Measuring depression in nursing home residents with the MDS and GDS: an observational psychometric study

The Medical Complexity of Newly Admitted Long-Term Care Residents Before and During the COVID-19 Pandemic in Ontario, British Columbia, and Alberta: A Serial Cross-Sectional Study

The COVID-19 pandemic had profound effects on the long-term care (LTC) setting worldwide, including changes in admission practices. We aimed to describe the characteristics and medical complexity of newly admitted LTC residents before (March 1, 2019 to February 29, 2020) and during (March 1, 2020 to March 31, 2021) the COVID-19 pandemic via a population-based serial cross-sectional study in Ontario, Alberta, and British Columbia, Canada. With data from the Minimum Data Set 2.0 we characterize the medical complexity of newly admitted LTC residents via the Geriatric 5Ms framework (mind, mobility, medication, multicomplexity, matters most) through descriptive statistics (counts, percentages), stratified by pandemic wave, month, and province. We included 45 756 residents admitted in the year prior to and 35 744 during the first year of the pandemic. We found an increased proportion of residents with depression, requiring extensive assistance with activities of daily living, hip fractures, antipsychotic use, expected to live <6 months, with pneumonia, low social engagement, and admitted from acute care. Our study confirms an increase in medical complexity of residents admitted to LTC during the pandemic and can be used to plan services and interventions and as a baseline for continued monitoring in changes in population characteristics over time.

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.

Psychometric characteristics of comprehensive geriatric assessments (CGAs) for long-term care facilities and community care: A systematic review

BACKGROUND

Comprehensive Geriatric Assessments (CGAs) have been incorporated as an integrated care approach effective to face the challenges associated to uncoordinated care, risk of hospitalization, unmet needs, and care planning experienced in older adult care. As they assessed different dimensions, is important to inform about the content and psychometric properties to guide the decisions when selecting and implementing them in practice. This systematic review provides a comprehensive insight on the strengths and weaknesses of the CGAs used in long-term care settings and community care.

METHODS

A systematic search was conducted in PubMed, CINAHL, and Web of Science Core Collection. Studies published up to July 13, 2021, were considered. Quality appraisal was performed for the included studies.

RESULTS

A total of 10 different CGAs were identified from 71 studies included. Three instruments were reported for long-term care settings, and seven for community care. The content was not homogenous and differed in terms of the detail and clearness of the areas being evaluated. Evidence for good to excellent validity and reliability was reported for various instruments.

CONCLUSIONS

Setting more specific and clear domains, associated to the special needs of the care setting, could improve informed decisions at the time of selecting and implementing a CGA. Considering the amount and quality of the evidence, the instrument development trajectory, the validation in different languages, and availability in different care settings, we recommend the interRAI LTCF and interRAI HC to be used for long-term facilities and community care.

Social Engagement and Distress Among Home Care Recipients During the COVID-19 Pandemic in Ontario, Canada: A Retrospective Cohort Study

OBJECTIVES

To examine factors associated with distressing social decline and withdrawal during the COVID-19 pandemic for home care recipients.

DESIGN

Retrospective cohort.

SETTING AND PARTICIPANTS

Home care recipients age 18 years or older in Ontario, Canada without severe cognitive impairment with an assessment and follow-up between September 1, 2018 and August 31, 2020.

METHODS

Data were collected using the interRAI home care. Outcomes of interest were distressing decline in social participation and social withdrawal. Independent variables were entered into multivariable longitudinal generalized estimating equations. Interaction terms with the pandemic were tested. Those significant at P < .01 were retained in final models and reported as odds ratios (ORs), 95% confidence intervals (CIs).

RESULTS

We compared 26,492 and 19,126 home care recipients before and during the pandemic, respectively. The pandemic was associated with greater odds of experiencing distressing social decline (OR 1.28, 95% CI 1.22‒1.34) and withdrawal (OR 1.09, 95% CI 1.04‒1.15). Living alone (OR 1.13, 95% CI 1.05‒1.22), frailty (OR 3.21, 95% CI 2.76‒3.73), health instability (OR 2.22, 95% CI 2.02‒2.44), and depression (OR 2.14, 95% CI 2.01‒2.29) increased the odds of distressing social decline. Older age (OR 0.71, 95% CI 0.65‒0.77), functional impairment (OR 0.58, 95% CI 0.51‒0.67), and receiving caregiving (OR 0.73, 95% CI 0.67‒0.79) decreased the odds. Home care recipients with mild/moderate dementia were less likely to experience distressing social decline during the pandemic. Those who lived alone were more likely. Frailty (OR 9.49, 95% CI 7.69‒11.71) and depression (OR 2.76, 95% CI 2.55‒3.00) increased the odds of social withdrawal. Functional impairment (OR 0.32, 95% CI 0.27‒0.39), congestive heart failure (OR 0.77, 95% CI 0.70‒0.84), and receiving caregiving (OR 0.50, 95% CI 0.46‒0.55) decreased the odds. Home care recipients age 18‒64 years and older than 75 years were less likely to experience social withdrawal during the pandemic.

CONCLUSIONS AND IMPLICATIONS

Social support interventions should focus on supporting those living alone, with frailty, health instability, or depression.

Predictors of change over time in satisfaction with outdoor activities ratings among long-term care services and supports recipients

OBJECTIVES

To identify predictors of change in older adults' satisfaction with outdoor activities ratings over the first two years of enrollment in long-term services and supports (LTSS).

METHODS

Self-rated satisfaction with outdoor activities (not at all satisfied to extremely satisfied) was the primary outcome of this secondary data analysis. Mixed-effects linear regression modeling with a backward elimination process was used for analyses.

RESULTS

In the final model (N = 453) older LTSS recipients at baseline had lower ratings of satisfaction with outdoor activities over time, whereas younger recipients had higher ratings over time. Those who moved into a residential facility at baseline had an increase in outdoor activity satisfaction ratings over time compared to older adults who received home and community-based services that had a decrease.

DISCUSSION

LTSS clinicians can use these findings to support older adults with decision-making around enrollment into LTSS, address preferences, and develop person-centered care interventions for outdoor activity.

AI Prediction of Brain Signals for Human Gait Using BCI Device and FBG Based Sensorial Platform for Plantar Pressure Measurements

Artificial intelligence (AI) in developing modern solutions for biomedical problems such as the prediction of human gait for human rehabilitation is gaining ground. An attempt was made to use plantar pressure information through fiber Bragg grating (FBG) sensors mounted on an in-sole, in tandem with a brain-computer interface (BCI) device to predict brain signals corresponding to sitting, standing and walking postures of a person. Posture classification was attained with an accuracy range between 87–93% from FBG and BCI signals using machine learning models such as K-nearest neighbor (KNN), logistic regression (LR), support vector machine (SVM), and naïve Bayes (NB). These models were used to identify electrodes responding to sitting, standing and walking activities of four users from a 16 channel BCI device. Six electrode positions based on the 10–20 system for electroencephalography (EEG) were identified as the most sensitive to plantar activities and found to be consistent with clinical investigations of the sensorimotor cortex during foot movement. A prediction of brain EEG corresponding to given FBG data with lowest mean square error (MSE) values (0.065–0.109) was made with the selection of a long-short term memory (LSTM) machine learning model when compared to the recurrent neural network (RNN) and gated recurrent unit (GRU) models.

Effect of Early Palliative Care on End-of-Life Health Care Costs: A Population-Based, Propensity Score-Matched Cohort Study

PURPOSE

This study aimed to investigate the impact of early versus not-early palliative care among cancer decedents on end-of-life health care costs.

METHODS

Using linked administrative databases, we created a retrospective cohort of cancer decedents between 2004 and 2014 in Ontario, Canada. We identified those who received early palliative care (palliative care service used in the hospital or community 12 to 6 months before death [exposure]). We used propensity score matching to identify a control group of not-early palliative care, hard matched on age, sex, cancer type, and stage at diagnosis. We examined differences in average health system costs (including hospital, emergency department, physician, and home care costs) between groups in the last month of life.

RESULTS

We identified 144,306 cancer decedents, of which 37% received early palliative care. After matching, we created 36,238 pairs of decedents who received early and not-early (control) palliative care; there were balanced distributions of age, sex, cancer type (24% lung cancer), and stage (25% stage III and IV). Overall, 56.3% of early group versus 66.7% of control group used inpatient care in the last month (P < .001). Considering inpatient hospital costs in the last month of life, the early group used an average (±standard deviation) of $7,105 (±$10,710) versus the control group of $9,370 (±$13,685; P < .001). Overall average costs (±standard deviation) in the last month of life for patients in the early versus control group was $12,753 (±$10,868) versus $14,147 (±$14,288; P < .001).

CONCLUSION

Receiving early palliative care reduced average health system costs in the last month of life, especially via avoided hospitalizations.

Mood Disturbances Across the Continuum of Care Based on Self-Report and Clinician Rated Measures in the interRAI Suite of Assessment Instruments

BACKGROUND

Mood disturbance is a pervasive problem affecting persons of all ages in the general population and the subset of those receiving services from different health care providers. interRAI assessment instruments comprise an integrated health information system providing a common approach to comprehensive assessment of the strengths, preferences and needs of persons with complex needs across the continuum of care.

OBJECTIVE

Our objective was to create new mood scales for use with the full suite of interRAI assessments including a composite version with both clinician-rated and self-reported items as well as a self-report only version.

METHODS

We completed a cross-sectional analysis of 511,641 interRAI assessments of Canadian adults aged 18+ in community mental health, home care, community support services, nursing homes, palliative care, acute hospital, and general population surveys to develop, test, and refine new measures of mood disturbance that combined clinician and self-rated items. We examined validity and internal consistency across diverse care settings and populations.

RESULTS

The composite scale combining both clinician and self-report ratings and the self-report only variant showed different distributions across populations and settings with most severe signs of disturbed mood in community mental health settings and lowest severity in the general population prior to the COVID-19 pandemic. The self-report and composite measures were strongly correlated with each other but differed most in populations with high rates of missing values for self-report due to cognitive impairment (e.g., nursing homes). Evidence of reliability was strong across care settings, as was convergent validity with respect to depression/mood disorder diagnoses, sleep disturbance, and self-harm indicators. In a general population survey, the correlation of the self-reported mood scale with Kessler-10 was 0.73.

CONCLUSIONS

The new interRAI mood scales provide reliable and valid mental health measures that can be applied across diverse populations and care settings. Incorporating a person-centered approach to assessment, the composite scale considers the person's perspective and clinician views to provide a sensitive and robust measure that considers mood disturbances related to dysphoria, anxiety, and anhedonia.

A Cross-Sectoral Comparison of Prevalence and Predictors of Symptoms of Depression Over Time Among Older Adults in Ontario, Canada

OBJECTIVES

Late-life depression, a common mental health issue, poses a significant burden of illness globally. We investigated factors associated with symptoms of depression among older adults across 3 health sectors in Ontario, Canada.

METHOD

Electronic health assessment data on older adults aged 60 years+ in home care (HC; N = 359 217), long-term care (LTC; N = 125 496), and palliative care (PC; N = 29 934) were examined. Change in symptoms of depression, measured using the interRAI Depression Rating Scale (DRS), over time was examined, including predictors of the development of depression.

RESULTS

At baseline, symptoms of depression were observed in 19.1% (HC), 24.2% (LTC), and 11.9% (PC). This increased to 20.6% (HC), 33.8% (LTC), and 13.2% (PC) at follow-up. For most older adults, DRS scores remained the same across sectors over time. Three independent variables emerged consistently across sectors as the main risk and protective factors for symptoms of depression.

CONCLUSION

Although variations in the risk and protective factors for late-life depression were demonstrated across each sector, some commonalities emerged including unmanaged pain, symptoms of depression at baseline, social connectedness, and activity.

Evaluating the Effect of COVID-19 Pandemic Lockdown on Long-Term Care Residents' Mental Health: A Data-Driven Approach in New Brunswick

Long-term care (LTC) residents, isolated because of the COVID-19 pandemic, are at increased risk for negative mental health outcomes. The purpose of our article is to demonstrate how the interRAI LTC facility (LTCF) assessment can inform clinical care and evaluate the effect of strategies to mitigate worsening mental health outcomes during the COVID-19 pandemic. We present a supporting analysis of the effects of lockdown in homes without COVID-19 outbreaks on depression, delirium, and behavior problems in a network of 7 LTC homes in New Brunswick, Canada, where mitigative strategies were deployed to minimize poor mental health outcomes (eg, virtual visits and increased student volunteers). This network meets regularly to review performance on risk-adjusted quality of care indicators from the interRAI LTCF and share learning through a community of practice model. We included 4209 assessments from 765 LTC residents between January 2017 to June 2020 and modeled the change within and between residents for depression, delirium, and behavioral problems over time with longitudinal generalized estimating equations. Though the number of residents who had in-person visits with family decreased from 73.2% before to 17.9% during lockdown (chi square, P < .001), the number of residents experiencing delirium (4.5%-3.5%, P = .51) and behavioral problems (35.5%-30.2%, P = .19) did not change. The proportion of residents with indications of depression decreased from 19.9% before to 11.5% during lockdown (P < .002). The final multivariate models indicate that the effect of lockdown was not statistically significant on depression, delirium, or behavioral problems. Our analyses demonstrate that poor mental health outcomes associated with lockdown can be mitigated with thoughtful intervention and ongoing evaluation with clinical information systems. Policy makers can use outputs to guide resource deployment, and researchers can examine the data to identify better management strategies for when pandemic strikes again.

Predictors of change over time in subjective daytime sleepiness among older adult recipients of long-term services and supports

OBJECTIVES

Daytime sleepiness is associated with multiple negative outcomes in older adults receiving long-term services and supports (LTSS) including reduced cognitive performance, need for greater assistance with activities of daily living and decreased social engagement. The purpose of this study was to identify predictors of change in subjective daytime sleepiness among older adults during their first 2 years of receiving LTSS.

DESIGN AND SETTING

Secondary analysis of data from a prospective longitudinal study of older adults who received LTSS in their homes, assisted living communities or nursing homes interviewed at baseline and every 3 months for 24 months.

PARTICIPANTS

470 older adults (60 years and older) newly enrolled in LTSS (mean = 81, SD = 8.7; range 60-98; 71% women).

MEASUREMENTS

Subjective daytime sleepiness was assessed every 3 months through 2 years using the Epworth Sleepiness Scale. Multiple validated measures were used to capture health-related quality of life characteristics of enrollees and their environment, including symptom status (Symptom Bother Scale), cognition (Mini Mental Status Exam), physical function (Basic Activities of Daily Living), physical and mental general health, quality of life (Dementia Quality of Life, D-QoL), depressive symptoms (Geriatric Depression Scale) and social support (Medical Outcomes Survey-Social Support).

RESULTS

Longitudinal mixed effects modeling was used to examine the relationship between independent variables and continuous measure of daytime sleepiness. Increased feelings of belonging, subscale of the D-QoL (effect size = -0.006, 95% CI: -0.013 to -0.0001, p = 0.045) and higher number of depressive symptoms (effect size = -0.002, 95% CI: -0.004 to -0.001, p = 0.001) at baseline were associated with slower rates of increase in daytime sleepiness over time.

CONCLUSIONS

Comprehensive baseline and longitudinal screening for changes in daytime sleepiness along with depression and perceived quality of life should be used to inform interventions aimed at reducing daytime sleepiness among older adults receiving LTSS.

Effect of Academic Detailing on Promoting Appropriate Prescribing of Antipsychotic Medication in Nursing Homes: A Cluster Randomized Clinical Trial

Importance

Strategies to reduce the inappropriate prescription of antipsychotics have been the focus of recent attention but have shown considerable variation in their effectiveness.

Objective

To evaluate the effectiveness of academic detailing in nursing homes targeting appropriate prescribing of antipsychotics.

Design, Setting, and Participants

We conducted a pragmatic, cluster randomized clinical trial comparing the effect of academic detailing vs usual care on prescribing antipsychotics in 40 nursing homes with 5363 residents in Ontario, Canada. Data were collected from October 2015 to March 2016 and analyzed from April to August 2018. Primary analyses were conducted using intention to treat.

Intervention

Academic detailing delivered by health professionals (eg, nurses or pharmacists) who arranged meetings (with administrators, physicians, pharmacists, nurses, and support workers), presentations, group visits (with 2-6 clinicians), and 1-on-1 visits (traditional academic detailing visits). Academic detailers had direct and ongoing contact with the nursing homes from the time of launch.

Main Outcomes and Measures

The primary outcome, defined at the level of the resident, was whether continuous antipsychotics were dispensed in the past week. Secondary outcomes included prescribing of other psychotropic medications and clinical outcomes and scores. Prescribing outcomes were assessed at baseline and at 3, 6, and 12 months, and clinical outcomes and scores were assessed at baseline and 3 and 6 months.

Results

A total of 40 nursing homes with 5363 residents were randomized, with 18 intervention homes (45.0%; 2303 [42.9%] residents) and 22 control homes (55.0%; 3060 [57.1%] residents). Participants in the intervention and control groups had similar median (interquartile range) age (86 [79-91] years vs 85 [78-90] years) and sex (674 [29.3%] men vs 970 [31.7%] men). At 12 months, there was no statistically significant difference in the frequency of daily antipsychotic use (intervention: 569 patients [25.2%]; control: 769 [25.6%]; odds ratio, 1.06; 95% CI, 0.93-1.20; P = .49). There were no significant differences in the rates of health care utilization, but the intervention group did experience a statistically significant reduction in pain compared with the control group (mean [SD] pain score, 0.30 [0.59] vs 0.38 [0.66]; P < .001) and depression (mean [SD] Depression Rating Scale score, 2.18 [2.37] vs 2.81 [2.65]; P < .001) at 6 months.

Conclusions and Relevance

The intervention did not further reduce antipsychotic prescribing in nursing homes beyond system-level secular trends occurring alongside usual care. Our findings highlight the need for a more targeted approach to quality improvement strategies, including academic detailing, that account for the timing and topic of interventions.

Trial Registration

ClinicalTrials.gov Identifier: NCT02604056.

Construct Validation of the Mealtime Relational Care Checklist for Individual Resident Use in Long-Term Care

Background and Purpose

To determine the construct validity of the Mealtime Relational Care Checklist (M-RCC) when used with individual residents.

Methods

Data was collected from 639 residents from 32 long-term care homes; M-RCC was completed at three meals for each resident and averaged. Bivariate analyses determined associations between the M-RCC and other resident level and dining room level measures.

Results

Resident M-RCC was positively and significantly (p < .05) associated with three of five summary scales from Dining Environment Audit Protocol and Meal Time Scan as well as resident malnutrition risk (rs = 0.23). M-RCC was negatively associated with protein intake (gram per kilogram body weight; rs = -0.13) and Cognitive Performance Score (t-value = 4.48).

Conclusions

The resident level M-RCC was significantly associated with other measures in expected directions demonstrating construct validity.

Effects of a Multimodal Exercise Program Plus Neural Gliding on Postural Control, Pain, and Flexibility of Institutionalized Older Adults: A Randomized, Parallel, and Double-Blind Study

BACKGROUND AND PURPOSE

The effect of adding neural mobilization to a multimodal program of exercises has not been investigated, despite its potential positive effects. The aim of this study was to compare the acute effects of a multimodal exercise program and neural gliding against a multimodal exercise program only, on pain intensity, gait speed, Timed Up and Go (TUG) test, lower limb flexibility, and static balance of institutionalized older adults.

METHODS

Older adults who were institutionalized (n = 26) were randomized to receive a multimodal exercise program plus neural gliding or a multimodal exercise program only. Both interventions were delivered twice a week for 8 weeks. Participants were assessed for pain, gait velocity, balance, flexibility, and TUG at baseline and postintervention.

RESULTS

A significant main effect of time for pain intensity (F1,24 = 8.95, P = .006), balance (F1,24 = 10.29, P = .004), and gait velocity (F1,24 = 5.51, P = .028) was observed, indicating a positive impact of both interventions. No other significant effects were found (TUG and flexibility; P > .05).

DISCUSSION

A 45-minute multimodal exercise program, twice a week for 8 weeks, has a positive impact on pain intensity, balance, and gait velocity, but neural gliding has no additional benefit. It is unclear whether dose and type of neural mobilization may have had an impact on results. Considering the structural and physiological changes that tend to occur with age, future studies could explore the effects of neural tensioning or of higher doses of neural mobilization.

CONCLUSIONS

This study suggests that adding neural gliding to a multimodal exercise program has no additional benefit.

Potential quality indicators for seriously ill home care clients: a cross-sectional analysis using Resident Assessment Instrument for Home Care (RAI-HC) data for Ontario

Background

Currently, there are no formalized measures for the quality of home based palliative care in Ontario. This study developed a set of potential quality indicators for seriously ill home care clients using a standardized assessment.

Methods

Secondary analysis of Resident Assessment Instrument for Home Care data for Ontario completed between 2006 and 2013 was used to develop quality indicators (QIs) thought to be relevant to the needs of older (65+) seriously ill clients. QIs were developed through a review of the literature and consultation with subject matter experts in palliative care. Serious illness was defined as a prognosis of less than 6 months to live or the presence of severe health instability. The rates of the QIs were stratified across Ontario’s geographic regions, and across four common life-limiting illnesses to observe variation.

Results

Within the sample, 14,312 clients were considered to be seriously ill and were more likely to experience negative health outcomes such as cognitive performance (OR = 2.77; 95% CI: 2.66–2.89) and pain (OR = 1.59; 95% CI: 1.53–1.64). Twenty subject matter experts were consulted and a list of seven QIs was developed. Indicators with the highest overall rates were prevalence of falls (50%) prevalence of daily pain (47%), and prevalence of caregiver distress (42%). The range in QI rates was largest across regions for prevalence of caregiver distress (21.5%), the prevalence of falls (16.6%), and the prevalence of social isolation (13.7%). Those with some form of dementia were most likely to have a caregiver that was distressed (52.6%) or to experience a fall (53.3%).

Conclusion

Home care clients in Ontario who are seriously ill are experiencing high rates of negative health outcomes, many of which are amenable to change. The RAI-HC can be a useful tool in identifying these clients in order to better understand their needs and abilities. These results contribute significantly to the process of creating and validating a standardized set of QIs that can be generated by organizations using the RAI-HC as part of normal clinical practice.

The Effects of Tai Chi on Heart Rate Variability in Older Chinese Individuals with Depression

Background Very little research has been done to simultaneously investigate the effects of Tai Chi (TC) on depression and heart rate variability (HRV). This study, therefore, attempted to explore the effects of TC on depression and on HRV parameters. Methods Sixty older individuals with depression score of 10 or above (the Geriatric Depression Scale, GDS) were randomly assigned into two groups: TC (n = 30) and control group (n = 30). Participants in the experimental group participated in a 24-week TC training program (three 60-min sessions per week), whereas individuals in the control group maintained their unaltered lifestyle. Depression and HRV were measured using the GDS and digital electrocardiogram at baseline and after the 24-week intervention. Results The TC had produced significant positive chances in depression and some HRV parameters (mean heart rate, RMSSD, HF, LFnorm, and HFnorm) (p < 0.05), whereas these positive results were not observed in the control group. Conclusions The results of this study indicated that TC may alleviate depression of the elderly through modulating autonomous nervous system or HRV parameters. This study adds to a growing body of research showing that TC may be effective in treating depression of the elderly. Tai Chi as a mild to moderate mind-body exercise is suitable for older individuals who suffer from depression.

Construct validity of the Dining Environment Audit Protocol: a secondary data analysis of the Making Most of Mealtimes (M3) study

BACKGROUND

Research has demonstrated the importance of physical environments at mealtimes for residents in long term care (LTC). However, a lack of a standardized measurement to assess physical dining environments has resulted in inconsistent research with potentially invalid and unreliable conclusions. The development of a standardized, construct valid instrument that assesses dining rooms is imperative to systematically examine physical environments in LTC. The purpose of this study was to determine the construct validity of the new Dining Environment Audit Protocol (DEAP) tool.

METHODS

Secondary data collected from the Making Most of Mealtimes (M3) study was used for this analysis. Data were collected in 32 long term care homes, which included 82 dining rooms and 639 residents. A variety of resident and dining room level constructs were compared to the summative scales found on the DEAP using Spearman correlations and Student t-tests. A regression analysis identified individual characteristics assessed with DEAP that were associated with the summative scales of homelikeness and functionality.

RESULTS

Regression analysis (p < 0.05) identified that the DEAP homelikeness scale was positively associated with a view of the garden/green space, presence of a clock and a posted menu. The functionality scale was positively associated with number of chairs and lighting, while negatively associated with furniture with rounded edges and clutter. Additionally, the functionality scale was positively associated (p < 0.05) with the Mealtime Scan physical scale (ρ = 0.52), the dining room Mealtime-Relational Care Checklist (M-RCC) (ρ = 0.25), the DEAP total score (ρ = 0.56), and the Mini Nutritional Assessment- Short Form (ρ = 0.26). Homelikeness was positively associated (p < 0.05) with the DEAP total score (ρ = 0.53), staff Person Directed Care score (ρ = 0.49) and the resident Cognitive Performance Scale (t = 2.56), while negatively associated with energy (ρ = -0.26) and protein intake (ρ = -0.24). The homelikeness and functionality scales were also associated with one another (ρ = 0.26).

CONCLUSION

The construct validity of the DEAP was supported through significant correlations with a variety of measures that are theoretically related to the homelikeness and functionality of LTC dining rooms. This secondary analysis supports the use of the DEAP in future research to quantify the physical environment of LTC dining rooms. Protocol registered with ClinicalTrials.gov ID: NCT02800291; Registered retrospectively June 7, 2016.

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.

The wish to die among palliative home care clients in Ontario, Canada: A cross-sectional study

Background

In the pursuit to provide the highest quality of person centered palliative care, client preferences, needs, and wishes surrounding end of life should be used to inform the plan of care. During a clinical assessment for care services, clients may voluntarily express a ‘wish to die’ either directly to the clinician or it may be indirectly reported second-hand to the clinician through an informal caregiver or family member. This is the first study using data gathered from the interRAI Palliative Care Assessment instrument (interRAI PC) to examine socio-demographic, clinical, and psycho-social factors of palliative home care clients with the voluntary expression of a ‘wish to die now’. Factors associated with the risk for depression within this group were also identified. Awareness and understanding of clients who express the ‘wish to die’ is needed to better tailor a person-centered approach to end-of-life care.

Methods

This cross-sectional study included assessment records gathered from 4,840 palliative home care clients collected as part of pilot implementation of the interRAI PC assessment instrument in Ontario, Canada from 2006 through 2011.

Results

During the clinical assessment, 308 palliative home care clients (6.7 %) had voluntarily expressed a ‘wish to die now’. Independent factors emerging from multivariate logistic regression analyses predicting the expression of a ‘wish to die’ included not being married/widowed, a shorter estimated prognosis, depressive symptoms, functional impairment, too much sleep (excessive amount), feeling completion regarding financial/legal matters, and struggling with the meaning of life. Among persons who expressed a ‘wish to die now’, those who exhibited depressive symptoms (23.8 %, n = 64) were also more likely to exhibit cognitive impairment, have decline in cognition in the last 90 days, exhibit weight loss, have informal caregivers exhibiting distress, ‘not have a consistent positive outlook on life’ and report ‘struggling with the meaning of life’.

Conclusion

When clients voluntary express a wish to die clinicians should take notice and initiate follow-up to better understand the context of this meaning for the individual. Clients who expressed a ‘wish to die’ did not all experience pain, depression, and psychological distress suggesting an individualized approach to care management be taken.

Measures to assess commonly experienced symptoms for people with dementia in long-term care settings: a systematic review

BACKGROUND

High symptom burden is common in long-term care residents with dementia and results in distress and behavioral challenges if undetected. Physicians may have limited time to regularly examine all residents, particularly those unable to self-report, and may rely on reports from caregivers who are frequently in a good position to detect symptoms quickly. We aimed to identify proxy-completed assessment measures of symptoms experienced by people with dementia, and critically appraise the psychometric properties and applicability for use in long-term care settings by caregivers.

METHODS

We searched Medline, EMBASE, PsycINFO, CINAHL and ASSIA from inception to 23 June 2015, supplemented by citation and reference searches. The search strategy used a combination of terms: dementia OR long-term care AND assessment AND symptoms (e.g. pain). Studies were included if they evaluated psychometric properties of proxy-completed symptom assessment measures for people with dementia in any setting or those of mixed cognitive abilities residing in long-term care settings. Measures were included if they did not require clinical training, and used proxy-observed behaviors to support assessment in verbally compromised people with dementia. Data were extracted on study setting and sample, measurement properties and psychometric properties. Measures were independently evaluated by two investigators using quality criteria for measurement properties, and evaluated for clinical applicability in long-term settings.

RESULTS

Of the 19,942 studies identified, 40 studies evaluating 32 measures assessing pain (n = 12), oral health (n = 2), multiple neuropsychiatric symptoms (n = 2), depression (n = 8), anxiety (n = 2), psychological wellbeing (n = 4), and discomfort (n = 2) were included. The majority of studies (31/40) were conducted in long-term care settings although none of the neuropsychiatric or anxiety measures were validated in this setting. The pain assessments, PAINAD and PACSLAC had the strongest psychometric evidence. The oral health, discomfort, and three psychological wellbeing measures were validated in this setting but require further psychometric evaluation. Depression measures were poor at detecting depression in this population. All measures require further investigation into agreement, responsiveness and interpretability.

CONCLUSIONS

Measures for pain are best developed for this population and setting. All other measures require further validation. A multi-symptom measure to support comprehensive assessment and monitoring in this population is required.

Risk and protective factors associated with intentional self-harm among older community-residing home care clients in Ontario, Canada

OBJECTIVE

We aim to concurrently examine risk and protective factors associated with intentional self-harm among community-residing older adults receiving home care services in Ontario, Canada.

METHODS

Administrative health data from the home care sector were linked to hospital administrative data to carry out the analyses. Home care data are collected in Ontario using the Resident Assessment Instrument-Home Care (RAI-HC), an assessment tool that identifies strengths, preferences and needs of long-stay home care clients. The sample included Ontario home care clients aged 60 years or older assessed with the RAI-HC between 2007 and 2010 (N = 222,149). Multivariable analyses were performed using SAS.

RESULTS

Hospital records of intentional self-harm (ISH) were present in 9.3 cases per 1000 home care clients. Risks of ISH included younger age (60-74 years; OR = 3.14, CI: 2.75-3.59), psychiatric diagnosis (OR = 2.29, CI: 2.06-2.54), alcohol use and dependence (OR = 1.69, CI: 1.34-2.14), psychotropic medication (OR = 1.94, CI: 1.75-2.15) and depressive symptoms (OR = 1.58, CI: 1.40-1.78). Protective effects were found for marital status and positive social relationships, yet these effects were more pronounced for men. Cognitive performance measures showed the odds of ISH 1.86 times higher for older adults with moderate to severe cognitive impairment.

CONCLUSIONS

This study based on provincial data points to tangible areas for preventative assessment by frontline home care professionals. Of interest were the risk and protective factors that differed by sex. As demand for home care in Canada is expected to increase, these findings may inform home care professionals' appraisal and approach to suicide prevention among community-residing older adults.

Antipsychotic and Benzodiazepine Drug Changes Affect Acute Falls Risk Differently in the Nursing Home

BACKGROUND

Psychotropic drugs increase the risk of falls, but they are still frequently prescribed to treat behavioral symptoms associated with dementia in the nursing home. We examined whether there is an acute increased risk of falls in the days following a change to an antipsychotic or benzodiazepine drug prescription.

METHODS

We collected information on 594 long-stay nursing home residents from two facilities who fell at least once between September 1, 2010 and May 31, 2013. Psychotropic drug changes were ascertained from the facilities' computerized medication administration log. We used the case-crossover design to compare the frequency of antipsychotic and benzodiazepine drug changes during the days before a fall with the frequency of drug changes at more remote times.

RESULTS

Mean age was 87.5 years, and 75.1% were female. The risk of falls was higher in the 24 hours following benzodiazepine initiation compared with other times (odds ratio [OR] 3.79, 95% confidence interval [CI] 1.10, 13.00). There was no clear difference in risk following antipsychotic initiation (OR 2.42, CI 0.58, 10.06), but this could be due to the small sample size. Stopping a benzodiazepine was associated with a significantly reduced fall risk (OR 0.26, 95% CI 0.08-0.91).

CONCLUSIONS

Benzodiazepines pose an immediate threat to fall risk, whereas it is less clear if antipsychotics also pose an immediate risk. Nursing home staff should be particularly vigilant in the days following the new prescription for a benzodiazepine in an effort to prevent injury.

Who receives rehabilitation in canadian long-term care facilities? A cross-sectional study

PURPOSE

To describe the proportion of residents receiving occupational therapy (OT) and physical therapy (PT) and the factors associated with receiving PT in long-term care (LTC) facilities across five provinces and one territory in Canada.

METHODS

Using a population-based, retrospective analysis of cross-sectional data, the proportion of LTC facility residents in each province or territory receiving three different amounts (time and frequency) of PT, OT, or both before July 1, 2013, was calculated according to the Resource Utilization Groups-III rehabilitation classifications. Twenty-three variables from the Resident Assessment Instrument 2.0, such as age and cognition, were examined as correlates; those significant at p<0.01 were included in a multivariate logistic regression.

RESULTS

Between 63.7% and 88.6% of residents did not receive any PT or OT; 0.8%-12.6% received both PT and OT; 5.8%-29.5% received an unspecified amount of PT; 1.9%-7.0% received 45 minutes or more of PT 3 days or more per week; and fewer than 1% received 150 minutes or more of PT on 5 or more days per week. Province, age, cognitive status, depression, clinical status, fracture, multiple sclerosis, and self-rated potential for improvement were associated with PT irrespective of time intensity.

CONCLUSIONS

The proportion of LTC residents receiving rehabilitation services varies across Canada and appears to be associated with physical impairments and the potential for improvement; older residents with cognitive impairment or mood disorders are less likely to receive rehabilitation services. Future recommendations should consider what is driving the patterns of service use, determine whether the resources available are appropriate, and address the most appropriate goals for residents in LTC.

Effect of the overlap syndrome of depressive symptoms and delirium on outcomes in elderly adults with hip fracture: a prospective cohort study

OBJECTIVES

To analyze the incidence of the overlap syndrome of depressive symptoms and delirium, risk factors, and independent and dose-response effect of the overlap syndrome on outcomes in elderly adults with hip fracture.

DESIGN

Prospective cohort study.

SETTING

University hospital.

PARTICIPANTS

Individuals with hip fracture without delirium (N = 277; aged 78.0 ± 8.2) consequently enrolled in a prospective cohort study.

MEASUREMENTS

Depressive symptoms were assessed using the Geriatric Depression Scale and cognitive status using the Short Portable Mental Status Questionnaire upon hospital admission. Incident delirium was assessed daily during the hospital stay using the Confusion Assessment Method. Information on complications acquired in the hospital, severity of complications, re-interventions, length of hospital stay, and 1-month mortality was recorded.

RESULTS

Thirty (10.8%) participants had depressive symptoms alone, 88 (31.8%) delirium alone, 60 (21.7%) overlap syndrome, and 99 (35.7%) neither condition. According to multivariate regression analysis, participants with the overlap syndrome had significantly higher incidence of vision impairment (P = .02), longer time-to-surgery (P = .03), and lower cognitive function (P < .001) than participants with no depressive symptoms and no delirium. In the adjusted regression analysis, participants with neither condition were at lower risk of complications than those with the overlap syndrome (P = .03). After adjustment, participants with the overlap syndrome were at higher risk of longer hospital stay independently (P = .003) and in a dose-response manner in the following order: no depression and no delirium, depressive symptoms alone, delirium alone, and the overlap syndrome (P = .002).

CONCLUSION

Depressive symptoms and delirium increase the likelihood of adverse outcomes after hip fracture in a step-wise manner when they coexist. To reduce the risk of adverse outcome in individuals with hip fracture, efforts to identify, prevent, and treat this condition need to be increased.

Screening for geriatric depression in residential care facilities: a systematic narrative review

Studies in residential care facilities suggest that routine screening can assist in the early detection of geriatric depression. However, the effectiveness of screening instruments in residential care in the US and Canada has not been adequately evaluated. We conducted a systematic narrative review of the English-language literature published between 2000 and 2010 on screening instruments used for depression detection in older adults living in residential care facilities. The review yielded nine scales and their modifications tested in residential care, which we evaluated. We provide specific recommendations for the use of effective scales and discuss implications for practice, policy and research.

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

Background

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

Methods/Design

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

Discussion

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

Trial registration

Current Controlled Trials ISRCTN96090441. Registered 31 July 2014.

Estimating the effect of incident delirium on short-term outcomes in aged hip fracture patients through propensity score analysis

AIM

We aimed to evaluate the factors contributing to delirium after hip fracture and assess the effect of incident delirium on short-term clinical outcomes.

METHODS

A total of 270 non-delirious, consecutive hip fracture patients 60 years and older were included in a prospective cohort study. The patients were assessed with respect to physical status according to the American Society of Anesthesiologists classification, medical comorbidities with the Charlson Comorbidity Index, cognitive function with the Portable Mental Status Questionnaire and depression with the Geriatric Depressive Scale. Incident delirium was evaluated daily. Clinical outcomes and 1-month mortality were recorded.

RESULTS

Incident delirium was present in 53.0% of patients. Patients with delirium were older (P = 0.046), had higher American Society of Anesthesiologists and Charlson Comorbidity Index scores (P < 0.001), lower Portable Mental Status Questionnaire scores and higher Geriatric Depressive Scale scores (P < 0.001, P = 0.003, respectively). After adjusting for age, multivariate regression analysis in the first model showed that patients with delirium were at higher risk of reintervention plus death (P < 0.05), complications P < 0.001), a higher severity complication score (P < 0.05) and longer length of hospital stay (P < 0.001). In the second model, after adjusting for propensity score, patients with delirium were at higher risk of reintervention plus death (P < 0.05) and longer length of hospital stay (P < 0.01).

CONCLUSIONS

Patients who are older, with worse physical status, worse cognitive function and depression are more likely to develop delirium after hip fracture. Incident delirium has negative independent effects on short-term outcomes in elderly patients after hip fracture.

Predictors of severe pain in the immediate postoperative period in elderly patients following hip fracture surgery

INTRODUCTION

The aim of this study was to identify risk factors for severe postoperative pain immediately after hip-fracture surgery.

PATIENTS AND METHODS

Three hundred forty-four elderly patients with an acute hip fracture were admitted to the hospital during a 12-months period. All patients who entered the study answered a structured questionnaire to assess demographic characteristics, previous diseases, drug use, previous surgery, and level of education. Physical status was assessed through the American Society of Anesthesiologists' preoperative risk classification, cognitive status using the Short Portable Mental Status Questionnaire, and depression using the Geriatric Depression Scale. The presence of preoperative delirium using the Confusion Assessment Method was assessed during day and night shifts until surgery. Pain was measured using a numeric rating scale (NRS). An NRS ≥ 7 one hour after surgery indicated severe pain.

RESULTS

Patients with elementary-level education (8 yr in school) presented a higher risk for immediate severe postoperative pain than university-educated patients (> 12 yr in school) (P < 0.05). Higher cognitive function was associated with higher postoperative pain (P < 0.01). Patients with symptoms of depression and patients with preoperative delirium presented a higher risk for severe pain (P < 0.05, P < 0.01, respectively). Multivariate analysis showed that depression and a low level of education were independent predictors of severe pain immediately after surgery.

CONCLUSION

Depression and lower levels of education were independent predictors of immediate severe pain following hip-fracture surgery. These predictors could be clinically used to stratify analgesic risk in elderly patients for more aggressive pain treatment immediately after surgery.

Initial validation of the Chinese interRAI Mental Health in people with psychiatric illness

OBJECTIVE

The purpose of this study was to determine the reliability and validity of the Chinese interRAI Mental Health (MH) among people with psychiatric illnesses.

METHODS

Study participants were 157 individuals with psychiatric illnesses living in a psychiatric long-term care facility or halfway house in Hong Kong. The authors prepared the Chinese interRAI MH. A panel of bilingual healthcare professionals examined the quality of the translation. The reliability of the 6 scales embedded in the instrument was examined using Cronbach's alphas, intraclass correlations, and Kappa coefficients. Pearson's product moment correlations, Spearman's order correlations, and independent t-tests were used to determine the concurrent and construct validity of the scales.

RESULTS AND CONCLUSIONS

Internal consistency values (α = 0.66-0.95) and test-retest reliability coefficients (ICC = 0.76-0.97; κ = 0.75-1.00) of the scales were found to be satisfactory. All 6 scales correlated significantly with the criterion measures. As expected, 3 scales relating to cognition, activities of daily living (ADL), and instrumental ADL discriminated among individuals living in two types of residential setting. Chinese interRAI MH was found to be a valid and reliable tool useful for the clinicians in Hong Kong.

Daytime sleepiness: a risk factor for poor social engagement among the elderly

BACKGROUND

The aim of this study was to investigate the relationship between social engagement and daytime sleepiness among aged residents of a veterans' housing facility in Taiwan.

METHODS

A total of 597 men were enrolled in this cross-sectional study. Each subject was assessed with the Resident Assessment Instrument-Minimum Data Set, Geriatric Depression Scale, Pittsburgh Sleep Quality Index, and Mini-Mental State Examination. Social engagement was measured with the Index of Social Engagement (ISE), and daytime sleepiness was defined according to the relevant Pittsburgh Sleep Quality Index subcomponent. Subjects were divided into two groups according to their ISE levels. A multivariate logistic regression model was used to examine the association between ISE and other variables.

RESULTS

The sample's mean age was 80.8 ± 5.0 years (range: 65-99 years). Mean ISE score was 1.5 ± 1.3 (range 0-5), with 52% of participants reporting poor social engagement (ISE = 0-1). Mean Pittsburgh Sleep Quality Index global score was 5.6 ± 3.6 (range: 0-18), and 31% of participants reported daytime sleepiness. The analysis was adjusted for level of depression, cognitive impairment, dependence in activities of daily life, unsettled relationships, and illiteracy. After adjustment, daytime sleepiness was found to be independently associated with subjects' level of social engagement (odds ratio: 2.5; 95% confidence interval: 1.7-3.8; P < 0.001).

CONCLUSIONS

Daytime sleepiness and poor social engagement are common among aged residents of a veterans' housing facility. Subjects experiencing daytime sleepiness but not poor general sleep quality were at increased risk of poor social engagement. The clinical care of older residents must focus on improving daytime sleepiness to enhance their social engagement.

Exercise for depression in elderly residents of care homes: a cluster-randomised controlled trial

BACKGROUND

Depression is common and is associated with poor outcomes among elderly care-home residents. Exercise is a promising low-risk intervention for depression in this population. We tested the hypothesis that a moderate intensity exercise programme would reduce the burden of depressive symptoms in residents of care homes.

METHODS

We did a cluster-randomised controlled trial in care homes in two regions in England; northeast London, and Coventry and Warwickshire. Residents aged 65 years or older were eligible for inclusion. A statistician independent of the study randomised each home (1 to 1·5 ratio, stratified by location, minimised by type of home provider [local authority, voluntary, private and care home, private and nursing home] and size of home [<32 or ≥32 residents]) into intervention and control groups. The intervention package included depression awareness training for care-home staff, 45 min physiotherapist-led group exercise sessions for residents (delivered twice weekly), and a whole home component designed to encourage more physical activity in daily life. The control consisted of only the depression awareness training. Researchers collecting follow-up data from individual participants and the participants themselves were inevitably aware of home randomisation because of the physiotherapists' activities within the home. A researcher masked to study allocation coded NHS routine data. The primary outcome was number of depressive symptoms on the geriatric depression scale-15 (GDS-15). Follow-up was for 12 months. This trial is registered with ISRCTN Register, number ISRCTN43769277.

FINDINGS

Care homes were randomised between Dec 15, 2008, and April 9, 2010. At randomisation, 891 individuals in 78 care homes (35 intervention, 43 control) had provided baseline data. We delivered 3191 group exercise sessions attended on average by five study participants and five non-study residents. Of residents with a GDS-15 score, 374 of 765 (49%) were depressed at baseline; 484 of 765 (63%) provided 12 month follow-up scores. Overall the GDS-15 score was 0·13 (95% CI -0·33 to 0·60) points higher (worse) at 12 months for the intervention group compared with the control group. Among residents depressed at baseline, GDS-15 score was 0·22 (95% CI -0·52 to 0·95) points higher at 6 months in the intervention group than in the control group. In an end of study cross-sectional analysis, including 132 additional residents joining after randomisation, the odds of being depressed were 0·76 (95% CI 0·53 to 1·09) for the intervention group compared with the control group.

INTERPRETATION

This moderately intense exercise programme did not reduce depressive symptoms in residents of care homes. In this frail population, alternative strategies to manage psychological symptoms are required.

FUNDING

National Institute for Health Research Health Technology Assessment.

An evaluation of data quality in Canada's Continuing Care Reporting System (CCRS): secondary analyses of Ontario data submitted between 1996 and 2011

Background

Evidence informed decision making in health policy development and clinical practice depends on the availability of valid and reliable data. The introduction of interRAI assessment systems in many countries has provided valuable new information that can be used to support case mix based payment systems, quality monitoring, outcome measurement and care planning. The Continuing Care Reporting System (CCRS) managed by the Canadian Institute for Health Information has served as a data repository supporting national implementation of the Resident Assessment Instrument (RAI 2.0) in Canada for more than 15 years. The present paper aims to evaluate data quality for the CCRS using an approach that may be generalizable to comparable data holdings internationally.

Methods

Data from the RAI 2.0 implementation in Complex Continuing Care (CCC) hospitals/units and Long Term Care (LTC) homes in Ontario were analyzed using various statistical techniques that provide evidence for trends in validity, reliability, and population attributes. Time series comparisons included evaluations of scale reliability, patterns of associations between items and scales that provide evidence about convergent validity, and measures of changes in population characteristics over time.

Results

Data quality with respect to reliability, validity, completeness and freedom from logical coding errors was consistently high for the CCRS in both CCC and LTC settings. The addition of logic checks further improved data quality in both settings. The only notable change of concern was a substantial inflation in the percentage of long term care home residents qualifying for the Special Rehabilitation level of the Resource Utilization Groups (RUG-III) case mix system after the adoption of that system as part of the payment system for LTC.

Conclusions

The CCRS provides a robust, high quality data source that may be used to inform policy, clinical practice and service delivery in Ontario. Only one area of concern was noted, and the statistical techniques employed here may be readily used to target organizations with data quality problems in that (or any other) area. There was also evidence that data quality was good in both CCC and LTC settings from the outset of implementation, meaning data may be used from the entire time series. The methods employed here may continue to be used to monitor data quality in this province over time and they provide a benchmark for comparisons with other jurisdictions implementing the RAI 2.0 in similar populations.

Apathy and weight loss in nursing home residents: longitudinal study

OBJECTIVES

Determine which behavioral syndromes of dementia are independently related to weight loss.

DESIGN

Longitudinal study using four subsequent quarterly Minimum Data Set (MDS) 2.0 assessments. Characteristics obtained in one period were related to weight loss observed in the next period.

SETTING

Eight nursing homes in the Netherlands.

PARTICIPANTS

The initial population was 2031 nursing home residents with four quarterly MDS assessments within a period of 15 months. We selected 1850 subjects who were at least 65 years old at the time of the first assessment and who were not comatose.

MEASUREMENTS

Information about the presence of four behavioral syndromes (depression, apathy, agitation, and rejection of care), demographic data, cognition status, body mass index (BMI), and time that residents were involved in activities were obtained from MDS 2.0.

RESULTS

Bivariate correlation showed that weight loss at follow-up assessments was related to all baseline behavioral syndromes, degree of cognitive impairment, body mass index, and time that residents were involved in activities. Multivariable binary logistic regression with these factors showed that the only behavioral syndrome that was independently related to subsequent weight loss was apathy. In multivariable analysis, the degree of cognitive impairment and BMI were also independently related to weight loss.

CONCLUSION

These results suggest that of all behavioral factors we have assessed, apathy had the strongest association with weight loss in nursing home residents even when adjusted for the degree of cognitive impairment.

Good news and bad news: depressive symptoms decline and undertreatment increases with age in home care and institutional settings

OBJECTIVES

Examination of prevalence of depressive symptoms among older persons in home care (HC) and complex continuing care (CCC) hospitals/units, factors associated with depressive symptoms in those settings, and rate of antidepressant use among older persons with depressive symptoms.

DESIGN

Observational study using data from interRAI assessments used in normal clinical practice. Logistic regression models were used to identify factors associated with depressive symptoms in the frail elderly and treatment approaches were described.

SETTINGS

Fourteen HC agencies and 134 CCC hospitals/units in Ontario, Canada.

PARTICIPANTS

Older persons (N = 191,9871) aged 65 years and older, including 114,497 persons from HC and 77,490 persons from CCC.

MEASUREMENT

Data were collected using Resident Assessment Instrument 2.0 (RAI 2.0) (1996-2004) in CCC and Resident Assessment Instrument for Home Care (RAI-HC) (2003-2004) in HC.

RESULTS

Prevalence of depressive symptoms among older HC enrollees was lower (12.0%) than in CCC (23.6%). It decreased significantly with age in HC (to about 6% in those older than 95 years) but there were not substantial age differences in CCC. Common factors associated with depressive symptoms in both types of care were cognitive impairment, instability of health, daily pain, disability in activities of daily living; however, advanced age lost its protective effect in CCC. Less than half of the persons in HC and CCC with depressive symptoms were treated with antidepressants and their use decreased with age.

CONCLUSIONS

Undertreatment of depressive symptoms among older persons remains a serious problem. Learning more about factors associated with depressive symptoms among the oldest old might improve detection and treatment of depression.

Acute care inpatients with long-term delayed-discharge: evidence from a Canadian health region

Background

Acute hospital discharge delays are a pressing concern for many health care administrators. In Canada, a delayed discharge is defined by the alternate level of care (ALC) construct and has been the target of many provincial health care strategies. Little is known on the patient characteristics that influence acute ALC length of stay. This study examines which characteristics drive acute ALC length of stay for those awaiting nursing home admission.

Methods

Population-level administrative and assessment data were used to examine 17,111 acute hospital admissions designated as alternate level of care (ALC) from a large Canadian health region. Case level hospital records were linked to home care administrative and assessment records to identify and characterize those ALC patients that account for the greatest proportion of acute hospital ALC days.

Results

ALC patients waiting for nursing home admission accounted for 41.5% of acute hospital ALC bed days while only accounting for 8.8% of acute hospital ALC patients. Characteristics that were significantly associated with greater ALC lengths of stay were morbid obesity (27 day mean deviation, 99% CI = ±14.6), psychiatric diagnosis (13 day mean deviation, 99% CI = ±6.2), abusive behaviours (12 day mean deviation, 99% CI = ±10.7), and stroke (7 day mean deviation, 99% CI = ±5.0). Overall, persons with morbid obesity, a psychiatric diagnosis, abusive behaviours, or stroke accounted for 4.3% of all ALC patients and 23% of all acute hospital ALC days between April 1^st 2009 and April 1^st, 2011. ALC patients with the identified characteristics had unique clinical profiles.

Conclusions

A small number of patients with non-medical days waiting for nursing home admission contribute to a substantial proportion of total non-medical days in acute hospitals. Increases in nursing home capacity or changes to existing funding arrangements should target the sub-populations identified in this investigation to maximize effectiveness. Specifically, incentives should be introduced to encourage nursing homes to accept acute patients with the least prospect for community-based living, while acute patients with the greatest prospect for community-based living are discharged to transitional care or directly to community-based care.

Violence against radiologists. I: Prevalence and preventive measures

PURPOSE

Violence in the workplace is a specific risk for healthcare workers. Radiologists, especially when involved in emergency services, share that risk. Very few studies in the literature have researched this topic. This study aimed to evaluate the prevalence of violent behaviour in a large sample of Italian radiologists and analyse the phenomenon and its consequences with a view to proposing preventive measures.

MATERIALS AND METHODS

A total of 992 radiologists (61.5% men) taking part in a national radiology congress agreed to respond to a questionnaire on violence that contained the Violent Incident Form by Arnetz for the description of violent incidents in healthcare practice.

RESULTS

Some 6.8% of radiologists in public hospitals experienced physical abuse in the previous 12 months, for the most part from patients or their companions. The prevalence of physical abuse is greatest among younger healthcare individuals with less clinical experience, with no differences between sexes. Among younger radiologists, one in five suffered at least one act of physical abuse in a working year. Nonphysical violence is more widespread and throughout radiologists' working lives affects 65.2% of them. In this case, almost half of the violent incidents originate from colleagues. A total of 5.5% of respondents stated that they were victims of abuse at the time of the survey. In most cases, the violent incidents remain unreported. The immediate consequences of violence in the workplace are emotions such as anger, disappointment, humiliation, anxiety, fear, distress, a feeling of helplessness and isolation, occasionally a feeling of guilt or of having done wrong and a desire to take revenge, change behaviour or change workplace.

CONCLUSIONS

The extent of the problem calls for the adoption of a series of measures aimed at eliminating the causes of the various forms of workplace violence.

Gender specific temporal and cross-sectional associations between BMI-class and symptoms of depression in the elderly

OBJECTIVE

The aim of the study was the gender specific analysis of cross-sectional and longitudinal associations between body mass index class (BMI-class) and symptoms of depression in a representative sample of elderly German people.

METHODS

At the baseline of the ESTHER study (2000-2002), 9953 participants completed a comprehensive questionnaire including items regarding weight, height, and depression history. After five years, 7808 participants again completed the questionnaire and the 15-item geriatric depression scale (GDS-15). BMI was classified into five classes: normal weight, 18.5≤BMI<25; overweight, 25≤BMI<30; obesity class I, 30≤BMI<35; obesity class II, 35≤BMI<40; obesity class III, BMI≥40.

RESULTS

Logistic regression analysis for the cross-sectional data at five-year follow-up, adjusted for age, education, marital status, smoking, multimorbidity, physical activity, self-perceived cognitive impairment, and use of antidepressants, showed that the odds for depression were significantly elevated for women in obesity class II and significantly decreased for overweight men. The longitudinal analysis showed a similar pattern: Women in obesity classes II and III at baseline had significantly higher odds for being depressive five years later than women with normal weight at baseline (class II: OR=1.67; 95%CI=[1.06; 2.64]; class III: OR=2.93; 95%CI=[1.37; 6.26]; overweight men had lower odds than normal-weight men (OR=0.69; 95%CI=[0.51;0.92]).

CONCLUSION

The relationship between obesity and symptoms of depression appears to be heterogeneous across BMI-classes. Women are more affected than men by obesity class II and III; overweight appears to be associated with reduced risk of depression in elderly men.

Association between the prevalence of depression and age in a large representative German sample of people aged 53 to 80 years

OBJECTIVE

The aim of the study was to determine the association between the prevalence of clinically significant depression and age in a large representative sample of elderly German people.

METHODS

In the second follow-up (2005-2007) of the ESTHER cohort study, the 15-item geriatric depression scale (GDS-15) as well as a sociodemographic and clinical questionnaire were administered to a representative sample of 8270 people of ages 53 to 80 years. The prevalence of clinically significant depression was estimated using a GDS cut-off score of 5/6. Prevalence rates were estimated for the different age categories. Association between depression and age was analyzed using logistic regression, adjusted for gender, co-morbid medical disorders, education, marital status, physical activity, smoking, self-perceived cognitive impairment, and anti-depressive medication.

RESULTS

Of the participants, 7878 (95.3%) completed more than twelve GDS items and were included in the study. The prevalence of clinically significant depression was 16.0% (95%CI = [15.2; 16.6]). The function of depression prevalence dependent on age group showed a U-shaped pattern (53-59: 21.0%, CI = [18.9; 23.3]; 60-64: 17.7%, CI = [15.7; 19.7]; 65-69: 12.6%, CI = [11.2; 14.0]; 70-74: 14.4%, CI = [12.6; 16.0]; 75-80: 17.1%, CI = [14.9; 19.4]). Adjusted odds ratios showed that the chances of being depressive decrease with the age category but remain relatively stable for people aged 65 and over.

CONCLUSIONS

The prevalence of depression in the elderly seems to be associated with the age category. Adjusted odds ratios showed that people aged 60 and older had lower chances of being depressive than people aged 53 to 59 years.

A multilevel analysis of aggressive behaviors among nursing home residents

Individual and organizational characteristics associated with aggressive behavior among nursing home residents were examined among a sample of 5,494 residents from 23 facilities using the Minimum Data Set 2.0 and the Organizational Social Context scale. On admission, some individual level variables (age, sex, depression, activities of daily life [ADL] impairments, and cognitive impairments) and no organizational level variables were associated with aggressive behaviors. Over time, aggressive behaviors were linked with some individual characteristics (age, sex, and ADL impairments) and several organizational level variables (stressful climates, less rigid cultures, more resistant cultures, geographic location, facility size and staffing patterns). Findings suggest multi-faceted change strategies are needed.