Disability in long-term care residents explained by prevalent geriatric syndromes, not long-term care home characteristics: a cross-sectional study

Effectiveness of physical rehabilitation on physical functioning and quality of life for long-term care residents with dementia: a systematic review and meta-analysis

OBJECTIVE

The objective of this review was to evaluate the effectiveness of physical rehabilitation versus non-rehabilitation comparators on physical functioning and quality of life for long-term care (LTC) residents with dementia.

INTRODUCTION

LTC residents living with dementia often have impaired physical functioning and quality of life. Physical rehabilitation can improve physical functioning and quality of life for individuals living with dementia; however, many LTC residents with dementia do not receive physical rehabilitation and providers are unsure what interventions to employ. A synthesis of studies examining physical rehabilitation will help guide practice in the LTC sector where most residents live with dementia. Previous syntheses have focused on all residents in LTC, specific professions, interventions, or people with dementia in the community. Our review focuses on LTC residents with dementia and a broader definition of physical rehabilitation.

INCLUSION CRITERIA

This review includes studies that evaluate physical rehabilitation in comparison with non-rehabilitation controls among LTC residents with any severity of dementia. We included studies that measure the effect on activities of daily living, performance-based physical functioning, and self- or proxy-rated quality of life.

METHODS

Searches were conducted in APA PsycINFO (EBSCOhost), CINAHL (EBSCOhost), PubMed (National Library of Medicine), Embase, Scopus, and the Cochrane CENTRAL database with no date or language limitations. Two independent reviews assessed the studies against the inclusion criteria. Two independent reviewers extracted data and conducted a quality assessment using a structured extraction form. Certainty of evidence was ascertained using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Where possible, studies were pooled in meta-analyses; otherwise, a narrative synthesis was performed.

RESULTS

Thirty-three studies were included (n = 3072 participants); 27 were randomized control trials and the remaining 6 were non-randomized trials. The overall risk of bias of the included studies was low to unclear. Many of the included studies focused on increasing activity or walking, while few were individually tailored or at an intensity appropriate to induce therapeutic effects on physical function. Physical function was also measured via several outcome measures, limiting our ability to pool results. There was low certainty evidence that physical rehabilitation improved activities of daily living (12 RCTs, 1348 participants, SMD 0.78; 95% CI 0.27 to 1.30) and the Short Physical Performance Battery Score (3 RCTs, 258 participants, MD 3.01 points; 95% CI 1.37 to 4.66) compared with non-rehabilitation interventions. There was low to moderate certainty evidence that physical rehabilitation demonstrated no change in the 30-Second Sit to Stand Test (2 RCTs, 293 participants, MD 0.79 repetitions; 95% CI -0.45 to 2.03), 6-Minute Walk Test (4 RCTs, 363 participants, MD 17.32 meters; 95% CI -29.41 to 64.05), gait speed (4 RCTs, 400 participants, MD 0.10 meters/seconds; 95% CI -0.02 to 0.22), Timed Up and Go Test (3 studies, 275 participants, MD -2.89 seconds; 95% CI -6.62 to 0.84), or quality of life (4 RCTs, 419 participants, SMD 0.20; 95% CI -0.08 to 0.47).

CONCLUSIONS

This review demonstrates that physical rehabilitation may improve activities of daily living for LTC residents living with dementia, though the evidence is of low certainty. The effect of physical rehabilitation on specific functional tasks, like gait speed and quality of life, are less clear. Future research should examine the effects of individualized, progressive interventions on outcome measures that reflect the capacity and preferences of LTC residents with more advanced dementia.

REVIEW REGISTRATION

PROSPERO CRD42022308444.

Exploring Early, Middle, and Late Loss in Basic Activities of Daily Living among Nursing Home Residents: A Multicenter Observational Study

Nursing home (NH) residents commonly face limitations in basic activities of daily living (BADLs), following a hierarchical decline. Understanding this hierarchy is crucial for personalized care. This study explores factors associated with early, middle, and late loss in BADLs among NH residents. A multicenter cross-sectional study was conducted in 30 NHs in Catalonia, Spain. Dependent variables were related to limitations in BADLs: early loss (self-care-related BADLs: personal hygiene, dressing, or bathing), middle loss (mobility-related BADLs: walking or wheelchair handling, toileting, and transferring), and late loss (eating). Independent variables were based on a comprehensive geriatric assessment and institutional factors. Logistic regression was used for the multivariate analyses. The study included 671 older adults. Early loss in BADLs was significantly associated with urinary incontinence, cognitive impairment, and falls. Middle loss in BADLs was linked to fecal incontinence, urinary incontinence, ulcers, and cognitive impairment. Late loss in BADLs was associated with fecal incontinence, the NH not owning a kitchen, neurological disease, cognitive impairment, dysphagia, polypharmacy, and weight loss. These findings highlight the need to address geriatric syndromes, especially cognitive impairment and bladder/bowel incontinence. Monitoring these syndromes could effectively anticipate care dependency. The presence of kitchens in NHs may help to address limitations to eating, allowing for potential personalized meal adaptation.

Resident-, family-, and staff-identified goals for rehabilitation of long-term care residents with dementia: a qualitative study

BACKGROUND

Long-term care (LTC) residents with dementia can benefit from rehabilitation to improve function and quality of life. However, specific goals for rehabilitation with this population are not always clear. The purpose of this study was to describe the goals for rehabilitation for LTC residents with dementia from the perspective of residents, family, and staff.

METHODS

This was a phenomenological qualitative study. LTC residents with moderate to severe dementia, family members, and staff were recruited from two LTC homes in Halifax, Nova Scotia. Data were collected through semi-structured interviews and field notes from observations with residents while they were being active within the home. Data were analyzed via the principles of thematic content analysis, mapped onto the International Classification of Functioning, Disability, and Health (ICF) Model, and reported by the participant group (i.e., residents, family, or staff).

RESULTS

The 15 participants were three female residents aged 82 to 98 years, seven predominantly (86%) female family members aged 56 to 74 years, and five staff members (two females, three males, aged 22 to 55 years) who were physiotherapists, a physiotherapy assistant, a healthcare aide, and a registered licenced practical nurse. Most identified goals fell within the activities and participation constructs of the ICF model and focused on maintaining or improving function, mobility, and quality of life. Specific themes included preventing falls, walking or locomoting, stair climbing, maintaining activities of daily living, engaging in enjoyable exercise, maintaining independence and human connections, keeping busy, leaving the home for activities, and participating in group activities.

CONCLUSIONS

Rehabilitation goals for LTC residents living with dementia often focus on quality of life and functional activities and participation in LTC and family activities and events. Function and quality of life are interrelated, whereby functional goals influence quality of life. While some goals focus on improvement in function, maintenance or prevention of decline were also key elements. Future work should ensure rehabilitation interventions are developed relative to individually identified goals, and interventional success is measured in relation to the goal.

A qualitative exploration of Chinese rural older adults' adaption experience to disability in Henan Province

BACKGROUND

The global population is ageing in a serious way and the number of disabled elderly people is increasing. Disability is a combination of physical and functional impairments, activity limitations, and social participation restrictions that significantly affect the quality of life of older adults. This study used the Roy adaptation model to examine the adaptive strategies of rural disabled elderly.

METHODS

An interview outline was prepared based on the Roy Adaptation Model, in-depth interviews were conducted with eligible rural elderly with disabilities using purposive sampling. Interview data were analyzed using the colaizzi method to obtain relevant themes and sub-themes of the adaptation experience.

RESULTS

Fifteen eligible disabled elderly participated in the interview, with an average age of 73.7 years old, showing different adaptation experiences in different aspects, a total of 5 themes and 18 sub-themes were extracted: (a)physiological function adaptation: learning to monitor physiological indicators, active medical compliance behavior, active rehabilitation exercise, adjusting lifestyle and coping with failure, (b) self-concept adaptation: adjustment of gratitude mentality, self-consolation, transferring the attention, seeking emotional comfort, and negative emotional response, (c) role function adaptation: positive self-care role, negative family role and escape of social role, (d) interdependence adaptation: actively seeking support and complex social coping, and (e) adaptation influencing factors: personal factors, caregiver factors and the policy factors.

CONCLUSIONS

The disabled elderly show different adaptation strategies in four ways, and are affected by personal factors, caregiver factors and policy factors. A multi-faceted support system for the disabled elderly is recommended, and the caregivers should be trained in all-round care knowledge and skills.

Sarcopenia is associated with mortality in non-critical elderly patients visiting the emergency department

Introduction

Geriatric syndrome (GS) increases risk of disability and mortality in older adults. Sarcopenia is a predominant illness of GS and accelerate its progression. This study aimed to investigate associations between mortality, emergency department (ED) re-visits and GS-related illnesses among older adults who visited the ED.

Method

This retrospective observational study enrolled elderly patients who visited the ED in our hospital between January 2018 and October 2020. Patients were evaluated for potential sarcopenia, which was defined by both low handgrip strength and calf circumference. Follow-up was at least 6 months. Data of age, gender, mortality, ED re-visits, and GS-related illnesses were collected and analyzed for associations.

Results

A total of 273 older adults aged 74 years or older were included, of whom 194 were diagnosed with possible sarcopenia. Older adults with possible sarcopenia also had significantly lower body mass index (BMI); a higher proportion needed assistance with daily activities; more had malnutrition, frailty, and history of falls (all p < 0.001) and acute decline in activities of daily living (p = 0.027). Multivariate analysis showed that possible sarcopenia [adjusted hazard ratio, aHR): 9.89, 95% confidence interval (CI): 1.17-83.81, p = 0.036], living in residential institutions (aHR: 2.85, 95% CI: 1.08-7.50, p = 0.034), and frailty (aHR: 7.30, 95% CI: 1.20-44.62, p = 0.031) were associated with mortality. Aged over 85 years (adjusted odds ratio: 2.44, 95% CI: 1.25-4.80, p = 0.02) was associated with ED re-visits.

Conclusion

Sarcopenia is associated with mortality among older adults who visit ED. Initial screening for sarcopenia and relevant risk factors among older adults in the ED may help with early intervention for those at high-risk and may improve their prognosis.

Effectiveness of physical rehabilitation in improving physical functioning and quality of life for long-term-care residents with dementia: a systematic review protocol

OBJECTIVE

The objective of this review is to evaluate the effectiveness of physical rehabilitation versus non-rehabilitation control in improving physical functioning and quality of life in long-term care residents with dementia.

INTRODUCTION

Many long-term-care residents live with dementia and have impaired physical function and poor quality of life. Physical rehabilitation can improve physical function and quality of life for people living with dementia, yet many long-term-care residents with dementia do not receive this intervention, and health care providers are unsure of which rehabilitation interventions are effective. Studies synthesizing effective rehabilitation programs are needed to guide practice in the long-term-care sector where many residents live with dementia. Previous studies have focused broadly on long-term care, specific professions, interventions or outcomes, or people with dementia in the community. Our review will focus on long-term-care residents living with dementia and a broader definition of physical rehabilitation.

INCLUSION CRITERIA

This review will include studies that evaluate physical rehabilitation in comparison with non-rehabilitation controls among long-term-care residents with any severity of dementia. We will include studies that measure the effect on performance-based physical functioning and self- or proxy-reported quality of life.

METHODS

Searches will be conducted in APA PsycINFO (EBSCO), CINAHL (EBSCO), MEDLINE (Ovid), Embase, Scopus, and the Cochrane CENTRAL database with no date or language limitations. Two independent reviewers will conduct a critical appraisal of eligible studies, assess methodological quality, and extract the data. Where possible, studies will be pooled in a statistical meta-analysis.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022308444.

The short-term effect of a modified comprehensive geriatric assessment and regularly case conferencing on neuropsychiatric symptoms in nursing homes: a cluster randomized trial

Aims

To investigate the short-term effect of implementing a modified comprehensive geriatric assessment and regularly case conferencing in nursing homes on neuropsychiatric symptoms.

Background

Neuropsychiatric symptoms are common and may persist over time in nursing home residents. Evidence of effective interventions is scarce.

Design

A parallel cluster-randomised controlled trial.

Methods

The intervention was monthly standardised case conferencing in combination with a modified comprehensive geriatric assessment. The control group received care as usual.

Main outcome measure.

The total score on the short version of the Neuropsychiatric Inventory (NPI-Q, 12-items).

Results

A total of 309 residents at 34 long-term care wards in 17 nursing homes (unit of randomisation) were included. The intervention care units conducted on average two case conference-meetings (range 1–3), discussing a mean of 4.8 (range 1–8) residents. After 3 months, there were no difference of NPI-Q total score between the intervention (-0.4) and the control group (0.5) (estimated mean difference = -1.0, 95% CI -2.4 to 0.5, p = 0.19). There was a difference in favour of the intervention group on one of the secondary outcome measures, the apathy symptoms (-0.5 95% CI: -0.9 to -0.1, p = 0.03).

Conclusion

In this study there were no short-term effect of case conferencing and modified comprehensive geriatric assessments after three months on the total score on neuropsychiatric symptoms. The intervention group had less apathy at 3 months follow-up compared to those receiving care as usual. The findings suggest that a more comprehensive intervention is needed to improve the total Neuropsychiatric symptoms burden and complex symptoms.

Trial registration

Due to delays in the organisation, the study was registered after study start, i.e. retrospectively in Clinicaltrials.gov # NCT02790372 at https://clinicaltrials.gov/; Date of clinical trial registration: 03/06/2016.

Identifying Unexpected Deaths in Long-Term Care Homes

OBJECTIVES

Predicting unexpected deaths among long-term care (LTC) residents can provide valuable information to clinicians and policy makers. We study multiple methods to predict unexpected death, adjusting for individual and home-level factors, and to use as a step to compare mortality differences at the facility level in the future work.

DESIGN

We conducted a retrospective cohort study using Resident Assessment Instrument Minimum Data Set assessment data for all LTC residents in Ontario, Canada, from April 2017 to March 2018.

SETTING AND PARTICIPANTS

All residents in Ontario long-term homes. We used data routinely collected as part of administrative reporting by health care providers to the funder: Ontario Ministry of Health and Long-Term Care. This project is a component of routine policy development to ensure safety of the LTC system residents.

METHODS

Logistic regression (LR), mixed-effect LR (mixLR), and a machine learning algorithm (XGBoost) were used to predict individual mortality over 5 to 95 days after the last available RAI assessment.

RESULTS

We identified 22,419 deaths in the cohort of 106,366 cases (mean age: 83.1 years; female: 67.7%; dementia: 68.8%; functional decline: 16.6%). XGBoost had superior calibration and discrimination (C-statistic 0.837) over both mixLR (0.819) and LR (0.813). The models had high correlation in predicting death (LR-mixLR: 0.979, LR-XGBoost: 0.885, mixLR-XGBoost: 0.882). The inter-rater reliability between the models LR-mixLR and LR-XGBoost was 0.56 and 0.84, respectively. Using results in which all 3 models predicted probability of actual death of a resident at <5% yielded 210 unexpected deaths or 0.9% of the observed deaths.

CONCLUSIONS AND IMPLICATIONS

XGBoost outperformed other models, but the combination of 3 models provides a method to detect facilities with potentially higher rates of unexpected deaths while minimizing the possibility of false positives and could be useful for ongoing surveillance and quality assurance at the facility, regional, and national levels.

Geriatric syndromes and subsequent health-care utilization among older community dwellers in Stockholm

Little is known about the long-term effect of geriatric syndromes on health-care utilization. This study aims to determine the association between geriatric syndromes and health-care utilization during a four-year period among older community dwellers. Based on the Stockholm Public Health Cohort study, a total number of 6700 community dwellers aged ≥65 years were included. From a baseline survey in 2006, geriatric syndromes were defined as having at least one of the following: insomnia, functional decline, urinary incontinence, depressive symptoms and vision impairment. Health-care utilization was identified by linkages at individual level with register data with a four-year follow-up. Cox regression was performed to estimate the associations. Compared to those without geriatric syndromes, participants with any geriatric syndromes had a higher prevalence of frequent hospitalizations, long hospital stays, frequent outpatient visits and polypharmacy in each of the follow-up years. After controlling for covariates, having any geriatric syndromes was associated with higher levels of utilization of inpatient and outpatient care as well as polypharmacy. The association was stable over time, and the fully adjusted hazard ratio (95% confidence interval) remained stable in frequent hospitalizations (from 1.89 [1.31, 2.73] in year 1 to 1.70 [1.23, 2.35] in year 4), long hospital stay (from 1.75 [1.41, 2.16] to 1.49 [1.24, 1.78]), frequent outpatient visits (from 1.40 [1.26, 1.54] to 1.33 [1.22, 1.46]) and polypharmacy (from 1.63 [1.46, 1.83] to 1.53 [1.37, 1.71]). Having any geriatric syndromes is associated with higher levels of health-care utilization among older community dwellers, and the impact of geriatric syndromes is stable over a four-year period.

Effects of leisure-time physical activity interventions on frailty-related characteristics of frail older adults in long-term care: a systematic review

Background: The proportion of frailty in older adults is increasing in many countries. Demand for institutional long-term care followed by an increasing globally. Aims: The effects of leisure-time physical activity (LTPA) interventions on frail older adults in long-term care facilities (LTCFs) of randomized controlled trials. Design: A literature searches of the published articles indexed in CINAHL, MEDLINE, PsycINFO, ProQuest, and Google Scholar between 2000 and 2017 was conducted. Methods: The inclusion criteria were divided into four sections: (1) design: randomized controlled trials; (2) sample population: LTCF adults aged 60 years or over with frailty; (3) intervention: LTPA; and (4) body composition: physical, functional or neuropsychological tests as either the primary or the secondary outcomes. Results: Three main themes were identified (the particular monitor, intervention duration and outcome measurement dimensions). Impact statement and conclusions: LTPA interventions effectively improved the physical performance and body composition of frail older adults in LTCFs. Nevertheless, an optimal combination of intensity, duration and frequency is crucial.

Increasing Complexity of New Nursing Home Residents in Ontario, Canada: A Serial Cross-Sectional Study

OBJECTIVES

The main objective of the study was to investigate annual changes in the sociodemographic characteristics, morbidity, and functional status of new nursing home residents in Ontario, Canada, between 2000 and 2015. A secondary objective was to develop and assess the quality of an algorithm for ascertaining admissions into publicly funded nursing homes in Ontario using a combination of health administrative data sources that indirectly identifies the residential status of new nursing home residents.

DESIGN

Population-based serial cross-sectional study with an accompanying quality assessment study of algorithms.

SETTING

Publicly funded nursing care homes in Ontario, Canada.

PARTICIPANTS

The reference standard for the assessment of algorithm performance was 21 544 newly admitted nursing home residents identified from the Resident Assessment Instrument-Minimum Data Set in 2012. The selected algorithm was then used to identify serial cross-sectional cohorts of newly admitted residents between 2000 and 2015 that ranged in size between 14 651 and 23 630 residents.

MEASUREMENTS

Sociodemographic characteristics, morbidity, and functional status of new residents were determined upon admission to examine patterns in the cohorts' profiles.

RESULTS

The proportion of residents aged 85 years and older increased from 45.1% to 53.8% over 16 years. The proportions of individuals with seven or more chronic conditions (from 14.1% to 22.1%) and with nine or more prescription medications (from 44.9% to 64.2%) have also increased in parallel over time. Hypertension, osteoarthritis, and dementia were the most prevalent conditions captured, with the proportion of incoming residents with dementia increasing from 42.3% to 54.1% between 2000 and 2015. Newly admitted residents were more likely to have extensive physical and cognitive impairments upon admission.

CONCLUSION

Admission trends show that new residents were older and had greater multimorbidity and limitations in physical functioning over time. J Am Geriatr Soc 68:1293-1300, 2020.

Long-Term Care Residents' Geriatric Syndromes at Admission and Disablement Over Time: An Observational Cohort Study

Background

Disablement occurs when people lose their ability to perform activities of daily living (ADLs) like bathing and dressing, and is measured as the rate of increasing disability over time. We examined whether balance impairment, cognitive impairment, or pain among residents at admission to long-term care homes were predictive of their rate of disablement over the subsequent 2 years.

Methods

Linked administrative databases were used to conduct a longitudinal cohort study of 12,334 residents admitted to 633 long-term care (LTC) homes between April 1, 2011 and March 31, 2012, in Ontario, Canada. Residents received an admission assessment of disability upon admission to LTC using the RAI-MDS 2.0 ADL long-form score (ADL LFS, range 0–28) and at least two subsequent disability assessments. Multivariable regression models estimated the adjusted association between balance impairment, cognitive impairment, and pain present at admission and residents’ subsequent disablement over 2 years.

Results

This population sample of newly admitted Ontario long-term care residents had a median disability score of 13 (interquartile range [IQR] = 7, 19) at admission. Greater balance impairment and cognitive impairment at admission were significantly associated with faster resident disablement over 2 years in adjusted models, while daily pain was not.

Conclusions

Balance impairment and cognitive impairment among newly admitted long-term care home residents are associated with increased rate of disablement over the following 2 years. Further research should examine the mechanisms driving this association and identify whether they are amenable to intervention.

A path analysis on the direct and indirect effects of the unit environment on eating dependence among cognitively impaired nursing home residents

BACKGROUND

This study aims to estimate the direct and indirect effects of the unit environment alongside individual and nursing care variables on eating dependence among residents who are cognitively impaired and living in a nursing home.

METHOD

A multicentre observational study was carried out in 2017: 13 Italian nursing homes were involved in data collection. Included residents were aged > 65 at baseline, living in the considered facility for the last 6 months and during the entire study period and having received at least one comprehensive assessment. Data were collected (a) at the individual level: eating dependence using the Edinburgh Feeding Evaluation in Dementia Scale and other clinical variables; (b) at the nursing care level with daily interventions to maintain eating independence assessed with a checklist; and (c) at the nursing home level, using the Therapeutic Environment Screening Survey for Nursing Homes.

RESULTS

One thousand twenty-seven residents were included with an average age of 85.32 years old (95% CI: 84.74-85.89), mainly female (781; 76%). The path analysis explained the 57.7% variance in eating dependence. Factors preventing eating dependence were: (a) at the individual level, increased functional dependence measured with the Barthel Index (β - 2.374); eating in the dining room surrounded by residents (β - 1.802) as compared to eating alone in bed; and having a close relationship with family relatives (β - 0.854), (b) at the nursing care level, the increased number of interventions aimed at promoting independence (β - 0.524); and (c) at the NH level, high scores in 'Space setting' (β - 4.446), 'Safety' (β - 3.053), 'Lighting' (β - 2.848) and 'Outdoor access' (β - 1.225). However, environmental factors at the unit level were found to have also indirect effects by influencing the degree of functional dependence, the occurrence of night restlessness and the number of daily interventions performed by the nursing staff.

CONCLUSION

Eating dependence is a complex phenomenon requiring interventions targeting individual, nursing care, and environmental levels. The NH environment had the largest direct and indirect effect on residents' eating dependence, thus suggesting that at this level appropriate interventions should be designed and implemented.

Quadriceps muscle strength is a discriminant predictor of dependence in daily activities in nursing home residents

Objective

This study aimed to explore the relationship between dependence in Activities of Daily Living and muscle strength, muscle morphology and physical function in older nursing home residents, taking possible confounders into consideration.

Methods

A total of 30 nursing home residents (age, 85.6±7.1 years) were included in this observational cross-sectional study. Performance of basic Activities of Daily Living (ADL) was assessed with the Resident Assessment Instrument and categorized as either independent or dependent. Isometric grip, quadriceps and elbow-flexor strength were determined by hand-dynamometry, muscle thickness and echo intensity by B-mode ultrasonography, a sit-to-stand task by using a stop watch and physical activity by the German-Physical-Activity Questionnaire. Degree of frailty was evaluated according to Fried’s frailty criteria, whereas cognition, depression, incontinence, pain and falls were part of the Resident Assessment Instrument.

Results

Dependence in Activities of Daily Living was negatively correlated with physical activity (r_s = -0.44, p = .015), handgrip (r_s = -0.38, p = .038), elbow-flexor (r_s = -0.42, p = .032) and quadriceps strength (r_s = -0.67, p < .001), analysed by Spearman’s correlation. Chronic diseases (r_s = -0.41, p = .027) and incontinence (r_s = -0.39, p = .037) were positively correlated with ADL while the other variables were not related. Only quadriceps strength remained significant with logistic regression (Wald(1) = 4.7, p = .03), when chronic diseases, quadriceps and handgrip strength were considered (R² .79). 11 kg was the best fitting value in this sample to predict performance in Activities of Daily Living, evaluated with Receiver-Operating Characteristic analysis, with a sensitivity of 100% and a specificity of 79%.

Conclusion and implication

Quadriceps strength had a positive independent relationship with performance in ADL in the nursing home residents studied. Although a large prospective study is needed to verify the results, maintaining quadriceps strength above 11 kg may be helpful in retaining independence in this cohort.

Staff experiences with implementing a case conferencing care model in nursing homes: a focus group study

Background

A majority of nursing home residents have dementia, and many develop neuropsychiatric symptoms. These symptoms are often caused by neuropathological changes in the brain, but modifiable factors related to quality of care also have an impact. A team-based approach to care that include comprehensive geriatric assessments to facilitate clinical decision-making and structured case conference meetings could improve quality of care and quality of life for the residents. Despite recommendations to adopt this approach, dementia care does not reach standards of evidence-based practice. Better implementation strategies are needed to improve care. A cluster randomised controlled trial with a 12-month intervention was conducted, and the experiences of staff from the intervention nursing homes were explored in a qualitative study after the trial was completed. The aim of the present study was to describe: (i) staff’s experiences with the intervention consisting of comprehensive geriatric assessments of nursing home residents and case conferencing, and (ii) enablers and barriers to implementing and sustaining the intervention.

Methods

Four focus groups with a total of 19 healthcare staff were interviewed, representing four out of eight intervention nursing homes. Thematic content analysis was used to interpret the transcribed data.

Results

Two major themes emerged: 1) learning experiences and 2) enablers and barriers to implementation. The participants had experienced learning both on an organisational level: improvements in care and an organisation that could adjust and facilitate change; and on an individual level: becoming more conscious of residents’ needs and acquiring skills in resident assessments. Participants described important enabling factors such as managerial support, drivers for change, and feasibility of the intervention for the local nursing home. Barriers to implementing and sustaining the intervention were time constraints, lack of staff training, unsuitable electronic patient record system for care planning and high complexities of care and instabilities that are present in nursing homes.

Conclusions

Quality improvements in nursing homes are difficult to sustain. In order to offer residents high quality of care that meet their individual needs, it is important for management and nursing home staff to be aware of and understand factors that enable or constrain change.

Determinants of quality of life in the older residents of long-term care facilities using the World Health Organization International Classification of Functioning, Disability and Health framework in Taiwan

Objectives: The purpose of this study was to identify determinants within the International Classification of Functioning, Disability and Health as a conceptual framework regarding the quality of life of older long-term care facility residents.Methods: A questionnaire-based cross-sectional design was conducted. All participants (n = 210) completed a questionnaire that included the Sheltered Care Environmental Scale, the Beck Depression Inventory, the Short Physical Performance Battery, the Mini-Mental State Examination, the World Health Organization Disability Assessment Schedule, and the World Health Organization Quality of Life Scale. The outcome was assessed using mixed-design multiple regression with a covariance model and hierarchical regression.Results: Personal factors, environmental factors, body function and structures, and activity and participation explained 35.9%, 18.5%, 25.2%, and 52.1% of the variability in quality of life, respectively. The hierarchical model included 10 variables and explained 84.3% of the total variability in quality of life.Conclusions: Activity and participation showed high explanatory power for the quality of life of older long-term care facility residents. The influence of activity and participation in the older population is an important issue, although these factors remain relatively unexplored. This exploratory study used the International Classification of Functioning, Disability and Health as a conceptual framework to provide a more sophisticated understanding of quality of life.Implications for rehabilitationAlthough the viewpoint of quality of life involves many more factors than an understanding of an individual disease or disability condition, activity and participation were found to be the most important factors.Simple clinical measures, such as activity limitations and participation restrictions, can be used as clinical markers of quality of life, thus enabling rehabilitation professionals to determine the quality of life of older people in institutions.The conceptual framework of determinants of quality of life that this study reports may be helpful for rehabilitation professionals to explore with patients to implement interventions.

Associations between clinical indicators of quality and aged-care residents’ needs and consumer and staff satisfaction: the first Australian study

Objectives To ascertain Australian multistate prevalence and incidence of five commonly collected clinical indicators of aged-care home quality and to measure associations between these clinical indicators and levels of care needs and consumer and staff satisfaction. Methods A retrospective analysis of national audit data collected from 426 facilities between 2015 and 2016 was performed. Regression models were used to examine associations between five clinical indicators (falls, pressure injury, physical restraint, unplanned weight loss and polypharmacy) and level of care needs measured by the Aged Care Funding Instrument (ACFI) and consumer and care staff survey responses. Results With the exception of polypharmacy, commonly collected negative clinical outcomes were rare events. Compared with care homes with &lt;25% of residents having high-level care needs (high ACFI), homes with 25&lt;75% high-ACFI residents had more occurrences of all negative clinical outcomes except pressure injury. Homes with ≥75% high-ACFI residents reported the highest rates of polypharmacy (odds ratio 1.48, 95% confidence interval 1.39 – 1.57). Falls, unplanned weight loss and pressure injury were inversely associated with satisfaction scores adjusted for residents’ level of care needs. Conclusions This first Australian study of multistate clinical indicator data suggests interpretation of clinical indicators of aged-care home quality requires consideration of the level of residents’ care needs. What is known about the topic? Many Australian aged-care providers use quality indicators (QI) through benchmarking companies or in-house programs. The five most widely used aged-care clinical QIs in Australia are falls, pressure injury, physical restraint, unplanned weight loss and polypharmacy. Prevalence and incidence of these QIs are highly variable among Australian studies. A consistent message in the international literature is that residents’ clinical characteristics influence QI outcomes at baseline and may continue to influence outcomes over time. Study of associations between Australian aged-care home characteristics and QI outcomes has been limited. What does this paper add? This is the first Australian study of multistate clinical QI data. It is also the first to consider the level of resident care needs in the interpretation of clinical QI outcomes and exploration of the association between level of consumer and staff satisfaction and QI outcomes. What are the implications for practitioners? Understanding the connections between aged-care home characteristics, consumer and staff perceptions and clinical QIs is crucial in the meaningful interpretation of QI outcomes in context. With the recent introduction of the National Aged Care Quality Indicator Program, it is timely to review national policy, to gauge current quality of care and the measure of care quality in the sector, and to develop directions for possible research to inform and resolve debates regarding the potential influence and unplanned effects that such a program may have.

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSIONS

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