Management of Chronic Pain in Long-Term Care: A Systematic Review and Meta-Analysis

ObjectivesPain, a complex subjective experience, is common in care home residents. Despite advances in pain management, optimal pain control remains a challenge. In this updated systematic review, we examined effectiveness of interventions for treating chronic pain in care home residents.DesignA Cochrane-style systematic review and meta-analysis using PRISMA guidelines.Setting and ParticipantsRandomized and nonrandomized controlled trials and intervention studies included care home residents aged ≥60 years receiving interventions to reduce chronic pain.MethodsSix databases were searched to identify relevant studies. After duplicate removal, articles were screened by title and abstract. Full-text articles were reviewed and included if they implemented a pain management intervention and measured pain with a standardized quantitative pain scale. Meta-analyses calculated standardized mean differences (SMDs) using random-effect models. Risk of bias was assessed using the Cochrane Risk-of-Bias Tool 2.0.ResultsWe included 42 trials in the meta-analysis and described 13 more studies narratively. Studies included 26 nondrug alternative treatments, 8 education interventions, 7 system modifications, 3 nonanalgesic drug treatments, 2 analgesic treatments, and 9 combined interventions. Pooled results at trial completion revealed that, except for nonanalgesic drugs and health system modification interventions, all interventions were at least moderately effective in reducing pain. Analgesic treatments (SMD ?0.80; 95% CI ?1.47 to ?0.12; P = .02) showed the greatest treatment effect, followed by nondrug alternative treatments (SMD ?0.70; 95% CI ?0.95 to ?0.45; P < .001), combined interventions (SMD ?0.37; 95% CI ?0.60 to ?0.13; P = .002), and education interventions (SMD ?0.31; 95% CI ?0.48 to ?0.15; P < .001).Conclusions and ImplicationsOur findings suggest that analgesic drugs and nondrug alternative pain management strategies are the most effective in reducing pain among care home residents. Clinicians should also consider implementing nondrug alternative therapies in care homes, rather than relying solely on analgesic drug options.     

Effectiveness of hospital-based strategies for improving childhood immunization coverage: A systematic review

BackgroundHospital settings represent an opportunity to offer and/or promote childhood vaccination. The purpose of the systematic review was to assess the effectiveness of different hospital-based strategies for improving childhood vaccination coverage.MethodsA systematic search of multiple bibliographic databases, thesis databases, and relevant websites was conducted to identify peer-reviewed articles published up to September 20, 2021. Articles were included if they evaluated the impact of a hospital (inpatient or emergency department)-based intervention on childhood vaccination coverage, were published in English or French, and were conducted in high-income countries. High quality studies were included in a narrative synthesis.ResultsWe included 25 high quality studies out of 7,845 unique citations. Studies focused on routine, outbreak, and influenza vaccines, and interventions included opportunistic vaccination (i.e. vaccination during hospital visit) (n = 7), patient education (n = 2), community connection (n = 2), patient reminders (n = 2), and opportunistic vaccination combined with patient education and/or reminders (n = 12). Opportunistic vaccination interventions were generally successful at improving vaccine coverage, though results ranged from no impact to vaccinating 71 % of eligible children with routine vaccines and 9–61 % of eligible children with influenza vaccines. Interventions that aimed to increase vaccination after hospital discharge (community connection, patient education, reminders) were less successful.ConclusionsSome interventions that provide vaccination to children accessing hospitals improved vaccine coverage; however, the baseline coverage level of the population, as well as implementation strategies used impact success. There is limited evidence that interventions promoting vaccination after hospital discharge are more successful if they are tailored to the individual.     

The Impact of Pharmacologic and Nonpharmacologic Interventions to Improve Physical Health Outcomes in People With Dementia: A Meta-Review of Meta-Analyses of Randomized Controlled Trials

ObjectivesWe summarized and compared meta-analyses of pharmacologic and nonpharmacologic interventions targeting physical health outcomes among people with dementia.DesignThis is a systematic review and meta-analysis.Setting and ParticipantsPeople with dementia, confirmed through validated assessment measures.MethodsMajor databases were searched until October 21, 2019. Effect sizes [standardized mean difference (SMD)/Hedges g or risk ratio (RR)] were compared separately.ResultsOf 3773 search engine hits, 4 meta-analyses were included, representing 31 meta-analyzed trials and 10,054 study participants. Although meta-analyses were generally of adequate high quality, meta-analyzed studies were less so. Nutritional supplements were the only one to show a weight-increasing effect [SMD 0.53, 95% confidence interval (CI) 0.38–0.68, ie, medium effect; N = 12, n = 748]. Acetylcholinesterase inhibitors are associated with an increased risk for weight loss (RR 2.1, 95% CI 1.5‒3.0; N = 9, n = 7010). For the treatment of pain, sensory stimulation has a medium effect (SMD –0.58, 95% CI –0.99 to −0.17; N = 6, n = 199), whereas physical activity has a small effect (SMD –0.24, 95% CI –1.06 to 0.59; N = 2, n = 75). When exploring the characteristics of the psychosocial interventions, group-based interventions demonstrated a medium (SMD –0.55, 95% CI –1.02 to −0.09; N = 6, n = 157) and individual psychosocial interventions a small effect (SMD –0.27, 95% CI –1.06 to 0.53; N = 2, n = 55).Conclusions and ImplicationsDespite frequent physical comorbidities, the current evidence for pharmacologic and nonpharmacologic interventions in people with dementia to prevent and treat these conditions is still in its infancy, and larger trials targeting a wide range of physical health outcomes are urgently needed. Based on the SMDs and RRs, nutritional supplements can be recommended as an intervention to treat malnutrition. Clinicians should be careful in treating patients with acetylcholinesterase inhibitors, as it shows medium weight reducing effects. For the treatment of comorbid pain, sensory stimulation and psychosocial interventions are recommended.     

Impact of mHealth Interventions on Supporting Dietary Adherence in Cardiovascular Disease: A Systematic Review

IntroductionA systematic review was conducted to determine if mobile health (mHealth) interventions, and which intervention characteristics, effectively support dietary adherence and reduce risk factors in patients with cardiovascular disease (CVD).MethodUsing 7 databases, studies involving adult participants with specific CVD diagnoses, mHealth intervention testing, and dietary adherence assessment were identified. Systematic reviews, qualitative studies, or studies testing interventions involving open dialogue between participants and health care providers or researchers were excluded. Two independent reviewers conducted screening and assessed the risk of bias.ResultsThirteen studies involved participants with prehypertension (n = 1), hypertension (n = 9), coronary artery disease (n = 2), and heart failure (n = 1). mHealth interventions in 8 studies improved dietary adherence, 4 showed mixed results, and 1 showed no improvements. Eight studies found interactive text and/or application-based mHealth intervention features effectively improved dietary adherence. One study had a low risk of bias, 2 had some concerns/moderate risk, and 10 had a high/critical or serious risk.DiscussionIn most included studies, mHealth interventions positively impacted dietary adherence for patients with CVD.Implications for Research and PracticeClinicians may recommend mHealth interventions to support nutrition education and self-management for their patients with CVD.     

Molecular Epidemiology and Risk Factors for Extended-Spectrum β-Lactamase–Producing Enterobacterales in Long-Term Care Residents

ObjectivesWe aimed to assess the burden of extended-spectrum β-lactamase (ESBL)-producing Enterobacterales in Swiss long-term care facilities (LTCFs) to describe the molecular epidemiology, describe the intrainstitutional and regional clusters of resistant pathogens, and identify independent institution- and resident-level factors associated with colonization.DesignCross-sectional study.Setting and ParticipantsFrom August to October 2019, we performed a point prevalence study among residents from 16 LTCFs in Western and Eastern Switzerland (8 per region).MethodsResidents underwent screening for ESBL-producing Enterobacterales (ESBL-E); whole-genome sequencing (WGS) was performed. We gathered institution-level (eg, number of beds, staff-resident ratio, alcoholic hand rub consumption) and resident-level [eg, anthropometric data, time in facility, dependency, health care exposure, antibiotic treatment, proton-pump inhibitor (PPI) use] characteristics. Factors associated with colonization were identified using a generalized linear model.ResultsAmong 1185 eligible residents, 606 (51%) consented to the study. ESBL-E prevalence was 11.6% (70/606), ranging from 1.9% to 33.3% between institutions, with a median of 12.5% in the West and 6.9% in the East (P = .03). Among 59 Escherichia coli (from 58 residents), multilocus sequence type (ST) 131 was most common (n = 43/59, 73%), predominantly its subclone H30R1 (n = 37/43, 86%). WGS data identified multiple intrainstitutional and regional clusters. Independent risk factors for ESBL carriage were previous ESBL colonization [adjusted odds ratio (aOR) 23.5, 95% confidence interval (CI) 6.6-83.8, P < .001), male gender (aOR 2.6, 95% CI 1.5-4.6, P = .002), and use of PPIs (aOR 2.2, 95% CI 1.2-3.8, P = .01).Conclusions and ImplicationsOverall ESBL-E prevalence in Swiss LTCF residents is low. Yet, we identified several clusters of residents with identical pathogens within the same institution. This implies that particularly affected institutions might benefit from targeted infection control interventions. PPI use was the only modifiable factor associated with carriage of ESBL producers. This study adds to the growing list of adverse outcomes associated with PPIs, calling for action to restrict their use in the long-term care setting.     

Nutrition Education Package Focusing on Infant and Young Child Feeding in Tanzania

ObjectiveTo evaluate the effectiveness of a nutrition education package on feeding practices, nutrient intakes and growth of infants in rural Tanzania.DesignCluster-randomized controlled trial in 18 villages allocated to nutrition education package (n = 9) or routine health education (n = 9 villages), measured at baseline (6 months) and end of the trial (12 months).SettingMpwapwa district.ParticipantsInfants aged 6–12 months and their mothers.Intervention(s)Six months of nutrition education package (group education, counseling, cooking demonstrations) and regular home visits by village health workers.Main Outcome Measure(s)Primary outcome measure was the mean change in length-for-age z-scores. Secondary outcomes included mean changes in weight-for-length z-scores (WLZ), intakes of energy, fat, iron and zinc, the proportion of children consuming foods from ≥ 4 food groups (ie, dietary diversity) and consuming the recommended number of semisolid/soft meals and snacks per day (ie, meal frequency).AnalysisMultilevel mixed-effects regression models.ResultsMean change in length-for-age z-scores (β = 0.20, P = 0.02), energy (in kcal) (β = 43.8, P = 0.02), and fat (in grams) (β =2.7, P = 0.03) intakes were significant in the intervention but not in the control group. There was no effect on iron and zinc intakes. More infants in the intervention than the control group consumed meals from ≥ 4 food groups (71.8% vs 45.3%, P = 0.002). The mean increase in meal frequency (β = 0.29, P = 0.02) and dietary diversity (β = 0.40, P = 0.01) were more significant in the intervention than control.Conclusions and ImplicationsThe nutrition education package is feasible and can be implemented with high coverage, demonstrating the potential to improve feeding practices, nutrient intake and growth in rural Tanzania.     

Potential Overtreatment and Undertreatment of Type 2 Diabetes Mellitus in Long-Term Care Facilities: A Systematic Review

ObjectiveTo investigate the prevalence, outcomes, and factors associated with potential glycemic overtreatment and undertreatment of type 2 diabetes mellitus (T2DM) in long-term care facilities (LTCFs).DesignSystematic review.Setting and ParticipantsResidents with T2DM and aged ≥60 years living in LTCFs.MeasuresArticles published between January 2000 and September 2020 were retrieved following a systematic search of MEDLINE, EMBASE, Cochrane Library, CINAHL plus, and gray literature. Inclusion criteria were the reporting of (1) potential overtreatment and undertreatment quantitatively defined (implicitly or explicitly) based on hemoglobin A1c (HbA1c) and/or blood glucose; (2) prevalence, outcomes, and associated factors of potential glycemic overtreatment and undertreatment; and (3) the study involved residents of LTCFs.ResultsFifteen studies were included. Prevalence of potential overtreatment (5%–86%, n = 15 studies) and undertreatment (1.4%–35%, n = 8 studies) varied widely among facilities and geographical locations, and according to definitions used. Prevalence of potential overtreatment was 16%–74% when defined as treatment with a glucose-lowering medication in a resident with ≥1 hypoglycemia risk factor or serious comorbidity, together with a HbA1c <7% (n = 10 studies). Potential undertreatment was commonly defined as residents on glucose-lowering medication having HbA1c >8.5% and the prevalence 1.4%–14.8% (n = 6 studies). No studies prospectively measured resident health outcomes from overtreatment and undertreatment. Potential overtreatment was positively associated with use of oral glucose-lowering medications, dementia diagnosis or dementia severity, and/or need for assistance with activities of daily living (n = 2 studies). Negative association was found between potential overtreatment and use of insulin/combined insulin and oral glucose-lowering medication. No studies reported factors associated with potential undertreatment.Conclusions and ImplicationsThe prevalence of potential glycemic overtreatment and undertreatment varied widely among residents with T2DM depending on the definition(s) used in each study. Longitudinal studies examining associations between glycemic management and health outcomes, and the use of consensus definitions of overtreatment and undertreatment are required to establish findings about actual glycemic overtreatment and undertreatment in LTCFs.     

Changes in Fruit and Vegetable Consumption of Third-Grade Students in Body Quest: Food of the Warrior,a 17-Class Childhood Obesity Prevention Program

ObjectiveTo increase fruit and vegetable (FV) consumption of youth in Body Quest: Food of the Warrior (BQ), a childhood obesity prevention program.DesignQuasi-experimental.SettingSupplemental Nutrition Assistance Program–Education eligible schools (n = 60).ParticipantsThird-grade students (n = 2,477).InterventionTreatment groups (n = 1,674) self-reported foods consumed through the School Lunch Program for 17 weekly assessments; they participated in BQ curriculum, iPad app education, and weekly FV tastings. Control groups (n = 803) completed only pre- and post-assessments.Main Outcome MeasureWeekly FV consumed through School Lunch Program.AnalysisANCOVA and growth modeling.ResultsFrom before to after the program, the treatment group demonstrated significant, moderate increases in fruit (P < .01) and vegetable (P < .001) consumptions, increasing from 7 to 8 weekly FV servings. After the program, the treatment group consumed significantly (P < .001) more FV than the control group. Fruit and vegetable consumption increased to class 10 and then stabilized. From before to after the program, all FV predictors were significantly higher and included gender (vegetables), race (FV), and free/reduced lunch (fruit).Conclusions and ImplicationsNutrition programs can increase FV intake. Even moderate increases in FV intake can be an initial step for the prevention of chronic disease.     

A New Care Model Reduces Polypharmacy and Potentially Inappropriate Medications in Long-Term Care

ObjectivesAssess the impact of a new pharmaceutical care model on (1) polypharmacy and (2) potentially inappropriate medication (PIM) use in long-term care facilities (LTCFs).DesignPragmatic quasi-experimental study with a control group. This multifaceted model enables pharmacists and nurses to increase their professional autonomy by enforcing laws designed to expand their scope of practice. It also involves a strategic reorganization of care, interdisciplinary training, and systematic medication reviews.Setting and ParticipantsTwo LTCFs exposed to the model (409 residents) were compared to 2 control LTCFs (282 residents) in Quebec, Canada. All individuals were aged 65 years or older and residing in included LTCFs.MeasuresPolypharmacy (≥10 medications) and PIM (2015 Beers criteria) were analyzed throughout 12 months between March 2017 and June 2018. Groups were compared before and after implementation using repeated measures mixed Poisson or logistic regression models, adjusting for potential confounding variables.ResultsOver 12 months, for regular medications, polypharmacy decreased from 42% to 20% (exposed group) and from 50% to 41% (control group) [difference in differences (DID): 13%, P < .001]. Mean number of PIMs also decreased from 0.79 to 0.56 (exposed group) and from 1.08 to 0.90 (control group) (DID: 0.05, P = .002).Conclusions and ImplicationsCompared with usual care, this multifaceted model reduced the probability of receiving ≥10 medications and the mean number of PIMs. Greater professional autonomy, reorganization of care, training, and medication review can optimize pharmaceutical care. As the role of pharmacists is expanding in many countries, this model shows what could be achieved with increased professional autonomy of pharmacists and nurses in LTCFs.     

Nutrition Interventions in Low-Income Rural and Urban Retail Environments: A Systematic Review

BackgroundNutrition interventions promoting healthy food choices aim to address health challenges of residents in low-income environments. Research about the effectiveness of nutrition interventions in low-income populations is limited, particularly for those in rural areas. Behavioral economics (BE) strategies demonstrate effectiveness for improving eating behaviors in some settings. However, the efficacy of BE interventions in retail food stores serving low-income populations residing in rural and urban geographies is nascent.ObjectiveThis systematic literature review aims to identify and compare nutrition interventions implemented in rural and urban low-income retail food stores, including BE strategies when applied.MethodsThis review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Reviewers searched five databases for peer-reviewed publications from October 2010 to October 2019. Included studies implemented a nutrition intervention in low-income retail food stores and provided a quantitative outcome evaluation with results separated by rural and urban geography. BE interventions were analyzed based on the MINDSPACE framework for behavior change.ResultsForty-six separate publications (n = 20 rural, n = 26 urban) in the United States, Canada, Europe, New Zealand, and Australia were included. Researchers independently rated publications as low risk of bias (n = 4), moderate (n = 18), or high risk of bias (n = 24) using the Quality Assessment Tool for Quantitative Studies. Studies (n = 18) demonstrated positive outcomes for customer purchases, store sales, or participant intake of targeted healthy foods. Overall, most effective interventions included point-of-purchase signage (n = 16) and product placement strategies (n = 4 urban). Rural studies included financial incentives combined with participant education (n = 2) and incorporated culturally appropriate messengers and/or symbols (n = 5) to improve healthy food purchases and intake.ConclusionsImproved research quality and tailored evidence-based interventions, including BE strategies, are necessary in retail food environments to promote healthy eating behaviors in low-income populations.     

Effects of Dietary Approaches to Stop Hypertension (DASH) diet on some risk for developing type 2 diabetes: A systematic review and meta-analysis on controlled clinical trials

ObjectiveType 2 diabetes is a major public health problem. The Dietary Approaches to Stop Hypertension (DASH) eating pattern may contribute to managing risk factors of type 2 diabetes. The objective of this study was to conduct a systematic review and meta-analysis on randomized controlled trials (RCTs) that examine the effects of DASH diet consumption on the indices of glycemic control such as fasting blood glucose (FBG), serum fasting insulin level, and Homeostatic Model Assessment insulin resistance (HOMA-IR).MethodsWe searched Pubmed, EMBASE, Science direct, ISI web of science, and Google Scholar for RCTs until July 2012. In total we found 20 articles that examine the effect of DASH diet on FBG (n = 9), fasting insulin (n = 7) and HOMA-IR (n = 4) met the inclusion criteria, respectively.ResultsMeta-analysis showed that the DASH diet can significantly reduce fasting insulin concentration (mean difference ?0.15; 95% confidence interval [CI], ?0.22 to ?0.08; P < 0.001). Subgroup analysis based on the study period showed that the DASH diet could significantly reduce fasting insulin levels when prescribed for more than 16 wk (mean difference ?0.16; 95% CI, ?0.23 to ?0.08; P < 0.001). Meta-analysis could not show a beneficial effect of the DASH diet on FBG (mean difference ?0.26; 95% CI, ?0.56 to 0.05; P = 0.1), and HOMA-IR (mean difference ?0.26; 95% CI, ?0.56 to 0.05; P = 0.1).ConclusionsThe DASH dietary pattern may lead to an improvement in insulin sensitivity independent of weight loss. The DASH diet may play an important role in glycemic control in long- term interventions. Additional prospective studies regarding the association between DASH diet and risks for type 2 diabetes are necessary.     

Factors Associated with Perception of the Quality of Physicians' End-of-life Communication in Long-Term Care Facilities: PACE Cross-Sectional Study

ObjectiveTo examine factors associated with perceived quality of communication with physicians by relatives of dying residents of long-term care facilities (LTCFs).DesignA cross-sectional retrospective study in a representative sample of LTCFs conducted in 2015. In each LTCF, deaths of residents during the 3 months before the researcher's visit were reported. Structured questionnaires were sent to the identified relatives of deceased residents.Settings and participantsA total of 736 relatives of deceased residents in 210 LTCFs (in Belgium, Finland, Italy, the Netherlands, and Poland).MethodsThe Family Perception of Physician-Family Communication scale (FPPFC) was used to assess the quality of end-of-life (EOL) communication with physicians as perceived by relatives. We applied multilevel linear regression models to find factors associated with the FPPFC score.ResultsThe quality of EOL communication with physicians was perceived by relatives as higher when the relative spent more than 14 hours with the resident in the last week of the resident's life (b = 0.205; P = .044), and when the treating physician visited the resident at least 3 times in the last week of the resident's life (b = 0.286; P = .002) or provided the resident with palliative care (b = 0.223; P = .003). Relatives with higher emotional burden perceived the quality of EOL communication with physicians as lower (b = −0.060; P < .001). These results had been adjusted to countries and LTCF types with physicians employed on-site or off-site of the facility.ConclusionThe quality of EOL communication with physicians, as perceived by relatives of dying LTCF residents, is associated with the number of physician visits and amount of time spent by the relative with the resident in the last week of the resident's life, and relatives' emotional burden.ImplicationsLTCF managers should organize care for dying residents in a way that enables frequent interactions between physicians and relatives, and emotional support to relatives to improve their satisfaction with EOL communication.     

Testing the Implementation of Function-focused Care in Assisted Living Settings

ObjectivesThe purpose of this study was to evaluate the Function-Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT) intervention.DesignFFC-AL-EIT was a randomized controlled pragmatic trial including 85 sites and 794 residents.InterventionFFC-AL-EIT was implemented by a Research Nurse Facilitator working with a facility champion and stakeholder team for 12 months to increase function and physical activity among residents. FFC-AL-EIT included (Step I) Environment and Policy Assessments; (Step II) Education; (Step III) Establishing Resident Function-Focused Care Service Plans; and (Step IV) Mentoring and Motivating.Setting and ParticipantsThe age of participants was 89.48 years [standard deviation (SD) = 7.43], and the majority were female (n = 561; 71%) and white (n = 771; 97%).MethodsResident measures, obtained at baseline, 4, and 12 months, included function, physical activity, and performance of function-focused care. Setting outcomes, obtained at baseline and 12 months, included environment and policy assessments and service plans.ResultsReach was based on 85 of 90 sites that volunteered (94%) participating. Effectiveness was based on less decline in function (P < .001), more function-focused care (P = .012) and better environment (P = .032) and policy (P = .003) support for function-focused care in treatment sites. Adoption was supported with 10.00 (SD = 2.00) monthly meetings held, 77% of settings engaged in study activities as or more than expected, and direct care workers providing function-focused care (63% to 68% at 4 months and 90% at 12 months). The intervention was implemented as intended, and education was received based on a mean knowledge test score of 88% correct. Evidence of maintenance from 12 to 18 months was noted in treatment site environments (P = .35) and policies continuing to support function-focused care (P = .28)].Conclusions and ImplicationsThe Evidence Integration Triangle is an effective implementation approach for assisted living. Future work should continue to consider innovative approaches for measuring RE-AIM outcomes.     

Efficacy and Generalizability of Falls Prevention Interventions in Nursing Homes: A Systematic Review and Meta-analysis

ObjectivesTo determine the efficacy of fall intervention programs in nursing homes (NHs) and the generalizability of these interventions to people living with cognitive impairment and dementia.DesignSystematic review and meta-analysis.Setting and ParticipantsNH residents (n = 30,057) living in NHs defined as residential facilities that provide 24-hours-a-day surveillance, personal care, and some clinical care for persons who are typically aged ≥65 years with multiple complex chronic health conditions.MethodsMeta-analysis of falls prevention interventions on number of falls, fallers, and recurrent fallers.ResultsThirty-six studies met inclusion criteria for the systematic review. Overall, fall prevention interventions reduced the number of falls [risk ratio (RR) = 0.73, 95% confidence interval (CI) = 0.60-0.88], fallers (RR = 0.80, 95% CI = 0.72-0.89), and recurrent fallers (RR = 0.70, 95% CI = 0.60-0.81). Subanalyses revealed that single interventions have a significant effect on reducing fallers (RR = 0.78, 95% CI = 0.69-0.89) and recurrent fallers (RR = 0.60, 95% CI = 0.52-0.70), whereas multiple interventions reduce fallers (RR = 0.69, 95% CI = 0.39-0.97) and multifactorial interventions reduce number of falls (RR = 0.65, 95% CI = 0.45-0.94).Conclusions and ImplicationsExercise as a single intervention reduced the number of fallers and recurrent fallers by 36% and 41%, respectively, in people living in NHs. Other effective interventions included staff education and multiple and multifactorial interventions. However, more research on exercise including people with cognitive impairment and dementia is needed to improve the generalizability of these interventions to the typical NH resident.     

Dietary Supplement Intake and Factors Associated with Increased Use in Preadolescent Endurance Runners

BackgroundThe prevalence of dietary supplement intake among preadolescent endurance runners is currently unknown.ObjectiveOur aim was to describe use of dietary supplements, higher-risk supplements, and sport foods among preadolescent endurance athletes and identify associated characteristics of dietary supplement users in this population.DesignThis was a retrospective, cross-sectional study.Participants/settingParticipants were 2,113 preadolescent endurance runners (male: n = 1,255, female: n = 858; mean age ± standard deviation = 13.2 ± 0.9 years).Main outcome measuresUse of dietary supplements, higher-risk dietary supplements, and sport foods on 2 or more days per week during the past year.Statistical analyses performedMann-Whitney U tests, χ² tests, univariate and multivariate analyses.ResultsTwenty-six percent (n = 551) of preadolescent runners used dietary supplements on 2 or more days per week during the past year; 1.3% (n = 27) reported taking higher-risk supplements. Compared with male runners, female runners reported higher use of 1 or more supplements (32.5% vs 21.7%; P < .001) and 4 or more supplements (4.0% vs 1.9%; P = 0.005), multivitamin/minerals (24.2% vs 14.4%; P < .001), vitamin D (12.4% vs 5.6%; P < .001), calcium (8.9% vs 4.8%; P < .001), iron (3.1 vs 1.1%; P < .001), probiotic supplements (8.2% vs 1.3%; P < .001), and diet pills (0.5% vs 0.0%; P = .02). Male runners reported higher use of creatine (1.3% vs 0.0%; P < .001) and sport foods, including protein bars and drinks (19.5% vs 8.4%; P < .001), energy bars (23.5% vs 9.7%; P < .001), and carbohydrate-electrolyte drinks (27.9% vs 13.3%; P < .001) than female runners. Factors independently associated with a higher likelihood for dietary supplement use included weight loss in the past year, female (vs male) gender, following a vegetarian diet, skipping meals, attempting to gain weight, and history of a running-related bone stress injury.ConclusionsMore than one-quarter of preadolescent runners regularly consumed dietary supplements. Behaviors consistent with dietary restriction and history of bone stress injury were associated with higher likelihood for supplement use. Further work to understand supplement use patterns and potential value for nutrition education is advised to optimize health of preadolescent runners.     

Time Trends in Opioid Use by Dementia Severity in Long-Term Care Nursing Home Residents

ObjectiveCurrent information on opioid use in nursing home residents, particularly those with dementia, is unknown. We examined the temporal trends in opioid use by dementia severity and the association of dementia severity with opioid use in long-term care nursing home residents.DesignRepeated measures cross-sectional study.SettingLong-term care nursing homes.ParticipantsUsing 20% Minimum Data Set (MDS) and Medicare claims from 2011-2017, we included long-term care residents (n = 734,739) from each year who had 120 days of consecutive stay. In a secondary analysis, we included residents who had an emergency department visit for a fracture (n = 12,927).MeasurementsDementia was classified as no, mild, moderate, and severe based on the first MDS assessment each year. In the 120 days of nursing home stay, opioid use was measured as any, prolonged (>90 days), and high-dose (≥90 morphine milligram equivalent dose/day). For residents with a fracture, opioid use was measured within 7 days after emergency department discharge. Association of dementia severity with opioid use was evaluated using logistic regression.ResultsOverall, any opioid use declined by 8.5% (35.2% to 32.2%, P < .001), prolonged use by 5.0% (14.1% to 13.4%, P < .001), and high-dose by 21.4% (1.4% to 1.1%, P < .001) from 2011 to 2017. Opioid use declined across 4 dementia severity groups. Among residents with fracture, opioid use declined by 9% in mild, 9.5% in moderate, and 12.3% in severe dementia. The odds of receiving any, prolonged, and high-dose opioids decreased with increasing severity of dementia. For example, severe dementia reduced the odds of any [23.5% vs 47.6%; odds ratio (OR) 0.56, 95% confidence interval (CI) 0.55-0.57], prolonged (9.8% vs 20.7%; OR 0.69, 95% CI 0.67-0.71), and high-dose (1.0% vs 2.3%; OR 0.69, 95% CI 0.63-0.74) opioids.Conclusions and ImplicationsUse of opioids declined in nursing home residents from 2011 to 2017, and the use was lower in residents with dementia, possibly reflecting suboptimal pain management in this population.