Oral health of Adelaide nursing home residents: longitudinal study

Objective: The Adelaide Dental Study of Nursing Homes aimed to quantify oral disease experience, incidence and increments in Adelaide nursing home residents. Methods: Questionnaires and dental inspections were completed at baseline and at 1‐year for residents from randomly selected Adelaide nursing homes. Results: The residents were very functionally dependent, cognitively impaired and behaviourally difficult older adults with complex oral problems and dental treatment needs. The prevalence of edentulism (total tooth loss) (63%) decreased and more residents were retaining natural teeth. Existing residents had a mean of 10.8 teeth present and new residents had a mean of 12.7 teeth present. Residents’ previous experiences of caries (decay) were high – existing residents had a mean of 1.2 decayed teeth and new residents had a mean of 0.8 decayed teeth. Residents’ caries increments (new decay) over the 1‐year period were high (coronal = 2.5 surfaces; root = 1.0 surfaces), especially in those who had lost weight and who could eat fewer food types. These levels of caries were many times greater than had been reported for community‐dwelling older adults. Large accumulations of plaque, calculus and debris (food) were evident on residents’ natural teeth and dentures, especially those with dementia. Up to 25% of residents owned dentures that were not worn. Residents with dementia gave their carers complex and challenging oral hygiene care problems. Existing and new residents had similar general health and oral health characteristics, with the exceptions that new residents had significantly more filled tooth surfaces, and fewer decayed retained roots. Conclusion: New residents were being admitted to the nursing homes with a compromised oral health status or developed severe oral diseases and conditions within several months of their admittance. Residents’ oral diseases, especially coronal and root caries, rapidly progressed during their stay in residential care.     

Medication use in a cohort of newly admitted nursing home residents (Ageing@NH) in relation to evolving physical and mental health

BackgroundMedication use is high among nursing home (NH) residents, but there is a lack of longitudinal studies, determining medication use at admission and its evolution over time.AimDescribing the evolution of the medication use two years after entering a NH, compared to the baseline observations and exploring the relation to the physical and mental health.MethodsData from the observational prospective Ageing@NH study, based on an inception cohort of newly admitted residents at NHs (65+) was used, selecting those consenting and with medication chart available. Information about socio-demographic, functional and mental characteristics, as well as medication use, was collected at baseline, year 1 and year 2.ResultsMedication chart was available for n = 741 at baseline (mean age 83.8, 66% female), and for n = 342 residents in year 2. The mean number of total medications increased from 8.9 to 10.1 (p-value < 0.001). Polypharmacy was high, with an increase in extreme polypharmacy from 23% to 32%. The biggest increase was noted in the respiratory (from 17% to 27%) and alimentary medications (from 80% to 87%). Cardiovascular medication use in year 2, was lower in those with stable high dependency (77%) and those evolving from low to high dependency (79%), than those with stable low dependency (89%) (p < 0.025). For residents with or evolving to dementia symptoms, decline in most medication groups was observed, especially in pain and sleeping medications, while antipsychotics use increased.ConclusionAlthough medication use was high, signs of deprescribing were noted when the physical and mental health of the residents declined.     

Improving food intake in nursing home residents with feeding assistance: a staffing analysis.

BACKGROUND: Recommendations have been made to increase the number of nursing home (NH) staff available to provide feeding assistance during mealtime. There are, however, no specific data related to two critical variables necessary to estimate mealtime staffing needs: (1) How many residents are responsive to feeding assistance? (2) How much staff time is required to provide feeding assistance to these residents? The purpose of this study was to collect preliminary data relevant to these two issues. METHODS: Seventy-four residents in three NHs received a 2-day, or six-meal, trial of one-on-one feeding assistance. Total percentage (0% to 100%) of food and fluid consumed during mealtime was estimated across 3 days during usual NH care and 2 days during the intervention. The amount of time that staff spent providing assistance and type of assistance (i.e., frequency of verbal and physical prompts) was measured under each condition. RESULTS: One half (50%) of the participants significantly increased their oral food and fluid intake during mealtime. The intervention required significantly more staff time to implement (average of 38 minutes per resident/meal vs 9 minutes rendered by NH staff). CONCLUSIONS: The time required to implement the feeding assistance intervention greatly exceeded the time the nursing staff spent assisting residents in usual mealtime care conditions. These data suggest that it will almost certainly be necessary to both increase staffing levels and to organize staff better to produce higher quality feeding assistance during mealtimes.     

Seniors for Justice: a political and social action group for nursing home residents.

This article describes a political and social action group of cognitively intact nursing home residents. Organized in response to residents' desire to "do something" about social issues, the group is coordinated by one of the nursing home's recreational therapists, who expected participation in the group to maximize residents' autonomy and sense of control. Benefits mentioned by the participants included: the opportunity to communicate their thoughts, keeping busy, and feeling part of the larger community.     

The use of diarrhoeal management counselling cards for community health volunteer training in Indonesia: the HealthCom Project.

The Indonesian Ministry of Health relies on a network of over a million kader (community health volunteers) to bring primary health care to the village level. In West Java, the Department of Health's Control of Diarrhoeal Disease (CDD) Program recently carried out an extensive research and development effort to produce effective job aids for the kader in CDD and a training programme to teach their use. A set of counselling cards was produced to provide kader with a tool to diagnose and treat diarrhoea and teach the proper use of ORS. Researchers conducted a controlled evaluation in which they measured the cards' effectiveness through observations of kader performance and interviews with mothers they had counselled. In the intervention group, 15 kader underwent two days training in the use of the cards when diagnosing and advising treatment for cases of diarrhoea in their villages. The 16 control kader received comparable CDD training without the cards. Each group provided lists of local mothers they pledged to counsel during the coming weeks. Follow-up interviews were held with these mothers to test their level of knowledge on CDD and to observe their ability to mix ORS properly. Significant performance differences between the intervention kader and mothers, and the control kader and mothers, were demonstrated. The intervention kader were consistently more accurate in their diagnoses and recommendations for treatment with a mean of 83% accuracy vs 68% for the control kader. Mothers counselled by the intervention kader also prepared ORS significantly better than the mothers counselled by the control kader, with 97 vs 74% accuracy.     

A cluster randomized controlled trial of an adapted U.S. model of pharmaceutical care for nursing home residents in Northern Ireland (Fleetwood Northern Ireland study): a cost-effectiveness analysis

OBJECTIVES: To evaluate the cost‐effectiveness of an adapted U.S. model of pharmaceutical care to improve psychoactive prescribing for nursing home residents in Northern Ireland (Fleetwood NI Study). DESIGN: Economic evaluation alongside a cluster randomized controlled trial. SETTING: Nursing homes in NI randomized to intervention (receipt of the adapted model of care; n=11) or control (usual care continued; n=11). PARTICIPANTS: Residents aged 65 and older who provided informed consent (N=253; 128 intervention, 125 control) and who had full resource use data at 12 months. INTERVENTION: Trained pharmacists reviewed intervention home residents' clinical and prescribing information for 12 months, applied an algorithm that guided them in assessing the appropriateness of psychoactive medication, and worked with prescribers (general practitioners) to make changes. The control homes received usual care in which there was no pharmacist intervention. MEASUREMENTS: The proportion of residents prescribed one or more inappropriate psychoactive medications (according to standardized protocols), costs, and a cost‐effectiveness acceptability curve. The latter two outcomes are the focus for this article. RESULTS: The proportions of residents receiving inappropriate psychoactive medication at 12 months in the intervention and control group were 19.5% and 50.4%, respectively. The mean cost of healthcare resources used per resident per year was $4,923 (95% confidence interval (CI)=$4,206–5,640) for the intervention group and $5,053 (95% CI=$4,328–5,779) for the control group. The probability of the intervention being cost‐effective was high, even at low levels of willingness to pay to avoid a resident receiving inappropriately prescribed psychoactive medication. CONCLUSION: The Fleetwood NI model of care was more cost‐effective than usual care.     

Consensus statement on improving the quality of mental health care in U.S. nursing homes: management of depression and behavioral symptoms associated with dementia

The American Geriatrics Society and American Association for Geriatric Psychiatry Expert Panel on Quality Mental Health Care in Nursing Homes developed this consensus statement.
The following organizations were represented on the expert panel and have reviewed and endorsed ^* the consensus statement:
Alzheimer's Association, American Association for Geriatric Psychiatry, American Association of Homes and Services for the Aging, American College of Health Care Administrators, American Geriatrics Society, American Health Care Association, American Medical Directors Association, American Society on Aging, American Society of Consultant Pharmacists, Gerontological Society of America, National Association of Directors of Nursing Administration in Long-Term Care, National Citizen's Coalition for Nursing Home Reform, National Conference of Gerontological Nurse Practitioners.
The following organizations were also represented on the expert panel and reviewed and commented on the consensus statement:
American Psychiatric Association: Council on Aging, American Psychological Association.     

Effect of antipsychotic withdrawal on behavior and sleep/wake activity in nursing home residents with dementia: a randomized, placebo-controlled, double-blinded study. The Bergen District Nursing Home Study

OBJECTIVES: To explore the effect on sleep/wake activity and on behavioral and psychological symptoms of the withdrawal of antipsychotic medications from nursing home (NH) patients with dementia. DESIGN: Randomized, placebo-controlled, double-blind trial. SETTING: NHs in Bergen, Norway. PARTICIPANTS: Thirty patients (mean age 83.5) taking haloperidol, risperidone, or olanzapine for nonpsychotic symptoms. Intervention: Study participants were randomly assigned to withdrawal (intervention group) or continued treatment with antipsychotic medications (reference group) for 4 consecutive weeks. MEASUREMENTS: Behavioral rating using the Neuropsychiatric Inventory Questionnaire (NPI-Q) and actigraphy. RESULTS: After antipsychotic withdrawal, behavioral scores remained stable or improved in 11 of 15 patients, whereas four had worsening scores. Actigraphy revealed decreased sleep efficiency after drug discontinuation and increased 24-hour and night activity in both groups. Actigraphy records of nighttime and daytime activity indicated sleep problems and restlessness, in terms of the NPI-Q. One patient was restarted on antipsychotics. CONCLUSION: Antipsychotic drug withdrawal affected activity and sleep efficiency over the short term. Increases in total activity and impaired sleep quality after drug discontinuation should be monitored, because the long-term effect of these changes is not known. The NPI-Q and actigraphy are feasible tools that disclose relevant changes occurring during antipsychotic withdrawal in NH patients with dementia. Their use in clinical practice should be substantiated by larger studies.