The National Pressure Ulcer Long-Term Care Study: pressure ulcer development in long-term care residents

OBJECTIVES: To identify resident, treatment, and facility characteristics associated with pressure ulcer (PU) development in long-term care residents. DESIGN: Retrospective cohort study with convenience sampling. SETTING: Ninety-five long-term care facilities participating in the National Pressure Ulcer Long-Term Care Study throughout the United States. PARTICIPANTS: A total of 1,524 residents aged 18 and older, with length of stay of 14 days or longer, who did not have an existing PU but were at risk of developing a PU, as defined by a Braden Scale for Predicting Pressure Sore Risk score of 17 or less, on study entry. MEASUREMENTS: Data collected for each resident over a 12-week period included resident characteristics (e.g., demographics, medical history, severity of illness using the Comprehensive Severity Index, Braden Scale scores, nutritional factors), treatment characteristics (nutritional interventions, pressure management strategies, incontinence treatments, medications), staffing ratios and other facility characteristics, and outcome (PU development during study period). Data were obtained from medical records, Minimum Data Set, and other written records (e.g., physician orders, medication logs). RESULTS: Seventy-one percent of subjects (n=1,081) did not develop a PU during the 12-week study period; the remaining 29% of residents (n=443) developed a new PU. Resident, treatment, and facility characteristics associated with greater likelihood of developing a Stage I to IV PU included higher initial severity of illness, history of recent PU, significant weight loss, oral eating problems, use of catheters, and use of positioning devices. Characteristics associated with decreased likelihood of developing a Stage I to IV PU included new resident, nutritional intervention (e.g., use of oral medical nutritional supplements and tube feeding for >21 days), antidepressant use, use of disposable briefs for more than 14 days, registered nurse hours of 0.25 hours per resident per day or more, nurses' aide hours of 2 hours per resident per day or more, and licensed practical nurse turnover rate of less than 25%. When Stage I PUs were excluded from the analyses, the same variables were significant, with the addition of fluid orders associated with decreased likelihood of developing a PU. CONCLUSION: A broad range of factors, including nutritional interventions, fluid orders, medications, and staffing patterns, are associated with prevention of PUs in long-term care residents. Research-based PU prevention protocols need to be developed that include these factors and target interventions for reducing risk factors.     

Stage 2 pressure ulcer healing in nursing homes

OBJECTIVES: To identify resident and wound characteristics associated with Stage 2 pressure ulcer (PrU) healing time in nursing home residents. DESIGN: Retrospective cohort study with convenience sampling. SETTING: One hundred two nursing homes participating in the National Pressure Ulcer Long‐Term Care Study (NPULS) in the United States. PARTICIPANTS: Seven hundred seventy‐four residents aged 21 and older with length of stay of 14 days or longer who had at least one initial Stage 2 (hereafter Stage 2) PrU. MEASUREMENTS: Data collected for each resident over a 12‐week period included resident characteristics and PrU characteristics, including area when first reached Stage 2. Data were obtained from medical records and logbooks. RESULTS: There were 1,241 initial Stage 2 PrUs on 774 residents; 563 (45.4%) healed. Median time to heal was 46 days. Initial area was significantly associated with days to heal. Using Kaplan‐Meier survival analyses, median days to heal was 33 for small (≤1 cm²), 53 days for medium (>1 to ≤4 cm²), and 73 days for large (>4 cm²) ulcers. Using Cox proportional hazard regression models to examine effects of multiple variables simultaneously, small and medium ulcers and ulcers on residents with agitation and those who had oral eating problem healed more quickly, whereas ulcers on residents who required extensive assistance with seven to eight activities of daily living (ADLs), who temporarily left the facility for the emergency department (ED) or hospital, or whose PrU was on an extremity healed more slowly. CONCLUSION: PrUs on residents with agitation or with oral eating problems were associated with faster healing time. PrUs located on extremities, on residents who went temporarily to the ED or hospital, and on residents with high ADL disabilities were associated with slower healing time. Interaction between PrU size and place of onset was also associated with healing time. For PrU onset before or after admission to the facility, smaller size was associated with faster healing time.     

Long-term care liability for pressure ulcers

More than 20% of residents who have been in long-term care (LTC) facilities for 2 or more years will develop at least one pressure ulcer (PU). Residents suffer pain, disfigurement, and decreased quality of life, and their risk of illness and death increases. LTC facilities face censure from residents, their families, and surveyors and the threat of expensive lawsuits. Lawsuits are typically based on contentions of residents with a PU--or their advocates--that the LTC facility was negligent and failed to provide the care that, by industry standards, it must provide to prevent or manage such wounds (managing pressure, incontinence, and nutrition). In this article, data from 1999 and 2002 are presented, showing that lawsuits related to PUs are increasingly common and costly for LTC owners and care providers. Residents realized some type of recovery against the facility in 87% of the cases (verdicts for the resident plus settlements) and were awarded amounts as high as $312 million in damages. Even LTC administrators who believe that care in their facility equals or exceeds industry standards often settle lawsuits out of court to avoid jury verdicts. The data also show that jury awards were highest for PUs caused by multiple factors and that the highest awards for PUs caused by a single factor were seen when that factor was inadequate nutrition. LTC providers can help improve the health and quality of life of their residents, improve survey results, and minimize their risk of expensive lawsuits by developing, implementing, and documenting a plan of basic measures to prevent PUs.     

Black/White differences in pressure ulcer incidence in nursing home residents

OBJECTIVES: To compare black and white nursing home residents with respect to the incidence of nursing home (NH)-acquired pressure ulcers (PUs) and to examine the role of resident characteristics and facility characteristics in explaining differences between the racial groups. DESIGN: Prospective cohort study conducted between 1992 and 1995. SETTING: Fifty-nine Maryland NHs. PARTICIPANTS: A total of 1,938 residents (301 black, 1,637 white) aged 65 and older newly admitted to participating NHs. MEASUREMENTS: The outcome variable was the first occurrence of a Stage 2, 3, or 4 PU as determined based on medical record review. The predictor variable was race (black, white). Eight resident characteristics (age, sex, number of activity of daily living dependencies, bedfast, PU on admission to facility, incontinence, dementia, and whether the resident was on Medicaid) and three facility characteristics (number of beds, for-profit ownership status, and urban/nonurban location) were considered as possible confounding variables. RESULTS: The incidence of PUs was 0.38 per person-year in the NH. The rate for blacks was significantly higher than for whites (0.56 vs 0.35 per person-year) (P<.001). In multivariate analysis, controlling for eight resident characteristics and three facility characteristics, race was significantly associated with PU incidence (hazard ratio comparing blacks with whites=1.31, 95% confidence interval=1.02-1.66). CONCLUSION: Blacks have a higher incidence of NH-acquired PUs than whites; resident characteristics appear to mediate the higher risk. Future research should aim to identify modifiable factors that explain differences between racial groups in PU risk and to develop solutions to prevent the suffering and cost associated with PUs.     

The occurrence of pressure ulcers in three nursing homes

Background: In the 27 nursing homes located within the Veterans Affairs (VA) Central Region, the proportion of residents with pressure ulcers in 1986 varied from 2% to 16%. Three of these nursing homes were selected for study: nursing home A from the highest prevalence quintile, B from close to the median, and C from the lowest quintile. Methods: Two indicators of pressure ulcer occurrence were calculated: the point-in-time prevalence of bedsores and the percentage of residents who were free of pressure ulcers at the beginning of a six-month study period but who had bedsores six months later. Data were also collected in each nursing home to determine the bedsore status at the time of admission and the resident’s location if and when a bedsore began. Results: The three institutions were generally similar in available measures of casemix and severity of illness. The ratio of nursing and medical personnel to residents was 29%–76% lower in nursing home A than in B or C. In nursing home A, the turnover of nursing personnel was about twice as rapid as that in B or C. In each institution the pressure ulcer statistics showed little variation from one six-month period to another. The average rates in nursing home A were 15.3% for prevalence and 10.3% for the six-month conversion from bedsore-negative to bedsore-positive status. The average rates in facilities B and C were, respectively, 6.9% and 3.5% for prevalence and 4.7% and 4.2% for the six-month conversion from negative to positive status. Furthermore, the number of new bedsores that developed during uninterrupted nursing home residence, per 100,000 resident days, was 36.5 in A, 10.8 in B, and 2.1 in C. Conclusions: The pressure ulcer statistics in nursing homes B and C were consistently superior to those in A. The interinstitutional differences could not be explained by the comparisons of scoring methodologies and of casemixes that were made. It is hypothesized that more favorable staffing patterns in B and C than in A contributed to more effective prevention of bedsores in the former two institutions. Received from the Geriatric Medicine Sections, Veterans Affairs Medical Centers, Milwaukee, Wisconsin, Tomah, Wisconsin, and Togus, Maine. Supported by the Department of Veterans Affairs Medical Research Service.     

Pressure ulcer prevalence in long-term nursing home residents since the implementation of OBRA '87. Omnibus Budget Reconciliation Act

OBJECTIVES: To evaluate change in pressure ulcer prevalence in long-term nursing home residents since the implementation of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87). DESIGN: Cross-sectional comparison of two time periods. SETTING: Ninety-two nursing homes scheduled for a quality-of-care survey randomly selected from 22 representative states. PARTICIPANTS: Four thousand six hundred seventy-nine residents who had resided in the facility for at least 100 days were evaluated: 2,336 during 1992-1994 and 2,343 during 1997-1998. MEASUREMENTS: Trained registered nurses collected data on pressure ulcer prevalence, stage, and risk factors from medical record review during on-site evaluations. Risk-adjusted differences were estimated using logistic regression. RESULTS: Unadjusted prevalence rates for all stages of pressure ulcers (8.52% vs 8.54%, P =.983) and those rated stage 2 or greater (5.31% vs 5.63%, P =.624) did not differ between the two time periods. After adjustment for urinary incontinence, immobility, poor nutrition, and history of previous pressure ulcers, the relative odds of having a pressure ulcer in 1992/4 versus 1997/8 was 1.06 (95% confidence interval (CI) = 0.84-1.34) for all stages and 1.21 (95% CI = 0.92-1.60) for stages 2 and greater. CONCLUSIONS: No change in pressure ulcer prevalence was demonstrated since implementation of OBRA '87 in this nationally derived sample of long-term nursing home residents.     

Loneliness in Old Age: Interventions to Curb Loneliness in Long-Term Care Facilities

Presently there is little analytical research examining practical interventions to address loneliness in long-term aged care. Thus, a review of the literature was conducted to identify and examine the usefulness of current interventions. A broad range of activities were found to benefit lonely residents. Animal-assisted therapy was the most widely implemented strategy and was both appropriate and effective for cognitively impaired and non-impaired residents. Collaborative group approaches to improve cognitive aging were highly beneficial to residents as was indoor gardening, group use of game consoles and increased social contact with family or friends mediated via videoconferencing. Continued innovation and adaptation of practices to provide stimulation and increase social connectedness are needed, in conjunction with rigorous research methodologies, to determine effectiveness and appropriateness of those interventions to reduce loneliness for residents in long-term care facilities.     

Impact of pain on outcomes in long-term care residents with and without multiple sclerosis

OBJECTIVES: To compare long-term care (LTC) residents with and without multiple sclerosis (MS); to compare admission status of pain, physical disability, pressure ulcers, depression, and cognitive performance in LTC residents with and without MS; and to examine the impact of MS and pain on outcomes 90 and 180 days after LTC admission. DESIGN: Retrospective analysis of a large data set. SETTING: LTC facilities in Missouri. PARTICIPANTS: Residents admitted to non-hospital-based LTC facilities. MEASUREMENTS: Minimum Data Set/Resident Assessment Instrument, Version 2.0; Activities of Daily Living Scale; Cognitive Performance Scale. RESULTS: Residents with and without MS had similar pain prevalence and intensity after admission, with daily pain more frequent in residents with MS (P=.03). On admission, residents with MS had more physical disability (P<.001) and a greater prevalence of pressure ulcers (P=.004) and depression (P<.001) than residents without MS. In all LTC residents, initial pain status was associated with physical disability (P<.001), pressure ulcers (P<.001), depression (P<.001), and cognitive performance (P<.001) 90 and 180 days after admission. A diagnosis of MS was associated with physical disability (P<.001) 90 and 180 days after admission and pressure ulcer development 180 days after admission (P=.02). CONCLUSION: Residents with MS were more physically disabled and had more frequent pain and a higher prevalence of pressure ulcers and depression on admission than residents without MS. Pain, or lack thereof, in residents with and without MS on admission may warn of problems that could occur within 6 months after admission to a LTC facility.     

Group Therapy in Long Term Care Sites

ABSTRACT

Group therapy is an intervention that is particularly suited for residents in long term care settings, because it can reduce social isolation and efficiently address the common issue of adjustment to institutional living. This article first specifies the types of groups that should be offered in long term care settings as a function of therapeutic aims and resident composition. It then enumerates Yalom's common curative factors and how they are reflected in the group process with frail nursing home residents. The unique elements in doing group therapy within long term care sites are then discussed. Next, the meager research on group psychotherapy in long term care sites is summarized, and a plea is made for more empirical studies to be conducted in this exciting but neglected area. Finally, reimbursement issues for group therapy in nursing homes are briefly considered.     

The Influence of Long-Term Care Insurance on the Likelihood of Nursing Home Admission

OBJECTIVES: To determine the effect of long-term care (LTC) insurance on nursing home use.
DESIGN: Longitudinal analysis, 1998 to 2006 waves of the Health Retirement Study.
SETTING: Community-dwelling nationally representative sample.
PARTICIPANTS: Nineteen thousand one hundred seventy adults aged 50 and older, 1998 wave.
METHODS: Two groups of respondents were created at baseline: those with and without an LTC insurance policy. Respondents admitted to the nursing home from 1998 to 2006 were identified. Propensity scores were used to control for known predictors of LTC insurance possession. A Cox proportional hazards model was used to compare the probability of nursing home admission over 8 years of follow-up for respondents possessing LTC insurance and those without a policy.
RESULTS: Of the 19,170 respondents aged 50 and older in 1998, 1,767 (9.2%) possessed LTC insurance. A total of 1,778 (8.5%) were admitted to a nursing home during the 8-year period: 149 (8.7%) of those with LTC insurance and 1,629 (8.4%) of those without LTC insurance. The hazard ratio, adjusted for propensity score, for those with LTC insurance entering a nursing home compared with those without was 1.07 (95% confidence interval=0.83–1.38). Likelihood of nursing home admission was relatively low because the low-risk population included in the study, limiting the power to detect small differences in risk of nursing home utilization between groups.
CONCLUSION: There was no difference in nursing home utilization between low-risk older adults who did and did not possess an LTC insurance policy.     

Five-year alcohol and drug treatment outcomes of older adults versus middle-aged and younger adults in a managed care program

AIMS: This study compared 5-year treatment outcomes of older adults to those of middle-aged and younger adults in a large managed care chemical dependency program. We examined age group differences in individual, treatment and extra-treatment factors, which may influence long-term outcome. DESIGN: Seventy-seven per cent of original study participants completed a telephone interview 5 years after out-patient chemical dependency treatment at Kaiser Permanente. This sample (N = 925) included 65 patients aged 55-77, 296 patients aged 40-54 and 564 patients aged 18-39 (age at baseline). MEASUREMENTS: Measures at follow-up included alcohol and drug use, Addiction Severity Index (ASI), Alcoholics Anonymous Affiliation Scale, social resource and self-reported health questions. Mortality data were obtained from contact with family members of patients as well as automated health plan records. FINDINGS: Older adults were less likely to be drug-dependent at baseline than younger and middle-aged adults, and had longer retention in treatment than younger adults. At 5 years, older adults were less likely than younger adults to have close family or friends who encouraged alcohol or drug use. Fifty-two per cent of older adults reported total abstinence from alcohol and drugs in the previous 30 days versus 40% of younger adults. Older women had higher 30-day abstinence than older men or younger women. Among participants dependent only on alcohol, there were no significant age differences in 30-day abstinence. In logistic regression analysis, age group was not significant. Variables associated with greater age that independently predicted 30-day abstinence in the logistic regression model included longer retention in treatment and having no close family or friends who encouraged alcohol or drug use at 5 years; female gender was also significant. CONCLUSIONS: Results indicate that older adults have favorable long-term outcome following treatment relative to younger adults, but these differences may be accounted for by variables associated with age such as type of substance dependence, treatment retention, social networks and gender. Age differences in these characteristics inform intervention strategies to support long-term recovery of older adults and provide direction for investigation of how age affects outcome.     

Similarities and differences in attitudes toward long-term care between Japanese Americans and Caucasian Americans

The purpose of this study was to compare attitudes toward the use of long-term care between older Japanese Americans (n = 1,244) and older Caucasian Americans (n = 1,354). When presented with a hypothetical situation in which they have dementia, 39% of older Japanese Americans and 42% of older Caucasians intended to be cared for at home, whereas 53% versus 38%, respectively, intended to use nursing home care (P <.001). If the hypothetical situation was hip fracture, 81% of older Japanese Americans and 72% of older Caucasians intended to be cared for at home, with 13% of both groups intending to use nursing home care (P = NS). The subjects' perceptions of what their families, friends, ministers, and communities would want them to choose differed, with more uncertainty among Caucasians (P <.001). For provision of home care, Japanese Americans were more likely to rely on loved ones than Caucasians, who were more likely to rely on paid providers. Multivariate logistic regression showed ethnicity to be independently related to intention to use nursing home care in the dementia scenario, controlling for demographic variables. Being married lowered the odds of intending to use nursing homes in any situation. We conclude that Caucasian Americans intend to use paid home health care at higher rates than Japanese Americans if they become disabled by dementia. Japanese Americans demonstrated more certainty about the influences of others on their opinions, suggesting a more stable cultural norm in this population, and intended to use more nursing home care in the event of permanent debility (dementia).     

Delirium and transition to a nursing home of hospitalized older adults: A controlled trial of assessing the interdisciplinary team‐based “geriatric” care and care coordination by non‐geriatrics specialist physicians

Aim: To examine whether a team‐based inpatient “geriatric” care model provided by non‐geriatrics specialist physicians was associated with changes in the occurrence of delirium and transition to a nursing home. Methods: We carried out an intervention (interdisciplinary; ITD group) control (usual care group) study comparing the outcomes of hospitalized older adults cared for by non‐geriatrics specialist physicians. Compared with the usual care group, the ITD intervention group provided additional value: geriatric care and care coordination by leading daily ITD team meetings. Results: After adjusting for patient demographics and clinical characteristics, the probability of transition to a nursing home in the ITD intervention group was significantly lower (odds ratio 0.52; 95% confidence intervals, 0.16–0.94; P = 0.008) than that in the usual care group. However, there was no significant difference in the predicted probabilities of delirium between the ITD intervention and usual care groups. Conclusion: As compared with the usual care group, a significantly lower probability of transition to a nursing home was observed in the ITD intervention group, but the probabilities of delirium between the ITD intervention and usual care groups did not differ significantly. Geriatr Gerontol Int 2013; 13: 342–350 .