Suicide Risk in Nursing Homes and Assisted Living Facilities: 2003–2011

Objectives. We investigated the epidemiology of suicide among adults aged 50 years and older in nursing homes and assisted living facilities and whether anticipating transitioning into long-term care (LTC) is a risk factor for suicide.Methods. Data come from the Virginia Violent Death Reporting System (2003–2011). We matched locations of suicides (n = 3453) against publicly available resource registries of nursing homes (n = 285) and assisted living facilities (n = 548). We examined individual and organizational correlates of suicide by logistic regression. We identified decedents anticipating entry into LTC through qualitative text analysis.Results. Incidence of suicide was 14.16 per 100 000 in nursing homes and 15.66 in the community. Better performance on Nursing Home Compare quality metrics was associated with higher odds of suicide in nursing homes (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.21, 3.14). Larger facility size was associated with higher suicide risk in assisted living facilities (OR = 1.01; 95% CI = 1.00, 1.01). Text narratives identified 38 decedents anticipating transitioning into LTC and 16 whose loved one recently transitioned or resided in LTC.Conclusions. LTC may be an important point of engagement in suicide prevention.Approximately 40% of adults aged 65 years and older will need skilled residential nursing care at some point in their lifetime.1 Older adults have among the highest suicide risks in the United States2; the rate of suicide among men aged 65 years and older is 30 per 100 000; by contrast, it is 7 per 100 000 for men younger than 25 years.3 A key element of suicide prevention is the identification of points of engagement to interact with potential victims.4 Risk factors for suicide, such as social isolation, depression, and functional impairment, are common among long-term care (LTC) residents,5–7 and these facilities may therefore be important locations for preventing suicide among older adults. Indeed, the 1987 Nursing Home Reform Act mandated screening of LTC admissions to facilitate appropriate placement and increased psychiatric services,8 and the Minimum Data Set 3.0 includes a mandatory screener for depressive symptoms and suicidal ideation.9 Nearly 1.5 million adults reside in nursing homes,10,11 and another 1 million reside in assisted living facilities.12Little is known regarding risk and protective factors for suicide in LTC.13 In 2011 the Substance Abuse and Mental Health Services Administration released a tool kit on preventing suicide in senior-living communities, which notes,

We do not know how many residents of senior living communities attempt suicide or die by suicide. But, we do know that a suicide in a facility . . . profoundly impacts the lives of everyone concerned—residents, families, and staff.^14(p4)

Suicidal ideation is common among LTC residents, with between 5% and 33% reporting ideation (active or passive) within the past month.15 As a result, suicide risk may be substantial in these facilities despite countervailing factors such as regular monitoring by staff and limited access to lethal means. The handful of studies that have compared incidence of completed suicide in LTC to the general community are mixed, with 1 reporting higher16 and another reporting lower17 risk in these settings.Suicidal behavior in LTC likely reflects a combination of factors shared with community cases (e.g., presence of a psychiatric disorder), as well as factors that are unique to LTC (e.g., facility characteristics). For example, bed size (number of beds) and high staff turnover have been associated with higher risk of suicidal behaviors among residents.18,19 However, these studies were conducted in the 1980s, prior to the growth of assisted living,20 which reduces their applicability to modern facilities. Finally, it is unknown whether the transition to LTC, or the process of having a loved one transition, is a risk factor for suicide.21 These transitions often involve a complex interplay of social and psychological factors, including feelings of autonomy, social connectedness, and identity,22,23 and can produce feelings of anxiety, loneliness, and hopelessness because they affect a people’s sense of being at home, which is not simply their physical residence.24 Such transitions have potential implications for the psychological well-being of caregivers of the person moving into LTC as well.25To identify whether LTC settings are important points of engagement for reducing suicide risk among older adults,4,26 we analyzed data from the 2003 to 2011 Virginia Violent Death Reporting System (VVDRS). We aimed to (1) describe the epidemiology of completed suicide in nursing homes and assisted living facilities, (2) examine whether facility characteristics were related to suicide risk, and (3) assess whether the process of transitioning into an LTC facility was associated with suicide.     

Trends in Postacute Care and Staffing in US Nursing Homes, 2001–2010

Objective

The objective of this study was to document the growth of postacute care and contemporaneous staffing trends in US nursing homes over the decade 2001 to 2010.

Design

We integrated data from all US nursing homes longitudinally to track annual changes in the levels of postacute care intensity, therapy staffing and direct-care staffing separately for freestanding and hospital-based facilities.

Setting

All Medicare/Medicaid-certified nursing homes from 2001 to 2010 based on the Online Survey Certification and Reporting System database merged with facility-level case mix measures aggregated from resident-level information from the Minimum Data Set and Medicare Part A claims.

Measurements

We created a number of aggregate case mix measures to approximate the intensity of postacute care per facility per year, including the proportion of SNF-covered person days, number of admissions per bed, and average RUG-based case mix index. We also created measures of average hours per resident day for physical and occupational therapists, PT/OT assistants, PT/OT aides, and direct-care nursing staff.

Results

In freestanding nursing homes, all postacute care intensity measures increased considerably each year throughout the study period. In contrast, in hospital-based facilities, all but one of these measures decreased. Similarly, therapy staffing has risen substantially in freestanding homes but declined in hospital-based facilities. Postacute care case mix acuity appeared to correlate reasonably well with therapy staffing levels in both types of facilities.

Conclusion

There has been a marked and steady shift toward postacute care in the nursing home industry in the past decade, primarily in freestanding facilities, accompanied by increased therapy staffing.     

State-by-State Variation in the Number of Children and Young Adults in Nursing Homes, 2005–2012

Objectives One goal of Healthy People 2020 is to reduce the number of children and young adults living in nursing homes. However, little is known about the prevalence of nursing home use among children and young adults on a state-by-state basis. The objective of this study was to determine the prevalence of nursing home use among children and young adults in each state from 2005 to 2012. The study also looked for prevalence trends between 2005 and 2012. Methods The Centers for Medicare and Medicaid Services Minimum Data Set and US Census data were used to calculate the prevalence of nursing home residents among children and young adults aged 0–30 in each US state in 2012 and assess trends in each state from 2005 to 2012. Results In 2012, the prevalence of nursing home residents among children and young adults aged 0–30 varied across states, ranging from 14 in 100,000 (New Jersey) to 0.8 in 100,000 (Alaska). Testing for trends from 2005 to 2012 also revealed significant trends (p?<?0.05), with Florida trending upward with borderline statistical significance (p?=?0.05) and six states trending downward. Conclusion There is wide variation in the prevalence of nursing home residents among children and young adults aged 0–30 across states. There is also variation in the nursing home prevalence trends across states. Observed variations may represent potential opportunities for some states to reduce their population of children and young adults in nursing homes.     

Nursing Homes and Long Term Care After COVID-19: A New ERA?

The journal of nutrition, health & aging -     

Linguistic Stereotyping in Older Adults’ Perceptions of Health Care Aides

The cultural and linguistic diversity of the U.S. health care provider workforce is expanding. Diversity among health care personnel such as paraprofessional health care assistants (HCAs)—many of whom are immigrants–means that intimate, high-stakes cross-cultural and cross-linguistic contact characterizes many health interactions. In particular, nonmainstream HCAs may face negative patient expectations because of patients’ language stereotypes. In other contexts, reverse linguistic stereotyping has been shown to result in negative speaker evaluations and even reduced listening comprehension quite independently of the actual language performance of the speaker. The present study extends the language and attitude paradigm to older adults’ perceptions of HCAs. Listeners heard the identical speaker of Standard American English as they watched interactions between an HCA and an older patient. Ethnolinguistic identities—either an Anglo native speaker of English or a Mexican nonnative speaker–were ascribed to HCAs by means of fabricated personnel files. Dependent variables included measures of perceived HCA language proficiency, personal characteristics, and professional competence, as well as listeners’ comprehension of a health message delivered by the putative HCA. For most of these outcomes, moderate effect sizes were found such that the HCA with an ascribed Anglo identity—relative to the Mexican guise—was judged more proficient in English, socially superior, interpersonally more attractive, more dynamic, and a more satisfactory home health aide. No difference in listening comprehension emerged, but the Anglo guise tended to engender a more compliant listening mind set. Results of this study can inform both provider-directed and patient-directed efforts to improve health care services for members of all linguistic and cultural groups.     

Hearing Loss and Older Adults’ Perceptions of Access to Care

We investigated whether hard-of-hearing older adults were more likely to report difficulties and delays in accessing care and decreased satisfaction with healthcare access than those without hearing loss. The Wisconsin Longitudinal Study (2003–2006 wave, N = 6,524) surveyed respondents regarding hearing, difficulties/delays in accessing care, satisfaction with healthcare access, socio-demographics, chronic conditions, self-rated health, depression, and length of relationship with provider/site. We used multivariate regression to compare access difficulties/delays and satisfaction by respondents’ hearing status (hard-of-hearing or not). Hard-of-hearing individuals comprised 18% of the sample. Compared to those not hard-of-hearing, hard-of-hearing individuals were significantly more likely to be older, male and separated/divorced. They had a higher mean number of chronic conditions, including atherosclerotic vascular disease, diabetes and depression. After adjustment for potential confounders, hard-of-hearing individuals were more likely to report difficulties in accessing healthcare (Odds Ratio 1.85; 95% Confidence Interval 1.19–2.88). Satisfaction with healthcare access was similar in both groups. Our findings suggest healthcare access difficulties will be heightened for more of the population because of the increasing prevalence of hearing loss. The prevalence of hearing loss in this data is low and our findings from a telephone survey likely underestimate the magnitude of access difficulties experienced by hard-of-hearing older adults. Further research which incorporates accessible surveys is needed. In the meantime, clinicians should pay particular attention to assessing barriers in healthcare access for hard-of-hearing individuals. Resources should be made available to proactively address these issues for those who are hard-of-hearing and to educate providers about the specific needs of this population.     

Copper for the Prevention of Outbreaks of Health Care–Associated Infections in a Long-term Care Facility for Older Adults

ObjectiveWe aimed to study the efficacy of copper as an antimicrobial agent by comparing incidence rates during outbreaks in areas equipped vs not equipped with copper surfaces in a long-term facility for dependent older adults (nursing home).DesignProspective observational pilot study in a nursing home.Setting and participantAll persons resident in the nursing home belonging to Reims University Hospital, from February 1, 2015 to June 30, 2016, were included.MethodsIncidence rates for health care–related infections during outbreaks occurring during the study period were compared between the wing that was equipped and the wing that was not equipped with copper surfaces. Results are expressed as relative risks (RRs) and 95% confidence intervals (95% CIs).ResultsDuring the study period, 556 residents were included; average age was 85.4 ± 9.2 years, and 76% were women. Four outbreaks occurred during the study period: 1 influenza, 1 keratoconjunctivitis, and 2 gastroenteritis outbreaks. The risk of hand-transmitted health care–associated infection was significantly lower in the area equipped with copper surfaces (RR 0.3, 95% CI 0.1-0.5).Conclusions and implicationsIn our study, copper was shown to reduce the incidence of hand-transmitted health care–associated infections and could represent a relatively simple measure to help prevent HAIs in nursing homes.     

What Do We Know About Knowledge Translation in the Care of Older Adults? A Scoping Review

ObjectivesThe recent emphasis on knowledge translation (KT) in health care is based on the premise that quality of care improves when research findings are translated into practice. This study aimed to identify the extent, nature, and settings of KT research pertaining to the care of older adults.Design and MethodsWe searched Medline, CINAHL, The Cochrane Library, and EMBASE for systematic reviews related to KT using the terms knowledge translation, research use, evidence-based practice, clinical practice guidelines, or diffusion of innovations. Then we searched the systematic reviews to identify included articles related to older adults. We used quantitative content analysis to summarize the information.ResultsTwo of the 53 systematic reviews about KT focused on the care of older adults. One examined the impact of quality systems on care processes and outcomes for long term care residents. The other studied the effectiveness of active-mode learning programs on physician behavior. Sixty-one of the 1709 primary research articles (3.6%) pertained to the care of older adults. Thirty of these were conducted in long term care facilities, 26 in outpatient clinics, 2 in hospitals, and 3 in multiple settings. Most studies focused on KT interventions targeting professionals (eg, prescribing medications). Organizational interventions (eg, modifying roles) were few; financial and regulatory interventions were rare.ConclusionWe identified a gap in KT research pertaining to the care of older adults. KT intervention research focusing on organizational, financial, and regulatory areas is warranted. The connection between geriatrics and KT is fertile ground for future research.     

Clinicians’ Implicit Ethnic/Racial Bias and Perceptions of Care Among Black and Latino Patients

PURPOSE

We investigated whether clinicians’ explicit and implicit ethnic/racial bias is related to black and Latino patients’ perceptions of their care in established clinical relationships.

METHODS

We administered a telephone survey to 2,908 patients, stratified by ethnicity/race, and randomly selected from the patient panels of 134 clinicians who had previously completed tests of explicit and implicit ethnic/racial bias. Patients completed the Primary Care Assessment Survey, which addressed their clinicians’ interpersonal treatment, communication, trust, and contextual knowledge. We created a composite measure of patient-centered care from the 4 subscales.

RESULTS

Levels of explicit bias were low among clinicians and unrelated to patients’ perceptions. Levels of implicit bias varied among clinicians, and those with greater implicit bias were rated lower in patient-centered care by their black patients as compared with a reference group of white patients (P = .04). Latino patients gave the clinicians lower ratings than did other groups (P <.0001), and this did not depend on the clinicians’ implicit bias (P = .98).

CONCLUSIONS

This is among the first studies to investigate clinicians’ implicit bias and communication processes in ongoing clinical relationships. Our findings suggest that clinicians’ implicit bias may jeopardize their clinical relationships with black patients, which could have negative effects on other care processes. As such, this finding supports the Institute of Medicine’s suggestion that clinician bias may contribute to health disparities. Latinos’ overall greater concerns about their clinicians appear to be based on aspects of care other than clinician bias.Key words: race, ethnicity, communication, prejudice, patient-centered care, healthcare disparities, primary care, practice-based research     

Reducing Fluoroquinolone Use and Clostridioides difficile Infections in Community Nursing Homes Through Hospital–Nursing Home Collaboration

ObjectiveNursing homes (NHs) are an important target for antibiotic stewardship (AS). We describe a collaborative model to reduce Clostridioides difficile infections (CDIs) in NHs through optimization of antibiotic use including a reduction in high-risk antibiotics such as fluoroquinolones.DesignQuasi-experimental, pre- and post-intervention study.Setting and participantsSix NHs in Monroe County, NY.MethodsA hospital-based AS expert team assisted NHs in identifying targets for improving antibiotic use. Interventions included (1) collaboration with a medical director advisory group to develop NH consensus guidelines for testing and treatment of 2 syndromes (urinary tract infections and pneumonia) for which fluoroquinolone use is common, (2) provision of multifaceted NH staff education on these guidelines and education of residents and family members on the judicious use of antibiotics, and (3) sharing facility-specific and comparative antibiotic and CDI data. We used Poisson regression to estimate antibiotic use per 1000 resident days (RD) and CDIs per 10,000 RD, pre- and post-intervention. Segmented regression analysis was used to estimate changes in fluoroquinolone and total antibiotic rates over time.ResultsPostintervention, the monthly rate of fluoroquinolone days of therapy (DOT) per 1000 RD significantly decreased by 39% [rate ratio (RR) 0.61, 95% confidence interval (CI) 0.59-0.62, P < .001] across all NHs and the total antibiotic DOT decreased by 9% (RR 0.91, 95% CI 0.90-0.92, P < .001). Interrupted time series analysis of fluoroquinolone and total DOT rates confirmed these changes. The quarterly CDI rate decreased by 18% (RR 0.82, 95% CI 0.68-0.99, P = .042).Conclusions and implicationsA hospital-NH partnership with a medical director advisory group achieved a significant reduction in total antibiotic and fluoroquinolone use and contributed to a reduction in CDI incidence. This approach offers one way for NHs to gain access to AS expertise and resources and to standardize practices within the local community.     

State Variation in Long-Term Care Availability,Regulation, and Cost and Suicide Mortality Among Older Adults in the United States: 2010–2015

ObjectivesResidential long-term care (LTC) facilities may be key settings for the prevention of suicide among older adults; however, little is known about the relationship between statewide policies determining characteristics of LTC facilities and suicide mortality. The primary goal of this study was to evaluate the association between state policies regarding availability, regulation, and cost of LTC and suicide mortality among adults aged 55 and older in the United States over a 5-year period.DesignLongitudinal ecological study.Setting and ParticipantsLTC residents from 16 states reporting mortality data to the National Violent Death Reporting System (NVDRS) from 2010 to 2015.MethodsWe linked suicide data from the NVDRS and data sources on LTC services and regulations for 16 states. We applied a natural language-processing algorithm to identify suicide deaths related to LTC. We used fixed effect regression models to assess whether state variation in LTC characteristics is related to variation in the rate of suicide (both overall and related to LTC) among older adults.ResultsThere were 25,040 suicides among those aged 55 and older reported to the NVDRS during the study period; 382 suicides were determined to be associated with LTC in some manner. After adjusting for state-level characteristics, greater average nursing home capacity was significantly associated with increase in the cumulative incidence of suicide related to LTC (β = 0.087, SE = 0.026, P < .01), but not overall suicide incidence. Neither cost nor regulation measures were significantly associated with state-level LTC-related suicide incidence.Conclusions and ImplicationsState-level variations in LTC facility capacity are related to variation in LTC-related suicide incidence among older adults. Given the challenges of preventing suicide among older adults through facility- or individual-level interventions, policies governing the features and provision of LTC services may therefore serve as a means for public health suicide prevention.     

Intakes of Calcium and Phosphorus and Calculated Calcium-to-Phosphorus Ratios of Older Adults: NHANES 2005–2006 Data

Background: High intakes of dietary phosphorus (P), relative to calcium (Ca) intake, are associated with a lower calcium:phosphorus ratio (Ca:P) ratio which potentially has adverse health effects, including arterial calcification, bone loss, and death. A substantial percentage of older adults (50 to 70 and 71 plus years) who have a higher risk of fracture rate than younger adults typically have low intakes of dietary Ca that are dominated by higher intakes of dietary P from natural and fortified foods, and lower Ca:P ratios than desirable. Objective: This investigation was undertaken to examine Ca and P intakes and the resulting Ca:P ratios (by mass) across gender and older adult age groups, using data from the National Health and Nutrition Examination Survey (NHANES) 2005–2006. Design: NHANES data are based on a cross-sectional sample of the non-institutionalized United States (US) population within various regions. This sample is selected to be representative of the entire US population at all ages. National Cancer Institute (NCI) methods and SAS survey procedures were used for analyses. Ca:P ratios were calculated using total Ca from both foods and supplements, whereas P intakes were calculated from food composition values and supplements. The amounts of P additives in processed foods are not available. Results: Mean Ca and P intakes demonstrated lower intakes of Ca and higher intakes of P compared to current Recommended Dietary Allowances (RDAs). The Ca:P ratios in older male and female adults were influenced by both low-Ca and high-P dietary consumption patterns. Conclusions: Both low total Ca intakes and high P amounts contribute to lower Ca:P ratios, i.e., ~0.7:1.0, in the consumption patterns of older adults than is recommended by the RDAs, i.e., ~1.5:1.0. Whether Ca:P ratios lower than recommended contribute to increased risk of bone loss, arterial calcification, and all-cause mortality cannot be inferred from these data. Additional amounts of chemical P additives in the food supply may actually reduce even further the Ca:P ratios of older adults of both genders, but, without P additive data from the food industry, calculation of more precise ratios from NHANES 2005–2006 data is not possible.     

High Prevalence of Physical Frailty Among Community-Dwelling Malnourished Older Adults–A Systematic Review and Meta-Analysis

Background

Malnutrition and frailty are two geriatric syndromes that significantly affect independent living and health in community-dwelling older adults. Although the pathophysiology of malnutrition and physical frailty share common pathways, it is unknown to what extent these syndromes overlap and how they relate to each other.

Occupational Therapy in Diabetic Care—Areas of Need Perceived by Older Adults with Diabetes

This study explored the perception of older adults with diabetes regarding the areas of service considered helpful to their daily activities and routines. A survey questionnaire was designed and given to 52 community-dwelling older adults with diabetes. Results showed that cholesterol control, managing blood sugar, foot care, fatigue management and pacing, and pain management/reduction were the areas of most concern that deserve services. The findings suggest that, in providing holistic client-centered interventions to individuals with diabetes, occupational therapists need to be able to prioritize clients' concerns and help them incorporate diabetes management into their routines and lifestyle.     

Screening for Hypertension Among Older Adults: A Primary Care ��High Risk�� Approach

Background:

Recommendations for early detection and management of elevated blood pressure through opportunistic clinic-based screening may be inadequate for the rural population in India as access to health facilities is limited.

Materials and Methods:

Sixteen Health Aides (trained primary care workers) were trained to measure blood pressure using a standardized training procedure. Six of those assessed competent in initial evaluation were allotted a stratified random sample of about 150 persons each, 50 years or over, in the village under their care to measure blood pressures during their regular scheduled visits.

Results:

14/16 of the health aides (83%) met the stipulated criteria for the simulation study using a module from British Hypertension Society. In the field survey of 920 individuals where 20% of the population was evaluated by a blinded investigator, the weighted Kappa for agreement, using normal, pre-hypertension and hypertension as categories, ranged between 62% and 89%. Only 75/286 (25%) of those detected to be hypertensive knew their status prior to the study. All those detected with hypertension were referred to a physician at a referral facility. 70% of those referred were evaluated at the referral facility and 64% of them initiated on treatment for hypertension within 3 months.

Conclusion:

Using primary care workers to screen for hypertension through the model suggested here will ensure that the population over 50 years of age will be screened once every 2 years without burdening the worker. This screening process will enable the health system to identify and cater to needs of this vulnerable population.