerous behavioral symptoms, in a resource-poor environment, was emphasized. The implementation of best-practice guidelines was illustrated through 3 explanatory themes ("human suffering"; "the interface between resident and nursing home"; and "power and knowledge: complex stakeholder dynamics"), which conceptualize how different nursing homes strike this "fine balance."

CONCLUSIONS

Implementing evidence-based antipsychotic prescribing practices for nursing home residents with dementia remains a significant challenge. Greater policy and institutional support is required to help stakeholders strike that "fine balance" and ultimately make better prescribing decisions. This study has generated a deeper understanding of this complex issue and will inform the development of an evidence-based intervention.

The Impact of Dementia Special Care Units on Quality of Care: An Instrumental Variables Analysis

OBJECTIVE

To compare the quality of care following admission to a nursing home (NH) with and without a dementia special care unit (SCU) for residents with dementia.

DATA SOURCES/STUDY SETTING

National resident-level minimum dataset assessments (MDS) 2005-2010 merged with Medicare claims and provider-level data from the Online Survey, Certification, and Reporting database.

STUDY DESIGN

We employ an instrumental variable approach to address the endogeneity of selection into an SCU facility controlling for a range of individual-level covariates. We use "differential distance" to a nursing home with and without an SCU as our instrument.

DATA COLLECTION/EXTRACTION METHODS

Minimum dataset assessments performed at NH admission and every quarter thereafter.

PRINCIPAL FINDINGS

Admission to a facility with an SCU led to a reduction in inappropriate antipsychotics (-9.7 percent), physical restraints (-9.6 percent), pressure ulcers (-3.3 percent), feeding tubes (-8.3 percent), and hospitalizations (-14.7 percent). We found no impact on the use of indwelling urinary catheters. Results held in sensitivity analyses that accounted for the share of SCU beds and the facilities' overall quality.

CONCLUSIONS

Facilities with an SCU provide better quality of care as measured by several validated quality indicators. Given the aging population, policies to promote the expansion and use of dementia SCUs may be warranted.

Sensory stimulation for persons with dementia: a review of the literature

AIMS AND OBJECTIVES

To provide an overview of available sensory stimulation interventions, and their effect on persons with dementia and to present theoretical and methodological characteristics of the studies included.

BACKGROUND

Different sensory stimulation interventions are used for persons with dementia to increase alertness, reduce agitation and improve quality of life. However, the effect of these interventions is not clear, neither are their characteristics.

DESIGN

A systematic search and review of the literature with description of the content and an evaluation of theoretical and methodological approaches.

METHODS

Systematic searches in CINAHL, PubMed (Medline), The Cochrane library and PsycINFO. Studies included have been subject to quality assessment by means of Critical Appraisal Skills Programme.

RESULTS

Fifty-five studies were included and thirty of these documented significant effect. The effect of the sensory stimulation interventions mainly reported on negative behaviours, except from five studies assessing quality of life and well-being. The majority of the studies had methodological limitations. The different sensory stimulation interventions were organised into eight categories: music, light therapy, acupressure/reflexology, massage/aromatherapy and doll therapy/pet therapy/toy therapy, the Sonas programme and Snoezelen.

CONCLUSIONS

More studies are needed to clarify appropriate substantial background for the specific interventions. However, most of the studies based their interventions on a theoretical foundation. Furthermore, more research is needed to measure the effect of sensory stimulation on communication as well as quality of life. In addition, studies are to focus on whether the effect depends on the stage of dementia.

RELEVANCE TO CLINICAL PRACTICE

Nurses are to be aware of sensory stimulation as a possible intervention to improve persons' quality of life.

Associations between social network characteristics, cognitive function, and quality of life among residents in a dementia special care unit: A pilot study

Social integration has a significant influence on physical and mental health. Older adults experience an increased risk of social isolation as their social networks contract. The purpose of this study is to examine associations between dementia special care unit residents' overall well-being and cognition with structural aspects of their coresident relationships. Design and Methods Measures of social network structure were calculated from self-reported social contact data within three cohorts of residents in one dementia special care unit. Pearson correlations were used to describe associations between overall quality of life and cognition, with network characteristics indicative of social integration. Results Approximately half the ties sent or received were reciprocated and positive associations were found between social integration and quality of life. However, inconsistent associations were found between social integration and cognitive function. Friendship ties were more frequent between people of adjacent cognitive status categories. In addition, comparing across personal networks, residents tended to be tied to residents of higher quality of life status (43.3%, n = 13 personal networks) as opposed to lower (30%, n = 9 networks) or same (26.7%, n = 8 networks). There is a strong positive correlation between quality of life and respondent's betweenness centrality, suggesting that individuals with high quality of life tend to be important intermediaries between others in the community. Implications Among the "oldest old," quality of life and cognitive function are unevenly distributed, yet these health indicators tend to cluster in social networks. This reinforces that while quality of life may be highly individual, it is in part linked to relationships with others.

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.

Role of antipsychotics for treating behavioral and psychological symptoms of dementia

Over the past three decades, concerns about the high prevalence of antipsychotic use in the nursing homes (NHs) for the management of behavioral and psychological symptoms of dementia continue to be emphasized and intervened by many. However, despite the numerous side effects and the recent blackbox warning by the United States Food and Drug Administration about the increased risks for stroke and sudden death associated with the use of antipsychotics in dementia, the prevalence of antipsychotic use in NHs remains high. While the use of antipsychotics appeared to have modest efficacy in reducing symptoms of aggression and psychosis in dementia, there is insufficient evidence to routinely recommend the use of alternative psychopharmacological treatments for these symptoms. Hence, clinicians have to balance the safety warnings against the need to treat these symptoms in order to prevent harm to the resident that may result from his/her dangerous behaviors. Although the use of antipsychotics may be warranted in some cases, organizational, resource and training support should be provided to encourage and equip NH staff to participate in interventions so as to minimize inappropriate use of these medicines in NHs. This review will discuss the place in therapy, the trend and appropriateness of antipsychotic use in NHs, as well as the effectiveness of current and future strategies for reducing antipsychotic use in the NHs.

Dementia special care units: a comparison with standard units regarding residents' profile and care features

BACKGROUND

Unlike other countries, no data about residents and care features in Special Care Units (SCUs) in Spanish nursing homes have been reported to date. The present paper is the first to analyze the characteristics of residents with dementia and the features of provided care in SCUs in comparison to residents with dementia in standard beds, thus not receiving specialized care in nursing homes in Spain.

METHODS

Data on residents with dementia were collected in 11 nursing homes. Residents with diagnosis of dementia and Mini-Mental State Examination scores of less than 27 were randomly selected in each center. Altogether 197 residents were assessed: 102 (52%) placed in SCUs, and 95 (48%) in standard beds. Analyses of the characteristics of residents in SCUs versus standard beds regarding socio-demographic and clinical variables, features of the care provided, and residents' quality of life (QoL) were performed using univariate and multivariate tests (binary logistic regression analysis).

RESULTS

Residents in SCUs did not differ from those in standard beds in socio-demographic variables. Placement of residents in SCUs seemed to be related with the presence of severe cognitive and functional impairment and aggressive behaviors. Being in an SCU conveyed a higher probability of having individual bedroom and bathroom; nevertheless, there were no differences in the care provided in SCUs, considering use of nappies, and feeding and restraint systems. Patients in SCUs showed lower QoL reported by the staff.

CONCLUSIONS

Although residents in SCUs present higher levels of impairment, there are no real differences in the care provided besides a higher probability of having individual rooms. Regulations on required features for SCUs in Spain are necessary to guarantee that care provided to residents is truly special.

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.

The feasibility of measuring social networks among older adults in assisted living and dementia special care units

BACKGROUND

Studies indicate that social integration has a significant influence on physical and mental health. Older adults experience an increased risk of social isolation as their social networks decline with fewer traditional opportunities to add new social relationships. Deaths of similar aged friends, cognitive and functional impairments, and relocating to a nursing home (NH) or assisted-living (AL) facility contribute to difficulties in maintaining one's social network. Due to the paucity of research examining the social networks of people residing in AL and NH, this study was designed to develop and test the feasibility of using a combination of methodological approaches to capture social network data among older adults living in AL and a dementia special care unit NH.

METHODS

Social network analysis of both egocentric and sociocentric networks was conducted to visualize the social networks of 15 residents of an AL neighborhood and 12 residents of a dementia special care unit NH and to calculate measures network size, centrality, and reciprocity.

RESULTS

The combined egocentric and sociocentric method was feasible and provided a robust indicator of resident social networks highlighting individuals who were socially integrated as well as isolated.

Patient participation in special care units for persons with dementia

The aim of this study was to explore the experience of nursing personnel with respect to patient participation in special care units for persons with dementia in nursing homes, with focus on everyday life. The study has an explorative grounded theory design. Eleven nursing personnel were interviewed twice. Patient participation is regarded as being grounded in the idea that being master of one’s own life is essential to the dignity and self-esteem of all people. Patient participation was described at different levels as letting the resident make their own decisions, adjusting the choices, making decisions on behalf of the residents and forcing the residents. The educational level and commitment of the nursing personnel and how often they were on duty impacted the level that each person applied, as did the ability of the residents to make decisions, and organizational conditions, such as care culture, leadership and number of personnel.

Gender differences in home care clients and admission to long-term care in Ontario, Canada: a population-based retrospective cohort study

Background

Home care is integral to enabling older adults to delay or avoid long-term care (LTC) admission. To date, there is little population-based data about gender differences in home care users and their subsequent outcomes. Our objectives were to quantify differences between women and men who used home care in Ontario, Canada and to determine if there were subsequent differences in LTC admission.

Methods

This is a population-based retrospective cohort study. We identified all adults aged 76+ years living in Ontario and receiving home care on April 1, 2007 (baseline). Using the Resident Assessment Instrument – Home Care (RAI-HC) linked to other databases, we characterized the cohort by living condition, health and functioning, and identified all acute care and LTC use in the year following baseline.

Results

The cohort consisted of 51,201 women and 20,102 men. Women were older, more likely to live alone, and more likely to rely on a child or child-in-law for caregiver support. Men most frequently identified a spouse as caregiver and their caregivers reported distress twice as often as women’s caregivers. Men had higher rates of most chronic conditions and were more likely to experience impairment. Men were more likely to be admitted to hospital, to have longer stays in hospital, and to be admitted to LTC.

Conclusions

Understanding who uses home care and why is critical to ensuring that these programs effectively reduce LTC use. We found that women outnumbered men but that men presented with higher levels of need. This detailed gender analysis highlights how needs differ between older women, men, and their respective caregivers.

The influence of cognitive impairment, special care unit placement, and nursing facility characteristics on resident quality of life

OBJECTIVE

We examined the (a) influence of nursing facility characteristics on resident quality of life and (b) the impact of cognitive impairment and residence on a dementia special care unit(SCU) on QOL after controlling for resident and facility characteristics.

METHOD

Multilevel models (resident and facility) were estimated for residents with and without cognitive impairment on conventional units and dementia SCU. Data came from the 2007 Minnesota Nursing Home Resident Quality of Life and Consumer Satisfaction Survey (N = 13,983).

RESULTS

Level of resident CI was negatively related to QOL, although residing on a dementia SCU was positively related to QOL. Certified Nursing Assistant and activity personnel hours per resident day had a positive relationship with resident QOL.

DISCUSSION

Our results highlight the need to ensure adequate levels of paraprofessional direct care staff and the availability of dementia-focused (SCU)s despite current constraints on long-term care funding.

The quality of advanced dementia care in the nursing home: the role of special care units

BACKGROUND

The quality of nursing home care for residents with advanced dementia has been described as suboptimal. One relatively understudied factor is the impact of special care units (SCUs) for dementia for residents at the end stage of this disease.

OBJECTIVE

To examine the association between residence in an SCU and the quality of end-of-life care for nursing home residents with advanced dementia.

RESEARCH DESIGN

This study used longitudinal data on 323 nursing home residents with advanced dementia living in 22 Boston-area facilities. Using multivariate methods, we analyzed the association between residence in an SCU and measures of quality of end-of-life care including: treatment of pain and dyspnea, prevalence of pressure ulcers, hospitalization, tube feeding, antipsychotic drug use, advance care planning, and health care proxy (HCP) satisfaction with care.

RESULTS

A total of 43.7% residents were cared for in an SCU. After multivariate adjustment, residents in SCUs were more likely to receive treatment for dyspnea, had fewer hospitalizations, were less likely to be tube fed, and more likely to have a do-not-hospitalize order, compared with non-SCU residents. However, non-SCU residents were more likely to be treated for pain, had fewer pressure ulcers, and less frequent use of antipsychotic drugs than SCU residents. HCPs of SCU residents reported greater satisfaction with care than HCPs of non-SCU residents.

CONCLUSIONS

Residence in an SCU is associated with some, but not all, markers of better quality end-of-life care among nursing home residents with advanced dementia.

Racial differences in dementia care among nursing home residents

OBJECTIVES

This article aims to describe potential racial differences in dementia care among nursing home residents with dementia.

METHODS

Using data from the 2004 National Nursing Home Survey (NNHS) in regression models, the authors examine whether non-Whites are less likely than Whites to receive special dementia care--defined as receiving special dementia care services or being in a dementia special care unit (SCU)--and whether this difference derives from differences in resident or facility characteristics.

RESULTS

The authors find that non-Whites are 4.3 percentage points less likely than Whites to receive special dementia care.

DISCUSSION

The fact that non-Whites are more likely to rely on Medicaid and less likely to pay out of pocket for nursing home care explains part but not all of the difference. Most of the difference is due to the fact that non-Whites reside in facilities that are less likely to have special dementia care services or dementia care units, particularly for-profit facilities and those in the South.

Does cognitive impairment influence quality of life among nursing home residents?

PURPOSE

We investigated the relationship between cognitive status and quality of life (QOL) of Minnesota nursing home (NH) residents and the relationship between conventional or Alzheimer's special care unit (SCU) placement and QOL. The study may inform development of dementia-specific quality measures.

DESIGN AND METHODS

Data for analyses came from face-to-face interviews with a representative sample of 13,130 Minnesota NH residents collected through the 2007 Minnesota NH Resident Quality of Life and Consumer Satisfaction survey. We examined 7 QOL domains: comfort, meaningful activities, privacy, environment, individuality, autonomy, relationships, and a positive mood scale. We applied multilevel models (resident and facility) to examine the relationship between the resident's score on each QOL domain and the resident's cognitive impairment (CI) level and SCU placement after controlling for covariates, such as activities of daily living dependency, pain, depression or psychiatric diagnosis, and length of stay.

RESULTS

Residents with more severe CI reported higher QOL in the domains of comfort and environment and lower QOL in activities, individuality, privacy and meaningful relationships, and the mood scale. Residents on SCU reported higher QOL in the meaningful activities, comfort, environment, and autonomy domains but had lower mood scores.

IMPLICATIONS

Our findings point to QOL domains that show significant variation by CI and thus may be of greatest interest to consumers, providers, advocacy groups, and other stakeholders committed to improving dementia care. Findings are particularly applicable to the development of NH quality indicators that more accurately represent the QOL of NH residents with CI.

‘You’ve got to keep account of heads all the time’: staff perceptions of caring for people with dementia

Research aim: Little is known regarding the pressures of working within dementia care units, as the majority of literature has focused broadly on long-term care rather than the provision of specialised dementia care. This study aimed to explore the perceptions of staff in relation to their capacity to manage behaviour and care needs of people with dementia living within the dementia-specific environment. Individual interviews were conducted with 35 care staff from three dementia care units in Brisbane, Australia.

Major findings: Four themes were identified: role definition, relationships, workplace environment, and workforce issues. Although the findings highlight the importance of peer support for staff when managing difficult situations, questions regarding the quality of peer support and its impact on care provision were raised.

Conclusions: Dementia units are complex systems with well-motivated and educated staff contributing to the effectiveness of the care. An understanding of care staff, perceptions of their role and its effects on care practices can help to identify appropriate support structures and training strategies, thereby improving job satisfaction for staff and quality of life for the residents with dementia.

From Institution to ‘Home’: Family Perspectives on a Unique Relocation Process

Cette étude phénoménologique et herméneutique a donné un aperçu des expériences des membres des familles des résidents qui ont été diagnostiqués d’une démence légère à modérée et qui ont été déménagés de leur institution de soins dans une résidence medicalisée unique. Des entrevues semi-dirigées ont été realisées avec 10 membres de la famille, dont six thèmes ont émergé : (a) la communication en cours, (b) de secours et de contentement, (c) des activités significatives, (d) un environnement amélioré, (e) le fonctionnement amélioré, et (f) le personnel engagé. Ces résultats ont des implications importantes pour la prestation des soins et la planification des programmes futurs dans les soins aux résidents ayant des besoins spéciaux. Surtout, nous pouvons conclure que les résultats axés sur le client des soins produit des résultats positifs pour les résidents et les membres des familles.

The effect of labeling on employee perceptions of residents living on Alzheimer's disease specialized care units

OBJECTIVES

This study examined whether labeling influenced nursing home employees' perceptions of residents and how those perceptions could affect resident-caregiver interactions.

DESIGN

This was a small descriptive study using vignettes and questionnaires.

SETTING

Two nursing homes (one rural, one urban) in New England.

PARTICIPANTS

Forty-three nursing home employees including registered nurses, certified nursing assistants, activities staff, and others.

MEASUREMENTS

All participants read a vignette based on the behavior of a fictional resident and rated their perceptions of the behavior, indicated whether and how they would report the event, and made recommendations for possible courses of action. Although vignettes were the same, the resident label varied: Alzheimer's disease specialized care unit (ADSCU) resident or resident of a non-specialized long-term care unit.

RESULTS

Employees who read the vignette for the ADSCU resident rated the resident's behavior as more problematic, inappropriate, and aggressive than the same behavior for non-ADSCU residents.

CONCLUSION

The effect of the label of "ADSCU resident" may have implications for care provided in specialized long-term care environments.

Physical restraint use and falls in nursing homes: a comparison between residents with and without dementia

AIMS

To estimate the use of different types of physical restraints and assess their associations to falls and injuries among residents with and without Alzheimer's disease (AD) or dementia in US nursing homes.

METHODS

Data were from the 2004 National Nursing Home Survey. AD or dementia was identified using International Classification of Diseases, Ninth Revision (ICD-9) codes. Analyses were conducted with the Surveyfreq and Surveylogistic procedures in SAS v.9.1.

RESULTS

Residents with either AD or dementia were more likely to be physically restrained (9.99% vs 3.91%, P < .001) and less likely to have bed rails (35.06% vs 38.43%, P < .001) than those residents without the disease. The use of trunk restraints was associated with higher risk for falls (adjusted odds ratio [AOR] = 1.66, P < .001) and fractures (AOR = 2.77, P < .01) among residents with the disease. The use of full bed rails was associated with lower risk for falls among residents with and without the disease (AOR = 0.67 and AOR = 0.72, Ps < .05, respectively).

CONCLUSIONS

The use of a trunk restraint is associated with a higher risk for falls and fractures among residents with either AD or 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).

Staffing levels in rural nursing homes: a mixed methods approach

This mixed methods study used multiple regression analyses to examine the impact of organizational and market characteristics on staffing hours and staffing mix, and qualitative interview to explore the challenges and facilitators of recruiting and retaining qualified staff. Rural nursing homes (NHs) certified by Medicare or Medicaid (N = 161) were sampled from the Online Survey Certification and Reporting system. A subsample (n = 23) was selected purposively for the qualitative analysis. Smaller NHs or government-affiliated homes had more total nursing hours per resident day and more hours of care by certified nursing assistants and RNs than larger and nongovernment-affiliated homes; however, almost 87% of NHs in this study were below the national recommendation for RN hours. Informants voiced challenges related to enough staff, qualified staff, and training staff. Development of nursing resources is critical, especially in rural locales where aging resources may not be well developed.

Associations of special care units and outcomes of residents with dementia: 2004 national nursing home survey

PURPOSE

We compared the rates of specialized care for residents with Alzheimer's disease or dementia in special care units (SCUs) and other nursing home (NH) units and examined the associations of SCU residence with process of care and resident outcomes.

DESIGN AND METHODS

Data came from the 2004 National Nursing Home Survey. The indicators of process of care included physical restraints, continence management, feeding tubes, and influenza and pneumococcal vaccinations. Resident outcomes included pressure ulcers, hospitalization, emergency room visits, weight loss, and falls. Analyses were conducted by using Stata SE version 10.

RESULTS

Multivariate logistic regression analyses show that SCU residents were more likely to have received specialized dementia care and specialized behavioral problem management. They were less likely to have bed rails (adjusted odds ratio [AOR] = 0.39, AOR = 0.35, ps < .01), use catheters (AOR = 0.33, AOR = 0.33, ps < .01), and yet more likely to have toilet plans/bladder training for incontinence control (AOR = 1.90, AOR = 1.62, ps < .01) than those in regular units and those in NHs without an SCU. Moreover, SCU residents were less likely to have pressure ulcers, hospitalization than those in regular units, and less likely to have experienced weight loss than those in NHs without an SCU. However, they were more likely to have falls (AOR = 1.32, AOR = 1.36, ps < .05) than those in regular units and those in NHs without an SCU.

IMPLICATIONS

Our study shows that SCU residents had, in general, better process of care than those in regular units and in NHs without an SCU. Further studies are needed to assess specific outcome changes among SCU residents and to evaluate the cost-effectiveness of having such units.

Conversion diversion: participation in a social HMO reduces the likelihood of converting from short-stay to long-stay nursing facility placement

OBJECTIVES

To determine the effect of a Social Health Maintenance Organization (S/HMO) on diverting older adults admitted into a nursing facility from converting to long-stay placement.

DESIGN

Members of the SCAN S/HMO and those in Medicare Fee-For-Service were compared on successful discharge to the community after being admitted to nursing facilities between January 1, 2001, and December 31, 2003.

SETTING

Skilled nursing facilities in 4 counties in Southern California (Los Angeles, Orange, San Bernardino, Riverside).

PARTICIPANTS

Data (N = 4635) were extracted from Minimum Data Set (MDS) 2.0 records for nursing facility residents in the S/HMO or the Medicare Fee-for-Service 5% sample who were aged 65 and older with an episode of care greater than 14 days.

MEASUREMENTS

Predisposing, enabling, and need measures were used to predict successful discharge to the community within 90 days.

RESULTS

After controlling for selected sociodemographics, comorbidities, behavioral issues, mental health conditions, and other risk factors, being enrolled in the S/HMO increased the likelihood of successful discharge by 26%.

CONCLUSION

With systemic increases in short-stay patients, research on diversion must look past the avoidance of unnecessary entry to nursing facilities, to the successful transition of short-stay residents to the community. As described in this study, the S/HMO model is an important but largely unaddressed method of avoiding the conversion to long-stay.

The basis for improving and reforming long-term care. Part 4: identifying meaningful improvement approaches (segment 1)

While many aspects of nursing home care have improved over time, numerous issues persist. Presently, a potpourri of approaches and a push to "fix" the problem have overshadowed efforts to correctly define the issues and identify their diverse causes. Together, the two segments of this fourth and final article (divided between this month's issue and the next one) in the series identify strategies that should tie reform efforts together. This Segment 1 of Article 4 discusses the need to judge initiatives and proposals by how well they support and/or promote critical elements such as the care delivery process and clinical problem solving and decision making activities. It also covers the need to critically scrutinize and modify the conventional wisdom and to suppress "political correctness" thatcontinues to inhibit vital critical inquiry and dialogue that are needed to define issues correctly and make further progress. Ultimately, relatively uncomplicated and inexpensive strategies have the potential to bring dramatic progress. But there needs to be more willingness to rethink the issues and reconsider current approaches.

Research on treating neuropsychiatric symptoms of advanced dementia with non-pharmacological strategies, 1998-2008: a systematic literature review

BACKGROUND

Advanced dementia is characterized by severe cognitive and functional impairments that lead to almost total dependency in self-care. Neuropsychiatric symptoms (NPS) are common in advanced dementia, diminishing quality of life and increasing the care burden. The challenge for health care providers is to find safe and effective treatments. Non-pharmacological interventions offer the potential for safer alternatives to pharmacotherapy, but little is known about their efficacy. This review evaluates the published literature on non-pharmacological interventions for treating NPS in advanced dementia.

METHODS

A literature search was undertaken to find non-pharmacological intervention studies published between 1998 and 2008 that measured NPS outcomes in individuals diagnosed with advanced dementia. Strict inclusion criteria initially required that all study participants have severe or very severe dementia, but this range was later broadened to include moderately severe to very severe stages.

RESULTS

Out of 215 intervention studies, 21 (9.8%) specifically focused on treatments for individuals with moderately severe to very severe dementia. The studies provide limited moderate to high quality evidence for the use of sensory-focused strategies, including aroma, preferred or live music, and multi-sensory stimulation. Emotion-oriented approaches, such as simulated presence may be more effective for individuals with preserved verbal interactive capacity.

CONCLUSIONS

Most studies of interventions for dementia-related NPS have focused on individuals with mild to moderate cognitive impairment. Individuals with severe cognitive impairment do not necessarily respond to NPS treatments in the same manner. Future studies should be specifically designed to further explore the stage-specific efficacy of non-pharmacological therapies for patients with advanced dementia. Areas of particular need for further research include movement-based therapies, hands-on (touch) therapies, and interventions that can be provided during personal care routines. Interventions appear to work best when they are tailored to balance individual arousal patterns.

Risiken von Antipsychotika im Alter, speziell bei Demenzen 1Prof. Dr. Hans Gutzmann zum 60. Geburtstag gewidmet

Antipsychotika werden häufig zur Behandlung von herausforderndem Verhalten bei Demenz eingesetzt. Antipsychotika der zweiten Generation («atypische Neuroleptika») spielen dabei mittlerweile eine größere Rolle als die älteren Substanzen. Der nur mäßigen Wirksamkeit stehen schwerwiegende Risiken gegenüber: so ist unter allen Antipsychotika die Mortalität insgesamt erhöht, aber auch das Risiko für plötzlichen Herztod, Schlaganfallereignisse oder venöse Thrombosen. Die Unterschiede zwischen Antipsychotika der ersten und der zweiten Generation sind dabei gering: hochpotente Antipsychotika der ersten Generation führen häufiger zu extrapyramidalmotorischen Symptomen, unter Antipsychotika der zweiten Generation ist das allgemeine Mortalitätsrisiko wahrscheinlich etwas geringer, andererseits wahrscheinlich venöse Thrombosen und metabolische Nebenwirkungen häufiger. Für die übrigen Nebenwirkungen bestehen keine gesicherten Unterschiede. Angesichts der großen Heterogenität der Antipsychotika erscheint der Nutzen einer pauschalen Aufteilung in Antipsychotika der ersten und zweiten Generation fragwürdig. Für die Auswahl einer Substanz sind substanzspezifische Nebenwirkungen, Dosierung, Aufdosierungsgeschwindigkeit sowie Beachtung von Komorbidität, Kontraindikationen und Arzneimittelinteraktionen in Relation zum individuellen Patienten erheblich wichtiger als die Wahl nach bloßer pauschaler Zuordnung zu einer dieser beiden Gruppen. Am wichtigsten ist aber, dass Antipsychotika nur bei klarer Indikation zur Anwendung kommen!

End-of-life care in U.S. nursing homes: nursing homes with special programs and trained staff for hospice or palliative/end-of-life care

BACKGROUND

The degree to which nursing homes have internal programs for hospice and palliative care is unknown. We used self-reported data from the 2004 National Nursing Home Survey (NNHS) to estimate the prevalence of special programs and (specially) trained staff (SPTS) for hospice or palliative/end-of-life care in U.S. nursing homes. Factors associated with the presence of SPTS for hospice or palliative/end-of-life care were identified.

METHODS

We merged 2004 NNHS data for 1174 nursing homes to county-level data from the 2004 Area Resource File and to Nursing Home 2004 Online Survey, Certification, and Reporting data. chi(2) tests and logistic regression models were applied.

RESULTS

Twenty-seven percent of U.S. nursing homes reported (internal) SPTS for hospice or palliative/end-of-life care. After controlling for covariates, we found nonprofit status, being in the southern region of the United States, having an administrator certified by the American College of Health Care Administrators, contracting with an outside hospice provider, and having other specialty programs to be associated with a greater likelihood of nursing homes having SPTS for hospice or palliative/end-of-life care. The largest effects were observed for nursing homes with programs for behavioral problems (adjusted odds ratio [AOR] 3.59; 95% confidence interval [CI] 2.40, 5.37) and for pain management (AOR 5.92; 95% CI 4.09, 8.57).

CONCLUSION

The presence of internal SPTS for hospice or palliative/end-of-life care is prevalent in U.S. nursing homes, and may be preceded by hospice contracting and/or the implementation of specialty programs that assist nursing homes in developing the expertise needed to establish their own palliative care programs.

Dementia of the Alzheimer type

Dementia of the Alzheimer type is a progressive, fatal neurodegenerative condition characterized by deterioration in cognition and memory, progressive impairment in the ability to carry out activities of daily living, and a number of neuropsychiatric symptoms. This narrative review summarizes the literature regarding descriptive epidemiology, clinical course, and characteristic neuropathological changes of dementia of the Alzheimer type. Although there are no definitive imaging or laboratory tests, except for brain biopsy, for diagnosis, brief screening instruments and neuropsychiatric test batteries used to assess the disease are discussed. Insufficient evidence exists for the use of biomarkers in clinical practice for diagnosis or disease management, but promising discoveries are summarized. Optimal treatment requires both nonpharmacological and pharmacological interventions, yet none have been shown to modify the disease's clinical course. This review describes the current available options and summarizes promising new avenues for treatment. Issues related to the care of persons with dementia of the Alzheimer type, including caregiver burden, long-term care, and the proliferation of dementia special care units, are discussed. Although advances have been made, more research is needed to address the gaps in our understanding of the disease.