Common and gender specific factors associated with one-year mortality in nursing home residents

OBJECTIVES: To identify common and gender-specific factors associated with mortality in two distinct nursing home (NH) populations: newly admitted (NA), and long-stay (LS) residents. DESIGN: A retrospective cohort study. SETTING: NH facilities in the state of New York. PARTICIPANTS: A total of 59,080 NA female and 28,080 NA male NH residents, and 24,260 LS female and 8,928 LS male NH residents evaluated between June 1994 and December 1997 who were at least 65 years of age. MEASUREMENTS: Minimum Data Set information including measures of health, functional, cognitive, psychological, and social status. RESULTS: Multivariate proportional hazards regression results indicate that in NA residents, use of feeding tubes, bowel incontinence, and refuses fluids were associated with mortality in women only, whereas fever was associated with mortality in men only. Cancer and congestive heart failure (CHF) were more strongly associated with mortality in women than men. In LS residents, deterioration in communication, refuses fluids, use of indwelling catheters, and deterioration in cognition were associated with mortality in women but not men. Bedfast most of the time, use of new medications, and a balance problem were associated with mortality in men but not women. Shortness-of-breath was more strongly associated with mortality in women than men. CONCLUSIONS: In both NA and LS residents, although men and women share many common factors associated with mortality, each gender has some unique factors associated with mortality. Furthermore, the strength of some common factors is significantly different across genders. These readily available data could be useful in making medical decisions and advance directive planning, and in the development of quality improvement initiatives and mortality prediction models.     

Use of the mini nutritional assessment tool in elderly people from long-term institutions of Southeast of Brazil

Background: the Mini Nutritional Assessment (MNA) is a multidimensional method of nutritional evaluation that allows the diagnosis of malnutrition and risk of malnutrition in elderly people, it is important to mention that this method has not been well studied in Brazil.Objective: to verify the use of the MNA in elderly people that has been living in long term institutions for elderly people.Design: transversal study.Participants: 89 people (≥ 60 years), being 64.0% men. The average of age for both genders was 73.7±9.1 years old, being 72.8±8.9 years old for men, and 75.3±9.3 years old for women.Setting: long-term institutions for elderly people located in the Southeast of Brazil.Methods: it was calculated the sensibility, specificity, and positive and negative predictive values. It was data to set up a ROC curve to verify the accuracy of the MNA. The variable used as a “standard” for the nutritional diagnosis of the elderly people was the corrected arm muscle area because it is able to provide information or an estimative of the muscle reserve of a person being considered a good indicator of malnutrition in elderly people.Results: the sensibility was 84.0%, the specificity was 36.0%, the positive predictive value was 77.0%, and the negative predictive value was 47.0%; the area of the ROC curve was 0.71 (71.0%).Conclusion: the MNA method has showed accuracy, and sensibility when dealing with the diagnosis of malnutrition and risk of malnutrition in institutionalized elderly groups of the Southeastern region of Brazil, however, it presented a low specificity.     

Preventing assaults by nursing home residents: nursing assistants' knowledge and confidence--a pilot study

OBJECTIVE: To describe the frequency and context of assaults against nursing assistants (NAs) from residents and to describe NAs' beliefs about their violence prevention knowledge and self-efficacy to prevent assaults from residents. DESIGN: Survey. SETTING: Six nursing homes. PARTICIPANTS: A total of 138 nursing assistants. MEASUREMENTS: NAs completed two investigator-developed surveys, the Demographic and Employment Questionnaire and the Knowledge and Self-Efficacy Survey. The Demographic and Employment Questionnaire included questions about race, gender, age, and education, current and previous employment, number of residents usually assigned, frequency of assaults, and training on workplace violence. On the Knowledge and Self-Efficacy Survey, the participants used a five-point Likert scale to rate their knowledge and confidence in recognizing and preventing assaults from residents. RESULTS: Assaults against nursing assistants from residents in nursing homes were common; 59% stated they were assaulted at least once a week and 16% stated they were assaulted daily. Fifty-one percent stated that they had been injured in their lifetime from an assault from a resident, and 38% of those injured received medical attention for an injury. On the Likert items, nursing assistants reported that they believed they had the most knowledge (mean = 3.76) and confidence (mean 3.81) in their ability to recognize when a resident is agitated or becoming aggressive. In comparison, NAs rated lower their knowledge (mean = 3.45) and confidence in their ability (3.50) to keep residents from becoming agitated or aggressive (mean 3.50). NAs rated lowest their knowledge (3.42) and confidence (mean = 3.47) in their ability to decrease residents' agitation and aggressiveness once they become agitated or aggressive. CONCLUSIONS: These findings provide useful information that supports the need for violence prevention education and for developing violence prevention programs in nursing homes.     

Mini Nutritional Assessment (MNA) is Rather a Reliable and Valid Instrument to Assess Nutritional Status in Iranian Healthy Adults and Elderly with a Chronic Disease

This study aimed to evaluate the usefulness of the Mini Nutritional Assessment (MNA) to assess nutritional status of Iranian population and to compare its psychometric properties between patients suffering from a chronic disease, healthy elderly and younger adults. As a group of elderly with a chronic disease, 143 Parkinson’s disease (PD) patients and as the control group, 467 healthy persons were enrolled. The Persian-translated version of MNA was filled-up through interviews together with anthropometric measurements. Cronbach’s α coefficient of entire MNA was 0.66 and 0.70 in healthy individuals and PD patients, respectively. The total MNA score could significantly discriminate the ones with BMI ≥ 24kg/m² in both groups. In general, MNA was a valid and reliable tool for nutritional assessment. We acknowledge study limitations including lack of serum measurements and a selection bias towards mild-to-moderate PD. MNA is a more reliable tool in older healthy individuals and rather younger elderly with PD.     

成都市敬老院老年人口腔健康认知、行为的调查分析

目的了解上海市松江区敬老院老年人口腔健康情况,为提高其口腔健康水平提供参考依据。方法通过对松江区15家敬老院共375名老年人问卷调查和口腔检查,分析其牙缺失、义齿修复、牙周状况及口腔卫生习惯等状况。结果375名老年人中失牙率达到94.13%,女性失牙率(96.09%)高于男性(91.03%)(P < 0.01);全口无牙颌率为28.27%,女性全口无牙颌比例(34.35%)明显多于男性(18.62%)(P < 0.05);全口义齿修复率为91.51%(97/106)。人均存牙数为11.54颗,男性人均存牙数(14.48颗/人)明显多于女性(9.70颗/人)(P < 0.05)。上、下颌牙的后牙的失牙率均显著高于其前牙失牙率(P < 0.01)。基本不刷牙的比例为20.53%,每天刷牙大于等于2次比例为33.33 %。结论目前松江区敬老院老年人口腔健康口腔状况不容乐观,需多部门联合加强辖区敬老院老人口腔保健的宣教力度,提升居民口腔保健意识,改善老年人的缺牙修复水平,提高其生活质量。     

A club of friends: enrolling nursing home residents in an adult day program

OBJECTIVE: To evaluate an innovative approach to maintaining physical, cognitive, and social functioning in frail, elderly nursing home residents at risk for transfer from a minimal care unit. SUBJECTS/SETTING: Nineteen Russian-speaking residents of the Jewish Home in San Francisco who were newly enrolled in an on-site adult day care program. METHODS: A formal evaluation of the program employed a repeated measures design with assessments at baseline and at Months 2, 3, 4, 6, and 9. Outcomes included stability of living situation, functional status, physical and mental health, cognitive functioning, sense of well-being and quality of life, and satisfaction with the program. RESULTS: During this period, the cohort was medically stable and, although some evidenced cognitive decline, there was little change in their functional status. Nearly all of the residents reported improvement from baseline in some aspects of their lives, with the greatest proportions reporting positive changes in social support and quality of life. CONCLUSIONS: Findings from this evaluation suggest that activities programming using the model described here may enhance the quality of life for some nursing home residents and enable them to remain in the least restrictive, as well as the least costly, living situation possible.     

Nursing home resident barriers to effective pain management: why nursing home residents may not seek pain medication

OBJECTIVES: Multiple barriers to effective pain management are present in the nursing home setting. The purpose of this analysis was to determine the extent to which residents in pain declined to request pain medication from the staff, and the reasons provided by the residents to explain this behavior. DESIGN: Every 3 months, a 20% sample of residents in 12 nursing homes was administered a short pain interview, then observed for pain indicators. Medical records were reviewed at the same time for documentation about pain and its treatment. All residents were asked if they had pain (or a similar word) now or in the past 24 hours. They were also asked if they had pain but did not request pain medication. If affirmative, the resident was asked to provide up to three reasons for not requesting medication. SETTING: The study was conducted in 12 Colorado nursing homes, located in both urban and rural settings. PARTICIPANTS: A total of 2033 nursing home residents completed pain interviews and/or were observed for pain indicators by trained research assistants. These interviews took place before, during, and after implementation of an intervention to improve pain practices. MEASUREMENTS: A cognitive organizing structure was used to categorize resident responses into a coherent classification. Individual responses were assigned by team members to the appropriate category using a consensus process. The final classification scheme consisted of 10 categories of reasons why residents do not request pain medication. RESULTS: More than one-half of residents (59.5%) reporting pain in the past 24 hours did not request medication for that pain. Subjects in pain were most likely to state medication concerns or stoicism as the reasons for not requesting pain medication. Concerns about staff reactions to a request or perceptions that the staff was too busy were also mentioned frequently by the residents. Subgroup analyses suggested that residents in pain but not requesting pain medication were significantly more likely to be in rural rather than urban nursing homes (67.9% vs. 52.9%, P < or = .01), and white as compared to nonwhite ethnicity (60.6% vs. 52.1%, P < or = .05). They also tended to be older on average (80.4 +/- 12.1 years vs. 77.9 +/- 12.7 years, P < or = .01) than residents who did request pain medication. Finally, residents in pain but not requesting pain medication were significantly more likely to report having both continuous (c) and intermittent (i) pain (71.8% [c + i] vs. 61% [c] or 56.5% [i], P < or = 0.01). CONCLUSION: Interventions to reduce pain in nursing home residents need to be responsive to the concerns of the residents. It must be acknowledged that resident preferences and beliefs may lead to declined pain interventions regardless of the staff's motivation to make the resident more comfortable. Staff nurses also need to make a more concerted effort to systematically assess pain and offer pain medication to residents rather than rely on resident requests.     

Assessing the prevalence of malnutrition with the Mini Nutritional Assessment (MNA) in a nationally representative sample of elderly Taiwanese

Objective: The study was to determine whether the Mini Nutritional Assessment (MNA) could be used as a tool to effectively identify malnourished elderly in a non-Caucasian population.Design: The study was a part of a population-based multistage random sample survey.Setting: In-home face-to-face interviews.Participants: Randomly selected 1583 men and 1307 women, 65 years or older, in Taiwan.Measurements: Assessing nutritional risk status of participants with the Mini Nutritional Assessment.Results: The prevalence of malnutrition is 1.7% in elderly men and 2.4% in elderly women, 65 years or older. The proportion at risk of malnutrition is 13.1%.Conclusion: To the best of our knowledge, this is the first study to apply the MNA to estimate the prevalence of malnutrition in the elderly in a nationally representative sample. Results suggest that the MNA can identify malnourished elderly in a non-Caucasian population. However, it appears that the functionality of the instrument can be improved by adapting population-specific anthropometric cutoff standards. Former Taiwan Provincial Institute of Family Planning.     

Development of definitions for acute illness in nursing home residents based on chart-recorded physical exam findings

OBJECTIVES: To develop and test simple, chart-based criteria for acute illness in nursing home residents for clinical and epidemiological study. DESIGN: Observational study. SETTING: A 409-bed not-for-profit nursing home. PARTICIPANTS: 102 custodial care residents. MEASUREMENTS: Physical exam findings commonly performed in nursing home residents were used to define 10 acute conditions. Residents were observed prospectively to test the clinical relevance of these definitions. Episodes of acute illness satisfying definition criteria were identified, as well as treatment changes, hospitalizations, and deaths. RESULTS: During a median follow-up of 60 days, 43 acute illnesses occurred, affecting 30 (29%) residents. Of these episodes, 77% were associated with treatment changes, hospitalization, or death. The new definitions captured 79% of all episodes of acute illness. The most common diagnoses were urinary tract infection, lower respiratory infection, and gastroenteritis/gastrointestinal upset. Independent risk factors for acute illness were gastrostomy feeding, depression, and history of fracture. CONCLUSIONS: Acute illness in the nursing home is common and frequently associated with treatment changes, hospitalization and death. It can be identified using a small number of chart-recorded physical exam-based findings as criteria.     

Recent changes in stroke history, mobility status and life expectancy at admission among nursing home residents in Japan

We investigated changes in the condition of elderly people at admission to nursing homes, their prognosis after admission and recent changes of mortality risk factors among the residents. We then examine the possible relationship between the changes identified and discuss the possible effects of changes in social policy. A retrospective cohort study using survival analysis was conducted among 407 residents of three nursing homes in Toyama, Japan who were admitted between 1976 and 1990. By reviewing medical and care notes, we abstracted the admission date, gender, age at admission, stroke history, physical activity and date of discharge or death for each subject. Positive stroke history was defined as medical certification of thromboembolic or haemorrhagic stroke before admission. The level of physical activity at admission was classified as either mobile or immobile, according to whether it was possible to get out of bed without assistance from another person. Data were compared for subjects admitted during the two periods of 1976–82 and 1983–90. The latter period includes the year, 1985, when the Medical Service Law in Japan was amended for the purpose of effective allocation of medical resources. In comparison with that for the first admission period, the mean age at admission for the second period was significantly higher in both males and females. The age- and gender-adjusted odds ratio of stroke history to immobile status decreased from 4.7 for the first admission period to 2.2 for the second. The 5-year survival rate decreased, from 51 to 30% (P≤ 0.0001). In multivariate analysis, the relative hazard (RH) of mortality of the subjects in the later admission period to those in the earlier period was 2.0 [95% confidence interval (CI): 1.4–2.8], while the RH was not significant for either gender or age. Immobile status without stroke history showed the highest RH. The RH of the interaction of mobile status with stroke history and late admission period was significantly lower than 1.0. The study indicates that: the relative importance of stroke history in immobile status has decreased among the nursing home population, stroke history among the mobile subjects has become less predictive of poor prognosis after admission, the life expectancy after admission has declined, and the increased mortality is related to factors other than physical activity status and may be attributable to the recent reorganization of medical resources.     

Rheumatoid cachexia,central obesity and malnutrition in patients with low-active rheumatoid arthritis: feasibility of anthropometry,Mini Nutritional Assessment and body composition techniques

Background and aims  The concurrent decrease in fat free mass (FFM) and increase in fat mass (FM), including central obesity, in patients with rheumatoid arthritis (RA) may be related to increased cardiovascular morbidity as well as to functional decline. The objectives of this study were to evaluate body composition and nutritional status in patients with RA and the feasibility of bioelectrical impedance (BIA) to detect rheumatoid cachexia. Methods  Eighty RA outpatients (76% women), mean age 61 (range 22–80) years and with mean disease duration of 6 (range 1–52) years, were assessed by body mass index (BMI), waist circumference (WC), whole-body dual-energy X-ray absorptiometry (DXA), BIA and the Mini Nutritional Assessment (MNA). Results  Fat free mass index (FFMI; kg/m²) was low in 26% of the women and in 21% of the men. About every fifth patient displayed concomitant low FFMI and elevated fat mass index (FMI; kg/m²), i.e. rheumatoid cachexia. BMI and MNA were not able to detect this condition. Sixty-seven percent had increased WC. Reduced FFM was independently related to age (p = 0.022), disease duration (p = 0.027), ESR (p = 0.011) and function trendwise (p = 0.058). There was a good relative agreement between DXA and BIA (FM r ² = 0.94, FFM r ² = 0.92; both p < 0.001), but the limits of agreement were wide for each variable, i.e. for FM −3.3 to 7.8 kg; and for FFM −7.9 to 3.7 kg. Conclusion  Rheumatoid cachexia and central obesity were common in patients with RA. Neither BMI nor MNA could detect this properly. There was a good relative agreement between DXA and BIA, but the limits of agreement were wide, which may restrict the utility of BIA in clinical practice. This work has in part been presented at the Congress of American College of Rheumatology in San Francisco, October 2008.     

Detecting systematic discrepancies in nursing home assessments of residents

Medicare and Medicaid reimbursement received by nursing homes are linked to the care needs of residents in a facility. Thus, a facility may have an incentive to overestimate the care needs of residents. To evaluate this, a sample of nursing homes in Ohio was selected, and independent assessors were sent to sampled facilities, and the rating of residents by the independent assessor was compared to a similar rating by the staff at nursing homes. We first evaluated whether the independent assessors were homogeneous with respect to agreement with nursing facility assessors using a permutation test procedure. Since there was evidence of heterogeneity among the independent assessors, we evaluated agreement between the independent nurse and facility assessors separately for each independent nurse. Responses were collapsed into three categories: independent assessor was lower, equal or greater than the facility assessor. Under a null hypothesis that lower and greater categories were equally probable, the maximum likelihood estimate of the vector of probabilities corresponding to these categories was constructed for each independent assessor. The P-value for detecting a difference between independent and facility assessors was calculated for each facility by summing the multinomial probabilities of obtaining a result at least as extreme as observed in the direction of the “lower” category being more probable. Five of the 39 facilities had P-value < 0.10 with three of the low P-value facilities occurring in reviews by one of the independent assessors. We believe that there is not evidence of systematic differences between the facility assessors and independent assessors although a caveat associated with this statement is the power of this assessment procedure is strongly linked to number of cases reviewed per facility along with the size of the effect expected. We believe this provides a screening mechanism to identify facilities where additional samples are warranted.     

Absent voices compromise the effectiveness of nursing home regulation: a critique of regulatory reform in the UK nursing home industry

Over the last decade there has been consistent pressure for the healthcare services in the UK to become more accountable to users. Now over half the healthcare beds in England are in the privatised nursing home sector, and regulation of the sector is under reform. Yet requirements for user accountability have not been reflected in these reforms. In other sectors, consumer involvement in regulatory agencies and processes is seen as important to the success of the regulatory enterprise. But in the care sector neither users nor their representatives have been given legal rights of involvement in the National Care Standards Commission or in regulatory processes. This paper argues that failure to involve users not only places the regulation enterprise at risk of capture by the industry, but will also weaken the legitimacy of the new Commission.