Application of the Person-Centered Care to Manage Responsive Behaviors in Clients with Major Neurocognitive Disorders: A Qualitative Single Case Study

OBJECTIVES

Our study aimed to describe "how" and "why" the person-centered care (PCC) approach was applied within a long-term care (LTC) community to manage responsive behaviors (RBs) in individuals with major neurocognitive disorders.

METHODS

A descriptive holistic single case study design was employed in the context of an LTC community in Quebec, using semi-structured interviews and non-participatory observations of experienced care providers working with clients with RBs, photographing the physical environment, and accessing documents available on the LTC community's public website. A thematic content analysis was used for data analysis.

RESULTS

The findings generated insight into the importance of considering multiple components of the LTC community to apply the PCC approach for managing RBs, including a) creating a homelike environment, b) developing a therapeutic relationship with clients, c) engaging clients in meaningful activities, and d) empowering care providers by offering essential resources.

CONCLUSIONS

Applying and implementing the PCC approach within an LTC community to manage clients' RBs is a long-term multi-dimensional process that requires a solid foundation.

CLINICAL IMPLICATIONS

These findings highlight the importance of considering multiple factors relevant to persons, environments, and meaningful activities to apply the PCC approach within LTC communities to manage RBs.

The PREvention Program for Alzheimer's RElated Delirium (PREPARED) cluster randomized trial: a study protocol

BACKGROUND

Delirium is a significant cause of morbidity and mortality among older people admitted to both acute and long-term care facilities (LTCFs). Multicomponent interventions have been shown to reduce delirium incidence in the acute care setting (30-73%) by acting on modifiable risk factors. Little work, however, has focused on using this approach to reduce delirium incidence in LTCFs.

METHODS

The objective is to assess the effectiveness of the multicomponent PREPARED Trial intervention in reducing the following primary outcomes: incidence, severity, duration, and frequency of delirium episodes in cognitively impaired residents. This 4-year, parallel-design, cluster randomized study will involve nursing staff and residents in 45-50 LTCFs in Montreal, Canada. Participating public and private LTCFs (clusters) that provide 24-h nursing care will be assigned to either the PREPARED Trial intervention or the control (usual care) arm of the study using a covariate constrained randomization procedure. Approximately 400-600 LTC residents aged 65 and older with dementia and/or cognitive impairment will be enrolled in the study and followed for 18 weeks. Residents must be at risk of delirium, delirium-free at baseline and have resided at the facility for at least 2 weeks. Residents who are unable to communicate verbally, have a history of specific psychiatric conditions, or are receiving end-of-life care will be excluded. The PREPARED Trial intervention consists of four main components: a decision tree, an instruction manual, a training package, and a toolkit. Primary study outcomes will be assessed weekly. Functional autonomy and cognitive levels will be assessed at the beginning and end of follow-up, while information pertaining to modifiable delirium risk factors, medical consultations, and facility transfers will be collected retrospectively for the duration of the follow-up period. Primary outcomes will be reported at the level of intervention assignment. All researchers analyzing the data will be blinded to group allocation.

DISCUSSION

This large-scale intervention study will contribute significantly to the development of evidence-based clinical guidelines for delirium prevention in this frail elderly population, as it will be the first to evaluate the efficacy of a multicomponent delirium prevention program translated into LTC clinical practice on a large scale.

TRIAL REGISTRATION

NCT03718156 , ClinicalTrials.gov .

Influence of Lifestyle Redesign® on Health, Social Participation, Leisure, and Mobility of Older French-Canadians

IMPORTANCE

Developed in California to enable community-dwelling older adults to maintain healthy and meaningful activities, Lifestyle Redesign^® is a well-known cost-effective preventive occupational therapy intervention. The impact of a newly adapted French version on older French-Canadians was, however, unknown.

OBJECTIVE

To explore the influence of Lifestyle Redesign on older French-Canadians' health, social participation, leisure, and mobility.

DESIGN

A mixed-methods design included a preexperimental component (questionnaires administered before and after the intervention and 3 and 6 mo postintervention) and an exploratory descriptive qualitative clinical study. Individual semidirected interviews were digitally audiotaped and transcribed, then underwent thematic content analysis using mix extraction grids.

SETTING

Community.

PARTICIPANTS

Sixteen volunteers (10 women) aged 65-90 yr (mean = 76.4, standard deviation = 7.6), 10 without and 6 with disabilities. Inclusion criteria were age ≥65 yr, normal cognitive functions, residence in a conventional or senior home, and French speaking.

INTERVENTION

French-Canadian 6-mo version of Lifestyle Redesign.

OUTCOMES AND MEASURES

Health, social participation, leisure, and mobility were measured using the 36-item Short Form Health Survey, Social Participation Scale, Leisure Profile, and Life-Space Assessment, as well as a semistructured interview guide.

RESULTS

The French-Canadian Lifestyle Redesign had a beneficial effect on participants' mental health (p = .02) and interest in leisure (p = .02) and, in those with disabilities, social participation (p = .03) and attitudes toward leisure (p = .04). Participants reported positive effects on their mental health, leisure, mobility, and social participation, including frequency and quality of social interactions, and indicated that having an occupational routine fostered better health. None of the participants reported no effect.

CONCLUSION AND RELEVANCE

The translated and culturally adapted Lifestyle Redesign is a promising occupational therapy intervention for community-dwelling older French-Canadians.

WHAT THIS ARTICLE ADDS

This study sheds light on the influence of the French-Canadian version of the intervention not only on older adults' health and social participation but also on their leisure activities and life-space mobility, two important outcomes not addressed in previous Lifestyle Redesign studies. Moreover, this study provides an in-depth understanding of the Lifestyle Redesign experience of French-Canadian older adults with and without disabilities, including participants with significant communication and mobility disabilities.

The OptimaMed intervention to reduce inappropriate medications in nursing home residents with severe dementia: results from a quasi-experimental feasibility pilot study

BACKGROUND

Medication regimens in nursing home (NH) residents with severe dementia should be frequently reviewed to avoid inappropriate medication, overtreatment and adverse drug events, within a comfort care approach. This study aimed at testing the feasibility of an interdisciplinary knowledge exchange (KE) intervention using a medication review guidance tool categorizing medications as either "generally", "sometimes" or "exceptionally" appropriate for NH residents with severe dementia.

METHODS

A quasi-experimental feasibility pilot study with 44 participating residents aged 65 years or over with severe dementia was carried out in three NH in Quebec City, Canada. The intervention comprised an information leaflet for residents' families, a 90-min KE session for NH general practitioners (GP), pharmacists and nurses focusing on the medication review guidance tool, a medication review by the pharmacists for participating residents with ensuing team discussion on medication changes, and a post-intervention KE session to obtain feedback from team staff. Medication regimens and levels of pain and of agitation of the participants were evaluated at baseline and at 4 months post-intervention. A questionnaire for team staff explored perceived barriers and facilitators. Statistical differences in measures comparing pre and post-intervention were assessed using paired t-tests and Cochran's-Q tests.

RESULTS

The KE sessions reached 34 NH team staff (5 GP, 4 pharmacists, 6 heads of care unit and 19 staff nurses). Forty-four residents participated in the study and were followed for a mean of 104 days. The total number of regular medications was 372 pre and 327 post-intervention. The mean number of regular medications per resident was 7.86 pre and 6.81 post-intervention. The odds ratios estimating the risks of using any regular medication or a "sometimes appropriate" medication post-intervention were 0.81 (95% CI: 0.71-0.92) and 0.83 (95% CI: 0.74-0.94), respectively.

CONCLUSION

A simple KE intervention using a medication review guidance tool categorizing medications as being either "generally", "sometimes" or "exceptionally" appropriate in severe dementia was well received and accompanied by an overall reduction in medication use by NH residents with severe dementia. Levels of agitation were unaffected and there was no clinically significant changes in levels of pain. Staff feedback provided opportunities to improve the intervention.

Use of medications that antagonize mediators of inflammatory responses may reduce the risk of delirium in older adults: a nested case-control study

OBJECTIVE

The objective of this study is to explore whether the use of medications that antagonize mediators of inflammatory responses reduces the risk of delirium in older adults.

METHODS

A nested case-control study was conducted using data from a prospective study of delirium in older long-term care residents from 7 long-term care facilities in Montreal and Quebec City, Canada. The Confusion Assessment Method was used to diagnose incident delirium. The use of medications that antagonize mediators of inflammatory responses was determined by examining facility pharmacy databases and coding medications received daily by each resident. Risk sets were built using incidence density sampling: each risk set consisted of a case with incident delirium and all controls without incident delirium at the same date and facility. Conditional logistic regression was used to assess the association of exposure to inflammation antagonist medications with the incidence of delirium.

RESULTS

Of 254 residents, 95 developed incident delirium during 24 weeks (cases); each case was matched with up to 35 controls. Unadjusted and adjusted odds ratios (95% CI) of delirium for residents exposed to at least one inflammation antagonist medication were 0.53 (0.34, 0.81) and 0.60 (0.38, 0.92), respectively. Estimates of the risk of incident delirium associated with specific medications and medication classes were mostly protective but not statistically significant.

CONCLUSION

The use of medications that antagonize mediators of inflammatory responses may reduce the risk of delirium in older adults. Despite study limitations, the findings merit further investigation using larger patient samples, more precise measures of exposure and better control of potential confounding variables. Copyright © 2016 John Wiley & Sons, Ltd.

RADAR: A Measure of the Sixth Vital Sign?

The objective of this study was to investigate the potential of RADAR (Recognizing Active Delirium As part of your Routine) as a measure of the sixth vital sign. This study was a secondary analysis of a study (N = 193) that took place in one acute care hospital and one long-term care facility. The primary outcome was a positive sixth vital sign, defined as the presence of both an altered level of consciousness and inattention. These indicators were assessed using the Confusion Assessment Method. RADAR identified 30 of the 43 participants as having a positive sixth vital sign and 58 of the 70 cases as not, yielding a sensitivity and specificity of 70% and 83%, respectively. Positive predictive value was 71%. RADAR's characteristics, including its brevity and acceptability by nursing staff, make this tool a good candidate as a measure of the sixth vital sign. Future studies should address the generalizability of RADAR among various populations and clinical settings.

Participation needs of older adults having disabilities and receiving home care: met needs mainly concern daily activities, while unmet needs mostly involve social activities

BACKGROUND

Participation is a key determinant of successful aging and enables older adults to stay in their homes and be integrated into the community. Assessing participation needs involves identifying restrictions in the accomplishment of daily and social activities. Although meeting participation needs involves older adults, their caregivers and healthcare providers, little is known about their respective viewpoints. This study thus explored the participation needs of older adults having disabilities as perceived by the older adults themselves, their caregivers and healthcare providers.

METHODS

A qualitative multiple case study consisted of conducting 33 semi-structured interviews in eleven triads, each composed of an older adult, his/her caregiver and a healthcare provider recruited in a Health and Social Services Centre (HSSC) in Québec, Canada. Interview transcripts and reviews of clinical records were analyzed using content analysis and descriptive statistics based on thematic saliency analysis methods.

RESULTS

Aged 66 to 88 years, five older adults had physical disabilities, five had mild cognitive impairment and one had psychological problems, leading to moderate to severe functional decline. Caregivers and healthcare providers were mainly women, respectively retired spouses and various professionals with four to 32 years of clinical experience. Participation needs reported by each triad included all domains of participation. Needs related to daily activities, such as personal care, nutrition, and housing, were generally met. Regarding social activities, few needs were met by various resources in the community and were generally limited to personal responsibilities, including making decisions and managing budgets, and some community life activities, such as going shopping. Unmet needs were mainly related to social activities, involving leisure, other community life activities and interpersonal relationships, and some daily activities, including fitness and mobility.

CONCLUSIONS

This study highlights the complexity of older adults' participation needs, involving daily as well as social activities. Properly assessing and addressing these needs is thus necessary to improve older adults' health and well-being. Discrepancies in the various actors' perceptions of participation needs must be further explored. Additional research would help better understand how to optimize the contribution of community organizations and caregivers.

Six-month outcomes of co-occurring delirium, depression, and dementia in long-term care

OBJECTIVES

To describe the 6-month outcomes of co-occurring delirium (full syndrome and subsyndromal symptoms), depression, and dementia in a long-term care (LTC) population.

DESIGN

Observational, prospective cohort study with 6-month follow-up conducted from 2005 to 2009.

SETTING

Seven LTC facilities in the province of Quebec, Canada.

PARTICIPANTS

Newly admitted and long-term residents recruited consecutively from lists of residents aged 65 and older admitted for LTC, with stratification into groups with and without severe cognitive impairment. The study sample comprised 274 residents with complete data at baseline on delirium, dementia, and depression.

MEASUREMENTS

Outcomes were 6-month mortality, functional decline (10-point decline from baseline on 100-point Barthel scale), and cognitive decline (3-point decline on 30-point Mini-Mental State Examination). Predictors included delirium (full syndrome or subsyndromal symptoms, using the Confusion Assessment Method), depression (Cornell Scale for Depression in Dementia), and dementia (chart diagnosis).

RESULTS

The baseline prevalences of delirium, subsyndromal symptoms of delirium (SSD), depression, and dementia were 11%, 44%, 19%, and 66%, respectively. By 6 months, 10% of 274 had died, 19% of 233 had experienced functional decline, and 17% of 246 had experienced cognitive decline. An analysis using multivariable generalized linear models found the following significant interaction effects (P < .15): between depression and dementia for mortality, between delirium and depression for functional decline, and between SSD and dementia for cognitive decline.

CONCLUSION

Co-occurrence of delirium, SSD, depression, and dementia in LTC residents appears to affect some 6-month outcomes. Because of limited statistical power, it was not possible to draw conclusions about the effects of the co-occurrence of some syndromes on poorer outcomes.

Match between needs and services for participation of older adults receiving home care

Purpose

– This paper aims to explore the match between needs and services related to participation for frail older adults receiving home care.

Design/methodology/approach

– A qualitative multiple case study was conducted with 11 triads each involving an elder, a caregiver and a healthcare provider working in a Health and Social Services Centers (HSSCs).

Findings

– Although HSSCs in Québec are supposed to promote social integration and participation of older adults, services provided to the older adults in this study focused mainly on safety and independence in personal care, dressing, mobility and nutrition, without fully meeting older adults’ needs in these areas. Discrepancies between needs and services may be attributable to the assessment not covering all the dimensions of social participation or accurately identifying older adults’ complex needs; older adults’ and their caregivers’ difficulties identifying their needs and accepting their limitations and the assistance offered; healthcare providers’ limited knowledge and time to comprehensively assess needs and provide services; guidelines restricting the types and quantity of services to be supplied; and limited knowledge of older adults, caregivers and healthcare providers about services and resources available in the community.

Originality/value

– To improve and maintain older adults’ participation, a more thorough assessment of their participation, especially in social activities, is required, as is greater support for older adults and their families in using available community resources. It is also important to review the services provided by HSSCs and to optimize partnerships with community organizations.

Environmental factors predict the severity of delirium symptoms in long-term care residents with and without delirium

OBJECTIVES

To identify potentially modifiable environmental factors (including number of medications) associated with changes over time in the severity of delirium symptoms and to explore the interactions between these factors and resident baseline vulnerability.

DESIGN

Prospective, observational cohort study.

SETTING

Seven long-term care (LTC) facilities.

PARTICIPANTS

Two hundred seventy-two LTC residents aged 65 and older with and without delirium.

MEASUREMENTS

Weekly assessments (for up to 6 months) of the severity of delirium symptoms using the Delirium Index (DI), environmental risk factors, and number of medications. Baseline vulnerability measures included a diagnosis of dementia and a delirium risk score. Associations between environmental factors, medications, and weekly changes in DI were analyzed using a general linear model with correlated errors.

RESULTS

Six potentially modifiable environmental factors predicted weekly changes in DI (absence of reading glasses, aids to orientation, family member, and glass of water and presence of bed rails and other restraints) as did the prescription of two or more new medications. Residents with dementia appeared to be more sensitive to the effects of these factors.

CONCLUSION

Six environmental factors and prescription of two or more new medications predicted changes in the severity of delirium symptoms. These risk factors are potentially modifiable through improved LTC clinical practices.

The course of subsyndromal delirium in older long-term care residents

OBJECTIVE

To determine the course of incident subsyndromal delirium (SSD) in older long-term care (LTC) residents. A secondary objective was to explore the use of a more restrictive definition of SSD on the findings of the study.

DESIGN

Cohort study with repeated weekly assessments for up to 6 months.

SETTING

Seven LTC facilities in Montreal and Quebec City, Canada.

PARTICIPANTS

LTC residents aged 65 and more and free of delirium core symptoms at baseline.

MEASURES

The Mini-Mental State Examination (MMSE), Confusion Assessment Method (CAM), Delirium Index (DI), Hierarchic Dementia Scale, and Barthel Index were completed at baseline. The MMSE, CAM, and DI were repeated weekly for 6 months. SSD1 required one or more CAM core symptoms; SSD2, a more restrictive definition, required two or more CAM core symptoms.

RESULTS

Sixty-eight residents had 129 incident episodes of SSD1: 32 had one episode and 36 had two or more episodes. Episodes lasted 7 - 133 days, mean 13.7 (SD: 14.8) days; mean number of symptoms per episode was 1.1 (SD: 0.4). Rates of recovery at 1, 2, and 4 weeks and 6 months were 45.7%, 61.2%, 64.6%, and 78.3%, respectively. Thirty-three residents had 49 episodes of SSD2: 21 had 1 episode and 12 had 2 or more episodes. Use of the more restrictive definition significantly increased time to recovery and reduced rate of recovery.

CONCLUSION

Episodes of SSD in older LTC residents appeared to last 7-133 days (mean: 13.7) and were often recurrent. Use of a more restrictive definition resulted in a more protracted course.

Nursing Documentation in Long-Term Care Settings

In this study on nursing documentation in long-term care facilities, a set of 9 delirium symptoms was used to evaluate the agreement between symptoms reported by nurses during monthly interviews and those documented in the nursing notes for the same 7-day observation period. Residents aged 65 and above ( N = 280) were assessed monthly over a 6-month period for the presence of delirium and its symptoms using the Confusion Assessment Method. The proportion of symptoms documented in the nursing notes ranged from 1.9% to 53.5%. A trend toward a lower proportion of documented symptoms for higher resident−nurse ratios was observed, although the difference was not statistically significant. Efforts should be made to improve the situation by revisiting the content of academic and clinical training given to nurses in addition to exploring innovative ways to make nursing documentation more efficient and less time-consuming within the current context of nurses’ work overload.

The course of delirium in older long-term care residents

OBJECTIVE

The purpose of this study was to determine the course of delirium in older long-term care (LTC) residents.

METHODS

A prospective cohort study of 279 residents in seven LTC facilities in Montreal and Quebec City, Canada, was conducted. The Mini Mental State Examination (MMSE), Confusion Assessment Method (CAM), Delirium Index (DI), Hierarchic Dementia Scale, Barthel Index, and Cornell Scale for Depression were completed at baseline. The MMSE, CAM, and DI were repeated weekly for 6 months. Information on medical problems and medication was abstracted from resident charts. Data were analyzed using descriptive statistics, Cox proportional hazard regression, and logistic regression.

RESULTS

Of the 279 residents, 41 (14.7%) had 61 CAM-defined incident episodes of delirium: 28 (10%) had one episode and 13 (4.7%) had two or more episodes. Episode duration was 7-63 days, mean, 11.3 (SD, 10.1) days. The mean episode DI score was 11.5 (SD, 3.5). Rates of recovery at 1, 2, 4, and 24 weeks were 57.4%, 67.2% 77.1%, and 80.3%, respectively. Most episodes were preceded or followed by one or more CAM core symptoms of delirium, sometimes lasting many weeks.

CONCLUSIONS

Confusion Assessment Method-defined incident episodes of delirium in older LTC residents appear to last longer than episodes in acute care hospital patients, but rates of recovery at 4 and 24 weeks are similar. Notably, most episodes were preceded or followed by one or more CAM core symptoms of delirium. These findings have implications for clinical practice and research in LTC settings.

Development of a delirium risk screening tool for long-term care facilities

OBJECTIVE

The aim of this study is to develop a delirium risk screening tool for use in long-term care (LTC) facilities.

METHODS

The sample comprised residents aged 65 years and over of seven LTC facilities in Montreal and Quebec City, Canada, admitted for LTC. Primary analyses were conducted among residents without delirium at baseline. Incident delirium was diagnosed using multiple data sources during the 6-month follow-up. Risk factors, all measured at or prior to baseline, included the following six groups: sociodemographic, medical, cognitive status, physical function, agitated behavior, and symptoms of depression. Variables were analyzed individually and by group using Cox regression models. Clinical judgment was used to select the most feasible among similarly performing factors.

RESULTS

The cohort comprised 206 residents without delirium at baseline; 69 cases of incident delirium were observed (rate 7.6 per 100 person weeks). The best-performing screening tool comprised five items, with an overall area under the curve of 0.82 (95% CI 0.76, 0.88). These items included brief measures of cognitive status, physical function, behavioral, and emotional problems. Using cut-points of 2 (or 3) over 5, the scale has a sensitivity of 90% (63%), specificity of 59% (85%), and positive predictive value of 52% (66%).

CONCLUSIONS

This brief screening tool allows nurses to identify LTC residents at increased risk for delirium. These residents can be targeted for closer monitoring and preventive interventions.

Effect of an Interdisciplinary Educational Program on Antipsychotic Prescribing Among Residents With Dementia in Two Long-Term Care Centers

The effect of an educational program on antipsychotic prescribing was assessed in two Canadian long-term care centers (LTCC). In each center (Center A residents, n = 258 and Center B residents, n = 191, with dementia at program inception), the rate of change in the odds of using antipsychotics in residents was estimated using mixed-effects logistic regression during a 6-month program period and a 4-month postprogram period, with baseline proportions of use estimated during the 6 months prior to the program. Preprogram proportions of antipsychotic use were 41.6% and 46.2%, respectively. Antipsychotic use decreased during the program in both centers: (odds ratio with 95% CI: 0.943 per week [0.921, 0.965] and 0.969 per week [0.944, 0.994], respectively). During the postprogram period, antipsychotic use increased in Center A (1.039 per week [1.007, 1.072]) but decreased progressively in Center B. The study results suggest the need to implement an ongoing educational program in LTCC.

Prevalence and incidence of delirium in long-term care

OBJECTIVES

(1) To describe the prevalence and 6-month incidence of delirium in long-term care facility (LTCF) residents age 65 and over; (2) To describe differences in these measures by resident baseline characteristics.

METHODS

A multisite, prospective observational study was conducted in seven LTCFs in the province of Quebec, Canada. Residents of age 65 and over were recruited into two cohorts: Cohort A with a Mini-Mental State Examination (MMSE) score of 10 or more and Cohort B with an MMSE score of less than 10. Baseline resident measurements were obtained from research resident assessments, nurse interviews, and chart review. Weekly resident assessments for up to 24 weeks included the Confusion Assessment Method (CAM).

RESULTS

Two hundred seventy-nine residents were recruited and completed baseline delirium assessments: 204 in Cohort A and 75 in Cohort B. The prevalence of delirium at baseline was 3.4% in Cohort A and 33.3% in Cohort B. The incidence of delirium among those without delirium at baseline (per 100 person-weeks of follow-up) was 1.6 in Cohort A and 6.9 in Cohort B. In multivariate analyses, a diagnosis of dementia, moderate to severe cognitive impairment, and depressive symptoms at baseline were associated with a greater prevalence and incidence of delirium.

CONCLUSION

Delirium is an important clinical problem in LTCF residents, particularly among those with moderate to severe cognitive impairment at baseline.

[Management of osteoporosis in short-term geriatric units]

OBJECTIVE

To identify the recommendations in Canadian and American clinical practice guidelines for the management of osteoporosis that are applicable to vulnerable, older patients in short-term geriatric units (STGU).

DESIGN

Modified Delphi approach according to the RAND/UCLA method.

SETTING

A panel of experts from various regions of Quebec.

PARTICIPANTS

The panel consisted of 6 physicians, 5 pharmacists, and 3 nutritionists recognized by their peers for their expertise in STGU.

METHODS

Eleven recommendations from the North American guidelines were submitted to a panel of experts who were asked to identify those most appropriate for the management of osteoporosis in STGU. Each expert's level of agreement with the recommendations and the experts' general level of agreement were used to determine the relevance of the recommendations.

FINDINGS

The experts reached a consensus on each of the 11 recommendations. Seven recommendations were deemed appropriate for the management of osteoporosis in vulnerable, older patients in STGU. Bone mineral density measurement as a parameter for follow-up was the only recommendation deemed inappropriate in this context. The experts remained uncertain about 3 recommendations: systematic screening for osteoporosis by bone mineral density measurement; systematic screening or evaluation of the risk factors for fractures; and pharmacologic prevention in vulnerable, older patients with an increased risk of fracture.

CONCLUSION

Some of the recommendations issued in the North American recommendations appear to be less appropriate for managing osteoporosis in vulnerable, older patients in STGU. The recommendations retained in this study could be used to standardize interventions for these patients and to determine the extent to which current practice follows the recommendations.

Effect of an interdisciplinary educational program on antipsychotic prescribing among nursing home residents with dementia

OBJECTIVE

To assess the effect of an interdisciplinary educational program in reducing the use of antipsychotics in nursing home residents with dementia.

METHODS

We conducted a longitudinal pilot study to test the implementation of a 7-month interdisciplinary educational program in a fixed cohort of residents with dementia receiving antipsychotics. The program included consciousness-raising, educational sessions, and clinical follow-up. Administrators, physicians, pharmacists, nursing staff, and personal care attendants were involved. The effect of the program was assessed over a 6-month period, in terms of the proportion of discontinuations and dose reductions of antipsychotics. Repeated measures for use of other psychotropics and restraints, frequency of disruptive behaviors, and stressful events experienced by nursing staff and personal care attendants were simultaneously assessed.

RESULTS

Among the 81 residents still present at the end of the program, there were 40 (49.4%) discontinuations and 11 (13.6%) dose reductions. No significant changes were found in the use of other psychotropics, the use of restraints, or in the number of stressful events experienced by nursing staff and personal care attendants. The frequency of disruptive behaviors decreased significantly over the 6-month period (p<0.001).

CONCLUSIONS

Our interdisciplinary educational program led to a substantial reduction in the number of residents receiving antipsychotics and to a decrease in the frequency of disruptive behaviors. Our findings suggest that implementation of recognized practice guidelines could be an effective way to target residents who might not benefit from antipsychotics or who may tolerate a dose reduction.

Non-pharmacological interventions for aggressive behavior in older adults living in long-term care facilities

BACKGROUND

Aggressive behavior (AB) is common in institutional settings. It is an important issue because of its consequences on both the person manifesting such behaviors and their caregivers. Although there are numerous studies assessing non-pharmacologic strategies to manage AB in older adults, no extensive review of the literature is available. This review synthesizes the current knowledge on the effectiveness of non-pharmacological interventions in institutional settings.

METHOD

Papers describing the assessment of a non-pharmacological intervention to manage AB in which participants were at least 60 years old and living in a long-term care facility were selected mainly by searching various databases.

RESULTS

A total of 41 studies were identified and included in the review. These studies mainly use quasi-experimental designs and include less than 30 participants. Sixty-six percent (27/41) of the studies report either a statistically or behaviorally significant reduction of AB as a result of a non-pharmacological intervention. Staff training programs and environmental modifications appear to be the most effective strategies.

CONCLUSION

Non-pharmacological interventions seem effective for managing AB. Future studies on the effectiveness of these interventions need to be more rigorous. Development in this field needs to be based on knowledge regarding the determinants of AB in older adults.

Prevalence of physical and verbal aggressive behaviours and associated factors among older adults in long-term care facilities

BACKGROUND

Verbal and physical aggressive behaviours are among the most disturbing and distressing behaviours displayed by older patients in long-term care facilities. Aggressive behaviour (AB) is often the reason for using physical or chemical restraints with nursing home residents and is a major concern for caregivers. AB is associated with increased health care costs due to staff turnover and absenteeism.

METHODS

The goals of this secondary analysis of a cross-sectional study are to determine the prevalence of verbal and physical aggressive behaviours and to identify associated factors among older adults in long-term care facilities in the Quebec City area (n = 2,332).

RESULTS

The same percentage of older adults displayed physical aggressive behaviour (21.2%) or verbal aggressive behaviour (21.5%), whereas 11.2% displayed both types of aggressive behaviour. Factors associated with aggressive behaviour (both verbal and physical) were male gender, neuroleptic drug use, mild and severe cognitive impairment, insomnia, psychological distress, and physical restraints. Factors associated with physical aggressive behaviour were older age, male gender, neuroleptic drug use, mild or severe cognitive impairment, insomnia and psychological distress. Finally, factors associated with verbal aggressive behaviour were benzodiazepine and neuroleptic drug use, functional dependency, mild or severe cognitive impairment and insomnia.

CONCLUSION

Cognitive impairment severity is the most significant predisposing factor for aggressive behaviour among older adults in long-term care facilities in the Quebec City area. Physical and chemical restraints were also significantly associated with AB. Based on these results, we suggest that caregivers should provide care to older adults with AB using approaches such as the progressively lowered stress threshold model and reactance theory which stress the importance of paying attention to the severity of cognitive impairment and avoiding the use of chemical or physical restraints.

Use of neuroleptics: study of institutionalized elderly people in Montreal, Que

OBJECTIVE

To determine the prevalence of neuroleptic use in long-term care institutions in the greater Montreal, Que, area and to estimate the extent of use of atypical neuroleptics.

DESIGN

Cross-sectional study in which single-day chart reviews were conducted to evaluate the prevalence of use of conventional and atypical neuroleptics.

SETTING

Ten long-term care institutions in the greater Montreal area.

PARTICIPANTS

Two thousand, four hundred sixty residents aged 65 years or older living in 10 long-term care institutions in and around Montreal.

MAIN OUTCOME MEASURES

Single-day medication profiles compiled by institutions' pharmacists.

RESULTS

Among patients in the 10 participating institutions, use of neuroleptics ranged from 15% to 37% with a mean of 25.2% (620/2460). Atypical neuroleptics were prescribed to 15.6%, conventional neuroleptics to 7.6%, and a combination of both to 2.0% of the 2460 patients.

CONCLUSION

Use of neuroleptics was relatively prevalent, and there was wide use of atypical neuroleptics in Montreal-area long-term care institutions. There is little information on the safety and efficacy of these medications for institutionalized elderly people.

Suboptimal duration of antidepressant treatments in the older ambulatory population of Quebec: association with selected physician characteristics

OBJECTIVES

To assess the association between selected physician characteristics and suboptimal duration of antidepressant use in the older outpatient population.

DESIGN

Follow-up of patients who were prescribed an antidepressant treatment by a cohort of physicians in Quebec.

SETTING

Community-based older outpatient population in Quebec.

PARTICIPANTS

Retrospective cohort of 1,301 general practitioners (GPs) and 236 psychiatrists followed from 1991 to 1997.

MEASUREMENTS

Treatment duration of less than 180 days in 1996/97.

RESULTS

Premature interruption of antidepressant treatment was very frequent (44.7%). GPs, physicians who practice in metropolitan or urban regions, and those who have a proportion of older patients in their practice of less than 50% show a higher rate of premature interruption. These associations could not be accounted for by the choice of products, dosage, or patient characteristics.

CONCLUSION

We have identified physician characteristics that are associated with suboptimal duration of antidepressant use and conclude that further interventions should target subgroups of physicians.

Review of outcome measurement instruments in Alzheimer's disease drug trials: psychometric properties of functional and quality of life scales

The psychometric properties of functional and quality of life outcome measures that were used for the purpose of showing changes in antidementia drug trials for Alzheimer's disease are described and critiqued. The seven functional scales reviewed for reliability, validity, and responsiveness to change included the Geriatric Evaluation by Relative's Rating Instrument, the Physical Self-Maintenance Scale, the Instrumental Activities of Daily Living, the Blessed Dementia Scale, Part 1 and its revised version, the Interview for Deterioration in Daily Living with Dementia, the Unified Activities of Daily Living, and the Dependence Scale. The Progressive Deterioration Scale and Quality of Life Assessment were classified as quality of life scales. The majority of the scales were found to exhibit serious limitations, such as incomplete reliability and validity assessment for the intended uses. The most pervasive problem was a lack of data on responsiveness to change. It is recommended that further research be conducted to develop new tools or enhance existing measures for the assessment of both quality of life and functional ability.

Single-dose pharmacokinetics of ampicillin and tobramycin administered by hypodermoclysis in young and older healthy volunteers

1. To test the feasibility of administering antibiotics by subcutaneous infusion to the elderly, we compared the pharmacokinetics of tobramycin (single dose of 80 mg) given by hypodermoclysis (HDC) with the kinetics of the antibiotic injected intravenously (i.v.) in 10 young (< 50 years old) and 10 elderly (> 65 years old) healthy volunteers. Similar studies were performed with ampicillin (single dose of 1 g) in 12 young and 10 older healthy volunteers. 2. Compared with the i.v. route, HDC delayed the time to reach the maximal plasma concentration (tmax) of tobramycin in young volunteers: 32 +/- 6 (s.d.) min vs 88 +/- 46, P < 0.005, and older volunteers: 27 +/- 4 min vs 89 +/- 15, P < 0.005. Administration of the antibiotics by HDC was well tolerated. The plasma concentration of tobramycin 30 min after the end of infusion (C60) was lower (P < 0.05) following HDC than after the i.v. route in both young, 2.2 +/- 0.7 vs 3.5 +/- 0.8 micrograms ml-1, and elderly subjects, 2.2 +/- 0.8 vs 3.8 +/- 0.9. micrograms ml-1. 3. The area under the curve (AUC) of tobramycin given by HDC was slightly smaller than when given i.v., i.e. in young subjects: 740 +/- 225 (s.d.) vs 893 +/- 223 micrograms ml-1 min, NS, and in the elderly: 980 +/- 228 vs 1056 +/- 315 micrograms ml-1 min, NS. 4. When ampicillin was administered by HDC, the tmax was also delayed in young volunteers: 45 +/- 18 vs 23 +/- 6 min, and in the elderly: 49 +/- 18 vs 27 +/- 4 min, P < 0.005, the AUC was greater by HDC than i.v. in the young volunteers: 4527 +/- 1658 micrograms ml-1 min vs 3810 +/- 1033 micrograms ml-1 min and in the elderly: 6795 +/- 2094 micrograms ml-1 min vs 4217 +/- 1518 micrograms ml-1 min, and the C60 was higher by HDC in the young: 27 +/- 7 vs 24 +/- 9 micrograms ml-1, and in the elderly: 32 +/- 9 vs 23 +/- 11 micrograms ml-1, P < 0.05. 5. In conclusion, HDC delays the entry of the antibiotic into the systemic circulation, but did not affect the amount available. HDC was well tolerated and could become an adequate method for antibiotic administration to the elderly.

[Osteoporosis in 1993. An information update]

This survey provides family physicians with an update on the physiopathological mechanisms of osteoporosis and a guide for rational investigation. It also summarises new methods of preventing and treating osteoporosis.