Home care patients in four Nordic capitals - predictors of nursing home admission during one-year followup

Association between choices of transportation means and instrumental activities of daily living: observational cohort study of community-dwelling older adults

INTRODUCTION

The association between the physical health of older people and the frequency of going out has been reported, and in recent years, local governments have developed transportation support programs for older people. Although previous studies show an association between the frequency of going out and functional health status, little has been reported on the impact of the choice of means of transport on instrumental activities of daily living (IADL).

OBJECTIVE

To evaluate the association between choice of transportation means and the risk of decline in IADL among older adults.

METHODS

We conducted an observational, population (community-dwelling)-based cohort study using data from the Resident Health Status Survey, and longitudinal panel data at 2-time points in 2016 and 2019. In addition, we combined this panel data and a database on people who were certified as requiring long-term care to identify participants' IADL. The propensity score matching method was used to classify the respondents into two groups, "active means of transportation" and "passive means of transportation," and determine the risk of a decline in means-tested independence after 3 years.

RESULTS

Active means were used by 6,280 (76.2%) and passive means were used by 1,865 (22.6%). 999 (12.1%) individuals declined in IADL in 2019. The results of the comparison by balancing the attributes of "active means of transportation" and "passive means of transportation," with propensity score matching, showed that "passive means of transportation" were more likely to be "active" than "passive means of transportation," and "active" was more likely to be "passive" The risk of IADL decline was significantly higher than that of "active means of transportation" with an RR of 1.93 (95% CI: 1.62-2.30).

CONCLUSION

Passive means of transportation in older adults could be a possible risk for decreasing IADL 3 years later. Increasing the number of opportunities and places in the community for older adults to use active means of transportation may be effective in encouraging socially independent living among older adults.

Multimorbidity Patterns and 6-Year Risk of Institutionalization in Older Persons: The Role of Social Formal and Informal Care

OBJECTIVES

The aim was to evaluate patterns of multimorbidity that increase the risk of institutionalization in older persons, also exploring the potential buffering effect of formal and informal care.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

The population-based Swedish National study on Aging and Care in Kungsholmen, Stockholm, Sweden.

MEASURES

In total, 2571 community-dwelling older adults were grouped at baseline according to their underlying multimorbidity patterns, using a fuzzy c-means cluster algorithm, and followed up for 6 years to test the association between multimorbidity patterns and institutionalization.

RESULTS

Six patterns of multimorbidity were identified: psychiatric diseases; cardiovascular diseases, anemia, and dementia; metabolic and sleep disorders; sensory impairments and cancer; musculoskeletal, respiratory, and gastrointestinal diseases; and an unspecific pattern including diseases of which none were overrepresented. In total, 110 (4.3%) participants were institutionalized during the follow-up, ranging from 1.7% in the metabolic and sleep disorders pattern to 8.4% in the cardiovascular diseases, anemia, and dementia pattern. Compared with the unspecific pattern, only the cardiovascular diseases, anemia, dementia pattern was significantly associated with institutionalization [relative risk ratio (RRR) = 2.23; 95% confidence interval (CI) 1.07‒4.65)], after adjusting for demographic characteristics and disability status at baseline. In stratified analyses, those not receiving formal care in the psychiatric diseases pattern (RRR 3.34; 95% CI 1.20‒9.32) and those not receiving formal or informal care in the 'cardiovascular diseases, anemia, dementia' pattern (RRR 2.99; 95% CI 1.20‒7.46; RRR 2.79; 95% CI 1.16‒6.71, respectively) had increased risks of institutionalization.

CONCLUSIONS AND IMPLICATIONS

Older persons suffering from specific multimorbidity patterns have a higher risk of institutionalization, especially if they lack formal or informal care. Interventions aimed at preventing the clustering of diseases could reduce the associated burden on residential long-term care. Formal and informal care provision may be effective strategies in reducing the risk of institutionalization.

Does Psychotropic Drug Prescription Change in Nursing Home Patients the First 6 Months After Admission?

OBJECTIVES

To explore the course of psychotropic drug (PTD) prescription from admission (BL) to 6-month follow-up (6m) in Norwegian nursing homes (NHs). To examine how clinical variables, such as neuropsychiatric symptoms (NPS), cognition, physical health, and NH characteristics at BL are associated with prescription rates at 6 months.

DESIGN

An observational longitudinal cohort study (data from the Resource Use and Disease Course in Dementia-Nursing Home study) designed to examine the course of dementia, psychiatric and somatic diseases, and drug prescriptions in NH patients during the first 6 months after admission.

SETTING AND PARTICIPANTS

We included 696 patients at admission to 47 representative Norwegian NHs.

METHODS

Demographic and clinical characteristics at BL and 6m are presented. Dementia severity was assessed by the Clinical Dementia Rating scale and the Functional Assessment Staging of Alzheimer's Disease scale. Final diagnosis was made by 2 of the authors (G.S. and S.B.) according to ICD-10 criteria. Prevalence, incidence, and persistence rates of PTD prescriptions for people with dementia are presented. Generalized mixed models were used to identify possible predictors for the course of PTD prescription from BL to 6m.

RESULTS

Prescription rates of antidepressants, antipsychotics, anxiolytics, sedatives, and hypnotics increased in people with dementia from BL (67.5% received at least 1 PTD) to 6m (74.0% received at least 1 PTD). Younger age and higher Neuropsychiatric Inventory-affective subsyndrome score at BL were associated with higher odds of antidepressant prescription, whereas patients with higher comorbidity at BL had lower odds of receiving antidepressants, both at BL and 6m. Higher Neuropsychiatric Inventory-affective subsyndrome scores at BL were associated with higher odds of sedative and hypnotic prescription at both assessment points.

CONCLUSIONS AND IMPLICATIONS

PTD prescription rates increase from BL to 6m. Medication appropriateness should be frequently evaluated after admission to optimize PTD prescriptions.

Health and care service utilisation and cost over the life-span: a descriptive analysis of population data

BACKGROUND

Current demographic changes affect both the level and composition of health and care needs in the population. The aim of this study was to estimate utilisation and cost for a comprehensive range of health and care services by age and gender to provide an in-depth picture of the life-span pattern of service needs and related costs.

METHODS

Data on service use in 2010 for the entire population in Norway were collected from four high-quality national registers. Cost for different services were calculated combining data on service utilisation from the registries and estimates of unit cost. Data on cost and users were aggregated within four healthcare services and seven long-term care services subtypes. Per capita cost by age and gender was decomposed into user rates and cost per user for each of the eleven services.

RESULTS

Half of the population is under 40 years of age, but only a quarter of the health and care cost is used on this age group. The age-group of 65 or older, on the other hand, represent only 15% of the population, but is responsible for almost half of the total cost. Healthcare cost dominates in ages under 80 and mental health services dominates in adolescents and young adults. Use of other healthcare services are high in middle aged and elderly but decreases for the oldest old. Use of care services and in particular institutional care increases in old age. Healthcare cost per user follows roughly the same age pattern as user rates, whereas user cost for care services typically are either relatively stable or decrease with age among adults. Gender differences in the age pattern of health and care costs are also revealed and discussed.

CONCLUSION

The type of services used, and the related cost, show a clear life-span as well as gender pattern. Hence, population aging and narrowing gender-gap in longivety calls for high policy awarness on changing health and care needs. Our study also underscores the need for an attentive and pro-active stance towards the high service prevalence and high cost of mental health care in our upcoming generations.

Does Community-Level Social Capital Predict Decline in Instrumental Activities of Daily Living? A JAGES Prospective Cohort Study

Instrumental activities of daily living (IADL) represent the most relevant action capacity in older people with regard to independent living. Previous studies have reported that there are geographical disparities in IADL decline. This study examined the associations between each element of community-level social capital (SC) and IADL disability. This prospective cohort study conducted between 2010 and 2013 by the Japan Gerontological Evaluation Study (JAGES) surveyed 30,587 people aged 65 years or older without long-term care requirements in 380 communities throughout Japan. Multilevel logistic-regression analyses were used to determine whether association exists between community-level SC (i.e., civic participation, social cohesion, and reciprocity) and IADL disability, with adjustment for individual-level SC and covariates such as demographic variables, socioeconomic status, health status, and behavior. At three-year follow-up, 2886 respondents (9.4%) had suffered IADL disability. Residents in a community with higher civic participation showed significantly lower IADL disability (odds ratio: 0.90 per 1 standard deviation increase in civic participation score, 95% confidence interval: 0.84⁻0.96) after adjustment for covariates. Two other community-level SC elements showed no significant associations with IADL disability. Our findings suggest that community-based interventions to promote community-level civic participation could help prevent or reduce IADL disability in older people.

Nursing staff's responses to thematic content of patients' expressed worries: observing communication in home care visits

Background

The aim of the study was to explore the thematic content of older persons’ expressed worries in home care visits, and how nursing staff respond to different thematic contents.

Methods

The study had a descriptive, observational design, including 195 audio-recorded Norwegian home care visits with 33 nursing staff and 48 older persons. In all, 638 patient cues/concerns (worries) and subsequent nursing staff’s responses were identified using Verona Coding Definitions of Emotional Sequences. A novel thematic coding scheme was used to label the thematic content of the cues/concerns. The nursing staff’s responses were grouped based on communicative function as emotion-focused, content-focused or ignoring/blocking the cue/concern. Group difference was analysed using Pearson’s chi-squared test, Fisher’s exact test, and adjusted residuals.

Results

The theme of worries was associated with elicitation of the cue/concern, either elicited by the nursing staff or spontaneously expressed by the patient (Chi-square, p< 0.001). “Ageing and bodily impairment” was the most common theme (66%) and was equally elicited by patients and nursing staff. Worries about “Relationships with others” (9%), “Health care-related issues” (15%) and “Life narratives and value issues” (9%) were mainly elicited by nursing staff. The nursing staff response was associated with the theme of worries (p˂0.001). For the sub-themes of “Ageing and bodily impairment”, Coping with existential challenges received more frequently emotion-focused responses (adjusted residuals: 3.2) and Expression of pain felt in the moment were more frequently ignored/blocked (adjusted residuals: 4.0, Fisher’s exact test, p< 0.001). For the sub-themes of “Relationships with others”, Being a burden more frequently received a content-focused response (adjusted residuals: 2.8), while Losing social ties more frequently received an emotion-focused response (adjusted residuals: 3.1, Fisher’s exact test, p = 0.009).

Conclusion

“Ageing and bodily impairment” was the most common theme and more frequently elicited by the older persons than other themes. Emotionally focused nursing staff responses were most common when addressing existential challenges and fear of losing social ties. Whereas nursing staff showed a tendency to ignore patients’ spontaneous expressions of pain. Further research should explore the influence of nursing staff’s responses on quality of care and patient satisfaction.

Development and validation of classifiers and variable subsets for predicting nursing home admission

Background

In previous years a substantial number of studies have identified statistically important predictors of nursing home admission (NHA). However, as far as we know, the analyses have been done at the population-level. No prior research has analysed the prediction accuracy of a NHA model for individuals.

Methods

This study is an analysis of 3056 longer-term home care customers in the city of Tampere, Finland. Data were collected from the records of social and health service usage and RAI-HC (Resident Assessment Instrument - Home Care) assessment system during January 2011 and September 2015. The aim was to find out the most efficient variable subsets to predict NHA for individuals and validate the accuracy. The variable subsets of predicting NHA were searched by sequential forward selection (SFS) method, a variable ranking metric and the classifiers of logistic regression (LR), support vector machine (SVM) and Gaussian naive Bayes (GNB). The validation of the results was guaranteed using randomly balanced data sets and cross-validation. The primary performance metrics for the classifiers were the prediction accuracy and AUC (average area under the curve).

Results

The LR and GNB classifiers achieved 78% accuracy for predicting NHA. The most important variables were RAI MAPLE (Method for Assigning Priority Levels), functional impairment (RAI IADL, Activities of Daily Living), cognitive impairment (RAI CPS, Cognitive Performance Scale), memory disorders (diagnoses G30-G32 and F00-F03) and the use of community-based health-service and prior hospital use (emergency visits and periods of care).

Conclusion

The accuracy of the classifier for individuals was high enough to convince the officials of the city of Tampere to integrate the predictive model based on the findings of this study as a part of home care information system. Further work need to be done to evaluate variables that are modifiable and responsive to interventions.

Content validation of a tool for assessing risks for drug-related problems to be used by practical nurses caring for home-dwelling clients aged ≥65 years: a Delphi survey

PURPOSE

Home care services are becoming a critically important part of health care delivery as populations are aging. Those using home care services are increasingly older, more frail than previously, and use multiple medications, making them vulnerable to drug-related problems (DRPs). Practical nurses (PN) visit home-dwelling aged clients frequently and, thus, are ideally situated to identify potential DRPs and, if needed, to communicate them to physicians for resolution. This study developed and validated the content of a tool to be used by PNs for assessing DRP risks for their home-dwelling clients aged ≥65 years.

METHODS

The first draft of the tool was based on two systematic literature reviews and clinical experience of our research group. Content validity of the tool was determined by a three-round Delphi survey with a panel of 18 experts in geriatric care and pharmacotherapy. An agreement by ≥80% of the panel on an item was required.

RESULTS

The final tool consists of 18 items that assess risks for DRPs in home-dwelling aged clients. It is divided into four sections: (1) Basic Client Data, (2) Potential Risks for DRPs in Medication Use, (3) Characteristics of the Client's Care and Adherence, and (4) Recommendations for Actions to Resolve DRPs.

CONCLUSIONS

The Delphi process resulted in a structured DRP Risk Assessment Tool that is focused on the highest priority DRPs that should be identified and resolved. The tool also assists the PNs to identify solutions to these problems, which is a unique feature compared to similarly purposed prior tools.

Nursing home admission during the first year after hospitalization - the contribution of cognitive impairment

OBJECTIVE

The importance of cognitive and physical functioning for nursing home admission among medically hospitalized older patients is rarely studied in a one-year follow-up perspective. This study aims to explore the association between patient characteristics and nursing home admission within one year after hospitalization in persons 65 years or more.

DESIGN

A one-year longitudinal study.

METHODS

We included 463 (234 women) persons aged 65 years or more from internal medical wards in a rural area of Norway. Cognitive function was assessed using the Mini Mental State Examination; physical and instrumental functional status was assessed using the physical self-maintenance scale and instrumental activities of daily living scale of Lawton and Brody. Comorbidity was measured with the Charlson index. Admission to nursing home within one year (yes versus no) was analyzed using logistic regression analysis and Cox proportional hazard regression analysis.

RESULTS

The mean age of the sample was 80.5 (SD 7.4) years, mean Mini Mental State Examination score was 24.1 (SD 3.8) (maximum score is 30). In adjusted analysis participants with cognitive impairment (a Mini Mental State Examination score <25) or impaired physical functioning at baseline had higher risk of admission to nursing home within one year (OR 3.0, 95%CI 1.5-6.2 and OR 3.5, 95%CI 1.8-9.6, respectively). The time before admission was also associated with cognitive impairment and impaired physical functioning in the adjusted analysis (HR 2.6 95%CI 1.4-4.8 and HR 3.7, 95%CI 1.5-8.9, respectively).

CONCLUSION

Impaired cognitive and physical functioning increased the risk for nursing home admission within one year after hospitalization. However, putative regressors, such as education and social network were not included in the analysis.

Hip fracture and urinary incontinence--use of indwelling catheter postsurgery

BACKGROUND

Norway has a higher incidence of hip fractures than any other country. For older individuals, a hip fracture may cause dramatic changes in health status like incontinence and daily activities. Patients with hip fractures are at high risk of urinary incontinence (UI) after surgical repair. A urinary indwelling catheter (UIC) is inserted preoperatively, but should be removed within 24 hours. Our aims were to identify indicators that might predict clinical challenges related to urinary incontinence 1 year after hip fractures.

METHODS

Inclusion criteria were patients with hip fracture age 65 years or older. They were admitted form their own home to two acute-care hospitals during 2004-2006. We used the Resident Assessment Instrument for Acute Care.

RESULTS

A total of 331 patients were included. Thirty-five (11%) had UIC 72 hours after surgery. These patients had more frequently experienced delirium, urinary tract infection, cognitive impairment and discouragement than their counterparts. After 12 months, patients with previous UI had lower functioning levels than those with no previous UI. They had moved four times more frequently to a nursing home and had over twice the mortality.

CONCLUSIONS

Patient with UI should be followed up with a multidisciplinary team after discharged from hospital.