Burdensome Transitions at the End of Life Among Long-Term Care Residents With Dementia

ObjectivesThe purpose of the study was to examine the frequency of burdensome care transitions at the end of life, the difference between different types of residential care facilities, and the changes occurring between 2002 and 2008.DesignA nationwide, register-based retrospective study.SettingResidential care facilities offering long-term care, including traditional nursing homes, sheltered housing with 24-hour assistance, and long-term care facilities specialized in care for people with dementia.Study groupAll people in Finland who died at the age of 70 or older, had dementia, and were in residential care during their last months of life.Main outcome measuresThree types of potentially burdensome care transition: (1) any transition to another care facility in the last 3 days of life; (2) a lack of continuity with respect to a residential care facility before and after hospitalization in the last 90 days of life; (3) multiple hospitalizations (more than 2) in the last 90 days of life. The 3 types were studied separately and as a whole.ResultsOne-tenth (9.5%) had burdensome care transitions. Multiple hospitalizations in the last 90 days were the most frequent, followed by any transitions in the last 3 days of life. The frequency varied between residents who lived in different baseline care facilities being higher in sheltered housing and long-term specialist care for people with dementia than in traditional nursing homes. During the study years, the number of transitions fluctuated but showed a slight decrease since 2005.ConclusionsThe ongoing change in long-term care from institutional care to housing services causes major challenges to the continuity of end-of-life care. To guarantee good quality during the last days of life for people with dementia, the underlying reasons behind transitions at the end of life should be investigated more thoroughly.     

Web-Based Delirium Prevention Application for Long-Term Care Facilities

ObjectiveA web-based application was developed for medical staff to easily access and use a comprehensive delirium prevention management program—comprising risk prediction, assessment, and intervention—even in long-term care facilities with insufficient systems.DesignA randomized control trial.Setting and ParticipantsA long-term care facility with 250 beds in Korea. Participants were 130 facility residents aged 18 or older who understood the purpose of this study and for whom a legal representative provided participation consent. Participants were randomly assigned to the intervention and control groups (n = 65 per group).MethodsThe participants’ risk of delirium episodes was predicted using the web-based application Web_DeliPREVENT_4LCF. Delirium was assessed using the built-in Short Confusion Assessment Method (S-CAM). Among the intervention group, nonpharmacological, multicomponent delirium prevention interventions guided by the application were applied to participants who were predicted to be at risk for delirium or tested positive for delirium. The intervention was provided for 30 days.ResultsThe intervention group had a 0.30 times lower incidence of delirium [95% confidence interval (CI) 0.12–0.79; P = .015] and 0.08 times lower 1-month hospitalization mortality (95% CI 0.01–0.79; P = .031) than the control group. There were no differences between the 2 groups in delirium severity, mortality, and 3-month hospitalization mortality, long-term care facility discharge, and length of stay.Conclusions and ImplicationsThe Web_DeliPREVENT_4LCF was effective in reducing delirium episodes and 1-month in-hospital mortality. Therefore, even in Korean long-term care facilities, which lack manpower and electronic medical record systems compared with general hospitals, the health care professional can easily access and use the app for early detection and preventive intervention for residents’ delirium.RegistrationKCT0005804.     

Deprescribing Blood Pressure Treatment in Long-Term Care Residents

ObjectivesTo evaluate the incidence of deprescribing of antihypertensive medication among older adults residing in Veterans Affairs (VA) nursing homes for long-term care and rates of deprescribing after potentially triggering events.DesignRetrospective cohort study.Setting and ParticipantsLong-term care residents aged 65 years and older admitted to a VA nursing home from 2006 to 2019 and using blood pressure medication at admission.MethodsData were extracted from the VA electronic health record, and Centers for Medicare & Medicaid Services Minimum Data Set and Bar Code Medication Administration. Deprescribing was defined on a rolling basis as a reduction in the number or dose of antihypertensive medications, sustained for ≥2 weeks. We examined potentially triggering events for deprescribing, including low blood pressure (<90/60 mmHg), acute renal impairment (creatinine increase of 50%), electrolyte imbalance (potassium below 3.5 mEq/L, sodium decrease by 5 mEq/L), and falls.ResultsAmong 31,499 VA nursing home residents on antihypertensive medication, 70.4% had ≥1 deprescribing event (median length of stay = 6 months), and 48.7% had a net reduction in antihypertensive medications over their stay. Deprescribing events were most common in the first 4 weeks after admission and the last 4 weeks of life. Among potentially triggering events, a 50% increase in serum creatinine was associated with the greatest increase in the likelihood of deprescribing over the subsequent 4 weeks: residents with this event had a 41.7% chance of being deprescribed compared with 11.5% in those who did not (risk difference = 30.3%, P < .001). A fall in the past 30 days was associated with the smallest magnitude increased risk of deprescribing (risk difference = 3.8%, P < .001) of the events considered.Conclusions and ImplicationsDeprescribing of antihypertensive medications is common among VA nursing home residents, especially after a potential renal adverse event.     

Associations Between Nutritional Status,Frailty and Health-Related Quality of Life Among Older Long-Term Care Residents in Helsinki

The aim of this study was to examine how nutritional status modifies the association between frailty and health-related quality of life (HRQoL) among older nursing home residents. We also investigated how residents’ energy intake is linked to frailty score. A total of 486 older (> 65 years of age) nursing home residents living in Helsinki, Finland were included to this cross-sectional study. We collected data on the residents’ background information, HRQoL by 15D, nutritional status by Mini Nutritional Assessment (MNA), frailty status (Fried’s phenotype criteria; pre-frail: 1–2 criteria and frail: 3–5) and energy intake (one- or two-day food records). The frail residents were more often malnourished and had lower HRQoL than those in the prefrail group. Energy and protein intakes were significantly lower among frail women than prefrail women. Energy intake was linearly associated with frailty points. When residents in the frail and prefrail groups were divided according to their nutritional status, both nutritional status and frailty were associated with HRQoL, but there was no interaction. Both nutritional status and frailty were associated with HRQoL, and lower energy intake indicated a higher frailty score. An adequate energy intake may promote residents’ HRQoL and prevent frailty in long-term care.     

Utilization by Long-Term Nursing Home Residents Under Accountable Care Organizations

ObjectivesNursing home care is common and costly. Accountable care organization (ACO) payment models, which have incentives for care that is better coordinated and less reliant on acute settings, have the potential to improve care for this high-cost population. We examined the association between ACO attribution status and utilization and Medicare spending among long-term nursing home residents and hypothesized that attribution of nursing home residents to an ACO will be associated with lower total spending and acute care use.DesignObservational propensity-matched study.Setting and ParticipantsMedicare fee-for-service beneficiaries who were long-term nursing home residents residing in areas with ≥5% ACO penetration.MethodsACO attribution and covariates used in propensity matching were measured in 2013 and outcomes were measured in 2014, including hospitalization (total and ambulatory care sensitive conditions), outpatient emergency department visits, and Medicare spending.ResultsNearly one-quarter (23.3%) of nursing home residents who survived into 2014 (n = 522,085, 76.1% of 2013 residents) were attributed to an ACO in 2013 in areas with ≥5% ACO penetration. After propensity score matching, ACO-attributed residents had significantly (P < .001) lower hospitalization rates per 1000 (total: 402.9 vs 419.9; ambulatory care sensitive conditions: 64.4 vs 71.4) and fewer outpatient ED visits (29.9 vs 33.3 per 100) but no difference in total spending ($14,071 vs $14,293 per resident, P = .058). Between 2013 and 2014, a sizeable proportion of residents’ attribution status switched (14.6%), either into or out of an ACO.Conclusions and ImplicationsACO nursing home residents had fewer hospitalizations and ED visits, but did not have significantly lower total Medicare spending. Among residents, attribution was not stable year over year.     

Use of Antipsychotic Drugs Among Residents With Dementia in European Long-Term Care Facilities: Results From the SHELTER Study

BackgroundBehavioral and psychological symptoms of dementia (BPSD) are common reasons for use of antipsychotic drugs among older individuals with dementia. These drugs are not approved for such use and both the Food and Drug Administration and European Medicines Agency have issued warnings to limit such use.ObjectivesThis study aimed to describe patterns of antipsychotic drug use in a sample of nursing home residents with dementia in 7 European countries and Israel.DesignThis cross-sectional, retrospective cohort study used data from the SHELTER study that collected comprehensive resident data using the interRAI Long-Term Care Facility instrument.MethodsFifty-seven long-term care facilities participated from 8 countries, and the sample included 4156 long-term care residents from these settings. Individuals with dementia, both Alzheimer and non-Alzheimer types, were identified. Potential correlates of any antipsychotic and atypical versus conventional antipsychotic drug use among residents with dementia were identified using generalized estimation equation modeling.ResultsA total of 2091 individuals with dementia were identified. Antipsychotic drug use among these individuals varied by country, with overall prevalence of use being 32.8% (n = 662). Among antipsychotic users, 7 in 10 were receiving atypical agents. Generalized estimation equation analysis revealed that the strongest correlate of any antipsychotic drug use was severe behavioral symptoms, which increased the likelihood by 2.84. Correlates of atypical versus conventional antipsychotic drug use included psychiatric services, more than 10 medications, moderate behavioral symptoms, and female gender.ConclusionDespite recommendations to avoid the use of antipsychotic drugs in patients with dementia, a large proportion of residents in European long-term care facilities continue to receive such agents. Future work should not only establish the appropriateness of such use through outcomes studies, but explore withdrawal strategies as well as alternative treatment modalities.     

Review of Nutrition Screening and Assessment Practices for Long-Term Care Residents

Abstract

The older adult population in Canada is growing, creating a greater demand for long-term care (LTC) facilities. Seniors living in LTC are more vulnerable to malnutrition, making it important to implement nutrition screening tools on a routine basis. The purpose of this study was to explore the practices of Registered Dietitians (RDs) related to nutritional screening, nutritional assessment, and follow-ups conducted within LTC facilities. This study also explored possible barriers hindering the application of these practices. Nine RDs from two health regions in Southern Saskatchewan completed a phone interview to address nutrition care practices/policies and barriers in LTC facilities. Results showed a considerable amount of variability in nutrition care practices for screening and assessment with lack of time identified as the greatest barrier. These findings highlight the importance of having consistent policies and a sufficient amount of RDs available in LTC facilities to provide the expected level of nutrition care for residents.