Do impaired older persons with health care needs occupy U.S. assisted living facilities? An analysis of six national studies

OBJECTIVES: The assisted living facility (ALF) is the fastest-growing noninstitutional long-term care alternative for frail older persons in the United States. This analysis assesses the extent to which older persons with physical and cognitive disabilities and health care needs occupy ALFs in the United States. METHODS: Information on study design and six indicators of the occupancy patterns of older persons in ALFs were abstracted from six national studies. The collected data were based on reports by the administrators of ALFs. RESULTS: The six reviewed studies had several methodologic weaknesses, resulting in different statistical populations of ALFs, samples with very different numerical and attribute properties, and findings based on disparate indicators. The older residents in ALFs were less physically and cognitively impaired than those in nursing homes. ALF facilities were more likely to admit or retain frail older persons when they had relatively minor or less serious physical or cognitive impairment or health care needs. DISCUSSION: ALFs are currently serving older residents who require less nursing care and who are less functionally and cognitively impaired than those found in nursing homes. The more restrictive admitting and discharge criteria of a substantial share of ALFs guarantee their less frail occupant profile. This is, however, an extraordinarily diverse shelter and care alternative, and very frail older persons with serious chronic health problems can be found in ALFs. Average duration of stays may be as long as 3 years. Researchers must conduct more carefully executed studies with replicable methodologies that produce unbiased and generalized findings.     

The association between specific nurse case management interventions and elder health

OBJECTIVES: To describe the association between specific nursing interventions performed in the context of nurse case management and older people's quality of life and functional ability. DESIGN: Longitudinal. SETTING: Nurse case management through a university hospital and two community health centers. PARTICIPANTS: One hundred seventy-five community-dwelling frail older persons (> or =70 and at risk for repeated hospitalizations). MEASUREMENTS: Specific groups of nursing interventions provided in the context of nurse case management over a 10-month period--coping assistance, lifespan care, risk management, and physical comfort promotion--were focused on. These interventions were recorded using a standardized nursing language. Outcomes were measured using telephone and home interview and medical record review using the 36-item Short Form and the Older American Resources and Services Multidimensional Functional Assessment Questionnaire. RESULTS: Older people receiving coping assistance interventions demonstrated an increase in instrumental activity of daily living functioning although they had lower general health, role-emotional, and mental health scores. CONCLUSION: Coping assistance is one nursing intervention of several provided in the context of nurse case management that is independently associated with improving the functional status of frail older persons even in the presence of declining health normally associated with aging over several months. Examining the relationships between specific nursing activities and health outcomes of frail older persons may be useful in furthering understanding of the results of randomized trials of nurse case management in this population.     

The influence of protein-calorie malnutrition on quality of life in nursing homes

BACKGROUND: Up to 85% of the older adults living in our nation's nursing homes suffer from protein-calorie malnutrition (PCM). Early identification and treatment of PCM can reduce or prevent hospital stays, reduce complications, and decrease mortality. We describe the influence of PCM on quality of life in nursing homes, using archived data from the Minimum Data Set. METHODS: The study was guided by the Quality Nutrition Outcomes-Long Term Care Model, which posits a pathway whereby organizational issues influence nutritional status, consisting of body mass index (BMI), serum albumin levels, and prealbumin levels, and subsequent quality of life, morbidity, and health care utilization. A cross-sectional design was used to analyze Minimum Data Set assessment data already collected from a previous study. The sample for this analysis was 311 nursing home residents, aged 65 years or older, who lived in three nursing homes in eastern Washington. RESULTS: Of the participants, 38.6% were malnourished. PCM (measured by BMI) influenced quality of life for these residents in that there was a significant relationship between BMI and functional status (eating, personal hygiene, and toilet use) and BMI and psychosocial well-being (initiative or involvement, unsettled relationships, and past roles). Depression was not a significant indicator of low BMI in these nursing home residents. CONCLUSIONS: Low BMI, indicating PCM, was found to negatively influence quality of life in this study. Understanding the relationship between quality of life and PCM could lead to improved quality of life for older adults in nursing homes and guide future innovative intervention studies aimed at preventing PCM.     

Standards of medical care for nursing home residents in Europe

ObjectiveNursing home inhabitants represent the most vulnerable and frail group of older people. They have more complex medical backgrounds and more significant care requirements. With an ever-ageing European population, the number of people requiring nursing home care will only increase. It is important then that we optimise the medical care of older people living in nursing homes.MethodsFormalized care standards are essential to optimal care but we feel that such guidelines are lacking. We decided to investigate this by means of a survey on nursing home care standards sent to the geriatric medicine societies around Europe.ResultsOnly five of 25 (20%) health services have a requirement for specific training in geriatric medicine for doctors in nursing homes, while only three of 25 (12%) countries have written medical care standards applicable to nursing home care provided by professional organizations. Four of 25 (16%) had a nursing home doctor society and one of these, The Netherlands, provided written medical care standards for nursing homes which were also adopted by the relevant general practitioner society.DiscussionThe Europe-wide deficiency of documented care standards for nursing homes is alarming. It should be a prerequisite that physicians dealing with these complex patients have undertaken some level of specific training in geriatric medicine. It is important that geriatricians, old age psychiatrists and family doctors across European countries engage more formally on the development of appropriate models for both developing care standards and specifying appropriate training and support for doctors working in nursing homes.     

Effect of statin (HMG-Co-A-Reductase Inhibitor) use on 1-year mortality and hospitalization rates in older patients with cardiovascular disease living in nursing homes

OBJECTIVES: To quantify the effect of statins on 1-year mortality, hospitalizations, and decline in physical function among patients with cardiovascular disease (CVD) aged 65 and older living in nursing homes. DESIGN: Retrospective cohort study. SETTING: All Medicare/Medicaid certified nursing homes (N = 1,492) in Maine, New York, Mississippi, and South Dakota. PARTICIPANTS: We identified 51,559 older patients with CVD from a population database that merged sociodemographic data and functional, clinical, and drug treatments from more than 300,000 newly admitted nursing home residents from 1992 to 1997. Statin users (n = 1,313) were matched with nonusers (n = 1,313) in the same facilities. MEASUREMENTS: All-cause mortality, hospitalization, combined endpoint of mortality or hospitalization, and decline in physical function were determined at 1 year, and survival analysis was performed. RESULTS: Prevalence of statin use in this frail older cohort with CVD was 2.6%. Statin use varied by age, gender, comorbid condition, medication use, and cognitive and physical function. One-year mortality was 229/1,000 person-years in the statin group and 404/1,000 person-years in the nonusers, with an adjusted hazard rate ratio (HRR) of 0.69, 95% confidence interval (CI) = 0.58-0.81. The estimated number needed to treat was seven (95% CI = 5-13). This association with improved all-cause mortality was evident for women and men and for age groups 75 to 84, and 85 and older. CONCLUSION: Statin therapy is associated with improved clinical outcomes, including reduction in 1-year all-cause mortality, and the combined endpoint of death or hospitalization in a frail older population with CVD. Some caution should be taken in interpreting these results because potential bias from residual confounding could affect these results.     

The effect of urinary incontinence on quality of life in older nursing home residents

OBJECTIVES: To determine whether nursing home residents with urinary incontinence (UI) have worse quality of life (QoL) than continent residents, whether the relationship between UI and QoL differs across strata of cognitive and functional impairment, and whether change in continence status is associated with change in QoL. DESIGN: Retrospective cohort study using a Minimum Data Set (MDS) database to determine cross-sectional and longitudinal (6 month) associations between UI and QoL. SETTING: All Medicare- or Medicaid-licensed nursing homes in Kansas, Maine, Mississippi, New York, and South Dakota during 1994 to 1996. PARTICIPANTS: All residents aged 65 and older, excluding persons unable to void or with potentially unstable continence or QoL status (recent nursing home admission, coexistent delirium, large change in functional status, comatose, near death). MEASUREMENTS: UI was defined as consistent leakage at least twice weekly over 3 months and continence as consistent dryness over 3 months. QoL was measured using the validated MDS-derived Social Engagement Scale. RESULTS: Of 133,111 eligible residents, 90,538 had consistent continence status, 58,850 (65%) of whom were incontinent. UI was significantly associated with worse QoL in residents with moderate cognitive and functional impairment. New or worsening UI over 6 months was associated with worse QoL (odds ratio = 1.46, 95% confidence interval = 1.36-1.57) and was second only to cognitive decline and functional decline in predicting worse QoL. CONCLUSION: This is the first study to quantitatively demonstrate that prevalent and new or worsening UI decreases QoL even in frail, functionally and cognitively impaired nursing home residents. These results provide a crucial incentive to improve continence care and quality in nursing homes and a rationale for targeting interventions to those residents most likely to benefit.     

Aging, Prospective Memory, and Health-Related Quality of Life in HIV Infection

HIV infection and older age are each independently associated with lower health-related quality of life (HRQoL) and deficits in prospective memory (PM), which is a distinct aspect of cognition involving the ability to “remember to remember” to do something at a future occasion. The present study investigated associations between PM and HRQoL in 72 older (≥50 years) and 41 younger (≤40 years) HIV-infected adults. Self-reported PM complaints predicted HRQoL across the entire sample, but there was a significant interaction between performance-based PM and age group on HRQoL, such that lower time-based PM was associated with lower HRQoL only in the younger cohort. Within the younger group, time-based and self-reported PM significantly predicted mental HRQoL independent of other risk factors (e.g. depression). These findings suggest that PM plays a unique role in HRQoL outcomes among younger persons living with HIV infection and support the examination of other age-related factors (e.g. effective use of compensatory strategies) that may regulate the adverse impact of PM on everyday functioning.     

Successful Cognitive Aging and Health-Related Quality of Life in Younger and Older Adults Infected with HIV

Neurocognitive impairments commonly occur and adversely impact everyday functioning in older adults infected with HIV, but little is known about successful cognitive aging (SCA) and its health-related quality of life (HRQoL) correlates. Seventy younger (≤40 years) and 107 older (≥50 years) HIV+ adults, as well as age-matched seronegative comparison groups of younger (N = 48) and older (N = 77) subjects completed a comprehensive battery of neuropsychological, psychiatric, medical, and HRQoL assessments. SCA was operationalized as the absence of both performance-based neurocognitive deficits and self-reported symptoms (SCA-ANDS) as determined by published normative standards. A stair-step decline in SCA-ANDS was observed in accordance with increasing age and HIV serostatus, with the lowest rates of SCA-ANDS found in the older HIV+ group (19 %). In both younger and older HIV+ adults, SCA-ANDS was strongly related to better mental HRQoL. HIV infection has additive adverse effects on SCA, which may play a unique role in mental well-being among HIV-infected persons across the lifespan.     

Interdisciplinary End-of-Life Care in Nursing Homes

ABSTRACT

About 25% of deaths in the United States now occur in nursing homes, and this proportion is increasing. Current end-of-life (EOL) care in these facilities faces substantial challenges, including under-management of pain, dyspnea, and other symptoms, a clash of cultures between palliative care/hospice teams and the nursing facility, and reimbursement policy that discourages the use of hospice. For ethnic minorities, these challenges are more striking. Improvement in EOL care in nursing homes requires integration between the traditional rehabilitative/restorative mission of long-term care and the palliative model of hospice. Education, better utilization of hospice, cooperation in quality improvement, and changes in reimbursement policy will lead to better care for these increasingly frail and elderly patients.     

Housing for the elderly in Taiwan

Traditionally, the care of elderly persons was the responsibility of families. However, the structure of families is changing, while the number of aged persons, particularly the frail elderly, is rising. The current living arrangements in housing include living in multigenerational dwellings, family dwellings and institutions or collective dwellings. Frail elderly in need of long-term care live in nursing homes. In the future, housing options must have better space standards and must be barrier-free. Elderly residents must have access to support services and health services in the community. There is a growing demand for institutions and nursing homes because of the special care needs of the frail elderly. A Commissioner of the National Council on Ageing Welfare.     

Outcomes of care within a multiple-case study in the evaluation of the experimental National Health Service nursing homes

This paper reports outcome data from a multiple-case study of the three experimental NHS nursing homes and six hospital wards undertaken as part of the evaluation of the experimental NHS nursing homes. While all subjects were very frail, NHS nursing home residents were found to be less frail than those in hospital wards. Significant differences in favour of the NHS nursing homes were found in the proportion of subjects engaged in meaningful activity during the mornings and afternoons, in the amount of activity and contact with others during the hour preceding lunchtime, and in amount of verbal interactions over lunchtime, particularly when choices were offered. These outcome data support the findings of other studies carried out as part of the evaluation that there is no evidence to imply that continuing-care accommodation should not be provided in NHS nursing homes.     

Length of stay in VA nursing homes. Comparative characteristics of brief-, medium-, and long-stay residents

To examine the patterns and determinants of length of stay among residents of nursing homes of the Department of Veterans Affairs (VA), the authors conducted a retrospective follow-up study of all persons (n = 4,918) admitted to VA nursing homes between October 1986, and April 1987, using computerized records of the VA. Brief-stay (< 1 month; n = 1,139) residents had most often had previous admissions to VA nursing homes and were usually discharged alive from the nursing home. Medium-stay (1-6 months; n = 1,947) residents were the least functionally impaired and most likely to receive rehabilitative services. Long-stay residents (> 6 months; n = 1,832) were older and more functionally impaired than other residents. Medium- and long-stay residents of VA nursing homes most resembled "short-" and "long-stay" residents among non-VA nursing home residents, respectively. Brief-stay residents may be persons admitted for "respite" services or may be serial users of both VA and non-VA health services. Further study of this population may identify opportunities to decrease "revolving-door" use of nursing home services.     

An Expert Opinion from the European College of Gerodontology and the European Geriatric Medicine Society: European Policy Recommendations on Oral Health in Older Adults

This is an expert opinion paper on oral health policy recommendations for older adults in Europe, with particular focus on frail and care‐dependent persons, that the European College of Gerodontology (ECG) and the European Geriatric Medicine Society (EUGMS) Task and Finish Group on Gerodontology has developed. Oral health in older adults is often poor. Common oral diseases such as caries, periodontal disease, denture‐related conditions, hyposalivation, and oral pre‐ and cancerous conditions may lead to tooth loss, pain, local and systemic infection, impaired oral function, and poor quality of life. Although the majority of oral diseases can be prevented or treated, oral problems in older adults remain prevalent and largely underdiagnosed, because frail persons often do not receive routine dental care, due to a number of barriers and misconceptions. These hindrances include person‐related issues, lack of professional support, and lack of effective oral health policies. Three major areas for action are identified: education for healthcare providers, health policy action plans, and citizen empowerment and involvement. A list of defined competencies in geriatric oral health for non‐dental healthcare providers is suggested, as well as an oral health promotion and disease prevention protocol for residents in institutional settings. Oral health assessment should be incorporated into general health assessments, oral health care should be integrated into public healthcare coverage, and access to dental care should be ensured.     

An overview of diabetes mellitus in older persons.

Diabetes mellitus is very common in older persons. Changes in exercise habits, body habitus, leptin, amylin, tumor necrosis factor alpha, and nitric oxide all play a role in the pathogenesis of age-related insulin resistance. In older persons elevated glucose levels not only produce retinopathy, neuropathy, and nephropathy but also decrease quality of life, pain tolerance, cognition, and functional status and increase injurious falls, nocturia, incontinence, pressure ulcers, and orthostatic hypotension. The availability of multiple new therapies has enhanced the ability of physicians to improve glycemic control in older persons without unacceptable levels of hypoglycemia. Caregivers play an important role in the management of older diabetics. Depression increases mortality rate and hospital admissions in older diabetics. In many nursing homes the quality of diabetic care is marginal. A new causative theory of the metabolic syndrome involving cytokines and nitric oxide-the NO cytokine theory-is proposed.     

Future issues for the long-term care insurance system in Japan

Although the prevention and reduction of requirements for long-term care is one of the main aims of the long-term care insurance system, most of care-recipients have deteriorated in their certified care levels since the implementation of the system in 2000. Demands for services at facilities rather than in-home services are increasing. Waiting lists for public nursing homes are becoming longer and longer. Residential care in for-profit private homes is growing rapidly. Homicides of disabled older persons by their exhausted caregivers are still prevalent. Concerning these serious situations, retaining the human dignity of care-recipients should be the most essential issue of the long-term care insurance system.     

Functional disability of older persons in long-term care facilities in Korea

The aim of this study was to examine functional disability of older persons in long-term care facilities and to identify factors associated with their levels of functioning. The first national survey of older residents in nursing and residential care homes in Korea was conducted in 1999. Of the 1105 respondents who completed the interview 73% in residential care homes and 88% in nursing homes reported limitations in functioning. The percentage of persons with three or more limitations in activities of daily living (ADL) was 63% among nursing home residents and 36% among those at residential care homes. Overall, persons of older age, female, widowed, with less family support, and bearing out-of-pocket costs of medical care tended to show higher levels of disability. Presence of arthritis, hypertension, and stroke was found to be significantly associated with increased likelihood of disability. Multivariate analysis revealed variability in the associations by type of facility. Characteristics such as older age, women, and stroke were significantly associated with a higher likelihood of disability for those in both residential and nursing homes. Arthritis, fracture, exercise, and contact with family members, however, were found to be independently associated with disability among those in residential care homes only. Recent government proposals to improve care delivered to long-term care residents need to take into account their differing levels of functional disability and its associated care needs.     

Nursing homes: a suitable alternative to hospital care for older people in the UK?

Over the past two decades nursing homes have become the major supplier of long-stay care for frail older people in the UK. Demographic projections indicate that the volume of nursing home places will continue to increase to keep pace with demand and that the population of homes will become steadily more dependent. Little systematic research exists to indicate how nursing home care compares with hospital care; the evidence that does exists tends to be restricted to local studies and thus is not generalizable. Local studies indicate that in both care settings there are shortfalls in terms of meeting basic quality of care standards. Despite this, there is obvious potential for nursing homes to act as an alternative to hospitalization, provided that there is suitable access for residents to specialist care and, for example, appropriate administration of medicines. Proposed changes in government policy will introduce more uniform standards in nursing homes and associated inspection structures and procedures. However, further research is needed to ascertain the clinical and consumer value of different interventions in nursing homes, and the cost-benefit of enhancing provision available in terms of preventing or forestalling demand on hospitals or reducing hospital length of stay. In the light of the commitment to develop evidence based practice, it is important that such research is urgently advanced to eliminate poor practice. In our rights conscious society, future generations of older people are unlikely to be as tolerant of substandard care.     

Intergenerational Relationships and Family Care and Support for Thai Elderly

Intergenerational relations between older age parents and their children remain pervasive in Thailand. Over 70% of older persons live with or next to a child. Material assistance from children remains substantial. Desertion of elderly parents is quite rare. Family members, particularly children, are the main persons providing assistance to frail older persons. Nevertheless, co-residence with children has declined and living alone or only with a spouse has increased. Given projected smaller family sizes of future cohorts of older persons and the increasing migration of their children, these trends are certain to continue. Widespread access to telephones helps elderly parents to maintain social contact with distant children. Still, reduced numbers of adult children and their increased migration pose challenges for personal care of the elderly. Clearly adaptations by family and state are needed if the quality of life of Thai elders is to continue to improve.     

Epidemiology and management of end-stage renal disease in the elderly

Elderly patients with end-stage renal disease (ESRD) are at increased risk of developing aging-related problems, such as frailty, impaired physical function, falls, poor nutrition and cognitive impairment. These factors affect dialysis outcomes, which can be very poor in frail, elderly patients who often experience a decline in overall health and physical function and have short survival. The default treatment option for these patients is hospital-based hemodialysis, often with little consideration of how this modality will affect the survival or quality of life of individual patients. A comparison of quality of life of elderly patients on hemodialysis versus peritoneal dialysis shows that those on peritoneal dialysis have less illness intrusion. Assisted peritoneal dialysis enables a greater number of frail, elderly patients to have dialysis in their own homes. Dialysis may not extend survival for those with multiple comorbidities, so conservative care (nondialysis treatment) should be considered. To improve the outcomes of elderly patients with ESRD, it is necessary to develop a realistic approach to overall prognosis, quality of life and how the patient copes with the disabilities associated with aging. This approach includes having discussions regarding choice of treatment and end-of-life goals with patients and families.