Informal care provided in US nursing homes: Reduced from 2010 to 2021 and lower for Medicaid residents

BACKGROUND

Little is known about the trend of informal care (unpaid care provided by family or other caregivers) provided to nursing home residents before or during the COVID-19 pandemic. This study assessed this trend during 2010-2021, for all and Medicaid versus non-Medicaid residents.

METHODS

Using data from the RAND Health and Retirement Study longitudinal file, our study sample included a total of 2025 resident-years (860 for Medicaid and 1165 for non-Medicaid residents). We fit two-part regression models to determine adjusted trends in average amount of informal care over time, and difference by resident Medicaid status.

RESULTS

Informal care received by residents reduced substantially over time, from an average of 39.2 h in the past month of interview in 2010-11 to 23.2 h in 2018-19, and then to 11.2 h in the COVID-19 pandemic (2020-21). The reduced hours were due to both reduced percentages of nursing home residents who received any informal care and reduced hours of care among those who did receive it over time. Multivariable analyses confirmed this trend and similar downward trends for Medicaid versus non-Medicaid residents. Medicaid residents on average received 10.02 fewer hours of informal care per month (95% confidence interval -17.16, -2.87; p = 0.006) than non-Medicaid residents after adjustment for resident characteristics and time trends.

CONCLUSION

Informal care provided to nursing home residents during 2010-2021 reduced over time, especially during the COVID-19 pandemic (2020-21). Medicaid residents tended to receive less informal care than non-Medicaid residents.

Multi-Level Factors Associated with Relationship-Centred and Task-Focused Mealtime Practices in Long-Term Care: A Secondary Data Analysis of the Making the Most of Mealtimes Study

Mealtimes in long-term care (LTC) can reinforce relationships between staff and residents through relationship-centred care (RCC) practices; however, meals are often task-focused (TF). This cross-sectional study explores multi-level contextual factors that contribute to RCC and TF mealtime practices. Secondary data from residents in 32 Canadian LTC homes were analyzed (n = 634; mean age 86.7 ± 7.8; 31.1% male). Data included resident health record review, standardized mealtime observation tools, and valid questionnaires. A higher average number of RCC (9.6 ± 1.4) than TF (5.6 ± 2.1) practices per meal were observed. Multi-level regression revealed that a significant proportion of variation in the RCC and TF scores was explained at the resident- (intraclass correlation coefficient [ICC]RCC = 0.736; ICCTF = 0.482), dining room- (ICCRCC = 0.210; ICCTF = 0.162), and home- (ICCRCC = 0.054; ICCTF = 0.356) levels. For-profit status and home size modified the associations between functional dependency and practices. Addressing multi-level factors can reinforce RCC practices and reduce TF practices.

Why Men Fare Worse: A Mixed-Methods Study Examining Gender Differences in Nursing Home Resident Quality of Life

BACKGROUND AND OBJECTIVES

Despite research documenting gender differences in numerous outcomes in later life, we know little about gender differences in quality of life (QoL) for nursing home (NH) residents. This study examines the relationship between gender and residents' QoL, including possible reasons for differences observed.

RESEARCH DESIGN AND METHODS

We used a mixed-methods design including surveys with a random sample of Minnesota NH residents using a multidimensional measure of QoL (n = 9,852), resident clinical data, facility-level characteristics (n = 364), interviews with residents (n = 64), and participant observations. We used linear mixed models and thematic analysis of resident interviews and observations to examine possible gender-related differences in residents' QoL.

RESULTS

After controlling for individual and facility characteristics, men reported lower overall QoL than women, including significantly lower ratings in several QoL domains. In interviews, men noted being less satisfied with activities than women, having fewer friends, and being less able to rely on family for support. Some women described the NH as a place of respite, but men more often described being dissatisfied with life in the NH and undesirable for long-term living. Our observations were consistent with interview findings but provide additional nuances, such as that some men organized their own social groups.

DISCUSSION AND IMPLICATIONS

Our findings suggest that men and women experience QoL differently in NHs, with men reporting lower QoL in several domains. Tailoring more activities for men and finding ways to strengthen relationships for men in NHs could help reduce the gender differences in QoL we observed.

Psychosocial factors influencing the eating behaviours of older adults: A systematic review

Our understanding of how eating behaviours change in later life have been dominated by the studies of physiological and biological influences on malnutrition. Insights from these studies were consequently used to develop interventions, which are predominantly aimed at rectifying nutritional deficiencies, as opposed to interventions that may enable older adults to eat well and enjoy their food-related life well into older age. The objective of the present review is to summarise the existing knowledge base on psychosocial influences on eating behaviours in later life. Following comprehensive searches, review, and appraisal, 53 articles were included (22 qualitative and 31 quantitative) to provide a greater understanding of the mechanisms underpinning the psychosocial factors influencing eating behaviours. Our analysis identified eight underpinning psychosocial factors that influences eating behaviours in later life; (1) health awareness & attitudes, (2) food decision making, (3) perceived dietary control, (4) mental health & mood, (5) food emotions & enjoyment, (6) eating arrangements, (7) social facilitation, and (8) social support. The importance and lasting influence of early food experiences were also identified as contributing to eating behaviours in later life. The review concludes with the call for further investigation into specific psychosocial factors that influence eating behaviour, calls for improvements in methodologies, and a summary of psychosocial barriers and enablers to eating well in later life.

Dyadic interactions and physical and social environment in dementia mealtime care: a systematic review of instruments

Using valid instruments to measure dyadic interactions and physical and social environment during mealtime care of persons with dementia is critical to evaluate the process, fidelity, and impact of mealtime interventions. However, the characteristics and quality of existing instruments remain unexplored. This systematic review described the characteristics and synthesized the psychometric quality of instruments originally developed or later modified to measure mealtime dyadic interactions and physical and/or social dining environment for people with dementia, on the basis of published reports between January 1, 1980 and December 31, 2020. We identified 26 instruments: 17 assessed dyadic interactions, one assessed physical environment, and eight assessed physical and social environment. All instruments were used in research and none in clinical practice. All instruments were observational tools and scored as having low psychometric quality, except for the refined Cue Utilization and Engagement in Dementia (CUED) mealtime video-coding scheme rated as having moderate quality. Reasons for low quality are the use of small samples compared with the number of items, limited psychometric testing, and inadequate estimates. All existing tools warrant further testing in larger diverse samples in varied settings and validation for use in clinical practice. The refined CUED is a potential tool for use and requires testing in direct on-site observations.

Impact of COVID-19 on Relationship-Centred Residential Dining Practices

This study describes changes in dining practices and provider perspectives on meal-related challenges due to the coronavirus disease (COVID-19) pandemic. An online survey was disseminated between July and September 2020 through stakeholder networks and social media with 1,036 respondents. Altered dining practices included residents eating in rooms (54.3%), spacing residents in common areas for meals (69.3%), and disposable dish use (44.9%). The most common mealtime challenges were reduced socializing opportunities at meals (29.3%), inadequate staffing (22.8%), reduced family/volunteer help (16.7%), and assisting residents to eat (10.5%). Many participants (72.2%) felt conflict balancing safety and relationship-centred care. Geographic region, home size, building age, respondent’s job title, pre-pandemic relationship-centred practices, and mealtime satisfaction, and some pandemic-initiated practices were associated with mealtime challenges and feeling conflicted in binary logistic regression analyses. Considering trade-offs between safety and relational aspects of mealtimes during the pandemic is crucial.

Dehydration in the nursing home: Recognition and interventions taken by Dutch nursing staff

Aims

To examine which signs/symptoms registered nurses (RNs) and certified nurse assistants (CNAs) (nursing staff) in Dutch nursing homes associate with dehydration, if they observe these signs/symptoms themselves and what they do after observing them.

Design

A cross‐sectional study.

Methods

In February 2020, using an online questionnaire based on a diagnostic strategy to diagnose dehydration, nursing staff was asked: (1) which signs/symptoms they associate with dehydration; (2) if they observe these signs/symptoms themselves; and (3) which actions they take after observing these signs/symptoms in a resident. Descriptive statistics and Chi‐square statistics were used to describe the answers and explore significant differences between groups.

Results

In total, 250 RNs and 226 CNAs participated. Among RNs, 67%–99% associated the signs/symptoms of the strategy to dehydration compared with 45%–98% of the CNAs. RNs and CNAs often indicated to observe signs/symptoms from the strategy themselves (80.1% and 92.6%), but they also often relied on information given by other care professionals and the informal caregiver. Interventions taken were mainly focused on communicating findings to colleagues.

Conclusion

Many signs/symptoms from the diagnostic strategy trigger nursing staff to think of dehydration. Results also show that a variety of formal and informal caregivers are involved in dehydration care. As RNs and CNAs did often not receive dehydration training after entering workforce, this could have limited their ability to recognize signs/symptoms related to dehydration. To ensure timely recognition of dehydration, a clear description of roles and responsibilities about dehydration care in, and between, formal and informal caregivers is essential with structurally embedded dehydration training in the nursing home.

Impact

Tackling dehydration in the nursing home requires interdisciplinary collaboration and communication with family members. Without clear roles and responsibilities, a risk of dehydration can be left unattended.

Mealtime care and dietary intake in older psychiatric hospital inpatient: A multiple case study

AIMS

To investigate the energy and protein adequacy of meals and dietary intake of older psychiatric inpatients and describe patient and mealtime factors potentially influencing intake.

DESIGN

Multiple case studies.

METHODS

Psychiatric inpatients aged 65 years and older, admitted to a single mental health ward during the 6-week study period (April-May 2019) were eligible for inclusion. Dietary intake was observed for two consecutive days each week (minimum four observation days). Visual plate waste methods were used to estimate patients' dietary intake at mealtimes, with energy and protein intake calculated using known food composition data and compared with estimated requirements. Medical records were reviewed weekly to collect information on potential factors related to intake and mealtime care. Data from all sources were first summarized in a case record for within-case analysis using descriptive statistics, followed by cross-case analysis.

RESULTS

Eight participants (five men, age 67-90 years, two underweight and one overweight, and four requiring some mealtime assistance) had 5-12 days of observation data recorded. Three met their estimated daily energy and protein requirements throughout the study period, while the remaining five participants did not. The main barriers identified as contributing to insufficient energy and protein intake were as follows: missing meals (asleep and treatment); inadequate food provided (insufficiency of the standard hospital menu); and need for increased mealtime assistance.

CONCLUSION

Poor dietary intake may be common among older psychiatric patients, suggesting that they may also need nursing and multidisciplinary nutrition care interventions shown to effectively prevent and treat malnutrition in other older inpatient groups.

IMPACT

Older psychiatric patients experience similar nutrition and mealtime issues to other older inpatients. This study highlights the need for nurses and the multidisciplinary team to ensure patients order and receive adequate food, especially when they miss meals and that they receive proactive mealtime assistance.

Interventions to foster family inclusion in nursing homes for people with dementia: a systematic review

BACKGROUND

Family inclusion in nursing homes is central to the provision of individualized care for people with dementia. Although positive effects can be recognized, barriers have been identified that hamper family inclusion in nursing homes. Specifically for people with dementia, insight into the content of interventions to foster family inclusion is lacking.

METHODS

A systematic review was performed by systematically searching the databases PubMed, Cinahl, PsycInfo and Embase. Studies were eligible if they examined (1) nursing home settings, (2) interventions to foster the inclusion of family members from people with dementia, (3) were original research articles in which effects/experiences of/with these interventions were evaluated, and (4) were written in English, Dutch or German. Findings were summarized systematically.

RESULTS

Twenty-nine studies were included. Two interventions were targeted at creating family-staff partnerships from a two-way perspective. Other interventions focused on single components, such as including family members in formal decisions (n = 9), enabling them to make better informed decisions and/or participate more actively (n = 7), or providing psychoeducation for family members (n = 3). Within the interventions, family and staff members are often treated differently. Effects on actual increase in family inclusion remain unclear.

CONCLUSIONS

Very few interventions exist that try to enhance equal family-staff partnerships in nursing homes. Future interventions should pay specific attention to mutual exchange and reciprocity between family and staff. As little is known about promising (components of) interventions to foster family inclusion in nursing homes for people with dementia, more effectiveness research is needed.

"Tailoring homely meals": Family members' motivations underlying nursing home visits during residents' meals

AIM

Elderly nursing home residents are often malnourished or at risk of malnutrition. Family members often visit residents during mealtimes, which might be an ideal opportunity for interventions targeted at improving the nutritional status of older residents. Therefore, this study aimed to explore motivations behind family member visits with nursing home residents during mealtime in Taiwan.

METHODS

This phenomenological study was conducted with family members of residents from four nursing homes in Taiwan. Participants were purposively sampled. Data were collected with individual face-to-face interviews from 18 family members. Data from transcribed audio-recorded interviews were analyzed using the approach of van Manen.

RESULTS

Analysis of the interview data identified the essence of motivations underlying family members' visits to nursing home residents during mealtimes, which we termed "tailoring homely meals." This referred to providing food tailored to residents' needs, providing a comforting family atmosphere, assisting residents during mealtime, and monitoring food consumption.

CONCLUSIONS

The motivations of family members to visit during mealtime could guide healthcare professionals working with East Asian populations in developing interventions to reduce the possibility of malnutrition, while also improving their quality of life. We recommend providing the following for nursing home residents: a nutritious and balanced diet, supporting their independence and ability to feed themselves, and encouraging involvement of family members during mealtimes.

Self-feeding dependence incidence and predictors among nursing home residents: Findings from a 5 year retrospective regional study

The aim of this regionally-based, retrospective study was to describe the incidence of self-feeding dependence and predictors among elderly patients admitted from 2008 to 2013 to 105 Italian nursing homes. Data reported in a regional database collected at the time of nursing home admission and every 6 months up to the resident's death were accessed. The self-feeding degree of dependence was the dependent variable; at the individual and nursing home levels, explanatory variables were those collected at nursing home admission and every 6 months. The structural equation model and the ordinal polynomial logit regression analysis were performed. A total of 13 175 records of residents when admitted to the nursing home and their following 69 341 records, were included. At the time of nursing home admission, 6496 residents (49.3%) reported a certain degree of dependence in self-feeding and showed slight worsening in their dependence every 6 months. At the individual level, the increased functional dependence raised the proportional odds ratios of approximately 4.36 times of an increased dependence in self-feeding; the degree of cognitive impairment, the lack of social interactions, the occurrence of pressure sores, comorbidities, as well as the clinical instability and time all raised the risk of self-feeding dependence progression. At the nursing home level, an increased number of beds emerged as a factor also increasing the proportional odds of dependence in self-feeding. Factors affecting self-feeding dependence are multi-faceted at the individual and at the nursing home levels.

High feeding dependence prevalence in residents living in Italian nursing homes requires new policies: Findings from a regionally based cross-sectional study

OBJECTIVES

An increased amount of functional dependence has been reported among residents living in nursing homes. Among others, feeding dependence is one of the most complex needs to satisfy: behind the attempt to personalise meals with individual preferences and clinical regimens, all residents require help at the same moment and for long periods of time, three or more times a day. With the intent of debating policy implications, the aims of this study were to advance the knowledge in the field of feeding dependence prevalence and predictors in Italy, a country where life expectancy is among the highest in the World.

METHOD

A large retrospective regionally-based study approaching all nursing homes (n = 105) was performed in 2014; all residents (n = 10,900) were eligible and those with a completed assessment recorded in the regional database and aged >65 years (n = 8875) were included.

RESULTS

1839 residents (20.7%) were in total need of help in feeding on a daily basis. At the multilevel analysis, predictors were moderate/severe dementia (OR 4.044, CI 95% 3.213-5.090); dysphagia (OR 4.003 CI 95% 3.155-5.079); pressure sores (OR 2.317 CI 95% 1.803-2.978); unintentional weigh loss (OR 2.197 CI 95% 1.493-3.233); unsociability (OR 1.561 CI 95% 1.060-2.299); and clinical instability (OR 1.363 CI 95% 1.109-1.677).

CONCLUSIONS

The feeding dependence prevalence emerged seem to be unique compared to that documented at the international levels. Modifiable and unmodifiable predictors found require new policies regarding workforce skills-mix and shifts schedules; as well as alliances with families, associations and communities' stakeholders. According to the complexity of the resident profile emerged, staff education and training is also recommended.

The Effect of Dining Room Physical Environmental Renovations on Person-Centered Care Practice and Residents’ Dining Experiences in Long-Term Care Facilities

This qualitative study evaluated the effect of dining room physical environmental changes on staff practices and residents’ mealtime experiences in two units of a long-term care facility in Edmonton, Canada. Focus groups with staff ( n = 12) and individual interviews with unit managers ( n = 2) were conducted. We also developed and used the Dining Environment Assessment Protocol (DEAP) to conduct a systematic physical environmental evaluation of the dining rooms. Four themes emerged on the key influences of the renovations: (a) supporting independence and autonomy, (b) creating familiarity and enjoyment, (c) providing a place for social experience, and (d) challenges in supporting change. Feedback from the staff and managers provided evidence on the importance of physical environmental features, as well as the integral nature of the role of the physical environment and organizational support to provide person-centered care for residents.

Family Involvement in Nursing Homes: Are Family Caregivers Getting What They Want?

The provision of person-centered care for nursing home residents with dementia suggests the need for family caregiver involvement. In this article, we argue that optimal family involvement differs by family caregiver and therefore depends on the degree to which family caregivers consider their own involvement to be important. In this Canadian study, we compare the importance that 135 family caregivers of residents with dementia place on 20 kinds of involvement with the degree to which they perceive opportunities for involvement. Family Involvement Congruence Scores are calculated in three ways: those for whom involvement is important, those for whom involvement is not important, and an overall congruence score. Congruence scores varied by involvement type. These scores show promise for use in future research on family caregiver involvement and as tools for use by facilities as they endeavor to meet family caregiver expectations for involvement.

Malnutrition in the nursing home

PURPOSE OF REVIEW

Malnutrition in the nursing home is increasingly recognized as a major international research priority, given the expanding geriatric populations, serious consequences, and challenges conducting research in nursing homes. This review examines the recent literature and suggests implications for research and practice.

RECENT FINDINGS

Across the recent studies, approximately 20% of nursing home residents had some form of malnutrition. However, malnutrition definitions were variable and prevalence ranged from 1.5 to 66.5%. Depression, cognitive impairment, functional impairment, and swallowing difficulty were consistently associated with malnutrition. Mortality was the major consequence of malnutrition among nursing home residents, whereas higher BMIs had lower risks of mortality. Beneficial interventions to reduce malnutrition in the nursing home included dietary supplements, greater resident role in food choice, and staff training programs.

SUMMARY

To truly tackle the issue of malnutrition in the nursing home setting, a consistent definition is needed. We strongly recommend that an expert consensus panel identify a standard set of measures to more accurately compare the prevalence across countries. Given the mortality consequences of malnutrition and the paucity of intervention studies, research on interventions for malnutrition in the nursing home needs to be a higher priority for facilities, researchers, and funding agencies.