Validity and responsiveness to change of clinically derived MDS scales in Alzheimer disease outcomes research

Detecting agitation and aggression in persons living with dementia: a systematic review of diagnostic accuracy

OBJECTIVE

40-60% of persons living with dementia (PLWD) experience agitation and/or aggression symptoms. There is a need to understand the best method to detect agitation and/or aggression in PLWD. We aimed to identify agitation and/or aggression tools that are validated against a reference standard within the context of PLWD.

METHODS

Our study was registered on PROSPERO (CRD42020156708). We searched MEDLINE, Embase, and PsycINFO up to April 22, 2024. There were no language or date restrictions. Studies were included if they used any tools or questionnaires for detecting either agitation or aggression compared to a reference standard among PLWD, or any studies that compared two or more agitation and/or aggression tools in the population. All screening and data extraction were done in duplicates. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data extraction was completed in duplicates by two independent authors. We extracted demographic information, prevalence of agitation and/or aggression, and diagnostic accuracy measures. We also reported studies comparing the correlation between two or more agitation and/or aggression tools.

RESULTS

6961 articles were screened across databases. Six articles reporting diagnostic accuracy measures compared to a reference standard and 30 articles reporting correlation measurements between tools were included. The agitation domain of the Spanish NPI demonstrated the highest sensitivity (100%) against the agitation subsection of the Spanish CAMDEX. Single-study evidence was found for the diagnostic accuracy of commonly used agitation scales (BEHAVE-AD, NPI and CMAI).

CONCLUSIONS

The agitation domain of the Spanish NPI, the NBRS, and the PAS demonstrated high sensitivities, and may be reasonable for clinical implementation. However, a limitation to this finding is that despite an extensive search, few studies with diagnostic accuracy measurements were identified. Ultimately, more research is needed to understand the diagnostic accuracy of agitation and/or aggression detection tools among PLWD.

Performance of the Cognitive Performance Scale of the Resident Assessment Instrument (interRAI) for Detecting Dementia amongst Older Adults in the Community

The Cognitive Performance Scale (CPS) in the widely used interRAI suite of instruments is of interest to clinicians and policy makers as a potential screening mechanism for detecting dementia. However, there has been little evaluation of the CPS in home care settings. This retrospective diagnostic study included 134 older adults (age ≥ 65) who were discharged from two acute psychogeriatric inpatient units or assessed in two memory clinics. The reference test was a diagnosis of clinical dementia, and the index test was interRAI CPS measured within 90 days of discharge. The overall accuracy of the CPS was good, with an area under the Receiver Operating Characteristic curve of 0.82 (95% CI = 0.75–0.89). The optimal cut point was 1/2, coinciding with the recommended cut point, with good sensitivity (0.90, 95% CI = 0.81–0.96) but poor specificity (0.60, 95% CI = 0.46–0.72). Positive predictive value improved from 0.72 (95% CI = 0.66–0.78) to 0.89 (95% CI = 0.75–0.96) when using a cut point of 2/3 instead of 1/2. If the results of the present study are replicated with more generalisable interRAI samples, older adults with a CPS of 3 or above, but without a formal diagnosis of dementia, should be referred for further cognitive assessment.

An MDS 3.0 Distressed Behavior in Dementia Indicator (DBDI): A Clinical Tool to Capture Change

BACKGROUND/OBJECTIVES

Persons with dementia frequently demonstrate distress behaviors in dementia (DBD), associated with poorer outcomes. This study aimed to create a measure of DBD from routinely administered Minimum Data Set (MDS 3.0) behavior section items that demonstrated sensitivity to change, for evaluation of intervention efforts for VA Community Living Center (CLCs) residents exhibiting DBD.

SETTING

72 VA nursing home settings, or Community Living Centers (CLCs).

PARTICIPANTS

CLC residents with DBD (n = 302) were enrolled in an interdisciplinary behavioral intervention between 2013 and 2017.

DESIGN

A factor analysis of MDS behavior section items from assessments closest to baseline was conducted. Internal consistency, hypothesized associations between MDS factors and clinical measures, and sensitivity to detect change over time was explored.

MEASUREMENTS

Residents were assessed at baseline and post-intervention using the MDS behavior section items and a validated clinical measure of DBD.

RESULTS

The Distress Behavior in Dementia Indicator (DBDI) was created as a consistent factor with internal consistency, and was related to a validated measure as predicted at baseline and post-intervention. Sensitivity to change was demonstrated by using change score correlations (r = 0.40-0.50), effect size (d = 0.63), and reliable change indices.

CONCLUSION

The DBDI is recommended for routine use in CLCs to evaluate impact of intervention effectiveness and provide quality improvement feedback.

Impact of deprescribing AChEIs on aggressive behaviors and antipsychotic prescribing

INTRODUCTION

We evaluated the impact of deprescribing acetylcholinesterase inhibitors (AChEIs) on aggressive behaviors and incident antipsychotic use in nursing home (NH) residents with severe dementia.

METHODS

We conducted a retrospective study of Medicare claims, Part D, Minimum Data Set for NH residents aged 65+ with severe dementia receiving AChEIs in 2016. Aggressive behaviors were measured using the aggressive behavior scale (ABS; n = 30,788). Incident antipsychotic prescriptions were evaluated among antipsychotic non-users (n = 25,188). Marginal structural models and inverse probability of treatment weights were used to evaluate associations of AChEI deprescribing and outcomes.

RESULTS

The severity of aggressive behaviors was low at baseline (mean ABS = 0.5) and was not associated with deprescribing AChEIs (0.002 increase in ABS, P = .90). Incident antipsychotic prescribing occurred in 5.1% of residents and was less likely with AChEI deprescribing (adjusted odds ratio = 0.52 [0.40-0.68], P <.001]).

DISCUSSION

Deprescribing AChEIs was not associated with a worsening of aggressive behaviors or incident antipsychotic prescriptions.

The Minimum Data Set Agitated and Reactive Behavior Scale: Measuring Behaviors in Nursing Home Residents With Dementia

OBJECTIVES

Interventions aimed at managing agitated and aggressive behaviors in dementia without the use of antipsychotics are currently being tested in nursing homes (NHs). Researchers and clinicians require a measure that can capture the severity of residents' behaviors. We test the internal consistency and construct validity of the Agitated and Reactive Behavior Scale (ARBS), a measure created using data from mandatory NH assessments.

DESIGN

Cross-sectional.

SETTING AND PARTICIPANTS

The 2016 national sample of 15,326 Centers for Medicare and Medicaid Services-certified NHs. The analytic sample included 489,854 new admissions and 765,367 long-stay residents (at least 90 days in NH). All participants have a dementia diagnosis.

METHODS

Minimum Data Set (MDS), version 3.0. The ARBS is a composite measure of (1) physical behavioral symptoms directed at other people; (2) verbal behavioral symptoms directed at other people; (3) other behavioral symptoms not directed at other people; and (4) rejection of care. Variables used to establish construct validity included degree of cognitive impairment, use of medications for managing agitation and aggression, and co-occurring conditions associated with agitated and aggressive behaviors (eg, schizophrenia, depression, or delirium).

RESULTS

This report has 3 important findings: (1) the ARBS score has borderline-adequate internal consistency (α = .64-.71) in the national population NH residents with dementia; (2) only 18% of new admissions and 21% of long-stay residents with dementia evidence any agitated or aggressive behaviors in the last week, as rated in the MDS assessment; and (3) the ARBS demonstrates good construct validity; it increases with cognitive impairment, treatment with relevant medications, and co-occurring psychiatric conditions and symptoms.

DISCUSSION

Nationally available MDS data may significantly underestimate the prevalence of agitated and aggressive behaviors among NH residents with dementia.

CONCLUSIONS AND IMPLICATIONS

Researchers conducting pragmatic trials of non-pharmaceutical interventions to manage behaviors in NH residents with dementia should consider the likely underdetection of these behaviors in the available MDS data.

Memantine for dementia

BACKGROUND

Memantine is a moderate affinity uncompetitive antagonist of glutamate NMDA receptors. It is licensed for use in moderate and severe Alzheimer's disease (AD); in the USA, it is also widely used off-label for mild AD.

OBJECTIVES

To determine efficacy and safety of memantine for people with dementia. To assess whether memantine adds benefit for people already taking cholinesterase inhibitors (ChEIs).

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register of trials (http://www.medicine.ox.ac.uk/alois/) up to 25 March 2018. We examined clinical trials registries, press releases and posters of memantine manufacturers; and the web sites of the FDA, EMEA and NICE. We contacted authors and companies for missing information.

SELECTION CRITERIA

Double-blind, parallel group, placebo-controlled, randomised trials of memantine in people with dementia.

DATA COLLECTION AND ANALYSIS

We pooled and analysed data from four clinical domains across different aetiologies and severities of dementia and for AD with agitation. We assessed the impact of study duration, severity and concomitant use of ChEIs. Consequently, we restricted analyses to the licensed dose (20 mg/day or 28 mg extended release) and data at six to seven months duration of follow-up, and analysed separately results for mild and moderate-to-severe AD.We transformed results for efficacy outcomes into the difference in points on particular outcome scales.

MAIN RESULTS

Across all types of dementia, data were available from almost 10,000 participants in 44 included trials, most of which were at low or unclear risk of bias. For nearly half the studies, relevant data were obtained from unpublished sources. The majority of trials (29 in 7885 participants) were conducted in people with AD.1. Moderate-to-severe AD (with or without concomitant ChEIs). High-certainty evidence from up to 14 studies in around 3700 participants consistently shows a small clinical benefit for memantine versus placebo: clinical global rating (CGR): 0.21 CIBIC+ points (95% confidence interval (CI) 0.14 to 0.30); cognitive function (CF): 3.11 Severe Impairment Battery (SIB) points (95% CI 2.42 to 3.92); performance on activities of daily living (ADL): 1.09 ADL19 points (95% CI 0.62 to 1.64); and behaviour and mood (BM): 1.84 Neuropsychiatric Inventory (NPI) points (95% CI 1.05 to 2.76). There may be no difference in the number of people discontinuing memantine compared to placebo: risk ratio (RR) 0.93 (95% CI 0.83 to 1.04) corresponding to 13 fewer people per 1000 (95% CI 31 fewer to 7 more). Although there is moderate-certainty evidence that fewer people taking memantine experience agitation as an adverse event: RR 0.81 (95% CI 0.66 to 0.99) (25 fewer people per 1000, 95% CI 1 to 44 fewer), there is also moderate-certainty evidence, from three additional studies, suggesting that memantine is not beneficial as a treatment for agitation (e.g. Cohen Mansfield Agitation Inventory: clinical benefit of 0.50 CMAI points, 95% CI -3.71 to 4.71) .The presence of concomitant ChEI does not impact on the difference between memantine and placebo, with the possible exceptions of the BM outcome (larger effect in people taking ChEIs) and the CF outcome (smaller effect).2. Mild AD (Mini Mental State Examination (MMSE) 20 to 23): mainly moderate-certainty evidence based on post-hoc subgroups from up to four studies in around 600 participants suggests there is probably no difference between memantine and placebo for CF: 0.21 ADAS-Cog points (95% CI -0.95 to 1.38); performance on ADL: -0.07 ADL 23 points (95% CI -1.80 to 1.66); and BM: -0.29 NPI points (95% CI -2.16 to 1.58). There is less certainty in the CGR evidence, which also suggests there may be no difference: 0.09 CIBIC+ points (95% CI -0.12 to 0.30). Memantine (compared with placebo) may increase the numbers of people discontinuing treatment because of adverse events (RR 2.12, 95% CI 1.03 to 4.39).3. Mild-to-moderate vascular dementia. Moderate- and low-certainty evidence from two studies in around 750 participants indicates there is probably a small clinical benefit for CF: 2.15 ADAS-Cog points (95% CI 1.05 to 3.25); there may be a small clinical benefit for BM: 0.47 NOSGER disturbing behaviour points (95% CI 0.07 to 0.87); there is probably no difference in CGR: 0.03 CIBIC+ points (95% CI -0.28 to 0.34); and there may be no difference in ADL: 0.11 NOSGER II self-care subscale points (95% CI -0.35 to 0.54) or in the numbers of people discontinuing treatment: RR 1.05 (95% CI 0.83 to 1.34).There is limited, mainly low- or very low-certainty efficacy evidence for other types of dementia (Parkinson's disease and dementia Lewy bodies (for which CGR may show a small clinical benefit; four studies in 319 people); frontotemporal dementia (two studies in 133 people); and AIDS-related Dementia Complex (one study in 140 people)).There is high-certainty evidence showing no difference between memantine and placebo in the proportion experiencing at least one adverse event: RR 1.03 (95% CI 1.00 to 1.06); the RR does not differ between aetiologies or severities of dementia. Combining available data from all trials, there is moderate-certainty evidence that memantine is 1.6 times more likely than placebo to result in dizziness (6.1% versus 3.9%), low-certainty evidence of a 1.3-fold increased risk of headache (5.5% versus 4.3%), but high-certainty evidence of no difference in falls.

AUTHORS' CONCLUSIONS

We found important differences in the efficacy of memantine in mild AD compared to that in moderate-to-severe AD. There is a small clinical benefit of memantine in people with moderate-to-severe AD, which occurs irrespective of whether they are also taking a ChEI, but no benefit in people with mild AD.Clinical heterogeneity in AD makes it unlikely that any single drug will have a large effect size, and means that the optimal drug treatment may involve multiple drugs, each having an effect size that may be less than the minimum clinically important difference.A definitive long-duration trial in mild AD is needed to establish whether starting memantine earlier would be beneficial over the long term and safe: at present the evidence is against this, despite it being common practice. A long-duration trial in moderate-to-severe AD is needed to establish whether the benefit persists beyond six months.

A randomised controlled trial of Lavender (Lavandula Angustifolia) and Lemon Balm (Melissa Officinalis) essential oils for the treatment of agitated behaviour in older people with and without dementia

OBJECTIVE

Lavender and Lemon Balm essential oils are popular in the management of older person agitation due to their ease of application, minimal side effects and low interaction with concurrent medications. This study addressed limitations in the literature to evaluate and compare effectiveness of Lavender and Lemon Balm essential oils on the agitated behaviour of older people with and without dementia living in residential aged care facilities [RACFs].

METHODS

Forty-nine nursing home residents with dementia (n=39) and without dementia (n=10) exhibiting agitation participated in this study. Participants were randomised to a counterbalanced, repeated measures design experiment that tests the treatments Lavender, Lemon Balm, and Placebo (Sunflower oil). Treatments were administered once daily for two-weeks followed by a two-week washout period before commencing the subsequent treatment. All participants trialed all three treatments over a 10-week period. Data were collected on the Neuropsychiatric Inventory (NPI) and Cohen-Mansfield Agitation Inventory (CMAI).

RESULTS

A significant difference was shown when essential oils effect were compared between the cognitive groups. Post hoc analysis reports Lemon Balm more effective in reducing NPI agitation (p = .04) and CMAI physical non-aggressive behaviour (PNAB) (p = .02) in residents without dementia. Lemon Balm less effective in reducing NPI irritability (p = 0.01) and Lavender more effective in reducing CMAI PNAB (p = 0.04) in dementia.

CONCLUSION

The findings support an opposing effect of Lemon Balm and Lavender in reducing agitated behaviour between the participant cognitive groups. There was no reduction in agitation with treatments when compared to placebo independent of cognitive groups.

Individual risk factors for possible undetected dementia amongst community-dwelling older people in New Zealand

There is general acknowledgement of the importance of early diagnosis of dementia, yet there are still high rates of undetected dementia internationally. The aim of this cross-sectional study was to determine the sociodemographic characteristics associated with possible undetected dementia in a large sample of community-dwelling older New Zealanders. The sample consisted of older people (age ≥ 65) who had received the homecare version of the international Residential Home Care Assessment version 9.1 over a two-year period and who were screened positive for possible dementia on the international Residential Assessment’s Cognitive Performance Scale. People with possible alternative explanations for impaired cognitive performance such as depression and other neurological conditions were excluded from analysis. The 5202 eligible individuals were categorized into two groups: (1) those with a recorded diagnosis of dementia (64%) and (2) those without a recorded diagnosis of dementia (i.e. possible undetected dementia group) (36%). Logistic regression was used to evaluate the association between individual characteristics and possible undetected dementia. Significant risk factors for being in the possible undetected dementia group included Asian ethnicity, living alone, not having participated in long-standing social activities recently, major life stressors, and limited accessibility of their house. The knowledge gained from this study could enable targeting of services and resources for the groups at risk of undetected dementia to have a more equitable access to early diagnosis.

Making the Most of Mealtimes (M3): protocol of a multi-centre cross-sectional study of food intake and its determinants in older adults living in long term care homes

BACKGROUND

Older adults living in long term care (LTC) homes are nutritionally vulnerable, often consuming insufficient energy, macro- and micronutrients to sustain their health and function. Multiple factors are proposed to influence food intake, yet our understanding of these diverse factors and their interactions are limited. The purpose of this paper is to fully describe the protocol used to examine determinants of food and fluid intake among older adults participating in the Making the Most of Mealtimes (M3) study.

METHODS

A conceptual framework that considers multi-level influences on mealtime experience, meal quality and meal access was used to design this multi-site cross-sectional study. Data were collected from 639 participants residing in 32 LTC homes in four Canadian provinces by trained researchers. Food intake was assessed with three-days of weighed food intake (main plate items), as well as estimations of side dishes, beverages and snacks and compared to the Dietary Reference Intake. Resident-level measures included: nutritional status, nutritional risk; disease conditions, medication, and diet prescriptions; oral health exam, signs of swallowing difficulty and olfactory ability; observed eating behaviours, type and number of staff assisting with eating; and food and foodservice satisfaction. Function, cognition, depression and pain were assessed using interRAI LTCF with selected items completed by researchers with care staff. Care staff completed a standardized person-directed care questionnaire. Researchers assessed dining rooms for physical and psychosocial aspects that could influence food intake. Management from each site completed a questionnaire that described the home, menu development, food production, out-sourcing of food, staffing levels, and staff training. Hierarchical regression models, accounting for clustering within province, home and dining room will be used to determine factors independently associated with energy and protein intake, as proxies for intake. Proportions of residents at risk of inadequate diets will also be determined.

DISCUSSION

This rigorous and comprehensive data collection in a large and diverse sample will provide, for the first time, the opportunity to consider important modifiable factors associated with poor food intake of residents in LTC. Identification of factors that are independently associated with food intake will help to develop effective interventions that support food intake.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02800291 , retrospectively registered June 7, 2016.

Convergent Validity, Concurrent Validity, and Diagnostic Accuracy of the interRAI Depression Rating Scale

AIMS

Depression Rating Scale (DRS) is one of the clinical outcome measures of the International Resident Assessment Instrument (interRAI) assessment. The primary aim of this study is to investigate the diagnostic accuracy and concurrent validity of the 3-day assessment window version of the DRS.

METHODS

The performance of DRS was compared with a gold standard clinical diagnosis of depression in 92 patients (age ≥65) who had interRAI version 9.1 Home Care assessment completed within 30 days of discharge from psychogeriatric inpatient care or memory clinic assessment.

RESULTS

The DRS had poor diagnostic accuracy for depression diagnosis with an area under the curve of 0.68 (95% confidence interval [CI] = 0.57-0.77). The DRS score had a poor to moderate correlation with the Health of the Nation Outcome Scale 65+ depression item score ( r_s = 0.30, 95% CI = 0.09-0.48, P = .006).

CONCLUSION

This study and the existing literature raise concerns that the DRS is not an adequate measure of depression.

Impact of Malnutrition on Physical, Cognitive Function and Mortality among Older Men Living in Veteran Homes by Minimum Data Set: A Prospective Cohort Study in Taiwan

OBJECTIVES

To evaluate the prevalence of malnutrition and its impact on mortality, functional decline and cognitive impairment among elder residents in long-term care settings.

DESIGNS

A prospective cohort study.

SETTINGS

Two veteran homes in Taiwan.

PARTICIPANTS

A total of 1,248 male residents aged equal or more than 65 years.

MEASUREMENTS

Charlson's comorbidity index (CCI), Minimum data set (MDS), resident assessment protocols (RAP), Activity of daily living-Hierarchy scale, Cognitive Performance Scale, MDS Social engagement scale.

RESULTS

The mean age of participants is 83.1 ± 5.1 years, and the prevalence of malnutrition was 6.1%. Inadequate dietary content (57.9%) and unintentional weight loss (31.6%) account for the majority of malnutrition identified by MDS tool. Higher 18-month mortality rate (25% vs. 14.2%), higher baseline CCI (median 1 vs. 0), and higher baseline sum of RAP triggers (median 8.5 vs. 5) were noted among residents with malnutrition. Furthermore, malnutrition was shown predictive for functional decline (OR: 3.096, 95% CI: 1.715-5.587) and potential cognitive improvement (OR: 2.469, 95% CI: 1.188-5.128) among survivors after adjustment for age, body mass index and CCI.

CONCLUSION

Malnutrition among elder men residing in veteran homes was associated with multimorbidities and higher care complexity, and was predictive for mortality and functional decline.

Dual Sensory Impairment and Cognitive Decline: The Results From the Shelter Study

OBJECTIVES

To examine whether nursing home residents with concurrent vision and hearing impairment, dual sensory impairment (DSI), have a greater cognitive decline over time than do those without sensory impairment and whether social engagement modifies this association.

METHODS

Based on the Services and Health for Elderly in Long TERm Care study, 1,989 nursing home residents who were assessed using the interRAI LTCF at 6-month intervals over 1 year were included. Multivariate linear regression models with time-variant exposure variables of sensory impairment and social engagement using generalized estimating equations were performed to predict cognitive function measured by the Cognitive Performance Scale (range 0-6).

RESULTS

Residents with DSI had a greater cognitive decline [changes in Cognitive Performance Scale over 1 year = 1.12 (95% confidence interval = 0.81:1.42)] compared to those with either vision or hearing impairment [0.67 (0.53:0.64)] and those without sensory impairment [0.56 (0.48:0.64)]. A lower level of social engagement was also associated with a greater cognitive decline. The combined exposure variable of sensory impairment and social engagement revealed the greatest cognitive decline for socially disengaged residents with DSI [1.87 (1.24:2.51)] and the potential effect modification of social engagement on the association between DSI and cognitive decline; DSI was not associated with a greater cognitive decline among socially engaged residents, while it was associated among socially disengaged residents

DISCUSSION

Cognitive function declines faster in nursing home residents with DSI only when residents were not socially engaged. Therefore, residents with DSI might cognitively benefit from interventions to improve involvement in social life at nursing homes.

Effect of medications on physical function and cognition in nursing home residents with dementia

OBJECTIVES

To assess the effectiveness of medications used in the management of Alzheimer's disease and related dementias (ADRD) on cognition and activity of daily living (ADL) trajectories and to determine whether sex modifies these effects.

DESIGN

Two-year (2007-2008) longitudinal study.

SETTING

Medicare enrollment and claims data linked to the Minimum Dataset 2.0.

PARTICIPANTS

Older nursing home (NH) residents with newly diagnosed ADRD (n = 18,950).

MEASUREMENTS

Exposures included four medication classes: antidementia medications (ADMs), antipsychotics, antidepressants, and mood stabilizers. Outcomes included ADLs and cognition (Cognitive Performance Scale (CPS)). Marginal structural models were employed to account for time-dependent confounding.

RESULTS

The mean age was 83.6, and 76% of the sample was female. Baseline use of ADMs was 15%, antidepressants was 40%, antipsychotics was 13%, and mood stabilizers was 3%. Mean baseline ADL and CPS scores were 16.6 and 2.1, respectively. ADM use was not associated with change in ADLs over time but was associated with a slower CPS decline (slope difference: -0.09 points/year, 99% confidence interval (CI) = -0.14 to -0.03). Antidepressant use was associated with slower declines in ADL (slope difference: -0.36 points/year, 99% CI = -0.58 to -0.14) and CPS (slope difference: -0.12 points/year, 99% CI = -0.17 to -0.08). Sex modified the effect of both antipsychotic and mood stabilizer use on ADLs; female users declined most quickly. Antipsychotic use was associated with slower CPS decline (slope difference: -0.11 points/year, 99% CI = -0.17 to -0.06), whereas mood stabilizer use had no effect.

CONCLUSION

Despite the observed statistically significantly slower declines in cognition with ADMs, antidepressants, and antipsychotics and the slower ADL decline found with antidepressants, it is unlikely that these benefits are of clinical significance.

Longitudinal differences in pain among older adult Home and Community Based Waiver Program participants in relation to diagnosis of cancer

Generalized estimating equation analyses models were used to examine the longitudinal association between pain and diagnosis of cancer among older adult, Home and Community Based Waiver Program participants. Daily pain was reported by over half, with 29% experiencing daily pain that was unusually intense. Diagnosis of cancer was a significant predictor of daily pain only as an interaction term with cognitive impairment. Being female, having a medical diagnosis of depression, or increasing measure of comorbid conditions significantly increased the likelihood of daily pain. In comparison, increasing age, being of African American, Hispanic, or "other" race resulted in a significantly decreased likelihood of daily pain.

Clinical changes in older adults during hospitalization: responsiveness of the interRAI acute care instrument

OBJECTIVES

To evaluate the responsiveness of the Minimum Data Set interRAI Acute Care (AC), a comprehensive geriatric assessment system, to detect clinical changes in patient status during hospital stays.

DESIGN

An explorative secondary data-analysis comparing prospectively collected data with the interRAI AC before hospitalization, upon admission, and at discharge.

SETTING

Clinicians from multiple disciplines in nine geriatric and eight nongeriatric wards of nine acute hospitals performed the assessment.

PARTICIPANTS

The interRAI AC was administered serially to 256 geriatric inpatients (aged 83.2 ± 5.2; 60% female).

MEASUREMENTS

Responsiveness (capacity to detect changes in patients) was calculated for the output scales on five domains: activities of daily living (ADLs), cognition, communication, depressive symptoms, and pain. Internal responsiveness was evaluated using the Friedman test and Guyatt technique.

RESULTS

Significant differences in clinical status were found for all five domains, based on the Friedman test. Post hoc tests revealed differences between each assessment period, except for cognition and communication from admission to discharge and for depressive symptoms from before admission to discharge. The Guyatt Responsiveness Index showed good to excellent capacity to detect longitudinal changes during hospitalization for cognition, communication, and pain and substantial performance for ADLs and depressive symptoms.

CONCLUSION

In older inpatients, fluctuations in ADLs, cognition, communication, depressive symptoms, and pain can be captured using the interRAI AC output scales, enabling clinicians to evaluate longitudinal changes from admission to discharge and to provide a comparison with patient status before the acute onset of the illness. These results support the use of these scales in geriatric and nongeriatric wards.

Psychotropic drug initiation or increased dosage and the acute risk of falls: a prospective cohort study of nursing home residents

Background

Previous studies suggest that psychotropic drug changes may signal an acute period of time whereby a person is highly vulnerable to fall. It is unknown whether certain classes of psychotropic agents are less safe with respect to the acute risk of falls. Our purpose was to compare fall rates in the 7 days following a change of an antidepressant, antipsychotic, or benzodiazepine. We also identified specific times when residents are at high risk for falls with respect to a psychotropic drug change.

Methods

Residents in our one-year study included 851 long term care residents from two nursing home facilities in Boston, MA, U.S.A. (May 2010 - May 2011). Drug changes (i.e., new prescriptions or increased dose of a previously used drug) were ascertained using the computerized provider order entry system, whereas falls were ascertained by incident reports. Negative binomial regression was used to compare the rate of falls following a drug change between medication classes. Further, we calculated the rate of falls for each of the 7 days before and 7 days after a psychotropic drug change.

Results

Forty-eight percent of residents were prescribed a new prescription or increased dose of a psychotropic drug during the study. The rate of falls was similar in the 7 days following a change to a SSRI versus non-SSRI antidepressant (11.9 versus 14.4 falls/1,000 person years; p = 0.58), a typical versus an atypical antipsychotic (25.4 versus 17.1 falls/1,000 person years; p = 0.10), or a short versus long acting benzodiazepine (15.2 versus 13.9 falls/1,000 person years; p = 0.23). Fall risk was highest on day 4 before the drug change (19.0 falls/1,000 person days), on the day of the drug change through 2 days after the drug change (17.6-20.3 falls/1,000 person days), and 5-6 days after the drug change (17.6-19.0 falls/1,000 person days).

Conclusions

In the nursing home, risk of falls was similar following a psychotropic drug change of any class. We observed higher fall risk in the days before, but mostly after the drug change. We recommend that nursing home residents be closely monitored following a psychotropic drug change in an effort to reduce falls.

Stakeholder perspectives on transitions of nursing home residents to hospital emergency departments and back in two Canadian provinces

Major gaps exist in our understanding of transitions in care for older persons living in nursing homes. The purpose of the study was to identify key elements, from multiple stakeholder perspectives, that influence the success of transitions experienced by nursing home residents when they required transfer to a hospital emergency department. This interpretive descriptive study was conducted in two cities in the Canadian provinces of British Columbia and Alberta. Data were collected from 71 participants via focus groups and individual interviews with nursing home residents, family members, and professional healthcare providers working in nursing homes, emergency departments, and emergency medical services. Transcripts were analyzed using constant comparison. The elements contributing to the success of transitions reflected a patient- and family-centered approach to care. Transitions were influenced by the complex interplay of multiple elements that included: knowing the resident; critical geriatric knowledge and skilled assessment; positive relationships; effective communication; and timeliness. When one or more of the elements was absent or compromised, the success of the transition was also compromised. There was consistency about the importance of all the identified elements across all stakeholder groups whether they are residents, family members, or health professionals in nursing homes, emergency departments or emergency medical services. Aspects of many of these elements are modifiable and suggest viable targets for interventions aimed at improving the success of transitions for this vulnerable population.