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Feyman Y, Griffith KN, Dorneo A, Simmons SF, Roumie CL, Mattocks KM. Physicians and Specialties in the Veterans Health Administration's Community Care Network. JAMA Netw Open 2024; 7:e2410841. [PMID: 38739394 DOI: 10.1001/jamanetworkopen.2024.10841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
This cross-sectional study of data from the US Veterans Health Administration examines the availability of services provided through community care networks by specialty and clinical characteristics.
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Affiliation(s)
| | - Kevin N Griffith
- VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Allison Dorneo
- VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Health, Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Sandra F Simmons
- VA Tennessee Valley Health Care System, GRECC, South Nashville, Tennessee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christianne L Roumie
- VA Tennessee Valley Health Care System, GRECC, South Nashville, Tennessee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kristin M Mattocks
- UMass Chan Medical School, Worcester, Massachusetts
- VA Central Western Massachusetts Healthcare System, Leeds
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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. Implementation considerations of deprescribing interventions: A scoping review. J Intern Med 2024; 295:436-507. [PMID: 36524602 DOI: 10.1111/joim.13599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Over half of older adults experience polypharmacy, including medications that may be inappropriate or unnecessary. Deprescribing, which is the process of discontinuing or reducing inappropriate and/or unnecessary medications, is an effective way to reduce polypharmacy. This review summarizes (1) the process of deprescribing and conceptual models and tools that have been developed to facilitate deprescribing, (2) barriers, enablers, and factors associated with deprescribing, and (3) characteristics of deprescribing interventions in completed trials, as well as (4) implementation considerations for deprescribing in routine practice. In conceptual models of deprescribing, multilevel factors of the patient, clinician, and health-care system are all related to the efficacy of deprescribing. Numerous tools have been developed for clinicians to facilitate deprescribing, yet most require substantial time and, thus, may be difficult to implement during routine health-care encounters. Multiple deprescribing interventions have been evaluated, which mostly include one or more of the following components: patient education, medication review, identification of deprescribing targets, and patient and/or provider communication about high-risk medications. Yet, there has been limited consideration of implementation factors in prior deprescribing interventions, especially with regard to the personnel and resources in existing health-care systems and the feasibility of incorporating components of deprescribing interventions into the routine care processes of clinicians. Future trials require a more balanced consideration of both effectiveness and implementation when designing deprescribing interventions.
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Affiliation(s)
- Jinjiao Wang
- Elaine, Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Harriet J. Kitzman Center for Research Support, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- UR Medicine Home Care, University of Rochester Medical Center, Rochester, New York, USA
- University of Rochester Medical Center, Finger Lakes Geriatric Education Center, Rochester, New York, USA
| | - Kobi Nathan
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Donna M Fick
- Ross and Carol Nese College of Nursing, Penn State University, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Department of Medicine, Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Wang J, Shen JY, Yu F, Nathan K, Caprio TV, Conwell Y, Moskow MS, Brasch JD, Simmons SF, Mixon AS, Norton SA. Challenges in Deprescribing among Older Adults in Post-Acute Care Transitions to Home. J Am Med Dir Assoc 2024; 25:138-145.e6. [PMID: 37913819 PMCID: PMC10843747 DOI: 10.1016/j.jamda.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Medications with a higher risk of harm or that are unlikely to be beneficial are used by nearly all older patients in home health care (HHC). The objective of this study was to understand stakeholders' perspectives on challenges in deprescribing these medications for post-acute HHC patients. DESIGN Qualitative individual interviews were conducted with stakeholders involved with post-acute deprescribing. SETTING AND PARTICIPANT Older HHC patients, HHC nurses, pharmacists, and primary/acute care/post-acute prescribers from 9 US states participated in individual qualitative interviews. MEASURES Interview questions were focused on the experience, processes, roles, training, workflow, and challenges of deprescribing in hospital-to-home transitions. We used the constant comparison approach to identify and compare findings among patient, prescriber, and pharmacist and HHC nurse stakeholders. RESULTS We interviewed 9 older patients, 11 HHC nurses, 5 primary care physicians (PCP), 3 pharmacists, 1 hospitalist, and 1 post-acute nurse practitioner. Four challenges were described in post-acute deprescribing for HHC patients. First, PCPs' time constraints, the timing of patient encounters after hospital discharge, and the lack of prioritization of deprescribing make it difficult for PCPs to initiate post-acute deprescribing. Second, patients are often confused about their medications, despite the care team's efforts in educating the patients. Third, communication is challenging between HHC nurses, PCPs, specialists, and hospitalists. Fourth, the roles of HHC nurses and pharmacists are limited in care team collaboration and discussion about post-acute deprescribing. CONCLUSIONS AND IMPLICATIONS Post-acute deprescribing relies on multiple parties in the care team yet it has challenges. Interventions to align the timing of deprescribing and that of post-acute care visits, prioritize deprescribing and allow clinicians more time to complete related tasks, improve medication education for patients, and ensure effective communication in the care team with synchronized electronic health record systems are needed to advance deprescribing during the transition from hospital to home.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, NY, USA.
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Kobi Nathan
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; University of Rochester-Home Care, University of Rochester Medical Center, Rochester, NY, USA; Finger Lakes Geriatric Education Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Marian S Moskow
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, NY, USA
| | - Judith D Brasch
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, NY, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA; Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda S Mixon
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA; Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sally A Norton
- School of Nursing, University of Rochester, Rochester, NY, USA
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Wang J, Shen JY, Yu F, Nathan K, Caprio TV, Conwell Y, Moskow MS, Brasch JD, Simmons SF, Mixon AS, Norton SA. How to Deprescribe Potentially Inappropriate Medications During the Hospital-to-Home Transition: Stakeholder Perspectives on Essential Tasks. Clin Ther 2023; 45:947-956. [PMID: 37640614 PMCID: PMC10841554 DOI: 10.1016/j.clinthera.2023.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/24/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
PURPOSE Nearly all older patients receiving postacute home health care (HHC) use potentially inappropriate medications (PIMs) that carry a risk of harm. Deprescribing can reduce and optimize the use of PIMs, yet it is often not conducted among HHC patients. The objective of this study was to gather perspectives from patient, practitioner, and HHC clinician stakeholders on tasks that are essential to postacute deprescribing in HHC. METHODS A total of 44 stakeholders, including 14 HHC patients, 15 practitioners (including 9 primary care physicians, 4 pharmacists, 1 hospitalist, and 1 nurse practitioner), and 15 HHC nurses, participated. The stakeholders were from 12 US states, including New York (n = 29), Colorado (n = 2), Connecticut (n = 1), Illinois (n = 2), Kansas (n = 2), Massachusetts (n = 1), Minnesota (n = 1), Mississippi (n = 1), Nebraska (n = 1), Ohio (n = 1), Tennessee (n = 1), and Texas (n = 2). First, individual interviews were conducted by experienced research staff via video conference or telephone. Second, the study team reviewed all interview transcripts and selected interview statements regarding stakeholders' suggestions for important tasks needed for postacute deprescribing in HHC. Third, concept mapping was conducted in which stakeholders sorted and rated selected interview statements regarding importance and feasibility. A content analysis was conducted of data collected in the individual interviews, and a mixed-method analysis was conducted of data collected in the concept mapping. FINDINGS Four essential tasks were identified for postacute deprescribing in HHC: (1) ongoing review and assessment of medication use, (2) patent-centered and individualized plan of deprescribing, (3) timely and efficient communication among members of the care team, and (4) continuous and tailored medication education to meet patient needs. Among these tasks, developing patient-centered deprescribing considerations was considered the most important and feasible, followed by medication education, review and assessment of medication use, and communication. IMPLICATIONS Deprescribing during the transition of care from hospital to home requires the following: continuous medication education for patients, families, and caregivers; ongoing review and assessment of medication use; patient-centered deprescribing considerations; and effective communication and collaboration among the primary care physician, HHC nurse, and pharmacist.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, New York.
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona
| | - Kobi Nathan
- Division of Geriatrics and Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York; Wegmans School of Pharmacy, St. John Fisher College, Rochester, New York
| | - Thomas V Caprio
- Division of Geriatrics and Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York; University of Rochester Home Care, University of Rochester Medical Center, Rochester, New York; Finger Lakes Geriatric Education Center, University of Rochester Medical Center, Rochester, New York
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | - Marian S Moskow
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, New York
| | - Judith D Brasch
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, New York
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee; Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amanda S Mixon
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sally A Norton
- School of Nursing, University of Rochester, Rochester, New York
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Strayer TE, Hollingsworth EK, Shah AS, Vasilevskis EE, Simmons SF, Mixon AS. Why do older adults decline participation in research? Results from two deprescribing clinical trials. Trials 2023; 24:456. [PMID: 37464431 PMCID: PMC10353211 DOI: 10.1186/s13063-023-07506-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 07/10/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Heterogenous older adult populations are underrepresented in clinical trials, and their participation is necessary for interventions that directly target them. The purpose of this study was to evaluate reasons why hospitalized older adults declined participation in two deprescribing clinical trials. METHODS We report enrollment data from two deprescribing trials, Shed-MEDS (non-Veterans) and VA DROP (Veterans). For both trials, inclusion criteria required participants to be hospitalized, age 50 or older, English-speaking, and taking five or more home medications. Eligible patients were approached for enrollment while hospitalized. When an eligible patient or surrogate declined participation, the reason(s) were recorded and subsequently analyzed inductively to develop themes, and a chi-square test was used for comparison (of themes between Veterans and non-Veterans). RESULTS Across both trials, 1226 patients (545 non-Veterans and 681 Veterans) declined enrollment and provided reasons, which were condensed into three themes: (1) feeling overwhelmed by their current health status, (2) lack of interest or mistrust of research, and (3) hesitancy to participate in a deprescribing study. A greater proportion of Veterans expressed a lack of interest or mistrust in research (42% vs 26%, chi-square value = 36.72, p < .001), whereas a greater proportion of non-Veterans expressed feeling overwhelmed by their current health status (54% vs 35%, chi-square value = 42.8 p < 0.001). Across both trials, similar proportion of patients expressed hesitancy to participate in a deprescribing study, with no significant difference between Veterans and non-Veterans (23% and 21%). CONCLUSIONS Understanding the reasons older adults decline participation can inform future strategies to engage this multimorbid population.
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Affiliation(s)
- Thomas E Strayer
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA.
- Division of Geriatrics, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA.
| | - Emily K Hollingsworth
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Division of Geriatrics, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
| | - Avantika S Shah
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Eduard E Vasilevskis
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, 1310 24Th Ave. S, Nashville, TN, 37212, USA
- Section of Hospital Medicine, Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, 2525 West End Ave. Suite 450, Nashville, TN, 37203, USA
| | - Sandra F Simmons
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Division of Geriatrics, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, 1310 24Th Ave. S, Nashville, TN, 37212, USA
| | - Amanda S Mixon
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, 1310 24Th Ave. S, Nashville, TN, 37212, USA
- Section of Hospital Medicine, Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, 2525 West End Ave. Suite 450, Nashville, TN, 37203, USA
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Kim JL, Lewallen KM, Hollingsworth EK, Shah AS, Simmons SF, Vasilevskis EE. Patient-Reported Barriers and Enablers to Deprescribing Recommendations During a Clinical Trial (Shed-MEDS). Gerontologist 2023; 63:523-533. [PMID: 35881109 PMCID: PMC10028229 DOI: 10.1093/geront/gnac100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Effective deprescribing requires shared decision making between a patient and their clinician, and should be used when implementing evidence-based deprescribing conversations. As part of the Shed-MEDS clinical trial, this study assessed barriers and enablers that influence patient decision making in deprescribing to inform future implementation efforts and adaptations. RESEARCH DESIGN AND METHODS Shed-MEDS, a randomized controlled deprescribing trial, included hospitalized older adults discharging to post-acute care facilities. A trained clinician reviewed each participant's medical history and medication list to identify medications with potential for deprescribing. The study clinician then conducted a semistructured patient-centered deprescribing interview to determine patient (or surrogate) concerns about medications and willingness to deprescribe. Reeve et al.'s (2013) framework was used to categorize barriers and enablers to deprescribing from the patient's perspective, including "appropriateness of cessation," "fear," "dislike of a medication," "influences," and "process of cessation." RESULTS Overall, participants/surrogates (N = 177) agreed with 63% (883 total medications) of the study clinician's deprescribing recommendations. Thematic analysis revealed that "appropriateness" of a medication was the most common barrier (88.2%) and enabler (67.3%) to deprescribing. Other deprescribing enablers were in the following domains: "influences" (22.7%), "process" (22.5%), "pragmatic" (19.4%), and "dislike" (5.3%). DISCUSSION AND IMPLICATIONS Use of a semistructured deprescribing interview conversation tool allowed study clinicians to elicit individual barriers and enablers to deprescribing from the patient's perspective. Participants in this study expressed more agreement than disagreement with study clinicians' deprescribing recommendations. These results should inform future implementation efforts that incorporate a patient-centered framework during deprescribing conversations. CLINICAL TRIALS REGISTRATION NUMBER NCT02979353.
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Affiliation(s)
- Jennifer L Kim
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Kanah M Lewallen
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Emily K Hollingsworth
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Avantika S Shah
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, & Clinical Center (GRECC), VA Tennessee Healthcare System, Nashville, Tennessee, USA
| | - Eduard E Vasilevskis
- Geriatric Research, Education, & Clinical Center (GRECC), VA Tennessee Healthcare System, Nashville, Tennessee, USA
- Section of Hospital Medicine, Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Vasilevskis EE, Shah AS, Hollingsworth EK, Shotwell MS, Kripalani S, Mixon AS, Simmons SF. Deprescribing Medications Among Older Adults From End of Hospitalization Through Postacute Care: A Shed-MEDS Randomized Clinical Trial. JAMA Intern Med 2023; 183:223-231. [PMID: 36745422 PMCID: PMC9989899 DOI: 10.1001/jamainternmed.2022.6545] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/04/2022] [Indexed: 02/07/2023]
Abstract
Importance Deprescribing is a promising approach to addressing the burden of polypharmacy. Few studies have initiated comprehensive deprescribing in the hospital setting among older patients requiring ongoing care in a postacute care (PAC) facility. Objective To evaluate the efficacy of a patient-centered deprescribing intervention among hospitalized older adults transitioning or being discharged to a PAC facility. Design, Setting, and Participants This randomized clinical trial of the Shed-MEDS (Best Possible Medication History, Evaluate, Deprescribing Recommendations, and Synthesis) deprescribing intervention was conducted between March 2016 and October 2020. Patients who were admitted to an academic medical center and discharged to 1 of 22 PAC facilities affiliated with the medical center were recruited. Patients who were 50 years or older and had 5 or more prehospital medications were enrolled and randomized 1:1 to the intervention group or control group. Patients who were non-English speaking, were unhoused, were long-stay residents of nursing homes, or had less than 6 months of life expectancy were excluded. An intention-to-treat approach was used. Interventions The intervention group received the Shed-MEDS intervention, which consisted of a pharmacist- or nurse practitioner-led comprehensive medication review, patient or surrogate-approved deprescribing recommendations, and deprescribing actions that were initiated in the hospital and continued throughout the PAC facility stay. The control group received usual care at the hospital and PAC facility. Main Outcomes and Measures The primary outcome was the total medication count at hospital discharge and PAC facility discharge, with follow-up assessments during the 90-day period after PAC facility discharge. Secondary outcomes included the total number of potentially inappropriate medications at each time point, the Drug Burden Index, and adverse events. Results A total of 372 participants (mean [SD] age, 76.2 [10.7] years; 229 females [62%]) were randomized to the intervention or control groups. Of these participants, 284 were included in the intention-to-treat analysis (142 in the intervention group and 142 in the control group). Overall, there was a statistically significant treatment effect, with patients in the intervention group taking a mean of 14% fewer medications at PAC facility discharge (mean ratio, 0.86; 95% CI, 0.80-0.93; P < .001) and 15% fewer medications at the 90-day follow-up (mean ratio, 0.85; 95% CI, 0.78-0.92; P < .001) compared with the control group. The intervention additionally reduced patient exposure to potentially inappropriate medications and Drug Burden Index. Adverse drug event rates were similar between the intervention and control groups (hazard ratio, 0.83; 95% CI, 0.52-1.30). Conclusions and Relevance Results of this trial showed that the Shed-MEDS patient-centered deprescribing intervention was safe and effective in reducing the total medication burden at PAC facility discharge and 90 days after discharge. Future studies are needed to examine the effect of this intervention on patient-reported and long-term clinical outcomes. Trial Registration ClinicalTrials.gov Identifier: NCT02979353.
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Affiliation(s)
- Eduard E. Vasilevskis
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Avantika Saraf Shah
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Sunil Kripalani
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amanda S. Mixon
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandra F. Simmons
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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Jordano JO, Vasilevskis EE, Duggan MC, Welch SA, Schnelle JF, Simmons SF, Ely EW, Han JH. Effect of physical and occupational therapy on delirium duration in older emergency department patients who are hospitalized. J Am Coll Emerg Physicians Open 2023; 4:e12857. [PMID: 36776211 PMCID: PMC9902677 DOI: 10.1002/emp2.12857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/22/2022] [Accepted: 11/03/2022] [Indexed: 02/10/2023] Open
Abstract
Objective Delirium in older emergency department (ED) adults is associated with poorer long-term physical function and cognition. We sought to evaluate if the time to and intensity of physical and/or occupational therapy (PT/OT) are associated with the duration of ED delirium into hospitalization (ED delirium duration). Methods This is a secondary analysis of a prospective cohort study conducted from March 2012 to November 2014 at an urban, academic, tertiary care hospital. Patients aged ≥65 years presenting to the ED and who received PT/OT during their hospitalization were included. Days from enrollment to the first PT/OT session and PT/OT duration relative to hospital length of stay (PT/OT intensity) were abstracted from the medical record. ED delirium duration was defined as the duration of delirium detected in the ED using the Brief Confusion Assessment Method. Data were analyzed using a proportional odds logistic regression adjusted for multiple variables. Adjusted odds ratios (ORs) were calculated with 95% confidence intervals (95%CI). Results The median log PT/OT intensity was 0.5% (interquartile range [IQR]: 0.3%, 0.9%) and was associated with shorter delirium duration (adjusted OR, 0.39; 95% CI, 0.21-0.73). The median time to the first PT/OT session was 2 days (IQR: 1, 3 days) and was not associated with delirium duration (adjusted OR, 1.02; 95% CI, 0.82-1.27). Conclusion In older hospitalized adults, higher PT/OT intensity may be a useful intervention to shorten delirium duration. Time to first PT/OT session was not associated with delirium duration but was initiated a full 2 days after the ED presentation.
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Affiliation(s)
| | - Eduard E. Vasilevskis
- Department of Medicine, Section of Hospital MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA,Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA
| | - Maria C. Duggan
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA,Department of Medicine, Division of Geriatric MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Sarah A. Welch
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA,Department of Physical Medicine and RehabilitationVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - John F. Schnelle
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA,Department of Medicine, Division of Geriatric MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Sandra F. Simmons
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA,Department of Medicine, Division of Geriatric MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - E. Wesley Ely
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) CenterDivision of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jin H. Han
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA,Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. How "age-friendly" are deprescribing interventions? A scoping review of deprescribing trials. Health Serv Res 2023; 58 Suppl 1:123-138. [PMID: 36221154 DOI: 10.1111/1475-6773.14083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To assess how age-friendly deprescribing trials are regarding intervention design and outcome assessment. Reduced use of potentially inappropriate medications (PIMs) can be addressed by deprescribing-a systematic process of discontinuing and/or reducing the use of PIMs. The 4Ms-"Medication", "Mentation", "Mobility", and "What Matters Most" to the person-can be used to guide assessment of age-friendliness of deprescribing trials. DATA SOURCE Published literature. STUDY DESIGN Scoping review. DATA EXTRACTION METHODS The literature was identified using keywords related to deprescribing and polypharmacy in PubMed, EMBASE, Web of Science, ProQuest, CINAHL, and Cochrane and snowballing. Study characteristics were extracted and evaluated for consideration of 4Ms. PRINCIPAL FINDINGS Thirty-seven of the 564 trials identified met the review eligibility criteria. Intervention design: "Medication" was considered in the intervention design of all trials; "Mentation" was considered in eight trials; "Mobility" (n = 2) and "What Matters Most" (n = 6) were less often considered in the design of intervention. Most trials targeted providers without specifying how matters important to older adults and their families were aligned with deprescribing decisions. OUTCOME ASSESSMENT "Medication" was the most commonly assessed outcome (n = 33), followed by "Mobility" (n = 13) and "Mentation" (n = 10) outcomes, with no study examining "What Matters Most" outcomes. CONCLUSIONS "Mentation" and "Mobility", and "What Matters Most" have been considered to varying degrees in deprescribing trials, limiting the potential of deprescribing evidence to contribute to improved clinical practice in building an age-friendly health care system.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Kobi Nathan
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Arizona State University, Edson College of Nursing and Health Innovation, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- University of Rochester Medical Center, Department of Medicine, Division of Hematology/Oncology, Rochester, New York, USA
| | - Donna M Fick
- Penn State University, Ross and Carol Nese College of Nursing, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Division of Geriatrics & Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Wang J, Shen JY, Yu F, Conwell Y, Nathan K, Shah AS, Simmons SF, Li Y, Ramsdale E, Caprio TV. Medications Associated With Geriatric Syndromes (MAGS) and Hospitalization Risk in Home Health Care Patients. J Am Med Dir Assoc 2022; 23:1627-1633.e3. [PMID: 35490716 PMCID: PMC9547843 DOI: 10.1016/j.jamda.2022.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/18/2022] [Accepted: 03/20/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Polypharmacy is common in home health care (HHC). This study examined the prevalence of medications associated with geriatric syndromes (MAGS), its predictors, and association with subsequent hospitalization in HHC. DESIGN Analysis of HHC electronic medical records, the Outcome and Assessment Information Set (OASIS), and Medicare HHC claims. SETTING AND PARTICIPANTS A total of 6882 adults ≥65 years old receiving HHC in 2019 from a large, not-for-profit home health agency serving multiple counties in New York State. MEASURES MAGS use was identified from active medications reconciled during HHC visits (HHC electronic medical records). MAGS use was operationalized as count and in quartiles. Hospitalization during the HHC episode was operationalized as a time-to-event variable (ie, number of days from HHC admission to hospitalization). We used regression analyses to identify predictors of MAGS use, and survival analyses to examine the association between MAGS and hospitalization. RESULTS Nearly all (98%) of the HHC patients used at least 1 MAGS and 41% of all active medications used by the sample were MAGS. More MAGS use was found in HHC patients who were community-referred, taking more medications, and having more diagnoses, depressive symptoms, and functional limitations. Adjusted for covariates, higher MAGS quartiles were not independently associated with the risk of hospitalization, but higher MAGS quartiles combined with multimorbidity (ie, having ≥10 diagnoses) were associated with a 2.3-fold increase in hospitalization risk (hazard ratio 2.24; 95% confidence interval: 1.61-3.13; P < .001), relative to the lowest quartile of MAGS use and having <10 diagnoses. CONCLUSIONS AND IMPLICATIONS More than 40% of medications taken by HHC patients are MAGS. Multimorbidity and MAGS use collectively increased the risk of hospitalization by up to 2.3 times. HHC clinicians should carefully review patients' medications and use information about MAGS to facilitate discussion about deprescribing with patients and their prescribers.
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Affiliation(s)
- Jinjiao Wang
- Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, NY, USA
| | - Jenny Y Shen
- University of Rochester Medical Center, Department of Medicine, Rochester, NY, USA
| | - Fang Yu
- Arizona State University, Edson College of Nursing and Health Innovation, Phoenix, AZ, USA
| | - Yeates Conwell
- University of Rochester Medical Center, Department of Psychiatry, Rochester, NY, USA
| | - Kobi Nathan
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; St. John Fisher College, Wegmans School of Pharmacy, Rochester, NY, USA
| | - Avantika S Shah
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Medicine, Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN, USA
| | - Sandra F Simmons
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Medicine, Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Yue Li
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Erika Ramsdale
- Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; University of Rochester Medical Home Care, University of Rochester Medical Center, Rochester, NY, USA; Finger Lakes Geriatric Education Center, University of Rochester Medical Center, Rochester, NY, USA
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11
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Hacker ML, Tomaras MC, Simmons SF, Schnelle JF, Charles D. Enhancing Performance of a Spasticity Screening Tool Using the Minimum Data Set. J Am Med Dir Assoc 2021; 23:178-179. [PMID: 34555341 DOI: 10.1016/j.jamda.2021.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Mallory L Hacker
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Miranda C Tomaras
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandra F Simmons
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research Education and Clinical Center, Tennessee Valley VA Healthcare System, Nashville, TN, USA
| | - John F Schnelle
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David Charles
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
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12
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Tomaras MC, Simmons SF, Schnelle JF, Charles D, Hacker ML. The Minimum Data Set: An Opportunity to Improve Spasticity Screening. J Am Med Dir Assoc 2020; 22:608-612. [PMID: 32893138 DOI: 10.1016/j.jamda.2020.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 10/23/2022]
Abstract
Spasticity is a common movement disorder that arises from trauma or disease affecting the central nervous system. Untreated spasticity can result in limitations in completing activities of daily living, painful limb contractures, and other conditions associated with loss of mobility. In the long-term care setting, this treatable condition is prevalent, yet often unrecognized likely because of a lack of spasticity-trained practitioners. A recently published spasticity referral tool holds promise for addressing the underdiagnosis of spasticity in the long-term care population. The Minimum Data Set (MDS) would be an ideal mechanism for increasing the diagnosis and treatment of spasticity because it is a government-directed comprehensive screening tool that informs care plans for all residents residing in federally funded long-term care facilities. The MDS could easily integrate the published referral assessment to record the presence of spastic postures and muscle rigidity. We propose expanding the MDS to include 3 questions related to spasticity to improve the recognition and treatment of this prevalent and treatable condition.
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Affiliation(s)
- Miranda C Tomaras
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN.
| | | | | | - David Charles
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN
| | - Mallory L Hacker
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN; Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
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Gill CE, Hacker ML, Meystedt J, Turchan M, Schnelle JF, Simmons SF, Habermann R, Phibbs FT, Charles D. Prevalence of Spasticity in Nursing Home Residents. J Am Med Dir Assoc 2020; 21:1157-1160. [PMID: 32085950 DOI: 10.1016/j.jamda.2020.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 01/03/2020] [Accepted: 01/05/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine the prevalence, rate of underdiagnosis and undertreatment, and association with activities of daily living dependency of spasticity in a nursing home setting. DESIGN Cross-sectional study. SETTING AND PARTICIPANTS This study is an analysis of a deidentified data set generated by a prior quality improvement project at a 240-bed nursing home for residents receiving long-term care or skilled nursing care services. METHODS Each resident was examined by a movement disorders specialist neurologist to determine whether spasticity was present and, if so, the total number of spastic postures present in upper and lower limbs was recorded. Medical records, including the Minimum Data Set, were reviewed for neurologic diagnoses associated with spasticity, activities of daily living (ADL) dependency, and prior documentation of diagnosis and past or current treatments. Ordinary least squares linear regression models were used to evaluate the association between spasticity and ADL dependency. RESULTS Two hundred nine residents (154 women, 81.9 ± 10.9 years) were included in this analysis. Spasticity was present in 22% (45/209) of residents examined by the neurologist. Only 11% of residents (5/45) had a prior diagnosis of spasticity and were receiving treatment. Presence of spasticity was associated with greater ADL dependency (χ2 = 51.72, P < .001), which was driven by lower limb spasticity (χ2 = 14.56, P = .006). CONCLUSIONS AND IMPLICATIONS These results suggest that spasticity (1) is common in nursing homes (1 of 5 residents), (2) is often not diagnosed or adequately treated, and (3) is associated with worse ADL dependency. Further research is needed to enhance the rates of diagnosis and treatment of spasticity in long-term care facilities.
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Affiliation(s)
- Chandler E Gill
- Department of Neurology, Rush University Medical Center, Chicago, IL
| | - Mallory L Hacker
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN; Department of Medicine, Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN
| | - Jacqueline Meystedt
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN
| | - Maxim Turchan
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN
| | - John F Schnelle
- Department of Medicine, Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN
| | - Sandra F Simmons
- Department of Medicine, Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN; Geriatric Research Education & Clinical Center, Tennessee Valley VA Healthcare System, Nashville, TN
| | - Ralf Habermann
- Geriatric Research Education & Clinical Center, Tennessee Valley VA Healthcare System, Nashville, TN
| | - Fenna T Phibbs
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN
| | - David Charles
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN.
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Ballesteros-Pomar MD, Cherubini A, Keller H, Lam P, Rolland Y, Simmons SF. Texture-Modified Diet for Improving the Management of Oropharyngeal Dysphagia in Nursing Home Residents: An Expert Review. J Nutr Health Aging 2020; 24:576-581. [PMID: 32510109 DOI: 10.1007/s12603-020-1377-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES This paper provides evidence-based and, when appropriate, expert reviewed recommendations for long-stay residents who are prescribed texture-modified diets (TMDs), with the consideration that these residents are at high risk of worsening oropharyngeal dysphagia (OD), malnutrition, dehydration, aspiration pneumonia, and OD-associated mortality, poorer quality of life and high costs. DESIGN Nestlé Health Science funded an initial virtual meeting attended by all authors, in which the unmet needs and subsequent recommendations for OD management were discussed. The opinions, results, and recommendations detailed in this paper are those of the authors, and are independent of funding sources. SETTING OD is common in nursing home (NH) residents, and is defined as the inability to initiate and perform safe swallowing. The long-stay NH resident population has specific characteristics marked by a shorter life expectancy relative to community-dwelling older adults, high prevalence of multimorbidity with a high rate of complications, dementia, frailty, disability, and often polypharmacy. As a result, OD is associated with malnutrition, dehydration, aspiration pneumonia, functional decline, and death. Complications of OD can potentially be prevented with the use of TMDs. RESULTS This report presents expert opinion and evidence-informed recommendations for best practice on the nutritional management of OD. It aims to highlight the practice gaps between the evidence-based management of OD and real-world patterns, including inadequate dietary provision and insufficient staff training. In addition, the unmet need for OD screening and improvements in therapeutic diets are explored and discussed. CONCLUSION There is currently limited empirical evidence to guide practice in OD management. Given the complex and heterogeneous population of long-stay NH residents, some 'best practice' approaches and interventions require extensive efficacy testing before further changes in policy can be implemented.
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Affiliation(s)
- M D Ballesteros-Pomar
- María Ballesteros-Pomar, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, León, Spain,
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15
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Han JH, Chen A, Vasilevskis EE, Schnelle JF, Ely EW, Chandrasekhar R, Morrison RD, Ryan TP, Daniels JS, Sutherland JJ, Simmons SF. Supratherapeutic Psychotropic Drug Levels in the Emergency Department and Their Association with Delirium Duration: A Preliminary Study. J Am Geriatr Soc 2019; 67:2387-2392. [PMID: 31503339 DOI: 10.1111/jgs.16156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/03/2019] [Accepted: 07/05/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Polypharmacy is associated with delirium, but the mechanisms for this connection are unclear. Our goal was to determine the frequency of supratherapeutic psychotropic drug levels (SPDLs) in older hospitalized patients and if it is associated with the duration of emergency department (ED) delirium. DESIGN Secondary analysis of a prospective cohort study. SETTING Tertiary care academic medical center. PARTICIPANTS ED patients 65 years or older who were admitted to the hospital. MEASUREMENTS Delirium was assessed in the ED and during the first 7 days of hospitalization using the modified Brief Confusion Assessment Method. Drug concentrations were determined in serum samples collected at enrollment via a novel platform based on liquid chromatography-tandem mass spectrometry capable of identifying and quantitating 78 clinically approved medications including opioids, benzodiazepines, antidepressants, antipsychotics, and amphetamines. Patients with serum psychotropic drug concentrations above established reference ranges were considered supratherapeutic and have a SPDL. We performed proportional odds logistic regression to determine if SPDLs were associated with ED delirium duration adjusted for confounders. Medical record review was performed to determine if the doses of medications associated with SPDLs were adjusted at hospital discharge. RESULTS A total of 158 patients were enrolled; of these, 66 were delirious in the ED. SPDLs were present in 11 (17%) of the delirious and 4 (4%) of the non-delirious ED patients. SPDLs were significantly associated with longer ED delirium duration (adjusted proportional odds ratio = 6.0; 95% confidence interval = 2.1-17.3) after adjusting for confounders. Of the 15 medications associated with SPDLs, 9 (60%) were prescribed at the same or higher doses at the time of hospital discharge. CONCLUSION SPDLs significantly increased the odds of prolonged ED delirium episodes. Approximately half of the medications associated with SPDLs were continued after hospital discharge at the same or higher doses. J Am Geriatr Soc 67:2387-2392, 2019.
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Affiliation(s)
- Jin H Han
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee.,Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alex Chen
- Department of Emergency Medicine, Division of Medical Toxicology and Precision Medicine, University of Arizona College of Medicine, Phoenix, Arizona
| | - Eduard E Vasilevskis
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee.,Department of Medicine, Division of General Internal Medicine and Public Health, Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John F Schnelle
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee.,Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E Wesley Ely
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee.,Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rameela Chandrasekhar
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | | | | | - Sandra F Simmons
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee.,Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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16
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Vasilevskis EE, Shah AS, Hollingsworth EK, Shotwell MS, Mixon AS, Bell SP, Kripalani S, Schnelle JF, Simmons SF. A patient-centered deprescribing intervention for hospitalized older patients with polypharmacy: rationale and design of the Shed-MEDS randomized controlled trial. BMC Health Serv Res 2019; 19:165. [PMID: 30871561 PMCID: PMC6416929 DOI: 10.1186/s12913-019-3995-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 03/06/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Polypharmacy is prevalent among hospitalized older adults, particularly those being discharged to a post-care care facility (PAC). The aim of this randomized controlled trial is to determine if a patient-centered deprescribing intervention initiated in the hospital and continued in the PAC setting reduces the total number of medications among older patients. METHODS The Shed-MEDS study is a 5-year, randomized controlled clinical intervention trial comparing a patient-centered describing intervention with usual care among older (≥50 years) hospitalized patients discharged to PAC, either a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IPR). Patient measurements occur at hospital enrollment, hospital discharge, within 7 days of PAC discharge, and at 60 and 90 days following PAC discharge. Patients are randomized in a permuted block fashion, with block sizes of two to four. The overall effectiveness of the intervention will be evaluated using total medication count as the primary outcome measure. We estimate that 576 patients will enroll in the study. Following attrition due to death or loss to follow-up, 420 patients will contribute measurements at 90 days, which provides 90% power to detect a 30% versus 25% reduction in total medications with an alpha error of 0.05. Secondary outcomes include the number of medications associated with geriatric syndromes, drug burden index, medication adherence, the prevalence and severity of geriatric syndromes and functional health status. DISCUSSION The Shed-MEDS trial aims to test the hypothesis that a patient-centered deprescribing intervention initiated in the hospital and continuing through the PAC stay will reduce the total number of medications 90 days following PAC discharge and result in improvements in geriatric syndromes and functional health status. The results of this trial will quantify the health outcomes associated with reducing medications for hospitalized older adults with polypharmacy who are discharged to post-acute care facilities. TRIAL REGISTRATION This trial was prospectively registered at clinicaltrials.gov ( NCT02979353 ). The trial was first registered on 12/1/2016, with an update on 09/28/17 and 10/12/2018.
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Affiliation(s)
- Eduard E. Vasilevskis
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Section of Hospital Medicine, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - Avantika S. Shah
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
| | | | | | - Amanda S. Mixon
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Section of Hospital Medicine, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - Susan P. Bell
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN USA
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN USA
| | - Sunil Kripalani
- Vanderbilt University Medical Center, Section of Hospital Medicine, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - John F. Schnelle
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - Sandra F. Simmons
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
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Wang J, Dietrich MS, Bell SP, Maxwell CA, Simmons SF, Kripalani S. Changes in vulnerability among older patients with cardiovascular disease in the first 90 days after hospital discharge: A secondary analysis of a cohort study. BMJ Open 2019; 9:e024766. [PMID: 30700484 PMCID: PMC6352778 DOI: 10.1136/bmjopen-2018-024766] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES (1) To compare changes in vulnerability after hospital discharge among older patients with cardiovascular disease who were discharged home with self-care versus a home healthcare (HHC) referral and (2) to examine factors associated with changes in vulnerability in this period. DESIGN Secondary analysis of longitudinal data from a cohort study. PARTICIPANTS AND SETTING 834 older (≥65 years) patients hospitalised for acute coronary syndromes and/or acute decompensated heart failure who were discharged home with self-care (n=713) or an HHC referral (n=121). OUTCOME Vulnerability was measured using Vulnerable Elders Survey 13 (VES-13) at baseline (prior to hospital admission) and 30 days and/or 90 days after hospital discharge. Effects of HHC referral on postdischarge change in vulnerability were examined using three linear regression approaches, with potential confounding on HHC referral adjusted by propensity score matching. RESULTS Overall, 44.4% of the participants were vulnerable at prehospitalisation baseline and 34.4% were vulnerable at 90 days after hospital discharge. Compared with self-care patients, HHC-referred patients were more vulnerable at baseline (66.9% vs 40.3%), had more increase (worsening) in VES-13 score change (B=-1.34(-2.07, -0.61), p<0.001) in the initial 30 days and more decrease (improvement) in VES-13 score change (B=0.83(0.20, 1.45), p=0.01) from 30 to 90 days after hospital discharge. Baseline vulnerability and the HHC referral attributed to 14%-16% of the variance in vulnerability change during the 90 postdischarge days, and 6% was attributed by patient age, race (African-American), depressive symptoms, and outpatient visits and hospitalisations in the past year. CONCLUSION After adjusting for preceding vulnerability and covariates, older hospitalised patients with cardiovascular disease referred to HHC had delayed recovery in vulnerability in first initial 30 days after hospital discharge and greater improvement in vulnerability from 30 to 90 days after hospital discharge. HHC seemed to facilitate improvement in vulnerability among older patients with cardiovascular disease from 30 to 90 days after hospital discharge.
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Affiliation(s)
- Jinjiao Wang
- University of Rochester Medical Center, School of Nursing, Rochester, New York, USA
| | - Mary S Dietrich
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Susan P Bell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cathy A Maxwell
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sunil Kripalani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Simmons SF, Coelho CS, Sandler A, Shah AS, Schnelle JF. Managing Person-Centered Dementia Care in an Assisted Living Facility: Staffing and Time Considerations. Gerontologist 2018; 58:e251-e259. [PMID: 28575376 DOI: 10.1093/geront/gnx089] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Indexed: 11/14/2022] Open
Abstract
Background and Objectives To describe (a) the unlicensed staff time necessary to provide quality activities of daily living (ADL) care to residents receiving dementia care within an assisted living facility and (b) a staff management approach to maintain quality ADL care. Research Design and Methods Supervisory staff used a standardized observational method to measure ADL care quality and the staff time to provide care during the morning and evening across 12 consecutive months. Staff were given individual feedback about the quality of their care provision following each observation. Results The average staff time to provide ADL care averaged 35 (± 11) minutes per resident per care episode with bathing and 18 (± 6) minutes/resident/care episode without bathing. Morning ADL care required significantly more staff time than evening care. There was not a significant relationship between residents' levels of cognitive impairment or ADL dependency and the staff time to provide ADL care. Quality ADL care was maintained for 12 months. Discussion and Implications This study provides novel data related to the amount of staff time necessary to provide quality ADL care for persons with dementia in an assisted living care setting. This study also describes a standardized approach to staff management that was effective in maintaining quality ADL care provision. Assisted living facilities should consider these data when determining the necessary unlicensed staffing level to provide person-centered ADL care and how to effectively manage direct care providers.
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Affiliation(s)
- Sandra F Simmons
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville
| | - Chris S Coelho
- Abe's Garden®, Alzheimer's and Memory Care Center of Excellence, Nashville, Tennessee
| | - Andrew Sandler
- Abe's Garden®, Alzheimer's and Memory Care Center of Excellence, Nashville, Tennessee
| | - Avantika S Shah
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John F Schnelle
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville
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Simmons SF, Bonnett KR, Hollingsworth E, Kim J, Powers J, Habermann R, Newhouse P, Schlundt DG. Reducing Antipsychotic Medication Use in Nursing Homes: A Qualitative Study of Nursing Staff Perceptions. Gerontologist 2018; 58:e239-e250. [PMID: 28575301 DOI: 10.1093/geront/gnx083] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Indexed: 11/12/2022] Open
Abstract
Background and Objectives The purpose of this study was to use qualitative methods to explore nursing home staff perceptions of antipsychotic medication use and identify both benefits and barriers to reducing inappropriate use from their perspective. Research Design and Methods Focus groups were conducted with a total of 29 staff in three community nursing homes that served both short and long-stay resident populations. Results The majority (69%) of the staff participants were licensed nurses. Participants expressed many potential benefits of antipsychotic medication reduction with four primary themes: (a) Improvement in quality of life, (b) Improvement in family satisfaction, (c) Reduction in falls, and (d) Improvement in the facility Quality Indicator score (regulatory compliance). Participants also highlighted important barriers they face when attempting to reduce or withdraw antipsychotic medications including: (a) Family resistance, (b) Potential for worsening or return of symptoms or behaviors, (c) Lack of effectiveness and/or lack of staff resources to consistently implement nonpharmacological management strategies, and (d) Risk aversion of staff and environmental safety concerns. Discussion and Implications Nursing home staff recognize the value of reducing antipsychotic medications; however, they also experience multiple barriers to reduction in routine clinical practice. Achievement of further reductions in antipsychotic medication use will require significant additional efforts and adequate clinical personnel to address these barriers.
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Affiliation(s)
- Sandra F Simmons
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.,Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.,Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville
| | | | - Emily Hollingsworth
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.,Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jennifer Kim
- School of Nursing, Vanderbilt University, Nashville, Tennessee
| | - James Powers
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.,Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville
| | - Ralf Habermann
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Paul Newhouse
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville.,Center for Cognitive Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David G Schlundt
- Department of Psychology, Vanderbilt University, Nashville, Tennessee
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Wang J, Simmons SF, Maxwell CA, Schlundt DG, Mion LC. Home Health Nurses' Perspectives and Care Processes Related to Older Persons with Frailty and Depression: A Mixed Method Pilot Study. J Community Health Nurs 2018; 35:118-136. [PMID: 30024285 DOI: 10.1080/07370016.2018.1475799] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The objectives of this study were (1) to describe home health care (HHC) nurses' perception of and care processes related to geriatric depression and frailty, and (2) to identify barriers to care delivery for older persons with these two conditions. Ten semi-structured interviews were conducted with HHC nurses, and 16 HHC nursing visits to 16 older patients (≥65 years) were observed. Mixed method analysis showed that HHC nurses did not routinely assess for frailty and depression. Major barriers to care delivery included insufficient training, documentation burden, limited reimbursement, and high caseload. Addressing these barriers would facilitate HHC nursing care for frail, depressed elders.
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Affiliation(s)
- Jinjiao Wang
- a School of Nursing , University of Rochester Medical Center , Rochester , New York
| | - Sandra F Simmons
- b Center for Quality Aging, Division of Geriatrics, Department of Medicine , Vanderbilt University Medical Center , Nashville , Tennessee.,c Geriatric Research, Education and Clinical Center (GRECC) , VA Tennessee Valley Healthcare System , Nashville , Tennessee
| | - Cathy A Maxwell
- d School of Nursing , Vanderbilt University , Nashville , Tennessee
| | - David G Schlundt
- e Department of Psychology , Vanderbilt University , Nashville , Tennessee
| | - Lorraine C Mion
- f College of Nursing , The Ohio State University , Columbus , Ohio
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21
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Petersen AW, Shah AS, Simmons SF, Shotwell MS, Jacobsen JML, Myers AP, Mixon AS, Bell SP, Kripalani S, Schnelle JF, Vasilevskis EE. Shed-MEDS: pilot of a patient-centered deprescribing framework reduces medications in hospitalized older adults being transferred to inpatient postacute care. Ther Adv Drug Saf 2018; 9:523-533. [PMID: 30181860 PMCID: PMC6116773 DOI: 10.1177/2042098618781524] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/07/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Polypharmacy is common in hospitalized older adults. Deprescribing interventions are not well described in the acute-care setting. The objective of this study was to describe a hospital-based, patient-centered deprescribing protocol (Shed-MEDS) and report pilot results. METHODS This was a pilot study set in one academic medical center in the United States. Participants consisted of a convenience sample of 40 Medicare-eligible, hospitalized patients with at least five prescribed medications. A deprescribing protocol (Shed-MEDS) was implemented among 20 intervention and 20 usual care control patients during their hospital stay. The primary outcome was the total number of medications deprescribed from hospital enrollment. Deprescribed was defined as medication termination or dose reduction. Enrollment medications reflected all prehospital medications and active in-hospital medications. Baseline characteristics and outcomes were compared between the intervention and usual care groups using simple logistic or linear regression for categorical and continuous measures, respectively. RESULTS There was no significant difference between groups in mean age, sex or Charlson comorbidity index. The intervention and control groups had a comparable number of medications at enrollment, 25.2 (±6.3) and 23.4 (±3.8), respectively. The number of prehospital medications in each group was 13.3 (±4.6) and 15.3 (±4.6), respectively. The Shed-MEDS protocol compared with usual care significantly increased the mean number of deprescribed medications at hospital discharge and reduced the total medication burden by 11.6 versus 9.1 (p = 0.032) medications. The deprescribing intervention was associated with a difference of 4.6 [95% confidence interval (CI) 2.5-6.7, p < 0.001] in deprescribed medications and a 0.5 point reduction (95% CI -0.01 to 1.1) in the drug burden index. CONCLUSIONS A hospital-based, patient-centered deprescribing intervention is feasible and may reduce the medication burden in older adults.
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Affiliation(s)
- Alec W. Petersen
- Center for Quality Aging, Vanderbilt University
Medical Center, Nashville, TN, USA
| | - Avantika S. Shah
- Center for Quality Aging, Vanderbilt University
Medical Center, Nashville, TN, USA
| | - Sandra F. Simmons
- Center for Quality Aging, Vanderbilt University
Medical Center, Nashville, TN, USA
- Division of Geriatrics, Vanderbilt University
Medical Center, Nashville, TN, USA
- Geriatric Research Education and Clinical
Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | | | | | - Amy P. Myers
- Pharmaceutical Services, Vanderbilt University
Medical Center, Nashville, TN, USA
| | - Amanda S. Mixon
- Geriatric Research Education and Clinical
Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
- Section of Hospital Medicine, Vanderbilt
University Medical Center, Nashville, TN, USA
- Center for Clinical Quality and Implementation
Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan P. Bell
- Center for Quality Aging, Vanderbilt University
Medical Center, Nashville, TN, USA
- Division of Geriatrics, Vanderbilt University
Medical Center, Nashville, TN, USA
- Division of Cardiovascular Medicine, Vanderbilt
University Medical Center, Nashville, TN, USA
| | - Sunil Kripalani
- Section of Hospital Medicine, Vanderbilt
University Medical Center, Nashville, TN, USA
- Center for Clinical Quality and Implementation
Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John F. Schnelle
- Center for Quality Aging, Vanderbilt University
Medical Center, Nashville, TN, USA
- Division of Geriatrics, Vanderbilt University
Medical Center, Nashville, TN, USA
- Geriatric Research Education and Clinical
Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Eduard E. Vasilevskis
- Vanderbilt Center for Health Services Research,
Center for Quality Aging, Division of General Internal Medicine and Public
Health, Geriatric Research Education and Clinical Center, VA Tennessee
Valley, 2525 West End Ave, Suite 450, Nashville, TN 37203, USA
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Simmons SF, Coelho CS, Sandler A, Schnelle JF. A System for Managing Staff and Quality of Dementia Care in Assisted Living Facilities. J Am Geriatr Soc 2018; 66:1632-1637. [DOI: 10.1111/jgs.15463] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/03/2018] [Accepted: 05/04/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Sandra F. Simmons
- Center for Quality Aging; Vanderbilt University Medical Center; Nashville Tennessee
- Division of Geriatrics, Department of Medicine; Vanderbilt University Medical Center; Nashville Tennessee
- Geriatric Research, Education and Clinical Center; Veterans Affairs Tennessee Valley Healthcare System; Nashville Tennessee
| | - Chris S. Coelho
- Abe's Garden; Alzheimer's and Memory Care Center of Excellence; Nashville Tennessee
| | - Andrew Sandler
- Abe's Garden; Alzheimer's and Memory Care Center of Excellence; Nashville Tennessee
| | - John F. Schnelle
- Center for Quality Aging; Vanderbilt University Medical Center; Nashville Tennessee
- Division of Geriatrics, Department of Medicine; Vanderbilt University Medical Center; Nashville Tennessee
- Geriatric Research, Education and Clinical Center; Veterans Affairs Tennessee Valley Healthcare System; Nashville Tennessee
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Jacobsen JML, Schnelle JF, Saraf AA, Long EA, Vasilevskis EE, Kripalani S, Simmons SF. Preventability of Hospital Readmissions From Skilled Nursing Facilities: A Consumer Perspective. Gerontologist 2018; 57:1123-1132. [PMID: 27927728 DOI: 10.1093/geront/gnw132] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 07/21/2016] [Indexed: 11/13/2022] Open
Abstract
Purpose of the Study A structured interview was conducted with Medicare patients readmitted to a private, tertiary teaching hospital from skilled nursing facilities (SNFs) to assess their perspectives of readmission preventability and their role in the readmission. Design and Methods Data were collected at Vanderbilt University Medical Center using a 6-item interview administered at the bedside to Medicare beneficiaries with unplanned hospital readmissions from 23 SNFs within 60 days of a previous hospital discharge. Mixed analytical methods were applied, including a content analysis that evaluated factors contributing to hospital readmission as perceived by consumers. Results Among 208 attempted interviews, 156 were completed, of which 53 (34%) respondents rated their readmission as preventable. 28.3% of the 53 consumers attributed the readmission to hospital factors, 52.8% attributed it to the SNF, and 18.9% believed both sites could have prevented the readmission. The primary driver of the readmission was a family member/caregiver in 31 cases and the patient in 24 of the 156 cases, amounting to 55 (35.3%) consumer-driven readmissions. Contributing factors included: premature hospital discharge (16.3%); poor discharge planning (16.3%); a clinical issue not resolved in the hospital (14.3%); inadequate treatment at the SNF (69.4%); improper medication management at the SNF (20.4%); and poor decision-making regarding the transfer (14.3%). Conclusions and Implications Interviewing readmitted patients provides information relevant to reducing readmissions that may otherwise be omitted from hospital and SNF records. Consumers identified quality issues at both the hospital and SNF and perceived themselves as initiating a significant number of readmissions.
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Affiliation(s)
- J Mary Lou Jacobsen
- Center for Quality Aging, Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville
| | - John F Schnelle
- Center for Quality Aging, Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville
| | - Avantika A Saraf
- Center for Quality Aging, Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emily A Long
- Center for Quality Aging, Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eduard E Vasilevskis
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville.,Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandra F Simmons
- Center for Quality Aging, Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville
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24
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Wang J, Dietrich MS, Simmons SF, Cowan RL, Monroe TB. Pain interference and depressive symptoms in communicative people with Alzheimer's disease: a pilot study. Aging Ment Health 2018; 22:808-812. [PMID: 28466655 PMCID: PMC6370478 DOI: 10.1080/13607863.2017.1318258] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To examine pain interference in verbally communicative older adults with mild to moderate Alzheimer's disease (AD) and to examine the association of pain interference with cognitive function and depressive symptoms. METHOD For this pilot study, we used a cross-sectional design to examine pain interference (Brief Pain Inventory-Short Form), cognitive function (Mini-Mental State Exam), and depressive symptoms (15-item Geriatric Depression Scale) in 52 older (≥65) communicative adults with AD who reported being free from chronic pain requiring daily analgesics. RESULTS Pain was reported to interfere with general activity (13.5%), mood (13.5%), walking ability (13.5%), normal work (11.5%), enjoyment of life (11.5%), relationships with other people (9.6%), and sleep (9.6%). Pain interference was significantly positively correlated with both cognitive function (rs = 0.46, p = 0.001) and depressive symptomology (rs = 0.45, p = 0.001), indicating that greater reported pain interference was associated with better cognitive function and more depressive symptoms. CONCLUSION Among older people with AD who report being free from chronic pain requiring daily analgesics, 2 in 10 are at risk of pain interference and depressive symptoms. Those with better cognitive function reported more pain interference and depressive symptoms, meaning pain is likely to be under-reported as AD progresses. Clinicians should regularly assess pain interference and depressive symptoms in older persons with AD to identify pain that might be otherwise overlooked..
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Affiliation(s)
- Jinjiao Wang
- Vanderbilt University School of Nursing, Nashville, TN, USA
| | - Mary S. Dietrich
- Vanderbilt University School of Nursing, Nashville, TN, USA,Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sandra F. Simmons
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ronald L. Cowan
- Vanderbilt University School of Medicine, Nashville, TN, USA,Department of Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Todd B. Monroe
- Vanderbilt University School of Nursing, Nashville, TN, USA,Vanderbilt University School of Medicine, Nashville, TN, USA,Department of Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, TN, USA
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Simmons SF, Coelho CS, Sandler A, Schnelle JF. A Quality Improvement System to Manage Feeding Assistance Care in Assisted-Living. J Am Med Dir Assoc 2018; 19:262-269. [DOI: 10.1016/j.jamda.2017.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 10/18/2022]
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Cohn JA, Shah AS, Goggins KM, Simmons SF, Kripalani S, Dmochowski RR, Schnelle JF, Reynolds WS. Health literacy, cognition, and urinary incontinence among geriatric inpatients discharged to skilled nursing facilities. Neurourol Urodyn 2018; 37:854-860. [PMID: 28762548 PMCID: PMC5794668 DOI: 10.1002/nau.23368] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 06/26/2017] [Indexed: 11/10/2022]
Abstract
AIMS To investigate the association between health literacy and cognition and nursing and patient-reported incontinence in a geriatric inpatient population transitioning to skilled nursing facilities (SNF). METHODS Health literacy, depression, and cognition were assessed via the Brief Health Literacy Screen (BHLS), Geriatric Depression Scale 5-item (GDS) and Brief Interview for Mental Status (BIMS), respectively. Multivariable logistic regression assessed the association between BHLS score and incontinence by: (1) nursing-reported urinary incontinence during hospitalization; and (2) patient self-reported "bladder accidents" in the post-enrollment study interview. RESULTS A total of 1556 hospitalized patients aged 65 and older met inclusion criteria, of whom 922 (59.3%) were women and 1480 had available BHLS scores. A total of 464 (29.8%) and 515 (33.1%) patients had nursing-reported and self-reported urinary incontinence, respectively. Nursing-reported incontinence was significantly associated with lower BHLS (ie, poorer health literacy) (aOR 0.93, 95%CI 0.89-0.99) and BIMS (ie, poorer cognition) (aOR 0.90, 95%CI 0.83-0.97) scores and need for assistance with toileting (aOR 7.08, 95%CI 2.16-23.21). Patient-reported incontinence was significantly associated with female sex (aOR 1.62, 95%CI 1.19-2.21), increased GDS score (ie, greater likelihood of depression) (aOR 1.22, 95%CI 1.10-1.36) and need for assistance with toileting (aOR 2.46, 95%CI 1.26-4.79). CONCLUSIONS Poorer health literacy and cognition are independently associated with an increased likelihood of nursing-reported urinary incontinence among geriatric inpatients transitioning to SNF. Practitioners should consider assessment of health literacy and cognition in frail patients at risk for urinary incontinence and that patient and nursing assessment may be required to capture the diagnosis.
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Affiliation(s)
- Joshua A Cohn
- Department of Urologic Surgery, Medical Center, North Nashville, Tennessee
| | - Avantika S Shah
- Department of Urologic Surgery, Medical Center, North Nashville, Tennessee
| | - Kathryn M Goggins
- Department of Urologic Surgery, Medical Center, North Nashville, Tennessee
| | - Sandra F Simmons
- Department of Urologic Surgery, Medical Center, North Nashville, Tennessee
| | - Sunil Kripalani
- Department of Urologic Surgery, Medical Center, North Nashville, Tennessee
| | - Roger R Dmochowski
- Department of Urologic Surgery, Medical Center, North Nashville, Tennessee
| | - John F Schnelle
- Department of Urologic Surgery, Medical Center, North Nashville, Tennessee
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Vasilevskis EE, Ouslander JG, Mixon AS, Bell SP, Jacobsen JML, Saraf AA, Markley D, Sponsler KC, Shutes J, Long EA, Kripalani S, Simmons SF, Schnelle JF. Potentially Avoidable Readmissions of Patients Discharged to Post-Acute Care: Perspectives of Hospital and Skilled Nursing Facility Staff. J Am Geriatr Soc 2016; 65:269-276. [PMID: 27981557 DOI: 10.1111/jgs.14557] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hospital readmissions from skilled nursing facilities (SNFs) are common. Previous research has not examined how assessments of avoidable readmissions differ between hospital and SNF perspectives. OBJECTIVES To determine the percentage of readmissions from post-acute care that are considered potentially avoidable from hospital and SNF perspectives. DESIGN Prospective cohort study. SETTING One academic medical center and 23 SNFs. PARTICIPANTS We included patients from a quality improvement trial aimed at reducing hospital readmissions among patients discharged to SNFs. We included Medicare patients who were discharged to one of 23 regional SNFs between January 2013 and January 2015, and readmitted to the hospital within 30 days. MEASUREMENTS Hospital-based physicians and SNF-based staff performed structured root-cause analyses (RCA) on a sample of readmissions from a participating SNF to the index hospital. RCAs reported avoidability and factors contributing to readmissions. RESULTS The 30-day unplanned readmission rate to the index hospital from SNFs was 14.5% (262 hospital readmissions of 1,808 discharges). Of the readmissions, 120 had RCA from both the hospital and SNF. The percentage of readmissions rated as potentially avoidable was 30.0% and 13.3% according to hospital and SNF staff, respectively. Hospital and SNF ratings of potential avoidability agreed for 73.3% (88 of the 120 readmissions), but readmission factors varied between settings. Diagnostic problems and improved management of changes in conditions were the most common avoidable readmission factors by hospitals and SNFs, respectively. CONCLUSION A substantial percentage of hospital readmissions from SNFs are rated as potentially avoidable. The ratings and factors underlying avoidability differ between hospital and SNF staff. These data support the need for joint accountability and collaboration for future readmission reduction efforts between hospitals and their SNF partners.
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Affiliation(s)
- Eduard E Vasilevskis
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Joseph G Ouslander
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida
| | - Amanda S Mixon
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee.,Center for Clinical Quality and Implementation Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Susan P Bell
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - J Mary Lou Jacobsen
- Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee.,Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Avantika A Saraf
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel Markley
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly C Sponsler
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jill Shutes
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida
| | - Emily A Long
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Center for Clinical Quality and Implementation Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandra F Simmons
- Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee.,Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John F Schnelle
- Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee.,Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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28
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Simmons SF, Hollingsworth EK, Long EA, Liu X, Shotwell MS, Keeler E, An R, Silver HJ. Training Nonnursing Staff to Assist with Nutritional Care Delivery in Nursing Homes: A Cost-Effectiveness Analysis. J Am Geriatr Soc 2016; 65:313-322. [PMID: 28198565 DOI: 10.1111/jgs.14488] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To determine the effect and cost-effectiveness of training nonnursing staff to provide feeding assistance for nutritionally at-risk nursing home (NH) residents. DESIGN Randomized, controlled trial. SETTING Five community NHs. PARTICIPANTS Long-stay NH residents with an order for caloric supplementation (N = 122). INTERVENTION Research staff provided an 8-hour training curriculum to nonnursing staff. Trained staff were assigned to between-meal supplement or snack delivery for the intervention group; the control group received usual care. MEASUREMENTS Research staff used standardized observations and weighed-intake methods to measure frequency of between-meal delivery, staff assistance time, and resident caloric intake. RESULTS Fifty staff (mean 10 per site) completed training. The intervention had a significant effect on between-meal caloric intake (F = 56.29, P < .001), with the intervention group consuming, on average, 163.33 (95% CI = 120.19-206.47) calories per person per day more than the usual care control group. The intervention costs were $1.27 per person per day higher than usual care (P < .001). The incremental cost-effectiveness ratio for the intervention was 134 kcal per dollar. The increase in cost was due to the higher frequency and number of snack items given per person per day and the associated staff time to provide assistance. CONCLUSION It is cost effective to train nonnursing staff to provide caloric supplementation, and this practice has a positive effect on residents' between-meal intake.
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Affiliation(s)
- Sandra F Simmons
- Division of Geriatrics, Department of Medicine, Vanderbilt University, Nashville, Tennessee.,Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Center for Quality Aging, Nashville, Tennessee.,Geriatric Research, Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Emily K Hollingsworth
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Center for Quality Aging, Nashville, Tennessee
| | - Emily A Long
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Center for Quality Aging, Nashville, Tennessee
| | - Xulei Liu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | | | - Ruopeng An
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, Illinois
| | - Heidi J Silver
- Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, Vanderbilt University, Nashville, Tennessee
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Schnelle JF, Schroyer LD, Saraf AA, Simmons SF. Determining Nurse Aide Staffing Requirements to Provide Care Based on Resident Workload: A Discrete Event Simulation Model. J Am Med Dir Assoc 2016; 17:970-977. [DOI: 10.1016/j.jamda.2016.08.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 08/19/2016] [Indexed: 11/17/2022]
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Saraf AA, Petersen AW, Simmons SF, Schnelle JF, Bell SP, Kripalani S, Myers AP, Mixon AS, Long EA, Jacobsen JML, Vasilevskis EE. Medications associated with geriatric syndromes and their prevalence in older hospitalized adults discharged to skilled nursing facilities. J Hosp Med 2016; 11:694-700. [PMID: 27255830 PMCID: PMC5048583 DOI: 10.1002/jhm.2614] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 04/25/2016] [Accepted: 04/28/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND More than half of the hospitalized older adults discharged to skilled nursing facilities (SNFs) have more than 3 geriatric syndromes. Pharmacotherapy may be contributing to geriatric syndromes in this population. OBJECTIVES Develop a list of medications associated with geriatric syndromes and describe their prevalence in patients discharged from acute care to SNFs. DESIGN Literature review and multidisciplinary expert panel discussion, followed by cross-sectional analysis. SETTING Academic medical center in the United States PARTICIPANTS: One hundred fifty-four hospitalized Medicare beneficiaries discharged to SNFs. MEASUREMENTS Development of a list of medications that are associated with 6 geriatric syndromes. Prevalence of the medications associated with geriatric syndromes was examined in the hospital discharge sample. RESULTS A list of 513 medications was developed as potentially contributing to 6 geriatric syndromes: cognitive impairment, delirium, falls, reduced appetite or weight loss, urinary incontinence, and depression. Medications included 18 categories. Antiepileptics were associated with all syndromes, whereas antipsychotics, antidepressants, antiparkinsonism, and opioid agonists were associated with 5 geriatric syndromes. In the prevalence sample, patients were discharged to SNFs with an overall average of 14.0 (±4.7) medications, including an average of 5.9 (±2.2) medications that could contribute to geriatric syndromes, with falls having the most associated medications at discharge at 5.5 (±2.2). CONCLUSIONS Many commonly prescribed medications are associated with geriatric syndromes. Over 40% of all medications ordered upon discharge to SNFs were associated with geriatric syndromes and could be contributing to the high prevalence of geriatric syndromes experienced by this population. Journal of Hospital Medicine 2016;11:694-700. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Avantika A Saraf
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alec W Petersen
- School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Sandra F Simmons
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - John F Schnelle
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Susan P Bell
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amy P Myers
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amanda S Mixon
- Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emily A Long
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - J Mary Lou Jacobsen
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Eduard E Vasilevskis
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
- Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee.
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
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Hollingsworth EK, Long EA, Simmons SF. Comparison Between Quality of Care Provided by Trained Feeding Assistants and Certified Nursing Assistants During Between-Meal Supplementation in Long-Term Care Settings. J Appl Gerontol 2016; 37:1391-1410. [DOI: 10.1177/0733464816669806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The purpose of this study was to compare the quality of feeding assistance provided by trained non-nursing staff with care provided by certified nursing assistants (CNAs). Research staff provided an 8-hr training course that met federal and state requirements to non-nursing staff in five community long-term care facilities. Trained staff were assigned to between-meal supplement and/or snack delivery for 24 weeks. Using standardized observations, research staff measured feeding assistance care processes between meals across all study weeks. Trained staff, nurse aides, and upper level staff were interviewed at 24 weeks to assess staff perceptions of program impact. Trained staff performed significantly better than CNAs for 12 of 13 care process measures. Residents also consumed significantly more calories per snack offer from trained staff ( M = 130 ± 126 [ SD] kcal) compared with CNAs ( M = 77 ± 94 [ SD] kcal). The majority of staff reported a positive impact of the training program.
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Affiliation(s)
| | - Emily A. Long
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandra F. Simmons
- Vanderbilt University Medical Center, Nashville, TN, USA
- Tennessee Valley Healthcare System, Nashville, TN, USA
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Simmons SF, Bell S, Saraf AA, Coelho CS, Long EA, Jacobsen JML, Schnelle JF, Vasilevskis EE. Stability of Geriatric Syndromes in Hospitalized Medicare Beneficiaries Discharged to Skilled Nursing Facilities. J Am Geriatr Soc 2016; 64:2027-2034. [PMID: 27590032 DOI: 10.1111/jgs.14320] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess multiple geriatric syndromes in a sample of older hospitalized adults discharged to skilled nursing facilities (SNFs) and subsequently to home to determine the prevalence and stability of each geriatric syndrome at the point of these care transitions. DESIGN Descriptive, prospective study. SETTING One large university-affiliated hospital and four area SNFs. PARTICIPANTS Fifty-eight hospitalized Medicare beneficiaries discharged to SNFs (N = 58). MEASUREMENTS Research personnel conducted standardized assessments of the following geriatric syndromes at hospital discharge and 2 weeks after SNF discharge to home: cognitive impairment, depression, incontinence, unintentional weight loss, loss of appetite, pain, pressure ulcers, history of falls, mobility impairment, and polypharmacy. RESULTS The average number of geriatric syndromes per participant was 4.4 ± 1.2 at hospital discharge and 3.8 ± 1.5 after SNF discharge. There was low to moderate stability for most syndromes. On average, participants had 2.9 syndromes that persisted across both care settings, 1.4 syndromes that resolved, and 0.7 new syndromes that developed between hospital and SNF discharge. CONCLUSION Geriatric syndromes were prevalent at the point of each care transition but also reflected significant within-individual variability. These findings suggest that multiple geriatric syndromes present during a hospital stay are not transient and that most syndromes are not resolved before SNF discharge. These results underscore the importance of conducting standardized screening assessments at the point of each care transition and effectively communicating this information to the next provider to support the management of geriatric conditions.
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Affiliation(s)
- Sandra F Simmons
- Divisions of Geriatrics, Department of Medicine, Vanderbilt University, Nashville, Tennessee. .,Divisions of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee. .,Center for Quality Aging, Department of Medicine, Vanderbilt University, Nashville, Tennessee.
| | - Susan Bell
- Divisions of Geriatrics, Department of Medicine, Vanderbilt University, Nashville, Tennessee.,Center for Quality Aging, Department of Medicine, Vanderbilt University, Nashville, Tennessee.,Geriatric Research, Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Avantika A Saraf
- Center for Quality Aging, Department of Medicine, Vanderbilt University, Nashville, Tennessee.,Geriatric Research, Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
| | | | - Emily A Long
- Center for Quality Aging, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - J M L Jacobsen
- Divisions of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee.,Center for Quality Aging, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - John F Schnelle
- Divisions of Geriatrics, Department of Medicine, Vanderbilt University, Nashville, Tennessee.,Divisions of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee.,Center for Quality Aging, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Eduard E Vasilevskis
- Divisions of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee.,Center for Quality Aging, Department of Medicine, Vanderbilt University, Nashville, Tennessee.,Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, Tennessee
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Simmons SF, Schnelle JF, Sathe NA, Slagle JM, Stevenson DG, Carlo ME, McPheeters ML. Defining Safety in the Nursing Home Setting: Implications for Future Research. J Am Med Dir Assoc 2016; 17:473-81. [DOI: 10.1016/j.jamda.2016.03.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 03/08/2016] [Indexed: 12/21/2022]
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Abstract
Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on two issues. First, there is a need for higher minimum nurse staffing standards for U.S. nursing homes based on multiple research studies showing a positive relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing. Second, the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.
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Affiliation(s)
- Charlene Harrington
- R.N. Professor Emeritus of Nursing and Sociology, Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA
| | - John F Schnelle
- Hamilton Professor of Medicine and Director of the Center for Quality Aging, Department of Medicine, Division of Geriatrics, Vanderbilt University, Nashville, TN, USA.; Division of General Internal Medicine and Public Health, Center for Quality Aging, Vanderbilt University, Nashville, TN, USA.; Department of Veterans Affairs, Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Margaret McGregor
- Clinical Associate Professor, Director of Community Geriatrics, University of British Columbia Department of Family Practice, Vancouver, BC, USA
| | - Sandra F Simmons
- Division of General Internal Medicine and Public Health, Center for Quality Aging, Vanderbilt University, Nashville, TN, USA.; Department of Veterans Affairs, Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA.; Associate Professor, Department of Medicine, Division of Geriatrics, Vanderbilt University, Nashville, TN, USA
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Harrington C, Schnelle JF, McGregor M, Simmons SF. The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes. Health Serv Insights 2016; 9:13-9. [PMID: 27103819 PMCID: PMC4833431 DOI: 10.4137/hsi.s38994] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 03/08/2016] [Accepted: 03/14/2016] [Indexed: 11/05/2022] Open
Abstract
Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on two issues. First, there is a need for higher minimum nurse staffing standards for U.S. nursing homes based on multiple research studies showing a positive relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing. Second, the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.
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Affiliation(s)
- Charlene Harrington
- R.N. Professor Emeritus of Nursing and Sociology, Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA
| | - John F Schnelle
- Hamilton Professor of Medicine and Director of the Center for Quality Aging, Department of Medicine, Division of Geriatrics, Vanderbilt University, Nashville, TN, USA.; Division of General Internal Medicine and Public Health, Center for Quality Aging, Vanderbilt University, Nashville, TN, USA.; Department of Veterans Affairs, Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Margaret McGregor
- Clinical Associate Professor, Director of Community Geriatrics, University of British Columbia Department of Family Practice, Vancouver, BC, USA
| | - Sandra F Simmons
- Division of General Internal Medicine and Public Health, Center for Quality Aging, Vanderbilt University, Nashville, TN, USA.; Department of Veterans Affairs, Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA.; Associate Professor, Department of Medicine, Division of Geriatrics, Vanderbilt University, Nashville, TN, USA
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Bell SP, Vasilevskis EE, Saraf AA, Jacobsen JML, Kripalani S, Mixon AS, Schnelle JF, Simmons SF. Geriatric Syndromes in Hospitalized Older Adults Discharged to Skilled Nursing Facilities. J Am Geriatr Soc 2016; 64:715-22. [PMID: 27059831 DOI: 10.1111/jgs.14035] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine the prevalence, recognition, co-occurrence, and recent onset of geriatric syndromes in individuals transferred from the hospital to a skilled nursing facility (SNF). DESIGN Quality improvement project. SETTING Acute care academic medical center and 23 regional partner SNFs. PARTICIPANTS Medicare beneficiaries hospitalized between January 2013 and April 2014 and referred to SNFs (N = 686). MEASUREMENTS Project staff measured nine geriatric syndromes: weight loss, lack of appetite, incontinence, and pain (standardized interview); depression (Geriatric Depression Scale); delirium (Brief Confusion Assessment Method); cognitive impairment (Brief Interview for Mental Status); and falls and pressure ulcers (hospital medical record using hospital-implemented screening tools). Estimated prevalence, new-onset prevalence, and common coexisting clusters were determined. The extent to which treating physicians commonly recognized syndromes and communicated them to SNFs in hospital discharge documentation was evaluated. RESULTS Geriatric syndromes were prevalent in more than 90% of hospitalized adults referred to SNFs; 55% met criteria for three or more coexisting syndromes. The most-prevalent syndromes were falls (39%), incontinence (39%), loss of appetite (37%), and weight loss (33%). In individuals who met criteria for three or more syndromes, the most common triad clusters were nutritional syndromes (weight loss, loss of appetite), incontinence, and depression. Treating hospital physicians commonly did not recognize and document geriatric syndromes in discharge summaries, missing 33% to 95% of syndromes present according to research personnel. CONCLUSION Geriatric syndromes in hospitalized older adults transferred to SNFs are prevalent and commonly coexist, with the most frequent clusters including nutritional syndromes, depression, and incontinence. Despite the high prevalence, this clinical information is rarely communicated to SNFs on discharge.
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Affiliation(s)
- Susan P Bell
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Eduard E Vasilevskis
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Geriatric Research Education and Clinical Center, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Avantika A Saraf
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - J M L Jacobsen
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Geriatric Research Education and Clinical Center, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee.,Center for Health Services Research, Vanderbilt University, Nashville, Tennessee
| | - Sunil Kripalani
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Center for Health Services Research, Vanderbilt University, Nashville, Tennessee.,Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee
| | - Amanda S Mixon
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Geriatric Research Education and Clinical Center, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - John F Schnelle
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Geriatric Research Education and Clinical Center, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee.,Division of Geriatrics, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Sandra F Simmons
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Geriatric Research Education and Clinical Center, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee.,Division of Geriatrics, Department of Medicine, Vanderbilt University, Nashville, Tennessee
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Schnelle JF, Simmons SF. Managing Agitation and Aggression in Congregate Living Settings: Efficacy and Implementation Challenges. J Am Geriatr Soc 2016; 64:489-91. [PMID: 27000322 DOI: 10.1111/jgs.13947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- John F Schnelle
- Division of Geriatrics, Center for Quality Aging, Vanderbilt University, Nashville, Tennessee.,Department of Medicine, Vanderbilt University, Nashville, Tennessee.,Geriatric Research, Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Sandra F Simmons
- Division of Geriatrics, Center for Quality Aging, Vanderbilt University, Nashville, Tennessee.,Department of Medicine, Vanderbilt University, Nashville, Tennessee.,Geriatric Research, Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
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Simmons SF, Keeler E, An R, Liu X, Shotwell MS, Kuertz B, Silver HJ, Schnelle JF. Cost-Effectiveness of Nutrition Intervention in Long-Term Care. J Am Geriatr Soc 2015; 63:2308-16. [PMID: 26503137 DOI: 10.1111/jgs.13709] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To determine the cost-effectiveness of two nutrition interventions on food, beverage, and supplement intake and body weight. DESIGN Randomized, controlled trial. SETTING Five skilled nursing home facilities. PARTICIPANTS Long-stay residents with orders for nutrition supplementation (N = 154). INTERVENTION Participants were randomized into a usual care control group, an oral liquid nutrition supplement (ONS) intervention group, or a snack intervention group. Research staff provided ONS, according to orders or a variety of snack foods and beverages twice per day between meals, 5 days per week for 24 weeks and assistance to promote consumption. MEASUREMENTS Research staff independently weighed residents at baseline and monthly during the 24-week intervention. Resident food, beverage and supplement intake and the amount of staff time spent providing assistance were assessed for 2 days at baseline and 2 days per month during the intervention using standardized observation and weighed intake procedures. RESULTS The ONS intervention group took in an average of 265 calories more per day and the snack intervention group an average of 303 calories more per day than the control group. Staff time required to provide each intervention averaged 11 and 14 minutes per person per offer for ONS and snacks, respectively, and 3 minutes for usual care. Both interventions were cost-effective in increasing caloric intake, but neither intervention had a significant effect on body weight, despite positive trends. CONCLUSION Oral liquid nutrition supplements and snack offers were efficacious in promoting caloric intake when coupled with assistance to promote consumption and a variety of options, but neither intervention resulted in significant weight gain.
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Affiliation(s)
- Sandra F Simmons
- Center for Quality Aging, Division of Geriatrics, Vanderbilt University, Nashville, Tennessee.,Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Nashville, Tennessee
| | - Emmett Keeler
- Rand Corporation, Santa Monica, California.,Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, Illinois
| | - Ruopeng An
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, Illinois
| | - Xulei Liu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - Brittany Kuertz
- Center for Quality Aging, Division of Geriatrics, Vanderbilt University, Nashville, Tennessee
| | - Heidi J Silver
- Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - John F Schnelle
- Center for Quality Aging, Division of Geriatrics, Vanderbilt University, Nashville, Tennessee.,Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Nashville, Tennessee
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Monroe TB, Misra S, Habermann RC, Dietrich MS, Bruehl SP, Cowan RL, Newhouse PA, Simmons SF. Specific Physician Orders Improve Pain Detection and Pain Reports in Nursing Home Residents: Preliminary Data. Pain Manag Nurs 2015; 16:770-80. [PMID: 26259882 DOI: 10.1016/j.pmn.2015.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 05/29/2015] [Accepted: 06/03/2015] [Indexed: 10/23/2022]
Abstract
Despite evidence that many nursing home residents' pain is poorly managed, reasons for this poor management remain unanswered. The aim of this study was to determine if specific order sets related to pain assessment would improve pain management in nursing home (NH) residents. Outcomes included observed nurse pain assessment queries and resident reports of pain. The pretest/post-test study was performed in a 240-bed for-profit nursing home in the mid-southern region of the United States and participants were 43 nursing home residents capable of self-consent. Medical chart abstraction was performed during a 2-week (14-day) period before the implementation of specific order sets for pain assessment (intervention) and a 2-week (14-day) period after the intervention. Trained research assistants observed medication administration passes and performed participant interviews after each medication pass. One month after intervention implementation, 1 additional day of observations was conducted to determine data reliability. Nurses were observed to ask residents about pain more frequently, and nurses continued to ask about pain at higher rates 1 month after the intervention was discontinued. The proportion of residents who reported pain also significantly increased in response to increased nurse queries (e.g., "Do you have any pain right now?"), which underscores the importance of nurses directly asking residents about pain. Notably 70% of this long-stay NH population only told the nurses about their pain symptoms when asked directly. Findings uncover that using specific pain order sets seems to improve the detection of pain, which should be a routine part of nursing assessment.
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Affiliation(s)
- Todd B Monroe
- Vanderbilt University School of Nursing, Nashville, Tennessee.
| | - Sumathi Misra
- Palliative Medicine Program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ralf C Habermann
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary S Dietrich
- Vanderbilt University Schools of Medicine and Nursing, Nashville, Tennessee
| | - Stephen P Bruehl
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ronald L Cowan
- Department of Radiology, Vanderbilt University Medical Center, Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Paul A Newhouse
- Vanderbilt University School of Medicine, Vanderbilt Center for Cognitive Medicine, Vanderbilt University Medical Center, Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (TVHS-GRECC), Nashville, Tennessee
| | - Sandra F Simmons
- Vanderbilt University Department of Medicine, Center for Quality Aging and the Division of Geriatrics and the Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
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Simmons SF, Schnelle JF, Saraf AA, Simon Coelho C, Jacobsen JML, Kripalani S, Bell S, Mixon A, Vasilevskis EE. Pain and Satisfaction With Pain Management Among Older Patients During the Transition From Acute to Skilled Nursing Care. Gerontologist 2015; 56:1138-1145. [PMID: 26185153 DOI: 10.1093/geront/gnv058] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 04/05/2015] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Approximately 20% of hospitalized Medicare beneficiaries are discharged from the hospital to skilled nursing facilities (SNFs); and up to 23% of SNF patients return to the hospital within 30 days of hospital discharge, with pain as one of the most common symptoms precipitating hospital readmission. We sought to examine the prevalence of moderate to severe pain at hospital discharge to SNF, the incidence of new moderate to severe pain (relative to prehospitalization), and satisfaction with pain management among older acute care patients discharged to SNF. DESIGN AND METHODS Structured patient interviews were conducted with 188 Medicare beneficiaries discharged to 23 area SNFs from an academic medical center. Pain level (0-10) and satisfaction with pain management were assessed upon hospital admission, discharge, and within 1 week after transition to SNF. RESULTS There was a high prevalence of moderate to severe pain at each time point including prehospital (51%), hospital discharge (38%), and following SNF admission (53%). Twenty-eight percent of participants reported new moderate to severe pain at hospital discharge, whereas 44% reported new moderate to severe pain following SNF admission. Most participants reported being "satisfied" with their pain treatment, even in the context of moderate to severe pain. IMPLICATIONS Moderate to severe pain is a common problem among hospitalized older adults discharged to SNF and continues during their SNF stay. Pain assessment and management should involve a specific, planned process between hospital and SNF clinicians at the point of care transition, even if patients express "satisfaction" with current pain management.
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Affiliation(s)
- Sandra F Simmons
- Division of Geriatrics, Department of Medicine, Vanderbilt University, Nashville, Tennessee. .,Department of Medicine, Center for Quality Aging, Vanderbilt University, Nashville, Tennessee.,Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - John F Schnelle
- Division of Geriatrics, Department of Medicine, Vanderbilt University, Nashville, Tennessee.,Department of Medicine, Center for Quality Aging, Vanderbilt University, Nashville, Tennessee.,Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Avantika A Saraf
- Department of Medicine, Center for Quality Aging, Vanderbilt University, Nashville, Tennessee.,Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Chris Simon Coelho
- Division of Geriatrics, Department of Medicine, Vanderbilt University, Nashville, Tennessee.,Department of Medicine, Center for Quality Aging, Vanderbilt University, Nashville, Tennessee
| | - J Mary Lou Jacobsen
- Division of Geriatrics, Department of Medicine, Vanderbilt University, Nashville, Tennessee.,Department of Medicine, Center for Quality Aging, Vanderbilt University, Nashville, Tennessee
| | - Sunil Kripalani
- Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Susan Bell
- Department of Medicine, Center for Quality Aging, Vanderbilt University, Nashville, Tennessee.,Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Amanda Mixon
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee.,Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee
| | - Eduard E Vasilevskis
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee.,Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee
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Vasilevskis EE, Simmons SF. Simple solutions may not work for complex patients: A need for new paradigms in geriatric hospital medicine. J Hosp Med 2015; 10:343-4. [PMID: 25641782 PMCID: PMC4412786 DOI: 10.1002/jhm.2327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 01/08/2015] [Indexed: 01/21/2023]
Affiliation(s)
- Eduard E Vasilevskis
- Geriatric Research, Education and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee; Department of Medicine, Center for Health Services Research, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee; Center for Quality Aging, Vanderbilt University, Nashville, Tennessee
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Simmons SF, Rahman AN. Next Steps for Achieving Person-Centered Care in Nursing Homes. J Am Med Dir Assoc 2014; 15:615-9. [DOI: 10.1016/j.jamda.2014.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 06/04/2014] [Indexed: 10/25/2022]
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Abstract
The purpose of this study was to determine: (a) the frequency of family visitation during mealtime and (b) whether the presence of family during meals had an impact on the quality of feeding assistance care and resident intake. Participants included 74 nursing home residents from two Veterans Affairs (VA) and four community facilities in one geographic region. Mealtime periods in which family was present were compared with mealtime periods when family was not present for the same resident. Results showed that family visitation was infrequent during mealtime; however, feeding assistance time was significantly higher when visitors were present. Despite the increase in assistance time, there was not a significant difference in intake. Strategies that encourage the involvement of family in mealtime assistance may have additional benefits not directly associated with meal consumption, including providing family members with meaningful activity during a visit and enhancing residents’ quality of life and well-being.
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Affiliation(s)
| | | | - Sandra F. Simmons
- Vanderbilt University, Nashville, TN, USA
- VA Medical Center, Nashville, TN, USA
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Simmons SF, Durkin DW, Shotwell MS, Erwin S, Schnelle JF. A staff training and management intervention in VA long-term care: impact on feeding assistance care quality. Transl Behav Med 2013; 3:189-99. [PMID: 24073169 DOI: 10.1007/s13142-013-0194-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Efforts to translate efficacious interventions into long-term care practice have had limited success due to the lack of consideration of key translational intervention components. A multi-faceted intervention was implemented in two veteran affairs facilities to improve feeding assistance care. There were three study phases: baseline, intervention, and follow-up. During each phase, trained research staff conducted standardized observations of 12 meals/participant to assess feeding assistance care quality. The staff received three initial training sessions followed by six consecutive weeks of feedback sessions wherein the observation-based care process measures were shared with the staff. There were significant, but modest, improvements in mealtime feeding assistance care processes, and most of the improvements were maintained during follow-up. A multi-faceted intervention resulted in significant, but modest, improvements in mealtime feeding assistance care quality. Organizational (staff schedules, communication) and environmental (dining location) barriers were identified that interfered with improvement efforts.
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Affiliation(s)
- Sandra F Simmons
- Center for Quality Aging, Division of General Internal Medicine and Public Health, School of Medicine, Vanderbilt University, 2525 West End Avenue, Suite #350, Nashville, TN 37203 USA ; Geriatric Research, Education and Clinical Center, VA Medical Center, Nashville, TN USA
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Monroe TB, Misra SK, Habermann RC, Dietrich MS, Cowan RL, Simmons SF. Pain reports and pain medication treatment in nursing home residents with and without dementia. Geriatr Gerontol Int 2013; 14:541-8. [PMID: 24020433 DOI: 10.1111/ggi.12130] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2013] [Indexed: 11/27/2022]
Abstract
AIM The purpose of this pilot study was to determine if a diagnosis of dementia influenced pain self-reports and pain medication use in a group of verbally communicative nursing home (NH) residents. METHODS The study design was a between groups, cross-sectional chart audit and a seven-question structured pain interview comparing outcomes in residents with and without a diagnosis of dementia. The study was carried out at a large metropolitan NH in the southern USA. The participants consisted of 52 long-stay NH residents capable of self-consent with at least one order for pain medication (opioid or non-narcotic) either pro re nata, scheduled or both. Approximately 40% (n = 20) had a diagnosis of dementia. RESULTS Although each group had similar pain-related diagnoses, residents without a dementia diagnosis were significantly more likely to have a medication order for an opioid (OR 4.37,95% CI 1.29-14.73, P = 0.018). Based on self-reported pain interview responses, no statistically significant differences were identified between the groups for chronic pain symptoms. However, among residents who reported current pain, those with a dementia diagnosis reported greater pain intensity (based on a 0-10 numeric rating scale) than did those without dementia (median 8.0 vs 6.0, respectively; P = 0.010). CONCLUSIONS Verbally communicative NH residents with mild and moderate cognitive impairment can report their pain symptoms and pain intensity. Nurses in long-term care might assume that residents with dementia cannot reliably self-report their pain; however, suffering from untreated severe pain could exacerbate cognitive impairment, worsen functional impairment and severely impair sleep. A brief, focused pain interview might be one method for increasing the detection of moderate to severe pain in verbally communicative NH residents with dementia.
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Affiliation(s)
- Todd B Monroe
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA; Institute of Imaging Science, Vanderbilt University, Nashville, Tennessee, USA
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Buchowski MS, Simmons SF, Whitaker LE, Powers J, Beuscher L, Choi L, Ikizler TA, Chen K, Shnelle JF. Fatigability as a function of physical activity energy expenditure in older adults. Age (Dordr) 2013; 35:179-187. [PMID: 22113348 PMCID: PMC3543733 DOI: 10.1007/s11357-011-9338-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Accepted: 10/25/2011] [Indexed: 05/31/2023]
Abstract
Increased fatigue is a predictor of morbidity and mortality in older adults. Fatigability defines a change in performance or self-reported fatigue in response to physical activity (PA). However, the relationship of fatigability to PA-related energy expenditure (PAEE) is unknown. Changes in performance, fatigue, and energy expenditure were measured simultaneously in 17 adults (11 females, 74-94 years old) performing eight standardized PA tasks with various energy expenditure requirements in a whole-room indirect calorimeter. Change in performance was objectively measured using a PA movement monitor and change in fatigue was self-reported on a seven-point scale for each task. Performance and perceived fatigability severity scores were calculated as a ratio of change in performance and fatigue, respectively, and PAEE. We found that change in both objective performance and self-reported fatigue were associated with energy expenditure (Spearman rho = -0.72 and -0.68, respectively, p < 0.001) on a task requiring relatively high level of energy expenditure. The performance and perceived fatigability severity scores were significantly correlated (rho = 0.77, p < 0.001) on this task. In summary, results of this proof of concept pilot study show that both perceived and performance fatigability severity scores are related to PAEE-induced fatigue on a task requiring relatively high level of energy expenditure. We conclude that fatigability severity is a valid measure of PAEE-induced fatigue in older adults.
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Affiliation(s)
- Maciej S Buchowski
- Energy Balance Laboratory, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University, 1161 21st Avenue South, Nashville, TN 37232, USA.
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Schnelle JF, Rahman A, Durkin DW, Beuscher L, Choi L, Simmons SF. A controlled trial of an intervention to increase resident choice in long term care. J Am Med Dir Assoc 2013; 14:345-51. [PMID: 23294967 DOI: 10.1016/j.jamda.2012.11.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 11/28/2012] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate an intervention to improve staff offers of choice to nursing home residents during morning care. DESIGN A controlled trial with a delayed intervention design. SETTING Four community, for-profit nursing homes. PARTICIPANTS A total of 169 long-stay nursing home residents who required staff assistance with morning care and were able to express their care preferences. INTERVENTION Research staff held weekly training sessions with nurse aides (NAs) for 12 consecutive weeks focused on how to offer choice during four targeted morning care areas: when to get out of bed, when to get dressed/what to wear, incontinence care (changing and/or toileting), and where to dine. Training sessions consisted of brief video vignettes illustrating staff-resident interactions followed by weekly feedback about how often choice was being provided based on standardized observations of care conducted weekly by research staff. MEASUREMENTS Research staff conducted standardized observations during a minimum of 4 consecutive morning hours per participant per week for 12 weeks of baseline and 12 weeks of intervention. RESULTS There was a significant increase in the frequency that choice was offered for 3 of the 4 targeted morning care areas from baseline to intervention: (1) out of bed, 21% to 33% (P < .001); dressing, 20% to 32% (P < .001); incontinence care, 18% to 23%, (P < .014). Dining location (8% to 13%) was not significant. There was also a significant increase in the amount of NA staff time to provide care from baseline to intervention (8.01 ± 9.0 to 9.68 ± 9.9 minutes per person, P < .001). CONCLUSION A staff training intervention improved the frequency with which NAs offered choice during morning care but also required more time. Despite significant improvements, choice was still offered one-third or less of the time during morning care.
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Affiliation(s)
- John F Schnelle
- Vanderbilt University, School of Medicine, Division of General Internal Medicine and Public Health, Center for Quality Aging, Nashville, TN, USA.
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Durkin DW, Umayam SP, Sims N, Cleeton P, Simmons SF. Whom Do Veteran Nursing Home Residents Prefer to Talk to About Satisfaction With Care?: Implications for Nursing Staff. J Gerontol Nurs 2012. [DOI: 10.3928/00989134-20121109-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Durkin DW, Umayam SP, Sims N, Cleeton P, Simmons SF. Whom do veteran nursing home residents prefer to talk to about satisfaction with care?: implications for nursing staff. J Gerontol Nurs 2012. [PMID: 23189996 DOI: 10.3928/00989134-20121112-99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The purpose of this study was to determine whom residents in U.S. Department of Veterans Affairs (VA) nursing homes prefer to talk to about their quality of care. A total of 127 participants in three VA facilities completed a structured, in-person interview. Nearly half (47.6%) reported that they prefer talking with facility staff about their quality of care, with the most preferred staff being licensed nurses and physicians. However, 26% reported being hesitant to express complaints for fear of reprisal. Participants also reported being least comfortable talking to direct care staff (nurse aides) if they saw another resident being mistreated. These findings suggest that licensed nurses and primary care professionals, both of whom are in frequent contact with residents, should routinely ask residents questions about their quality of care so that nursing home residents have ample opportunity to express concerns. Finally, asking satisfaction questions routinely may also enable facilities to address problems as they occur.
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Affiliation(s)
- Daniel W Durkin
- Department of Social Work, University of West Florida, 11000 University Parkway, Pensacola, FL 32514, USA.
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Rahman AN, Applebaum RA, Schnelle JF, Simmons SF. Translating research into practice in nursing homes: can we close the gap? Gerontologist 2012; 52:597-606. [PMID: 22394494 PMCID: PMC3463418 DOI: 10.1093/geront/gnr157] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 12/05/2011] [Indexed: 11/14/2022] Open
Abstract
PURPOSE A gap between research and practice in many nursing home (NH) care areas persists despite efforts by researchers, policy makers, advocacy groups, and NHs themselves to close it. The reasons are many, but two factors that have received scant attention are the dissemination process itself and the work of the disseminators or change agents. This review article examines these two elements through the conceptual lens of Roger's innovation dissemination model. DESIGN AND METHODS The application of general principles of innovation dissemination suggests that NHs are characteristically slow to innovate and thus may need more time as well as more contact with outside change agents to adopt improved practices. RESULTS A review of the translation strategies used by NH change agents to promote adoption of evidence-based practice in NHs suggests that their strategies inconsistently reflect lessons learned from the broader dissemination literature. IMPLICATIONS NH-related research, policy, and practice recommendations for improving dissemination strategies are presented. If we can make better use of the resources currently devoted to disseminating best practices to NHs, we may be able to speed NHs' adoption of these practices.
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Affiliation(s)
- Anna N Rahman
- Davis School of Gerontology, University of Southern California, 3715 McClintock Ave., Los Angeles, CA 90089-0191, USA.
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