Nutritional Status and the Incidence of Pneumonia in Nursing Home Residents: Results From the INCUR Study

ObjectivesTo examine the predictive value of the Mini Nutritional Assessment-short form (MNA-SF) and its individual items on the incidence of pneumonia.DesignProspective observational cohort study over 1-year of follow-up.ParticipantsA total of 773 older persons (74.4% women) living in 13 French nursing homes from the Incidence of pNeumonia and related ConseqUences in nursing home Residents (INCUR) study.MeasurementsNutritional status was assessed using the MNA-SF questionnaire at baseline. Diagnosis of pneumonia was based on clinical conditions retrieved from a medical chart. Cox proportional hazard models were applied to test whether the MNA-SF score and its single components predict pneumonia events over 1 year of follow-up.ResultsAfter 1 year of follow-up, 160 (21%) incident cases of pneumonia were recorded. Mean age of participants was 86.2 (SD 7.5) years. Mean MNA-SF score was 9.8 (SD 2.4), with more than half of the participants (58.7%) being at risk of malnutrition (8–11 points). The total MNA-SF score and its categories did not predict the studied outcome. However, a single component of the MNA-SF score, specifically decreased mobility, was a significant risk factor for pneumonia (hazard ratio 2.289; 95% confidence interval 1.357–3.860; P = .002), independently of potential confounders.ConclusionsThe total MNA-SF score did not predict the incidence of pneumonia. However, decreased mobility was a significant risk factor, implying that individual components of the MNA-SF should be more carefully explored to verify whether they might be used for detecting specific declines of the health status in nursing home residents, thus potentially improving the risk profile estimation of such a complex population.     

Frailty Screening (FRAIL-NH) and Mortality in French Nursing Homes: Results From the Incidence of Pneumonia and Related Consequences in Nursing Home Residents Study

Objectives

To investigate the ability of the fatigue, resistance, ambulation, incontinence or illness, loss of weight, nutritional approach, and help with dressing (FRAIL-NH) tool to predict mortality.

Associations Between Intrinsic Capacity and Adverse Events Among Nursing Home Residents: The INCUR Study

ObjectivesThe predictive ability of the novel intrinsic capacity (IC) construct has been scarcely investigated in the nursing home setting. The objective of this study was to investigate the associations of IC and its individual domains with mortality, hospitalization, pneumonia onset, and functional status decline in a population of nursing home residents (NHRs).DesignWe undertook an analysis using data from the INCUR study, a prospective observational study. Data were collected at baseline, at 6 and 12 months by trained staff.Setting and ParticipantsA total of 371 NHRs (mean age 85.91 ± 7.34) dwelling in Southern France.MethodsA baseline IC composite score was constructed from scores in the Short Physical Performance Battery, Abbreviated Mental Test, 10-item Geriatric Depression Scale, The Short Form of the Mini-Nutritional Assessment, and self-reported hearing and vision impairments. Adverse outcomes were registered by medical records checking. Functional status evolution was evaluated through changes in the Katz Index. Cox regression was used for associations between IC and its domains and adverse outcomes. Linear mixed models were used in the case of functional status evolution.ResultsOur analysis revealed associations between a composite score of IC and death [hazard ratio 0.33; 95% confidence interval (CI) 0.15–0.73] and functional status evolution (β = 0.14; 95% CI 0.018–0.29) in our population. Although greater values in IC vitality/nutrition domain were associated with survival (HR 0.84; 95% CI 0.70–0.99), IC cognitive domain was associated with decreased odds of hospitalization (HR 0.91; 95% CI 0.84–0.99) and lower declines in functional status (β = 0.04; 95% CI 0.01–0.07), whereas the IC locomotion domain was inversely associated with pneumonia incidence (HR 0.84; 95% CI 0.72–0.98).Conclusions and ImplicationsOur results contribute to preliminary evidence linking greater IC levels and lower risk of late-life adverse outcomes.     

Association of Polypharmacy With 1-Year Trajectories of Cognitive and Physical Function in Nursing Home Residents: Results From a Multicenter European Study

Objectives

To test the association between polypharmacy and 1-year change in physical and cognitive function among nursing home (NH) residents.

Prevalence and Correlates of Cardiovascular Medication Use Among Nursing Home Residents With Ischemic Heart Disease: Results From the SHELTER Study

ObjectivesDespite being the highest group of users of many medications, older individuals remain underrepresented in clinical trials. This leaves a gap in evidence to guide management of many conditions, such as ischemic heart disease (IHD), in this population. This study aimed to describe factors associated with IHD medication use among nursing home residents in 7 European countries and Israel to depict challenges facing disease management in this population.DesignThis study was a retrospective cohort analysis.Setting and ParticipantsThe sample included 4156 nursing home residents in the SHELTER study.MeasurementAll residents were assessed using the interRAI Long-Term Care Facility (LTCF) instrument. Use of angiotensin-converting enzyme inhibitor (ACEi) and/or angiotensin receptor blocker (ARB), beta-blocker (BB), antiaggregants (including acetylsalicylic acid [ASA]) and statins was analyzed. Based on the use of these medications, residents were classified into groups by medication use (as nonusers, 1–2 medications, or 3–4 medications). Generalized Estimation Equation modeling was used to explore predictors of medication use from items on the LTCF instrument as well as facility questionnaire.ResultsOf the 1050 residents with IHD, medication use was 77.7% overall, but only 16.9% were receiving 3 to 4 medications. Use of antiaggregants was highest at 51.7% and variations in medication use were observed by country (highest in France and lowest in Italy). Functional disability was the strongest predictor of medication use, reducing the likelihood of any or optimal management. Severe cognitive impairment also reduced the likelihood of optimal management, and comorbidity generally increased the likelihood of medication use. Polypharmacy reduced the likelihood of use of 3 to 4 medications for IHD.ConclusionOptimal management of IHD in nursing home residents was low and varied by country. Individual characteristics seemed to predict IHD medication use, suggesting prescribing bias and an effect of population differences from clinical trial cohorts.     

The Impact of Dysphagia on Mortality of Nursing Home Residents: Results From the nutritionDay Project

Objectives

Dysphagia is a frequent finding in nursing home residents. The aim of this study is to evaluate the association of dysphagia and mortality in nursing home residents and identify further risk factors for mortality in residents with dysphagia.

Advance Directive and End-of-Life Care Preferences Among Nursing Home Residents in Wuhan,China: A Cross-Sectional Study

Objectives

To describe Chinese nursing home residents' knowledge of advance directive (AD) and end-of-life care preferences and to explore the predictors of their preference for AD.

Design

Population-based cross-sectional survey.

Settings

Nursing homes (n = 31) in Wuhan, Mainland Southern China.

Participants

Cognitively intact nursing home residents (n = 467) older than 60 years.

Measures

Face-to-face questionnaire interviews were used to collect information on demographics, chronic diseases, life-sustaining treatment, AD, and other end-of-life care preferences.

Results

Most (95.3%) had never heard of AD, and fewer than one-third (31.5%) preferred to make an AD. More than half (52.5%) would receive life-sustaining treatment if they sustained a life-threatening condition. Fewer than one-half (43.3%) chose doctors as the surrogate decision maker about life-sustaining treatment, whereas most (78.8%) nominated their eldest son or daughter as their proxy. More than half (58.2%) wanted to live and die in their present nursing homes. The significant independent predictors of AD preference included having heard of AD before (odds ratio [OR] 9.323), having definite answers of receiving (OR 3.433) or rejecting (OR 2.530) life-sustaining treatment, and higher Cumulative Illness Rating Scale score (OR 1.098).

Conclusions

Most nursing home residents did not know about AD, and nearly one-third showed positive attitudes toward it. AD should be promoted in mainland China. Education of residents, the proxy decision maker, and nursing home staff on AD is very important. Necessary policy support, legislation, or practice guidelines about AD should be made with flexibility to respect nursing home residents' rights in mainland China.     

Nutritional Status and Related Factors in Elderly Nursing Home Residents: Comparative Cross-Sectional Study in Migrants and Native Germans

Former guest workers in Germany who stayed on after retirement are now older than 70 years. Nursing homes (NH) are broadening their offer to meet specific requirements of this population. The nutritional status and related problems of the older ethnic minority group living in German NH has so far not been investigated. The aim of this study was, thus, to compare the nutritional situation of older migrants to that of native residents in two “multicultural” NH (cross-sectional study). All residents 65 years and older with a migration background were enrolled and compared to nonmigrants using frequency matching for age and gender. Nutritional status was assessed using body mass index (BMI; cut-off for undernourishment: BMI < 22 kg/m²) and calf circumference (CC; CC < 31 cm). Care staff completed a questionnaire on residents' health. Consecutive 3-day food records were evaluated to analyze the intake of energy, macro-, and micronutrients.

Participants were n = 23 migrants (76 ± 6 years, 52% female) and n = 37 nonmigrants (78 ± 7 years, 59% female). Undernourishment was more prevalent in migrants according to BMI (39 vs. 11%; P < 0.05) and CC (57 vs. 22%; P < 0.05). Main nutritional problems in both groups were “loss of appetite” (56 vs. 19%; P < 0.05) and “refusal to eat” (56 vs. 25%; P < 0.05). Energy intake was low (6.4 ± 1.4, 6.8 ± 1.6 MJ/d). More than 50% of participants fell below recommended values for vitamin C, B₁, B₆, D, folate, calcium, and iron; 61% of the migrants had a low vitamin B₁₂ intake. Migrant NH residents were more often undernourished than German NH residents.     

Change in Advance Care Plans of Nursing Home Residents With Dementia and Pneumonia: Secondary Analysis of Randomized Controlled Trial Data

ObjectivesTo explore changes in advance care plans of nursing home residents with dementia following pneumonia, and factors associated with changes. Second, to explore factors associated with the person perceived by elderly care physicians as most influential in advance treatment decision making.DesignSecondary analysis of physician-reported PneuMonitor trial data.Setting and ParticipantsThe PneuMonitor trial took place between January 2012 and May 2015 in 32 nursing homes across the Netherlands; it involved 429 residents with dementia who developed pneumonia.MethodsWe compared advance care plans before and after the first pneumonia episode. Generalized logistic linear mixed models were used to explore associations of advance care plan changes with the person most influential in decision making, with demographics and indicators of disease progression. Exploratory analyses assessed associations with the person most influential in decision making.ResultsFor >90% of the residents, advance care plans had been established before the pneumonia. After pneumonia, treatment goals were revised in 15.9% of residents; 72% of all changes entailed refinements of goals. Significant associations with treatment goal changes were not found. Treatment plans changed in 20.0% of residents. Changes in treatment decisions were more likely for residents who were more severely ill (odds ratio 1.5, 95% CI 1.2-1.9) and those estimated to live <3 months (odds ratio 3.3, 95% CI 1.9-5.8). Physicians reported that a family member was often (47.4%) most influential in decision making. Who is most influential was associated with the resident’s dementia severity.Conclusions and ImplicationsOverall, changes in advance care plans after pneumonia diagnosis were small, suggesting stability of most preferences or limited dynamics in the advance care planning process. Advance care planning involving family is common for nursing home residents with dementia, but advance care planning with persons with dementia themselves is rare and requires more attention.     

Community Discharge of Nursing Home Residents: The Role of Facility Characteristics

Objective

Using a socio‐ecological model, this study examines the influence of facility characteristics on the transition of nursing home residents to the community after a short stay (within 90 days of admission) or long stay (365 days of admission) across states with different long‐term services and supports systems.

Data Source

Data were drawn from the Minimum Data Set, the federal Online Survey, Certification, and Reporting (OSCAR) database, the Area Health Resource File, and the LTCFocUs.org database for all free‐standing, certified nursing homes in California (n = 1,127) and Florida (n = 657) from July 2007 to June 2008.

Study Design

Hierarchical generalized linear models were used to examine the impact of facility characteristics on the probability of transitioning to the community.

Principal Findings

Facility characteristics, including size, occupancy, ownership, average length of stay, proportion of Medicare and Medicaid residents, and the proportion of residents admitted from acute care facilities are associated with discharge but differed by state and whether the discharge occurred after a short or long stay.

Conclusion

Short‐ and long‐stay nursing home discharge to the community is affected by resident, facility, and sometimes market characteristics, with Medicaid consistently influencing discharge in both states.     

Quality of Life and Pneumonia in Nursing Home Residents: A 1-Year Observational Study

ObjectivesTo compare the evolution of quality of life (QoL) in nursing home residents (NHRs) with and without (hospitalization for) pneumonia.DesignTwelve-month prospective, observational study.Setting and ParticipantsParticipants of the Incidence of pNeumonia and related ConseqUences in nursing home Resident (INCUR) study were included. The INCUR study included 800 NHRs in France for which comprehensive assessments were performed at baseline, 6 months, and 12 months in 2012-2013.MethodsParticipants’ health related QoL was assessed at 3 time points: baseline, 6 months, and 12 months. NHRs with or without pneumonia and hospitalizations for this condition at any time during follow-up were compared using adjusted mixed effects linear regressions on the QoL outcome. Pre- and postpneumonia QoL were compared using a Wilcoxon signed-rank test.ResultsA total of 622 NHRs (mean age 86.2 years; 73.3% women) were included; 13.8% (n = 86) died, 19.9% (n = 124) developed at least 1 episode of pneumonia and 6.4% (n = 40) were hospitalized for pneumonia. Median QoL was 70 at baseline [n = 436, interquartile range (IQR) = 50-90], 80 at 6 months (n = 546, IQR = 50-90), and 76 at 12 months (n = 468, IQR = 50-80). QoL in NHRs with pneumonia showed a 2-point decrease during the 12-month follow-up, whereas QoL in NHRs without pneumonia showed an 8-point increase during follow-up. QoL in NHR hospitalized for pneumonia showed a 16-point decrease during the 12-month follow-up, whereas QoL in NHRs in the control group showed a 6-point increase. In linear regressions, neither pneumonia nor hospitalization for pneumonia were significantly associated with the evolution of QoL during follow-up. No significant difference was found between pre- and postpneumonia QoL.Conclusions and ImplicationsQoL in NHRs remains stable over 12 months regardless of pneumonia events but seems to decline in NHRs hospitalized for pneumonia. Uncaptured short-term variations of QoL after pneumonia and/or related hospitalizations may occur.     

Nursing Home Resident Admission Characteristics and Potentially Preventable Emergency Department Transfers

ObjectivesTo determine which nursing home (NH) resident-level admission characteristics are associated with potentially preventable emergency department (PPED) transfers.DesignWe conducted a population-level retrospective cohort study on NH resident data collected using the Resident Assessment Instrument-Minimum Data Set Version 2.0 and linked to the National Ambulatory Care Reporting System for ED transfers.SettingWe used all NH resident admission assessments from January 1, 2017, to December 31, 2018, in Ontario.ParticipantsThe cohort included the admission assessment of 56,433 NH residents.MethodsPPED transfers were defined based on the International Classification of Disease, Version 10 (Canadian) We used logistic regression with 10-fold cross-validation and computed average marginal effects to identify the association between resident characteristics at NH admission and PPED transfers within 92 days after admission.ResultsOverall, 6.2% of residents had at least 1 PPED transfer within 92 days of NH admission. After adjustment, variables that had a prevalence of 10% or more that were associated with a 1% or more absolute increase in the risk of a PPED transfer included polypharmacy [of cohort (OC) 84.4%, risk difference (RD) 2.0%], congestive heart failure (OC 29.0%, RD 3.0%), and renal failure (OC 11.6%, RD 1.2%). Female sex (OC 63.2%, RD -1.3%), a do not hospitalize directive (OC 24.4%, RD -2.6%), change in mood (OC 66.9%, RD -1.2%), and Alzheimer's or dementia (OC 62.1%, RD -1.2%) were more than 10% prevalent and associated with a 1% or more absolute decrease in the risk of a PPED.Conclusions and ImplicationsThough many routinely collected resident characteristics were associated with a PPED transfer, the absence of sufficiently discriminating characteristics suggests that emergency department visits by NH residents are multifactorial and difficult to predict. Future studies should assess the clinical utility of risk factor identification to prevent transfers.     

Nursing Assistant Beliefs About Their Roles and Nursing Home Residents: Implications for Nursing Home Social Work Practice

The purpose of this study is to examine beliefs and assumptions held by nursing assistants working in nursing homes using a qualitative approach. Unchallenged notions about residents and the roles held by nursing assistants influence their way of interacting with residents, which inevitably influences quality of care in nursing homes. When nursing assistants have an opportunity to be heard and mentored by social workers, they can address and resolve the dilemma of providing informal care as a formal caregiver by discussing what is acceptable and appropriate in nursing home care.     

Deprescribing in Nursing Home Residents on Polypharmacy: Incidence and Associated Factors

ObjectivesTo assess 1-year incidence and factors related to deprescribing in nursing home (NH) residents in Europe.DesignLongitudinal multicenter cohort study based on data from the Services and Health for Elderly in Long TERm care (SHELTER) study.SettingNHs in Europe and Israel.Participants1843 NH residents on polypharmacy.MethodsPolypharmacy was defined as the concurrent use of 5 or more medications. Deprescribing was defined as a reduction in the number of medications used over the study period. Residents were followed for 12 months.ResultsResidents in the study sample were using a mean number of 8.6 (standard deviation 2.9) medications at the baseline assessment. Deprescribing was observed in 658 residents (35.7%). Cognitive impairment (mild/moderate impairment vs intact, odds ratio [OR] 1.41, 95% confidence interval [CI] 1.11-1.79; severe impairment vs intact, OR 1.60, 95% CI 1.23-2.09), presence of the geriatrician within the facility staff (OR 1.41, 95% CI 1.15-1.72), and number of medications used at baseline (OR 1.10, 95% CI 1.06-1.14) were associated with higher probabilities of deprescribing. In contrast, female gender (OR 0.76, 95% CI 0.61-0.96), heart failure (OR 0.69, 95% CI 0.53-0.89), and cancer (OR 0.64, 95% CI 0.45-0.90) were associated with a lower probability of deprescribing.Conclusions and ImplicationsDeprescribing is common in NH residents on polypharmacy, and it is associated with individual and organizational factors. More evidence is needed on deprescribing, and clear strategies on how to withdraw medications should be defined in the future.     

Staff Training Interventions to Improve End-of-Life Care of Nursing Home Residents: A Systematic Review

ObjectivesThe aim was to review evidence from all randomized controlled trials (RCTs) using palliative care education or staff training as an intervention to improve nursing home residents' quality of life (QOL) or quality of dying (QOD) or to reduce burdensome hospitalizations.DesignA systematic review with a narrative summary.Setting and ParticipantsResidents in nursing homes and other long-term care facilities.MethodsWe searched MEDLINE, CINAHL, PsycINFO, the Cochrane Library, Scopus, and Google Scholar, references of known articles, previous reviews, and recent volumes of key journals. RCTs were included in the review. Methodologic quality was assessed.ResultsThe search yielded 932 articles after removing the duplicates. Of them, 16 cluster RCTs fulfilled inclusion criteria for analysis. There was a great variety in the interventions with respect to learning methods, intensity, complexity, and length of staff training. Most interventions featured other elements besides staff training. In the 6 high-quality trials, only 1 showed a reduction in hospitalizations, whereas among 6 moderate-quality trials 2 suggested a reduction in hospitalizations. None of the high-quality trials showed effects on residents' QOL or QOD. Staff reported an improved QOD in 1 moderate-quality trial.Conclusions and ImplicationsIrrespective of the means of staff training, there were surprisingly few effects of education on residents' QOL, QOD, or burdensome hospitalizations. Further studies are needed to explore the reasons behind these findings.     

The Effect of Advance Care Planning Intervention on Hospitalization Among Nursing Home Residents: A Systematic Review and Meta-Analysis

ObjectiveTo evaluate the effect of advance care planning (ACP) interventions on the hospitalization of nursing home residents.DesignSystematic review and meta-analysis.Setting and ParticipantsNursing homes and nursing home residents.MethodsA literature search was systematically conducted in 6 electronic databases (Embase, Ovid MEDLINE, Cochrane Library, CINAHL, AgeLine, and the Psychology & Behavioral Sciences Collection), in addition to hand searches and reference list checking; the articles retrieved were those published from 1990 to November 2021. The eligible studies were randomized controlled trials, controlled trials, and pre-post intervention studies describing original data on the effect of ACP on hospitalization of nursing home residents; these studies had to be written in English. Two independent reviewers appraised the quality of the studies and extracted the relevant data using the Joanna Briggs Institute abstraction form and critical appraisal tools. A study protocol was registered in PROSPERO (CRD42022301648).ResultsThe initial search yielded 744 studies. Nine studies involving a total of 57,180 residents were included in the review. The findings showed that the ACP reduced the likelihood of hospitalization [relative risk (RR) 0.54, 95% CI 0.47-0.63; I² = 0%)], it had no effect on emergency department (ED) visits (RR 0.60, 95% CI 0.31-1.42; I² = 99), hospice enrollment (RR 0.98, 95% CI 0.88-1.10; I² = 0%), mortality (RR 0.83, 95% CI 0.68-1.00; I² = 4%), and satisfaction with care (standardized mean difference: ?0.04, 95% CI ?0.14 to ?0.06; I² = 0%).Conclusion and ImplicationsACP reduced hospitalizations but did not affect the secondary outcomes, namely, ED visits, hospice enrollment, mortality, and satisfaction with care. These findings suggest that policy makers should support the implementation of ACP programs in nursing homes. More robust studies are needed to determine the effects of ACP on ED visits, hospice enrollment, mortality, and satisfaction with care.     

Characteristics Associated with Feeding Tube Placement: Retrospective Cohort Study of Texas Nursing Home Residents with Advanced Dementia

ObjectivesTo investigate resident-level, provider-type, nursing home (NH), and regional factors associated with feeding tube (FT) placement in advanced dementia.DesignRetrospective cohort study.Setting and ParticipantsNH residents in Texas with dementia diagnosis and severe cognitive impairment (N = 20,582).MethodsThis study used 2011-2016 Texas Medicare data to identify NH residents with a stay of at least 120 days who had a diagnosis of dementia on Long Term Care Minimum Data Set (MDS) evaluation and severe cognitive impairment on clinical score. Multivariable repeated measures analyses were conducted to identify associations between FT placement and resident-level, provider-type, NH, and regional factors.ResultsThe prevalence of FT placement in advanced dementia in Texas between 2011 and 2016 ranged from 12.5% to 16.1% with a nonlinear trend. At the resident level, the prevalence of FT decreased with age [age > 85 years, prevalence ratio (PR) 0.60, 95% confidence interval (CI) 0.52-0.69] and increased among residents who are black (2.74, 95% CI 2.48-3.03) or Hispanic (PR 1.91, 95% CI 1.71-2.13). Residents cared for by a nurse practitioner or physician assistant were less likely to have an FT (PR 0.90, 95% CI 0.85-0.96). No facility characteristics were associated with prevalence of FT placement in advanced dementia. There were regional differences in FT placement with the highest use areas on the Texas-Mexico border and in South and East Texas (Harlingen border area, PR 4.26, 95% CI 3.69-4.86; San Antonio border area, PR 3.93, 95% CI 3.04-4.93; Houston, PR 2.17, 95% CI 1.87-2.50), and in metro areas (PR 1.36, 95% CI 1.22-1.50).Conclusions and ImplicationsRegional, race, and ethnic variations in prevalence of FT use among NH residents suggest opportunities for clinicians and policy makers to improve the quality of end-of-life care by especially considering other palliative care measures for minorities living in border towns.