Use of physical restraints and psychotropic medications in Alzheimer special care units in nursing homes

The "CHROME criteria": Tool to optimize and audit prescription quality of psychotropic medications in institutionalized people with dementia

OBJECTIVE

Describe and validate the CHROME (CHemical Restraints avOidance MEthodology) criteria.

DESIGN

Observational prospective longitudinal study.

SETTING

Single nursing home in Las Palmas de Gran Canaria, Spain.

PARTICIPANTS

288 residents; mean age: 81.6 (SD 10.6). 77.4% had dementia.

INTERVENTION

Multicomponent training and consultancy program to eliminate physical and chemical restraints and promote overall quality care. Clinicians were trained in stringent diagnostic criteria of neuropsychiatric syndromes and adequate psychotropic prescription.

MEASUREMENTS

Psychotropic prescription (primary study target), neuropsychiatric syndromes, physical restraints, falls, and emergency room visits were semi-annually collected from December 2015 to December 2017. Results are presented for all residents and for those who had dementia and participated in the five study waves (completer analysis, n=107).

RESULTS

For the study completers, atypical neuroleptic prescription dropped from 42.7% to 18.7%, long half-life benzodiazepines dropped from 25.2% to 6.5%, and hypnotic medications from 47.7% to 12.1% (p<0.0005). Any kind of fall evolved from 67.3 to 32.7 (number of falls by 100 residents per year). Physicians' diagnostic confidence increased, while the frequency of diagnoses of neuropsychiatric syndromes decreased (p<0.0005).

CONCLUSIONS

Implementing the CHROME criteria reduced the prescription of the most dangerous medications in institutionalized people with dementia. Two independent audits found no physical or chemical restraint and confirmed prescription quality of psychotropic drugs. Adequate diagnosis and independent audits appear to be the keys to help and motivate professionals to optimize and reduce the use of psychotropic medication. The CHROME criteria unify, in a single compendium, neuropsychiatric diagnostic criteria, prescription guidelines, independent audit methodology, and minimum legal standards. These criteria can be easily adapted to other countries.

[Use of sedating medication and physical restraints for patients with dementia in acute care hospitals : A non-randomized case control study]

Hintergrund

Auf Menschen mit Demenz mit stationär behandlungsbedürftiger Akuterkrankung ist der Großteil der Akutkrankenhäuser kaum vorbereitet. Dies birgt die Gefahr der Überforderung für das Personal. Demenzerkrankungen sind der häufigste Grund dafür, dass Krankenhauspersonal sedierende Medikamente verabreicht und bewegungseinschränkende Maßnahmen einsetzt.

Zielsetzung

Die vorliegende Studie untersucht Faktoren, die den (unangemessenen) Einsatz von sedierenden Medikamenten und bewegungseinschränkenden Maßnahmen beeinflussen.

Methoden

Eine nichtrandomisierte Fall-Kontroll-Studie wurde in 2 internistischen Abteilungen in Hamburg durchgeführt. In der Interventionsgruppe wurde ein spezielles Versorgungskonzept für Menschen mit Demenz implementiert. Die Versorgungsart in der Kontrollgruppe entsprach der Regelversorgung. Mit logistischen Regressionen wurden Zusammenhänge zwischen Faktoren wie Alter, Demenzschweregrad, Verhaltensauffälligkeiten, Barthel-Index oder Versorgungsart und dem Einsatz sedierender Medikamente bzw. bewegungseinschränkender Maßnahmen untersucht.

Ergebnisse

Herausfordernde Verhaltensweisen (OR = 1,32) und die Zugehörigkeit zur Kontrollgruppe (OR = 1,94) sind signifikant mit dem Einsatz sedierender Medikamente assoziiert. Ein geringerer Barthel-Index, längere Aufenthaltsdauer und die eine Behandlung in der Kontrollgruppe sind signifikant mit einer höheren Wahrscheinlichkeit des Einsatzes bewegungseinschränkender Maßnahmen assoziiert.

Diskussion

Der Einsatz sedierender Medikamente als auch bewegungseinschränkender Maßnahmen variiert stark zwischen Interventions- und Kontrollgruppe. Andere Studien, die zu ähnlichen Ergebnissen kommen, sehen verschiedene Bausteine spezieller Versorgungskonzepte als Gründe für diese Unterschiede. Dazu zählen neben der baulichen Gestaltung und räumlichen Aspekten auch demenzspezifische Schulungsangebote und ein angemessener Personalschlüssel. Dies vermag auch Unruhe und herausfordernde Verhaltensweisen aufseiten der Patienten zu reduzieren. Der Verzicht auf Sedierung und bewegungseinschränkende Maßnahmen hat nicht zuletzt auch positive Auswirkungen auf die Lebensqualität von Menschen mit Demenz.

Restraint use among selected hospitalized elderly patients in Cairo, Egypt

Objective

This study’s primary objective was to investigate the prevalence of physical and chemical restraint use in selected elderly hospitalized patients.

Results

This study was conducted in April 2014 in four major acute care hospitals. Trained data collectors assessed the use of physical and chemical restraint among all admitted elderly patients. There were 287 elderly patients (median age 64 years, 46% women). 32 patients were restrained. The overall prevalence of restraints was 11.1%, with physical restraint use alone at 3.2% and chemical restraints use alone at 7.3%. Restraint use varied by hospital type, with the highest at the private hospital (22.9%) and the lowest at the two university hospitals (< 6%). In conclusion the prevalence of physical and chemical restraint use among admitted elderly patients in Egypt is comparable to that seen in developed countries. However, the use appears to vary widely by hospital type. The use of restraints in the elderly remains an important question considering the increasing number of elderly.

Electronic supplementary material

The online version of this article (10.1186/s13104-017-2978-x) contains supplementary material, which is available to authorized users.

Identifying Consistent and Coherent Dimensions of Nursing Home Quality: Exploratory Factor Analysis of Quality Indicators

BACKGROUND

There is a general belief that the markers of nursing home quality do not aggregate easily. Identifying consistent and coherent dimensions of quality that usefully summarize the multiplicity of nursing home quality measures is an important goal. It would simplify interpretation and help consumers, their families and advocates to choose nursing facilities.

OBJECTIVES

This study uses quality indicators (QIs) from a state nursing home report card to explore the dimensionality of quality in nursing homes and to determine whether aggregation at the resident versus facility level yields the same underlying dimensions.

DESIGN

Cross-sectional study.

SETTING

382 Medicare- and/or Medicaid-certified nursing homes in Minnesota.

PARTICIPANTS

Residents admitted to the nursing homes during 2011-2012.

MEASUREMENTS

16 QIs obtained from the Minimum Data Set 3.0 assessment instrument between 2011 and 2012 were used in the exploratory factor analysis.

RESULTS

Factor analysis results suggest four main factors or dimensions to characterize facility performance: continence care (including 4 QIs), restraints and behavioral symptoms (including 3 QIs), care for specific conditions (including 6 QIs), and physical functioning (including 3 QIs). The resident-level and facility-level results generally agreed for 11 QIs.

CONCLUSION

Nursing home quality of care can be captured in summary measures, which can be used by consumers, providers and researchers. Reporting at the resident or facility level will depend on the purpose. These summary measures can be used by policy-makers to identify and reward high-performing facilities and by families to choose nursing facilities for care.

Risk Factors for Physical Restraint Use in Nursing Homes

This study examined the impact of the Nursing Home Reform Act of 1987 on resident-and-facility-level risk factors for physical restraint use in nursing homes. Data on the 1990 and 1993 cohorts were obtained from 268 facilities in 10 states, and data on a 1996 cohort were obtained from the Medical Expenditure Panel Survey, which sampled more than 800 nursing homes nationwide. Multivariate logistic regression models were generated for each cohort to identify the impact of resident- and facility-level risk factors for restraint use. The results indicate that the use of physical restraints continues to decline. Thirty-six percent of the 1990 cohort, 26 percent of the 1993 cohort, and 17 percent of the 1996 cohort were physically restrained. Although there was a reduced rate of restraint use from 1990 to 1996, similar resident-level factors but different facility-level factors were associated with restraint use at different points in time.

Nursing home residents with Alzheimer’s disease in special care units compared to other residents with Alzheimer’s disease

The purpose of the study was to compare nursing home residents with Alzheimer’s disease (AD) in special care units (SCUs) to other AD residents.

We analyzed 49,627 admission assessments recorded in the Minimum Data Set during 2000 for residents with AD, with 11,311 in SCUs. We compared these two groups of AD residents for demographic characteristics, health status, and treatments.

SCU residents were significantly more likely to be male, younger, white, married, and self pay than other AD residents. SCU residents were significantly more likely to have poorer cognitive function and communication skills while other AD residents were significantly more likely to be totally activities of daily living (ADL) dependent, more physically disabled, and have cardiac-related conditions. SCU residents were significantly more likely to receive daily anti-psychotic, anti-anxiety, or anti-depressant medications than other AD residents. Other AD residents were more likely to receive a range of treatments and procedures, while SCU residents were more likely to receive intervention programs for mood, behavior, or cognitive loss.

The implications of this are that SCU residents and other AD residents represent distinct nursing home populations. SCU residents are more likely to have cognitive decline and behavior problems while other AD residents are more likely to have greater physical disability and life-threatening co-morbidities.

Psychotropic Drug Use in a Nursing Home: A 6-Year Retrospective

The Omnibus Budget Reconciliation Act of 1987 (OBRA) was a public policy initiative intended to improve nursing home residents’quality of life by providing strict guidelines for the prescription of psychotropic drugs (PD) and physical restraints. This study documents and explains the use of PDs in one nursing home at three points in time: well before (1988), immediately before (1990), and well after (1994) OBRA implementation. In 1994, 64.5% of residents in the nursing home had prescriptions for PDs compared with 71% in 1988 and 1990, but those with a PD prescription had more than one (mean = 2.19). After OBRA implementation, antipsychotic and antidepressant use was higher than at earlier data collection points, whereas anti-anxiety medication prescription was at its lowest. In addition, diagnoses of depression and cognitive impairment had increased dramatically by 1994. Explanations for these findings are provided, including possible aging of residents, change in staffing levels, caregiver anomie, the impact of another legislative bill, and the introduction of the minimum data set.

Reducing Physical Restraints in Nursing Homes: A Report From Maria Wolff and Sanitas

OBJECTIVE

Physical restraints are associated with severe side effects and suffering. A comprehensive, person-centered, methodology was implemented in 41 Spanish nursing homes to safely eliminate restraints.

METHODS

Data were collected in 2 waves: September 2011 (at the beginning of the intervention, n = 4361) and September 2014 (n = 5051). Use of 10 different types of physical restraints was recorded, as well as frequency of psychotropic medication prescription, falls, and mortality.

RESULTS

Mean age was 83.4 (SD 8.5) and 63.5% of the residents had dementia. Frequency (95% confidence interval) of people having at least 1 restraint was reduced from 18.1% (17.0-19.3) to 1.6% (1.3-2.0). Use of benzodiazepines was also reduced, with no significant changes in other psychotropic medications and mortality. The rate of total falls increased from 13.1% (12.1-14.1) to 16.1% (15.1-17.1), with no significant increase in injurious falls.

CONCLUSION

Physical restraints can almost completely be eliminated with reasonable levels of safety.

Differences in Case Conferences in Dementia Specific vs Traditional Care Units in German Nursing Homes: Results from a Cross-Sectional Study

OBJECTIVES

To investigate differences in the provision and performance of case conferences for people with dementia between dementia special care units (DSCUs) and traditional care units (TCUs) in nursing homes. Because DSCUs employ more staff, we expect the likelihood of the provision of case conferences to be higher in DSCUs.

DESIGN

Observational cross-sectional study. Residents from DSCUs and TCUs were compared using genetic propensity score matching over all of the observed potential covariates, including the characteristics that served as admission criteria for DSCUs. Because of the multisite structure of the data, clustering was accounted for with a generalized mixed model.

SETTING

DSCUs are defined as units within nursing homes that offer care exclusively to residents with dementia and that charge higher rates for the specialized care provided. TCUs are defined as care units for residents with and without dementia.

PARTICIPANTS

A matched sample was drawn out of a convenience sample of 1808 residents from 51 nursing homes. It consisted of 264 residents from 16 DSCUs and 264 residents from 48 TCUs.

INTERVENTIONS

None.

MEASUREMENTS

Data regarding the provision of case conferences were collected by the nurses using the Dementia Care Questionnaire. Other collected data included challenging behavior (Neuropsychiatric Inventory Questionnaire), mobility (Physical Self-Maintenance Scale), cognitive impairment (Dementia Screening Scale), and sociodemographic information.

RESULTS

In the DSCU group, case conferences were provided to 91% (n = 224) of the residents; in the TCU group, 82.5% (n = 203) received a case conference. After adjusting for clustering, no significant difference between DSCUs and non-DSCUs was found. The topic "challenging behaviors" was discussed more often in case conferences in TCUs.

CONCLUSIONS

Case conferences are a widespread intervention in German nursing homes, including both DSCUs and TCUs. The provision of a case conference is not a special feature of DSCUs.

Role of antipsychotics for treating behavioral and psychological symptoms of dementia

Over the past three decades, concerns about the high prevalence of antipsychotic use in the nursing homes (NHs) for the management of behavioral and psychological symptoms of dementia continue to be emphasized and intervened by many. However, despite the numerous side effects and the recent blackbox warning by the United States Food and Drug Administration about the increased risks for stroke and sudden death associated with the use of antipsychotics in dementia, the prevalence of antipsychotic use in NHs remains high. While the use of antipsychotics appeared to have modest efficacy in reducing symptoms of aggression and psychosis in dementia, there is insufficient evidence to routinely recommend the use of alternative psychopharmacological treatments for these symptoms. Hence, clinicians have to balance the safety warnings against the need to treat these symptoms in order to prevent harm to the resident that may result from his/her dangerous behaviors. Although the use of antipsychotics may be warranted in some cases, organizational, resource and training support should be provided to encourage and equip NH staff to participate in interventions so as to minimize inappropriate use of these medicines in NHs. This review will discuss the place in therapy, the trend and appropriateness of antipsychotic use in NHs, as well as the effectiveness of current and future strategies for reducing antipsychotic use in the NHs.

Dementia special care units: a comparison with standard units regarding residents' profile and care features

BACKGROUND

Unlike other countries, no data about residents and care features in Special Care Units (SCUs) in Spanish nursing homes have been reported to date. The present paper is the first to analyze the characteristics of residents with dementia and the features of provided care in SCUs in comparison to residents with dementia in standard beds, thus not receiving specialized care in nursing homes in Spain.

METHODS

Data on residents with dementia were collected in 11 nursing homes. Residents with diagnosis of dementia and Mini-Mental State Examination scores of less than 27 were randomly selected in each center. Altogether 197 residents were assessed: 102 (52%) placed in SCUs, and 95 (48%) in standard beds. Analyses of the characteristics of residents in SCUs versus standard beds regarding socio-demographic and clinical variables, features of the care provided, and residents' quality of life (QoL) were performed using univariate and multivariate tests (binary logistic regression analysis).

RESULTS

Residents in SCUs did not differ from those in standard beds in socio-demographic variables. Placement of residents in SCUs seemed to be related with the presence of severe cognitive and functional impairment and aggressive behaviors. Being in an SCU conveyed a higher probability of having individual bedroom and bathroom; nevertheless, there were no differences in the care provided in SCUs, considering use of nappies, and feeding and restraint systems. Patients in SCUs showed lower QoL reported by the staff.

CONCLUSIONS

Although residents in SCUs present higher levels of impairment, there are no real differences in the care provided besides a higher probability of having individual rooms. Regulations on required features for SCUs in Spain are necessary to guarantee that care provided to residents is truly special.

How to avoid and prevent coercion in nursing homes

In many Western countries, studies have demonstrated extensive use of coercion in nursing homes, especially towards patients suffering from dementia. This article examines what kinds of strategies or alternative interventions nursing staff in Norway used when patients resist care and treatment and what conditions the staff considered as necessary to succeed in avoiding the use of coercion. The data are based on interdisciplinary focus group interviews with nursing home staff. The study revealed that the nursing home staff usually spent a lot of time trying a wide range of approaches to avoid the use of coercion. The most common strategies were deflecting and persuasive strategies, limiting choices by conscious use of language, different kinds of flexibility and one-to-one care. According to the staff, their opportunities to use alternative strategies effectively are greatly affected by the nursing home’s resources, by the organization of care and by the staff’s competence.

The quality of advanced dementia care in the nursing home: the role of special care units

BACKGROUND

The quality of nursing home care for residents with advanced dementia has been described as suboptimal. One relatively understudied factor is the impact of special care units (SCUs) for dementia for residents at the end stage of this disease.

OBJECTIVE

To examine the association between residence in an SCU and the quality of end-of-life care for nursing home residents with advanced dementia.

RESEARCH DESIGN

This study used longitudinal data on 323 nursing home residents with advanced dementia living in 22 Boston-area facilities. Using multivariate methods, we analyzed the association between residence in an SCU and measures of quality of end-of-life care including: treatment of pain and dyspnea, prevalence of pressure ulcers, hospitalization, tube feeding, antipsychotic drug use, advance care planning, and health care proxy (HCP) satisfaction with care.

RESULTS

A total of 43.7% residents were cared for in an SCU. After multivariate adjustment, residents in SCUs were more likely to receive treatment for dyspnea, had fewer hospitalizations, were less likely to be tube fed, and more likely to have a do-not-hospitalize order, compared with non-SCU residents. However, non-SCU residents were more likely to be treated for pain, had fewer pressure ulcers, and less frequent use of antipsychotic drugs than SCU residents. HCPs of SCU residents reported greater satisfaction with care than HCPs of non-SCU residents.

CONCLUSIONS

Residence in an SCU is associated with some, but not all, markers of better quality end-of-life care among nursing home residents with advanced dementia.

A national survey of the use of physical restraint in long-term care hospitals in Japan

AIMS AND OBJECTIVES

To investigate the prevalence of physical restraints in the long-term care hospitals in Japan and to examine the factors of physical restraint use, including the specific skills/techniques that the staff use to minimise the restraints. Background.  Despite the national efforts to nullify physical restraint, it is still prevalent in long-term care facilities in and out of Japan. More detailed information regarding what affects physical restraint is needed.

DESIGN

Cross-sectional mail survey.

METHOD

A questionnaire was sent to a nursing ward manager of the random sample of long-term care facilities in Japan.

RESULTS

The average rate of physical restraint was 25·5%. Altogether, 81·0% of the restrained clients were under restraint for more than one month. The most prevalent method of restraint was bilateral bedrails, followed by the use of coveralls and gloves. Factors of restraint were different depending on the type of restraint, suggesting specific approaches are needed for specific type of restraint.

CONCLUSIONS

Physical restraint is still prevalent in Japanese long-term care hospitals, and nurses need to develop effective intervention approach to redesigning practice related to physical restraints. Specialised intervention approach seems needed depending on the types of restraint.

RELEVANCE TO CLINICAL PRACTICE

Specific approach should be developed to minimise the physical restraint in long-term care hospitals in Japan.

Evaluation of special and traditional dementia care in nursing homes: results from a cross-sectional study in Germany

OBJECTIVE

Two-thirds of all residents in nursing homes in Germany suffer from some type of dementia. We investigated whether or not dementia patients receiving special (segregated or partially segregated) care exhibited a better quality of life than their counterparts residing in traditional nursing homes.

METHODS

In a cross-sectional study in 28 special dementia care facilities in the city of Hamburg (admission criterion: mobile dementia patients with behaviour problems) 594 residents were compared to a group of nursing home residents with dementia (n = 573) in 11 randomly selected nursing homes who were receiving traditional integrative care. Primary features such as cognitive and functional impairment, and behaviour problems were assessed by qualified nursing staff.

RESULTS

Controlling for confounding variables, for dementia patients in special care units as compared to a reference group in traditional integrative care, the level of volunteer caregiver involvement was higher and there was more social contact to staff, fewer physical restraints, more involvement in home activities, and more frequent use of psychiatrists. There was no significant difference between the two care settings with regard to overall use of psychotropic drugs, however, residents in special dementia care used antipsychotics significantly less often and antidepressants more often.

CONCLUSIONS

Significant differences for a number of indicators of the quality of life point in favour of special dementia care. Future evaluation studies ought to examine not only the general efficacy of types of care designed especially for dementia patients but also the efficacy of the respective individual components (i.e. caregiver ratio).

Associations of special care units and outcomes of residents with dementia: 2004 national nursing home survey

PURPOSE

We compared the rates of specialized care for residents with Alzheimer's disease or dementia in special care units (SCUs) and other nursing home (NH) units and examined the associations of SCU residence with process of care and resident outcomes.

DESIGN AND METHODS

Data came from the 2004 National Nursing Home Survey. The indicators of process of care included physical restraints, continence management, feeding tubes, and influenza and pneumococcal vaccinations. Resident outcomes included pressure ulcers, hospitalization, emergency room visits, weight loss, and falls. Analyses were conducted by using Stata SE version 10.

RESULTS

Multivariate logistic regression analyses show that SCU residents were more likely to have received specialized dementia care and specialized behavioral problem management. They were less likely to have bed rails (adjusted odds ratio [AOR] = 0.39, AOR = 0.35, ps < .01), use catheters (AOR = 0.33, AOR = 0.33, ps < .01), and yet more likely to have toilet plans/bladder training for incontinence control (AOR = 1.90, AOR = 1.62, ps < .01) than those in regular units and those in NHs without an SCU. Moreover, SCU residents were less likely to have pressure ulcers, hospitalization than those in regular units, and less likely to have experienced weight loss than those in NHs without an SCU. However, they were more likely to have falls (AOR = 1.32, AOR = 1.36, ps < .05) than those in regular units and those in NHs without an SCU.

IMPLICATIONS

Our study shows that SCU residents had, in general, better process of care than those in regular units and in NHs without an SCU. Further studies are needed to assess specific outcome changes among SCU residents and to evaluate the cost-effectiveness of having such units.

The effect of multisensory stimulation on persons residing in an extended care facility

BACKGROUND

Non-pharmacological interventions, such as multisensory stimulation environments (MSSE), have demonstrated the ability to reduce inappropriate behavior among individuals with Alzheimer's disease.

METHODS

In this study, we compared the incidences of problematic behavior among individuals with Alzheimer's disease residing in a long-term care facility who were and were not exposed to an MSSE. Retrospective data were obtained using the Psychotic Behavior Assessment Record (PBAR), mandated by Medicare to be used when antipsychotic medications are administered. Psychotic Behavior Assessment Record data were collected using the first and sixth month of admission for residents after appropriate consent was secured.

RESULTS

Documented disruptive behavior included pacing, exit-seeking activities, hitting, yelling, and aggressive talking. The use of the MSSE resulted in a decrease in the number of incidences of disruptive behavior, but not the behaviors present.

CONCLUSION

The use of MSSE, as a non-pharmacological intervention, demonstrates the ability to decrease the number of incidences of disruptive or problematic behavior. The use of these interventions, where feasible, should be considered prior to the use of pharmacological methods.

Special care units for dementia individuals with behavioural problems

BACKGROUND

The behavioural problems of people with dementia are often considered as one of the most challenging issues in caring. Special Care Units (SCUs) have flourished since the 1980s with the aim of taking care of dementia patients, usually those with Alzheimer's disease, and in particular for those with behavioural problems. Although lacking a standard definition, SCUs are usually situated within nursing homes and commonly include the features of trained staffing, special programming, a modified physical environment, and family involvement. The costs of SCUs are commonly higher than for 'standard' nursing home care. However, evaluat ions of the outcomes of SCUs have yielded conflicting results. A systematic review of this evidence is therefore warranted .

OBJECTIVES

To evaluate the effect of SCUs on behavioural problems, mood, use of restraints and psychotropic medication in patients with dementia.

SEARCH STRATEGY

The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library, MEDLINE, EMBASE, PsycINFO and CINAHL on 6 September 2007 using the search terms: Special Care Units or SCUs. The CDCIG Specialized Register contains records from major healthcare databases including MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, and LILACS as well as many ongoing trial databases and grey literature sources.

SELECTION CRITERIA

All randomized controlled trials (RCTs) in which the outcomes of SCUs were compared against traditional nursing units (nursing homes, skilled nursing facilities) were included.

DATA COLLECTION AND ANALYSIS

Two reviewing authors independently read the full reports of the potentially eligible studies and selected those that met the inclusion criteria. Discrepancies were resolved by discussions among the two reviewing authors. Final consensus was reached with input from a third member of the team when necessary.

MAIN RESULTS

No RCTs meeting the selection criteria were identified. Since it is unlikely, for ethical and practical reasons that an RCT of SCUs will be conducted, a systematic review of non-RCTs using the same protocol and criteria was conducted. There were eight non-RCTs that fulfilled the criteria for inclusion. Only four studies had data which could be extracted for pooling in meta-analysis. Differences between comparator groups in these nonRCTs ? for example in severity of dementia - w ere not adequately adjusted for and were common in the trial which accounted for almost all of the positive outcomes of SCUs (Nobili, 2006)All of the results of the outcomes came only from single studies except for "physical restraint use" at 6 months, which included data from two studies. A small improvement in total Neuropsychiatric Inventory scores, favouring SCU was noted in one study at 6, 12 and 18 months. The use of physical restraints was less common in SCUs at 6 and 12 months (OR= 0.46 (95% CI 0.27 to 0.80), p=0.006; and OR=0.49 (0.27 to 0.88), p=0.02 respectively). Patients in SCUs were less depressed at 3 months than those in traditional nursing home (WMD -6.30 (-7.88 to -4.72) Cornell points, p<0.00001). There was only one observation that favoured the control group: a small but significant effect favouring traditional nursing home care was observed at 6 months in the mean number of psychotropic medications used (WMD 0.20, CI 0.00 to 0.40, z=1.96, P=0.05).

AUTHORS' CONCLUSIONS

There are no identified RCTs investigating the effects of SCUs on behavioural symptoms in dementia, and no strong evidence of benefit from the available non-RCTs. It is probably more important to implement best practice than to provide a specialized care environment. The routine collection of data on behaviour, restraint and psychotropic drug use across multiple nursing home settings offers the best modality for formal evaluation of the benefit or otherwise of SCUs.

Trends in mental health admissions to nursing homes, 1999-2005

OBJECTIVE

The study examined 1999-2005 data on first-time nursing home admissions of individuals with mental illness, dementia, or both to identify trends and characteristics.

METHODS

The Minimum Data Set was used to estimate the number and percentage of persons newly admitted to nursing homes who had mental illness (schizophrenia, bipolar disorder, depression, or an anxiety disorder), dementia, or both from 1999 to 2005. Data from 2005 were used to compare demographic characteristics and comorbid conditions of the three groups and treatments received.

RESULTS

The number of individuals admitted with mental illness increased from 168,721 in 1999 to 187,478 in 2005. The 2005 number is more than 50% higher than the number admitted with dementia only (118,290 in 2005). The increase was driven by growth in admissions of persons with depression--from 128,566 to 154,262 in 2005. Persons admitted with depression had higher rates of comorbid conditions than those admitted with dementia or with neither dementia nor mental illness. They also had high rates of antidepressant treatment and high rates of receipt of training in skills required to return to the community.

CONCLUSIONS

Current trends show that the proportion of nursing home admissions with mental illness, in particular depression, has overtaken the proportion with dementia. These changes may be related to increased recognition of depression, availability of alternatives to nursing homes for persons with dementia, and increased specialization among nursing homes in the care of postacute, rehabilitation residents. In light of these trends, it is critical to ensure that nursing homes have resources to adequately treat residents with mental illness to facilitate community reintegration.

Trends in mental health admissions to nursing homes, 1999-2005

OBJECTIVE

The study examined 1999-2005 data on first-time nursing home admissions of individuals with mental illness, dementia, or both to identify trends and characteristics.

METHODS

The Minimum Data Set was used to estimate the number and percentage of persons newly admitted to nursing homes who had mental illness (schizophrenia, bipolar disorder, depression, or an anxiety disorder), dementia, or both from 1999 to 2005. Data from 2005 were used to compare demographic characteristics and comorbid conditions of the three groups and treatments received.

RESULTS

The number of individuals admitted with mental illness increased from 168,721 in 1999 to 187,478 in 2005. The 2005 number is more than 50% higher than the number admitted with dementia only (118,290 in 2005). The increase was driven by growth in admissions of persons with depression--from 128,566 to 154,262 in 2005. Persons admitted with depression had higher rates of comorbid conditions than those admitted with dementia or with neither dementia nor mental illness. They also had high rates of antidepressant treatment and high rates of receipt of training in skills required to return to the community.

CONCLUSIONS

Current trends show that the proportion of nursing home admissions with mental illness, in particular depression, has overtaken the proportion with dementia. These changes may be related to increased recognition of depression, availability of alternatives to nursing homes for persons with dementia, and increased specialization among nursing homes in the care of postacute, rehabilitation residents. In light of these trends, it is critical to ensure that nursing homes have resources to adequately treat residents with mental illness to facilitate community reintegration.

Does the presence of a dementia special care unit improve nursing home quality?

OBJECTIVE

This study quantifies the effect of a new dementia special care unit (D-SCU) on the provision of care to all residents in a nursing home (NH).

METHOD

The authors use data from the On-line Survey Certification and Reporting system to identify free-standing NHs that first reported a D-SCU between 1996 and 2003 (N = 1,519). Fixed-effects models estimate the effect of a new D-SCU on the prevalence of each outcome (physical restraints, feeding tubes, and psychotropic medications) while controlling for secular trends.

RESULTS

For all NHs, the use of physical restraints declined, the use of antipsychotics increased, and other measures remained relatively constant. The introduction of a D-SCU was not associated with changes in trends for any measure.

DISCUSSION

Differences in care processes between NHs with and without D-SCUs are the result of differences in their underlying approach to care, not the result of care practice diffusion from the D-SCU.

Dying with dementia in long-term care

PURPOSE

To better understand the experiences and potential unmet need of persons who die in long-term care.

DESIGN AND METHODS

We conducted after-death interviews with staff who had cared for 422 decedents with dementia and 159 who were cognitively intact and received terminal care in U.S. nursing homes (NHs) or residential care-assisted living (RC-AL) settings. We conducted family caregiver interviews for 293 decedents.

RESULTS

We noted no differences between decedents with and without dementia in terms of pain, psychosocial status, family involvement, advance care planning, most life-prolonging interventions, and hospice use. Dying residents with dementia tended to die less often in a hospital, have less shortness of breath, receive more physical restraints and sedative medication, and use emergency services less frequently on the last day of life. Persons with dementia dying in RC-AL settings tended to have more skin ulcers and poorer hygiene care than nondemented persons in RC-AL settings. In comparison with persons dying with dementia in NHs, those in RC-AL settings tended to be restrained less often, have emergency services called more often on the day of death, and have family more satisfied with physician communication.

IMPLICATIONS

These results suggest that the overall quality of care for persons dying with dementia in long-term-care settings may not differ markedly from that provided to persons who are cognitively intact. Similarly, large discrepancies in the overall quality of palliative care for persons with dementia in RC-AL facilities and NHs were not identified. However, numerous specific areas for care improvement were noted.

Dementia of the Alzheimer type

Dementia of the Alzheimer type is a progressive, fatal neurodegenerative condition characterized by deterioration in cognition and memory, progressive impairment in the ability to carry out activities of daily living, and a number of neuropsychiatric symptoms. This narrative review summarizes the literature regarding descriptive epidemiology, clinical course, and characteristic neuropathological changes of dementia of the Alzheimer type. Although there are no definitive imaging or laboratory tests, except for brain biopsy, for diagnosis, brief screening instruments and neuropsychiatric test batteries used to assess the disease are discussed. Insufficient evidence exists for the use of biomarkers in clinical practice for diagnosis or disease management, but promising discoveries are summarized. Optimal treatment requires both nonpharmacological and pharmacological interventions, yet none have been shown to modify the disease's clinical course. This review describes the current available options and summarizes promising new avenues for treatment. Issues related to the care of persons with dementia of the Alzheimer type, including caregiver burden, long-term care, and the proliferation of dementia special care units, are discussed. Although advances have been made, more research is needed to address the gaps in our understanding of the disease.

Is dementia special care really special? A new look at an old question

OBJECTIVES

To quantify differences in care provided to nursing home (NH) residents with dementia living on and off dementia special care units (SCUs).

DESIGN

Cross-sectional study using propensity score adjustment for resident and NH characteristics.

SETTING

Free-standing NHs in nonrural U.S. counties that had an SCU in 2004 (N=1,896).

PARTICIPANTS

Long-stay (> or = 90 days) NH residents with a diagnosis of Alzheimer's disease or dementia and at least moderate cognitive impairment (N=69,131).

MEASUREMENTS

Resident-level NH care processes such as physical restraints, bed rails, feeding tubes, psychotropic medications, and incontinence care.

RESULTS

There was no difference in the use of physical restraints (adjusted odds ratio (AOR)=0.94, 95% confidence interval (CI)=0.79-1.11), but SCU residents were less likely to have had bed rails (AOR=0.55, 95% CI=0.46-0.64) and to have been tube fed (AOR=0.36, 95% CI=0.30-0.43). SCU residents were more likely to be on toileting plans (AOR=1.23, 95% CI=1.08-1.39) and less likely to use pads or briefs in the absence of a toileting plan (AOR=0.73, 95% CI=0.61-0.88). SCU residents were more likely to have received psychotropic medications (AOR=1.23, 95% CI=1.05-1.44), primarily antipsychotics (SCU=44.9% vs non-SCU=30.0%).

CONCLUSION

SCU residents received different care than comparable non-SCU residents. Most strikingly, SCU residents had greater use of antipsychotic medications.

The use of propensity score methods in psychiatric research

The use of propensity score methods has become increasing widespread in public health, in medicine and in many other settings involving research with observational studies. The methods provide a useful and straightforward way of simultaneously controlling for many variables that potentially confound the relationship between a specific outcome and the treatment or exposure under study. The methods assist the researcher in avoiding certain dangers in more traditional regression modelling and, in the case of binary outcomes, allow for the control of a greater number of potential confounders. The use of propensity score techniques has been fairly limited in psychiatry, largely to studies of health care delivery and use. An introduction to propensity score methods is given and a series of examples illustrating their use in psychiatric research is presented.

Prevalence of psychotropic drug use in nursing homes for the aged in Quebec and in the French-speaking area of Switzerland

BACKGROUND

The use of psychotropic drugs is high in institutionalised elderly, which raises the question of its appropriateness. This study aimed to: (1) estimate the use of psychotropics, for each family, in terms of the prevalence and dosage among the elderly in nursing homes in French-speaking Switzerland and Quebec; and (2) assess, for each family of psychotropic drugs and for each care facility, the prevalence of use and departure from average prescription (ratio of observed-to-expected prevalence).

METHOD

An administrative database was used for this cross-sectional analysis. The sample included 8183 Quebec and 7592 Swiss long-term care residents. Three classes of psychotropics (antipsychotics, antidepressants, hypnotics-anxiolytics) were defined as dichotomous variables. Logistic regressions were conducted to identify residents characteristics associated with the use of each psychotropic type and to compute expected prevalence.

RESULTS

Swiss residents were slightly older and less dependent than Quebec residents. Use of psychotropic drugs was higher in Swiss than in Quebec residents, on the whole as well as for each family of drug. A total of 78.1% of Swiss residents used at least one drug as compared to 66.9% in Quebec. Ninety percent of residents were given less than 7 defined daily doses per week, irrespective of the drug family. According to Beer's criteria, only 4.9% of prescriptions were inadequate. In Quebec and in Switzerland, the prevalence of antidepressant use was associated with the prevalence of hypnotic-anxiolytic use. No ratios of observed-to-expected reached statistical significance.

INTERPRETATION

There was a considerable use of psychotropics in Quebec and Switzerland with, seemingly, no dramatic departure from the average practice. Our data cannot tell if there is a global overuse of psychotropics, but indicated that dosage and medication selection seem adequate. Physicians should critically reassess the necessity of prescribed medications for their patients.

Concealment of drugs in food and beverages in nursing homes: cross sectional study

OBJECTIVE

To examine the practice of concealing drugs in patients' foodstuff in nursing homes.

DESIGN

Cross sectional study with data collected by structured interview.

SETTING

All five health regions in Norway.

PARTICIPANTS

Professional carers of 1362 patients in 160 regular nursing home units and 564 patients in 90 special care units for people with dementia.

MAIN OUTCOME MEASURES

Frequency of concealment of drugs; who decided to conceal the drugs; how this practice was documented in the patients' records; and what types of drugs were given this way.

RESULTS

11% of the patients in regular nursing home units and 17% of the patients in special care units for people with dementia received drugs mixed in their food or beverages at least once during seven days. In 95% of cases, drugs were routinely mixed in the food or beverages. The practice was documented in patients' records in 40% (96/241) of cases. The covert administration of drugs was more often documented when the physician took the decision to hide the drugs in the patient's foodstuff (57%; 27/47) than when the person who made the decision was unknown or not recorded (23%; 7/30). Patients who got drugs covertly more often received antiepileptics, antipsychotics, and anxiolytics compared with patients who were given their drugs openly.

CONCLUSIONS

The covert administration of drugs is common in Norwegian nursing homes. Routines for such practice are arbitrary, and the practice is poorly documented in the patients' records.

Minimizing the use of restrictive devices in dementia patients at risk for falling

The accumulating empirical evidence demonstrates that restrictive devices can be removed without negative consequences. Most importantly, use of nonrestrictive measures has been correlated with positive patient outcomes and represents care that is dignified and safe for confused elders. Most of these nonrestrictive approaches promote mobility and functional recovery; however, testing of individual interventions is needed to further the science. As the research regarding restrictive devices has been translated into professional guidelines and regulatory standards, the prevalence of usage has declined dramatically. New institutional models of care discouraging routine use of restrictive devices also will foster innovative solutions to clinical problems associated with dementia.

Cognitive impairment and resource use of nursing home residents: a structural equation model

BACKGROUND

Only a few studies have examined relationships between cognitive impairment and resource use of nursing home residents, and these studies have yielded mixed results.

METHODS

To develop and test structural equation models for relationships between cognitive impairment, covariates, and resource use of nursing home residents on Alzheimer special care units (SCUs) and conventional units.

RESEARCH DESIGN

Analysis of data obtained in 1999 from an Indiana nursing facility time study that measured resident-specific direct care minutes per day, and assessment data from the Minimum Data Set (version 2.0).

PARTICIPANTS

Participants were 1290 residents without specialized nursing requirements or licensed therapies: 447 drawn from 22 SCUs in 16 facilities, 485 from 16 conventional units in the same facilities, and 358 from units in 13 facilities without SCUs.

MEASURES

Direct care resource use (weighed minutes/d), Cognitive Performance Scale, activities of daily living (ADLs), clinically complex conditions, daily behavioral problems, physical restraints, psychotropic medication, and Alzheimer or dementia diagnosis.

RESULTS

Cognitive impairment had a substantial indirect effect on resource use in facilities with and without SCUs. This effect was mediated largely through ADL dependency and SCU placement. Severity of cognitive impairment was strongly related to ADL dependency, and ADL, in turn, was a strongly related to resource use. Also, residents on SCUs used significantly more direct care resources than residents on conventional units.

CONCLUSIONS

This study demonstrates relationships between cognitive impairment, covariates, and resource use for nursing home residents on SCUs and conventional units. It also raises issues about reimbursement for care of dementia residents.

Factors influencing prescription of CNS medications in different elderly populations

Factors influencing the use of neuroleptic and other CNS-acting medications ('antidepressants' and 'hypnotics/anxiolytics') were examined in different elderly populations (> 65 years): long-stay care hospital subjects (n = 381), nursing home subjects (n = 1247), private residential home subjects (n = 321), statutory residential home subjects (n = 525), old age psychiatry facility subjects (n = 48), community dwellers (n = 97), in different geographical areas (urban n = 1223 and rural n = 1396). Neuroleptics were prescribed in 28% of the individuals, hypnotics/anxiolytics in 33% and antidepressants in 12%. Prescription of neuroleptics was significantly predicted by institutional placement (other than long-stay care hospital facility), lower cognitive function and rural geographical area. Age greater than 75 years and lower functional score (lower dependency) significantly decreased the likelihood of receipt of neuroleptics. Antidepressant use was significantly less likely in male subjects, patients with cognitive impairment and patients greater than 85 years. Institutional placement (other than long-stay care hospital facility and old age psychiatry facility) and rural locality predicted increased likelihood of antidepressant prescription. Institutional placement (other than long-stay care hospital facility) and geographical (rural) location were significant independent predictors of hypnotic/anxiolytic use. Prescription of hypnotic/anxiolytic drug class was significantly less likely in those individuals with lower cognitive status. In this representative elderly cohort, patient characteristics: age, sex, cognitive score, functional score, place of residence and geographical location markedly influenced drug utilisation.

Dementia

Alzheimer's disease is the most common cause of dementia, but often several other conditions causing dementia are present on brain autopsies. Palliative care medical issues are similar in all late stage progressive degenerative dementias and include; cardiopulmonary resuscitation, transfer to acute care setting, antibiotic therapy, and tube feeding. Behavioral symptoms of dementia include agitation and resistiveness to care. Quality of life of individuals suffering from dementia is enhanced by availability of meaningful activities and by avoidance of restraints. Family support and involvement are crucial for optimal care. Formulation of advanced directives or an advance proxy plan is important for assuring the patient's previous wishes or best interests are considered when decisions about treatment strategies are made.

Multivariate matching and bias reduction in the surgical outcomes study

BACKGROUND

Outcomes studies often need a level of detail that is not present in administrative data, therefore requiring abstraction of medical charts. Case-control methods may be used to improve statistical power and reduce abstraction costs, but limitations of exact matching often preclude the use of many covariates. Unlike exact matching, multivariate matching may allow cases to be matched simultaneously on hundreds of covariates.

OBJECTIVES

To develop multivariate matched case-control pairs in a study of death after surgery in the Medicare population.

RESEARCH DESIGN

Using 830 randomly selected index cases of patients who died within 60 days from admission, controls were found who did not die within that time period, matching on risk for death and other patient characteristics with up to 173 variables used simultaneously in the matching algorithms.

SUBJECTS

General and orthopedic Medicare surgical cases in Pennsylvania from 1995 to 1996. Controls were either selected from across the entire state (108,765 possible subjects), or from within the same hospital as the case.

MEASURES

Percent bias reduction and the average difference between cases and controls in units of standard deviations.

RESULTS

Matched controls were far more similar to cases (deaths) upon admission to the hospital than typical patients, both in statewide and within hospital matches. Bias reduction was usually greater than 50% and often approached 100%. The difference between cases and matched controls for most variables was usually below 0.2 SD.

CONCLUSIONS

Multivariate matching methods may aid in conducting studies with Medicare claims records by improving the quality of matches, thereby achieving a better understanding of the etiology of outcomes.