Factors associated with discharge from hospital to residential aged care for younger people with neuropsychiatric disorders: an exploratory case-control study in New South Wales, Australia

OBJECTIVES

To examine the sociodemographic and diagnostic factors associated with a discharge from hospital to residential aged care (RAC) for younger people (aged 15-64 years) with neuropsychiatric disorders.

DESIGN

An exploratory case-control study using a historic cohort of people with neuropsychiatric disorders. Cases were people transferred to RAC on hospital discharge during the study period. Controls were people not transferred to RAC on discharge during the study period.

SETTING

Public and private hospital admissions in New South Wales (NSW), Australia.

PARTICIPANTS

People aged 15-64 years with a neuropsychiatric disorder hospitalised in NSW between July 2002 and June 2015 (n=5 16 469).

OUTCOME MEASURES

The main outcome was transferred to RAC on discharge from hospital. We calculated ORs for sociodemographic and diagnostic factors to determine factors that may impact discharge to RAC.

RESULTS

During the period of data capture, 4406 people were discharged from hospitals to RAC. Discharge to RAC was most strongly associated with diagnoses of progressive neurological and cognitive disorders. Acute precipitants of RAC transfer included a broad range of conditions and injuries (eg, Wernicke's encephalopathy, stroke, falls) in the context of issues such as older age, not being partnered (married or de facto), living in areas of lower socioeconomic status, functional issues and the need for palliative care.

CONCLUSIONS

There are multiple intersecting and interacting pathways culminating in discharge from hospital to RAC among younger people with neuropsychiatric disorders. Improved capacity for interdisciplinary home care and alternative housing and support options for people with high support needs are required.

A Cross-Sectional, Correlational Study Comparing Individual Characteristics of Younger and Older Nursing Home Residents Using Western Canadian Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0

OBJECTIVE

To compare characteristics of nursing home (NH) residents by age categories in Western Canada.

DESIGN

A cross-sectional, correlational analysis of secondary data.

SETTING AND PARTICIPANTS

89,231 residents living in Western Canada NHs in the provinces of Alberta, Manitoba, and British Columbia in 2016 and 2017.

METHODS

Resident characteristics (age, sex, marital status, body mass index, medical diagnoses, cognitive function, physical function, depressive symptoms) came from the Resident Assessment Instrument-Minimum Data Set 2.0 and were analyzed using chi-square, analysis of variance, and post hoc pairwise tests. Human developmental stage age categories were used to create 5 age groups: 18-34, 35-50, 51-64, 65-80, and 81 years and older.

RESULTS

The demographics, medical diagnoses, cognitive function, and physical function characteristics of NH residents among 5 age groups differed considerably (all P < .001). Residents aged 18-34 years were predominately male, never married, with a higher incidence of paralysis and traumatic brain injury. Residents aged 35-50 years had a higher incidence of stroke and multiple sclerosis, and residents aged 51-64 years mainly were morbidly obese and more prone to depression. Residents aged 65-80 years were predominately married and more prone to diabetes, and residents aged 81 years and older were predominately widowed, with a higher incidence of dementia compared with others.

CONCLUSIONS AND IMPLICATIONS

Findings describe the uniqueness of younger NH age groups and indicate that the youngest NH residents often have the severe disability and a modest support system (as defined by partnered status) compared to older residents in NHs. Future studies must analyze longitudinal data that track the growth of, and changes in, residents' health and functional status.

How Does a Foucauldian Genealogical Approach Enhance the Study of Long-Term Care through a Critical Disability Lens?

Younger disabled adults in long-term care, particularly those with physical disabilities and chronic illnesses, receive care that does not fit their needs. This article looks at whether a Foucauldian genealogical approach would enhance a study that focuses on the societal values that have allowed this situation to persist. It looks at the historical and cultural contingencies of genealogy, and its ability to explore the complex power relations at play, in normalization and biopower. It concludes that there is a place for this approach–one that can be adapted from the 1970s approach of Foucault to fit power dynamics and positioning in care in the 2020s.

Nursing home directors of nursing experiences regarding safety among residents with obesity

The prevalence of nursing home (NH) residents with obesity is rising. Perspectives of NH Directors of Nursing (DONs) who oversee care trajectories for residents with obesity is lacking. This study aimed to describe the experiences of NH DONs regarding care and safety for NH residents with obesity. An adapted version of Donabedian's structure-process-outcome model guided this qualitative descriptive study. Semi-structured interviews were conducted with 15 DONs. Data were analyzed using directed content analysis, and findings are presented under the model's constructs. We learned that admission decisions for NH referrals of patients with obesity are complex due to reimbursement issues, available space and resources, and resident characteristics. DONs described the need to coach and mentor Certified Nursing Assistants to provide safe quality care and that more staff education is needed. We identified novel findings regarding the challenges of short-term residents' experience transitioning out of care due to limited resources.

Younger Nursing Home Residents: A Scoping Review of Their Lived Experiences, Needs, and Quality of Life

OBJECTIVES

The percentage of younger nursing home (NH) residents (ages 18-64 years) in some countries such as the United States and Canada has been increasing over the years. In fact, it is generally held that younger NH residents are considerably different from the older residents (age ≥65 years). There is a need to understand who they are, why they resided in NHs, and their quality of life (QoL). The aims of the study were to describe the experiences, needs, and QoL among younger residents living in NHs.

DESIGN

Scoping review.

SETTINGS AND PARTICIPANTS

(Younger) Residents of NHs.

METHODS

Five databases (PubMed, CINAHL, PsycINFO, Web of Science, and Scopus) and Google Scholar were used to search for relevant studies. PRISMA diagram was used to guide this scoping review.

RESULTS

The key findings of the study cover 5 themes: (1) Confinement, (2) Lack of socialization, (3) Lack of privacy, (4) Lack of appropriate settings, and (5) Loss of identity, as well as results of QoL were generated.

CONCLUSIONS AND IMPLICATIONS

This scoping review provides a deeper understanding of the lived experiences, needs, and QoL among younger NH residents. The results provide suggestions for future studies regarding new interventions to optimize the QoL of NH residents.

Probable Delirium and Associated Patient Characteristics in Long-Term Care and Complex Continuing Care: A Population-Based Observational Study

OBJECTIVES

To estimate the prevalence of probable delirium in long-term care (LTC) and complex continuing care (CCC) settings and to describe the resident characteristics associated with probable delirium.

DESIGN

Population-based cross-sectional study using routinely collected administrative health data.

SETTING AND PARTICIPANTS

All LTC and CCC residents in Ontario, Canada, assessed with the Resident Assessment Instrument-Minimum Dataset (RAI-MDS) assessment between July 1, 2016, and December 31, 2016 (LTC n=86,454, CCC n=10,217).

METHODS

Probable delirium was identified via the delirium Clinical Assessment Protocol on the RAI-MDS assessment, which is triggered when individuals display at least 1 of 6 delirium symptoms that are of recent onset and different from their usual functioning. RAI-MDS assessments were linked to demographic and health services utilization databases to ascertain resident demographics and health status. Multivariable logistic regression was used to identify characteristics associated with probable delirium, with adjusted odds ratios (ORs) and 95% confidence intervals (CIs) reported.

RESULTS

Delirium was probable in 3.6% of LTC residents and 16.5% of CCC patients. LTC patients displayed fewer delirium symptoms than CCC patients. The most common delirium symptom in LTC was periods of lethargy (44.6% of delirium cases); in CCC, it was mental function varying over the course of the day (63.5% of delirium cases). The odds of probable delirium varied across individual demographics and health characteristics, with increased health instability having the strongest association with the outcome in both care settings (LTC: OR 30.4, 95% CI 26.2-35.3; CCC: OR 21.0, 95% CI 16.7-26.5 for high vs low instability).

CONCLUSIONS AND IMPLICATIONS

There were differences in the presentation and burden of delirium symptoms between LTC and CCC, potentially reflecting differences in delirium severity or symptom identification. Several risk factors for probable delirium in LTC and CCC were identified that may be amenable to interventions to prevent this highly distressing condition.

A scoping review to explore the experiences and outcomes of younger people with disabilities in residential aged care facilities

OBJECTIVE

In Australia, over 6,000 adults younger than 65 have been inappropriately placed in nursing homes designed to accommodate older adults. The primary aim of this review was to map the literature on the experiences and outcomes of young people with disability who are placed in aged care.

METHODS

A scoping review of the published literature from 2009-2018 was conducted using Embase, Medline, PsycINFO and Scopus.

RESULTS

Eleven articles were identified (7 qualitative, 3 mixed methods, 1 quantitative). Results demonstrated the inability of aged care facilities to meet the basic human needs of young people (e.g., privacy, physical, sexual, social, nutritional, emotional need) and highlighted the lack of choice young people with disability have in regards to rehabilitation and housing. There was limited data relating to the trajectory and support needs of young people placed in aged care facilities.

CONCLUSIONS

This review highlights the negative outcomes young people experience while living in aged care. Future research should investigate the trajectory and support needs of young people in aged care facilities. Systemic changes are required to meet the needs of young people with complex needs at risk of admission to aged care including timely rehabilitation and housing and support options.

Sharing stories of lived experience: A qualitative analysis of the intersection of experiences between storytellers with acquired brain injury and storytelling facilitators

Introduction

Narrative storytelling is a relational process. While interest in storytelling in brain injury rehabilitation is increasing, little attention has been directed to the interpersonal relationships experienced through storytelling. As part of a larger study exploring narrative storytelling, this paper reports on the intersection of experiences between those sharing their story and those listening to the story.

Method

A qualitative grounded theory approach informed all stages of the study. In-depth interviews were conducted with adult storytellers with severe acquired brain injury and facilitators of a storytelling advocacy programme.

Findings

Analysis of the intersection of data from 28 transcripts of interviews with eight storytellers and six facilitators was conducted. Two key relationships emerged to be central to the storytelling experience: (1) a collaborative partnership between the storytellers and the advocacy organisation, and (2) an intentional story-sharing relationship between the storytellers and facilitators. The advocacy context of helping others through story-sharing was central to the meaningfulness of the experience.

Conclusion

Narrative storytelling is a social relationship experience with much potential for building relationships in rehabilitation. Sharing stories of lived experience of disability presents an opportunity for meaningful occupational engagement, enabling social connectedness and contribution to society.

Deaths of young people living in residential aged care: a national population-based descriptive epidemiological analysis of cases notified to Australian coroners

AIM

This study provides a descriptive epidemiological analysis stratified by age of deaths reported to Australian Coroners of residential aged care facility residents aged under 65 years.

METHOD

A national population-based retrospective analysis was conducted of deaths of Australian residential aged care facility residents reported to Australian Coroners between 2000 and 2013. Descriptive statistics compared adult residents categorised using age by factors relating to the individual, incident and death investigation.

RESULTS

Of the 21,736 deaths of residential aged care facilities residents aged over 20 years reported to Australian Coroners, 782 (3.6%) were of residents aged 20-64 years. Natural cause deaths occurred at similar rates irrespective of age. Intentional external cause deaths were higher in residents aged 20-64 years (5.3% vs. 16.0%; OR 3.43, 95% CI 2.0-5.9; p < 0.001), with suicide rates three times that of the over 65 years group (13.2% vs. 4.1%; OR 0.28, 95% CI 0.16-0.51; p < 0.001). External cause deaths from choking and falls were most common in the younger and older groups respectively.

CONCLUSIONS

More is required to prevent external cause deaths in young residential care facility residents.IMPLICATIONS FOR REHABILITATIONOne in seven (14.1%) deaths of people aged 20-64 years in residential aged care facilities are premature and potentially avoidable. The more common external causes of death include suicide, choking and falls.The prevalence and causes of preventable deaths in this study provide a basis for prompting and developing more specific prevention policies and practices to reduce harm for young people in residential aged care. Specifically, addressing loneliness would improve social inclusion, mental health and suicide risk. Better management of progressive neurological conditions with multidisciplinary team and re-ablement programs would reduce risk of choking and falls.Improving outcomes for young people in residential aged care requires a co-ordinated, multisector approach comprising relevant government departments, aged care providers, researchers and clinicians.Effective planning requires more information about the cause and nature of deaths, and due to the small event counts, this would ideally involve an international collaboration.

The Things that Help, the Things that Get in the Way: Working Together to Improve Outcome Following Acquired Brain Injury

Working in neurological rehabilitation brings with it numerous opportunities to gain an understanding of the factors that contribute to shaping meaningful living and wellbeing for those tackling the major life changes encountered following acquired brain injury (ABI). These opportunities come in many forms: challenging and brave clients, wise and worrying families, questioning and inspiring colleagues, empowering and limiting work environments and rigid and advancing policy and legislative contexts.

Our personal and collective understanding ofthe things that helpandthe things that get in the wayof effective rehabilitation continuously emerges from the convergence of the experience and knowledge afforded by these opportunities. The aim of this paper is to considerthe things that helpandthe things that get in the wayas they have been identified by people with ABI, their families and those who work with them and have been further evidenced through research targeted towards improving short, medium and long-term outcomes for those living with the consequences of ABI. Thesethingsas discussed in this paper capture the essential role of the self, the importance of rights and access to rehabilitation, the impact of the family and the contribution of social connection.

“Time's Up”: The Experience of Entering Residential Aged Care for Young People with Acquired Neurological Disorders and Their Families

Background and aims: Previous research has highlighted that living in residential aged care (RAC) is associated with a range of negative outcomes for adults with acquired neurological disorders. This study sought to understand the lived experience of entering RAC for young people and their family members and characterise their needs during this process.

Method: Data included 64 written and verbal submissions to the 2015 Senate Inquiry into the Adequacy of existing residential care arrangements available for young people with severe physical, mental or intellectual disabilities in Australia. In line with hermeneutic tradition, text was analysed using thematic analysis.

Results: Entry to RAC was experienced as a complex process that coalesced around three key events: an unexpected health crisis, a directive that time's up and the individual is required to leave the healthcare setting, with a subsequent decision to move into RAC. This decision was made in the absence of time, knowledge of options or adequate support.

Conclusions: Findings suggest that there are both immediate practice changes and longer term policy responses that can support the health and disability systems to uphold the rights of people with acquired disability to choose where and how they will live their lives.

Repeat emergency department visits by nursing home residents: a cohort study using health administrative data

BACKGROUND

Nursing home (NH) residents are frequent users of emergency departments (ED) and while prior research suggests that repeat visits are common, there is little data describing this phenomenon. Our objectives were to describe repeat ED visits over one year, identify risk factors for repeat use, and characterize "frequent" ED visitors.

METHODS

Using provincial administrative data from Ontario, Canada, we identified all NH residents 65 years or older who visited an ED at least once between January 1 and March 31, 2010 and then followed them for one year to capture all additional ED visits. Frequent ED visitors were defined as those who had 3 or more repeat ED visits. We used logistic regression to estimate risk factors for any repeat ED visit and for being a frequent visitor and Andersen-Gill regression to estimate risk factors for the rate of repeat ED visits.

RESULTS

In a cohort of 25,653 residents (mean age 84.5 (SD = 7.5) years, 68.2% female), 48.8% had at least one repeat ED visit. Residents who experienced a repeat ED visit were generally similar to others but they tended to be slightly younger, have a higher proportion male, and a higher proportion with minimal cognitive or physical impairment. Risk factors for a repeat ED visit included: being male (adjusted odds ratio 1.27, (95% confidence interval 1.19-1.36)), diagnoses such as diabetes (AOR 1.28 (1.19-1.37)) and congestive heart failure (1.26 (1.16-1.37)), while severe cognitive impairment (AOR 0.92 (0.84-0.99)) and 5 or more chronic conditions (AOR 0.82 (0.71-0.95)) appeared protective. Eleven percent of residents were identified as frequent ED visitors, and they were more often younger then 75 years, male, and less likely to have Alzheimer's disease or other dementias than non-frequent visitors.

CONCLUSIONS

Repeat ED visits were common among NH residents but a relatively small group accounted for the largest number of visits. Although there were few clear defining characteristics, our findings suggest that medically complex residents and younger residents without cognitive impairments are at risk for such outcomes.

Adding insult to brain injury: young adults' experiences of residing in nursing homes following acquired brain injury

PURPOSE

There is general consensus that adults under age 65 with acquired brain injury residing in nursing homes is inappropriate, however there is a limited evidence base on the issue. Previous research has relied heavily on third-party informants and qualitative studies have been of questionable methodological quality, with no known study adopting a phenomenological approach. This study explored the lived experiences of young adults with brain injury residing in aged care facilities.

METHODS

Interpretative phenomenological analysis was employed to collect and analyze data from six semi-structured interviews with participants regarding their experiences of living in nursing homes.

RESULTS

Two themes were identified, including "Corporeal prison of acquired brain injury: broken selves" and "Existential prison of the nursing home: stagnated lives". Results illustrated that young adults with acquired brain injury can experience aged care as an existential prison in which their lives feel at a standstill. This experience was characterized by feelings of not belonging in a terminal environment, confinement, disempowerment, emptiness and hope for greater autonomy through rehabilitation.

CONCLUSION

It is hoped that this study will provide relevant professionals, services and policy-makers with insight into the challenges and needs of young adults with brain injury facing these circumstances. Implications for rehabilitation This study supports the contention that more home-like and age-appropriate residential rehabilitation services for young adults with acquired brain injury are needed. As development of alternative accommodation is a lengthy process, the study findings suggest that the interim implementation of rehabilitative care in nursing homes should be considered. Taken together with existing research, it is proposed that nursing home staff may require training to deliver evidence-based rehabilitative interventions to those with brain injury. The present findings add support to the call for systemic change in Ireland, to clarify the acquired brain injury care pathway and establish integrated rehabilitation services.

Young people in aged care: progress of the current national program

Objective. The aim of this paper is to examine the progress and effect of the current 5-year $244 million national Young People in Residential Aged Care program on the reduction of young people in aged care. Method. Semi-structured telephone interviews with 20 service providers, 10 advocacy organisations and 6 public servants across Australia actively involved in the implementation of the program. Results. The development of new accommodation options has been slow. The 5-year program aims to move 689 young people out of nursing homes; in the first 4 years of the initiative only 139 people had moved out. The lives of those who have been helped by the program have been enormously improved. Conclusions. This study highlights the challenges of achieving a long-term reduction in the number of young people in residential aged care, including the challenge of achieving systemic change to prevent new admissions. Implications. The accommodation options currently being developed for this target group will soon be at capacity. Without sustained investment in developing alternative accommodation options and resources to implement systemic change ~250 people under 50 are likely to continue to be admitted to aged care each year in Australia. What is known about the topic? Prior to the current 5-year, $244 million, national Young People in Residential Aged Care program there were more than 1000 Australians under 50 years of age who lived in aged care facilities. Aged care is not designed or resourced to facilitate the active involvement of young people with high clinical needs in everyday activities or support their continued participation in the life of their community. What does this paper add? In the first 4 years of the national program only 139 people moved out of aged care. The lives of those who have been helped by the program have been enormously improved. The program is unlikely to result in a long-term reduction in the number of young people in aged care. What are the implications for practitioners? Systemic change and sustained investment in accommodation options is required to resolve the issue of young people in aged care.