A randomised,double-blind,placebo-controlled clinical study: the effects of a synbiotic,Lepicol, in adults with chronic,functional constipation

The study objective was to evaluate the safety and effects of Lepicol® (pysllium fibre, inulin and 5 probiotic strains) in adults with chronic, functional constipation during a 4 week intervention. 69 subjects with functional constipation according to Rome III criteria were randomised to receive Lepicol (n?=?35) or placebo (n?=?34) daily. Both groups had improved frequency of bowel movements, with an increase of 1.082 bowel movements in the Lepicol group over placebo after one week, and 1.079 more than placebo after week 2, but with no significant difference at week 4. Both groups showed significant improvements in quality of life scores at 4 weeks, with the average score being 12.033% better in the Lepicol group, which also had 15.2% improvement in intensity of symptoms and 28.5% increase in satisfaction with quality of life compared to the placebo. Symptoms of constipation improved to a greater degree and there was a significant reduction in laxative use in the Lepicol group.     

Increased stool frequency occurs when finely processed pea hull fiber is added to usual foods consumed by elderly residents in long-term care

Dietary fiber fortification of food offers a preventative strategy that is a less invasive alternative to laxatives and enemas in the management of constipation in elderly individuals. To determine if a moderate increase in fiber provided in foods would increase bowel movement frequency among elderly institutionalized residents, data were collected on the same elderly residents (n=114) before and during a 6-week intervention. The intervention consisted of adding finely processed pea hull fiber (1-3 g/serving) to 3 to 4 foods each day. Laxative and enema use was monitored. Mean number of bowel movements/month increased from 18.7+/-9.4 to 20.1+/-9.6 (n=114, P=.034), and in 17 residents with low baseline frequency, the increase was highly significant (8.8+/-1.0 to 12.6+/-3.8 bowel movements/month, P=.001). With treatment, prune-based laxative administration decreased (P<.001). Thus, addition of a moderate amount of finely processed fiber to foods results in increased bowel frequency in institutionalized elderly individuals.     

Management of constipation in residents with dementia: sorbitol effectiveness and cost

OBJECTIVE: The objective of this report is to describe a cost-effective strategy for management of constipation in nursing home residents with dementia. DESIGN: We conducted a prospective observational quality improvement study of 41 residents with chronic constipation and receiving an osmotic laxative. Sorbitol was substituted for lactulose. SETTING: The study was conducted at a dementia special care unit at a Veterans Administration hospital. MEASUREMENT: We measured the number and amount of laxative use over a period of 4 weeks that were required to maintain regular bowel function. RESULTS: There was no difference in efficacy of lactulose and sorbitol. Use of additional laxatives was infrequent: Milk of Magnesia on approximately 10% of days/patient, bisacodyl suppository on 2% to 4% of days/patient, and Fleet enema only on 3 occasions. The cost of constipation management using routine administration of sorbitol and as-needed use of other laxatives was 27% to 55% lower than the cost of other constipation management strategies reported in the literature. CONCLUSION: Substitution of sorbitol for lactulose does not change efficacy of the treatment and decreases cost. Regular use of an osmotic laxative avoids the costs and discomforts of rectal laxatives.     

Energy-dense meals improve energy intake in elderly residents in a nursing home

BACKGROUND: Several studies have shown that malnutrition is common among nursing home residents. AIM: We hypothesized that addition of natural energy-dense ingredients to a standard diet would improve voluntary energy intake and ability to perform activities of daily living (ADL) and decrease infections in elderly residents under nursing home care. METHODS: Thirty-five residents in a municipality nursing home (median age 83 years) were served either a standard diet (1600 kcal/day) (control group, n=18) or the same meals fortified with natural energy-dense ingredients (2100 kcal/day) (experimental group, n=17). Energy intake and ADL function were measured before and after the intervention. All episodes of infection were registered. Non-parametric statistics were used. RESULTS: Energy intake increased in the experimental group from 23.5 (21.3-28.5) kcal/kg/body weight before, to 31.9 (29.7-33.7) kcal/kg/body weight during the intervention (P<0.001). There was no change in energy intake in the control group. ADL function in the experimental group was unchanged, while it decreased significantly in the control group (P<0.001). The number of infections tended to be lower in the experimental group than in the control group (5 vs 13). The cost for the energy-dense ingredients was approx. 0.11 EUR per resident and day. CONCLUSIONS:Addition of natural energy-dense ingredients to regular meals is an inexpensive way to improve voluntary energy intake in elderly nursing home residents, a treatment that was accompanied by maintained ADL function.     

The nursing home versus the hospital as the place of dying for nursing home residents in Japan

OBJECTIVES: To determine the characteristics of nursing home residents that are associated with dying in a nursing home versus a hospital in Japan. DESIGN: Retrospective case-control study. SETTING: A nonprofit nursing home with 110 beds in Tokyo, Japan. PARTICIPANTS: Eighty-six nursing home residents who died in the nursing home (n=43) or in a hospital (n=43) between 1 April 1999 and 30 September 2004. MEASUREMENTS: Nursing home records were reviewed to gain information regarding the following domains: demography, the family decision-maker, health status, resident and family preference for nursing home end-of-life care, and presence of a full-time physician. RESULTS: The variables older age [adjusted odds ratio (adjusted OR)=1.08, 95% confidence interval (95% CI)=1.01-1.17], the family decision-maker's preference for nursing home end-of-life care (adjusted OR=3.95, 95% CI=1.21-12.84), and presence of a full-time physician (adjusted OR=3.74, 95% CI=1.03-13.63) were associated with dying in the nursing home. CONCLUSION: Older age, the family's preference for nursing home end-of-life care, and the presence of a full-time physician were significantly related to dying in the nursing home versus in a hospital.     

Low serum folic acid levels in a nursing home population: a clinical experience.

Four hundred fifty-five residents of the Wisconsin Veterans Home had fasting serum specimens obtained for folic acid as part of standard practice. Twenty-nine percent were taking folic acid supplements. Six percent (n = 28) were taking phenytoin, a folate antagonist. No resident receiving a folate supplement (400 mcg/day) had a low serum folic acid level. This finding may be important for practitioners selecting a dose of folic acid for nursing home patients. Of the 325 residents not receiving a folate supplement, nine (3%) had low folic acid levels (< 2.5 ng/mL). Two of the nine were receiving phenytoin. Five were characterized by staff as eating well. As low serum levels are preventable with a multivitamin, we believe that supplementation with a multivitamin containing 400 mcg folic acid/day should be considered in nursing home residents.     

The Burden and Treatment of Chronic Constipation Among US Nursing Home Residents

ObjectiveTo evaluate the burden of chronic constipation (CC) and the use of drugs to treat constipation (DTC) in 2 complementary data sources.DesignRetrospective cohort study.Setting and ParticipantsUS nursing home residents aged ≥65 years with CC.MethodsWe conducted 2 retrospective cohort studies in parallel using (1) 2016 electronic health record (EHR) data from 126 nursing homes and (2) 2014-2016 Medicare claims, each linked with the Minimum Data Set (MDS). CC was defined as (1) the MDS constipation indicator and/or (2) chronic DTC use. We described the prevalence and incidence rate of CC and the use of DTC.ResultsIn the EHR cohort, we identified 25,739 residents (71.8%) with CC during 2016. Among residents with prevalent CC, 37% received a DTC, with an average duration of use of 19 days per resident-month during follow-up. The most frequently prescribed DTC classes included osmotic (22.6%), stimulant (20.9%), and emollient (17.9%) laxatives. In the Medicare cohort, a total of 245,578 residents (37.5%) had CC. Among residents with prevalent CC, 59% received a DTC and slightly more than half (55%) were prescribed an osmotic laxative. Duration of use was shorter (10 days per resident-month) in the Medicare (vs EHR) cohort.Conclusions and ImplicationsThe burden of CC is high among nursing home residents. The differences in the estimates between the EHR and Medicare data confirm the importance of using secondary data sources that include over-the-counter drugs and other treatments unobservable in Medicare Part D claims to assess the burden of CC and DTC use in this population.     

Rurality and nursing home quality: results from a national sample of nursing home admissions

OBJECTIVES: We examined differences in quality of care among nursing homes in locales of varying degrees of rurality. METHODS: We classified locales into 4 classes according to rurality. We analyzed a 10% sample of nursing home admissions in the United States in 2000 (n=198613) to estimate survival models for 9 quality indicators. RESULTS: For postacute admissions, we observed significant differences in rates of decline for residents in facilities in large towns compared with urban areas, but differences in quality were both negative and positive. Among admissions for long-term or chronic care, rates of decline in 2 of 9 quality areas were lower for residents in isolated areas. CONCLUSIONS: We observed significant differences in a number of quality indicators among different classes of nursing home locations, but differences varied dramatically according to type of admission. These differences did not exhibit the monotonicity that we would have expected had they derived solely from rurality. Also, quality indicators exhibited more similarities than differences across the 4 classes of locales. The results underscore the importance, in some instances, of emphasizing the effects of specific settings rather than some continuum of rurality and of moving beyond the assumption that nursing home residents constitute a homogeneous population.     

The cost of treating pneumonia in the nursing home setting

OBJECTIVE: To determine the costs of treating pneumonia in the nursing home setting and explore what factors are most responsible for that cost with a view to reducing cost. DESIGN: Prospective cohort study. SETTING: Thirty-six Missouri nursing homes participating in the study from April 1997 through September 1998. PARTICIPANTS: Nursing home residents with pneumonia who were not hospitalized (n = 502). We included residents evaluated in the emergency department (ED) and returned to the nursing home without admission. MEASUREMENTS: Residents were evaluated by project nurses. Examination findings, diagnostic testing, and treatment information for 30 days following evaluation were abstracted from medical records. Bills were obtained for individuals evaluated in the ED. RESULTS: There was significant variation in the cost of treating pneumonia in nursing homes. Episode costs were higher for residents seen in the ED of a hospital, residents with decubitus ulcers, black residents, and residents in larger facilities. Although total episode costs were related to illness severity, most of the variation in cost is not explained by resident or illness characteristics. The average cost for treating an episode of pneumonia in the nursing home, over and above usual care, was $458. CONCLUSIONS: There is wide variation in treatment for residents with similar clinical presentations. For residents at low risk of mortality, using less expensive antibiotics and reducing ED evaluation could result in cost reductions, although the effect on outcomes is unknown.     

广东省2城市居民凉茶认知情况、饮用状况及影响因素研究

目的了解广东居民对凉茶的认知情况、饮用状况及影响因素,为居民正确饮用凉茶提供科学指导。方法采用分层随机抽样方法选取现居住于广州市和肇庆市的居民,用社区街头拦截和入户面对面调查方式对抽中的调查对象进行问卷调查,调查内容包括人口学特征,如性别、年龄、籍贯、文化程度等,对凉茶属性、主要成分的认知,凉茶的饮用状况及饮用习惯等。对调查结果进行描述性流行病学分析,对凉茶饮用习惯的影响因素进行单因素和多因素的logistic回归分析。结果共调查2154名居民,其中广州1005人（占46．7％）,肇庆1149人（53．3％）。男性957人（占44．4％）,女性1197人（55．6％）;以12—19岁组人数最多（522人,占24．2％）;籍贯以广东为主（1781人,占82．7％）。调查对象中98．7％（2127／2154）知道1种及以上的凉茶,49．2％（1047／2127）认为凉茶属于中草药。43．7％（942／2154）知道6种及以上凉茶成分。99．1％（2108／2127）知道任1种凉茶的调查对象曾喝过1种或以上凉茶,其中,有799人（37．6％,799／2127）具有较为固定的凉茶饮用习惯。多因素logistic回归分析结果表明,年龄30～39岁（OR=1．47）、40—49岁（OR=1．58）、t〉50岁（OR=1．70）,籍贯为广东（OR=2．92）,现居广州（OR=2．97）,知道凉茶成分的种类1～5种（OR：2．28）及t〉6种以上者（OR=3．40）具有饮用凉茶习惯的可能性更大（P〈0．05或P〈0．01）。结论凉茶在广东2城市居民中具有较高的接受度,年龄、籍贯、现居地和对凉茶成分的了解程度是影响凉茶饮用行为的因素,可针对不同人群进行相应的宣教及干预,以促进凉茶文化的传播和发展。     

Hospitalization of nursing home residents: the effects of states' Medicaid payment and bed-hold policies

OBJECTIVE: Hospitalizations of nursing home residents are costly and expose residents to iatrogenic disease and social and psychological harm. Economic constraints imposed by payers of care, predominantly Medicaid policies, are hypothesized to impact hospitalizations. DATA SOURCES/STUDY SETTING: Federally mandated resident assessments were merged with Medicare claims and eligibility files to determine hospitalizations and death within 150 days of baseline assessment. Nursing home and market characteristics were obtained from the Online Survey Certification and Reporting, and the Area Resource File, respectively. States' average daily Medicaid nursing home payments and bed-hold policies were obtained independently. STUDY DESIGN: Prospective cohort study of 570,614 older (> or =65-year-old), non-MCO (Medicare Managed Care), long-stay (> or =90 days) residents in 8,997 urban, freestanding nursing homes assessed between April and June 2000, using multilevel models to test the impact of state policies on hospitalizations controlling for resident, nursing home, and market characteristics. PRINCIPAL FINDINGS: Overall, 99,379 (17.4 percent) residents were hospitalized with rates varying from 8.4 percent in Utah to 24.9 percent in Louisiana. Higher Medicaid per diem was associated with lower odds of hospitalizations (5 percent lower for each $10 above average $103.5, confidence intervals [CI] 0.91-0.99). Hospitalization odds were higher by 36 percent in states with bed-hold policies (CI: 1.12-1.63). CONCLUSIONS: State Medicaid bed-hold policy and per-diem payment have important implications for nursing home hospitalizations, which are predominantly financed by Medicare. This study emphasizes the importance of properly aligning state Medicaid and federal Medicare policies in regards to the subsidy of acute, maintenance, and preventive care in the nursing home setting.     

Efficacy and safety of a natural mineral water rich in magnesium and sulphate for bowel function: a double-blind,randomized, placebo-controlled study

Purpose

The present placebo-controlled, double-blind, randomized trial aimed to investigate whether a natural mineral water rich in magnesium sulphate and sodium sulphate (Donat Mg) may help to improve bowel function.

Methods

A total of 106 otherwise healthy subjects with functional constipation were randomly assigned to consume 300 or 500 mL of a natural mineral water as compared to placebo water, over a course of 6 weeks. The 300-mL arms were terminated due to the results of a planned interim analysis. Subjects documented the complete spontaneous bowel movements, spontaneous and overall bowel movements/week, stool consistency, gastrointestinal symptoms and general well-being in a diary. Change in the number of complete spontaneous bowel movements was defined as the primary outcome.

Results

For the 75 subjects in the 500-mL arms, the change in the number of complete spontaneous bowel movements per week tended to be higher in the active group when compared to placebo after 6 weeks (T2 = 1.8; p _value = 0.036; one-sided). The mean number of spontaneous bowel movements significantly increased over the course of the study, with significant differences between study arms considering the whole study time (F test = 4.743; p _{time × group} = 0.010, 2-sided). Stool consistency of spontaneous bowel movements (p < 0.001) and the subjectively perceived symptoms concerning constipation (p = 0.005) improved significantly with the natural mineral water as compared to placebo.

Conclusions

The daily consumption of a natural mineral water rich in magnesium sulphate and sodium sulphate improved bowel movement frequency and stool consistency in subjects with functional constipation. Moreover, the subjects’ health-related quality of life improved.

Clinical Trial Registration

EudraCT No 2012-005130-11.

     

Green Tea Consumption Affects Cognitive Dysfunction in the Elderly: A Pilot Study

Green tea is known to have various health benefits for humans. However, the effect of green tea consumption on cognitive dysfunction remains to be clinically verified. We conducted a clinical study to investigate the effects of green tea consumption on cognitive dysfunction. Twelve elderly nursing home residents with cognitive dysfunction (Mini-Mental State Examination Japanese version (MMSE-J) score: <28) participated in the study (2 men, 10 women; mean age, 88 years). The participants consumed green tea powder 2 g/day for 3 months. After three months of green tea consumption, the participants’ MMSE-J scores were significantly improved (before, 15.3 ± 7.7; after, 17.0 ± 8.2; p = 0.03). This result suggests that green tea consumption may be effective in improving cognitive function or reducing the progression of cognitive dysfunction; however, long-term large-scale controlled studies are needed to further clarify the effect.     

An overview of nursing home facilities: data from the 1997 National Nursing Home Survey

OBJECTIVE: This report presents estimates on the number and distribution of nursing home facilities, their services, current residents, and discharges in the United States during 1997. METHODS: Data presented in this report are estimates based on a sample of nursing home facilities, residents, and discharges from the 1997 National Nursing Home Survey (NHHS). The survey collects information about providers and recipients of care from nursing home facilities. NHHS has been periodically conducted by the National Center for Health Statistics since 1973. RESULTS: In 1997 there were an estimated 1.6 million current residents and 2.4 million discharges from 17,000 nursing homes nationwide. These facilities were predominantly proprietary and certified by both Medicare and Medicaid. There was an average of 107 beds per nursing home with an occupancy rate of 88 percent and a discharge rate of 130 patients per 100 beds. The majority of nursing home residents and discharges were elderly, white, and female.     

Comparison of two different approaches for the application of the mini nutritional assessment in nursing homes: Resident interviews versus assessment by nursing staff

Background

When the Mini Nutritional Assessment (MNA©) was developed, the authors did not specifically focus on the nursing home setting. Due to a number of particularities of nursing home residents, such as cognitive and linguistic disabilities, a number of uncertainties with regard to its application await clarification.

Aims and objectives

The aim of this study was to compare the results of two different modes of MNA application in nursing homes: resident interviews versus assessment by nursing staff.

Method

The MNA was applied to 200 residents of two municipal nursing homes in Nuremberg, Germany. First one-on-one interviews of the residents were conducted by two researchers from our group. Next, the MNA was applied by the attending nursing staff who was blinded to the results of the first MNA. To evaluate the prognostic properties of the two different approaches, data on mortality of the screened residents were collected during a six-month follow-up period.

Results

Among 200 residents (f 147 m 53, f 86.5±7.4 y. m 83.0±8.5 y.), the MNA could be applied t 138 residents (69. 0%) by one-on-one interviews and to 188 residents (94.0%) by the nursing staff. 15.2% of the residents were categorised as malnourished by the interviews and 8.7% by the nursing staff’s assessment. The agreement of the two forms was low for the MNA short form (weighted kappa = 0.31; 95% CI: 0.14 ? 0.47) as well as for the full MNA (weighted kappa = 0.35; 95% CI: 0.27 ? 0.44). After exclusion of residents with cognitive impairment (n=89), agreement for the full version increased (weighted kappa = 0.47, 95% CI 0. 25 ? 0.68). 25 (12.5%) study participants deceased during the follow-up period. Mortality was significantly associated with the mortality for both approaches, while the MNA application by the nursing staff proved to be superior (nursing staff p<0.001, residents p<0.05).

Conclusions

The results of the MNA in nursing home residents may differ substantially when resident interviews are compared to assessment by nursing staff. The authors recommend that the MNA should be routinely applied by the nursing staff. The application rate is higher and interference with cognitive as well as linguistic deficits is lower. In future studies, the mode of MNA application in nursing home residents should be clearly stated to facilitate comparability of results.     

Effects of chicory inulin in constipated elderly people: a double-blind controlled trial

The impact of the daily consumption of 15 g chicory native inulin on fecal levels of bifidobacteria, stool parameters and quality of life of elderly constipated volunteers was investigated in a randomized, double-blind, controlled versus placebo clinical trial. The impact of supplementation on constipation was assessed with questionnaires on bowel motor function parameters, visual analogue scales on bowel symptoms and quality of life. Fecal bacteria counts were determined at the beginning and at the end of the supplementation. Inulin supplementation led to a significant increase in total fecal bacteria (P < 0.01) and bifidobacteria (P < 0.001) concentrations after 28 days of consumption. Volunteers (n = 25) in the inulin group reported increased satisfaction about digestion (P < 0.01) and reduced defecation difficulties (P < 0.001) during the supplementation. Slight gastrointestinal symptoms (flatulence) were reported but did not lead to discontinuation. Daily supplementation with 15 g inulin improves constipation and quality of life in an elderly population with constipation.     

Factors associated with potentially preventable hospitalization among nursing home residents in New York State with chronic kidney disease

ObjectiveIdentify clinical and organizational factors associated with potentially preventable ambulatory care sensitive (ACS) hospitalization among nursing home residents with chronic kidney disease.MethodsNew York State Nursing home residents (n = 5449) age 60+ with chronic kidney disease and were hospitalized in 2007. Data included residents’ sociodemographic and clinical characteristics, nursing home organizational factors, and ACS hospitalizations. Multivariate logistic regression quantified the association between potential determinants and ACS hospitalizations (yes versus no).ResultsPrevalence of chronic kidney disease among nursing home residents is 24%. Potentially avoidable ACS hospitalization among older nursing home residents with chronic kidney disease is 27%. Three potentially modifiable factors associated with significantly higher odds of ACS hospitalization include the following: presence of congestive heart failure (OR = 1.4; 95% CI 1.24–1.65), excessive medication use (OR = 1.3; 95% CI 1.11–1.48), and the lack of training provided to nursing staff on how to communicate effectively with physician about the resident’s condition. (OR = 1.3; 95% CI 0.59–0.96).ConclusionTo reduce potentially preventable ACS hospitalization among chronic kidney disease patients, congestive heart failure and excessive medication use can be kept stable using relatively simple interventions by periodic multidisciplinary review of medications and assessing appropriate response to therapy; and communication training be provided to nursing staff on how to articulate to the responsible physician important changes in the patients’ condition.