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.     

To What Extent Do Local Nursing Home Prescribing Patterns Relate to Psychotropic Prescribing in Assisted Living?

ObjectiveIn nursing homes (NHs), psychoactive medication use has received notable attention, but less is known about prescribing in assisted living (AL). This study examined how antipsychotic and antianxiety medication prescribing in AL compares with NHs.DesignObservational, cross-sectional AL data linked to publicly reported NH measures.Setting and ParticipantsRandom sample of 250 AL communities and the full sample of 3371 NHs in 7 states.MethodsWe calculated the percentage of residents receiving antipsychotics and antianxiety medications. For each AL community, we calculated the distance to NHs in the state. Linear models estimated the relationship between AL prescribing and that of the closest and farthest 5 NHs, adjusting for AL characteristics and state fixed effects.ResultsThe prescribing rate of potentially inappropriate antipsychotics (i.e., excluding for persons with recorded schizophrenia and Tourette syndrome) and of antianxiety medications (excluding for those on hospice) in AL was 15% and 21%, respectively. Unadjusted mean antipsychotic prescribing rates were nominally higher in AL than NHs (14.8% vs 14.6%; P = .056), whereas mean antianxiety prescribing was nominally lower in AL (21.2% vs 22.6%; P = .032). In adjusted analyses, AL rates of antipsychotic use were not associated with NH rates. However, being affiliated with an NH was associated with a lower rate of antipsychotic use [b = −0.03; 95% confidence interval (CI) −0.50 to −0.001; P = .043], whereas antianxiety rates were associated with neighboring NHs’ prescribing rates (b = 0.43; 95% CI 0.16–0.70; P = .002).Conclusions and ImplicationsThis study suggests reducing antipsychotic medication use in NHs may influence AL practices in a way not accounted for by local NH patterns. And, because antianxiety medications have not been the focus of national campaigns, they may be more subject to local prescribing behaviors. It seems advantageous to consider prescribing in AL when efforts are implemented to change NH prescribing, as there seems to be related influence whether by affiliation or region.     

Quality and Safety in Long-Term Care in Ontario: The Impact of Language Discordance

ObjectivesThis study compared quality indicators across linguistic groups and sought to determine whether disparities are influenced by resident-facility language discordance in long-term care.DesignPopulation-based retrospective cohort study using linked databases.Setting and ParticipantsRetrospective cohort of newly admitted residents of long-term care facilities in Ontario, Canada, between 2010 and 2016 (N=47,727). Individual residents' information was obtained from the Resident Assessment Instrument Minimum Data Set (RAI-MDS) to determine resident's primary language, clinical characteristics, and health care indicators.MeasuresMain covariates of interest were primary language of the resident and predominant language of the long-term care facility, which was determined using the French designation status as defined in the French Language Services Act. Primary outcomes were a set of quality and safety indicators related to long-term care: worsening of depression, falls, moderate-severe pain, use of antipsychotic medication, and physical restraints. Multivariable logistic regression models were used to assess the impact of resident's primary language, facility language, and resident-facility language discordance on each quality indicator.ResultsOverall, there were few differences between francophones and anglophones for quality and safety indicators. Francophones were more likely to report pain (10.9% vs 9.9%; P = .001) and be physically restrained (7.3% vs 5.2%; P < .001), whereas a greater proportion of anglophones experienced worsening of depressive symptoms (24.0% vs 22.9%; P = .001). However, quality indicators were generally worse for francophones in Non-Designated facilities, except for pain, which was more commonly reported by francophones in French-Designated facilities. Anglophones were more likely to be physically restrained in French-Designated facilities (6.7% vs 5.1%; P < .001).Conclusions and ImplicationsFor francophones, quality indicators tended to be worse in the presence of resident-facility language discordance. However, these findings did not persist after adjusting for individual- and facility-level characteristics, suggesting that the disparities observed at the population level cannot be attributed to linguistic factors alone.     

Defining the Core Skills and Activities of the Attending Physician in Post-Acute and Long-Term Care

The American Board of Post-Acute and Long-Term Care Medicine (ABPLM) contracted with a psychometric firm to perform a 3-phase Job Analysis following best practices. Literature was reviewed, a task force of subject matter experts was convened, a survey was developed and sent via Survey Monkey to attending physicians practicing in post-acute and long-term care settings (PALTC). The task force refined a comprehensive list of the tasks, knowledge, and medical knowledge needed in the role of attending physician in PALTC. These items were written as statements and edited until consensus was reached on their accuracy, conciseness, and lack of overlap. Task statements described distinct, identifiable, and specific practice-related activities relevant across multiple care settings. Knowledge statements described previously acquired information considered necessary to effectively perform such tasks. The survey consisted of 260 items, including 21 demographic questions, 115 task statements, 73 knowledge statements, and 72 medical knowledge statements. The survey was disseminated via e-mail invitations to Society for Post-Acute and Long-Term Care (AMDA) members and through an online link available through ABPLM’s website. A total of 389 respondents participated. Survey data were analyzed with statistical analysis software SPSS. For each task and knowledge statement, an Overall Task Rating and Knowledge Rating were developed by combining the importance rating weighted at 65% and (for task) the frequency rating or (for knowledge) the cognitive level weighted at 35%. One task statement and 1 medical knowledge statement had a mean importance rating lower than 2.5 and were dropped from further review, resulting in a final count of 114 task, 73 knowledge, and 71 medical knowledge statements (258 total). The results of this Job Analysis highlight the unique and specific nature of medical care provided by attending physicians across a range of PALTC settings. These findings lay a foundation for Focused Practice Designation or Subspecialty in PALTC and changes in practice and policy.     

Reimagining Nutrition Care and Mealtimes in Long-Term Care

Poor food and fluid intake and subsequent malnutrition and dehydration of residents are common, longstanding challenges in long-term care (LTC; eg, nursing homes, care homes, skilled nursing facilities). Institutional factors like inadequate nutrition care processes, food quality, eating assistance, and mealtime experiences, such as staff and resident interactions (ie, relationship-centered care) are partially responsible and are all modifiable. Evidence-based guidelines on nutrition and hydration for older adults, including those living with dementia, outline best practices. However, these guidelines are not sector-specific, and implementation in LTC requires consideration of feasibility in this setting, including the impact of government, LTC home characteristics, and other systems and structures that affect how care is delivered. It is increasingly acknowledged that interconnected relationships among residents, family members, and staff influence care activities and can offer opportunities for improving resident nutrition. In this special article, we reimagine LTC nutrition by reframing the evidence-based recommendations into relationship-centered care practices for nutrition care processes, food and menus, eating assistance, and mealtime experience. We then expand this evidence into actions for implementation, rating these on their feasibility and identifying the entities that are accountable. A few of the recommended activities were rated as highly feasible (6 of 27), whereas almost half were rated moderate (12/27) and the remainder low (9/27) owing to the need for additional staff and/or expert staff (including funding), or infrastructure or material (eg, food ingredients) investment. Government funding, policy, and standards are needed to improve nutrition care. LTC home leadership needs to designate roles, initiate training, and support best practices. Accountability will result from enforcement of policies through auditing of practice. Further evidence on these desirable nutrition care and mealtime actions and their benefit to residents’ nutrition and well-being is required.     

Long-Term Care Facilities (LTCFs) During the COVID-19 Pandemic—Lessons From the Asian Approach: A Narrative Review

ObjectivesThe COVID-19 pandemic put into question the organizational skills of LTCF. The containment measures implemented in several Asian countries avoided heavy death tolls in LTCF in contrast to other countries across the globe. The aim of this review is therefore to investigate and illustrate the measures that were undertaken in Asia to contain and prevent the spread of the COVID-19 pandemic in LTCF.DesignNarrative review.Setting and ParticipantsAsian older subjects institutionalized in LTCF.MethodsBroad literature research from July 2020–April 2021. The following search terms were used: “COVID-19 Nursing homes” AND the country of interest or “contact tracing.” Eligible categories for inclusion comprise editorials, reviews, government guidelines, letters to the editor, and perspectives. The COVID-19 measures were then subdivided into different sections and compiled into an evidence table.ResultsPrompt measures were put into action since the beginning of the pandemic that avoided the spread of COVID-19 in LTCF. Examples range from simple acts of proper hand hygiene and environmental disinfection, swab testing, social distancing, preventive measures on health care workers, organizational measures such as quarantine, outbreak control, visitor restrictions, relationship with acute hospitals, and admission policy. Technology also played a fundamental role in promoting social distancing by using specific robots and in managing contact tracing.Conclusions and ImplicationsThe Asian preventive control guidelines are similar to those recommended elsewhere. Difference in timing and past experience with prior outbreaks such as SARS and MERS might have favored the Asian response. Furthermore, sociocultural values toward older persons by protecting and making sure that LTCF are part of the health care system could have also played a role.     

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.     

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

ObjectivesTo estimate the prevalence of probable delirium in long-term care (LTC) and complex continuing care (CCC) settings and to describe the resident characteristics associated with probable delirium.DesignPopulation-based cross-sectional study using routinely collected administrative health data.Setting and ParticipantsAll LTC and CCC residents in Ontario, Canada, assessed with the Resident Assessment Instrument–Minimum Dataset (RAI-MDS) assessment between July 1, 2016, and December 31, 2016 (LTC n=86,454, CCC n=10,217).MethodsProbable delirium was identified via the delirium Clinical Assessment Protocol on the RAI-MDS assessment, which is triggered when individuals display at least 1 of 6 delirium symptoms that are of recent onset and different from their usual functioning. RAI-MDS assessments were linked to demographic and health services utilization databases to ascertain resident demographics and health status. Multivariable logistic regression was used to identify characteristics associated with probable delirium, with adjusted odds ratios (ORs) and 95% confidence intervals (CIs) reported.ResultsDelirium was probable in 3.6% of LTC residents and 16.5% of CCC patients. LTC patients displayed fewer delirium symptoms than CCC patients. The most common delirium symptom in LTC was periods of lethargy (44.6% of delirium cases); in CCC, it was mental function varying over the course of the day (63.5% of delirium cases). The odds of probable delirium varied across individual demographics and health characteristics, with increased health instability having the strongest association with the outcome in both care settings (LTC: OR 30.4, 95% CI 26.2-35.3; CCC: OR 21.0, 95% CI 16.7-26.5 for high vs low instability).Conclusions and ImplicationsThere were differences in the presentation and burden of delirium symptoms between LTC and CCC, potentially reflecting differences in delirium severity or symptom identification. Several risk factors for probable delirium in LTC and CCC were identified that may be amenable to interventions to prevent this highly distressing condition.     

Assessing Residents’ Perceptions of Their Relocation to Long-Term Care: Psychometric Validation of the View of Relocation Scale

ObjectivesRelocation to long-term care is a major challenge for older people. The View of Relocation Scale (VRS) was developed to address the need for a brief instrument to assess residents’ perceptions of the relocation.DesignSecondary analysis of data collected in a cluster randomized trial. The psychometric properties of the VRS examined in this study included factorial structure (using exploratory factor analysis), unidimensionality (Rasch modeling), internal consistency reliability (Kuder-Richardson Formula 20, squared multiple correlations, and item-total correlations), and known groups validity (analysis of variance). The results were used to identify the psychometrically most robust items for inclusion into the final version of the instrument.Setting and ParticipantsParticipants were 202 long-term care residents in Melbourne, Australia (mean age = 85.52 years, standard deviation = 7.33), who had relocated to the facility a mean of 4.4 weeks previously. Residents with moderately severe and severe dementia were excluded.MeasuresThe VRS was developed following a review of the literature describing residents’ views of relocation and was designed for administration shortly after their relocation.ResultsThere was support for a 2-factor, 10-item solution, with separate subscales assessing Perceived Control (degree of control in the decision making and planning for the relocation) and Perceived Need (perceived need for the relocation to long-term care). Participants who were admitted directly from hospital reported higher perceived need but lower perceived control than those admitted to the facility from home.Conclusion and ImplicationsThe VRS can be used to understand the impact of older people's perceptions of relocation to long-term care on their subsequent adjustment and well-being, and to identify those who may benefit from tailored support.     

嘎木朱尔涂膜剂的毒性试验研究

目的：为使嘎木朱尔涂膜剂的临床用药安全、合理,而对其毒性作用进行了考察。方法：将嘎木朱尔涂膜剂分为高、中、低三个剂量组（按其浓度为0．172g/ml,0.086g/ml,0.043g/ml）给药,用于家兔皮肤,同时做空白基质对照,测定其涂膜剂对家兔皮肤的急性毒性、长期毒性试验。结果：各给药剂量组和空白基质对照组对家兔的体重增长,脏器系数（g/ml）、血液常规,生物化学等项指标的测定均无显著性差异（P＜0．05）。结论：嘎木朱尔涂膜剂用于家兔皮肤无毒并能加快受损皮肤的愈合。