Impact of care settings on residents' functional and psychosocial status, physical activity and adverse events

Comparison of mortality and hospitalizations of older adults living in residential care facilities versus nursing homes or the community. A systematic review

Residential care facility may provide a transition between living at home and a nursing home for dependent older people or an alternative to nursing homes. The objective of this review was to compare mortality and hospitalizations of older adults living in residential care facilities with those living in nursing homes or in the community. We searched Medline, Scopus and Web of Science from inception to December 2022. Fifteen cohort studies with 6 months to 10 years of follow-up were included. The unadjusted relative risk (RR) of mortality was superior in nursing homes than in residential care facilities in 6 of 7 studies (from 1.3 to 1.68). Conversely, the unadjusted relative risk of hospitalizations was higher in residential care facilities in 6 studies (from 1.3 to 3.37). Studies conducted on persons with dementia found mixed results, the only study adjusted for co-morbidities observing no difference on these two endpoints. Compared with home, unadjusted relative risks were higher in residential care facilities for mortality in 4 studies (from 1.34 à 10.1) and hospitalizations in 3 studies (from 1.12 to 1.62). Conversely, the only study that followed older adults initially living at home over a 10-year period found a reduced risk of heavy hospital use (RR = 0.68) for those who temporarily resided in a residential care facilities. There is insufficient evidence to determine whether residential care facilities might be an alternative to nursing homes for older people with similar clinical characteristics (co-morbidities and dementia). Nevertheless, given the high rate of hospitalizations observed in residential care facilities, the medical needs of residents should be better explored.

Model Testing of the Factors That Influence Performance of Function Focused Care and Function Among Assisted Living Residents

The purpose of this study was to test a model of factors associated with participating in function focused care. Function focused care is a philosophy of care in which residents are encouraged to engage in functional and physical activities during care interactions. This was a secondary data analysis using data from the Dissemination and Implementation of Function Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT) study. Residents (n = 550) were recruited from 59 AL settings. The majority were female (n = 380, 69%) and White (n = 536, 97%). Model testing was done. Comorbidities, quality of interactions, environments, profit status, cognitive impairment, depression, and function were associated with function focused care and accounted for 17% of the variance. Next steps should include intervening on changeable factors (e.g., environments) and adding factors to better explain performance of function focused care such as motivation, resilience, and staff satisfaction.

Testing the Implementation of Function-focused Care in Assisted Living Settings

OBJECTIVES

The purpose of this study was to evaluate the Function-Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT) intervention.

DESIGN

FFC-AL-EIT was a randomized controlled pragmatic trial including 85 sites and 794 residents.

INTERVENTION

FFC-AL-EIT was implemented by a Research Nurse Facilitator working with a facility champion and stakeholder team for 12 months to increase function and physical activity among residents. FFC-AL-EIT included (Step I) Environment and Policy Assessments; (Step II) Education; (Step III) Establishing Resident Function-Focused Care Service Plans; and (Step IV) Mentoring and Motivating.

SETTING AND PARTICIPANTS

The age of participants was 89.48 years [standard deviation (SD) = 7.43], and the majority were female (n = 561; 71%) and white (n = 771; 97%).

METHODS

Resident measures, obtained at baseline, 4, and 12 months, included function, physical activity, and performance of function-focused care. Setting outcomes, obtained at baseline and 12 months, included environment and policy assessments and service plans.

RESULTS

Reach was based on 85 of 90 sites that volunteered (94%) participating. Effectiveness was based on less decline in function (P < .001), more function-focused care (P = .012) and better environment (P = .032) and policy (P = .003) support for function-focused care in treatment sites. Adoption was supported with 10.00 (SD = 2.00) monthly meetings held, 77% of settings engaged in study activities as or more than expected, and direct care workers providing function-focused care (63% to 68% at 4 months and 90% at 12 months). The intervention was implemented as intended, and education was received based on a mean knowledge test score of 88% correct. Evidence of maintenance from 12 to 18 months was noted in treatment site environments (P = .35) and policies continuing to support function-focused care (P = .28)].

CONCLUSIONS AND IMPLICATIONS

The Evidence Integration Triangle is an effective implementation approach for assisted living. Future work should continue to consider innovative approaches for measuring RE-AIM outcomes.

The Impact of a Randomized Controlled Trial Testing the Implementation of Function-Focused Care in Assisted Living on Resident Falls, Hospitalizations, and Nursing Home Transfers

The purpose of this study was to test the impact of function-focused care on adverse outcomes in assisted living. This was a randomized trial including 85 settings. The age of the 794 recruited participants was 89.48 (SD = 7.43) years, the majority was female (n = 561, 71%) and White (n = 771, 97%). The percentage of residents in the treatment group experiencing a fall decreased at 12 months from 26% to 20% and the control group increased from 24% to 25%, p = .02. A greater percentage of residents in the treatment group transferred to nursing facilities at 4 months (4-1% in control vs. 4-5% in treatment, p = .02) and 12 months (4-2% in control and 4-7% in treatment, p = .01). There was no treatment effect on emergency room or hospital transfers. The findings support the safety of function-focused care related to falls and need for hospital transfers.

Pain Incidence, Treatment, and Associated Symptoms in Hospitalized Persons with Dementia

BACKGROUND

Moderate to severe pain has been frequently reported in hospitalized older adults. Pain in hospitalized persons with dementia within the context of other common symptoms, functional decline, delirium, and behavioral and psychological symptoms of dementia (BPSD), has received little attention.

AIMS

Describe the incidence of pain, the pharmacologic management of pain, and the association of pain with physical function, delirium, and BPSD in hospitalized persons with dementia.

DESIGN

Descriptive, cross-sectional study.

SETTING

Six medical units in three hospitals.

PARTICIPANTS

Baseline data from 299 hospitalized persons with dementia enrolled in the Family-centered Function-focused Care (Fam-FFC) cluster randomized trial.

METHODS

Descriptive analyses of pain used the Pain Assessment in Advanced Dementia (PAINAD) scale and the use of medication for pain management. Linear regression analyses tested relationships between pain and:1) physical function (Barthel Index), 2) delirium severity (Confusion Assessment Method Severity Short Form) and 3) BPSD severity (Neuropsychiatric Inventory- Questionnaire).

RESULTS

The majority of the sample was female (61.9%), non-Hispanic (98%), and Black (53.2%), with a mean age of 81.58 (SD=8.54).Of the 299 patients, 166 (56%) received pain medication. Of the 108 individuals who demonstrated pain, 40% (n=43) did not receive pain medication. When controlling for age, gender, cognition, and comorbidities, pain was significantly associated with function, delirium severity, and BPSD severity.

CONCLUSIONS

Results suggest that pain may be undertreated in hospitalized persons with dementia, and should be considered upon admission to optimize function, decrease delirium, and prevent or decrease BPSD.

Patterns of Sedentary Behavior among Older Adults in Care Facilities: A Scoping Review

Understanding the sedentary patterns can guide the design of strategies to engage older adults in physical activity. This scoping review aimed to synthesize available evidence on sedentary behaviors in care facilities. We searched PubMed/MEDLINE and Web of Science for studies published from inception through October 2020. Eighteen studies were included and reviewed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Data obtained were analyzed based on levels of care provided. Overall, daily sedentary time was higher among residents in high level care facilities (e.g., nursing homes) (11.6 h/day) than intermediate/mixed level care facilities (e.g., assisted living) (9.5 h/day). In intermediate/mixed level care facilities, television (TV) viewing was the most common sedentary activity (2.5-2.9 h/day; 26% of daily sedentary time), while napping was the most favorite sedentary activity (4.7 h/day; 36% of waking hours) in high level care facilities. Sex differences in daily patterns of sedentary behavior (sedentary time, uninterrupted bouts, and bout durations) were commonly observed in intermediate/mixed level care facilities, as exemplified by men being more sedentary by 0.7-1.1 h/day. In summary, this study highlights distinctive sedentary patterns among older adults residing in different levels of care facilities, addressing a pressing need for customized interventions to engage care facility residents in physical activity.

Impact of Disturbed Rest-activity Rhythms on Activities of Daily Living in Moderate and Severe Dementia Patients

PURPOSE

People with dementia exhibit disturbed rest-activity rhythms and extended sleep duration issues throughout their disease. Little is known about the effects of these issues on clinical problems for those with moderate and severe dementia. This cross-sectional study aimed to examine the associations of disturbed rest-activity rhythms and extended sleep duration with activities of daily living (ADL).

METHODS

Sleep parameters were measured using an actigraphy device. Cognitive function was assessed using the Mini-Mental State Examination and Cognitive Test for Severe Dementia, the Hyogo Activities of Daily Living Scale was used to assess ADL, and behavioral and psychological symptoms of dementia were assessed using the Neuropsychiatric Inventory-Nursing Home scale. Associations among rest-activity rhythms, sleep duration, and other clinical variables were analyzed with multiple linear regression. Clinical variables were compared between 2 groups categorized by onset timing of rest peak.

PATIENTS

Sixty-four participants with moderate and severe dementia were assessed.

RESULTS

In the correlation analysis, unstable daily rest-activity rhythm was associated with lower ADL. In the multiple linear regression analysis, low intradaily variability, and long daytime sleep duration were associated with low ADL. Aberrant rest peak timing showed lower ADL compared with nonaberrant timing.

CONCLUSIONS

Abnormal rest-activity rhythm and sleep duration in persons with moderate and severe dementia may affect ADL.

Reliability and Validity of the Checklist for Function-Focused Care in Service Plans

The purpose of this study was to test the reliability and validity of the Checklist for Function-Focused Care in Service Plans. Function-focused care is a care approach that optimizes function and physical activity during all care interactions. This study used baseline data from the first cohort of the study titled Dissemination and Implementation of Function-Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT). A total of 242 participants were recruited from 26 assisted living facilities. The majority of participants were White, female, and unmarried. There was support for internal consistency with an alpha coefficient of .96, interrater reliability with a correlation of .80, construct validity based on Rasch analysis and INFIT statistics ranging from 0.69 to 1.29, and a significant association with function-focused care activities. Although there is some support for reliability and validity of the measure, modifications are recommended to add more challenging items.

Pain Assessment, Management, and Impact Among Older Adults in Assisted Living

OBJECTIVES

The purpose of this study was to describe the incidence, pharmacologic management, and impact of pain on function, agitation, and resistiveness to care among assisted living residents.

DESIGN

This was a descriptive study.

DATA SOURCES

Baseline data from 260 residents in the second cohort of the study Dissemination and Implementation of Function Focused Care for Assisted Living Using the Evidence Integration Triangle.

REVIEW/ANALYSIS METHODS

Descriptive analyses for the Pain Assessment in Advanced Dementia (PAINAD), Visual Descriptor Scale (VDS), and use of medication for pain management and hypothesis testing using linear regression analyses were performed.

RESULTS

The majority of the sample was female (71%) and white (96%) with a mean age of 87 (standard deviation = 7). Fifty-two out of the 260 residents (20%) reported pain based on either the PAINAD or the VDS. Out of the total 260 residents, 75 (29%) received pain medication. Twenty-two out of the 52 individuals (42%) reporting pain were not getting pain medication. Controlling for age, gender, and cognition, the PAINAD was significantly associated with agitation, function, and resistiveness to care and the VDS was only associated with function.

CONCLUSIONS

The incidence of pain was low among participants based on the PAINAD or the VDS. Pain measured by the PAINAD was significantly associated with function, agitation, and resistiveness to care.

A value-critical policy analysis of the nursing home reform act: a focus on care of African American and Latino residents

Improving nursing home care has been a central legislative focus since the 1980s; The major response effort to address these reports of poor-quality care was first met with a federal rule in 1987, the Nursing Home Reform Act (NHRA). Since enactment of the NHRA in 1987, and despite an increasing utilization of nursing home care by aging minorities, the standardization of care practice, or quality indicators (e.g., structural, process, and outcome measures), within long-term nursing home care have remained relatively unchanged. This paper reports a value-critical policy analysis of the most recent final action rule, effective on November 28 of 2016 by the Centers for Medicare and Medicaid Services (CMS) with a particular focus on its impact on African-American and Latino older adults. This paper presents results of two policy analyses. Taken together, this merged analysis focuses on an overview of the problem, the groups most affected by the problem, current program goals and objectives, forms of benefits and services, and a current state of the social problem. Following the analysis, we present changes and improvements to be made, as well as proposals for reform and recommendations for policy changes.

Testing of the Function Focused Environment Assessment and the Function Focused Policy Assessment in Assisted Living

This study tested two new instruments, the Function Focused Environment Assessment (FF-EA) and the Function Focused Policy Assessment (FF-PA). The measures were developed for clinical evaluation of AL settings to help optimize function and physical activity among residents. A total of 106 AL settings and 242 residents were included. There was evidence of item reliability (0.92) and interrater reliability (kappa=0.40, p=.015; percent agreement 85%) of FF-EA and item reliability (0.89) and interrater reliability (kappa=0.48, p=.001, percent agreement 82%) of the FF-PA, and support for validity of both measures based on INFIT and OUTFIT statistics and hypothesis testing.

Physical Activity and Function in Assisted Living Residents

The purpose of this study was to consider the feasibility, reliability, and validity of MotionWatch 8. A total of 249 residents were recruited from 26 assisted living settings. Data collection included demographics, comorbidities, function (Barthel Index), physical activity (MotionWatch 8), and falls. The mean age of participants was 86.86 ( SD = 7.0), the majority were women 179 (74%) and White ( N = 232, 96%). A total of 86% of participants wore the MotionWatch 8. There were no significant differences in physical activity over 3 days of testing. The MotionWatch 8 findings were significantly associated with activities of daily living (ADL) function. There were no significant differences in ADL function or physical activity between those who did and did not fall. The study provides additional support for the feasibility, reliability, and validity of the MotionWatch 8 and confirms that older adults living in assisted living settings spend the majority of their time in sedentary activity.

Physical Function, Relocation, and Mortality Outcomes in Residential Care and Assisted Living Residents

Objective: This study aimed to identify predictors of 6-month physical function and 12-month relocation or death in 272 residents of 34 residential care/assisted communities. Method: Measures collected at baseline, 6, and 12 months included health and demographic characteristics; self-reported pain, fatigue, and depressive symptoms; exercise self-efficacy, barriers, and expectations; attitudes on aging; performance-based physical function and physical activity; and community demographics, programs, and policies. GLIMMIX procedures for regression analyses with community as a random effect were run. Results: Better baseline physical function and grip strength, female sex, and residential care community predicted better 6-month physical function. At 12 months, 25.6% had relocated or died. The odds of 12-month relocation or death for 1-point increase in physical function score was 0.84 and for 1-point increase in depression score was 1.16. Discussion: Targets to promote longer tenure in residential care/assisted living include programs to ameliorate functional decline and depression screening and treatment.

A pilot exploration of the effect of designated Function Focused Care on mobility, functional dependence and falls frequency in Dutch nursing home residents

In recent years, there has been a gradual change in nursing home care from care providers doing as many things as possible for residents to a philosophy where patients are encouraged to become more involved in their care and activities of daily living. Function Focused Care (FFC) is a methodology to stimulate the involvement of residents on a daily basis that has shown to be safe and effective in improving ADL-functioning. We implemented FFC in four nursing homes with 53 residents. This first pilot project in Dutch nursing homes has replicated the finding that FFC inspires functional independence, but also revealed a reduction in the number of falls among fallers.

Dissemination and Implementation of Function Focused Care for Assisted Living

Assisted living (AL) settings are residential settings that provide housing and supportive services for older and disabled adults. Although individuals in AL are less functionally impaired than those in nursing home settings, they engage in limited amounts of physical activity and experience more rapid functional decline than their peers in nursing homes. Function Focused Care for Assisted Living (FFC-AL) was developed to prevent decline, improve function, and increase physical activity among residents living in these settings. The purpose of this study was to disseminate and implement the previously established, effective FFC-AL approach to 100 AL settings. Evidence of our ability to successfully disseminate and implement FFC-AL across these settings was established using the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance model. Settings were eligible to participate if they had more than eight beds and identified a nurse (i.e., registered nurse, licensed practical nurse, or direct care worker) champion to facilitate the implementation process. Setting recruitment was done via mailed invitations to 300 eligible ALs and e-mails to relevant AL organizations. Evidence of reach was based on our ability to recruit 99 ALs with adoption of the intervention in 78 (78%). There was a significant improvement in policies supporting function-focused care and in establishing environments that supported function-focused care, and there was evidence of enduring changes in settings indicative of maintenance. We were able to implement all aspects of the intervention although challenges were identified. Future work should focus on using more face-to-face interactions with champions along with identified stakeholders, evaluating characteristics of champions to establish those who are most successful, and recruiting residents to obtain resident-specific outcomes.

Predicting Functional Decline and Recovery for Residents in Veterans Affairs Nursing Homes

PURPOSE OF THE STUDY

This article describes methods and accuracy of predicting change in activities of daily living (ADLs) for nursing home patients following hospitalization.

DESIGN AND METHODS

Electronic Health Record data for 5,595 residents of Veterans Affairs' (VAs') Community Living Centers (CLCs) aged 70 years and older were analyzed within the VA Informatics and Computing Infrastructure. Data included diagnoses from 7,106 inpatient records, 21,318 functional status evaluations, and 69,140 inpatient diagnoses. The Barthel Index extracted from CLC's Minimum Data Set was used to assess ADLs loss and recovery. Patients' diagnoses on hospital admission, ADL status prior to hospitalization, age, and gender were used alone or in combination to predict ADL loss/gain following hospitalization. Area under the Receiver-Operator Curve (AUC) was used to report accuracy of predictions in short (14 days) and long-term (15-365 days) follow-up post-hospitalization.

RESULTS

Admissions fell into 7 distinct patterns of recovery and loss: early recovery 19%, delayed recovery 9%, delayed recovery after temporary decline 9%, early decline 29%, delayed decline 10%, delayed decline after temporary recovery 6%, and no change 18%. Models accurately predicted ADL's 14-day post-hospitalization (AUC for bathing 0.917, bladder 0.842, bowels 0.875, dressing 0.871, eating 0.867, grooming 0.902, toileting 0.882, transfer 0.852, and walking deficits was 0.882). Accuracy declined but remained relatively high when predicting 14-365 days post-hospitalization (AUC ranging from 0.798 to 0.875).

IMPLICATIONS

Predictive modeling may allow development of more personalized predictions of functional loss and recovery after hospitalization among nursing home patients.