A longitudinal study looking at and beyond care recipient health as a predictor of long term care home admission

Glucose-lowering medicines use before and after entry into long-term care facilities

AIM

To examine changes in the use of glucose-lowering medicine (GLM) 12 months before and 12 months after long-term care facility (LTCF) entry among people with diabetes.

MATERIALS AND METHODS

A national retrospective cohort study was conducted using linked health and aged care data from the Registry of Senior Australians National Historical Cohort. Residents of LTCFs with diabetes aged 65 years or older from 2015 to 2019 were included. Prevalence of GLM use and the number of defined daily doses (DDDs) dispensed per 1000 resident-days were estimated quarterly (91-day) using Poisson regression models, or negative binomial regression when overdispersion was present.

RESULTS

Among the 50 993 residents studied (median age 84 years), the prevalence of GLM use was 58.4% (95% confidence interval [CI] 58.0%-58.8%) in the 9-12 months pre-LTCF entry and 56.3% (95% CI 55.9%-56.8%) in the 9-12 months post-entry. The number of DDDs/1000 resident-days increased from 1015.2 (95% CI 1002.3-1028.1) to 1253.8 (95% CI 1168.4-1339.3) during the same period. GLM use in the 3 months pre-entry was 56.8% (95% CI 56.4%-57.2%) compared with 61.7% (95% CI 61.3%-62.1%) in the 3 months post-entry, with the increased use driven mainly by insulin. No marked changes in the number of GLMs dispensed or GLM type were observed at 9-12 months post-entry compared with 3 months pre-entry. Among 22 792 individuals dispensed a GLM in the 3 months prior to LTCF entry, 50.2% continued the same GLM at 9-12 months post-entry.

CONCLUSIONS

GLM use peaked in the first 3 months following LTCF entry, driven mainly by insulin, hence, residents may benefit from close monitoring of diabetes treatment during this period.

Impact of Care-Recipient Relationship Type on Quality of Life in Community-Dwelling Older Adults With Dementia Over Time

INTRODUCTION

Maintaining quality of life (QoL) has been identified as the primary goal of care services for person living with dementia (PLWD).

METHODS

A secondary analysis was conducted on five rounds of the National Health and Aging Trends Study (NHATS) over 4 years. A generalized estimating equation (GEE) was used to examine the prediction of relationship type on older adults' QoL through four domains: mental health, general health, functional limitations, and pain.

RESULTS

older adults cared for by an adult-child or multiple caregivers predicted increased risk for functional limitations after adjustment for their socio-demographic and dementia status (IRR = 1.53, CI [1.26, 1.86]; IRR = 1.36, CI [1.14, 1.61], respectively). The interaction between the relationship type and education was significant. Older adults with a high school education or below, who were cared for by an adult child, had a significantly higher risk of increasing functional limitations over 4 years compared to those cared for by a spouse/partner (contrast = .50, P = .01, 95% CI [.07, .93]; contrast=.52, P = .03, 95% CI [.03, 1.02]; respectively). Similarly, older adults with a high school education, who were cared for by multiple caregivers, also experienced a significantly higher risk of increasing functional limitations than those cared for by a spouse/partner (contrast = .44, P = .03, 95% CI [.02, .85]).

CONCLUSION

Our findings provide evidence of the significant contribution of relationship type on PLWD's QoL changes over time. They also help to prioritize resource allocation while addressing PLWD's demands by socio-demographics such as education level.

Profiling the medical, functional, cognitive, and psychosocial care needs of adults assessed for home care in Ontario, Canada: The case for long-term 'life care' at home

Calls to leverage routinely collected data to inform health system improvements have been made. Misalignment between home care services and client needs can result in poor client, caregiver, and system outcomes. To inform development of an integrated model of community-based home care, grounded in a holistic definition of health, comprehensive clinical profiles were created using Ontario, Canada home care assessment data. Retrospective, cross-sectional analyses of 2017-2018 Resident Assessment Instrument Home Care (RAI-HC) assessments (n = 162,523) were completed to group home care clients by service needs and generate comprehensive profiles of each group's dominant medical, functional, cognitive, and psychosocial care needs. Six unique groups were identified, with care profiles representing home care clients living with Geriatric Syndromes, Medical Complexity, Cognitive Impairment and Behaviours, Caregiver Distress and Social Frailty. Depending on group membership, between 51% and 81% of clients had identified care needs spanning four or more Positive Health dimensions, demonstrating both the heterogeneity and complexity of clients served by home care. Comprehensive clinical profiles, developed from routinely collected assessment data, support a future-focused, evidence-informed, and community-engaged approach to research and practice in integrated home-based health and social care.

Primary health care service utilisation before and after entry into long-term care in Australia

OBJECTIVES

To examine utilisation of primary health care services (subsidised by the Australian Government, Medicare Benefits Schedule, MBS) before and after entry into long-term care (LTC) in Australia.

METHODS

A retrospective cohort study of older people (aged ≥65 years) who entered LTC in Australia between 2012 and 2016 using the Historical Cohort of the Registry of Senior Australians. MBS-subsidised general attendances (general practitioner (GP), medical and nurse practitioners), health assessment and management plans, allied health, mental health services and selected specialist attendances accessed in 91-day periods 12 months before and after LTC entry were examined. Adjusted relative changes in utilisation 0-3 months before and after LTC entry were estimated using risk ratios (RR) calculated using Generalised Estimating Equation Poisson models.

RESULTS

235,217 residents were included in the study with a median age of 84 years (interquartile range 79-89) and 61.1% female. In the first 3 months following LTC entry, GP / medical practitioner attendances increased from 86.6% to 95.6% (aRR 1.10 95%CI 1.10-1.11), GP / medical practitioner urgent after hours (from 12.3% to 21.1%; aRR 1.72, 95%CI 1.70-1.74) and after-hours attendances (from 18.5% to 33.8%; aRR 1.83, 95%CI 1.81-1.84) increased almost two-fold. Pain, palliative and geriatric specialist medicine attendances were low in the 3 months prior (<3%) and decreased further following LTC admission.

CONCLUSION

There is an opportunity to improve the utilisation of primary health care services following LTC entry to ensure that residents' increasingly complex care needs are adequately met.

Identifying Predictors of Nursing Home Admission by Using Electronic Health Records and Administrative Data: Scoping Review

Background

Among older adults, nursing home admissions (NHAs) are considered a significant adverse outcome and have been extensively studied. Although the volume and significance of electronic data sources are expanding, it is unclear what predictors of NHA have been systematically identified in the literature via electronic health records (EHRs) and administrative data.

Objective

This study synthesizes findings of recent literature on identifying predictors of NHA that are collected from administrative data or EHRs.

Methods

The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines were used for study selection. The PubMed and CINAHL databases were used to retrieve the studies. Articles published between January 1, 2012, and March 31, 2023, were included.

Results

A total of 34 papers were selected for final inclusion in this review. In addition to NHA, all-cause mortality, hospitalization, and rehospitalization were frequently used as outcome measures. The most frequently used models for predicting NHAs were Cox proportional hazards models (studies: n=12, 35%), logistic regression models (studies: n=9, 26%), and a combination of both (studies: n=6, 18%). Several predictors were used in the NHA prediction models, which were further categorized into sociodemographic, caregiver support, health status, health use, and social service use factors. Only 5 (15%) studies used a validated frailty measure in their NHA prediction models.

Conclusions

NHA prediction tools based on EHRs or administrative data may assist clinicians, patients, and policy makers in making informed decisions and allocating public health resources. More research is needed to assess the value of various predictors and data sources in predicting NHAs and validating NHA prediction models externally.

Inter-provincial variation in older home care clients and their pathways: a population-based retrospective cohort study in Canada

BACKGROUND

In Canada, publicly-funded home care programs enable older adults to remain and be cared for in their home for as long as possible but they often differ in types of services offered, and the way services are delivered. This paper examines whether these differing approaches to care shape the pathway that home care clients will take. Older adult client pathways refer to trajectories within, and out of, the home care system (e.g., improvement, long term care (LTC) placement, death).

METHODS

A retrospective analysis of home care assessment data (RAI-HC was linked with health administrative data, long-term care admissions and vital statistics in Nova Scotia Health (NSH) and Winnipeg Regional Health Authority (WRHA). The study cohort consists of clients age 60 + years, admitted to home care between January 1, 2011 to December 31, 2013 and up to four years from baseline. Differences in home care service use, client characteristics and their pathways were tested across the two jurisdictions overall, and among the four discharge streams within jurisdictions using t-tests and chi-square tests of significance.

RESULTS

NS and WHRA clients were similar in age, sex, and marital status. NS clients had higher levels of need (ADL, cognitive impairment, CHESS) at base line and were more likely discharged to LTC (43% compared to 38% in WRHA). Caregiver distress was a factor correlated with being discharged to LTC. While a third remained as home care clients after 4 years; more than half were no longer in the community - either discharged to LTC placement or death. Such discharges occurred on average at around two years, a relatively short time period.

CONCLUSIONS

By following older clients over 4 years, we provide enhanced evidence of client pathways, the characteristics that influence these paths, as well as the length of time to the outcomes. This evidence is central to identification of clients at risk in the community and aids in planning for future home care servicing needs that will allow more older adults to remain living in the community.

Bridge or Barrier? The Impact of Network Capital on the Receipt of Long-Term Care Services in Germany

OBJECTIVES

In Germany, roughly 8.3 million people are in need of care, but only one-third of them receive state care benefits. The study investigates whether the individual network of a care-seeking person, as well as its resources, interact with health status on the likelihood of accessing formal care services.

METHODS

German data from the Survey of Health, Ageing and Retirement in Europe (SHARE) from 2015 were used in several Firth logistic regressions with interaction terms.

RESULTS

Health limitations are a significant predictor for the probability of receiving formal care benefits. As moderating factors, caregivers from the immediate family as well as caregivers with lower levels of education tend to contribute to an increase in this probability.

DISCUSSION

Findings are based on a limited data set and indicate the importance of further research in this area to examine the mechanisms of access to formal care more precisely.

Improving the wellbeing of caregivers of patients with COPD using a home-based pulmonary rehabilitation programme

Objectives

The aim of this study was to evaluate the effects of a home-based pulmonary rehabilitation (PR) programme on anxiety and depressive symptoms, general fatigue and burden in informal caregivers of patients with COPD. We also evaluated the baseline characteristics of both patients and caregivers that contributed to the change in caregiver's outcomes after PR.

Methods

In this retrospective study, patients with COPD were referred to an 8-week home-based PR programme consisting of a weekly supervised 90-min session. Informal caregivers were invited to participate in PR according to the patient's preference and its availability. Caregivers received educational support, behavioural therapies and self-management strategies using the same methods as for patients. Burden, anxiety and depressive symptoms, and general fatigue of caregivers were assessed at baseline and at the end of PR.

Results

241 patients with COPD and 138 (57.3%) caregivers were included. The majority of the caregivers were women (70.5%) and spouses (90.3%) and had at least three comorbidities (57.3%). A large proportion of caregivers showed baseline high burden, anxiety symptoms and abnormal fatigue (40%, 40% and 45%, respectively). Burden, anxiety and depressive symptoms, and general fatigue of informal caregivers were all improved after PR (p<0.05). Long-term oxygen therapy and/or noninvasive ventilation, coronaropathy and/or peripheral arterial disease and a higher baseline modified Medical Research Council Dyspnoea scale score in patients with COPD were associated with a decrease in caregiver's burden after PR.

Conclusion

A large proportion of caregivers of patients with COPD showed anxiety symptoms, fatigue and a high burden. These outcomes were improved by integrating the caregiver into a home-based PR programme.

Caring for older men and women: whose caregivers are more distressed? A population-based retrospective cohort study

BACKGROUND

To our knowledge, no population-based studies have examined whether family or friend caregivers of men and women differ in their experience of distress over time. Thus, we aimed to describe, on a population-level and longitudinally, how older men and women care-receivers differed in their health and care needs, compare their caregivers' distress trajectories, and identify factors that contribute to the observed differences.

METHODS

This is a population-based, retrospective cohort study using routinely collected data. We examined longitudinally 485,407 community-dwelling Ontario residents, aged over 50 years, who have received at least one Residential Assessment Instrument-Home Care (RAI-HC) assessment between April 2008 and June 2015. Descriptive analyses were performed on the demographic characteristics, health profiles, and care needs of men and women. We also compared their caregivers' baseline and one-year change in distress status. Logistic regressions were performed to examine if the effect of gender on caregiver distress is reduced after controlling for care-receiver's health and functional status as well as their caregiver's kinship and co-residence status.

RESULTS

Men (39.5% of our cohort) were frailer, required more care, were mostly cared for by their spouses (52%), and mostly lived with their caregiver (66%). In contrast, women (60.5%) were more likely cared for by their child/child-in-law (60%), less likely to live with caregivers (47%), and received less care. Caregivers of men were more likely to be distressed at baseline (27.7% versus 20.4% of women caregivers) and remain distressed (74.6% versus 69.5%) or become distressed (19.3% versus 14.3%) throughout the year. In logistic regression modelling, the effect of care-receiver's gender on caregiver distress is reduced from an unadjusted odds ratio of 1.49 (95% CI: 1.47-1.51) to 1.17 (95% CI: 1.15-1.19) when care-receiver's health and caregiving factors are controlled for.

CONCLUSION

Older men and women differed in health and care needs. Caregivers, especially those caring for men, were often distressed and remained so through time. These results highlight the need for policies that account for the differential care needs and caregiver profiles of men and women in order to offer targetted and appropriate support.

Polypharmacy and potential drug–drug interactions among Greenland’s care home residents

Background:

As lifetime expectancy in Greenland is steadily increasing, so is the proportion of elderly Greenlanders. Old age is associated with polypharmacy, and in this study, we aim to describe the prevalence and characteristics of polypharmacy among the care home residents in Greenland.

Methods:

Eight care homes in Greenland were visited between 2010 and 2016. Questionnaires including information on prescribed medication and comorbidities were collected and analyzed. Drugs were categorized according to Anatomical Therapeutic Chemical (ATC) category, and potential drug–drug interactions (pDDIs) were assessed using the Danish Interaction Database. Polypharmacy was defined as five or more prescribed drugs.

Results:

All 244 eligible residents were included in the study. The median number of prescribed drugs per resident was six, and women were prescribed more drugs than men (median six versus five). More than 60% of all residents fulfilled the criteria for polypharmacy. The residents in the polypharmacy group had a higher body mass index (26.9 versus 24.3) and more chronic diseases (median two versus one), and more often pulmonary (14% versus 1%) or endocrine disease (22% versus 2%) than in the non-polypharmacy group. The most prescribed drugs belonged to ATC category N (nervous system, 78% of the residents). Finally, pDDIs were found among 61% of the residents and were more common in the capital (77%), which also had the highest proportion of residents with polypharmacy (77%).

Conclusion:

This is the first study to describe the patterns of polypharmacy and pDDIs among the elderly in care homes in Greenland. Our findings indicate that polypharmacy is as common in Greenland as elsewhere in the Western world, but there are local differences in the prevalence.

Plain Language Summary

Polypharmacy among the elderly in care homes in Greenland

The lifetime expectancy of the Greenlandic population is increasing, and so is the number of elderly Greenlanders. Previous studies have shown that the elderly have a higher risk of being treated with five drugs or more which is called polypharmacy. Polypharmacy can cause unwanted interactions and side effects. In this study, we examine the characteristics of the residents in Greenlandic care homes belonging to this group.

Using questionnaires, we gathered information from 244 residents from care homes in eight different towns and settlements in Greenland. Data included types of medication prescribed to the resident, age, gender, cause of stay, and medical history, which allowed us to compare the results between genders and towns.

We found that among 244 residents, more than half of all residents were prescribed five or more different drugs, and women were generally prescribed more drugs than men. Those prescribed five or more drugs had a higher body mass index and more diseases than those prescribed fewer drugs. We also found that certain types of medication, mainly painkillers, were the most prescribed. Finally, residents in the care home in Greenland’s capital Nuuk were more often prescribed five or more drugs than elsewhere in Greenland, indicating local differences in Greenland.

Our results give an essential insight into the health and medication of the most fragile elderly in Greenland. Polypharmacy seems to be as common here as elsewhere in the Western world and is a point of focus.

Creating opportunities to improve detection of older adult abuse: a national interRAI study

Despite being recognized as a major global health issue, older adult abuse (OAA) remains largely undetected and under-reported. Most OAA assessment tools fail to capture true prevalence. Follow up of patients where abuse exposure is not easily determined is a necessity. The interRAI-HC (International Resident Assessment Instrument—Home Care) currently underestimates the extent of abuse. We investigated how to improve detection of OAA using the interRAI-HC. Analysis of 7 years of interRAI-HC data from an Aotearoa New Zealand cohort was completed. We identified that through altering the criteria for suspicion of OAA, capture rates of at-risk individuals could be nearly doubled from 2.6% to 4.8%. We propose that via adapting the interRAI-HC criteria to include the "unable to determine" whether abuse occurred (UDA) category, identification of OAA sufferers could be substantially improved. Improved identification will facilitate enhanced protection of this vulnerable population.

What matters to people aged 80 and over regarding ambulatory care? A systematic review and meta-synthesis of qualitative studies

The growing percentage of the population aged 80 and over is challenging for healthcare systems, as frailty and other complex health issues are common in this age group. In order to provide patient-centered ambulatory healthcare, their preferences and expectations need to be explored. Therefore, the aim of this study was to systematically search for and synthesize qualitative evidence on how people aged 80 and over believe ambulatory healthcare (medical and nursing care) should be delivered to them. Medline, PsycINFO, CINAHL, Web of Science Core Collection and Google Scholar were searched for full research reports of qualitative studies focusing on the preferences, wishes, needs, expectations and experiences of people aged 80 and over regarding ambulatory medical and nursing care. The results were screened by two independent reviewers using a two-step approach. The included studies were meta-synthesized using Thomas and Harden’s ‘thematic synthesis’ approach in order to gain a new, second-order interpretation of the findings of the primary studies. In the intermediate synthesis step, 14 aspects of healthcare structures and care relationships were identified as relevant. Based on these, three underlying wishes were found: feeling safe, feeling like a meaningful human being, and maintaining control and independence. The results of this review are in line with other research, such as reviews focusing on the preferences of the younger age group (65–80). However, the importance of aspects of care relationships as an integral part of favorable ambulatory healthcare and the wish to be strengthened as a meaningful human being are emphasized more strongly.

Evaluating the provision of Further Enabling Care at Home (FECH+) for informal caregivers of older adults discharged home from hospital: protocol for a multicentre randomised controlled trial

INTRODUCTION

There are personal and societal benefits from caregiving; however, caregiving can jeopardise caregivers' health. The Further Enabling Care at Home (FECH+) programme provides structured nurse support, through telephone outreach, to informal caregivers of older adults following discharge from acute hospital care to home. The trial aims to evaluate the efficacy of the FECH+ programme on caregivers' health-related quality of life (HRQOL) after care recipients' hospital discharge.

METHODS AND ANALYSIS

A multisite, parallel-group, randomised controlled trial with blinded baseline and outcome assessment and intention-to-treat analysis, adhering to Consolidated Standards of Reporting Trials guidelines will be conducted. Participants (N=925 dyads) comprising informal home caregiver (18 years or older) and care recipient (70 years or older) will be recruited when the care recipient is discharged from hospital. Caregivers of patients discharged from wards in three hospitals in Australia (one in Western Australia and two in Queensland) are eligible for inclusion. Participants will be randomly assigned to one of the two groups. The intervention group receive the FECH+ programme, which provides structured support and problem-solving for the caregiver after the care recipient's discharge, in addition to usual care. The control group receives usual care. The programme is delivered by a registered nurse and comprises six 30-45 min telephone support sessions over 6 months. The primary outcome is caregivers' HRQOL measured using the Assessment of Quality of Life-eight dimensions. Secondary outcomes include caregiver preparedness, strain and distress and use of healthcare services. Changes in HRQOL between groups will be compared using a mixed regression model that accounts for the correlation between repeated measurements.

ETHICS AND DISSEMINATION

Participants will provide written informed consent. Ethics approvals have been obtained from Sir Charles Gairdner and Osborne Park Health Care Group, Curtin University, Griffith University, Gold Coast Health Service and government health data linkage services. Findings will be disseminated through presentations, peer-reviewed journals and conferences.

TRIAL REGISTRATION NUMBER

ACTRN12620000060943.

Sex Differences in Behavioral and Psychological Signs and Symptoms of Dementia Presentation Regarding Nursing Home Residents with Cognitive Impairment Suffering from Pain - Results of the Services and Health for Elderly in Long-Term Care Study

OBJECTIVE

Behavioral and psychological symptoms of dementia (BPSD) place a heavy burden on patients as well as caregivers. Recently, pain was identified as an important determinant of BPSD. However, it is not yet known what influence sex has on BPSD and pain. Thus, the present study aimed to identify possible associations between BPSD, pain, and sex.

DESIGN

A retrospective evaluation of cross-sectional data derived from the Services and Health for Elderly in Long-Term Care (SHELTER) Study database, a cross-national European study on nursing home residents.

SETTING AND PARTICIPANTS

The study involved 4156 residents who were assessed using the interRAI instrument for Long-Term Care Facilities. Included in the analysis were only patients with cognitive impairment (n = 2822) (67.9%) of which 712 (25.2%) were male and 2110 (74.8%) were female.

METHODS

Differences in prevalence were tested using the χ² test while bivariate logistic regression models were used to evaluate factors associated with sex.

RESULTS

Men showed behavioral symptoms such as wandering, verbal and physical abuse as well as sexual uninhibited behavior significantly more often than women. Regarding psychiatric symptoms, only depression was significantly more frequent in women. Surprisingly, in the presence of pain these differences in BPSD incidence between men and women were no longer detectable. Logistic regression analysis showed that in women with dementia/communication problems, the presence of pain could be indicated by resistance to care, sleeping disorders, and possibly by the presence of delusions and anxiety whereas in men it was related to abnormal thought processes, and in both sexes to depression CONCLUSIONS AND IMPLICATIONS: From a clinical point of view, resistance to care and sleeping disorders in women and abnormal thought processes in men as well as depression in both sexes should be seen as indicators of possible underlying pain in noncommunicative people. Thus, knowledge of sex-specific BPSD presentations can improve pain management in this particularly patient group.

Family Physician's and Primary Care Team's Perspectives on Supporting Family Caregivers in Primary Care Networks

Background. Research, practice, and policy have focused on educating family caregivers to sustain care but failed to equip healthcare providers to effectively support family caregivers. Family physicians are well-positioned to care for family caregivers. Methods. We adopted an interpretive description design to explore family physicians and primary care team members’ perceptions of their current and recommended practices for supporting family caregivers. We conducted focus groups with family physicians and their primary care team members. Results. Ten physicians and 42 team members participated. We identified three major themes. “Family physicians and primary care teams can be a valuable source of support for family caregivers” highlighted these primary care team members’ broad recognition of the need to support family caregiver’s health. “What stands in the way” spoke to the barriers in current practices that precluded supporting family caregivers. Primary care teams recommended, “A structured approach may be a way forward.” Conclusion. A plethora of research and policy documents recommend proactive, consistent support for family caregivers, yet comprehensive caregiver support policy remains elusive. The continuity of care makes primary care an ideal setting to support family caregivers. Now policy-makers must develop consistent protocols to assess, and care for family caregivers in primary care.

Caregiving Factors as Predictors of Care Recipient Mortality

OBJECTIVE

Assess a conceptual model linking caregiving factors to care recipient mortality in a large representative sample of older adults with disability.

DESIGN

Descriptive longitudinal study with 5-year mortality follow-up among older adults with disability. Baseline in person and telephone interviews/assessments of older adults with disability and their family caregivers carried out in 2011.

SETTING

Representative samples of older US population and their family caregivers.

PARTICIPANTS

US representative samples of older adults with disability aged 65 and over (National Health and Aging Study) and their family caregivers (National Study of Caregiving; www.nhats.org; N = 1,262).

MEASUREMENT

Controlling for known risk factors for mortality in older adults, including age, gender, race, education, socioeconomic status, disability, and cognitive status, we assess the role of three caregiving factors (depression, anxiety, and burden) and three mediating factors (care recipient depression, anxiety, and unmet needs for care) as predictors of care recipient mortality.

RESULTS

Caregiver burden, care recipient depression, and care recipient unmet needs are independent predictors of care recipient mortality.

CONCLUSION

Caregiving factors may play an important role in the survival of their care recipients. This is a relatively unexplored research area that calls for fine-grained studies capturing caregiver-care recipient health-related interactions over time.

Predictive factors for entry to long-term residential care in octogenarian Māori and non-Māori in New Zealand, LiLACS NZ cohort

BACKGROUND

Long-term residential care (LTC) supports the most vulnerable and is increasingly relevant with demographic ageing. This study aims to describe entry to LTC and identify predictive factors for older Māori (indigenous people of New Zealand) and non-Māori.

METHODS

LiLACS-NZ cohort project recruited Māori and non-Māori octogenarians resident in a defined geographical area in 2010. This study used multivariable log-binomial regressions to assess factors associated with subsequent entry to LTC including: self-identified ethnicity, demographic characteristics, self-rated health, depressive symptoms and activities of daily living [ADL] as recorded at baseline. LTC entry was identified from: place of residence at LiLACS-NZ interviews, LTC subsidy, needs assessment conducted in LTC, hospital discharge to LTC, and place of death.

RESULTS

Of 937 surveyed at baseline (421 Māori, 516 non-Māori), 77 already in LTC were excluded, leaving 860 participants (mean age 82.6 +/- 2.71 years Māori, 84.6 +/- 0.52 years non-Māori). Over a mean follow-up of 4.9 years, 278 (41% of non-Māori, 22% of Māori) entered LTC; of the 582 who did not, 323 (55%) were still living and may yet enter LTC. In a model including both Māori and non-Māori, independent risks factors for LTC entry were: living alone (RR = 1.52, 95%CI:1.15-2.02), self-rated health poor/fair compared to very good/excellent (RR = 1.40, 95%CI:1.12-1.77), depressive symptoms (RR = 1.28, 95%CI:1.05-1.56) and more dependent ADLs (RR = 1.09, 95%CI:1.05-1.13). For non-Māori compared to Māori the RR was 1.77 (95%CI:1.39-2.23). In a Māori-only model, predictive factors were older age and living alone. For non-Māori, factors were dependence in more ADLs and poor/fair self-rated health.

CONCLUSIONS

Non-Māori participants (predominantly European) entered LTC at almost twice the rate of Māori. Factors differed between Māori and non-Māori. Potentially, the needs, preferences, expectations and/or values may differ correspondingly. Research with different cultural/ethnic groups is required to determine how these differences should inform service development.

Caregiver Eligibility for Support Services: Correlates and Consequences for Resource Utilization

Policymakers and community organizations have implemented numerous programs and services to support the more than 40 million family caregivers in the United States. However, the existence of such services is not sufficient to ensure equitable and optimal access and utilization. Using data from the Caregiving in the US study (2015; n = 1,185), we estimated that nearly one in five family caregivers do not meet broad eligibility criteria for support services. This resource gap was particularly likely to affect high-priority populations such as those caring for someone with a mental health problem. Furthermore, ineligible caregivers had lower service utilization and increased financial strain. The findings highlight a pattern of vulnerability among caregivers who do not meet broad eligibility criteria for financial support resources. Careful policy consideration is needed to determine how support services should be allocated to maximize caregiver and care recipient outcomes at the population level.

Supporting community-dwelling older people with cognitive impairment to stay at home: A modelled cost analysis

OBJECTIVE

To model the potential financial implications of Australian programs supporting cognitively impaired community-dwelling older people.

METHODS

Markov cohort models of (a) an observational study of a residential dyadic training program for carers and people with dementia (GTSAH) and (b) a frailty intervention (FIT) in a cognitively impaired subgroup. Direct health and social welfare costs accrued over 5 years (2018 $AUD prices) were captured. GTSAH costs $3755, FIT costs $1834, and permanent residential aged care (P-RAC) costs $237 per day.

RESULTS

Modelling predicted costs break even in approximately 5 months for GTSAH and 7 months for FIT, after which these interventions saved funds. The primary driver of savings was the P-RAC cost (discounted at 5%/annum), at $121 030 for GTSAH vs $231 193 for standard care; and $47 857 with FIT vs $111 359 for standard care.

CONCLUSIONS

Programs supporting cognitively impaired community-dwelling older people could be financially beneficial; further evaluation and implementation would be a worthwhile investment.

Developing and validating models for predicting nursing home admission using only RAI-HC instrument data

OBJECTIVE

In recent years research has identified important predictors for nursing home admission (NHA). However, as far as we know, the previous risk models use complex variable sets from many sources and the output is a single risk value. The objective of this study was to develop an NHA risk model with a variable set from single data source and richer output information.

METHODS

In this study, we developed a model selecting variables only from the RAI-HC (Resident Assessment Instrument - Home Care) system. Furthermore, we used principal component analysis and K-means clustering to target proper interventions for high-risk clients.

RESULTS

The performance of the model was close to the complex previous model (recall [Formula: see text] vs. [Formula: see text] and specificity [Formula: see text] vs. [Formula: see text]). For the risk clients, three intervention clusters (deficiency in physical functionality, deficiency in cognitive functionality and depression and mood disorders) were found.

CONCLUSION

The NHA risk model and intervention clusters are important because they enable the identification of proper interventions for the right clients. The fact that the model with RAI-HC data alone was accurate enough simplifies the integration of the NHA risk model into practice because it uses data from one system and the algorithm can be integrated easily into the source system.

Evaluating case management as a complex intervention: Lessons for the future

The methodological challenges to effectiveness evaluation of complex interventions has been widely discussed. Bottom-up case management for frail older person was implemented in Belgium, and indeed, it was evaluated as a complex intervention. This paper presents the methodological approach we developed to respond to four main methodological challenges regarding the evaluation of case management: (1) the standardization of the interventions, (2) stratification of the frail older population that was used to test various modalities of case management with different risks groups, (3) the building of a control group, and (4) the use of multiple outcomes in evaluating case management. To address these challenges, we developed a mixed-methods approach that (1) used multiple embedded case studies to classify case management types according to their characteristics and implementation conditions; and (2) compared subgroups of beneficiaries with specific needs (defined by Principal Component Analysis prior to cluster analysis) and a control group receiving 'usual care', to evaluate the effectiveness of case management. The beneficiaries' subgroups were matched using propensity scores and compared using generalized pairwise comparison and the hurdle model with the control group. Our results suggest that the impact of case management on patient health and the services used varies according to specific needs and categories of case management. However, these equivocal results question our methodological approach. We suggest to reconsider the evaluation approach by moving away from a viewing case management as an intervention. Rather, it should be considered as a process of interconnected actions taking place within a complex system.

Comparing Changes and Transitions of Home Care Clients in Retirement Homes and Private Homes

Long-stay home care clients mostly reside in private homes or retirement homes, and the type of residence may influence risk factors for long-term care placement. This multi-state analytic study uses RAI-Home Care and administrative data from the Hamilton Niagara Haldimand Brant Local Health Integration Network to model conceptualized states of risk at baseline through a 13-month follow-up period. Modifiable risk factors in these states were client loneliness or depressive symptoms, and caregiver distress. A higher adjusted likelihood of being discharged deceased was found for the lowest-risk clients in retirement homes. Adjusting for client, service, and caregiver characteristics, retirement home residency was associated with higher likelihood of placement in a long-term care home; reduced caregiver distress; and increased client loneliness/depression. As an alternative to private home settings as the location for aging in place among these long-stay home care clients, retirement home residency represents some trade-offs between client and informal caregiver.

Caregiver Interventions for Adults Discharged from the Hospital: Systematic Review and Meta-Analysis

OBJECTIVES

To review the evidence evaluating the effectiveness of informal caregiver interventions to facilitate the recovery of older people discharged from the hospital.

DESIGN

Systematic review and meta-analysis.

SETTING

Hospital and community.

METHODS

Published and unpublished randomized and nonrandomized controlled trials assessing the effectiveness of informal caregiver interventions to support the recovery of older people discharged from the hospital were identified (to March 2019). The primary outcome was patient health-related quality of life (HRQOL). Secondary outcomes included patient function, caregiver burden, caregiver HRQOL, psychological distress, adverse events, and health resource use. Studies were critically appraised and meta-analyzed.

PARTICIPANTS

Adults who had been admitted to the hospital.

RESULTS

A total of 23 studies were eligible (4695 participants). The indication for hospital admission was stroke in 21 trials (91%). Interventions consisted of training and/or skills-based programs, with or without home visits/telephone follow-up. Caregiver interventions for patients following stroke may provide no benefit for patient HRQOL at 12 months (standardized mean difference = .29; 95% confidence interval = -.12 to .69; low-quality evidence). Caregiver interventions demonstrated benefit for caregiver burden and both patient and caregiver anxiety at 12 months. No consistent effect was found on functional outcomes, depression, HRQOL, adverse events, or health resource use measures.

CONCLUSIONS

Informal caregivers who receive training to facilitate the recovery of older people discharged from the hospital following stroke may have a lower burden and reduced anxiety at 12 months compared with those who do not. However, the evidence was moderate to low quality. Further study is warranted to explore whether caregiver interventions can be modified for nonstroke populations such as those with hip fracture. J Am Geriatr Soc 67:1960-1969, 2019.

Sociodemographic Factors and Characteristics of Caregivers as Determinants of Skilled Nursing Facility Admissions When Modeled Jointly With Functional Limitations

OBJECTIVES

We examined whether previously identified relationships between sociodemographic factors and caregivers for skilled nursing facility (SNF) admissions are replicated when jointly accounting for longitudinal change in functional limitations. We further explored the impact of caregivers by investigating the relationship between caregiver's characteristics and SNF admissions.

DESIGN

Longitudinal follow-up study.

SETTING

The United States of America.

PARTICIPANTS

In total, 3875 older Americans from the 2011-2015 rounds of the National Health and Aging Trends Study linked with Centers for Medicare and Medicaid Services.

MEASURES

Sociodemographic factors and caregiver's characteristics were used to predict change in functional limitations from baseline and time to first SNF admission using a joint modeling approach.

RESULTS

In total, 11.3% of the study population had a SNF admission during follow-up. For sociodemographic factors, non-Hispanic white, <9th grade education, and having at least 1 caregiver were associated with higher hazards of SNF admission than other race/ethnicity, college or higher education, and no caregiver, respectively. In contrast, living with a partner or living with others was associated with lower hazard of SNF admissions. For characteristics of caregivers, medical-supportive caregiver was associated with increased hazard of SNF admissions, whereas partner caregiver was protective of SNF admissions. Jointly modeling SNF admissions and change in functional limitations resulted in greater precision of effect estimates than modeling these outcomes separately.

CONCLUSIONS AND IMPLICATIONS

The study provides insight that can help identify high-risk populations for future interventions to prevent or delay SNF admissions. The relation between caregivers and SNF admissions depended on caregiver's characteristics. Future work should focus on providing help to those without a partner caregiver or needing help managing their health to ensure independent living and improve the well-being of older adults. Precision increased when jointly modeling the SNF admission with change in functional limitations.

Institutional caregiver experiences in child care

ABSTRACT Objective: to know the experience of institutional caregivers in child care. Method: qualitative research that used the Attachment Theory and the Symbolic Interactionism. Fifteen caregivers were interviewed, in 2015, in a child care institution based in a municipality in the south of Brazil. Data were analyzed through content analysis. Results: two categories emerged from the study: Embracing the children in the institution; Helping children adapt to institutionalization. Institutionalization imposes several social ills, such as abandonment and violence. These must be faced by caregivers, generating sadness and revolt. In addition, institutionalization leaves a mark on the child’s life, which belongs to no one, nor has his individuality and subjectivity preserved. Conclusion and Implications for practice: it is necessary to provide caregivers psychological support and Permanent Education so that they are supported in the work, improving the conditions of care offered to the child.